In This Issue

Blanket approach to STDs?

While many remote Indigenous communities have screening and treatment programs for sexually transmitted diseases (STDs) such as chlamydia, gonorrhoea and trichomoniasis, the prevalence of these infections often remains high. It’s time for a new approach, say Bowden and Fethers (→ “Let’s not talk about sex”: reconsidering the public health approach to sexually transmissible infections in remote Indigenous populations in Australia). If the World Health Organization recommends whole-of-community treatment for trachoma control, why shouldn’t we institute it for the three commonest STDs?

No magic bullet for ADHD

Stimulants can no longer be considered the mainstay of therapy for all children with attention deficit hyperactivity disorder, says Rey (→ In the long run, skills are as good as pills for attention deficit hyperactivity disorder). A recent long-term follow-up of children with ADHD involved in the United States Multimodal Treatment Study revealed that, while children given stimulants did better by the study’s end-point of 14 months than those receiving tailored psychosocial treatment or routine community care, there was little difference between the groups after 3 years.

Bright future for rural training

Early indications from several small recent studies published in the MJA are that the proliferation of rural training options in our medical schools is not in vain. Particularly encouraging is the experience of Flinders University (Worley et al, “Vocational career paths of graduate entry medical students at Flinders University: a comparison of rural, remote and tertiary tracks”). Since 1996, students have been able to choose to do their entire third year at Flinders Medical Centre or in one of two rural settings. Those who responded to a survey in late 2005 were much more likely to be in training for rural practice if they had chosen the rural option as undergraduates. Also encouraging is the news that medical schools are beginning to join forces to build and nurture high-quality rural training, rather than competing for this scarce resource. Page et al describe such a venture in “Medical schools can cooperate: a new joint venture to provide medical education in the Northern Rivers region of New South Wales”.

For whose benefit?

In an article published last year, Richards and Rogers suggested several interventions that could be performed on potential cadaveric organ donors before death to maintain the viability of their organs. In a feisty Matters Arising, readers debate the ethics of this practice.

Don’t “dis” TB

In Australia in 2008, ask Bastian and Krause in this issue’s lead editorial, why would the MJA editors see fit to devote so many pages to tuberculosis? Having raised this question, they go on to make a good argument for more focus on this disease, which, despite its rarity in Australia, affects our displaced, disadvantaged, dispossessed and immunologically disabled, and continues to be a major cause of morbidity and mortality for our not-so-distant neighbours (→ Tuberculosis: the dis-ease that didn’t dis-appear).

Indeed, the ravages of TB are never far from our shores, as Gray et al found when looking at its occurrence in detained illegal Indonesian fishermen (→ Tuberculosis in illegal foreign fishermen: whose public health are we protecting?). While we are doing a good job of detecting TB in this group, we are failing to treat them adequately. Also to our north, Gilpin et al have detected cases of multidrug-resistant TB in residents of the Western Province of Papua New Guinea who sought treatment on two open-border islands in the Torres Strait (→ Evidence of primary transmission of multidrug-resistant tuberculosis in the Western Province of Papua New Guinea).

One of the purposes of publishing these articles is to put TB on the radar of your clinical thinking. In this vein, Lim et al describe their justified suspicions in a case of granulomatous hepatitis (→ Granulomatous hepatitis: tuberculosis or not?), and Gupta et al remind us that TB should be excluded before starting patients with inflammatory diseases on tumour necrosis factor a inhibitors (→ Tumour necrosis factor α inhibitors: screening for tuberculosis infection in inflammatory bowel disease). As illustrated by Massasso and colleagues’ challenging case of iliopsoas bursitis, this is not always straightforward (→ Joined at the hip: rheumatoid arthritis and tuberculosis).

Speaking of clinical radars, a diagnosis of TB should also get you thinking about HIV infection. Emerson and Post contend that all patients with proven TB should be offered an HIV test (→ To routinely offer testing for HIV infection in all cases of tuberculosis: a rational clinical approach?).

Finally, two studies look at TB in Australian hospitals. A search of the records of a Sydney chest clinic revealed the merits of the clinic’s policy of directly observed therapy (Dobler et al, “Recurrence of tuberculosis at a Sydney chest clinic between 1994 and 2006: reactivation or reinfection?”). Among 848 patients with culture-positive TB between 1994 and 2006, three had recurrent disease: in two cases strains were different from the initial culture, suggesting reinfection during visits to high-incidence countries rather than reactivation, leaving only one case of true recurrence. And a Sydney children’s hospital (Letters, “Tuberculosis in children: a tertiary centre perspective”) has experienced an increase in cases of latent TB as the children of refugees have presented for testing, but no marked increase in active disease.

Many of these articles reveal advances in diagnosis, epidemiological expertise and therapy that Australia should be sharing with the world — or at least our little corner of it — a challenge that we should not dismiss.

Five phrenicotomies in humans have shown that his operation is simple to perform and not severe on the patient . . . The first patient suffered from advanced tuberculosis on the right side of the lung . . . The interruption of the phrenic nerve relieved the annoying compulsive cough, which ceased at once . . . In the fourth and fifth cases, both with tuberculosis, the coughing stopped and the sputum decreased after the phrenicotomy.