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A review of early intervention in youth psychosis

Early intervention in youth psychosis has been a topic of contentious discussion. In particular, there is a lack of consensus regarding how early to treat patients with a psychotic disorder. There has been a recent push to provide treatment early in the development of psychosis, specifically to patients in an ultra-high risk or prodromal stage. There is also debate about the types of interventions that should be used, such as psychoeducation, psychotherapy and pharmacotherapy. In Australia, these uncertainties have been reflected by the production of conflicting guidelines by key stakeholders in this area. There are significant arguments both for and against the practice of early intervention. This article explores these arguments and reviews current practices in Australia. A number of updated recommendations are also set out in accordance with the findings of this article.

Introduction

A review of early intervention in youth psychosisPsychotic disorders are characterised by the presence of symptoms that reflect an excess or distortion of normal functions. For example, hallucinations, delusions, thought disorder and disorganised behaviour are symptoms characteristic of psychosis. Patients diagnosed with schizophrenia must demonstrate positive symptoms or severe negative symptoms (e.g. flattened affect, social withdrawal) in addition to deterioration in their social and vocational functioning. [1] Hence, the diagnosis is typically made after the onset of significant symptomology.

McGorry et al. [2] argue that late-stage diagnosis of a psychotic illness leads to delayed and inconsistent management of these patients. The concept of “early intervention” refers to appropriately managing patients in the early stages of psychotic disease, to minimise long-term negative social and psychological outcomes. As such, it represents a secondary prevention strategy and a paradigm shift in the way schizophrenia and other psychotic disorders are viewed; rather than being seen as illnesses with an inevitably poor social and functional outcome, they are viewed as conditions whose course can be altered
by recognition of the early warning signs and application of timely intervention. [2] The proponents of early intervention argue that many of the recognised risk factors for the development and progression of a psychotic disorder (e.g. disrupted peer and family networks, substance A review of early intervention in youth psychosis use, depression) are recognisable in advance and can be acted upon. [2]

The clinical staging model [3] proposes that psychiatric illnesses should be viewed as a sequence of stages that increase in disease severity. Employing the appropriate treatment modality at a particular stage would allow regression of the disease to an earlier stage. The clinical stages of early psychosis include the ‘ultra-high risk’ stage, the ‘first psychotic episode’ stage and the ‘first 5 years after diagnosis’ stage. [2]

The ‘ultra-high risk’ stage is the stage preceding the first psychotic episode. Although the first psychotic episode is often the first recognised sign of a psychotic illness, retrospective analysis reveals many changes occur in an individual’s thoughts and behaviour in the period preceding the psychotic episode. This is known as the ‘prodromal phase’. To intervene at this stage, it is clearly necessary to be able to identify this period in advance, and a considerable research effort is being focused on developing prospective criteria for this purpose. Two tools currently in use are the Positive and Negative Syndrome Scale (PANSS) or Attenuated Positive Symptoms (APS) approach and the Basic Symptoms (BS) approach. [4] The PANSS is a 30-point questionnaire with a 7-point rating for each question. It covers positive symptoms (e.g. delusions, hallucinations), negative symptoms (e.g. social withdrawal, blunted affect) and general symptoms of psychopathology (e.g. depression, poor insight, feelings of tension). [5] The Basic Symptoms approach focuses on subtler, self-experienced subclinical symptoms such as thought interference, disturbance of receptive language, inability to divide attention between tasks and derealisation. [6]

Intervention at the ‘first psychotic episode’ stage is largely aimed at reducing the duration of untreated psychosis (DUP), as a high DUP has been shown to result in poorer outcomes. Some authors have argued that untreated psychosis can lead to irreversible brain damage. [7,8] Although this theory has yet to receive widespread support, the personal, social and societal consequences of untreated psychosis can have a tremendous impact on the patient’s ability to recover from the episode. [2] Functional MRI brain imaging studies have shown decreased memory encoding in patients with schizophrenia and interestingly, decreased posterior cingulate activity in patients with ongoing first-episode psychosis compared to those showing remission at one year. [9] Such alterations in brain activity in patients more likely to proceed to a significant psychotic illness has exciting implications for the use of fMRI as a tool in screening for patients most likely to benefit from early intervention.

The ‘first 5 years after diagnosis’ stage is a crucial period that determines a patient’s long-term outcome. It is the time most likely to result in suicide, disengagement, relapse, [2] long-term treatment resistance and the break down and accumulation of disabilities in personal, social and occupational settings. [10] Mason et al. [11] suggest that the level of disability accumulated in the first 2 years of psychosis may in fact ‘set a ceiling for recovery in the long term’. Hence, intervention at this period is important. Maintaining a steady support structure especially tailored towards young people receiving a diagnosis of psychosis is likely to maximise chances of engagement with mental health care, life-style modifications, and adequate family involvement. [2]

Current Practice
There are currently a number of different practices/guidelines in Australia relating to early intervention in youth psychosis. The Royal Australian and New Zealand College of Psychiatrists (RANZCP) has produced clinical practice guidelines for schizophrenia, which include recommendations for patients at ultra-high risk (UHR). [12] Orygen Youth Health and headspace have also developed guidelines, called ‘The Australian Clinical Guidelines for Early Psychosis’, which are now in the second edition. [13]

Australia has established the first clinical and research clinic in the world for individuals considered to be at imminent risk of psychosis. The Personal Assessment and Crisis Evaluation (PACE) clinic was established by Orygen in Melbourne in 1994. [14] The clinic receives referrals from general practice, school counsellors and various health services. [14] They facilitate case management and provide a variety of in-house support services to families and carers including group programs, vocational and educational assistance, and occupational therapy. [15] Orygen, in conjunction with the Australian General Practice Network, the Australian Psychological Society and the Brain and Mind Research Institute also established headspace, which is a national youth mental health foundation. [16] The aim of headspace was to facilitate early intervention by increasing community awareness, clinician training and taking a youth-specific approach to management, as well as utilising multidisciplinary care. [16,17] Another service available is the Early Psychosis Prevention and Intervention Centres (EPPIC). In the 2010-11 and 2011-12 budgets, the Federal Government allocated $247m to the establishment of a network of 16 of these centres across Australia, modelled upon Orygen’s EPPIC centre in Melbourne. [18] A more detailed summary of the current guidelines/practices existing in Australia for youth psychosis is listed in Table 1.

Table 1. Current practice (guidelines and health services) in Australia for youth psychosis.

Guideline
Recommendation
RANZCP Clinical Practice Guidelines for the Treatment of Schizophrenia and Related Disorders (2005) [12] Assessment and close monitoring every 2-4 weeks along with the provision of information to the patient and their family about the risk and likelihood of progression. Other techniques such as cognitive behavioural therapy (CBT), stress management and vocational rehabilitation should be employed depending on any concurrent psychosocial difficulties. Antipsychotics are only to be prescribed when the patient has been frankly psychotic for over a week, or in cases when milder symptoms are associated with a risk of self-harm or aggression (however, patients without such a history are often treated regularly with antipsychotics and the primary concern here is that they may have a delirium or physical illness, which should be excluded first). [12]
The Australian Clinical Guidelines for Early Psychosis [13] Commencement of CBT for all patients identified as being at ultra-high risk is recommended. Family, vocational, educational and accommodation support should also be provided as required in a low stigma setting. Antipsychotic medication should only be considered once full threshold psychotic symptoms have been sustained for over a week, or if there is rapid deterioration accompanied by psychotic-like symptoms. [13]
Health Service
Nature of service provided
The Personal Assessment and Crisis Evaluation (PACE) clinic PACE provides information to individuals and their families about what it means to be at risk of psychosis. [14] They facilitate case management and provide a variety of in-house support services to families and carers including group programs, vocational and educational assistance and occupational therapy. [15] Specific treatment is largely in the form of voluntary participation in clinical trials, such as those looking at antipsychotic use or CBT in ultra-high risk individuals. [14]
Headspace These centres for 12-25 year olds combine specialist mental health, drug and alcohol and primary care services, vocational services and training, and employment support within a youth and family-friendly environment. [16,17] Headspace centres are also tasked with developing awareness campaigns for their local community and providing training for primary care and other workers using an evidence-based approach. [16]
Early Psychosis Prevention and Intervention Centres (EPPIC) Provide comprehensive in-patient and mobile components and aim to identify patients as early as possible and deliver phase-specific bestpractice interventions to psychotic individuals between the ages of 15 to 24. [19] This model has also been adopted widely around the world, including in the UK [20] and the US. [21]

 

The early intervention model has also been subject to some criticism. The major basis for this is a lack of evidence, especially with regard to the use of anti-psychotics in the prodromal stages of psychotic illness and the significant cost associated with creating a clinical infrastructure for patients who may never proceed to a long-term psychotic illness.

Results and Discussion

Evidence for early intervention

There is evidence from several small studies that psychotherapy such as CBT [22] and pharmacotherapy [3,23] can reduce the progression of ultra-high risk individuals to first episode psychosis.

Wyatt et al. [8] reviewed 22 studies, of varying study designs, which included contemporaneous control group studies, cohort studies, mirror image studies and early intervention studies. In these studies, patients with schizophrenia were either given or not given neuroleptics at a specific time during the course of their illness. 19 of the studies, in particular, looked at patients who were experiencing their first psychotic episode. After re-analysing the data, Wyatt et al. [8] showed that early intervention with a neuroleptic in first-break schizophrenic patients improved the long-term course of the illness, commonly assessed based on re-hospitalisation and relapse rates. It was also shown that with the use of neuroleptics, the length of the initial psychotic period was reduced. In addition, when neuroleptics were discontinued, it resulted in poorer outcomes as the patients were not able to return to their previous level of functioning and relapses occurred more frequently. Neuroleptic medication has the strongest support for relapse prevention in schizophrenia and is the basis of most interventions.

It has been suggested that the duration of untreated psychotic episodes directly correlates with less complete recovery, a higher rate of relapse and increased levels of compromised functioning, since these episodes have a toxic effect on the brain. [7,8,24-26] These studies, both retrospective and prospective, suggest that a longer DUP in the early stage of schizophrenia is associated with a longer time to remission, a lower level of recovery, a greater likelihood of relapse and a worse overall outcome.

Studies have shown that raising public awareness and using mobile outreach detection teams to identify candidate patients [27] has significantly reduced DUP, leading to beneficial outcomes. In particular there has been a reduction in negative symptoms in schizophrenic patients.

Arguments against early intervention

There are certain groups who are against early intervention. One of the arguments against early intervention relates to whether it is cost effective, as resources may be diverted from treatment programs for patients who already have an established diagnosis of psychosis. In addition, they argue that the great majority of high-risk patients do not in fact progress to frank psychosis. There is also the argument that some patients seeking early intervention may not have ‘true prodromal’ features, thus inflating the numbers of those who actually require early intervention. These arguments are discussed in more detail below.

Economic cost of early intervention may be infeasible

Those against early intervention believe the increased attention and funding given to early intervention diverts funding away from treatment in those with established psychosis. [28-30] They also argue that proponents of early intervention have touted the cost-effectiveness of early intervention as such programs utilise more outpatient resources compared to inpatient resources, thus reducing overall healthcare costs (with outpatient services being much cheaper than inpatient treatment). However, critics of early intervention have pointed out that implementation of a cost-effective treatment actually increases total costs [31,32] since cheaper treatment would have a much higher uptake compared to an expensive alternative, thus raising the total cost of treatment. In addition, Amos argues that total healthcare costs are further increased since in-patient costs are not reduced with early intervention. [33] This is because 80% or more of hospital costs are fixed costs and by shifting psychosis treatment to largely outpatient settings in the community, community costs increase but hospital costs are not reduced. [33] This is corroborated by previous studies, which show an increase in total costs when hospitalisation rates had been reduced. [34,35]

Most high-risk patients do not progress to frank psychosis

One possible explanation for this is that a subset of adolescents whom are identified as being UHR may just be odd adolescents that become odd adults with few progressing to a frank psychosis. The prominent child psychiatrist Sula Wolff was the first to describe these odd adolescents in her book, Loners: The Life Path of Unusual Children. [36] Her research has shown that while odd qualities such as those found in schizoid and schizotypal disorders are found pre-morbidly in patients with schizophrenia, very few children with such personality traits/disorders go on to develop schizophrenia. For example, in 1995 Wolff undertook a records survey of all psychiatric hospital admissions in Scotland. Overall, 5% of schizoid young people were affected by schizophrenia in adulthood compared to a population prevalence rate in the UK of 0.31-0.49%. [36] These numbers suggest that while the risk for schizophrenia in schizoid children is higher than that of the general population, it is still low. To reiterate, there may be a proportion of patients who are flagged as being prodromal but whom actually have qualities consistent with schizoid personality disorder that will never progress to psychosis.

Recently, there has been a decline in the proportion of patients at high risk of psychosis actually progressing to frank psychosis

This decline has important ramifications for the practice of early intervention. A decline in the transition rate of patients identified as UHR has been reported within the PACE clinic (Melbourne, Australia) and in other UHR clinics as well. [37,38] As an example, The PACE clinic has reported that each successive year between 1995-2000 had a rate equal to 0.8 of the previous year. [38] The reported decline in transition rate was not due to differing patient characteristics across the years, such as gender, age, family history, baseline functioning and degree of psychopathology and psychiatric symptoms. [38] Additionally, the UHR criteria remained unchanged in the PACE clinic between 1995-2000. [38]

There are a number of possible explanations for the declining transition rate to psychosis. Firstly, UHR patients are being detected more quickly than in the past (the duration of symptoms prior to detection is getting shorter). [38] However, it is unclear whether the resulting decline in transition rate is due to earlier treatment (which may be more effective than delayed treatment), the identification of increased numbers of false positives (those who are not going to progress to psychosis) or a combination of both. [38] There may also be an effect from clinicians becoming better at managing UHR patients. [38] Additionally, it has been noted that the decline in transition rate was more prominent for patients who met two of the UHR inclusion criteria simultaneously compared to those who met only one of the criteria. [38] This could have been due to the increased emphasis which was placed on detection of patients who met both criteria, both in the UHR clinic and from referrers, thereby leading to earlier detection and treatment. [38] This is also in keeping with the wider community shift and preoccupation towards early psychosis and its recognition, and the increase in available referral pathways.

The decline in transition rate also raises questions about the validity of intervention approaches, such as pharmacotherapy and psychosocial treatment, on patients who may not ultimately transition to psychosis. [38] Such intervention may be harmful and therefore unjustified in this context. The UHR concept, which is used extensively in psychosis research, may also have to be re-visited if many of the identified patients are not transitioning. [38]

Due to the uncertainties regarding the basis for the declining transition rate, a review of the role of UHR clinics may be warranted. [38] It may be necessary to initially monitor patients and treat conditions such as depression, substance use problems and anxiety disorders while withholding antipsychotic treatment until features suggestive of transition occur, such as worsening of sub-threshold psychotic symptoms. [38] This may be prudent in the context of detecting increasing numbers of patients who were never destined to transition to psychosis. In any case, further research is needed to clarify the ongoing uncertainties in this area.

Bias in patient selection

Specialised teams set up to treat early psychosis engage with anyone who is seeking help. However, Castle [39] believes that this would skew the treatment group, as it would engage those with help-seeking behaviours rather than prodromal psychosis. Furthermore, it also raises the issue that those seeking help may have signs and symptoms of what is a normal developmental process or a ‘psychosis proneness’, which is part of a normal distribution within the general population. [40] Thus, these individuals may not require treatment for psychosis at all as they would either grow out of ‘psychotic proneness’ or would
stabilise and never develop psychosis.

Prescribing anti-psychotics to a population that is not psychotic: An ethical implication

The potential dangers of psychotropic drugs on young people are outlined in the United Nations Convention on the Rights of the Child, where children are recognised as being particularly deserving of protection from unnecessary exposure to psychotropic substances. [41] However, much of the research into early intervention includes administration of a low dose of antipsychotics as a crucial and efficacious treatment option. [42] Furthermore, antipsychotics are known to have serious side effects including sedation, weight gain, mild sexual dysfunction and disconcerting extrapyramidal symptoms (EPS) such as pseudoparkinsonism, akathisia, acute dystonia, and tardive dyskinesia. [43] While these effects have a stronger association with first generation antipsychotics, there is increasing evidence suggesting that second generation antipsychotics (SGA) are associated with significant side effects such as weight gain, hyperprolactinemia and EPS in the adolescent population.

Summary and recommendations

In view of the currently available literature, the authors make the following summary and recommendations with regards to early intervention in psychosis.

  • Psychosis is a highly disabling condition with detrimental impacts on patients’ relationships and occupational and social functioning
  • Possible interventions that delay or prevent transition from the prodromal period to psychosis are important, both clinically and economically
  • A systematic review by the Cochrane Database found limited evidence about interventions to prevent psychosis. Despite this, early intervention facilities such as headspace are widespread in Australia

Our recommendations

  1. We do not recommend the use of antipsychotics in children and adolescents who have been identified as at increased risk but who have not yet progressed to frank psychosis. Exposing children and adolescents to the serious side effects of antipsychotics is both unethical and inappropriate considering a proportion of these patients will not progress to psychosis.
  2. We recommend more research into safer, less harmful interventions such as omega-3 fatty acids and psychotherapy. For omega-3 fatty acids, evidence suggests a beneficial effect on transition rates compared to placebo. [44] However, this evidence comes from a single trial with few participants. A replication study with a larger sample size is needed to more definitively ascertain the merit of this intervention
  3. As previously discussed, preliminary evidence shows that CBT may reduce the transition rate to psychosis. Further research should be undertaken to conclusively establish the benefit of psychotherapy in high-risk individuals. Further research should
    include investigation of the cost-effectiveness of psychotherapy as an early intervention for youth psychosis. In addition, research should aim to identify any detrimental effects associated with providing psychotherapy to patients who do not progress to psychosis.
  4. Patients identified as being at risk of developing psychosis should be monitored closely by a multi-disciplinary team. Team members may include a general practitioner, social worker, psychiatrist and psychologist. By closely monitoring at-risk patients, their progression into frank psychosis can be detected earlier and appropriate treatment given in a timely manner. Prompt detection and treatment of psychosis is crucial, as delayed untreated psychosis has been shown to result in poorer outcomes.

Table 2. Summary of the evidence supporting and arguments against early intervention in psychosis.

Evidence supporting early intervention Evidence from small studies showing psychotherapy such as CBT and pharmacotherapy can reduce the progression
of ultra-high risk individuals to first episode psychosis.Studies show that raising public awareness and using mobile outreach detection teams to identify candidate patients significantly reduces the duration of psychosis.
Arguments not in favour of early intervention The economic cost of early intervention may be infeasible.Most patients identified as being high risk do not progress to frank psychosis.Treatment teams for early psychosis may disproportionately target patients with “help
seeking behaviour” and thereby treat more patients who simply display signs and symptoms of a normal developmental process or “psychosis proneness”.The negative ethical implications associated with prescribing antipsychotics to a population that is not psychotic.

Acknowledgements

The authors would like to thank Professor Jeff Cubis and Professor David Harley for their guidance and expert opinion on the matter.

Conflict of interest

None declared.

Correspondence

H C Y Yu: u4788941@anu.edu.au

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Feature Articles Articles

Dealing with futile treatment: A medical student’s perspective

A 76 year old man with metastatic liver cancer lies feebly in his hospital bed surrounded by family. He’s in cardiac and respiratory failure. Attached to him are multiple lines, cannulas and monitors. There are more machines present than people. Despite this, his breathing is laboured, he’s gaunt, and he is clearly suffering. In a rare moment of lucidity, he gestures for his son to come closer and whispers: “No more.” An obviously grief stricken man turns to the rest of the family, gestures, and heads outside to make one of the most difficult decisions he will ever make.

Confused and anxious, a fifteen year old boy sits and listens to the pros and cons of stopping his grandfather’s treatment being discussed by the doctors and the family. Questions keep popping up in his head “Why is he giving up? How could they consider withdrawing treatment, the same treatment that was obviously keeping this man alive? How could anyone live with that decision?”

How do I know this? Because I was that fifteen year old boy.

It is, perhaps, ironic that modern advances in medicine have made it feasible to sustain life and sometimes suffering, for an indefinite period. [1] The dramatic improvement in technology for life preservation has created ambiguity and has dehumanised the dying process. The result of this is that very difficult legal and moral decisions must now be made about transitions from aggressive treatment to palliative care. [2] At times, the existence of this technology creates a moral obligation to use it, especially when societal belief is that to treat is to care. [3]

It was all too much back then for a teenage boy, but now ten years down the line, is it still too much for a medical student? After all, what can we as mere fledgling trainees do to help ease those heavy burdens? Reflecting on these experiences helps address the powerlessness we experience in these morally and ethically challenging cases and serves as a reminder to everyone that even as mere ‘students’, we are capable of playing a vital therapeutic role in the care of patients whose treatments have been deemed futile.

Defining futility

Looking back at that period of time now, it is difficult to justify the last few weeks of futile treatment that my grandfather received.

How does one decide when treatment is futile? Some have defined it quantitatively as treatments that have less than a 10% chance of success, [4] while others have tried to express it qualitatively as “treatment which provides no chance of meaningful prolongation of survival or may only briefly delay the inevitable death of the patient.” [5] The majority of physicians will deem this poor outcome unsatisfactory and thus the treatment futile; however, most families will not. [6] Whatever the definition, futile treatment is not a black and white concept, but must be considered as a complex composite of quality of life issues that need to be discussed either with the patient early in their diagnosis, or with their legal next of kin. [5]

Ethical decisions

This choice is difficult enough for clinicians with years of health-care experience, let alone medically untrained families under stress, grieving for the imminent loss of a loved one.

How are these decisions made? There are no protocols or parameters set out which suggest treatment should be withdrawn. While students are often taught to use the four principles of bioethics: beneficience, non-maleficience, autonomy and justice to guide them through ethically challenging cases, [7] the general public often places a special emphasis on beneficence, and thus consider continuing treatment as the only option. This was demonstrated in a questionnaire study by Rydvall and Lynoe (2008), asking both physicians and the general public when they believed treatments should be withdrawn from terminally ill patients. While the majority of physicians chose to withdraw treatment early on to prevent further suffering, the majority of the general public chose to continue aggressive treatment until the very end, stating that the first task of health care professionals is to save lives. [8]

This highlights the higher expectations that the general public may have of what the health care system should achieve, [8] which can lead to points of contention and miscommunication when it comes to making critical care decisions. The role of the medical student in these cases is often as a moderator; to listen, discuss and bridge the gap of communication between the two understandably apprehensive parties.

The therapeutic use of self

The feeling of helplessness was overwhelming, none of the doctors paid me any attention; I was just a child after all, not worthy of their attention or time. But he was my grandfather, not just their patient.

The concept of ‘therapeutic use of self’ is the use of oneself as a therapeutic agent by integrating and empathising with the patient and their family. This can be to alleviate fear or anxiety, provide reassurance and obtain or provide necessary information in an attempt to relieve suffering. [9] This is particularly relevant in circumstances where treatments have a limited effect on the disease process, where suffering is prolonged rather than prevented.

Medical school does not always formally teach the importance of connecting with patients and the therapeutic role that students play. [10] Many young aspiring doctors seek to emulate the ‘professional’ and sometimes detached demeanour of their more senior counterparts; often getting too close to the patients is seen to be a one way street towards emotional burnout. However, therapeutically, the importance of being physically near patients and their families during their personal illness and distress cannot be over stated. [9]

While many students may claim to never have enough time in their schedules, they are often the most time-rich personnel. For this reason they are often the only ones who have the opportunity to sit down with the family and the patient. This is not to take away, explain or understand the pain, but rather as a symbol of support, so that they know we are witnesses to their suffering and that they have not been abandoned. [10]

Withdrawing versus withholding

The debate went on throughout the night: “We’re abandoning him?”

“No, it’s for the best, he doesn’t need to go through any more of this, the doctor said there’s no way he’s going to get better.”

“You want to stop all treatments? We should be trying new things not stopping old treatments!”

Traditional medical training places an emphasis on the acquisition of skills and expertise to help ‘fix’ the patients or their diseases. Interestingly, many clinicians are more comfortable withholding treatment – that is, not beginning new aggressive treatments – than stopping currently initiated treatments. [1,11,12] This may be because withdrawing attaches a feeling of responsibility and culpability for the death. [3,13] To avoid this, clinicians will often only withdraw support when it becomes clear that death will occur regardless of further treatment. In this way, a “causative link between non-treatment and death is avoided.” [14]

Increasingly in today’s medical system, a simple ‘fix’ does not exist for many patients and their diseases. For these patients, success is judged not on the amelioration of the pathological process, but instead, on whether a good quality of life can be achieved in spite of the presence of chronic disease. Various religions and cultures have differing views on quality of life arguments adding a further layer of complexity to the decision making process. Therefore it is important to take the background of the patient and their relatives into consideration. [3]

Similarly, individual variations exist between physicians, because although each will use the most current evidence available to decide plans for the best outcome, each person is influenced by their own ethical, social, moral and religious views. [3] This perhaps, is the reason why the modern curriculum has incorporated elements of personal reflection, professionalism and social foundations of medicine to guide students into thinking more reflectively and sensitively, allowing for a more holistic patient-centered approach.

Moral decisions

“He’s not going to get better,” I was told, “The doctors said we should stop the treatments because all they’re doing is causing him to suffer.” Even I could understand that decision when it was justified to me like that. Unfortunately others don’t necessarily see it that way.

Moral situations often arise when clinicians tell relatives that they believe treatment will not help the patient recover, and the option is given to withdraw aggressive treatment in favour of palliative care. Many perceive continued treatment to not only be life sustaining, but also potentially curative, and thus moving onto palliative care is often interpreted as a choice to end their loved one’s life. [5] Some feel it is better to watch their relative die while undergoing treatment rather than live with the belief that they consented to death. [3, 5] Unsurprisingly, relatives will often demand that “everything be done” to preserve life. [5, 15, 16]

It is important to remind family that withdrawing futile treatment does not mean withdrawing all treatment. Palliative management including analgesia, respect for dignity, and support will always be provided throughout the ordeal. [2] We must be mindful that in this day of medical advancements, it is quite common that caring for a chronically ill loved one becomes the sole purpose in the carer’s life. The health care system has generated a ‘patient support system’ in which the carer has one role, and is deprived of energy and time for anything else, forgoing careers, friends and hobbies. It is perhaps unsurprising, that towards the end of a patient’s life, the carer maybe unwilling to let go of the only remaining source of meaning in their life. [6]

These difficult decisions often don’t need to be made if adequate preparation has been made beforehand, by having advanced care directives documented and a durable power of attorney arranged before the condition of the patient declines. These items can make a world of difference for both the family and the health care staff. [13]

Final thoughts

Would I have done anything differently if I had the maturity and the training that I have now?

Medical students in general feel that completing a full history and examination is the extent of what they can offer to patients; [16] however, this is often not the case. Their support and knowledge base is invaluable to patients and their family. Students play a vital therapeutic role in assisting the patient and family to come to terms with the limitations of modern medicine, and to recognise that extension of the dying process undermines what both the medical team and the family ultimately want – a dignified and peaceful death.

It is easy to objectively look at a patient with whom we’ve had no past relationship and decide what the right choice is. But for families, it will never be that straight forward when a decision has to be made about a loved one. During these times, as medical students, we need more than the ability to communicate effectively, we need the mental fortitude to be able to step into that dark and difficult place with the patient and their family to truly connect, and be there for them not only with our book smarts, but as figures of support and strength.

Never underestimate the therapeutic potential of who we are. While we may lack the mountains of factual knowledge of our senior colleagues, we have the potential to excel in the more humanistic aspects of patient care. By learning to approach these cases with compassion and humility, we can hope that our presence and understanding will render healing in situations that cannot be cured by our medical knowledge. [10]

As he requested, treatment was withdrawn and palliative care started, the 76 year old grandfather, father, and husband returned home and passed away in a dignified and peaceful way surrounded by family.

Acknowledgements

The author would like to thank his grandfather who gave him the world by teaching him to how to learn.

The author would also like to acknowledge the fantastic feedback provided by both reviewers which allowed him to gain a greater understanding into this fascinating topic.

Conflict of interest

None declared.

Correspondence

M Li: michael.li@anu.edu.au

References
[1] Slomka J. The negotiation of death: clinical decision making at the end of life. Soc Sci Med. 1992; 35(3): 251-9.
[2] Kasman DL. When is medical treatment futile? A guide for students, residents, and physicians. J Gen Intern Med. 2004; 19(10): 1053-6.
[3] Reynolds S, Cooper AB, McKneally M. Withdrawing life-sustaining treatment: ethical considerations. Surg Clin North Am. 2007; 87(4): 919-36, viii.
[4] Howard DS, Pawlik TM. Withdrawing medically futile treatment. J Oncol Pract. 2009; 5(4): 193-5.
[5] Murphy BF. What has happened to clinical leadership in futile care discussions? Medical Journal of Australia. 2008; 188(7): 418-9.
[6] Hardwig J. Families and futility: forestalling demands for futile treatment. J Clin Ethics. 2005; 16(4): 335-44.
[7] Beauchamp TL, Childress JF. Principles of biomedical ethics. New York: Oxford University Press; 1994.
[8] Rydvall A, Lynoe N. Withholding and withdrawing life-sustaining treatment: a comparative study of the ethical reasoning of physicians and the general public. Crit Care. 2008; 12(1): R13.
[9] Bartholomai S. Therapeutic Use of Self/Building a Therapeutic Alliance. In: Hospital I, editor.; 2008.
[10] Kearsley JH. Therapeutic Use of Self and the Relief of Suffering. CancerForum. 2010; 34(2).
[11] Pawlik TM, Curley SA. Ethical issues in surgical palliative care: am I killing the patient by “letting him go”? Surg Clin North Am. 2005; 85(2): 273-86, vii.
[12] Iserson KV. Withholding and withdrawing medical treatment: an emergency medicine perspective. Ann Emerg Med. 1996; 28(1): 51-4.
[13] Scanlon C. Ethical concerns in end-of-life care. Am J Nurs. 2003; 103(1): 48-55; quiz 6.
[14] Seymour JE. Negotiating natural death in intensive care. Soc Sci Med. 2000; 51(8): 1241-52.
[15] Foster LW, McLellan LJ. Translating Psychosocial Insight into Ethical Discussions Supportive of Families in End-of-Life Decision Making. Social Work in Helath Care. 2002; 35(3): 37-51.
[16] Frank J. Refusal: deciding to pull the tube. J Am Board Fam Med. 2010; 23(5): 671-3.

Categories
Review Articles Articles

Australia’s experience of Bordetella pertussis and a proposed national preventive strategy into the future

Elimination of Bordetella pertussis, an exclusively human pathogen, has proven to be elusive in Australia despite universal vaccination. Australia has witnessed a resurgence of pertussus particularly in infants less than 6 months old, and adults over 20 years old. This resurgence has resulted in high notification rates, morbidity and mortality in the two age groups. This may be due to the largely asymptomatic presentation in young infants and adults, as well as sub-optimal immunity due to lack of development, or waning immunity in adults. Various levels of prevention need to be identified so that a national preventative strategy may be sought to reduce the impact of pertussis infection amongst Australians in the future.

 
Introduction
Pertussis is an acute illness caused by Bordetella pertussis, a Gram-negative coccobacillus with exclusive affinity for the mucosal layers of the human respiratory tract. Pertussis is highly contagious and spread by air borne respiratory droplets when an infected person coughs or sneezes, or via direct contact with secretions from the nose or throat. [1] Following an incubation period of 9-10 days, patients usually present with an irritating cough that gradually becomes paroxysmal and lasts for 1-2 months. [2] However, in adults and older children, the diagnosis of pertussis is often subclinical and delayed due to an absence of classical symptoms, resulting in potential transmission of infection for several weeks. [3] In Australia, the preferred methods for laboratory diagnosis of pertussis are culture and polymerase chain reaction (PCR), and it is recommended in most cases that both tests be performed. However, there is a trend to move towards PCR, which provides rapid results, and is more sensitive in previously immunised individuals, and more likely to be positive in patients who have received antimicrobial treatment than culture. [1-4]
 
Since the 1950s, effective pertussis immunisation programs have reduced hospitalisations and deaths in Australia dramatically. [4] Currently, the acellular pertussis vaccine (DTPa) is safer and more effective than whole cell pertussis vaccine (DTPw), which is no longer used in Australia. [1] DTPa vaccines are associated with lower incidence of fever and local reactions than DTPw, and serious side effects are rare. [1,6] DTPa is free for Australian children at 2, 4 and 6 months of age, with a booster available at 4 years and during adolescence. [5] Despite the availability of vaccines in Australia, it remains a challenging disease to control among two age groups: under the age of 6 months who suffer the most severe infections and highest mortality, and those older than 20 years. [1,6] Adolescents and adults are an important reservoir for infection as they are capable of transmitting pertussis to infants who were too young to have received two or more DTPa vaccines required for optimum protection. [1]
 
Epidemiology
In Australia, pertussis cases are notifiable under each state and territory Public Health Act. [4] There were 34,490 pertussis notifications received by the National Notifiable Diseases Surveillance System (NNDS) in 2010, the highest recorded since 1991 (Figure 1). A general increase in endemic peaks have occurred every 4-5 years since national notifications became available in 1991, occurring in 1997 (12,232 notifications), 2001 (9,530 notifications), 2005 (11,168 notifications) and 2010 (34,490 notifications). A clear seasonal pattern exists, with the highest number of notifications in the spring and summer months (between August and February) each year between 1993 and 2010. [2] In terms of age specifi c pertussis incidence rates, children less than 1 year old had the highest annual notification rate in all of the analysed years, and high rates were also observed in 5-9 years olds, with a peak notification rate in 1997 of 194 cases / 100,000. [4] Adults aged 20-59 years accounted for 56% of notifications, with elderly patients aged 60 years and over accounting for 15% of notifications in 2005 (Figure 2). Recently, there has been a rise in notification rates in the 20-59 year old age group, and in those over the age of 60, increasing by 57% and 17% respectively in 2010. This is in contrast to the relatively steady annual rates previously seen in these age groups between 1993-2003.
Hospitalisations, which refer to a period of time when a patient is confined to a hospital, followed a similar pattern to notifications (Figure 1) with a total of 1,478 separations recorded during 1998-2008 (Figure 3). Of these separations, they were most prominent in the 0-4 age categories, with 967 separations (Table 1). Peak separations occurred in the period of 2001-2002 (258 separations), 2004-2005 (222 separations) and 2007-2008 (250 separations).
There were 9,338 hospital bed days recorded for all ages during 1998-2008, with the highest number of hospital bed days toward the 0-4 year old group. Total hospital bed stays peaked during 2001-2002 (1,628 days) and 2004-2005 (1,640 days). Over the two years 2003-2004, two deaths were recorded where pertussis was the underlying cause, with both occurring in 2004; one case was 1 month of age and the other a 95 year old patient. [2] During 1993-2002, there was a total of 16 deaths attributed to pertussis, of which 15 (94%) occurred in infants less than 6 months of age. [6]
The latest study by Australian Department of Health and Ageing showed that between 2003-2005, only 37% of infants less than 6 months were fully vaccinated, and 12% partially vaccinated. [2,4] There are proposed explanations for increasing pertussis rates seen amongst infants in the less than 6 months of age group. Two or more doses of a pertussis-containing vaccine appear to be needed for protection, and infants less than 6 months of age are likely to be too young under Australian immunisation schedules to have reliably received two or more doses. [3] It is also likely that adults, particularly parents, are a significant source of infection to infants. Regarding individuals aged 20 and over, it is likely that increased notifications are related to greater use of serology as a diagnostic tool, and an ageing population. [4,8]
Also, waning immunity following infant vaccination and reduced opportunities for boosting immunity due to reduced circulation of pertussis may also contribute to increased susceptibility to pertussis infection and disease in the 20 years and over population. [3,8]
 
Risk factors
Understanding the risk factors for pertussis infection is essential to target areas of concern, and to provide a skeleton for drafting a national preventative strategy. They include:

  • Infants and children who are not immunised yet. In infants, the first dose of vaccine is immunogenic only from the age of 6 weeks, thus infants less than 6 weeks are at the highest risk of pertussis infection, often from the parents. [1-6]
  • Infants under 12 months old. Infants are particularly prone to infection prior to receiving the first two doses of DTPa. Adolescents and adults are an important reservoir for infection as they are capable of transmitting pertussis to infants. [1] In addition to increased susceptibility of acquiring infection, infants are also most at risk of developing severe complications, such as apnoea, bacterial pneumonia, pulmonary hypertension and cor-pulmonale. [5,10]
  • Adolescents aged between 12-17 years. Immunity, whether from immunisation or past history of Bordatella pertussis infection, decreases after approximately 6-10 years, resulting in renewed susceptibility to infection. Thus for most adolescents, if they do not receive a booster shot during adolescence, they are at risk, as their last dose of DTPa would have been at 4 years of age in Australia. [1-3,7,9]
  • Living in the same house or working in close contact with someone infected with Bordatella pertussis. Studies have demonstrated that households with members who have culture-positive Bordatella pertussis were more likely to have greater secondary spread. Hence, proximity is an important predictor of household and community-aquired infection, with adolescents being at higher risk compared with other age groups. [13] Additionally, adults working with young children, especially childcare workers and healthcare workers in contact with infected infants are at a higher risk of contracting Bordetella pertussis infection. [1]
  • Persons with immunodeficiency and other underlying medical conditions. These include patients who have congenital or acquired immunodefi ciency, cystic fibrosis, chronic heart failure, diabetes and chronic lung disease.
  • Indigenous Australian Infants. One study demonstrated that 52% of pertussis hospitalisations in Indigenous infants occurred at 0-2 months of age, and rates in these indigenous infants were signifi cantly higher in remote areas. Also, indigenous infants had higher hospitalisation rates and were more frequently delayed of vaccination than age matched non-indigenous infants. [14]

Prevention activities
When thinking about prevention in population health, there is consideration towards four types of prevention:

  • Primordial Prevention: Avoid the emergence and establishment of ‘upstream’ factors such as social, cultural and economic factors that contribute to increased disease incidence.
  • Primary Prevention: Preventing disease from occurring in the first place; to reduce the incidence of disease. [15]
  • Secondary Prevention: Reducing morbidity and mortality by improving the outcome of disease (such as early diagnosis and treatment) that has already developed. [15]
  • Tertiary Prevention: Reducing the progress or complications of disease and implying better rehabilitation or quality of life in the longer term. [15]

Table 2 outlines how these different types of prevention could be implemented in Australia in the future.
 
A national preventative strategy
A national preventative health strategy requires effective health promotion programmes. Health promotion is the process of strengthening the capability of individuals to take action and the capacity of communities to act collectively to exert control over the determinants of their health. [19]
 
Program Planning
Target Populations: Epidemiological and demographic information suggests that infants aged less than 6 months are at the highest risk of severe pertussis disease due to partial immunisation. Also, there is an increasing number of notification s in adults aged 20 years and over. [1] These two age groups could be extensively targeted as they are both a community need and are perceived as priority for intervention.
Vaccination Timing: There is evidence to suggest inadequacy of vaccination programs which provide doses at 2, 4, and 6 months, 4 years and in adolescence. There may be a role for earlier vaccination in order to protect those under 6 months of age. Furthermore, there may also be a role for the inclusion of those over the age of 20 in the national immunisation programme, as well as health care and childcare workers. Moreover, investment in screening, surveillance and patient education should be recommended.
Resource allocation: There is a need to mobilise resources. There may be a role for lobbying national and state governments to devote a greater proportion of the national budget to health care and disease prevention. Furthermore, there may be a role for the private sector (e.g. pharmaceutical companies) to also invest further in this disease in the form of vaccines, treatments, educational materials and awareness strategies. Human resources must also match financial resources, with appropriate medical staff providing increased vaccination and health promotion on this issue. Finally, building sustainable relationships between different bodies is key to the long-term success of health promotion, e.g. between Medicare Australia, the Australian Medical Association, public hospitals, pharmaceutical companies, state and federal health ministries.
 
Programme Implementation
Establishing an evidence base: This could be done by randomised controlled trial of vaccinating infants at the onset of labour, and another booster shot before the current regimen at 2 months to assess clinical outcomes. A randomised trial could also be done for adults over 20 years in limited geographical areas to assess efficacy, human resources and costs. A trial of up-skilling healthcare workers to be competent for routine pertussis screening in hospitals may be implemented and tried. Additionally, production of pamphlets and utilising media to promote health awareness of pertussis could be trialled to assess coverage, efficacy, cost and human resources.
Health promotion actions: Traditionally, health promotion activities have focused on public information, education or communication as the main method for improving knowledge and changing behaviours and thus, this should be emphasised in a pertussis preventative strategy. Dissemination of information through mass media by advertising, radio, posters and pamphlets around healthcare centres could be implemented in a cost effective way.
Organisations could also work together with pharmaceutical companies supplying vaccination. Furthermore, identified cases of pertussis should be reported early to a public health authority by private and public hospitals. Finally, prior to registration of doctors with the medical board, they could be required to undergo pertussis training.
 
Monitoring and recording of programme implementation and quality control
Increased attention must be given to the development of performance indicators which can be used to assist in assessing good management of people and resources, and assessment of success or failure. [19]
Cost-benefit analysis may be assessed for each class of preventative strategy, the availability of staff for an increasingly elderly population, assessment of penetration and impact of mass media and pamphlets for patient education could be accounted by production of surveys, and public notification s, mortality and morbidity data may constantly be monitored to assess efficacy of increased DTPa.
 
Program evaluation
Health literacy may be evaluated using measures such as assessing pertussis-related knowledge, attitudes, motivation, behavioural intentions, personal skills and self efficacy of the public. [19]
Outcomes regarding internal governmental policy developmental process, and lobbying leading to legislative change could be reviewed using measures such as policy statements, resource allocation and organisational practices. Finally, data of social outcomes (such as quality of life, equity) and health outcomes (national data on reduced morbidity, disability, avoidable mortality) may be evaluated to assess whether the preventative strategy was successful, or, if there are any program failures, may be traced to re-examine potential solutions.
 
Conclusion
Despite the largely successful history of immunisation in dramatically decreasing the incidence of pertussis, especially in terms of the number of hospitalisations and deaths, a number of changes to the immunisation strategy may be overdue. Control of the disease still remains a challenge in 21st century Australia, with increased notification rates documented in those under the age of 6 months and over the age of 20. GPs, often the fi rst point of contact, should familiarise themselves with the epidemiology those at greatest risk of pertussis, and off er vaccination accordingly. Moreover, individuals, health professionals, health organisations and governments must work synergistically to develop novel preventative strategies against modifi able risk factors, such as by increasing the number of booster vaccines, increasing surveillance, and greater dissemination of information to the population, to minimise burden of the disease for a sustainable future.
 
Acknowledgements
I would like to acknowledge Prof. Gabrielle Bammer, Director, National Centre for Epidemiology and Population Health and A/Prof. David Harley, Associate Dean of Population Health Teaching and Learning for awarding the ANU Medical School Population Health Prize towards this article.
Conflicts of interest
None Declared.
Correspondence
J Choi: josephchoi7@gmail.com
  
References
[1] Australia. Pertussis Vaccines for Australians: Information for Immunization Providers. National Centre for Immunisation Research and Surveillance fact sheet. November; 2009.
[2] Australia. Vaccine Preventable Diseases and Vaccination Coverage in Australia 2003-2005. Australian Government Department of Health and Ageing. November; 2007.
[3] Wood N, McIntyre P. Pertussis: Review of epidemiology, diagnosis, management and prevention. Paediatr Respir Rev. 2008;9:201-12.
[4] Quinn H, McIntyre. Pertussis epidemiology in Australia over the decade 1995-2005: Trends by region and age group. Commun Dis Intell. 2007;31:205-15.
[5] Paterson J, Sheppeard V. Nosocomial pertussis infection of infants: Still a risk in 2009. Commun Dis Intell. 2010;34:440-3.
[6] Senanayake S. Pertussis in Australia today: A disease of adolescents and adults that can kill infants. Aust Fam Physician. 2007;36:51-5.
[7] Australian Institute of Health and Welfare Interactive National Hospital Data [Internet]. 2010 [Cited 2011 May 14] Available from: http://aihw.gov.au/hospitas/datacubes/index.cfm.
[8] Cherry J. The epidemiology of pertussis: A comparison of the epidemiology of the disease pertussis with the epidemiology of Bordetella pertussis infection. Paediatrics. 2003;115:1422-7.
[9] Weekly epidemiological record: Pertussis Vaccines WHO position paper, 2010. World Health Organization. 2010;85:385-400.
[10] Long, S. Age Specifi c Presentation and Burden of Pertussis. Adv Stud Med. 2005;5:S444-9.
[11] Yeh S, Mink C, Edwards M, Torchia M. Clinical Features and Diagnosis of Bordetella pertussis infection in infants and children. Waltham, MA, USA: Up to Date; 2010.
[12] Wright S and Tenn N. Pertussis Infection in Adults. South Med J. 1998;91:702-9.
[13] Biellik R, Patriarca P, Mullen J, Rovira E, Brink E, Mitchell P, et al. Risk factors for community and household acquired Pertussis during a large scale outbreak in central Wisconsin. J Infect Dis. 1988;157:1134-40.
[14] Kolos V, Menzies R, McIntyre P. Higher pertussis hospitalization rates in indigenous Australian infants, and delayed vaccination. Vaccine. 2006;25(4):588-90.
[15] Webb P, Bain C and Pirozzo S (2005) Essential Epidemiology. New York, USA:Cambridge University Press; 2005.
[16] Yeh S, Edwards M, Torchia M. Treatment and prevention of Bordetella pertussis infection in infants and children. Waltham, MA, USA: Up to Date; 2010.
[17] Forsyth K, Konig C, Tan T, Caro J, Plotkin S. Prevention of pertussis: Recommendations derived from the second Global Pertussis Initiative roundtable meeting. Vaccine. 2007;25:2634-42.
[18] Mills S. Now wash your Steth. Medical Student Journal of Australia. 2011;2:42-3.
[19] Pencheon D, Guest C, Melzer D, Gray J. Oxford Handbook of Public Health. Oxford, United Kingdom: Oxford University Press; 2001.

Categories
Feature Articles

Up the creek without a paddle: An Australian take on disaster medicine

Figure 1. Participants are assessed in water rescue from a previous module during a water rafting exercise. Here, participants begin to resuscitate an unconscious patient during a disaster simulation.

Disaster medicine is a subject category that invokes thoughts of emergency medicine on a much grander scale; one that involves all levels of healthcare governance. But in reality, it is an area of medicine that is often neglected in Australia, despite its pertinence in this land of extremes. This has been shown to be currently so with the education of Australian medical students, where it is perceived as being too “young a branch on the old tree of medicine.” [1] But what exactly is disaster medicine, and why is there a lack of discussion of this field in a country so often threatened by disasters, natural and man-made? This was recently investigated by a delegation of medical students across Australia during a summer course in disaster medicine and management. They were amongst the 41 students, across five continents, that converged upon Gadjah Mada University in Yogyakarta, Indonesia under the auspices of the World Health Organisation and the Indonesian Ministry of Health. The following article explores the nature of disaster medicine. It then outlines the experiences of students undertaking the summer course run in Indonesia in this area. Finally, it provides an insight into the potential value of incorporating disaster medicine training into the Australian medical education curriculum.

Introduction

Imagine you are on placement in a rural location in the middle of summer enjoying your free time when wildfires rapidly surround and engulf the town you are based in. Local gas explosions rock the area, as you see dozens of patients with severe burns or in critical conditions lying on the ground. Some are conscious, screaming or clutching their abdomens, while others are unconscious and there is word of hundreds more streaming into the local hospital to escape the fires. All desperately need your help. Hysteria erupts and communication lines are down due to the catastrophe that has suddenly occurred. With nothing in hand, what do you do with no one else on the scene? Who do you save and how do you deal with streams of panicking individuals?

The term ‘disaster medicine’ is difficult to define, and over the years numerous definitions have been proposed as the discipline began to flourish. The World Health Organisation (WHO) defines ‘disaster’ as an occurrence where normal conditions of existence are disrupted and the level of suffering exceeds the capacity of the hazard-affected community to respond to it. [2] The distinct difference between disaster and emergency…

Categories
Book Reviews

‘Moore’ than just a doorstop: Clinically Oriented Anatomy vs. Gray’s Anatomy for Students

The study of anatomy is often a challenging endeavour for many medical students. Central to the learning process is the use of a good textbook. Two of the most often recommended texts for medical students are Gray’s Anatomy for Students (GAS), descended from the iconic text by Henry Gray, and Clinically Oriented Anatomy (COA), by Moore, Dalley and Agur.

Both texts employ a regional approach to the study of anatomy. GAS separates each chapter into four sections: Conceptual Overview, Regional Anatomy, Surface Anatomy and Clinical Cases. The conceptual overview aims to provide the very basic concepts of each region in a concise summary before moving on to an increasingly detailed description. While this approach may be useful for the beginner or reviewer, the inevitable repetition creates a degree of redundancy. COA presents information in a ‘bones up’ format, progressively adding surrounding structures before detailing the arthrology of each region. Each chapter concludes with a series of radiographic images to complement integration and understanding.

Certain striking distinctions are evident in the textual quality of each book. GAS aims to strip away irrelevant information into an easy-to-read summation while leaving intricate details for other texts. While this provides an excellent introduction for the neophyte, COA includes more rigorous explanations concerning the finer points and the complex interaction with surrounding structures. An enlightening example of the differing styles can be observed through the treatment attributed to the sternocleidomastoid (SCM) muscle. A concise, tabular description of muscular attachments, innervations and basic function is provided in GAS in association with a stylised diagram indicating its position in the neck. Conversely, COA devotes an entire four page sub-section to a detailed discussion of the manner in which body position and the use of synergist muscle groups can alter function of the SCM beyond an isolated view of the muscle acting independently in the anatomical position. Thus, while simplified to enhance the initial integration of basic concepts, GAS may simultaneously perpetuate certain erroneous notions concerning the nature of anatomical function. On the other hand, the text in COA may reduce its effectiveness for the uninitiated, while GAS may prove to be too simplistic for the interested student.

Both books approach diagrammatical representation through the use of computer-generated imagery, though distinct dissimilarities are visible. COA depicts each region by incorporating detailed and realistic diagrams which are thoroughly labelled. In contrast, GAS represents analogous images through a distinctly stylised fashion. Major structures are portrayed in an idealistic mode, which, in combination with relatively sparse labelling, may impede practical application, particularly in medical courses focussed on anatomical dissections. However the simplified overview, devoid of extensive detail, is potentially easier to comprehend for the less experienced anatomist. In addition to detailed, accurate labels, COA consolidates diagrammatic elements through representations in various anatomical planes. The depiction of distinct layers within each system aids the appreciation of the detailed nature of such structures. Ultimately, COA associates these illustrative characteristics through the use of numerous, detailed figures within each specified anatomical region. The use of COA may prove to be beneficial, both in dissection and in providing a broader scope of understanding.

The integration of clinical aspects throughout a text is essential to the effective understanding of anatomical information. Both books appear to have achieved a relatively streamlined integration of such information through the utilisation of clinical vignettes. Complemented with relevant diagrams, topics covered in the text of these vignettes include information relating to development, anatomical variation, radiology and pathology. For those without significant exposure to anatomy, having clinical information presented in such a fashion is an ideal mode for the consolidation of vital concepts. The use of end of chapter case studies in GAS allows the reader to evaluate their own level of understanding, a feature that is absent in COA. Radiological correlations in GAS are discussed further through an in-text approach. Alternatively, COA utilises radiological imaging juxtaposed with easily understood computer generated diagrams, allowing the student to…

Drake R, Vogl W, Mitchell A. Gray’s Anatomy for Students. London: Churchill Livingstone; 2009.

RRP: $138.00

Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy, Sixth Edition. Baltimore: Lippincott Williams & Wilkins; 2009.

RRP: $129.80