General medicine

Charles Bridges-Webb was born on 15 October 1934 in Castlemaine, Victoria. A country doctor’s son, he graduated from the University of Melbourne in 1957 and went on to become an international figure in general practice research. Charles commenced his research, which he called “organised curiosity”,1 while a rural general practitioner in Traralgon, in south-eastern Victoria. He was appointed foundation Professor of Community Medicine (later renamed General Practice) at the University of Sydney in 1975, and was Head of Department until his retirement in 1994. Charles was a member of the Royal Australian College of General Practitioners (RACGP) Research Committee for 20 years and an RACGP representative on the National Health and Medical Research Council. He was an inaugural member of the Australian Association of Academic General Practice and its president from 1989 to 1991. Charles was an international leader in the development of morbidity surveys, and his publication on morbidity in general practice2 is one of the most important research publications from Australian general practice, offering an understanding of health and disease in the community. As member (1972–1998) and Chair (1991–1998) of the International Classification Committee of the World Organization of Family Doctors, Charles was a key developer of the International Classification of Primary Care, now the official World Health Organization classification system for primary care. In retirement, Charles was Director of the RACGP research unit and Chair of the Australian General Practice Statistics and Classification Centre (home of the BEACH [Bettering the Evaluation and Care of Health] program). He also spent time enjoying his extensive garden, working as a lay preacher and writing his autobiography.3 In 2002, Charles was made an Officer of the Order of Australia for services to primary health care research and general practice. A quiet, philosophical man, Charles saw the good in everyone and encouraged their strengths. He was notable for his generosity in sharing his talents and time, especially with young researchers, for his loving partnership with his wife Anne, and his ability to balance his extraordinary professional contributions with family life. Charles died in Sydney on 16 June 2010 and is survived by Anne and his four children, Andrew, Ian, David and Kate.

Michael R Kidd · Helena C Britt · Graeme C Miller · Deborah C Saltman

To the Editor: I agree with the claim by Richardson that “the overlap between [primary care and emergency department (ED)] services is not as important as many have claimed” and that “‘primary care patients’ and ‘ED [Australasian Triage Scale] category 4 and 5’ patients are not interchangeable”.1 A review of the literature — especially from New Zealand — would show there are considerable differences between patients who attend the two types of services. For example, a comparison of patients with asthma attending either a Wellington after-hours medical centre or an ED service located only 800 metres away2 found that the after-hours medical centre was more likely to see younger patients who live further from the service, are given repeat medications, and are referred back to their general practitioner. In contrast, the ED patients were less likely to be referred by a GP and more likely to be admitted to hospital with asthma than patients attending the after-hours centre. Thus, the two services differed in terms of their clinical policies (repeat prescribing and referral) and patients’ demographic characteristics (age, place of residence). I applaud Richardson for highlighting the powerful effects of hospital policies on the behaviour of people outside hospital walls by saying, “it is not the so-called primary care patients who are blocking ambulances from offloading — it is the ‘access block’ patients waiting for beds on the inpatient wards who are inappropriately occupying ED space and staff time”. This claim has nothing to do with the kind of patients who attend primary care services, but more to do with the influence of management policies arising from within hospitals on patient flow from primary care. It confirms research in New Zealand demonstrating how hospital policies (on advertising their services) can have powerful contradictory effects on attendance at EDs. In some cases, people have been subjected to hospitals advertising the clear message that people should attend the ED when they should be seen in primary care instead; and in other cases, people are dissuaded from attending the ED when they are subjected to advertisements about the poor choices people make to attend a hospital. In each case, it is the hospital policy that determines the direction of flow, not the patients in primary care.3-5

Marjan Kljakovic

To the Editor: Observing jugular venous pressure (JVP) is central to cardiovascular examination. Lewis, in 1930,1 was the first to report the use of the external jugular vein as a manometer for recording pressure in the right atrium. Unfortunately, some textbooks on clinical examination and many clinical teachers incorrectly state that the external jugular is unreliable for measuring JVP and that only the internal jugular should be used. The problem with this is that the internal jugular vein is located deep within the neck, where it is covered by the sternomastoid muscle and is therefore not usually visible. Lewis used the sternal angle as a reference point, presuming that it lay 5 cm above the centre of the right atrium in all positions of the patient between lying and sitting. A recent study using computed tomography to examine 160 patients noted that the median vertical distance between the sternal angle and the mid right atrium was 5.4 cm, thus confirming that Lewis’s estimate of the sternal angle in relation to the right atrium was correct (bearing in mind that adults are taller than they were in the 1920s).2 The mean right atrial pressure is the mean of the peak and trough of the external jugular wave above the sternal angle expressed in cm H2O. Over the past few decades, several studies have confirmed that the original findings of Lewis were correct: there is no significant difference in JVP whether it is measured using the internal or external jugular vein, and the external jugular pulse accurately reflects directly measured right atrial pressure.3 In a study of 52 patients with chronic congestive heart failure who had right heart catheterisation, elevation of the JVP showed 57% sensitivity for a raised pulmonary capillary wedge pressure (≥ 18 mmHg) and 93% specificity for non-elevation of JVP, corresponding with a capillary wedge pressure of ≤ 18 mmHg. If elevated JVP was inducible as well, sensitivity increased to 81% and specificity dropped to 80%, with a predicted accuracy of 81%.4 Generations of frustrated medical students and doctors who have stared intently at their patients’ necks awaiting that elusive flicker of the internal jugular pulse have been overlooking an accurate source of clinical information — namely the pulse in the external jugular vein. Lewis was right 80 years ago: measuring the external JVP is a valuable clinical tool and should be practised frequently.

David M Colquhoun · Glenn Jenkins

Family history has a role, but who should be responsible for exploring and recording it? The increasing age, number and comorbidities of hospital inpatients has increased the load on emergency departments and necessitated significant redesign, including the introduction of short-stay and medical assessment units. These units are diverse in their casemix, but common factors include higher acuity of illness and expedited discharge. Obtaining a complete history of a patient’s acute illness and longstanding comorbidities, as well as his or her social and psychological issues, represents the ideal standard of care. Obviously, however, there are tensions between providing holistic care and continuity of care to the patient and achieving the rapid turnover required in such units. Genetic markers and tests are increasingly available for an expanding range of conditions. Genetic counselling has moved from specialised clinics into the mainstream practice of many disciplines. The inheritance of disease is rarely a simple algorithm, and these new genetic tools provide complexity rather than clear direction. Relevant guidelines are uncommon outside cancer medicine. Family history is a frequent criterion for determining further genetic testing. For example, the Amsterdam criteria for diagnosis of hereditary non-polyposis colorectal cancer (HNPCC) include a family history of at least three relatives with HNPCC-associated cancer.1 There can be harm in failing to interpret genetic tests correctly, and the complexity of many conditions demands a high level of knowledge. “Genetic literacy” is a term that has been used to describe competence in this area.2 However, it seems unreasonable to expect all doctors to be skilful at all times in eliciting and interpreting the family history and then appropriately counselling and testing each patient. Family history is an older tool than genetic testing and is poorly defined, applied and understood.3 Even now, there is not enough evidence to gauge its reliability and role.4 The family history can aid stratification of a patient’s risk of heritable conditions, and it has diagnostic utility for disorders with classic Mendelian inheritance, but it may be less useful in disorders with multifactorial inheritance or more complex genetic expression. In this issue of the Journal Langlands and colleagues report that family history is not recorded in the case notes of most medical short-stay patients.5 They argue that a family history offers potential health gains for the patient and relatives and suggest that there should be increased focus on this element of the medical history. However, this seems unrealistic in the context of increased workload and time pressures, particularly in a hospital short-stay unit. The acute admission is not an ideal setting for detailed and accurate history taking; patients are usually unwell and access to their family is compromised. The family history recorded is often inaccurate4 or misleading, not only because the level of health literacy among patients is variable but also because familial clustering is not distinguished from heritable disease. The accuracy of reporting of family history is rarely studied, but it has been shown that it can be poor in patients with cancer4 or cardiovascular disease.6 The primary care setting affords better opportunities to explore and record family history and to make adjustments after clarification with relatives. Certain conditions (eg, malignant hyperthermia, Huntington disease) drive consideration of genetic testing of the affected individual and sometimes lead to testing of family members. The counselling required should form part of an ongoing relationship with the patient and family. As Langlands and colleagues state,5 the family history may be a casualty of increasing numbers of acute hospital admissions. Perhaps it is a justifiable casualty in the acute health care environment, as long as information is elicited accurately afterwards. Ideally, a patient should have his or her acute illness diagnosed and managed within the acute admission, with a clear plan then delineated for follow-up, which includes notification of those who will be responsible for doing so. It is important to have a use for any family history information once it is accurately obtained. In future, the acquisition of a family history must embrace the developments in our understanding of genetic disease. Without diminishing the role of specialised genetic units, primary care clinicians and specialists in chronic care will need to assume greater responsibility for exploring family history. Screening assessments can identify those requiring a more comprehensive review. We would argue that, under present circumstances and with doubt hanging over its sensitivity, specificity and effect on health outcomes,3,4 the family history is a justifiable omission from many acute hospital admissions. The concept of holistic care is a noble one and, if we are to work within a new paradigm of shorter hospital inpatient stays, we will need to develop a strategy for preserving this concept. Certain diseases, such as unprovoked venous thromboembolism, should trigger an immediate focus on family history, but a routine family history is best ascertained when people are not acutely unwell. If we are serious about disease prevention and the role of genetics in modern medical management, more guidance is needed in terms of which patient groups will benefit from genetic testing and how any positive results will be managed. An integrated approach should include guidance for screening that is based on a better defined family history that has been obtained in the non-acute setting. This approach requires protocols for disease-specific genetic testing and specialist referrals for further assessment and management. A recent National Institutes of Health conference offers hope in this regard.3

Josephine S Thomas BM BS, FRACGP, FRACP · Campbell H Thompson DPhil, FRACP, MD

It is time to reconsider the clinical benefits arising from family history and start making better use of it A patient’s family history may aid clinical diagnosis and contribute to disease risk assessment and prediction. It frequently yields valuable social history, including information about family support structures and insights into individual beliefs about illness.1 Although taking family history is traditionally regarded as a routine part of the medical history, it is not used in a systematic way in clinical practice. In this issue of the Journal, Langlands and colleagues report the results of an audit in an Australian teaching hospital, which found that nearly three-quarters of patients admitted to a short-stay medical unit had no documentation of family history having been considered as part of the diagnostic assessment.2 A similar situation exists in primary care. Although there are no published comparable data from Australian general practice, a primary care study in the United States found that only 16% of subjects (n = 362) had any record of their family history in their clinical chart, including 15 individuals at high risk of an inherited cancer syndrome.3 Internationally, there is growing recognition that a family medical history can support tailored disease prevention, which may be more effective than existing approaches.4 This is also reflected in the Australian Medicare-funded adult health assessment for people aged 45–49 years at risk of developing chronic disease, which specifically includes assessment of the family history of chronic diseases such as diabetes and cardiovascular disease. Family history can also inform the formulation and weighting of differential diagnoses in presentations for a range of common conditions. The risk of many serious diseases is increased in the presence of a family history of the disorder, representing not only shared genetic factors but also environmental and behavioural exposures. For example, the relative risk of breast cancer is 1.4 times higher for women aged 60 years or older if they have a first-degree relative diagnosed with the disease after the age of 60 years; this risk is more than five times higher for women younger than 40 years with a first-degree relative diagnosed before the age of 40.5 Eleven per cent of women with breast cancer have a first-degree relative with the disease. The relative risk of colorectal cancer for a 50-year-old is increased from around twofold with one affected first-degree relative to almost fourfold in people with at least two affected first-degree relatives.6 About 15%–20% of people with colorectal cancer have an affected first-degree relative. In a US population-based study, 14% of the population had a family history of ischaemic heart disease, but these people accounted for 72% of early ischaemic heart disease and 48% of all cases of the disease.7 A parental history of type 2 diabetes is associated with a relative risk of 2.2 and a lifetime risk of 40%.8 These familial disease risks should be compared with other traditional risk factors that are routinely screened for in general practice. For instance, isolated hypertension is associated with a relative risk of 1.8 for ischaemic heart disease and is present in 14% of men and 5% of women with a coronary event.9 There are effective interventions for primary and secondary prevention of all these common diseases, ranging from disease surveillance to drug treatments and lifestyle management. There is some evidence that having knowledge of a family history of a specific condition is associated with improved uptake of a range of disease-preventive activities for breast, colorectal and skin cancer.10-12 Therefore, it is possible that identifying people with a family history of disease could act as an additional motivator for them to change their lifestyle or participate in disease screening. Why then do clinicians continue to neglect the family history as part of routine diagnostic assessment and disease prevention? The experienced clinician will know that recording a patient’s family history to assess disease risk ideally requires a three-generation pedigree, but this can take up to 30 minutes, which is unrealistic in most clinical settings. However, not all patients require such a detailed assessment. Simple, self-completed family history screening questionnaires could provide an answer. Several of these already exist, but many are disease-specific and few have been formally tested to determine their screening characteristics.13 Clinicians also cite patients’ uncertainty about their family history as a barrier. However, a systematic review of self-reported family history found high positive predictive values for cancer in first-degree relatives (breast, 93%; prostate, 85%; colon, 81%), although information was less accurate about second-degree relatives (breast, 91%; prostate, 80%; colon, 77%).14 Of course, sometimes the patient’s perception of his or her family history can be just as important as the reality in determining the patient’s risk perception, illness beliefs and likely response to medical advice. Better methods of recording family history are also required, particularly as we move towards an electronic health record in Australia. Tailored clinical software is potentially the most effective tool for recording and updating a patient’s family history, although current clinical software systems do not support the creation of pedigrees. Previous trials have demonstrated the capacity of computerised pedigree tools to improve the assessment of disease risk and identify those individuals who may benefit most from seeing a clinical geneticist.15 However, while clinicians continue to ignore the importance of the family history in diagnosis and risk assessment, software companies have little incentive to integrate family history tools into their systems. Raising awareness among consumers is an alternative approach that may drive clinicians to consider family history more often. A family health history campaign run in New South Wales in 2007 resulted in increased community awareness and discussions about family history within families and between patients and their general practitioners.16 While DNA-based disease risk prediction remains to be proven as an effective clinical tool, family history is a simple but potent tool that is available now for disease prevention. Langlands and colleagues audit findings show that this important element of the clinical history is seldom included in routine patient assessments.2 The family history should not be seen as a relic of medical school teaching; it is time to reconsider the clinical benefits arising from family history and start making better use of it in clinical practice.

Jon D Emery MB BCH, FRACGP, DPhil · Fiona M Walter MB BCh, FRCGP, MD · David Ravine MB BS, MD, FRCPath

To the Editor: The clinical justification for a medical intervention depends on absolute prevalence (p) of a disease or condition in a population and the relative risk reduction (R) that would result from the intervention. These variables determine the “number needed to treat” (NNT) to prevent one occurrence of a disease, according to the formula NNT = [100 ÷ (P × R)], where P and R are expressed as percentages. This principle applies to thromboprophylaxis in medical patients. However, the prevalence of venous thromboembolism (VTE) in hospitalised patients is uncertain. The main justification for medical thromboprophylaxis given on the National Institute of Clinical Studies (NICS) website1 is an unpublished report prepared by the University of Western Australia (UWA) on behalf of the NICS.2 The report noted that 40.8% of all hospital cases of VTE were “medical” rather than “surgical” or “idiopathic” (primary) cases, but the prevalence of VTE (overall or in each subgroup) was not stated. We obtained coded separation data for all multiday admissions to Royal Perth Hospital (RPH) for the most recent 2-year period with complete data (2005–2007). We searched for VTE events with a principal or secondary coding, and classified them as medical or surgical VTE cases according to the definitions used in the UWA report (for medical VTE, “admissions in which a diagnosis of VTE was recorded as a complication or in a diagnostic field other than the principal diagnosis OR admissions with VTE as the principal diagnosis within 3 months of a non-surgical [medical] admission”).2 We acknowledge that the use of prophylaxis during the index admission or any previous admission within 3 months (which we did not measure) may have meant that we underestimated the prevalence of VTE. Prevalence was calculated by dividing the event number by the total number of admissions or by the number of medical or surgical admissions, as required (expressed as a percentage). At RPH over the 2-year period, 805 VTE events (574 in medical and 231 in surgical patients) were observed in 72 991 medical and 29 177 surgical admissions (total, 102 168 admissions). These included 357 pulmonary emboli (44.3%), 207 of which were primary events. Of the 805 VTE events, 312 (38.8%) were medical, 209 (26.0%) surgical and 284 (35.3%) idiopathic (the corresponding proportions in the UWA report were 40.8%, 37.7% and 21.5%, respectively). The overall VTE rate in the medical patient population was 0.79%, but for “medical VTE” as defined in the UWA report,2 the rate was 0.43%. In surgical patients, the rate of VTE was 0.79% in our study, or 0.72% based on the UWA definition. Hence, according to the definitions used by the UWA report, “surgical VTE” is actually more frequent than “medical VTE”. Our study confirms that about 40% of VTE is in medical patients, but that the absolute prevalence is low (0.43%). This is similar to the rate of 0.4% reported in the PREVENT (Prevention of Recurrent Venous Thromboembolism) study.3 The 40% figure is not relevant for consideration of prophylaxis, as it depends on the number of non-medical events. The low prevalence is directly relevant, and weakens the case, as previously argued, for routine thromboprophylaxis.4 In summary, the NICS support for medical thromboprophylaxis may be biased by its reliance on the UWA report. The risk is of overuse of drugs that cause bleeding, and hence of doing more harm than good.5

J Alasdair Millar · Glenda E Lee · Rinaldo Ienco

To the Editor: Hudson and colleagues showed that rural patients are a willing teaching resource for medical students, but that there are problems in using this resource.1 My experience shows the problems and opportunities. I have long provided a consultant paediatric service to two rural hospitals and an Aboriginal community in south-east Queensland. Clinical demands are large; resources are minimal. Waiting time from referral to consultation is 4–12 months. Many children with schooling problems lose a year of education waiting for diagnosis and treatment, and many have physical and behavioural conditions seldom seen in city practice. Few families are insured; bulk-billing is the norm. I spend 4 days a month in the area. Hospital staff make the appointments, and I use hospital records for my clinical notes. Hospitals provide clinical and personal accommodation, but not a secretarial service or funds for travel. Facilities are poor by city standards and financial returns meagre. I finish my clinics early then spend 3–4 hours each day typing letters to referring doctors and other paperwork. This is wasteful use of skilled time. Several problems and opportunities regarding medical education in rural specialist practice are evident: The need for more clinical teaching for medical students is real and urgent. As rural patients are available and willing, we should use them. Lack of specialists to meet clinical needs and to meet teaching needs are two sides of the same problem. Specialist clinics and teaching should be done in local hospitals that already have basic facilities, but most rural hospitals are already stretched and cannot take on an extra load. Medical specialists must be used efficiently. Additional administrative staff are needed to organise appointments, type letters and do general paperwork. Suitable clinic space and nursing assistance are also needed. Payments to visiting specialists should be sessional rather than case based, so that teaching carries no financial penalty. Payments for clinical and teaching sessions, travel, and accommodation should be sufficient to attract specialists and consultants. Some costs could be recouped by bulk-billing. Ideally, the specialist or consultant would provide long-term continuity to patients and staff — in contrast to registrars, who tend to be transient. Rural specialist practice is an untapped resource for teaching. Given suitable conditions, senior medical staff could develop its potential while providing a much-needed clinical service.

Alan E Dugdale

Stepped-care approaches may offer a solution to delivering accessible, effective and efficient services for individuals with depression. In stepped care, all patients commence with a low-intensity, low-cost treatment. Treatment results are monitored systematically, and patients move to a higher-intensity treatment only if necessary. We deliver a stepped-care model targeting patients with depression. The first step consists of “watchful waiting”, as half of all patients with a depressive episode recover spontaneously within 3 months. The second step, guided self-help, is the key element of the stepped-care model. Guided self-help, especially when offered through the internet, is effective and cost-efficient. The third step consists of brief face-to-face psychotherapy. Finally, in the fourth step, longer-term face-to-face psychotherapy and antidepressant medication might be considered. Patients are monitored by one person, a care manager, who is responsible for the decision to step up to the next treatment and for continuity of care. The different treatments within the stepped-care model are evidence-based. Data on cost-effectiveness of the full model are still scarce, but we recently demonstrated that the incidence of new cases of depression and anxiety could be halved by introducing stepped care. Effects of web-based guided self-help could be enhanced by incorporating them in a stepped-care model.

Annemieke van Straten PhD · Wike Seekles MSc · Nelleke J van ‘t Veer-Tazelaar MA · Aartjan T F Beekman MD, PhD · Pim Cuijpers PhD

To the Editor: Childhood obesity is a growing concern, with an estimated 22% of Australian children considered to be overweight or obese.1 Overweight and obese Indigenous children are at high risk of developing chronic conditions such as ischaemic heart disease and type 2 diabetes,2 contributing to increased mortality.3 Given the paucity of studies assessing rates of overweight and obesity in Indigenous children in urban areas, we conducted a pilot study to determine whether the Aboriginal and Torres Strait Islander child health check (Medicare item 708) is a useful tool for opportunistically assessing dietary habits, blood pressure and rates of overweight and obesity in children attending the Inala Indigenous Health Service. Data were collected from April 2008 to September 2008, and were compared with the 2006 Healthy Kids Queensland (HKQ) Survey.4 Of the 129 children aged 5–14 years who had health checks during the study period, 50 (39%) participated in our study (25 girls). Of those who participated, 36% (18 of 50) were overweight or obese, compared with 21% (751 of 3561) in the HKQ Survey (χ2 = 6.54; P = 0.01) (Box). Of the 41 participants for whom z scores for waist circumference could be calculated, 19 were ≥ 90th centile. Half of the Inala participants (23 of 46 for whom data were available) consumed takeaway food at least once a week, compared with 33% (1048 of 3185) in the HKQ Survey (χ2 = 5.98; P = 0.01). Non-diet soft drinks were consumed at least once a week by 38% (18 of 47 for whom data were available) of Inala participants, compared with 24% (750 of 3129) of the HKQ population (χ2 = 5.19; P = 0.02). Fewer than two-thirds of Inala participants consumed the minimum recommended amounts of fruit, and fewer than half consumed the minimum recommended amounts of vegetables. Our study demonstrates that the Aboriginal and Torres Strait Islander child health checks are a worthwhile screening tool for overweight and obesity. However, recruitment was slow. Even with practice nurses actively inviting potential participants by telephone, only 5% of school-aged children on the clinic’s register attended during the study period suggesting that most of them were well. Opportunistic recruitment of children attending the clinic to see the doctor was difficult, with only one-third participating. Furthermore, addition of the food frequency questionnaire to the child health check increased consultation length, which was at times frustrating for families and clinic staff. What could we do differently? Promoting child health checks to families through fun campaigns, which aim to educate families on the benefits of preventive health checks, and using a quicker health check tool could boost recruitment. Child health check clinics could be run within schools or as special child-friendly clinics during out-of-school hours or school holidays. Our results, limitations notwithstanding, are alarming for this Indigenous community. The addition of waist circumference and blood pressure measurement (with age-appropriate tables) would enhance an already valuable tool — the Aboriginal and Torres Strait Islander child health check — in the early detection of chronic disease risk factors. Weight categories of children from the Inala Indigenous Health Service study and the Healthy Kids Queensland Survey

Annie R Fonda · Geoffrey K Spurling · Deborah A Askew · Peter S W Davies · Noel E Hayman

To the Editor: Improving access to appropriate, good-quality care in the antenatal and postnatal period is a key part of closing the acknowledged gap between Indigenous and other Australians in perinatal outcomes.1 Previous research in a large Aboriginal medical service in Queensland demonstrated sustained improvements in perinatal outcomes associated with a quality improvement approach.2 Here we describe patterns of the delivery of maternity care and service gaps on a broad scale, using data from baseline clinical audits in 34 Indigenous primary health centres participating in a national quality improvement intervention.3 Participating services were located across the Northern Territory (Top End and Central Australia), North Queensland, Far West New South Wales and Western Australia. Details of the audit methods have been described previously.4 Briefly, a random sample of up to 30 clinical records in each service was assessed to determine the degree of adherence to recommended protocols and procedures in the antenatal and postnatal periods.5 Records of women with an infant aged 2–14 months and who had been resident in the community for at least 6 months of the infant’s gestation were considered eligible for our study. The study was approved by the human research ethics committees in each region, and their Indigenous subcommittees where required. Clinical records of 535 women were assessed. Eighty-nine per cent of the women were Indigenous. However, compared with services in the NT, WA and North Queensland, services in Far West NSW had a higher proportion of non-Indigenous women presenting for antenatal or postnatal care (34% v 0–6%; P < 0.05). Overall, less than half of all women presented for care in the first trimester of pregnancy (Box). Documentation of routine antenatal investigations and brief interventions or advice regarding health behaviour varied, but generally these services appeared to be underutilised. There was relatively good documentation of follow-up of identified problems relating to hypertension or diabetes, with over 70% of identified women being referred to a general practitioner or obstetrician. However, follow-up of other identified problems, such as inadequate rubella immunity, was poor. Although 53% of women had a recorded postnatal visit, documentation of advice regarding health risk factors during the postnatal period was poor. For about half of all women there was documentation about breastfeeding advice and contraception. But advice about smoking, nutrition or mood (depression) was recorded for only 19%–21% of all women, and advice about sudden infant death syndrome prevention, injury prevention or infection/hygiene was recorded for only 4%–5% of all women. The clinical audit data presented here indicate that participating services had both strengths and weaknesses in delivering maternal health care. Nevertheless, improving adherence to recommended screening investigations and brief interventions or advice about health behaviours, particularly smoking cessation, in the antenatal and postnatal period were identified as clear areas for improvement across all services. This information represents baseline data to inform the long-term monitoring of a quality improvement intervention. More broadly, it should be useful for informing local, regional and national efforts to promote and assess the quality of primary maternal health care for Indigenous women, and thus help address the persisting unacceptably high rates of poor Indigenous perinatal outcomes in Australia. Documented pregnancy care across regions Characteristic NT Top End NT Central Australia Far West NSW Western Australia North Queensland Total Number of health centres | number of client records audited 13 | 136 2 | 45 6 | 103 9 | 193 4 | 58 34 | 535 Proportion of women with estimated gestational age < 12 weeks at first antenatal visit 49% 44% 35% 42% 34% 42% Mean number of antenatal visits 9 10 5 6 7 7* Proportion of women with folate prescribed before 20 weeks 29% 49% 3% 33% 24% 27%* Any use of: Cigarettes 41% 40% 39% 42% 55% 43% Alcohol 12% 27% 19% 25% 31% 22%* Illicit drugs 7% 2% 17% 8% 7% 9% Brief interventions or counselling Smoking cessation† 48% 67% 35% 49% 41% 46% Antenatal education 51% 93% 51% 46% 47% 52%* Nutrition 53% 76% 18% 32% 59% 41%* Breastfeeding 21% 51% 17% 25% 19% 24% Alcohol and other substance abuse 37% 56% 12% 39% 34% 34%* Investigations at first antenatal assessment Blood group/Rh 96% 100% 65% 77% 79% 82%* Antibodies 93% 100% 66% 70% 78% 79%* Midstream urine (MSU) 91% 96% 40% 67% 76% 71%* Full blood examination (FBE) 95% 100% 64% 73% 79% 80%* Rubella 92% 100% 61% 70% 78% 77%* Hepatitis B surface antigen 91% 100% 56% 75% 79% 78%* Syphilis serology 94% 100% 58% 55% 81% 72%* HIV 80% 89% 14% 72% 59% 63%* Offered anomaly screening 6% 33% 17% 20% 0% 15%* Other investigations Ultrasound before 16 weeks 32% 49% 38% 39% 24% 36% Ultrasound at 16–20 weeks 47% 69% 31% 41% 34% 42% 50g or 75g glucose challenge test (GCT) or glucose tolerance test (GTT) 78% 49% 33% 38% 66% 51%* FBE (20–28 weeks) 82% 69% 24% 46% 60% 54%* Low vaginal swab for group B streptococcus (34–37 weeks) 49% 62% 31% 29% 10% 35%* Follow-up of abnormal findings Record of abnormal standard GCT 17% (23/136) 22% (10/45) 10% (10/103) 4% (7/193) 17% (10/58) 11% (60/535)* GTT undertaken 87% (20/23) 90% (9/10) 80% (8/10) 43% (3/7) 60% (6/10) 77% (46/60) Anaemia (Hb < 100 g/L) 14% (19/136) 22% (10/45) 11% (11/103) 12% (24/193) 3% (2/58) 12% (66/535)* Iron prescribed 84% (16/19) 100% (10/10) 91% (10/11) 75% (18/24) 50% (1/2) 83% (55/66) Follow-up FBE or Hb test done 42% (8/19) 90% (9/10) 36% (4/11) 46% (11/24) 50% (1/2) 50% (33/66) Nitrites detected by dipstick 21% (28/136) 33% (15/45) 5% (5/103) 24% (46/193) 10% (6/58) 19% (100/535)* Urine sent for culture and sensitivity 96% (27/28) 100% (15/15) 100% (5/5) 93% (43/46) 100% (6/6) 96% (96/100) Oral antibiotic prescribed 93% (26/28) 60% (9/15) 80% (4/5) 37% (17/46) 83% (5/6) 61% (61/100)* Record of a normal follow-up MSU 46% (13/28) 100% (15/15) 40% (2/5) 26% (12/46) 83% (5/6) 47% (47/100)* Rubella antibodies negative or low-titre 35% (47/136) 7% (3/45) 15% (15/103) 15% (28/193) 7% (4/58) 18% (97/535)* Rubella vaccination given postnatally 36% (17/47) 67% (2/3) 13% (2/15) 32% (9/28) 0 (0/4) 31% (30/97) GTT = glucose tolerance test. Hb = haemoglobin. NSW = New South Wales. NT = Northern Territory. * P < 0.05 for comparisons between regions. † Among those who used cigarettes: NT Top End (n = 56), NT Central Australia (n = 18), Far West NSW (n = 40), WA (n = 82), North Queensland (n = 32); total N = 228.

Alice R Rumbold · Ross S Bailie · Damin Si · Michelle C Dowden · Catherine M Kennedy · Rhonda J Cox · Lynette O’Donoghue · Helen E Liddle · Ru K Kwedza · Sandra C Thompson · Hugh P Burke · Alex D Brown · Tarun Weeramanthri · Christine M Connors

To the Editor: The Australian Government is seeking to reduce Indigenous disadvantage through its “Closing the Gap” strategy.1 One challenge, however, is incomplete identification of Indigenous status in health and administrative data collections and the necessary caution in interpreting statistics because of such underestimates.2-5 For planning, expenditure, access to and equity of health services, governments need to ensure that Indigenous data collections are accurate. A key area of interest is self-reported Indigenous identification in mainstream general practice settings. Research has focused on general practitioners’ perspectives,6 but not those of Indigenous patients. We conducted a qualitative study that explored the views of Indigenous Australians residing in the Australian Capital Territory who were recruited through a range of Indigenous organisations and differed in age, sex and social background. Participants gave written informed consent to face-to-face interviews, in which they were invited to describe their experiences of being asked their Indigenous status in mainstream general practice settings — including their understanding of why people are asked about their Indigenous identity and views on how they should be asked. Of the 28 participants (age range, 18–78 years), 12 were men, 18 were Aboriginal, five were Torres Strait Islander, and five identified as both Aboriginal and Torres Strait Islander. All had used mainstream general practice services in the ACT. Six reported ever having identified as Indigenous in that setting, although it is unclear how many were asked their Indigenous status. Some reported having been mistaken for being either from another country or non-Indigenous. All stated they would identify as Indigenous if asked, but felt it was essential to be provided with information explaining the rationale for the question — in particular, how it would benefit them if they did identify as such. It was suggested that pamphlets or posters explaining the benefits of identifying could create cultural safety. Participants emphasised the need for appropriate training of practice staff on the rationale for asking the identifier question and how to ask it respectfully. Several themes reflecting issues that would influence an individual’s decision to identify as Indigenous emerged: previous racism in the community; the patient–doctor relationship; the perception that discussing identity would lengthen consultation times; practice staff’s assumed motives for asking; and recognition of the culture and diversity of Indigenous Australians (Box). The principal message was that the process for asking needs to be kept brief and simple. An acceptable form of words was agreed by all participants to be: “For the purpose of providing the best care possible, can you please tell me if you are Aboriginal and/or Torres Strait Islander?” This research highlights the need for GPs to “Just ask!” and to ensure that the Indigenous identifier question and explanation are conveyed consistently and appropriately. Further research in other primary care settings could evaluate the approach that we advocate. Aboriginal medical services provide culturally secure services based on Aboriginal preferences.7 Participants in this study have provided guidance on how similarly culturally secure services could be provided in mainstream general practice. Themes identified from interviews with 28 Indigenous respondents about identifying as Indigenous in mainstream general practice Importance of the patient–doctor relationship “I think it is important to start building relationships between medical professionals and Indigenous people, so that Indigenous people can start becoming more informed about their health and be more proactive in managing it more.” Rationale for asking about Indigenous identity “. . . I can understand why a mainstream service would see if a person wants to identify or not so that they can get those Medicare items. So it needs to be done without someone getting offended. I know that I would be offended if it was done in a mainstream area and a big deal made of just for the money. It’s how you portray it to the Indigenous person so that they don’t get offended.” Creating cultural safety in general practice “When you see posters and pamphlets and information then you think, ‘Oh, so maybe this surgery is OK’. You’re more comfortable in coming back and volunteering information. It is all about creating an environment that enables that.” Mistaken identities of Aboriginal and Torres Strait Islanders “Some of them have asked if I was from PNG [Papua New Guinea], and um [I’m] . . . not really a Torres Strait Islander, I don’t know, it must be my features. They naturally assume that I am from PNG.” Who should ask the question? “I think the doctor. Because then they get an idea of your background and . . . it gives them a good idea of where you come from and what sort of illnesses are around the place.” Just ask! “I love who I am, I don’t mind saying where I’m from.”

Angela Scotney · Jillian A Guthrie · Kamalini Lokuge · Paul M Kelly

Objective: To identify the number of Australian clinical practice guidelines, and their key characteristics.Design, setting and participants: Clinical practice guidelines that were produced or reviewed between 2003 and 2007 for use in Australia at a national or state level were identified by approaching health-related organisations and searching websites. Their characteristics were abstracted from the published guidelines and publicly accessible accompanying material.Main outcome measures: Number of clinical practice guidelines, key health areas, documentation of evidence search and appraisal processes, numbers and types of guideline producers and funders, presence of competing interest statements.Results: 313 clinical practice guidelines were identified, of which 91 (29%) were evidence-documented, either in the guideline itself or in an accessible accompanying document. Over 80 guideline producers were identified. Federal or state government agencies produced or contributed funding to 53% of the guidelines (167/313); 28% of the guidelines supported by government agencies (46/167) were categorised as evidence-documented. A review date was specified in 52% of evidence-documented guidelines (47/91), but a third of these had passed the review date at the time of our study and no updated guidelines were found. Areas with a large burden of disease did not necessarily receive government support for guideline development. Most guidelines (246/313; 79%) made no mention of possible competing interests of members of the guideline development group.Conclusions: A more coordinated approach to identifying national priorities for developing and updating clinical practice guidelines may produce better returns on investment in Australian guidelines. In addition, more transparency in documenting the guideline development process, including details on competing interests, is needed.

Heather A Buchan MB ChB, MSc, FAFPHM · Kay C Currie BA, GradDipAppPsych, MPH · Emma J Lourey BA(Hons) · Geraint R Duggan BA(Hons), RN, MBioethics

Objective: To compare rates of visits to a general practitioner between users and non-users of mental health services (MHS).Design, participants and setting: Population-based retrospective cohort study of 204 727 users and 294 076 matched non-users of MHS in Western Australia from 1 January 1990 to 30 June 2006, based on linked records of the use of MHS, hospital admissions, Medicare claims for GP and specialist services, electoral roll registration and deaths.Main outcome measures: Adjusted rate ratios (ARRs) for the number of visits to GPs by users of MHS relative to non-users, and for different categories of mental disorders.Results: Relative to non-users of MHS, the ARR of visits to GPs by users of MHS was 1.622 (95% CI, 1.613–1.631) overall, and was elevated in each separate category of mental illness. ARRs were highest for alcohol/drug disorders, schizophrenia and affective psychoses (2.404, 1.834 and 1.798, respectively). The results were not changed by location (metropolitan, rural or remote addresses). However, the 4% of MHS users with no fixed address had a very low ARR of visits to GPs (0.058; 95% CI, 0.057–0.060).Conclusions: Users of MHS visit GPs substantially more often than non-users, with the exception of those with no fixed address who seldom see a GP at all.

Qun Mai MB BS, MPH · C D’Arcy J Holman MPH, PhD, FAFPHM · Frank M Sanfilippo BPharm, PGradDipPharm, PhD · Jonathan D Emery MB BCh, DPhil, FRACGP · Louise M Stewart BSc(Hons), GradDipPublicHealth

To the Editor: From 30 September 2009, the Australian Government began offering free pandemic (H1N1) 2009 influenza vaccine (Panvax, CSL Limited, Melbourne, VIC), using either 10-dose (5 mL) or 20-dose (10 mL) vials.1 Multidose vials are not used routinely in Australia, and are designed for high-volume vaccination clinics.2 Once pierced, a Panvax vial must be used within 24 hours or discarded.3 We investigated vaccine wastage in general practice during the first month of the vaccine’s availability. We randomly selected 300 of 697 known general practices within the Sydney South West Area Health Service. A one-page audit of vaccine vials received and consumed, and of patients vaccinated to 31 October 2009 was faxed to practices. One reminder fax was sent. Faxes were successfully delivered to 271 practices and 146 (54%) responded. Twelve responses (4%) were substantially incomplete, leaving 134 (49%) for analysis. Practices reported vaccinating 28 445 people. A median of 70% (interquartile range, 50%–90%) of people immunised belonged to a priority group. An estimated 49 130 doses were consumed, indicating that 20 685 doses (42%) were wasted. A median of 40% of doses were wasted per practice. Three practices (2%) had administered only one dose per multidose vial. There was significantly less wastage in practices with access to 5 mL vials (median wastage, 30%) than practices that had only 10 mL vials (median wastage, 50%) (P < 0.001; Wilcoxon rank-sum test). There was no significant difference in the proportion of doses wasted between the 70 practices that organised vaccination clinics and the 63 practices that did not (median wastage, 43% v 40%; P = 0.9; Wilcoxon rank-sum test). There was also no statistically significant difference in the proportion wasted between solo and multidoctor practices (median wastage, 43% v 34%; P = 0.2; Wilcoxon rank-sum test) although the absolute wastage level was lower for multidoctor practices. These results provide evidence that multidose vials (discarded within 24 hours of first use) are an inefficient method of presenting pandemic influenza vaccines for general practice use. Wastage was substantial. This study is limited to the program’s first month, so initial results may not reflect results over the whole program. However, if similar wastage occurred nationally, over 7.5 million of the 19 million doses available to Australians could be wasted. Nevertheless, the low unit cost and rapid production advantages of multidose vials may justify their use when faced with an urgent threat, and if used in mass vaccination clinics. Wastage could be reduced by increasing the availability of 5 mL multidose vials, but not (according to our data) by organising general practice vaccination clinics. Extending the vaccine shelf-life from 24 hours to 28 days, to align with licence conditions in the United States,4 could decrease wastage, as it may be that the short shelf-life results in more wastage than does supplying the vaccine in multidose vials. No rationale for the shorter shelf-life in Australia has been found, but we surmise it was set as a precaution to reduce the risk of contamination. Doses saved through reduced wastage could be used to increase Australia’s donation of vaccine to developing countries.5

Caroline E Turnour · Stephen J Conaty · Michelle A Cretikos

To the Editor: Newby and Robertson’s study of the effect of computerised prescribing on the frequency of repeat prescriptions for antibiotics is important in highlighting unnecessary repeat prescribing.1 However, their work has highlighted another issue — researchers’ growing habit of using the prescription of selected antibiotics to infer indication, and then to measure appropriateness of care. When using the term “upper respiratory tract infections” (URTIs), do the authors mean viral infections or all URTIs, including bacterial infections? They state: While we did not include data on the indication for treatment in our study, the antibiotics we chose are those commonly used for respiratory tract infections. Therefore, the continued high rate of repeat ordering for these antibiotics remains a concern.1 We support the latter statement wholeheartedly, but the inference that the antibiotics examined in the study were used to manage URTIs (because these antibiotics are “commonly used to treat URTIs”) is inappropriate and incorrect. A media report misguidedly described Newby and Robertson’s study as examining “how GPs’ use of computerised prescribing systems affects antibiotic prescribing for upper respiratory tract infection.”2 The study was not about prescribing of antibiotics for URTIs, but this implication is apparent in their article. From the national Bettering the Evaluation and Care of Health (BEACH) program 2006–2009,3 we examined 20 011 general practitioner prescriptions for Newby and Robertson’s selected antibiotics: amoxycillin, amoxycillin/clavulanate, roxithromycin, and cefaclor. We would usually include cephalexin, because it is prescribed as often as cefaclor for URTIs at BEACH encounters, but we have limited our comparison to the above four antibiotics. In the BEACH program, GPs link the prescription to the problem being managed so we can determine the indication for which these antibiotics have been prescribed. Over the 3-year period of the 2006–2009 BEACH program, only 21.1% of these antibiotics were prescribed for URTIs (adults [≥ 15 years], 20.6%; children [0–14 years], 22.7%). In four out of five cases, the prescriptions were for acute bronchitis, sinusitis, acute otitis media or myringitis, tonsillitis, urinary tract infections, skin infections, pneumonia, and a variety of systemic infections. It cannot be assumed that a URTI is the indication simply because these antibiotics are most commonly used for its management, and by inference, that GPs are prescribing inappropriately. Newby and Robertson are not alone — the 2010 Productivity Commission report used the number of prescriptions for “antibiotics most commonly used to treat URTI” as one indicator of the appropriateness of GP services.4 These antibiotics are, in most cases, prescribed for indications other than URTI. The appropriateness of this prescribing cannot be assessed without knowledge of the indication, and without clear guidelines as to what level of antibiotic prescribing for each indication is “best” quality.

Joan V Henderson · Christopher M Harrison · Helena C Britt

In reply: We accept the evidence presented by Henderson and colleagues that the antibiotics examined in our study are not used exclusively for upper respiratory tract infections (URTIs), and we acknowledge in our article the lack of information on indication for treatment. However, data from the Bettering the Evaluation and Care of Health (BEACH) program have been used by others to suggest that the four antibiotics represent over 60% of the prescribed antibiotics for URTIs.1 Our study does not assess the appropriateness of the antibiotic choices, focusing instead on duration of therapy as implied by the issuing of repeat prescriptions. Irrespective of indications for use of these antibiotics, our data still support our primary conclusion that computerised prescribing is associated with increased repeat ordering for these, and probably other, antibiotics. The increase in repeat ordering could possibly be explained if doctors who use computers to prescribe see “sicker” patients or a significantly different case-mix from those who write prescriptions by hand. However, the size of the difference (70% v 40% of prescriptions with repeats, respectively), the consistency across the antibiotics examined, and the identical rate of repeat ordering on handwritten prescriptions in both surveys, makes this conclusion unlikely.

David A Newby · Jane Robertson

Older road users. Myths and realities, a guide for medical and legal professionals. Morris S Odell, Editor. Tucson, Ariz: Lawyers & Judges Publishing Company, Inc, 2009 (xvi + 302 pp). ISBN 978 1 933264 70 7. Traffic medicine is an emerging discipline, so not many resources are available on the subject. The fact that the editor of this book, Morris Odell — a Forensic Physician at the Victorian Institute of Forensic Medicine in Melbourne — is also my former teacher for whom I have great respect, made me read it with added interest. The proportion of elderly drivers is expected to rise significantly in the next 50 years and the role of medical practitioners in assessing their medical fitness to drive will increase. At present, there are no strict guidelines for assessing elderly drivers’ medical fitness to drive since, in many instances, the evidence available is contradictory. This book acknowledges the limitations of the assessment process, but provides abundant information to help readers form their own opinions. I found this approach to be unbiased, unintrusive and fair. The book was commissioned by VicRoads, in response to the 2003 Inquiry into Road Safety for Older Road Users by the Victorian Parliament Road Safety Committee. It addresses the main factors that affect driving skills — vision, cognition and motor function, with particularly interesting chapters on the effects of prescription drugs, and respiratory and sleep disorders. In addition, it examines different patterns of road injuries and the distinct crash epidemiology of elderly drivers. Odell has assembled a stellar team of contributing authors and the information provided is contemporary, easy to understand and backed up by evidence. The assessment options and principles of the assessment process of elderly drivers are explored in detail but the book stops short of recommending a particular assessment tool. Furthermore, it does not take a preferred position or make recommendations for when the elderly should not drive. This omission could be compensated by grabbing a copy of Austroad’s Assessing fitness to drive 2003, which gives strict recommendations for when people should not be driving. Apart from these small omissions, this is a great reference that gave me a lot of answers to questions that I haven’t been able to find for years. It will benefit medical and legal professionals whose work involves elderly drivers, as well as students and young doctors who would like to learn more about the relationship between different medical conditions and their impact on driving safety.

Ilian Kamenoff

Putting to rest the myth that emergency department overcrowding is due to a lack of primary care services Australia’s emergency departments (EDs) are dangerously overcrowded, but a study by Buckley and colleagues in this issue of the Journal1 should be the last nail in the coffin of the long-discredited myth that the root cause is a lack of primary care services. This study used a time series approach to identify a real — but clinically insignificant — change in ED workload after the opening of an after-hours primary care service in the New South Wales inland rural city of Wagga Wagga. The Australian public are entitled to receive high-quality and available care in both primary care and emergency settings, but the overlap between these services is not as important as many have claimed.2,3 In a rural location without pre-existing after-hours primary care services, the introduction of such a service, which treated 14 patients daily on average, was associated with an adjusted daily reduction in ED presentations of seven patients with an Australasian Triage Scale (ATS) category of 4 or 5 (lower urgency). As the authors note, because non-admitted low-urgency patients tend to have low resource needs, this reduction of 8% of total ED presentations would correspond to a lesser reduction in workload. Based on published Wagga Wagga Base Hospital data and accepted casemix measures, this reduction would translate to around 3% of this rural ED’s costs and no more than 4% of its ED medical and nursing staff time. These figures are higher than some other Australian estimates,4,5 mostly from studies in cities with pre-existing after-hours services. However, they remain consistent with the observation from these studies that the overall weekly primary care workload in an ED amounts to no more than one patient per hour. In Wagga Wagga, few general practices open for more than 55 hours per week, and the after-hours service opens for 27 hours, but the ED is always open and is the only source of medical care in this community for more than half the 168 hours in each week. It is no surprise that some patients who could reasonably go elsewhere will present to the ED. Buckley et al’s results show that the after-hours clinic treated an average of 3.7 patients per hour. During the hours the clinic was open, the reduction in ED presentations was 1.8 patients per hour and, when it was closed (ie, the rest of the week), the reduction in ED presentations was 0.2 patients per hour. It is unlikely that extending the clinic’s opening hours would make much difference: opening during office hours would probably reduce presentations to existing general practices, and opening later at night would likely be uneconomical. Although, as the study authors note, general practitioners working in EDs in the United Kingdom have been shown to be more cost-efficient than junior medical staff in the same environment, the actual cost of emergency medicine is dominated by infrastructure and staff expenses 24 hours per day.6 EDs have a high average cost per patient and a low marginal (incremental) cost for additional low-acuity presentations, especially compared with off-site after-hours clinics, where expenses are dominated by medical labour, and the average and marginal costs are much closer together. Even if patients were 100% interchangeable, a new after-hours service would likely represent an increase in total cost to the community, because it would not reduce the need for the “public good” of a 24-hour service available at the hospital. Despite its limitations, this study confirms that “primary care patients” and “ED ATS category 4 and 5 patients” are not interchangeable. It is to be expected that there is some overlap between patients who might want to present to an ED and those who might want to go to a GP — just as there may be overlap between patients going to a GP or a gynaecologist for a Pap smear, or between those going to a thoracic surgeon or a respiratory physician for investigation of a lung mass. However, the finding that 96% of the weekly workload of an ED cannot be substituted by an after-hours service confirms that patients are largely presenting appropriately. By comparison, at least a third of average ED staff workload (and more than half in some places) consists of providing care to those who have completed their emergency treatment and are waiting for an inpatient bed,7 sometimes for days. Australian EDs are dangerously overcrowded with patients, many of whom should not be in EDs because they would be better managed elsewhere. But it is not the so-called primary care patients who are blocking ambulances from offloading8 — it is the “access block” patients waiting for beds on the inpatient wards who are inappropriately occupying ED space and staff time.

Drew B Richardson MB BS(Hons), FACEM, GradCertHE

Mosby’s dictionary of medicine, nursing & health professions, 2nd Australian and New Zealand edition . Peter Harris, Sue Nagy, Nicholas Vardaxis, editors. Sydney: Elsevier Australia, 2009 (xvi + 2015 pp). ISBN 978 0 7295 3909 8. The first Australian and New Zealand edition of this popular American dictionary was published in 2006. It was a landmark achievement, with its Asia-Pacific orientation in both content and style. For instance, entries included the “bluebottle jellyfish”, common to Australasian waters. Local spelling and phonetic pronunciation guides were also provided. However, almost as soon as it was published, the need for a continuing process of review and revision was recognised. And so, editors-in-chief Peter Harris, Sue Nagy and Nicholas Vardaxis led a team of 60 specialists to produce further refinements, which resulted in this second edition. The language of medicine is constantly evolving to keep up with the latest developments in research and technology. Thus, some of the new terms in the second edition include Hendra virus, Nipah virus, swine flu and vancomycin-resistant enterococcus. There were some 40 000 entries and 2400 colour images in the first edition. More than 500 images, 300 drug entries and 73 tables have been added or updated in this edition. The many useful appendices cover areas such as nutrition guidelines, immunisation schedules, infection control and herb–drug interactions. Charts and graphs range in content from lung sounds and burn depths to contraceptive effectiveness and cardiac arrhythmias. Simple devices such as extensive cross-referencing and a thumb-style index make navigation easy. The bonus “Evolve” website access provides many free online resources, such as all the images from the book, directories of key health organisations and health promotion information. This strategy has enabled the dictionary to be confined to a single volume that is still kept current through the website. This dictionary can help health professionals and students become familiar with new medical terminology and techniques, and thus improve their communication and outcomes. Certainly, as a proofreader for the Journal, I’m sure to refer to it at least once a week.

Gita Sankaran

Objective: To assess the views, needs and intended behaviour of general practitioners and practice nurses (PNs) regarding pandemic influenza.Design, setting and participants: A postal survey of GPs and PNs in four Divisions of General Practice in New South Wales, selected to represent a diverse sample of practices from inner-city, semi-urban and rural areas. The study was undertaken from 1 February to 1 April 2009.Main outcome measures: GPs’ and PNs’ responses to survey statements assessing their awareness and perceived personal risk, intended behaviour in the event of a pandemic, and expectations surrounding antivirals, vaccine and personal and family protection.Results: Of 390 general practice staff who were sent the survey, 139 (36%) completed it. Most respondents felt confident that they possessed the necessary knowledge (71.5%, 98/137) and skills (73.7%, 101/137) to provide patient care during an influenza pandemic. Although 38.7% (53/137) stated that they would visit quarantined symptomatic patients, 41.6% (57/137) were unsure. More than half the respondents (53.2%, 74/139) stated that they would require access to vaccination and antivirals for their family as well as themselves before they would attend symptomatic patients at the general practice.Conclusion: These findings provide evidence of the need to ensure that general practice staff have access to personal and family protection to encourage an adequate response to a pandemic situation.

Holly Seale BSc, MPH, PhD · Kirsten F Ward BHSc · Nick Zwar MB BS, FRACGP, PhD · Debbie Van · Julie Leask BSc, MPH, PhD · C Raina MacIntyre MB BS, FRACP, PhD

Objective: To examine the comparative prevalence and distribution of obesity and psychological disturbance in the asthma and non-asthma populations, and to determine how these comorbidities are associated with physical functioning.Design, setting and participants: A South Australian population-representative study of 3175 adults who provided data on asthma, psychological morbidity, physical functioning, and body mass index. Bivariate and multivariate analyses identified how these comorbidities were distributed in asthma and non-asthma subpopulations, and the variance in physical functioning that they explained.Main outcome measures: Rates of obesity and psychological morbidity, and physical functioning scores in asthma and non-asthma populations.Results: Men and women in the asthma population had similar prevalences of obesity (35.3% v 33.6%) and psychological morbidity (29.5% v 29.4%). When compared with non-asthma controls, both comorbidities were significantly higher only in men with asthma. The prevalence of psychological morbidity within different weight categories in the asthma population compared with non-asthma weight-category controls varied by sex. Physical functioning was lower in the asthma population than the non-asthma population (46.6 [95% CI, 45.9–47.3] v 48.8 [95% CI, 47.8–50.0]; P < 0.001), and psychological morbidity explained 22% of this variance.Conclusions: Psychological morbidity and obesity are common in people with asthma. The sex-specific variation in psychological morbidity across weight categories suggests that future studies of psychological morbidity in groups with asthma should adopt designs that consider sex-specific controls rather than comparisons between the sexes.

David H Wilson PhD, MPH, BEd · Sarah L Appleton BA · Anne W Taylor PhD, MPH, BA · Graeme Tucker BSc · Richard E Ruffin AM, MD, BSc(Hons), FRACP · Gary Wittert MB BCh, MD, FRACP · Graeme Hugo PhD, BA(Hons), MA · Robert D Goldney MB BS, MD · Christopher Findlay PhD, MEc · Robert J Adams MB BS, MD, FRACP

Objective: To evaluate the impact of an acute assessment unit (AAU) on length of hospital stay (LOS), emergency department (ED) waiting times, direct discharge rate, unplanned readmission rate and all-cause hospital mortality of general medical patients.Design and setting: Retrospective comparison of data for general medical patients admitted to a tertiary teaching hospital in Adelaide, South Australia, before and after the establishment of an AAU (reference years, 2003 [before] and 2006 [after]).Main outcome measures: Mean LOS, ED waiting times and all-cause hospital mortality during calendar years 2003 (pre-establishment) and 2006 (post-establishment).Results: Following the establishment of an AAU, the mean LOS shortened (from 6.8 days in 2003 to 5.7 days in 2006; P < 0.001) despite a 50.5% increase in the number of admissions (from 2652 to 3992). The number of admitted patients waiting in the ED more than 8 hours for a hospital bed decreased (from 28.7% to 17.9%; P < 0.001), as did the number waiting more than 12 hours (from 20.2% to 10.4%; P < 0.001). The rates of unplanned readmission within 7 and 28 days did not change. The all-cause hospital mortality for general medical admissions was 4.6% in 2003 v 3.7% in 2006 (P = 0.056).Conclusion: The establishment of an AAU within the general medical service coincided with decreases in both LOS and ED waiting times, despite a 50% increase in admissions. This structural reform in the process of acute medical care may have contributed to the improvement in these key health care performance indices without compromising the quality of patient care.

Jordan YZ Li MB BS, FRACP · Tuck Y Yong MB BS, FRACP · Denise M Bennett RN, RM, MBA · Lauri T O’Brien RN, RM, BN · Susan Roberts RN, BN, MNsg · Paul Hakendorf BSc, MPH · David I Ben-Tovim PhD, FRANZCP, MRCP(Psych) · Paddy A Phillips DPhil, FRACP, FRCP · Campbell H Thompson MD, DPhil, FRACP

The real man’s tool box. A DIY health manual for men. Tammy Farrell. Sydney: Hachette, 2009 (294 pp). ISBN 978 0 7336 2394 3 Written by a registered nurse and nutritionist, The real man’s tool box aims to educate the average bloke with humour, vignettes and sound advice. The book covers common areas of men’s health, with an emphasis on cardiovascular, gastrointestinal, prostate, mental, and genital health. Given the author’s background in nutrition it is not surprising that this subject also has significant emphasis. Some less commonly discussed topics are covered, such as the Men’s Shed movement and “secret women’s business”. The real man’s toolbox fits into the “self-help books for men” genre which includes: Every man by Derek Lllewellyn-Jones, Men’s health by Ian Hamilton Craig, Man maintenance by Jill Margo and The M factor by Andrew Pattison. Its arrival is timely and it’s probably the easiest read in this series. The book has drawn upon many reputable sources for its information, including the Heart Foundation, beyondblue, Cancer Council and Diabetes Australia. It has an excellent bibliography of web-based references and a substantial glossary. The section on “Your personal logbook” is a lay version of the Royal Australian College of General Practitioners’ “Red book”. The information is up to date and accurate. The target audience is the health-illiterate male, especially the ones interested in cars. The author has chosen basic, conversational-style language with plenty of anecdotes and case studies. Simple anatomy and physiology is covered using slang, often with plumbing or mechanical metaphors. It is likely that health professionals might find this book rather hackneyed, containing too many lists and prescriptive advice. However, the target audience male patients with minimum health knowledge should benefit by gaining a practical knowledge of their bodies and how doctors could help them “get their body serviced”.

Nicholas B Cooling

Clinical record Patient 1 A 90-year-old man with bilateral neovascular age-related macular degeneration (AMD) presented with sudden onset of painful visual loss in his left eye. Visual acuity in his right eye was 1/60 due to scarring associated with AMD, and visual acuity in his left eye had deteriorated to hand movements; it had previously been 6/120. He had been taking warfarin for about 2 years for atrial fibrillation and a transient ischaemic attack. The international normalised ratio (INR) had previously been measured almost weekly, but as it had been stable at 2.5–2.9 (target INR, 2.0–3.0), it had not been measured for 6 weeks. B-mode ultrasonography and dilated fundus examination revealed massive suprachoroidal haemorrhage (Figures A and B). The INR was 6.0, which was reversed with intravenous administration of two units of fresh frozen plasma and 1 mg of vitamin K. Visual acuity in the patient’s left eye deteriorated to light perception. As there were no signs of spontaneous improvement and this had been his better eye, surgery was performed to drain the haemorrhage. After surgery, the haemorrhage decreased in size but his vision did not improve. Patient 2 An 82-year-old man presented with a 3-week history of a shadow in his left eye. He had been taking low-dose aspirin for ischaemic heart disease and stroke, but had no known ocular history. On examination, visual acuity was 6/5 and hand movements in his right and left eye, respectively, and massive subretinal haemorrhage was noted in the left eye. Non-neovascular AMD was present in his right eye, and the haemorrhage in his left eye was presumed to be due to a combination of neovascular AMD and the effects of aspirin. He was offered surgery, but declined as there was little chance of improvement in central vision. Subsequently, he gradually lost all vision (including light perception) in his left eye. Aspirin was continued because of his significant cardiovascular history. Over the following year, neovascular AMD developed in his right eye and visual acuity dropped from 6/5 to 6/36 (Figure C). He was treated with regular intravitreal ranibizumab injections, and his vision stabilised. However, several months later, vision in his right eye suddenly deteriorated to vague perception of light. On examination of his right eye, there was no view of the fundus due to a dense cataract and vitreous haemorrhage, but B-mode ultrasonography once again revealed massive choroidal, subretinal and vitreous haemorrhage. The patient was still taking low-dose aspirin therapy, which was subsequently ceased. In an attempt to preserve vision in his only seeing eye, he underwent vitrectomy and silicone oil insertion, but there was no improvement and he subsequently lost light perception in his right eye. A: B-mode ultrasonogram of Patient 1’s left eye, showing massive suprachoroidal haemorrhage. B: Fundus photograph of Patient 1’s left eye, showing massive suprachoroidal haemorrhage bulging forward (therefore largely out of focus). C: Fundus photograph of Patient 2’s right eye, showing right neovascular AMD with subretinal haemorrhage, prior to development of massive suprachoroidal, subretinal and vitreous haemorrhage. Age-related macular degeneration affects about one-third of people aged over 75 years.1 Of those with AMD, 10%–15% develop the neovascular (“wet”) form,2 characterised by abnormal new blood vessel formation in the choroid, under the retina. These abnormal vascular membranes are prone to rupture, leading to subretinal bleeding, fibrous scar formation and severe visual loss. Many older patients who have AMD also take medications that can exacerbate or promote bleeding, such as anticoagulants or antiplatelet agents. In rare cases, intraocular bleeding — in the form of subretinal, suprachoroidal, or vitreous haemorrhage — can be catastrophic and blinding. Previous reports link systemic anticoagulation therapy to intraocular haemorrhage and blindness in AMD patients,3-7 including a recent report in this Journal.8 In two of these reports, patients taking warfarin had very high INRs (4.1 in one case;3 6.3 in the other4). Other reports link systemic anticoagulation therapy to spontaneous suprachoroidal haemorrhage, even in the absence of neovascular AMD.9-11 Additionally, patients with neovascular AMD can develop massive submacular haemorrhage, even if they are not taking antiplatelet or anticoagulant agents. Unfortunately, as many patients with AMD have one eye with poor visual acuity due to macular scarring, it is all the more catastrophic when a massive haemorrhage leads to blindness in their “good” eye. We suggest that the risk of catastrophic bleeding may be stratified, with the greatest risk being associated with anticoagulants (eg, warfarin), followed by antiplatelet agents (eg, clopidogrel and ticlopidine, with aspirin conferring a lower risk). In addition, we would expect a greater risk with combination therapy comprising simultaneous use of multiple antiplatelet and/or anticoagulant agents. In the cases reported here, we suggest that haemorrhage is likely to have been more severe and blinding than it would have been in a patient who was not taking those medications. Although these medications should not be withheld in cases where they are warranted to reduce cardiovascular morbidity and mortality, they are not without risk, and a careful risk–benefit analysis should be performed for each patient before they are prescribed. For example, the risk of stroke is different among patients with simple atrial fibrillation compared with aortic valve replacement. It has been previously noted that if a patient has only one functioning eye, the patient’s general practitioner or cardiologist should seek an ophthalmologist’s opinion to assess the risk of neovascular AMD in the seeing eye before, or soon after, commencing warfarin.12 Further, ophthalmologists should ask their patients whether they take warfarin, and should communicate to the treating doctor whether a patient has, or is at high risk of developing, neovascular AMD.12 Patients taking warfarin who develop neovascular AMD should be advised to maintain an INR at the lower end of the recommended range.3 In addition, we recommend that it would be prudent for INR monitoring to be at the more frequent end of the spectrum. Lessons from practice Patients taking warfarin who develop neovascular age-related macular degeneration (AMD) should maintain an international normalised ratio (INR) at the lower end of the recommended range. INR monitoring should be more frequent for patients with neovascular AMD. If a patient has only one functioning eye, an ophthalmologist should assess the risk of developing neovascular AMD in the seeing eye before, or soon after, commencing warfarin or an antiplatelet agent, including aspirin. Ophthalmologists should ask all patients whether they take warfarin, and should communicate to the treating doctor whether this patient has, or is at high risk of developing, neovascular AMD.

Helen M Garrott FRANZCO,MB BS(Hons), BMedSc · Richard J Haynes MB BCh, FRCOphth, MD

To the Editor: We read with interest Walters and Dawson’s call for a clinical revolution to tackle access block1 and are heartened by the interest shown by general physicians in a problem that primarily affects the emergency department (ED). The efficient management of admitted medical patients is paramount to patient flow within the hospital, and “buy-in” from general physicians is essential. When considering any new model of care, it is important to note that longer patient assessments in ED by emergency doctors has a relatively small effect on access block; the claim that the length of assessments is a significant factor in access block has been established as a “myth” by investigators who have mapped process times.2 Therefore, it is unlikely that substituting one workforce of acute physicians for another would make any difference to overall patient flow through the ED. On the contrary, it is likely to be associated with increased costs3 and adverse effects on the emergency medicine labour supply.4 In addition, the ability and willingness of the general physician workforce to implement and sustain the newer role of “acute physician” is unknown. The root cause of access block lies in ward-bed shortages, ward processes and community capacity, which should be solved by improved flow processes across the continuum of care. Access block will not be solved by a second tier of acute physicians duplicating the role of emergency physicians. However, there are many aspects of Walters and Dawson’s model of change that would improve patient flow, in particular: improved rostering of medical staff; improved access to pathology and radiology services; and, perhaps, specific retraining of medical staff in the efficient discharge of inpatients. These aspects should be rigorously explored as we strive together to tackle access block.

Biswadev Mitra · Peter A Cameron · Pieter De Villiers Smit