Letters

In reply: As we mentioned in our article, erythromycin is the drug of choice for treatment and prophylaxis of pertussis in people of all ages.1 Several statements can be made about the use of macrolides in this condition.2 Firstly, erythromycin has been shown to decrease the duration of illness when given early in pertussis infection and to eliminate Bordetella pertussis from the nasopharynx. Secondly, erythromycin therapy for index cases has been shown to reduce the rate of secondary cases of pertussis in households in uncontrolled studies.3 However, in a recent randomised placebo-controlled study, while erythromycin reduced the incidence of culture-positive pertussis in household contacts there was no reduction in respiratory symptoms.4 Thirdly, clarithromycin and azithromycin have been shown to be at least as effective as erythromycin in treating pertussis in two small comparative studies.5 As Massie et al point out, there are no clinical studies of the use of roxithromycin in this condition, and laboratory in-vitro sensitivity studies suggest roxithromycin may be inferior to erythromycin. Roxithromycin is the most widely used macrolide in Australia, but it requires a leap of faith and extrapolation to prescribe this drug for prophylaxis or treatment of pertussis. In the one case in our series where roxithromycin was prescribed, this was not our decision. We would have recommended erythromycin on the basis of the available clinical evidence. Vaccination is preferable to antibiotic prophylaxis for long-term control of pertussis.

Joseph G McCormack · Natalie M Spearing · Robert L Horvath

To the Editor: Van Der Weyden has asked a provocative question about the relevance of what he calls "medicine's homage to health".1 In so doing, he pays his own homage to a world where boundaries are sharp and healing becomes reduced to a matter of applying "bioscience to matters of mind and body". While I daresay many editors of biomedical journals would share his view, he is only highlighting an age-old tension. Indeed, Crookshank wrote in 1926 about the Ancient Greek schools of Cos and Cnidus, and of their debate about doctrines of the natural/descriptive and the conventional/academic approaches to medical knowledge.2 The Coans promoted the importance of the influence of the individual and society on the presentation of illness, and managed illness holistically with regimens oriented towards the needs of the individual, while the Cnidans oriented their practice around the distinctions between diseases, treating specific diseases with specific remedies.3 These differing approaches to illness and disease highlight the conflict between cybernetic and linear thought which has underpinned medical history ever since. It is rarely understood that the linear doctrine of biomedicine has only become dominant in the last century or so. Medicine's isolation from contemporary scientific thought explains our long delay in confronting the challenges of systems thinking — challenges that the basic and applied sciences took on in the early years of the 20th century.4 Our contemporary error is in assuming that the accumulation of data that passes for modern medical knowledge is sufficient to deal with the tasks of medicine. The disquiet expressed by Van Der Weyden is only a symptom of the continuing inability of a mechanistic view of medicine to deal with caring for patients in the real world.

Grant M Russell

In reply: Russell implies that my recent column on the boundaries of medicine1 conveys the premise that medicine is a defined and discrete discipline underpinned by biomedical science. So it did, but the contention is not mine, it is that of Seldin.2 However, no one would deny that biomedical knowledge is the best developed and most powerful component of modern medicine; nor would they deny that there are other intrinsic components, such as the art of caring.3 My argument is that the boundaries between medicine and health have become blurred with modernity's overwhelming homage to health.4 Furthermore, the very nature of health is difficult to define, shaped, as it is, by variable psychological, socioeconomic and cultural factors. If, in fact, health is the World Health Organization's utopian "the complete [my emphasis] physical, psychological and social well being", then most of us are unhealthy.5 My purpose was to question the boundaries of medicine and health. In particular, to question where the responsibility for attaining the modern Shangri-La of health rests — with the individual, society or medicine?

Martin B Van Der Weyden

To the Editor: Interpretation of the report describing the first death attributed to the Irukandji syndrome should be tempered by the fact that significant unstated assumptions have been made in attributing the cause of death to a jellyfish.1 While envenomation by a jellyfish remains the likely diagnostic possibility, no evidence is presented that unequivocally confirms a jellyfish as the lethal agent. Several methods could have been used to support or confirm the diagnosis of jellyfish envenomation, including sampling of nematocysts from the victim's skin (before or after death), jellyfish capture, or reports of other similar, but less severe, stings from the same beach around the time the victim was stung. In severe jellyfish envenomation, attempts are often made to harvest nematocysts from patients' skin, most commonly by skin scraping or by sticky tape sampling.2 Recovered nematocysts may help to identify the species, and confirm the diagnosis.3 Although successful nematocyst recovery is uncommon in Irukandji syndrome, it is disappointing that "no attempt was made to sample nematocysts"1 given the relative simplicity of the procedure and the importance of this case. The authors state that "no sting site was clearly delineated",1 but then go on to say that there were, in fact, areas of "skin flushing and intermittent diaphoresis"1 over a significant period of time. Sticky tape sampling of these areas may have yielded nematocysts, allowing positive species identification. Postmortem skin sections have also been employed in Chironex fleckeri fatalities, and have shown nematocyst barbs on the victim's skin.4 Postmortem examination may also have revealed other contributing factors. I am particularly interested in the assertion that almost every Irukandji syndrome patient in the Whitsundays develops a "rise in cardiac troponin levels".1 In fact, the cited article makes no mention of troponin, simply stating that CK-MB (creatine kinase isoenzyme) levels "can be abnormal",5 and that "some severe cases [of Irukandji syndrome] may have a CK-MB [level] well above the normal range".5 Many aspects of the diagnosis and treatment of jellyfish envenoming remain controversial. Accurate reporting of unusual cases is thus of the utmost importance.

Paul M Bailey

To the Editor: In their Notable Case on jellyfish envenomation causing Irukandji syndrome,1 Fenner and Hadok suggest that similar deaths may have occurred in the past, with the relationship to Irukandji syndrome not being recognised. However, their call for urgent research into developing an antivenom needs to be based on a clear understanding about the risk of death. Unfortunately, they have not presented data that clearly establish causation or support their conclusions about treatment and the need for further research. While they reported a history that supports envenomation, there was no confirmation by detection of nematocysts or autopsy to examine for other causes of death. An alternative explanation could be that the patient was overcoagulated and died from complications of an intracerebral haemorrhage. While it is clear that blood pressure must be monitored, to suggest that it must be treated with phentolamine is not supported by this case report. Clearly, supportive management and, in particular, the optimal treatment of cardiovascular complications needs to be defined and may obviate the need for antivenom.

Andrew H Dawson

In reply: While overcoagulation causing intracerebral haemorrhage could have caused the death of the patient we described,1 he was normotensive until developing signs and symptoms of Irukandji syndrome some 20 minutes after being stung. The Irukandji syndrome is, and always has been, a clinical diagnosis only. Biochemical and pathological test results become abnormal later, but are not diagnostic — actual cause and effect have been described only once, with the experiment unlikely to be repeated!2 Nematocyst studies, while established for Chironex fleckeri,3,4 have never identified species associated with Irukandji syndrome, except Carukia barnesi, which appears to occur in the Cairns area only. Other species probably cause the more severe syndrome seen in the Whitsundays and on the Great Barrier Reef, where these deaths occurred.5 One of us (P J F) is possibly the only person to have captured specimens likely responsible for causing Irukandji syndrome from the Whitsundays, and the species remain unidentified, as they are a new species and not described to date. Also, when the moribund patient was admitted, no obvious sting site was visible, and a negative skin scraping would not rule out a jellyfish sting. Phentolamine has previously proved effective for relieving distressing autonomic symptoms,6 and not just for cardiovascular complications, although it appeared ineffective at the lower doses used in our patient. However, nothing appears to prevent toxic cardiac dilatation occasionally occurring later in the syndrome.7 Further research is currently under way. Antivenom development may prevent some (possibly all) major symptoms of Irukandji syndrome. However, production is impossible until sufficient specimens of all species (some six to 10) causing the syndrome are caught and their venom assessed. Such advances are many years away and may never be achieved with current poor levels of funding. Cardiac markers for jellyfish envenomation have previously been identified.5,8 Since 1999 troponin level has replaced creatine kinase isoenzyme (CK-MB) level, and both are invariably raised in patients stung by the Whitsunday jellyfish. Thus, the words "cardiac markers" should have been used in the article and for not doing so I apologise. Despite C. barnesi stings being common at north Cairns beaches, it has taken six years of dragging the beaches, with nets to catch jellyfish of this species. The thought of trying to catch a 12 mm jellyfish that makes erratic and irregular appearances in several hundred square kilometres of ocean around the Whitsunday Islands is totally daunting, but the possibility is being assessed. Such a venture will depend on funding becoming available. Other stings were reported in the area at the time of our patient's death and are well known at the resorts where people who have been stung in surrounding areas are taken for treatment. However, stings remain erratic; they have no predictable patterns of appearance, and unfortunately prophecy is currently impossible.

Peter J Fenner · John C Hadok

To the Editor: The article by Tan and Fitzgerald1 raises numerous concerns. The authors report that their recommended personal protective equipment (PPE) conforms to standards "in a hospital environment where the chemical vapour concentration will not be high". At the same time, the authors acknowledge data indicating most patients from a disaster will present to the local hospital by private transport (ie, without triage, decontamination, or prehospital care). These two considerations are incompatible and further ignore the possibility of the hospital as a direct terrorist target. The authors' assertion that their three decontamination lines "allow mass casualties, as well as trolleys and equipment, to be decontaminated quickly, efficiently, and in an orderly fashion" is simply not evidence based. Of greater concern, the authors report "major considerations were policies and plans [referring to the hospital External Disaster Committee] and the emergency department response". Although this bottom-up approach to disaster planning is typical, it pays inadequate attention to interdisciplinary issues of proper hazard identification and management, environmental health, syndromic surveillance, and field outbreak investigation. Readers seeking robust emergency department templates are better referred to other sources for guidance.2,3 Of greatest concern, the authors report "our recommendations are similar to systems in the US and Israel, but much less intensive, as the threat of a terrorist attack here is perceived to be much lower". The three references cited for that statement date back to 1994, with none more recent than 1999. Moreover, the logic of the unreferenced threat assertion confuses hazard and risk. Although the absolute probability of a given hazard may be low, the risk attending that hazard encompasses vulnerability of the exposed population. With weapons of mass destruction, the conditional probability of catastrophic public health consequences is high — one event is the only number you will ever need. The current public health context of chemical–biological–radiological (CBR) incident management in Victoria is one of limited experience, performance improvement indicators, and budgetary support from public health authorities. Public health is at risk when authorities report that "faced with dozens of requests each day to attend sites to assess white powder, the stretch capacity did not exist and nor should it".4 As a result, the leading trauma centre in Australia extracts $20 000 from its existing operations budget to discharge its CBR responsibilities. This is not good enough. Nevertheless, the authors deserve credit for their initiative. Until cross-trained and disaster-experienced healthcare authorities reprioritise, this article shows the reader an excellent way to play a very weak hand.

David A Bradt

To the Editor: Tan and Fitzgerald's template for emergency department response to chemical–biological–radiological hazards appears to be based on a dubious assumption of a low level of risk.1 A recent report details exposure of emergency department staff to potentially fatal secondary contamination during a hazardous materials incident, highlighting the need for staff to have the appropriate training and equipment to deal with these events.2 I believe the level of Personal Protective Equipment (PPE) proposed by Tan and Fitzgerald is inadequate. The "facemask with filter" they describe is classified as Level C respiratory protection, and this level only conforms to the Australian Standard (for PPE) when the identity of the chemical and its vapour concentration are known, and when these do not exceed the filtering capacity of the particular filter mask being used.3,4 In the initial confusion of a hazardous materials incident, the identity of the chemical agent and its vapour will not be known. There may even be misinformation: during the 1995 Tokyo sarin attack, for example, initial advice to hospitals by the Tokyo fire service was that the incident was "a gas explosion in the Tokyo subway".5 Emergency department staff must be able to respond before the nature and severity of the chemical hazard can be determined. The only respiratory protection which conforms with the Australian Standard for PPE when the nature and severity of the chemical hazard has not been determined is the supplied gas respirator with full face shield of Level A (an encapsulating suit and self-contained breathing apparatus) or Level B (a non-encapsulating suit with self-contained breathing apparatus or a full face respirator on a gas line).3,4 Confronted with a hazardous materials emergency, potentially involving very toxic chemicals, emergency department staff need to have complete confidence in their own protection. This is only possible with the use of supplied gas respirators (Level A or B PPE), which provide complete respiratory protection. An additional problem with Level C air-purifying respirators is that their performance may be adversely affected by water ingress into the filter, which could occur during the decontamination procedures described in the template. Tan and Fitzgerald also propose having a clerk don PPE and enter the contaminated zone. Any stationery taken into a contaminated area would have to be decontaminated before being taken out to a "clean" area, and it is not clear what a clerk would add to the initial response within a contaminated zone.

Antony Nocera

In reply: We thank Bradt for his interest in our article and acknowledge his expertise in this field, which he has gathered in the United States and other countries. We also thank Nocera for his interest in our article. Our aim was to stimulate interest among the medical community in chemical–biological–radiological (CBR) response. The interdisciplinary issues mentioned by Bradt were mentioned in our article, but not in detail because of space limitations. Our personal protective equipment (PPE) conforms to Australian standards1-3 and the three decontamination lines are in keeping with other institutions. We are not aware of any simple decontamination system which, evidence-based, is superior. The choice of PPE in the ideal situation would be one that would provide adequate protection in all situations with a minimal amount of training, maintenance and expense. Nocera is correct in stating that the respiratory protection in an unidentified chemical hazard is Level A or B. These PPEs are expensive, bulky (which results in poor manual dexterity), and their use requires specialised training. The amount of chemical present on a victim surviving long enough to self-present to an emergency department is significantly less than that involved at the site of the incident. Therefore, the level of protection required for hospital staff would be less than that required by emergency rescue workers. Our PPEs were supplied by the Victorian health authorities. It is more important for staff to be familiar with their PPEs and for hospitals to have a CBR response that is regularly practised than having excessive protection that is limited to personnel who have undergone specialised training. The role of the clerk is to take patient details. These are radioed to staff in the hospital to help identify and correctly label patients, which is very important in mass casualty situations. Recent experience has demonstrated that terrorist acts are a worldwide phenomenon, and Australians are potential targets. This underlines the need for comprehensive training and maintenance of hospitals' CBR response. Since publication of the article, Victorian health authorities have reprioritised, and we therefore feel we have achieved the aims of our article.

Gim A Tan · Mark C B Fitzgerald

To the Editor: White emphasised problems that can arise if medical decisions are overly reliant on the results of laboratory tests.1 He relates the case of a patient who, because of a peculiarity of her immunology, consistently produced a false-positive test result. In probabilistic language, the issue is are there risks of both random errors and patient-specific errors? It is important to distinguish between them. Suppose a test has a false-positive rate of 10%. If this is truly random error, the probability of two false-positive results in the same person is 1%, and the probability of three false-positive results is tiny. But if it is due to there being 10% of healthy people for whom the test is invalid and who consistently give a positive result, the probability of two false-positive results in the same person is 10%, and the probability of three false-positive results is 10%! Major textbooks of medicine have excellent chapters on decision-making. These warn about limitations of sensitivity and specificity (eg, that data from the general population may not apply to people who have tested positive in screening). But, other than this, little is said about reasons for errors in testing, and the consequences for how sensitivity and specificity should be used. In most cases, the impression given is that errors occur completely randomly. However, it appears that White's example, in which repeated testing led to repeated errors, is not unique. Lee2 writes as follows: "Suppose a low-risk patient has an abnormal lung ventilation–perfusion scan. Obtaining that same test result over and over will not truly raise that patient's probability of coronary disease further and further." Perhaps Goldman3 had something similar in mind when writing, "It may be quite difficult to distinguish random laboratory errors from test results that might be falsely positive or negative because of coexistence of a process that can affect the test". Lists of possible reasons4,5 for errors include both short-acting (eg, distracting external noise, and biochemical effects of foods recently eaten) and long-term (eg, physical handicaps, and demographic factors) influences. I wonder if information about tests should routinely include separate random and patient-specific components of sensitivity and specificity. For example, it might be stated that a false-positive rate of 15% arises from 10% random errors and 5% patient-specific factors, or that a false-negative rate of 10% arises from 3% random errors and 7% patient-specific factors. This is the conclusion I have been led to by White's article.

T Paul Hutchinson

In reply: Many factors potentially contribute to error in generating a diagnostic test result, and include random pre-analytical errors arising from patient preparation and specimen collection, random errors associated with the act of measurement, and systematic errors caused by, for example, drug interference. Tested individuals may also harbour an interfering substance, such as a drug or immunoglobulin. The theoretical and practical description of these components of test error is generally well understood and documented by laboratories, and the basics of test error and diagnostic sensitivity and specificity are taught in medical schools. However, I think trying to apply probability data to a test result for a specific patient is of limited value to the treating doctor. The commoditisation and automation of much of pathology testing contributes to a perception that tests are 100% reliable, and there is also a perhaps related decline in communication between requester and provider. Most tests have limitations, many inconsequential, some important and patient-specific. Although Hutchinson draws a valid conclusion, I hope readers also concluded that communication with diagnostic laboratories remains important for safe patient care, and that test results still need to be interpreted in the context of other clinical information about a patient, and not accepted without question.

Graham H White

To the Editor: In reviewing the CD-ROM containing an integrated set of Therapeutic guidelines (eTG complete),1 Mann noted that, although utility was improved, the cost was high ($220 for a first user, and $110 for each subsequent user, compared with $264 for a set of the printed volumes which could be shared within a practice).2 Unfortunately, the cost of distilling evidence-based knowledge is also high, especially for publications that require regular review and update. In addition, there are extra costs involved in electronic conversion (text to HTML), reformatting material to fit computer screens, creating expandable and collapsible tables of contents (JavaScript) and searchable indexes. There is also a need to ensure that the electronic version works with a range of common operating systems (Windows, Macintosh and Linux) and with varied and ever-changing web browsers (eg, Netscape and Internet Explorer). In short, producing electronic versions of print publications requires additional resources, stringent quality control and considerable pre-release testing. In the near future, guideline producers face an additional technological challenge: the need to move from "static" HTML-tagged documents to "active" XML-tagged documents, in which the data elements and underlying logic are machine-readable and thus capable of interacting with the health worker and the emerging electronic medical record (computerised decision support). These developments (and Mann's concerns) raise the question as to who should pay for best-practice guidelines, including the evolving electronic conversion. Currently, the Australian government appears to lack a coherent approach to the provision of health information, at least with respect to best-practice clinical guidelines. For example, the Federal Government currently funds revision, production and distribution of The Australian immunisation handbook3 and the Manual of use and interpretation of pathology tests.4 More recently, the government has commendably funded a national subscription to the Cochrane Library. However, the government does not fund other equally valuable resources, such as the Australian medicines handbook5 or Therapeutic guidelines.1 The latter survive solely on a user-pays market model. It can be argued that it is time that the government adopted a more even-handed approach to stimulate the uptake of national best-practice guidelines and related services, perhaps by reimbursing health workers who subscribed to such services with practice incentive payments. This would lower the cost of practitioners acquiring national information resources, preserve the market model and assist guideline producers to meet the ongoing challenges of electronic conversion by improving their income stream.

Ken J Harvey

To the Editor: I was pleased to read the article on Ross River virus (RRV) disease by Mylonas and colleagues,1 because it included information on the cost of the disease. This makes it much easier to do something practical from a government and health economics perspective about the problem of RRV. The cost of $1018 per patient, including costs of negative tests looking for cases, sums to a total estimated cost to the nation of $5 million per annum (based on the reported average of 5000 cases per year in the study by Harley and colleagues2). Of note, $567 was spent per patient on diagnostic tests (56% of the total cost per patient), while the authors noted that in many cases the condition was self-limiting. I begin to wonder what is the use of spending $567 per patient diagnosed to prove a largely self-limiting condition that is treated symptomatically? Banning RRV testing could save $2.8 million per annum, which would be immediately available for mosquito control measures, and perhaps vaccine research, to reduce the burden of RRV disease. We could model the impact of a vaccination program — vaccine development cost, vaccine unit production cost, vaccine delivery, population target, and savings in disease prevented — to determine whether funding of vaccine research is worthwhile. The point is that without economic data we cannot make sensible "evidence-based" clinical management decisions. We are trapped in a scientific paradigm, and the health system implements unpopular cost–control interventions because it needs to control spiralling costs. We clinicians need to do better. If other researchers would follow the lead of Mylonas and colleagues and explore the economics of their subject, we would be able to make more rational choices about healthcare. It is up to clinicians to understand the economic agenda and suggest interventions that make both economic and clinical sense. We can then begin to make more efficient and rational use of our health dollars, relieving stress on a stressed system.

Ian R Cheong

To the Editor: Dugdale proposed recently in the Journal that people who have a skin reaction to mosquito bites are less likely to be infected by Ross River virus than those who do not.1 As he quotes Kumar, who made a similar comment about malaria infection,2 one could presumably extend his idea to other conditions transmitted by mosquitoes. This accords with my own personal experience of dengue fever acquired in Fiji. While serving there, I had two separate proven infections with dengue virus. As I react very little to mosquito bites, I could not identify the time of infection. Indeed, on the first occasion, I had just returned from a three-month stay in Adelaide and could not recall being bitten by a mosquito at all. In contrast, my wife, who developed large weals whenever bitten, went through at least three epidemics of dengue without being infected. My advice to travellers who consult me is that there is an advantage to reacting badly to mosquitoes, as one is then more likely to take anti-mosquito precautions, whereas the non-reactor is more likely to disregard them. However, Dugdale's suggestion that a local inflammatory reaction may be a factor in defence against infection is intriguing and worth following up. It should be simple to enquire retrospectively about reactions to mosquito bites in those who have had a mosquito-borne disease, as Dugdale has done for Ross River virus infection. This would provide evidence on which to base pathological and immunological studies.

Michael Sorokin

To the Editor: Dugdale recently suggested that people who develop skin reactions to mosquito bites may be protected against Ross River virus (RRV) disease.1 He noted that seven patients with a history of RRV disease all reported no skin reaction to mosquito bites, and 18 patients with no past history of RRV disease reported reacting to such bites. We argue that this correlation is entirely to be expected, as the lack of reaction to mosquito bites illustrates that the individuals have been previously exposed to many bites. At least two studies have shown a clear inverse correlation between mosquito exposure and bite reactions.2,3 Clearly, exposure to a large number of mosquito bites increases the risk of infection.4 Thus, a reaction to mosquito bites probably does not protect against RRV disease, but is simply a marker for low exposure to mosquito bites and therefore low risk of RRV infection. The rationale behind the association of itching bites and protection against RRV infection is also tenuous. Virus is likely to reach the circulation within seconds of introduction by the mosquito, whereas allergic reactions take minutes to develop. It is unlikely that a local reaction will affect viral replication at distant sites. In Dugdale's study, only people with a history of symptomatic RRV disease had undergone RRV serological testing. As about 30% of Queenslanders are seropositive,5 and 60%–75% of RRV infections are thought to be asymptomatic,6 some of the 18 people with no past history of RRV disease might be expected to have had asymptomatic RRV infection. This raises the question, does reaction to mosquito bites correlate with asymptomatic RRV infection?

Peter A Ryan · Jillann F Farmer · Brian H Kay · Andreas Suhrbier

To the Editor: I support Tattersall and colleagues1 in their attempt to use a wee bit of science and a dose of common sense to improve doctors' letters. While I would love to receive letters based on their proposed "prompt sheet", and should really try much harder myself to follow it, I'd be only too pleased — in the interim, while we await enlightenment — to receive any letter from some of my colleagues with whom I share what is supposed to be "multidisciplinary care" of patients. There is a research project in this for the brave to find out why, too often, communication is not merely inadequate but non-existent.

Alan Rodger

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

Peter G Thompson

To the Editor: The article on the risks of baby walkers by Thompson is welcome.1 However, he used a broad definition of "serious" (ie, those children who required admission to hospital). Readers should be aware that some of these accidents cause major disfiguring injuries with life-long consequences. Burns sustained as a result of being in a baby walker are more extensive and deeper than those of the average patient admitted to our Burns Unit. In the 5 years to July 2000, 24 patients were admitted to the Burns Unit at The Children's Hospital at Westmead (the NSW State Paediatric Burn Referral Unit) with burns as a result of being in a baby walker. As baby walkers are used by children before they can walk, all were 13 months old or younger (range, 6–13 months), whereas only 15% of all admissions are under one year. In the same 5-year period, 178 patients were under 12 months, with the number rising to 246 if those under 13 months are also included. Only one of the group with burns from using a baby walker was older than 12 months, and only by a day. (Ironically, he was burnt while playing in a baby walker that he had been given for his birthday the day before.) The baby-walker burns were extensive — the largest burn covered 48% of the body surface, with the average being 17%. Deep burns were more common than average, 19 of the 24 children needed grafting (80%) versus only 50% of all admissions. Grafting means that the burns are deep enough to cause permanent scarring. Eight of the 24 required admission to the intensive care unit. Of the 24 children, 21 had scald burns, mostly due to the child being able to reach a cord, tablecloth or container; two had contact burns because the child could reach out to a hot stove; and one sustained a flame burn, because the child moved close to a parent starting a fire with flammable fluid. Thus, the danger results from the child being able to reach higher and move faster than expected. No improvement has been evident in the last 2 years. From July 2000 to June 2002, seven more children were admitted with burns caused by baby walkers: six spill scalds (four water and two oil) and one contact burn (iron pulled down). This helps confirm Thompson's contention that regulations (introduced in September 2000) will not stop baby-walker injuries. Apart from the danger of severe injury, baby walkers impede normal balanced muscle development and so are deleterious to every child who uses one. Apart from being a child-minding device, they have only potential for harm. Now that Thompson has shown that the "safety standards" do not protect children from injury, it is time for them to be banned altogether.

Hugh C O Martin

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

Richard L Hockey · Rob Pitt

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

Donald D Beard

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

Susan J Harnett · SK Cyril Wong · Gavin W Lackey

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

Greg A Lovell · Phillipa J Hay

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

Kerry J Breen

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

Keith V Woollard

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

Russell L Gruen