Volume 176 Issue 12

Ethics and putting the patient first are the primary considerations in deciding what is acceptable advertising of medical services by doctors Type "cosmetic surgery" into your Internet search engine and several hundred thousand sites will appear. All enthuse about the benefits and increasing popularity of their techniques. They identify and detail medical practitioners qualified to work their miracles on the human body. Few negatives are to be found in such promotional material, and much of the hype is not dissimilar to that used to market other lifestyle products. This is but part of the global rise of the entrepreneurial approach to healthcare. Cosmetic surgery is in demand because of the changing culture and attitude of patients. For some in today's world there is a need to satisfy a desire for what, in times gone by, would be unrealistic expectations — changes to their bodies to enhance their appearance — at least in their own eyes. If we take the definition used by the New South Wales Committee of Inquiry into Cosmetic Surgery, "cosmetic surgery" is any cosmetic procedure "performed to reshape normal structures of the body or to adorn part of the body, with the aim of improving the consumer's appearance and self-esteem". It "is initiated by the consumer, not medical need", and "excludes reconstructive surgery".1 This lies outside the traditional boundaries of medicine, which saw the profession dedicated to saving lives, healing and promoting health.2 Cosmetic surgery is not rebatable under Medicare, nor covered by health insurance. There are relatively few referrals. However, it does provide a service for which consumers are prepared to pay. Traditionally, the medical profession has prohibited advertising in its codes of ethics. The traditional view is that doctors should develop a reputation for excellence based on a reputation among their peers, rather than by the advertising of their services directly to the public. This minimises the opportunity for patients to be misled by claims of superiority of a technique or individual. Particularly in Australia and the United Kingdom, general practitioners have long been "gatekeepers" to specialist services. This role has helped maintain quality care for patients and has probably helped to contain overall costs in the healthcare system. But with the demise of paternalism, both in society and in the professions, this way of doing things has attracted increasing criticism. Undoubtedly, this forms part of the rationale for applying trade practice law to the health sector and to advertising by doctors, and to the interpretation of such law by the Australian Competition and Consumer Commission. Under federal law in Australia the Trade Practices Act 1974 (Cwlth) now permits advertising, unless it is likely to mislead or deceive. Direct advertising by doctors to the public is now lawful. The article by Ring in this issue of the Journal (page 597)3 asks if ethical standards are a casualty in the promotion of cosmetic surgery, and shows that this specialty is being seen as part of the beauty industry rather than a procedure for meeting health needs. The promotional strategies used do not sit well within the medical environment. The beauty industry promotes a body image that draws on vanity rather than on health. It creates expectations linked to perpetual youth, which can feed insecurities in people of both sexes, and contributes to a youth culture which treats with contempt the results of the ageing process.2 On the other hand, people who wish to change their image are now being informed that there are treatments available. The World Medical Association Declaration on the Rights of the Patient says that, "The patient has the right to self-determination, to make free decisions regarding himself/herself. The physician will inform the patient of the consequences of his/her decision".4 Should not patient autonomy include the freedom of adults to purchase these treatments, as long as the advertising surrounding them remains within the ethical boundaries of truthfulness? Where should the boundaries lie between medicine as traditionally defined, and lifestyle-modification medicine? The Australian Medical Association (AMA) Code of Ethics encourages doctors to promote the health and well-being of their patients and prohibits doctors from behaving in their own self-interest. It also says that doctors have "a responsibility to their patients to recommend only those diagnostic procedures necessary to assist in the care of patients and only that therapy necessary for their well being".5 Many patients would say that changing their image through cosmetic surgery is for their well-being, as it would improve their quality of life. It is a personal decision based on personal perceptions. If we consider that cosmetic surgery is part of medicine, then the advertising and promotion of such procedures must adhere to the ethical guidelines of the medical profession. The AMA believes that, as a general principle, advertisements must be honest, must not exploit patients' vulnerability or lack of medical knowledge, and should provide only factual information. Any advertisement for a doctor's services should present information that is reasonably necessary for making an informed decision about the appropriateness and availability of the medical services offered.6 In recognition of the need for a middle ground between the traditional ban on advertising and the current deregulated environment, the Medical Practitioners Board of Victoria has produced draft guidelines which will provide clear guidance for doctors who wish to advertise their services. A summary of the guidelines is presented in the Box.7 Summary of the Medical Practitioners Board of Victoria's draft guidelines for medical advertising7* Ban the use of "before and after" photography, which is common in advertisements for cosmetic surgery. Limit advertising to a factual statement of services offered. Warn against the creation of "unwarranted or unrealistic" patient expectations of treatment. Continue the ban on the use of patient testimonials. Prohibit advertising which encourages inappropriate use of medical services and contains information or language which could cause fear or distress or make people believe their health may suffer from not using a medical service. * Reproduced with permission. Whether we agree with changes in contemporary views which have allowed doctors to enter the free market of advertised services, or prefer the traditional culture, the one interwoven thread which must run unbroken through the fabric of medical practice is that of standards of ethical practice and the primacy of the patient.

Trevor J Mudge MB BS, FRACOG · Dorothy A Dashwood BEd, GradDipAdmin

Exposure of the thyroid gland to any irradiation requires lifelong follow-up supervision One of the questions most frequently asked by patients about to receive radioactive iodine as therapy for non-malignant conditions is whether it will result in bodily cancer. This question has been satisfactorily answered in the negative,1,2 so strong reassurance can be given. No such reassurance can be given for the malignant effects of therapeutic external beam irradiation on the thyroid gland. In childhood, the sensitive thyroid gland can be exposed to therapeutic irradiation directly, as in the treatment of localised neck tumours such as lymphoma or sarcoma and in total-body irradiation before bone marrow transplantation. Where the thyroid gland is not directly the target of therapy, it can be affected by scatter irradiation, as occurs during prophylactic cranial irradiation of the central nervous system in haematological malignancies. Thus far, no measures have been found to protect the thyroid gland from external irradiation in these settings. In this issue of the Journal (page 584), Somerville and her colleagues report the first Australian experience in a study encompassing a large number of children recruited to the Late Effects Oncology Clinic of the Children's Hospital at Westmead.3 The period of study covers 10 years. The sample population was divided into a group who received direct irradiation and another, designated as "scatter", in which there was exposure to the upper half of the body as external beam irradiation but no direct irradiation of the thyroid gland. The study was designed to emulate the approach that would commonly be used by a clinician seeking evidence of change in the thyroid gland. Palpation was used to delineate size and other characteristics. The customary thyroid function tests were carried out. These findings were supplemented by high-resolution ultrasound examination of the neck, and, if the findings warranted, fine-needle aspiration biopsy was undertaken. Suspicious findings from any of these evaluations led usually to surgery, but an abnormal ultrasound result was the chief indication for surgery. Some surprising and important revelations have come to light: Palpation of the thyroid gland was unreliable and misleading in a significant proportion of patients, with a preponderance of non-discovery. Ultrasound examination was almost always abnormal when the thyroid gland was palpable, and abnormal in more than 50% of patients in which the gland could not be felt. Thyroid function tests gave little warning of malignancy, and the elevation of thyroid-stimulating hormone in inadequately supplemented patients, although noted, gave no pointer to the status of the thyroid gland as a whole or the underlying presence of malignancy. Fine-needle aspiration biopsy was carried out in a few patients, but did not materially influence their management. The authors advocate total thyroidectomy for multiple nodules on ultrasound examination or where new nodules appear after partial thyroidectomy. Twenty-five patients from the direct-irradiation group had abnormal ultrasound results and underwent surgery, whether or not the thyroid gland was palpable; six of them harboured malignancy. On the other hand, in the scatter group, of 24 patients with similarly abnormal ultrasound results 12 were affected. Not only were localised recurrences frequent, but additional cancers in other areas of the body were noted by the authors, so vigilance in this respect is required. When surgery was carried out, the histological appearance of glands exposed to both types of irradiation indicated widespread damage and evidence of increased endothelial activity ranging from scarring through to nuclear atypia. There are important lessons to be learned. Exposure of the thyroid gland to any irradiation requires lifelong supervision and introspection. This should include high-resolution ultrasound. The extent of thyroid exposure to radiation may be arcane and not recalled when the highlight of the history is focused on areas away from the gland. Most radiation oncology units in Australia have follow-up facilities, but the duration of follow-up is not uniform. Moreover, patients travel and disperse, so their supervision will be most likely carried out by doctors with less experience of such patients. In this regard the American Thyroid Association publishes an excellent information sheet for patients.4 The article concludes with a series of pertinent recommendations which emanate from the study. Although false positive results can occur, the risks demonstrated in this study indicate that the management regimen recommended by Somerville et al far outweighs a sanguine approach to the problem. Implicit in this is the importance of providing patients with information about the potential risks and the need for regular assessment. Somerville et al observe that the Australian experience has disclosed a greater incidence of thyroid abnormality than seen in some other countries. This may derive from differing methods in the extent and depth of the studies, together with the sophistication of the ultrasound. The magnitude of the dose in the reported series did not seem to influence the emergence of malignancy. Only time from the administration of the radiation therapy was important. It will be interesting to learn of the further evolving experience. In this regard, results of fluorodeoxyglucose positron emission tomography, in association with rising thyroglobulin levels, seem to give a clearer delineation of recurrent malignancy than can be obtained by other methods.5 There may come a time when it will be possible to protect patients from scatter irradiation involving the head, neck or upper-body region in the treatment of more generalised cancer such as leukaemia. However, such protection does not appear to be imminent and, even if attained, there will still be a group of potential thyroid cancer subjects as a legacy of the current therapeutic era.

Alex K Cohen AO, MD, FRACP · Agatha A van der Schaaf FRACP

Appropriate use of ambulatory blood pressure monitoring can be cost effective The rationale for the use of ambulatory blood pressure monitoring (ABPM) has been the subject of critical reviews and published guidelines.1-6 Perhaps the most important and challenging finding to emerge from ambulatory blood pressure research has been the detection of "white coat" hypertension (also known as isolated clinic hypertension) in about 20% of subjects with repeatedly elevated casual blood pressure readings taken in the doctor's clinic.7,8 The condition can only be detected by ABPM or self-monitoring, and there are no specific predisposing factors. For people with white coat hypertension and no evidence of cardiovascular disease or comorbidities such as diabetes or renal disease, most experts agree that the best policy is to monitor their clinic blood pressure regularly, with self-monitoring at home, and repeat ABPM at one- to two-yearly intervals. The importance of continued monitoring is borne out by the evidence now emerging that white coat hypertension may not be an entirely innocent phenomenon.5,6 The initial studies that examined the cost savings in the detection of white coat hypertension by ABPM7,8 did not consider the need for long-term surveillance and the conversion of patients with white coat hypertension to established hypertension; this might be as high as 75% over six years of follow-up.9 The development of hypertension on ABPM criteria could not be predicted by changes in clinic blood pressures. The cost-analysis study of ABPM in Australian general practice reported by Ewald and Perkarsky in this issue of the Journal (page 580)10 is important for a number of reasons. The study confirms the high prevalence of white coat hypertension previously reported in the Australian community,11 and reflects current general practice, because GPs decided on the basis of conventional clinic readings that drug treatment was indicated before ordering ABPM. This cost analysis is the first such study based on Australian data, including best estimates of current pharmacological management of hypertension in Australia. It has also factored in a 10% per year conversion rate from white coat hypertension to established hypertension. The sensitivity analysis showed that all monitoring strategies (ABPM at 1-, 2-, or 3-year intervals) were less expensive than no monitoring over a projected seven-year period. The study almost certainly underestimated the average costs of investigations of hypertension, including standard investigations, documentation of target-organ effects and specific investigations in selected subjects to exclude secondary hypertension. The potential costs of adverse drug reactions were not considered. However, both of these would amplify the difference towards greater cost saving with the use of ABPM. Another important attributable cost is that of the perception of unwellness that accompanies inappropriate labelling as "hypertensive", which can lead to loss of productivity, sick leave, anxiety and the development of symptoms. There are other groups of patients in whom ABPM might have cost-saving benefits. Staessen et al12 reported on a study in 419 patients randomised to be treated according to their daytime ambulatory blood pressure or their clinic blood pressure, with the latter group receiving usual care. The mean follow-up was six months, and the two groups had similar mean left ventricular mass at the end of the study. The ambulatory blood pressure group had a 19% decrease in antihypertensive drug use and an 11% fall in doctors' fees. Some treated hypertensive patients exhibit a marked difference between ambulatory blood pressure and clinic blood pressure, and assessment of the effectiveness of antihypertensive therapy using clinic blood pressure readings tends to overestimate responses to drug therapy by including the "placebo" component of the reduction in blood pressure, which is minimal with ABPM. The results of the Syst-Eur study of systolic hypertension show that conventional clinic blood pressure measurements lead to an overestimate of the prevalence of isolated systolic hypertension among elderly patients.13 This suggests the potential for excessive treatment and associated complications in a significant proportion of elderly patients. This white coat effect is reproducible.14 The recognition of white coat hypertension in pregnancy, which may occur in as much as 30% of pregnancies,15 has the potential to reduce anxiety, hospital admissions and drug use, with significant cost savings. Some notes of caution are warranted. A major one is that we still await the results of definitive outcome studies in controlled trials comparing management of hypertension based on clinic blood pressure versus ambulatory blood pressure. The technique of ABPM is specialised, and service providers must use validated monitors and quality control measures. Current provision of ABPM is not regulated in Australia and is not recognised through the Medical Benefits Scheme. Another cautionary note is that all available evidence suggests that hypertension in our community is more undertreated than overtreated. The use of self-monitoring is also increasing, although there are more concerns with self-recording devices. In a recent analysis,16 only five of 23 devices met acceptable criteria. A combination of the two has a lot to offer: ABPM may be better for the initial diagnosis of hypertension and for predicting prognosis, while self-monitoring may be of more value for the long-term follow-up of patients. ABPM is an important diagnostic tool in the management of hypertension. The study by Ewald and Perkarsky indicates that appropriate use can be of cost benefit to the Australian community.

Barry P McGrath MB BS MD FRACP

Rapid treatment of people believed to be infected, and chemoprophylaxis of all close contacts, are the essentials of both immediate and broader public health management of this disease Although not common, invasive infection with Neisseria meningitidis can be devastating to affected patients and families, and, despite modern treatment, has a case-fatality risk of about 9%.1 In a small proportion of affected patients the disease runs a fulminant course, with death supervening in less than 12 hours. As a result, the disease is a cause of public alarm and receives intense media coverage. In its initial stages the disease may not be recognised, yet an adequate response requires decisive and rapid action from both clinicians and communicable disease control services. To help practitioners meet these demands, in 1996 the National Health and Medical Research Council published guidelines for controlling meningococcal disease.2 These guidelines have recently been superseded by guidelines produced by the Communicable Diseases Network.3,4 While vaccines are available against some serogroups of meningococci (polysaccharide vaccines effective against serogroups A, C, W-135 and Y, and conjugate vaccine against serogroup C), they are not currently recommended for routine use in Australia. As a consequence, and as there is no vaccine against serogroup B, the mainstay of the public health control of invasive meningococcal disease rests on timely and effective treatment of cases and public health interventions to prevent secondary cases (those which follow and are associated with primary cases). Meningococci may be associated with a wide range of clinical syndromes, from asymptomatic nasopharyngeal carriage, through pneumonia, septic arthritis and conjunctivitis to meningitis and septicaemia. Meningococcal septicaemia, with or without meningitis, can be particularly life-threatening and has considerably higher mortality than meningococcal meningitis. Invasive meningococcal disease and meningococcal conjunctivitis may be followed by secondary cases, and both require public health interventions.5 The most characteristic feature of meningococcal septicaemia is a haemorrhagic (ie, petechial or purpuric) rash that does not blanch under pressure. Deaths from meningococcal septicaemia may be prevented by early antibiotic treatment. Patients with suspected meningococcal septicaemia who are given parenteral benzylpenicillin by general practitioners are 2.5 times less likely to die than those not given penicillin.6 The greatest benefit of parenteral penicillin is seen in those who are most ill — those with a haemorrhagic rash. For optimal benefit, benzylpenicillin should be given intravenously. However, if this is not possible, it is quite appropriate to administer benzylpenicillin intramuscularly. All general practitioners should have benzylpenicillin in their surgeries and emergency bags, and should be ready to administer it immediately to a patient with an acute systemic febrile illness and either a petechial or purpuric rash. Box 1 shows dosage guidelines based on United Kingdom recommendations,7 presented in this form here for simplicity in emergency situations. There are other, equally valid guidelines available.8 The use of empirical benzylpenicillin does not necessarily obscure a microbiological diagnosis. While giving penicillin before blood and cerebrospinal fluid specimens are taken does reduce the proportion of positive cultures, it is still possible to isolate meningococci from nasopharyngeal swabs or detect meningococcal DNA by polymerase chain reaction.9 Characterisation of meningococci from these sources may be useful in the public health management of affected patients. Patients presenting to a hospital emergency department with suspected invasive meningococcal disease need to be seen urgently. If a presumptive diagnosis of invasive meningococcal disease is made, they should receive their first dose of antibiotics as soon as possible and no later than 30 minutes after arrival. In some patients other bacterial meningitides may not have been excluded, and empirical therapy with cefotaxime or ceftriaxone plus penicillin or amoxycillin should be used.6 These drugs are intended to cover listeriosis, and pneumococcal and meningococcal meningitis. Antibiotic regimens should then be modified as diagnostic and sensitivity information becomes available. If a general practitioner encounters a patient with a non-specific febrile illness which is not sufficiently distinctive or severe to require referral to hospital, the patient should be kept under frequent review. If a rash develops, or the patient's condition deteriorates in any way, the patient should contact his or her general practitioner urgently or go immediately to a hospital emergency department. Once a presumptive diagnosis is made, the relevant public health unit should be notified immediately so that contacts can be identified and the public health response determined. A public health response is required after diagnosis of either a probable or confirmed case of invasive meningococcal disease, or of conjunctivitis caused by infection with groupable meningococci. Meningococci coincidentally isolated from oropharyngeal, genital or anal swabs are of no public health consequence, and do not require a public health response. Nasopharyngeal carriage of meningococci is common — about 10% of the population carry meningococci at any given time,10 not all of which are virulent strains. In North American and European populations the average duration of meningococcal carriage is about nine months; it is an immunising process, with protective antibodies developing soon after acquisition. Factors associated with an increased risk of carriage include smoking and living in crowded circumstances. Contrary to popular belief, a patient with meningococcal disease is not an efficient transmitter of the meningococcus that is causing the illness. Rather, it is the carrier who transmitted the organism to the patient in the first instance who is much more likely to transmit the meningococcus again, causing further cases.11 The public health response targets people who have been in contact with a patient with meningococcal disease in the seven days before onset of disease. The response comprises providing information to contacts (taking into consideration their cultural and literacy needs), and chemoprophylaxis for each person in the network of close contacts. The rationale for chemoprophylaxis is to eliminate meningococci from any carrier within the network of contacts close to the index case and thereby reduce the risk to other susceptible individuals. This rationale must be explained, and the possible adverse reactions and interactions with other medications need to be discussed. Ideally, chemoprophylaxis should be given as soon as possible (within 24 hours) after the diagnosis of the index case. 1: Doses of parenteral benzylpenicillin for treating suspected cases of meningococcal disease Age group Dose of parenteral penicillin Children aged < 1 year 300 mg Children aged 1–9 years 600 mg Adults or children aged 10 years or over 1200 mg 2: Public health responses in defined settings in which a case of invasive meningococcal disease has occurred Setting Information* and chemoprophylaxis Information* only Household† of an affected person All Not applicable Child-care facilities Children and staff in the same room for 4 or more hours at one time in the 7 days before the onset of illness All other children and staff at the facility Education facilities Very close contacts (essentially those who have been "household-like" contacts) All other students in the same classroom (schools) or tutorial groups (universities) Those who have shared saliva with an affected person (eg, mouth kissing, sharing drink bottles and "bongs") All Even though they may not have shared saliva with a case, other members of any sporting team with an affected member should be given information Those exposed to an affected person after the onset of symptoms Very close household-like contacts; health carers who have either intubated the patient without a face mask or performed mouth-to-mouth resuscitation All others concerned that they may have had contact with the affected person after the onset of symptoms * The disease, including the common signs and symptoms, must be described and the mode of transmission explained. Appropriate action if symptoms suggesting meningococcal infection occur should be described. † "Households" include people in the same dormitory, military barracks or hostel bunkroom in the seven days before the onset of symptoms. This also includes those in seats adjacent to the affected person during long distance travel (8 hours or more). Sexual contacts should be managed as household contacts.

Robert G Hall

Objective: To explore, among middle-aged women, the relationship between having ever had cosmetic surgery and the frequency of use of other health services.Design: Retrospective analysis of cross-sectional survey data from the Women's Health Australia (WHA) study.Setting and participants: A nationally representative sample of the "mid-aged" (45–50 years) cohort of women who participated in the 1996 WHA baseline postal survey. Responses were received from 14 100 women (a response rate of 54%).Results: Seven per cent of women reported ever having had cosmetic surgery. After adjusting for demographic variables, multivariate analysis confirmed that women who had had cosmetic surgery were significantly more likely to use health services more frequently (eg, surgical procedures, consultations with specialists and alternative healthcare providers). Cosmetic surgery was also associated with a greater number of chronic illnesses and use of medication for anxiety and sleep problems.Conclusion: Further research is needed to determine whether cosmetic surgery is directly related to health conditions or to attitudinal or psychosocial variables. Such research should examine whether alternative interventions may be more cost-effective in dealing with the issues that motivate women to seek cosmetic surgery.

Rafat Hussain MB BS, PhD · Margot Schofield MClinPsych, PhD · Deborah Loxton BPsych(Hons)

Objective: To compare the cost of ambulatory blood pressure monitoring (ABPM) with the putative savings made through treatment avoided by identification and non-treatment of those with "white coat" hypertension.Design: A cost analysis based on a model of four alternative strategies (no ABPM, yearly, two-yearly, or three-yearly monitoring) over a seven-year period applied to a case series from Australian general practice.Participants: 62 patients newly diagnosed by their GPs as having hypertension and requiring drug treatment.Main outcome measures: The proportion of patients shown to not need treatment. The discounted costs to the Pharmaceutical Benefits Scheme, Medical Benefits Scheme and patients.Results: 16 of 62 patients (26%; 95% CI, 15%–37%) were normotensive on ABPM and did not require treatment. All monitoring strategies are more expensive in the first year, but the initial costs are offset by year 3 and the monitoring strategies are cost saving thereafter. Sensitivity analysis shows that this result holds across a range of costs of pharmacotherapy and proportion of patients with white coat hypertension.Conclusion: The additional costs of 24-hour ABPM in the first year are offset by savings associated with patients with white coat hypertension who would otherwise have been treated.

Ben Ewald BMed, MMedSci(Epid) · Brita Pekarsky BEc(Hons), DipHEc

Objectives: To describe a cohort of survivors of childhood malignancy at risk of developing thyroid abnormality, and propose guidelines for management of such patients.Design: Retrospective case series.Setting: Late-effects oncology clinic at a large children's hospital in Sydney.Subjects: 142 patients who had received irradiation to the thyroid from the 1970s onwards, who attended the late-effects clinic from May 1989 to December 1998.Interventions: Thyroid palpation by an endocrinologist or surgeon, serum thyroid-stimulating hormone assay and thyroid ultrasound examination were performed on all subjects and, depending on findings, some subjects proceeded to fine-needle biopsy or surgery (total thyroidectomy). A few patients required adjuvant 131I administration.Outcome measures: Radiation dose received; results of thyroid palpation; thyroid function tests; ultrasound findings; diagnosis of the abnormalities; and outcomes of surgical interventions.Results: 49 subjects (24 of 65 patients who received scatter irradiation to the thyroid and 25 of 78 patients who received direct irradiation) had thyroid surgery. Of these, 12 in the scatter and six in the direct irradiation group were found to have thyroid malignancy. Fifty subjects with abnormal ultrasound results remain under surveillance. Having a palpable thyroid was predictive of malignancy, but age at original diagnosis, sex, current age, time since irradiation, radiation dose, nodule type and nodal involvement were not.Conclusion: There is a significant risk of cancer in thyroid glands exposed to radiation as part of therapy for childhood cancer. This risk is greater for patients who received scatter (versus direct) irradiation. Nodular change is usually not apparent for many years, so lifelong surveillance is necessary. Palpation alone is not sufficient to detect thyroid cancer and thyroid ultrasound examination is recommended.

Helen M Somerville MB BS, MPaed · Albert H Lam MD, FRACR · Michael M Stevens MB BS, FRACP · Kate S Steinbeck PhD, FRACP · Graham Stevens MD, FRANZCR · Leigh W Delbridge MB BS, FRACS

End-organ damage associated with hypertension is more closely related to ambulatory blood pressure (ABP) than clinic or casual blood pressure measurements. ABP measurements give better prediction of clinical outcome than clinic or casual blood pressure measurements. The technique of ABP monitoring (ABPM) is specialised; validated monitors and appropriate quality control measures should be used. Interpretation of ABP profile should include mean daytime, night-time (sleep) and 24-hour measurements, and consideration of diary information and time of drug treatment. Reports may also include ABP "loads" (percentage area under the blood pressure curve above set limits) for daytime and night-time periods. Normal blood pressure values for adults are < 135/85 mmHg for daytime, < 120/75 mmHg for night-time, and < 130/80 mmHg for 24 hours. ABPM is indicated to exclude "white coat" hypertension and has a role in assessing apparent drug-resistant hypertension, symptomatic hypotension or hypertension, in the elderly, in hypertension in pregnancy, and to assess adequacy of control in patients at high risk of cardiovascular disease. White coat hypertension requires continued surveillance; patients who display this phenomenon may, in time, develop established hypertension. Appropriate use of ABPM may result in cost savings. Randomised controlled trials comparing management based on clinic or casual versus ABP measurements are needed.

and on behalf of the National Blood Pressure Advisory Committee of the National Heart Foundation of Australia

Within the past five years, medical practitioners have seen major changes to the ways in which they are entitled to promote their services in Australia. The current approach was formalised as a result of the State-by-State deregulation of advertising by doctors through concerted action by the Australian Competition and Consumer Commission (ACCC), which did so in order to enable equal opportunity to all businesses in compliance with the National Competition Policy.1,2 Box 1 outlines the current conditions for medical advertising. In 1998, the then Head of the NSW Health Care Complaints Commission (HCCC) sounded a cautionary note about the risks to the medical profession from a shift to "competitive principles", and the potential effects of this in compromising the traditional medical ethics that have guided the behaviour of members of the profession "since Hippocrates".1 Concerns about implications for the profession have also been expressed by the Australian Medical Association (AMA), with one of the key points in its current position statement on advertising and endorsement being that: "The promotion of a doctor's medical services as if the provision of such services were no more than a commercial product or activity is likely to undermine public confidence in the medical profession."4 Evidence that some practitioners of cosmetic surgery were in the vanguard of the profession in promoting their services in this way was presented to the New South Wales Inquiry into Cosmetic Surgery conducted in 1999 by the NSW HCCC. The Committee of that Inquiry concluded that a number of the promotional practices "may be in breach of professional standards and fair trading laws".5 Two years on, the ways in which a subset of plastic and other cosmetic surgeons continue to promote their practice2,6 require the medical profession to consider, fair trading laws aside, some important questions about the implications of such commercial strategies for both the cosmetic surgery sector, and for the profession as a whole. It should be noted that the term "cosmetic surgery", as used in this article, is in accordance with its definition by the NSW Committee of Inquiry into Cosmetic Surgery. Key points of that definition are listed in Box 2. Are ethical standards a casualty in the promotion of cosmetic surgery?Doctors strive to prolong life, and have earned some of the credit for the fact that we are living in a society that is ageing healthily as our life expectancy continues to grow. It is therefore somewhat anomalous that the public face of cosmetic surgery includes promotions which play on the insecurities associated with the superficial consequences of ageing. Specifically, there is considerable evidence that the highly profitable tactic of targeting the appearance of ageing as an undesirable quality is being exploited by some medical practitioners, using methods similar to the beauty industry's approach of stigmatising this normal bodily process. The allegation that doctors have made a substantial contribution to the reconstruction of ageing for profit is, of course, not new.7,8 By 1990, in America, Naomi Wolf (in her book The beauty myth7) had described a key marketing strategy for cosmetic surgery — namely, classifying ageing as ugly, and ugliness as a disease for which cosmetic surgery practitioners had the most effective treatment.7 She also questioned whether such exploitation of women's insecurities about their appearance was "subject to the ethics of the genuine medical profession".7 These are now matters that also need to be examined in the Australian context. This can be done on the basis of examples of anti-ageing strategies drawn from Australian media and attributed to Australian medical practitioners. The following examples fall into two categories: textual references, and the use of enhanced and idealised images that could be construed as misleading. The majority of the examples come from recent issues of Australian Cosmetic Surgery Magazine.9 This is a quarterly publication distributed through newsagents since 1998 (by which time, it should be noted, advertising by doctors had been deregulated in the three most populous States in response to the requirements of the ACCC10). Key aspects of this magazine are that: Many of the articles are identified as being authored by, or substantively based on interviews with, named medical practitioner contributors. Many of the contributors also have an advertisement within the magazine, either on the same page as one of those articles, or in another part of the magazine. The contributors are introduced in an illustrated list at the front of the magazine.9 It is relevant to note that, while there are substantial and often publicly aired areas of professional conflict between different categories of surgeons who practise cosmetic surgery,5,11 they use similar promotional strategies within the covers of Australian Cosmetic Surgery Magazine.9 Text messagesTypically, negative comments about the appearance of ageing have focused on aspects of the face and skin (usually, but not always, in reference to women). Box 3 shows examples of the ways in which some doctors have characterised normal bodily changes as undesirable changes in appearance. In each of the articles from which the quotes were drawn, the doctor offered cosmetic solutions to the targeted features. Enhanced and idealised imagesSince the linking of questionable anti-ageing images and cosmetic surgery was raised in Australia in 1998,12 quite a lot has happened, and nothing much has changed. Examples of "ideal" and enhanced images used in magazines were presented to the 1999 NSW Inquiry into Cosmetic Surgery.5 The key elements of the images that were presented included a number of tactics that are standard practice in the beauty industry. They have, however, been specifically criticised as being neither appropriate nor acceptable promotional strategies for medical practitioners. The NSW Inquiry, for example, concluded that advertising practices that "may be in breach of professional standards and fair trading laws" included: "use of models, implying the model has had the procedure or that the procedure can achieve the results (with or without a disclaimer)"; and " 'before-and-after' photographs that have been enhanced, or are different in size, colour or pose, or give a misleading impression of long-term effects of a treatment".5 One of the outcomes of the Inquiry was the recommendation for development of a guide by the ACCC and the HCCC "on the application of fair trading laws to the promotion of health services".5 When the guide was published, both of the above practices were specifically targeted as potentially misleading.3 It is therefore highly significant that, over a year after the publication of the guide, many of the same, or very similar, kinds of photographs were still being used. Examples of such illustrations can be seen in magazine advertisements and in a more neutral and widely accessible form of commercial media, the Yellow Pages telephone directories. Some advertisements for cosmetic surgery, for example, include photographs of youthful and idealised female features, or enhanced "after" pictures. These images provide a graphic demonstration of the gulf between the promotion of cosmetic surgery and the promotion of other areas of medical practice at this time. Where does cosmetic surgery belong?"Anti-ageing" is one of the most powerful contemporary marketing devices used by the beauty industry. Essentially, it involves exploiting the insecurities wrought by the appearance of ageing, and is a part of the broader strategy of promoting idealised or enhanced standards of appearance as an incentive for buying cosmetic products and services.7 It has a long-established history of targeting women, and, more recently, men, and functions under the socially accepted banner of caveat emptor. The issue here, however, is not whether such tactics are a good or a bad thing or to make any such moral judgements. It is the question of their place within the practice of medicine, as conventionally defined; that is, as "the science or practice of the diagnosis and treatment of illness and injury and the preservation of health".13 Concerns about the place of cosmetic surgery have, in fact, been raised by some of its practitioners. For example, the NSW Inquiry into Cosmetic Surgery cited the Australian Society of Plastic Surgeons (ASPS) as expressing "concern about the promotion of an attitude that cosmetic surgery is just another beauty product".5 A member of the ASPS placed the blame for this attitude on "women's magazines, regrettably, and the media generally".5 However, as the examples cited in this article suggest, "the media" may only be part of the problem, and it is noteworthy that, at the same Inquiry, a cosmetic surgeon described his area of practice in the following terms: "You have to recognise that cosmetic surgery is the nearest thing you're going to get to retail medicine — or retail surgery. You're not treating sick people, we're not treating people who need to have pathology addressed. This is the surgical or medical end of the beauty industry".14 Certainly, there is evidence that the ASPS is right in its reported perception of how the media is currently constructing cosmetic surgery. Recent editions of the magazines Good Medicine and the Australian Women's Weekly (AWW), for example, both classified anti-ageing features involving cosmetic surgery solutions in the "beauty" and "fashion and beauty" sections of their respective contents pages.15,16 Each of the ensuing feature stories expanded on the legitimacy of that location. The introductory text to the Good Medicine article, "Lift your spirits", stated that: "Sophisticated medical technology is making cosmetic surgery an increasingly popular beauty option for many thousands of Australians who want to give themselves a much-needed boost of confidence."17 AWW's story, "Stop the clock", presented a range of "cosmetic fixes", stating in its introduction: "Even the most effective anti-ageing creams can only do so much — that's why an increasing number of women are turning to cosmetic surgeons and dermatologists for high-tech treatments."18 Statements such as these suggest that "anti-ageing" cosmetic surgery and allied procedures are being socially classified as a beauty want rather than a health need. This classification also applies more broadly to the practice of cosmetic surgery as a whole, and is, in fact, consistent with the definition of cosmetic surgery given earlier in this article as the basis for the NSW Inquiry into Cosmetic Surgery.5 At this early phase of deregulated advertising by doctors, the nature of cosmetic surgery, and the perhaps consequent way in which some of its practitioners have adopted commercial strategies from the beauty industry, has clearly opened up some interesting areas of debate for the medical profession as a whole. Should current promotions of cosmetic surgery be a focus of professional concern?First of all, there is the issue of cosmetic surgery itself, and the extent to which some ways of promoting this burgeoning area of medical practice meld with accepted visions of what being a doctor is all about. Do such visions include the application of medical technology, techniques and procedures to consumer needs which have been defined as "non-medical",5 and with what may be seen as some of the sophistry of commercial advertising techniques? More specifically, does the profession see the latter aspects of such applications as simply an extension of core business for doctors, or a worrying expansion into a grey area of mixed allegiances and hazy ethical boundaries that need to be examined? What are the implications of commercially structured promotional strategies for the tradition of "Trust me, I'm a doctor"?It could, more broadly, be argued that the way in which cosmetic surgery is being promoted by some practitioners in Australia today makes it an important test case for how the medical profession and the community want to see the future direction of the profession develop. The AMA's concerns, cited at the beginning of this article, about the potential for such promotional strategies to "undermine public confidence in the medical profession"4 need to be taken seriously. Would the continuing and potentially expanding use of such strategies presage a decline in the role of trust within a doctor–patient/client/consumer relationship? And would any such decline be of concern to the medical profession, or just be seen as a natural and acceptable consequence of a progression towards the more commercialised practice of medicine? 1: Advertising: what doctors can and can not — and should and should not — do* The National Competition Policy requires that "strict controls on advertising" have to be eased "where anticompetitive effects do not have countervailing public benefits". However, the subsequent changes in the laws do not result in a "free for all where anything goes". Advertising and other promotional activity must comply with: the rules of the Commonwealth Trade Practices Act 1974, which prohibits a range of misleading, deceptive and unconscionable conduct, and misrepresentations; the relevant State and Territory Fair Trading Acts; and "any specific medical and health practitioner regulations that remain". Some equivocation applies, however, with regard to the distinction that the Trade Practices Act draws between misleading content and "puffery or self-evident exaggeration". While there is a reluctance at the legal level to elevate puffery "to the status of potentially misleading conduct", it is recommended that – in the case of complex areas such as medical and health care – puffery "should be avoided or used with extreme caution". This echoes a broader caveat laid down for practitioners: that consumers "are best protected when they are fully informed and when medical and health professionals maintain professional and ethical standards". * Drawn from a 2000 guide to the Trade Practices Act 1974 (Cwlth) for health and medical professionals.3 2: Current parameters of cosmetic surgery Cosmetic surgery: is any cosmetic procedure "performed to reshape normal structures of the body or to adorn parts of the body, with the aim of improving the consumer's appearance and self-esteem"; "is initiated by the consumer, not medical need"; and "excludes reconstructive surgery which is . . . [generally] performed to improve functions, but may also be done to approximate a normal appearance".5 3: Quotes from cosmetic and plastic surgeons* ". . . lower face and neck . . . is the area where the by-product of ageing is most obvious with defects such as 'turkey neck', double chin, jowl fat and platysma bands. This area is most susceptible to gravity pull and is usually regarded as the ageing area . . ." ". . . as a natural part of the ageing process, most people develop deposits of fat underneath the eye and on the eyelid which make them appear older than they are . . ." [included for its curious logic]. ". . . as we age, the globe of the eye tends to descend and fall backwards due to gravity and subcutaneous fat fades away. This causes the eyelids and folds around the eyes to become crepey [sic] and wrinkled giving an untidy and withered appearance . . ." * From publicly available magazines published in 2000 and 2001.

Anne L Ring PhD, GradDipHlthEd

Both men and women are becoming increasingly concerned about their physical appearance and are seeking cosmetic enhancement. Most studies report that people are generally happy with the outcome of cosmetic procedures, but little rigorous evaluation has been done. More extensive ("type change") procedures (eg, rhinoplasty) appear to require greater psychological adjustment by the patient than "restorative" procedures (eg, face-lift). Patients who have unrealistic expectations of outcome are more likely to be dissatisfied with cosmetic procedures. Some people are never satisfied with cosmetic interventions, despite good procedural outcomes. Some of these have a psychiatric disorder called "body dysmorphic disorder".

David J Castle MSc, MD, FRANZCP · Roberta J Honigman BComm, BSocWork, Grad Dip Conflict Resolution · Katharine A Phillips MD

Although most naturally occurring infections with anthrax and plague are cutaneous, both organisms are most likely to be deliberately disseminated in aerosolised form, resulting in severe pulmonary illness. Mortality from both would be high and rapid in the absence of early and effective treatment, making swift and effective liaison between alert clinicians and public health authorities crucial to an effective response. Differentiating features include mediastinal widening (anthrax) and haemoptysis (plague). Doxycycline and ciprofloxacin are effective agents for prophylaxis and treatment for both diseases. Medical advocacy for strengthening the Biological Weapons Convention, particularly with an enforceable protocol including verification and compliance provisions, is needed.

Michael Whitby FRACP, FRCPA · Tilman A Ruff MB BS(Hons), FRACP · Alan C Street MB BS, FRACP · Frank Fenner MD, FRS

Soft tissue infections are common and usually respond rapidly to oral antibiotics; if empirical therapy fails then exposure to unusual organisms should be considered. Septic arthritis requires early recognition, identification of the infecting pathogen and urgent joint washout to prevent irreversible cartilage and bone destruction. Prosthetic joint infection is uncommon but has high morbidity; the best outcomes are achieved with removal of the prosthesis and replacement after at least six weeks of antibiotic therapy. Osteomyelitis often complicates diabetic foot infection with ulceration and is rarely cured by antibiotics alone; early surgical intervention achieves the best outcome.

Series Editors:

To the Editor: The recent article by the Obstetric Medicine Group of Australasia alluded to the increasing relevance and importance of thrombophilia screening following adverse pregnancy outcomes, namely recurrent miscarriage, stillbirth, retarded intrauterine growth and pre-eclampsia.1 Formerly, these outcomes were generally attributed to "placental insufficiency", where a cause was not readily identified. Screening for disorders in the uteroplacental circulation after such adverse pregnancy outcomes was formerly confined to investigations for an autoimmune basis, such as antinuclear antibodies, anticentromere antibodies, anti-DNA antibodies and the lupus inhibitor. However, in recent years, it has become more apparent that inherited or acquired thrombophilias may play a significant role in certain adverse pregnancy outcomes.2-5 Reports from Israel2,3 and elsewhere have suggested that thrombophilias can be found in up to 65% of women with recurrent pregnancy loss of unknown cause, as well as in cases of intrauterine growth retardation, stillbirth, placental abruption and pre-eclampsia. It is also known that certain thrombophilic factors are more likely to produce thrombogenic changes and hence are possible deficiencies in the uteroplacental circulation. Preliminary work has shown that treating women who have had recurrent pregnancy loss complicated by thrombophilia with antithrombotic agents (low molecular weight heparins) is beneficial, with improved pregnancy outcomes in a significant number of these cases.3 With the growing understanding of the role of thrombophilias in pregnancy, it seems that thrombophilia screening will assume a more prominent role in investigating patients after recurrent miscarriage, stillbirth, intrauterine growth retardation and pre-eclampsia.

David Morgans

To the Editor: I agree with the assessment by Del Mar and colleagues of available data according to evidence-based guidelines on hormone replacement therapy (HRT) after mastectomy.1 As they note, these data are not definitive. Standard practice has been to avoid oestrogen use in women with a history of breast cancer. Ours is an increasingly litigious society and courts make decisions according to different criteria than do scientists. In particular, precedent is very important to the law of tort, even if the scientific basis for the precedent is unproven. For some years now, I have seen 100 or more new patients per year with recently diagnosed early breast carcinoma. By the time I see them, every single one already knows that: anti-oestrogens are used in treatment of breast cancer; and women are at least 30% more likely to develop breast cancer after five years of HRT. Further, these women fear recurrence of breast cancer more than any other health problem. Hence, I am concerned that the sound evidence-based conclusions reached by Del Mar and colleagues could be successfully challenged in court by a woman who developed recurrence of breast cancer while receiving HRT. In addition to the costs and stress for the individual practitioner involved and other members of his medical indemnity organisation, such action would set back scientific enquiry into this important subject, possibly forever. There is a wealth of well conducted research into non-oestrogenic management for menopausal symptoms. Lifestyle measures (clothing and activity) and dietary modifications (avoiding spicy foods, alcohol) have a role in well-being. Oral progestogens, clonidine, venlafaxine, black cohosh, and probably tibilone, all produce better outcomes than placebo.2 Evening primrose oil, pyridoxine, dong quai, Chinese herbs, progestogen and yam creams, and phytoestrogens do not work better than placebo.3 The last may actually be harmful. Advisory statements for general practitioners about oestrogen replacement therapy for managing menopausal symptoms after breast cancer should be prefaced with this information, as should any discussion with patients. I do prescribe oestrogens for distressing menopausal symptoms after breast cancer treatment, but only after several consultations to allow time for women to appreciate the uncertainties involved.

Robert N Hitchins

To the Editor: I was pleased to see the issue of hormone replacement therapy (HRT) after breast cancer raised by Del Mar and colleagues in a recent issue of the Journal.1 However, I was a little disappointed to see that Australian research in this area had been "missed" by their search.2,3 There are a number of other studies that I am aware of which would suggest to me that perhaps their search technique was not particularly thorough.4-7 Nonetheless, I should add that I do agree with their conclusions. In fact, I am not aware of any clinical trials that have shown an adverse effect of HRT after a diagnosis of breast cancer. However, the studies examined by Del Mar and colleagues are all population studies and not randomised controlled trials. I also think it's important that the readers of the Journal understand that there are other strategies for controlling menopause symptoms after breast cancer, such as the use of progestins, antidepressants and stress-reduction techniques. Even though the evidence we have suggests that HRT after breast cancer is "safe", we do not have even one published randomised trial on this question, so caution should be the rule. HRT after breast cancer should always be viewed as a last resort.

Robert N Hitchins MB BS, FRACP, FAChPM · Christopher M Pyke MB BS, FRACS, FACS

To the Editor: While I have little concern with the conclusion of the article by Del Mar and colleagues,1 I have some concerns about its use to portray a mode of healthcare delivery where any given health practitioner, armed only with what can be gleaned from the Internet, can issue advice. For example, in such a circumstance, should not the general practitioner also refer to the National Health and Medical Research Council clinical practice guidelines on the management of early breast cancer,2 which suggests that the "safety of oestrogen replacement therapy in women with breast cancer has not yet been established", and, further, that "HRT [hormone replacement therapy] and women with breast cancer" is an area where research is needed? Should the doctor also point out to the patient that she is eligible to enter a prospective randomised trial looking at the use of HRT following breast cancer treatment versus the best non-hormonal treatment of menopausal symptoms, currently being administered by the Australian and New Zealand Breast Cancer Trials Group (as part of International Breast Cancer Study Group trial 17-98)? How should practitioners protect themselves when they find the management they are recommending is outside that recommended in the evidence-based guidelines published by specialty groups? A few other minor points: the content of the article refers to women with breast cancer, whereas the title refers only to women who have had mastectomy, and the imaginary patient asked about loss of libido, which was not addressed at any subsequent point in the article.

Christopher B Del Mar MD FRACGP FAFPHM · Paul P Glasziou PhD FRACGP FAFPHM

In reply: Eden, Pyke and Hitchins are happy with the findings of the rapid literature search that we performed for the general practitioner who wanted to know about the safety of HRT in a woman treated for breast cancer. However, they have concerns with the process. Eden is worried that we missed two Australian publications on the issue. In fact, they misunderstand our intentions. Firstly, we did not raise the issue, nor deliver an "advisory statement". It was the general practitioner who asked the question. We were trying to provide a rapid (few days) and responsive service to provide credible information to help a doctor manage a patient. Secondly, we were not able to undertake a full systematic review (which would take a full-time researcher as long as six months and would cost accordingly).1 Instead, our best strategy was to use a cascade process of searching, looking first for the most rigorous study types that would answer the clinical question. If not available we go to the next most rigorous, and so on, stopping when we find the relevant evidence.2 For this question, the ideal study type would be a meta-analysis of randomised controlled trials (RCTs). However, no RCTs were available (as Eden, and the guidelines to which Pyke refers, note), and we had to content ourselves with observational studies. We should remember that no evidence for safety is not the same as evidence for danger. What is important is that we did not miss any trials. Legal issues worry many doctors, even when decisions are supported by best research evidence,3 but, rather than pose a medicolegal threat, we believe that this evidence-based approach is more likely to protect doctors. Why? Failures in communication are the most common preventable cause for doctors being sued by patients.4 Yet, taking the trouble to find empirical information such as this and then discussing it with the patient is surely the most effective way of communicating the pros and cons of different treatment strategies (including, we agree, alternatives such as those mentioned by Hitchins). In the end the patient has to decide on the basis of the risks and benefits, and the choice can often be extremely difficult. It is likely to be more dangerous to assume the patient has abdicated this responsibility to the doctor without checking first. Can doctors be sued for a "safe" decision that leaves a patient exposed to unnecessary symptoms? It may be dangerous to assume that doctors can play "safe" in any one direction. Why do experts take exception when non-experts delve in their areas for the best evidence to manage patients? After all, a cat may look at a king.5 Experts seem to welcome the attention, but seem to think they should be dispensing the information. However, until the information can be delivered more effectively, this sort of stopgap system will have to do.

Robert N Hitchins

To the Editor: Fitzgerald and Isaacs' recent article on genotype–phenotype correlations in healthcare professionals describes some truly original research in an area of exceptional relevance.1 However, some of their conclusions fail the analytical technique described by others as "the common sense test".2 Most obviously, the finding of complete deletion of all personality genes in orthopaedic surgeons sits uncomfortably with clinical experience, which suggests a plethora of witty and indeed charismatic members of that specialty. The authors have erred in making an admission of reading The Medical Journal of Australia on at least a semi-regular basis as an inclusion criterion for the study. As this would include only a minuscule proportion of the orthopaedic population, their sampling was surely unrepresentative. By the same criterion, it is likely that there are few theatre sisters who would admit to being semi-regular readers of the Journal. Those who do are probably married to members of the medical profession, which would explain the (bel) indifference phenotype.

Dominic A Fitzgerald · David Isaacs

To the Editor: The recent article by Chapman et al1 and a case report published some years previously in the Journal2 indicated that hyponatraemia may occur during indapamide therapy. However, it should be noted that the data came from spontaneous adverse drug reaction reporting, and therefore can give no indication of the incidence or relative risk of hyponatraemia compared with other diuretics. Nor can it give the incidence of hyponatraemia as a proportion of side effects occurring during indapamide therapy. The presentation of these data appears to cause some confusion, including an interpretation that hyponatraemia was more common with indapamide therapy than other diuretics.3 However, adverse events may be more likely to be reported for drugs which are usually well tolerated. Hyponatraemia led to discontinuation of therapy in only eight out of 3000 patients in the PROGRESS study.3,4 Previous controlled studies of indapamide (2.5 mg or sustained-release 1.5 mg daily) have found no significant overall changes in serum sodium levels.3 Hyponatraemia associated with indapamide therapy may occur with a recommended dose of 2.5 mg, which does not have a significant diuretic effect. Indapamide appears to be useful for treating central diabetes insipidus, raising the possibility that hyponatraemia occurs because of an inappropriate antidiuretic hormone secretion syndrome.6 Indapamide-related hyponatraemia may be more common in elderly women,1 as is the case for hyponatraemia associated with selective serotonin reuptake inhibitors. Hyponatraemia associated with indapamide therapy appears to be sporadic and uncommon and may be avoided by appropriate monitoring of serum electrolyte levels.

Laurence G Howes · John McEwen · John E Marley

In reply: We welcome Brown's observations. However, with regard to orthopaedic surgeons, we are unaware of any correlation between affability and ability.

Lachlan Brown MB BS, FRACGP

In reply: Howes writes that previous studies have not shown significant hyponatraemia with indapamide. Our article highlighted that hyponatraemia was reported in a much larger proportion of all types of adverse drug reactions to indapamide than to chlorothiazide in Australia. As we clearly acknowledged, "Voluntary reporting systems do not provide a basis for calculating incidence or robust risk estimates". In the PROGRESS study, 1770, and not 3000, participants were exposed to 2–2.5 mg of indapamide.1 The mean age of participants given active therapy in that study was 64 years and 30% were women. Details of the eight patients withdrawn because of hyponatraemia were not published. Importantly for indapamide, chlorothiazide and the other comparator (hydrochlorothiazide with amiloride), more than 80% of the patients with hyponatraemia in our study of Australian adverse reaction reports were aged 65 years or older (mean age for indapamide, 69.3 years, unpublished data), and at least 78% were female. Given that indapamide formulations have been promoted as a replacement for chlorothiazide notwithstanding the acknowledged limitations of the data, our article was appropriate in alerting practitioners to the possibility of hyponatraemia, particularly in elderly women.

Laurence G Howes MB BS, PhD, FRACP · John McEwen MB BS, MSc, MPS · John E Marley MD, MB ChB

To the Editor: I was impressed by the article on the seven deadly genes in a recent issue of the Journal.1 Your readers may also be interested to learn that we have recently discovered an entire family of antisocial recessive genes in colleagues and patients. 2 These include the stalk-r gene (not only in patients who stalk doctors, but also in doctors who molest their patients3) and the hum-r gene for socially inappropriate comicality, which clearly invites correlation with the dub (formerly cyn) gene for cynicism and medical humour.1 I cordially wish Fitzgerald and Isaacs the Best of British (and Irish) luck with the lofty ambitions expressed in the penultimate paragraph of their discussion; and, together with Arthur Koestler, we speculate that "in lieu of abolishing language the only way to curb human destructiveness would be to retool the brain", and that "advances in genetic engineering might encourage evolution along its path".4

Lachlan Brown

To the Editor: Your editorial comment1 about the fact that the "Death and Dying" issue of the Journal [19 November 2001] contained no obituaries because "the obituary tray was empty" prompts me to make a suggestion. Having, over the years, written obituaries for colleagues, including one for my own father, I have always believed we would do colleagues a great favour if each of us wrote our own obituary and left it in the keeping of a colleague, to be dealt with at the appropriate time. Not only would it ensure that the obituary included services for which the departed would like to be remembered, but it would also save the writer of the obituary a great deal of time in research. PS. Now in my own 91st year, I've not yet written my own obituary.

H Stuart Patterson

Emeritus Professor Wallace Ironside, Foundation Professor of Psychological Medicine at Monash University, Melbourne, died in Sydney on 19 July 2001. He was a pioneer of academic psychiatry in New Zealand and Australia. Wallace Ironside was born in China on 31 July 1917. After undergraduate medical training at Aberdeen University and war service in Italy, he trained in psychiatry at the Royal Aberdeen Infirmary (1946–1947) and worked at the Crichton Royal Hospital in Dumfries, Scotland (1947–1949), where Douglas McCalman and W Mayer-Gross shaped his lifelong interest in developmental and dimensional issues of psychopathology. He was a lecturer at Leeds University, UK, from 1949 to 1952. From 1959 to 1960, as a Fellow in George Engel's Department of Psychiatry in Medicine at the University of Rochester, New York, Wallace consolidated his special interest in liaison psychiatry and medical education. Engel's biopsychosocial model became the basis of integrated medical education in the Western world. Wallace promoted Engel's model when appointed to the Foundation Chair of Psychological Medicine at Otago University, Dunedin, New Zealand, in 1953, and later to the Foundation Chair of Psychological Medicine at Monash University, Melbourne, in 1969. There, he initiated a teaching program that had medical students considering psychosocial issues from their first day and following the psychosocial health of families over time. With clinician colleagues, he initiated a training program for psychiatrists that was based in general hospitals rather than psychiatric institutions, and had them enrol in a Master's degree in Psychological Medicine. His research focused on emotionally deprived children. Wallace was President of the Royal Australian and New Zealand College of Psychiatrists from 1972 to 1973, and cofounder and inaugural President of the Victorian Association of Psychoanalytic Psychotherapists, 1975–1976. He served on a number of hospital boards and National Health and Medical Research Council committees. After retirement from Monash University in 1982, Wallace continued his academic and clinical activities for a further seven years, retiring from these only when his hospital, Prince Henry's, was demolished and its functions relocated to Monash Medical Centre. There, his influence is still strongly felt: the Centre is a bastion of liaison psychiatry that continues the fight to have all patients seen as integrated human beings with biological, psychological and social needs. A new generation of students and psychiatrists receive this wisdom; this is Wallace Ironside's memorial.

Graeme C Smith MD DPM FRANZCP

Decision making in health and medicine. Integrating evidence and values. M G Myriam Hunink, Paul P Glasziou, Joanna E Siegel et al. Cambridge: Cambridge University Press, 2001 (xvi + 388 pp). ISBN 0 521 77029 7. Like the practice of medicine itself, this book is not for the faint-hearted. Not because it is difficult to read or to understand, but because, unless you are already skilled in decision analysis, you will find it new, thought provoking and rigorous. The consequences of embracing its message are profound. Its fundamental premiss is that medicine (defined in its broadest sense to cover clinical medicine, population research, policy development and health management) is about uncertainty and the need to make decisions despite this uncertainty. For example, you have just diagnosed a 58-year-old man with atrial fibrillation. If you prescribe warfarin you can reduce his risk of embolic stroke by 70%, but this benefit comes at the price of an increased risk of haemorrhage, and the need for regular blood tests and avoidance of activities that increase his risk of injury. How do you weigh up the probabilities and incorporate into the decision your patient’s individual values about what is important to him? This book presents an approach and a handful of tools for making complex, value-laden decisions such as this. The approach, PROACTIVE, is adapted from a generic approach to decision making. As the authors say, one of its greatest strengths is that it requires you to make the decision-making process transparent. By carefully outlining your decision, viewing it from other perspectives and considering what the important objectives are, the best decision may become readily apparent without having to go any further. If you need to work quantitatively with probabilistic data, to make trade-offs between benefits and risks (or length of life versus quality of life, or costs versus benefits), and to incorporate people’s values and preferences, the book provides detailed guidance on the tools that are available. It takes the novice from a definition of a probability and a proportion all the way to advanced microsimulation modelling. Decision making in health and medicine updates the 1980 book Clinical decision analysis. It has a broader framework, and covers population health decision-making. It also includes more information on diagnostic testing, methods for measuring and incorporating quality-of-life measures and newer approaches to modelling. To support it, there is an accompanying CD with solutions to exercises, decision-analytical software, examples of decision-analytic models using the software, spreadsheets and references with abstracts. It is an extraordinarily ambitious book that achieves its aim. Alexandra L BarrattEpidemiologistUniversity of Sydney, NSW

Alexandra L Barratt

An 88-year-old man was admitted to hospital with "collapse", manifested as hypotension and fever. It was noted that he had gaze palsies. He had been admitted for a three-day period, 12 days earlier, with a urinary tract infection, which was treated with intravenous, then oral, antibiotics. On this occasion he was again started on intravenous antibiotic therapy. He was seen by an ophthalmologist, and a cranial computed tomography (CT) scan was arranged. Later that evening, the ward nurses sought further medical review, as the patient remained hypotensive, with a systolic blood pressure of 80 mmHg. On examination he was observed to have a partial left third cranial nerve palsy and complete right third cranial nerve palsy (see Box, A). A presumptive diagnosis of pituitary apoplexy was made, and the patient was commenced immediately on intravenous fluids and hydrocortisone 100 mg, 12-hourly. The CT scan (Box, B) confirmed the diagnosis, showing a pituitary tumour measuring 12 mm in diameter. The salient feature is the variegated appearance, suggesting haemorrhage within the tumour. In patients presenting with the constellation of collapse and gaze palsies, a diagnosis of pituitary apoplexy should be considered. The mechanism of third-nerve palsy is illustrated in the Box (C). The condition is life-threatening, but responds well to appropriate treatment. After the patient had undergone hypophysectomy, the gaze palsies took about three months to resolve completely. The patient remains active on pituitary replacement therapy only. Cranial nerve palsy caused by pituitary tumour This picture of the patient's eyes 12 hours after commencing hydrocortisone (A) shows partial left third cranial nerve palsy and complete right third cranial nerve palsy. A computed tomographic image (B) shows a 12 mm diameter pituitary tumour with haemorrhage (arrow). The mechanism of third cranial nerve palsy is illustrated in C: as the tumour expands, it involves the optic chiasm anteriorly and displaces the carotid siphon laterally. The third cranial nerve is vulnerable to lateral displacement. (Adapted from Patten J. Neurological differential diagnosis. New York: Springer Verlag, 1982.) A: Patient's eyes B: Computed tomography scan C: Mechanism of third cranial nerve palsy

Dan Harmelin BSc DipEd MB BS FRACP

Critical timing New evidence from experimental mice further supports the idea that the early postnatal period is a critical time for establishing lifelong anxiety behaviour. The findings implicate serotonin, known to be important in mood regulation, with its agonists used therapeutically in humans as anxiolytics. American scientists had previously shown that mice bred with no serotonin-1A receptors (5-HT1AR knockouts) were more “anxious” than wild mice on three standard tests (eg, in a novel environment they took longer to start eating). In a new transgenic mouse, it is possible to turn off the expression of these serotonin receptors at will by feeding the mouse doxycycline. Researchers found that mice fed doxycycline to switch off the receptors during the embryonic and early postnatal period developed pronounced anxiety as adults (similar to 5-HT1AR knockouts). Mice fed doxycycline as adults were not affected. Nature 2002; 416: 396-400 Sleeping babies Melbourne researchers have shown, in a randomised controlled trial, that a simple behavioural intervention in babies reported to have severe sleep problems reduces both the baby’s sleep problems and the mother’s symptoms of depression. They studied 156 mothers of babies aged 6 to 12 months. Mothers being treated for postnatal depression were excluded. The intervention group received three consultations and a tailored sleep management plan (“controlled crying” in most cases), while mothers in the control group received only a letter describing normal infant sleep patterns. After two months, sleep problems had resolved in 53 of 76 infants in the intervention group, compared with 36 of 76 control-group infants. At four months, however, there was no significant difference. Maternal report of depression symptoms decreased significantly at two months, and this was sustained at four months for mothers with high depression scores. BMJ 2002; 324: 1062-1067 Peanuts Researchers in the United Kingdom have collected data which will reassure parents that the risk of their child dying as a result of food allergy is very small. From 1990 to 2000, only eight children (from a population base of 13 million) died from a food-allergic reaction. This translates to an incidence of 0.006 deaths per 100 000 children per year or, for the food-allergic child, a risk of 1 in 800 000 per year. Four of the eight deaths were reactions to milk, two to peanuts (in children aged 13 and 15), one to egg white and one to mixed food. Prospectively collected data from the last two years of the study identified 55 severe non-fatal reactions, and a strong association between coexisting asthma and reaction severity. Arch Dis Child 2002; 86: 236-239 Diabetes risk A large cross-sectional study of people being treated for schizophrenia has found a significant association between treatment with atypical neuroleptics and diabetes mellitus. The US Veterans Administration database was used to identify all patients with schizophrenia who had received a prescription for a neuroleptic during a four-month period, and the subgroup who also had a diagnosis of diabetes mellitus. Altogether, 22 648 (58.6%) patients had received an atypical, and 15 984 a typical, neuroleptic. Among patients younger than 60 years, but not in older age groups, those receiving atypical neuroleptics had significantly higher rates of diabetes than those receiving typical neuroleptics. In patients younger than 40 years, each of the atypical neuroleptics was associated with increased risk of diabetes (odds ratios: clozapine, 2.13; olanzapine, 1.64; quetiapine, 1.82, and risperidone, 1.51). Am J Psychiatry 2002; 159: 561-566 Healthy lifestyle Aerobic exercise reduces blood pressure in both hypertensive and normotensive subjects, according to a recent meta-analysis. The study, from the United States, identified 54 randomised controlled trials, median duration 12 weeks, conducted among a total of 2419 participants of different ethnic backgrounds and hypertensive status (mean ages, 21 to 79 years). Most trials had recruited people with sedentary lifestyles to exercise on a bike, to walk or to jog for up to 150 minutes per week. Aerobic exercise was associated with a significant reduction in mean systolic and diastolic blood pressure (–3.84 mmHg and –2.58 mmHg, respectively). Ann Intern Med 2002; 136: 493-503