Research

Objective: To document the prevalence of polycystic ovary syndrome (PCOS) and its associated characteristics in a sample of urban Indigenous women.Design: A cross-sectional survey of Indigenous women, including biochemical and anthropometric assessments. PCOS was assessed using the National Institutes of Health 1990 criteria.Setting and participants: Indigenous women, aged 15–44 years, living in a defined area in and around Darwin, Northern Territory, Australia, September 2003 – March 2005.Main outcome measures: Proportion of participants with PCOS overall and measures of obesity.Results: Among 248 women eligible for assessment, the proportion who had PCOS was 15.3% (95% CI, 10.8%–19.8%). The proportion with PCOS was similar across age groups, but was significantly higher (P = 0.001) in women with a body mass index (BMI) of ≥ 30.0 kg/m2 (30.5%) compared with women with a BMI of 25.0–29.9 kg/m2 (8.2%) or a BMI of < 25.0 kg/m2 (7.0%).Conclusions: A high proportion of these Indigenous women had PCOS. The significant relationship with obesity gives a strong rationale for screening for PCOS during routine care of Indigenous women who are obese and of reproductive age.

Jacqueline A Boyle FRANZCOG, MPH · Joan Cunningham ScD · Kerin O'Dea PhD · Terry Dunbar BBus, MProfEdTraining, PhD Candidate · Robert J Norman MD, FRANZCOG, FRCPA

Objective: To compare three cystic fibrosis (CF) newborn screening strategies used in Victoria since 1989.Design, setting and participants: Retrospective review of newborn screening and clinical records for people with CF born in Victoria between 1989 and 2008 to compare screening strategies: repeat immunoreactive trypsinogen (IRT) testing (IRT/IRT, 1989–1990), IRT and p.F508del mutation analysis (IRT/p.F508del, 1991–2006) and IRT with analysis of 12 CFTR mutations (IRT/12 mutations, 2007–2008).Main outcome measures: Total number of infants screened, people identified with CF (by screening or clinical diagnosis), number of CF-affected terminations of pregnancy, and number of carriers detected.Results: There were 420 people born with CF (live-birth prevalence, 1/3139; 95% CI, 1/2853–1/3462) and 78 CF-affected pregnancy terminations (overall prevalence, 1/2647; 95% CI, 1/2425–1/2896). Of the babies born with CF, 283 (67.4%) were detected by newborn screening alone, 61 (14.5%) had meconium ileus, 33 (7.9%) had a family history of CF, nine (2.1%) were diagnosed antenatally, and 34 (8.1%) were missed by screening (17 missed because IRT level was < 99th percentile, two with repeat IRT level not elevated, 14 without a screened CFTR mutation, and one with missing data). The sensitivities of the protocols were 86.6% for IRT/IRT, 89.9% for IRT/p.F508del, and 95.8% for IRT/12 mutations. Including 12 mutations in the analysis detected one patient who would otherwise have been missed and, had this protocol been implemented from 1989, it would have detected four others.Conclusion: Most babies with CF without meconium ileus, a family history or antenatal diagnosis are detected by newborn screening. Despite improved sensitivity with the 12-mutation analysis, most infants detected would have been diagnosed using the IRT/p.F508del protocol.

R John H Massie MB BS, PhD, FRACP · Lisette Curnow BSc · Judith Glazner RN · David S Armstrong MB ChB, FRACP, MD · Ivan Francis BSc, GradDipCompSc

Objectives: To identify patterns of khat use among Somali-Australians in Australia and to explore their views about the links between khat use and personal health.Design, setting and participants: Qualitative study using semistructured focus groups among adult members of Somali communities in Brisbane, Sydney, Melbourne and Perth who volunteered to attend focus groups in January and December 2010.Main outcome measures: Emergent themes related to Somali-Australians’ understanding of the links between khat use and personal health.Results: Nineteen focus groups included 114 participants. Khat use was reported to be common among the Somali community, and more common among men than women. Khat was usually chewed in prolonged sessions, producing mild psychostimulant effects such as increased energy, enhanced mood, reduced appetite and reduced sleep. Khat was widely perceived to be a food, not a drug, and as harmless, or even beneficial, to the user’s health. Many users reported discontinuation effects such as lethargy, sleep disturbances and mood problems after sessions of heavy khat use, and some reported self-medicating with alcohol to cope with such problems. Problems of addiction to khat were identified by some participants, but not all believed it is addictive. Many khat users reported visiting their health professionals for treatment of adverse effects and failing to disclose their khat use.Conclusions: Health professionals require greater awareness of khat use and related health problems. Health promotion activities targeting communities with high levels of khat use are required to increase understanding of the potential risks of regular khat use, to promote harm-reduction strategies, and to increase awareness of services available for those experiencing harm. Health professionals should consider targeted screening for khat use among individuals from Horn of Africa communities who present to health services.

Heather Douglas LLB, LLM, PhD · Merali Boyle LLB(Hons), BSc · Nicholas Lintzeris MB BS, PhD, FAChAM

Objective: To determine whether sleep duration of Australian adults has declined over recent years.Design: Analysis of nationally representative data from repeated cross-sectional time-use surveys conducted in 1992, 1997 and 2006.Setting: Private households in Australia.Participants: Respondents aged 15 years and over (N = 21 195) who completed time-use diaries over two consecutive days.Main outcome measure: Change in sleep duration by sociodemographic group.Results: Mean sleep duration was 8 h 20 min in 1992, 8 h 33 min in 1997, and 8 h 30 min in 2006 (SEM for all years, 1 min). After adjustment for sampling during weekends and different seasons, there was no significant change in sleep duration from 1992 to 2006 (adjusted difference, 2 min; 95% CI, − 2 to 5 min; P = 0.33). The only significant decreases in sleep duration were observed in people aged 65 years and over (adjusted difference, 12 min; 95% CI, 4–19 min; P < 0.001), people with no income (adjusted difference, 17 min; 95% CI, 7–27 min; P = 0.001) and male carers (adjusted difference, 31 min; 95% CI, 9–53 min; P = 0.002), although people in these groups reported over 8 h sleep on average.Conclusions: Most Australian adults were not sleeping less in 2006 than they did in 1992. Public health concerns over declining sleep duration do not appear to be warranted. Investigation of possible changes in quality of sleep is required.

Yu Sun Bin BSc(Hons) · Nathaniel S Marshall PhD · Nicholas S Glozier MB BS, MRCPsych, PhD

Objectives: To examine the circumstances of animal exposure in a case series of Australian travellers who required rabies postexposure prophylaxis, and to assess the appropriateness of current guidelines for rabies pre-exposure vaccination.Design, participants and setting: Prospective case series of 65 returned travellers who presented to four Australian travel medicine clinics between 1 April 2009 and 31 July 2010 for rabies post-exposure prophylaxis.Main outcome measures: Demographic characteristics associated with risk of injury; countries where injuries occurred; circumstances of the injuries; and travellers’ experiences of obtaining postexposure prophylaxis overseas.Results: Animal bites and scratches occurred most commonly among travellers aged 20–29 years. Most injuries occurred in Bali, Indonesia (30 [46%]) and Thailand (21 [32%]), and the most common animals responsible for the injuries to the 65 travellers were monkeys (29 travellers [45%]) and dogs (27 [42%]). Thirty-nine of the travellers (60%) initiated contact with the animal. Forty travellers (62%) were able to commence rabies vaccination overseas, but only nine (14%) were able to obtain rabies immunoglobulin overseas.Conclusions: Most travellers had difficulty obtaining rabies postexposure prophylaxis overseas, resulting in significant delays in appropriate treatment. We recommend that current National Health and Medical Research Council guidelines for at-risk persons be broadened, and that the risk of rabies and the option of pre-exposure vaccination be discussed with all travellers to rabies-endemic areas.

Deborah J Mills MB BS · Colleen L Lau MB BS, MPH · Philip Weinstein MAppEpi, PhD, FAFPHM

Objective: To explore Australian general practitioners’ and pharmacists’ preferences in relation to content, format and usability of drug interaction alerts in prescribing and dispensing software.Design, participants and setting: Surveys that sought opinions on drug interaction decision support were mailed to a random sample of GPs and community pharmacists (1000 of each) in June 2010.Main outcome measures: Usefulness of various components of drug interaction information; preferred format of drug interaction alerts; levels of agreement on the value of various usability features; aspects of drug interaction decision support users would most like to change.Results: Surveys were returned by 219 GPs and 170 pharmacists. Of the 191 GPs and 138 pharmacists included in the analysis, the vast majority considered severity, clinical effects and management advice to be mostly or sometimes useful in drug interaction alerts. The most popular drug interaction alert format — favoured by 131 GPs (69%) and 115 pharmacists (83%) — was one with headings and one or two succinct bullet points under each. The vast majority of respondents also wanted to be able to differentiate drug interaction alerts by severity, and a majority agreed that it should be made more difficult to override alerts for severe interactions and that it should be mandatory to provide a reason for doing so.Conclusions: GPs and pharmacists want drug interaction alert information to be relevant, useful, concise, and easy to read and comprehend. Software vendors and knowledge providers could improve drug interaction decision support by making changes to the content and format of drug interaction alerts according to our recommendations.

Kitty H Yu BPharm(Hons), PhD · Michelle Sweidan BPharm, MPH, MHealthSci (PublicHealthPractice) · Margaret Williamson BPharm, GradDipAppEpi, MPH · Amanda Fraser MB BS(Hons), FRACGP, MPH

Objectives: To examine the levels and growth rates of absolute funding to mental health research from 2001 to 2010, compared with other National Health Priority Areas (NHPAs), and the relative rate of mental health funding compared with other NHPAs, by taking disease burden into account. The quality of Australian research in mental health was also examined using objective indicators of research strength.Design and setting: Retrospective analysis of levels of funding overall and as a function of mental health domains using data from the National Health and Medical Research Council, with and without adjustment for burden of disease. A keyword analysis was used to assess the success rate of mental health project grant applications. Objective indicators of the quality of Australian mental health research were sought from citation indicators.Main outcome measures: Funding for mental health research relative to disease burden; funding according to disease category; project grant success rates.Results: Using actual and adjusted figures, mental health research received a lower proportion of health funding than other NHPAs, including cancer, diabetes and cardiovascular disease. Research projects into substance misuse and autism were proportionately better funded than those in anxiety, depression or schizophrenia. A significant proportion of mental health research funding was awarded to research into ageing. Citation data indicated that mental health research in Australia performed better than research in neuroscience, clinical medicine, microbiology, and pharmacology and toxicology, and at a comparable level to immunology research, despite poor levels of funding.Conclusions: Low levels of funding for mental health research appear to be largely attributable to low capacity. Mental health research in Australia is of high quality, and efforts are needed to build capacity.

Helen Christensen PhD, MPsychol(Hons) · Philip J Batterham MPH, PhD · Ian B Hickie MD · Patrick D McGorry PhD · Philip B Mitchell AM, MD, FRANZCP · Jayashri Kulkarni PhD

Objective: To examine the effects of paternal depression during children’s first year on their wellbeing at 4–5 years of age using a large, representative sample of Australian families.Design, setting and participants: Prospective study of Australian families from 2004 to 2008. Two-biological-parent families (n = 2620) from the Longitudinal Study of Australian Children were included if depression measures were available for both parents in 2004, behavioural and developmental measures were available for children in 2008, and the families had not separated by 2008.Main outcome measure: Child scores on the Strengths and Difficulties Questionnaire and on a set of Derived Outcome Indices, measured when the child was 4–5 years old. Logistic regression modelling was used to investigate how early paternal depression in 2004 influenced child outcomes 4 years later.Results: Early paternal depression was a significant predictor of a range of poorer child outcomes (odds ratio [OR] for behavioural difficulties, 3.34 [95% CI, 3.06–3.65]; OR for a low development and wellbeing score, 2.70 [95% CI, 2.44–2.98]). These effects remained significant after controlling for both early maternal depression and later paternal depression (adjusted OR for behavioural difficulties, 1.93 [95% CI, 1.75–2.14]; OR for a low development and wellbeing score, 1.65 [95% CI, 1.48–1.85]).Conclusions: Depression in fathers during the first year of a child’s life can have a detrimental impact on their child’s behaviour, and social and emotional development at the point of school entry, in addition to and uniquely compared with depression in mothers. Early intervention to identify and address the mental health needs of fathers is required for the benefit of fathers, children and families.

Richard J Fletcher PhD · Emily Feeman PhD · Craig Garfield MD, MAPP · Graham Vimpani FRACP, FAFPHM, PhD

Objective: To measure alcohol-related harms to the health of young people presenting to emergency departments (EDs) of Gold Coast public hospitals before and after the increase in the federal government “alcopops” tax in 2008.Design, setting and participants: Interrupted time series analysis over 5 years (28 April 2005 to 27 April 2010) of 15–29-year-olds presenting to EDs with alcohol-related harms compared with presentations of selected control groups.Main outcome measures: Proportion of 15–29-year-olds presenting to EDs with alcohol-related harms compared with (i) 30–49-year-olds with alcohol-related harms, (ii)15–29-year-olds with asthma or appendicitis, and (iii) 15–29-year-olds with any non-alcohol and non-injury related ED presentation.Results: Over a third of 15–29-year-olds presented to ED with alcohol-related conditions, as opposed to around a quarter for all other age groups. There was no significant decrease in alcohol-related ED presentations of 15–29-year-olds compared with any of the control groups after the increase in the tax. We found similar results for males and females, narrow and broad definitions of alcohol-related harms, under-19s, and visitors to and residents of the Gold Coast.Conclusions: The increase in the tax on alcopops was not associated with any reduction in alcohol-related harms in this population in a unique tourist and holiday region. A more comprehensive approach to reducing alcohol harms in young people is needed.

Steve R Kisely MD, PhD, FAFPHM · Joanne Pais MSc · Angela White MCP, PhD, MAPS(Clin) · Jason Connor PhD, MAPS · Lake-Hui Quek PhD · Julia L Crilly BNurs, MN(Hons), PhD · David Lawrence PhD

Objective: To determine whether emergency department (ED) patients’ self-rated levels of anxiety are affected by exposure to purpose-designed music or sound compositions with and without the audio frequencies of embedded binaural beat.Design, setting and participants: Randomised controlled trial in an ED between 1 February 2010 and 14 April 2010 among a convenience sample of adult patients who were rated as category 3 on the Australasian Triage Scale.Interventions: All interventions involved listening to soundtracks of 20 minutes’ duration that were purpose-designed by composers and sound-recording artists. Participants were allocated at random to one of five groups: headphones and iPod only, no soundtrack (control group); reconstructed ambient noise simulating an ED but free of clear verbalisations; electroacoustic musical composition; composed non-musical soundtracks derived from audio field recordings obtained from natural and constructed settings; sound composition of audio field recordings with embedded binaural beat. All soundtracks were presented on an iPod through headphones. Patients and researchers were blinded to allocation until interventions were administered. State–trait anxiety was self-assessed before the intervention and state anxiety was self-assessed again 20 minutes after the provision of the soundtrack.Main outcome measure: Spielberger State–Trait Anxiety Inventory.Results: Of 291 patients assessed for eligibility, 170 patients completed the pre-intervention anxiety self-assessment and 169 completed the post-intervention assessment. Significant decreases (all P < 0.001) in anxiety level were observed among patients exposed to the electroacoustic musical composition (pre-intervention mean, 39; post-intervention mean, 34), audio field recordings (42; 35) or audio field recordings with embedded bianaural beats (43; 37) when compared with those allocated to receive simulated ED ambient noise (40; 41) or headphones only (44; 44).Conclusion: In moderately anxious ED patients, state anxiety was reduced by 10%–15% following exposure to purpose-designed sound interventions.Trial registration: Australian New Zealand Clinical Trials Registry ACTRN 12608000444381.

Tracey J Weiland BBSc(Hons), PhD/MPsych · George A Jelinek MB BS, MD, FACEM · Keely E Macarow BA, MA, PhD · Philip Samartzis GradDipArt · David M Brown DipArt, MA · Elizabeth M Grierson LicDip, MA, PhD · Craig Winter MB BS, MBA, FACEM

Objective: To assess which patient characteristics influence the assessments of urgency for surgery by orthopaedic surgeons and non-orthopaedic professionals.Design, setting and participants: Cross-sectional study of 80 patients requiring elective hip or knee replacement attending a public hospital orthopaedic outpatient clinic or orthopaedic surgeon’s private rooms. Patients were interviewed after being placed on the surgery waiting list. The interview asked about the severity of their joint disease and its effects on physical capability, psychological distress and social circumstances. Patient interviews were summarised and presented to assessors who ranked groups of eight patients in order of their perceived urgency for surgery. Eleven orthopaedic surgeon assessors completed 360 patient ratings and nine non-orthopaedic assessors from various professions, including physiotherapy, social work, research, management and engineering, completed 720 patient ratings.Main outcome measures: Visual analogue scale rating of patient urgency for surgery; patient rankings for surgery; scores for individual domain contributions to urgency rating.Results: A broad spread of perceived urgency was evident among the patients. For each group of eight patients, there was moderate agreement on overall urgency rankings between the two groups of assessors. Linear regression demonstrated that pain was the dominant determinant of urgency score for both assessor groups. Orthopaedic surgeons also took into account limitations to mobility and concurrent medical illness but gave less priority to psychological distress or social circumstances. For the non-orthopaedic assessors, limitations to mobility, social circumstances and psychological distress also contributed to urgency.Conclusion: Both orthopaedic surgeons and non-orthopaedic professionals considered pain the most important factor in establishing urgency and priority for joint replacement. Only the non-orthopaedic professionals considered psychosocial factors important when determining priority for surgery. Broader community discussion about prioritisation for elective surgery is needed to facilitate agreement about which patients factors should be considered.

Andrea J Curtis BSc(Hons), PhD · Rory Wolfe BSc, PhD · Colin O H Russell MB ChB, FRACS · Barry G Elliott MB BS, FRACS, FAOrthA · John A L Hart FRACS, FAOrthA, FASMF · John J McNeil PhD, FRACP, FAFPHM

To calculate cost savings to the Australian federal and state governments from the reduction in twin and triplet birth rates for infants conceived by assisted reproductive technology (ART) since 2002, and to determine the number of ART treatment programs theoretically funded by means of these savings.

Georgina M Chambers BAppSci(MLS), MBA, PhD · Peter J Illingworth MD(Hons), FRANZCOG, CREI · Elizabeth A Sullivan MD, MPH, FAFPHM

To describe the clinical outcomes for all HIV-serodiscordant couples attending an assisted reproduction program.

on behalf of the CVI Study Group

Objective: To describe why, when and to whom general practitioners refer women with symptoms possibly attributable to cervical, endometrial or ovarian cancers, and to identify patient and GP factors that predict referral to either a gynaecologist or a gynaecological oncologist.Design and setting: A national survey of GPs between 1 April and 31 August 2009 using a randomised incomplete block design based on case vignettes, and using a self-completed postal or online questionnaire.Participants: A sample of GPs, stratified by location and randomly selected from a database of GPs maintained by the Australasian Medical Publishing Company.Main outcome measures: Proportion of vignettes that were deemed to reflect a high probability of cancer being referred; and the patient and clinician factors that were the strongest predictors of referral.Results: Of the 3082 GPs who were selected for participation, 1402 responded, giving a response rate of 45.5%. Overall, for vignettes identified as describing women with a high probability of cancer, 75% were referred by metropolitan GPs and 73% by rural practitioners. Metropolitan GPs were significantly more likely to refer women in scenarios indicative of endometrial cancer than rural GPs. For all three cancers, GPs were significantly more likely to refer a patient to a gynaecologist (between 70.8% and 95.4%) than a gynaecological oncologist. Metropolitan GPs had significantly greater access to both private and public gynaecological oncologists than their rural counterparts. Referral rates were higher for ovarian and cervical cancer (83% and 80%, respectively) and lower for endometrial cancer (68%). For all three cancers, patient factors were stronger predictors of referral than the demographic factors of participating GPs.Conclusion: There appears to be significant variation in referral practices among GPs and this variation is greater for endometrial cancer, for which there are currently no evidence-based clinical practice guidelines in Australia. There is a need for further research into understanding the basis of these differences, including a review of the existing guidelines for ovarian and cervical cancer and the development of guidelines for endometrial cancer.

Shanthi A Ramanathan BA, MHlthSci(Hons) · Genevieve Baratiny BSc(Hons), PhD · Nigel P Stocks MD, FRACGP, FAFPHM · Andrew M Searles BEc, MMedStats, PhD · Russell J Redford BSc, DipCompSc

Objectives: To describe the prevalence of lifetime and 12-month stimulant use disorders in the Australian population, and to compare the prevalence estimates from a population survey with prevalence estimates derived using indirect methods.Design and setting: Data were drawn from the 2007 National Survey of Mental Health and Wellbeing, which sampled 8841 residents of private dwellings in Australia in 2007. Interviews were conducted by lay interviewers using the Composite International Diagnostic Interview.Main outcome measures: Lifetime and 12-month rates of stimulant use and stimulant use disorders (abuse, dependence) diagnosed according to the Diagnostic and statistical manual of mental disorders, 4th edition.Results: Lifetime prevalence of stimulant use disorders was 3.3%, and 12-month prevalence was 0.6%, equating to more than 97 000 Australians. Nearly half of those who had used stimulants on more than five occasions met criteria for a lifetime disorder. More than 8% of men aged 16–29 years met criteria for a lifetime stimulant use disorder. Prevalence estimates were consistent with recent estimates using indirect methods.Conclusions: Stimulant use disorders affect a significant number of Australians, and are most common in the age groups at greatest risk for development of psychosis.

Grant E Sara MM, MM(Psychother), FRANZCP · Philip M Burgess MA, PhD · Meredith G Harris BA(Hons), MPASR, MPH · Gin S Malhi MD, FRCPsych, FRANZCP · Harvey A Whiteford MB BS, MPH, FRANZCP

Objectives: To report risk factors, aetiology and neuroimaging features among a large series of young Australian patients who were admitted to hospital for a first-ever occurrence of ischaemic stroke; to analyse the effect of age, sex and ethnicity on the presence of risk factors; and to compare Australian and overseas data.Design, setting and patients: Retrospective evaluation of data for all patients aged from 15 to 50 years who were admitted to a public hospital in Adelaide, South Australia, from January 2006 to June 2010 with a primary diagnosis of ischaemic stroke.Results: Among 326 patients (184 males), the most frequent stroke risk factors overall were dyslipidaemia (187), smoking (161), hypertension (105) and obesity (92). Fifty-one patients used illicit drugs, mostly comprising marijuana and amphetamines. The most frequent stroke aetiologies overall were cardioembolism (85), arterial dissection (49), and small-vessel occlusion (31). Cardioembolism was highly prevalent among our study population compared with patients in other countries. Neuroimaging showed that more patients in our study had strokes that involved both vascular territories concurrently (9%) compared with patients in other countries.Conclusions: Risk factors, aetiology and features of ischaemic stroke among young people in Adelaide differ significantly from published data for young patients around the world. Patients in Adelaide are more likely to be obese, to be misusing marijuana and amphetamines, to suffer a cardioembolic event and to have a stroke that concurrently affects both the anterior and posterior cerebral circulation.

Matthew C L Phillips MB BS · James M Leyden MB BS, FRACP · Woon K Chong MB BS, FRANZCR · Tim Kleinig MB BS(Hons), PhD, FRACP · Philippa Czapran MB BS · Andrew Lee MB BS, FRACP · Simon A Koblar BM BS, FRACP, PhD · Jim Jannes MB BS, FRACP, PhD

Objective: To report outcomes from the first 2 years of the National Hand Hygiene Initiative (NHHI), a hand hygiene (HH) culture-change program implemented in all Australian hospitals to improve health care workers’ HH compliance, increase use of alcohol-based hand rub and reduce the risk of health care-associated infections.

M Lindsay Grayson MD, FRACP, FAFPHM · Philip L Russo MClinEpid, BN · Marilyn Cruickshank RN, PhD, FRCNA · Jacqui L Bear BEc, MLitt, GradCertMgmt · Christine A Gee MBA · Clifford F Hughes AO, FRACS, FACS · Paul D R Johnson MB BS, PhD, FRACP · Rebecca McCann BSc(Nursing) · Alison J McMillan MBA, BEd, RN · Brett G Mitchell RN, MAdvPrac, DTN · Christine E Selvey MB BS, MSc · Robin E Smith MBA · Irene J Wilkinson BSc(Hons), MPH

Objective: To determine the risk of stroke associated with non-steroidal anti-inflammatory drug (NSAID) use.Design, setting and participants: Retrospective cohort study of 162 065 Australian veterans with incident dispensing of an NSAID between 1 January 2001 and 31 December 2008, using prescription event sequence symmetry analysis.Main outcome measures: Hospitalisation for stroke, ischaemic stroke or haemorrhagic stroke.Results: The absolute risk of stroke was low: 7.1/1000 people/year. Incident use of NSAIDs was associated with a 1.88 times increased risk (95% CI, 1.70–2.08) of hospitalisation for stroke (ischaemic or haemorrhagic) following first ever dispensing of an NSAID. This equates to an increased absolute risk of 13.4 strokes/1000 people/year. Significant positive associations between starting an NSAID and having a hospitalisation for stroke were found for most NSAIDs, with adjusted sequence ratios ranging from 1.44 (95% CI, 1.16–1.80) for indomethacin to 1.80 (95% CI, 1.59–2.04) for rofecoxib.Conclusions: Incident use of NSAIDs was associated with an increased risk of stroke. Increased awareness of the potential for serious adverse cardiovascular events, together with individual assessment of cardiovascular risk, careful deliberation of the balance between risk and benefits and appropriate supervision, is required when initiating NSAID therapy.

Gillian E Caughey BSc(Hons), PhD · Elizabeth E Roughead BPharm, MAppSc, PhD · Nicole Pratt BSc, PhD · Graeme Killer AO, MB BS, MSc · Andrew L Gilbert BPharm, DipAppPsych, PhD

Objective: To assess the frequency of, and risk factors for, colonisation with vancomycin-resistant enterococci (VRE), Clostridium difficile and extended-spectrum β-lactamase (ESBL)-producing organisms in residential aged care facilities (RACFs).Design, setting and participants: We conducted a point prevalence survey in October – November 2010 in three RACFs associated with our health service. A single faecal sample was collected from each participating resident and screened for the presence of VRE, C. difficile and ESBL-producing organisms. Presence of risk factors for antibiotic-resistant organisms was identified using a questionnaire.Main outcome measures: Prevalence of colonisation with VRE, C. difficile and ESBL-producing organisms; molecular typing of ESBL-producing organisms; prevalence of risk factors including presence of a urinary catheter, recent inpatient stay in an acute care setting and recent antibiotic consumption.Results: Of 164 residents in the three facilities, 119 (73%) were screened. Mean age of screened residents was 79.2 years, and 61% were women; 74% had resided in the RACF for > 12 months, 21% had been given antibiotics within the past month and 12% had been in an acute care centre within the past 3 months. Overall rates of VRE (2%) and C. difficile (1%) colonisation were low, but ESBL-producing Escherichia coli was detected in 14 residents (12%) overall, with half of these residing in one wing of an RACF (27% of wing residents tested). Ten of the 14 ESBL-producing isolates had identical molecular typing patterns and belonged to genotye CTX-M-9. Eight of 13 residents had persistent colonisation on repeat testing 3 months later.Conclusion: We found a high prevalence of multiresistant ESBL-producing E. coli in RACF residents. A clonal relatedness of isolates suggests possible transmission within the facility. RACFs should have programs emphasising processes that will limit spread of these organisms, namely good hand hygiene compliance, enhanced environmental cleaning and dedicated antimicrobial stewardship programs.

Rhonda L Stuart MB BS, FRACP, PhD · Despina Kotsanas BSc(Hons), MClinEpi · Brooke Webb BAppSc(Lab Med) · Susan Vandergraaf BN · Elizabeth E Gillespie BN, MPubHlth · Geoffrey G Hogg MB BS, FRACP, FRCPA · Tony M Korman MB BS, FRACP, FRCPA

Objective: To determine whether premigration screening for tuberculosis is worth undertaking in visa applicants, and whether screening resources are being appropriately directed towards intending migrants at highest risk of tuberculosis.Design, setting and participants: A 12-month survey of all intending migrants with tuberculosis necessitating treatment detected during the premigration health assessment process, whose medical examinations were submitted to the Department of Immigration and Citizenship’s Global Health Branch for assessment by a Medical Officer of the Commonwealth between 1 July 2009 and 30 June 2010.Main outcome measures: Individuals diagnosed with active tuberculosis; proportions diagnosed by sputum smear and culture tests or clinically, and with susceptibility test results; distribution of visa types among people diagnosed.Results: In premigration assessments, 519 people were diagnosed with active tuberculosis (prevalence, 137 per 100 000 in examined population). The top source countries for people with tuberculosis were the Philippines (21.8%), India (16.8%), Vietnam (16.2%) and China (8.3%). Positive sputum smear test results were submitted for 67 cases (12.9%). Positive culture test results were obtained in 230 cases (44.3%), but only 95 of these (41.3%) had susceptibility test results, with 83 fully susceptible. Four people had multidrug-resistant tuberculosis (prevalence, 1.06 per 100 000 population). Five people had both active tuberculosis and HIV infection. Of all those diagnosed with tuberculosis, 162 (31.2%) were intending students, 82 (15.8%) were intending visitors, and 53 (10.2%) were applicants for humanitarian (refugee and Special Humanitarian Program) visas.Conclusions: Premigration health screening of intending migrants is identifying substantial numbers of people who would have required treatment for tuberculosis after arrival in Australia. The high proportion of students, visitors and refugee and humanitarian entrants with tuberculosis validates the current screening program. The screening is of benefit to the applicants, whose tuberculosis is treated earlier than it otherwise would have been, and to the Australian population, by averting exposure to people with active tuberculosis.

Kathleen King BSc(Hons), MB ChB, FRCPath · Paul J Douglas MB BS, MHA, FRACMA · Ken Beath BE, MAppStat, PhD

Objective: To determine perceptions of barriers to admission to subacute care from acute hospital care, and barriers to subsequent discharge from subacute care.Design, participants and setting: Web-based survey of key stakeholders using Likert scales and closed questions. Prompts were emailed repeatedly to potential participants in Australia between 15 May and 24 July 2009. Participants were physicians working in inpatient rehabilitation medicine and aged care units, as well as senior hospital managers with responsibility for patient flow.Main outcome measures: Perceived admission and discharge barriers in subacute care.Results: Half of the 101 respondents reported barriers to admission to subacute hospitals as moderate, severe or extreme, and 81% reported a similar grading of severity for barriers to discharge. There was no relationship between these perceptions and whether respondents worked only in the public hospital system (barriers to access: χ2 = 0.02 [df = 1; P = 1.0]; and barriers to discharge: χ2 = 0.0 [df = 1; P = 1.0]). The most commonly reported barriers to admission were: availability of beds (61% of respondents); physical, environmental and equipment inadequacies (62% of respondents); and allied health or nursing staff issues (55% of respondents). The most commonly reported barriers to discharge included: waiting for a more appropriate setting of care (76% of respondents) and funding for home modifications, equipment or carers (55% of respondents). There was no relationship between respondents’ position and their reporting of various admission (χ2 = 6.2; df = 8; P = 0.6) or discharge barriers (χ2 = 13.8; df = 12; P = 0.3).Conclusion: There is a strong perception among key stakeholders in subacute care that there are major barriers to patient admission and discharge. Redistributing proposed funding for inpatient subacute beds to measures for overcoming these barriers is likely to improve patient flow though the whole hospital system.

Peter W New MB BS, MClinEpi, FAFRM(RACP) · Peter A Cameron MB BS, MD, FACEM · John H Olver MB BS, MD, FAFRM(RACP) · Johannes U Stoelwinder MB BS, MD, FRACMA

Objective: To evaluate mammography screening outcomes in women with a personal history of breast cancer (PHBC), who have an increased risk of recurrent or new breast cancer, relative to women without PHBC.Design, setting and participants: Retrospective study of 713 191 screening mammograms from two groups of women — those with versus those without PHBC — who participated in the BreastScreen WA program in Western Australia between 1997 and 2006.Main outcome measures: Cancer detection rate (CDR), recall to assessment rate, recall positive predictive value (PPV) for cancer, and distribution of cancer characteristics within and between the two groups.Results: Screening detected 4125 breast cancers: CDR per 10 000 screens was significantly higher in women with PHBC (95.5; 95% CI, 78.3–112.7) than in women without PHBC (57.2; 95% CI, 55.4–58.9). Recall to assessment rate per 10 000 screens was lower in women with PHBC (385.2; 95% CI, 350.6–419.8) than in women without PHBC (504.9; 95% CI, 499.7–510.2). Recall PPV was higher for women with PHBC (24.8%; 95% CI, 21.0%–28.9%) than those without PHBC (11.2%; 95% CI, 10.9%–11.6%). Cancer characteristics were consistent with early detection (most were smaller than 2 cm and node-negative) and were similarly distributed in both groups, except for tumour grade, with PHBC women having fewer low-grade cancers and slightly more high-grade cancers than women without PHBC.Conclusions: The relative rate of cancer detection between women with PHBC and women without PHBC who attended an Australian population-based breast screening program was similar to estimates from international studies. Recall rates were within national standards. Screen-detected cancers had similar characteristics in both groups, except for tumour grade. These data support national integration of mammography screening for women with PHBC into BreastScreen, although evaluation of interval cancers will be necessary.

Nehmat Houssami MB BS, FAFPHM, PhD · Janette J Tresham BSc(Agric) · Lin Fritschi MB BS, FAFPHM, PhD · Liz E Wylie MB BS, FRANZCR

Objective: To determine the current level of knowledge of first aid for a burn injury and sources of this knowledge among the general population of New South Wales.Design, setting and participants: People aged 16 years or older were interviewed as part of the 2007 NSW Population Health Survey, a continuous telephone survey of NSW residents.Main outcome measure: Weighted proportion of the population with optimal first aid knowledge for burns.Results: In total, 7320 respondents were asked questions related to burn injuries and first aid. Of the surveyed population, 82% reported that they would cool a burn with water, and 9% reported that they would cool the burn for the recommended 20 minutes. Few respondents reported that they would remove the patient’s clothing and keep the injured person warm. The most common sources of first aid information were a first aid book (42%) and the internet (33%). Speaking a language other than English at home, and being over 65 years of age were associated with a lack of first aid knowledge.Conclusions: A minority of people living in NSW know the optimal time for cooling a burn injury and other appropriate first aid steps for burns. This study demonstrates a gap in the public’s knowledge, especially among non-English speaking people and older people, and highlights the need for a clear, consistent first aid message.

Lara A Harvey BSc, MPH · Margo L Barr BSc, MPH · Roslyn G Poulos MB BS(Hons), PhD, FAFPHM · Caroline F Finch BSc, MSc, PhD · Shauna Sherker BSc, MSc, PhD · John G Harvey MB BS, FRACS, FRCS

Objective: To use population-level data to monitor the impact on smoking cessation activity of the April 2010 Australian tobacco tax increase.Design and setting: The Cancer Institute NSW [New South Wales] Tobacco Tracking Survey (CITTS) is a continuous tracking telephone survey conducting about 50 interviews per week. Data from February to September in 2009 and 2010 were analysed (ie, data on people who quit smoking in the 3 months before and 5 months after the tax increase in 2010 were compared, and quitting activity over the same period in 2009 was also analysed).Participants: Adult smokers and smokers who had stopped smoking in the previous 12 months; 2009 (n = 1604); 2010 (n = 1699).Main outcome measure: Recent quitting (defined as stopping smoking or trying to quit within a 1-month period).Results: 22% of the sample reported that they had quit smoking in May 2010, compared with 13% in April 2010 and 12% in May 2009. Respondents interviewed in the 3 months after the tax increase (May–July) were significantly more likely to report quitting than those interviewed in the 3 months before the tax increase (odds ratio, 1.84; 95% CI, 1.26–2.69; P < 0.01). This increase in quitting activity was not sustained in the subsequent months (August–September).Conclusions: The tobacco tax increase was associated with a short-term increase in the rate of smoking cessation among NSW adult smokers and recent quitters, suggesting that regular increases in tobacco tax may further encourage quitting activity.

Sally M Dunlop PhD · Trish F Cotter BSc, MPH · Donna A Perez BSc

Objective: To assess mortality trends among people with cystic fibrosis (CF) in Australia.Design and setting: We augmented Australian summary data for deaths from CF registered during 1979–2005 with information from Australian transplant centres on lung transplantation among CF patients for 1989–2005 to allow us to follow trends in all “mortality events” (death or lung transplantation).Main outcome measure: Age at death or lung transplantation.Results: Between 1979 and 2005, the mean age at death increased from 12.2 years to 27.9 years for males and from 14.8 years to 25.3 years for females. Overall, female deaths in childhood (0–14 years) occurred at an age-standardised rate of 0.40 per 100 000 (95% CI, 0.34–0.45) during 1979–2005, which exceeded the corresponding rate for males of 0.24 (95% CI, 0.20–0.28) per 100 000. Among 0–14-year-old boys, event rates declined markedly after 1989, but they declined later and more gradually for girls, with the result that the age-standardised rate for girls was 2.38 times that of boys during 1989–2005 (95% CI, 1.69–3.36).Conclusions: The pattern of CF mortality in Australia has changed substantially. Mortality rates continue to be higher for girls than for boys, but death in childhood has become uncommon. Survival has increased since 1979, but females continue to have reduced length of life.

David W Reid BSc, MB ChB · C Leigh Blizzard PhD · Dace M Shugg RN · Ceri Flowers BSc · Catherine Cash BSc · Hugh M Greville MD