Showing papers in "The Medical Journal of Australia in 2001"

Statin-associated myopathy.

Abstract: Myopathy occurs in 0.1%-0.2% of patients receiving statins in clinical trials. This adverse effect is shared by all statins, but is more common with cerivastatin, especially in combination with gemfibrozil. The risk of myopathy is increased by: the use of high doses of statins, concurrent use of fibrates, concurrent use of hepatic cytochrome P450 inhibitors, acute viral infections, major trauma, surgery, hypothyroidism and other conditions. Statin-associated myopathy should be suspected when a statin-treated patient complains of unexplained muscle pain, tenderness or weakness. Statin therapy should be stopped in cases of suspected myopathy, and serum creatine kinase levels should be checked and monitored. No specific therapies other than statin withdrawal and supportive measures for rhabdomyolysis are currently available.

Prevalence of overweight and obesity in Australian children and adolescents: reassessment of 1985 and 1995 data against new standard international definitions.

Abstract: Objective To review the prevalence of overweight and obesity in Australian children and adolescents in two national samples, 10 years apart, using the new standard international definitions of the International Obesity Task Force Childhood Obesity Working Group. Design Body mass index (BMI) cut-off points defining overweight and obesity were applied to the individual BMI values in the two cross-sectional samples. Setting Australian community. Participants 8,492 schoolchildren aged 7-15 years (Australian Health and Fitness Survey, 1985) and 2,962 children aged 2-18 years (National Nutrition Survey, 1995). Main outcome measure Prevalence of overweight and obesity. Results In the 1985 sample, 9.3% of boys and 10.6% of girls were overweight and a further 1.7% [corrected] of boys and 1.6% [corrected] of girls were obese. In the 1995 sample, overall 15.0% of boys (varied with age from 10.4% to 20.0%) and 15.8% of girls (varied with age from 14.5% to 17.2%) were overweight, and a further 4.5% of boys (2.4%-6.8%) and 5.3% of girls (4.2%-6.3%) were obese. The prevalence of overweight and obesity in the 1995 sample peaked at 12-15 years in boys and 7-11 years in girls. In schoolchildren aged 7-15 years, the rates represent a relative risk of overweight in 1995 compared with 1985 of 1.79 (95% CI, 1.59-2.00) and of obesity of 3.28 (95% CI, 2.51-4.29). Compared with previous estimates from these samples, the revised prevalence data are slightly higher for the 1985 data and considerably higher for the 1995 data. Conclusion The secular trend of increasing overweight and obesity in the decade from 1985 and the high prevalence rates in Australian children and adolescents are a major public health concern.

Risk of death from methicillin-resistant Staphylococcus aureus bacteraemia: a meta-analysis.

Abstract: Objective To estimate the risk of death from healthcare-associated (nosocomial) bacteraemia caused by methicillin-resistant Staphylococcus aureus (MRSA), and compare it with that of nosocomial bacteraemia caused by methicillin-sensitive S. aureus (MSSA), by meta-analysis of selected studies. Data sources Medline, EMBASE, Current Contents and Cochrane Library were searched for the period January 1978 (or earliest date of the database, if later than 1978) to December 2000. Study selection Studies which compared mortality of nosocomial MRSA and MSSA bacteraemia. Data synthesis Nine studies were analysed. All but one found an increased relative risk (RR) of death from MRSA bacteraemia, with RR ranging from 0.89 to 4.94. Meta-analysis showed that patients with MRSA bacteraemia have an RR of death, compared with patients with MSSA bacteraemia, of 2.12 (95% CI, 1.76-2.57) using the fixed-effect method, and 2.03 (95% CI, 1.55-2.65) using the random-effect method. Conclusion MRSA bacteraemia is associated with a real increase in risk of death, further justifying ongoing MRSA surveillance and control in healthcare facilities.

The medical emergency team.

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Development of a simple screening tool for common mental disorders in general practice.

Abstract: OBJECTIVE: To develop and validate a self-report screening tool for common mental disorders DESIGN AND SETTING: Sequential development and validation studies in three cohorts of patients in general practice and one cohort of patients in a specialist psychiatry clinic PARTICIPANTS: 1585 patients in general practice examined cross-sectionally and longitudinally; 46515 patients attending 386 general practitioners nationwide; 364 patients participating in a longitudinal study of psychiatric disorders in general practice; and 522 patients attending a specialist psychiatry clinic MAIN OUTCOME MEASURES: Performance of the 12 items from the 34-item SPHERE questionnaire against DSM-III-R and DSM-IV diagnoses of psychiatric disorder, self-reported Brief Disability Questionnaire findings, GPs' ratings of patients' needs for psychological care and degree of risk resulting from mental disorder, and patients' and GPs' reports of reasons for presentation RESULTS: Six somatic and six psychological questions identify two levels (and three types) of mental disorder: patients reporting both characteristic psychological and somatic symptoms (Level 1, Type 1), and patients reporting either psychological symptoms (Level 2, Type 2) or somatic symptoms (Level 2, Type 3) This classification system predicts disability ratings (Level 1, 82 "days out of role in the last month" and Level 2, 41 and 54 "days out of role in the last month" for Types 2 and 3, respectively), rates of lifetime psychiatric diagnoses (Level 1, 63% and Level 2, 59% and 48%, respectively), both patients' and GPs' report of reasons for presentation, and doctors' ratings of risk as a result of mental disorder There are important and differing sociodemographic correlates for the three types of mental disorders CONCLUSION: A classification system based on the 12 items from the 34-item SPHERE questionnaire can be used to identify common mental disorders This system has acceptable validity and reliability, and is suited specifically for general practice settings

The epidemiology of dog walking: an unmet need for human and canine health.

Abstract: Objective To describe the prevalence of dog walking in New South Wales, and to identify potential health gains if more dogs were walked. Design Cross-sectional analytical survey. Setting and participants 894 adults in NSW in 1998 (among the owners of approximately two million domestic dogs in NSW who were potential participants in dog-walking behaviours). Interventions None yet. Main outcome measures Dog walking hours per week; other DogEpi concepts to illustrate the public health gains include the DAF (dog attributable fraction), and the BBR (benefits to bites ratio). Results The response rate to the survey was 74%. 46% of households in NSW had a dog and, overall, dog owners walked 18 minutes per week more than non-dog owners. However, more than half of dog owners did not walk their dogs, and were less likely than non-owners to meet recommended levels of physical activity sufficient for health benefits. If all dog owners walked their dogs, substantial disease prevention and healthcare cost savings of $175 million per year might accrue. Conclusions There are potential benefits of dog walking for human health; currently, among dog owners, much of this benefit remains to be realised. There are also likely benefits for canine health. Dog walking should be promoted through national strategies recommending "Walkies for all by the year 2010".

Vitamin D deficiency in veiled or dark-skinned pregnant women

Abstract: Objectives: To determine the vitamin D status of veiled or dark-skinned pregnant women, because of their known increased risk of vitamin D deficiency. Design: An audit of vitamin D status. Setting: An antenatal clinic in a major metropolitan teaching hospital, Melbourne, Victoria. Participants: Pregnant women attending the clinic who agreed to be screened. Main outcome measures: Serum 25-hydroxyvitamin D 3 (25OHD 3 ) level at first visit to the antenatal clinic. Results: Of 94 women, 82 were screened. Sixty-six women (80%) had 25OHD 3 values below the test reference range (22.5-93.8nmol/L) Conclusions: Our findings are a cause for concern, because vitamin D deficient women are at risk of bone disease and their children at risk of neonatal hypocalcaemia and rickets.

Regional variation in the incidence of end-stage renal disease in Indigenous Australians.

Abstract: Objective: To evaluate regional variation in the incidence of end-stage renal disease (ESRD) in Indigenous Australians, and to examine the proximity to ESRD treatment facilities of Indigenous patients. Design: Secondary data review, with collection of primary data regarding patients' place of residence before beginning ESRD treatment. Participants: Indigenous ESRD patients who commenced treatment in Australia during 1993-1998. Methods: We obtained data from the Australian and New Zealand Dialysis and Transplant Registry regarding 719 Indigenous patients who started ESRD treatment between 1 January 1993 and 31 December 1998. We obtained primary data from the treating renal units to determine the place of residence before beginning renal replacement therapy. We calculated the average annual incidence of ESRD for each of the 36 Aboriginal and Torres Strait Islander Commission regions using population estimates based on the 1996 Census, and calculated standardised incidence ratios with 95% confidence intervals for each region. We compared the number of cases with the treatment facilities available in each region. Main outcome measure: Regional standardised ESRD incidence for Indigenous Australians referenced to the total resident population of Australia. Results: Standardised ESRD incidence among Indigenous Australians is highest in remote regions, where it is up to 30 times the national incidence for all Australians. In urban regions the standardised incidence is much lower, but remains significantly higher than the national incidence. Forty-eight per cent of Indigenous ESRD patients come from regions without dialysis or transplant facilities and 16.3% from regions with only satellite dialysis facilities. Conclusions: There is marked regional variation in the incidence of ESRD among Indigenous Australians. Because of the location of treatment centres, there is inequitable access to ESRD treatment services for a significant proportion of Indigenous patients.

Psychological disturbances in asylum seekers held in long term detention: a participant-observer account

Abstract: The process of applying for refugee status in Australia is complex, lengthy and often poorly understood by asylum seekers. The psychological reaction patterns of detainees whose claims for asylum are unsuccessful are characterised by stages of increasing depression, punctuated by periods of protest, as feelings of injustice overwhelm them. These reactions have a marked secondary impact on their children in detention. The prolonged detention of asylum seekers appears to cause serious psychological harm. Even if many of those who spend long periods of time are not deemed to have proven their refugee claims, this administrative decision should not be grounds for inflicting grave ongoing psychological injury on the applicants.

The mental health implications of detaining asylum seekers.

Abstract: The possible mental health impact on asylum seekers of Australia's policy of mandatory detention is an issue of special relevance to health professionals and the public. Independent commissions of inquiry in Australia have found varying degrees of mental distress to be common in detained asylum seekers. Research studies in Australia and elsewhere suggest that detained asylum seekers may have suffered greater levels of past trauma than other refugees, and this may contribute to their mental health problems, with their detention providing a retraumatising environment. Studies are urgently required to examine the mental health consequences of detention, and to determine the effect of detention on acculturation and adaptation for asylum seekers subsequently released into the community.

Vitamin D status of women in the Geelong Osteoporosis study: association with diet and casual exposure to sunlight

Abstract: OBJECTIVE To assess vitamin D intake and casual exposure to sunshine in relation to serum 25-hydroxyvitamin D (25OHD) levels. DESIGN Cross-sectional study of a population-based, random sample of women aged 20-92 years, assessed between 1994 and 1997. SETTING AND PARTICIPANTS 861 women from the Barwon Statistical Division (population, 218000), which includes the city of Geelong (latitude 38 degrees south) in Victoria. MAIN OUTCOME MEASURES Vitamin D intake; serum 25OHD level; season of assessment; exposure to sunshine. RESULTS Median intake of vitamin D was 1.2 microg/day (range, 0.0-11.4 microg/day). Vitamin D supplements, taken by 7.9% of participants, increased intake by 8.1% to 1.3 microg/day (range, 0.0-101.2 microg/day) (P< 0.001). A dose-response relationship in serum 25OHD levels was observed for sunbathing frequency before and after adjusting for age (P< 0.05). During winter (May-October), serum 25OHD levels were dependent on vitamin D intake (partial r2= 0.01; P<0.05) and were lower than during summer (November-April) (age-adjusted mean, 59nmol/L [95% Cl, 57-62] v 81 nmol/L [95% CI, 78-84]; P<0.05). No association was detected between serum 25OHD and vitamin D intake during summer. The prevalences of low concentrations of serum 25OHD were, for <28nmol/L, 7.2% and 11.3% overall and in winter, respectively; and, for <50 nmol/L, 30.0% and 43.2% overall and in winter, respectively. CONCLUSIONS At latitude 38 degrees south, the contribution of vitamin D from dietary sources appears to be insignificant during summer. However, during winter vitamin D status is influenced by dietary intake. Australia has no recommended dietary intake (RDI) for vitamin D, in the belief that adequate vitamin D can be obtained from solar irradiation alone. Our results suggest that an RDI may be needed.

Childhood post-streptococcal glomerulonephritis as a risk factor for chronic renal disease in later life.

Abstract: Objective: To test the hypothesis that post-streptococcal glomerulonephritis (PSGN) in childhood is a risk factor for chronic renal disease in later life. Design: Retrospective cohort study. Setting: A remote Aboriginal community in the "Top End" of the Northern Territory that experienced two epidemics of PSGN in 1980 and 1987, respectively. Participants: 472 people who were aged 2-15 years during either epidemic. They were categorised by clinical features recorded during the epidemics as having clinically defined PSGN (63), "abnormal urine" (haematuria or proteinuria; 86) or controls (323). Outcome measures: Urinary albumin to creatinine ratio (ACR), haematuria (by dipstick urinalysis), blood pressure, serum creatinine level, and calculated glomerular filtration rate (GFR) during community screening in 1992-1998. Results: Overt albuminuria (ACR > 34 mg/mmol) was present at follow-up in 13% of the PSGN group, 8% of the abnormal urine group, and 4% of the control group. The odds ratio (OR) for overt albuminuria in those with a history of PSGN compared with the control group, adjusted for age and sex, was 6.1 (95% Cl, 2.2-16.9). Haematuria (> trace) was present in 21% of the PSGN group compared with 7% of the control group (adjusted OR, 3.7; 95% Cl, 1.8-8.0). There were no significant differences between the groups in blood pressure, serum creatinine, level or calculated GFR. Conclusion. In this population, a history of PSGN in childhood is a risk factor for albuminuria and haematuria in later life.

Vitamin D deficiency in mothers of infants with rickets.

Abstract: Objective: To identify infants treated for vitamin D deficiency rickets, and to determine the incidence of vitamin D deficiency in their mothers and their mothers' country of origin. Design: A retrospective audit of the medical records of children diagnosed with vitamin D deficiency rickets. Inpatients were identified by discharge diagnoses of vitamin D deficiency or hypocalcaemia and outpatients by pharmacy dispensing of cholecalciferol. Setting: The Women's and Children's Health Care Network and the Southern Health Care Network (Melbourne, VIC) from June 1994 to February 1999. Patients: 55 children with vitamin D deficiency rickets. Results: Fifty-four of the 55 children were born to mothers with ethnocultural risk factors for vitamin D deficiency. Vitamin D status had been assessed in 31 of the 55 mothers (56%): 25 (81%) had 25-hydroxyvitamin D 3 concentrations ≤ 25 nmol/L, consistent with osteomalacia. Conclusion: Vitamin D deficiency continues to occur in children of migrant families. When infants are diagnosed with vitamin D deficiency, vitamin D levels in their mothers and siblings should also be assessed.

Male infertility: the case for continued research.

Abstract: I s AUSTRALIA, MALE INFE RTILln ' affects one ma n in20, con tribu tes to half of all jnfertiliry prob lemsin relationships, and is the underlying reason for 40%of in ferti le couples using assisted -reprod uction technologies (ARTs). It is a major health problem, plac ing a heavy psychosocial b urden on affected men and theirpartners and a financial burd en on the cc mmuniry, Intracyt oplasmicsperminjection (l CSI) has revolutionised mfer tili ry practice. Any manwith viable sperm found at any point in the geni tal tract can now father his own chi l dren. Erroneou sly, themedia reported this development as signalling that male in f ertiliry was \"cured\". Such pronouncements may result in failure 10 assess men for infe rtility and encourageth e viewthat further research on maleinferti lity can be sealed back, We stro ngly disagre e. For all men present ing with an infert ility problem, a medical history shouldbe taken, and an examina tion and appropriate investigations carr iedc u r. Accurate diagnosis may promp t alternative, less expensive treatm ents that do not expose the female partner to the risks associated with ART (such asovarianhyperst imu[ation syndrome). For e xample. infertility related to a pituitary prola ctinomais best managed with a dopamine agonist rath er th an ICSt. A diagnos is will also satisfy the man 's le gitimate desire to underst and the reason for his infertility. Testicu lar examination is mandatory : a P raderorchldometer is used for volume estimation and careful palpa tion is performed . A past his tory of cryptorchidism is commonin infert ile men . Moreover, thiscondition and infertility arc primary risk factors for testicular cancer .' It is alsoimportant to detect and treat androgen deficiency, which is more common in infert ilemen, to improvequality of life and pre ven t lon g-term sequelae such as osteoporosis . Erectile dysfunc tion and infrequent or p oorly rimed intercourse may be remediable with speci fic therap y or counselling.Deficiency of pitu itarygonado tropins, although rare (occurr ing in less than 1% of inferti le men),must be considered in me diagnoetic work-up, as infert ility resulting from thi s condition is amenableto gonadotropin therapy. Of the identifiable causes of male infer tility, Obstruct ion is the m ost commo n.Obstruction is increasingly man aged with le Sl because surgery is e ither impossible or compares poor ly. Examples include bilatera l congenital absence of me vas (B CAV) . epididyma l or ejaculatoryduetobstruct ion, and vasectomy-related infer tility (me la rgestsinglegroup). Surgical reversal of vasec tomy offers only a 50% prospect of restoring fert ility. As men rarely sto re spermbefore vasectomy. couples who areinfertile as a resu lt of the pr ocedure now gene rally opt forART with testicula r or epididymal sperm (particu larly since the removal of the Medicare rebate for vas イ ・ カ ・ イ ウ 。ャ セ I N Sperm autoimmunity affecting sperm motility, vitality or fun ction is now managed by re SI r ather than immunosuppressivedrug the rapy.

Caffeine-induced cardiac arrhythmia: an unrecognised danger of healthfood products

Abstract: We describe a 25-year-old woman with pre-existing mitral valve prolapse who developed intractable ventricular fibrillation after consuming a "natural energy" guarana health drink containing a high concentration of caffeine. This case highlights the need for adequate labelling and regulation of such products.

Unmet need for recognition of common mental disorders in Australian general practice.

Abstract: Objective: To determine the rate and predictors of unmet need for recognition of common mental disorders in Australian general practice. Design and setting: Cross-sectional national audit of general practices throughout Australia in 1998-1999. Participants: 46 515 ambulatory care patients attending 386 GPs. Screening tools: Prevalence of common mental disorders - 12 items from the 34-item SPHERE self-report questionnaire and associated classification system; prevalence of recognition of mental disorders by GPs - GPs reporting whether patients had depression, anxiety, mixed depression/anxiety, somatoform, or other psychological disorder; predictors of unmet need for recognition of mental disorders - self-report questions about demography for patients and GPs, and about practice organisation for GPs. Main outcome measures: Reported recognition of psychological disorders by GPs; actual prevalence of disorders; and patient, GP and practice characteristics predicting the failure to recognise disorders. Results: GPs did not recognise mental disorder in 56% (11 922/21210) of patients. These comprised 46% (5134/11 060) of patients in the higher level of mental disorders, and (in the second level of disorders) 58% (2906/5036) of patients with predominantly psychological symptoms, and 76% (3882/5114) of those with predominantly somatic symptoms. Patients more likely to have their need for psychological assessment met had the following characteristics: middle-aged (odds ratio [OR], 1.76; 95% Cl, 1.59-1.96), female (OR, 1.19; 95% Cl, 1.12-1.27), Australian-born (OR, 1.16; 95% Cl, 1.08-1.24), unemployed (OR, 1.75; 95% Cl, 1.64-1.89), single (OR, 1.52; 95% Cl, 1.41-1.61), presenting with mainly psychological symptoms (OR, 3.54; 95% Cl, 3.28-3.81), and presenting for psychological reasons (OR, 4.20; 95% Cl, 3.02-5.82). Characteristics of doctors associated with meeting patients' need for assessment were being aged over 35 years (OR, 1.51; 95% Cl, 1.09-2.08), having an interest in mental health (OR, 1.27; 95% CI, 1.15-1.41), having had previous mental health training (OR, 1.29; 95% Cl, 1.15-1.45), being in part-time practice (OR, 1.23; 95% Cl, 1.09-1.39), seeing fewer than 100 patients per week (OR, 1.29; 95% Cl, 1.13-1.47), working in practices with fewer than 2000 patients (OR, 1.28; 95% Cl, 1.13-1.45) and working in regional centres (OR, 1.16; 95% Cl, 1.05-1.28). Conclusion: Unmet need for recognition of common mental disorders remains high. Predictors of unmet need include a somatic symptom profile and practitioner and organisational characteristics which impede the provision of high quality mental health services.

Evidence-based medicine: useful tools for decision making.

Abstract: Evidence-based medicine (EBM) integrates clinical experience and patient values with the best available research information. There are four steps in incorporating the best available research evidence in decision making: asking answerable questions; accessing the best information; appraising the information for validity and relevance; and applying the information to patient care. Applying EBM to individual patients requires drawing up a balance sheet of benefits and harms based on research and individual patient data. The most realistic and efficient use of EBM by clinicians at the point of care involves accessing and applying valid and relevant summaries of research evidence (evidence-based guidelines and systematic reviews). The future holds promise for improved primary research, better EBM summaries, greater access to these summaries, and better implementation systems for evidence-based practice. Computer-assisted decision support tools for clinicians facilitate integration of individual patient data with the best available research data.

Improving diabetes care in the primary healthcare setting: a randomised cluster trial in remote Indigenous communities.

Abstract: Objective: To evaluate a system for improving diabetes care in remote Indigenous communities. Design: Randomised, unblinded cluster trial over one year (1 March to 29 February 2000). Participants and setting: Primary healthcare staff in 21 primary healthcare centres in the Torres Strait and Northern Peninsula Area (NPA) Health Service District, north Queensland, and 678 people with diabetes, mostly Torres Strait Islanders. Intervention: Diabetes recall system established at eight of the 21 sites, as well as staff training in basic diabetes care, regular phone calls from the project officer, a two-monthly newsletter and a mid-project workshop. Main outcome measures: Regular checks of weight, blood pressure, eye and foot care, serum lipid levels and glucose monitoring and control, urinary albumin to creatinine ratio and serum creatinine levels, and administration of recommended vaccines; hospitalisation in the previous 12 months. Results: There was improvement in most measures at most sites, except for blood pressure monitoring and control, and vaccination status. Intervention sites showed greater improvement in most indicators than control sites (combined relative risk [RR], 1.21; 95% Cl, 1.03-1.43). The intervention group showed a 32% reduction in hospital admissions for diabetes-related conditions over the study period (P = 0.012). At follow-up, patients in intervention sites were 40% less likely to be hospitalised for a diabetes-related condition than those in control sites (RR, 0.60; 95% Cl, 0.41-0.86; P = 0.007). Conclusion: A simple recall system, managed by local healthcare workers and supported by a diabetes outreach service, achieved significant improvements in diabetes care and reduced hospitalisations in a high-risk population.

Chronic heart failure in Australian general practice. The Cardiac Awareness Survey and Evaluation (CASE) Study.

Abstract: Objectives To investigate the frequency and general practitioner awareness of patients with chronic heart failure (CHF), and to evaluate a cardiac algorithm and document cardiac investigations performed in establishing this diagnosis. Design and setting Between March and August 1998, consecutive patients aged 60 years and older presenting to their GP were assessed. In patients previously diagnosed with CHF, aetiology and diagnostic assessments were documented. In patients with suspected CHF (by a standardised algorithm, based on World Health Organization guidelines), further investigations and GP diagnosis were recorded. Patients 80 consecutive patients were assessed by each of 341 GPs throughout Australia, reflecting the Australian metropolitan/rural population mix of 1996. This provided a total of 22060 evaluable patients. Main outcome measures Estimated numbers of patients with CHF in general practice (previously and newly diagnosed); major aetiological factors; use of ancillary diagnostic tests; drugs prescribed. Results CHF was diagnosed in 2905 of 22060 patients (13.2%) (2485 previously diagnosed and 420 newly diagnosed). Major aetiological factors were ischaemic heart disease and hypertension. Echocardiography had been performed in 64% of previously diagnosed patients, but was performed in only 22% of possible CHF patients. Angiotensin-converting enzyme (ACE) inhibitors were prescribed in 58.1% of patients with CHF. Patients with evidence of left ventricular dysfunction were more likely to have received ACE inhibitors. Conclusions CHF appears to be very common in the elderly, based on GP diagnosis of the condition. Of 100 patients aged 60 years and over presenting to their GP, two new cases of CHF will be detected using a simple clinical algorithm in conjunction with appropriate diagnostic tests. ACE inhibitors appear to be underutilised.

Detecting and reducing hospital adverse events: outcomes of the Wimmera clinical risk management program.

Abstract: Objectives: To determine if an integrated clinical risk management program that detects adverse patient events in a hospital, analyses their risk and takes action can alter the rate of adverse events. Design: Longitudinal survey of adverse patient events over eight years of progressive implementation of the risk management program. Participants and setting: 49 834 inpatients (July 1991 to September 1999) and 20050 emergency department patients (October 1997 to September 1999) at a rural base hospital in the Wimmera region of Victoria. Main outcome measures: Rates of adverse events detected by medical record review and clinical incident and general practitioner reporting. Results: The annual rate of inpatient adverse events decreased between the first and eighth years of the study from 1.35% of all patient discharges (69 events) to 0.74% (49 events) (P<0.001). Absolute risk reduction was 0.61% (95% Cl, 0.23%-0.99%), and relative risk reduction was 44.9% (95% Cl, 16.9%-72.9%). The quarterly rate of emergency department adverse events decreased between the first and eighth quarters of monitoring from 3.26% of all attendances (84 events) to 0.48% (12 events) (P<0.001). Absolute risk reduction was 2.78% (95% Cl, 2.04%-3.52%), and relative risk reduction was 85.3% (95% Cl, 62.7%-100%). Conclusions: Adverse patient events can be detected, and their frequency reduced, using multiple detection methods and clinical improvement strategies as part of an integrated clinical risk management program.

Outcome of critically ill patients undergoing interhospital transfer.

Abstract: Objective To quantify the morbidity and mortality associated with acute interhospital transfer of critically ill patients requiring intensive care (ICU) services. Design Three-year (1 July 1996-30 June 1999) retrospective case-control study based on review of patients' medical records. Setting Metropolitan hospitals in Melbourne, Victoria. Participants 73 (of 75) consecutive, critically ill patients from one metropolitan teaching hospital who were transferred to other hospitals because ICU services were not available. Outcome measures Primary endpoints included inhospital mortality and length of stay in ICU and hospital. Secondary endpoints included time from study entry to ICU admission and the change in predicted mortality risk after resuscitation and transfer to ICU (inter- or intrahospital transfer). Results The Transfer Group experienced a significant delay in admission to ICU (5.0 [4.0-6.0] v 3.0 [2.0-5.5] hours; P=0.001), and a longer stay in ICU (48 [33-111] v 44 [25-78] hours; P=0.04), and hospital (10 [3-14] v 6 [3-13] days; P=0.02). Hospital mortality in the Transfer Group (24.7%) was not statistically different from that in the Control Group (17.8%; P= 0.41; OR, 1.5; 95% CI, 0.68-3.4). Conclusion Acute interhospital transfer is associated with a delay in ICU admission and a longer stay in ICU and hospital, but no statistically significant difference in mortality. A study of over 300 patient transfers would be required to clarify the morbidity and mortality risk of acute interhospital transfer.

Non-multiresistant and multiresistant methicillin-resistant Staphylococcus aureus in community-acquired infections

Abstract: Objective To survey Staphylococcus aureus strains isolated from patients presenting from the community, comparing clinical features and antibiotic sensitivity profiles between multiresistant and non-multiresistant methicillin-resistant and methicillin-sensitive isolates. Design Retrospective case series. Participants and setting Patients who presented to emergency or dermatology departments in hospitals served by the South Western Sydney Area Health Service between 1 May 1998 and 30 April 1999. All patients with methicillin-resistant S. aureus (MRSA) and the first 100 with methicillin-sensitive S. aureus were eligible. Main outcome measures Patient demographic characteristics; risk factors; clinical presentation; treatment; outcome; and isolate antibiotic susceptibility. Results 139 patients were eligible, and 122 had clinical records available. Ten of these 122 (8%) had multiresistant MRSA, 26 (21%) non-multiresistant MRSA and 86 (70%) methicillin-sensitive S. aureus. Among patients with non-multiresistant MRSA, 29% (7/24) were born in New Zealand, Samoa or Tonga, a higher proportion than among those with multiresistant MRSA or methicillin-sensitive S. aureus (P= 0.03). Nearly half (44%) of non-multiresistant MRSA strains were community-acquired in patients with no risk factors. Two-thirds of patients with non-multiresistant MRSA (17/26) presented with cellulitis or abscess, and 58% (11/19 evaluable patients) required surgical treatment. Conclusions Non-multiresistant MRSA strains are common, especially among people born in New Zealand, Samoa or Tonga, and are usually community acquired. Medical practitioners should routinely swab all staphylococcal lesions for culture and sensitivity.

Training general practitioners to recognise and respond to psychological distress and suicidal ideation in young people.

Abstract: OBJECTIVE: To determine the effectiveness of a training program for general practitioners in recognising and responding to psychological distress and suicidal ideation in young people. DESIGN AND SETTING: The study, conducted in general practice surgeries in Tasmania, Victoria and Western Australia in 1996 and 1997, used a pre-/posttest design to audit consecutive young patients presenting in the six weeks before and the six weeks after the GPs' participation in the training program. PARTICIPANTS: Consisted of 23 GPs who attended a youth suicide prevention workshop and 423 patients aged 15-24 years who presented to the GPs' surgeries (203 pre-workshop and 220 post-workshop). INTERVENTION: GPs attended a one-day training workshop designed to enhance their ability to recognise, assess and manage young patients at risk of suicide. MAIN OUTCOME MEASURES: Scores on three patient self-report inventories (General Health Questionnaire-12 [GHQ-12], Center for Epidemiological Studies Depression Scale [CES-D] and Depressive Symptom Inventory--Suicidality Subscale [DSI-SS]); a GP-completed form for each patient summarising presenting complaint(s), psychological assessment and proposed management plan. RESULTS: After training, GPs demonstrated increased recognition rates of psychologically distressed patients scoring above the cut-offs of the GHQ-12 (48% increase; odds ratio [OR], 1.748; 95% CI, 0.904-03.381) and CES-D (39.5% increase; OR, 2.067; 95% CI, 1.031-4.143); enquiry about suicidal ideation increased by 32.5% (OR, 1.483; 95% CI, 0.929-2.366); and identification of suicidal patients (determined by DSI-SS score) increased by 130% (OR, 3.949; 95% CI, 1.577-9.888). Training did not lead to any significant change in GPs' patient management strategies. CONCLUSIONS: A one-day training course can significantly enhance GP detection rates of psychological distress and suicidal ideation in young patients, but higher recognition rates do not necessarily lead to changes in patient management.

Poisoning with the recreational drug paramethoxyamphetamine ("death").

Abstract: OBJECTIVE To describe the clinical features of paramethoxyamphetamine (PMA; "death") poisoning and to compare these with those of people with self-reported "ecstasy" poisoning. DESIGN Retrospective casenote review. PARTICIPANTS AND SETTING 22 patients who presented to the Emergency Department of the Royal Adelaide Hospital (RAH), a major metropolitan teaching hospital, between 1 January 1996 and 31 December 1998 with PMA poisoning identified through urine drug screens; and 61 patients with self-reported ecstasy poisoning between 1 September 1997 and 31 December 1998 found through the hospital databases. RESULTS Patients with PMA poisoning presented with tachycardia (64%), hyperthermia (temperature > 37.5 degrees C; 36%), coma (41%), seizures (32%), arrhythmias (23%), and QRS intervals > or = 100 ms (50%) with greater frequency and often greater severity than those with self-reported ecstasy poisoning. Two patients with PMA poisoning presented with severe hypoglycaemia (blood glucose level, 7.5 mmol/L). CONCLUSIONS At our hospital, PMA poisonings accounted for most of the severe reactions among people who believed they had taken ecstasy. Hypoglycaemia and hyperkalaemia may be specific to PMA poisoning. PMA toxicity should be suspected with severe or atypical reactions to "ecstasy", and confirmed by chromatographic urine drug screens.

Cholesterol-lowering medications reduce the risk of age-related maculopathy progression.

Abstract: "McCarty CA et al. Cholesterol-lowering medications reduce the risk of age-related maculopathy progression. MJA 2001; 175: 340-. ©Copyright 2001. The Medical Journal of Australia - reproduced with permission".

Mortality and life-years lost due to alcohol: a comparison of acute and chronic causes

Abstract: Objectives: (i) To estimate the numbers of deaths and person-years of life lost (PYLL) due to high-risk alcohol consumption in Australia during 1997, using current estimates of consumption. (ii) To compare the number of deaths and PYLL due to acute conditions associated with bouts of intoxication and chronic conditions associated with long-term misuse of alcohol. Methods: All Australian deaths during 1997 related to conditions considered to be partially or wholly caused by high-risk alcohol consumption were extracted from the Australian Bureau of Statistics Mortality Datafile and adjusted by alcohol aetiologic fractions calculated for Australia in 1997. A life-table method was used to estimate the PYLL for deaths from alcohol-caused conditions. Main outcome measures: Numbers of all deaths and PYLL due to chronic and acute alcohol-related conditions. Results: Of the 3290 estimated alcohol-caused deaths in 1997, chronic conditions (eg, alcoholic liver cirrhosis and alcohol dependence) accounted for 42%, acute conditions (eg, alcohol-related road injuries and assaults) for 28°o and mixed (chronic and acute) for 30%. Of the 62914 estimated potential life years lost, acute conditions were responsible for 46%, chronic for 33% and mixed for 21%. The average number of years of life lost through deaths from acute conditions was more than twice that from chronic conditions, because the former mostly involved younger people. Conclusions: In view of the societal burdens imposed by premature deaths, more effective public health strategies are needed to reduce the harm associated with occasional high-risk drinking (as well as sustained high-risk drinking), especially among young people.

Quitting smoking in pregnancy.

Abstract: Smoking doubles the risk of having a low-birthweight baby and significantly increases the rate of perinatal mortality and several other adverse pregnancy outcomes.The mean reduction in birthweight for babies of smoking mothers is 200 g.High quality interventions to help pregnant women quit smoking produce an absolute difference of 8.1% in validated late-pregnancy quit rates.If abstinence is not achievable, it is likely that a 50% reduction in smoking would be the minimum necessary to benefit the health of mother and baby.Healthcare providers perform poorly in antenatal interventions to stop women smoking. Midwives deliver interventions at a higher rate than doctors.The efficacy of nicotine replacement therapy has not been established in pregnancy. Currently, its use should only be considered in women smoking more than 10 cigarettes per day who have made a recent, unsuccessful attempt to quit and who are motivated to quit.Relapse prevention programs have shown little success in the postpartum period.

A randomised controlled trial of the outcome of health assessment of people aged 75 years and over.

Abstract: Objectives: To measure the outcomes of a health assessment, conducted by a nurse, of people aged 75 years and older (75+HA) living independently in their own homes. Design: Randomised controlled trial (RCT). Setting: A convenience sample of six general practices within the Adelaide Western Division of General Practice (AWDGP). A random sample of 100 participants was drawn from practice age-sex registers. Data were collected in initial visits between 1 August 1998 and February 1999, then in follow-up visits one year later. Participants: Participants were aged 75 years and over on 1 August 1998 and living independently in the community. 145 eligible patients were invited to join the study, and 100 of these consented to enrol (69%). Intervention: A 75+HA conducted in the participant's home by a nurse and reported to their usual general practitioner. Main outcome measures: Primary: number of problems in each group; number of participants with problems; and mortality. Secondary: physical function; psychological (including cognitive) function; falls; and admission to institution. Results: There were no significant differences between the control and intervention groups at follow-up in the number of problems, the number of participants with problems, or mortality, In the intervention group, there was significant improvement in self-rated health, geriatric depression score (GDS 15), and number of tails. Conclusions: This RCT has not demonstrated improvement in health status of the intervention group which received a 75+HA compared with a control group left to usual care.

Fibroadenoma of the breast.

Abstract: Fibroadenoma of the breast is a common cause of a benign breast lump in premenopausal women. The consensus view is that women with fibroadenomas are not at significant increased risk of developing breast cancer. Diagnosis is based on the combination of clinical examination, imaging and non-surgical tissue biopsy (the triple test). A clinical diagnosis of fibroadenoma alone is unreliable and does not exclude malignancy even in younger women. The choice of imaging is mammography, combined with ultrasound in older women, and ultrasound alone in younger women. Tissue biopsy, by either fine-needle aspiration or core biopsy, is the most accurate means of establishing the diagnosis. Traditionally, symptomatic fibroadenomas were treated by surgical excision, and this option should always be offered. There is increasing evidence that a conservative approach is safe and acceptable, provided the result of an adequate triple test is both negative for cancer and consistent with a fibroadenoma. Patients who choose conservative management need to be informed of the limitation of the tests, and must be assessed promptly if there is symptomatic or clinical change.