trials that disregard patients' different pathological and clinical states' " or that include drastically different treatment arms' can hardly be expected to appeal to well informed participants.Research, planning, and audit committees should include women with breast cancer to help the other members appreciate the range of women's experience and knowledge.'3 There are so many women with breast cancer that finding ones with the type of expertise and experience appropriate to the committee's task should be easy.'4 That breast cancer is so common is not an enviable attribute, but, for understanding and working with patients' views, it is a convenient one.CHARLOTTE WILUAMSON

Many boys with Duchenne's muscular dystrophy present with global developmental delay before specific motor disabilities are noticed

In the Royal New Zealand Plunket Society's 1990-91 Cohort study, 581 of 4,286 women questioned (13.7%) had not initiated antenatal care until after the first trimester. These late attenders were more likely to be non-European or of high parity; 42.9% of Pacific Islander mothers and 28.9% of Maori mothers did not initiate antenatal care until after the first trimester. Late attenders were also more likely to be unmarried, of lower socioeconomic status, young or with lower educational attainment. The reason for delayed antenatal care needs to be investigated and mothers who are high parity and non-European need to be particularly targeted to encourage them to attend for antenatal care early.

posts that address problems of inner cities-for example, homelessness and drug misuse. We have been able to extend training based in general practice within the three year scheme when necessary.' Research by the South London Organisation of Vocational Training Schemes has shown that many registrars do not feel ready to enter general practice after vocational training (C Vaughan, personal communication). We provide a fourth year of training in the form of a vocational training associate scheme, which addresses registrars' further learning needs while giving them time to gain experience and confidence in practice. This initiative, in its second year, has also been able to support 34 local practices under stress.These changes have allowed us to recruit a full complement of high quality registrars to our schemes and increase the number of locally trained doctors becoming principals in south London. The training issues have become too complex to be solved by appending general practice training to hospital training. We look forward to the results of the evaluation of our innovations. These results will inform the debate about developing excellent training for general practice that will supply highly trained general practitioners for inner cities into the next century.

Contributors and sources: DI is a former family doctor and was president of the GMC when the 1990s reforms of medical regulation, including revalidation, were first introduced. This article reflects his open commitment to the principles of patient centred health care. Competing interests: None declared.

In the Royal New Zealand Plunket Society's 1990-91 cohort study, of 3902 children, 985 (25.2%) had fallen behind the immunization schedule by 6 months of age. These children were more likely to be from lower socio-economic groups or to have mothers who were older, with high or low education, or of higher parity. The infants were also more likely to be from non-European families, or to have unemployed fathers. Eight hundred and ten (82.2%) of the incompletely immunized children at that age could be brought up-to-date with their immunizations by a single visit to the doctor. The most common reason for delaying immunization was that the baby was sick. This was a false contraindication in 69.2, 79.0 and 78.4% of these children at the 6 week, 3 month and 5 month immunization, respectively.

Perspectives'Copying letters to patients is coming to a clinic near you'

Introduction Surgical site infections (SSIs) are a significant source of morbidity and mortality in the Asia–Pacific region (APAC), adversely impacting patient quality of life, fiscal productivity and placing a major economic burden on the country’s healthcare system. This commentary reports the findings of a two-day meeting that was held in Singapore on July 30–31, 2019, where a series of consensus recommendations were developed by an expert panel composed of infection control, surgical and quality experts from APAC nations in an effort to develop an evidence-based pathway to improving surgical patient outcomes in APAC. Methods The expert panel conducted a literature review targeting four sentinel areas within the APAC region: national and societal guidelines, implementation strategies, postoperative surveillance and clinical outcomes. The panel formulated a series of key questions regarding APAC-specific challenges and opportunities for SSI prevention. Results The expert panel identified several challenges for mitigating SSIs in APAC; (a) constraints on human resources, (b) lack of adequate policies and procedures, (c) lack of a strong safety culture, (d) limitation in funding resources, (e) environmental and geographic challenges, (f) cultural diversity, (g) poor patient awareness and (h) limitation in self-responsibility. Corrective strategies for guideline implementation in APAC were proposed that included: (a) institutional ownership of infection prevention strategies, (b) perform baseline assessments, (c) review evidence-based practices within the local context, (d) develop a plan for guideline implementation, (e) assess outcome and stakeholder feedback, and (f) ensure long-term sustainability. Conclusions Reducing the risk of SSIs in APAC region will require: (a) ongoing consultation and collaboration among stakeholders with a high level of clinical staff engagement and (b) a strong institutional and national commitment to alleviate the burden of SSIs by embracing a safety culture and accountability.