Regardless of the fate of the “alcopops” tax, and of the $300 million in revenue raised from its trial, the debate surrounding the controversial initiative has brought into focus the very real and increasing problem of alcohol-related harm in Australia. To keep our coverage current, the Journal has taken the approach of publishing online before print much of the material we have received on this topic. As the debate continues, this issue contains a second statement from the Alcohol Advisory Group of the Royal Australasian College of Physicians, calling for broad-based alcohol taxation reform, an overhaul of alcohol promotion, improved treatment and an updated national alcohol strategy (National alcohol policy after “alcopops”: what next?). A collection of Letters, previously published online, reflect a range of opinions about these and other measures (“Health experts reject industry-backed funding for alcohol research”).
Children with hepatitis
As reflected by the logo for World Hepatitis Day (19 May 2009) on this issue’s cover, one in 12 people worldwide now have either chronic hepatitis B (HBV) or C (HCV) infection, with about a million fatalities per year. In “Chronic hepatitis B and C infection in children in New South Wales”, Nightingale and colleagues examine an issue that has been under-researched in Australia — chronic hepatitis rates in children. Comparing the records of paediatric gastroenterology, hepatology, infectious diseases and refugee clinics in New South Wales during 2000-2007 with notifications to the NSW Health Notifiable Diseases Database, the researchers found that most children aged <18 years with chronic hepatitis were not referred for specialist treatment (referral rates of 79/930 for HBV and 29/777 for HCV). Although advanced liver disease was uncommon in children who were referred, the authors express concern that opportunities for early intervention may be being missed.
Warfarin balancing act
The coordination of warfarin management in the community could be improved, say Lowthian and colleagues (→ Who is responsible for the care of patients treated with warfarin therapy?), after interviewing 40 patients who had been over-anticoagulated (international normalised ratio [INR] ≥ 6), and 36 of their treating doctors. Despite some up-and-coming contenders, warfarin is still the mainstay of oral anticoagulation in Australia, and most of the INR monitoring is done by general practitioners using private pathology services. The interviews revealed that 30 of the 40 patients had problems that could complicate their management, such as cognitive impairment, depression and poor adherence, and that the treating GPs had varying attitudes about their own and the pathology provider’s roles in warfarin monitoring.
How long should patients keep taking warfarin after having an episode of venous thromboembolism? The answer depends on the site and size of the thrombus, the presence or absence of reversible risk factors, and the balance between the risk of recurrence after stopping warfarin, and bleeding while taking it. Raju et al provide a useful guide to recommended treatment duration in “Duration of anticoagulant therapy for venous thromboembolism”, but the authors acknowledge that the decision for some patients is far from straightforward. Brukner’s educated Personal perspective provides a useful insight into helping individual patients make the difficult call on how long is long enough (→ Stop taking warfarin? No way!).
Stroke prevention better than cure
Management of known risk factors is a much more effective way of preventing disabling stroke than thrombolysis with tissue plasminogen activator, say Kleinig et al, after looking back at the general practice and medical specialist records of patients admitted to the Royal Adelaide Hospital Stroke Unit over 12 months. Among 183 patients who presented to the unit with fatal or disabling stroke, 135 had at least one suboptimally managed risk factor. When factors were weighted for their relative risk reductions if treated, it was estimated that 70 strokes could have been prevented with optimal management: smoking, uncontrolled hypertension and suboptimal anticoagulation accounted for 90% of cases. Twenty-nine patients who would have been eligible for thrombolysis but did not receive it were identified, giving an estimated four disabling strokes that could have been prevented in this way (→ Stroke prevention and stroke thrombolysis: quantifying the potential benefits of best practice therapies).
Difficult infection questions
Clostridium difficile antibiotic-associated diarrhoea has been around for more that 30 years, but the epidemiology of the bacteria is evolving in somewhat worrying ways, as outlined by Riley in Is Clostridium difficile a threat to Australias biosecurity?. A fluoroquinolone-resistant strain that is epidemic in Europe and North America had not been detected in Australia when we commissioned this informative editorial, but there has now been a case (Riley and colleagues, “First Australian isolation of epidemic Clostridium difficile PCR ribotype 027”), albeit probably acquired in the United States. C. difficile infection is often acquired in the hospital setting, and health care-acquired infections are the subject of another interesting contribution from Gilbert and colleagues (→ Infection control, ethics and accountability), who view failure to comply with handwashing and other infection control measures as an ethical issue. And, for a final infectious diseases fix, turn to Lessons from practice: the case presented by Hughes and Axt is a reminder that osteomyelitis is still a devastating infection, and that ongoing review and investigation is warranted in patients who continue to complain of symptoms after seemingly trivial accidents (→ Life-threatening pelvic osteomyelitis: pelvic destruction in an 8-year-old boy).
Another time . . . another place
Franklin D Roosevelt
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