The Medical Journal of Australia

[Ethics and Law] Challenges to Australia’s national health policy from trade and investment agreements

Deborah H Gleeson, Kyla S Tienhaara and Thomas A Faunce — Thu, 29 Mar 2012 00:00:00 GMT

Med J Aust 2012; Online first
Recent federal trade policy commitments could protect Australia’s tobacco control legislation and the Pharmaceutical Benefits Scheme in the Trans-Pacific Partnership Agreement negotiations

[Editorials] Coming out: is the Mardi Gras still needed?

Ruth P McNair and Tonda L Hughes — Mon, 05 Mar 2012 00:00:00 GMT

Med J Aust 2012; 196 (4): 224-224.
Health providers can be advocates and opinion leaders for social change

[Editor's Choice] What does obesity mean for individual and population health?

Annette Katelaris — Mon, 20 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (3): 151.
It’s no secret that overweight and obesity are a modern epidemic. They are associated with many adverse health outcomes and are therefore an important issue in the realms of both individual and public health. Articles published in this issue of the Journal remind us not only of these realities but also that we still have a long way to go in understanding the links between obesity and poor health. In this issue, we look at the role of exercise in maintaining health, and at obesity from childhood through adolescence and into the reproductive years.

[Editorials] The problem just keeps getting bigger

Anthea M Magarey — Mon, 20 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (3): 152-153.
Physical activity and healthy eating are key components in preventing and managing obesity

[Editorials] Challenges and opportunities for the Pharmaceutical Benefits Scheme

Philip M Clarke — Mon, 20 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (3): 153-154.
Price disclosure will only go part of the way to achieving lower prices for generic drugs

[Editorials] Patient aggression: a serious issue requiring a dedicated organisational response

Brett McDermott — Mon, 20 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (3): 154-155.
Staff safety is improved by clear procedures for managing abuse and assault

[Perspectives] A healthy dose of disinvestment

Ray N Moynihan — Mon, 20 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (3): 158.
The challenge of removing what’s useless, harmful or cost-ineffective

[Perspectives] Well meant or well spent? Accountability for $8 billion of mental health reform

Sebastian P Rosenberg, John Mendoza and Lesley Russell — Mon, 20 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (3): 159-161.
Despite significant recent public investment in mental health, do we really know what Australia is getting for its money?

[Perspectives] Controlling occupational cancers in Australia

Mon, 20 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (3): 162-164.
We have no strategy for measuring rates, mitigating risk and meeting individuals’ needs

[Perspectives] Why exercise is an important component of risk reduction in obesity management

Daniel J Green and Andrew J Maiorana — Mon, 20 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (3): 165-166.
Non-surgical intervention has many benefits

[Perspectives] Legal clarification of “loss of chance of a better outcome” in Australia

Neera Bhatia and James Tibballs — Mon, 20 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (3): 167-168.
A High Court of Australia ruling has reinstated the need for patients to prove causation of injury

[Letters] What is wrong with Medicare?

Mon, 20 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (3): 169-170.
To the Editor: Since the claims made by Webber in his recent article1 were, in his own words, not based on any substantiated data, it is disappointing that the Medical Journal of Australia did not seek to contact either the Australian Society of Ophthalmologists (ASO) or the Royal Australian New Zealand College of Ophthalmologists (RANZCO) for comment.

[Letters] A Pandora’s box: sustainable pharmaceutical supply

Robert Pearce, Simon Quilty, Jacqueline Kewley and Lisa M Harris — Mon, 20 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (3): 170-171.
To the Editor: After our recently published article1 and subsequent criticism2 that shortages in benzylpenicillin were a “storm in a teacup”, we would like to detail the increasing number of drug shortages at John Hunter Hospital. Not only does this pose increasing costs to pharmacy but there are escalating threats to patient care.

[Letters] Soft drink consumption and obesity in NSW school students

Chris E Rissel, Tracie A Reinten-Reynolds, Li M Wen and Louise L Hardy — Mon, 20 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (3): 171-172.
To the Editor: In 2007, the sale of sugar-sweetened drinks was banned in New South Wales government schools.1 The ban followed growing evidence linking soft drinks with obesity, and findings from the 2004 NSW Schools Physical Activity and Nutrition Survey (SPANS) that almost 60% of boys and around 40% of girls reported drinking a cup (250 mL) or more of soft drink per day.2 Using the most recent SPANS data, collected in 2010, we explored whether soft drink consumption is associated with obesity among school students.3

[Letters] A to X: the problem of categorisation of drugs in pregnancy — an Australian perspective

Ronald P Batagol || Adam P Morton || Debra S Kennedy — Mon, 20 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (3): 172-173.
To the Editor: As an author, researcher and lecturer on the safety of drugs used in the obstetric setting for over 30 years — during which I participated in successive Medicines in Pregnancy Working Parties of the Australian Drug Evaluation Committee and Therapeutic Goods Administration (TGA) — I share Kennedy’s concerns about the alphabetical drug categorisation system currently used in Australia.1 I am also concerned that, since the demise in 2008 of the Prescribing Medicines in Pregnancy TGA Advisory Group (which provided ongoing external clinical expertise to the TGA), there has been a complete lack of action, preparation and consultation with external sources of expertise and experience by the TGA with regard to the safety of drugs used in pregnancy. Expert consultation would be invaluable in preparing for the overseas “game-changing” developments in labelling relating to safety of drugs used during pregnancy, as identified by Kennedy. These changes in labelling are primarily being driven in the United States, with the aim of providing definitive, well substantiated advice to patients and health professionals — advice that reflects the consensus of expert opinion in a way that the alphabetical system, by its inherent structural and functional limitations, is unable to do.

[Letters] Australian general practitioner doctorates and doctoral candidates, 2005–2009

Gerard F Gill — Mon, 20 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (3): 173.
To the Editor: The decline in the number of National Health and Medical Research Council (NHMRC) scholarships awarded to general practitioners over the past 9 years reflects continuing problems in Australia’s capacity to produce a good base of general practice researchers. Since 1998, 20 GPs have received NHMRC doctoral scholarships; nine of these were granted in 2002 and six were granted after 2002.

[Clinical Focus] Physical activity guidelines for preschoolers: a call for research to inform public health policy

Mon, 20 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (3): 174-176.
There are many challenges in developing evidence-based physical activity guidelines for preschoolers that can ensure health benefits for children. Guidelines for the preschool years have recently been developed in several countries, but there are notable inconsistencies in the amount of physical activity regarded as sufficient for this age group. Given the currently high prevalence of childhood obesity, there is an urgent need for evidence-based studies to inform the development of community-targeted programs to ensure healthy levels of physical activity in young children. Our article outlines the global recommendations for physical activity for children ≤ 5 years of age. We identify gaps in the literature and suggest recommendations for future research and public health policy.

[Clinical Focus — Practical Neurology — 7] Recurrent headaches with visual disturbance

Alessandro S Zagami and Sian L Goddard — Mon, 20 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (3): 178-183.
Headache, particularly migraine, is the commonest neurological problem with which patients present to general practitioners and neurologists. Episodic migraine affects up to 18% of women and 6% of men. Acute migraine attacks can be severely disabling and chronic migraine is even more disabling. Of the mental and neurological disorders, migraine ranks eighth worldwide in terms of disability. Migraine is one of the primary headaches and may occur with or without aura. Differentiation from other severe primary headaches, such as cluster headache, is important for management. The vast majority of patients with migraine can be satisfactorily helped and treated. This involves acute and prophylactic drug therapy and management of triggers. In patients with migraine, medication overuse headache and chronic migraine need to be identified and treated.

[Research] Overweight and obesity in Australian mothers: epidemic or endemic?

H David McIntyre, Kristen S Gibbons, Vicki J Flenady and Leonie K Callaway — Mon, 20 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (3): 184-188.
Objectives: To document temporal trends in maternal overweight and obesity in Australian women and to examine associations with pregnancy outcomes. Design, setting and participants: Retrospective 12-year cohort study of 75 432 women with singleton pregnancies who had pre-pregnancy height and weight data available and who gave birth in a tertiary referral maternity hospital in Brisbane between January 1998 and December 2009. Main outcome measures: Maternal body mass index (BMI); prevalence of overweight and obesity, and pregnancy complications including hypertension, gestational diabetes, caesarean delivery, and perinatal morbidity and mortality. Results: From 1998 to 2009, class III and class II obesity increased significantly (from 1.2% to 2.0%, and 2.5% to 3.2%, respectively), while the proportions of underweight women and those with class I obesity fell slightly (from 7.9% to 7.4%, and 7.7% to 7.5%, respectively). Increasing maternal BMI was associated with many adverse pregnancy outcomes, including hypertension in pregnancy, gestational diabetes, caesarean delivery, perinatal mortality (stillbirth and neonatal death), babies who were large for gestational age, and neonatal morbidities including hypoglycaemia, jaundice, respiratory distress and the need for neonatal intensive care (P < 0.001 for all). Most associations remained significant after adjusting for maternal age, parity, insurance status, smoking status, ethnicity and year of the birth. The frequency of congenital anomalies was not associated with maternal BMI (P = 0.71). Conclusions: Maternal overweight and obesity are endemic challenges for Australian obstetric care and are associated with serious maternal and neonatal complications, including perinatal mortality.

[Research] What factors are associated with excess body weight in Australian secondary school students?

Mon, 20 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (3): 189-192.
Objectives: To examine the prevalence of overweight and obesity in Australian secondary school students and identify factors associated with excess adiposity. Design, setting and participants: Cross-sectional survey of students aged 12–17 years (in school years 8–11) who completed the National Secondary Students’ Diet and Activity survey in 2009–10, which included a web-based self-report questionnaire and height and weight measurements. Main outcome measures: Overweight and obesity based on international standard body mass index (BMI) cut-offs for children and adolescents. Results: Data were analysed for 12 188 students. Just under one in four students were either overweight (18%) or obese (5%). After adjusting for demographic and health-behaviour characteristics, males were more likely than females to be overweight or obese (OR, 1.23; 95% CI, 1.07–1.40; P = 0.004), as were both low (OR, 1.67; 95% CI, 1.40–1.99; P < 0.001) and medium (OR, 1.33; 95% CI, 1.14–1.55; P < 0.001) socioeconomic position (SEP) students compared with high SEP students. Students engaging in low levels of physical activity (OR, 1.21; 95% CI, 1.08–1.36; P = 0.001), more time in small-screen recreation (OR, 1.18; 95% CI, 1.05–1.32; P = 0.005), and short sleep duration (OR, 1.22; 95% CI, 1.05–1.41; P = 0.008) also had higher odds of being overweight or obese. Conclusions: There is a need for interventions to reduce overweight and obesity during adolescence. Preventive measures should include a focus on facilitating physical activity and reducing sedentary behaviour, as well as promoting adequate sleep, particularly among young people from lower SEP neighbourhoods who appear to be most susceptible.

[Research] Outcomes from the REACH Registry for Australian general practice patients with or at high risk of atherothrombosis

Mon, 20 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (3): 193-197.
Objective: To report on 1-year cardiovascular (CV) event rates in patients with established cardiovascular disease (CVD) or with multiple cardiovascular risk factors. Design, patients and setting: Prospective cohort study of 2873 patients at high risk of atherothrombosis based on the presence of multiple risk factors and overt coronary artery disease (CAD), cerebrovascular disease (CerVD) or peripheral arterial disease (PAD) presenting to 273 Australian general practitioners; this study was conducted as part of the international REACH Registry. Main outcome measures: One-year rates of cardiovascular death, myocardial infarction, stroke, and hospitalisation for cardiovascular procedures. Results: The cardiovascular death rate at 1 year was 1.4%. The combined cardiovascular death, non-fatal MI, stroke and hospitalisation rate for vascular disease affecting one location at 1 year was 11%. Even for patients with no overt disease, but with multiple risk factors, the 1-year combined event rate was 4.2%. The highest combined event rate was in patients with PAD (21.0%), and in patients with atherothrombotic disease identified in all three locations (coronary arteries, cerebrovascular system and peripheral arteries) at 39%. Conclusion: The rate of clinical events in community-based patients with stable atherothrombotic disease increases dramatically with the severity of disease and the number of vascular beds involved. Where disease was evident in all three locations, and for patients with PAD alone, the 1-year risk of cardiovascular events was substantially increased. Poor adherence to statin therapy in the secondary preventive setting is a major treatment gap that needs to be closed; the influences of obesity and diabetes warrant further investigation.

[Research] Aggression management in a children’s hospital setting

Sandy M Hopper, Franz E Babl, Claire E Stewart and Jia Wei Woo — Mon, 20 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (3): 198-201.
Objectives: To describe the development, structure and implementation of a formal system of aggression management, and to document its utilisation during the first year of operation. Design and setting: A prospective audit at the Royal Children’s Hospital, a major children’s hospital in Melbourne. Main outcome measures: Analysis of utilisation patterns from prospective data forms augmented by retrospective review of security logs and medical records for 14 months from launch in December 2006. Results: Staff from four different clinical areas, led by an emergency consultant and a hospital administrator, made up the rostered multidisciplinary “code grey” team. Over 14 months, there were 104 incidents when the team was activated, involving patients in 75 cases and visitors in 29 cases. Incidents occurred at equal frequency on wards and in the emergency department. Patients involved were most commonly affected by a mental disorder, frustration and/or a developmental disability. The apparent cause of visitor aggression was mainly frustration and occasionally drugs. The majority of patient aggressors showed physical aggression towards people or objects or self-harming behaviour. Visitor aggressors were mostly verbally aggressive (and occasionally physically violent). For patients, the team used verbal de-escalation (56/75 events), physical restraint (34/75), sedation (23/75) and mechanical restraint (15/75). For visitors, verbal de-escalation occurred in 17/29 cases and 10/29 visitors left or were removed. Several patient and staff injuries were documented. Conclusions: An aggression management team can be established in a children’s hospital setting. This team structure provides a useful response to concerns about staff safety and optimal patient care.

[Case reports — Lessons from practice] Meningitis and pneumonitis caused by pet rodents

Lito E Papanicolas, Judith M Holds and Narin Bak — Mon, 20 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (3): 202-203.
This case highlights the importance of history-taking and the need to perform blood cultures in patients presenting with fever. The differential diagnoses considered were wide and included bacterial sepsis, viral infection and autoimmune disease. Bacterial sepsis from streptococcal, meningococcal or staphylococcal infection was considered most likely in this patient. Definitive diagnosis was helped by the isolation of S. moniliformis from blood culture, which allowed targeted therapy and improved prognosis.

[Reflections] You and me

Hilton Immerman — Mon, 20 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (3): 204.
Dr Hilton Immerman and Dr Josef McDonald (“Macca”) speak of their association as mentor and Indigenous medical student

[Reflections] The two of us

Josef McDonald — Mon, 20 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (3): 205.
Medicine was one of many options that I considered at the end of high school, along with engineering and even astronomy. But my interests in science and social justice drew me to medicine and, in the summer before commencing my studies, I was naively confident and felt as though the world was my oyster. These feelings were short-lived when I moved to Randwick in February 2005 to begin my medical studies at the University of New South Wales.

[Book review] Practical advice on sexual health

Janice G Newton — Mon, 20 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (3): 206.
THIS HANDBOOK is an excellent resource for all primary care providers and medical students. The first edition was published in 2006. Since then, there have been a number of developments within the practice of reproductive and sexual health.

[Book review] Regimental doctor in “Sufferer’s Paradise”

Bruce H Short — Mon, 20 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (3): 206.
RETIRED COLONEL Tony White of the Royal Australian Army Medical Corps served in South Vietnam in 1967, and this narrative is largely based on his detailed correspondence with his family at the time. The title, Starlight, refers to the radio call sign for army doctors and medics.

[App review] Healthy eating app

Ruth M Armstrong — Mon, 20 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (3): 207.
DESPITE having spent many a rapturous hour staring at the back of cereal packets, I tried not to take it personally when I heard Professor Bruce Neal from the George Institute saying, on ABC Radio, that anyone who reads and understands an Australian nutritional panel is a weirdo.

[Obituary] Clement J Walter ASTC, MB BS, DO, FRANZCO

Alfred W Wechsler, Donald B Dunlop and Ian B Wechsler — Mon, 20 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (3): 207
Clement J Walter was a talented, innovative and understated ophthalmologist.

[Perspectives] A plea for professional independence

Hans Peter Dietz and Barrie J Stokes — Mon, 06 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (2): 104-105.
When “should not” becomes “must not” — how mandatory compliance with guidelines can threaten professional independence

[Perspectives] The Sydney University Medical Program: highlights and lessons

Kerry J Goulston and R Kim Oates — Mon, 06 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (2): 106-107.
The formula for reform works, but is the next review already overdue?

[Letters] What is wrong with Medicare?

Peter C Arnold — Mon, 06 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (2): 108.
To the Editor: I would like to add my perspective, after nearly 50 years of experience in Australian medicine, to the very welcome articles by Moynihan1 and Webber.2

[Letters] Wind farms and health: who is fomenting community anxieties?

Daniel Shepherd — Mon, 06 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (2): 108.
To the Editor: By his deployment of ad hominem arguments, outdated or industry-sponsored research, comparison to an unrelated phenomenon, and a biased selection of case studies and research reports, I fear the pro-wind-industry opinions expressed by Chapman1 will only serve to exacerbate the psychogenic and sociogenic processes he laments.

[Letters] Should doctors feel able to practise according to their personal values and beliefs?

William R Adam || Murat Civaner — Mon, 06 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (2): 109.
To the Editor: An ethical concern that was raised by Conway in his article supporting the freedom to practise in accordance with conscience1 related to the problems that arise when patients — specifically children — are unable to express a considered opinion on any conflict between their clinicians and their legal guardians about their best interests.

[Letters] Should more Australian doctors be salaried than paid by fee-for-service?

Matthew H R Anstey and Stephen P Gildfind — Mon, 06 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (2): 109-110.
To the Editor: In his Opposing Views article, Travis claims that fee- for-service (FFS) “provides the best transparency, accountability and incentive for everyone”.1 However, FFS models reward volume and intensity, rather than quality of outcomes. Evidence suggests that FFS results in increased numbers of patient visits, investigations and procedures,2 which contribute to inflation in the cost of health care.3

[Letters] Increasing numbers of inmate separations from Australian prisons

Kristy A Martire and Sarah Larney — Mon, 06 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (2): 110.
To the Editor: In 2009, we calculated that an estimated 50 405 prison inmate separations occurred in Australia in the 2007–08 financial year,1 and argued that the significant mortality risks associated with release from custody necessitated accurate and routine dissemination of such information. We believe this is still required, and that reporting the most current estimate of inmate separations may help facilitate better through-care and post-release health service provision. Our previous estimates have been used to contextualise discussions of prisoner health,2 estimate the number of post-release deaths,3 and advocate for needle and syringe programs in Australian prisons.4

[Letters] Impact of incident location on long-term pedestrian mortality and major trauma in inner Sydney

Mon, 06 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (2): 110-111.
To the Editor: Significant mortality and morbidity occur among pedestrians involved in road traffic incidents.1 The National Road Safety Strategy 2001–20102 aimed to achieve a 40% decrease in pedestrian fatalities in Australia through road safety measures, including urban speed limit reductions. To assess the impact of such measures, we examined the long-term mortality trend in pedestrians presenting to an inner Sydney major trauma centre and determined whether incident location was a predictor of major trauma (defined as in-hospital mortality, intensive care unit admission and/or Injury Severity Score > 15).

[Letters] An unrecognised case of tenofovir-associated Fanconi syndrome

Mon, 06 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (2): 111-112.
To the Editor: Tenofovir disoproxil fumarate is a nucleotide analogue reverse transcriptase inhibitor that is used in Australia as first-line antiviral treatment for HIV infection.1,2 Tenofovir may be nephrotoxic, particularly affecting proximal tubular function.3 We report a case of tenofovir-associated Fanconi syndrome, which demonstrates the need for vigilance in patients taking tenofovir.

[Letters] Barriers to recruitment in cancer trials: no longer medical oncologists’ attitudes

Rachel F Dear, Alexandra L Barratt and Martin H N Tattersall — Mon, 06 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (2): 112-113.
To the Editor: Participation by patients in cancer clinical trials is low. Doctors’ reluctance to participate in clinical trials has been reported as a key barrier to recruitment.1

[Letters] Conflict of interest guidelines for clinical guidelines

Peter J McLaren — Mon, 06 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (2): 113.
To the Editor: I am disappointed by Williams and colleagues’ blinkered view on “conflict of interest”.1 Their focus is solely on that of influence by profit-making medical supplies companies, often loosely referred to as “big pharma”.

[Clinical focus — Practical neurology] Memory loss

Leon A Flicker, Andrew H Ford, Christopher D Beer and Osvaldo P Almeida — Mon, 06 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (2): 114-117.
Most older people with memory loss do not have dementia. Those with mild cognitive impairment are at increased risk of progressing to dementia, but no tests have been shown to enhance the accuracy of assessing this risk. Although no intervention has been convincingly shown to prevent dementia, data from cohort studies and randomised controlled trials are compelling in indicating that physical activity and treatment of hypertension decrease the risk of dementia. There is no evidence that pharmaceutical treatment will benefit people with mild cognitive impairment. In people with Alzheimer’s disease, treatment with a cholinesterase inhibitor or memantine (an N-methyl- D-aspartate receptor antagonist) may provide symptomatic relief and enhance quality of life, but does not appear to alter progression of the illness. Non-pharmacological strategies are recommended as first-line treatments for behavioural and psychological symptoms of dementia, which are common in Alzheimer’s disease. Atypical antipsychotics have modest benefit in reducing agitation and psychotic symptoms but increase the risk of cardiovascular events. The role of antidepressants in managing depressive symptoms in patients with mild cognitive impairment is uncertain and may increase the risk of delirium and falls.

[Clinical Focus — Systematic review] Mental health of Indigenous Australians: a review of findings from community surveys

Anthony F Jorm, Sarah J Bourchier, Stefan Cvetkovski and Gavin Stewart — Mon, 06 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (2): 118-121.
Objective: To assemble what is known about the mental health of Indigenous Australians from community surveys. Data sources: A systematic search was carried out of publications and data sources since 2000 using PubMed, PsycINFO, Australian Medical Index, the National Library of Australia and datasets known to the authors. Study selection: Surveys had to involve representative sampling of a population, identify Aboriginal and Torres Strait Islander people and include a measure of mental health. Data extraction: 11 surveys were found. Data were extracted on prevalence rates for Indigenous people by age and sex, along with comparison data from the general population, where available. Data synthesis: Across seven studies, Indigenous adults were consistently found to have a higher prevalence of self-reported psychological distress than the general community. However, two studies of Indigenous adolescents did not find a higher prevalence of psychological distress. Two surveys of parents and carers of Indigenous children and adolescents found a higher prevalence of behaviour problems. Conclusions: There is an inequality in mental health between Indigenous and non-Indigenous Australians that starts from an early age. This needs to be a priority for research, preventive action and health services.

[Research] Emergency department overcrowding, mortality and the 4-hour rule in Western Australia

Gary C Geelhoed and Nicholas H de Klerk — Mon, 06 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (2): 122-126.
Objective: To assess whether emergency department (ED) overcrowding was reduced after the introduction of the 4-hour rule in Western Australia and whether any changes in overcrowding were associated with significant changes in patient mortality rates. Design, setting and patients: Quasi-experimental intervention study using dependent pretest and post-test samples. Hospital and patient data were obtained for three tertiary hospitals and three secondary hospitals in Perth, WA, for 2007–08 to 2010–11. Main outcome measures: Mortality rates; overcrowding rates. Results: No change was shown in mortality from 2007–08 to 2010–11 for the secondary hospitals and from 2007–08 to 2009–10 for the tertiary hospitals. ED overcrowding (as measured by 8-hour access block) at the tertiary hospitals improved dramatically, falling from above 40% in July 2009 to around 10% by early 2011, and presentations increased by 10%, while the mortality rate fell significantly (by 13%; 95% CI, 7%–18%; P < 0.001) from 1.12% to 0.98% between 2009–10 and 2010–11. Monthly mortality rates decreased significantly in two of the three tertiary hospitals concurrently with decreased access block and an increased proportion of patients admitted in under 4 hours. Conclusion: Introduction of the 4-hour rule in WA led to a reversal of overcrowding in three tertiary hospital EDs that coincided with a significant fall in the overall mortality rate in tertiary hospital data combined and in two of the three individual hospitals. No reduction in adjusted mortality rates was shown in three secondary hospitals where the improvement in overcrowding was minimal.

[Research — Commentary] Emergency department targets: a watershed for outcomes research?

Drew B Richardson — Mon, 06 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (2): 126-127.
Early evidence is encouraging, but guarded optimism is advised

[Research] Demand at the emergency department front door: 10-year trends in presentations

Mon, 06 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (2): 128-132.
Objectives: To measure the increase in volume and age-specific rates of presentations to public hospital emergency departments (EDs), as well as any changes in ED length of stay (LOS); and to describe trends in ED utilisation. Design, patients and setting: Population-based retrospective analysis of Department of Health public hospital ED data for metropolitan Melbourne for 1999–00 to 2008–09. Main outcome measures: Presentation numbers; presentation rates per 1000 person-years; ED LOS. Results: ED presentations increased from 550 662 in 1999–00 to 853 940 in 2008–09. This corresponded to a 32% rise in rate of presentation (95% CI, 29%–35%), an average annual increase of 3.6% (95% CI, 3.4%–3.8%) after adjustment for population changes. Almost 40% of all patients remained in the ED for ≥ 4 hours in 2008–09, with LOS increasing over time for patients who were more acutely unwell. The likelihood of presentation rose with increasing age, with people aged ≥ 85 years being 3.9 times as likely to present as those aged 35–59 years (95% CI, 3.8–4.0). The volume of older people presenting more than doubled over the decade. They were more likely to arrive by emergency ambulance and were more acutely unwell than 35–59 year olds, with 75% having an LOS ≥ 4 hours and 61% requiring admission in 2008–09. Conclusion: The rise in presentation numbers and presentation rates per 1000 person-years over 10 years was beyond that expected from demographic changes. Current models of emergency and primary care are failing to meet community needs at times of acute illness. Given these trends, the proposed 4-hour targets in 2012 may be unachievable unless there is significant redesign of the whole system.

[Research] Psychosis in Indigenous populations of Cape York and the Torres Strait

Mon, 06 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (2): 133-135.
Objective: To describe and characterise treated psychotic disorders in the Indigenous populations of Cape York and the Torres Strait. Design: Cross-sectional analysis of patients with a psychotic disorder identified by treating psychiatrists. Setting and participants: Indigenous patients aged ≥ 15 years in Cape York and Torres Strait communities receiving treatment for a psychotic disorder over 3 months in 2010. Main outcome measures: Prevalence of psychosis diagnoses, intellectual disability, and substance use comorbidities. Results: 171 patients were included. The prevalence rate in this population was 1.68%, higher for males (2.60%) than females (0.89%), and twice as high in the Aboriginal (2.05%) than in the Torres Strait Islander (0.95%) population. High rates of alcohol and cannabis use were found. Comorbid intellectual disability was common and more frequent among Aboriginal patients. Conclusions: The burden of psychosis in the Indigenous population of Cape York and the Torres Strait is high. Further research is needed to understand the social determinants of these disorders and to design effective social and clinical measures to alleviate this burden.

[Research] Targeted primary care-based mental health services for young Australians

Mon, 06 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (2): 136-140.
Objective: To assess the extent to which youth-specific, mental health care centres engage young people (12–25 years of age) in treatment, and to report the degree of psychological distress, and the diagnostic type, stage of illness, and psychosocial and vocational impairment evident in these young people. Design and setting: Standardised clinical and self-report assessments of consecutive presentations at two youth-specific centres from October 2007 to December 2009. Both sites are operated by the Brain and Mind Research Institute in Sydney, Australia, as part of headspace: the National Youth Mental Health Foundation mental health care service. Results: Of 1260 young people assessed, 53% were male, and the mean (SD) age was 18.1 (3.9) years. Over 40% of the young people were self-referred, or their assessment was arranged by family or friends, or by other social agencies; 30% of young people were referred from other primary health providers. Almost 70% reported high or very high levels of psychological distress. More than 60% of subjects reported having 2 or more days “unable to function” within the past month, and clinicians rated over 50% as having at least moderate difficulty in social/occupational functioning. Importantly, 25% of subjects were receiving income support. Two-thirds of subjects were rated as being at the early stage of an illness, and almost half were diagnosed with anxiety or depressive syndromes. Conclusions: Targeted youth-specific mental health services, based in primary care settings, are able to engage young Australians, particularly young men, in treatment. Many of these young people report established patterns of psychosocial and vocational impairment.

[Reflections] Doctors and writing: stranger than fiction?

Dawn Barker — Mon, 06 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (2): 141.
The close between the science of medicine and the art of writing

[Obituary] Anthony Siew-Yin Leong MB BS, MD, FRCPA, FRCPath, FCAP, FHKCPath, FHKAM(Path)

Huy A Tran, Glen E M Reeves and Frederick W Hetherington — Mon, 06 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (2): 142.
Anthony Leong was born in Singapore in 1945 and graduated from the University of Malaya in 1969. He pursued postgraduate training in America, where he completed his pathology residency at the University of Washington, Seattle, between 1971 and 1973. In 1976, he migrated to Adelaide to continue his work in lymphoma and tissue processing, especially tissue staining and immunohistochemistry. He excelled in research and, in 1980, received a doctorate in medicine from the University of Adelaide, where he was Clinical Professor of Pathology from 1981 until 1996.

[Obituary] Walter Lowen

Richard J Lowen, Mark Lowen and Norma Gilbert — Mon, 06 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (2): 142.
Walter Lowen was born in Vienna on 10 March 1916 and spent his childhood in Lwow, Poland. A national junior table tennis champion, Walter contributed to Poland’s bronze medal at the Swaythling Cup world championships in London in 1935. Religious persecution in Europe spurred his migration to Australia in July 1939, a few months before he was due to complete his medical degree at the University of Lwow. In 1940, Walter was accepted into medicine at the University of Melbourne and, in 1941, he married Sima, whom he had met en route to Australia. Walter still pursued table tennis, winning the Australian singles title in 1948 as well as many state singles titles. In 2000, he was inducted into the Table Tennis Victoria Hall of Fame.

[Book Review] Holistic medical education

Richard B Hays — Mon, 06 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (2): 143.
THIS MAY BE a timely addition to medical school bookshelves, as so many new medical schools are engaged in curriculum development. Written by a respected Australian medical educator, the book promotes an integrated approach, and then attempts a comprehensive coverage of issues concerning design, implementation, assessment and evaluation, and blending theory with practice. The strength of the book lies in the international experience of the author who has, among other things, worked as a senior academic at the University of New South Wales in Sydney and the Arabian Gulf University in Bahrain.

[Book Review] Understanding whiplash

David G Vivian — Mon, 06 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (2): 143.
WHIPLASH is a controversial, but widely accepted, “diagnostic” term that describes a putative causal mechanism for a constellation of symptoms that are generally not underpinned by recognisable pathology. This reference book has the stated aim: “to bring together current knowledge of the whiplash condition that will allow all stakeholders involved in the management of patients with whiplash, from clinicians to policy makers, to gain greater understanding of this condition”.

[Editor's Choice] The 4-hour rule: does lowering the temperature treat the system?

Annette Katelaris — Mon, 06 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (2): 87.
The performance of hospital emergency departments (EDs) is often used politically as a barometer for the performance of the health system. EDs have many roles. As well as caring for the acutely unwell or injured, they are frequently left to deal with those unable or unwilling to access health care elsewhere, and those near the end of life who are unable to be managed in an aged care facility or at home. They are often the health service of first and last resort.

[Editorials] Emergency department overcrowding: the solution to any problem is a matter of relativity

George Braitberg — Mon, 06 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (2): 88-89.
Is the 4-hour rule achievable — and beneficial — in our current system of health care?

[Editorials] Aboriginal and Torres Strait Islander mental health: paradise lost?

Robert M Parker — Mon, 06 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (2): 89-90.
Broader thinking is needed to restore mental health in a vulnerable population

[Editorials] Improving the health of Australian children entering out-of-home care

Graham V Vimpani, Susan M Webster and Meredith J Temple-Smith — Mon, 06 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (2): 91-92.
Assessing health status is only the beginning

[Perspectives] Clinical pathways: a departure from the art of medicine

Ralph K Nanan, Alison S Poulton and Bernard L Champion — Mon, 06 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (2): 96.
Is canonical thinking inhibiting the flexibility and innovation required for expert clinical reasoning?

[Perspectives] Clinical deterioration in hospital inpatients: the need for another paradigm shift

Daryl A Jones, Nicola J Dunbar and Rinaldo Bellomo — Mon, 06 Feb 2012 00:00:00 GMT

Med J Aust 2012; 196 (2): 97-100.
Proactive recognition and response, pre-emptive management