Letters

In reply: Our article1 outlined evidence presented to the Supreme Court of New South Wales. The paucity of epidemiological evidence concerning an association between exposure to environmental tobacco smoke (ETS) and laryngeal cancer (two studies available) was offset by biological plausibility concerning the carcinogenicity of tobacco smoke. To that extent, the epidemiological evidence in question "supported" a clear inference of causality from other data. The views offered by Langlands and Gebski do not alter this consideration, and are otherwise without merit for several reasons. To restrict the inference reasonably drawn from epidemiological data to whether or not statistical significance is achieved is inadequate. To offer an overall conclusion other than one based on all the data (in this instance, both studies) is unsound. To publish imputations concerning a specific study in a context denying right of reply by the authors concerned is unfortunate. To identify an ethical problem predicated only on a perceived discontinuity between evidence accepted by a court and evidence accepted by the medico-scientific community is spurious. The Court in Sharp v Port Kembla RSL Club was provided with vigorous criticism of the epidemiological data. Most of the eight weeks of court time was occupied by a painstaking analysis of this and other causative issues. The Court then made a determination consistent with the medico-scientific evidence. Stewart BW, Semmler PCB. Sharp v Port Kembla RSL Club: establishing causation of laryngeal cancer by environmental tobacco smoke. Med J Aust 2002: 176; 113-116. (Received 18 Mar 2002, accepted 21 Mar 2002) South East Sydney Public Health Unit, Randwick, NSW. Bernard W Stewart, PhD, FRACP, Head, Cancer Control Program, and Professor, UNSW School of Paediatrics. Sir James Martin Chambers, Sydney, NSW. Peter C B Semmler, MA, QC, Senior Counsel. Correspondence: Professor B W Stewart, South East Sydney Public Health Unit, Locked Bag 88, Randwick, NSW 2031. stewartbATsesahs.nsw.gov.au AntiSpam note: To avoid spam, authors' email addresses are written with AT in place of the usual symbol, and we have removed "mail to" links. Replace AT with the correct symbol to get a valid address.

Bernard W Stewart · Peter C B Semmler

To the Editor: Donovan and colleagues bring attention to the restrictions placed by the Health Insurance Commission via the Medicare system on clinicians investigating patients for sexually transmitted infections (STIs).1 In their study of Sydney general practitioners, they suggested that reform was required to the three-test pathology testing rule to improve gonorrhoea screening in high-risk individuals living in a region of epidemic gonorrhoea. In the Kimberley region of Western Australia, where we practise, syphilis, gonorrhoea and chlamydia continue to be endemic. Best-practice guidelines for primary healthcare providers in WA state that investigation for other possible STIs is essential to the care of patients with STIs or HIV infection.2 Health policy should be based on best-practice standards. For patients with confirmed or suspected STIs, this means that Medicare funding should meet the full costs of all tests for suspected STIs (as indicated by clinical need and best-practice guidelines) to enable and facilitate effective control of these infections at the population health level. An Australian legal precedent exists for medical practitioners regarding testing for STIs. In the New South Wales Supreme Court case of BT v Oei, it was found that a doctor has a duty of care to offer testing for other STIs to a patient with one STI or a suspected STI.3 In that case, a sexual partner of an HIV-positive patient brought successful legal action against her partner's doctor for failing to diagnose HIV infection in her partner. The doctor was found negligent in failing to offer an HIV test to a patient with ongoing symptoms who had been found to be infected with hepatitis B virus and whose only risk factor for this infection was unprotected sex. The doctor's duty of care was found to extend to the patient's sexual partner, who became infected with HIV after unprotected sex with her partner. Given that best-practice guidelines and a legal precedent exist which confirm that a medical practitioner should offer testing for other STIs to a patient with one STI or a suspected STI, what are the medicolegal implications of the Health Insurance Commission's three-test rule? Comment: The Journal sought a comment from the Commonwealth Department of Health and Ageing, but after three months had yet to receive a response.

Graeme H Johnson MB BS (Hons), BMedSci(Hons) · Donna B Mak FAFPHM, FACRRM

In reply: We disagree with Wodak and colleagues in a number of respects. If the results of a hydromorphone trial were as good as Wodak et al claim a heroin trial would be, then a heroin trial would be unnecessary. We accept, as did the Dutch and Swiss, that politicians have the authority to make decisions about what medical research is permitted. The heroin trials in Switzerland and the Netherlands were approved by parliament and supported by referenda in cantons and cities in Switzerland. The Australian survey data cited by Wodak and colleagues indicate that a heroin trial would not have been approved if a referendum had been held in 2001. Nor do we think it would be supported by a free vote in Federal Parliament, as it was not supported by a similar vote at the NSW Drug Summit in 1999. Wodak et al present no evidence to support their claim that the delivery of a treatment that costs between A$25 000 and A$45 000 per patient per year in the Netherlands1 to less than 5% of the heroin-dependent population would have a detectable impact at the population level. A hydromorphone trial would provide a way of evaluating the role of injectable opioids in the treatment of heroin dependence. It would not prevent Wodak and colleagues from convincing the community that injectable heroin is the drug of choice to treat refractory heroin dependence.

Wayne D Hall PhD · Richard P Mattick PhD · Jo Kimber BSc (Hons)

To the Editor: Lamberth stated in his case report that Antarctic tourist ships should be equipped to provide life support, as well as better screening and education of Antarctic tourists.1 I recently travelled to both the Arctic and Antarctic as a medical officer on small ships, caring for seven passengers injured in a helicopter crash in the remote Russian Arctic and a 12-year-old with diabetic ketoacidosis in the Drake Passage, as well as numerous people with minor ailments. To compare these ships with large tropical cruise liners is unrealistic. Ships' medical supplies are selected with an appreciation of the casemix. A study of 16 Antarctic trips in 1997 and 1998 found that most problems were respiratory tract complaints, acute soft tissue injuries and complaints, sea sickness and dermatological problems.2 Few major incidents have been reported, and equipment for advanced life support is tailored to this. Paralysing agents and ventilators are not supplied. A single doctor with no nursing staff cannot safely care for a ventilated patient for 72 hours, as suggested by Lamberth, and the additional staff needed for this would be a huge additional expense for a very rare occurrence. While some ingenuity and adaptability may be required, the equipment supplied is adequate for the vast majority of events. Safety and preventive medicine are very much part of the ship's doctor's role. Most doctors give a brief lecture as part of the initial briefing of passengers. Seasickness, appropriate medication and safety on the ship are usually part of this. The passengers are predominantly elderly and, in my experience, many are fulfilling a long-held ambition to travel to the polar regions. Reputable companies require a fitness-to-travel assessment from passengers' general practitioners before the trip is confirmed. This assessment is tailored to potential problems in remote regions. I believe that excluding people from the wonders of polar travel on the basis of age or previous coronary artery disease would be a terrible shame, while accepting that there will always be a risk in travelling to remote locations. Having shared in the 90th birthday celebration of a woman with chronic obstructive pulmonary disease in the Arctic, I hope that I will still be able to enjoy such experiences at that age.

Eve R Merfield FACEM

To the Editor: Lamberth raised some worthwhile issues about small-ship adventure tourism to Antarctica in his recent case report describing the death of an 82-year-old tourist.1 This occurred in 1999, the season I started as medical director for the leading polar adventure tour company that chartered the vessel involved. I have some comments and an update. The former Soviet oceanographic research vessel was converted in the 1990s to carry 78 passengers. She had a two-bed infirmary and a procedure room with Russian and German medical supplies for passengers and crew, and carried a German- and English-speaking Russian doctor experienced with passenger ship medicine. The tour operator provided additional medical supplies and an emergency physician. Ventilatory support could have been provided, although not to the standard of a contemporary Australian intensive care unit. Polar adventure operations are very different from "tropical" cruise lines, which generally operate their own ships from home ports and cater for up to 3000 passengers with very different expectations.2 Operators require that prospective passengers submit a medical information form and a declaration from their personal physician that they are fit for the journey. The 82-year-old who died was a retired physician who did not declare the extent of his limitations, and who acted as his own medical advisor. His is the only death I am aware of after seven years' involvement in the industry. The medical declaration form has been modified and now addresses the risk factors identified by Lamberth. Prospective clients with questionable health are referred to the medical director. However, operators cannot verify declarations of good health, and physicians have been known to collude with passengers to avoid risk of rejection. Furthermore, "ageism" is as unacceptable as sexism and racism. I was present on the first passenger-circumnavigation of Antarctica in the company of several octogenarians and a 90-year-old, and on the first circumnavigation of the Arctic Ocean, with other octogenarians and a 92-year-old. Short trips to the Antarctic Peninsula are very different from scientific expeditions; Lamberth's suggestion that advising doctors should consider scientific expedition criteria is inappropriate. The International Association of Antarctic Tour Operators (<www.iaato.org>) is a voluntary association of competing adventure eco-tour operators whose purpose is to self-regulate the industry and to develop good standards. Standards for provision of medical supplies and capabilities are under development by this association.

Chris H Curry

In reply: I welcome Curry and Merfield's interest and comments. The patient described in my case report1 was not, as Curry states, "a retired physician". Nor did he provide his own health assessment, but had his assessment form filled out by another physician. Unfortunately, this form, along with those of 60 other passengers, was not made available to any doctor before embarkation. Curry confirms that many older passengers are travelling to Antarctica.2 Merfield's experiences attest to the potential for serious (including multiple casualty) incidents in this remote location. I agree that ageism per se is unacceptable. Rather, the issue is the provision of adequate facilities to deal with potential problems or, alternatively, warning as to the hazards. Advertising for Antarctic cruises emphasises the medical facilities provided. The public may not realise that a doctor with minimal equipment cannot deliver the same care available in a First World hospital. Curry's assertion that ventilation could have been provided illustrates this. Ventilation is more than placement of an endotracheal tube. It is ludicrous to suggest that, without oxygen, paralysing drugs, positive end-expiratory pressure or means to suction the copious thick secretions, hand-bagging for 36 hours while crossing the heavy seas of the Drake Passage might have altered the tragic outcome for this patient. I recommend a book by Levinson, a seasoned polar physician, and Ger on health aspects of polar tourism.3 They have collated the findings of a conference held on this topic at Cambridge in the United Kingdom in 1995. The book addresses what Levinson describes as "the often inadequate medical care which exists in these regions". He notes "major concerns . . . expressed by travel experts, the American Medical Association, the American College of Emergency Physicians, and other professional organisations."3 The survey by Curry and Johnston found that illnesses among their company's Antarctic tourists in 1997 and 1998 included cardiac arrest, acute myocardial infarction, severe pneumonia, diabetic ketoacidosis due to seasickness, haematemesis, anaphylaxis, ruptured ectopic pregnancy and acute appendicitis. The fact that polar trips are short does not seem to protect against potentially lethal diseases. Given the stress of this travel and the nature of the population involved, maybe the contrary applies.

Paul G Lamberth FACEM

To the Editor: The experience described by Jones on books as carriers of disease in a recent issue of the Journal,1 following Ferson's article in the Christmas issue,2 reminded me of my experience in about 1933 at the Coast Hospital (now Prince Henry Hospital) at Little Bay, Sydney. My mother was a medical resident at the Coast, which was the infectious diseases hospital for NSW. She developed acute diphtheria and was admitted. I (aged five) and my sister had been immunised and were not sick. However, we were throat swabbed, and the swabs were positive for Corynebacterium diphtheriae. We spent three weeks in the hospital with no treatment until we returned negative throat swabs. While waiting to be admitted to the "blocks", we saw children with shaven heads through glass doors, and I've always assumed they were the ones with scarlet fever, as did Jones.1 I was given The Anzac book, on Gallipoli, to browse through. This is now a collector's item and very valuable. Then, much to my chagrin, I was not allowed to take it home. Later, in 1953, I was to return to my old ward as a resident medical officer, although I was never to find out what happened to all those books!

John V Roche MB BS, FRACGP, D(Obs), RCOG, DRACOG

To the Editor: Hall et al1 argue that a hydromorphone trial would break the current deadlock in Australia over prescription heroin research. But would it? If hydromorphone was demonstrated to be an effective intervention for treating refractory heroin users, researchers would then wish to compare both hydromorphone and prescription heroin against the gold standard, oral methadone. The Prime Minister has stated publicly that proceeding with a prescription heroin trial "would send a wrong message". This claim is still unsupported by evidence. Clinicians and researchers should steadfastly oppose political interference in medical research from however august a level, especially when there is such a strong rationale for the trial and when researchers have so scrupulously followed scientific process. Such interference would not be tolerated in other areas of medical research and should not be tolerated in this field. The results of a recent large randomised controlled trial2 of prescription heroin in the Netherlands, while yet to be published in a peer-reviewed journal, provide strong additional support for an Australian trial. In contrast, Hall et al1 cite no previous evaluation of the efficacy of hydromorphone in managing heroin dependence. In Switzerland, prescription heroin is reserved strictly for treating refractory patients and accounts for fewer than 5% of all treatment provided.3 The importance of attracting and retaining this group in treatment is probably far greater than their small numbers might suggest, as there is reason to believe that they contribute disproportionately to the immense social costs of heroin use in the community. (By analogy, the heaviest-drinking 10% in a community account for half the total alcohol consumed.) Those who inject heroin very much more frequently than the community mean are probably responsible for a disproportionate share of crime and enlisting new recruits. Prescription heroin was selected as the experimental intervention in studies in Switzerland, the Netherlands, Germany and Spain and is now being considered seriously in Canada. The reasons advanced by Hall et al1 are all cogent arguments for conducting a trial of hydromorphone additional to an evaluation of prescription heroin. Hall et al are concerned about lack of community support for a heroin trial in Australia, but in a recent national opinion poll4 45% of respondents expressed support, while 47% were opposed. The case for an Australian heroin trial, with or without additional trials, remains compelling.

Alex D Wodak FRACP · Alison J Ritter PhD · Charles RR Watson PhD

To the Editor: I read with interest the accounts of de Costa, Walton, and Flynn and Atkinson dealing with the Professional Standards Committee (PSC) of the NSW Medical Board and the behaviour of the Health Care Complaints Commission (HCCC).1-3 I would like to add a few comments arising from my personal experience of appearing before the PSC. The PSC is supposed to be non-adversarial. The Medical Practice Act 1992 (NSW) states that the doctor under investigation and the HCCC are not to be represented by a solicitor or barrister, but could be assisted by one. In my case, I soon realised that the HCCC Hearings Officer opposing me was dauntingly competent in court craft. She was, in fact, a very experienced solicitor who had for a long time been in practice outside Australia but was not registered as a solicitor in New South Wales. As a result of my application to the Supreme Court, this malpractice was stopped by Justices Dunford and O'Keefe.4, 5 Note that Justice O'Keefe ruled that a person qualified in law could represent the HCCC in PSC hearings, provided the person had never been registered as a legal practitioner. I would like to pose three questions. Firstly, why was it left to me, someone inexperienced in legal processes, to call a halt to this inequity? Secondly, why did the Medical Board countenance this malpractice, when it was manifestly in breach of the Medical Practice Act and most unfair to the medical practitioners whose welfare is its responsibility? And thirdly, why did legal representatives of the medical defence organisations continue to permit this obvious imposition on the doctors whom they had been paid to defend? In my case, evidence obtained in confidence from peer reviewers has been published in the journal of the Health Care Complaints Commission, even though the action against me has not yet come to hearing. The HCCC's practice of publishing such information prior to hearings has been sanctioned by the Medical Tribunal.6 It is my belief that the HCCC has brought the NSW medical regulatory bodies into disrepute by its malpractices, its disrespect for the wishes of Parliament and its lack of a long-term perspective.

Richard F Gorman MBBS DO FRACO

To the Editor: I am a general practitioner who has specialised solely in the field of cosmetic medicine since 1988. I have been the subject of an investigation by the Health Care Complaints Commission (HCCC) and a resultant Professional Standards Committee (PSC) hearing, in which peer reviewers with significant conflicts of interest were used. The process was triggered by a complaint from a patient who had developed blisters and superficial crusting after facial laser hair removal treatment. This is a recognised complication that the patient was aware of when giving consent for the procedure. The HCCC briefed a dermatologist, Dr "X", to comment on the treatment of which the patient had complained. The HCCC further instructed Dr X: "Your report need not be confined to the above questions [relating to such treatment] but should include any other matters you consider relevant and significant." I was referred to the PSC primarily on matters unrelated to the treatment that had led to the patient's complaint. Before the PSC hearing I submitted various documents to the HCCC: (a) a copy of a newspaper advertisement for laser hair removal in which Dr X had stated "Trust only a dermatologist to recommend a safe and reliable method of managing unwanted hair" and "Prospective clients should closely check the qualifications of their laser practitioner and look for the letters FACD"; (b) a report from another dermatologist stating that Dr X "does have a history of a negative attitude to general practitioners who specialise in lasers. He has been seen on television on several occasions espousing this view."; (c) expert reports from two dermatologists expressing views contrary to the opinions of Dr X that had triggered my PSC referral; and (d) statutory evidence from a patient treated in his practice that Dr X's own clinical practice was contrary to that which he had advised the HCCC I should have followed. The NSW Medical Board appointed as a PSC representative at my hearing a dermatologist who was a co-advertiser for laser hair removal with Dr X. The dermatologist in question was later removed (with difficulty) on objection. The PSC systematically disregarded expert evidence I had presented in favour of evidence presented by the HCCC. I have been told that this is a common occurrence. I sincerely hope that the NSW Government Inquiry into the HCCC, to be released in 2002, will address the abuse of this system by biased reviewers. However, justice cannot be guaranteed when the HCCC and NSW Medical Board both effectively collude to prosecute these cases. PSC hearings should be administered by an independent body.

Geoffrey K Heber MB BS DipRACOG MBA

To the Editor: The Acts constituting the NSW Medical Board and Health Care Complaints Commission (HCCC) unfortunately permit inequitable joint functioning of these agencies. The provision that the complainant may appeal an unsatisfactory decision of a Medical Board's Professional Standards Committee (PSC) to the Medical Tribunal is misleading.1 The HCCC chooses its peer reviewer in any matter, investigates, recommends that the Board take action (or not), prosecutes matters at a hearing (or not) and is the only complainant allowed to appeal.2 Clearly, the skills, methods, and decisions of the HCCC and the Board must be beyond reproach. The HCCC selects peer reviewers to consult during the investigation of a complaint.3 They are paid to report on documents and to appear as witnesses before any committee or tribunal of inquiry — either before an in camera PSC of the Board or at a Medical Tribunal, chaired by a judge in open court. Peer review reports, which are legally privileged and generally inscrutable, may be selectively biased. My own involvement (as a complainant disallowed appellant standing from the PSC, and as an occasional consultant to a complainant and to the defence in other, separate psychiatric complaint matters) has led me to conclude that some peer review reports are inconsistent with minimal professional requirements or even duplicitous. Blind faith in a system comprising these two statutory bodies and an anonymous peer reviewer is inappropriate. The NSW Administrative Decisions Tribunal (ADT) has judged disclosure of the membership lists of HCCC peer review panels to be in the public interest. In 1999, the ADT inquired into the selection of the list of psychiatrist peer reviewers when dealing with an application for disclosure based on the Freedom of Information Act 1989 (NSW).4 The list proved to have evolved over an unknown period, through unknown differing methods (such as recommendations from unidentifiable practitioners or staff), for unknown precipitating reasons, and at unknown times. There was no general awareness within Medical Colleges or other medical associations of the selection process or of the members who may be thus empowered. This, when we know that, as a profession, we cannot be uniformly sensible, ethical or emotionally stable. The HCCC and the NSW Medical Board are thus vulnerable to corrupt influence. The NSW Parliamentary Committee on the HCCC has sought submissions from the public and has been conducting an inquiry since November 2001 to determine necessary improvements to the functioning of the HCCC. I believe professional bodies need to take a resolute lead, declare their intentions, identify their roles, consult with their members and heed their responses. Ideally, each will clarify its policies and procedures for regulation and will demand proper functioning from the agencies with statutory responsibilities.

Eleanor Dawson

In reply: A Medical Board's role is to protect the public by ensuring that appropriate standards of conduct and practice are maintained by registered medical practitioners. In New South Wales, the NSW Medical Board administers the disciplinary provisions under the Medical Practice Act 1992 (NSW). Included in this legislation is the Medical Tribunal/Professional Standards Committee (PSC) model that has been the subject of comment in recent correspondence. It is important to note that the Medical Board, the Health Care Complaints Commission (HCCC), the Medical Tribunal and PSCs are all independent bodies in their own right. The Medical Board welcomes constructive comment on the system and its administration. It meets regularly with the major parties (HCCC, United Medical Protection, and the Australian Medical Association [AMA] as the doctors' professional body) to discuss the workings of the disciplinary system, to identify problems and shortcomings, and to develop solutions. Inevitably, there will be aspects of the process that participants do not like — who enjoys being taken to court, in any circumstances? As in all legal and quasi-legal processes, the parties are unlikely to uniformly praise the impartiality or quality of witnesses, experts, and the judiciary. Processes are in place to minimise the possibility of conflict of interest, or the perception of bias. On the rare occasion when a panellist is challenged, a conservative approach is generally taken, and a replacement found. Heber raises concerns about an inquiry extending beyond the parameters of the original patient complaint. In a protective jurisdiction, it would be quite wrong to limit a case to what the complainant had been able to articulate. Not infrequently, a patient's unhappiness is focused on what, from a medical perspective, is relatively minor, while seriously poor conduct or practice is not recognised as such. The legislation specifically envisages an "inquiry", which, subject to natural justice requirements, may go beyond the original complaint. To deny this would be inconsistent with the protective nature of the jurisdiction. The issues raised by Dawson and Gorman concentrate on procedures adopted by the HCCC regarding peer review and representation before hearings. The Board understands that the HCCC has a detailed policy document, prepared in consultation with stakeholders including the AMA and United Medical Protection, regarding the selection and utilisation of peer reviewers and expert witnesses. The Board is also aware of wider concerns in the legal system regarding the use of "hired guns" as distinct from impartial peers or experts, and when concerns have been brought to its attention suggesting even a perception of bias it has taken steps to address them. The Board and members appointed to sit on PSCs and Medical Tribunals take their roles very seriously, and do so with a sense of professional responsibility, while acknowledging the difficulty of sitting in judgement on their peers. Criticisms are carefully considered and practices changed where appropriate. At all times, the Board must ensure that it acts fairly and in accordance with its charter of public protection.

Brian C McCaughan MB BS FRACS

To the Editor: A number of recently published articles indicate that the prevalence of overweight and obesity in children is increasing at an alarming rate on a national1 and international2 level. Overweight children are more likely to become overweight adults and to experience chronic health problems associated with adult obesity. We report results obtained from a survey of primary schoolchildren on the New South Wales Central Coast which extends the time series from that in the article by Magarey and colleagues (1985 and 1995 data)1 to the year 2000. We undertook a cross-sectional study of children at a Central Coast primary school in November 2000 as part of a community study. This study was approved by the Central Coast Health Ethics Committee. All children in each class were asked to take part. With parental consent, weight and height were measured in children from all class groups (aged 7–11 years) by child health nurses using standardised procedures. Children were classified as overweight or obese using the standard international cutoffs for body mass index.3 They were compared with data obtained during the 1985 Australian Health and Fitness Survey (AHFS85) and the National Nutrition Survey of 1995 (NNS95).1 A total of 268 children (127 girls, 141 boys) were surveyed (average of 25 girls and 28 boys of each age). This represented a 70% response rate. The Table shows that the incidence of overweight and obesity in Australian children has continued to increase, with relative risks for the increase between 1985 and 1995 of 1.37 (95% CI, 1.07–1.75) for boys and 1.82 (95% CI, 1.49–2.22) for girls, and relative risks for the increase between 1995 and 2000 of 1.71 (95% CI, 1.21–1.43) for boys and 1.21 (95% CI, 0.87–1.67) for girls. Our findings indicate a marked increase in proportions for boys in only five years since NNS95. While the increase for girls was not statistically significant, the pattern is consistent. Prevalence of overweight and obesity in children aged 7–11 years for 1985, 1995 and 2000 Sex Year Number Overweight (%) Obese (%) Overweight + obese (%) Boys 19851 2425 9.7 1.5 11.2 19951 457 11.6 3.7 15.3 2000 141 16.3 9.9 26.2 Girls 19851 2443 11.0 1.9 12.9 19951 430 17.2 6.3 23.5 2000 127 21.3 7.1 28.4 Thus, the incidence of overweight and obesity in Australian children is steadily increasing. Importantly, according to the 1996 Census Socio-Economic Indexes for Areas,4 the school we surveyed is situated in an area ranked in the middle quintile for relative socioeconomic disadvantage (state and national average), and is immediately adjacent to one 4th- and several 1st-quintile and 2nd-quintile areas. We believe our findings are representative of the Australian population of children. The challenge to healthcare workers is significant. The National Health and Medical Research Council's Acting on Australia's weight5 identifies goals for preventing further weight gain in adults, and eventually reducing the proportion of the adult population that is overweight or obese, and to ensure the healthy growth of children. Recommended strategies range from national dietary and physical activity guidelines to increasing physical activity through the design of towns, transport systems and public recreational facilities. Effective strategies are urgently needed to alter food intake and physical activity at individual, school, community and population levels.

Susan Goodman · Peter R Lewis MB BS, FAFPHM · Andrew J Dixon · Cheryl A Travers

To the Editor: One concern that medical practitioners and pharmacists have about patient counselling is the uncertainty about the amount of information which should be given to patients, especially regarding possible adverse reactions to medications.1 Studies have found that providing information on possible adverse reactions can affect patients' willingness to take the medication.1 Research in cognitive psychology provides clear evidence that the order in which information is presented has a significant influence on judgement. Information received first is likely to have a disproportionately large effect on judgement, the "primacy effect".2-4 Despite clear evidence supporting the "order effect" in diverse areas, research has not been undertaken to investigate whether the order effect is present in medication information. To test the hypothesis that differently ordered sequences of the same information about a drug can result in different judgements,5 804 subjects were presented with a short description of a fictitious medication. The descriptions were presented in one of two formats (Box): (A) positive–negative (therapeutic benefits followed by potential adverse reactions) or (B) negative–positive order (potential adverse reactions followed by therapeutic benefits). The surveys were randomly distributed to university students, mindful of the limitation of extrapolating the data to the general population. Subjects rated the medication (from very bad to very good) and the likelihood of taking the medication (from very unlikely to very likely) on seven-point Likert scales. For analysis, we used the independent sample t test, which is robust and therefore considered suitable for this analysis. Two descriptions of a fictitious medicine for treatment of diabetes A: Diabetic MedicationThis medication is effective; it lowers sugar levels. It makes one feel better and boosts energy. It may cause nausea and headache. B: Diabetic MedicationThis medication may cause headache and nausea. It boosts energy and makes one feel better. It is effective; it lowers sugar levels. Of the 804 completed questionnaires, 403 were in the positive–negative order and 401 were in the negative–positive order. Participants given the positive–negative description of the medication rated it more positively (mean, 4.43; SD, 1.02) than those given the negative–positive description (mean, 3.70; SD, 1.62) (P < 0.001). Similarly, participants reported a higher likelihood of taking the medication when information was presented in the positive–negative order (mean, 4.23; SD, 1.62) compared with the negative–positive order (mean, 3.54; SD, 1.66) (P < 0.001). We found that the order of presentation of medication information significantly affected judgement of the medication. Subjects rated the medication more favourably when positive information was presented first. These results suggest a potential benefit in presenting medication benefits before discussion of possible adverse effects. Such an approach might apply to medical practitioners and other healthcare professionals when counselling patients. It might also be a consideration in the format of written information, such as Consumer Medicine Information.

Abilio C de Almeida Neto BScPsychol(Hons), PhD · Timothy F Chen BPharm, DipHPharm · Joyce H L Chan BPharm(Hons)

To the Editor: The conclusion of Holland et al that horse-related injuries in children account for a considerable number of deaths and injury is unarguable.1 In New Zealand, hospitalisation rates for falls from horses and rugby injuries are comparable.2 Despite these disconcerting facts, the data on horse-riding injuries need to be put in a balanced perspective. The frequency of injuries in adult equestrian activity, Pony Club riding, occupational riding (including professional jockeys) and riding for leisure are quite different. Collective raw data are misleading. The freak accident of actor Christopher Reeve in 1995, with the resulting much-publicised quadriplegia, brought public attention worldwide to the question of acute spinal cord injury (ASCI) in horse riding and led to widespread parental concern about "spine safety" in this sport. Spinecare Foundation was subsequently involved in a review of 32 patients with ASCIs from horse riding admitted to the spinal cord injury units at Royal North Shore and Prince Henry hospitals, Sydney, for the years 1976 to 1996.3 Occupational and leisure riding accounted for 88% of injuries. ASCIs occurred in only two riders under the aegis of the Equestrian Federation of Australia — one while competing and the other while training. There were no injuries in children younger than 14 years of age in any form of riding. Most importantly, in the study period, there had been no ASCIs in Pony Club riders, of which there were 22 000 in New South Wales in 1996. Neither had there been an ASCI in those who participated in Riding for the Disabled. In the context of these comments, it is relevant to briefly revisit the contentious topic of Down syndrome children taking part in Riding for the Disabled and in sport generally. Since 1970 (from when accurate records are available), no child with Down syndrome in NSW has had an ASCI in any sport, let alone in a well-defined non-sporting accident. There is simply no case for the radiological screening of the cervical spine for atlanto-axial instability in asymptomatic children with Down syndrome before they undertake Riding for the Disabled. The indications for this examination have been set down.4 We hold that the public and the medical profession can continue to be reassured by this information. Certainly, a child wearing a lap seat belt or other poorly fitting restraint in the rear passenger compartment of a car is at infinitely greater risk for spinal cord injury than when astride a horse at Pony Club. Further, as Holland et al have documented,1 if he or she is wearing a protective helmet the chances of head injury would be reduced significantly. Safety in all potentially dangerous sports should be foremost in the minds of those who administer, supervise and participate in such games. As yet there are no hard data to support the wearing of body protectors to reduce the risk of ASCI, or other vertebral injuries, in horse riding. In reply: One of the reasons for publishing our data was to raise the level of awareness of both the frequency and severity of horse-related trauma in Australian children.1 This trauma appeared to be associated with a low level of compliance with basic safety measures, in particular the use of a Standards-approved riding helmet.1,2 We stated clearly in our article that the risk of injury needed to be viewed in the context of the important social and health benefits of horse-riding as a sporting and leisure activity.1 Taylor and Roe have commented on the perceived benefits of Riding for the Disabled, especially in children with Down syndrome. Certainly, the available data suggest that in this strictly supervised scenario horse riding would appear to be very safe.3 However, the evidence for therapeutic benefit would appear to be relatively weak, and the risks of this form of equestrianism cannot be compared with the more common interaction that might occur between a normal child and horse.4 The incidence of spinal cord injury in children fortunately appears low, at less than 2% of children admitted with all forms of traumatic injury.5 In this context, the use of spinal cord injury as a measure of the safety of a sport for children is flawed. While children may be at greater risk of injury when inappropriately restrained in a motor-vehicle accident, this fact in itself does not make horse-riding, or indeed any other high-risk sporting activity, safe. The use of appropriate safety devices and responsible adult supervision does.

Thomas K F Taylor DPhil(Oxon), FRCS, FRACS · Justin P Roe MB BS, FRACS · Andrew J A Holland BSc, MB BS, FRACS, FRACS(Paed) · Gerard T Roy

To the Editor: In their case report entitled "Dangerous bodies", Nocera and colleagues described a case of poisoning with aluminium phosphide tablets,1 which generate the fumigant gas phosphine when exposed to moisture.2 The foul odour emanating from the patient alarmed hospital staff, leading to evacuation of the emergency department. After the patient died, they sealed his body in an impervious suit and bin. It was buried, without autopsy, using earth-moving equipment — it being considered too dangerous to do this by hand. The burial was filmed for television. The article sought to highlight risks to hospital staff from poisoned patients and indicated that phosphine gas emanating from this patient could be toxic before it was able to be smelt. Despite stated fears of extreme toxicity, no air samples were collected for analysis, and the sole symptom among staff was nausea (not unexpected given the smell). In parts of India, where wheat is commonly stored in the home before being ground into flour, aluminium phosphide tablets are widely available for household use to stem insect attack on the grain.3,4 Ingestion of these tablets is a common way to attempt suicide, with perhaps as many as 15 000 cases per year, two-thirds of which are fatal. The hospital in the city of Chandigarh, in northern India, treats about 50 cases per year. The breath of patients who have ingested aluminium phosphide has a characteristic garlic-like odour. Diagnosis is based on history and a positive result (blackening) on tests of the patient's breath with paper moistened with fresh silver nitrate solution. Hospital staff take no special precautions during resuscitation, and surviving patients are managed with routine supportive care. Autopsies are routine. No threat is perceived by hospital staff. Metal phosphides have been safely used by trained people in Australia for decades. They are Schedule 7 poisons and so require an expensive permit for purchase. Consequently, their use for suicide is rare. Nocera and colleagues understandably reacted with caution to an unusual situation. However, we consider that, in documenting their experience, they overstated the risk. Because of the legal and ethical issues involved in patient care in a situation of alleged risk, we consider that risk estimates should, when possible, be based on available evidence rather than theoretical possibilities. In general, apart from a few highly toxic, mainly anticholinesterase compounds that can be absorbed through the skin (eg, sarin and tabun), there are no known poisons that will seriously endanger hospital staff routinely caring for patients in an emergency department. Competing interests: The authors have no association with companies that manufacture or market aluminium phosphide, and had no financial support for preparation of this letter. In reply: In our article, we clearly stated that the emergency department was evacuated on the instructions of officers from the New South Wales Fire Brigades.1 The officers then placed the patient's body within a fire brigade hazardous materials encapsulated suit and, when that began to distend with phosphine gas emissions from the body, into a hazardous materials recovery bin. In contrast, Christophers and colleagues state that staff at the hospital in Chandigarh, India, take no special precautions in antemortem or postmortem care of patients who have taken aluminium phosphide tablets. I am disappointed that they provide no data on air sampling for phosphine gas during this care to justify this practice. Our case highlights the problems confronting emergency department staff with a critically ill patient and an unknown chemical hazard. In this case, the chemical hazard was not correctly identified for over 30 minutes. The risk cannot be estimated, as suggested by Christophers and colleagues, until the chemical agent and its vapour concentration are correctly identified. Retrospective determinations cannot be used to guide the immediate emergency department response, or to determine what personal protective equipment is needed by staff during the initial confusion of a hazardous materials incident. In addition to organophosphates, over 30 chemical agents have the potential to be used as chemical weapons. Furthermore, the toxicity profiles of many industrial chemicals are unknown or incomplete. We do not believe that any hospital or emergency department staff should be exposed to avoidable danger during antemortem or postmortem care of patients, or that healthcare institutions should be exempt from their statutory obligations under occupational health and safety legislation.

Allen J Christophers · Surjit Singh · David G Goddard · Antony Nocera FACEM, MSc (Emergency Planning and Disaster Management)

To the Editor: Your readers might be interested to examine the full story of Dorothy Reed's initial encounter with William Osler,1 and to learn that he later apologised for his initial negative reaction to her expressed intention to enter medical school, and gave her great support. She later said of him: "He was my friend and to me William Osler has always stood for the greatest personality and the soundest medical teaching possible at that time." Some of her unpublished memoirs are included in a book edited by Jill Ker Conway.2

Tony E Seymour

To the Editor: The South Pacific Underwater Medicine Society (SPUMS) recommends that, before starting scuba-diving activities, all candidates undertake a medical assessment by a doctor trained in diving medicine. SPUMS recommends a minimum age of 14 years for all entry-level scuba activities, as does Australian Standard 4005.1. This recommendation is based on the belief that younger children do not have the emotional maturity and confidence to safely manage underwater emergencies. Such emergencies, which may include running out of air, being separated from your buddy, being caught in a strong current, and equipment malfunction, can all result in panic.2,3 A diver who panics will typically make a rapid ascent to the surface, risking life-threatening pulmonary barotrauma and decompression illness.2 Commercial scuba diving instructor agencies are introducing a number of introductory activities for children as young as eight years. SPUMS urges caution in assessing young children as fit to dive. Medical practitioners making these assessments should clearly understand the nature of the activity to be undertaken, the equipment to be used and the nature of the environment in which the training is to occur. They should also understand the nature of the certification to be awarded. The presence of at least one legal guardian during this assessment is desirable to ensure that the risks are fully understood and to ensure the desire for the child to undertake the activity is not that of the parents alone. An individual may meet the criteria laid down in a standard or understand and accept the risks of an aquatic sport. However, it is not clear that a young child is mature enough to make this informed choice.4 Clearly, some 14-year-olds also lack sufficient maturity, and an experienced diving physician will advise them to delay their open-water certification course until greater maturity is demonstrated. Alternatively, some children younger than 14 years may be completely safe in undertaking a highly structured, one-on-one, supervised scuba experience in a swimming pool. However, it should be understood that trialling scuba equipment in a swimming pool has resulted in significant morbidity. SPUMS continues to recommend a minimum age of 14 years for all entry-level scuba activities involving open-water dives, and recommends caution in assessing younger children for all other scuba experiences.

Robyn M Walker MB BS, DPHM

To the Editor: Some of the principles underlying evidence-based medicine (EBM)* might have been around far longer than we tend to believe. Here is a fragment of one of the 8777 brief suttas (discourses) collected in the Anguttara-nikaya, or "Collection of the gradual sayings", one of the oldest Buddhist texts. The Buddha preaches to the Kalamas people: Yes, Kalamas, you may well doubt, you may well waver. In a doubtful matter wavering does arise. Now look you, Kalamas. Be ye not misled by report or tradition or hearsay. Be not misled by proficiency in the collections [citing the authority of religious texts], nor by mere logic or inference, nor after considering the reasons, nor after reflection on and approval of some theory, nor because it fits becoming, nor out of respect for a recluse (who holds it) . . . But if at any time ye know of yourselves: these things are profitable, they are blameless, they are praised by the intelligent; these things, when performed and undertaken, conduce to profit and happiness — then, Kalamas, do ye, having undertaken them, abide therein.1 This sutta shows the importance of mistrusting unquestioned tradition, even before the days of odds ratios, cost-effectiveness ratios or confidence intervals. Perhaps the lesson for innovative modern supporters of EBM2 would be to concentrate on higher ideals like "profit" (in the sense of beneficence or prosperity) and "happiness" as the really significant outcomes we should be aiming at. * The decision to send this note to the Journal is, of course, evidence-based. The Medical Journal of Australia (MJA) is second only to the BMJ in publishing the largest number of references indexed under the MeSH term "evidence-based medicine" in English-language journals. On a proportional basis, the MJA is at the top of the list: since November 1996 it has published 125 "EBM" articles out of a total of 2553, while the BMJ has published 248 "EBM" articles out of 14966 (OR, 3.06; 95% CI, 2.44–3.83). Could it be that MJA readers are three times more interested in EBM-related topics than BMJ readers?

Diego Rosselli MD EdM MSc

To the Editor: I wish to commend the Journal for publishing the article by Cunningham1 and the analysis of her findings in the accompanying editorial.2 Both articles stress the need for improved communication between Indigenous patients and hospital staff. The Kimberley Interpreting Service provides accredited Aboriginal language interpreters for six Kimberley languages, and is involved in training other interpreter candidates. We have been operating since November 2000 and are currently looking for funding to continue offering our service into the future. To date, we have been working primarily in the legal sector and are quite perplexed as to why we do not receive bookings from the health services. In 2002, the Kimberley Interpreting Service is targeting the health sector through a number of strategies, including the production of a promotional poster for use in hospitals and clinics, articles in medical publications, and face-to-face meetings with health professionals. I encourage your readers to find out more about our service and to pass the message on to colleagues. We can be contacted at kisATwn.com.au, or please visit our website at http://members.westnet.com.au/mirima/

Tea C Dietterich

To the Editor: Warfarin is frequently used in the same population that is at risk of age-related macular degeneration (ARMD), the commonest cause of blindness in the elderly. A recent report has suggested that warfarin may cause severe intraocular haemorrhage and loss of vision in the minority of patients who have the neovascular form of ARMD.1 We have also seen this occur in patients taking warfarin. There are methodological imperfections in the report, and the association is certainly not proven. Nevertheless, it would seem prudent to exercise some caution in the use of warfarin in patients who are or may be at risk. Our preliminary recommendations (pending a prospective study) are: If a patient has only one functioning eye (for whatever reason), an ophthalmologist's opinion should be sought as to the risk of neovascular ARMD in the seeing eye before or soon after commencing warfarin therapy. Low-risk patients are easily identified and warfarin use in these patients should have no visual sequelae. In patients considered at high risk of neovascular ARMD, the use of warfarin may carry a (currently unquantifiable) risk of visual loss. Alternatives to warfarin should be considered, and the possible risks of taking, or not taking, warfarin should be discussed with the patient. If a patient has two seeing eyes, the risk of bilateral visual loss from warfarin must be exceedingly small, and indeed there have not even been anecdotal reports of such an event. Warfarin can be used in such patients without regard to ocular status. Ophthalmologists should ask all patients they examine whether they take warfarin and should communicate to the treating doctor the presence or absence of factors that put this patient at high risk of neovascular ARMD.

Lionel M Kowal FRANZCO · C Alex Harper FRANZCO

To the Editor: I wish to report a case of quinine-induced disseminated intravascular coagulation (DIC) and haemolytic–uraemic syndrome (HUS). A 78-year-old woman presented with nausea, vomiting, diarrhoea, fever and confusion three hours after taking 150 mg of quinine for leg cramps. Five months earlier she had been admitted overnight for similar symptoms after quinine ingestion, her symptoms resolving over 12 hours without sequelae. Before this she had ingested quinine infrequently for the preceding five years without complication. Her past history included hypertension, hypercholesterolaemia and glaucoma; medications were simvastatin, lisinopril and latanoprost eye drops. On presentation her temperature was 40ºC, blood pressure was 150/90 mmHg; physical examination was otherwise unremarkable. Initial investigations showed serum creatinine concentration, 0.11 mmol/L (reference range, 0.05–0.10 mmol/L); platelet count, 124 × 109/L (reference range, 150–400 × 109/L); prothrombin time, 21.2 seconds (reference range, 11s–16s); activated partial thromboplastin time, 66.3 seconds (reference range, 25s–42s); fibrinogen concentration, 2.1 g/L (reference range, 1.5–4.0 g/L); and D-dimer level, > 4.0 mg/L (reference range, < 0.35 mg/L). No haemolysis was present on the initial blood film. The patient rapidly developed oliguric renal failure, progressive coagulopathy and thrombocytopenia. There was no focus of infection, and blood, urine and faecal cultures were negative. Urine microscopy showed 3 × 106 leukocytes per litre (reference range, < 10 × 106/L), 270 × 106 erythrocytes per litre (reference range, < 10 × 106/L) and granular casts. Her urine output improved following infusions of saline, dopamine and high dose frusemide, but renal function continued to deteriorate. The coagulopathy had resolved by 48 hours after taking the quinine, but thrombocytopenia and renal function continued to worsen, with a platelet count of 18 × 109/L and a serum creatinine concentration of 0.58 mmol/L, evidence of haemolysis with fragmentation of red blood cells, elevated concentrations of lactate dehydrogenase (2450 U/L; reference range, 110–250 U/L) and bilirubin (32 µmol/L; reference range, < 20 µmol/L), and low haptoglobin concentration (< 0.06 g/L; reference range, 0.3–2.15 g/L), consistent with haemolytic–uraemic syndrome. The patient was treated with four cycles of plasma exchange with 3 L volumes, corticosteroids and two cycles of haemodialysis over 11 days. Renal function gradually improved, although the serum creatinine concentration remained elevated at 0.17 mmol/L two months later. The most common adverse reaction to quinine is thrombocytopenia. Six cases of DIC and 10 cases of HUS following quinine ingestion have been previously reported.1-5 This is the first report of both DIC and HUS occurring together after exposure to quinine. Many of the case reports describe multiple presentations before quinine was identified as the precipitant. It is important that prescribers are aware of this rare but serious reaction which may occur following exposure to quinine, and that a history of ingestion is sought in anyone presenting with otherwise unexplained DIC or HUS.

Andrew P Morton MB BS, FRACP

To the Editor: In 1998, the Australasian Diabetes in Pregnancy Society (ADIPS) published management guidelines for gestational diabetes mellitus (GDM).1 Recently, the American College of Obstetricians and Gynecologists (ACOG) published its clinical management guidelines for GDM.2 The Table shows there are few differences from the ADIPS guidelines. At this stage, ADIPS does not consider existing evidence warrants revision of its guidelines. ADIPS will retain its existing criteria for the diagnosis of GDM based on a 75 g oral glucose tolerance test (OGTT) pending publication of the Hyperglycaemia and Adverse Pregnancy Outcome Study.3 The results of this international prospective study of 25 000 pregnant women should be available in June 2004. A second publication, the draft National evidence-based guidelines for the management of Type 2 diabetes mellitus,4 does not include GDM, but initially recommended that "women with previous GDM should be retested every three years for undiagnosed Type 2 diabetes". This periodicity was selected to retest for undiagnosed disease when the cumulative risk of developing diabetes had reached 5%. The time interval was selected on the basis of European studies. In contrast, the ADIPS guidelines recommended testing every 1–2 years, but gave no reason for this, apart from the high risk of progression to diabetes among women of certain ethnic backgrounds who had had past GDM (as high as 47% over five years in Latino women5). A further, unstated reason for the 1–2-yearly testing was the major concern that fetal exposure to undiagnosed diabetes in any subsequent pregnancies could result in malformations. The following has now been inserted into the draft Type 2 guidelines: 4 "The guideline conclusion to retest women with previous GDM every 3 years represents minimum criteria. More frequent retesting may be appropriate depending on clinical circumstances, especially during the child bearing years." ADIPS supports this amendment fully and has revised its own guidelines in relation to maternal follow-up after GDM as follows: All women with previous GDM to be offered testing for diabetes with a 75 g OGTT 6–8 weeks after delivery; Repeat testing should be performed every 1–2 years among women with normal glucose tolerance and the potential for further pregnancies; If pregnancy is not possible, follow-up testing should be performed every 3 years, with more frequent retesting depending on clinical circumstances (eg, ethnicity, past history of insulin treatment in pregnancy, recurrent episodes of GDM). Differences between management guidelines for gestational diabetes mellitus (GDM) from the Australasian Diabetes in Pregnancy Society (ADIPS, 1998) and the American College of Obstetricians and Gynecologists (ACOG, 2001) [Table corrected on 27 August 2002.] ADIPS ACOG Universal versus selective screening by blood test Universal unless low GDM incidence or resources limited No recommendation. States that "many physicians elect to screen all pregnant patients as a practical matter" Differences in definition of low risk for GDM Age < 30 years, obesity, family history of diabetes Age < 25 years, body mass index < 25 kg/m2. No known diabetes in first-degree relative Oral glucose tolerance test used 75 g, 2-hour, 2-point blood sampling 100 g, 3-hour, 4-point blood sampling Criteria for diagnosis of GDM Plasma glucose level: Fasting, ≥ 5.5 mmol/L and/or 2-hour, ≥ 8.0 mmol/L Plasma glucose level: Fasting, ≥ 5.3 mmol/L; 1-hour, ≥ 10.0 mmol/L 2-hour, ≥ 8.6 mmol/L; 3-hour, ≥ 7.8 mmol/L; (2 or more time points need to elevated) Insulin therapy commenced after medical–nutrition therapy Plasma glucose level: Fasting, ≥ 5.5 mmol/L and/or 1-hour postprandial, ≥ 8.0 mmol/L and/or 2-hour postprandial, ≥7.0 mmol/L Plasma glucose level: Fasting, ≥ 5.3 mmol/L and/or 1-hour postprandial, ≥ 7.2–7.8 mmol/L and/or 2-hour postprandial, ≥ 6.7 mmol/L

on behalf of the Australasian Diabetes in Pregnancy Society

To the Editor: While we enjoyed reading Sewell's article summarising advances in paediatrics, there was no mention of developments in general paediatric surgery.1 About a third of all patients admitted to a paediatric hospital have surgical conditions. Viable advances would thus have significant implications for many children and their families. Prevention: Although vaccination against infectious diseases remains vital, the greatest killer of children in Australia is trauma.2 Detailed analysis of patterns of injury morbidity and mortality enable recommendations for prevention to be made. Legislation to reduce the risk of scalding was enacted in 1999 in NSW to regulate the temperature of hot water in new homes. Similar measures, in addition to educating families and their local doctors, have been proposed to prevent driveway and horse-related trauma in children.3,4 Overseas data confirm that such interventions may be effective in helping to reduce Australia's present mortality rate from injury of 9.5 per 100 000 children in 1991–1995 to Sweden's rate of 5.2 per 100 000.5 Diagnosis: Laser Doppler imaging of paediatric burns will enable the surgeon to determine the requirement for operative intervention within 48 hours of the burn, expediting treatment and reducing costs.6 In conjunction with the use of cultured keratinocytes, the risk of subsequent scarring should be minimised.7 Antenatal diagnosis of hydronephrosis and hydroureter has assisted in our understanding of the natural history of urological disease in childhood, helping refine the indications for surgical intervention.8 Intervention: The safety of early surgical intervention in childhood is now well established. Many common conditions such as hypospadias are now optimally treated before the child's first birthday, requiring earlier referral.9 Minimally invasive surgery has now evolved into a useful additional technique in children, in conjunction with the development of appropriate indications, suitable instruments and specialist surgical skills.10 While brevity may be an editorial necessity, paediatric surgery encompasses many areas. Although our selection represents a personal choice, advances require active involvement and consultation with colleagues across all specialties.

Andrew J A Holland · Daniel T Cass · John Pitkin

In reply: The points made by three senior surgeons at The Children's Hospital at Westmead Hospital, emphasising important areas of progress in general paediatric surgery, are valid and point to the wide range of advancing activities in paediatric care. Given the difficulty of covering all areas in a brief article, I am pleased that the Letters to the Editor section of the Journal provides another opportunity to broaden the discussion.

Jillian R Sewell