D’oh, who’s smokin’?
Australia has much to celebrate on World No Tobacco Day (31 May): thanks to a raft of public health measures introduced over the past few decades, our smoking rates have fallen to among the lowest in the world, and we are starting to see a downturn in tobacco-related illnesses. Although direct advertising of cigarettes on television has been banned since the 1970s, there is still concern and some evidence that children who see characters on TV programs smoking might be influenced to take it up themselves. With this in mind, Eslick and Eslick made the supreme sacrifice of watching 18 seasons of the popular cartoon series The Simpsons, to tally the instances of smoking. In a show whose appeal relies on mockery, it is difficult to gauge how the audience might be influenced, but, like many other adverse human behaviours, smoking has not been spared exposure by the program (→ Smoking and The Simpsons).
New understandings in DSD
The management of disorders of sex development (DSD), previously known as intersex, is changing with the availability of new genetic tests and the involvement of an array of medical specialists and interest groups. Most DSD are diagnosed at birth, but, as illustrated in the case reported by Parker et al, though rare, the first presentation can be with malignancy in an intra-abdominal gonad in adult life (→ Hysterectomy in a phenotypic male with advanced gonadal malignancy and intersex). According to Warne and Hewitt, the need for feminising surgery for babies with ambiguous genitalia is currently under review, particularly in patients with a Y chromosome who may not be happy with their gender assignment in later life. Any treatment plan, however, should involve removal or re-siting of intra-abdominal gonads, and vigilance for any malignant change (→ Disorders of sex development: current understanding and continuing controversy).
Viva medical research
On the occasion of Medical Research Week (29 May – 5 June), Brown and Sorrell remind us that biomedical research is an ever-changing spectrum, ranging from genetics through individualised treatment to the health of populations (→ Building quality in health — the need for clinical researchers). Clinical researchers provide the vital link between the many facets, and should be encouraged and nurtured in every way possible. Good examples of translational research are provided by Lee and colleagues (→ Molecular biomarkers to individualise treatment: assessing the evidence), who describe how biomarkers can be used to predict patient outcomes and incorporated into trial designs to guide treatment; and Ronaldson and McNeil, who discuss the emerging use of genetic markers to identify people prone to serious drug reactions (→ Improving drug safety by locating genetic markers for hypersensitivity reactions).
Lawyers, compensation and health consumption
People who engage the services of a lawyer after being hospitalised for major trauma use health services more frequently over the next few years, say researchers from New South Wales. Harris and colleagues surveyed 355 patients who had been admitted to a metropolitan trauma centre with severe accidental injury over the 5 years from May 1999 to April 2004: 153 patients (43%) had made a compensation claim and 128 (36%) had engaged a lawyer. Those who had engaged a lawyer were much more likely than those who had not to have had four or more health care visits over the previous 3 months. Health service use did not appear related to the severity of the initial injury, but increased with unemployment and pre-existing chronic illness. Having a head injury and increased time since the injury were associated with lower health service use (→ The effect of compensation on health care utilisation in a trauma cohort).
Intuitively, using point-of-care testing (PoCT) to monitor diabetes, hyperlipidaemia and anticoagulant therapy in general practice patients should lead to enhanced feedback and better control. A multicentre, cluster randomised trial involving almost 5000 patients in 53 general practices used non-inferiority analysis to look at both the percentage of patients and the percentage of tests with results in the target range, over 18 months (Bubner et al, “Effectiveness of point-of-care testing for therapeutic control of chronic conditions: results from the PoCT in General Practice Trial”). Using these criteria, PoCT was deemed equivalent to or better than laboratory testing for monitoring glycated haemoglobin, urine albumin, albumin-creatinine ratio, total cholesterol and triglyceride levels, but was inferior for high-density lipoprotein cholesterol level and international normalised ratio.
In the Supplement included with this issue, Jorm reminds us that clinical handover is “the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis”, and that this occurs, on some level, more than 7 million times per year in Australian hospitals. Commissioned by the Australian Commission on Safety and Quality in Health Care, the articles in the Supplement tackle many of the common handover challenges encountered in various clinical contexts.
Another time . . . another place
The medical profession has a responsibility not only for the cure of the sick and for the prevention of disease but for the advancement of knowledge upon which both depend. This third responsibility can only be met by investigation and experiment.
Robert A McCance, 1950
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