Showing papers in "The Medical Journal of Australia in 2013"

Global trends in testosterone prescribing, 2000-2011: expanding the spectrum of prescription drug misuse.

Abstract: Objective To provide the first multinational survey of temporal trends in testosterone prescribing, given that anecdotal evidence indicates that it is increasing in some countries, including Australia. Design Sales data for all testosterone products were obtained for 41 countries for each year from 2000 to 2011. For each testosterone product type (injectable, implantable, oral, transdermal), units sold were converted into defined monthly doses per year, reflecting total testosterone prescribing per product. Main outcome measures National testosterone prescribing rate overall and per product type on a per capita basis. Results For every region and 37 of 41 countries, there was a major and progressive increase in defined monthly doses per year per capita over the 11 years surveyed. In most countries, the increases were steeper for the last half of the survey period. The proportion of testosterone prescribing represented by transdermal testosterone products, a surrogate measure of prescribing for older men, increased even more than did the total usage of testosterone products. Conclusions In the absence of any new indications, off-label testosterone prescribing has increased in most countries in 2000-2011, especially over the last half of the period. The increased testosterone prescribing appears to be primarily for older men and driven by clinical guidelines that endorse testosterone prescribing for age-related functional androgen deficiency (andropause). By eliminating the fundamental distinction between pathological and functional androgen deficiency, these guidelines tacitly promote increased testosterone prescribing, bypassing the requirement for high-quality clinical evidence of safety and efficacy and creating dramatic increases in prescription of testosterone products.

Over 150 potentially low-value health care practices: an Australian study.

Abstract: Objective To develop and apply a novel method for scanning a range of sources to identify existing health care services (excluding pharmaceuticals) that have questionable benefit, and produce a list of services that warrant further investigation. Design and setting A multiplatform approach to identifying services listed on the Australian Medicare Benefits Schedule (MBS; fee-for-service) that comprised: (i) a broad search of peer-reviewed literature on the PubMed search platform; (ii) a targeted analysis of databases such as the Cochrane Library and National Institute for Health and Clinical Excellence (NICE) "do not do" recommendations; and (iii) opportunistic sampling, drawing on our previous and ongoing work in this area, and including nominations from clinical and non-clinical stakeholder groups. Main outcome measures Non-pharmaceutical, MBS-listed health care services that were flagged as potentially unsafe, ineffective or otherwise inappropriately applied. Results A total of 5209 articles were screened for eligibility, resulting in 156 potentially ineffective and/or unsafe services being identified for consideration. The list includes examples where practice optimisation (ie, assessing relative value of a service against comparators) might be required. Conclusion The list of health care services produced provides a launchpad for expert clinical detailing. Exploring the dimensions of how, and under what circumstances, the appropriateness of certain services has fallen into question, will allow prioritisation within health technology reassessment initiatives.

Vitamin D and health in pregnancy, infants, children and adolescents in Australia and New Zealand: a position statement

Abstract: • The recommended level for serum 25-hydroxyvitamin D (25(OH)D) in infants, children, adolescents and during pregnancy and lactation is ≥ 50 nmol/L. This level may need to be 10-20 nmol/L higher at the end of summer to maintain levels ≥ 50 nmol/L over winter and spring. • Sunlight is the most important source of vitamin D. The US recommended dietary allowance for vitamin D is 600 IU daily in children aged over 12 months and during pregnancy and lactation, assuming minimal sun exposure. • Risk factors for low vitamin D are: lack of skin exposure to sunlight, dark skin, southerly latitude, conditions affecting vitamin D metabolism and storage (including obesity) and, for infants, being born to a mother with low vitamin D and exclusive breastfeeding combined with at least one other risk factor. • Targeted measurement of 25(OH)D levels is recommended for infants, children and adolescents with at least one risk factor for low vitamin D and for pregnant women with at least one risk factor for low vitamin D at the first antenatal visit. • Vitamin D deficiency can be treated with daily low-dose vitamin D supplements, although barriers to adherence have been identified. High-dose intermittent vitamin D can be used in children and adolescents. Treatment should be paired with health education and advice about sensible sun exposure. Infants at risk of low vitamin D should be supplemented with 400 IU vitamin D₃ daily for at least the first year of life. • There is increasing evidence of an association between low vitamin D and a range of non-bone health outcomes, however there is a lack of data from robust randomised controlled trials of vitamin D supplementation.

Screening, referral and treatment for depression in patients with coronary heart disease.

Abstract: In 2003, the National Heart Foundation of Australia position statement on "stress" and heart disease found that depression was an important risk factor for coronary heart disease (CHD). This 2013 statement updates the evidence on depression (mild, moderate and severe) in patients with CHD, and provides guidance for health professionals on screening and treatment for depression in patients with CHD. The prevalence of depression is high in patients with CHD and it has a significant impact on the patient's quality of life and adherence to therapy, and an independent effect on prognosis. Rates of major depressive disorder of around 15% have been reported in patients after myocardial infarction or coronary artery bypass grafting. To provide the best possible care, it is important to recognise depression in patients with CHD. Routine screening for depression in all patients with CHD is indicated at first presentation, and again at the next follow-up appointment. A follow-up screen should occur 2-3 months after a CHD event. Screening should then be considered on a yearly basis, as for any other major risk factor for CHD. A simple tool for initial screening, such as the Patient Health Questionnaire-2 (PHQ-2) or the short-form Cardiac Depression Scale (CDS), can be incorporated into usual clinical practice with minimum interference, and may increase uptake of screening. Patients with positive screening results may need further evaluation. Appropriate treatment should be commenced, and the patient monitored. If screening is followed by comprehensive care, depression outcomes are likely to be improved. Patients with CHD and depression respond to cognitive behaviour therapy, collaborative care, exercise and some drug therapies in a similar way to the general population. However, tricyclic antidepressant drugs may worsen CHD outcomes and should be avoided. Coordination of care between health care providers is essential for optimal outcomes for patients. The benefits of treating depression include improved quality of life, improved adherence to other therapies and, potentially, improved CHD outcomes.

Sleep loss and circadian disruption in shift work: health burden and management.

Abstract: About 1.5 million Australians are shift workers. Shift work is associated with adverse health, safety and performance outcomes. Circadian rhythm misalignment, inadequate and poor-quality sleep, and sleep disorders such as sleep apnoea, insomnia and shift work disorder (excessive sleepiness and/or insomnia temporally associated with the work schedule) contribute to these associations. Falling asleep at work at least once a week occurs in 32%-36% of shift workers. Risk of occupational accidents is at least 60% higher for non-day shift workers. Shift workers also have higher rates of cardiometabolic diseases and mood disturbances. Road and workplace accidents related to excessive sleepiness, to which shift work is a significant contributor, are estimated to cost $71-$93 billion per annum in the United States. There is growing evidence that understanding the interindividual variability in sleep-wake responses to shift work will help detect and manage workers vulnerable to the health consequences of shift work. A range of approaches can be used to enhance alertness in shift workers, including screening and treating sleep disorders, melatonin treatment to promote sleep during the daytime, and avoidance of inappropriate use of sedatives and wakefulness-promoters such as modafinil and caffeine. Short naps, which minimise sleep inertia, are generally effective. Shifting the circadian pacemaker with appropriately timed melatonin and/or bright light may be used to facilitate adjustment to a shift work schedule in some situations, such as a long sequence of night work. It is important to manage the health risk of shift workers by minimising vascular risk factors through dietary and other lifestyle approaches.

Public health implications of sleep loss: the community burden.

Abstract: Poor sleep imparts a significant personal and societal burden. Therefore, it is important to have accurate estimates of its causes, prevalence and costs to inform health policy. A recent evaluation of the sleep habits of Australians demonstrates that frequent (daily or near daily) sleep difficulties (initiating and maintaining sleep, and experiencing inadequate sleep), daytime fatigue, sleepiness and irritability are highly prevalent (20%-35%). These difficulties are generally more prevalent among females, with the exception of snoring and related difficulties. While about half of these problems are likely to be attributable to specific sleep disorders, the balance appears attributable to poor sleep habits or choices to limit sleep opportunity. Study of the economic impact of sleep disorders demonstrates financial costs to Australia of $5.1 billion per year. This comprises $270 million for health care costs for the conditions themselves, $540 million for care of associated medical conditions attributable to sleep disorders, and about $4.3 billion largely attributable to associated productivity losses and non-medical costs resulting from sleep loss-related accidents. Loss of life quality added a substantial further non-financial cost. While large, these costs were for sleep disorders alone. Additional costs relating to inadequate sleep from poor sleep habits in people without sleep disorders were not considered. Based on the high prevalence of such problems and the known impacts of sleep loss in all its forms on health, productivity and safety, it is likely that these poor sleep habits would add substantially to the costs from sleep disorders alone.

Acute coronary syndrome care across Australia and New Zealand: The SNAPSHOT ACS study

Abstract: To characterise management of suspected acute coronary syndrome (ACS) in Australia and New Zealand, and to assess the application of recommended therapies according to published guidelines. All patients hospitalised with suspected or confirmed ACS between 14 and 27 May 2012 were enrolled from participating sites in Australia and New Zealand, which were identified through public records and health networks. Descriptive and logistic regression analysis was performed. Rates of guideline-recommended investigations and therapies, and inhospital clinical events (death, new or recurrent myocardial infarction [MI], stroke, cardiac arrest and worsening congestive heart failure). Of 478 sites that gained ethics approval to participate, 286 sites provided data on 4398 patients with suspected or confirmed ACS. Patients' mean age was 67 2013s (SD, 15 2013s), 40% were women, and the median Global Registry of Acute Coronary Events (GRACE) risk score was 119 (interquartile range, 96-144). Most patients (66%) presented to principal referral hospitals. MI was diagnosed in 1436 patients (33%), unstable angina or likely ischaemic chest pain in 929 (21%), unlikely ischaemic chest pain in 1196 (27%), and 837 patients (19%) had other diagnoses not due to ACS. Of the patients with MI, 1019 (71%) were treated with angiography, 610 (43%) with percutaneous coronary intervention and 116 (8%) with coronary artery bypass grafting. Invasive management was less likely with increasing patient risk (GRACE score 200, 36.1%; P This first comprehensive combined Australia and New Zealand audit of ACS care identified variations in the application of the ACS evidence base and varying rates of inhospital clinical events. A focus on integrated clinical service delivery may provide greater translation of evidence to practice and improve ACS outcomes in Australia and New Zealand.

Insomnia: prevalence, consequences and effective treatment

Abstract: Insomnia is common and can have serious consequences, such as increased risk of depression and hypertension. Acute and chronic insomnia require different management approaches. >Chronic insomnia is unlikely to spontaneously remit, and over time will be characterised by cycles of relapse and remission or persistent symptoms. Chronic insomnia is best managed using non-drug strategies such as cognitive behaviour therapy. For patients with ongoing symptoms, there may be a role for adjunctive use of medications such as hypnotics.

Uptake of influenza vaccine by pregnant women: a cross-sectional survey

Abstract: death. 1-3 A growing body of evidence supports the safety and effectiveness of inactivated influenza vaccine during pregnancy. A recent review concluded that influenza vaccine is safe to administer during any trimester. 4 Two recent randomised controlled trials found that babies born to vaccinated mothers had a reduced risk of contracting influenza in the first 6 months of life. 5,6 The 9th edition of the Australian immunisation handbook recommends influenza vaccine for all pregnant women who will be in their second or third trimester during influenza season, although it can be given in any trimester. 7 The vaccine is free for all pregnant women. Uptake of influenza vaccine by pregnant women in Australia is low, with estimates ranging from about 7% to 40%. 8-11 However, these estimates are often from relatively small samples at single sites dependent on local vaccination policies and procedures. Our aims were to determine the uptake of seasonal influenza vaccine among a larger sample of pregnant women residing in New South Wales, and to identify barriers and facilitators to vaccine uptake in pregnancy.

Difficult but necessary conversations--the case for advance care planning.

Abstract: Many patients at the end of life receive care that is inappropriate or futile and, if given the opportunity to discuss their care preferences well ahead of death, may well have chosen to forgo such care. Advance care planning (ACP) is a process of making decisions about future health care for patients in consultation with clinicians, family members and important others, and to safeguard such decisions if patients were to lose decisional capacity. Although ACP has existed as an idea for decades, acceptance and operationalisation of ACP within routine practice has been slow, despite evidence of its benefits. The chief barriers have been social and personal taboos about discussing the dying process, avoidance by medical professionals of responsibility for initiating, coordinating and documenting discussions about ACP, absence of robust and standardised procedures for recording and retrieving ACP documents across multiple care settings, and legal and ethical concerns about the validity of such documents. For ACP to become part of mainstream patient-centred care, accountable clinicians working in primary care, hospitals and nursing homes must effectively educate colleagues and patients about the purpose and mechanics of ACP, mandate ACP for all eligible patients, document ACP in accessible formats that enable patient wishes to accurately guide clinical management, devise methods for reviewing ACP decisions when clinically appropriate, and evaluate congruence between expressed patient wishes and actual care received. Public awareness campaigns coupled with implementation of ACP programs sponsored by collaborations between hospital and health services, Medicare locals and residential care facilities will be needed in making system-wide ACP a reality.

Respiratory symptoms and illness in older Australians: the Burden of Obstructive Lung Disease (BOLD) study

Abstract: Objective: To measure the prevalence of chronic obstructive pulmonary disease (COPD) among people aged 40 years or older in Australia. Design, setting and participants: A cross-sectional study of people in the community aged ≥ 40 years, selected at random using electoral rolls, in six sites chosen to reflect the sociodemographic and geographic diversity of Australia, conducted between 2006 and 2010. Standardised questionnaires were administered by interview. Forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and the FEV1/FVC ratio were measured by spirometry, before and after bronchodilator administration. Main outcome measure: Prevalence of COPD, classified according to Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2006 criteria. Results: Complete data were available for 1620 men (participation rate, 26%) and 1737 women (participation rate, 28%). The prevalence of GOLD Stage II or higher COPD (defined as post-bronchodilator FEV1/FVC ratio < 0.70 and FEV1 < 80% predicted) was 7.5% (95% CI, 5.7%–9.4%) among people aged ≥ 40 years, and 29.2% (95% CI, 18.1%–40.2%) among those aged ≥ 75 years. Among people aged ≥ 40 years, the prevalence of wheeze in the past 12 months was 30.0% (95% CI, 27.5%–32.5%), and prevalence of shortness of breath when hurrying on the level or climbing a slight hill was 25.2% (95% CI, 22.7%–27.6%). Conclusions: Symptoms and spirometric evidence of COPD are common among people aged 40 years or older and increase with age. Further research is needed to better understand the diagnosis and management of COPD in Australia, along with continuing efforts to prevent the disease.

"Down the drain": carbapenem-resistant bacteria in intensive care unit patients and handwashing sinks

Abstract: OBJECTIVES Clinical utility of carbapenem antibiotics is under threat because of the emergence of acquired metallo-β-lactamase (MBL) genes. We describe an outbreak in an intensive care unit (ICU) possibly associated with contaminated sinks. DESIGN, SETTING AND PARTICIPANTS Four clusters of gram-negative bacteria harbouring the MBL gene blaIMP-4 were detected in the ICU at Dandenong Hospital between November 2009 and July 2012. Epidemiological investigations were undertaken in order to identify a common point source. During September 2012, screening using rectal swabs for all ICU patients, and environmental swabs targeting all ICU handwashing sinks and taps were collected. Samples were cultured onto selective carbapenem-resistant Enterobacteriaceae (CRE) agar. Suspected CRE isolates were further characterised using the modified Hodge test and VITEK 2 and confirmed by polymerase chain reaction and sequencing of MBL genes. Clinical and environmental CRE isolates were typed by pulsed-field gel electrophoresis. RESULTS Ten clinical isolates and one screening isolate of CRE (consisting of Klebsiella pneumoniae [5], Serratia marcescens [4], Enterobacter cloacae [1] and Escherichia coli [1]) were detected with the blaIMP-4 gene over the 30-03 period. S. marcescens was isolated persistently from the grating and drain of eight central sinks. Molecular typing confirmed that clinical and environmental isolates were related. Tap water cultures were negative. Several attempts to clean and decontaminate the sinks using detergents and steam cleaning proved unsuccessful. CONCLUSION This report highlights the importance of identification of potential environmental reservoirs, such as sinks, for control of outbreaks of environmentally hardy multiresistant organisms.

Cost savings from a telemedicine model of care in northern Queensland, Australia

Abstract: Objective: To conduct a cost analysis of a telemedicine model for cancer care (teleoncology) in northern Queensland, Australia, compared with the usual model of care from the perspective of the Townsville and other participating hospital and health services. Design: Retrospective cost–savings analysis; and a one-way sensitivity analysis performed to test the robustness of findings in net savings. Participants and setting: Records of all patients managed by means of teleoncology at the Townsville Cancer Centre (TCC) and its six rural satellite centres in northern Queensland, Australia between 1 March 2007 and 30 November 2011. Main outcome measures: Costs for set-up and staffing to manage the service, and savings from avoidance of travel expenses for specialist oncologists, patients and their escorts, and for aeromedical retrievals. Results: There were 605 teleoncology consultations with 147 patients over 56 months, at a total cost of $442 276. The cost for project establishment was $36 000, equipment/maintenance was $143 271, and staff was $261 520. The estimated travel expense avoided was $762 394; this figure included the costs of travel for patients and escorts of $658 760, aeromedical retrievals of $52 400 and travel for specialists of $47 634, as well as an estimate of accommodation costs for a proportion of patients of $3600. This resulted in a net saving of $320 118. Costs would have to increase by 72% to negate the savings. Conclusion: The teleoncology model of care at the TCC resulted in net savings, mainly due to avoidance of travel costs. Such savings could be redirected to enhancing rural resources and service capabilities. This teleoncology model is applicable to geographically distant areas requiring lengthy travel.

Human papillomavirus vaccine coverage among female Australian adolescents: success of the school-based approach.

Abstract: Objective To describe quadrivalent human papillomavirus (HPV) vaccination coverage achieved in the HPV vaccination catch-up program for girls aged 12-17 years. Design Analysis of data from the Australian National HPV Vaccination Program Register. Participants Girls aged 12-17 years as at 30 June 2007. Main outcome measures HPV vaccine coverage by dose (1, 2 and 3), age and state of residence, using Australian Bureau of Statistics estimates of resident populations as the denominator. Results Notified vaccination coverage for girls aged 12-17 years nationally was 83% for dose 1, 78% for dose 2 and 70% for dose 3. The Australian Capital Territory and Victoria recorded the highest three-dose coverage for the 12-17-year-old cohort overall at 75%. The highest national three-dose coverage rate by age was achieved in 12-year-olds (74%). In Queensland, coverage among Indigenous girls compared with non-Indigenous girls was lower with each dose (lower by 4% for dose 1, 10% for dose 2 and 15% for dose 3). This pattern was not seen in the NT, where initial coverage was 17% lower among Indigenous girls, but the course completion rate among those who started vaccination was identical (84%). Conclusions The catch-up HPV vaccination program delivered over 1.9 million doses of HPV vaccine to girls aged 12-17 years, resulting in 70% of girls in this age group being fully vaccinated. The range in coverage achieved and the lower uptake documented among Indigenous girls suggest that HPV vaccination programs can be further improved.

Over 150 potentially low-value health care practices: an Australian study.

Abstract: MJA 198 (2) · 4 February 2013 84 TO THE EDITOR: The article by Elshaug and colleagues on potentially low-value health care services1 raises an important issue, given spiralling health care costs and limited resources. However, we are concerned by the authors’ claim that use of prophylactic implantable cardioverter defibrillators (ICDs) “did not reduce the risk of death, was more expensive and less effective than control therapy”. Elshaug and colleagues did not consider six large randomised trials showing survival benefit from prophylactic ICD implantation compared with medical therapy in patients with severe left ventricular dysfunction,2 and instead presented two trials associated with neutral outcomes.3,4 The authors failed to appreciate that these two trials assessed prophylactic ICD implantation (i) early (ie, 6–40 days) after myocardial infarction3 and (ii) at the time of elective coronary artery bypass graft (CABG) surgery, respectively.4 ICDs are not approved for use in these situations in Australia (see Medicare Benefit Schedule criteria for prophylactic ICD implantation; http:// www9.health.gov.au/mbs/ search.cfm?q=38387&sopt=S). In addition, the CABG trial used a superseded epicardial defibrillator system.4 Moreover, studies have shown that prophylactic ICD implantation is cost-effective and is comparable to other “cost-effective” medical interventions, including antihypertensive therapy and hospital haemodialysis.4,5 This costeffectiveness is acknowledged by both Australian and international guidelines. Given the widespread implications of the study by Elshaug and colleagues on health care provision by Medicare, the authors must take care to present a balanced and objective analysis to ensure that health professionals are not misled and that appropriate health care is delivered in Australia.

Psychosocial risk factors for coronary heart disease.

Abstract: In 2003, the National Heart Foundation of Australia published a position statement on psychosocial risk factors and coronary heart disease (CHD). This consensus statement provides an updated review of the literature on psychosocial stressors, including chronic stressors (in particular, work stress), acute individual stressors and acute population stressors, to guide health professionals based on current evidence. It complements a separate updated statement on depression and CHD. Perceived chronic job strain and shift work are associated with a small absolute increased risk of developing CHD, but there is limited evidence regarding their effect on the prognosis of CHD. Evidence regarding a relationship between CHD and job (in)security, job satisfaction, working hours, effort-reward imbalance and job loss is inconclusive. Expert consensus is that workplace programs aimed at weight loss, exercise and other standard cardiovascular risk factors may have positive outcomes for these risk factors, but no evidence is available regarding the effect of such programs on the development of CHD. Social isolation after myocardial infarction (MI) is associated with an adverse prognosis. Expert consensus is that although measures to reduce social isolation are likely to produce positive psychosocial effects, it is unclear whether this would also improve CHD outcomes. Acute emotional stress may trigger MI or takotsubo ("stress") cardiomyopathy, but the absolute increase in transient risk from an individual stressor is low. Psychosocial stressors have an impact on CHD, but clinical significance and prevention require further study. Awareness of the potential for increased cardiovascular risk among populations exposed to natural disasters and other conditions of extreme stress may be useful for emergency services response planning. Wider public access to defibrillators should be available where large populations gather, such as sporting venues and airports, and as part of the response to natural and other disasters.

Peripheral intravenous catheter-associated Staphylococcus aureus bacteraemia: more than 5 years of prospective data from two tertiary health services.

Abstract: Objectives To determine the incidence, risk factors for and outcomes of Staphylococcus aureus bacteraemia (SAB) associated with peripheral intravenous catheters (PIVCs) Design, setting and patients A review of prospectively collected data from two tertiary health services on all health care-associated SAB episodes occurring in adults aged > 17 2013s from January 2007 to July 2012 Main outcome measures Numbers of health care-associated SAB episodes; device type, location of insertion, device dwell time and outcome at 7 and 30 days for all SAB episodes associated with use of a PIVC; rates of SAB per 10 000 occupied bed-days (OBDs) Results Overall, 137 of 583 health care-associated-SAB episodes (235%) were deemed to be PIVC associated, with an incidence of 026/10 000 OBD The mean dwell time for PIVCs was 35 days (range, 025-9 days) and 452% of SABs occurred in PIVCs with a dwell time ≥ 4 days Of the PIVC-associated SAB episodes, 396% involved PIVCs inserted in the ED, 396% involved PIVCs inserted on wards and 208% involved PIVCs inserted by the ambulance service Of the PIVC-associated SABs occurring within 4 days of insertion, 61% were inserted by ED staff or the ambulance service PIVC-associated SAB were associated with a 30-day all-cause mortality rate of 265% Conclusion PIVC-associated SAB is an under-recognised complication The high incidences of SAB associated with PIVCs inserted in emergency locations and with prolonged dwell times support recommendations in clinical guidelines for routine removal of PIVCs

Building healthy bones throughout life: an evidence-informed strategy to prevent osteoporosis in Australia

Abstract: Osteoporosis imposes a tremendous burden on Australia: 1.2 million Australians have osteoporosis and 6.3 million have osteopenia. In the 2007–08 financial year, 82 000 Australians suffered fragility fractures, of which > 17 000 were hip fractures. In the 2000–01 financial year, direct costs were estimated at $1.9 billion per year and an additional $5.6 billion on indirect costs. Osteoporosis was designated a National Health Priority Area in 2002; however, implementation of national plans has not yet matched the rhetoric in terms of urgency. Building healthy bones throughout life, the Osteoporosis Australia strategy to prevent osteoporosis throughout the life cycle, presents an evidence-informed set of recommendations for consumers, health care professionals and policymakers. The strategy was adopted by consensus at the Osteoporosis Australia Summit in Sydney, 20 October 2011. Primary objectives throughout the life cycle are: to maximise peak bone mass during childhood and adolescence to prevent premature bone loss and improve or maintain muscle mass, strength and functional capacity in healthy adults to prevent and treat osteoporosis in order to minimise the risk of suffering fragility fractures, and reduce falls risk, in older people. The recommendations focus on three affordable and important interventions — to ensure people have adequate calcium intake, vitamin D levels and appropriate physical activity throughout their lives. Recommendations relevant to all stages of life include: daily dietary calcium intakes should be consistent with Australian and New Zealand guidelines serum levels of vitamin D in the general population should be above 50nmol/L in winter or early spring for optimal bone health regular weight-bearing physical activity, muscle strengthening exercises and challenging balance/mobility activities should be conducted in a safe environment.

Patterns of care for men diagnosed with prostate cancer in Victoria from 2008 to 2011.

Abstract: OBJECTIVE To describe patterns of care for men diagnosed with prostate cancer in Victoria, Australia, between 2008 and 2011. DESIGN, SETTING AND PATIENTS Men who were diagnosed with prostate cancer at 11 public and six private hospitals in Victoria from August 2008 to February 2011, and for whom prostate cancer notifications were received by the Prostate Cancer Registry. MAIN OUTCOME MEASURES Characteristics of men diagnosed with prostate cancer; details of treatment provided within 12 months of diagnosis, according to National Comprehensive Cancer Network risk categories; and characteristics of men who did not receive active treatment within 12 months of diagnosis. RESULTS Treatment details were collected for 98.1% of men who were assessed as eligible to participate in the study (2724/2776) and were confirmed by telephone 12 months after diagnosis for 74.4% of them (2027/2724). Most patients (2531/2724 [92.9%]) were diagnosed with clinically localised disease, of whom 1201 (47.5%) were at intermediate risk of disease progression. Within 12 months of diagnosis, 299 of the 736 patients (40.6%) who had been diagnosed as having disease that was at low risk of progression had received no active treatment, and 72 of 594 patients (12.1%) who had been diagnosed as having disease that was at high risk of progression had received no active treatment. Of those diagnosed as having intermediate risk of disease progression, 54.5% (655/1201) had undergone radical prostatectomy. Those who received no active treatment were more likely than those who received active treatment to be older (odds ratio [95% CI], 2.96 [2.01-4.38], 10.94 [6.96-17.21] and 32.76 [15.84-67.89], respectively, for age 65-74 2013s, 75-84 2013s and ≥ 85 2013s, compared with < 55 2013s), to have less advanced disease (odds ratio [95% CI], 0.20 [0.16-0.26], 0.09 [0.06-0.12] and 0.05 [0.02-0.90], respectively, for intermediate, high and very high-risk [locally advanced] or metastatic disease, compared with low-risk disease) and to have had their prostate cancer notified by a private hospital (odds ratio [95% CI], 1.35 [1.10-1.66], compared with public hospital). CONCLUSION Our data reveal a considerable "stage migration" towards earlier diagnosis of prostate cancer in Victoria and a large increase in the use of radical prostatectomy among men with clinically localised disease.

Increasing incidence of hospitalisation for sport-related concussion in Victoria, Australia.

Abstract: OBJECTIVE: To describe trends in hospitalisation for sport-related concussion. DESIGN, SETTING AND PATIENTS: Analysis of routinely collected hospital admissions data from all Victorian hospitals (public and private) over the 2002-03 to 2010-11 financial 2013s for patients aged ≥ 15 2013s with a diagnosis of concussion and an ICD-10-AM external cause activity code indicating sport. MAIN OUTCOME MEASURES: Number and cost of hospitalisations; rate of hospitalisation per 100 000 participants overall and for specific sports; and percentage change in frequency and hospitalisation rate per 100 000 participants over 9 2013s. RESULTS: There were 4745 hospitalisations of people aged ≥ 15 2013s for sport-related concussion, with a total hospital treatment cost of $17 944 799. The frequency of hospitalisation increased by 60.5% (95% CI, 41.7%-77.3%) over the 9 2013s, but could only partially be explained by increases in sports participation, as the rate per 100 000 participants also increased significantly, by 38.9% (95% CI, 17.5%-61.7%). After adjustment for participation, rates were highest for motor sports, equestrian activities, Australian football, rugby and roller sports. The greatest significant increases in rates were seen in roller sports, rugby, soccer and cycling. CONCLUSIONS: The frequency and participation-adjusted rate of hospitalisation for sport-related concussion, both overall and across several sports, increased significantly over the 9 2013s. These findings, along with high levels of public concern, make prevention of head injury in sport a population health priority in Australia. Language: en

Quantifying the proportion of general practice and low-acuity patients in the emergency department.

Abstract: OBJECTIVE To accurately estimate the proportion of patients presenting to the emergency department (ED) who may have been suitable to be seen in general practice. DESIGN Using data sourced from the Emergency Department Information Systems for the calendar 2013s 2009 to 2011 at three major tertiary hospitals in Perth, Western Australia, we compared four methods for calculating general practice-type patients. These were the validated Sprivulis method, the widely used Australasian College for Emergency Medicine method, a discharge diagnosis method developed by the Tasmanian Department of Human and Health Services, and the Australian Institute of Health and Welfare (AIHW) method. MAIN OUTCOME MEASURE General practice-type patient attendances to EDs, estimated using the four methods. RESULTS All methods except the AIHW method showed that 10%-12% of patients attending tertiary EDs in Perth may have been suitable for general practice. These attendances comprised 3%-5% of total ED length of stay. The AIHW method produced different results (general practice-type patients accounted for about 25% of attendances, comprising 10%-11% of total ED length of stay). General practice-type patient attendances were not evenly distributed across the week, with proportionally more patients presenting during weekday daytime (08:00-17:00) and proportionally fewer overnight (00:00-08:00). This suggests that it is not a lack of general practitioners that drives patients to the ED, as weekday working hours are the time of greatest GP availability. CONCLUSION The estimated proportion of general practice-type patients attending the EDs of Perth's major hospitals is 10%-12%, and this accounts for < 5% of the total ED length of stay. The AIHW methodology overestimates the actual proportion of general practice-type patient attendances.

Shift to earlier stage at diagnosis as a consequence of the National Bowel Cancer Screening Program.

Abstract: Under this publisher’s copyright policy, authors are not permitted to make work available in an institutional repository.

Medical graduates becoming rural doctors: rural background versus extended rural placement.

Abstract: Objectives To determine whether recruitment of rural students and uptake of extended rural placements are associated with students' expressed intentions to undertake rural internships and students' acceptance of rural internships after finishing medical school, and to compare any associations. Design, setting and participants Longitudinal study of three successive cohorts (commencing 2005, 2006, 2007) of medical students in the Sydney Medical Program (SMP), University of Sydney, New South Wales, using responses to self-administered questionnaires upon entry to and exit from the Sydney Medical School and data recorded in rolls. Main outcome measures Students' expressed intentions to undertake rural internships, and their acceptance of rural internships after finishing medical school. Results Data from 448 students were included. The proportion of students preferring a rural career dropped from 20.7% (79/382) to 12.5% (54/433) between entry into and exit from the SMP. A total of 98 students took extended rural placements. Ultimately, 8.1% (35/434) accepted a rural internship, although 14.5% (60/415) had indicated a first preference for a rural post. Students who had undertaken an extended rural placement were more than three times as likely as those with rural backgrounds to express a first preference for a rural internship (23.9% v 7.7%; χ(2) = 7.04; P = 0.008) and more than twice as likely to accept a rural internship (21.3% v 9.9%; χ(2) = 3.85; P = 0.05). Conclusion For the three cohorts studied, rural clinical training through extended placements in rural clinical schools had a stronger association than rural background with a preference for, and acceptance of, rural internship.

Australia is continuing to make progress against cancer, but the regional and remote disadvantage remains.

Abstract: Objective: To measure progress, over the past decade, in reducing the disadvantage in cancer death rates among people living in regional and remote areas of Australia.Design: Analysis of routinely collected death certificate and corresponding population data from the Australian Bureau of Statistics.Setting: Population-based, Australia-wide comparison of mortality rates in regional and remote areas compared with metropolitan areas from 1 January 2001 to 31 December 2010.Main outcome measures: Absolute and relative excess of cancer deaths in regional and remote areas.Results: The number of excess cancer deaths in regional and remote areas from 2001 to 2010 was 8878 (95% Cl, 8187-9572). For men, the age-standardised mortality ratios (comparing regional and remote areas with metropolitan areas) showed no evidence of improvement, from 1.08 in 1997-2000 to 1.11 in 2006-2010. For women, they increased from 1.01 in 1997-2000 to 1.07 in 2006-2010. The age-standardised cancer death rate in regional and remote areas (annual percentage change [APC], - 0.6%; 95% Cl, - 0.8% to - 0.4%) is decreasing more slowly than in metropolitan areas (APC, - 1.1%; 95% CI, -1.3% to -1.0%).Conclusions: The regional and remote disadvantage for cancer deaths has been recognised as a problem for more than two decades, yet we have made little progress. This is not surprising - we have not invested in research into solutions. The benefits of laboratory and clinical research to identify innovative cancer treatments will not be fully realised across the entire Australian population unless we also invest in health systems and policy research.

Characteristics of the community-level diet of Aboriginal people in remote northern Australia

Abstract: Objective: To describe the nutritional quality of community-level diets in remote northern Australian communities. Design, setting and participants: A multisite 12-month assessment (July 2010 to June 2011) of community-level diet in three remote Aboriginal communities in the Northern Territory, linking data from food outlets and food services to the Australian Food and Nutrient Database. Main outcome measures: Contribution of food groups to total food expenditure; macronutrient contribution to energy and nutrient density relative to requirements; and food sources of key nutrients. Results: One-quarter (24.8%; SD, 1.4%) of total food expenditure was on non-alcoholic beverages; 15.6% (SD, 1.2%) was on sugar-sweetened drinks. 2.2% (SD, 0.2%) was spent on fruit and 5.4% (SD, 0.4%) on vegetables. Sugars contributed 25.7%–34.3% of dietary energy, 71% of which was table sugar and sugar-sweetened beverages. Dietary protein contributed 12.5%–14.1% of energy, lower than the recommended 15%–25% optimum. Furthermore, white bread was a major source of energy and most nutrients in all three communities. Conclusion: Very poor dietary quality continues to be a characteristic of remote Aboriginal community nutrition profiles since the earliest studies almost three decades ago. Significant proportions of key nutrients are provided from poor-quality nutrient-fortified processed foods. Further evidence regarding the impact of the cost of food on food purchasing in this context is urgently needed and should include cost–benefit analysis of improved dietary intake on health outcomes.

Injury trends and mortality in adult patients with major trauma in New South Wales.

Abstract: OBJECTIVE: To examine trends in mechanism and outcome of major traumatic injury in adults since the implementation of the New South Wales trauma monitoring program, and to identify factors associated with mortality. DESIGN AND SETTING: Retrospective review of NSW Trauma Registry data from 1 January 2003 to 31 December 2007, including patient demographics, year of injury, and level of trauma centre where definitive treatment was provided. PARTICIPANTS: 9769 people aged ≥ 15 years hospitalised for trauma, with an injury severity score (ISS) > 15. MAIN OUTCOME MEASURES: The NSW Trauma Registry outcome measures included were overall hospital length of stay, length of stay in an intensive care unit and inhospital mortality. RESULTS: There was a decreasing trend in severe trauma presentations in the age group 16-34 years, and an increasing trend in presentations of older people, particularly those aged ≥ 75 years. Road trauma and falls were consistently the commonest injury mechanisms. There were 1328 inhospital deaths (13.6%). Year of injury, level of trauma centre, ISS, head/neck injury and age were all independent predictors of mortality. The odds of mortality was significantly higher among patients receiving definitive care at regional trauma centres compared with Level I centres (odds ratio, 1.34; 95% CI, 1.10-1.63). CONCLUSIONS: Deaths from major trauma in NSW trauma centres have declined since 2003, and definitive care at a Level 1 trauma centre was associated with a survival benefit. More comprehensive trauma data collection with timely analysis will improve injury surveillance and better inform health policy in NSW. Language: en

Snakebite in Australia: a practical approach to diagnosis and treatment.

Abstract: Snakebite is a potential medical emergency and must receive high-priority assessment and treatment, even in patients who initially appear well. Patients should be treated in hospitals with onsite laboratory facilities, appropriate antivenom stocks and a clinician capable of treating complications such as anaphylaxis. All patients with suspected snakebite should be admitted to a suitable clinical unit, such as an emergency short-stay unit, for at least 12 hours after the bite. Serial blood testing (activated partial thromboplastin time, international normalised ratio and creatine kinase level) and neurological examinations should be done for all patients. Most snakebites will not result in significant envenoming and do not require antivenom. Antivenom should be administered as soon as there is evidence of envenoming. Evidence of systemic envenoming includes venom-induced consumption coagulopathy, sudden collapse, myotoxicity, neurotoxicity, thrombotic microangiopathy and renal impairment. Venomous snake groups each cause a characteristic clinical syndrome, which can be used in combination with local geographical distribution information to determine the probable snake involved and appropriate antivenom to use. The Snake Venom Detection Kit may assist in regions where the range of possible snakes is too broad to allow the use of monovalent antivenoms. When the snake identification remains unclear, two monovalent antivenoms (eg, brown snake and tiger snake antivenom) that cover possible snakes, or a polyvalent antivenom, can be used. One vial of the relevant antivenom is sufficient to bind all circulating venom. However, recovery may be delayed as many clinical and laboratory effects of venom are not immediately reversible. For expert advice on envenoming, contact the National Poisons Information Centre on 13 11 26.

Risk factors for erectile dysfunction in a cohort of 108 477 Australian men.

Abstract: OBJECTIVES: To quantify relationships between erectile dysfunction (ED), ageing and health and lifestyle factors for men aged 45 years and older. DESIGN: Cross-sectional, population-based study seeking data on health, sociodemographic and lifestyle factors by questionnaire (the 45 and Up Study). PARTICIPANTS AND SETTING: 108 477 men aged 45 years or older, living in New South Wales, and recruited into the 45 and Up Study between 10 January 2006 and 17 February 2010. MAIN OUTCOME MEASURES: Self-reported ED. RESULTS: In the 101 674 men reporting no prior diagnosis of prostate cancer, 39.31% (95% CI, 39.01%-39.61%) had no ED, 25.14% (95% CI, 24.87%-25.40%) had mild ED (ie, experienced ED sometimes), 18.79% (95% CI, 18.55%-19.03%) had moderate (ie, usually experienced) ED and 16.77% (95% CI, 16.55%-17.00%) had complete ED. After adjusting for sociodemographic characteristics, the odds of moderate/complete ED increased by 11.30% (OR, 1.11; 95% CI, 1.11-1.12) each year from the age of 45 years. Overall, the risk of moderate/complete ED was higher among men with low socioeconomic status, high body mass index, those who were sedentary, current smokers and those with diseases including diabetes, heart disease, and depression/anxiety, compared with men without these risk factors. Moderate alcohol consumption was associated with a significantly reduced risk of ED in men aged 45-54 years, but not in older men. Almost all men aged 75 or older reported moderate/severe ED; however, increased physical activity was associated with a lower odds of ED in this group. CONCLUSIONS: In a large population-based cross-sectional study, ED increased considerably with age. There are a range of potentially modifiable risk factors for ED, including smoking, low physical activity, and high body mass index.

Growth and pubertal development of adolescent boys on stimulant medication for attention deficit hyperactivity disorder

Abstract: OBJECTIVE To investigate the growth and pubertal attainment of boys with attention deficit hyperactivity disorder (ADHD) on stimulant medication. DESIGN, SETTING AND PARTICIPANTS Longitudinal study of boys aged 12.00-15.99 years at recruitment in 2005-2011, with stimulant-treated ADHD for at least 3 years, attending three paediatric practices (subjects), compared with longitudinal data from 174 boys from the Nepean longitudinal study (controls). MAIN OUTCOME MEASURES Subjects' growth parameters before treatment were compared with controls aged 7 or 8 years; growth parameters and longitudinal changes on treatment to ages 12.00-13.99 and 14.00-15.99 years were compared with controls reviewed at 13 and 15 years of age, respectively. The subjects' pubertal staging and height velocity were related to their treatment history. RESULTS Sixty-five subjects were recruited; mean duration of treatment was 6.3 ± 1.9 years. At baseline, their growth parameters were not significantly different from those of the controls after adjusting for age. Compared with the controls, after adjusting for current age and baseline growth parameter z score, subjects aged 12.00-13.99 years had significantly lower weight and body mass index (P < 0.01), and those aged 14.00-15.99 years had significantly lower height and weight (P < 0.05). At 12.00-13.99 years of age, the subjects were comparable to the controls in their pubertal development adjusted for age, but those aged 14.00-15.99 years reported significant delay (mean Tanner stage, 3.6 for subjects v 4.0 for controls; P < 0.05). The dose of medication was inversely correlated with the height velocity from baseline to 14.00-15.99 years of age (P < 0.05). CONCLUSIONS Prolonged treatment (more than 3 years) with stimulant medication was associated with a slower rate of physical development during puberty. To maintain adequate height velocity during puberty, we recommend keeping the dose as low as possible.

Chiropractic Observation and Analysis Study (COAST): providing an understanding of current chiropractic practice

Abstract: Objectives: COAST (Chiropractic Observation and Analysis Study) aimed to describe the clinical practices of chiropractors in Victoria, Australia. Design: Cross-sectional study using the BEACH (Bettering the Evaluation and Care of Health) methods for general practice. Setting and participants: 180 chiropractors in active clinical practice in Victoria were randomly selected from the list of 1298 chiropractors registered on Chiropractors Registration Board of Victoria. Twenty-four chiropractors were ineligible, 72 agreed to participate, and 52 completed the study. Main outcome measures: Each participating chiropractor documented encounters with up to 100 consecutive patients. For each chiropractor–patient encounter, information collected included patient health profile, patient reasons for encounter, problems and diagnoses, and chiropractic care. Results: Data were collected on 4464 chiropractor–patient encounters from 52 chiropractors between 11 December 2010 and 28 September 2012. In most (71%) encounters, patients were aged 25–64 years; 1% of encounters were with infants (age < 1 year; 95% CI, 0.3%–3.2%). Musculoskeletal reasons for encounter were described by patients at a rate of 60 per 100 encounters (95% CI, 54–67 encounters) and maintenance and wellness or check-up reasons were described at a rate of 39 per 100 encounters (95% CI, 33–47 encounters). Back problems were managed at a rate of 62 per 100 encounters (95% CI, 55–71 encounters). The most frequent care provided by the chiropractors was spinal manipulative therapy and massage. Conclusions: A range of conditions are managed by chiropractors in Victoria, Australia, but most commonly these conditions are musculoskeletal-related. These results can be used by stakeholders of the chiropractic profession in workforce development, education and health care policy.