Volume 184 Issue 11

Global warming is real, so what are we going to do about it, who will do it, and when? Climate change is now widely acknowledged as the greatest environmental threat that human civilisation faces.1 During 2005 there was a perceptible shift in scientific assessment of the consequences of increasing greenhouse gas accumulation in Earth’s atmosphere. Normally cautious climate scientists went on record with warnings that potentially unstoppable “runaway” climate change is now becoming a real risk. The faster than expected melting of Greenland ice, slowing of ocean currents, and possible reversal of terrestrial ecosystems (see Box) from carbon “sinks” to net sources of carbon dioxide emissions are prominent examples of non-linear change. Impacts of climate change on the biosphere are now clear, including melting of polar ice, shrinking of glaciers, and shifts in the biotic cycles and behaviours of birds, insects and plants. International assessments have sounded serious environmental alarms before, but the emerging evidence on climate change now brings an unprecedented urgency to policy debates. In the past year, public (and belatedly, political) discussion in Australia has moved on from questioning whether there is a human influence on climate change. The questions now being framed are what we should be doing about this, and who should be responsible? A 2°C limit to avoid dangerous climate changeLargely unchecked greenhouse gas emissions to date have already committed future societies to temperature increases. British Prime Minister, Tony Blair, commissioned a conference in Exeter in 2005 to answer the question “What level of greenhouse gases in the atmosphere is self-evidently too much?”.2 A limit in global mean surface temperature to 2°C above preindustrial times has since been recognised, in many ways, as a reasonably close marriage of pragmatism and science. Many small ecosystems in Australia are likely to be lost or severely damaged with temperature increases of 1–2°C (including the Great Barrier Reef, Kakadu, the Alpine zone, and the World Heritage rainforest area)3 as plants and animals are unable to adapt or migrate. Above 2°C, agricultural yields are predicted to fall, several billion people would experience increased water stress, additional hundreds of millions may go hungry, sea level rise may displace millions from coasts, and infectious disease risks multiply. Achieving a global average 2°C limit would result in slightly different temperature increases across Australia (lower than this in the south and greater warming towards the centre of the continent). Compared with the estimated future impacts of the current emissions trajectory, a 2°C limit would substantially reduce the annual heat-related mortality in Australia, as well as the southward extension of some mosquito-borne diseases.4 The immediate priority: reducing emissionsAchieving the widely proposed 2°C ceiling on global temperature increases means a rapid transition from fossil fuels to environmentally sound energy sources — within decades.5 Delays beyond that will necessitate far deeper and more rapid emission cuts to achieve this goal. The inertia of the socioeconomic system means that we cannot expect to be able to turn it around more quickly in future than we can now. Further, recent research by major Australian businesses (including BP Australia, Westpac, Insurance Australia Group, and Origin Energy) indicates there will be economic disadvantages if we delay. If early action is taken, a 60% reduction in Australian greenhouse gas emissions by 2050 is possible while still maintaining strong economic growth (with real gross domestic product [GDP] averaging 2.1% per year). Compared with this, postponing action to 2022 would result in lower real GDP growth of an average 0.2% per year, through to 2050.6,7 Climate change is a global problem that requires responses at multinational as well as national levels. The European Union plans to reduce its greenhouse gas emissions in line with a global 2°C target, and is investing in infrastructure, technologies and social policies. Sweden has announced a policy of non-reliance on oil by 2020.8 In contrast, climate change mitigation policy in Australia still lags behind Europe, and our government has not yet set a national greenhouse gas emissions reduction target beyond 2012. Procrastinating on reducing emissions means we are betting on future technological improvements to make the transition as seamless as possible. So far, there is no simple technological fix on the horizon to cure an overheating planet. The benefits of geosequestration (piping carbon dioxide emissions from power stations into storage wells), for example, have still to be proven in terms of efficacy, affordability and safety. It is far more likely that, as with preventive strategies for other major public health problems (such as smoking cessation or obesity reduction), we will need a “portfolio” approach to reducing emissions. While the full benefits from global greenhouse gas mitigation will only be experienced by future generations, the ancillary benefits of local emissions reduction policies would have immediate health benefits. For example, air pollution from motor vehicles caused an estimated 900–2000 early deaths in Australia in the year 2000, entailing direct costs of between $1.1 and $2.6 billion. A 50% reduction in vehicle-related emissions in the combined Sydney and Melbourne regions could avert 300–500 premature deaths per year from air pollution in those cities.4 Less car dependence (with a shift to public transport, walking and bike riding) would presumably also have substantial health and social benefits, through increased physical activity and social interaction. Adaptation measuresIt has been widely assumed that wealthy human societies will be able to buffer themselves from the more severe impacts of climate change, at least initially. However, events such as Hurricane Katrina and the European heatwave have shown that societies everywhere are vulnerable to extreme and unpredictable weather. In the late summer of 2003, an unprecedented heatwave in Northern Europe led to several tens of thousands of premature deaths.9 Elderly people were most vulnerable, as thermoregulatory ability usually decreases with age.10 The main contributing factor to this is reduced physical activity, leading to lower muscle strength, sweating capacity and cardiovascular reserve, and to lower cardiovascular stability. Drugs that affect body fluid balance, vasodilator activity and cardiac function are potentially harmful during extreme heat events. We know much more about the population-level risks that contribute to increased mortality during heatwaves. People in urban and suburban regions typically have far higher rates of mortality than rural regions. In France, many nursing homes were not air-conditioned, hospitals were understaffed, and families were holidaying (and hence unavailable to support elderly or mentally ill relatives) during what would usually have been a mild summer holiday period.11 Social isolation has also been linked to increased risk of death during heatwaves in the United States.12 The Australian Government has focused its policy development on identifying the risks and vulnerabilities of sectors to adapting to climate change.7 Health departments in several Australian states have commissioned studies of climate change adaptation needs: strategies, such as heatwave forecasting systems and associated directives for workplaces and nursing homes, and alerts for general practitioners, are now in the process of being developed. Details of adaptive strategies to reduce the impact of climate change will be local and context-dependent, although much can be generalised from experiences elsewhere. To support policy, we need more evidence about local conditions that modify heatwaves (such as the heat-island effect, household design to reduce heat retention, and social connectedness). We know that many bacteria (such as salmonellae) are sensitive to climatic conditions. It is less clear how the changing climate will interact with land use and social practices in a particular region to influence the vector, host (eg, domestic or native animal) and pathogen transmission routes for water-borne and food-borne diseases. We are beginning to understand the challenge that human-induced climate change poses for us, in terms of the likely impacts on humans. Anticipatory and precautionary adaptation is more effective and less costly than last-minute emergency adaptation or retrofitting.13 Even so, relying on incremental adaptation to lessen the evolving risks to health is as inappropriate as progressive multiplication of the number of defibrillator stations in a society undergoing an uptrend in coronary heart disease mortality. In the best traditions of public health, the focus must be on primary prevention — global greenhouse gas abatement. Individuals, families and communities should contribute to the collective effort, but the issue is so large in scale and so systemic in nature that only government-led mitigation can ensure that climate change is slowed and, hopefully, arrested. Glossary Ecosystem: A functional unit of interdependent organisms, together with their physical environment, linked together through nutrient cycling and energy flow. An ecosystem can be any size — a pond, field, forest, or Earth’s biosphere — but it always functions as a whole unit. Fossil fuels: Fuels such as coal, oil and gas made by the decomposition of ancient plant and animal remains which give off carbon dioxide when burned. Geosequestration: Sequestration is the storage of greenhouse gases from the atmosphere by plants or technological measures. Plants absorb carbon dioxide, release the oxygen and store the carbon in the soil. Geosequestration refers to the storage of carbon dioxide in underground reservoirs (such as old oil or gas wells). Greenhouse gases: Molecules (such as carbon dioxide and methane) that warm the atmosphere because they absorb some of the radiation that is emitted from the surface of Earth. Heat-island effect: Dark, dense materials (such as roof tiles or asphalt) absorb more heat from the sun than surrounding objects, and release the heat into houses and city areas in the evenings. In an urban heat island the temperature of a city can be 2–10°C higher than the surrounding rural area. The larger and more population-dense an urban area, the more pronounced is the heat-island effect. Landscape and housing design, vegetation, building spacing and paving materials all contribute to the heat-island effect.

Rosalie E Woodruff PhD, MPH · Anthony J McMichael FACOM, MB BS, PhD · Simon Hales MB BChir, MPH, PhD

The opportunity for informed choice in screening is limited Commencing in mid 2006, the Australian Government will phase in a national bowel cancer screening program for men and women who turn 55 or 65 years of age, and for those who participated in the government’s pilot screening program, conducted from November 2002 to June 2004.1 Eligible people will be invited to complete an immunochemical faecal occult blood test (FOBT) in the privacy of their own home and mail it in for analysis.2 Consumers will not be offered a choice of screening test. The government came to this position after commissioning a review of the costs, benefits and harms of different screening options3 and evaluating the pilot screening program.1 The study by The Multicentre Australian Colorectal-neoplasia Screening (MACS) Group in this issue of the Journal (A comparison of colorectal neoplasia screening tests: a multicentre community-based study of the impact of consumer choice)4 suggests that participation in screening does not differ significantly between different screening tests that might be offered. The implication is that consumer choice can be taken out of the equation if maximising participation is the primary objective of screening. If consumer choice does not influence participation, then why not offer a range of screening tests? This invites two prior questions — to what extent should the Australian Government be concerned about consumer choice and participation, and what criteria should be applied to determining screening options? For decades, Australia has accepted the World Health Organization guidelines for evaluating the worth of screening. These guidelines, recently updated, state “. . . in screening there is an ethical responsibility to conduct programs that will be of overall benefit to those who are screened and will minimize harm and anxiety that will arise. It is not simply the offering of medical tests for people to accept or reject as they wish. This responsibility implies that if evidence is not available from valid studies on the effectiveness of screening, screening should not be offered.”5 Although one in six participants in the MACS Group trial participated in a screening strategy other than FOBT,4 neither flexible sigmoidoscopy, computed tomography colonography nor colonoscopy meet the WHO criteria for a screening test. As yet, there is no trial evidence that any of these tests reaches an acceptable ratio of population benefits to harms and costs that would warrant their inclusion in a national screening program. The results of the MACS Group trial raise important questions about whether participation in screening is an appropriate measure of success and whether participation itself is an adequate measure of consumer choice. The traditional view, one shared by the updated WHO guidelines, is that participation is a measure of success.5 All things being equal, the more people who are screened, the greater the reduction in bowel cancer mortality in the population. That line of reasoning is incontestable. What is contestable is whether people who participate in screening make an informed choice. The MACS Group suggest that the one reason why their participation rates (averaging 20.9% over all screen tests) were lower than the government pilot projects (45.4%)1 and other international programs is that the Group were required to “present the invitation as a clinical research project with due informed consent” (our emphasis). This, argues the MACS Group, may have contributed to a lower participation rate. They then suggest that a “guided choice” following formal clinical review might improve participation. The Australian Government should seriously consider providing a decision-support system that allows consumers to decide whether they want to take up the offer of screening, based on information of benefits, harms and the process of testing. This should include a guide to screening options. Not everyone will want or need a “guided choice”. Our previous study of consumer choice of FOBT screening found that a third of the target group opted for screening no matter what the ratio of harms to benefits, 55% took up the offer of a guided choice (weighing up the benefits and harms), and 12% chose outright not to be screened.6 Even if 30% of the target screening group take up the offer of a guided choice by a general practitioner, based on the 75% Medicare rebate for a level-B GP consultation, the cost per life-year saved (LYS) of biennial FOBT screening without a routine GP consultation would increase from about $13 5007 to $21 000 per LYS. If 70% of the target population opt for a GP visit, the cost per LYS is $31 300 — more than double the cost effectiveness ratio for a screening program without a routine visit to the GP. Even so, this figure is comparable to other cancer screening programs. The challenge is to develop an affordable decision-support system — one that is either self-directed or one that offers restricted access to an additional GP consultation. This applies equally to those aged under 55 years who will not be eligible for screening in the national program. Unless the national program actively engages the community, GPs and pharmacists in screening and diagnostic assessment of people with a positive FOBT, the opportunity for an informed choice and participation is limited. A key question for the National Bowel Cancer Screening Program is whether setting participation targets and using them to measure the success of screening is appropriate. Falling short of a 70% target participation rate shouldn’t be taken as a public health failure if it can be shown that consumers have had an opportunity to make an informed choice (alone or with their GP), using a decision-support system if they wish to do so. Informed consumers making smart choices about screening — now that would be a public health success.

Glenn P Salkeld GradDipHealthEcon, MPH, PhD · Jane M Young MPH, PhD, FAFPHM · Michael J Solomon MB BCh, MSc, FRACS

Guidelines for GPs need to tackle the tough issues These are interesting times in Australian mental health. On a daily basis, the gap between best practice guidelines and the quality of services delivered widens. Rapid advances in clinical neurosciences give us real enthusiasm for new approaches to treatment. By contrast, national and state-based inquiries highlight fundamental failures in acute and ongoing care. Although major service redevelopments continue, we do not yet provide an integrated health services response. All our governments now concede that a new round of investment, innovation and coordinated reform is essential. Substantial new investments are justified and necessary if we are to see genuine innovation, improved access to care, and better health outcomes in the mental health service environment. The production of guidelines for bipolar disorder internationally reflects the therapeutic gains that should be available for people with this common and disabling illness.1,2 However, when guidelines target general practitioners, like the recommendations provided by Mitchell et al in this issue of the Journal (The management of bipolar disorder in general practice),3 some hard questions need to be asked. Are they relevant to general practice in Australia? Do they connect with the target audience? Are the recommendations achievable in our health care environment? In recent years, most GPs feel that they have received truck loads of worthy guidelines from their specialist colleagues. Although guidelines are critical to improving health care quality, in the end most fail to recommend strategies that lead to real impacts on clinical practice. The mental health field is no exception. It too is awash with new guidelines.4 Surprisingly, given that 75% of mental health consultations take place in the primary care environment, few have targeted general practice. A notable exception is the guidelines for the treatment of depression in general practice settings, commissioned by beyondblue: the national depression initiative.5 From a GP’s perspective, most mental health guidelines don’t concede basic service limitations. First, GPs are not an unlimited mental health resource. In fact, recent data indicate a major slowing in the rate of increase in the treatment of common mental disorders in primary care settings.6 Second, mental health guidelines compete with all other medical guidelines for attention. Simply producing more guidelines for more disorders doesn’t increase the likelihood that recommendations will be put into action. Producing more guidelines for closely related topics (eg, bipolar depression,3 major depression in specialist settings,7 major depression in primary care,5 youth depression8) also doesn’t help. Third, simply extrapolating evidence from studies conducted in patients with severe, chronic or complex disorders encountered in specialist treatment centres may not only be scientifically questionable, but may particularly annoy GPs.9 Most importantly, “GP guidelines” for mental disorders should deal explicitly with the key issues: identification of less severe forms of the disorder; management of medical comorbidity; overlap with alcohol and substance misuse; limited geographical and economic access to specialist psychological support; use of alternative treatments for less severe or less complex cases; and implications of poor access to specialist assessment during acute phases of illness. Providing a detailed list of reasons for specialist referral does not assist those GPs who struggle on a daily basis to connect with any specialist support in the private or public sector. Rather than addressing such issues, specialist psychiatry has a particular knack for creating more disorders, more subcategories and more complex treatment regimens.1-3 The self-explanatory nature of manic-depressive illness has been replaced by the more opaque terms “bipolar I”, “bipolar II”, “bipolar depression”, “mixed episodes”, “rapid cycling”, and “cyclothymia”. However, if such fine-grained differentiation is not associated with quite specific differences in treatment or prognosis, or is not based on a solid evidence base,10 then it holds little appeal. The medical, psychosocial and legal consequences of a GP making a diagnosis of bipolar disorder are potentially considerable. To suggest that these can be minimised by having all such decisions reviewed by a specialist is highly optimistic, especially given the decreasing availability and inequitable access to such resources. While recent improved access to psychological therapies through partnerships in general practice,11 and proposed direct referral mechanisms to clinical psychologists,12 are most welcome, it is not yet clear whether these developments will increase access for patients with bipolar disorder to the more intensive and targeted therapies they require. From a primary care perspective, the most useful mental health guidelines tackle the tough issues that cross a GP’s desk on a daily basis.9 Where are the best sources of self-help, self-monitoring, detailed illness descriptions, and family education to be found? Are there high quality e-health resources available?13 What options are available to a GP when patients become a danger to themselves or their reputations? How should a GP deal with poor compliance? What are the cost implications for patients of particular management plans (eg, costs of travel to specialist appointments)? What should the GP do when specialist services are not available? What are a GP’s responsibilities when the patient doesn’t return for follow-up appointments and/or medication monitoring? How should a GP document mental health consultations in their medical records? What other clinical or management resources are available? Is additional training required to deliver the therapies recommended in the guidelines? While the recommendations presented by Mitchell et al,3 and the related technical summaries, do provide useful clues, insufficient attention to these practice-based issues risks an overall negative rating from the target audience.

Ian B Hickie MD FRANZCP · Grant A Blashki MD, FRACGP

A clash of purpose between a journal’s editors and its owner 20 February 2006 may well be the day that marked the beginning of the decline of the CMAJ (Canadian Medical Association Journal) as a widely respected national and international journal. On that day John Hoey, Editor-in-Chief of the CMAJ for 10 years, and his Deputy Editor Anne Marie Todkill were summarily dismissed by Graham Morris, the president of CMA Media Inc which publishes the CMAJ.1 As to the reasons for the firings, Morris said, “I felt that after 10 years it was time for a fresh approach.”2 His rationale was greeted with disbelief and derision from leaders in the publishing field. Frank Davidoff, Editor Emeritus of the Annals of Internal Medicine was reported as saying, “Oh, come on! A summary firing without a cause? I mean, how naïve do they think people are?”, adding, “I think it could be the death knell of this Journal”.3 The dismissal of Hoey and Todkill provoked editorial comments in the Lancet4 and the British Medical Journal (BMJ),5 and condemnations from the Council of Science Editors, the World Association of Medical Editors and the International Committee of Medical Journal Editors — all parties called for the Canadian Medical Association (CMA) to respect editorial independence.4 Within 3 weeks, the CMAJ was reduced to a shell of its former self. The journal’s Acting Editor-in-Chief, Stephen Choi, resigned, along with its Editorial Fellow and a number of Associate Editors. Their resignations were provoked by the failure of the CMA to agree to Choi’s request that the publisher and the owner of the journal, CMA Holdings, a commercial subsidiary of the CMA, not interfere with editorial content.6 In dire straits, the CMA turned to Bruce Squires, the previous Editor-in-Chief, to resume this role in an acting capacity. Seventy-one-year-old Squires declined and urged the CMA to heed Choi’s request for editorial independence. Finally, 16 of the 19 members of the CMAJ editorial board resigned.6,7 There was dismay and disquiet in the Canadian medical community. Anger among academics, researchers and clinicians followed, with calls for a boycott of submissions to the CMAJ and the activation of a worldwide petition for editorial autonomy at the CMAJ, and the reinstatement of Hoey and Todkill. There was even talk of setting up an open-access journal in competition with the CMAJ.7,8 Caught in this imbroglio, the CMA desperately needed a circuit breaker. This came with two announcements. The first announced yet another Acting Editor, Noni MacDonald (a former Dean of Medicine), the assembly of a new editorial board, and the release by the CMA of nine interim principles for editorial governance, including editorial independence.9,10 The second was more striking, announcing the formation of a panel of eminent authorities to “review the Canadian Medical Association Journal’s (CMAJ) governance structure and to provide objective recommendations to further the CMAJ’s continued commitment to editorial independence and maintaining excellence in reporting on the science and art of medicine.”11 The review panel, chaired by Antonio Lamer, a former Chief Justice of the Canadian Supreme Court, is to report soon. Despite these measures, dissatisfaction remains. It is obvious the current turmoil was driven by matters other than the desire to seek new directions.2 What then was behind the sacking of Hoey and Todkill? During Hoey’s tenure, there were smouldering tensions between the CMAJ and CMA as to who should have control over the journal’s content, particularly if this was politically or commercially awkward for the CMA.6,7 These tensions reached a climax in the months immediately before the sackings, with two CMAJ news items — the Plan B story (a CMAJ investigation of over-the-counter dispensing of the newly approved emergency contraceptive pill by Canadian pharmacists) and the Tony Clement story (an article commenting on his appointment as Minister of Health in the Conservative Canadian Government, which was critical of his stance on privatisation of health services).12 In late 2005, reporters from the CMAJ began an investigation into the circumstances surrounding over-the-counter dispensing of the emergency contraceptive pill — the investigation became know as the Plan B story. They asked 13 women to purchase the pill and report the conditions for its procurement. They found that the women had been asked private and personal questions by pharmacists, in accordance with the guidelines of the Canadian Pharmacists Association (CPhA). On learning of the investigation, the CPhA complained to the CMA that the exercise was not investigative journalism, but research, and thus should have had ethical approval. They also objected to what they considered to be covert observation of pharmacists. Hoey was instructed by CMA executives to pull the article; he did not, but when it appeared, details of the personal questions had been expunged. This was tantamount to censorship. After complaints by privacy commissioners following the publication of the story, the CPhA instructed its members to desist from extracting private information from consumers. However, the damage to CMAJ editorial independence had been done. This blatant breach was publicly exposed in a CMAJ editorial in December 2005, which noted that, “As a serious vehicle for science, news and opinion, CMAJ cannot avoid the discussion of contentious issues. It is not unexpected for tensions to arise between the association and the journal from time to time, for our mandates are not the same.”13 To bring the matter to a head, Hoey asked an ad hoc committee of the editorial board to review matters related to the handling of the Plan B story. During its deliberations, the committee’s attention was drawn to further instances of tampering with another news item — the Tony Clement story. This article, which was critical of Clement’s stance on privatisation of health services, was published electronically on 7 February 2006, but was subsequently removed from the website. It reappeared on 22 February 2006 as a different report, less critical of the Minister and more in harmony with the CMA stance on privatisation. The full texts of both versions are detailed in the final report of the ad hoc committee, chaired by Jerome Kassirer, the previous Editor-in-Chief of the New England Journal of Medicine, and with high-level individuals in medical publishing, journalism and academic medicine as members.12 After duly examining all relevant issues, the committee dismissed the complaints of the CPhA and reaffirmed the legitimacy of responsible journalism as an integral part of modern medical journals, drawing attention to this practice in the Lancet, BMJ, Science, Nature and the Journal of the American Medical Association. Significantly, it suggested that the CMA and CMA Holdings had a decision to make: either support editorial independence or run the risk of the CMAJ degenerating into “an association rag.” The committee also noted that, “Despite claims by the CMA, . . . the editorial autonomy [of the CMAJ] is to an important degree illusory” and that “Publishers have the option of dismissing an editor who exhibits a pattern of incompetence, misconduct or fiscal irresponsibility. As long as editors hold their position, however, they must be free to make editorial decisions independently of the ideological, strategic or commercial interests of the publisher. The editor’s conduct should be judged against the ideals of the medical profession and against standards of accuracy, precision and fairness. Editorial decisions should not be judged against the particular aims of the CMA.”12 In this context, the CMA President, Ruth Collins–Nakai, more recently revealed that “irreconcilable differences” between the editors and the publisher of the CMAJ were the real reasons for the sacking of Hoey and Todkill.14 Publishers and editors worldwide now await with interest the findings of the Lamer panel. Meanwhile, what can we learn from the CMAJ crisis? Editorial independence will only work if there is a clear understanding between owners and editors of journals as to a journal’s mission, and the empowerment of an editor or groups of editors to implement this mission and to be responsible for the cover-to-cover content of the journal. Essential to this process is the trust that editors will realise the stated ideals by making sound decisions and, at the same time, enjoy the freedom to publish controversial material, even when this is at odds with the purpose, politics and practices of the body owning the journal. In short, editorial independence is built on mutual respect, open communication and a clear understanding of boundaries.15 These appear to have been in short supply in the Hoey affair.

Martin B Van Der Weyden MD, FRACP, FRCPA

Objective: International guidelines and local practices for colorectal cancer screening suggest an important role for several different screening tests, and for consumer choice. We aimed to determine whether choice of test improved participation in screening.Design: A randomised comparative study offering one of six screening strategies: faecal occult blood testing (FOBT), FOBT and flexible sigmoidoscopy (FS), computed tomography colonography (CTC), colonoscopy, or one of two groups offered a choice of these strategies (one of which was sent an FOBT kit with the letter of invitation, while the other was required to request an FOBT kit by telephone if that was the test chosen).Setting and participants: 1679 people aged 50–54 or 65–69 years, randomly selected from the electoral roll in metropolitan Perth, Adelaide and Melbourne.Main outcome measures: Participation, yield of advanced colorectal neoplasia (CRN), acceptability and safety.Results: 346 (20.6%) were excluded from screening, mostly for a recent examination (165), symptoms (72) or personal or family history of colorectal neoplasia or cancer (83). 278 of the 1333 eligible (20.9%; 95% CI, 18.7%–23.1%) participated in screening. Participation was similar by age and sex, but lower in Perth than Adelaide (17.1% v 24.2%; P = 0.01). Participation by screening group was: FOBT, 27.4%; FOBT/FS, 13.7% (P < 0.001 compared with FOBT); CTC, 16.3% (P = 0.005); colonoscopy, 17.8% (P = 0.02); or a choice of test 18.6% (“with FOBT kit”; P = 0.03) or 22.7% (“without FOBT kit”; P = 0.3). Yield of advanced CRN was higher in participants screened by colonoscopy than FOBT (7.9% v 0.8%; P = 0.02). All tests were well accepted and no serious complications arose from screening.Conclusion: A choice of screening test did not improve participation. Participation by FOBT was higher than by other tests. Yield of advanced colorectal neoplasia on an intention-to-screen basis, determined by test sensitivity and participation, is likely to be a critical determinant of the effectiveness of screening strategies.

The Multicentre Australian Colorectal-neoplasia Screening (MACS) Group

Objectives: To determine the incidence of adverse events in patients admitted in the year 2003–04 to selected Victorian hospitals; to identify the main hospital-acquired diagnoses; and to estimate the cost of these complications to the Victorian and Australian health system.Design: The patient-level costing dataset for major Victorian public hospitals, 1 July 2003 – 30 June 2004, was analysed for adverse events by identifying C-prefixed diagnosis codes denoting complications, preventable or otherwise, arising during the course of hospital treatment. The in-hospital cost of adverse events was estimated using linear regression modelling, adjusting for age and comorbidity.Main outcome measures: Cost of each patient admission (“admitted episode”), length of stay and mortality.Results: During the designated timeframe, 979 834 admitted episodes were in the sample, of which 67 435 (6.88%) had at least one adverse event. Patients with adverse events stayed about 10 days longer and had over seven times the risk of in-hospital death than those without complications. After adjusting for age and comorbidity, the presence of an adverse event adds $6826 to the cost of each admitted episode. The total cost of adverse events in this dataset in 2003–04 was $460.311 million, representing 15.7% of the total expenditure on direct hospital costs, or an additional 18.6% of the total inpatient hospital budget.Conclusion: Adverse events are associated with significant costs. Administrative datasets are a cost-effective source of information that can be used for a range of clinical governance activities to prevent adverse events.

Jonathon P Ehsani MPH(Int) · Terri Jackson PhD · Stephen J Duckett PhD, DSc, FASSA

Objective: To determine the prevalence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) carriage and infection among children living in an Indigenous community in Queensland.Design, setting and participants: Swabs for culture of S. aureus were collected from the nose, throat and skin wounds of primary school children.Main outcome measures: MRSA carriage, antibiotic sensitivity, genotype, and presence of the virulence factor Panton–Valentine leukocidin (PVL); and epidemiological risk factors for MRSA carriage.Results: 92 (59%) of 157 eligible children were included in the study. Twenty-seven (29%) carried S. aureus; 14 of these (15% of total) carried MRSA. MRSA was isolated from 29% of wound swabs, 8% of nose swabs, and 1% of throat swabs. Fourteen of 15 MRSA isolates were sensitive to all non-β-lactam antibiotics tested. Eight children (9%) carried CA-MRSA clonal types: six carried the Queensland clone (ST93), and two carried the South West Pacific clone (ST30). All these isolates carried the virulence factor PVL. The remaining six children carried a hospital-associated MRSA strain (ST5), negative for PVL.Conclusions: We have identified a high prevalence of CA-MRSA carriage in school children from a Queensland Indigenous community. In this setting, antibiotics with activity against CA-MRSA should be considered for empiric therapy of suspected staphylococcal infection. Larger community-based studies are needed to improve our understanding of the epidemiology of CA-MRSA, and to assist in the development of therapeutic guidelines for this important infection.

Susan Vlack FAFPHM · Leonie Cox PhD · Anton Y Peleg FRACP · Condy Canuto MAE · Christine Stewart · Alzira Conlon · Alex Stephens BSc(Hons) · Philip Giffard PhD · Flavia Huygens PhD · Adam Mollinger MB BS · Renu Vohra FRCPA · James S McCarthy FRACP

Objectives: To identify the prevalence of blood-borne viruses (BBVs) testing, counselling and vaccination services by drug and alcohol services for injecting drug users in Australia.Design, setting and participants: Cross-sectional survey of drug and alcohol agencies throughout Australia.Outcome measures: Current availability of testing, counselling and vaccination services for hepatitis B virus (HBV), hepatitis C virus (HCV) and HIV; availability of medical coverage; and barriers to greater provision of services.Results: Survey responses were provided by 222 agencies nationally (61% response rate). About three-quarters of agencies provided some access to HIV, HBV, and HCV testing and HBV vaccinations, but only a third offered these services routinely on site. HBV vaccination availability differed depending on the primary function of the agency, with drug dependence units and needle and syringe programs more likely to provide vaccination on site. The major barriers preventing agencies from providing routine on-site BBV services are lack of access to medical staff and trained personnel; the cost of providing these services; and a lack of facilities.Conclusions: The restricted provision of BBV services represents missed opportunities to reduce individual and community morbidity and to maximise the potential savings from preventable disease in relation to HBV infection. To address key barriers and patient retention issues, it is necessary to expand the role of non-medical staff, increase the use of shorter HBV vaccination schedules, and identify and maintain local clinical partnerships between public and private service providers.

Adam R Winstock MSc, MRCPsych, FAChAM · Caroline M Anderson GradDipSc(Psych), BA · Janie Sheridan PhD, MRPharmS, MPS(NZ)

Objective: To review our experience with percutaneous radiofrequency ablation (RFA) for osteoid osteoma.Participants, design and setting: Retrospective review of 24 patients with osteoid osteoma treated with percutaneous RFA at St Vincent’s Hospital, Melbourne, from August 2000 to February 2005.Main outcome measures: Initial response to treatment, return of symptoms, time to recurrence, complications and histopathological correlation.Results: In 23 of 24 patients, there was immediate relief of symptoms. One-third of patients had a return of symptoms. The 24 patients underwent a total of 32 RFA procedures. Of the eight patients who had a recurrence, five had an initial lesion ≥ 10 mm in maximum diameter. Twenty-three of the 24 patients were pain-free at the end of the study period. Patients were followed up for a median of 26 months. There were no long-term complications.Conclusions: Percutaneous RFA is a safe and efficacious treatment for osteoid osteoma with a low morbidity rate. Despite recurrence after treatment, re-treatment is simple and effective.

Richard A Kjar MB BS · Gerard J Powell MB BS, FRACS · Stephen M Schilcht MB BS, FRANZCR · Peter J Smith MB BS, FRANZCR · John Slavin MB BS, FRACPA · Peter F M Choong MD, FRACS

General practitioners have a key role in managing patients with bipolar disorder, a condition which affects at least one in 200 Australians each year and is the sixth leading cause of disability in the population. Although diagnosis and treatment of the illness is complex, effective treatment can lead to good outcomes for many patients. GPs can contribute significantly to early recognition of bipolar disorder, avoiding the long delays in accurate diagnosis that have been reported. As in other complex recurrent or persistent illnesses, GPs are well placed to coordinate multidisciplinary “shared care” with specialists and other health care professionals. GPs also provide continuing general medical care for patients with bipolar disorder, and are in a unique position to understand patients’ life circumstances and to monitor their progress over time. The last decade has seen many advances in medication for bipolar disorder, including the introduction of new therapies and the refinement of treatment protocols using older medications. There has also been increasing recognition of the contribution of psychological therapies to symptom relief, relapse prevention, optimal function, and quality of life.

Philip B Mitchell MD, FRANZCP, FRCPsych · Jillian R Ball PhD · James A Best MB BS, FRACGP · Bronwyn M Gould MB BS, MPsycholMed · Gin S Malhi MD, FRANZCP, MRCPsych · Geoffrey J Riley MRCPsych, FRANZCP, FRACGP · Ian G Wilson PhD, FRACGP

In the wake of findings from the Bundaberg Hospital and Forster inquiries in Queensland, periodic public release of hospital performance reports has been recommended. A process for developing and releasing such reports is being established by Queensland Health, overseen by an independent expert panel. This recommendation presupposes that public reports based on routinely collected administrative data are accurate; that the public can access, correctly interpret and act upon report contents; that reports motivate hospital clinicians and managers to improve quality of care; and that there are no unintended adverse effects of public reporting. Available research suggests that primary data sources are often inaccurate and incomplete, that reports have low predictive value in detecting “outlier” hospitals, and that users experience difficulty in accessing and interpreting reports and tend to distrust their findings.

Ian A Scott FRACP, MHA, MEd · Michael Ward MB BS, FRACP

Objective: To examine media stories on research presented at scientific meetings to see if they reported basic study facts and cautions, and whether they were clear about the preliminary stage of the research.Design and setting: Three physicians with clinical epidemiology training analysed front-page newspaper stories (n = 32), other newspaper stories (n = 142), and television/radio stories (n = 13) identified in LexisNexis and ProQuest searches for research reports from five scientific meetings in 2002–2003 (American Heart Association, 14th Annual International AIDS Conference, American Society of Clinical Oncology, Society for Neuroscience, and the Radiological Society of North America).Main outcome measures: Media reporting of basic study facts (size, design, quantification of results); cautions about study designs with intrinsic limitations (animal/laboratory studies, studies with < 30 people, uncontrolled studies, controlled but not randomised studies) or downsides (adverse effects in intervention studies); warnings about the preliminary stage of the research presented at scientific meetings.Results: 34% of the 187 stories did not mention study size, 18% did not mention study design (another 35% were so ambiguous that expert readers had to guess the design), and 40% did not quantify the main result. Only 6% of news stories about animal studies mentioned their limited relevance to human health; 21% of stories about small studies noted problems with the precision of the finding; 10% of stories about uncontrolled studies noted it was not possible to know if the outcome really related to the exposure; and 19% of stories about controlled but not randomised studies raised the possibility of confounding. Only 29% of the 142 news stories on intervention studies noted the possibility of any potential downside. Twelve stories mentioned a corresponding “in press” medical journal article; two of the remaining 175 noted that findings were unpublished, might not have undergone peer review, or might change.Conclusions: News stories about scientific meeting research presentations often omit basic study facts and cautions. Consequently, the public may be misled about the validity and relevance of the science presented.

Steven Woloshin MD, MS · Lisa M Schwartz MD, MS

Australian doctors have a particular responsibility in the fight to achieve urgent international reductions in carbon dioxide emissions Most people in the scientific community believe that global warming is occurring, and that it will cause dramatic changes in climate patterns, with potentially serious effects on human health in the form of widespread epidemics, trauma, malnutrition and, in vulnerable areas, famine.1,2 The special danger to children has been stressed.3 Recent observations on the shrinking Antarctic ice mass suggest that the pace of these changes far exceeds that previously predicted.4 There is now little contention that global warming is largely the result of carbon dioxide and other greenhouse gas emissions resulting from human energy consumption,2 and that these effects are just within reach of reversal only if worldwide emissions are rapidly stabilised. Medical debate about global warming has so far emphasised planning and response.2,5 It is therefore timely that we draw a parallel to medical involvement in the nuclear weapons disarmament movement in the 1980s. At that time, it rapidly became clear to physicians that civil defence planning for a medical response to nuclear weapons attack was not only futile, but dangerously counter-productive because it fostered a false community belief in a medical fix, thereby reducing the political incentive for preventive action. A remarkably unified international medical response helped turn political attention to prevention of accidental or intentional use of nuclear weapons through political initiatives. Economic factors may have ultimately secured the end of the Cold War, and nuclear weapons have not disappeared. However, the influence of the Nobel Peace Prize-winning organisation, International Physicians for Prevention of Nuclear War, was significant in the withdrawal from the brink of catastrophe, particularly because its protagonists had the ear of both United States and Soviet leaders.6 Doctors now have a similar particular responsibility in the fight to achieve urgent international reductions in carbon dioxide emissions. Firstly, we can point to the futility of expending our energy, enterprise and long-term investment in advancing health care in the absence of action to preserve a liveable planet. Secondly, we can measure and communicate the effects of the threat of global environmental destruction on the current mental health of our children. At the height of the Cold War, when nuclear war appeared imminent, through accident or pre-emptive strike, school children reacted with despair and loss of motivation.7,8 Many children thought they would not survive to adulthood. We can actively contribute to the debate on global warming by providing good data on this specific issue, but the nuclear weapons experience suggests that our children and grandchildren will react to expanding knowledge of climate change with despair. Thirdly, we are in a strong position to draw attention to the psychology of denial, despondency and paralysing helplessness that characterises human response to the threat of overwhelming catastrophe.9 We can help professionally in the educated and rational process of action that can reverse this paralysis, pointing to the astounding historical successes that can result when an active community converts hopelessness into anger and political action. The abolition of slavery and the end of apartheid are just two examples. In each case, the central humanitarian principles that underpin medicine were guiding principles for those who went into the battle for change, in both cases against seemingly insurmountable economic odds. Australian doctors have a special responsibility because of the influence of Australia in Asian, American and European discussions on reducing green house gas emissions. We can inform the debate with reliable data on the mental and physical health consequences of global warming, and use our professional voice and leadership to instil it with urgency.

Richard F Kefford MB BS, FRACP, PhD

Acute generalised exanthematous pustulosis (AGEP) is a clinical reaction pattern that is induced, in over 90% of cases, by systemic drugs (most frequently antibacterial drugs). This is the first reported case of AGEP caused by the herbal remedy Ginkgo biloba. Clinical recordA 45-year-old man developed a symmetrical maculopapular eruption on his limbs. Within 2 days, the rash generalised to involve the face. Disseminated non-follicular small pustules on erythematous skin were predominant (Box 1). The palms, soles and mucous membranes were spared. His body temperature was 38.8°C. The rash had developed 48 hours after starting oral Ginkgo biloba treatment for tinnitus (Ginkgo biloba was the only ingredient listed on the medication). The patient denied previously taking Ginkgo biloba and was not on any other medication. He reported no previous adverse drug reactions and no history of psoriasis. Blood tests returned the following results: C-reactive protein 135 mg/L (reference range [RR], < 12 mg/L); white blood cells 17.2 × 109/L (RR, 4.0–11.0 × 109/L); neutrophils 15.8 × 109/L (RR, 2.0–7.5 × 109/L); and eosinophils 0.79 × 109/L (RR, 0.04–0.40 × 109/L). A skin biopsy showed neutrophil-containing spongiotic pustules in the epidermis and a mixed cellular infiltrate with oedema in the papillary dermis, consistent with acute generalised exanthematous pustulosis (Box 2). The rash cleared within 10 days after withdrawal of Ginkgo biloba. The patient refused a follow-up cutaneous patch test. DiscussionAcute generalised exanthematous pustulosis (AGEP) is considered to be a clinical reaction pattern, induced, in over 90% of cases, by systemic drugs. It is a rare presentation of an adverse drug reaction most frequently triggered by antibacterial drugs. AGEP can be difficult to distinguish from other pustular dermatoses. To my knowledge, this is the first reported case of AGEP caused by the herbal remedy Ginkgo biloba. Ginkgo fruits and seeds have been used in traditional Chinese medicine for millennia, mostly to treat asthma and chilblains. The flavonoids and terpene lactones from the ginkgo leaf, which today is used for medicinal purposes, are associated with diverse pharmacological actions. In clinical practice, ginkgo is mostly used to treat memory impairment,1,2 dementia,3 tinnitus4 and intermittent claudication.5 In some European countries, ginkgo is registered for these indications; in the United States, it is marketed as a dietary supplement. In-vitro and in-vivo studies suggest that ginkgo has antioedemic, antihypoxic, antioxidant, metabolic, antiplatelet, haemorrhagic, microcirculatory and free-radical-scavenging actions.6,7 Reported adverse skin reactions to Ginkgo biloba include contact dermatitis and diffuse morbilliform eruption. The primary allergens from the ginkgo leaf appear to be ginkgolic acids. Ginkgolic acid molecules have similar side-chains to the catechols of the poison ivy group and are suspected of displaying some cross-allergenicity.8 Allergic contact dermatitis to the Rhus antigen present in the ginkgo fruit seeds has been extensively documented.8,9 This raises the question of whether or not ginkgolic acids could evoke a systemic reaction if taken orally. Systemic contact dermatitis can develop from oral challenge after contact sensitisation with other allergens.10 The criteria for diagnosis of AGEP are defined by the EuroSCAR score.11 Features of the condition include acute onset of small, sterile, non-follicular pustules on erythematous skin beginning in intertriginous areas or on the face; systemic signs, with fever over 38°C (in a typical course, an acute rash appears within 1–2 days and resolves by skin desquamation within 4–10 days after discontinuation of the causative agent); and neutrophilia, in the setting of a consistent histological pattern.11 The patient described here had a classic drug-induced AGEP with typical morphology, course and histology and a validation score of 12 points (the range for definite AGEP is 8–12).11 Ginkgo biloba treatment is commonly recommended by non-medical practitioners. With the rise of complementary and alternative medicine, there may be an increase in frequency and type of adverse reactions to this treatment. 1 Disseminated small pustules on erythematous skin 2 Histological section of skin biopsy The section shows neutrophil-containing spongiotic pustules (black arrow) in the epidermis and a mixed cellular infiltrate with oedema (clear arrow) in the papillary dermis (haematoxylin–eosin stain, original magnification &times 100).

Robert S Pennisi MPhil, FRACGP, DPD

A 31-year-old woman presented with a tender left axillary mass. There was no history of concurrent fevers, sweats or recent illness. She was born in Australia and had not travelled overseas recently. Examination showed a left axillary mass measuring 5 cm in diameter. There was no other lymphadenopathy, no hepatosplenomegaly, nor any breast masses. Aspiration produced 10 mL of purulent fluid. Polymorphs were seen on microscopy but no Mycobacterium spp or other organisms were grown on culture. Histological sections of an excisional biopsy showed nodules of epithelioid histiocytes and giant cells with central necrosis in fibrous stroma, consistent with necrotic granulomatous lymphadenitis (Box, A). The woman’s symptoms resolved, but the mass re-accumulated after 2 years. An autoimmune process was presumed. As the mass resolved with a trial of prednisone 25 mg daily followed by methotrexate 12.5 mg per week (as a steroid-sparing agent), no further biopsy was undertaken. After 6 months of methotrexate treatment the mass recurred. Histological sections from a repeat excisional biopsy revealed the fibrous capsule of a hydatid cyst and multiple scolices. The capsule contained a patchy mixed inflammatory infiltrate and granulomatous reaction with giant cells (Box, B). Hydatid serological testing (by indirect haemagglutination) was positive at a titre of 1 : 640. The presumed exposure was from time spent about 25 years earlier on a farm in rural New South Wales where offal was fed to working dogs. Three months after commencement of albendazole therapy, the lesion was significantly reduced in size.1 Primary axillary hydatid disease is rare, with only nine previous case reports in the literature.2,3 The causes of granulomatous lymphadenitis can be classified as infective or non-infective, and among these causes, tuberculosis is the most common aetiological agent.4 We believe this to be the first case of axillary hydatid disease presenting as necrotising granulomatous lymphadenitis. Hydatid disease should be considered in the differential diagnosis of granulomatous lymphadenitis. Histological sections of excisional biopsy of axillary mass A: First biopsy, showing a central area of necrosis (arrow) surrounded by granulomatous inflammation (haematoxylin–eosin stain, original magnification × 100). B: Second biopsy, showing the characteristic laminated membrane of a hydatid cyst with associated scolices (arrows) (haematoxylin–eosin stain, original magnification × 40).

Armand Borovik MB BS · David Massasso MB BS · Kathy Gibson BA(Hons), BM BCh, PhD

Born on 5 October 1915 in Sydney, Charles Sara was a well known Sydney anaesthetist. Charles studied medicine at the University of Sydney. After graduating in 1940 and completing his residency at Royal South Sydney Hospital, he saw active military service in World War II, receiving the Pacific Star, War Medal, Defence Medal and Australian Service Medal. Charles gained the Diploma of Anaesthetics of the University of Sydney in 1950. He worked for many years as an Honorary Anaesthetist (and later Consultant) at the Royal Alexandra Hospital for Children, the Royal Prince Alfred Hospital and the United Dental Hospital, Sydney. From 1966 to 1975, he was a Lecturer in anaesthesia in the Faculty of Dentistry at the University of Sydney. In 1975, his pioneering work in dental anaesthesia was acknowledged by his being awarded the Belisario Award of the Australian Society for the Advancement of Anaesthesia and Sedation in Dentistry, for “outstanding contribution in the field of dental anaesthesia and sedation” over 25 years. Charles served the Australian Society of Anaesthetists as Treasurer, then Secretary, from 1954 to 1959, and was Chairman of the New South Wales Section from 1960 to 1961. Elected a Foundation Member and Fellow of the Faculty of Anaesthetists of the Royal Australasian College of Surgeons at its inauguration in 1952, he was a member of the Faculty’s Court of Examiners, then Vice-Chairman of the Court, from 1961 to 1970. As a member of the Board of Faculty from 1967 to 1974, Charles contributed enormously to the establishment of the Faculty’s training program in anaesthesia. On his retirement from the Board, he was fittingly awarded the Robert Orton Medal for meritorious service to anaesthesia, the highest honour of the Faculty. He was also the Faculty representative to the Standards Association of Australia and was consultant to the Coronial Investigation Unit for Anaesthetic and Drug-Related Mortality. Charles was a skilful, thoughtful and helpful colleague who was greatly respected by the surgeons he worked with. He was an encouraging mentor with an outgoing, genial personality and a hearty laugh. He published original articles on a wide range of topics and took a scientific approach to the many challenges in the developing specialty of anaesthesia. His leisure interests were many and varied. In his youth, Charles was a keen and competitive surf lifesaver, and participated in the rescue of well over 100 people swept out to sea on Black Sunday (6 February 1938) at Bondi Beach. Reading, amateur radio and film-making were other pursuits. Sadly, he became progressively disabled by complications following surgery for a meningioma and died on 28 December 2005. He is survived by his wife Barbara, son Antony and daughter Angela.

Jeanette Thirlwell

William Heath was born on 23 July 1925 in Casterton, western Victoria. The eldest of seven children, he was educated by the nuns at the Convent of Mercy School in Casterton. Bill’s father died when he was 14, so at the age of 15 he commenced work as a clerk with the AMP Society, a relationship which continued throughout his life and culminated in the position of Chief Medical Officer of the AMP Society. At the age of 18, Bill joined the Royal Australian Air Force and trained as a pilot. After the war, he returned to AMP for a year before commencing a medical degree at the University of Melbourne. After graduating with honours in 1953, he completed his training at St Vincent’s Hospital, Melbourne. Awarded a National Heart Foundation Travelling Scholarship in 1961, Bill took his young family to the United States to work as a cardiovascular research fellow at Georgetown University in Washington, DC, from 1962 to 1964. Bill then returned to Melbourne and quickly established an extensive private practice in Collins Street. He was much sought after as a clinician, teacher and source of expert medicolegal opinion. He held many board appointments, including Medical Director of the Mercy Hospital, Chief Medical Officer at Munich Reinsurance Company, and Treasurer and Secretary of the Medical Defence Association of Victoria. Bill was Honorary Physician to Pope John Paul II, Queen Elizabeth II, the Duke of Kent, the Prince and Princess of Wales, and the Queen of Denmark and Prince Consort, during their respective visits to Victoria. A deeply religious and compassionate man, Bill worked tirelessly caring for the less fortunate in our community, looking after alcoholics, drug addicts, homeless people and many others. A man of great good humour, Bill held very definite and firm opinions about most matters and had a very select list of dislikes (with parking attendants and Mexican waves being near the top of the list). Bill was a keen traveller, a lover of good food and wine, and an enthusiastic supporter of various clubs, including the Essendon Football Club, the Melbourne Cricket Club and the Kooyong Lawn Tennis Club. His last 2 years were blighted by a very aggressive lymphoma, involving recurrent visits to hospital and the traumas of chemotherapy and septicaemia. He died on 22 October 2005. Bill will be remembered as an eminent cardiologist, a very fine doctor and a true gentleman. He is survived by his wife Ann and children Jane, Simon, Susan, John, David and Sarah.

Bernard S Gilligan

To the Editor: Boerhaave’s syndrome is a rare condition in which increased intra-oesophageal pressure associated with forceful vomiting leads to spontaneous oesophageal rupture. Although the condition mostly affects middle-aged men,1 we present here a case arising as a complication of appendicitis in a child. A 10-year-old boy presented with a 4-day history of abdominal pain, diarrhoea and bloodstained vomiting. He was febrile and tachycardic, with a mildly distended abdomen but no peritonism. Chest and abdominal x-rays were normal. Over the next 6 hours, despite being given 4 litres of normal saline intravenously, the patient became hypotensive, oliguric and hypoxic, with increased abdominal guarding. A perforated appendix was suspected and an urgent laparotomy was planned. A preoperative chest x-ray revealed a large left-sided hydropneumothorax causing tracheal deviation. Insertion of an intercostal catheter immediately returned 600 mL of haemoserous fluid. At laparotomy, amid gross purulent contamination, a perforated appendix was removed. A subsequent computed tomography (CT) scan of the thorax showed contained mediastinal contrast extravasation with an associated air/fluid level from the lower oesophagus on the left side (Box), suggesting oesophageal rupture and establishing Boerhaave’s syndrome. Intravenous antibiotics and nasogastric and pleural drainage were instituted. A repeat CT scan of the thorax 3 days later showed no further mediastinal contrast extravasation. The child improved clinically until spiking high temperatures on the seventh day postoperatively. A chest x-ray showed a left-sided pleural effusion. Thoracoscopy revealed a loculated empyema. This was managed by a formal decortication via a left lateral thoracotomy. The patient was discharged after 2 weeks. Vomiting is a common presenting symptom in acute appendicitis. Yet there is only one previously reported case of Boerhaave’s syndrome secondary to acute appendicitis.1 Therefore, this unusual complication of acute appendicitis may be missed. Without treatment, 100% mortality is expected.2 In retrospect, it was evident that our patient showed the classical clinical symptoms of Boerhaave’s syndrome: a history of prolonged haematemesis, systemic compromise and a left-sided tension hydropneumothorax.2,3 As an initial chest x-ray may be normal, a repeat x-ray is worthwhile in any patient with prolonged vomiting. If clinical suspicion persists, a CT scan of the thorax, which is a more sensitive and specific test for detecting oesophageal rupture, is advisable.2,3 The management of Boerhaave’s syndrome involves initial resuscitation with broad-spectrum antibiotics, nasogastric intubation and pleural drainage.2-5 In recent literature, urgent operative intervention has been recommended to control communication between the oesophagus and mediastinum.2,3,5 In our case, we pursued non-operative management based on radiological evidence of a small, contained mediastinal collection and clinical improvement after pleural drainage. The present case highlights a rare complication of a common surgical condition and suggests that careful non-operative management may be successful. Computed tomography scan of thorax

Kenneth Wong · Gerard Roy

To the Editor: The arrest and imprisonment of 17 Australian-based suspected terrorists on 8 November 2005 underscores a need for Australian prison medical workers to implement strategies for either preventing or following up prison torture incidents. The definition of prison torture is problematic, not least because modern prisons evolved to sequester torture practices from public view.1 I define prison torture as custodial practices that: increase the likelihood of extreme deprivation in prison settings; facilitate traumatic stress on prisoners, resulting from beatings or excessive force used more as punishment than as restraint; result in inadequate or unaffordable health care; and/or expose prisoners to heightened risk of interpersonal violence and sexual assault. Advocates of prison torture regard it as a means of quickly extracting information, humiliating prisoners to the extent of weakening their resolve, and sending a “tough on crime” message to potential terrorists. However, as the well publicised Abu Ghraib prison incidents in Iraq demonstrate, torture practices diminish the moral clout of implicated military physicians and governments.2 Physical and psychological scars from torture commonly lead to depression, major disconnection of victims from friends and family, and occasionally suicide. Confessions obtained under torture conditions are inadmissible in modern legal systems. Moreover, graphic torture incidents may be framed by terrorist organisations as recruitment tools. The 1975 World Medical Association Declaration prohibits doctors’ involvement in torture.3 Unfortunately, active medical complicity in prison torture did not end with the Nazi era.4 While Australian doctors have so far not been directly implicated in prison torture practices,5 the inability (or unwillingness) of Australian prison doctors to recognise and promptly speak out on such incidents in the past has been unfortunate. Prison torture practices in which doctors are actively or passively involved diminish the standing of the medical profession, whose members are expected to be advocates for people at risk of torture. With a likely increase in the number of people imprisoned for terrorist activities in Australian prisons, medical workers need to be trained in the proper application of the Istanbul Protocol6 — a 1999 international guideline for the investigation and documentation of torture and its consequences — to enhance their skills in suspecting, documenting, and reporting prison torture incidents. It is also important that prison doctors are not placed in a “dual loyalty conflict” with regard to the treatment of terrorist suspects.4 Such risks may be minimised by administering prison health care through mainstream health departments, as well as by regular anti-torture training programs for frontline prison workers.

Niyi Awofeso

To the Editor: I note with interest the findings of Diamond et al.1 However, I would like to make some comments about the validity of the results presented. The authors state that an intention-to-treat analysis was used. However, this was unusual as the intention was to treat everybody, with the control group being made up of patients who were offered the intervention but refused it because of the lack of published data on the safety of the procedure. There was a marked decrease in the pain scores at 24 hours in the intervention group. The methods state that all patients were offered similar analgesia titrated to individual need. However, there was no mention of how many of the intervention group (if any), compared with the control group, received parenteral analgesia. The intervention group may have tended to receive more parenteral analgesia than the control group, but this was not mentioned. Indeed, Predey et al2 specifically mention this possibility in their review. Diamond et al state that lower pain scores persisted in the vertebroplasty-treated group at 6 weeks. However, from the results given in Box 3, it seems that there was no clinically significant difference between the intervention and control groups at 6 weeks. I would have liked the report to have included pain scores at 1 week. The decision to use means ± 1 SD instead of 95% CIs in the results is interesting. One SD will only include 66% of a normal population whereas a 95% CI would refer to the mean ± 2 SDs. More importantly, the size of the SD introduces the possibility of an enormous spread in the pain scores for both groups, which was not commented on in the Results or the Discussion. Finally, it was unclear whether the patients were treated in the private or public hospital system. Regardless of my comments above, I applaud any attempt to treat back pain in elderly people (especially that caused by osteoporotic crush fractures) in a time-expedient fashion. I look forward to the day when this therapy is first-line treatment for this disease and not something to consider 2 weeks down the track. The cost savings in reduced length of stay and the decreased morbidity associated with this treatment, as well as the reduced geriatric workload with the more rapid improvement in function, must outweigh the initial up-front costs.

James L Mallows

In reply: We thank Mallows for his constructive comments, and would like to reply as follows. 1. Intention-to-treat analysis is normally associated with randomised controlled trials (RCTs). Our study was not an RCT, as patients who refused vertebroplasty formed the comparison group.1 We used intention-to-treat analysis to indicate that all patients who were assessed as eligible for our study at the outset were enrolled and were all included in the results presented, irrespective of subsequent events (ie, whether they were completely compliant, had died or were lost to follow-up). We thought it was important to make clear that the study was prospective, that all patients entered into the study were represented in the outcomes, and that patients had not been selected on the basis of later events or results. 2. A description of the analgesic requirements of a subgroup of the patients in our study has been published.2 More than 90% of the vertebroplasty-treated cohort were either able to cease or reduce their analgesia dose by at least 50% within 24 hours after the procedure. Before the procedure, an intravenous injection of pethidine (50–100 mg) was the only parenteral analgesia given routinely and would not have affected the pain scores at 24 hours. 3. Pain scores at 6 weeks were statistically lower in the vertebroplasty-treated group compared with the control group. The clinical significance was not apparent, as measured by the changes in the Barthel indices. This indicator is only a crude assessment of patients’ wellbeing, and a more detailed questionnaire of activities of daily living may have shown a difference. Pain scores recorded at 24, 48, 72 and 96 hours after the procedure would have been more sensitive, so that the additional pain, without vertebroplasty, could have been calculated from the area under the pain curve; the more data points, the more accurate the curve. 4. We elected to report the results as means ± 1 SD instead of 95% CIs. We used SDs to be consistent with our previous publications and other reports in this field. We agree that we could have used 95% CIs. 5. Patients were referred to Sydney Imaging Group from the inpatients and outpatients departments of St George public and private hospitals. All patients were treated without any out-of-pocket patient expenses. Private hospital inpatients were billed according to standard Medicare fees and outpatients were bulk-billed, which was revenue neutral for the radiology practice.

Terrence H Diamond · Carl Bryant · Lois Browne · William A Clark

To the Editor: We now know the outcome of the parliamentary vote on mifepristone (RU-486), which restored responsibility for its use to the Therapeutic Goods Association (TGA). Politicians from both houses used their conscience votes to support the scientific scrutiny of medical abortion. van Gend will now be worried about Australian women “demanding” abortions.1 However, abortion on demand in Australia does not exist. I refer van Gend to state laws which specify under what circumstances termination of pregnancy can take place. In no state can women “demand” an abortion whenever, wherever or however they wish. Regulations exist in all states and territories and, as a family doctor, van Gend must be aware of the multiple requirements. While there remains a lack of clarity about various state laws,2 the current position in Australia is that termination of pregnancy is available under certain conditions and in particular cases. The attempt by the Minister for Health Tony Abbott to influence women’s decisions about abortion by providing Medicare-funded, church-affiliated counselling for pregnant women3 has only further entrenched the view that the Minister is not able to speak for the majority of Australians. The previous situation whereby any Minister for Health, rather than the TGA, had the power to decide on the safety and efficacy of new medications before their entry into the pharmaceutical market place was ludicrous. Despite the endorsement of science over theology in health, and potential access to medical abortion, we still have the freedom of our own conscience. No one can force medical practitioners to prescribe mifepristone and no one can force women to accept medical (or surgical) abortions. Morals in Australia are a private matter and these decisions should be left to individuals and their families. Who would decide the authenticity of the medical grounds for abortion, mentioned by van Gend — doctors or priests, or academic ethicists, or feminists? van Gend is clearly not in favour of women deciding. I agree that more attention should be paid to the reasons for women stating they do not want to continue with a pregnancy, and, yes, we could do more to assist them. But I do not agree that excluding non-medical reasons is the answer — which, as van Gend points out, are financial hardship, relationship problems, single motherhood, and a completed family. To many, these appear convincing reasons to choose abortion. While this may not sit comfortably with van Gend’s medical paradigm, the “non-medical” reasons include the mental health of the woman (see the Menhennitt ruling which stipulates that an abortion is lawful if a doctor believes that the abortion is necessary to preserve her physical or mental health).4

Suzanne Belton

In reply: Belton is correct that “safety and efficacy of medications” is a matter for the Therapeutic Goods Association. The dispute was whether such limited criteria can meaningfully assess a drug designed to take life. The government needed to consider higher criteria for RU-486 — its ethical and medical justifiability. Doctors needed to advise the government on justifiable indications for RU-486, in contrast to the corrupt practice of abortion for non-medical reasons. That advice was withheld. The Australian Medical Association advised only on the ethically neutral question of “. . . who is best qualified to scientifically assess the safety and efficacy of a drug”.1 Such marginalisation of ethical concerns is consistent with the AMA’s earlier response in the context of late-term abortion: “There is no place for third parties — governments, over-zealous politicians and lawyers, hospital committees, or even the spectre of legal action”.2 This assertion of unchallengeable medical power over an unborn life is wrong. Belton’s notion that the morality of abortion is “a private matter” is wrong; neither parents nor doctors are above the moral and legal prohibition on intentional killing. “The law in this state has not abdicated its responsibility as guardian of the silent innocence of the unborn”,3 even if medical leaders have.

David van Gend

To the Editor: The report by Brooks and Ellis on the Health Workforce Innovation Conference held in November 2005 was, in my opinion, very misleading.1 I was one of about five doctors who attended this conference; the other 200 attendees were non-medical health care workers. It was fortuitous I attended — no invitation was extended to the Australian Society of Anaesthetists. Not only was the audience nearly exclusively composed of people dedicated to the introduction of non-doctors to replace doctors, but the presentations themselves included nobody expressing a contrary view. Such an unbalanced 2-day meeting therefore failed to truly examine medical task substitution. It failed to explore whether there truly is an inadequate number of doctors in Australia and whether the introduction of non-doctors to do medical work would actually save any money at all. In fact, the presentation by Sibbald indicated that nurse practitioners in the United Kingdom are no more cost effective: although they cost half as much, they take twice as long, so the overall cost is the same. The issue of the quality of Australian health care and how that quality would be affected by the introduction of non-doctors to do the doctoring was not addressed at all. There was also no examination of the consequences on the workforce of the rather illogical proposal to greatly expand the nurses’ scope of practice into medical work when there are already too few nurses in Australia. Such a proposal would surely only worsen the nursing workforce problem. Overall, the meeting was very disappointing, as it failed to approach the topic of medical task substitution in a balanced fashion, failed to justify why the proposal should be contemplated to begin with, failed to address whether there would be any improvement in health care delivery, failed to address whether there would be any reduction in health care costs, and absolutely failed to address how the proposed medical task substitution would not lead to an inevitable reduction in the quality of health care in Australia.

Gregory J Deacon

In reply: Deacon has unfortunately missed the whole point of the Health Workforce Innovation Conference. It was about innovation — new ways of doing things. It was also about health, not medicine — a concept that some doctors might find difficult to accept, but is actually the reality. Deacon seems to suggest that we still need to debate whether there is an “inadequate number of doctors in Australia” — surely most of us have moved on from there. One of the consequences of the “rather illogical proposal to greatly expand the nurses’ scope of practice” might be to retain nurses in the workforce. This, as most of us know, is a major issue. The Health Workforce Innovation Conference was not necessarily about saving costs; it was about producing a more effective health system and trying to provide for those who cannot access services because they are not available or there are long waiting lists for procedures that could well be done by other health professionals. A number of papers presented at the conference demonstrated that care could be provided by groups such as nurse practitioners or physician assistants without any reduction in quality, and it behoves Deacon (whom I assume is a believer in evidence-based practice) to present data to the contrary if he wishes to make those assertions. Deacon commented from the floor on a number of occasions, making the assertions that we would expect from an organisation which is dedicated to maintaining the status quo. I really think the time has come to move on.

Peter M Brooks

To the Editor: I would like to clarify several issues relating to the competing interests statement for my editorial in the 16 January issue of the Journal.1 In my statement, I declared that I have used several meal replacement products in clinical settings and that I am not employed by, and do not receive benefit from, any companies producing these products. By way of further information, I have used Optifast (Novartis) and Dr MacLeod’s (Orfam) products in clinical work in the past. These were always sold at cost to patients, or patients were referred to a chemist, so there was no direct financial benefit to me. I currently use KicStart (Pharmacy Health Solutions) as part of the kit for “Professor Trim’s weight loss program for men”. I purchase these in bulk at wholesale prices from the manufacturer and include them as part of the total program (which is much more than just meal replacement).

Garry J Egger

To the Editor: Reading the excellent Christmas edition of the Journal, I was struck by the symmetry of the computed tomography scans of rectus sheath haematomas in a husband and wife, reported by James and colleagues1 (Box). I was wondering if the couple had not been involved in a minor car accident or incident of heavy braking several days earlier, where the lap–sash or buckle of a seatbelt might explain the mirror injuries?

Mark R Nelson

In reply: The rare and spontaneous nature of rectus sheath haematoma leaves its origins open to such interesting questions. Neither of our patients was able to recall a history of motor vehicle trauma, but minor braking trauma certainly remains a possibility, as does respiratory infection leading to protracted cough. Computed tomography scans of matching rectus sheath haematomas in a 62-year-old woman (A) and her husband (B).

David James

To the Editor: I found the recent letter to the Editor from Riley1 fascinating, and the comment from Teo2 depressing in the extreme. Of the many factors that drove me from anaesthetic practice and into the houseboat business 4 years ago, the selfish attitude of many surgeons towards our communal working environment was high on the list. If all parties in an operating theatre wish to be “entertained” with music while operating on their fellow man, then I suppose it might be permissible (but one wonders what many patients would say if they knew). However, it seems quite beyond the autocratic mindset of many surgeons to understand that auditory input is important to anaesthetists for monitoring the patient and for communication between the anaesthetist, surgeon and nursing staff. To impose music as background noise is unacceptable to many of us, especially as auditory discrimination decreases with age. Riley’s description of video as well as audio to distract from the primary function of surgery beggars belief. I note that Teo agrees with me here. When are surgeons going to realise that surgery is only one part of the professional work that goes on in an operating theatre?

Douglas N Gow

Climate change. Turning up the heat. A Barrie Pittock. Melbourne: CSIRO Publishing, 2005 (viii + 316 pp). ISBN 0 643 06931 3. This is no doomsday book. Rather, it is a compilation of hard scientific data that the author uses to make projections about the sort of world our children and grandchildren will be living in in the future. Climate models are based on various types of human behaviour extending from “business as usual” to a scenario with reductions in material intensity and the introduction of clean, resource-efficient technologies. The “business as usual” scenario predicts an increase in extreme climatic events during this century. Worst hit would be low latitude countries. Flooding due to sea level rise, increased hurricane activity, and storm surges would displace millions of people on the Indian subcontinent. Australia and New Zealand would be obliged to take refugees. None of the Western nations are immune to the effects of climate change. The United States is particularly vulnerable. To quote from the book, “The city of New Orleans already lies below sea level and could be drowned by a combination of river flooding, storm surge and sea-level rise” (the book was already in the hands of the printer at the time of Hurricane Katrina). Difficult for the layman and politicians to understand are the long lag times in the climate system. Warming that has already occurred has set in place an irrevocable chain of events such as coral bleaching in the Great Barrier Reef, decreased snow fall on the Australian Alps, melting of the Greenland ice cap and the permafrost in Alaska, and breaking up of ice shelves in the Antarctic. The chapter on mitigation gives courses of action to limit global warming and offers some reason for hope (the author’s original title was Climate change: turning down the heat!). Intriguing is the potential of developing countries to “leapfrog” the industrialised nations by adopting clean technologies and achieving sustained economic growth without the pollution that characterised the Industrial Revolution in Western countries. The author, a world expert on climate change, has researched outside his field to analyse the socio-economic effects and health impacts. The book contains a comprehensive index and bibliography, and detailed notes can be accessed via a website. Robert M HareAnaesthetist Cabrini Hospital, Malvern, VIC

Robert M Hare

Third World health. Hostage to First World wealth. Théodore H MacDonald. Oxford: Radcliffe Publishing, 2005 (xi + 297 pp). ISBN 1 85775 769 6. There has probably never been more interest in Third World health than there is now. And there has probably never been a greater appreciation of the causes of Third World illness, and the interrelationship of these causes with First World wealth, trade and politics. At times, there also seems to be First World political will to do something about it all — but that soon peters out. Any book that starts with a glowing endorsement from Archbishop Emeritus Desmond Tutu deserves serious attention. What really works about this book is the mixture of personalised case studies, with a serious, rational and evidence-based exploration of data on such macro issues as trade deficits, World Bank loans and multinational companies’ trade practices. The link between Sath, a 27-year-old Cambodian woman who we meet on the first page, and who dies in complicated childbirth, and structural adjustment, the International Monetary Fund, the Group of Eight and (dare I utter it) globalisation, is made explicit. While there may be little in this book that is new to the serious student of these issues, what is provided is a thoroughly comprehensive review and explication of the issues. The writing is clear and accessible, although I rapidly tired of the use of “etc”. From personal experience through travelling and talking to colleagues working in the Third World, there seems to be little positive progress in terms of turning back the tide of poverty, illness and economic stagnation. In many ways governments have failed, as have United Nations agencies. Now it seems to be the turn of the mega-philanthropists; witness the work of the Gates Foundation and the Ellison Institute. Only time will tell whether they make any difference. At a time when the world is richer than ever before, there are more acutely poor people than ever before, and this is clearly a deep tragedy. At least we can continue to try to understand the multiple, complex and interrelated reasons for it, and try to do something about it. David WilkinsonDeputy Head of School, Professor of Primary Care, University of Queensland, QLD

David Wilkinson

Preventing chronic diseases: a vital investment. World Health Organization. Geneva: World Health Organization, 2005 (xiv + 182 pp). ISBN 92 4 156300 1. Of the 58 million deaths in 2005, two thirds were due to chronic diseases. Up to one third of these occurred among people of working age. Although health improvement is central to three of the eight United Nations Millennium Development Goals (MDGs) that seek to halve poverty by 2015, chronic diseases are not mentioned. This is epidemiologically way off beam and politically erratic. This handsomely presented monograph produced by a World Health Organization team with Robert Beaglehole, an outstanding global health epidemiologist once from New Zealand but now in Geneva, as editor-in-chief, lifts the discussion about chronic disease by providing a practical approach to its prevention in developing countries. The authors offer strategies to reduce annually projected chronic disease death rates by 2% between 2005 and 2015. This is audacious, but so are the MDGs, and so for the first time we have a goal to energise and manage our response to chronic disease. The monograph provides a summary of the current and projected burden of chronic diseases, the urgent need for action, and a review of successful actions taken in controlling chronic diseases in less developed countries. A stepwise approach is proposed, similar to that produced by Ruth Bonita (also from NZ), and WHO colleagues for the evaluation of health gain programs more generally, as a guideline for ministries of health, beginning with “core”, moving on to “expanded” and then on to “desirable” actions. Each step is accompanied by milestones, which strengthen the proposed planning procedure. The monograph departs dramatically from previous volumes about chronic diseases that, although lacking the bright cover, resembled the White Pages telephone directory in layout, tedious content and ability to inspire. Here instead are modern graphics, coloured and boxed stories of individuals struggling with chronic disease, and case studies of national success, bringing the challenge of chronic disease to life. This is done without recourse to tabloid sensationalism: the facts presented are sound and serious. The WHO was beaten up many decades ago by organised medicine (from the United Kingdom and the United States especially) when it showed an interest in matters other than infectious disease — taking business away from the lads in the white coats. Its recent efforts in tobacco control have been spectacular and exceptional but occurred at a high price to those involved, with American tobacco lobbies dealing heavy blows. Time for a change. There’s more to life and death than germs, and if this volume signals WHO’s return to an interest in health as a whole, it is thrice welcome. Masoud Mirzaei and Stephen R LeederAustralian Health Policy Institute, University of Sydney, NSW Competing interests: Professor Stephen Leeder was one among a large panel of reviewers of drafts of the monograph.

Masoud Mirzaei · Stephen R Leeder

Turning it off . . . . . . then on again Hormonal male contraceptive regimens are not only effective but also reversible, according to an extensive data re-analysis. Australia-based researcher Liu and colleagues examined data from 1549 healthy men, aged 18 to 51 years, who had taken part in a total of 30 studies of male contraception with various androgen or androgen-progestagen regimens conducted between 1990 and 2005. Routes of administration varied and included oral, intramuscular, transdermal and subcutaneous routes. Overall, the average time to recovery to a fertile threshold of 20 million sperm per mL of semen was 3.4 months; with 90% recovery within 1 year and 100% within 2 years. Liu and colleagues say their findings increase the promise of new contraceptive drugs, allowing men to share more fairly “the satisfaction and burden” of family planning. Lancet 2006; 367: 1412-1420 Further, faster, longer A small trial conducted in Melbourne has suggested that the angiotensin-converting enzyme inhibitor ramipril may substantially improve the symptoms of intermittent claudication in some patients with peripheral arterial disease. Ahimastos and colleagues compared 10 mg ramipril daily with placebo in 40 people, mainly men, with stable intermittent claudication due to superficial femoral artery stenosis or occlusion and who did not have diabetes. After 6 months of treatment, ramipril was found to have improved the pain-free and maximum walking times over placebo by about 4 minutes and 7 minutes, respectively. Distance walked, speed of walking and the ability to climb stairs also improved. The researchers said ramipril may improve blood flow to the lower extremities via vasodilatation, angiogenesis (collateral formation) and atherosclerotic regression. Ann Intern Med 2006; 144: 660-664 To wet or not to get wet? North Queensland researchers have found that, at least in their tropical climate, allowing a wound to get wet in the first day or so after a minor skin excision will make no difference to the incidence of subsequent infection. Heal and colleagues ran a randomised controlled trial involving 857 general practice patients allocated to either keep their minor wounds dry and covered for 48 hours post-suturing or to remove the dressing and wet the wound within the first 12 hours. The infection rate in both groups was around 8% to 9%. BMJ 2006; 332: 1053-1056 Choosing the dark side? Belonging to the Goth subculture — a genre of punk with a dark and sinister aesthetic — is a strong predictor of self-harm and suicide attempt in teenagers, according to a small Scottish study. The study followed 1258 youngsters from the age of 11 to 19 years, seeking information about personal characteristics, including identification with any of various youth subcultures, such as heavy metal, grunge, skater and hip-hop, as well as asking about any self-harm and suicide attempts. Identifying with the Goth culture was the single, best predictor of either self-harm or suicide attempt, and was even stronger than prior depression. Researchers said their data suggested that young Goths either modelled their behaviour on that of their peers and sub-cultural icons or, more likely, were attracted to this subculture because they already had a propensity to self-harm. BMJ 2006; 332: 1058-1061 Health and drug alert Women taking selective serotonin reuptake inhibitors (SSRIs) in the latter half of their pregnancy may have an increased risk of their offspring developing persistent pulmonary hypertension of the newborn (PPHN), warns a health and drug alert in the CMAJ.1 The alert was based on a case-control study which found a dramatic sixfold increase in relative risk;2 however, the absolute risk of having a child with PPHN still remained low, rising from 0.1% to 0.6%, an absolute increase of 0.5%. 1. CMAJ 2006; 174: 1555-15562. N Engl J Med 2006; 354: 579-587 Trimming the not-so-fat Pioneering Australian researchers have deliberately crossed one of the usual thresholds for bariatric surgery (a BMI of 35 kg/m2 or more), with sizeable results.1 In a randomised controlled trial, they compared laparoscopic adjustable gastric banding with an intensive medical program in 80 adults with only a mild-to-moderate degree of obesity, that is, a BMI of 30 to 35 kg/m2. The medical program involved the use of behavioural modification, a very-low-calorie diet and pharmacotherapy with orlistat. Although at 6 months the two interventions had led to identical weight loss (13.8% of initial weight), at 2 years the surgical group had gone on to lose a total of 21.6% of their initial weight whereas the medical group had regained some weight. Four study participants in the surgical group required laparoscopic revision for prolapse of the posterior gastric wall through the gastric band. US editorialists hoped the study would not cause doctors and their patients to overlook the positive health benefits of a 5% to 10% weight loss achieved with lifestyle modification.2 1. Ann Intern Med 2006; 144: 625-6332. Ann Intern Med 2006; 144: 689-691 Dr Ann Gregory, MJA

Ann Gregory