Exchanges on the block

According to the Australasian College of Emergency Medicine, up to eight hours is a reasonable time for a person to spend in the emergency department before gaining access to a non-ED hospital bed. Waits longer than these constitute “access block”. Complying with this standard is becoming increasingly difficult for Australian hospitals as they juggle decreased bed numbers, workforce issues, social and political changes and funding shortfalls, say Cameron and Campbell (page 99). This issue of the Journal features short reports from all around Australia on the problem of access block and how the various hospitals featured are dealing with it (page 103). While individual efforts are often impressive, systemic solutions seem imperative.

Elderly Australians and absolute risk

We now realise that prescribing medication to treat isolated cardiovascular risk factors can be a waste of resources. People who will benefit from such treatments are those at high absolute risk of a cardiovascular event, once all their relevant characteristics have been factored in. In Australia, the equation we use to estimate such risk relies on data from the Framingham study. Are data from a US study that commenced more than 50 years ago applicable to Australians in 2002? Simons et al (page 113) present their evaluation of its utility in an elderly Australian population. Meanwhile, Tonkin et al (page 101) explain why estimating absolute risk, tailored to local conditions, is important.

Clues to a killer

We know that early antibiotic treatment is crucial to surviving meningococcaemia. Yet with all the will in the world people still die of this disease. Yung and McDonald bring several decades of clinical and teaching experience to the topic, and share some tips for early diagnosis on page 134.

Whatever happened to baby Jane?

“Munchausen by proxy syndrome” is a particularly disturbing form of child abuse in which the medical profession is unknowingly complicit. On page 130 Jureidini and colleagues ask some unsettling questions about how and why the treating doctors become part of the problem. In response, Moran (page 133) provides practical advice on treating children with unresolved clinical problems.

Frozen assets

In Australia and New Zealand, in 2000, there were more than 70 000 stored frozen embryos. Kovacs et al have examined the fate of embryos relinquished in Victoria, where embryos must be disposed of or donated to adopting couples after five years, and present their results on page 127.

Trail of blood

A study published in the Journal in 2001 revealed that about a third of red blood cell transfusions in Sydney hospitals were inappropriate. One difficulty with the study was the lack of a widely accepted “gold standard”. Clinical practice guidelines now exist, and the same researchers (Schofield et al, page 117) have used them to judge the appropriateness of platelet, fresh frozen plasma and cryoprecipitate transfusion in NSW public hospitals. Stand by for the “post-guideline” re-evaluation.

Costs in the country

More than 70% of general practice consultations are still bulk-billed, but this figure is dropping steadily. On page 122, Young and Dobson present results obtained from linking data from the Australian Longitudinal Study on Women’s Health with Medicare and Department of Veterans’ Affairs records of general practice consultations. The study examines out-of-pocket costs for women at different ages, in rural and urban locations, revealing yet another premium placed on rural living.

Read it and weep

Recently the editor of the Lancet did a small study in which he traced the published correspondence relating to three clinical trials. He found that the authors of the original research articles often did not answer all the critical comments in their replies to post-publication letters to the editor. More worryingly, valid criticisms were ignored when the trials were subsequently cited in clinical practice guidelines. At the MJA we take our post-publication correspondence very seriously. Turn to this issue’s Letters section for some important “postscripts” to several of last year’s articles.

Another time ... another place...

. . . emergency departments in Australia have undergone fundamental changes. They are no longer simply triage areas.

MJA 1989; 150: 546-548