In This Issue

Good advice

The strange beast on this issue’s cover may remind you of a saying attributed to Sir Alec Issigonis, designer of the Mini Minor car, “A camel is a horse designed by a committee”. Since its election 1 year ago, the federal government has created 10 new advisory bodies in addition to the 100 or more that were already established, say Russell et al, who offer some sound advice on maximising the effectiveness of these bodies and minimising the possibility of creating camels (→ Australian Government health advisory groups and health policy: seeking a horse, finding a camel). In October, one of the new bodies, the National Preventative Health Taskforce produced a discussion paper, Australia: the healthiest country by 2020. Although still open to discussion, their thoughts on the scourges of obesity, tobacco and alcohol are well worth reading (Moodie, “Australia: the healthiest country by 2020”).

Coordination improves trauma outcomes

A report from Cameron et al confirms a decrease in deaths due to trauma since the introduction of a statewide trauma care system that integrates prehospital care, hospital care and rehabilitation services in Victoria (→ A statewide system of trauma care in Victoria: effect on patient survival). Integrated trauma care systems are about identifying patients’ needs at first contact, expediting transport to major trauma centres and tracking outcomes. Integrated systems exist in all but three Australian states, say McDermott and Cordner, but they require committed competent staff, continuous monitoring, and responsive management to be effective (→ Victoria’s trauma care system: national implications for quality improvement).

Power to the patient

The idea of empowering patients with chronic disease to participate fully in their own management has been evolving in Australia since the 1980s, says Osborne in this issue’s supplement (→ Foreword). The supplement includes papers from a conference on this topic held last year. Another is planned in Melbourne later this month.

Frequent ED attenders need help

The death in September of a homeless man who was reputed to be the most frequent attender at a Sydney hospital’s emergency department (ED) sparked a spate of soul-searching in the city about the role of EDs in caring for people with mental and social problems. Judging from a study by Jelinek et al from Western Australia, many extremely frequent ED attenders fit into this category (→ Frequent attenders at emergency departments: a linked-data population study of adult patients). Almost 700 000 people attended the nine Perth hospital EDs in the 6.5-year study period; most (97.6%) attended fewer than five times per year. A breakdown of those who attended more often identified two distinct subgroups: moderately frequent attenders (5–19 visits/year), who were likely to have more urgent conditions and circulatory diseases and to require admission; and extremely frequent attenders (≥ 20 visits/year), who often had mental and behavioural disorders and alcohol intoxication.

A telling swelling

A woman with months of frontotemporal pain, who was taking corticosteroids for presumed temporal arteritis, developed a large soft tissue swelling over the painful region. Read our Diagnostic Dilemma to remind yourself that two separate pathological processes are rarely a good explanation for a clinical conundrum (Tacon et al, “Headache of a diagnosis: frontotemporal pain and inflammation associated with osteolysis”).

Surviving inoperable lung cancer

A study by Plumridge et al offers hope to people diagnosed with inoperable non-small cell lung cancer with the finding that, after a combination of chemotherapy and radical radiotherapy, the prognosis is poor but not hopeless (→ Long-term survival following chemoradiation for inoperable non-small cell lung cancer). Of 33 such patients who were enrolled in two separate trials at a dedicated cancer centre in Melbourne, six (18%) were still alive 9 years after the commencement of treatment. Median survival for the whole group was 2.1 years.

Folate stories

As the deadline approaches for mandatory folate fortification of bread-making flour in Australia, research published in this issue examines the effectiveness of folate awareness campaigns and voluntary fortification. Chan et al, from South Australia, have been tracking women’s knowledge about folate since 1994, using computer-assisted telephone interviews (→ Folate awareness and the prevalence of neural tube defects in South Australia, 1966–2007). Knowledge that adequate folate intake may prevent spina bifida increased steadily from 25.5% in 1994 to 77% in 2006 and 2007. There were accompanying improvements in knowledge about the timing of supplementation and reported intake: in 2006 and 2007, 63.7% of the women who had recently been pregnant had taken folic acid supplements. The total prevalence of neural tube defects (NTDs) fell from 2.06/1000 births in 1986–1990 (before statewide folate promotion) to 1.23/1000 births in 2002-2007 (after statewide folate promotion).

However, the authors of a separate study believe that voluntary measures have achieved all they are going to achieve, and welcome mandatory measures (du Plessis et al, “What has happened with neural tube defects and womens’ understanding of folate in Victoria since 1998?”). Women responding to the 2005 and 2006 Victorian Population Health Surveys were generally not sure about the role of folate, and few were taking supplements (15.9% and 30.3% of those aged 18–24 years and 30–34 years, respectively, in 2006). The prevalence of NTD pregnancies (including those terminated) fell from 1.7 to 1.4/1000 births between 1997 and 1999 and has remained constant since.

Another time . . . another place

Acute disease is an act of God; of chronic disease the patient himself is the author.