Letters

To the Editor: The Rural Doctors Association (RDA) of New South Wales, of which I am President, has been involved in desperately trying to keep maternity units close to people’s homes. The conclusion formed by Ford and colleagues in their recent report,1 that women with a previous postpartum haemorrhage should only deliver in units with a blood transfusion service, appears extraordinary and contradictory to their own findings. The authors based this conclusion on their finding that 5.8% of women had a postpartum haemorrhage in their first pregnancy, even though their definition of this was remarkably subjective and largely unscientific. They recognised in their study that the incidence of postpartum haemorrhage requiring transfusion is only 0.7%. Therefore, 88% of women defined as having a postpartum haemorrhage do not require a blood transfusion. I am bemused why the authors think 88% of women who did not require a blood transfusion but had a “postpartum haemorrhage” should only deliver in a unit with blood transfusion services. I doubt any of my colleagues would wish to deliver women who required a blood transfusion for a previous postpartum haemorrhage in a small unit. I refer Ford and colleagues, and readers, to a study by Tracy et al reported in January 2006.2 This was a much larger study of 750 491 women giving birth during 1999–2001. This study concluded that “In Australia lower hospital volume is not associated with increased adverse outcomes for low risk women”. In the past 10 years, we have seen the loss of 50% of our maternity units in NSW, and the rest are under severe stress due to the lack of staffing. I doubt that the sort of extraordinary conclusion made by Ford and colleagues will help us maintain services in rural NSW.

Leslie A Woollard

In reply: Safety and appropriateness are important principles underlying the provision of health care. Maternity care in Australia requires that women are offered care in an environment that is appropriate to their level of risk. Such a risk-management approach requires accurate data to inform the process, including accurate identification of women who may access local services as well as those who may benefit from higher levels of care. The aim of our study was to present risk estimates of recurrent postpartum haemorrhage (PPH) to better inform decision making by both clinicians and women about subsequent pregnancies. While we are aware of the struggles faced by rural maternity units, we estimated that only 0.2% of women giving birth in New South Wales would be affected by our suggestion that women with a history of PPH consider delivering at a hospital with onsite cross-match facilities. The definition of PPH that we used is consistent with that of the International classification of diseases1 and the NSW Department of Health’s PPH policy;2 this policy resulted from a review of hospital PPH policies sparked by a coronial inquest into a maternal death.3 In contrast to Tracy et al’s study, which only considered low-risk women and had no maternal morbidity outcomes,4 our study calculated risk among all women. Women with a PPH are at increased risk of transfusion, intensive care unit admission, unplanned procedure in the operating theatre, hysterectomy and major maternal morbidity.3 Where we have information about an increased risk of a potentially life-threatening event, surely we should communicate and act on this knowledge to achieve the best possible outcome for women and babies. In Canada, which has similar geographical challenges to those in Australia, it is recommended that where risk factors for PPH are identified, additional precautions such as intravenous access, coagulation studies, and availability of anaesthesia should also be considered.5 The key to successful regionalised maternity care is ensuring that women give birth in risk-appropriate settings.

Jane B Ford · Christine L Roberts · Jane C Bell · Charles S Algert · Jonathan M Morris

To the Editor: Pesce’s criticism of midwifery practice at Mareeba District Hospital1 requires rebuttal. His implication that the service is inefficient or pandering to “the powerful sway of maternity care politics” is incorrect and insults those who struggle to provide woman-centred care in a system focused on doctors. A private obstetrician in Sydney cannot understand midwifery workloads in a rural hospital without knowing the local environment and other impacts on the way clinicians work. The small group of midwives in Mareeba provide a highly valued service in their community, with few of the ancillary services taken for granted in metropolitan areas. In routine antenatal care, Dr Pesce presumably orders blood tests and then reviews the results filed in the chart or placed on his desk. A Mareeba midwife providing the same service will also perform the venepuncture, prepare a slide and spin the blood, arrange transport to the laboratory, make the next appointment, and file the results in the chart. A Mareeba midwife’s workload includes, among other things: Comprehensive perinatal care of inpatient midwifery clients; Postnatal and neonatal transfers from Cairns Base Hospital (CBH) (eg, to establish breastfeeding for low birthweight babies); 35–40 paediatric admissions per month; Emergency stabilisation and transfer of high-risk presentations (eg, a woman planning delivery with a private obstetrician in Cairns will nevertheless present to Mareeba when in labour at 32 weeks); Follow-up of high-risk or disadvantaged women who should attend CBH, but won’t for various social reasons; Lactation and parenting support for Mareeba women, regardless of where their deliveries occur; Pap smears and vaccinations; and Indirect care, including policy development, data collection, compilation of reports, professional development, inservice training and education. Pesce also criticised the low level of epidural use at Mareeba, which he says reflects a lack of access. However, models that provide one-to-one care in labour and promote continuity of care have been shown to decrease all interventions and increase maternal satisfaction.2,3 Perhaps the high use of epidurals and other interventions in modern tertiary units reflects a lack of access to such beneficial, woman-centred models of care.

L Gay Hawksworth

In reply: I am surprised that Hawksworth feels my editorial1 was critical of the Mareeba birth unit. There is no criticism of midwifery practice at Mareeba contained in the editorial. Several midwives have commended me for my support of the need for rural maternity units to evolve sustainable models of care based on the local workforce and infrastructure. Conversely, I received a few snide remarks from some obstetricians who felt that I had been too supportive. I have usually felt that when one is criticised by both sides in a controversial debate, one’s view is likely to be reasonable. I stand by my comments that the resourcing of the unit, based on staff–patient ratios and the availability of a nearby alternative service, would be the envy of many rural medical, surgical or community health teams. I also stand by my comments that a 1% rate of epidural use is more likely to reflect lack of access to an epidural service, rather than true patient preference. Reviews by a well known midwife of birth centre care and continuity of care confirm that these models of care decrease the use of epidural anaesthesia but are still associated with a 15% epidural rate.2,3 I am certain that if an epidural service were available, at least some of the Mareeba women would be grateful to have access to it.

Andrew F Pesce

To the Editor: Millar and colleagues recently described their comparison of the national inpatient medication chart (NIMC) with 14 other medication charts.1 They concluded that the NIMC contained design features that were adverse and therefore inferior to the medication chart previously used in their hospital. They also stated that the advantages expected by the Western Australian Director-General of Health in introducing the national chart were not experienced at their hospital. Millar et al failed to mention that the NIMC underwent an extensive process of piloting and evaluation in over 30 sites across the country in a structured before-and-after study.2 Failure to recognise (i) the benefits of standardisation as medical, nursing and pharmacy staff move between sites, (ii) the opportunities for structured safe medication practice training,3 and (iii) the value of the collaborative methods used will inhibit the possibility of overcoming problems like those identified by Millar et al in future redesign processes. Millar and colleagues themselves noted that “marked heterogeneity of chart design has been abolished by the NIMC”. The national pilot study considered the entire medication management cycle using a broad definition of medication error (“A prescribing decision or prescription writing process that results in an unintentional, significant reduction in the probability of treatment being timely and effective or increases the risk of harm, when compared with generally accepted practice”4). The NIMC was designed to reduce the risk of errors that prescribers have identified with previous charts.5 The NIMC also reduced the need for all staff to interpret unclear or incomplete prescriptions, thereby further reducing the risk of medication errors.2 We support the comments by Millar and colleagues that the process of implementing clinical practice change must involve significant buy-in and championing by clinicians. The implementation of the NIMC in Queensland recognised the importance of top-down support from senior health officials, combined with the need to increase clinicians’ awareness of risks of current systems and the need for a clear demonstration of the benefits of a revised system to bring about any substantial change in behaviour. We understand that the Australian Commission on Safety and Quality in Health Care has established a quality assurance process which operates at jurisdictional and national levels to adjust the NIMC on the basis of issues raised. This important platform will succeed in addressing the issues raised by Millar et al provided clinicians participate in this collaborative approach to medication safety. We have a rare opportunity, in which Australia is taking a leading role, to address one of the critical safety risks facing patients today. Let us all work together and criticise constructively within a framework of collaboration.

Ian D Coombes · Danielle A Stowasser · Carol M Reid · Charles A Mitchell

In reply: It is understandable that the designers of the national inpatient medication chart (NIMC) should wish to defend it against criticism, especially after 5 or more years of hard work and the major administrative achievement represented by the “top-down” implementation. It is regrettable that the chart at the centre of this otherwise admirable activity turns out to have significant weaknesses compared with the previous medication chart used at Royal Perth Hospital, and that the designers acknowledge this only obliquely by allowing for “future redesign”. Rather, they emphasise secondary outputs such as cross-border familiarity (which we discussed in our article1), “training in structured safe medication practice”, and “collaborative methods”. These supposed advantages are but small crumbs of comfort compared with the imposition of an unsatisfactory chart, loss of local autonomy and increased hazard for patients. There is no evidence that the NIMC has decreased medication errors, defined in relation to patient harm. There was indeed a pilot study, and we referred to it in two different contexts in our paper, but it assessed the chart on the basis of unsatisfactory process-based criteria similar to those employed after the chart was implemented. Perhaps a better indication of the problems of the pilot chart lies in the hundreds of suggested changes made from pilot sites to the NIMC Oversight Committee.2 We note that Coombes and colleagues do not dispute our scientific findings or the design faults we described. Their response repeats unverified claims of benefit that we discussed in our article, and seeks to reassure readers that a process is in place to “adjust the NIMC on the basis of issues raised”, thus acknowledging that “issues” exist. However, readers should be aware that the process referred to is subject to a set of ground-rules which prohibit changes to several design aspects of the chart that we criticised (eg, the block design of the pro re nata [PRN] section).3 Thus, the possibility that the NIMC will be substantially improved is remote. A more likely outcome is that Australia will be left with a chart that satisfies the superficial attraction of national standardisation but contains significant design flaws which represent a hazard to patients. A better approach would be to agree on binding national standard design elements and to restore to individual hospitals or health areas the right to design their own charts within these constraints — “think globally, act locally”.4

J Alasdair Millar · Robyn C Silla · Glenda E Lee · Ann Berwick

To the Editor: I wish to comment on Collignon’s recent editorial on methicillin-resistant Staphylococcus aureus (MRSA).1 The crux of the piece is his argument that what we need is interventional studies, not more studies documenting the extent of environmental contamination. This echoes the sentiment held by me and other colleagues working in the areas of infectious disease, microbiology and infection control. We do need more research and we need good data to evaluate interventions. However, we need to go one step further — a step that can and should be taken now, across the country. In 2006, I was part of a small team that reviewed the infection control program of a major teaching hospital in New South Wales. It became very clear that what is needed in infection control is a change in governance. At present, there is little ownership of nosocomial infections by clinicians or hospital administrators. Infection control intervention is perceived as belonging to the infection control practitioners, and not really the business of the doctors, nurses and other health workers who are caring for the individual patient. At worst, this attitude regards the necessary barrier precautions as an annoying, meddlesome burden imposed by some external agency. Clearly, such an attitude is unlikely to result in good compliance with containment measures. Infection control units have a very important role in terms of providing advice, consultancy and monitoring. But as long as there remains a general perception that nosocomial infections are solely the province of these units, progress in control is likely to be slow. One of the recommendations of our review was to change the governance structure as it relates to nosocomial infection. Elements of this included the following: Introducing infection control into the job descriptions of senior hospital executives and heads of departments; Conducting performance appraisals of these personnel to include infection control indicators; Seeking explicit agreement from all senior medical staff regarding compliance with infection control interventions; Requiring all departments to regularly and frequently review infection control indicators; and Requiring all departments to have regular, formal education sessions in infection control for all medical and nursing staff, including junior staff. We need a change in the mindset of clinicians. They must accept responsibility for what happens to their patients, including MRSA infections. These complications are no different from any others their patients may experience during their encounter with the hospital system.

Raymond C Chan

In reply: I heartily endorse Chan’s comments. To control infections in our hospitals, we desperately need not only a change in governance, but also a change in attitude. Chief executives of all hospitals, as well as all clinicians (nurses and doctors), need to take personal responsibility for serious infections that occur frequently in our hospitals. To do so, they also need to know how often these infections occur. We need robust and transparent measures — for example, data on health care-associated Staphylococcus aureus bloodstream infections, including methicillin-resistant S. aureus (MRSA),1 and deep-seated prosthetic joint infections. In recent years, faced with rising numbers of health care-associated infections, especially MRSA infections, the United Kingdom embraced necessary changes in governance. These included the promotion and use of seven key actions,2 with active surveillance and investigation being the first on the list. One of these mandatory surveillance measures was of all bloodstream infections caused by S. aureus (including MRSA)2,3 and the investigation of all episodes caused by MRSA with a “root-cause analysis”.2,4 There are early indications that the changes have successfully reduced the number of MRSA infections: from a peak of 3955 episodes of MRSA bloodstream infection occurring between October 2003 and March 2004, the number had fallen by over 40% to 2376 episodes in the period April 2007 to September 2007.3 Prevention and control of health care-associated infections must be a core part of clinical governance and patient safety programs in all hospitals. Chief executives and all clinical directors need to be aware of the numerous factors that must be given careful attention in order to reduce health care-associated infections. More importantly, they need to ensure that all appropriate steps are taken to prevent infection. This includes basic issues such as making sure that surfaces in clinical areas are adequately cleaned5 and that hand hygiene protocols are complied with — not just some of the time, but all of the time.

Peter J Collignon

To the Editor: Parasitic infections of the respiratory tract are rare causes of haemoptysis in Western communities, and are often clinically indistinguishable from pulmonary tuberculosis.1 We report a case of a 19-year-old Burmese factory worker who presented to our outpatients department with a history of haemoptysis for 4 years. He was born in Myanmar (Burma) and lived in Malaysia for 2 years before migrating to Australia. He had no past history of significance, and denied having any contacts with tuberculosis. He was a non-smoker and was taking no regular medications. His haemoptysis started in Myanmar, but increased in frequency after he migrated to Australia. He coughed up both fresh and old blood mixed with some sputum, and complained of weight loss of 6 kg, intermittent chest pain and headaches. He had no fever, night sweats, shortness of breath, dysuria, or gastrointestinal or neurological symptoms. He appeared well, and findings of a general physical examination were unremarkable. Chest x-rays from before this presentation, which included migrant screening x-rays, were normal, but his most recent chest x-ray revealed a round lesion posteriorly. A computed tomography scan organised by the patient’s general practitioner showed an area of consolidation at the base of his left lung, not typical of tuberculosis which was the primary suspect in this case. Blood tests showed a raised white cell count of 14. 5 × 109/L (reference range [RR], 4.0–11.0 × 109/L) with a neutrophil count of 11.33 × 109/L (RR, 2.0–7.5 × 109/L) and an eosinophil count of 0.51 × 109/L (RR, 0.04–0.4 × 109/L), an erythrocyte sedimentation rate of 44 mm/h (RR, 1–10 mm/h) and C-reactive protein level of 20 mg/mL (RR, < 5 mg/mL). The result of a QuantiFERON-TB Gold test for tuberculosis was negative. Attempts to obtain sputum samples were unsuccessful, and the patient underwent a bronchoscopy that revealed white milky mucous secretions within the lower lobe of the left lung, where a bronchial lavage was performed. Microscopy of bronchial washings revealed the presence of parasitic structures consistent with Paragonimus westermani (Box 1). Therapy with praziquantel was initiated at a dose of 1200 mg orally, twice daily for 2 days. His condition improved quickly and, on review in the outpatients department 4 weeks later, he had no clinically or radiologically evident recurrence of infection. Paragonimiasis is a common endemic infection in South-East and East Asia, particularly in India, China, Japan and the Philippines. Humans acquire the infection by eating raw or undercooked crayfish and freshwater crab, in which the metacercariae encyst. Once the organisms reach the duodenum, they excyst, penetrate the gut wall, and travel through the peritoneal cavity as immature flukes. They then migrate through the diaphragm and pleural space to reach the lungs, where they form adult worms.2 Early after infection, pleuritic chest pain may develop, in some cases accompanied by a pneumothorax or pleural effusion. Later, with invasion of the lung parenchyma, low-grade fever, cough or streaky haemoptysis may develop. Once the adult worms inhabit the lungs, usually after 2 months, recurrent haemoptysis becomes the cardinal symptom.3 Pulmonary paragonimiasis is most commonly misdiagnosed as tuberculosis, owing to many similarities in the clinical pictures of the two infections (Box 2).4,5 In a patient from a known endemic area, differential diagnoses should be considered and every effort should be made to obtain sputum samples or bronchial washings to distinguish between these two conditions. Serological tests are available if sputum or washings cannot be obtained. 1 Paragonimus westermani eggs detected on microscopy of bronchial washings 2 Similarities in the clinical pictures of paragonimiasis and tuberculosis Both are endemic in the same areas Neither responds to standard antibiotics Both produce chronic symptoms Symptoms of both include: Haemoptysis Weight loss Pleural effusion Chest pain

Murad G Ibrahim · Richard Bunter · Stanley Rajasooriar · Francis Thien

To the Editor: In recent years, solaria have multiplied across Australia. Solaria can emit higher concentrations of ultraviolet radiation than the midday summer sun.1 As exposure to ultraviolet radiation is a risk factor for skin cancer, including melanoma,2 it is not surprising that there is mounting evidence that solarium use increases melanoma risk.1,3-4 Public attention to this issue increased following coverage of Clare Oliver’s story in August 2007.5 Clare was dying from melanoma, which she attributed to her use of solaria. In the last weeks before her death, Clare publicly warned of the dangers of solaria. She featured in a television advertisement promoting the message “No tan is worth dying for”, launched nationally in February 2008. There is evidence that public awareness of the cancer risk of solaria increased after this media coverage. We surveyed adult Western Australians in September 2006, and again in 2007, about their perceptions of cancer risk factors. The survey was conducted by computer-assisted telephone interviewing using random-digit dialling from the Perth White Pages (2006, n = 196; 2007, n = 250). Ethical approval was granted by the Curtin University of Technology Human Research Ethics Committee. Participants were read a list of 16 factors (including solaria) and asked how each factor affected cancer risk (response categories: increase a lot; increase a little; decrease a little; decrease a lot; no effect). While risk perceptions for the other 15 factors remained constant, there was a substantial increase in the proportion of “increase a lot” responses for solaria (40% in 2006 v 72% in 2007; P = 0.001). Total “increase” responses were 71% in 2006 and 92% in 2007 (P < 0.001). In addition, Clare’s advocacy may have been a factor in increased regulation of the solarium industry. Until recently, the Australian solarium industry was unregulated, but operated under a voluntary code of practice. There is evidence that compliance with this code was lacking.6 The Australian Government has explored making the code of practice mandatory. As of 1 February 2008, the Victorian Government enacted regulations to tighten the control of solaria under the Radiation Act 2005 (Vic). Similar regulations were introduced in South Australia on 14 March 2008 and in Western Australia on 4 April 2008. There have been no campaigns about the dangers of solarium use in the general population, so it is very likely that this increase is due to the media coverage of Clare’s story. This and responses to other individuals’ personal stories7 provide evidence of how such stories can increase the community’s awareness of a health issue and gain support for legislative change.

Geoffrey Jalleh · Robert J Donovan · Chad Lin · Terry Slevin

To the Editor: We were interested to read the article on health services research (HSR) in Australia,1 and the previous editorial and articles on health technology assessment (HTA).2-5 In contrast to Australia’s prominent role in applying HSR and HTA to new pharmaceuticals, there has been very little local development of these techniques in evaluating new diagnostic technologies. The Quality Use of Diagnostic Imaging program of the Royal Australian and New Zealand College of Radiologists recently examined the introduction of new imaging technologies in Australia, with particular attention to Medicare Benefits Schedule funding. The major findings were: Delays of up to 7 years between the emergence of evidence for benefit from a new technology and Medicare listing. A large part of this delay was in the period before application to the Medical Services Advisory Committee (MSAC). A lack of significant permanent infrastructure for evidence-based assessment and prioritisation of new imaging technologies. This is in stark contrast to the situation for new pharmaceuticals and surgical procedures. Where some published evidence of clinical efficacy exists, but does not meet MSAC requirements, there is no mechanism to trigger targeted trials on questions of safety, efficacy, and cost-effectiveness. The generation of such evidence is costly, but, arguably, cost-effective in the longer term. Data collection by the Australian and New Zealand Association of Physicians in Nuclear Medicine during the interim funding of positron emission tomography has cost $2.5 million. This “coverage with evidence” approach is used in other countries, like the United States and the United Kingdom, to generate relevant evidence about the performance of emerging technologies when this does not exist in the published literature The current restriction of MSAC reviews to examining existing evidence, rather than sponsoring projects designed to provide specific relevant evidence, ensures continuing delays in the approval of new technologies for Medicare funding.

Nicholas J Ferris · Stacy K Goergen · Makhan S Khangure

To the Editor: The review of issues faced when training international medical graduates (IMGs) by Pilotto and colleagues is indeed timely.1 Their systematic presentation of these issues resonates loudly with many of the daily challenges of hospital practice. While their review referred to the shortfall of doctors, it failed to emphasise how critical this shortfall already is in some areas of hospital practice. As workloads escalate, IMGs increasingly underpin the provision of critical care clinical services. Among trainees in my department, the rise in the proportion of IMGs whose first language is not English has been dramatic, increasing from 22% of trainees in 2000 to 83% in 2007 (Box). In my experience, these doctors arrive with high expectations of the system that will train them to be critical care specialists, and place enormous pressure on themselves to achieve this. IMGs with English as a second language require greater early supervision to orient them to differences in hospital systems and language. Later, they require more assistance in preparing for the Fellowship examinations than IMGs whose first language is English. Between 2000 and 2007, an increasing clinical workload has left less time and resources for their training, and currently the needs of these IMGs are often not being met. These doctors are crucial to the provision of clinical services in our hospital, and their needs should not be ignored. Anecdotally, we are already seeing IMGs previously desperate for any training position now “cherry picking” hospitals with better resourced training programs. On average, compared with Australian medical graduates, IMGs with English as a second language spend longer in Fellowship training programs and are more likely to reattempt examinations; and the registration, training and examination fees for IMGs are considerable. The specialist medical colleges should already be in a position to fund initiatives for IMGs whose first language is not English. However, regrettably, as far as I am aware, they receive no specific help in undertaking the language-rich examination process for a Fellowship in critical care medicine. When I reflect on my specialty training, the thought of having to pursue this in an unfamiliar language is overwhelming. Not surprisingly, IMGs constantly perform under the pressure of “not measuring up”. Their appreciation of the help and training they receive is immense. However, I think one of my more important tasks as Supervisor of Training, particularly early in their training, is to remind IMGs of the great clinical work they perform day in, day out. The debt we owe them is also immense — who needs whom the most? Number of critical care trainees at Flinders Medical Centre, Adelaide, South Australia, 2000–2007, by origin and English-speaking status IMG = international medical graduate.

Andrew W Holt

To the Editor: In Victoria from 2000 to 2006, infectious syphilis notifications (primary, secondary and early latent infections) increased about 25-fold from 0.2 cases per 100 000 population in 2000 to 4.7 cases per 100 000 population in 2006.1 The number of new diagnoses of HIV has also increased since 2004.1 After observing a few patients presenting with both syphilis and a concurrent new HIV diagnosis, we investigated the association of the two diseases using retrospective laboratory data. As the Victorian Infectious Diseases Reference Laboratory (VIDRL) incorporates the state HIV reference laboratory and also acts as the reference laboratory for syphilis serological testing, it was possible to identify the HIV status and/or time of HIV diagnosis of 85% of patients identified with infectious syphilis, based on syphilis serological findings and polymerase chain reaction testing as previously described.2 Three hundred and forty-seven male patients fulfilled the criteria for infectious syphilis in the period 1 January 2000 to 30 December 2006. This represents 68% of all patients with infectious syphilis notified to the Victorian Department of Human Services over the period. Within the group of 347 patients, there were 310 with a single episode of Treponema pallidum infection, of whom 44.5% were HIV-positive. Thirty-seven patients were reinfected with syphilis, including 21 with their first episode recorded since 2000, and 11 with a serological pattern consistent with old treated syphilis recorded before reinfection during the study period. Of the 37 patients, 33 (of whom 23 were HIV-positive) had a second recorded episode and four (of whom three were HIV-positive) had a third recorded episode within the study period. Overall, 70.3% of patients with multiple episodes of syphilis were infected with HIV. Twenty patients presented with a concurrent diagnosis of infectious syphilis and previously un-diagnosed HIV infection. The trend over time is shown in the Box. Several international studies have highlighted the disproportionate incidence of syphilis in patients infected with HIV in recent years. There is now good evidence that syphilis and HIV act synergistically with regard to both transmission and progression of both diseases.3-5 The above data clearly demonstrate the strong association between HIV infection and infectious syphilis in Victoria, and this trend continued in the first half of 2007. Given the more frequent syphilis reinfections observed in the HIV-infected group, it indicates persons with HIV form a potential reservoir for syphilis infection in this state. We would strongly recommend that any patient presenting with possible syphilis or HIV infection in Victoria or elsewhere in Australia should be tested for both diseases. Episodes of infectious syphilis in Victoria by year of infection and HIV status * Patients with evidence of prior syphilis infection at an unknown time.

David E Leslie · Nasra Higgins · Christopher K Fairley

To the Editor: A 37-year-old male Sudanese refugee presented with lethargy, nausea, abdominal discomfort and bloating. He had chronic hepatitis B and a 2-year history of hazardous levels of alcohol consumption (90 g/day). On examination, there were no features of chronic liver disease. His liver enzyme levels were elevated (alkaline phosphatase, 189 U/L [reference range (RR), 40–110 U/L], γ-glutamyltransferase, 456 U/L [RR, < 50 U/L], alanine aminotransferase, 51 U/L [RR, < 45 U/L], and aspartate aminotransferase, 53 U/L [RR, < 40 U/L]), but synthetic function was preserved and serum bilirubin level was normal. Hepatitis B virus DNA was 1.3 × 103 IU/mL, consistent with a low-level viraemia, while HBeAg and anti-HBeAb were both non-reactive. His platelet count was reduced (115 × 109/L [RR, 140–400 × 109/L]), suggesting portal hypertension. The remainder of his chronic liver disease screen was unremarkable. Endoscopy revealed four grade 1 oesophageal varices, mild portal hypertensive gastritis, and patchy erosive duodenitis. The irregular liver and periportal fibrosis seen on ultrasound (Box 1) raised the possibility of cirrhosis. Subsequently, a biopsy of the liver showed preserved liver architecture, with periportal fibrosis and active schistosomiasis (Box 2). A diagnosis of Schistosoma mansoni infection was made, based on the histological appearance of the ova. S. mansoni is the leading cause of chronic liver disease and portal hypertension in sub-Saharan Africa.1,2 Adult worms reside in mesenteric vessels, but their migrating eggs lodge in hepatic presinusoidal radicals, resulting in inflammation and granuloma formation. The inflammatory reaction eventually leads to occlusion of portal veins and secondary portal hypertension.3 Hepatocellular function usually remains normal.1 Although the “gold standard” for diagnosis of S. mansoni infection is microscopic examination of faeces, this test may be negative (as it was in this case). Serological screening is recommended, but these assays cross-react with other helminthic infections and are unable to distinguish active infections from previous exposure.1 Praziquantel should be offered to previously untreated patients with positive serology results; after a single dose, 70%–100% of patients cease to excrete eggs.1 In patients who have left S. mansoni-endemic areas, an oral dose of 60 mg/kg split in two and given several hours apart should ensure cure.1 Our patient was treated with praziquantel, with ongoing follow-up for hepatitis B and portal hypertension. In retrospect, the patient’s history and the sonographic appearances were consistent with schistosomiasis. This clinical scenario is of increasing relevance, with a growing number of people from Africa now living in Australia. 1 Liver ultrasound Ultrasound shows an irregular liver with marked periportal fibrosis. There is no intra- or extrahepatic biliary tree dilatation. The portal vein flow is antegrade. No focal hepatic lesion is seen. 2 Liver biopsy specimen Preserved round to oval parasites with ova, some with a refractile exoskeleton and small lateral spine, can be seen. The viable forms suggest active infection. The surrounding inflammation contains numerous eosinophils, with fibrous expansion of the portal tracts. The adjacent liver revealed a preserved architecture with a normal METAVIR score of A0F0 (haematoxylin–eosin stain; low-power [A] and high-power [B] magnification).

James Daveson · Graeme Macdonald

To the Editor: Australians are fatter than they have ever been before. The prevalence of overweight and obesity (body mass index ≥ 25.0 kg/m2, or waist circumference > 80 cm for women or > 94 cm for men) in Australian adults is approaching 60% for both sexes and has more than doubled in the past 25 years.1 A prudent public health policy to fight the growing obesity epidemic would undoubtedly be to target strategies that avert this condition in the first place. So we were perplexed by the Australian Medical Association’s recent proposal to the Victorian Government to fund five public hospitals to provide 3000 obesity-related operations (ie, bariatric surgery) over the next 3 years.2 It appears the blueprint for the new millennium is to invest taxpayers’ money in modern technologies in an attempt to arrest overt clinical disease states. To attack the growing burden of obesity by investing in strategies that target secondary and tertiary treatment is an admission that we may win battles on a few fronts, but lose the war. We propose placing greater emphasis on implementing and enforcing primary prevention strategies to fight obesity. Primary defence mechanisms can decrease obesity prevalence by preventing the condition in the first place! Indeed, the health care industry is paradoxical in that its principal goal is to end health problems and human suffering, and by so doing put itself out of business.3 We need to attack the environmental roots of obesity, namely our sedentary lifestyles and caloric excess. Emphasis on secondary and tertiary prevention is too little, too late and will not reverse the growth of obesity — the funds to treat obese individuals are finite, while the number of Australians with the potential to become overweight or obese is not! In a letter to President Roosevelt voicing concerns about the Manhattan Project (the project to develop the atomic bomb during World War II),4 Niels Bohr wrote: A weapon of an unparalleled power is being created which will completely change all future conditions of warfare. Unless some agreement about the control of the use of the new active materials can be obtained in due time, any temporary advantage, however great, may be outweighed by a perpetual menace to human security. Obesity-related disorders impact on daily living. While bariatric surgery may provide a “magic bullet” for a few individuals, the time has come to legislate for minimum health standards, and to provide support for people to effect lifestyle changes to meet these requirements. Otherwise, obesity will remain a permanent threat to Australian society.

John A Hawley · David W Dunstan

Comment: Obesity is a complex public policy issue. There are no easy solutions, and the medical profession needs to work with communities, governments, researchers, teachers, parents, industry and others to help all Australians achieve and maintain a healthy weight. The Australian Medical Association (AMA) Victoria has six priority action areas to promote healthy weight: Ban food advertising to children; Simplify food labels; Promote physical activity every day; Improve clinical tools; Improve treatment options; and Evaluate and educate. Bariatric surgery is one of the treatment options that needs to be further explored. Among many other items, AMA Victoria’s state budget submission for the 2008–09 financial year1 calls for a trial of 3000 bariatric surgical procedures to be performed in public hospitals, as part of a comprehensive approach to weight loss. The evidence before AMA Victoria indicates that bariatric surgery is a safe and cost-effective treatment for a proportion of morbidly obese Victorians.2-5 However, bariatric surgery is an extreme response that should only be explored in extreme circumstances. There are many morbidly obese people who find themselves in these extreme circumstances and may benefit from the surgery if other approaches have failed. Further, bariatric surgery is cost-effective, as the costs are lower than the ongoing costs of treating chronic conditions associated with obesity. Bariatric surgery is not the only policy approach to obesity being pursued by AMA Victoria. We see it as a small part of the solution, although it has been a larger part of recent media attention on the issue. I am pleased that the AMA has been able to highlight obesity as an important public policy issue, and I look forward to working with a range of partners to explore possible solutions.

Douglas G Travis

To the Editor: The article by Haug and colleagues on household food stockpiling is a useful contribution to a neglected aspect of disaster planning.1 However, rather than providing a guide to what foods should be stockpiled, it may be more valuable to encourage families to increase the amount and rotation of the non-perishables they currently purchase. The authors seek to promote a balanced nutritional diet, but encouraging a family to continue their usual purchasing patterns when stockpiling for a pandemic or other disaster is a simpler, more sustainable, and possibly more effective way to promote household food stockpiling. We must assume that the family currently survives, for better or worse, on their current food purchase pattern. While the article states that supermarket stocks will become depleted within 2–4 weeks, it is likely that stocks would become significantly depleted at an individual store level within 2–3 days of the last truck delivery, particularly if panic stockpiling occurs. How long interruptions to the food supply chain last will depend on the nature of the disaster, but the Australian Government Department of Health and Ageing recommends that people have “enough fluids and food on hand to last you and your family a week.”2 It does not provide guidance on how much water is required per day. This is an important issue, as mains water could be unavailable within hours to days of electricity supply outages, because electricity is required to pump water into elevated water reservoirs to maintain water pressure. People may be unaware of their daily fluid requirements and may run out of water and other potable fluids before they run out of food. The US Health and Human Services recommends a 2-week food and water stockpile (“one gallon of water per person per day”), which is roughly equivalent to four litres per person per day.3 A random household survey in the Hunter Region of New South Wales after a storm-related disaster in June 2007 revealed that over 80% of households had enough non-perishable food for 3 days, but less than 40% had enough stored drinking water for 3 days (Hunter New England Health, unpublished data). Community continuity planning should be based on an understanding of baseline household food and water reserves, and household capacity and willingness to stockpile across all social strata. Governments should actively promote household stockpiling and identify strategies to bridge the shortfall in households unable to stockpile.

Craig B Dalton · Michelle A Cretikos · David N Durrheim

In reply: Dalton et al have raised several important points for discussion. They suggest that an adequate food “lifeboat” can be procured by simply encouraging a family to continue their usual purchasing patterns. Unfortunately, accumulating non-perishable items in this way would be a fast route to certain nutritional deficiency. It is the perishable items — fruit and vegetables, bread, meat and dairy products — that supply the bulk of micronutrients in modern food supplies. Within a few short months, an individual relying on usual pantry supplies could be suffering from acute deficiencies of vitamin C, and folate and other B vitamins. Babies conceived during this period would be at risk of neurological defects. We agree that an important issue is the possibility of failure of the mains water. Indeed, many of the foods in our list require water for cooking (rice, pasta etc). Rainwater tanks and the ability to sterilise water by gas heating or chemical means may be lifesavers. We agree that governments should be actively promoting appropriate stockpiling in homes, places of employment and in areas of essential infrastructure.

Jennie C Brand-Miller · Jennifer McArthur · Anna Haug

* It should be noted that the question mark in the title was added at the Editor's discretion. To the Editor: Why are those who market officially sanctioned information about pharmaceutical products not constrained by the advertising standards imposed on those who sell these products? Medicines Australia, which formulates a code of conduct for the pharmaceutical industry, imposes penalties, both financial and withdrawal of offending material, against misleading advertising of pharmaceutical products1,2 Why are similar standards not applied to advertising of information about these products? There are well documented flaws in Australian drug information sources,2,3 such as MIMS (the Monthly Index of Medical Specialties), that are based on product information (PI) authorised by the Therapeutic Goods Administration (TGA). Some PI is decades out of date;2 bottlenecks in updating TGA-approved PI are apparent.4 In this light, advertising of PI-based information in the bimonthly MIMS summaries seems anomalous. The April–May 2008 bimonthly print edition of MIMS claims to present “100% pure knowledge”, and states that “you can count on MIMS being up-to-the-minute”, and that “MIMS is essential knowledge that Australian health professionals can trust”. Previous bimonthly MIMS summaries make similar assertions. Until PI can be brought to an acceptable professional standard — a task that may be slow4 — it would seem appropriate to rein in misleading claims about PI widely used by health workers. Medicines Australia, or the National Prescribing Service, a government-funded body committed to “quality use of medicines”, could lead this initiative.

Jim R Stockigt

In reply: MIMS is held — and has long been held — in high regard in the Australian health care market. The vast majority of MIMS subscribers recognise that the quality information provided by MIMS is essential in their daily encounters with their patients. However, the product information (PI) produced in MIMS publications is only part of the information provided to health care professionals through various MIMS publications. Furthermore, it must be stated clearly that MIMS is not responsible for producing the PI-based drug information. This responsibility remains with the manufacturer, and the PI is subsequently approved by the Therapeutic Goods Administration (TGA). MIMS collates information from various sources, both locally and overseas, and publishes it in an easy-to-use, well structured and familiar format for its customers. MIMS has long been committed to providing such “essential knowledge that Australian health professionals can trust” since the introduction of the first MIMS publication 45 years ago. However, MIMS does acknowledge that there is an issue with some PI not being reviewed more regularly, and is committed to working closely with any appropriate organisation to address deficiencies in the current process. Nevertheless, it would seem inappropriate to say that PI for all drugs is not a quality information source. PI for the vast majority of drugs published in MIMS is as current as possible, given the constraints of publishing, the updating process by pharmaceutical companies and the delays in approvals through the TGA. The study reported and referenced by Stockigt focused on old, generic-based medicines.1 While there is an issue with manufacturers keeping these current, this is clearly a responsibility of the TGA and the manufacturer, not MIMS. PI for newer products is an important quality information source for the prescribers of medicines; if it were not, then the TGA would not permit manufacturers to make PI available in the first place. With respect to Stockigt’s concerns about the accuracy of MIMS advertising, we stand by our assertion that it is MIMS policy to provide the most up-to-date medicines information available, capably delivered by the MIMS professional editorial team.

Elizabeth A Donohoo

To the Editor: Recent media reports1 of events in Aurukun, Palm Island and other Indigenous communities in Queensland may have left the impression that most Indigenous people in the state live short, violent lives in remote, dysfunctional communities. However, census data from the Australian Bureau of Statistics (ABS) contradict one aspect of this impression: in fact, few Indigenous people live in remote communities, with the majority widely spread through the general population (Box). Over the past 10 years, the Indigenous population of Queensland has increased by 33.7% (Box). However, the number of people living in Aboriginal and Torres Strait Islander land council areas was almost stationary, dropping from 17 855 in 1996 to 17 739 in 2006, and the proportion of Indigenous people living in these areas decreased from 18.7% to 13.9% over the 10 years. The other six out of seven Indigenous people lived in the general community (Box). Twenty-four per cent lived in Brisbane city; suburb-by-suburb analysis showed most lived in less affluent areas of Brisbane but, even in these, the percentage of Indigenous people was only 1%–8% in each area. There are no major ghettos. In 2006, 32.4% of Indigenous people lived in south-east Queensland (classified as the “Brisbane Indigenous Region” by the ABS, Box); there is no land council area in this region. On North Stradbroke Island, a group of 366 Indigenous people living in the general community comprised 18% of the local population, but in all other locations the percentage of Indigenous people was well under 10%. Indigenous Australians have also moved to other cities in Queensland. In 1996, 42 571 Indigenous people (44.6% of the state’s Indigenous population) lived in a major city (Brisbane, the Gold Coast, Toowoomba, Rockhampton, Townsville or Cairns). By 2006, 61 672 Indigenous people lived in these cities. This is below the 67.1% for all Queenslanders, but is still nearly half (48.3%) of the Queensland Indigenous population. In the 1996, 2001 and 2006 ABS censuses, an Indigenous person was defined as someone who had ticked one of three boxes on the ABS census form stating that he or she is Aboriginal, Torres Strait Islander or both. All censuses have problems with accuracy of the data submitted and missing returns;2 however, as the results presented here were determined using the same methodology, show linear trends across the datasets, and identify only broad trends, I believe they are robust. Much of the increase in the Indigenous population is probably due to the higher birth rate of Aboriginal and Torres Strait Islander people (26.4/1000 v 12.9/1000 in the overall Queensland population).4 However, “migration” — people reclassifying themselves as Indigenous — may also contribute. These census data show that, as with other Australians, there is a net movement of Aboriginal people from rural to urban areas. Anecdotally, many people move from Indigenous communities and other rural areas to relatives in “town”; some stay for only a short time, but others remain in the city. This move is sometimes to the rural or urban fringe, but more often is into a stable integrated family group. Most Indigenous people in Queensland are widely spread through the general population. ABS census data on Queensland Indigenous people* 1996 2001 2006 Queensland population Total 3 368 850 3 655 139 4 046 880 Indigenous (% of total population) 95 518 (2.8%) 112 772 (3.1%) 127 684 (3.2%) Brisbane population Total 1 468 617 1 605 650 1 782 973 Indigenous (% of total population) 21 462 (1.5%) 26 453 (1.6%) 30 769 (1.7%) Indigenous population (% of Queensland Indigenous population) Brisbane 21 462 (22.5%) 26 453 (23.5%) 30 769 (24.1%) Brisbane Indigenous Region† na 36 323 (32.2%) 41 369 (32.4%) Major Queensland cities‡ 42 571 (44.6%) 52 385 (46.5%) 61 672 (48.3%) ATSI land council areas§ 17 855 (18.7%) 16 567 (14.7%) 17 739 (13.9%) ABS = Australian Bureau of Statistics. na = not available. ATSI = Aboriginal and Torres Strait Islander. * Data are collated from numerous sections of the 1996, 2001 and 2006 ABS censuses.2 † The Australian Indigenous Geographical Classification used by the ABS.3 ‡ Includes Brisbane. § Population for ATSI land council areas is total population.

Alan E Dugdale

To the Editor: As a junior doctor working in Central Australia, who has spent the past year rediscovering my own Aboriginal heritage, I read the recent articles on the Northern Territory intervention- with interest. All authors agree that the current state of health in NT communities is shameful, and that the causes include a wide range of social determinants. However, beyond these similarities there is almost complete discordance between the article by Glasson (of the NT Emergency Response Taskforce) and the other three articles by NT-based doctors (Tait, Boffa et al, and Brown and Brown). Glasson paints a demeaning and misleading picture of NT communities as exhibiting “a complete breakdown of normal mores”. This fits snugly with the “white blindfold” view, described by Tait, that will only further disempower marginalised Aboriginal people and communities. Glasson ignores the vast accumulated knowledge and successes attained by Aboriginal community-controlled health services (ACCHSs) and health workers, relegating their contribution to a half-sentence in his acknowledgements. Boffa and colleagues clearly outline the remarkable successes of ACCHSs and their repeatedly ignored calls for more resources. Glasson leaves no room for real community participation, and justifies the government’s heavy-handed approach as necessary for such a “crisis”. Brown and Brown describe convincingly the absolute necessity of Aboriginal rights and participation in any intervention conducted on their behalf, and the valiant long-term struggles by Aboriginal people to tackle the current situation. In response to the government’s intervention, in June 2007, Mark Wenitong, President of the Australian Indigenous Doctors’ Association, expressed concerns that remain relevant today: “As medical professionals, we question the notion that you can treat poverty, dispossession, marginalisation and despair (the root causes of substance misuse and sexual, physical and emotional abuse) with interventions that further contribute to poverty, dispossession, marginalisation and despair.” Indeed, the Ampe akelyernemane meke mekarle: “little children are sacred” report was very clear about the necessary approach to addressing the issues it raised: “What is required is a determined, coordinated effort to break the cycle and provide the necessary strength, power and appropriate support and services to local communities, so they can lead themselves out of the malaise: in a word, empowerment!” My experience working in NT Government hospitals and ACCHSs has revealed both the enormous challenges facing Abori-ginal people in the NT, and their remarkable resilience and capacity to achieve against all odds. As health professionals and Australian citizens we must recognise these efforts and support interventions that are evidence-based, respectful, and conceived in partnership with Aboriginal communities and their ACCHSs. Without this, the most expensive intervention will only ever amount to a superficial facelift.

Hamish R Graham

In reply: While I acknowledge the arguments many have put forward that the Northern Territory Emergency Response (NTER) has been too rapid and implemented without optimal community consultation — which some perceive to have disempowered Indigenous people — I stress the need to continue and indeed step-up momentum so that communities can regain control of their own futures as soon as possible. The positive impact of the NTER measures in creating better health, social and economic outcomes for Indigenous Australians will only be realised with the total support and focused energy of those “on the ground”, charged with delivering vital primary care and secondary intervention in NT communities. Without the continued engagement of these hardworking individuals who are able to establish the trust required to build bridges into these communities, the initiative is not sustainable. It is into the hands of those who live and work in Aboriginal communities that the NTER Taskforce and government agencies will pass the baton of change — we hope they will run with it.

William J H Glasson

To the Editor: Calcium and vitamin D play a central role in preventing osteoporosis and fractures,1 so a recent study published in the BMJ claiming that calcium supplements increased the risk of heart attacks and strokes in postmenopausal women2 naturally received widespread media attention — so much so that many patients are already stopping calcium treatment. The study, based on a previously published randomised controlled trial of calcium supplementation in 1471 healthy women,3 showed that self- or family-reported heart attack, stroke or sudden death was significantly more common in those taking calcium than in the placebo group (P = 0.008). This conflicted with the findings of a much larger study.4 Further, the difference became non-significant when the analysis was corrected for covariables (P = 0.08), or when the analysis was repeated using data on cardiovascular events obtained from medical records (P = 0.08). Yet, it still gained a place in a leading medical journal. The small excess of cardiovascular events in the women taking calcium could be due to chance and needs to be tested further; one way of doing this is to examine available data for evidence of mortality in patients taking calcium. We have done this. In the 29 randomised trials in a recent meta-analysis of the effect of calcium and vitamin D in fracture risk,1 five trials comprising 12 609 subjects provided crude mortality data.5-9 When these mortality data were pooled using a random effects model, there was no evidence that calcium supplementation increased mortality (Box). We find it hard to believe that calcium can have a significant adverse effect on cardiovascular disease without increasing mortality. Our reservations about this study are further strengthened by the weak theoretical basis of the case against calcium. Metastatic calcification in renal failure, which the authors quote as an analogy,2 is due to the high serum calcium–phosphorus (CaxP) product levels caused by hyperphosphataemia, which may be aggravated by calcium supplementation. In women without this condition, this degree of oversaturation cannot be reached by the 5% rise in plasma calcium10 resulting from the recommended dose of calcium citrate used for supplementation. Moreover, coronary blockage is not due to calcification of atheromatous vessels, which is a dystrophic calcification secondary to tissue damage, but rather to ruptured atheromatous plaques and the thrombi which form upon them. Thus, it is premature to conclude that calcium supplementation should not be given to older women. Effect of calcium supplementation on mortality, data pooled by a random effects model

Benjamin M P Tang · Christopher Nordin

To the Editor: Primary cerebral vasculitis (PCV) is a potentially fatal disease. Early diagnosis and therapy are vital. We describe a case where confounding factors delayed diagnosis. A 42-year-old woman presented with headache, nausea, vomiting, malaise and binocular blindness for 3 days. Two weeks previously, she had presented to the emergency department with headache and vomiting, but investigations, including computed tomography (CT) of the brain and lumbar puncture, gave normal results. She had a history of depression, was a smoker (20 pack-year history), and used cannabis regularly and alcohol occasionally, but denied other recreational drug use. Her mood appeared depressed. Vital signs and findings from a general examination were normal. Eye movements were full, direct and indirect pupillary reflexes were intact, and optic fundi were normal. Results of a CT angiogram were reported as normal by a consultant radiologist. Results of blood tests, including inflammatory markers, and a repeat lumbar puncture, were unremarkable. A toxicology screen was not performed. Depression with conversion disorder was diagnosed, and admission with analgesia was advised. A neurologist’s review on Day 2 did not detect organic disease. The mental health team diagnosed severe depression and prescribed antidepressants. On Day 4, the patient’s condition deteriorated and she become non-communicative with signs of right hemiplegia. An electroencephalogram showed polyrhythmic generalised slow waves consistent with encephalopathy. She was transferred to a tertiary centre where magnetic resonance imaging (MRI) and CT angiography of the brain showed multiple bilateral infarcts (Figure, A) with beaded arteries, the classic appearance of vasculitis. She was given high-dose prednisolone and cyclophosphamide. Investigations were negative for causes of secondary vasculitis. Her condition continued to deteriorate and she died 8 days after admission. Autopsy was refused. Subsequent review of the second CT scan detected irregular cerebral vessels (Figure, B). PCV is an uncommon disorder of the central nervous system, with unknown aetiology and no specific characteristic features, affecting small cerebral arteries but not extracranial vessels. Symptoms and signs vary but include headache, encephalopathy, seizures, personality change, weakness, and altered level of consciousness, as well as superimposed focal cranial neuropathy or hemiplegia. Recognition is difficult, but differentiation from reversible cerebral vasoconstriction syndrome is important.1,2 Brain biopsy is seen as the “gold standard” for diagnosing PCV. CT angiography may show diffuse or localised changes, with vessel beading, aneurysms, and luminal narrowing. MRI may show areas of white and grey matter infarction, or haemorrhage. MRI is more sensitive than CT, but less sensitive than CT angiography. Up to 100% of biopsy-positive cases appear abnormal on MRI. Suspected cases require careful clinical appraisal and either CT angiography or MRI, probably followed by an image-guided brain biopsy.3 Initial reported cases of PCV had a poor prognosis; most patients died within a few weeks.2 Immunosuppressive therapy with glucocorticoids and cyclophosphamide (as used in secondary severe vasculitis) may be beneficial, although there are no clinical trials.4 A future therapeutic alternative may be infliximab, which has been used successfully for one patient with cerebral vasculitis secondary to Behçet’s disease who had known elevated levels of tumour necrosis factor α.5 Despite increasing awareness and advances in angiography, PCV remains an uncommon diagnostic and therapeutic problem which should be considered in cases of severe, non-febrile neurological illness with stroke-like features. A: Magnetic resonance image showing multiple bilateral infarcts. B: Computed tomography angiogram showing irregular cerebral vessels (“beading”, arrows).

Sanjaya S Herath · Dayna B Law · Peter J O Stride · Vernon J Heazlewood · Luke S Gaffney