Volume 186 Issue 1

A program of this size is bound to experience challenges The National Health Service (NHS) in the United Kingdom is undertaking the world’s largest civil information technology (IT) project,1 committing £12.4 billion over 10 years to improve services and quality of patient care through the strategic use of IT.1 The size of this commitment makes the NHS National Programme for IT (NPfIT), delivered by the NHS Connecting for Health (CfH) agency, of major international importance. NPfIT covers 330 acute hospitals and mental health trusts, and primary and community care organisations across England (Scotland, Wales and Northern Ireland have opted not to participate). At the core of the program is the “Spine”, a central link to a patient register, electronic prescription service, messaging service, and a summary care record. A web-based booking system, Choose and Book, which allows patients to select or change appointment times, is currently used for 12% of bookings. Radiology picture archiving, electronic prescription transfer, email, and an NHS-wide directory have been implemented, but electronic patient records, a common user interface and secondary use of data are significantly delayed. The NHS chose to procure systems centrally and implement them locally. Procurements included NHS-wide systems (email and Choose and Book), enterprise-wide agreements (eg, with Microsoft), and five local service providers to implement the regional solutions. Local service providers are free to choose and change subcontractors. Local systems must conform to national standards, as in Australia where all jurisdictions have agreed to use standards promulgated by the National E-Health Transition Authority. Clear differences are our federal structure that allows each state its own procurement process, financial and regulatory framework, and controls, thus hindering the unified “big bang” approach possible for England. Once all costs of implementation and training are accounted for, the final budget for NPfIT could blow out to as much as £30 billion.2 In June 2006, the UK’s National Audit Office reported on CfH.3 Despite the cost overruns, delays,4 and growing clinical unrest, the report was less damning than expected. The muted response may reflect that some things have gone well, that a program of this size is bound to experience challenges, and the political cost should the program be perceived as a failure. Other nations grappling with health service reform can already learn many lessons from NPfIT. Get the procurement model right. Procuring contracts centrally resulted in vigorous supplier competition and saved about £4.5 billion. However, the speed of procurement meant that the NHS had not prepared key policy areas (eg, information governance), standards (eg, for messaging and clinical coding), and information system architecture (neither enterprise architecture nor detailed technical architecture was ready). Further, the contracts bound suppliers to a vague specification that has cost the NHS around £30 million in legal fees to sort out. Payment to suppliers is contingent on delivery of “working” systems (although up-front payments have occasionally been made). Consequently, the significant delays in systems roll-out have not as yet resulted in a national scandal because the public purse appears protected. Under-performing companies have not been paid, and some have suffered large, late-delivery penalties. For example, iSOFT is reported to be struggling because of its failure to deliver on time and the resulting penalties. It posted a £344 million annual loss, has taken a hammering in its share price, and is being investigated by regulators.5 It is not clear what risk- management process can handle the worst-case scenario of one or more providers going bankrupt, leaving complex “legacy software” that cannot be maintained by other organisations. Safety comes first. IT can be a powerful enabler, but if poorly implemented or used, it can result in patient harm.6 Yet system safety was not written into the initial procurement specifications.7 Somewhat late in the day, CfH developed a safety accreditation process and appointed a National Clinical Safety Officer. Failure to account for safety also brings commercial risks. A program failure, such as failing to correctly populate patient data into the allergy field of the shared records on the Spine, could easily generate widespread clinical misadventure, triggering massive legal claims and a stock market hammering. The delayed common user interface should have additional safety benefits. Once trained on one system, clinical staff can change their employment and, regardless of the next system used, still have some consistency of user interface and information presentation, hopefully resulting in reduced training time, increased clinician effectiveness and safer practices. Skills shortages will impede progress. CfH has been hampered by a workforce that lacks experience in large-scale IT implementation and familiarity with health services.8 Compounding this, the severe procurement contracts paradoxically may send some health IT companies to the wall, reducing the number of organisations able to implement systems in the UK, or elsewhere. Perhaps a staged approach, with systems roll-out designed to also increase the skills base and capacity of the workforce, might have been more sustainable. For the lifetime of CfH, there will always be questions about the capacity of CfH suppliers to deploy their best and brightest to other parts of the world. This is in part because suppliers may see success with CfH as a “loss leader” into the global market, and failure or delay there will also generate significant penalty. “Fast follower” nations hoping to capitalise on the investment of an “early adopter” nation like England may end up paying a premium on UK prices, rather than the cheaper prices some expect, as companies seek to recoup any losses incurred in the UK. Clinical engagement comes first, not last. A significant criticism in the National Audit Office report was that procurement occurred before clinical engagement, perhaps because extensive consultation was thought to slow the process. This has resulted in significant disquiet among some clinicians and the priorities of the program not fully matching those of the clinical community.9 How significant a failure this decision was will become clearer in time. Picking the wrong patient consent model may be a deal breaker. Patients must give consent for their information to be stored electronically and made available to others.10 CfH has chosen an “opt out” model in which patients by default are included within the system, and make an informed choice to leave it. For this to be fair, patients would need to be reached by an educational campaign before system implementation. Strident critics, such as the British Medical Association, counter that an informed choice to “opt in” would be a fairer model, as there is no room for doubt about a patient’s intentions. Given that the shared record is not yet widely available, there is significant room for increasing disquiet in years to come, not just among clinicians, but also the public. “Opting out”, while technically simpler, may end up being the Achilles heel of the new system should significant examples of breach of confidentiality hit the media. “Opting in” might eventually prove to be the cheaper model when all costs are considered, not just the technical ones. Clinical knowledge services are an early clinical winner. Almost ignored in the CfH program hype has been the NHS National Knowledge Service which provides, among other things, the electronic National Library for Health — a vast array of evidence sources for working clinicians. With no apparent significant delays in its delivery, no dependence on other components of CfH, and a relatively small budget by the program’s standards, it is likely that the IT system most clinicians see first and gain immediate benefit from will be Internet access to clinical evidence. Political leadership is key. CfH exists because of strong political support within the government and Cabinet, and direct leadership from the Prime Minister. Without such political leadership, it seems unlikely that modernisation on this scale would ever be attempted, nor steered over the inevitable road humps encountered on the way. Evaluation is not an afterthought. Too often, token effort is expended on measuring clinical improvements long after major decisions have been made and systems delivered. CfH has therefore established and funded an evaluation board. However, evaluation also has a major formative role — early versions of systems are iteratively trialled to make sure they fit into clinical workflows, are acceptable to clinicians, and don’t have negative side effects. The CfH decision to consult late with clinicians has meant that there were limited opportunities for formative evaluation to shape specifications, and we may now be seeing the opportunity cost of that decision. Perhaps history will record that the NHS was not sufficiently prepared to take on such a fast-paced, radical and extensive modernisation program, that it was compromised by workforce shortages in health informatics, and fell into the trap of leading with technology rather than clinical need. Perhaps countries like Australia will draw another, somewhat heretical, conclusion from the exercise — that IT is not like water, which can be delivered equally to all. With scarce resources, Australia should begin its IT modernisation program with just a few national clinical centres of excellence, where IT skills and efforts can be concentrated. With time, successful technologies, processes and work practices, as well as the personnel trained in them, can then migrate to the rest of the health system.

Enrico W Coiera MB BS, PhD

Getting the message right will help the public reduce their risk of mental illness In the 2006–07 budget, the Australian Government announced expenditure of $21.6 million over 4 years to improve community awareness of the link between using illicit drugs and the development of mental disorders. Community awareness programs to reduce the prevalence of unhealthy behaviours are nothing new; they have been around for decades for cancer, heart disease and infectious diseases. While campaigns focusing on the negative effects of drug misuse have already been delivered, this initiative breaks new ground. It will be the first large-scale campaign in Australia to tell the public what actions they can take to reduce their risk of developing mental disorders. Australia is not alone in this area, with both France and the United States launching campaigns in 2005 to alert the public to the potential link.1,2 However, it is too early to know whether these campaigns have had any effect. Probably the main reason that there have not been earlier campaigns on how to reduce the risk of mental disorders is a lack of evidence for causal links. How good then is the evidence that illicit drugs cause mental disorders? First, there is substantial agreement that an association exists between early onset of cannabis use and later psychotic symptoms or disorder,3 but there is ongoing disagreement regarding the causal basis of this association.4 Clearly, cannabis use is “neither a sufficient nor necessary cause for psychosis”,3 but it may “unmask” psychotic disorders in individuals who are vulnerable. The timing of drug exposure may be particularly critical here, especially given recent evidence that a specific polymorphism of the COMT (catechol-O-methyltransferase) gene conveyed increased risk of later psychosis only if cannabis was consumed during adolescence.5 Second, a number of studies have reported a modest association between early onset of regular cannabis use and later depression, although further research is required to determine whether this relates to a direct causal role or common psychosocial factors.6 The evidence implicating other illicit drugs is more limited. Methamphetamine, which is rapidly growing in popularity in Australia, has been consistently associated with a transient psychotic state that is more common in people dependent on this drug.7 A growing body of literature suggests that a significant minority of those regularly using methamphetamine are also at risk of more entrenched patterns of psychosis.8 While there is currently limited evidence of a direct causal relationship between illicit drug use and mental disorders, the issue becomes whether we can afford to wait and see if increasing early use of illicit drugs actually does lead to a rise in the incidence of mental disorders. If a community awareness campaign is to be effective, it needs to be appropriately targeted. Initiation of illicit drug use typically starts in adolescence, and the evidence points to those with the earliest onset of drug use as being at greatest risk of subsequent mental disorders. A campaign targeting an early adolescent audience requires clear, coherent and credible evidence-based messages that are balanced and free from political dogma. The messages must also be delivered in a format that is appealing and meaningful to adolescents and informed by current trends in media and information technology. This might include web-based campaigns and the development of related Internet sites. Whether the campaign also focuses on providing information for parents will need to be determined, as this would require a complementary set of relevant information and materials. Mass media campaigns in other areas of health have typically had very little effect, including when drug misuse prevention has been the goal.9 In many cases, the weak effect has been due to campaigns being insufficient in intensity. Nevertheless, there are lessons that can be learned from earlier campaigns and these need to be applied (see Box). Given that the campaign discussed here will be the first to address risk of mental disorders, it needs to be well evaluated, either through a staggered roll-out in which some regions serve as controls, or through a time-series analysis in which there are repeated measurements over time — before, during, and after the campaign. As the first of its kind in Australia, it is important that this campaign is done well. A bad start could set back a field with considerable potential. Reducing the prevalence of risky behaviours, like illicit drug use, is not the only approach. It is also possible to promote positive actions that all individuals can take to reduce their risk of mental disorders.12 Campaigns that focus on educating the public about other effective preventive strategies (eg, exercise) should also be a clear priority, similar to other areas of health policy. Indeed, we have good evidence regarding psychosocial factors that increase risk for both substance misuse and mental disorders, and we need to communicate this information to the wider community. We envisage a future in which the public will know as much about how to reduce their risk of mental disorders as they currently do about how to reduce their risk of cancer and heart disease. Principles of effective mass media campaigns9 and possible applications to a campaign promoting awareness of illicit drugs as a risk factor for mental disorders Carry out preliminary research with the target audience Carry out qualitative research with young people to help design the campaign and to get feedback about the effectiveness of messages. Use a theory to give the campaign a conceptual foundation There are several relevant theories of behaviour change, including the transtheoretical model (which specifies how to communicate with people who are at various stages of readiness to change)10 and the theory of planned behaviour (which looks at how behaviour is influenced by a person’s attitudes and those of the people closest to them, and whether the person believes that the behaviour is under volitional control).11 Segment the audience into subgroups of people whose message preferences are similar to one another Potential audience subgroups might include: young people currently using illicit drugs, adolescents not using drugs, people with a personal or family history of mental disorders, and parents. Design messages that are targeted to the audience subgroups Messages need to appeal to each group. For example, messages for young people might need to avoid preaching, use suitable role models, and include features such as humour, novelty and a fast pace. Place messages through appropriate media that are widely used by the audience The appropriate media may be quite different for each group (eg, the Internet or youth radio might be more appropriate for young people than for parents). Conduct a process evaluation to see that the messages reach the audience Surveys should be conducted to ensure that the messages have reached the target audiences with a high frequency of exposure. The approach should be changed if an audience is not being reached. Evaluate outcomes to find out whether the campaign caused any changes in target audience behaviour Measure changes in attitudes towards the link between drug use and mental disorders, as well as changes in drug use. Evaluate the effects using a staggered roll-out, with some regions used as controls, or a time-series design, which involves multiple measures before, during, and after the campaign.

Anthony F Jorm MPsychol, PhD, DSc · Dan I Lubman PhD, FRANZCP, FAChAM

Government, industry and the community can work together to reduce price disparities An Aboriginal Health Worker, Marinka Burton, shops at one of the Mai Wiru (good food) stores in the Pitjantjatjara Lands, South Australia. Details of the Mai Wiru program can be found at http://www.nganampahealth.com.au With the New Year come those grand statements of good intent — to eat less and live longer. But resolving to eat less is a luxury reserved for affluent people. This New Year, most of the world’s population will still be seeking to increase their food supply. This is not a matter irrelevant to Australia: Harrison and colleagues (page 9) remind us that not all Australians have an abundant, affordable and continuous supply of food.1 In their article, they report on a series of surveys — the Healthy Food Access Basket (HFAB) surveys — of selected food stores in Queensland. The surveys showed that, to meet their families’ basic food needs, Australian residents in very remote areas paid an average of about 30% ($114) more each fortnight than people living in cities. The price disparity was greater for basic, healthy food items than for “unhealthy” items such as takeaway food, soft drinks and tobacco. Moreover, at the time of the surveys, fewer of the basic healthy foods were available in remote stores than in city stores. Of particular concern were the higher increases in food prices over time in very remote areas — for example, between 2001 and 2004, the cost of the HFAB in very remote areas increased by 18% ($77.00), which was greater than the rise in the Consumer Price Index. Remote Australia is home to many Indigenous Australians. They are doubly disadvantaged, paying more for food and other essential goods, and having the lowest incomes of any population group. A detailed study of costs and incomes in a remote Indigenous community in South Australia found that basic living costs consumed up to 85% of family incomes, with food accounting for 35% of the total.2 In contrast, Australians in general spend less than 20% of the family income on food.3 Although remote Indigenous communities obtain their food from various sources, the local store remains the largest supplier of foods.4 Self-sufficiency in food (especially in the face of increasing drought) is not a viable option. Thus, inequitable food pricing is an issue for all remote communities. The poor health and nutritional status of Indigenous Australians, including extreme rates of obesity, diabetes mellitus, cardiovascular disease and end-stage renal disease, have been amply documented.5 The links between poverty, food insecurity and obesity have recently been outlined by Drewnowski and Specter,6 who argue that poor people all over the world maximise calories per dollar spent. Thus, less expensive, energy-dense foods with high fat and sugar content always win out in the shopping basket over more expensive, less energy-dense foods such as fruit and vegetables. Reducing the disparity between food prices in cities and remote areas would be one way to help Indigenous families make healthier food choices. Why are food prices higher in remote areas? Investigators have identified several reasons.7,8 Refrigerated road transport for food is expensive, and made more so by the goods and services tax (GST) and rising fuel costs. In addition, in the wet season, some communities rely on air transport for their supplies. Poor business and stock management practices, lack of accountability, and unusual or corrupt behaviour by store managers have meant higher mark-ups in stores. The lack of clear store governance roles and procedures set down by community committees has hindered attempts to improve store management practices. Store expenses, including managers’ salaries (set high to encourage recruitment to remote areas), electricity, shipping, refrigerated storage and stock spoilage costs, are often higher than those incurred by city retailers. Because of the small populations in remote areas, opportunities for achieving economies by bulk-buying from large wholesalers are limited. What is being done? An impressive array of local initiatives has been described in FoodNorth, a report commissioned by the Western Australian Government on behalf of the “Top End” states and the Northern Territory.7 The report investigated the issues of excessive food costs and limited availability, and documented examples of promising programs from remote Australia that address these problems. Recently, federal, state and territory agencies have initiated more expansive programs, including the Remote Indigenous Stores and Takeaways project and a new company, Outback Stores, established by Indigenous Business Australia with significant federal funding.9,10 These projects have been established in recognition that remote-area food stores are commercial enterprises (although in many cases community-controlled) and must make a profit to survive. At the same time, those concerned with the health and wellbeing of remote communities argue that remote stores have a social responsibility to supply healthy foods to communities that depend entirely on their stock. These dual, and potentially opposing, objectives of profit and social responsibility present a difficult, but not insurmountable, tension for food retail businesses in remote areas. Indeed, there have been considerable shifts in recent years in some communities, whose stores are pursuing better business practices for bigger profits, while improving the quality of the produce they sell — for example, by using multiple strategies that outline the roles and responsibilities of the store, the types of foods to be stocked and promoted, and the accountability requirements of managers to reduce store expenses. Improving retail management practices is expected to cut the need for high mark-ups on prices. Some communities are establishing buying groups to enable stores to bulk-buy at wholesale prices. Community stores are developing guidelines and manuals to improve training and industry practice. An example is the Freight improvement tool kit, which is designed to improve the efficiency of cold-chain perish-able food transport to remote areas.11 Schemes to recruit and train Indigenous people in retailing aim to improve the efficiency of store operations as well as providing employment opportunities. Leaders in the retail grocery industry, including Coles and Woolworths, are providing considerable pro bono support. In parallel, local communities are expanding and improving banking services to minimise stores’ financial losses from unofficial loans and credit lines. What can others do to help and support these heroic efforts? There is no shortage of ideas and plenty of work for us all — food retailers, bankers, food transport companies, land councils, Indigenous-run businesses, employment program managers, governments, health professionals, health-related data collection agencies, and academics. Public–private partnerships, particularly for retail and business training for Indigenous communities, need to be fostered and maintained. Government assistance to minimise GST costs and perhaps subsidise food transport costs is worthy of consideration. Continued support and investment in the current promising initiatives are required, including funding to evaluate programs and ensure they lead to reduced prices of healthy foods in remote areas, as well as other expected benefits such as improved employment rates, incomes and health of remote-dwelling Australians. To this end, several groups have argued for the development and maintenance of a system for routine monitoring of prices of selected foods, and a family food basket, Australia-wide.7,12,13 The HFAB surveys provide a useful model for further development of a national food price monitoring initiative. This New Year, let us resolve to help solve the problems of Australians living in remote areas who pay higher prices for food than we pay, but whose ability to pay is less than ours. Indeed, let us go beyond a resolution and — through greater citizen action, good business and a modicum of government intervention — assist our remote communities in righting this wrong.

Karen L Webb PhD, MPH · Stephen R Leeder AO, PhD, FRACP, FAFPHM

Objective: To assess changes in the cost and availability of a standard basket of healthy food items (the Healthy Food Access Basket [HFAB]) in Queensland over time.Design and participants: A series of four cross-sectional surveys (in 1998, 2000, 2001 and 2004) describing the cost and availability of foods in the HFAB over time. In the latest survey, 97 Queensland food stores across the five Australian Bureau of Statistics remoteness categories were compared.Main outcome measures: Cost comparisons for HFAB items by remoteness category for the 97 stores surveyed in 2004; changes in cost and availability of foods in the 81 stores surveyed since 2000; comparisons of food prices in the 56 stores surveyed in 1998, 2000, 2001 and 2004.Results: In 2004, the Queensland mean cost of the HFAB was $395.28 a fortnight. The cost of the HFAB was 29.6% ($113.89) higher in “very remote” areas than in “major cities” (P < 0.001). Between 2001 and 2004, the Queensland mean cost of the HFAB increased by 14.0% ($48.45), while in very remote areas the cost increased by 18.0% ($76.93) (P < 0.001). Since 2000, the annualised per cent increase in cost of the HFAB has been higher than the increase in Consumer Price Index for food in Brisbane. The cost of healthy foods has risen more than the cost of some less nutritious foods, so that the latter are now relatively more affordable.Conclusions: Consumers, particularly those in very remote locations, need to pay substantially more for basic healthy foods than they did a few years ago. Higher prices are likely to be a barrier to good health among people of low socioeconomic status and other vulnerable groups. Interventions to make basic healthy food affordable and accessible to all would help reduce the high burden of chronic disease.

Michelle S Harrison BSc, GradDipDiet, MPH · Terry Coyne BSc, MSc, PhD · Amanda J Lee BSc(Nutr), PostGradDipDiet, PhD · Dympna Leonard BSc(Diet), MPH · Simone Lowson BAppSc(Nutr), PostGradDipDiet, MPH · Anita Groos BSc(Hons), MSc, DrOecTroph · Bronwyn A Ashton BHMS(Ed), GradDipNutrDiet, MMedSc

Awareness of a serious Indigenous health problem in Australia did not emerge until the 1960s and 1970s. Much attention was focused at the time on poor pregnancy outcomes, high infant and young child mortality rates, and childhood malnutrition and impaired growth, often associated with high infectious disease burdens. Although that situation has improved somewhat, Indigenous infant and child health is still poor compared with that of other Australian children. Over recent decades, there has been a rapid rise among Indigenous people of nutrition-related “lifestyle” disorders such as obesity, cardiovascular disease, type 2 diabetes mellitus and chronic renal disease and their complications. This epidemic of disabling and often fatal chronic diseases in Indigenous Australians is also occurring in disadvantaged groups in many other countries. Control of this potentially disastrous epidemic must become a much higher priority in Indigenous health programs. Governments must commit to this task in cooperation and collaboration with Indigenous organisations and communities.

Michael S Gracey AO, MD, PhD, FRACP

To the Editor: Australia has one of the highest levels of food advertising on television in the developed world,1 with most advertisements being for foods that are high in fat, sugar, and/or salt.2 Evidence from international reviews suggests that television food advertising has an independent effect on children’s food preferences and purchasing requests.3,4 While the size of this effect is indeterminate, and the evidence base is correlational and therefore inadequate for making causal inferences,5 there is a highly plausible link between television food advertising and overweight and obesity. It is important to examine whether current regulations protect Australian children from excessive exposure to advertisements for unhealthy food on television. Methods used by food advertisers to circumvent or exploit loopholes in section 16 of the Children’s Television Standards Method Example Showing an advertisement twice within 30 minutes over several consecutive 30-minute periods An advertisement for a brand of chocolate breakfast cereal was shown 12 times during a 3-hour period (two advertisements per consecutive 30-minute period) Advertising multiple variations of a product within a 30-minute period A confectionery company advertised four different chocolate bars within a 30-minute period Currently, Australian children’s television advertising regulations are based on three regulatory codes that ostensibly aim to prevent misleading and excessive advertising to children. However, these codes lack precise definitions, allowing for subjective interpretation and creating loopholes that make the regulations difficult to enforce. Here, we focus on one of these regulatory codes, the Children’s Television Standards (CTS), presided over by the Australian Communications and Media Authority (ACMA) and available on their website at http://www.acma.gov.au. There is currently no published information available regarding successful complaints about breaches of the CTS since its inception in 1990. Section 16 of the CTS specifies that an advertisement may be broadcast no more than twice within a 30-minute children’s viewing period (C period). We examined whether any food advertisements breached CTS 16 in a regular week on three Sydney commercial television channels. As C periods are nominated at the discretion of broadcasters and are therefore difficult to identify, we selected periods when a high proportion of children were expected to be viewing (determined from ratings data from OzTAM, the official source of television ratings for metropolitan areas) and during programs that we believed were appealing to children. In 357 hours of television viewing during the study week in May 2006, 14 breaches of CTS 16 were observed for food advertisements during surmised C periods. Most (80%) were for high fat and/or high sugar foods. While the number of breaches represents a small proportion of total advertisements, it is important to remember that these data correspond to only one CTS clause in 1 week of television broadcasting. In addition, we found that food marketers circumvented or exploited a loophole in this clause 26 times during the study week. Examples of this circumvention are presented in the Box. Although not outright breaches, these instances illustrate that there are loopholes in the CTS that allow constant repetition of advertisements to children. Although the letter of the code may not be contravened in these cases, the essence of the code certainly is. Other researchers have observed breaches of the CTS. For example, Chapman and colleagues identified 194 breaches of the CTS during 645 hours of commercial television across rural and urban locations. The majority of these were breaches of CTS 20(2)(a), relating to the misuse of premium offers to market a product.2 The ACMA is presently reviewing the CTS, with plans to issue a discussion paper for public comment. This review is well overdue. Under the Broadcasting Services Act 1992 (Cwlth), the ACMA has a responsibility to protect children from the possible harmful effects of television viewing. To do this, significant amendments to the CTS are needed. There is a need to improve the clarity of the code, to expand C periods to include viewing times when high numbers of children are actually watching, to actively monitor advertisements, to adopt clear procedures for complaints and investigation of alleged breaches, and to impose penalties for confirmed breaches.

Bridget P Kelly BSc(Nutrition)Hons · Josephine Y Chau MPH, BSc(Hons)

To the Editor: To control the modern epidemics of preventable disease, Australia’s dietary guidelines recommend moderation in four nutritional areas — fat, saturated fat, sugar and salt. In spite of this, the obesity and diabetes epidemics seem unstoppable.1 This is hardly surprising — these guidelines seldom reach the public, and they recommend “moderation” without defining it. Zimmet and James recommend “traffic-light” food labels (red, amber, green) as a way of educating shoppers in the nutritional quality of foods.1 Traffic-light food labels2 promote the moderation message, with moderation indicated by an amber colour. Shoppers can see at a glance a food’s profile of compliance with the guidelines for each of the four areas where they call for moderation. Thus, salt content is moderate when the light for salt is amber, high when it is red and low when it is green. The same applies to fat, saturated fat and sugar. The colour coding is based on concentration in grams per 100 g or per 100 mL, with arbitrary boundaries (Box 1 and Box 2). The more green lights a food has, the healthier it is. With the aid of these labels, health professionals can treat hyperlipidaemia by dietary restriction, giving patients advice to shop exclusively for foods with green lights for fat and saturated fat. They can treat prehypertension (blood pressure, ≥ 120/80 mmHg) and thereby prevent hypertension by advising patients to eat foods with green lights for salt and green or amber in every other area.3-5 With the intention being to “guide the traffic”, the best approach would be flexible, holistic and specific for each food. For example, an amber light could recommend olive oil in moderation, even though it happens to be 100% fat. The natural sugar content of fresh fruits is high enough to give many fruits an amber rating, but moderation is hardly the right message for fruit. Australian traffic-light labels could avoid this, as the Australian dietary guidelines speak only of added sugar. Australia might add a traffic-light label for energy density (showing the same three colours based on kJ/100 g), and expand the saturated fat category to include trans fat, with very low thresholds triggering automatic red lights. Many shoppers would be surprised to find several of Australia’s best-selling breakfast cereals carrying two red lights (for added sugar and salt) and many processed meats with three or four red lights (for energy density, fat, saturated fat and/or salt). The Council of Australian Governments has announced a national campaign to arrest the growing epidemic of childhood obesity. Traffic-light labels would enable parents to protect their families from obesity by shopping almost exclusively for foods with green and amber traffic-light labels for fat, saturated fat, and added sugar. Food choices to control obesity involve a radical change in shopping behaviour, and traffic-light labels are expressly designed to promote radical change. They need to be mandatory, and they need to replace industry-sponsored schemes, which we believe are less likely to alter a customer’s buying patterns. 1 Lower and upper boundaries for the moderate (amber “traffic light”) category set in 2006 by the UK Food Standards Agency2 Food component Boundaries Fat Solids 3–20 g/100 g Drinks 1.5–10 g/100 mL Other liquids 3–20 g/100 mL Saturated fat Solids 1.5–5 g/100 g Liquids 0.75–2.5 g/100 mL Sugar Solids 5–15 g/100 g All liquids 2.5–7.5 g/100 mL Salt Solids 0.3–1.5 g/100 g All liquids 0.3–1.5 g/100 mL (equivalent to sodium 118–590 mg/100 g) The UK traffic-light label boundaries shown above treat all sodium as sodium chloride. If 118 mg is rounded to 120 mg/100 g, the boundary between moderate- and low-salt foods agrees with the international definition of low-salt foods (sodium, ≤ 120 mg/100 g). Front-of-pack traffic-light labels do not replace the technical Nutrition Information Panel. Beneficial nutrients are best promoted in this panel and, where permitted, in nutritional claims. The website <http://www.saltmatters.org> carries a longer article on the basic issues (click on Traffic Lights). 2 Example of traffic-light labelling Food carrying this label would be high in fat and saturated fat, low in sugar and medium (moderate) in salt. Red lights flag nutrient excess which is associated with preventable health problems, including, in this example, obesity, heart disease, metabolic syndrome and diabetes.

Trevor C Beard · Caryl A Nowson · Malcolm D Riley

A recent conference raised issues about the environment in which lifestyle choices are made Even before it had started, the recent 1-day conference “Obesity: should there be a law against it?” provoked controversy. The very title of the conference, convened by the University of Sydney’s Centre for Health Governance, Law and Ethics and the Australian and New Zealand Institute of Health Law and Ethics, elicited outraged responses. The recipient of much of the outrage, Conference Convener, Roger Magnusson (Associate Professor, Faculty of Law, University of Sydney), explained to the conference attendees that law’s perceived role in society is all about coercion. While law is a potent tool for public health and disease prevention, it needs to be able to “justify its involvement and defend itself from ideological attacks”. The conference’s quirky title went to the very core of the issue. Surely, adults have a right to choose to be overweight if it fits with their desired lifestyle. Shouldn’t the law stay away from our refrigerators and couches? An insightful early question from the floor was, “How can the law help frame the debate which is now framed as freedom of choice versus paternalism?” A distinguished international group of speakers presented a range of approaches to this dilemma. The Australian context: Boyd Swinburn (Chair in Population Health, School of Exercise and Nutrition Sciences, Deakin University) considered obesity in terms of the conventional epidemiological triad, where host factors (human biology and behaviour) interact with vectors (excessive energy intake and inadequate expenditure) and the environment (physical, economic, policy and sociocultural). By far the major environmental drivers, said Swinburn, are economic ones, and these are weighted on the side of obesity. Products such as energy-dense foods and cars are heavily promoted, while others such as bicycles, the exercise industry, and fruit and vegetables are not. “If you look at obesity from a libertarian perspective, it is difficult to argue for an approach that involves laws, regulations and enforceable policies; people have a right to be unhealthy if they choose to be. A protectionist approach can be used for children, whom it can be argued have a right to be healthy. However, even in adults you can justify policies such as detailed food labelling on the grounds that they will support healthy choices — making healthy choices easy choices.” While he acknowledged vast differences between the tobacco industry and the food industry, Chris Reynolds (Senior Lecturer in Law, Flinders University) pointed out the similarities in the way the two industries have marketed their products. Restrictions on marketing have had a major role in tobacco control, but so far in Australia, public policy for obesity has centred on exercise, education, and consideration of the built environment. Recent calls for controls on a range of other fronts, including food marketing, have been controversial and not supported by the federal government. While supportive of the idea of personal responsibility, Reynolds did not see this as excluding a community or collective response to public health issues. Personal choice will be influenced by the environment in which people are making that choice. “People are more likely to exercise personal responsibility if they’re not expected to swim against a current of advertising and promotion.” Elizabeth Handsley (Associate Professor, School of Law, Flinders University) is currently involved in a multinational study of the regulation of food advertising to children in Australia, the United States, Canada, the United Kingdom, Sweden and Norway. These countries vary in their regulatory structures, rules (from minimal restrictions to a complete ban), and sanctions imposed for breaches. Interesting issues raised include: who should be the regulator (industry is more efficient but government is more independent)?; to what extent should surveillance rely on public complaint versus active monitoring?; what are the relative roles of parents and society?; how should the “rules” be defined?; and, what sanctions should be imposed? The US and the UK: According to James Hodge (Associate Professor, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA), Americans are split between viewing obesity as a public health issue or as a personal issue, and are more likely to support interventions aimed at children. He gave a colourful account of a raft of US strategies, covering various areas of the law. These occur at every level of government, with state and even local government jurisdictions not waiting for the federal government to act. They include incentives to encourage healthier behaviour, disincentives to discourage unhealthy behaviour, litigation by injured (obese) people seeking recourse (this has generally not been successful and many states have introduced “personal responsibility” laws that prohibit it), and restriction of access to unhealthy foods (local governments achieve this via zoning laws). Robyn Martin (Professor, Public Health Law, University of Hertfordshire, UK, and Visiting Professor, Public Health Law, Chinese University of Hong Kong) pointed out that, although obesity affects many different nations, the context differs. In the UK, the context includes the political system, a culture of long working hours, class- and age-related food traditions, and even the climate! Over the past 5 years, obesity has been variously categorised in government documents as a medical problem, an economic problem, a societal problem, a public health problem and, most recently, by Prime Minister Tony Blair, as a personal problem. In a 2006 speech, he said: “Our public health problems are not, strictly speaking, public health questions at all. They are questions of individual lifestyle . . . the result of millions of individual decisions.” Even within this narrow framework, argued Martin, there is much that the government can do in the way of legal support and structures to make it easier for people to live healthily. A spurious dichotomy: Despite all the controversy, personal responsibility and the wider community response are not on opposite sides of the fence, says Chris Reynolds. “These two ideas are inextricably linked. One is necessarily supported and sustained by the other. The community must create the environment that maximises the potential for people to make healthy choices.” And Magnusson’s answer to that question from the floor about how the law can help reframe this debate? “We can turn it around and say that, if we really want to deliver on autonomy or individualism, we need to introduce legislation that allows people full freedom of choice.”

Ruth M Armstrong BMed

Objective: To document the risk-factor profile and risk-factor knowledge of patients with an acute coronary syndrome (ACS) not attending standard cardiac rehabilitation.Design and setting: Cross-sectional comparison in a tertiary hospital.Participants: Patients admitted to hospital with an ACS, residing within 20 km of the hospital, and without severe comorbidity who did not access cardiac rehabilitation (NCR) were compared with a group about to commence standard cardiac rehabilitation (SCR).Main outcome measures: Risk-factor profile, knowledge of risk factors via face-to-face assessment, quality of life.Results: Of the 446 patients eligible for cardiac rehabilitation, 208 attended for assessment (NCR: n = 144; SCR: n = 64). The NCR group had higher mean (± SEM) low-density lipoprotein (LDL) cholesterol levels (2.6 ± 0.1 v 2.3 ± 0.1; P = 0.02), and were more likely than the SCR group to have a total cholesterol level of > 4.0 mmol/L (78% v 53%; P < 0.001) and an LDL cholesterol level > 2.5 mmol/L (47% v 25%; P = 0.01). They were more likely than the SCR group to be physically inactive (77% v 22%; P < 0.001); obese (46% v 33%; P = 0.04); depressed (21% v 5%; P < 0.001); or current smokers (21% v 1%; P < 0.001). Compared with the SCR group, the NCR group also had higher risk scores (LIPID risk score) (4.5 v 2.1; P < 0.001); lower quality of life (Medical Outcome Short Form [SF-36] Health Survey); and significantly poorer knowledge of risk factors. Among patients with at least two modifiable cardiac risk factors, the NCR group were less likely than the SCR group to be able to state at least one risk factor (24% v 38%; P < 0.001).Conclusions: Patients not participating in cardiac rehabilitation after an ACS have more adverse risk profiles and poorer knowledge of risk factors compared with those about to commence cardiac rehabilitation. Alternate models for secondary prevention are required to improve health outcomes in patients not attending cardiac rehabilitation.

Julie Redfern BAppSc, BSc · Elizabeth R Ellis MHealthLaw, MSc, PhD · Tom Briffa BPhysEd, MPhysEd, PhD · S Ben Freedman MB BS,PhD, FRACP

Objective: To provide a contemporary picture of the general practitioner and specialist obstetric workforce in Victoria.Design, participants and setting: Postal census by questionnaire of all 317 Fellows and 961 Diplomates on the Victorian database of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists in September 2003.Main outcome measures: Sex, age and geographical distributions and patterns of retirement from and recruitment to the GP and specialist obstetric workforce in Victoria.Results: 244 Fellows (77.0%) and 652 Diplomates (67.8%) participated. The average age of Diplomates was 42 years; only 20% were involved in procedural obstetrics. Of GPs practising procedural obstetrics, 56% intended to cease within 7 years. Two-thirds of specialist obstetricians continued to practise obstetrics. Among those ceasing obstetrics, almost half had done so since 2000. Among Fellows ceasing obstetric practice, there is a peak in the 50–60-years age group, but cessation of obstetric practice occurred across all age groups.Conclusion: The proportion of GPs involved in procedural obstetrics has fallen markedly over the past decade, with half of those ceasing practice in the 40–50-years age group. New GPs entering the workforce with the Diploma and overseas doctors are unlikely to meet the procedural workforce shortfall. Attracting the large cohort of doctors aged 40–50 years back to obstetric practice must be a priority. Given the pattern of retirements from obstetrics, there will be insufficient numbers of specialists to maintain current levels of service. The reasons include non-participation in obstetrics by new graduates and international medical graduates, the inadequate number of new graduates, and the predominance of women among specialists aged under 40 years, whose work output tends to be affected by family commitments.

Cameron S Loy FRACGP, DCH, DRANZCOG · R Bruce Warton FRCOG, FRANZCOG, FRACMA · James A Dunbar MD, FRCPEdin, FRACGP

Objective: To describe the epidemiology of falls from ladders in a state-wide population.Design and setting: Retrospective review of data from the the Victorian State Trauma Registry and the Victorian Emergency Minimum Dataset on patients presenting to public hospital emergency departments (EDs) with injuries due to a fall while climbing a ladder, from 1 July 2001 to 30 June 2005.Main outcome measures: Overall trends in the incidence of ladder-related ED presentations, and in cases of major trauma, trends according to age, and trends according to activity at the time of the fall.Results: 4553 patients presented to EDs after falls from ladders in Victoria during the study period; 160 patients had injuries classified as major trauma. There has been a significant rise in the number of presentations to EDs following falls from ladders in Victoria, with a marked increase in the number of cases involving patients aged over 50 years and those climbing ladders outside of paid working conditions. Deaths occurred predominantly in the elderly after falls from heights above 1 metre.Conclusions: Despite knowledge of the dangers of falls from ladders, there has been a significant increase in the number of patients presenting to hospitals after ladder falls. Middle-aged to elderly patients undertaking unpaid work account for this increase. A targeted public health initiative is required to curb this trend.

Biswadev Mitra MB BS · Peter A Cameron MB BS, MD, FACEM · Belinda J Gabbe BPhysio(Hons), MAppSc, PhD

New national guidelines recommend that women who choose to drink alcohol during pregnancy “should have less than seven standard drinks” in any week and “no more than two standard drinks” on any one day, and that they should never become intoxicated. Exposure to alcohol at these recommended levels has been shown to affect brain development and certain behaviours in animals. Some longitudinal studies in human children have detected detrimental affects from exposure to low levels of alcohol. Normal public health standards for exposure to environmental toxins should be applied for the unborn baby. We do not know what level of alcohol exposure is safe and pregnant women can only be advised to abstain.

John S Whitehall FRACP, MRCP, DCH

Objective: To describe the epidemiology of mammal (human and non-human) bite injuries in Victoria.Participants, design and setting: Retrospective case series of injuries recorded in the Victorian Emergency Minimum Dataset (VEMD) (1998–2004) and deaths recorded in the National Coroners Information System (1 July 2000 – 1 June 2006).Main outcome measures: Frequency, nature and outcome of injury as a function of mammal, victim demographics and season.Results: Of 12 982 bite injuries identified in the VEMD, dogs, humans, and cats were implicated in 79.6%, 8.7%, and 7.2% of cases, respectively. Dog bite injuries were commonly sustained to the hands/wrists (31.3%) and face/head (25.4%); cat bites to the hands/wrists (67.6%) and arms (16.0%); and human bites to the hands/wrists (37.1%), arms (20.5%) and face/head (20.4%). Males comprised 73.7% and 56.3% of human and dog bite victims, respectively, while females comprised 64.1% of cat bite victims. A third of dog bite victims (33.4%) were children aged 14 years or less. Most human bite victims (79.8%) were adults aged 20–49 years, inclusive. More injuries were sustained on weekends and during the summer, 55.4% of injuries occurred in the home, and 11.6% of patients required hospital admission. Dog bites resulted in three deaths.Conclusions: Mammal bite injuries are common and often require inpatient care. Patterns of bite injuries relate to the type of mammal involved. These epidemiological data will inform prevention initiatives to decrease the incidence of mammal bites.

Catherine E MacBean BA(Hons) · David McD Taylor MD, MPH, FACEM · Karen Ashby BA, GradDipHealthSci, MPH

We report two cases of spotted black snake (Pseudechis guttatus) envenoming. One patient experienced localised burning pain around the bite and developed nausea, vomiting, diarrhoea, upper abdominal cramping and diaphoresis. He was treated with intravenous fluids and antiemetics, but no antivenom, and was discharged 23 hours after the bite. The second patient developed a severe headache, blurred vision and mild nausea, associated with severe pain and swelling of the bitten limb that took 4 days to resolve. No antivenom was given and the patient had no sequelae. Neither patient developed significant coagulopathy, myolysis or neuromuscular paralysis. Bites by this species appear to cause effects similar to those of the more common red-bellied black snake (P. porphyriacus). Clinical recordPatient 1A 47-year-old male farmer in the Upper Hunter region of New South Wales was bitten by a spotted black snake and developed non-specific systemic effects with localised pain and swelling. The snake came from under a bale of hay and bit him on the dorsal aspect of the right foot. He applied a 7.5 cm elastic bandage up to the knee within 5 minutes, and arrived at the local hospital asymptomatic. The patient had no significant past medical history and took no regular medications. The dead snake was identified as Pseudechis guttatus by G K I, using a key for identification.1 The patient was transferred to a larger hospital 2 hours and 20 minutes post-bite, and the first aid was reinforced. He had no abnormalities on examination. Thirty minutes after arrival, he developed burning pain around the bite, associated with nausea, vomiting, diarrhoea, upper abdominal cramping, and diaphoresis. This was treated with 10 mg intravenous metoclopramide and intravenous fluids. A snake venom detection kit swab from the bite site was positive in the black snake well. He had persistent vomiting, which was treated with 8 mg ondansetron. He was transferred to a tertiary hospital intensive care unit 7 hours post-bite. The symptoms gradually resolved, except for ongoing pain at the bite site. The following morning, 15 hours post-bite, he was asymptomatic except for persistent pain in the foot. The pressure bandage was removed, with no immediate change in his condition. There was mild bruising around the bite site and evidence of a second bite. He also had right, tender inguinal lymphadenopathy. About 20 minutes after removal of the bandage, the pain in the right leg increased significantly and he was treated with oral opiate analgesia. Results of coagulation studies remained normal and his creatine kinase had a minor elevation to 348 IU/L (reference range, 50–200 IU/L) 17 hours post-bite. The patient remained well and was discharged 23 hours after the bite. Patient 2A 33-year-old amateur herpetologist was bitten on the left hand by a captive spotted black snake while cleaning the cage. Identification of the snake as P. guttatus was confirmed by J W. The patient immediately applied a local pressure bandage with no splint. Over an hour, he developed a severe frontal headache, blurred vision, mild nausea and dizziness, and presented to hospital about 2 hours post-bite. He appeared to have mild slurring of speech, but no ptosis or other signs of neurotoxic envenoming. The bitten hand was very painful, with swelling and slight bruising (Box 1A). He was treated with intravenous fluids and analgesia, but no antivenom. Results of laboratory tests on admission were normal, except for the activated partial thromboplastin time, which was marginally elevated (41 seconds; reference range, 25–40 seconds). The following day, 13 hours post-bite, he had a persistent headache, mild nausea and severe pain in the bitten hand. Although the systemic symptoms resolved over 12 hours, the bitten hand remained painful and swollen, requiring parenteral opiate analgesia. Forty-eight hours post-bite, the pain and swelling extended to the left elbow (Box 1B,C), with axillary adenopathy. He was treated with intravenous flucloxacillin and seen by the surgical team. Compartment pressures were within the normal range and no surgical intervention occurred. Four days post-bite, the pain and swelling were subsiding significantly (Box 1D). He was discharged on oral flucloxacillin and recovered over several days. DiscussionBlack snakes are found throughout Australia, with mulga snakes (Pseudechis australis) occurring across most of the mainland except the east coast.2,3 In the east, the most common is the red-bellied black snake (P. porphyriacus), and most of the human population in this area will have encountered this snake at some stage. The spotted black snake or blue-bellied black snake (P. guttatus; Box 2) is less common, and primarily inhabits south-east Queensland and inland northern NSW.2,3 These cases suggest that spotted black snake bites are similar in effects to red-bellied black snake bites,2-4 including generalised systemic features and local effects, such as marked swelling and pain at the bite site. They were not similar to the more severe effects of mulga snakes3,5 and Collett’s snake (P. colletti),6 characterised by myotoxicity, anticoagulant coagulopathy and secondary renal impairment. The limited number of cases does not exclude the possibility that spotted black snake bite does occasionally cause significant myolysis like that from red-bellied black snake bite. Serial creatine kinase measurements should be done in all cases of spotted black snake bite with systemic envenoming. There is only one previous report of a bite by a juvenile spotted black snake.7 In that case, localised necrosis at the bite site was treated with surgical debridement. However, the report only included photographs and little further information. Animal studies have demonstrated that spotted black snake venom is both neurotoxic and myotoxic,8,9 and both effects are neutralised by black and tiger snake antivenoms. However, neither of our patients had any evidence of significant neurotoxicity or myotoxicity that may be expected from in-vitro studies. Neither patient was given antivenom, because there was no evidence of major systemic envenoming. As with red-bellied black snake envenoming, antivenom is only used when non-specific systemic effects do not respond to symptomatic treatment. It could be argued that, for Patient 1, who had ongoing vomiting, antivenom might have significantly reduced symptoms and resolved the vomiting, as it can do with red-bellied black snake bites. However, the vomiting responded to ondansetron, and use of antivenom always carries a risk of an allergic reaction. Although antibiotics were used in the second patient, the extensive local pain and swelling are more likely to be due to local venom effects and tissue reaction, also seen with red-bellied black snakes.4 1 Local and regional effects of the bite in Patient 2 A: The hand 3 hours post-bite. B: The forearm 48 hours post-bite. C: The hand 48 hours post-bite. D: The hand 4 days post-bite. Original photo copyright Dr Julian White. 2 Spotted brown colour phase of spotted or blue-bellied black snake, Pseudechis guttatus Original photo copyright Dr Julian White.

Melanie Jansen · Monique McLeod · Julian White MB BS, MD · Geoffrey K Isbister BSc, FACEM, MD

To the Editor: An experiment was recently conducted during a morning doctor’s seminar at the Busselton Hospital to assess four treatments for jellyfish stings using specimens of Carybdea species collected from the nearby waters of Geographe Bay. Two doctors and three medical students consented to participate. The tentacles of the jellyfish were dragged over the moistened forearm, producing two well separated stings on each forearm. After 5 minutes, there were visible red wheals developing at the sting sites. Four different treatment modalities were then tried, one at each sting location: ice, vinegar, aluminium sulfate, and hot water at about 45°C. The participants were asked to assess the degree of pain relief given by the treatment, and the time taken to achieve that pain relief (Box). Hot water was the only successful treatment, relieving 88% of the pain; all participants obtained significant relief in 4–10 minutes. Other treatments were incomplete and temporary. Hot water was later used to treat the other stings. It was also noted that the palpable wheals disappeared when hot water was used. This suggests that, in addition to relieving the pain, the heat treatment was stopping the inflammatory reaction. Heat has been advocated as a treatment for fish spine envenomations from various species, and early application of heat has been found to prevent long-term sequelae.1,2 I have previously reported my experiences with stings from the large tropical jellyfish Tamoya gargantua.3 Application of heat led to the relief of pain over 10–15 minutes. Loten et al recently reported the use of hot water in treating bluebottle Physalia physalia stings, and suggested the mechanism was through heat inactivation of the jellyfish toxin.4 There is an urgent need for knowledge of this simple remedy to be spread, and there is the potential that it could even be lifesaving when used with more serious jellyfish stings in the north of Australia. Degree of pain relief for the five participants (1–5) after various treatments for jellyfish sting Pain relief during treatment Continuing relief after treatment Treatment 1 2 3 4 5 Mean 1 2 3 4 5 Mean Ice 40% 0 75% 10% 0 25% 0 0 0 10% 0 2% Vinegar 30% 0 20% 0 0 10% 0 0 20% 0 0 4% Aluminium sulfate 75% 20% 30% 35% 50% 42% 0 20% 0 35% 50% 21% Hot water 90% 95% 90% 80% 85% 88% 90% 95% 90% 80% 85% 88% 0 means no relief of pain; 100% means complete relief of pain. The pain relief was temporary (pain returned when treatment stopped) for all except hot water and (to a lesser extent) aluminium sulfate.

John G Taylor

Radiographs of a woman presenting with abdominal pain revealed a large foreign body within the pelvis. A diagnosis of perforation of the colon was made, and at laparotomy an 8.5 cm long glass fragment was removed from the bowel. A laceration to the lower back, sustained in a fall onto a glass coffee table, had been explored and sutured 20 months earlier. Imaging findings showed the subsequent course of the overlooked glass fragment within the pelvis. Clinical record A Abdominal radiograph A: A large triangular foreign body is visible in the pelvis. Note the deformity of the right transverse processes of L4 and L5 (arrows). B Surgical photograph B: The sigmoid colon is opened to show a large triangular glass fragment in the lumen of the bowel. C Computed tomography scan C: A loop of terminal ileum is in continuity with the anterior surface of the right psoas muscle (arrow), directly in line with the bony tract created by the glass fragment. A 60-year-old woman presented to the emergency department complaining of abdominal pain, nausea and bloating, that had developed over the previous 3 days. On examination, there was generalised guarding and tenderness. A chest radiograph showed a pneumoperitoneum, and an abdominal radiograph showed a large, triangular, radiopaque foreign body within the pelvis (Figure, A). A diagnosis of bowel perforation by a foreign body was made, although the patient denied any history of foreign body insertion or ingestion. Further questioning revealed that 20 months earlier she had fallen onto a glass coffee table, sustaining a large laceration to the lower back, just above the natal cleft. She had presented to the emergency department of a large metropolitan hospital where the wound was explored and sutured, but no radiographs were taken. At laparotomy, the patient had faeculent peritonitis, with a small perforation of the antimesenteric wall of the sigmoid colon. An 8.5 cm long triangular fragment of glass was found within the mid sigmoid colon (Figure, B). A Hartmann’s procedure was performed. DiscussionInitially, this was a baffling case. The source of the glass foreign body was obviously the earlier coffee table accident — but how did the glass fragment get into the bowel and why did it take 20 months to present clinically with intestinal perforation? The radiographs and subsequent computed tomography (CT) scans provided the answers. The abdominal radiograph was reviewed the day after clinical presentation and surgery. It was noticed that there was partial bony fusion of the right transverse processes of the fourth and fifth lumbar vertebral bodies. A CT scan confirmed that new bone formation at this level had produced a solid block of bone with a central defect in the shape of a rectangle. It is thought that the glass fragment snapped off deep to the skin and fractured the right transverse processes of L4 and L5, with the subsequent fracture healing process giving rise to a perfect bony cast of the fragment. It is well documented that a fracture initiates a sequence of inflammation, repair and remodelling, and that the remodelling process continues for years.1 Another CT scan showed the bony tract caused by the glass fragment projecting anteriorly into the right psoas muscle. Directly anterior to this, the terminal ileum could be seen lying on the anterior surface of the right psoas muscle (Figure, C). It is thought that the sharp end of the glass fragment gradually worked its way out the front of the psoas muscle and into the terminal ileum. The radiographs and CT scans provide a vivid account of the course of the glass fragment after it penetrated the skin. All but the most superficial and easily explored penetrating injuries caused by glass should be assessed radiographically at the time of injury.2

Sally A Johnston MB BS · David A Lisle MB BS, FRANZCR · Roderick C Borrowdale MB BS, FRACS

Re: “Shrinking bottle syndrome”, by Sarah Newton, Hemant Agarwal, Joane Coleman and Srinivas Bolisetty, in the 20 February issue of the Journal (Med J Aust 2006; 184: 187). The second author’s name was incorrectly given as “Hemant Agarwal”. The correct name is “Hemant Jain”. The html and pdf versions of this article were corrected on 9 Nov 2006.

Sarah Newton · Hemant Jain · Joane Coleman · Srinivas Bolisetty

To the Editor: No one denies the right of insurers, or law firms acting for an interested party, to obtain information relating to a claim with due authority from the patient. After all, it’s fair enough for insurers to check the details of a claim. This system has worked well for decades and allows the insurance industry to operate reasonably and fairly. But a recent development gives cause for great concern. There is a trend among both insurers and lawyers to demand copies of a patient’s entire medical file. Not just details relevant to the claim, but the entire medical file, often extending for years before the relevant event. A cynic has suggested this is financially motivated, as a reasonable fee for copying and forwarding a file is likely to be less than the fee for reviewing the file and preparing a report. Another equally uncharitable explanation is that insurers are embarking on “fishing trips”, hoping to find grounds to mitigate a claim. I’m sure the industry could produce examples in which fishing trips have identified dishonest claims that might not otherwise have been detected. But I cannot justify sacrificing the privacy of many patients to expose the occasional fraudulent claim. In one case, one of my patients suffered a work-related injury that prevented her working as a private contractor for some months. The case was clear-cut, simple and straightforward. Yet the insurer refused to process her claim without receiving a copy of her entire file — including very personal details of a sexual assault nearly 20 years earlier, together with confirmation that she had contracted a sexually transmitted infection and details of her subsequent breakdown. For a vulnerable and very private person, it was a terrible ordeal to have this brought up and to have to sanction its disclosure to a claims officer. My financially strapped patient was held to ransom when the insurer advised that the claim would not be processed until the disclosure was authorised. How can the individual claimant ever stand up to a multinational insurer? And, in this case, appeals to the industry regulatory body were peremptorily dismissed. I support any stand by our profession against this unjustifiable invasion of privacy.

Bernard S Pearn-Rowe

Comment: Agents for a workers compensation authority commonly assert they have the right to see the patient’s entire medical history to assess whether the injury arose from work or from another past or current illness or injury. Two points need to be underscored. Firstly, patients have a right to waive their right to privacy. A consent for total disclosure, given when initiating a claim for compensation, could be invalid, as it is a consent given under (economic) duress — that is, payments will not commence unless the patient consents to full disclosure. A doctor may feel a duty to point out to the patient that full disclosure will reveal distressing matters from the patient’s past that the doctor believes are not relevant to the claim. The doctor may recommend that the patient seek legal advice on how to object to full disclosure. Whether the patient objects or agrees to total disclosure is a decision for the patient, not the doctor, with the help of legal advice. Doctors should not give that advice. Secondly, the legislation governing statutory compensation schemes in Australia gives extraordinarily broad powers to the relevant authority to demand information. For example, section 239 of Victoria’s Accident Compensation Act 1985 states that the Victorian WorkCover Authority (and its agents) may “require any person – to furnish the Authority with such information as the Authority requires . . . and may require the person to produce all books in the custody or under the control of the person relating thereto.” Doctors and medical records are not excluded from the broad sweep of section 239. Notwithstanding such clauses, a claimant can object directly to WorkCover about a request or demand to supply his or her entire medical history if the claimant believes there are matters not relevant to the claim that he or she does not wish to be disclosed. If that process fails, the claimant then has a number of legal avenues that can be pursued. Pearn-Rowe may be concerned at the David–Goliath imbalance of power between patient and insurer, but that does not justify omission of information because the doctor thinks it is not relevant. The Medical Defence Association of Victoria recently settled a case in which a member, asked to provide a “Personal medical attendant’s report” for a patient applying for a new disability insurance policy, omitted information about the patient’s history that would have affected the insurer’s assessment of the application. The patient had signed a consent for full disclosure. The insurer issued the policy, and a short time later the patient was diagnosed as suffering a major illness, the premonitory symptoms of which were described in the omitted information. Whether or not it was a deliberate omission was not the point — it was a negligent omission. In summary, the patient has a right to object to disclosure. If the patient chooses not to, the doctor has a legal obligation to comply with the literality of the patient’s signed consent for disclosure.

Paul Nisselle

A: Computed tomography (CT) scan showing proximal duodenal dilatation (arrow) tapering towards the point of obstruction (arrow head), resulting in the triangular shape of the duodenum. B: CT scan showing extensive hepatic portal venous gas (arrows) and a massively distended stomach. A 17-year-old man with a slim build presented with recurrent postprandial epigastric fullness and bilious vomiting. He was acutely unwell. An abdominal radiograph showed gastric and duodenal distension. Contrast computed tomography scans showed proximal duodenal dilatation (Box, A, arrow), with a triangular-shaped duodenum, extensive hepatic portal venous gas (Box, B, arrows), and a massively distended stomach. Superior mesenteric artery syndrome with hepatic portal venous gas was diagnosed. This syndrome occurs when the fat pad between the superior mesenteric artery and its origin at the aorta is lost, causing a sharp, narrow angle at the aortomesentery junction. The third portion of the duodenum is compressed and becomes obstructed when passing through this angle.1 Hepatic portal venous gas can develop as a result of bowel ischaemia. Surgical therapy with duodenojejunostomy is the treatment of choice for a severely ill patient, or when more conservative treatment has failed.2

Chi-Lun Tsai MD · Ming-Jenn Chen MD · Che-Kim Tan MD · Khee-Siang Chan MD · Kuo-Chen Cheng MD, FCCP

John William Dyer Middleton, general practitioner and colossus of the Australian wine industry, was born in Melbourne on 7 May 1924. Educated at Geelong Grammar School, John spent several years in the Royal Australian Air Force as a meteorologist before deciding to study medicine at the University of Melbourne. He graduated in 1951 with honours in all subjects, and was awarded the Exhibition and Fulton Scholarship in Obstetrics and Gynaecology and the Wyeth Prize in Clinical Obstetrics. He seemed destined for specialisation, but after 2 years’ residency at the Royal Melbourne Hospital, by which time he had married and had two children, he decided, in 1954, to join his friend Peter McMahon in a burgeoning general practice in semi-rural Lilydale, Victoria. The same year, John was appointed Shire Medical Officer for Health. His medical excellence saw him much in demand. However, his restless mind gradually led him in another direction. Aware of the Yarra Valley’s successful wine industry of a century earlier, he and McMahon became increasingly involved with viticulture and oenology. John travelled widely to wine regions in Australia and overseas, and, in 1971, purchased a magnificent farm (“Mount Mary”) overlooking the Yarra Valley and planted appropriate grapes. John and his wife Marli built and furbished a winery that simulated the operating theatre in organisation and cleanliness, but it was not until the mid 1980s that he gave up medical practice to concentrate full-time on winemaking. In the early years, medical friends acted as pickers on suitable Sunday mornings, arriving with family and friends and afterwards enjoying Marli’s magnificent alfresco lunches. Physically strong and with notable practical skills, John handled the diverse challenges arising in the winery himself, often using fitting and turning or welding skills learned at school. His wines soon achieved renown and demand exceeded supply. His annual newsletters, with their forthright and quirky views on wine-related matters, were a delight to read. As well as his interest in wine, John was a keen sailor, and became Commodore of the Eildon Boat Club. He was also a skilled marksman at clay-bird competitions and enjoyed relaxing at home playing the piano. John kept in touch with many of his medical contemporaries, and his fellow 1951 graduates were delighted when he provided all the wines for their 50-year reunion dinner. John died on 27 June 2006 from late complications after aortic aneurysm surgery. He is survived by Marli and his three children, Jill, David and Claire. David, a veterinarian, now manages the winery. With the succession at Mount Mary secured, John can rest in peace.

Geoffrey Sinclair

Intimate partner abuse and health professionals: new approaches to domestic violence. Gwenneth Roberts, Kelsey Hegarty, Gene Feder, editors. Philadelphia: Churchill Livingstone, 2006 (xvi + 240 pp). ISBN 0443074933. How times have changed! Fifteen years ago, intimate partner abuse was not an issue discussed in medical circles. Indeed, researchers in this field were often vilified and taken to task on publication of studies exposing the prevalence of this issue and the resultant morbidity associated with it. By contrast, today we see government advertisements on television telling us that “Australia says ‘No’” to domestic violence. Health professionals have a worthy resource in this book edited by Gwenneth Roberts and Kelsey Hegarty from Australia and Gene Feder from the United Kingdom. Intimate partner abuse and health professionals: new approaches to domestic violence gathers together and presents with great rigour the vast literature that has accumulated in this field over recent times. It covers the impact of intimate partner abuse, how common it is, and how health professionals can identify it and respond effectively. Difficult issues are addressed, such as the impact on children and challenges faced by general practitioners in dealing with both the perpetrator and the victim, as well as domestic violence in Indigenous communities and among gay and lesbian couples. The editors are experienced researchers in the area of intimate partner abuse, and the authors they have assembled provide a comprehensive and scholarly text. While practitioners and students may find the book too detailed, this text is ideal for researchers and teachers who require an in-depth understanding of the field, and for whom it provides a valuable synthesis of our current understanding of intimate partner abuse in the health care setting. Danielle MazzaAssociate Professor of General Practice, Monash University, Melbourne, VIC

Danielle Mazza

Sounds for silence. Babies settling and health guide + CD-ROM. Harry Zehnwirth. Melbourne: OKlDokie, 2005 (105 pp). ISBN 0 646 45384 X. Crying and settling problems are among the most common reasons new parents present to health professionals in the first few months of their baby’s life. Managing these problems can be a bewildering and exhausting process. This guide and CD, developed by Harry Zehnwirth, a Victorian paediatrician and father of four, are excellent value for money. The CD is a compilation of “white noise” and “environmental sounds” designed, when played loudly, to distract a baby from crying so they can then self-settle. Clinical experience suggests this is a cheap and almost certainly harmless approach to managing infant crying. The guide provides a sensible, practical and easy-to-read approach to sleep, crying and health in the first year of life. It covers normal patterns of sleep and crying, myths about causes of irritability (eg, wind), strategies for managing irritability, ways to encourage a baby to self-settle, and postnatal depression. Unlike other sleep and settling guides, this book covers a baby’s general health and development. One excellent section covers common parental concerns such as gastro-oesophageal reflux, skin blemishes and sticky eyes, and a section on “scary episodes” reassures parents about breath holding and choking. A separate section (titled “alarm bells”) provides clear signs for parents to identify an acutely unwell baby or a baby with possible developmental delay. There is great humour flowing throughout the book (for instance, the only stool colours to worry about are those of the St Kilda footy club — that is, red, white or black), and the text is complemented by bright photographs. The final pages include a trouble-shooting table in a question and answer format (eg, could cows milk protein intolerance be irritating your baby?), other sources of help (such as parenting centres and web-based resources, including http://www.soundsforsilence.com.au), and a behaviour diary to chart a baby’s sleep and crying patterns and response to intervention. Harriet HiscockPaediatrician, Centre for Community Child Health, Royal Children’s Hospital, Melbourne, VIC

Harriet Hiscock

Clinical sports nutrition. 3rd ed. Louise Burke, Vicki Deakin, editors. Sydney: McGraw-Hill Medical, 2006 (xxvi + 822 pp). ISBN 0074716026. Those familiar with previous editions of Clinical sports nutrition are most likely as excited as I am about the release of this latest version. The second edition has had pride of place on my bookshelf since it was purchased, with only this to knock it off its perch. New features include expert commentary on antioxidants, immune function and the female athlete triad. The International Olympic Committee consensus conference in 2004 provided an update on current thinking in sports nutrition (eg, guidelines for carbohydrate intake), which Clinical sports nutrition has incorporated. As in previous editions, both the editors and the chapter authors are leaders of their field, making this book an unofficial consensus statement for sports nutrition in Australia. Each chapter of the book (now “easy find” with shaded tabs) includes an appraisal of recent research on the topic and follows with practice tips. This combination of theory and practice provides a valuable tool for practitioners. Food products, nutrient reference values and units will be familiar to Australian health professionals. All of the key areas of sports nutrition are discussed, as well as several topics not usually covered by other sports nutrition texts (including athletes with special needs such as diabetes or disabilities, young athletes, and the older sportsperson). There are sections on catering for athletic groups, travel, and nutrition for special environments such as high altitude and extreme climates. All in all, those working primarily in the area of sports nutrition are likely to read the book cover to cover, despite its 800+ pages. Other practitioners, particularly sports physicians or exercise physiologists, may find it useful as a reference text. Bronwen LundySports Dietitian, Sydney Sports Medicine Centre, State Sports Centre, Sydney, NSW Order this book

Bronwen Lundy

Female genital mutilation. Comfort Momoh, editor. Oxford: Radcliffe Publishing, 2005 (iv + 172 pp). ISBN 1 85775 693 2. We are seeing an increased prevalence of female genital mutilation (FGM) in Australia due to increased numbers of women migrating from countries where FGM is widely practised, presenting some unique and important health issues. The issues surrounding FGM need to be dealt with in the context of a cultural background where this is normal practice (in Somalia and Sudan, more than 90% of women have undergone FGM), but also with reference to the fact that the practice of FGM is prohibited in Australia by specific legislation. Most practitioners, when dealing with FGM for the first time, do not have a clear understanding of the relevant issues and can find the experience confronting. Momoh’s Female genital mutilation is one of the few texts to comprehensively address these issues. Momoh has collected a group of authors with clinical experience and expertise in the area to create a text providing a very thorough analysis of FGM. Emphasis is, however, quite heavily weighted towards the sociological issues associated with FGM. Overall the chapters are well written, interesting and informative. They are well illustrated with both line drawings and colour photographs. For the practising clinician, though, not all of the chapters are relevant. Much of the information is presented with a strong focus on the United Kingdom experience. In particular, the overviews of the practice of FGM and discussions of its clinical management provide an excellent source of information for the practising clinician, covering all of the information necessary to assist in clinical management. For those seeking a broader discussion of the many issues surrounding FGM, these are also thoroughly covered (but, as noted, mostly from a UK perspective). At 172 pages, Female genital mutilation is eminently readable and affordable. Gregory J JenkinsObstetrician and Gynaecologist, Sydney, NSW

Gregory J Jenkins