Population genetic testing?
Homozygosity for a single gene mutation is responsible for most cases of haemochromatosis, but the existence of a genetic test for susceptibility to a common disease is not the only consideration in introducing population screening, says Allen (→ Population genetic screening for hereditary haemochromatosis: are we a step closer?). A recently completed 12-year follow-up of C282Y homozygous individuals has made it possible to predict which patients will develop symptomatic iron overload or haemochromatosis complications, leaving the way open for a screening strategy that considers factors such as individual vulnerability and age of onset.
Cholesterol: your role in its downfall
How low is low enough for cholesterol, who will most benefit from lipid-lowering therapy, and what medications will be most effective? These are questions that we continually revisit as the pool of evidence evolves, sometimes confusingly. Some challenging articles in this issue may influence your thinking on this subject.
A recent randomised trial testing the effect of adding ezetimibe to simvastatin in patients with familial hypercholesterolaemia showed that ezetimibe lowered low-density lipoprotein (LDL) cholesterol levels but had no effect on carotid artery intima-media thickness after 2 years. Should we revisit the maxim that no level is too low for LDL cholesterol in the light of these results? Not until the results of a trial assessing clinical cardiovascular endpoints become available in a few more years, advises Hamilton-Craig in “After ENHANCE: the cholesterol hypothesis is alive and well”.
While Australian guidelines encourage the use of a risk factor equation to calculate patients’ absolute risk of cardiovascular disease when making decisions about lipid-lowering therapy, Pharmaceutical Benefits Scheme (PBS) criteria for subsidising lipid-lowering drugs are based largely on lipid levels alone. According to Chen and colleagues’ analysis of data from over 8000 adults who participated in the AusDiab study, this approach results in somewhat of a mismatch, with many patients who would be considered at low risk based on the Framingham risk prediction equation) receiving lipid-lowering therapy, and more than 80% of those at high risk remaining untreated (→ How do the Australian guidelines for lipid-lowering drugs perform in practice? Cardiovascular disease risk in the AusDiab Study, 1999–2000).
According to the National Heart Foundation, under-45-year-olds need only have their serum lipid levels measured if they are in a high-risk group for cardiovascular disease. Earlier this year, however, two industry-sponsored groups launched whole-of-population cholesterol awareness and testing campaigns in Australia. In “High levels of confusion for cholesterol awareness campaigns”, Hall points out that this may lead to an increased demand for testing and treatment in low-risk groups, with obvious benefits for the companies involved. In response, Cobcroft, from Unilever, and Ketelbey from Pfizer, assert their companies’ commitment to population health.
Reforming our hospitals
If we want to move forward to strengthen our hospitals as leaders in clinical quality, research and innovation, we need to look back to the evolution of the university teaching hospital, says Penington (→ Rediscovering university teaching hospitals for Australia), and to take a good hard look at where we are today, adds Van Der Weyden (→ The viability of Australia’s teaching hospitals). There is no reason why Australian teaching hospitals should not join some of their international peers as centres of excellence in patient care, medical education and clinical research, but changes to the organisational structure and funding of health care will be needed to make this happen.
Pieces of the prostate puzzle
The increasing uptake of prostate-specific antigen (PSA) testing in NSW has been accompanied by an increase in the incidence of prostate cancer, and a decrease in prostate cancer mortality. So say Smith et al, after correlating Medicare claims for PSA testing since 1989 with over 30 years of cancer registry and population data (→ Prostate cancer and prostate-specific antigen testing in New South Wales). Their findings raise the possibility that widespread use of the controversial test is leading to earlier diagnosis and more effective treatment.
If doctors are confused about prostate cancer, it is not surprising that men consulting their general practitioners are often completely in the dark. In a survey of over 500 such men, Arnold-Reed et al found that, although 75% of them had undergone some sort of prostate-related examination or test, 48% were unaware that prostate cancer is the commonest male cancer, 35% did not know how it could be treated, and 53% were unaware of treatment side effects (→ Knowledge and attitudes of men about prostate cancer).
Spare the rods in kids’ asthma
A 3-day course of oral corticosteroids for children with asthma exacerbations who are not admitted to hospital is as efficacious as a 5-day course, say Chang et al (→ A 5- versus 3-day course of oral corticosteroids for children with asthma exacerbations who are not hospitalised: a randomised controlled trial). In a double-blind randomised controlled trial, 201 children were assigned to receive oral prednisolone (1 mg/kg) daily for either 3 or 5 days. About a third of the children in each group were symptom-free at 7 days, and there was no significant difference in scores of asthma-related morbidity at either 7 or 14 days.
Another time . . . another place
Publication of your online response is subject to the Medical Journal of Australia's editorial discretion. You will be notified by email within five working days should your response be accepted.