Volume 177 Issue 9

It’s time to adopt a cost-effective approach Hypertensive disorders in pregnancy, and particularly pre-eclampsia, remain major causes of maternal and perinatal mortality,1,2 accounting for 15% of maternal deaths and 4% of perinatal deaths. Therefore, a key aim of modern antenatal care is the timely detection and management of pre-eclampsia.1,2 A traditional belief is that this is best achieved by regular, and increasingly frequent, antenatal visits, allowing for both blood pressure measurement and dipstick urinalysis to detect new-onset proteinuria. This strategy underpins the schedule of antenatal care that is still most commonly followed in Australia; namely, monthly visits until 28 weeks of pregnancy, fortnightly visits until 36 weeks and weekly visits thereafter.3 However, it has been apparent for some time that the frequency of visits could be safely reduced without adversely affecting outcomes,4 a notion now confirmed by randomised controlled trials both in the developed and developing world.5 Similarly, it has long been recognised that dipstick urinalysis performs poorly in the detection of proteinuria,1 requiring confirmation by either a formal 24-hour urine collection or a spot urine protein/creatinine ratio.2 However, the accuracy of a dipstick reading is significantly improved if it is read with an automated device rather than visually,6 offering the possibility that routine automated testing for proteinuria may have a place in the detection of pre-eclampsia. In this issue of the Journal, the study by Murray and her colleagues (page 477) explores this possibility.7 The authors prospectively evaluated automated dipstick urinalysis in the diagnosis of pre-eclampsia in almost 1000 unselected women. In a quarter of the women who developed pre-eclampsia proteinuria arose before hypertension. From this, the authors concluded that if the initial screening urinalysis is negative then routine urinalysis thereafter is unnecessary in women with no high-risk factors for pre-eclampsia. These findings and conclusions should encourage providers of antenatal care to reflect on their own practice and to consider whether routine urinalysis is justified, thereby facilitating the provision of the most cost-effective care. The report by Murray et al should also stimulate us to reflect on the cost-effectiveness of the other tests routinely undertaken during antenatal care. It is of concern that there is considerable variation in routine antenatal testing in our hospitals, and that practice is often at odds with available evidence.8 These inconsistencies are not only indicative of inequalities in care, but also suggest wastage of precious and limited resources. Standardisation of antenatal care across Australia, through the development of clinical practice guidelines, might reasonably be expected to reduce this wastage. In the United Kingdom, the National Institute of Clinical Excellence has commissioned the development of such guidelines with 43 recognised stakeholders and a projected completion date by September 2003 (www.nice.org.uk). In Australia, through a project funded by the Victorian Department of Human Services, the three largest public hospital providers of maternity services in Victoria have already developed consensus guidelines on antenatal care. These encompass the delivery of antenatal care, including guidelines for most of the routine tests undertaken in pregnancy.8 These guidelines provide an evidence-based foundation for the rational delivery of antenatal care in these three hospitals. However, they offer far more. The guidelines could be used as a catalyst for the development of national guidelines for antenatal care. An important component of any such development, and one missing from the Three Centres Consensus Guidelines, must be a thorough cost-effectiveness analysis of the various tests and interventions recommended. A cost-effectiveness analysis is important because much of the evidence for the various antenatal testing is imported from overseas and may not be readily applicable to Australia. For example, a recent cost appraisal of screening methods for Down's syndrome in the United Kingdom costed a first-trimester ultrasound examination at about £4 ($12),9 a fraction of the Medicare cost in Australia ($60–$70). In addition, the prevalence of the various infections, such as syphilis and HIV, varies in different regions of Australia, and consequently the currently recommended strategies for screening may need to be modified on a regional basis.10 Such analyses are critical components of the further development of evidence guidelines, but, frustratingly, there has been little support at a national level for the funding necessary for their development and implementation. This is despite an estimate that between $75 million and $100 million is spent annually on antenatal screening in Australia.11

Euan M Wallace · Jeremy J N Oats

The second round of trials may provide more answers The coordinated care trials were nothing if not ambitious! In 1994, the Council of Australian Government proposed that the organisation, funding and management of health and community services could be restructured into three streams: 1 a general stream for individuals needing either occasional or uncomplicated healthcare; an acute stream for patients needing specialised services for acute illness; and a coordinated stream for patients requiring a mix of healthcare services over an extended period. It was assumed that in the last stream patients would benefit by having their care managed and coordinated. Following a national tender process, nine trials of coordinated care were activated and funded by the Commonwealth (Box 1). A central premise of the trials was that better coordination of the care of people with chronic or complex needs would reduce hospitalisation, and the savings could cover the costs of coordination. The coordinated care trials were the largest and most ambitious experiment of a new method of organising healthcare services ever attempted in Australia. The trials ran for two years. Evaluation was undertaken both nationally and at the local level. Much of the trial documentation and evaluation reports are available on the Commonwealth Department of Health and Ageing's website.3 Despite this effort and expenditure, the outcomes were disappointing (Box 1). In general, the trials did not demonstrate improved health and well-being of the participants. A significant reduction in hospital admissions in the intervention compared with the control group was seen in only three of the trials, and for most trials an accrued operating deficit was found. Was this ambitious healthcare experiment a failure? It is hard to say because, unfortunately, the design of the trials made it difficult for them to achieve their stated objectives. The trials included the following design shortcomings. Each trial was funded for two years, but the first six months were devoted to recruitment and the last six months were a wind-down phase. Thus, in many trials, the actual intervention was for 12 months or less, a very short period in which to make an impact on complex illnesses. Difficulty in recruiting sufficient numbers of participants forced many trials to relax inclusion criteria, with the result that many individuals entered in the trial were inherently unable to benefit from coordinated care, since they were not sick enough, or had insufficiently complex problems to warrant care coordination.4,5 In many trials, the same intervention was applied to all participants regardless of the severity of their condition or ability to respond to the intervention. Interventions varied markedly between trials. The chosen measure of well-being, the SF-36, was not optimal to assess the types of intervention, especially over the relatively short trial periods. Despite these shortcomings, the trials provided a number of benefits. Fundholding allowed trials to fund strategies such as quit smoking interventions that otherwise would not have been possible.6 Because of the evaluation needs, many service organisations received major technology upgrading of information systems. The trials received the full cooperation of the Health Insurance Commission, enabling the use of Pharmaceutical Benefits Scheme and Medical Benefits Scheme (MBS) information for evaluation purposes. New enhanced primary care MBS schedule items were announced shortly before the publication of the final results. Finally, much of the qualitative evaluation showed that participants in the intervention groups appreciated the extra coordination of their care. The new round of coordinated care trials that has just commenced (Box 2) has taken on board much of what has been learnt from the first round. The trials are for three years rather than two, have better-targeted interventions, and outcome measures have been carefully selected for their sensitivity to the type of intervention. The possibility remains, however, that the essential premise that better coordination reduces hospitalisation is misguided. It may be that lack of coordination in a complex care system operates as a functioning rationing system, so that better care coordination reveals unmet needs rather than resolving them. Experience in the mental health field implies that this may be so.7,8 With an ageing population and increasing burden of chronic diseases, the government has given priority to increased service coordination, vertical integration and cost containment. The coordinated care trials are just one of several strategies aimed at achieving these objectives. It might well be that the objectives are mutually exclusive and that improved coordination comes at a cost. 1: First round of coordinated care trials General coordinated care trials Nine trials in six States and Territories were funded, involving 10 967 intervention and 5571 control participants. Trials were designed as either randomised (where individuals were assigned at random to the intervention or control group) or geographically controlled (where two matched regions were used, one receiving the intervention). The trials ran from June 1997 to December 1999. Only the SA HealthPlus trial based participant inclusion on specific diagnoses, which included respiratory disease, diabetes, cardiovascular disease, stroke and somatisation. Primary hypothesis Coordination of care of people with chronic or complex needs results in improved participant health and well-being within existing resources. Eligibility Varied by trial, based on one or more of age, complex care needs, or specific diagnosis. Intervention Varied by trial, based on different models of care coordination, care planning and funds pooling. Outcome measures SF-36 measured at baseline, 12 months and 24 months. Health and community service use and expenditure from the Health Insurance Commission and other sources. Results Intervention groups did not perform better than control groups for either SF-36 scales or reductions in hospitalisation, readmission, or length of stay for those hospitalised. Trials were unable to fund coordinated care out of savings from reduced hospitalisation. Aboriginal coordinated care trials Four trials among Aboriginals and Torres Strait Islanders involved 6600 participants. The trials were located in Katherine West (NT), the Tiwi Islands (NT), Wilcannia (NSW) and Perth/Bunbury (WA), and were conducted between 1997 and 1999. Primary aims related to community empowerment and capacity building. The National Evaluation Summary outlines the background, description, experiences and outcomes of the trials.2 The national evaluation found that all trials showed enhanced service access, progress in infrastructure development, and improved individual and community empowerment. Funds pooling was successful in providing greater flexibility in resource allocation. 2: Second round of coordinated care trials Six trials (three general, three Aboriginal community). Began in late 2002 to run for three years. General trials Northern Venture: Continuation of Care 21 first-round trial, Adelaide. Team Care II: Continuation of Team Care first-round trial, Brisbane. Coordinated Health Care: Continuation of North Eastern first-round trial, Victoria. Coordinated Health Care has included specific diagnoses (respiratory disease, heart failure and complex diabetes) as part of its inclusion criteria. Team Care II and Coordinated Health Care are randomised controlled trials with about 2000 intervention participants and 1000 control participants expected. Northern Venture is a prospective intervention cohort trial using matched population controls. It will have about 2000 participants. Objectives 1. To identify people who are most likely to benefit from coordinated care. 2. To identify processes and infrastructure for effective integration and coordination of care. 3. To enhance the health status, quality of life and functional status of participants, and reduce the burden on carers. Outcome measures A range of quality-of-life, functional status and health assessment tools, plus carer instruments measured at baseline and at regular intervals. Health and community service use and expenditure from HIC and other sources. Aboriginal trials South West Aboriginal Medical Service (SWAMS): Continuation of SWAMS first-round trial, WA. Sunrise: Katherine East, NT. Mid North Coast: NSW. Objectives of Aboriginal trials 1. To improve the health of communities. 2. To improve community understanding or control of health and related services. Intervention Different models of care coordination, care planning and funds pooling. Outcome measures Access to primary healthcare services Involvement in population health programs Preventable hospital admissions Length of stay in hospital Improved processes of care Involvement of individuals in decisions about care Social concerns Preventable mortality

Adrian J Esterman MSc, CStat · David I Ben-Tovim PhD, FRANZCP

Simple statements of risks and benefits may not reveal the complexity of human responses to research participation In this issue of the Journal, Scott and colleagues (page 507) report on a retrospective study of family members' experience of participation in a previous study following their child's diagnosis with Ewing's sarcoma.1 The research is important because it casts empirical light on an ethical issue often debated in human research ethics committee meetings: how does research affect those who participate in it? Ethics committees can be very cautious about granting approval for research into sensitive areas because of concern about the impact on research participants. People participate in research for many reasons. They may feel an obligation to their doctor, they may not think they have a choice in the matter, they may hope or believe they will benefit from the research, or they may just wish to help others.2-4 Regardless of the reasons research participants may have for participating, the National Health and Medical Research Council (NHMRC) guidelines5 make clear that the primary duty of members of ethics committees is to attend to the "dignity and wellbeing" of research participants. Ethics committees focus, above all, on the risk of harm or discomfort to participants and on the requirement that participants make a free and informed choice to participate in research. Committees need to bear in mind that In clinical research . . . the risks of participation must be balanced by the possibility of intended benefits to the participants. In other research involving humans . . . the absence of intended benefits to a participant should justly be balanced by the absence of all but minimal risk.2 However, the data from Scott et al suggest that balancing risks and benefits is not necessarily a straightforward matter. How research participants experience risks and benefits can be rather complex. First — at least for research into sensitive areas such as serious and life-threatening illness — participants may find it painful and distressing to recall past events or articulate complex emotions. However, doing so in a supportive environment may actually be beneficial. Scott et al indicate that the benefits gained by participants in their study came despite the pain of talking about distressing events. I would argue that the evidence in their article suggests that some benefits seemed to accrue to participants because they could talk about painful experiences. Ethics committees may be able to separate out the risks and benefits conceptually, but in people's experience of taking part in research, as in other areas of our lives, things are seldom so tidy. Furthermore, the qualitative data reported imply that an additional benefit to participants was the opportunity to learn more about Ewing's sarcoma. Research participants often ask questions — about their illness and its treatment, about the researcher's opinion of the medical care they are receiving, or about other treatment alternatives that may be available. Participating in research can provide extra contact with "experts", which may be of benefit to participants. The question arises, "Is it ethical to inform prospective research participants of such benefits?". Members of ethics committees may not be comfortable with answering "yes" to this question, because they are likely to be worried about the coercive effect of such information. They may also be concerned about other factors that come into play when the researchers' role is extended to include answering participants' questions. They may be apprehensive about the possible effects on the scientific integrity of the research itself; they may believe that research staff are not the best people to answer questions about the participant's condition; or they may be concerned about role confusion for researchers when they also provide advice.6 In addition to considering how researchers should respond to requests for information, it is important to consider why researchers are being placed in this position at all. It is an indictment of our healthcare system that patients may think they need to take part in research in order to have their needs for information and reassurance met. The study by Scott et al also raises the tricky question of the role of altruism in research participation. Nearly all of the study participants felt that their involvement would benefit others. Researchers may encourage such beliefs, often in the context of explaining that they can not guarantee that the research will benefit the participants themselves. The possibility of benefit to others is sometimes all that can be held out as an incentive for potential participants. Even here, however, things are not that simple. Feeling that others are helped by our involvement in research can be of benefit to us, as concern for our own interests and concern for others' interests are actually closely intertwined.7,8 Sometimes we act altruistically because we enjoy the feeling of being an altruistic person and the positive response it engenders in others. In a sense, our self-interested choices can be re-interpreted as altruistic, and vice versa. In Scott and colleagues' study, feeling that others might benefit from their involvement perhaps offered the participants a way to make sense of difficult and otherwise inexplicable events. Finally, the whole issue of risks, benefits and altruism is further complicated by questions about whose notions of risks, benefits and altruism are to count. Ethics committee members, research participants and researchers are all likely to offer different interpretations of these concepts in specific situations. For example, should ethics committees intervene if research participants choose to believe their involvement will help other people like them if, in fact, there is little evidence that this will occur? Can committee members or researchers accurately judge the risks and benefits of research for a participant, or should the emphasis be principally on facilitating choice? Human emotions and ethics are complicated, and simple statements of risks, benefits and altruistic intent are unlikely to reveal the complexity of the situation. What are ethics committees, researchers and participants (potential and actual) to make of all this? They should, at least, recognise that guidelines are only that, and can never substitute for careful and nuanced consideration of the meanings of terms such as "risk" and "benefit". The NHMRC's Commentary on the national statement on ethical conduct in research involving humans, released this year, provides something of a roadmap in this area.9 But committees will still need skills, knowledge, time and resources to consider these issues thoughtfully. While skills and knowledge may not be in doubt, we know that many committees lack the time and resources needed to do justice to these thorny issues.10

Annette J Braunack-Mayer BMedSci(Hons) PhD

The 14th World Congress of Cardiology, held in Sydney 5–9 May 2002 (the first time ever in the antipodes), was a joint meeting with the 50th anniversary meeting of the Cardiac Society of Australia and New Zealand (CSANZ). The Congress is the principal meeting of the World Heart Federation, a body comprising all of the world's cardiac societies and heart foundations. Delegates came from 115 countries, and there was a total registration of just over 9000. More than 3000 abstracts were received from investigators in 82 countries. In addition to focusing on developments at the cutting edge of cardiovascular disease, the Congress explored themes such as the world burden of cardiovascular disease and the likely rise of this burden in the 21st century, particularly in developing countries — a prospect of particular concern to the World Heart Federation. Worldwide issuesIschaemic heart disease is the leading cause of death in developed countries. While age-adjusted mortality from the disease is gradually falling in developed countries, including Australia, it is set to become an epidemic in developing countries, and over the next 20 years will probably become the most important global health problem. This was put into perspective by Salim Yusuf (Director of Cardiology, McMaster University, Hamilton, Canada). George Mensah (Head, Cardiovascular Division, Centers for Disease Control and Prevention, Atlanta, USA) highlighted the fact that the epidemic of ischaemic heart disease is driven by tobacco use, particularly in Asian and former Eastern European countries, while Stephen Colagiuri (Director of Endocrinology, Prince of Wales Hospital, Sydney) emphasised the rapid increase in diabetes that is occurring with population aging and increasing overweight and obesity. David Wood (Professor of Preventive Cardiology, National Heart and Lung Institute, London, UK) made the point that both prevention and treatment must translate into practice the large scientific and clinical evidence base of effective measures, but that we should also focus on developing tools to assess future absolute risk of cardiovascular disease rather than concentrating only on individual risk factors. These measures should support compliance with therapeutic regimens (Martha Hill, Dean of Nursing, Johns Hopkins University, Baltimore, USA) and, very importantly, consider the underlying psychosocial and socioeconomic determinants of disease (Michael Marmot, Professor of Epidemiology and Public Health, University College, London, UK), particularly in the vastly populated poor regions of Asia (Sania Nishtar, Director, Heartfile, Pakistan). AtherosclerosisInflammation is now regarded as a key process in the development of atherosclerosis and the destabilisation and rupture of plaques in acute coronary syndromes and cardiac death. The role of activated macrophages and T lymphocytes in secreting matrix metalloproteinases and tissue factor during plaque rupture was highlighted.1 This information has almost immediate practical application: diagnostic assays for inflammatory markers such as C-reactive protein are predictive of risk of myocardial infarction, stroke and death in population studies. Valentin Fuster (Director, Weiner Cardiovascular Institute, Mount Sinai School of Medicine, New York, USA) also emphasised the need to find a systemic solution to atherosclerosis, possibly through novel approaches to reducing the effects of inflammation. In a plenary session on presymptomatic detection of atherosclerosis, the importance of defining high-risk populations was emphasised (Sidney Smith, Chief Scientific Officer, American Heart Association, Dallas, USA), as the first manifestation of vascular disease is often a catastrophe — myocardial infarction, stroke or sudden cardiac death. Techniques reviewed included global risk factor algorithms such as those based on the Framingham study (Sidney Smith, Chief Scientific Officer, American Heart Association, Dallas, USA), the use of ultrasound to estimate arterial-wall thickness (Olli Raitakari, Senior Lecturer, University of Turku, Turku, Finland), the use of computed tomography scanning with and without contrast to detect coronary calcification and/or define coronary stenoses, and the use of magnetic resonance imaging to outline areas of myocardial damage and even plaque characteristics. Steven Nissen (Vice Chairman, Cardiovascular Division, Cleveland Clinic, Cleveland, USA) presented exciting new data on the reversibility of atherosclerosis with aggressive cholesterol lowering. New intravascular ultrasound studies have shown that coronary plaques can undergo regression and stabilisation, potentially translating into clinical benefit for people with coronary artery disease. InterventionA major focus of interventional cardiology was the exciting results of trials using drug-eluting stent technology. Substudies from the RAVEL trial2 and smaller pilot registries suggest that sirolimus, a macrolide antibiotic with powerful antiproliferative properties, effectively prevents restenosis de novo not only in coronary lesions and femoral artery lesions but also with in-stent restenosis. Patients with diabetes seem to benefit to the same extent as those without diabetes. Promising data were also reported for stents eluting paclitaxel, while ongoing clinical trials are evaluating other drugs. ArrhythmiasThe highlight of the sessions on arrhythmias was the presentation by Bernard Gersh (Professor of Medicine, Mayo Clinic, Rochester, USA) of data from the AFFIRM study, in which 4060 patients with recent paroxysmal or chronic atrial fibrillation were randomly allocated to either a "rate control" arm (with emphasis on obtaining an acceptable ventricular response rate) or a "rhythm control" arm (with antiarrhythmic drugs and elective cardioversion to attain and maintain sinus rhythm). The primary outcome measure of the study was total mortality: there were 306 deaths in the rate control group, compared with 356 deaths in the rhythm control group (P = 0.056). For other endpoints, such as hospitalisation, ischaemic stroke and arrhythmia attributable to antiarrhythmic drugs, the rate control group also tended to do better. Nearly all strokes occurred in patients who had an international normalised ratio of less than 2.0 or who were not taking warfarin, emphasising the importance of anticoagulation therapy regardless of the treatment strategy. The general conclusion of this landmark study is that decisions on returning patients to sinus rhythm with aggressive antiarrhythmic therapies can be based largely on symptoms and patient preferences rather than the (incorrect) assumption that this approach will improve prognosis. Heart failureHeart failure remains the leading cause of medical admission in people over 65 years, and its prevalence is increasing as the population ages. The high level of morbidity associated with heart failure was illustrated by Duc and colleagues,3 who found that major depression is present in 18% of patients who have heart failure, and depressive symptoms in another 26%. These conditions are often unrecognised and untreated. The emerging role of B-type natriuretic peptide (BNP) in heart failure management was highlighted in the sessions. Post and colleagues4 reported that measuring BNP can help to distinguish cardiac causes of dyspnoea from non-cardiac causes in the emergency department. Mean levels of BNP were 83 pg/mL in patients with non-cardiac-related dyspnoea and 905 pg/mL in patients with heart failure. Aronson et al5 showed that administration of BNP increased heart rate variability, a surrogate for improved prognosis (heart rate variability is an indicator of autonomic function, low variability being associated with dysfunction and adverse prognosis). Carvedilol can be successfully initiated and titrated, and withdrawal rates have been low, even in high-risk groups such as elderly people6 and those with severe heart failure.7 Krum et al (in the COPERNICUS study)7 showed that within the first eight weeks of therapy there was no excess of clinical events, and death in high-risk groups was less for carvedilol than placebo (3 v 15 deaths; P = 0.005). The efficacy of biventricular pacing to achieve ventricular resynchronisation also received attention: the MIRACLE study8 of patients with moderately severe heart failure and wide QRS interval (> 130 msec) showed improved functional status, quality of life and exercise tolerance after this treatment. While "high tech" approaches to heart failure were featured in some presentations, a Spanish study showed that patient education through home visits, telephone contact and clinic review could halve the number of readmissions for heart failure.9 Other studies of home-based education also reinforced this finding, with Stewart et al, in a four-year follow-up study,10 demonstrating benefits in terms of reduced mortality and cost savings from reduced readmission. Acute coronary syndromesLars Wallentin (Director of Cardiology, Uppsala University Hospital, Uppsala, Sweden) presented late results from the FRISC2 study, which had shown the benefit of early revascularisation (by either angioplasty or bypass surgery) in patients with unstable angina or a small infarction. Benefit was maintained at two years, with death or infarction reduced from 16.3% to 12.1%. He speculated that these results will lead to increased intervention for acute coronary syndromes, but noted that the cost–benefit ratio could be maximised by selecting patients at increased risk based on clinical predictors. Despite the recent development of more powerful thrombolytic drugs than tissue plasminogen activator (tPA), initial studies showed no clinical benefit and possibly increased haemorrhage. It appears the thrombolytic ceiling has been reached, and this is probably also true of combinations of tPA with antithrombotic drugs. The one-year results of the GUSTO V study of abciximab plus tPA treatment for patients with ST-elevation infarction showed no reduction in mortality. This was similar to the 30-day findings in the same study (Michael Lincoff, Associate Professor of Medicine, Cleveland Clinic Foundation, Cleveland, USA). Thus, the significant early reduction in recurrent infarction and rescue angioplasty with abciximab did not translate into reduced late mortality. The most promising strategies for ST-elevation infarction involve prehospital fibrinolysis and early direct angioplasty. The latter strategy was investigated in a national study in Denmark (DANAMI-II), whose one-year results were presented by Henning Andersen (Professor of Cardiology, Skejby University Hospital, Aarhus, Denmark). There was reduced death and reinfarction in patients having angioplasty compared with those treated with thrombolytic agents, even though many were transported long distances by ambulance to the hospital performing the angioplasty. Most of the benefit was in reduced reinfarction, a result that may also be achievable with lytic therapy plus low molecular weight heparin, together with elective revascularisation in the first few days after infarction. Molecular biology In a plenary session on gene and cell therapy, speakers highlighted the potential and possible limitations of a molecular biology approach for end-stage heart disease. Genes to promote angiogenesis have been used in early clinical trials of patients with severe coronary and peripheral vascular disease, with some promising results summarised by Elizabeth Nabel (Director, Clinical Research Program, National Heart, Lung, and Blood Institute, Bethesda, USA). The next phase was to use endothelial progenitor cells to assist in the cellular component of the response. Early data on the possible benefit of muscle stem-cell therapy for severe heart failure were presented by French11 and Dutch12 investigators. There was some concern that skeletal myoblasts may contribute to arrhythmogenesis. The winner of the International and CSANZ Young Investigator Basic Science Award, Thomas Yeoh (Research Fellow, Victor Chang Institute, Sydney), presented data on the control mechanisms of proliferation of skeletal muscle stem cells. This area of research is receiving intense interest internationally. In a provocative presentation entitled "Bench to bedside", Claude Lenfant (Director, National Heart, Lung, and Blood Institute, Bethesda, USA) stressed the need for translating the discoveries in the basic sciences into clinical care. In other sessions, Christine Seidman (Professor of Medicine and Genetics, Harvard Medical School, Boston, USA) showed how understanding gene defects and the changes they produce in myocardial proteins is unlocking the mechanism of an increasing number of cardiomyopathies underlying heart failure. Highlights of the 14th World Congress of Cardiology* Worldwide issues Epidemic of cardiovascular disease in developing countries Tobacco, diabetes and obesity Global cardiovascular risk assessment Atherosclerosis Inflammation Presymptomatic detection of coronary artery disease Reversibility with aggressive cholesterol reduction Intervention Drug-eluting stents Arrhythmia Rate or rhythm control for atrial fibrillation Heart failure B-type natriuretic peptide Beta-blockers Outpatient management Acute coronary syndromes Acute intervention New fibrinolytics and antithrombotics Molecular biology Gene and cell therapy Genes and cardiomyopathy * Some of the highlights are available as a webcast on <http://www.prous.com/wcc2002/program.asp#> (accessed 8 September 2002, no longer available).

Saul B Freedman PhD, FRACP

Objectives: To determine whether routine urinalysis in the antenatal period facilitates diagnosis of pre-eclampsia. Can routine urinalysis during pregnancy be discontinued in women with normal results of dipstick urinalysis and microscopy at the first antenatal visit?Design: Prospective observational study.Setting: A metropolitan public hospital and a private hospital in Sydney (NSW).Participants: One thousand women were enrolled at their first antenatal visit (March to November 1999), and 913 completed the study.Outcome measures: The primary outcome was a diagnosis of de novo hypertension (gestational hypertension, pre-eclampsia, or pre-eclampsia superimposed on chronic hypertension).Results: Thirty-five women had dipstick proteinuria at their first antenatal visit. In 25 (71%) of these women, further dipstick proteinuria was detected during pregnancy, and two (6%) were diagnosed with pre-eclampsia. Of the 867 without dipstick proteinuria at the first visit, 338 (39%) had dipstick proteinuria (> 1+) at some time during pregnancy. There were no statistically significant differences in the proportion of women with and without dipstick proteinuria at their first visit who developed hypertension during pregnancy. Only six women developed proteinuria before the onset of hypertension. Women who had an abnormal result of a midstream urine test at their first visit, compared with women with a normal result, were more likely to have a urinary tract infection diagnosed during pregnancy; however, the numbers were small.Conclusion: In the absence of hypertension, routine urinalysis during pregnancy is a poor predictor of pre-eclampsia. Therefore, after an initial screening urinalysis, routine urinalysis could be eliminated from antenatal care without adverse outcomes for women.

Noreen Murray RM, BN · Caroline S E Homer RM, PhD · Gregory K Davis MD, FRACOG · Julie Curtis RN, RM · George Mangos MD, FRACP · Mark A Brown MD, FRACP

Objectives: To evaluate the effectiveness of coordinated care for chronic respiratory disease.Design and setting: Community-based geographical control study, in western (intervention) and northern (comparison) metropolitan Adelaide (SA).Participants: 377 adults (223 intervention; 154 comparison) with chronic obstructive pulmonary disease, asthma or other chronic respiratory condition, July 1997 to December 1999.Intervention: Coordinated care (includes care coordinator, care guidelines, service coordinator and care mentor).Main outcome measures: Hospital admissions (any, unplanned and respiratory), functionality (activities of daily living) and quality of life (SF-36 and Dartmouth COOP).Results: At entry to the study, intervention and comparison subjects were dissimilar. The intervention group was 10 years older (P < 0.001), less likely to smoke (P = 0.014), had higher rates of hospitalisation in the previous 12 months (P < 0.001) and had worse self-reported quality of life (SF-36 physical component summary score [P < 0.001] and four of nine COOP domains [P = 0.002–0.013]). After adjustment for relevant baseline characteristics, coordinated care was not associated with any difference in hospitalisation, but was associated with some improvements in quality of life (SF-36 mental component summary score [P = 0.023] and three of nine COOP domains [P = 0.008–0.031]) compared with the comparison group.Conclusions: Coordinated care given to patients with chronic respiratory disease did not affect hospitalisation, but it was associated with an improvement in some quality-of-life measures.

Brian J Smith MB BS, PhD · Heather J McElroy BSc(Hons) · Richard E Ruffin MD, FRACP · Adrian R Heard MPH, BSocAdmin · Peter A Frith MD, FRACP · Malcolm W Battersby MB BS, PhD · Adrian J Esterman BSc(Hons), MSc · Peter Del Fante MB BS(Hons), MSc(Public Health) · Peter J McDonald MB BS, FRACP

Objectives: To describe the epidemiology of gestational diabetes mellitus (GDM) in Victoria.Study design: Population study of all women having singleton births in Victoria in 1996.Methods: Probabilistic record linkage of routinely collected data and capture–recapture techniques to provide an estimate of the incidence of GDM.Main outcome measures: Risk factors for and the adverse outcomes associated with GDM compared with the non-diabetic population by univariate and multivariate analysis.Results: The estimated incidence of GDM was 3.6% (95% confidence interval [CI], 3.60%–3.64%). GDM is associated with women who are older, Aboriginal, non-Australian born, or who give birth in a larger hospital. The adverse outcomes associated with GDM pregnancies were hypertension/pre-eclampsia (adjusted odds ratio [OR], 1.6; 95% CI, 1.4–1.9), hyaline membrane disease (1.6; 1.2–2.2), neonatal jaundice (1.4; 1.2–1.7) and macrosomia (2.0; 1.8–2.3). Interventions during childbirth were also associated with GDM — for example, induction of labour (3.0; 2.7–3.4) and caesarean section (1.7; 1.6–1.9).Conclusion: Women with GDM had increased rates of hypertension, pre-eclampsia, induced labour, and interventional delivery. Their offspring had a higher risk of macrosomia, neonatal jaundice and hyaline membrane disease.

Christine A Stone GradDipEpidBiostat, MPH, MHSc(PHP) · Kylie A McLachlan MB BS, FRACP · Jane L Halliday PhD · Peter Wein MB BS, FRANZCOG, GradDipEpidBiostat · Christine Tippett MB BS, FRANZCOG, MRCOG

Objectives: To investigate the relationship between access block in the emergency department (ED) (defined as total time from arrival to transfer from the ED over eight hours) and inpatient length of stay (LOS).Design and setting: Retrospective cohort study of all admissions through the ED to a tertiary hospital in Canberra, Australian Capital Territory, during 1999.Main outcome measures: Total time in the ED and LOS, calculated in days from ED departure to hospital discharge (non-overnight admissions were assigned LOS of one day, and all LOS were truncated at 10 days).Results: 11 906 admissions were included, and 919 experienced access block (7.7%). Mean LOS was 4.9 days in those who experienced access block (95% CI, 4.7–5.1), compared with 4.1 days in the no-block group (95% CI, 4.0–4.2; P < 0.0001). Subgroup analysis showed that this "access block effect" occurred across different severities of illness and diagnoses. A strong relationship was found between longer LOS and arrival of access-block patients on the inpatient ward outside office hours (0800–1600 weekdays).Conclusions: This is the first study to show an association between access block and a measure of outcome outside the ED. If the effect of access block on LOS is reproduced in other settings, there are major implications for hospital management.

Drew B Richardson FACEM

Objective: To assess the practicality of using personal digital assistants (PDAs) for the collection of logbook data, procedural performance data and critical incident reports in anaesthetic trainees.Design: Pilot study.Setting: Two tertiary referral centres (in Victoria and New Zealand) and a large district hospital in Queensland.Participants: Six accredited Australian and New Zealand College of Anaesthetists (ANZCA) registrars and their ANZCA training supervisors.Interventions: Registrars and supervisors underwent initial training for one hour, and supervisors were provided with ongoing support.Main outcome measures: Reliable use of the program, average time for data entry and number of procedures logged.Results: ANZCA trainees reliably enter data into PDAs. The data can be transferred to a central database, where they can be remotely analysed before results are fed back to trainees.Conclusions: This technology can be used to monitor professional performance in ANZCA trainees.

Paul D Bent MB BS, BMedSci · Stephen N Bolsin MB BS, FANZCA · Bernie J Creati MB BS, FANZCA · Andrew J Patrick MB BS, FANZCA · Mark E Colson MB BS, FANZCA

Rheumatoid arthritis is a common disorder. Its various articular and extra-articular manifestations are well described, but less well known is the association between rheumatoid arthritis and malignancy. There is an intrinsic risk of lymphoma, particularly non-Hodgkin's lymphoma, in rheumatoid arthritis. In determining causality, it is difficult to separate the effects of treatment from those of the disease itself — most patients with rheumatoid arthritis are treated with more than one immunosuppressive agent during the course of their disease. Cyclosporin has been implicated in the development of lymphoma, predominantly in association with transplantation.1,2 In addition, there are an increasing number of reports of B-cell lymphomas in rheumatoid arthritis patients that would seem to implicate methotrexate.3-10 Clinical recordA 63-year-old white man with seropositive rheumatoid arthritis presented to our outpatient clinic with a 4-week history of right hip and buttock discomfort. He described a deep ache, with no radiation. The pain was worse on weight-bearing and during the night. He had had mild fevers, and had lost 7 kg in weight over the previous 2 months. His rheumatoid arthritis had been difficult to control in the 10 years since the initial diagnosis, and at the time of presentation his medications were methotrexate 20 mg weekly, cyclosporin 125 mg twice daily, sulfasalazine 1 g three times daily, and hydroxychloroquine 200 mg daily. He does not have Sjögren's syndrome. Intercurrent medical conditions included bronchiectasis since childhood and interstitial lung disease secondary to rheumatoid arthritis. Examination revealed painful restriction of movement of the right hip and swelling of the right buttock. Mild synovitis was present in the hands, shoulders, neck and knees. He also had clubbing, bilateral basal crepitations and splenomegaly (all longstanding). There was no lymphadenopathy. The erythrocyte sedimentation rate and C-reactive protein level were elevated at 84 mm/h (normal range, 0–14 mm/h) and 100 mg/L (normal range, < 10 mg/L), respectively. He had normocytic anaemia, with a haemoglobin level of 103 g/L (normal range, 130–180 g/L). His white cell count and platelet count were normal, as were liver function test results and electrolyte levels. His creatinine level had risen from 110 mol/L to 180 mol/L (normal range, 50–90 mol/L) over 3 months. Cyclosporin was stopped because of his worsening renal function. Radiography of his hips, pelvis and lumbosacral spine revealed mild degenerative changes only. A bone scan showed increased uptake in the region of the right buttock, right sacroiliac joint and the superior aspect of the right acetabulum. Computed tomography (CT) scan revealed diffuse swelling involving the right gluteus medius and piriformis muscles (Box, Figure 1). Magnetic resonance imaging (Box, Figure 2) confirmed these findings, but also showed swelling of the obturator internus and part of the gluteus maximus muscles, as well as some increased signal in the right iliac bone seen on T1-weighted images. Tissue from the right gluteus medius muscle was obtained by open biopsy. Histological examination revealed diffuse infiltration of malignant lymphoid cells (Box, Figure 3), with positive immunoperoxidase staining for the leukocyte common antigens CD20 and CD79. A diagnosis of diffuse large B-cell, non-Hodgkin's lymphoma was made. Staging (CT of the chest, abdomen and pelvis; bone marrow biopsy; and gallium scanning) revealed no other sites of lymphoma. Serological tests for HIV gave negative results. The malignant cells were negative for Epstein–Barr virus DNA by polymerase chain reaction. When the diagnosis was established, methotrexate was also stopped. The patient presented for CHOP-based chemotherapy (cyclophosphamide, adriamycin, vincristine, prednisolone) 19 days later (2 months after he stopped taking cyclosporin). The palpable swelling of the right buttock had disappeared, and a repeat CT scan confirmed resolution of the previously diffuse muscle swelling (Box, Figure 4). Chemotherapy was withheld. Fifteen months later, there has been no recurrence. His rheumatoid arthritis flared when he was taking sulfasalazine and hydroxychloroquine, and is being managed with combination corticosteroids and non-steroidal anti-inflammatory medication. DiscussionPatients with rheumatoid arthritis have been reported to have a two- to threefold increased risk of lymphatic cancer (eg, non-Hodgkin's and Hodgkin's lymphoma).3,4 The suggestion that disease-modifying drugs further increase this risk is controversial, as it is difficult to match patients for disease severity. Disease activity may, in itself, be a risk factor for development of lymphoma,5 and, because more potent immunosuppressive agents are used in more severe disease, there may not be a true relationship between treatments and lymphoma. However, lymphoma in patients taking cyclosporin in association with transplantation is well described, with a 28-times-higher prevalence.1 There is a predominance of non-Hodgkin's lymphoma, and suggestive evidence that Epstein–Barr virus plays a role in the aetiology of some of these lymphomas, with documented remission on reduction or cessation of the immunosuppressive therapy.2 There are an increasing number of reports of lymphoma in patients treated with methotrexate for rheumatoid arthritis.6-8 Extranodal involvement is common, occurring in 69% of cases, although, in contrast to findings in AIDS patients and patients having transplantation, high frequencies of brain involvement have not been found.6 The predominant lymphoma type is large B-cell, non-Hodgkin's lymphoma. Epstein–Barr virus has been found in the lymphoma cells in 41% of cases.6 The strongest causal link is spontaneous lymphoma remission after stopping methotrexate. This has been documented in at least 15 patients with rheumatoid arthritis,6-8 with remission occurring within 4 weeks of stopping the drug. Therefore, a period of observation without immunosuppressive treatment is mandatory. Given the widespread use of methotrexate in rheumatoid arthritis, the number of reported cases is small. The increased risk of lymphoma in rheumatoid arthritis patients treated with methotrexate is probably real, but it is a low risk. It has been suggested that this effect of methotrexate and of cyclosporin occurs only in the subgroup of rheumatoid arthritis patients who already have severely disturbed immunity.7,9,10 Immunosuppressive treatment may lead to even poorer oncogenic surveillance and the survival of a malignant clone. As combination therapy, such as methotrexate and cyclosporin, becomes more widespread, physicians will have to be more aware of the potential for lymphoma. Competing interestsNone identified. Imaging and histological examination of the right gluteal region of a man with rheumatoid arthritis 1: CT scan, showing diffuse swelling of the right gluteus medius and piriformis muscles. 2: MRI (T1-weighted), showing diffuse swelling of the right gluteus medius, piriformis and gluteus maximus muscles (also increased signal in the right iliac bone). 3: Histological examination of tissue from gluteus medius, showing cords of intermediate to large malignant lymphoid cells infiltrating skeletal muscle and fat. 4: CT scan 3 weeks after stopping immunosuppressive therapy, showing spontaneous resolution of the previous swelling of the right gluteus medius muscle.

Irwin G S Lim MB BS · James V Bertouch MB BS, MD, FRACP

Objective: To systematically review surveys of clinicians' attitudes to clinical practice guidelines.Data sources: MEDLINE, HealthStar, Embase and CINAHL were searched electronically for English-only surveys published from 1990 to 2000.Study selection: We included surveys with responses to one or more of seven propositions (see below). Studies were excluded if they had fewer than 100 respondents or if the response rate was less than 60%.Results: Thirty studies included responses to one or more of the seven items, giving a total of 11 611 responses. The response rate for the included studies was 72% (95% confidence interval [CI], 69%–75%). Clinicians agreed that guidelines were helpful sources of advice (weighted mean, 75%; 66%–83%), good educational tools (71%; 63%–79%) and intended to improve quality (70%; 60%–80%). However, clinicians also considered guidelines impractical and too rigid to apply to individual patients (30%; 23%–36%), that they reduced physician autonomy and oversimplified medicine (34%; 22%–47%), would increase litigation (41%; 32%–49%) and were intended to cut healthcare costs (52.8%; 39%–66%).Conclusions: Surveys of healthcare providers consistently report high satisfaction with clinical practice guidelines and a belief that they will improve quality, but there are concerns about the practicality of guidelines, their role in cost-cutting and their potential for increasing litigation.

Cynthia M Farquhar MB ChB, MD, FRANZCOG · Emma W Kofa BA · Jean R Slutsky PA, MSPH

Objective: To investigate family members' experiences of involvement in a previous study (conducted August 1995 to June 1997) following their child's diagnosis with Ewing's sarcoma.Design: Retrospective survey, conducted between 1 November and 30 November 1997, using a postal questionnaire.Participants: Eighty-one of 97 families who had previously completed an in-depth interview as part of a national case–control study of Ewing's sarcoma.Main outcome measures: Participants' views on how participation in the previous study had affected them and what motivated them to participate.Results: Most study participants indicated that taking part in the previous study had been a positive experience. Most (n = 79 [97.5%]) believed their involvement would benefit others and were glad to have participated, despite expecting and finding some parts of the interview to be painful. Parents whose child was still alive at the time of the interview recalled participation as more painful than those whose child had died before the interview. Parents who had completed the interview less than a year before our study recalled it as being more painful than those who had completed it more than a year before.Conclusions: That people suffering bereavement are generally eager to participate in research and may indeed find it a positive experience is useful information for members of ethics review boards and other "gatekeepers", who frequently need to determine whether studies into sensitive areas should be approved. Such information may also help members of the community to make an informed decision regarding participation in such research.

Debbie A Scott DipNurse, MPH · Frances M Boyle BA(Psych)(Hons), PhD · Christopher J Bain MBBS MPH · Patricia C Valery MD, MPH, PhD

There are few good-quality studies of the effectiveness of antibiotic treatment of proven group A streptococcal (GAS) pharyngitis in children; available data suggest that antibiotics may reduce symptom duration. While there is limited justification for antibiotic treatment of GAS pharyngitis to prevent acute rheumatic fever in non-Indigenous Australians, there is no justification for routine antibiotic treatment of all patients with sore throat. Two strategies are open to clinicians: not to treat GAS pharyngitis with antibiotics, in which case no investigations should be done; or to treat cases of sore throat with clinical features that suggest GAS, in which case diagnosis should be confirmed with a throat swab, and penicillin started while awaiting the result. Penicillin should be discontinued if the swab is negative, or continued for 10 days if it is positive for GAS. Surveillance of GAS infections and acute rheumatic fever is needed in Australia, as are further studies of effectiveness (including cost-effectiveness) of antibiotic treatment of proven GAS pharyngitis.

Margaret H Danchin MB BS · Nigel Curtis PhD, FRACP · Jonathan R Carapetis PhD, FRACP · Terence M Nolan PhD, FRACP

Information contained in letters of referral and reply often does not meet the information needs of letter recipients. Missing reports of previous investigations and insufficient detail in the referral letter to specialists are the most serious and common problems. General practitioners prefer structured, computer-generated letters to unstructured, dictated letters. Referring surgeons and GPs identify delay in receiving the reply letter and insufficient detail as relatively common problems after a new patient consultation. They want the reply letter to describe the proposed treatment, expected outcomes and any psychosocial concerns, yet these items are often omitted. A letter content and format prompt card has the potential to enhance the quality of correspondence between medical specialists and referring doctors. Specialist medical bodies should consider preparing prompt cards (setting out preferred information content and format for letters) to distribute to their members.

Martin H N Tattersall MA, MD, MSc, FRCP, FRACP · Phyllis N Butow PhD, MPH · Judith E Brown BA(Hons) Psych, GradDipPsych, DipEd BSc · John F Thompson MD, FRACS, FACS

To the Editor: The Victorian Health Records Act 2001 became operational on 1 July 2002. This legislation provides important protection for the individual against misuse of health information through the establishment of Health Privacy Principles. We support the spirit of this legislation, but would like to draw attention to its potential effects on multicentre research and disease surveillance. We recently began a study to estimate the burden of invasive group A streptococcal disease in Victoria. The study involves identification of patients through laboratory notifications, followed by collection of clinical data — a strategy similar to surveillance of notifiable diseases. The study is funded by the National Health and Medical Research Council. We have sought institutional ethics committee approval, and are obtaining individual informed consent from patients. Despite approval from the Human Research Ethics Committee of the Victorian Department of Human Services, concerns arising from the new privacy legislation led most Victorian healthcare institutions to also require approval by their own ethics committees. We have now applied to over 30 separate committees, and the process is not yet complete. This has been an enormous drain on resources, has necessitated our establishing complex administrative procedures, and delayed commencement of the project. Moreover, many committees have required that we pay an application fee of several hundred dollars. Some have been uncertain about the implications of the new legislation for our project, and have requested clarification from the Victorian Health Services Commissioner. Despite these processes, some clinicians we have contacted are unwilling to allow their patients to be approached for fear of breaching privacy legislation. Our protocol is not controversial, and no substantive issues have been raised by any of the ethics committees. While ethical clearance is crucial to the success of the project, we were unprepared for the amount of work, confusion and expense involved. It is possible that these difficulties could discourage other researchers from conducting similar studies in Victoria. Similar concerns have been raised in the United Kingdom since the introduction of new privacy laws.1 The Victorian legislation allows for research and surveillance activities using identifying data if they are in the public interest, or if it is impracticable to seek individual consent. However, the legislation does not provide guidelines on what constitutes public interest or when consent is impracticable. The extent to which this legislation affects multicentre research or surveillance projects needs to be clarified, and a more simplified ethical approval process for surveillance activities identified.

Jonathan R Carapetis · Jonathon W Passmore · Kerry Ann O'Grady

Comment: It is unfortunate that a valuable research project has apparently been made more difficult or delayed by the combination of complex new privacy law and longer-standing inefficiencies in the ethical review of multicentre research proposals. Both are issues with which the Australian Health Ethics Committee (AHEC) is grappling at present. Multicentre research was identified as a significant issue in the review that led to the revised 1999 National Statement on Ethical Conduct in Research Involving Humans.1 The Statement makes it clear that researchers have a role in negotiating with human research ethics committees and institutions to seek agreement that the ethical and scientific assessment of one committee or institution will be accepted by other sites. The National Statement equally empowers ethics committees to minimise unnecessary duplication. Ethics committees have been very slow to grasp the opportunities offered by the 1999 National Statement for reasons that may include the past practice of insisting that each committee make its own assessment. Initiatives are now in train in New South Wales, Victoria, Western Australia and Queensland to develop different forms of centralised assessment, but the benefits may take time to be realised. AHEC, through its bulletins and workshops for ethics committee members, has repeatedly reminded committees how to simplify multicentre review, but traditional practices appear to have obstructed this message. This letter is yet another opportunity to remind ethics committees and institutions that the National Statement permits and encourages them to exercise initiative, judgement and common sense in facilitating effective and timely review of multicentre research. With regard to the difficulties associated with the new privacy regimes being put in place by a combination of federal and State laws, AHEC anticipated some introductory problems in relation to human research. It is understandable that ethics committees and researchers will take time to adjust some of their established practices to comply with the law and associated guidelines. During the period of adjustment, some flexibility needs to be exercised by all parties. AHEC conducted a series of workshops in all capital cities earlier this year to assist researchers and ethics committees in this phase. An explanatory guide to the use of privacy law and the associated guidelines from the National Health and Medical Research Council was used at these workshops and will be made more widely available shortly. Finally, the federal legislation will be the subject of a systematic review after two years. Unintended consequences of the law should be addressed at that time. AHEC understands that, in Victoria, the Health Services Commissioner, whose office has responsibilty for supervising the application of the health privacy law, is in the process of producing a practical guide for Victorian healthcare researchers.

Kerry J Breen · Sandra M Hacker

Comment: As I understand Carapetis et al's study, the researchers determine who has a group A streptococcal infection from the laboratory that performs the test (as this infection is not a notifiable disease,1 there is no central source of information). The laboratory may be independent or in a public or private hospital, and may be situated anywhere in Victoria. The laboratory tells them who requested the test and the patient's name and infection status. The researchers then seek assistance from the hospital or doctor requesting the test in obtaining "individual informed consent" from the patient to release clinical information to the researchers. Each institution has required that its own human research ethics committee approve the project, as well as the Department of Human Services (DHS) Ethics Committee, before the laboratory releases information. This accords with the law, but the additional bureaucracy and costs involved will deter much important public health research. The law: In Victoria, public and private hospitals and their employees have a statutory duty of confidentiality under section 141 of the Health Services Act 1988 (Vic). There is an exception when the patient consents (s 141(3)(a)), but, in Carapetis et al's study, patients cannot be approached until the laboratory gives identifying information. Information may be divulged for medical research without patient consent if an ethics committee "established under the by-laws of the agency" has approved "the use to which the information will be put and the research methodology" (s 141(3)(g)). The giving of information must also accord with Health Privacy Principle (HPP) 2.2(g) in the Health Records Act 2001 (Vic): it must be necessary and "in the public interest"; it is impracticable to seek consent; identifying information is needed; identifying information will not be published; and it must conform with the Guidelines of the Health Services Commissioner.2 The federal Privacy Act 1988 (Cwlth) contains similar provisions.3 Options for change: The Health Services Commissioner has power to issue guidelines varying the subparagraphs of HPP 2, and even to lessen the level of privacy protection, if it is in the public interest to do so.4 However, guidelines cannot override the requirement in the Health Services Act that projects must be approved by the ethics committee "established under the by-laws of [each] agency". There are four options for change: The Health Services Act could be amended so that approval of one human research ethics committee is sufficient. The Secretary of the DHS could prescribe more diseases as notifiable,1 so that information is available centrally, and access could be authorised by the DHS Ethics Committee. The Secretary could request information from pathology laboratories for public health research and supply that to the researchers (laboratories would be protected under section 137 of the Health Act 1958 [Vic]). Institutions could amend their by-laws — or ethics committees could adopt a policy — that the institution will follow the approval of the DHS Ethics Committee in public health research.5 The last seems the simplest option, but historically this approach has not been favoured in multicentre trials in Australia.

Loane LC Skene

To the Editor: Diabetes is a leading cause of morbidity and mortality in Australia, with 50% of cases remaining undiagnosed.1 Consequently, the Australian National Diabetes Strategy has early detection of diabetes as a key priority.2 We undertook a study to determine the prevalence of abnormal glucose metabolism (impaired fasting glycaemia [IFG] and diabetes) in patients presenting in the fasted state for endoscopy or colonoscopy at a metropolitan teaching hospital. We used the definitions of abnormal glucose metabolism outlined by the World Health Organization in 19993 and published in a position statement in the Journal in April 1999.4 Two hundred and twenty-four patients gave informed consent and participated in the study, comprising 126 men and 98 women. Mean age (SD) was 75.1 years (6.9) for men and 60.9 years (17.6) for women. Twenty-four participants (11%) had known diabetes. The remaining 200 patients had fasting venous plasma glucose levels determined (Box). Patients with abnormal glucose metabolism (fasting plasma glucose level > 6.1 mmol/L) were offered further testing with a 2-hour oral glucose tolerance test (OGTT) after a 75 g glucose load. Nine patients initially classified with IFG had diabetes based on OGTT results. No patient classified with diabetes on initial testing was subsequently classified as not having diabetes by the OGTT. The overall prevalence of undiagnosed diabetes was 7% (15 patients). We demonstrated a high prevalence of abnormal glucose metabolism in a group of predominantly elderly patients presenting for gastroenterological procedures. Furthermore, subsequent investigation of these patients revealed that a substantial proportion who were classified with IFG on initial screening were classified with diabetes based on 2-hour OGTT results, highlighting the importance of this test in diagnosing diabetes. It is likely that we underestimated the prevalence of abnormal glucose metabolism, as OGTT was not performed in all patients. This is supported by results of the AusDiab study that revealed a high prevalence of abnormal glucose metabolism in older patients — 37% of those aged 55–64 years, 47% of those 65–74 years, and 53% of those 75 years and over.1 National Health and Medical Research Council guidelines suggest that all patients with a fasting plasma glucose level of 5.5–6.9 mmol/L be referred for OGTT.5 Based on this suggestion, an additional 28 patients in our study group would have had an OGTT. Measurement of fasting venous plasma glucose level is safe, relatively simple and inexpensive. Patient presentations in the fasted state for investigations and procedures provide an ideal opportunity for screening with this test. Patients with abnormal results should be referred for further testing with repeat fasting glucose determination or OGTT. This process may be facilitated by involving patients' general practitioners. Results of fasting plasma glucose tests in 224 patients presenting for gastroenterological procedures Fasting plasma glucose level Normal (< 6.1 mmol/L) 172 (77%) Impaired fasting glycaemia (≥ 6.1 mmol/L, < 7.0 mmol/L) 22 (10%)* Diabetes (≥ 7.0 mmol/L) 6 (3%)† Not tested (known diabetes) 24 (11%) * Diabetes was confirmed on subsequent oral glucose tolerance test (OGTT) in nine of these patients (four refused further testing). † Diabetes was confirmed on subsequent OGTT in all six patients.

Anthony T Zimmermann · Stephen N Stranks · Sally L Gall · Geoffrey S Hebbard

To the Editor: Thank you to McVeagh1 for highlighting some more of the amazing scientific evidence regarding the benefits of breastfeeding. It is extremely important to continue to emphasise the benefits to mother and child in order to strengthen the individual's resolve and the community's support for breastfeeding. However, my concern is whether the question "Is breastfeeding best practice?" should ever be posed in the first place. Do our natural physiological processes now need to be supported by an evidence base and scrutinised in terms of whether they conform to notions of "best practice"? And should the question about choice between breastfeeding and artificial feeding continue to be asked? McVeagh also posed the question, "Is there justification in the argument that women are being pushed too hard to breastfeed?". Can there ever be too much encouragement given to women to provide nutrition and nurturing hand-in-hand to their baby? We must keep emphasising that breastfeeding is not only about good nutrition, reduction in childhood obesity and other measurable health outcomes. Surely there must remain some areas in our lives that do not require evidence and scientific support. Breastfeeding is about loving and nurturing a baby. It is about human relationships. When one experiences a newborn latching on to feed, the clearly felt surge of hormones from breast to brain, the physical expression of these hormones as a palpable "let-down" reflex and the incredible sight of milk rushing from the breast on demand, we do not need science to tell us that this is one of life's most amazing and wonderful experiences, nor to confirm what breastfeeding mothers innately know to be best practice.

Sandra L Neate

In reply: I thank Neate for her comments and for challenging the need to ask "Is breastfeeding best practice?". I appreciate her sentiment that there is more to infant feeding than nutrition and health. However, while there are mothers who don't find breastfeeding pleasurable or easy and are deciding how long to persist; while there are mothers who opt not to exclusively breastfeed for six months or to wean before a year of age; while mothers' advisors prescribe solids or complementary feeds or weaning for myriad problems without evidence for effectiveness beyond a placebo effect; while some believe that the disadvantages of not breastfeeding only apply to infants in developing countries; while there are commercial interests promoting products that undermine exclusive breastfeeding; while the Australian government has not fully implemented the recommendations of the World Health Organization Code and subsequent resolutions;1 while health professionals are receiving "educational material" implying that a new additive makes commercial infant formula more like human milk; and while the scientifically minded among us just need to satisfy our curiosity, we need to know to what extent it matters if an infant is breastfed at all, breastfed exclusively, or breastfed for longer periods. Thank you for challenging the question. The weight of the evidence is such that the real question is not "Is breastfeeding best practice" but "By how much?".

Patricia McVeagh

To the Editor: The working group responsible for the recent chronic fatigue syndrome (CFS) guidelines needs to be congratulated for producing a sensible and well balanced document in a most controversial area.1 Larkins and Molesworth have contributed a somewhat predictable response.2 Some sufferers of CFS can be characterised by their capacity to react strongly to the suggestion that psychological factors may be involved in the pathogenesis of their condition.3 From the perspective of the consultation-liaison psychiatrist, their response can be written with the comments on physical and psychological issues substituted for one another. Hence it can read (1) there is no current evidence that the syndrome has a specific physical origin, and (2) there is evidence that a range of psychological issues occur in people with CFS, although it remains unclear whether these changes are primary or secondary. The mental health movement has worked hard in recent times to reduce the stigma associated with psychiatric conditions. The sufferers of chronic physical illness now accept the importance of looking after their emotional health as well as their physical well-being. Enlightened CFS sufferers and support groups accept the links between physical and psychological morbidity and do not mindlessly exclude the latter. There is ample evidence that cognitive–behavioural strategies and graded exercise programs assist those with CFS, and psychiatrists are skilled in providing these treatments.4

James D Hundertmark

To the Editor: The process of destigmatising chronic fatigue syndrome (CFS) is not advanced by either limiting enquiry to "acceptable" sciences or increasing the stigma already experienced by people with other neuropsychiatric disorders. Contrary to its intent, and in contrast to the recently published Royal Australasian College of Physicians (RACP) guidelines,1 the recent statement by the immediate past president of the RACP and the Chairman of the ME/Chronic Fatigue Syndrome Association of Australia2 is in danger of increasing the stigma for both people with CFS and people with other common mental disorders. Unfortunately, key propositions in their letter ("There is no evidence that the illness is primarily psychological in origin") are clearly at variance with the tone of the guidelines (see Box 1.5, p. S31; Box 1.7, p. S32; and, "Management" summary, p. S38). Their letter reinforces the classical "dualistic" and rather simplistic "biological" approach (eg, "There is significant evidence of a range of biological abnormalities occurring in people with CFS"). Unwittingly, it colludes with community-based beliefs that mental health problems are "not health",3 and often imaginary or under the voluntary control of the patient.4 There is no doubt that people with CFS share many experiences with people with other neuropsychiatric disorders. They both have daily experiences where their credibility is challenged, their disability is minimised and their needs for appropriate medical management are not met. Australian research and best practice have been recognised internationally for emphasising the integration of psychological, psychiatric and biological factors and respect for the experiences of persons with these debilitating disorders.5 Unfortunately, the major advances captured in the guidelines may now be undermined if the RACP is perceived to be backing away from supporting appropriate psychological assessment and provision of effective "psychological" treatments (such as cognitive–behavioural therapy and physical rehabilitation approaches). Similar equivocation has left clinical guideline processes in the United Kingdom in disarray.6 As demonstrated recently, prolonged fatigue syndromes are common in the Australian community, and the vast majority of those who seek healthcare services have concurrent depression or anxiety.7 Real progress towards destigmatisation, meaningful research progress and improved health services for people with CFS will only occur when the field is mature enough to deal with the clear relevance of psychological factors. Instead of rejecting "psychological factors" and associated treatments, relevant professional and consumer bodies should now join with the broader community movement towards increased community awareness of common neuropsychiatric disorders, genuine understanding of their (genetic, "biological", psychosocial and personal) causes and provision of effective (pharmacological and psychological) treatments.8

Ian B Hickie

To the Editor: In the recent letter from Larkins and Molesworth1 various statements are made on which I would like to comment. From time to time everyone becomes physically or mentally exhausted, whether or not it is related to activity. For some people this exhaustion becomes disabling. They deserve understanding and sympathy. We must do everything we possibly can to assist them to recover and to try to find possible causes. Larkins and Molesworth acknowledge that chronic fatigue syndrome is a serious, disabling illness. When does ordinary exhaustion become disabling? I would agree that at this stage there is no clinical evidence that the condition is primarily psychological. Nor is there evidence that it is primarily physical. There may be a mixture. What is the "significant evidence" of a range of biological abnormalities occurring in people with CFS? What are these biological abnormalities and what physiological evidence is there for each one of these abnormalities to produce fatigue? Larkins and Molesworth state that treatment plans should be "within the capabilities of the patient": is there evidence to indicate that stimulating each patient to do just that little more each day will do harm? It was stated that scientific evidence of the aetiology, pathology and treatment is grossly deficient. It is in fact absent. There is no evidence at all. Research is certainly required. One of the problems is that, as soon as a medical advisor informs a patient that investigations have shown no serious abnormality, the patient often goes away and says to himself or herself or family that the "doctor said there is nothing the matter with me and that it is all in my head". Nothing could be further from the truth. Something is the matter and it is up to us to find it out.

Donald D Beard

In reply: We thank the writers for their comments on the CFS guidelines1 and our joint letter about these guidelines.2 Hundertmark remarks on the interplay between physical and psychological factors in morbidity associated with CFS. We trust that our letter in no way contradicts this. Similarly, the inferences that Hickie drew from our letter are not supported by the text of the letter. Far from undermining the guidelines, our letter had the full support of the convenor of the working party responsible for the guidelines. As clearly discussed in the guidelines, in the absence of specific diagnostic tests it is likely that a range of factors may contribute to the pathogenesis of CFS. Assumption of a primarily "psychological" pathogenesis is as unjustified as assumption of a primary "physical" basis. There are "abnormal" test results in many people with CFS, including abnormalities of the hypothalamic–pituitary–adrenal axis and some abnormalities of immune function. As stated, it is controversial whether such abnormalities are primary or secondary. While cognitive–behavioural therapy with graded exercise is effective in some patients, the guidelines outline the deficiencies of the evidence which "significantly limit the generalisability of the findings". As the guidelines indicate, and as is supported by our letter, treatment should be designed in partnership with the patient, and tailored according to the patient's capacity and response. Finally, as implied by Beard's letter, we restate the need for further research into the aetiology, pathology and treatment of CFS. We believe that effective progress in the management of this complex and mysterious illness will be best achieved by positive and cooperative rather than adversarial relationships between those suffering from the condition and the doctors and researchers attempting to help them.

Richard G Larkins · Simon R Molesworth

To the Editor: Bolin et al,1 in their editorial accompanying articles by Yusoff et al2 and Bampton et al,3 took the opportunity to make their case for endoscopic screening for colorectal cancer. We believe that their editorial is seriously misleading. 1: It is misleading to suggest that the 27 case–control and cohort studies in the meta-analysis by Johns and Houston4 stratified the index case by age at diagnosis. The 2.25 risk quoted by Bolin et al refers to the overall risk of first-degree relatives in families with one affected relative. In those studies in which age was stratified in the meta-analysis, there is a spectrum of risk, with families with onset of bowel cancer at an older age having lifetime relative risks much less than the average. A subanalysis of seven studies with age stratification showed the risk to be 1.82 (95% CI, 1.47–2.25), where the index case was over 59 years at diagnosis. Whether a 1.8-fold risk elevation warrants colonoscopic surveillance could be debated. "First do no harm" is an important axiom in well-patient screening, so one should aim for an order of magnitude of benefit over risk, which in this situation is not secured until the patient being screened is older than the suggested 40 years of age. 2: The recommendation that colonoscopic follow-up of patients with only small, tubular, distal adenomas can be at less frequent intervals is not based on the US National Polyp Study,5 as suggested in the editorial. It is based on the large cohort study of Atkin et al,6 who reported that patients with this finding were actually at below-average risk (relative risk, 0.5) for subsequent colorectal cancer after prolonged follow-up. This occurred despite the inevitable "miss rates". The editorial by Bolin et al handles this issue unconvincingly. The main message of the US National Polyp Study5 was that follow-up (except in exceptional circumstances of numerous polyps, or incomplete removal of malignant polyps) is not needed at 12 months — after 3 years is adequate. The National Health and Medical Research Council guidelines extend this to 4–6 years in the low risk groups, as defined by Atkin et al.6 The Atkin et al data, however, are only Level 3 evidence. 3: Bolin et al1 completely miss the point about pilot programs of screening with faecal occult blood testing (FOBT). There is no intention to confirm evidence of mortality reduction. The pilot studies are neither designed to, nor capable of, doing this. Mortality reduction from FOBT is well established on Level 1 evidence. The pilot studies are in place to answer the very practical questions of how to implement large-scale screening programs in Australia; what logistic and resource issues are involved; how compliance and acceptance will best be secured; and how to approach difficult-to-access populations (perhaps with low health insurance rates as distinct from populations well supplied by colonoscopy services). The central issue in advocating a menu of options to individuals versus more prescriptive screening (based on FOBT) is whether the height of the scientific bar should be at Level 1 evidence or modestly robust Level 3 evidence (flexible sigmoidoscopy) or the less robust Level 3 evidence (colonoscopy), complemented by certain appeals to logic (carefully crafted in the editorial). Medical initiatives based on less than Level 1 evidence have a history of being shown to be wrong, and the concept of colonoscopic surveillance is not immune from this outcome. Where a significant outlay from the public purse is involved, the Federal Government is being appropriately prudent in acting on Level 1 evidence.

Finlay A Macrae · Geoffrey S Hebbard

In reply: Macrae and Hebbard fail to grasp the concept that colorectal cancer is the only potentially preventable cancer in men and one of the two preventable cancers in women. In any discussion about screening options, this fact must be kept clearly in focus. In terms of surveillance of first-degree relatives, we doubt the available evidence is of sufficient quality to be certain whether the absolute risk is 1.82 or 2.25. In either event, we would advocate colonoscopic surveillance. We would, however, agree with Macrae and Hebbard on the importance of safety issues. Elsewhere we have advocated confining the performance of colonoscopies to endoscopists with Conjoint Committee Accreditation, and ensuring that the procedures are undertaken in accredited, suitably equipped facilities.1 We find it difficult to understand why Macrae and Hebbard believe that "the main message of the US National Polyp Study2 was that follow-up . . . is not needed at 12 months". Showing a reduction in expected cancers of 90% seems to us a far more important finding. We would, however, point out that our editorial does not advocate routine colonoscopic follow-up at 12 months. In relation to the pilot faecal occult blood testing (FOBT) studies, we believe that Macrae and Hebbard have missed the point. They advocate delaying colorectal cancer screening for a further five years to await the results of studies which, many believe, will be both outdated and probably inconclusive. Their continued inflexible stand is one that is being rejected by a rapidly increasing number of countries, including the United States, Germany, Italy and the recently formed Global Alliance for the Prevention of Digestive Cancer. Colorectal cancer is the commonest cause of mortality in both non-smoking men and women, with a death from this disease every two hours in Australia. We suggest that introducing screening is far more urgent than Macrae and Hebbard advocate. We re-emphasise the point that individuals should, if they wish, be provided with the opportunity of selecting a screening program from a menu of options chosen after discussion with their primary medical carer.

Terry Bolin · Alistair E Cowen · Melvyn G Korman

To the Editor: I am writing in response to the letter from Zardawi in the 19 August 2002 issue of the Journal.1 Zardawi suggests that radiologists and pathologists should not talk to patients, and that their contract is with the referring doctor, not with the patient. On both counts he is mistaken. Patients who are worried and anxious are certainly in need of some communication with the doctors carrying out their investigations. Most doctors of experience will know what is appropriate by way of conveying any results and what should be left to the patient's own doctor. Only those in bondage to corporate medicine will require a formula to instruct them in correct behaviour. That there is a contract with the patient is attested by the many cases of litigation against radiologists and pathologists. Of course, it is more efficient if the doctor does not speak to the patient, as valuable time is saved, and even more efficient if the doctor's staff do not speak to the patient either. This is common practice, as reported daily by patients and confirmed by my own recent experience. Nothing was communicated to me except that if I wished to rewrite my physician's referral to indicate that I had a palpable lump (which I did not) there would be a Medicare rebate, and that otherwise there would not, and I would thus have to pay the full amount. I declined the offer. I then waited two weeks to know that my results were normal. Some patients report that they will travel 20 km across the city to visit a practice where the staff look up and speak when patients enter, and where the doctor is not too busy to speak to them. No doubt such "inefficient" practices will disappear in time. The case of nuclear medicine differs in that the Health Insurance Commission schedule of fees requires the physician to see and assess the patient and to supervise the procedure in order for a benefit to be legally payable. The nuclear medicine physician is therefore in a position to know what is appropriate to communicate to the patient. Most patients are grateful for the opportunity to discuss the findings and to understand the implications of what has been found. In the case of serious abnormalities, such as pulmonary embolism, it is imperative that the patient be made aware of the importance of the findings and the need for immediate treatment.

Josephine C Wiseman

A 39-year-old man was investigated for three episodes of facial swelling following dental procedures performed between 1999 and 2001. On two occasions the patient was hospitalised and given intravenous antibiotic treatment for cellulitis. The facial swelling was ipsilateral to the dental procedure, unresponsive to antihistamines and not associated with urticaria, laryngeal oedema or bronchospasm. It occurred within about 12 hours of the procedure and resolved over several days. The patient reported a history of rash after penicillin exposure but no prior reactions to local anaesthetic agents. Full blood count, serum complement C3 and C4 levels, C-1-esterase inhibitor level and function were all within the normal range. An antinuclear antibody test was negative, IgE levels were not raised and no latex-specific IgE was detected. Skinprick, intradermal and subcutaneous testing with normal saline, the amide anaesthetics lignocaine and citanest, and the ester anaesthetic procaine showed no evidence of an immediate type 1 allergic reaction. However, two days later the patient reported that a raised area of skin had appeared. Subcutaneous injection with lignocaine resulted in a localised raised erythematous rash 48 hours after injection. A less intense reaction occurred with citanest, and no reaction was detected with procaine or normal saline alone. Histopathology of the skin biopsy from the lignocaine challenge site is shown in Boxes 1 and 2. DiscussionLocal anaesthetics can be classified into ester-type agents (eg, procaine, benzocaine) and amide-type agents (eg, lignocaine, bupivacaine, mepivacaine). Although allergic reactions to local anaesthetic agents are uncommon, both type 1 reactions (via an IgE-mediated mechanism) and delayed-type hypersensitivity (DTH) reactions have been described.1-5 This patient demonstrated a DTH reaction to two agents from the amide class of anaesthetics. Presumably, sensitisation to lignocaine had occurred at the time of previous procedures using the agent. Cross-reactivity with another amide-type local anaesthetic is the most likely explanation for the less intense reaction seen with citanest. Although DTH reactions to local anaesthetics are rare, this case highlights the fact that DTH reactions should be considered in the differential diagnosis of local reactions after procedures using local anaesthesia. This may avoid unnecessary investigations, misdiagnoses and inappropriate treatment. 1: Lignocaine challenge site (skin biopsy; haematoxylin and eosin stain) A dense dermal lymphocytic infiltrate was present around vessels (arrow), with focal spread into the papillary dermis. (Skin from the procaine challenge site showed no such infiltrates.) 2: Lignocaine challenge site (skin biopsy; immunoperoxidase stain) The infiltrating lymphocytes showed strong staining for CD3 surface antigens, typical of a delayed-type hypersensitivity reaction. (Staining for CD4, CD8 and CD4 surface antigens was also positive.)

Louise A Evans MB BS PhD · Judy Pointing RN · Edward J Wills MD FRCPA · Stephen Adelstein MB BCh FRACP FRCPA PhD · John Michalopoulos BDS(Hons)

Ted Stuckey epitomised "quiet achievement". Born on 15 June 1908, he grew up in Inverell, in northern New South Wales, where he was dux of his school. Later, as a medical student living at St Andrew's College, Sydney University, he excelled academically and in sport. He represented the College in rowing, and played hockey for the College, the University, and a combined Australian universities' team. After doing his residency at the Royal Prince Alfred Hospital and the Royal Alexandra Hospital for Children (RAHC), Ted married Joan Vowell and moved into general practice in Scone, NSW. While working in this practice he obtained his Master of Surgery degree. Ted returned to Sydney in 1939 to become a paediatric surgeon, and was appointed Honorary Relieving Assistant Surgeon at RAHC. When war intervened, he joined the Field Ambulance Service. He served until late 1944 in Queensland, then New Guinea, becoming second-in-charge of the 111th Casualty Clearing Station and attaining the rank of Major. From 1945, as Honorary Assistant Surgeon at RAHC, Ted and his colleagues did pioneering work in cardiothoracic and abdominal surgery. Ted's brother Doug was also part of the Congenital Heart Disease team that was involved in the early development of cardiac catheterisation and angiocardiography. In 1948, Ted gained his Fellowship of the Royal Australasian College of Surgeons. In 1958 he was awarded a Fulbright scholarship to study at Harvard Medical School. From 1958 to 1966 he lectured in paediatric surgery at the University of Sydney. He continued at RAHC as an Honorary Consultant Surgeon until 1973. In later years, Ted adopted a more relaxed lifestyle, doing sessional work with the Commonwealth Health Department until 1988 and Surgical Assistant work until 1994 (then aged 86!). Ted was a founding member of the Medical Benefits Fund in 1945 and served on its Council until 1971. He was also heavily involved with the Australian Medical Association. He was a member (1953–1966) and president (1961–1962) of the NSW Branch Council; a member of the AMA Federal Council (1964–1966); Assistant General Secretary, then Deputy Secretary General (1966–1972); and Secretary General (1972–1973). He was made a Fellow of the AMA in 1964. He was secretary of the AMA/benefit fund working party, which produced a plan for a voluntary health insurance scheme that was largely adopted by the federal government and introduced in 1970. He was also a member of the Medical Benefits Schedule Advisory Committee. Although deeply committed to his profession, Ted remained a devoted husband and father to his five children. Over the years, he built for his family a swimming pool, a terraced garden with a badminton court, and three unique folding caravans in which he loved to take them on camping holidays. Ted died on 7 June 2002 of acute renal failure.

Michael EV Stuckey MB BS FRCS FRACS

Max Dunstone was born in Adelaide on 6 July 1926. He was educated at Parkside Primary School, Prince Alfred College and Adelaide University, graduating in medicine in 1948. After a year as Resident Medical Officer at the Royal Adelaide Hospital, he entered general practice in 1950. Max could be described as one of the best general practitioners in South Australia. He had a substantial obstetric practice, was an excellent family doctor, and excelled in the academic and research areas of general practice. He was discerning and sound in clinical diagnosis, conscientious and thorough. His thoughtfulness, kindness and compassion were appreciated by his patients, family and medical peers, who regarded him with much respect and affection. He even learned to speak Italian to develop better communication and empathy with his Italian patients. Max was regarded by his colleagues as an excellent teacher. He recognised the wealth of medical information available in general practice and was able to use it in a practical way in developing the Research Committee of the Royal Australian College of General Practitioners (RACGP). His involvement with the RACGP was extensive. He was one of the first Board members (from 1958). Between 1958 and 1990 he served on eight College committees, his most notable work being in the capacity of Chairman of the SA Faculty Research Committee (1960–1990) and Chairman of the National Research Committee of the RACGP Council (1976–1979). He became a Fellow in 1972, and was Chairman of the SA Faculty Board (1974–1976) and Provost (1976–1978). Max held other notable appointments during his career, including that of Medical Officer for the City of Adelaide Central Board of Health (1979–1994), Board member for the SA Cancer Registry Board (1976–1986), and Chairman of the Medical Records Committee and Peer Review Committee of the North Eastern Community Hospital (1978–2000). Max's innovative approach to research was acclaimed by his peers. His research articles, some of which were published in the Medical Journal of Australia, were influential in the field of obstetrics in South Australia during the late 1970s. At that time, GP obstetricians delivered 84% of infants born in South Australia and Max made an assessment of their performance. His research was probably one of the contributing factors to the rise in standards of obstetric practice: by the early 1980s, South Australia had the lowest perinatal mortality rate in the world, at 5.5 per 1000 (compared with Sweden [8] and Australia [9]). In his leisure time, Max enjoyed tennis, golf and stamp-collecting. He was of strong religious persuasion and was a warden of St Aidan's Anglican Church in Payneham, SA. In 1986, he was made a Member of the Order of Australia "for service to medicine as a general practitioner for 36 years, with involvement in community-based medical research". Max died on 7 April 2002 of cancer of the urinary tract. Vale to a great doctor of high achievement, integrity, equanimity and humility.

Robert Cooter AM MB BS FRACGP

Edwin Cordeaux Blomfield was born on 25 December 1917 at Inverell, New South Wales. His early schooling was in the New England region and he completed his secondary education at North Sydney Boys' High School. While studying medicine at the University of Sydney (1936–1942), he stayed at St Paul's College. After graduating, he spent three years as a Resident Medical Officer at Hornsby District Hospital, where he met his future wife, Florence Kelsey, a nursing sister. They were married in 1945. In 1947, after two years in the army, Ted set up a general practice at Pambula, on the far south coast of New South Wales. He was the sole medical practitioner, prescribing and dispensing medicines, attending clinics in adjacent towns, and visiting patients in isolated areas. In 1949, Ted moved with his family to Bega. During his many years there, he delivered more than 3000 babies in the district, and was a great teacher to both nurses and doctors. He was highly skilled in surgery, anaesthesia and obstetrics, and, as there were no specialist doctors resident in Bega Valley until 1968, he had to deal with many emergencies of various kinds. He was also a foundation member of the Bega branch of St John Ambulance Australia in 1986, and over the years gave freely of his time teaching first aid and supporting the service. Ted had a gentle nature and was generous and friendly, with a quick wit and an endless supply of jokes. He affected the lives of many people in his community. He contributed greatly to the life of St John's Anglican Church in Bega and was a long-standing member of the Rotary Club, which recognised his contribution with a Paul Harris Fellowship, one of its highest awards. He was a supporter of Little Athletics, Meals on Wheels, and other organisations. He was a director of the Bega and District Nursing Home and was involved with the planning of "Casuarina Hostel", an assisted-care facility for the elderly. In 1998, he was awarded the Medal of the Order of Australia for his services to the community. Ted's hobbies included surfing and photography, and in later years, especially after his retirement in 1997, he enjoyed travelling to many parts of Australia. Ted will be remembered for his dedication, sense of humour and caring nature. He was a humble man who always had time for people — one of nature's gentlemen. Ted died on 12 December 2001 of pneumonia, a late complication of cardiac bypass surgery.

John D McKee MB BS FRCS FRACS

Anaesthesia: a concise handbook. Graham Arthurs. London: Greenwich Medical Media, 2001 ($69.30, ix + 159 pp). ISBN 1 84110 080 3. This pocket-size book aims to bring together helpful information for safe and effective everyday anaesthetic practice. It is based upon the personal notes of the author and is made up of a series of topics organised in alphabetical order. Many pages are devoted to key areas such as airway management, cardiac resuscitation protocols, emergency scenarios and nerve blocks. The range of topics covered is broad. It includes such things as fluid resuscitation through a rectal tube (in the absence of IV access), how to set up tubing for one-lung lavage through a double-lumen endotracheal tube, and even how to manage the situation when penile turgescence limits the ability to pass the cystoscope! It also includes sections on CXR interpretation and management of asthma in the emergency department that would be better suited to a medical handbook. As a result of this breadth, there is often a lack of sufficient detail to make the book seriously worthwhile. Although some of the content relates more to the United Kingdom style of anaesthetic practice (which includes more intensive care), the book does contain some interesting case reports and anecdotes (which are well referenced) and does attempt to emphasise the physiological principles upon which many of our interventions are based. I have several criticisms. The book often fails to emphasise the key points of a topic. For example, the section on the treatment of hyponatraemia recommends the use of hypertonic saline without warning of the dangers of rapid over-correction, and the section on ventilating the asthmatic patient does not consider the issue of dynamic hyperinflation, which can be lethal in these patients. Also, some of the recommended treatments do not reflect contemporary practice (eg, intermittent CO2 inhalation as a treatment for postdural puncture headache). The book is not particularly well organised and is repetitive in places. Some important areas, such as postoperative nausea and vomiting, are given scant attention. Added to this, the “point form” style in which it is written makes it difficult to read. Although good in concept, I would find the book difficult to recommend to anaesthetic trainees or anaesthetists. It lacks sufficient detail to be of real use, has many gaps and describes many procedures or ideas more suited to Third World anaesthesia than current Australian practice. Sesto CairoAnaesthetist, Alfred Hospital Prahran, VIC

Sesto Cairo

Caesareans and support A 1995 Cochrane review concluded that providing women with continuous caregiver support during labour decreases the chance of caesarean delivery — an expensive prospect which North American researchers decided to test in their own environment of high intervention rates. Over two years, 6915 women from 13 hospitals with caesarean rates of > 15% were randomly allocated to receive continuous support from a specifically trained nurse or usual care. There was no difference in the rates of caesarean delivery between groups (12.5% v 12.6%). Neonatal and maternal outcomes (including the rates of postnatal depression at 6–8 weeks) were also similar. JAMA 2002; 288: 1373-1381 The politics of suicide Researchers from the University of Sydney say the risk of suicide in NSW is higher during periods of conservative government than when the Labor Party is in power. Their study looked at NSW suicide rates between 1901 and 1998 and correlated them with incumbent federal and state governments. After controlling for age, sedative availability, war and drought, suicide risk was lowest when the Labor Party formed both state and federal governments, and highest when a conservative party ruled at both levels (RRs 1.17 for men and 1.4 for women when “both conservative” was compared with “both labour”). Having a mixture of parties in power was associated with intermediate risk. J Epidemiol Community Health 2002; 56: 766-772 More aspirin story As the debate about the risks and benefits of aspirin continues, researchers from the United States have thrown their hat in the ring with the suggestion that aspirin protects women from lung cancer. Researchers from the New York University Women’s Health Study compared the aspirin use of 81 women who developed lung cancer during a median of 12 years follow-up with that of 808 matched controls. Exposure to aspirin in the month before enrolment in the study had no effect on the subsequent risk of lung cancer. However, women who stated that they had taken aspirin three or more times a week for at least six months were significantly less likely than those without such use to develop non-small-cell-lung cancer (but not lung cancer overall). The results are consistent with previous studies which found that non-small-cell lung cancers overexpress cyclo-oxygenase-2, an enzyme inhibited by aspirin and other non-steroidal anti-inflammatory drugs. Br J Cancer 2002; 87: 49-53 A kidney down A study conducted in Chennai, India, has found that people who sell a kidney for transplantation believe they are no better off for the transaction. Researchers used “snowball” sampling to identify 305 individuals (71% women) who had sold a kidney an average of six years previously. Ninety-six percent revealed that they sold the kidney to pay off debts, with only 5% reporting any altruistic intent. The average price paid was $US1070, and was often less than promised. Average family income reportedly declined by more than 30%, and the number of subjects living below the poverty line increased, following nephrectomy. Self-reported health status declined in 86%. Overall, 79% would not recommend that others sell a kidney. JAMA 2002; 288: 1589-1593 Happy and healthy? Despite the fact that it’s virtually impossible to do anything about your personality style, recently published research has linked health with personality and attitude. A study from the Mayo Clinic 1 followed up 447 patients who completed the Minnesota Multiphasic Personality Inventory (MMPI) between 1962 and 1965. On reanalysis of their MMPI answers according to an Optimism–Pessimism scale, 101 were rated as “optimistic”, 272 as “mixed” and 74 as “pessimistic”. Thirty years later the pessimists reported poorer physical and mental functioning (according to the 36-Item Short-Form Health survey) than both the optimists and the mixed group. A previous study by the same researchers found that optimists had a 50% lower risk of early death compared with those in a “mixed” group. Meanwhile, another US study 2 has examined the more complex attribute of cheerfulness (defined as a combination of optimism and sense of humour) in 1215 children. The children’s parents and teachers rated each child for possession of these traits from 1922 to 1923. By 1986, it emerged that the subjects who scored highly on the cheerfulness scale had higher mortality rates, which could be partially but not completely explained by their indulgence in more risk-taking behaviours, such as smoking, drinking and risky hobbies. The cheerful children were no more likely than their peers to have psychological problems, or to be obese, so the mediating factors remain uncertain. 1. Mayo Clin Proc 2002; 77: 748-753 2. Personality Soc Psychol Bull 2002; 28: 1155-1165