Volume 178 Issue 2

Assessing patients' spirituality provides important medical information In this issue of the Journal, Peach examines whether the medical profession in Australia ought to consider patients' religion or spirituality in clinical practice (page 86).1 There is much that Peach writes which I wholeheartedly support. This includes the important role that clergy play in medical settings, the need for further research on the health benefits (and risks) of spirituality in Australian patients, and the need to better understand the costs and benefits of Australian physicians making spiritual inquiries. However, on four points we disagree: Australians are not as religious as Americans and therefore religion is less important for Australian patients; although religion appears associated with health in the United States, there is little evidence for this in secularised Australia; assessing spirituality should probably be deferred to clergy or social workers; and until more is known, including spirituality in medical practice (in addition to addressing it in Australian medical schools) would be premature. Although Australians may be less religious than North Americans, the difference is not that great. Belief in God has decreased in Australia, but it has not gone away. In 1948, 95% believed in God; by 1975, the figure was 80%.2 In 1998, 74% believed in God, a higher spirit or life force,3 and according to the 1996 census only 0.05% of Australians are avowed atheists. When physical or emotional illness strikes, spiritual issues become even more important, as issues of meaning and purpose become relevant. This is particularly true for older adults with chronic illness, a population that will increase as Australians older than 65 years increase from 2.4 million people in 2001 to a projected 5.4 million in 2031.4 Even among younger patients, spiritual practices assume substantial importance. Consider a study of 108 patients (mean age 38 years) from medical practices in Sydney, in which researchers examined patients' experiences concerning the efficacy of 25 coping behaviours.5 Forty-one per cent of subjects indicated they would increase prayer in response to stress, 56% said prayer was helpful and, overall, prayer was ranked seventh in effectiveness, ahead of 18 other traditional coping behaviours, such as discussing the problem, seeking advice, spending time with friends, or socialising. Similar findings emerge among psychiatric patients. A study of 79 psychiatric patients at Broken Hill Base Hospital in New South Wales found that 79% rated spirituality as very important, 82% thought their therapist should be aware of their spiritual beliefs and needs, and 67% indicated that spirituality helped them cope with psychological pain.6 Thus, at least preliminary research suggests spiritual needs are not uncommon among Australian patients. Is religion related to better health in Australia? Although research is less plentiful than in the US, it is not entirely absent.7 Australian studies have found greater marital stability, less alcohol and illicit drug use, lower rates of and more negative attitudes toward suicide, less anxiety and depression, and greater altruism among the religious. Religiosity has also been associated with less cigarette smoking, more conservative sexual practices (reducing risk of sexually transmitted diseases), lower cortisol and catecholamine levels (for meditators), lower blood pressure, lower cholesterol, longer survival (Seventh Day Adventists), and even lower risk for colon cancer.8 Such findings are similar to those in the US,7 and, although more research is needed, these findings cannot be ignored. Because religion relates to health, and spiritual issues are important to many sick patients, deferring assessment of all such issues to clergy or social workers is probably unwise. Although physicians are not trained in this area, brief evaluation and orchestration of resources does not require great skills beyond what physicians already possess. Insufficient time is a problem, but it is not the main reason why physicians don't address spiritual issues. Rather, it is lack of comfort.9 Not knowing why or how to address such issues and feeling worried about imposing their beliefs on patients, not surprisingly they avoid the topic. Nevertheless, a brief spiritual history gathers information that is medically relevant and necessary to practice whole-person medicine.10 Are religious beliefs a source of comfort or stress in coping with illness? Does the patient have religious beliefs that could interfere or conflict with medical treatments? How might religious beliefs influence medical decision-making during serious or terminal illness? Is the patient part of a supportive faith community that can monitor and ensure compliance? Physicians also need to know their limits. If complex spiritual issues come up during assessment, then referral to trained clergy is appropriate and necessary. Physicians should not offer spiritual advice or counselling, or try to solve a patient's spiritual dilemmas. A patient who is not religious or does not wish to talk about such issues should not be pressed. Such inquiries must always be patient-centred, guided by the patient's wishes and religiosity, not the physician's. Nevertheless, taking a moment to listen, validate concerns, and mobilise spiritual resources are actions that physicians can do. Likewise, if the patient is a member of a faith community, then working with a parish nurse after discharge may ensure successful transition from hospital or medical office to home and community life.11 Exposing medical students in Australia to the role that religion plays in coping with illness and the research connecting religion and health should not be delayed. There is ample evidence to support some cautious first steps.12 Certainly, as Peach suggests, ongoing research is necessary. Nevertheless, religion is a powerful factor that can influence health, wellbeing, and medical decisions for better or worse. It should not be ignored or neglected by physicians.

Harold G Koenig M.D.

Self-experimentation in Australia is alive and well Many advances in modern medicine owe a great deal to human experimentation. Indeed, much of biomedical research is irrelevant to mainstream medicine unless its clinical utility is established through human experimentation, for, as observed by the English essayist Alexander Pope, "the proper study of mankind is man."1 Today the circumstances and conduct of human experimentation are painstakingly policed by ethics committees, but even such strict surveillance cannot guarantee safety: "because experiments with humans are voyages into the unknown, an element of risk is always involved; the potential for death, injury, or illness can be reduced, but it can not be eliminated."2 It is this very uncertainty that presents a dilemma for researchers. Sir George Pickering, past Regius Professor of Medicine at Oxford, delineated this quandary: "The experimenter has one golden rule to guide him . . . Is he prepared to submit himself to the procedure? If he is, and if the experiment is actually carried out on him, then it is probably justifiable. If he is not, then [it] should not be done."2 In short, the researcher should be the guinea pig. Risk-laden stories of researchers being guinea pigs abound in medicine's heritage. They include that of John Hunter, the 18th-century English anatomist and surgeon, who allegedly inoculated himself with venereal pus. The symptoms of gonorrhoea and primary syphilis were soon apparent and during the last 15 years of his life he was plagued by a legacy of angina pectoris presumably due to tertiary syphilis.2,3 Other celebrated accounts include that of Werner Forssmann, who, in the 1920s, catheterised his heart with ureteric tubes. This risk-laden technique lay fallow until the 1940s, when Cournand and Richards in the United States refined and employed it in ground-breaking work in cardiorespiratory physiology. In 1956, all three were awarded the Nobel Prize in Medicine or Physiology.2 In the 1950s the enthusiasm for self-experimentation within the Department of Internal Medicine at Washington University, St Louis, earned it the name the "Kamikaze School of Medicine".2 Bill Harrington, a young researcher, courted death from cerebral haemorrhage with profound thrombocytopenia after being infused with plasma from a patient with idiopathic thrombocytopenic purpura (ITP).2 A fellow researcher, Tom Brittingham III, repeatedly injected himself with leukaemic white cells in an attempt to produce white-cell antibodies. He almost killed himself when he had an anaphylactoid reaction accompanied by profound hypotension and severe pulmonary oedema after being infused with plasma from a patient with aplastic anaemia.2 Nonetheless, these unsettling self-experiments established the immune basis of ITP and white-cell-associated transfusion reactions. Harrington's work inspired Jan Dausset of Paris to pursue research into the immunology of ITP and white cells, which culminated in his being awarded the 1980 Nobel Prize for demonstrating human leukocyte antigen (HLA; the transplantation antigen) in white cells.2 Australian researchers have also succumbed to the human guinea pig syndrome. In 1951, as the first wave of myxomatosis raced along the Murray River, its arrival in Mildura coincided with an outbreak of Murray Valley encephalitis in the surrounding district. The public was gripped by fear that the myxoma virus was responsible for the outbreak of encephalitis. This fear reached such heights that the chairman of Mildura Base Hospital challenged R G Casey, the Minister responsible for the Commonwealth Scientific and Industrial Research Organisation (CSIRO), and Sir Frank Macfarlane Burnet, Director of the Walter and Eliza Hall Institute (WEHI), to test the harmlessness of the myxoma virus on themselves! Spurred on by intense media pressure, Macfarlane Burnet, Frank Fenner (Professor of Microbiology at the John Curtin School of Medicine, but working at WEHI) and Ian Clunies Ross (Director of the CSIRO) inoculated themselves with enough myxoma virus to kill 100–1000 rabbits. All three suffered no harm, and in true political style this fact was made public by Casey through an announcement in Federal Parliament.4 The culture of the Kamikaze School of Medicine was further manifest when Australian clinical researchers performed radiolabelled platelet studies on themselves,5 or underwent unpleasant bone marrow aspirations to procure marrow cells for drug studies.6,7 Finally, the experiments of Barry Marshall, who ingested Helicobacter pylori,8 are now legend in medicine. His self-experiments eventually turned prevailing concepts of peptic ulcer causation and treatment on their head. Now, in the new millennium, the report in this issue of the Journal by Landmann and Prociv attests that self-experimentation in Australia is alive and well. In a series of self-experiments these investigators have shown that dog hookworm (Ancylostoma caninum) infection causing symptomatic eosinophilic enteritis is more likely to enter the body orally than percutaneously.9 What drives researchers to be their own guinea pigs? Lawrence Altman, in his delightful book Who goes first? The story of self-experimentation in medicine, proposes a number of motivating factors.2 These include reliability (researchers being more likely to adhere compulsively to the research protocol), dependability (for observations and detecting problems with design), a spirit of adventure, first-hand experience, self-protection, convenience (avoiding the frustrations of recruiting and being involved in the nuances of informed consent) and experience (when the experiments involve risk, the experience of the researcher is important and many will risk exposing themselves rather than others). However, self-experiments are subject to criticism.2 Potential problems include loss of objectivity, cumulative exposure to risks and comorbidities in the self-researcher (including self-experimentation suicide), but particularly the inherent limitations of a research design focusing on a single subject.10 Despite all this, researchers who enlist as guinea pigs will continue to grace medical research. Modern research is increasingly complex, with sophisticated designs and statistics, bewildering technology and the added burden of the close monitoring of projects by ethics committees. This impersonal and mechanistic culture is far removed from the humanistic and romantic spirit of adventure embodied in altruistic self-experimentation. As long as human research is informed by the premise that "because we were venturing into the unknown . . . a man is entitled to risk his own life. He is not entitled to risk somebody else's",2 researchers as guinea pigs will always be with us.

Martin B Van Der Weyden MD, FRACP, FRCPA

Australia must consider carefully the implications of developing a specialty of hospital medicine A hospitalist is a clinician who safely manages a patient's acute hospital course and who specialises in hospital medicine, free of any compelling priorities of ambulatory care.1,2 Hospitalists work only with inpatients, taking over care from primary care physicians after admission to hospital. They are site-defined specialists with skills in general internal medicine,3 who care for patients with a wide range of organ derangements, illnesses (and ages) within the specific location of an acute hospital. The hospitalist movement is most active in the United States, with adherents soon to be comparable in numbers to cardiologists.4 Many leading US hospitals now have active hospitalist programs,5 and, in this setting, the hospitalist is usually a specialist physician. About half are general physicians rather than single-system specialists; the others are often specialists in intensive care.6 The US movement is establishing its own credentials as well as its own areas of research and teaching.5 The major "driver" for this trend in the US was initially related to funding. Hospitalists represent a rationalisation of the medical workforce within an acute hospital, appealing to a cost-oriented, managed-care model. The evidence for the impact of hospitalists is so far unconvincing, although there is some evidence that patient length of stay is decreased when hospitalists manage care.5 The evidence for improved quality of care and patient satisfaction is equivocal.5 What possible advantages would the hospitalist bring for Australian medicine in the new century? Those in favour of the concept suggest that a physician with specific training in acute hospital medicine would be more appropriate than the existing system in Australia, whereby the patient's admitting physician is usually trained as a single-system specialist. This is because a hospitalist has skills and training in general medicine, particularly acute medicine on a background of chronic complex conditions. Not only do they consequently have a more holistic approach to patients with complex, chronic problems, but they are also specifically trained in caring for the seriously ill and resuscitation. This set of skills may be especially relevant in Australian hospitals, where there is evidence of an alarming incidence of potentially preventable deaths and serious complications.7,8 Hospitalists may bring extra skills and expertise in acute medicine and resuscitation as a way of addressing this problem. In the US model, hospitalists also have skills in the organisational aspects of the hospital stay, including communication with all other inpatient services required by the patient, as well as in discharge planning and end-of-life care. Hospitalists in the US are also involved in the acute medical aspects of surgical and obstetric inpatient management. How does the US hospitalist concept "fit in" with current Australian hospital medicine? From an Australian perspective, considering the concept of a hospitalist may assist us in focusing on the changing patient population in our hospitals and re-examining what the role of an acute hospital is exactly. The US concept of the hospitalist suggests that hospital medicine can now essentially be viewed as a general specialty, with system specialists consulted as required. This would seem to require a radical departure from the current Australian model. However, in Australia, it is already common for single-system specialists to hand over care to more general acute-care physicians in the emergency department and intensive care unit. The complexities of acute medicine now demand its own specialists with general training and experience, such as those who practise emergency and intensive care medicine. This is because understanding not only how each organ is affected in acute insults, but also how the affected organs interact with each other, is crucial to the practice of acute medicine. A similar generalist approach is now being demanded in specialties such as geriatrics and rehabilitation. Further, with the increasing comorbid complexity of patients in acute hospitals, management by multiple referral is often required, especially in large teaching hospitals, with a potential danger of there being no generalist to pull it all together. Australian rural hospitals and smaller metropolitan hospitals resisted the move that occurred in the latter part of the last century to increased physician specialisation, often more by default than choice. The US hospitalist model represents a trend back to this "general physicians" concept and using single-system specialists as they once used to be — referring a patient only when the generalist requires an opinion. Perhaps geriatricians in Australia would consider that this concept is already incorporated into their own model of care. Single-system specialists in America seemed willing to forgo control of hospital care because it was interfering more and more with their professional life.4 Increasingly, specialist physicians are practising ambulatory medicine in outpatient settings or performing specialised procedural skills, often in non-hospital settings. With this change in practice arose the very practical issue of the amount of time left to manage increasingly ill and complex patients in an acute hospital setting. Similarly, surgeons spend much of their day either in an operating theatre or an outpatient setting. However, in the US, just as important in allowing professionally non-threatening expansion of the hospitalist model were the relatively low fees that non-procedural hospital inpatient care attracted. Do we need to develop site-specific acute hospital specialists in Australia? Is there a call for a hospitalist in Australia, similar to the US model: one whose training and skill covers acute medicine and resuscitation medicine, chronic and multisystem problems, as well as aged care and end-of-life care — a coordinator of admission and discharge planning, a clinical governance coordinator and a communicator between all the service providers involved in patient care? The current system of clinician responsibility in Australian hospitals has evolved over many years. This evolutionary process has been influenced by many factors, including accountability of the individual clinician, the patient–doctor relationship and continuity of care. Changing this system by replacing existing hospital specialists with hospitalists would radically change the way we deliver healthcare and, at this stage, the advantage of the hospitalist, even in the US setting, is speculative. Potential benefits to patients and the cost of this change would need to be carefully evaluated in the Australian setting — in the same way we would evaluate the relative cost–benefit of a new drug or procedure. Just as importantly, a well-informed debate is needed about important issues raised by the hospitalist concept. These include the future role of acute hospitals, the population of patients who may be managed in such hospitals and their expected needs, and how to set the balance between ambulatory and hospital-based care. In addition, if single-system specialists continue to play a central role in this environment, we need to think about how they will maintain their skills across a broad range of ambulatory and acute hospital care.

Ken Hillman FRCA, FJFICM

Objectives: To describe the prevalence of markers of growth, chronic and infectious disease in peripubertal Aboriginal children living in the Darwin Health Region in the "Top End" of the Northern Territory, and to compare prevalence between children living in urban and remote areas.Design: Cross-sectional survey nested in a prospective birth cohort.Subjects: 482 children living in the region who were recruited at birth (Jan 1987 to Mar 1990) and were followed up between 1998 and 2001, when aged 8–14 years.Main outcome measures: Selected parameters of growth and nutrition, infectious disease and potential markers of chronic adult disease were compared between children living at follow-up in suburban situations in Darwin–Palmerston (urban) and those living in rural communities with an Aboriginal council (remote).Results: Remote children were shorter than urban children (mean height, 141.7 v 146.3 cm; P < 0.001), lighter (median weight, 30.3 v 37.1 kg; P < 0.001) and had lower body mass index (median, 15.3 v 17.9 kg/m2; P < 0.001) and haemoglobin level (mean, 125.1 v 130.9 g/L; P < 0.001). Some potential markers of adult chronic disease were higher in urban than remote children: systolic blood pressure (mean, 109.6 v 106.2 mmHg; P = 0.004), and levels of total cholesterol (4.3 v 4.0 mmol/L; P < 0.001), high-density lipoprotein cholesterol (mean, 1.4 v 1.2 mmol/L; P < 0.001) and insulin (median, 7 v 4 mU/L; P = 0.007). Diastolic blood pressure, levels of red cell folate, serum glucose and low-density lipoprotein cholesterol, and urinary albumin–creatinine ratio did not differ by location. The prevalence of visible infections was also higher in remote than urban children (P < 0.05).Conclusion: As some markers of health differ between peripubertal Aboriginal children living in urban areas and those in remote areas, results of surveys in remote areas cannot be generalised to urban Aboriginal populations.

Dorothy E M Mackerras MPH, PhD · Alison Reid MSc · Susan M Sayers FRACP, PhD · Gurmeet R Singh MD · Kathryn A Flynn BNurs · Ingrid K Bucens FRACP

Objective: To investigate the toxicity of bupropion hydrochloride in deliberate self-poisoning in adults and accidental ingestion by children.Design and setting: Prospective study of cases identified from calls to the New South Wales Poisons Information Centre (NSW PIC), with follow-up through hospital medical records.Participants: Patients with bupropion poisoning managed in hospital, about whom the NSW PIC was contacted for advice, from 1 November 2000 to 31 July 2001 (59 adults and 10 children).Main outcome measures: Clinical effects, adverse outcomes (including seizures and death) and treatment.Results: 45 of the 59 adults were followed up (76%), 19 of whom had taken bupropion alone. Major clinical effects of bupropion included sinus tachycardia (83%), hypertension (56%), seizures (37%), gastrointestinal symptoms (37%) and agitation (32%). Seizures were dose-dependent, with those having seizures ingesting a significantly higher median dose (P = 0.02). All seizures were brief and self-limiting. 29 patients received decontamination therapy. 10 patients required pharmacological sedation, 10 were admitted to intensive care and six were intubated. None died. Eight of 10 accidental ingestions by children were followed up (80%); one child had symptoms (vomiting and hallucinations).Conclusions: Bupropion overdose caused significant clinical effects in adults, but few in children.

Corrine R Balit BPharm · Christa N Lynch BPharm · Geoffrey K Isbister BSc, MB BS FACEM

Objectives: To evaluate the effectiveness of a trachoma control program in a remote community before and after major environmental health improvements.Design: Before-and-after cross-sectional design. The control program was in three rounds — each consisting of community census, screening of children < 13 years, health promotion activities and antibiotic treatment. There were two housing and infrastructure surveys.Interventions: Treatment of affected children and their households with azithromycin at baseline, 7 and 21 months, and health promotions. Housing and sewerage infrastructure improvements were completed at 12 months.Setting: Large, remote Central Australian Aboriginal community, 1998–2000.Participants: All community residents.Main outcome measures: Prevalence of active trachoma among children under 13 years; community population changes; and adequacy of housing facilities for healthy living practices.Results: The prevalence of trachoma among children was 40% (95% CI, 32%–46%) at baseline, 33% (95% CI, 26%–40%) at 7 months' follow-up and 37% (95% CI, 29%–46%) at 21 months. These proportions were neither clinically nor statistically significantly different. There was a high degree of population mobility over the study period, with only 32% of residents appearing in all three censuses. The proportion of houses with completely adequate facilities increased from 0 to 16%.Conclusions: Population mobility (both within and between communities), inadequate housing and continued crowding (despite improvements), as well as uncertainty about compliance with antibiotic treatment, are the likely factors contributing to the lack of effect of this trachoma control program. Because of high population mobility, a region-wide approach is needed for effective trachoma control.

Dan P Ewald MAppEpid, FAFPHM · Gillian V Hall MB BS, PhD · Christine C Franks GradDipIndHealth, MAppEpid

Objective: To investigate possible routes for human infection by the dog hookworm (Ancylostoma caninum).Design, setting and participant: Relatively small numbers of infective larvae were administered orally and percutaneously to an informed healthy volunteer (J K L) under medical supervision, at intervals between May 1998 and May 1999.Main outcome measures: Symptoms; weekly blood eosinophil counts; faecal microscopy.Results: A marked blood eosinophilia followed a single oral exposure to 100 infective larvae, while faecal examination remained negative. Eosinophil counts then declined gradually, although a rapid, spontaneous rise several months later, at the beginning of spring, possibly indicated reactivation of dormant larvae. Blood eosinophil numbers did not rise significantly after percutaneous infection with 200 larvae. A subsequent, smaller, oral inoculum of 20 larvae provoked an eosinophil response similar to that of the first experiment.Conclusions: Our findings suggest that, following ingestion, some infective larvae of A. caninum develop directly into adult worms in the human gut (as they do in dogs). While the percutaneous route might be the most common means of human exposure to canine hookworm larvae, leading generally to subclinical infection, oral infection may be more likely to provoke symptomatic eosinophilic enteritis.

Juergen K Landmann BSc(Hons) · Paul Prociv MB BS, PhD, FRACP, FRCPA

Objectives: To assess the effect of two recalls of paracetamol products on rates of intentional and unintentional overdoses of paracetamol in all age groups, as well as any effect on poisoning by other agents.Design: A before-and-after epidemiological study using data from the Western Australian Health Services Research Linked Database, which records all admissions to public and private hospitals throughout the State.Main outcome measures: Hospital admissions in Western Australia for poisonings with all agents, including paracetamol and other over-the-counter analgesics.Results: There were 11 752 admissions for poisoning from 1996 to 2001. Paracetamol was the primary poisoning agent in 2266 (19.3%) admissions, aspirin in 120 (1%) and ibuprofen in 277 (2%). There was a significant decrease in the admission rate for paracetamol poisoning when sales were restricted in 2000 (rate ratio, 0.82; 95% CI, 0.68–0.99) compared with the same period in other years. There was no increase in poisoning with other agents at this time. However, admissions for paracetamol overdose also showed a large random variation that tended to obscure any effect.Conclusions: Our study highlights the need to control for random as well as seasonal fluctuations in admission rates, and for restrictions on paracetamol sales to last for several months across all retail outlets. Limiting access to paracetamol may reduce paracetamol poisonings without a coincident increase in the use of other agents.

Stephen R Kisely FRANZCP, FAFPHM · David Lawrence PhD · Neil J Preston MSc(Psychol)

Palmar erythema is a very unusual manifestation of sarcoidosis. We report on a patient whose presenting features of sarcoidosis were palmar erythema and a hoarse voice. The diagnosis was confirmed by palmar skin biopsy and the patient responded well to treatment with prednisolone. Sarcoidosis is a disease of unknown aetiology that can affect almost any organ of the body. Cutaneous involvement, occurring in up to 25% of cases of systemic sarcoidosis, is well recognised.1 However, palmar erythema is a very unusual skin manifestation of sarcoidosis — to our knowledge, it has been reported only once before in the literature.2 We describe a patient with palmar erythema and a hoarse voice who was subsequently shown to have sarcoidosis. Clinical recordA 58-year-old man presented complaining of increasing hoarseness of voice of three weeks' duration. The patient had also noticed increasing redness and a burning sensation over both palms. He had no history of any drug intake, fever, cough, breathlessness, chest pain, dysphagia, weight loss or anorexia. The patient was a non-smoker and did not consume alcohol. On examination, he had a confluent, non-blanching, macular, erythematous rash on both palms (Box 1), but no other skin rash elsewhere on the body. There was no thyromegaly or peripheral lymphadenopathy, and there were no abdominal, cardiovascular, respiratory or nervous system abnormalities. Ophthalmological examination was suggestive of episcleritis. Results of routine tests (including biochemical, haematological and liver function tests) were all normal except for a raised erythrocyte sedimentation rate (65 mm/hour). Indirect laryngoscopy performed to investigate the hoarseness revealed paralysis of the right vocal cord with no other local abnormality. The palate showed normal mobility and the bilateral gag reflex was normal. A chest x-ray showed clear lungs, with some mediastinal widening. A computed tomography scan of the thorax revealed enlarged mediastinal lymph nodes (Box 2). A Mantoux test was non-reactive. The serum level of angiotensin-converting enzyme was 76.2 U/L (normal range, 8–52 U/L). A skin biopsy taken from the palmar rash revealed non-caseating granulomas with multinucleated giant cells (Box 1). No acid-fast bacilli or fungal hyphae were detected on direct staining or subsequent culture of sputum and skin biopsy specimens. The histological features were thus suggestive of sarcoidosis. After two weeks' treatment with prednisolone 1 mg/kg per day, the patient's rash had resolved completely and the hoarseness was markedly reduced. A repeat computed tomography scan of the chest done after four weeks of treatment showed that the mediastinal lymph nodes had decreased in size. The patient has remained asymptomatic over seven months of follow-up. DiscussionSarcoidosis may involve any organ of the body and can have protean clinical manifestations, including skin lesions. Skin manifestations can be in the form of erythema nodosum (the most common), subcutaneous nodules, plaques, lupus pernio or maculopapular eruptions.3 Palmar erythema may be the presenting feature of a number of skin diseases such as eczema, psoriasis, tinea and pityriasis rubra pilaris.4 Isolated palmar erythema is commonly seen in pregnancy and liver diseases, and may occasionally occur in rheumatoid arthritis.5 However, as a manifestation of sarcoidosis, it is extremely rare.2 Interestingly, the only other reported patient presenting with palmar erythema was also of Indian origin. The diagnosis of cutaneous sarcoidosis is based on three features: clinical or radiological evidence of multisystem involvement; presence of non-caseating granulomas on histological examination; and failure to detect acid-fast bacilli or fungae by sputum or skin culture or in stained tissue sections. In our patient, all three features were present. An interesting feature was the patient's hoarse voice. Hoarseness in sarcoidosis may be caused by direct infiltration of the larynx,6 infiltration of the cranial nerves (especially IX and X),7,8 or compression of the recurrent laryngeal nerve by enlarged mediastinal lymph nodes, leading to vocal cord palsy.9 As indirect laryngoscopy did not show any local cause for the vocal cord palsy, the hoarseness in the present case was likely to be due to the third cause. A few series of cases of sarcoidosis have been reported from India.10-12 The clinical presentation in most of these cases included fever, weight loss, cough, breathlessness or hepatosplenomegaly. Skin lesions were reported in very few of the cases, and palmar erythema in none. Our patient was also somewhat atypical in having mediastinal lymphadenopathy, which is reported to be less common in India (28%) than in Western countries (70%).13 To our knowledge, sarcoidosis presenting as a combination of palmar erythema and hoarseness of voice has not previously been reported. Our case thus highlights the diverse clinical manifestations of this disease and emphasises the fact that palmar erythema may be the only visible sign of sarcoidosis. 1: Palmar erythema associated with sarcoidosis A: Diffuse erythematous macular rash seen on the palmar surface (biopsy site arrowed). B: Skin biopsy, showing non-caseating granulomas. C: Skin biopsy, showing multinucleated giant cell (arrowed). 2: Computed tomography scan of the thorax, showing right paratracheal lymphadenopathy

Ravinder P S Makkar MB BS, MD · Surabhi Mukhopadhyay MB BS, MD · Amitabh Monga MB BS, MD · Anju Arora MB BS, MD · Ajay K Gupta MB BS, MD

Objectives: To conduct a systematic review of the effects of genetic counselling and testing for familial breast cancer on women's perception of risk and psychological morbidity.Data sources: MEDLINE, PsychLIT and EMBASE were searched for the period 1980–2001.Study selection: Studies were eligible if published in a peer-reviewed journal in English, included women with a family history of breast cancer who underwent genetic counselling or testing and had either a randomised controlled trial or prospective design, with a pre- and at least one post-counselling assessment.Data synthesis: As there was considerable heterogeneity in populations and measures, results were summarised rather than subjected to meta-analysis.Results: Overall, genetic counselling and testing appear to produce psychological benefits and to improve accuracy of risk perception. Carriers of mutations in cancer predisposition genes did not experience significant increases in depression and anxiety after disclosure of their mutation status, while non-carriers experienced significant relief. Women who were tested but declined to learn their results seemed to be at greater risk of a worse psychological outcome.Conclusions: To date, the data on psychological outcomes after genetic counselling and testing are reassuring. However, few studies used a randomised trial design, limiting the strength of the conclusions. Follow-up to date has been short, and we know little about the long-term impact of testing on patient behaviours, perceptions and psychological state.

Phyllis N Butow PhD, MPH, MClinPsych · Elizabeth A Lobb PhD, MAppSci, BAdEd · Alexandra Barratt PhD, MB BS(Hons) · Bettina Meiser PhD, BAppSci · Katherine M Tucker FRACP

Chronic HBV infection is common in remote Aboriginal and Torres Strait Islander communities, where resources are scarce and patients may have several concurrent illnesses. The management of chronic HBV infection has changed over recent years, with greater application of serological and radiological investigations and new, more acceptable treatments for chronic liver disease, cirrhosis and hepatocellular carcinoma. Optimal follow-up procedures for patients with chronic HBV infection are still being debated, but may not be applicable to Aboriginal and Torres Strait Islander communities where factors such as endemicity, remoteness, frequent comorbidities, shorter life expectancy and cultural differences in health priorities must be taken into consideration. We have defined an algorithm to assist primary care providers caring for patients with chronic HBV infection in Aboriginal and Torres Strait Islander communities. Patients are divided into one of three categories for follow-up and referral based on clinical features, and results of liver enzyme and serological tests.

Dale A Fisher FRACP · Sarah E Huffam FRACP

Greater participation in religious activities is associated with better health outcomes. In the US, most inpatients have religious needs, but physicians address them only occasionally and infrequently refer patients to clergy. US medical students are learning to do spiritual assessments and integrate the findings into patient management, which may reverse this. Religion does not play a central role in the lives of Australians as it does for US citizens. Research is required to better understand the spirituality of Australians, its relationship to health and the benefit, cost and acceptability of doctors enquiring into spirituality compared with spiritual advisers and counsellors.

Hedley G Peach PhD, FFPHM

A 55-year-old taxi driver presented with a three-week history of intermittent sore throat associated with fever and rigors, which responded to paracetamol. On the morning of admission, he woke with severe aching pain in the left groin radiating to the scrotum, with associated vomiting, fever and rigors. There were no urinary symptoms and he had not had any recent new sexual contacts. His medical history included uncomplicated haemochromatosis only. Examination revealed a temperature of 39.6°C and sinus tachycardia. Otorhinopharyngeal, parotid and abdominal examinations were normal. Scrotal examination revealed a 4 cm, hot, swollen, erythematous area, with tenderness in the left epididymis and left testis. The results of investigations, including streptococcal serology (confirming recent infection) and ultrasound imaging, are shown in Box 1 and Box 2. Urine microscopy and culture were negative. Streptococcus pyogenes susceptible to penicillin was isolated from both aerobic and anaerobic blood culture bottles at 24 hours. Polymerase chain reaction tests of urine were negative for Neisseria gonorrhoeae and Chlamydia trachomatis. Despite commencement of intravenous penicillin, the patient required incision and drainage of the scrotum on Day 4. He was discharged from hospital nine days after presentation on a two-week course of oral amoxycillin and made a full recovery. DiscussionEpididymo-orchitis can result from bacterial or viral infections. Predisposing trauma may be identified, but the majority of cases appear to be idiopathic. Different types of causative bacteria occur more frequently in certain age groups: 1,2 for example, urinary tract pathogens (eg, Escherichia coli, Proteus mirabilis, Enterobacter spp.) in men over 35 years; sexually acquired pathogens (eg, N. gonorrhoeae, C. trachomatis) in sexually active men under 35 years; and pathogens acquired as part of a systemic infection (eg, Haemophilus influenzae, N. meningitidis, Mycobacterium tuberculosis) in preadolescent boys. In a few rare cases,1-3 streptococcal infections have been found to cause epididymo-orchitis as part of a local infection. However, all these cases occurred in preadolescent boys. There has been one report of a 17-year-old man with invasive group A streptococcal infection of the scrotum in the context of streptococcal toxic shock syndrome.4 Our case is unusual in that it occurred as a systemic illness in a 55-year-old man with haemochromatosis. This infection has not, to our knowledge, been previously described in association with haemochromatosis.5 1: Investigations Value Reference range Neutrophils 11.4 x 109/L 1.0–7.0 x 109/L C-reactive protein 98 mg/L < 3 mg/L Ferritin 205 μg/L 20-300 μg/L % Transferrin saturation 45% 20%–52% Streptococcal exotoxin AntiDNase B > 2560 < 320 Antistreptokinase > 20480 < 2560 Antistreptolysin O > 1200 < 300 2: Scrotal ultrasound images Left: Transverse image of the enlarged left testis (4.5 x 3 x 2 cm), with non-homogeneous echotexture and several small, rounded, echolucent cystic structures within the testis measuring 3 mm in diameter. The right testis showed similar, but less severe, features. Right: Longitudinal image of the enlarged left epididymis.

Sebastiaan J van Hal MB ChB · Robyn P Hardiman MB BS FRACP FRCPA

To the Editor: Thompson's report highlighting the danger of baby walkers and the applicability of the proposed Australian mandatory standard is welcome.1 However, we have some concerns with the statement that the injury data used in the analysis are "largely representative of such events in the major proportion of metropolitan Australia". The only data sources used were the South Australian Department of Human Services Injury Surveillance System and the original Victorian Injury Surveillance System. Equivalent data from Queensland, although readily available, were not used. An analysis of 177 baby-walker injuries recorded in the Queensland Injury Surveillance Information System (ISIS) for the period 1989–1994 shows that only 9% of injuries were not stability related, and that 73% were associated with steps and stairs. Among the cases admitted to hospital, only one was not related to stability or falls down steps or stairs. Examination of more recent Queensland injury surveillance data, although not directly comparable, reveals a similar pattern. These results, which appear to contradict the findings of Thompson, are not altogether surprising considering the differences in architectural styles between Queensland, with its high-set houses with verandahs and wooden steps, which present quite a different injury-prevention challenge to the style of housing more common in Adelaide and Melbourne. The introduction of a baby-walker standard to address the problem of stability and falls down steps and stairs would thus appear worthwhile in this setting. However, we accept that, in other parts of Australia, baby-walker-related injuries may be less amenable to prevention through this intervention. It is also of concern that the new standard is being promoted by the Commonwealth as able to prevent stair-related baby-walker injuries. In reality, this is not the case: a recent study by the US Consumer Product Safety Commission found that 15% of stair-related injuries involved the new-style walkers.2 Furthermore, introduction of the standard, and its ensuing publicity, may result in an increase in use of baby walkers, along with a perception that they are now safe. This has the potential to increase baby-walker injuries. It is our belief that, in this particular case, it may be better to keep publicity very low key. Finally, use of baby walkers has also been associated with a delay in normal physical development.3 For all these reasons we would continue to advocate that the use of baby walkers be actively discouraged.

Richard L Hockey · Rob Pitt

To the Editor: The article by Thompson recommended that baby walkers be banned.1 He described various injuries caused by baby walkers: An 8-month-old baby in a walker pulled the cord of a deep fryer and was splashed by oil, sustaining full-thickness burns to chest, abdomen and upper arms. A 10-month-old baby in a walker sustained severe finger laceration when a fly-screen door slammed shut. It is suggested that baby walkers allow babies to reach hazards, such as heaters, ashtrays, hot drinks, etc. However, all of these injuries result from lack of supervision. In any case, within a couple of months these babies will be standing and then walking and, without supervision, exactly the same injuries may occur. Most injuries in infants are related to an unsafe environment or inadequate supervision. One aspect that Thompson does not mention is walkers for disabled children. Does he recommend that these be banned? For infants and young children with severe disabilities, a walker is their only means of locomotion.

Donald D Beard

In reply: The support for my study1 is pleasing, especially the letter from Martin. I agree with Hockey and Pitt that including Queensland data would have enhanced my study, as Queensland is the only other Australian State with a substantial injury database like South Australia's and Victoria's. However, when I analysed the Queensland data only around 1% of baby-walker injuries could be classified as "proximity", compared with 20%–25% in Adelaide and Melbourne. Surveillance collection can very easily miss critical details. The SA questionnaire asks "What was the victim doing at the time of the injury?", then "What went wrong?" and, finally, "How exactly was the injury caused?". As an example, "a child in a baby walker accesses the fireplace and burns her hand". If one or two of the above questions are left out, or the coder does not capture all the detail, this narrative easily becomes "child burns hand on fireplace" and the detail that the baby walker facilitated the child's access to the fireplace is lost. In 1995, after the Victorian Injury Surveillance System moved to a "minimum" dataset, their "proximity" component dropped to just 1%, the same as for Queensland. Analysts at the Victorian Injury Surveillance System recommended that these post-1995 data not be used for my study. In my opinion the Queensland system has the same systematic problem, and discussions with Hockey suggest that this is a possibility (Richard Hockey, Senior Data Analyst, Queensland Injury Surveillance Unit, personal communication). My assertion — that the data I used are largely representative of baby walker injury events in metropolitan Australia — is justified, as any variations in "proximity" rates (even if they do exist) caused by different architectural styles in Queensland would represent only a very small proportion of the events Australia-wide. The presence of additional steps and higher steps would only explain a higher proportion of these types of injuries, and possibly increased severity, but not the almost total absence of "proximity" injuries, as there is no association between them. The recent finding by the US Consumer Product Safety Commission2 that steps and stairs injuries still occur with new-style walkers confirms the need to discontinue the proposed mandatory regulations and instigate an immediate ban. The letter from Beard is disturbing in its attitude. Inadequate supervision is another name for victim blaming, and an unsafe environment is a perfect description of a baby walker. Moreover, to suggest that the ban would include any form of purpose-designed apparatus, including a commercial baby walker, to assist disabled children is nonsense.

Peter G Thompson

To the Editor: Colorectal cancer is, after skin cancer, the most common cancer in Australia, with 11 245 new cases diagnosed in 1997, and over 4600 deaths.1 In clinical trials, screening programs using faecal occult blood testing (FOBT) have been shown to reduce mortality. The Commonwealth Department of Health and Ageing estimates that implementation of effective FOBT screening programs would save around 400 lives per year.1 However, such screening programs have not been widely implemented because of perceived difficulties with patient acceptance, funding, and the complexity of support structures. General practitioners are in the front line of healthcare, and well placed to institute FOBT screening. Thus, we established an opportunistic screening program whereby patients over the age of 50 years attending surgery are asked by reception staff to complete a short questionnaire while in the waiting room. This questionnaire, developed locally to quickly establish whether a patient has symptoms or a family history of bowel cancer, is given to the GP by the patient during the consultation. If the questionnaire indicates colorectal symptoms, appropriate clinical assessment is undertaken. If a family history of colorectal cancer is elicited, the GP further defines the patient's risk by using the established National Health and Medical Research Council guidelines.2 If there are neither symptoms nor a family history, the patient is offered annual FOBT screening. From 17 June to 30 September 2002, 731 patients under the care of 29 GPs completed the questionnaire. Our findings are summarised in the Box. GP-based opportunistic screening can reach significant numbers of people. Moreover, unlike other strategies (eg, distribution of test kits by pharmacies), review by GPs of patients' questionnaires ensures that cases unsuitable for FOBT screening (such as those with previously undeclared symptoms or family history) are appropriately assessed. Data reported so far on patients who completed general practice questionnaires for eliciting family history or symptoms of bowel cancer FOBT = faecal occult blood testing.

Susan J Harnett · SK Cyril Wong · Gavin W Lackey

To the Editor: To achieve greater dissemination of mental health education to general practitioners, the Adelaide Central and Eastern Division of General Practice developed a program to be taken to GPs, based on individual need and using a medical expert/facilitator. The "GP Meets the Psychiatrist Project" is an initiative of the Division in collaboration with the Eastern Mental Health Service, and supported by the Lundbeck Institute — a Danish foundation with a special interest in psychiatric education and pharmaceuticals (www.luinst.org). The specific objective of the project is to facilitate access by GPs to psychiatrist support, in the form of education and advice. This takes the form of a psychiatrist visiting a practice for a one-hour "open tutorial", on a topic preselected by the GPs in the practice. Lundbeck funded the psychiatrist's time. GPs were not funded, and no Continuing Medical Education points were sought for these sessions. The project began in February 2001, and during the year 75 GPs from 22 practices were involved. Following the tutorial, both the GPs and the psychiatrist completed an evaluation questionnaire that covered issues such as the topics chosen by GPs, discussion of medications, referral for psychiatrist support, the need for further sessions and how they rated the sessions.1 The main topics raised by GPs were depression, medication issues, difficulties with access to psychiatry services, psychosis, and management of acute situations or angry patients. GPs felt the sessions were very useful, and 87% were interested in having meetings with other specialists. From October 2001, 23 GPs rated the usefulness of the tutorial using a Likert scale of 1 ("no use") to 5 ("very useful"). The value of the tutorials was clearly demonstrated by the mean rating of 4.6. Three psychiatrists participated and all found the experience of attending general practices and running the sessions very rewarding. They found their assumptions about the nature of family medicine were often wrong; for example, they were interested to find that practices were often focused towards particular areas of health. The project has demonstrated the usefulness of tailoring education packages to the specific needs of GPs and has shown that this would be a suitable avenue to improve links between GPs and specialists. With specialist support, a similar session involving an endocrinologist discussing diabetes is now being run through the Division, with no funding, which suggests this type of program may be sustainable in the long term.

Greg A Lovell · Phillipa J Hay

To the Editor: Your enthusiastic comments accompanying the publication of a "physicians' charter" prepared by the Medical Professionalism Project1 do not acknowledge strikingly enhanced approaches to medical professionalism in Australia dating from the landmark Doherty Report in 1988.2 One of the most noticeable changes since that time is the emphasis now placed on professional development throughout medical school curricula3 and in the preregistration year.4,5 In addition, our medical colleges are poised to do more in this area in their postgraduate training and continuing professional development programs.6 You fail to point out that the "physicians' charter" contains nothing new, as an examination of the Code of Ethics of the Australian Medical Association will reveal.7 We are probably fortunate that an equivalent process of developing such a charter has not taken place in Australia. The document repeatedly speaks of a "contract with society", but it is an oddly one-sided contract, prepared without consulting members of the communities the authors purport to represent. The charter seems to be a response to frustrations and challenges caused by changes to healthcare systems, especially in the United States and Canada, and carries a tone of living in the past. There are effective means of engaging with our community to ensure that essential aspects of medical professionalism are valued and maintained.8 Many of these are already being used in Australia. I refer to such developments as community membership of medical boards, community input into selection of medical students, establishment of independent health complaints commissions and widespread engagement with the health consumer bodies by most sections of the profession. Additional initiatives that will assist the community to trust and value medical professionalism in Australia include the increased expectation that all doctors will engage in continuing medical education and the establishment by medical boards of pathways to identify and assist poorly performing doctors. Should the organised profession ever develop a similar charter for Australia, it is to be hoped that the authors will ensure that the concerns and needs of our broader community are taken into account and that we do not engage in the self-pity evident in the Medical Professionalism Project.

Kerry J Breen

To the Editor: You recently lent your support to the "physicians' charter" produced by the members of the Medical Professionalism Project.1 According to the document, the charter is part of the process of reforming healthcare systems. If the authors are hoping to use this document to change the way medicine is delivered, they should be prepared for criticism. The simplest criticism is that they present no evidence. Sweeping statements are made, without supporting documentation, about the potential for dishonest behaviour by physicians. Even broader generalisations are made about the appropriate way to run healthcare, again without evidence. The authors state that "physicians should never exploit patients for . . . personal financial gain or other private purpose". While the word "exploit" has a pejorative flavour, it is reasonable for doctors to be paid for what they do. The "sackcloth and ashes" version of medical practice appeals to a small minority. They then move deeper into socialist territory: "Medical professionalism demands that the objective of all healthcare systems be the availability of a uniform and adequate standard of care." But the standard of healthcare can never be uniform, and vigorous attempts to make it so could conceivably undermine its quality. "Political correctness" proceeds apace. "A commitment to equity entails the promotion of public health and preventive medicine . . .". Why, for goodness' sake? Preventive medicine is not always cost effective. The authors then propose their own version of health economics. In their view "the provision of unnecessary services not only exposes patients to avoidable harm and expense but also diminishes the resources available for others". This is not necessarily so. Some services will turn out to be superfluous. There are other areas of extravagance in our society (eg, fast cars, big houses, and all restaurants), but they still make an important contribution to the economy. Growth in healthcare expenditure expands the whole economy, and I am not aware of any evidence that spending in one area of healthcare necessarily deprives others. It could well be the reverse. Politically correct attitudes are widespread in the medical community,2 but should not be imposed on others, as the Editor was perhaps suggesting.

Keith V Woollard

To the Editor: Young doctors and medical students are acculturated into healthcare systems in which governments, corporations, consumer groups and other stakeholders have an increasing presence. These forces have so significantly altered medical practice in the United States, for example, that many doctors have questioned the applicability of traditional patient-centred values. Whether or not Australian doctors have faced such adversity, medical practice is becoming increasingly complex, and the Medical Professionalism Project's charter1 encourages us to consider how we might best serve the future needs of patients, families and the community. To this end, the charter upholds traditional patient-centred values while embracing less familiar civic responsibilities. It challenges us to think outside the doctor–patient dyad about what it means to be a doctor in contemporary Australian society. The inevitable rationing of finite health budgets, inequalities in access to and quality of care, and growing recognition of social determinants of health are all compelling reasons for engagement with social processes. The Australian medical profession has served us well through its health policy leadership. We have no reason for complacency, however, given the appalling state of Indigenous health, the challenges posed by rural and refugee populations and the progressive infiltration of for-profit interests into the Australian healthcare system. Upholding the principle of social justice will require skills not often called upon in medical practice. If we are to remain respected public advocates we will need heightened awareness of population health issues and the ability to effectively collaborate with other players. We will need ways of translating time-honoured virtues such as altruism and compassion into public arenas. Partnerships may open new opportunities in a publicly responsive and outward-looking profession, while retaining the inherent worth of patient care. By its social orientation, the charter does more than exalt old values in the face of modern healthcare challenges. It helps to articulate the aspirations of a more broadly engaged profession. The charter will be valuable to those of us near the start of our careers, for whom professionalism will be as much characterised by its engagement with the future as it is by its links with the past.

Russell L Gruen

In reply: I welcome the comments on the physicians' charter. The purpose in publishing the charter was to promote a dialogue on medical professionalism, as, in contrast to the continuing discussion and debate on professionalism in North America1-3 and the United Kingdom,4 interest in the subject in Australia is virtually absent. Enter the terms "medical professionalism" and "Australia" in PubMed and the search yields eight publications in the Australian literature over the past 30 years. Despite this meagre tally, Breen informs us that all is well, through the efforts of bodies such as the Australian Medical Council (AMC). While the AMC's efforts are commendable, its recommendations for instilling professional attitudes in medical students and interns must compete with other priorities in an already crowded curriculum and with the pressures of the intern year. Under the daily stresses of real life, abstract concepts of professionalism are likely to be given low priority. Breen also suggests that the medical colleges are "poised to do more in this area". This may be so, but a search of college websites reveals that most are silent on matters of professionalism. Finally, Breen laments that the physicians' charter contains nothing new — but no one really expects revolutionary concepts in precepts of professionalism, which have evolved over hundreds of years. Besides, what harm is there in being exposed to the views of our colleagues in the northern hemisphere? As the comments of Gruen suggest, the charter is one of the more broad-ranging contemporary expositions of medical professionalism. Woollard wants evidence for the principles of the charter and its purpose. He also suggests that it is tinged with socialism and "political correctness". But the medical ethics that underpin our professionalism are dependent not on evidence but on humanistic principles. He hints that making the objective of all healthcare systems "the availability of a uniform and adequate standard of care" smells of socialism. Perhaps so, but I prefer to think of it as embodying the Australian ethos of a "fair go". Finally, "political correctness" is a subjective rather than an objective concept. I thank my colleagues for their insightful comments and for starting the debate on new professionalism. Long may it continue.

Martin B Van Der Weyden

To the Editor: Optimising the management of cancer patients requires objective decisions about "best treatment" strategies, based on high quality data collected systematically from all treated patients (or at least a representative sample of them). Relating treatment and stage at diagnosis to individual outcome can allow monitoring of whether treatment is consistent with best practice, and can provide a systematic foundation for evidence-based care. Clinical cancer data collection also allows treatment services to be evaluated, as institutions can monitor throughput and endpoints. However, institution-based data collections may not be representative of all cancer patients, and aggregation of data from several institutions is needed to obtain a comprehensive picture. Population-based cancer registries, which operate in all Australian States and Territories, include data on the site and morphology of cancers. Notification of cases to the registries is mandatory for hospitals and pathology providers, and survival of patients is assessed by linkage to mortality data. The registers do not routinely record stage or treatment data. Until recently, there have been no nationally agreed data items or standard data definitions to facilitate the collation of clinical cancer data across institutions. In 1999, the National Cancer Control Initiative (NCCI) commissioned a nationwide consultation process to seek expert advice on developing a core clinical cancer data set. Representatives from the State and Territory population-based cancer registries, the Australian Institute of Health and Welfare and many large cancer treatment centres were consulted.1 A workshop was held in Melbourne in July 2000 to identify key items for inclusion in the data set, and a group was established to work on data definitions. These are now available on the NCCI's website (<http://www.ncci.org.au/projects/data/dat01.htm>). The data set is designed to be compatible with, and expand on, data currently collected by State cancer registries. Definitions are consistent with the New South Wales clinical cancer data set,2 and we acknowledge the input from this source. Items would be collected by treatment centres. Some institutions would need to standardise information already collected for ongoing patient management, while others would need to establish and maintain new collections. The Faculty of Radiation Oncology of the Royal Australian and New Zealand College of Radiologists has recommended incorporation of the NCCI data set into its proposed quality assurance program. Collation of data across institutions requires careful attention to patient identification issues in order to protect privacy and avoid duplication of data from multiple sources. Use of the data set by clinicians and health planners and evaluators at a national level is the ultimate aim. This would require funding and commitment, and attention to issues of privacy, confidentiality, and data ownership. At present, adoption of the data set on a voluntary basis by treatment centres is the best way forward.

Margaret P Staples · J Mark Elwood · Alan S Coates · Lizbeth M Kenny

To the Editor: We applaud the efforts of Wasiak et al to apply the principles of evidence-based medicine to answer clinical questions.1 However, it is important to understand the historical context of clinical trials reported in the literature, and, when necessary (eg, when conducting a meta-analysis or when the results of trials appear to conflict), to seek additional information from the authors. One of us (H K G) designed the randomised-controlled trial (RCT) reported by Corry et al.2 It was a pilot study and not a definitive clinical trial. The primary outcome measure was resonant frequency, an objective measure of muscle stiffness. This trial was conducted before the introduction of validated outcome measures for assessing upper limb function in children with cerebral palsy, and it was not possible to perform any sample size calculation for functional outcomes. At 12 weeks in the group receiving injections of botulinum toxin A, there was a significant difference in grasp and release but not in the ability to pick up coins. It is not surprising therefore that this study found significant decreases in muscle stiffness, but the functional results were inconclusive. The other RCT identified by Wasiak et al also involved one of us (D F).3 It was designed specifically to investigate functional outcomes, a sample size calculation was performed from pilot work, and a specific functional outcome measure (QUEST) was used. This study reported significant functional improvements after the use of botulinum toxin combined with occupational therapy. These two studies, when understood in their historical sequence, should therefore be considered complementary and not contradictory. It is important to assess the quality of randomised clinical trials as well as their conclusions (eg, using the Physiotherapy Evidence database PEDRO scale <http://ptwww.fhs.usyd.edu.au/pedro>).4,5 The smaller study by Corry et al2 had insufficient power and inadequate methodology to investigate functional outcomes. On the other hand, the conclusions of the study by Fehlings et al3 should be taken as the current level of evidence. We therefore submit that the conclusion drawn by Wasiak et al is incorrect. We support further research to evaluate and strengthen the evidence relating to botulinum toxin A and upper-extremity function.6

H Kerr Graham · Roslyn N Boyd · Darcy Fehlings

In reply: We thank Graham et al for their response to our article.1 It is important to understand that the clinician who posed the question regarding botulinum toxin A injection wished to find the "best available medical evidence". We were not asked to take account of the historical context of previously published articles, nor were we asked to exclude specific types of RCTs. If we were to exclude specific RCTs based on the preference of an author, then the strong methodological principles that surround the evidence-based practice movement would be open to extreme forms of bias. We also disagree that our conclusions were incorrect. Our reading of the article by Corry et al2 differed from that of Graham et al. We do not consider that their study showed that botulinum toxin injection significantly improved the function of the hemiplegic upper limb. Together with the results of the study by Fehlings et al,3 indicating a significant improvement in weight-bearing at four weeks (part of the QUEST assessment), our conclusion — that we could not support or refute the efficacy of botulinum toxin injections for improving upper-limb function in cerebral palsy because of differing opinions — remains unchanged.

Jason Wasiak · Brian J Hoare

To the Editor: I read with interest and alarm your comments on generalists and gerontology in the 16 September 2002 issue of the Journal.1 I believe the role of the general internal medicine physician in managing patients with complex multisystem disease is still important and will expand in the future. General physicians remain passionate about general medicine.2 General medicine has been threatened over the past 20 years by the emergence of the medical subspecialties. However, there is increasing recognition of the need for general medicine specialists, especially in North America and Europe. In Australia, general medical units are being established in the major teaching hospitals in capital cities. Sydney remains a unique exception — all of its general medical units were closed prior to the 2000 Olympics (for reasons that are unclear), and only one has subsequently been re-established (at Royal North Shore Hospital). The Internal Medicine Society of Australia and New Zealand (IMSANZ) has been active in promoting the role of the general physician. IMSANZ provides support for the professional profile and culture of general physicians throughout Australasia. We would welcome enquiries from trainees and physicians (<http://www.racp.edu.au/imsanz>). The Royal Australasian College of Physicians has recognised the necessity for a strong general physician workforce and will be holding a General Medicine Forum in March 2003 to examine the key issues confronting general medicine in Australia and New Zealand. By 2010 the majority of "baby boomers" will be in their sixties, or older, and will require the services of well trained general physicians to provide integrated, cost-effective, whole-of-patient specialist healthcare.

Leslie E Bolitho

Alzheimer’s disease. Ralph W Richter and Brigitte Z Richter. London: Mosby, 2001 (128 pp). ISBN 0 7234 3263 5. A small book for a big subject best describes this concise yet comprehensive handbook on Alzheimer’s disease. The authors have backgrounds in neurology, psychiatry and pharmacy, and have written a book that complements the plethora of similar short books on Alzheimer’s disease that are currently available. In a practical, no-nonsense style it covers the usual topics of diagnosis, disease stages, neuropathology, and drug treatment. It also includes information on diagnostic biomarkers for Alzheimer’s disease, explanations of the various cognitive tests that may be used, and an excellent chapter on current therapies that goes far beyond the cholinesterase inhibitors. The authors have also been adventurous in looking ahead at possible new approaches to treatment. There are a few negatives. As with any published material, parts of the book will be out of date very quickly and this has happened with the information on amyloid immunisation. The contact list is almost entirely North American, with a little United Kingdom information. However, the reference list is multinational, with contributions from many countries. The book is reasonably priced at $42. It is intended as an overview for the general practitioner, but it would also be very useful for health professionals working in the dementia field who are looking for more information, particularly in the area of current therapies. Susan E KurrleRehabilitation and Aged Care Physician Hornsby Ku-ring-gai Hospital, Hornsby, NSW

Susan E Kurrle

Multiple sclerosis. Sharon Warren and Kenneth Warren. Geneva: World Health Organization, 2001 (ix + 123 pp). ISBN 92 4 156203 X. The last fifteen years have seen not only an exponential growth in published research on multiple sclerosis but also an abundance of books on the subject. Despite this abundance, this relatively small paperback fills a real void in the market. The book reviews, summarises and provides an objective and considered opinion on epidemiological research into multiple sclerosis. It covers issues relating to diagnosis as well as research methodology, case-ascertainment methods, prevalence and incidence rates, environmental risk factors, genetic susceptibility, other risk factors and prognostic factors. The authors are eminent Canadian multiple sclerosis researchers. They provide an overview of the subject and bring together research from around the world in order to answer some of the difficult questions that our patients often ask. They do this by discussing, in depth and detail, the methodological aspects and the results of these studies in simple language. A separate section deals with prognostic indicators and the last chapter addresses challenges for future research. Multiple sclerosis should appeal to a wide range of readers, but especially to those starting out in the field, such as clinicians or researchers. It is scientific in its prose, but relatively easy to read for a person with multiple sclerosis who wants to know what the current state of knowledge is without spending a lot of money. It is not a book for those readers looking for information on the scientific aspects of the genetic basis of the disease or its management. It does, however, include a very good section on the epidemiological research into genetic susceptibility. I think the authors should be congratulated on producing a small, easy-to-read, comprehensive and objective book. It lends itself to a wide range of readers and should be updated regularly. For those of us who try but can’t always manage to read all that we want to on multiple sclerosis, the book is a valuable and easily accessible reference source. Garry D PearceMedical Director Multiple Sclerosis Society, NSW

Garry D Pearce

Anyone can do it A study in Scotland has shown that dermatologists, plastic surgeons and general surgeons all do an equally good job of excising primary malignant melanomas. The surgical background of the person removing the primary tumour had no bearing on the outcome or survival of 4159 patients who had their lesions excised between 1979 and 1998 and were followed up for an average of 10 years. Dermatologists treated the highest proportion of thin melanomas, and general surgeons treated more ulcerated lesions, but this was adjusted for in the analysis. Cosmetic outcome was not considered. The authors thus recommend referring melanoma patients according to shortest surgical waiting time rather than "surgical" specialty. BMJ 2002; 325: 1276-1277 Deadly side effects US researchers, using a national Food and Drug Administration database of adverse drug events, have found an alarming number of serious or fatal reactions in children under two years of age. Of 5976 adverse events reported in this age group over a three-year period (1997–2000), 1873 occurred in the first month of life. The number of events decreased with increasing age. There was an average of 243 medication-related deaths each year. In 24%, exposure to the drug was via the mother, during pregnancy, delivery or lactation: anti-HIV drugs were responsible for a quarter of these reactions. Seventeen drugs accounted for over half of all serious/fatal events, including two drugs for prophylaxis against respiratory syncytial virus (RSV) disease, six antibiotics and two analgesics. Palivizumab, a monoclonal antibody against RSV, was the top "offender" (28% of serious/fatal events); the analgesic acetaminophen was implicated in 413 reports and ranked seventh for serious/fatal events. Pediatrics 2002; 110: e53 Beware the zebra A study in the United States has found that elderly people are more likely to be struck by a motor vehicle when using a marked crossing than when crossing at an unmarked site. Between February 1995 and January 1999 researchers obtained police reports of all collisions between motor vehicles and pedestrians aged 65 years and over, within 30 feet of an intersection, in six cities in Washington and southern California. Some sort of a crossing was marked in 181 of 282 cases. Trained observers recorded environmental characteristics, traffic flow and speed, and pedestrian use at the accident sites and 564 matched sites (based on a classification of how major each road was) at the same day and time as when each accident occurred. After adjusting for all these factors, the presence of a marked crossing was associated with a more than twofold risk of being struck. The danger was greatest (3.6-fold) where the marked crossings had no traffic signals or stop signs. JAMA 2002; 288: 2136-2143 Staple poison The problem of arsenic contamination of tube-well water encompasses far more than what people drink, say researchers who have examined arsenic levels in samples of rice in order to quantify the problem of chronic arsenic exposure in Bangladesh. In an on-site experiment, the researchers asked two people to cook 500 g of rice in their usual way, which traditionally involves boiling it in a large amount of water and discarding the water after cooking. They then measured arsenic concentrations in the raw rice, the cooking water, the cooked rice and the discarded water, and calculated that the arsenic concentration in the cooked rice was actually higher than that of the raw rice and the adsorbed water combined. Given that Bangladeshi men consume an average of 1500 g of rice per day, high concentrations of arsenic in this staple food are likely to be contributing to the arsenic-related cancers and other symptoms suffered by tens of thousands of Bangladeshis. Lancet 2002; 360: 1839-1840 Toxic choices Most doctors sleep easier since the introduction and widespread use of the "newer antidepressants", which are up to 10 times safer in overdose than tricyclic antidepressants. But as the choice of drugs broadens, Australian researchers using UK data have found that safety in overdose is not necessarily a class effect. Using mortality and prescription data, the researchers derived a "fatal toxicity index" (FTI, deaths per million prescriptions) for 34 drugs used in treating depression. Overall, the serotoninergic drugs were much safer than the tricyclic antidepressants and monoamine oxidase inhibitors (FTIs 1.6, 34.8 and 20.0, respectively). However, one serotoninergic drug, venlafaxine, had an FTI of 13.2 — higher than all the other drugs in its class and similar to some of the less toxic tricyclic antidepressants. The researchers questioned the wisdom of using venlafaxine as a first-line drug for patients with suicidal ideation and stressed the need to consider toxicity based on individual drugs rather than drug class. BMJ 2002; 325: 1332-1333