Back to the drawing board
The problems of access block, overcrowding and error in our hospitals are well known. The authors of the Supplement with this issue, from NSW Health and Flinders Medical Centre in South Australia, believe that the solution to some of these problems lies in clinical process redesign — designing a process that ensures that the essential steps in the patient journey come together like clockwork and are simple for staff to follow — and they have some examples of successful programs to prove it!
CPAP or not CPAP
Obstructive sleep apnoea has been associated with cardiovascular and cerebrovascular disease and insulin resistance, and there is some evidence from observational studies that continuous positive airway pressure (CPAP) is beneficial in preventing some of these outcomes. So should we be actively investigating the many asymptomatic snorers who cross our practice thresholds, to see if they too will benefit from CPAP? Several trials are underway to answer this question, so hold fire for now, say Grunstein and Phillips (→ Obstructive sleep apnoea getting to the heart of the matter?).
Boosters need boosting
One factor contributing to parents’ reluctance to restrain children in booster seats for car travel may be the maximum weight recommendations, say Fitzharris et al (→ Booster seat use by children aged 4–11 years: evidence of the need to revise current Australasian standards to accommodate overweight children). Their 2005 survey required parents to measure their child’s height and weight, and report on the child’s usual mode of restraint in the car. While Australian standards currently recommend use of a booster seat for children 100–145 cm tall, only 29% of the 633 children in this height range were using them, with the balance restrained in adult seatbelts. However, 37% of the children in this height range were heavier than the Australian standard for booster seats of 14–26 kg, leading the authors to suggest that, as well as mounting an education campaign on the importance of booster seat use, booster seats should be designed to carry heavier children, and the standard should be amended.
Medical school selection shakeup
When selecting medical students for post-graduate entry, grade point average in the applicant’s undergraduate degree is the most discriminating factor, while interview performance is less predictive, and Graduate Australian Medical School Admissions Test scores add little. So say Wilkinson et al from the University of Queensland (UQ), whose study correlating the scores of 706 medical students in these three aspects of the school’s selection process with their academic performance in Years 1 and 4 underpinned the school’s recent decision to drop the interview from their selection process (→ Medical school selection criteria and the prediction of academic performance). In response, Powis cautions against a major shakeup in selection methods, given that academic performance at medical school was the sole outcome measured in the UQ study (→ Selecting medical students). Studies measuring the characteristics of graduates seem to be scarce, but suggest that applicants who interview well have higher scores in some desirable personal characteristics as interns. Working out what we need to measure and how to measure it is an ongoing challenge.
Soothing small beasts
While there is a plethora of complementary and self-help treatments available for the management of anxiety in children and adolescents, few have been adequately tested in clinical trials, say Parslow et al (→ Effectiveness of complementary and self-help treatments for anxiety in children and adolescents). Exceptions are bibliotherapy (the use of books), massage, melatonin and relaxation training, for which weak evidence exists in specific situations. The authors encourage doctors to discuss alternative treatments with patients, but acknowledge that the lack of good information will make it difficult to provide useful advice.
Hyperglycaemia in hospital linked with mortality
According to a study conducted on a general medical ward of a Melbourne hospital, patients who are not known to have diabetes, but are hyperglycaemic on hospital admission, are at increased risk of death (Baker et al, “Outcomes for general medical inpatients with diabetes mellitus and new hyperglycaemia”). Of 903 older patients managed on the ward during selected periods in 2003 and 2004, 49 (5.4%) died during their admission. Mortality among known diabetics was similar to that of patients with normoglycaemia (5% and 4.9%, respectively) but was raised in patients without known diabetes who had fasting plasma glucose (FPG) levels ≥7 mmol/L, and in the grey area of FPG 5.6–6.9 mmol/L (10.3% and 8%, respectively). Nearly half the patients with new hyperglycaemia (FPG ≥7 mmol/L) on admission also had raised HbA1c levels, suggesting high rates of unrecognised diabetes. Among all patients without known diabetes, raised HbA1c levels on admission predicted mortality (11.3% for HbA1c > 6 v 4.4% for HbA1c ≤ 6).
Another time . . . another place
William Osler, 1905
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