Feature Articles Articles

Probiotics: A New Recommendation with Proton Pump Inhibitors?


Clostridium difficile-Associated Diarrhoea (CDAD) is becoming a worldwide epidemic with significant patient morbidity and mortality, as well as increasing the costs to health care systems. Although CDAD is generally associated with antibiotic use, there are multiple studies demonstrating that proton pump inhibitors (PPIs) may also be linked with CDAD. This is particularly worrisome for physicians in general practice, where PPIs are among the most frequently prescribed drugs. [1]

Clostridium difficile is a gram-positive, spore-forming, anaerobic bacillus that may cause gastrointestinal infections with poor patient outcomes and significant medical costs. [2,3] In one study, 3% of C. difficile infections resulted in death or admission to an Intensive Care Unit. [4] In 2002, another study demonstrated a mortality rate of 15.7% due to C. difficile colitis. [5] Although there is no complete cost analysis done in Australia, the figures emerging from the United States are staggering, with the average C. difficile infection cost ranging between $10,970-$29,000 per patient [6,7] and the estimated annual cost of $55 million in the state of New York alone. [7]

The mechanism of infestation and standard treatment

C. difficile enters the human body by spores which are ingested orally. Five percent of the population carries C. difficile asymptomatically due to growth-regulation by gastrointestinal flora. [8] In the presence of antibiotics, normal flora may be reduced, allowing an over-colonization of C. difficile. Typically, C. difficile is treated with a 10-day course of metronidazole for less severe infections, or with vancomycin for severe infections, with recurrence rates as high as 25%. [9]

PPIs and the link with C. difficile

PPIs are a class of drugs frequently prescribed in the general practice setting for Gastro-Oesophageal-Reflux-Disease (GORD), [10] peptic ulcer disease [11] and related conditions. [12] PPIs inhibit the hydrogen-potassium ATPase of parietal cells in the stomach, decreasing gastric acid production, thereby settling acid-related gastric symptoms. General practitioners are prescribing PPIs with increasing frequency. This is not surprising, as between 3% and 7% of the population suffer from GORD. [13] The mechanism by which PPIs may lead to C. difficile colitis is unclear; it may be that reduced stomach acidity allows more of the bacterial spores to survive, thereby increasing bacterial load in the gastrointestinal system. [14]

There are multiple studies demonstrating a link between C. difficile and PPIs. [15-18] In one meta-analysis of case-control and cohort studies, it was shown that PPIs imparted a relative risk of 1.69 for the development of C. difficile infection. [19] Another meta-analysis published by Kwok et al. (2012)  suggested a 70% increase in risk of this infection. [20] Given the considerable risk of developing CDAD in association with PPIs, and the morbidity and mortality associated with CDAD, it is recommended that general practitioners use caution when prescribing these medications, observe patients for secondary diarrhoea and investigate with C. difficile cytotoxin assays.

A multi-center case control trial from the Netherlands identified that the greatest risk for development of C. difficile infection was within the first three months after initiation of antibiotics, with the risk peaking at one month and declining between one and three months. [21] According to this study, third-generation cephalosporins and carbapenems were associated with the greatest risk of CDAD.[21] Other risk factors for CDAD include living in long term care facilities, major bowel diseases such as Inflammatory Bowel Disease (IBD), colorectal cancer, radiation and chemotherapy, and age, with highest risk beyond the age of 65 years. [22] It is yet to be determined if similar risk factors are involved in the development of PPI-associated diarrhoea.

It should be noted that the meta-analytic link between PPIs and CDAD is criticized, as there are multiple methodological problems with many of the studies involved. [23] One criticism is that duration and dose of PPI exposure were not variables considered in the meta-analyses; therefore, the exposure-dependent and dose-dependent relationship cannot be established. [23] Further research is required to determine whether there is a causal relationship between PPI use and CDAD.

What can physicians do in the meantime while the link is investigated?

There may be a role for probiotics in the prevention of PPI related CDAD. Probiotics are broadly defined as live microorganisms that exert beneficial effect on the host. [24-26] The mechanism for this is unclear, but may involve the suppression of pathogenic bacteria and/or suppression of inflammation in the gut. [27] There are a wide range of probiotics marketed today to improve immune function including Bifidobacterium lactis, Lactobacillus reuteri, Lactobacillus rhamnosus and others for diarrhoea including Saccharomyces boulardii, Lactobacillus casei, Lactobacilus acidophilus and others. Lactobacillus, bifidobacteria and certain yeasts (eg: Saccharomyces) are the most common microbes used in commercial probiotics. These can be consumed as part of fermented foods, such as yogurt, or directly as supplements. Recommendation of the probiotic S. boulardii with antibiotics has shown a significant reduction in the incidence of antibiotic-associated-diarrhoea in two separate double-blind placebo controlled studies. [28,29] A meta-analysis reveals nine studies have shown use for both S. boulardii and lactobacilli in the prevention but not the treatment of CDAD. [30]

At this point there is no research examining the effects of probiotics regarding the prevention of PPI associated CDAD; however, it is reasonable to presume there may be a role for S. boulardii and lactobacilli in balancing the gastrointestinal tract flora whether the disruption of its microenvironment is secondary to antibiotics or PPIs. If future research demonstrates a similar reduction in PPI-related CDAD, as has been documented with antibiotic-related CDAD, there may be grounds for adjustment of future clinical recommendations to include probiotics with PPIs in the general practice setting.

In general practice, deciding whether to prescribe any medication requires evaluation of risks and benefits to the patient. As minimal risks have been reported in healthy individuals with probiotic use, [31] and given the potential benefit to reduce the incidence of CDAD, research needs to be done to determine whether there is benefit to prophylactically recommending S. boulardii with PPIs. It would be logistically difficult to ensure compliance and no use of alternate anti-acid medication in a randomly controlled longitudinal trial in the development of C. difficile infection. However, a well controlled prospective cohort study may minimize confounding factors and suggest causality by examining patients with limited comorbidities.

The risks of recommending probiotics

There are no systematic reviews demonstrating risk of probiotics; however, general practitioners should be aware that multiple case studies indicate there may be a risk of recommending probiotics in immunocompromised patients. These include cases of hepatic abscesses and pneumonia, [32] probiotic sepsis [33,34] and S. boulardii fungaemia. [35,36] There are no cases of such probiotic sepsis or fungaemia in healthy individuals.


Probiotics have been recommended in the prevention but not the treatment of C. difficile infection associated with antibiotics. While the pathogenesis of PPI-related CDAD is unknown, it presumably involves the disruption of gastrointestinal flora, which is potentially amenable to probiotic supplementation. Given minimal documented risks of probiotics in immunocompetent individuals, research needs to determine whether there are direct benefits of the use of probiotics in the prevention of PPI-related CDAD. Such recommendation on the part of the general practitioner may reduce morbidity and mortality associated with CDAD and reduce costs to the health care system.

Conflict of interest

None declared.


C Oitment:


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[2] Miller M, Gravel D , Mulvey M, Taylor G, Boyd D, Simor A, et al. Health care-associated Clostridium difficile infection in Canada: patient age and infecting strain type are highly predictive of severe outcome and mortality. Clin Infect Dis. 2010; 50: 194-200.

[3] Dubberke ER, Reske KA, Olsen MA, McDonald LC, Fraser VJ. Short- and long-term attributable costs of Clostridium difficile-associated disease in nonsurgical inpatients. Clin Infect Dis. 2008; 46: 497-504.

[4] Rubin MS, Bodenstein LE, Kent KC. Severe Clostridium difficile colitis. Dis Colon Rectum. 1995; 38(4): 350-354.

[5] Morris AM, Jobe BA, Stoney M, Sheppard BC, Deveney CW, Deveney KE. Clostridium difficile colitis: an increasingly aggressive iatrogenic disease? Arch Surg. 2002; 137(10): 1096-1100.

[6] McFarland LV, Surawicz CM, Rubin M, Fekety R, Elmer GW, Greenberg RN. Recurrent Clostridium difficile disease: epidemiology and clinical characteristics. Infect Cont Hosp Epidemiol. 1999; 20(1): 43-50.

[7] Lipp MJ, Nero DC, Callahan MA. The impact of hospital-acquired Clostridium difficile. J Gastroenterol Hepatol. 2012; 27(11): 1733-1737.

[8] Bartlett JG. Clostridium difficile: clinical considerations. Rev Infect Dis. 1990;12 (2):243-251.

[9] Bricker E, Garg R, Nelson R, Loza A, Novak T, Hansen J. Antibiotic treatment for Clostridium difficile-associated diarrhoea in adults. Cochrane Database of Syst Rev. 2007; (3): CD004610.

[10] McKeage K, Blick SK, Croxfall JD, Lyseng-Williamson KA, Keating GM. Esomeprazole: a review of its use in the management of gastric-acid related diseases in adults. Drugs. 2008; 68: 1571-1607.

[11] Saha SK, Saha SK, Masud H, Islam N, Ralhan AS, Roy PK, Hasan M. To compare the efficacy of triple therapy with furazolidone amoxicillin and omeprazole for two weeks and three weeks in the eradication of Helicobacter pylori in Bangladeshi duodenal ulcer patients. Bangladesh Med Res Counc Bull. 2011; 37(3): 83-87.

[12] Gerson LB, Mitra S, Blecker WF, Yeung P. Control of intra-esophageal pH in patients with Barrett’s esophagus on omeprazole sodium bicarbonate therapy. Ailment Pharmacol Ther; 2012; 35(7): 803-809.

[13] Digestive diseases in the United States: Epidemiology and Impact. NIH. 1994; 94-1447.

[14] Stevens V, Dumyati G, Brown J, Wijgaarden E. Differential risk of Clostridium difficile infection with proton pump inhibitor use by level of antibiotic exposure. Pharmacoepidemiol Drug Saf. 2011; 20(10): 1035-1042.

[15] Rotamel A, Poritz LS, Messaris E, Berg A, Stewart DB. PPI Therapy and Albumin are Better Predictors of Recurrent Clostridium difficile Colitis than Choice of Antibiotics. J Gastrointest Surg. 2012; 16(12): 2267-2273.

[16] Leonard AD, Ho KM, Flexman J. Proton pump inhibitors and diarrhoea related to Clostridium difficile infection in hospitalized patients: a case-control study. Intern Med J. 2012; 42(5): 591-594.

[17] Keuhn BM. Reflux drugs linked to C. difficle-related diarrhea. JAMA. 2012; 307(10): 1014.

[18] Kim YG, Graham DY, Jang BI. Proton pump inibitor use and recurrent Clostridium difficile-associated disease: a case-control analysis matched by propensity score. J Clin Gastroenterol. 2012; 46(5): 397-400.

[19] Janarthanan S , Ditah I , Adler DG, Ehrinpreis MN. Clostridium difficile associated

diarrhea and proton pump inhibitor therapy – a meta-analysis. Am J Gastroenterol. 2012; 107:1001-1010.

[20] Kwok CS , Arthur AK , Anibueze CI, Singh S, Cavallazzi R, Loke YK. Risk of Clostridium difficile infection with acid suppression agents and antibiotics: meta-analysis. Am J Gastroenterol. 2012; 107:1011-1019.

[21] Grigorios I, Leontiadis I, Miller M, Howden C. How Much Do PPIs Contribute to C. difficile Infections? The Am J Gastroenterol. 2012;107:1020-1021.

[22] Pillai A, Nelson RL. Probiotics for the treatment of Clostridium difficile-associated colitis in adults. The Cochrane Library. 2008; 3: 1-18.

[23] Hensgens MPM, Goorhuis A, Dekkers OM, Kuijper EJ. Time interval of increased risk for Clostridium difficile infection after exposure to antibiotics. J Antimicrob Chemother. 2011; 1-7

[24] Bartlett JG, Gerding DN. Clinical recognition and diagnosis of Clostridium difficile infection. Clin Infect Disease 2008; 46: s12-s18

[25] Dinleyici EC, Eren M, Ozen M, Yargic ZA, Vandenplas Y. Effectiveness and Safety of Saccharomyces boulardii for Acute Infectious Diarrhea. Expert op on boil therapy. 2012: 12(4); 395-410.

[26] Vitetta L. Probiotics, prebiotics and gastrointestinal health. Medicine Today. 2008;9(9): 65-70.

[27] Avadhani A, Miley H. Probiotics for prevention of antibiotic-associated diarrhea and Clostridium difficile-associated disease in hospitalized adults–a meta-analysis. J Am Acad Nurse Pract. 2011;23(6):269-274.

[28] Surawicz CM, Elmer GW, Speelman P, McFarland L, Chinn J, van Belle G. Prevention of antibiotic-associated diarrhoea by Saccharomyces boulardii: a prospective study. Gastro. 1989; 96: 981-988.

[29] McFarland LV, Surawicz CM, Greenberg RN, Elmer GW, Moyer KA, Melcher SA, et al. Prevention of B-lactam-associated diarrhoea by Saccharomyces boulardii compared with placebo. Am J Gastroenterol 1995; 90: 439-448.

[30] D’Souza AL, Rajkumar C, Cooke J, Bulpitt CJ. Probiotics in prevention of antibiotic associated diarrhea: meta-analysis. BMJ. 2002. 8; 324(7350): 1361

[31] Das RR, Naik SS, Singh M. Probiotics as additives on therapy in allergic airway diseases: a systematic review of benefits and risks. Biomed Res Int. 2013; Vol 2013, Article ID 231979, 10 pages. DOI: 10.1155/2013/231979.

[32] Kunz AN, Noel JM, Fairchok MP. Two cases of Lactobacillus bacteremia during probiotic treatment of short gut syndrome. J Pediatr Gastroenterol Nutr 2004;38:457-458.

[33] De Groote MA, Frank DN, Dowell E, Glode MP, Pace NR. Lactobacillus rhamnosus GG bacteremia associated with probiotic use in a child with short gut syndrome. Pediatr Infect Dis J. 2005;24:278-280.

[34] Hennequin C, Kauffmann-Lacroix C, Jobert A, Vlard JP, Ricour C, Jacquemin JL, et al. Possible role of catheters in Saccharomyces boulardii fungemia. Eur J Clin Microbiol Infect Dis. 2000;19:16-20.

[35] Bassetti S, Frei R, Zimmerli W. Fungemia with Saccharomyces cerevisiae after treatment with Saccharomyces boulardii. Am J Med 1998;105:71-72.

[36] Niault M, Thomas F, Prost J, Ansari FH, Kalfon P. Fungemia due to Saccharomyces species in a patient treated with enteral Saccharomyces boulardii. Clin Infect Dis. 1999; 28: 930.


Feature Articles Articles

Physician Assistants in Australia: the solution to workforce woes?

This article reviews the potential for Physician Assistants (PAs) within Australia. An introduction to the PA role, training, and relevant history is included, as is motivation for considering implementation of the role within Australia. It specifically addresses the prospect of improving rural and Indigenous health services. The possible impact on other roles within Australia, including Nurse Practitioners and medical students, is also considered. Finally, it is concluded that larger trials are required to adequately assess the benefit of the profession to Australia.

Introduction to Physician Assistants

With the recent suspension of the Physician Assistant (PA) training programme at The University of Queensland, and reservations expressed by nursing and medical organisations, there is potential for ambiguity regarding the prospects of the profession in Australia. [1,2] Whilst the concept is relatively new to the country, it is well-established internationally, [3] and in the United States has mitigated certain deficits in health service provision. [4]

A PA is a licensed medical professional who operates within a set scope of practice under the authority of a supervising doctor. [5] Whilst they may complete tasks independently, the supervising doctor has final responsibility for the PA and the clinical care they provide. [4] The role is not designed to serve as an independent practitioner. [4] Thus, a PA’s scope of practice can vary significantly, depending on the health facility at which they are employed, the extent of further training undertaken, and the degree of clinical autonomy the supervising doctor is willing to allow. [4]

The concept of the PA was introduced in the 1960s in response to both a shortage and uneven geographic distribution of doctors within the United States. [4,6] The founder of the PA movement, Eugene Stead, initially intended an advanced nursing programme. However, the National League of Nursing rejected this proposal, prompting the utilisation of trained military medics as the pioneering class. [7] The first cohort of PAs graduated in 1967, [8] and since then a large number of tertiary institutions have commenced training programmes. [4]

Entry into training programmes is competitive, with at least two years of university study usually required as a pre-requisite. [4] Most candidates also have at least four years prior experience in a medically related field, having transitioned from allied health and nursing careers. [1,4]  PAs train for an average of twenty-five months in a course now typically designed as a Masters level programme, representing an abridged version of traditional tertiary medical education. [4] Similar to other medical professionals, PAs are required to undergo continuing professional education and meet recertification requirements. [8] In the United States, the recertification period is currently six years, although this will be transitioning to ten years from 2014. [9]

The role of PAs includes taking patient histories, performing clinical exams, diagnostics, patient education, basic procedural work such as suturing, and providing general assistance to doctors as required. [4] PAs may also complete more advanced tasks under the delegated authority of doctors, including endoscopy, critical care, and specialist outpatient clinics. [10-12] Importantly, evidence shows that in specific clinical situations PAs can provide a level of care comparable to doctors. [4]

The significance of the PA role to the United States health care system is clear, with over seventy thousand practising in 2010. The profession has expanded consistently since 1991, with graduates from over 150 accredited training facilities set to see in excess of ninety thousand PAs in the United States by 2014. Growth in the profession is predicted to continue, with numbers estimated to exceed 125 000 by 2025. [13]

Motivation for considering the role in Australia

The PA role has been discussed as a potential solution to problems facing the medical workforce in Australia and, although small in size, results of trials in Queensland and South Australia have been encouraging. [12,14] The 2008 Parliamentary Library report and 2011 Health Work Force Australia report have also recommended the profession be considered given the challenges facing medical care in Australia. [12,14] An ageing population, increased patient expectations and the burden of chronic disease all place considerable strain on a system already understaffed, whose employees are demanding more work-life balance than before. [15,16] The size of this problem is clear, with estimates that by 2025 over twenty percent of the total workforce in Australia would need to be employed in the health system to maintain services at their current level. [17] The response has been to increase medical graduate numbers and recruit doctors internationally, yet with demand set to exceed supply, PAs represent a possible solution to Australia’s expanding medical workforce requirements. [18] Arguments have also been made that PAs could decrease Australia’s reliance on International Medical Graduates (IMGs), which would be a move toward “self reliance” as recommend by the National Health Workforce Strategic Framework in 2004. [19,20]

Although the workforce shortage is a serious issue, perhaps a greater concern is the financial sustainability of the health care system. In 2009, approximately ten percent of Australia’s Gross Domestic Product (GDP) was spent on health care. [19] This is expected to growth at a rate of 0.5% per year, meaning health expenditure will account for twenty percent of Australia’s GDP by 2020. [19] Therefore, in an effort to achieve sustainability, avenues to mitigate this rising financial burden must be explored.  This provides motivation to consider the PA role within Australia, especially given evidence demonstrating their potential cost-effectiveness. [18,21-23]

The 2011 Health Work Force Australia report indicated a number of possible roles for PAs in Australia, including providing services that have traditionally been the sole domain of doctors. [1] Whilst this may seem like a new paradigm, the concept of dispersing such knowledge and expertise amongst various members of the health workforce is not new to Australia. Such change can already be seen in the medical profession with the development of General Practitioner (GP) proceduralists who, particularly in rural areas, perform tasks previously only completed by specialists. [24] This dynamic practice has been essential to ensuring service viability in rural areas, including maintaining obstetric services. [24] Paramedics have also been shifting towards a more professional role, utilising expanded skills bases, and in some instances having admission rights to hospitals. [25,26] The Nurse Practitioner (NP) role has also expanded within Australia, and NPs now complete extended patient assessments, prescribe certain items independently, and collaborate with doctors where required. [27] Whilst there are some reservations about the expanding scope of practice for non-doctor roles, the success of such redistribution of tasks in Australia provides motivation to review the way in which medical care is provided. [28] However, to ensure quality of care and patient safety, this should continue forward with consultation from appropriate medical governing bodies. [27,29]

The potential role of Physician Assistants in rural Australia

Rural communities in Australia currently experience significant disadvantage in accessing health care, with staffing shortages being exacerbated by an uneven distribution of practitioners that favours metropolitan areas. [2] This issue is set to be compounded by an ageing rural workforce and resultant practitioner retirement. [1] To a large extent IMGs have helped minimise this effect, with over half of doctors working in areas classified as small rural to remote being trained internationally. [2] However, evidence suggests that IMGs bonded to work in rural Australia tend to be dissatisfied both personally and professionally, [30] demonstrating a clear need to find a sustainable rural health workforce.   This provides a perfect niche to utilise PAs, with some research in the United States showing that as a profession PAs may be more willing than doctors to move to areas of need, including rural locations. [18] Such use of PAs to mitigate rural health workforce shortages is supported by both the Australian College of Rural and Remote Medicine and the National Rural Health Alliance. [18]

In an Australian rural pilot trial in Cooktown, PAs significantly reduced the requirement for doctor overtime despite increased caseload. This shows potential to reduce doctor fatigue and consequently the rural attrition rate, which is essential to ensure continued viability of rural health services. [14] The potential benefit of PAs was further seen in a Mt. Isa trial, which coincided with an H1N1 outbreak. During this time period, PAs conducted a fast-tracked clinic to decrease the burden on emergency physicians. [14] The benefit of their input continued over the following months, with Emergency Department presentations, particularly in the lower triage categories, decreasing following initiation of a PA-led primary care clinic. [14]

Furthermore, PAs have the potential to improve Indigenous health services. In the Queensland pilot, PAs at Wujal Wujal, Karumba and Normanton at times worked under remote delegation, improving access of the local Indigenous community to health professionals. [2] If expanded, this could yield an important step forward in health equity by ensuring that medical professionals are on-site to deliver the services these areas require. However, patient feedback regarding this service was difficult to obtain, with very few Aboriginal and Torres Strait Islander (ATSI) patients completing the feedback survey. [2] Scope of practice for PAs at one trial site was also restricted for ATSI children, requiring approval from a supervising physician before initiation of any therapy for patients below a pre-determined age. This was prophylactic rather than in response to any actual breach of care, on the basis that presentations of children in this group often do not reflect the true breadth of underlying illness. [2] It should, however, be remembered that PAs participating in the trial were trained internationally. If PAs were trained locally in programmes designed to meet the health needs of Australian populations, such measures are unlikely to be necessary.

The Queensland PA trials yielded no safety or treatment concerns over twelve months. However, due to their size, limited analysis, and issues regarding scope of practice, the benefit of the role to the local health system was unable to be completely established. Therefore, given the potential utility, further study should be completed to demonstrate if PAs can adequately address the rural and Indigenous workforce shortage. For these trials to adequately assess the role in rural Australia, implementation of a proper support network and a change in legislation, particularly surrounding prescribing rights, would be required. [14,31]

Further potential roles of Physician Assistants in Australia

PAs could also increase the capacity of procedural units by taking responsibility for low-risk routine tasks such as endoscopy, running specialised outpatient clinics, and providing early assessment of new cases in emergency departments, allowing doctors to focus on more complex tasks. [2,10,18] The same is true of general practice, where PAs have been shown capable of managing the majority of minor cases to a similar level of care as GPs. [32] In a recent United Kingdom-based study, PAs were shown to expand the capacity of trial sites to provide primary care to their local population. [32] Specific tasks performed by PAs in this trial included follow up of laboratory results, basic procedural work, completing PAP smears, and patient education. One major difficulty encountered was the inability to prescribe under current legislation, which has also been reflected in Australian trials. [32]

Concerns regarding impact on other roles in the Australian health care system

Concerns have been voiced that PAs may encroach on the role currently held by Nurse Practitioners (NPs) including the Rural and Isolated Practice Registered Nurse role, which was specifically designed to meet rural needs. [2,31] Counter-arguments have been made that the NP role is protocol-driven and based on a nursing model of care, whilst the PA role is based on the medical model with a greater emphasis on diagnostics; therefore, unique roles for both professions could be determined. [2] Despite this, the overlap between the two roles is significant. [5,14,38] As such, further trials of PAs must examine the impact on the NP profession, which is now well-developed within Australia. [2]

In terms of quality of care, numerous studies have shown that in certain areas of clinical practice, NPs, PAs and doctors achieve similar clinical outcomes and a similar degree of patient satisfaction. [4,
34-38] Therefore, given the proven NP role, unless evidence is produced demonstrating enhanced quality of care or ability to undertake tasks not performed by NPs, the cost of implementing this profession in Australia’s health care system cannot be justified. Even if such novel roles or quality addition could be proven, the cost of introducing and sustaining PAs including physician supervision demands careful cost-benefit analysis. [31] This is particularly important in the current era of unsustainable medical expenditure. Furthermore, as Australia continues to face a so-called “tsunami” of medical students, the requirement for further low- to mid-level clinical roles, particularly those not yet well-established, must be seriously reviewed.

The effect on physician and medical student training must also be determined, particularly given the increased numbers of medical graduates. The National Health Workforce Taskforce report illustrated the extent of this problem, estimating that in comparison to 2005, in 2013 over 600 000 more medical placement days per annum will be required to train undergraduates. [2] Therefore, as the role of PAs is examined, it is essential to ensure junior doctor and medical student training is not impaired. There are as-yet unsubstantiated claims that PAs may allow more time for senior clinicians to teach. [2,14] However, more research and consideration into this as it applies to the Australian context is warranted. [2] This is particularly important as, despite large increases in the numbers of medical graduates, a significant proportion of senior consultants are approaching retirement age. [39] This may lead to diminished clinical exposure for medical students, a situation which could be further exacerbated should consultants also be tasked with fulfilling PA teaching and ongoing supervision requirements. This is an issue already considered in the Queensland pilot trials, where PA scope of practice for certain procedural skills was limited to ensure junior doctors gained the necessary experience. [2]


Trials in Australia regarding PAs have been limited and utilised internationally-trained recruits with proven clinical acumen. [2,12,14] Therefore, despite encouraging results, larger trials are required to determine their potential to benefit the Australian health care system. Even if the conclusion was drawn that the implementation of PAs was the best way to meet the requirements of the Australian health care system, there are still multiple barriers that would need to be addressed. These include setting up appropriate prescribing rights under the Pharmaceutical Benefits Scheme, without which their effectiveness would be severely limited. [12] The potential for roles in rural and remote communities and procedural work seems encouraging. [2,17] However, concerns regarding the impact on the proven NP role and medical student training must be addressed in further trials before conclusions can be drawn on the wider impact of implementation in Australia. [2,31]

Conflict of interest

None declared.


Natasha Duncan: for proofreading and providing constructive feedback.


B Powell:


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[24] Robinson M, Slaney GM, Jones GI, Robinson JB. GP proceduralists: ‘the hidden heart’ of rural and regional health in Australia. Rural Remote Health. 2010; 10: 1402.

[25] Blacker N, Pearson L, Walker T. Redesigning paramedic models of care to meet rural and remote community needs. Paper presented at: The 10th National Rural Health Conference; 2009 May 17-20; Cairns, Australia.

[26] O’Meara PF, Tourle V, Stirling C, Walker J, Pedler D. Extending the paramedic role in rural Australia: a story of flexibility and innovation. Rural Remote Health. 2012; 12: 1978.

[27] Carryer J, Gardner G, Dunn S, Gardner A. The core role of the nurse practitioner: practice, professionalism and clinical leadership. J Clin Nurs. 2006; 16: 1818-25.

[28] Lawson K, Gregory A, Van Der Weyden M. The medical colleges in Australia: besieged but bearing up. Med J Aust. 2005; 183(11/12): 646-51.

[29] Kidd MR, Watts IT, Mitchell CD, Hudson LG, Wenck BC, Cole NJ. Principles for supporting task substitution in Australian general practice. Med J Aust. 2006; 185(1): 20-22.

[30] McGrail MR, Humphreys JS, Joyce CM, Scott A. International medical graduates mandated to practice in rural Australia are highly unsatisfied: results from a national survey of doctors. Health Policy. 201; 108(2-3): 133-9.

[31] Bosley S, Dale J. Healthcare assistants in general practice: practical and conceptual issues of skill-mix change. Br J Gen Pract. 2008; 58(547):120-4.

[32] Parle JV, Ross NM, Doe WF. The medical care practitioner: developing a physician assistant equivalent for the United Kingdom. Med J Aust. 2006; 185(1): 13-7.

[33] Tuaoi L, Cashin A, Hutchinson M, Graham I. Nurse Practitioner preparation: is it time to move beyond masters level entry in Australia? Nurse Educ Today. 2011; 31(8): 738-42.

[34] Mundinger MO, Kane RL, Lenz ER, Totten AM, Tsai W, Cleary PD, Friedwald WT, Siu AL, Shelanski ML. Primary outcomes in patients treated by nurse practitioners or physicians. J Am Med Assoc. 2000; 283(1): 59-68.

[35] Lenz ER, Mundinger MO, Kane RL, Hopkins SC, Lin SX. Primary care outcomes in patients treated by nurse practitioners or physicians: two-year follow-up. Med Care Res Rev. 2004; 61(3): 332-51.

[36] Roy CL, Liang CL, Lund M, Boyd C, Katz JT, McKean S, Schnipper JL. Implementation of a physician assistant/hospitalist service in an academic medical center: Impact on efficiency and patient outcomes. J Hosp Med. 2008; 3(5): 361-8.

[37] Lesko M, Young M, Higham R. Managing inflammatory arthritides: Role of the nurse practitioner and physician assistant. J Am Acad Nurse Pract. 2010; 22(7): 382-92.

[38] Hooker RS, Everett CM. The contributions of physician assistants in primary care systems. Health Soc Care Community. 2012; 20(1): 20-31.

[39] Schofield DJ, Fletcher SL, Callander EJ. Ageing medical workforce in Australia – where will the medical educators come from? Hum Resour Health. 2009; 7: 82.


Review Articles Articles

Where to from here for Australian childhood obesity?

Aim: At least one in twenty Australian school children are obese. [1] The causes and consequences of childhood obesity are well documented. This article examines the current literature on obesity management in school-aged, Australian children. Methods: A systematic review was undertaken to examine the efficacy of weight management strategies of obese Australian school-aged children. Search strategies were implemented in Medline and Pubmed databases. The inclusion criteria required original data of Australian origin, school-aged children (4 to 18 years), BMI defined populations and publication within the period of January 2005 to July 2011. Reviews, editorials and publications with inappropriate focus were excluded. Thirteen publications were analysed. Results: Nine of the thirteen papers reviewed focused on general practice (GP) mediated interventions, with the remainder utilising community, school or tertiary hospital management. Limitations identified by GP-led interventions included difficulties recognising obese children, discussing obesity with families, poor financial reward, time constraints, and a lack of proven management strategies. A school-based program was investigated, but was found to be ineffective in reducing obesity. Successful community- based strategies focused on parent-centred dietary modifications or exercise alterations in children. Conclusion: Obesity-specific management programs of children are scarce in Australia. As obesity remains a significant problem in Australia, this topic warrants further focus and investigation.


In many countries the level of childhood obesity is rising. [2] Whilst the popular press have painted Australia as being in a similar situation, research has failed to identify significant increases in the level of childhood obesity since 1997, and in fact, recent data suggests a small decrease. [2,3] Nonetheless, an estimated four to nine percent of school-aged children are obese. [1,4] Consequently, the Australian government have pledged to reduce the prevalence of childhood obesity. [5]

In this review, articles defined Body Mass Index (BMI) by dividing weight (in kilograms) by the square of the height (in metres). [1] BMI was then compared to age- and gender-specific international set points. [6] Obesity was defined as children who had a BMI ≥ 95% of children with the same age and gender. [6] The subjects of this review, Australian school-aged children, were defined as those aged 4 to 18 years in order to include most children from preschool to the completion of secondary school throughout Australia. As evidence suggests that obese individuals have significantly worse outcomes than overweight children, this review focused on obesity rather than overweight and obese individuals. [1]

The aim of this article was to examine the recent Australian literature on childhood obesity management strategies.


Causes of obesity

A myriad of causes of childhood obesity are well established in the literature. Family and culture influence a child’s eating habits, their level of physical activity and ultimately their weight status. [4,7,8] Parental attributes such as maternal obesity and dismissive or disengaged fathers also play a role. [9] Notably, maternal depression or inappropriate parenting styles have little effect on obesity. [10] Children from lower socio-economic status (SES) are at a greater risk of being obese. [9,11-13]

Culture and genetic inheritance also influence a child’s chance of being obese. [8] Evidence suggests that culture influences an individual’s beliefs regarding body size, food and exercise. [7,14] O’Dea (2008) found that Australian children of European and Asian descent had higher rates of obesity when compared with those of Pacific Islander or Middle Eastern heritage. [8] Interestingly, there is conflicting evidence as to whether being an Indigenous Australian is an independent risk factor for childhood obesity. [7,9]

A child’s nutritional knowledge has little impact on their weight. Several authors have shown that while obese and non-obese children have different eating styles, they possess a similar level of knowledge about food. [4,13] Children with a higher BMI had lower quality breakfast and were more likely to omit meals in comparison to normal weight children. [4,7,13]

The environment in which a child lives may impact their weight status; existing literature suggests that the built environment has little influence over dietary intake, physical activity and ultimately weight status. [15,16] However, there is limited research presently available.

Consequences of obesity

Obesity significantly impacts a child’s health, resulting in poorer physical and social outcomes. [4,17] Obese children are at greater risk of becoming obese in adulthood. [4,18] Venn et al. (2008) estimates that obese children are at a four- to nine-fold risk of becoming obese adults. [18] Furthermore, obese children have an increased risk of acquiring type 2 diabetes, sleep apnoea, fatty liver disease, arthritis and cardiovascular disease. [4,19]

An individual’s social health is detrimentally affected by childhood obesity. Obese children have significantly lower self worth, body image and perceived level of social acceptance amongst their peers. [7,20,21] Indeed, overall social functioning is reduced in obese children. [17] Interestingly, some studies identify no differing rates of mental illness or emotional functioning between obese and non-obese children. [12,17,22,23]


Using Medline and Pubmed, searches were undertaken with the following MeSH terms: child, obesity and Australia. Review and editorial publication types were excluded, as only original data was sought for analysis. Further limits to the search included literature available in English, focused on school-aged children from 4 to 18 years, articles which defined obesity in their population using BMI, publications which addressed the research question (management of childhood obesity), and recent literature. Recent literature was defined as articles published from 1 January 2005 until 31 July 2011. This restriction was placed in part due to resource constraints, but January 2005 was specifically chosen, as this marked the introduction of several Australian government strategies to reduce childhood obesity. [5]

In total, 280 publications were identified in the Pubmed and Medline searches. The abstracts of these articles were manually assessed by the investigator for relevance to the research question and described inclusion and exclusion criteria. As a result of inappropriate topic focus, population, publication type, publication date and repetition, 265 articles were excluded. Ten articles were identified as pertinent via Pubmed. Medline searches revealed five articles of relevance, all of which were duplicated in the Pubmed search. Hence, ten publications were examined. Additionally, a search of relevant publications’ reference lists identified three further articles for analysis. Subsequently, this paper reviews thirteen articles.

Publications included in this study were either randomised controlled trials or cross-sectional analyses. The papers collected data from a variety of sources, including children, parents, clinicians and simulated patients. Consequently, population sizes varied greatly throughout the literature.


Much of the Australian literature on childhood weight management does not specifically focus on the obese; instead, it combines the outcomes of obese and overweight children, sometimes including normal weight children.

Thirteen intervention articles were identified in the literature, nine of which employed GP mediated interventions, with the remainder using a community-based approach, school-based or tertiary hospital mediated obesity management.

General practitioner intervention

The National Health and Medical Research Council (NHMRC) guidelines recommend biannual anthropometric screening for children; however, many studies illustrate that few GPs regularly weigh and measure children. [24,25] Whilst Dettori et al. (2009) reported 79% of GPs interviewed measure children’s weight and height, only half of their respondents regularly converted these figures to determine if a child was obese. [26] A possible reason for the low rates of BMI calculation may be that many GPs find it difficult to initiate discussions about weight status in children. [24-27] A number of authors have identified that some GPs fear losing business, alienating or offending their clients. [24,25,27]

There was wide variability in the tools GPs used to screen children, which may ultimately have led to incorrect weight classifications. [24] Spurrier et al. (2006) investigated this further, identifying that GPs may use visual cues to identify normal weight children; however, using visual cues alone GPs are not always able to recognise an obese from an overweight child or an overweight from a normal weight child. [28] Hence, GPs may fail to identify obese children if appropriate anthropometric testing is not performed.

There is mixed evidence regarding the willingness of GPs to manage obese children. Firstly, McMeniman et al. (2007) identified that GPs felt there was a lack of clear management guidelines, with the majority of participants feeling they would not be able to successfully treat an obese child. [27] Some studies identified that GPs see their role as gatekeeper for allied health intervention. [24,25] Another study showed that GPs preferred shared care, providing the primary support for obese children, which involved offering advice on nutrition, weight and exercise, whilst also referring onto other health professionals such as nutritionists, dieticians and physicians. [11]

Other factors impeding GP-managed programs are time and financial constraints. The treatment of childhood obesity in general practice is time consuming. [11,26,27] Similarly, McMeniman et al. [27] highlighted that the majority of responders (75%) felt that there was not adequate financial incentive to identify and manage obese children.

Evidence suggests that providing education to GPs on identifying and managing obesity could be useful in building their confidence. [26] One publication found that over half of GPs receiving education were able to better identify obese children. [26] Similarly, Gerner et al. (2010) illustrated, by using simulated patients, that GPs felt they had improved their competence in the management of obese children. [29] In the Live, Eat and Play (LEAP) trial, patient outcomes at nine months were compared to GP’s self-rated competence, simulated patient ratings and parent ratings on consultations. [29] Interestingly, simulated patient ratings were shown to be a good predictor of real patient outcomes, with higher simulated patient marks correlating to larger drop in a child’s BMI. [29]

Unfortunately, no trials illustrated an effective GP-led child obese management strategy. The LEAP trial, a twelve week GP-mediated intervention focused on nutrition, physical exercise and the reduction of sedentary behaviour, failed to show any significant decrease in BMI of the intervention group compared with the control. [30] Notably, the LEAP trial failed to separate the data of obese and non-obese children. [30]

Further analysis of the LEAP trial illustrated that the program was expensive, with the cost to an intervention family being $4094 greater than of that to a control family. [31] This is a significant burden on families, with an additional fiscal burden of $873 per family to the health sector. [31] Whilst these amounts are likely to be elevated due to the small number of children, program delivery is costly for both families and the health care sector. [31]

Community-based programs

Literature describing community-based obesity reduction was sparse. Two publications were identified, both of which pertained to the HICKUP trial. These articles illustrated that parent-centred dietary program and child-focused exercise approaches can be efficacious in weight reduction in a population of children including the obese. [32,33] In this randomised controlled trial, children were divided into three groups: i) parent-focused dietary program, ii) child-centred exercise, and iii) combination of the aforementioned. [32,33] Dietary programs focused on improving parenting skills to provide behavioural change in children, whilst physical activity program involved improving children’s fundamental skills and competence. [32,33] A significant limitation of the study was that children were identified through responding to advertising in school newsletters and GP practices, lending this investigation to volunteer bias. Additionally, the outcome data in these studies failed to delineate obese children from overweight or normal weight children.

School-based programs

Evidence suggests that an education and exercise-based program can be implemented into a school system. [34] The Peralta et al. (2009) intervention involved a small sample of twelve to thirteen year old boys who were either normal weight, overweight or obese, and were randomised to a control or intervention group. [34] The program’s curriculum focused on education as well as increasing physical activity. Education sessions were based on dietary awareness, goal se

Articles Review Articles

Vitamin D deficiency in the elderly: How can we improve rates of screening and supplementation in General Practice?

Aim: Vitamin D supplementation reduces falls and fractures in the elderly, yet screening and supplementation rates are generally inadequate. We therefore investigated whether rates of screening and supplementation could be improved through a brief, general practitioner (GP)-focussed, educational intervention. Methods: Clinical audits of vitamin D screening and supplementation in elderly patients attending a rural general practice were conducted before and after a GP educational intervention. Results: The simple GP educational intervention resulted in both vitamin D screening (11.1% versus 5% – 2 year period: and 6.11% versus 3.38% – 3 month period) and supplementation rates ≥ 700IU cholecalciferol daily (10% versus 5% – 2 year period; and 4.44% versus 0.97% – 3 month period) approximately doubling in elderly patients. Discussion: This preliminary study suggests that simple, cost-eff ective GP-focussed interventions can significantly improve vitamin D screening and supplementation rates in elderly patients, thereby potentially improving health outcomes in terms of falls and fractures in this ‘at risk’ population.

Feature Articles

A week in the Intensive Care Unit: A life lesson in empathy

Empathy and the medical student – Practice makes perfect?

The observation of another person in a particular emotional state has been shown to activate a similar autonomic and somatic response in the observer without the activation of the entire pain matrix, not requiring conscious processing, but able to be controlled or inhibited nonetheless. [2] This effectively means that when we see someone in physical or emotional distress, we too experience at least some aspect of that suffering without it even needing to be in the forefront of our consciousness. As medical students we are constantly told to “practice” being empathetic to patients and family members. What we are really practicing is consciously processing this suffering we unknowingly share with these people in order to develop rapport with them (if not just to impress medical school examiners).

We are taught an almost automated response to this distress, including a myriad of body language and particular phrases, such as “I imagine this must be very difficult for you,” to indicate to a patient that we are aware of the pain they are in. Surveys amongst critical care nurses have shown that gender, position, level of education and years of nursing experience have no significant relationship with the ability of a person to show empathy. [1] Thus it could be said that empathy is less of a skill which can be practiced until perfect, and more of a mindset that makes us as human as the people we treat…

Feature Articles

Self-taught surgery using simulation technology

During my elective term in early 2010 at the Royal Free Hospital, London, I was presented with a fantastic opportunity: to learn how to perform a laparoscopic gastric bypass procedure. The challenge was for myself, a medical student and complete novice in laparoscopic surgery, to use the hospital’s state-of-the-art screen-based simulation technology to become proficient in a specific operation within six weeks in this rapidly advancing area of surgery.

My training was to be undertaken using the Simbionix LAP Mentor (Simbionix, Cleveland, Ohio, USA): an advanced piece of technology made up of a computer with simulation software and accompanying hardware, consisting of ports and instruments. The difference between this and a video game is the presence of haptic feedback; when you hit something or pull it, you feel the corresponding tension, making it a highly realistic representation of surgery…

Feature Articles

Contemporary rural health workforce policy in Australia: Evidence-based or ease-based?


Australia has a history of a rural health workforce shortage. This shortage was originally perceived to be within the context of an overall oversupply of health practitioners throughout Australia, an assumption that is now believed to be erroneous. Likewise, interest group support for Government policy responses to the maldistribution has waned over time. Regardless, Australia has consistently experienced a shortage of health workers in rural areas.

This article critiques the development of contemporary rural health workforce policy in Australia against theories of policy development, highlighting the introduction of section 19AB (the “ten year moratorium”) in 1996 to the Health Insurance Act 1973 as a turningpoint for the selection of policy instruments.

The Australian Healthcare System

Medicare is Australia’s universal healthcare system. The provision of medical care by medical practitioners in Australia is regulated through Medicare Provider Numbers (MPNs). A doctor must obtain a MPN in order to charge fees for professional services rendered outside of salaried hospital positions. [1]

In 1996, the Australian Federal Government introduced an amendment to the Health Insurance Act 1973 (the Act), restricting access to MPNs by foreign graduates of an accredited medical school (FGAMS; a term which includes international students studying at Australian medical schools) and overseas trained doctors (OTDs). For simplicity, this article will hereafter use the term OTD to refer to both OTDs and FGAMS. Under the amendment, OTDs must wait a minimum period of ten years from the date of their first Australian medical registration before being eligible for a MPN. This requirement, introduced under section 19AB of the Act, has subsequently been referred to as the “ten year moratorium.”

By 1999, Government policy began to utilise section 19AB exemptions as a means to address rural health workforce shortage. OTDs willing to work in Districts of Workforce Shortage (DWS) were given access to MPNs. [2] These DWS are determined by the Federal Government’s Department of Health and Ageing (DoHA), and consistently have primarily been rural and remote areas.

Policy introduction: The Ten Year Moratorium

Issue identification

The introduction of section 19AB was undertaken within the context of a perceived oversupply of urban doctors and ballooning costs to the Government through Medicare’s fee-for-service system. [4-6] These costs were a result of the introduction of Medicare in 1984, which caused private health insurance rates to plummet, shifting responsibility for healthcare costs from individuals to the…

Book Reviews

Apley’s Concise System of Orthopaedics and Fractures

Solomon L, Warwick D, Nayagam S. Apley’s Concise System of Orthopaedics and Fractures. 3rd ed. London (UK): Hodder Arnold; 2005.

RRP AU$52.65

The 2006-2007 Australian Hospital Statistics demonstrated that fractures alone accounted for 173,410 separations from Australian Hospitals. [1] As such, all interns will see a potential orthopaedic patient at least once in their Emergency rotation and will require a sound knowledge of orthopaedics. Like all medical fields, knowledge is gathered from clinical rotations, doctors and peers. However, this learning will need to be supplemented with textbook study. One of the most popular medical student level textbooks for orthopaedics is Apley’s Concise System of Orthopaedics and Fractures. Currently in its third edition, Apley’s provides 390 pages of musculoskeletal medicine ranging from the classification and management of basic fractures to more obscure genetic conditions such as brittle bone disease.

Apley’s is separated into three general categories: General orthopaedics, Regional orthopaedics and Fractures and joint injuries. Each Orthopaedic condition is explained in the time-honoured method of history, examination findings, imaging and investigation findings, and management. This provides medical students with a well-structured and concise guide to the signs and symptoms of each specific condition. Furthermore, for some of the more common musculoskeletal conditions, such as osteoarthritis, considerable time has been donated to the pathophysiology and both the operative and non-operative treatment options.

One of the criticisms of this text is that there is information on some of the more obscure genetic orthopaedic conditions, unlikely to be useful in the acute setting. The section on fractures is detailed and provides information on the different types of fractures possible for every bone. For the average medical student on a standard orthopaedic rotation, it is unlikely that they will remember all of the specifics of each fracture type and eponyms, let alone their management. Further, Apley’s provides minimal therapeutic drug classification and doses for the management of some of the medically treated orthopaedic conditions.

A sufficient grounding in orthopaedics is essential for any intern. A significant proportion of this textbook is dedicated to fracture diagnosis and management, invaluable for the Emergency Department setting where acute traumatic injuries are more commonly treated, rather than progressive chronic conditions. Apley’s Concise System of Orthopaedics and Fractures provides an easy-to-read textbook for students wishing to learn the basics of the diagnosis and management of common orthopaedic conditions.

Conflicts of Interest

None declared.


[1] Australian Institute of Health and Welfare. Australian Hospital Statistics 2006-2007 [Internet]. Canberra: Australian Government; 2008 [updated 2008 May; cited 2010 July 10]. Available from:URL:

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

Case Reports

Use of retrograde intra-operative cholangiogram for detection and minimisation of common bile duct injury

Intraoperative cholangiogram during a laproscopic cholecystectomy


Iatrogenic bile duct injury (BDI) is a known complication of laparoscopic cholecystectomy with serious consequences for the health of the patient. Intra-operative cholangiogram (IOC) has been shown to reduce the incidence of a major BDI, and is currently used routinely by the majority of surgeons in Queensland. This case report details the use of a ‘retrograde IOC’ for the detection of a BDI after inadvertent cannulation of the common bile duct (CBD). Application of this method has the potential to improve patient outcomes in two ways. Firstly, by limiting the degree of damage to the CBD, it may facilitate a simpler and more successful repair. Secondly, it provides a method of laparoscopic confirmation of BDI and, where laparoscopic hepaticojejunostomy is available, can entirely prevent the need for an open procedure.