Showing papers in "The Medical Journal of Australia in 2009"

Depression, anxiety and their relationship with chronic diseases: a review of the epidemiology, risk and treatment evidence.

Abstract: Objective: To review the evidence for an association between depression and anxiety and the National Health Priority Area conditions — heart disease, stroke, diabetes mellitus, asthma, cancer, arthritis and osteoporosis — and for the effectiveness of treatments for depression and anxiety in these settings. Data sources: Systematic literature search of systematic reviews, meta-analyses and evidence-based clinical practice guidelines published between 1995 and 2007, inclusive. Data extraction: Each review was examined and summarised by two people before compilation. Data synthesis: Depression is more common in all disease groups than in the general population; anxiety is more common in people with heart disease, stroke and cancer than in the general population. Heterogeneity of studies makes determination of risk and the direction of causal relationships difficult to determine, but there is consistent evidence that depression is a risk factor for heart disease, stroke and diabetes mellitus. Antidepressants appear to be effective for treating depression and/or anxiety in patients with heart disease, stroke, cancer and arthritis, although the number of studies in this area is small. A range of psychological and behavioural treatments are also effective in improving mood in patients with cancer and arthritis but, again, the number of studies is small. Conclusion: The evidence for the association of physical illness and depression and anxiety, and their effects on outcome, is very strong. Further research to establish the effectiveness of interventions is required. Despite the limits of current research, policy and practice still lags significantly behind best evidence-based practice. Models of

A healthier future for all Australians: an overview of the final report of the National Health and Hospitals Reform Commission.

Abstract: After extensive community and health industry consultation, the final report of the National Health and Hospitals Reform Commission, A healthier future for all Australians, was presented to the Australian Government on 30 June 2009. The reform agenda aims to tackle major access and equity issues that affect health outcomes for people now; redesign our health system so that it is better positioned to respond to emerging challenges; and create an agile, responsive and self-improving health system for long-term sustainability. The 123 recommendations are grouped in four themes: Taking responsibility: supporting greater individual and collective action to build good health and wellbeing. Connecting care: delivering comprehensive care for people over their lifetime, by strengthening primary health care, reshaping hospitals, improving subacute care, and opening up greater consumer choice and competition in aged care services. Facing inequities: taking action to tackle the causes and impact of health inequities, focusing on Aboriginal and Torres Strait Islander people, people in rural and remote areas, and access to mental health and dental services. Driving quality performance: having leadership and systems to achieve the best use of people, resources and knowledge, including "one health system" with national leadership and local delivery, revised funding arrangements, and changes to health workforce education, training and practice.

Perinatal transmission of hepatitis B virus: an Australian experience.

Abstract: Objective: To determine the rate of perinatal hepatitis B virus (HBV) transmission in an Australian setting and to identify maternal virological factors associated with highest risk of transmission. Design, participants and setting: A prospective, observational study of perinatal ? transmission of HBV. Participants were pregnant women attending Sydney South West Area Health Service antenatal clinics who tested positive for hepatitis B surface antigen (HBsAg), and their babies. All babies were routinely offered hepatitis B immunoglobulin (HBIG) and HBV vaccination. Babies positive for HBsAg at 9-month follow-up underwent further virological testing, including HBV DNA sequencing. The study was conducted between August 2002 and May 2008. Main outcome measures: HBV DNA levels and demographic characteristics of HBsAg-positive pregnant women; proportion of their infants with active HBV infection at 9-month follow-up; maternal characteristics affecting transmission rate; HBV DNA sequencing of infected infants and their mothers. Results: Of 313 HBsAg-positive pregnant women, 213 (68%) were HBV DNA-positive and 92 (29%) were positive for hepatitis B "e" antigen (HBeAg); 138 babies born to HBV DNA-positive mothers were tested for HBV infection (HBsAg positivity) at about 9 months of age. Four cases of transmission were identified. All four mothers had very high HBV DNA levels (> 10 8 copies/mL) and were HBeAg-positive. Three of the four infants were infected with wild-type HBV strains, with identical maternal/infant isolates. The fourth mother-infant pair had an S gene variant, HBV D144E, which has been previously reported in association with vaccine/HBIG escape. (Unfortunately, HBIG was inadvertently omitted from the immunisation schedule of this infant.) Transmission rates were 4/138 (3%) from HBV DNA-positive mothers overall, 4/61 (7%) from HBeAg-positive mothers, and 4/47 (9%) from mothers with very high HBV DNA levels. No transmission was seen in 91 babies of mothers with HBV DNA levels < 10 8 copies/mL. Conclusion: In this cohort, HBV perinatal transmission was restricted to HBeAg-positive mothers with very high viral loads.

Myths versus facts in emergency department overcrowding and hospital access block.

Abstract: Overcrowding occurs when emergency department (ED) function is impeded, primarily by overwhelming of ED staff resources and physical capacity by excessive numbers of patients needing or receiving care. Access block occurs when there is excessive delay in access to appropriate inpatient beds (> 8 hours total time in the ED). Access block for admitted patients is the principal cause of overcrowding, and is mainly the result of a systemic lack of capacity throughout health systems, and not of inappropriate presentations by patients who should have attended a general practitioner. Overcrowding is most strongly associated with excessive numbers of admitted patients being kept in the ED. Excessive numbers of admitted patients in the ED are associated with diminished quality of care and poor patient outcomes. These include (but are not limited to) adverse events, errors, delayed time-critical care, increased morbidity and excess deaths (estimated as at least 1500 per annum in Australia). There is no evidence that telephone advice lines or collocated after-hours GP services assist in reducing ED workloads. Changes to ED structure and function do not address the underlying causes or major adverse effects of overcrowding. They are also rapidly overwhelmed by increasing access block. The causes of overcrowding, and hence the solutions, lie outside the ED. Solutions will mainly be found in managing hospital bedstock and systemic capacity (including the use of step-down and community resources) so that appropriate inpatient beds remain available for acutely sick patients.

Healthy country, healthy people: the relationship between Indigenous health status and "caring for country".

Abstract: Objective: To investigate associations between “caring for country” — an activity that Indigenous peoples assert promotes good health — and health outcomes relevant to excess Indigenous morbidity and mortality. Design, setting and participants: Cross-sectional study involving 298 Indigenous adults aged 15–54 years in an Arnhem Land community, recruited from March to September 2005. Main outcome measures: Self-reported involvement in caring for country, health behaviours and clinically measured body mass index (BMI), waist circumference, blood pressure, type 2 diabetes status, albumin to creatinine ratio (ACR), levels of glycated haemoglobin (HbA 1c ) and high-density lipoprotein (HDL) cholesterol, lipid ratio, score on the five-item version of the Kessler Psychological Distress Scale (K5), and 5-year cardiovascular disease (CVD) risk. Results: Controlling for sociodemographic characteristics and health behaviours, multivariate regression revealed significant and substantial associations between caring for country and health outcomes. An interquartile range rise in the weighted composite caring-for-country score was significantly associated with more frequent physical activity, better diet, lower BMI (regression coefficient [] = −2.83; 95% CI, −4.56 to −1.10), less abdominal obesity (odds ratio [OR], 0.43; 95% CI, 0.26–0.72), lower systolic blood pressure ( = −7.59; 95% CI, −12.01 to −3.17), less diabetes (OR, 0.12; 95% CI, 0.03–0.52), lower HbA 1c level ( = −0.45; 95% CI, −0.79 to −0.11), non-elevated ACR (OR, 0.28; 95% CI, 0.13–0.60), higher HDL cholesterol level ( = 0.06; 95% CI, 0.01–0.12), lower K5 score ( = −0.97; 95% CI, −1.64 to −0.31) and lower CVD risk ( = −0.77; 95% CI, −1.43 to −0.11). Conclusions: Greater Indigenous participation in caring for country activities is associated with significantly better health. Although the causal direction of these associations requires clarification, our findings suggest that investment in caring for country may be a means to foster sustainable economic development and gains for

Staphylococcus aureus bacteraemia: a major cause of mortality in Australia and New Zealand

Abstract: OBJECTIVE To document the types of, and mortality from, Staphylococcus aureus bacteraemia in Australia and New Zealand, and determine factors associated with mortality. DESIGN AND SETTING Prospective observational study in 27 independent or hospital pathology laboratories in Australia (24) and New Zealand (3), employing a web-based database to prospectively record demographic features, selected risk factors, principal antibiotic treatment and mortality data on all patients with positive blood cultures for S. aureus from June 2007 to May 2008. MAIN OUTCOME MEASURE 30-day all-cause mortality. RESULTS 1994 episodes of S. aureus bacteraemia were identified, and complete 30-day follow-up data were available for 1865. Most episodes had their onset in the community (60.8%; 95% CI, 58.7%-63.0%). Methicillin-resistant S. aureus (MRSA) caused 450 episodes (24.1%; 95% CI, 22.2%-25.9%), and 123 of these (27.3%) had a susceptibility profile consistent with community-associated MRSA. All-cause mortality at 30 days was 20.6% (95% CI, 18.8%-22.5%). On univariate analysis, increased mortality was significantly associated with older age, European ethnicity, MRSA infection, infections not originating from a medical device, sepsis syndrome, pneumonia/empyema, and treatment with a glycopeptide or other non-beta-lactam antibiotic. On multivariable analysis, independent predictors of mortality were age, sepsis syndrome, pneumonia/empyema, device-associated infection with a secondary focus, left-sided endocarditis, and treatment with a glycopeptide such as vancomycin, but not MRSA infection. CONCLUSIONS S. aureus bacteraemia is a common infection in both the community and hospitals in Australia and New Zealand, and is associated with appreciable mortality. Invasive MRSA infection may be more life-threatening, partly because of the inferior efficacy of the standard treatment, vancomycin. National web-based surveillance of S. aureus bacteraemia and its outcomes is not only important but also easily achievable.

An association between tick bite reactions and red meat allergy in humans

Abstract: Twenty-five patients living in a tick-endemic region of Sydney, New South Wales developed red meat allergy after experiencing large local reactions to tick bites This represents a potentially novel cross-reaction between an arthropod and a food protein (MJA 2009; 190: 510-511)

Cardiac arrest in a young man following excess consumption of caffeinated “energy drinks”

Abstract: An otherwise healthy 28-year-old man had a cardiac arrest after a day of motocross racing. He had consumed excessive amounts of a caffeinated "energy drink" throughout the day. We postulate that a combination of excessive ingestion of caffeine- and taurine-containing energy drinks and strenuous physical activity can produce myocardial ischaemia by inducing coronary vasospasm.

Burden of eating disorders in 5–13-year-old children in Australia

Abstract: Objective: To collect nationally representative epidemiological data on early-onset eating disorders (EOEDs) in children. Design: Prospective, active surveillance using the Australian Paediatric Surveillance Unit with key informant design. Setting: Child health specialists in Australia (July 2002 to June 2005). Patients: Incident cases of EOEDs in children aged 5–13 years. Main outcome measures: Disease rates, demographic characteristics, clinical features and complications, hospitalisation, psychological comorbidity, and concordance of clinical features with Diagnostic and statistical manual of mental disorders, fourth edition (DSM-IV) criteria. Results: We identified 101 children aged 5–13 years with EOEDs (median age, 12.2 years; range, 5.5–13.9 years), of whom one in four were boys. Most were hospitalised (78%), and the mean duration of hospitalisation was 24.7 days (range, 1–75 days). More than 70% of inpatients were admitted to specialised eating disorder units in paediatric teaching hospitals. Among inpatients, 37% met DSM-IV diagnostic criteria for anorexia nervosa; although 61% had life-threatening complications of malnutrition, only 51% met weight criteria. Psychological symptoms were similar to those in adults with anorexia nervosa: 67% of inpatients met both psychological diagnostic criteria for anorexia nervosa (fear of weight gain/fatness and misperception of body shape). Of 19 postmenarchal girls, 18 had secondary amenorrhoea. Nasogastric feeding was used in 58% of inpatients, and 34% received psychotropic medications. Conclusions: This is the first prospective national study of EOEDs. It demonstrates the limitations of applying DSM-IV diagnostic criteria for anorexia nervosa to young children; the high proportion of boys affected by EOEDs; and the significant psychological comorbidity and high frequency of hospitalisation associated with EOEDs. Potentially life-threatening medical complications are common at presentation, suggesting possible missed diagnoses and a need for education of health professionals. The study underlines the severity of EOEDs and the need for joint medical and psychiatric

Barriers to participation of Aboriginal people in cancer care: Communication in the hospital setting

Abstract: Objective: To report Aboriginal patients’ views about effective communication between Aboriginal people and health service providers in Western Australian hospital settings. Design, setting and participants: Qualitative study involving indepth interviews between 1 March 2006 and 30 September 2007 with 30 Aboriginal people affected by cancer from across WA. Main outcome measures: Aboriginal patients’ views about the quality of communication within the hospitals, factors impairing communication and suggestions for improvement. Results: Factors crucial to effective patient–provider communication such as language, shared understanding, knowledge and use of medical terminology require attention. Additionally, communication between Aboriginal people and health care professionals needs to be understood within a broader sociocultural and political context. Fear of the medical system and of being disempowered; mistrust; collective memories of the experience of colonisation and its aftermath; lack of understanding of Aboriginal customs, values, lifestyle and the importance of family and land; and experiences of racism were key issues impairing communication. Health service providers’ inability to interpret non-verbal communication and the symbolism of hospital environments also posed problems. Conclusion: Key areas for the attention of health service providers in communicating and caring for Aboriginal people in the hospital setting include culturally sensitive and empathetic personal contact, acknowledgement and respect for Aboriginal family structures, culture and life circumstances, an understanding of the significant role of non-verbal communication, and the importance of history, land and community. Employing more Aboriginal health workers in hospitals, and allowing Aboriginal people to participate at a decision-making level in hospitals is likely to improve Aboriginal people’s

Risks associated with low functional health literacy in an Australian population

Abstract: Robert J Adams, Sarah L Appleton, Catherine L Hill, Mark Dodd, Christopher Findlay and David H Wilson

Natural history, definitions, risk factors and burden of otitis media.

Abstract: Otitis media remains a major health problem in Australia, with an unacceptably great dichotomy of incidence and severity of otitis media and its complications between Indigenous and non-Indigenous Australians. Among most children with acute otitis media, infection resolves rapidly with or without antibiotics, with ongoing middle ear effusion the only sequela. Overcrowding, poor living conditions, exposure to cigarette smoke, and lack of access to medical care are all major risk factors for otitis media. Estimates of the number of cases of otitis media in 2008 vary between 992,000 and 2,430,000 Australians, with a total estimated cost of $100 - $400 million.

Dengue and climate change in Australia: predictions for the future should incorporate knowledge from the past.

Abstract: Dengue transmission in Australia is currently restricted to Queensland, where the vector mosquito Aedes aegypti is established. Locally acquired infections have been reported only from urban areas in the north-east of the state, where the vector is most abundant. Considerable attention has been drawn to the potential impact of climate change on dengue distribution within Australia, with projections for substantial rises in incidence and distribution associated with increasing temperatures. However, historical data show that much of Australia has previously sustained both the vector mosquito and dengue viruses. Although current vector distribution is restricted to Queensland, the area inhabited by A. aegypti is larger than the disease-transmission areas, and is not restricted by temperature (or vector-control programs); thus, it is unlikely that rising temperatures alone will bring increased vector or virus distribution. Factors likely to be important to dengue and vector distribution in the future include increased dengue activity in Asian and Pacific nations that would raise rates of virus importation by travellers, importation of vectors via international ports to regions without A. aegypti, higher rates of domestic collection and storage of water that would provide habitat in urban areas, and growing human populations in northern Australia. Past and recent successful control initiatives in Australia lend support to the idea that well resourced and functioning surveillance programs, and effective public health intervention capabilities, are essential to counter threats from dengue and other mosquito-borne diseases. Models projecting future activity of dengue (or other vector-borne disease) with climate change should carefully consider the local historical and contemporary data on the ecology and distribution of the vector and local virus transmission.

The health and wellbeing of junior doctors: insights from a national survey

Abstract: Junior doctors face specific pressures related to their professional stage and development and can be at risk of poor health. A confidential survey conducted in 2008 by the Australian Medical Association Council of Doctors in Training investigated the health and wellbeing of junior doctors. There were 914 completed surveys: 71% of junior doctors were concerned about their own health, and 63% about the health of a colleague. A majority of junior doctors met well established criteria for low job satisfaction (71%), burnout (69%) and compassion fatigue (54%). The early stages of a medical career are demanding, and the health and wellbeing of junior doctors must be a personal priority, as well as the responsibility of the medical profession in general, to ensure a healthy medical workforce in the future.

Reducing excessive weight gain in pregnancy: a randomised controlled trial.

Abstract: Objective: To determine if regular weight measurement throughout pregnancy can reduce excessive gestational weight gain. Design: A randomised controlled trial. Setting: A tertiary obstetric hospital in Melbourne, between July 2007 and May 2008. Participants: 236 pregnant women recruited at 14 weeks' gestation. Intervention: Women allocated to the intervention group were given a personalised weight measurement card, advised of their optimal gestational weight gain (based on their body mass index at the time of recruitment and the United States Institute of Medicine guidelines), and instructed to record their weight at 16, 20, 24, 28, 30, 32 and 34 weeks' gestation. The control group were weighed at recruitment, but were not given instructions about regular weight measurement. All participants were blinded to the purpose of the study. Main outcome measure: Weight gain from recruitment to follow-up at 36 weeks' gestation. Results: In the study population, there was a trend to less weight gain in the intervention group. The women in the intervention group experienced a mean (SD) per-week weight gain of 0.44 (0.173) kg compared with those in the control group, who gained 0.46 (0.156) kg/week (mean difference, 0.02 kg/week; 95% CI, −0.02 to 0.07 kg/week). The intervention significantly reduced gestational weight gain in the group of women who were overweight but not obese at recruitment: those in the intervention group (20 women) gained a mean (SD) of 0.42 (0.153) kg/week and the control group (18 women) gained 0.54 (0.123) kg/week (mean difference, 0.12 kg/week; 95% CI, 0.03 to 0.22 kg/ week; P =0 .01). Conclusion: Regular weight measurement in pregnancy was not found to be effective in reducing weight gain, except among women who were overweight but not obese before pregnancy. Trial registration:

The impact of otitis media on cognitive and educational outcomes

Abstract: Otitis media is a common disease in childhood that can adversely affect cognitive and educational outcomes. The literature in this area is equivocal, and findings may be influenced by research design. The impact of otitis media on individual children's development appears to depend on the inter-relationship between several factors. Children who have early-onset otitis media (under 12 months) are at high risk of developing long-term speech and language problems. Otitis media has been found to interact negatively with pre-existing cognitive or language problems. For biological or environmental reasons, some populations have a pattern of early onset, higher prevalence and episodes of longer duration; this pattern leads to a higher risk of long-term speech and language problems. These factors suggest that Indigenous children may be at higher risk of cognitive and educational sequelae than non-Indigenous children.

The community's attitude towards swine flu and pandemic influenza.

Abstract: Objective: To ascertain the beliefs, perceived risks and initial attitudes of the Australian community towards the influenza pandemic declared by the World Health Organization in response to the emergence of an A(H1 N1) influenza subtype. Design, setting and participants: Cross-sectional survey of Sydney residents during WHO Phase 5 of pandemic (H1 N1) 2009. Members of the public were approached in shopping and pedestrian malls in seven areas of Sydney between 2 May and 29 May 2009 to undertake the survey. The survey was also made available by email. Main outcome measures: Perceived personal risk and seriousness of the disease, opinion on the government and health authorities' response, feelings about quarantine and infection control methods, and potential compliance with antiviral prophylaxis. Results: Of 620 respondents, 596 (96%) were aware of pandemic (H1 N1) 2009, but 44% (273/620) felt they did not have enough information about the situation. More than a third (38%; 235/620) ranked their risk of catching influenza during a pandemic as low. When asked how they felt pandemic influenza would affect their health if they were infected, only a third (33%; 206/620) said "very seriously". Just over half of the respondents (58%; 360/620) believed the pandemic would be over within a year. Respondents rated quarantine and vaccination with a pandemic vaccine as more effective than hand hygiene for the prevention of pandemic influenza. Conclusions: Emphasising the efficacy of recommended actions (such as hand hygiene), risks from the disease and the possible duration of the outbreak may help to promote compliance with official advice.

Are the cardiometabolic complications of schizophrenia still neglected? Barriers to care.

Abstract: • Patients with schizophrenia have a wide range of risk factors for cardiometabolic disease, at rates 1.5–5 times greater than the general population. • Despite the provision of many sets of guidelines and protocols for screening and monitoring of cardiometabolic risks, morbidity and mortality rates for those with psychotic illnesses remain excessive and premature. • Surveys of mental health practitioners reveal a clear acknowledgement of the importance of managing cardiometabolic risks and subsequent comorbidity. However, inadequate screening rates of patients with antipsychotictreated mental illnesses suggest “knowing is not doing”.

Identifying existing health care services that do not provide value for money

Abstract: of 0.5% above the overall economic growth rate. Coupled with this projected increase in cost are concerns for the sustainability and quality of the Australian health care system. 2 Debate continues on issues such as hospital emergency and surgery waiting lists, models of funding and care, pharmaceutical benefit subsidies, workforce shortages, Indigenous health disadvantage and the role of primary prevention — to name but a few. To address the problems, federal and state/territory jurisdictions have several options, including accepting the increase in the proportion of GDP allocated to health care expenditure, thereby constraining spending in other portfolios, such as education and defence. However, we propose that potential exists for a cost-saving or cost-neutral agenda of resource reallocation within the existing health budget, aimed at improving the quality of care and health outcomes. In Australia, there is scope to identify ineffective interventions (relative to the cost of their subsidy by the taxpayer) and to assess the potential for reducing their use or removing them from government and insurance funding schedules. This would allow reallocation of funding to interventions and programs that offer more in terms of overall health gain and (cost-) effectiveness. As the resources available for health care are finite, this would reduce the extent of unnecessary suffering and premature death arising from the use of health technologies and practices that deliver less than the best-available value for money. 3,4 Here, we propose a dedicated program in Australian health policy that explicitly supports this undertaking. Internationally, the process has been referred to as “disinvestment”, 5-7 although it perhaps aligns better with notions of displacement and reallocation, or reinvestment. In the United Kingdom, disinvestment has been adopted by the National Health Service — utilising the services of the National Institute for Health and Clinical Excellence (NICE) — as a formal policy entitled “optimal practice reviews”. 8 Spain, France and Canada are also considering, or have adopted, similar formal policy initiatives. These countries recognise that the strategy offers promise in the face of ageing populations, increasing chronic disease, and the ensuing strain on health care sustainability. It also appears ethical to strive for appropriate, high-quality and effective care for the populations (and taxpayers), served at a cost they can afford. Finally, this strategy aligns with one of the “top ideas” developed from the long-term health strategy stream of the Australia 2020 Summit:

Telemedicine across the ages

Abstract: he “tyranny of distance” presents significant challenges for the Australian health industry, and is often a central reason for inequity of access to specialist services in rural and regional communities. The health care choices for patients in these areas are usually limited, particularly for patients with prolonged acute or chronic illnesses. The problems are amplified when communities are widely dispersed, and Queensland is a classic example. Queensland, the second largest state in Australia, spans about 1600 km from east to west and 2400 km from north to south. More than two-thirds of Queensland’s 4.2 million people live in the southeastern “corner” of the state, about 18% (770 000) live in major towns along the east coast, and 15% (650 000) are widely dispersed in remote townships. 1 Many smaller towns developed around rural properties, mine sites or Indigenous communities. Patients from rural and regional areas usually have no choice but to travel, and this generally means an inconvenient and costly journey far away from home, often with an end result of a 5- or 10minute specialist appointment. Alternatively, specialists or specialist teams may travel to regional centres for outreach clinics. These visits are usually short (1 or 2 days) and intermittent, and involve the sacrifice of valuable clinician time during transit to and from the regional centres. For many years, there has been much promise for the widespread use of telemedicine (the delivery of health services across a distance using communication methods such as videoconferencing and email) to support patients, especially in remote areas. The opportunities and benefits of telemedicine have been researched and discussed previously. 2,3 Logical reasons for conducting telemedicine include the large distances involved and centralisation of specialist services in major cities. However, the uptake of telemedicine has been disappointingly slow.

Prevalence of metabolic syndrome among Australians with severe mental illness

Abstract: Objective To assess the prevalence of metabolic syndrome and its association with sociodemographic, clinical and lifestyle variables among Australian patients with a variety of psychiatric disorders. Design and setting Cross-sectional study of patients attending a public mental health service in Western Australia between July 2005 and September 2006. Participants Patients who were aged 18-65 years; diagnosed with schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder with psychotic symptoms, drug-induced psychosis or borderline personality disorder; and currently taking at least one antipsychotic drug for a minimum of 2 weeks. Main outcome measures Prevalence of metabolic syndrome diagnosed with International Diabetes Federation criteria; fasting blood glucose and lipid levels; sociodemographic and lifestyle characteristics. Results Of 219 patients invited to participate, 203 agreed and had complete data. Prevalence of metabolic syndrome was 54% overall, and highest among patients with bipolar disorder or schizoaffective disorder (both 67%), followed by schizophrenia (51%). Sociodemographic variables, including age and ethnic background, were not significantly associated with metabolic syndrome, but a strong association was seen with mean body mass index. Other cardiovascular risk factors, such as smoking and substance misuse, were common among participants. Conclusions Prevalence of metabolic syndrome in this population was almost double that in the general Australian population, and patients with schizophrenia had a prevalence among the highest in the developed world. Prevalence was also high in patients with a variety of other psychiatric disorders.

Early evidence for direct and indirect effects of the infant rotavirus vaccine program in Queensland

Abstract: Objective: To assess the impact of introducing a publicly funded infant rotavirus vaccination program on disease notifications and on laboratory testing and results. Design and setting: Retrospective analysis of routinely collected data (rotavirus notifications [2006–2008] and laboratory rotavirus testing data from Queensland Health laboratories [2000–2008]) to monitor rotavirus trends before and after the introduction of a publicly funded infant rotavirus vaccination program in Queensland in July 2007. Main outcome measures: Age group-specific rotavirus notification trends; number of rotavirus tests performed and the proportion positive. Results: In the less than 2 years age group, rotavirus notifications declined by 53% (2007) and 65% (2008); the number of laboratory tests performed declined by 3% (2007) and 15% (2008); and the proportion of tests positive declined by 45% (2007) and 43% (2008) compared with data collected before introduction of the vaccination program. An indirect effect of infant vaccination was seen: notifications and the proportion of tests positive for rotavirus declined in older age groups as well. Conclusions: The publicly funded rotavirus vaccination program in Queensland is having an early impact, direct and indirect, on rotavirus disease as assessed using routinely collected data. Further observational studies are required to assess vaccine effectiveness. Parents and immunisation providers should ensure that all Australian children receive the recommended rotavirus vaccine doses in the required timeframe.

Gaps in cardiovascular disease risk management in Australian general practice.

Abstract: Objective: To evaluate the management of cardiovascular disease (CVD) risk in Australian general practice.

Improving Indigenous patients' access to mainstream health services: the Inala experience.

Abstract: In 1994, only 12 Indigenous people attended the mainstream general practice in Inala, south-western Brisbane, Queensland. An Indigenous community focus group and telephone interviews revealed deficits such as: few items (eg, artwork) that Indigenous people could identify with; lack of Indigenous staff; staff perceived as unfriendly; inflexibility regarding time; and intolerance of Indigenous children's behaviour. Access to the Inala Indigenous Health Service by Indigenous people improved when these issues were addressed, and has grown significantly every year from 1995 to 2008. Other important factors in improving access include: energetic Indigenous leadership; enabling bulk billing to increase funding; moving to a stand-alone clinic; and engaging with teaching, research and community programs. A Centre of Excellence in Indigenous Primary Health Care is envisaged as the next innovation required to improve access and quality of service, and to close the gap between Indigenous and non-Indigenous health outcomes.

Black Saturday: the immediate impact of the February 2009 bushfires in Victoria, Australia

Abstract: OBJECTIVE: To examine the response of the Victorian State Trauma System to the February 2009 bushfires. DESIGN AND SETTING: A retrospective review of the strategic response required to treat patients with bushfire-related injury in the first 72 hours of the Victorian bushfires that began on 7 February 2009. Emergency department (ED) presentations and initial management of patients presenting to the state's adult burns centre (The Alfred Hospital [The Alfred]) were analysed, as well as injuries and deaths associated with the fires. RESULTS: There were 414 patients who presented to hospital EDs as a result of the bushfires. Patients were triaged at the emergency scene, at treatment centres and in hospital. National and statewide burns disaster plans were activated. Twenty-two patients with burns presented to the state's burns referral centres, of whom 18 were adults. Adult burns patients at The Alfred spent 48.7 hours in theatre in the first 72 hours. There were a further 390 bushfire-related ED presentations across the state in the first 72 hours. Most patients with serious burns were triaged to and managed at burns referral centres. Throughout the disaster, burns referral centres continued to have substantial surge capacity. CONCLUSIONS: Most bushfire victims either died, or survived with minor injuries. As a result of good prehospital triage and planning, the small number of patients with serious burns did not overload the acute health care system. Language: en

Is symptom burden a predictor of anxiety and depression in patients with cancer about to commence chemotherapy

Abstract: Objectives : To assess the prevalence, severity and distress from physical symptoms and the prevalence of anxiety and depression in patients about to undergo chemotherapy for potentially curable cancers; and to explore the presence of symptom clusters and investigate their relationships with anxiety and depression. Design, participants and setting : Cross-sectional survey of 192 patients with breast or gastrointestinal cancers or lymphoma before first ever chemotherapy treatment with curative intent. Main outcome measures : Hospital Anxiety and Depression Scale to assess anxiety and depression and the Chemotherapy Symptom Assessment Scale to measure physical symptom prevalence, severity and distress ("bother"). Results : Prevalence of anxiety was 45% and depression 25%. The most prevalent physical symptoms were pain (48%), feeling unusually tired (45%) and difficulty sleeping (45%). Physical symptoms rated as most severe were pain (28%), difficulty sleeping (26%) and feeling unusually tired (19%). Physical symptoms causing the most distress were pain (39%), constipation (18%) and nausea (16%). Factor analysis of symptom distress scores indicated that five factors explained 36.7% of the variance and included: gastrointestinal (nausea, vomiting, pain), general malaise (tiredness, feeling weak, headaches), emotional (feeling depressed, feeling anxious), nutritional (changes to appetite, weight loss or gain) and general physical (mouth/throat problems, shortness of breath). Regression analysis indicated that symptom distress for the malaise (β=1.46; P<0.001), nutritional (β=0.70; P<0.05) and gastrointestinal (β=0.73; P<0.05) factors were independent predictors of depression. Conclusions : Before commencing chemotherapy, patients are already experiencing distressing symptoms and have high scores for anxiety and depression, partially explained by physical symptom distress. Patients should be routinely screened for both emotional and physical needs and appropriate interventions should be developed.

Teams communicating through STEPPS

Abstract: nor has it been introduced into a mental health care environment. We report here on a case study of the implementation of Team- STEPPS at an inpatient mental health facility in South Australia. We sought to determine whether the training intervention changed staff attitudes and behaviours and had an impact on patient care. Our aim was to evaluate the effectiveness of the intervention with measures developed to address three outcome constructs: observed team behav- iours; attitudes and opinions; and clinical performance and outcomes. 5 ABSTRACT Objective: To evaluate the effectiveness of the implementation of a TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) program at an Australian mental health facility. Design, setting and participants: TeamSTEPPS is an evidence-based teamwork training system developed in the United States. Five health care sites in South Australia implemented TeamSTEPPS using a train-the-trainer model over an 8-month intervention period commencing January 2008 and concluding September 2008. A team of senior clinical staff was formed at each site to drive the improvement process. Independent researchers used direct observation and questionnaire surveys to evaluate the effectiveness of the implementation in three outcome areas: observed team behaviours; staff attitudes and opinions; and clinical performance and outcome. The results reported here focus on one site, an inpatient mental health facility. Main outcome measures: Team knowledge, skills and attitudes; patient safety culture; incident reporting rates; seclusion rates; observation for the frequency of use of TeamSTEPPS tools. Results: Outcomes included restructuring of multidisciplinary meetings and the introduction of structured communication tools. The evaluation of patient safety culture and of staff knowledge, skills and attitudes (KSA) to teamwork and communication indicated a significant improvement in two dimensions of patient safety culture (frequency of event reporting, and organisational learning) and a 6.8% increase in the total KSA score. Clinical outcomes included reduced rates of seclusion. Conclusion: TeamSTEPPS implementation had a substantial impact on patient safety culture, teamwork and communication at an Australian mental health facility. It encouraged a culture of learning from patient safety incidents and making

Health and mortality consequences of abdominal obesity: evidence from the AusDiab study

Abstract: Objective: To provide an estimate of the morbidity and mortality resulting from abdominal overweight and obesity in the Australian population Design and setting: Prospective, national, population-based study (the Australian Diabetes, Obesity and Lifestyle [AusDiab] study) Participants: 6072 men and women aged ≥25 years at study entry between May 1999 and December 2000, and aged ≤75 years, not pregnant and for whom there were waist circumference data at the follow-up survey between June 2004 and December 2005 Main outcome measures: Incident health outcomes (type 2 diabetes, hypertension, dyslipidaemia, the metabolic syndrome and cardiovascular diseases) at 5 years and mortality at 8 years Comparison of outcome measures between those classified as abdominally overweight or obese and those with a normal waist circumference at baseline, and across quintiles of waist circumference, and (for mortality only) waist-to-hip ratio Results: Abdominal obesity was associated with odds ratios of between 2 and 5 for incident type 2 diabetes, dyslipidaemia, hypertension and the metabolic syndrome The risk of myocardial infarction among obese participants was similarly increased in men (hazard ratio [HR], 275; 95% CI, 108-703), but not women (HR, 143; 95% CI, 037-550) Abdominal obesity-related population attributable fractions for these outcomes ranged from 13% to 47%, and were highest for type 2 diabetes No significant associations were observed between all-cause mortality and increasing quintiles of abdominal obesity Conclusions: Our findings confirm that abdominal obesity confers a considerably heightened risk for type 2 diabetes, the metabolic syndrome (as well as its components) and cardiovascular disease, and they provide important information that enables a more precise estimate of the burden of disease attributable to obesity in Australia

The role of energy cost in food choices for an Aboriginal population in northern Australia.

Abstract: Objective: To explore the relationship between dietary quality and energy density of foods (MJ/kg) and energy cost ($/MJ) for an Aboriginal population living in a remote region of northern Australia. Design: For a 3-month period in 2005, we collected food and non-alcoholic beverage supply data from food outlets available to the study population. From these data, we compared the energy density of foods with their energy cost. Main outcome measures: Energy density and energy cost of food purchases. Results: The diet of the study population was high in refined carbohydrates and low in fresh fruit and vegetables. Foods with high energy density were associated with lower costs and contributed disproportionately to energy availability. Conclusion: The energy–cost differential between energy-dense, nutrient-poor foods and energy-dilute, nutrient-rich foods influences the capacity of Australian Aboriginal people living in remote communities to attain a healthy diet. This is consistent with the “economics of food choice” theory, whereby people on low incomes maximise energy availability per dollar in their food purchasing patterns, and has particular relevance for developing nutrition policy and strategies in Aboriginal communities, where poor MJA 2009; 190: 549–551 nutrition is a major determinant of preventable chronic disease.

Perinatal transmission of hepatitis B virus: an Australian experience.

Abstract: TO THE EDITOR: Wiseman and colleagues reported the 9-month virological follow-up of babies born to pregnant women attending urban antenatal clinics who tested positive for hepatitis B surface antigen (HBsAg). Evaluation of outcomes is vital to determine implementation and effectiveness of current policy. The authors state that hepatitis B immunoglobulin (HBIG) and hepatitis B virus (HBV) vaccine were delivered within 12 hours of birth to all infants of HBsAg-positive mothers. Nine months after birth, transmission was documented in only four infants, all of whom were born to mothers who were positive for hepatitis B “e” antigen (HBeAg) and had very high HBV DNA levels (>10 copies/mL). Yet one of the four infected infants had inadvertently not received the “routinely offered” HBIG. Whether any other babies (even if not infected) also failed to receive timely active and passive immunisation was not explicitly reported. The other three infected infants completed HBIG injection and HBV vaccination according to the “recommended schedule”. Given that the Australian immunisation handbook states that