Research

Objectives: To describe the demographics, clinical features and outcomes among people with cystic fibrosis (CF) in Australia and to estimate incidence of the disease.Design and setting: Cross-sectional analysis using data from the Australian Cystic Fibrosis Data Registry for 2009.Main outcome measures: Numbers of diagnoses, pulmonary and anthropometric measurements, microbiological culture results, rates of hospitalisation and transplantation, and numbers of medical complications and deaths.Results: In 2009, data were submitted on 2986 people (48% female). Median age was 17.6 years and 49% of people were aged 18 years or over. Seventy-eight people were newly diagnosed. Fourteen people died and 14 people underwent lung transplantation in the year. Lung function and nutrition were relatively normal among children but deteriorated (more rapidly) among adolescents. With increasing age, progressive respiratory disease was apparent, and the frequency of CF-related complications and use of health care resources increased. In all age groups, there was a wide range in severity of lung disease and nutritional status.Conclusions: CF remains a progressive respiratory disease and is associated with multisystem complications. The acceleration in disease severity in adolescence and early adulthood suggests that better treatment at these stages is required to further improve survival.

Scott C Bell MB BS, MD, FRACP · Peter T P Bye MB BS, PhD, FRACP · Peter J Cooper MB ChB, FRACP · A James Martin MB ChB, MRCP, FRACP · Karen O McKay LLB(Hons), PhD · Phillip J Robinson MD, PhD, FRACP · Gerard F Ryan MB BS, FRACP · Geoff C Sims BComm, GradDip(Pop health), GradCertBiostats

Objective: To investigate how Australian print news media portray psychiatric genetics.Design and setting: Content and framing analysis of a structured sample of print news items about psychiatric genetics published in Australian newspapers between 1996 and 2009.Main outcome measures: Identify dominant discourses about aetiology of mental illness, and perceived clinical outcomes and implications of psychiatric genetics research.Results: We analysed 406 eligible items about the genetics of psychiatric disorders. News coverage of psychiatric genetics has steadily increased since 1996. Items attributing the aetiology of psychiatric disorders to gene–environment interactions (51%) outnumbered items attributing only genetic (30%) or only environmental factors (20%). Of items that referred to heritability of mental illness, frames of genetic determinism (78%) occurred more frequently than probabilistic frames (22%). Of frames related to genetic prophesy, genetic optimism frames (78%) were used more frequently than frames of genetic pessimism (22%). Psychosocial and ethical implications of psychiatric genetics received comparatively relatively little coverage (23%). The analysis identified 22 predictions about psychiatric genetic discoveries and the availability of molecular-based interventions in psychiatry, most of which (20/22, 91%) failed to manifest by the predicted year.Conclusions: Excessive optimism about the power of genetic technology in psychiatric health care, perceived clinical benefits, and largely unfulfilled predictions about availability of these benefits could encourage unrealistic expectations about future molecular-based treatment options for mental health.

Alex Wilde BSc(Hons),PhD · Catriona Bonfiglioli BA(Hons), PhD · Bettina Meiser PhD · Philip B Mitchell AM, MD · Peter R Schofield PhD, DSc

Objective: To evaluate the effectiveness of the Practitioner Asthma Communication and Education (PACE) Australia program, an innovative communication and paediatric asthma management program for general practitioners.Design: Randomised controlled trial.Setting: General practices from two regions in metropolitan Sydney.Participants: 150 GPs, who were recruited between 2006 and 2008, and 221 children with asthma in their care.Intervention: GPs in the intervention group participated in two 3-hour workshops, focusing on communication and education strategies to facilitate quality asthma care.Main outcome measures: Patient outcomes included receipt of a written asthma action plan (WAAP), appropriate medication use, parent days away from work, and child days away from school or child care. GP outcomes included frequency of providing a WAAP and patient education, communication and teaching behaviour, and adherence to national asthma guidelines regarding medication use.Results: More patients of GPs in the intervention group reported receipt of a WAAP (difference, 15%; 95% CI, 2% to 28%; adjusted P = 0.046). In the intervention group, children with infrequent intermittent asthma symptoms had lower use of inhaled corticosteroids (difference, 24%; 95% CI, − 43% to − 5%; P = 0.03) and long-acting bronchodilators (difference, 19%; 95% CI, − 34% to − 5%; P = 0.02). GPs in the intervention group were more confident when communicating with patients (difference 22%; 95% CI, 3% to 40%; P = 0.03). A higher proportion of GPs in the intervention group reported providing a WAAP more than 70% of the time (difference, 23%; 95% CI, 11% to 36%; adjusted P = 0.002) and prescribing spacer devices more than 90% of the time (difference, 29%; 95% CI, 16% to 42%; adjusted P = 0.02).Conclusions: The PACE Australia program improved GPs’ asthma management practices and led to improvements in some important patient outcomes.Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12607000067471.

Smita Shah MB ChB, MCH · Susan M Sawyer MB BS, MD, FRACP · Brett G Toelle DipAppSc(Nursing), BA(Psychology), PhD · Craig M Mellis MPH, MD, FRACP · Jennifer K Peat PhD · Marivic Lagleva BSc(Hons) · Timothy P Usherwood MD, FRACGP, FRCP · Christine R Jenkins MB BS, MD

Objective: To evaluate the effectiveness of formal assessments of prevocational medical trainees (ie, interns, first-year residents and international medical graduates undergoing supervised training).Design and setting: Retrospective review of structured assessment forms that are completed by all prevocational trainees and their supervisors in New South Wales public hospitals. We reviewed the first 3390 assessment forms, representing assessments of 1072 trainees at 43 training sites (83% of all prevocational trainees in NSW) since January 2009.Main outcome measures: (i) Trainee ratings on 19 assessment items by self-assessment and by supervisor assessment; and (ii) quantity and quality of written comments provided in assessments.Results: At the end of term, 43% of trainees assessed themselves as performing “at expected level” on all 19 rating items. Nearly 99% of trainees were assessed by their supervisors as performing at or above the expected level on all assessment items. Written comments by supervisors were generally short and encouraging, but lacked specific feedback that trainees might use to guide improvements in performance.Conclusions: As currently used by trainees and supervisors, the assessment forms may underreport trainee underperformance, do not discriminate strongly between different levels of performance of trainees or the training system, and do not provide trainees with enough specific feedback to guide their professional development.

Craig M Bingham MA, DipEd · Roslyn Crampton MB BS, FACEM

Objective: To describe the frequency, characteristics, and outcomes of medicolegal disputes over informed consent.Design and setting: Retrospective review and analysis of negligence claims against doctors insured by Avant Mutual Group Limited and complaints lodged with the Office of the Health Services Commissioner of Victoria that alleged failures in the informed consent process and were adjudicated between 1 January 2002 and 31 December 2008.Main outcome measures: Case frequency (by medical specialty), type of allegation, type of treatment.Results: A total of 481 cases alleged deficiencies in the informed consent process (218 of 1898 conciliated complaints [11.5%]; 263 of 7846 negligence claims [3.4%]). 57% of these cases were against surgeons. Plastic surgeons experienced dispute rates that were more than twice those of any other specialty or subspecialty group. 92% of cases (442/481) involved surgical procedures and 16% (77/481) involved cosmetic procedures. The primary allegation in 71% of cases was that the clinician failed to mention or properly explain risks of complications. Five treatment types — procedures on reproductive organs (12% of cases), procedures on facial features excluding eyes (12%), prescription medications (8%), eye surgery (7%) and breast surgery (7%) — accounted for 46% of all cases.Conclusions: The typical dispute over informed consent involves an operation, often cosmetic, and allegations that a particular complication was not properly disclosed. With Australian courts now looking to patient preferences in setting legal standards of care for risk disclosure, medicolegal disputes provide valuable insights for targeting both quality improvement efforts and risk management activities.

Andrew J Gogos MB BS · Richard B Clark DHSc · Marie M Bismark MB ChB, LLB · Russell L Gruen MB BS, PhD · David M Studdert LLB, ScD, MPH

Objective: To define the effectiveness of recent efforts by the Australian Division of World Action on Salt and Health, and the Heart Foundation in New Zealand to reduce sodium levels in breads in Australia and New Zealand.Design and setting: Data on the sodium contents of packaged sliced bread products sold in Australian and New Zealand supermarkets were collected from the product labels of 157 breads in 2007 and 167 breads in 2010, and were compared overall, by bread type, by manufacturer, and between nations.Main outcome measures: Mean sodium values in bread and proportions of breads meeting the targets of 400 mg/100 g in Australia and 450 mg/100 g in New Zealand.Results: Overall mean sodium content in bread in Australia was 434 mg/100 g in 2007 and 435 mg/100 g in 2010; corresponding values for New Zealand were 469 mg/100 g and 439 mg/100 g. The proportion of Australian breads meeting the national target increased from 29% in 2007 to 50% in 2010; the proportion of New Zealand breads meeting the national target increased from 49% in 2007 to 90% in 2010. There were clear differences between the results achieved by different companies.Conclusions: Voluntary efforts by non-governmental organisations have had some impact on sodium levels in bread, particularly in New Zealand. However, substantial room for further improvement remains. If additional reductions are not achieved under the current voluntary arrangements, legislated approaches may be required.

Elizabeth K Dunford MPH · Helen Eyles MSc, PhD · Cliona Ni Mhurchu BSc(Hons), PhD · Jacqui L Webster MA, PhD · Bruce C Neal MB ChB, PhD

Objective: To determine whether an association exists between distance from radiotherapy facilities and survival outcomes of people diagnosed with rectal cancer.Design and setting: Descriptive population-based study using data from the Queensland Cancer Registry.Patients: All patients aged 20–79 years (n = 6848) diagnosed with invasive rectal cancer between 1 January 1996 and 31 December 2006.Main outcome measure: Cause-specific survival.Results: The 5-year cause-specific survival was 62% (95% CI, 61%–64%); it was strongly influenced by stage at diagnosis (American Joint Committee on Cancer, Stages I–IV), ranging from 86% (Stage I) to 9% (Stage IV). After adjusting for age, sex, and stage at diagnosis, patients who lived 100–199 km, 200–399 km and 400 km or more from a radiotherapy facility were 16%, 30%, and 25%, respectively, more likely to die from rectal cancer than patients living within 50 km of such a facility. On average, there was a 6% increase in mortality risk (95% CI, 3%–8%; P < 0.001) for each 100 km increment in distance from the nearest radiotherapy facility. Shared frailty models showed that this association persisted after adjusting for the correlation between individual cancer patients living in the same remoteness or area-level socioeconomic status categories.Conclusions: While centralisation of cancer treatment services has merit, our study provides evidence of a shorter survival for people with rectal cancer who live relatively far from radiotherapy facilities. It remains a priority to develop and implement policy, cultural and clinical measures to reduce the burden faced by rural and remote patients with rectal cancer.

Peter D Baade PhD, MMedSc, BAppSc(Hons) · Paramita Dasgupta PhD, MSc, BSc(Hons) · Joanne F Aitken PhD, MSc, BSc(Hons) · Gavin Turrell PhD, BA(Mgt/Adm)

Objective: To determine trends in incidence of malignant mesothelioma (MM) caused by exposure to asbestos during home maintenance and renovation.Design, setting and participants: Using the Western Australian Mesothelioma Register, we reviewed all cases of MM diagnosed in WA from 1960 to the end of 2008, and determined the primary source of exposure to asbestos. Categories of exposure were collapsed into seven groups: asbestos miners and millers from Wittenoom; all other asbestos workers; residents from Wittenoom; home maintenance/renovators; other people exposed but not through their occupation; and people with unknown asbestos exposure; or no known asbestos exposure. Latency periods and age at diagnosis for each group were calculated and compared.Results: In WA, 1631 people (1408 men, 223 women) were diagnosed with MM between 1960 and 2008. Since 1981, there have been 87 cases (55 in men) of MM attributed to asbestos exposure during home maintenance and renovation, and an increasing trend in such cases, in both men and women. In the last 4 years of the study (2005–2008), home renovators accounted for 8.4% of all men and 35.7% of all women diagnosed with MM. After controlling for sex and both year and age at diagnosis, the latency period for people exposed to asbestos during home renovation was significantly shorter than that for all other exposure groups, but the shorter follow-up and difficulty recalling when exposure first occurred in this group may partly explain this.Conclusions: MM after exposure to asbestos during home renovation is an increasing problem in WA, and these cases seem to have a shorter latency period than other types of exposure. MM cases related to renovation will probably continue to increase because of the many homes that have contained, and still contain, asbestos building products.

Nola J Olsen BAppSc, RGN · Peter J Franklin BSc(Hons), PostGradDipEnvSci, PhD · Alison Reid RGN, MSc, PhD · Nicholas H de Klerk BSc, MSc, PhD · Timothy J Threlfall MB BS, MPH, PhD · Keith Shilkin FRCPA, FCRPath, FHKCPath · Bill Musk FRACP, MSc, MD

Objective: To determine the prevalence of multiresistant organism (MRO) colonisation of reusable venesection tourniquets.Design and setting: A prospective study in a tertiary hospital to collect and analyse reusable venesection tourniquets for the presence of MROs — methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and extended-spectrum β-lactamase and metallo-β-lactamase-producing Enterobacteriaceae — using a sensitive enrichment method. Tourniquets were collected and tested during a 10-week period between September and November 2010.Main outcome measure: Prevalence of MRO colonisation of tourniquets.Results: The overall colonisation rate of 100 tourniquets randomly collected from general wards, ambulatory care areas and critical care areas was 78%. MROs were isolated from 25 tourniquets collected from a variety of hospital locations, including general wards, the intensive care unit, burns unit and anaesthetic bay. MRSA was isolated from 14 tourniquets and VRE from 19; both MRSA and VRE were isolated from nine tourniquets. There were no microorganisms isolated from 22 tourniquets.Conclusion: Reusable tourniquets can be colonised with MROs and may be a potential source of transmission of MROs to hospitalised patients.

Angie N Pinto MB BS, BSc, MPHTM · Thuy Phan BSc · Gabriela Sala BSc · Elaine Y L Cheong FRACP, FRCPA · Steven Siarakas BSc, PhD · Thomas Gottlieb FRACP, FRCPA

Objective: To document trends in: (i) prescribing of morphine and oxycodone; (ii) hospital separations for overdose; (iii) presentations for treatment of problems associated with these drugs; and (iv) oxycodone-related mortality data in Australia.Design and setting: Cross-sectional study analysing prescriptions for morphine and oxycodone based on figures adjusted using Australian Bureau of Statistics estimated resident population and prospectively collected data from: (i) the National Hospital Morbidity Database on hospital separations primarily attributed to poisoning with opioids other than heroin (“other opioids”); (ii) the Alcohol and Other Drug Treatment National Minimum Data Set for treatment episodes where morphine or oxycodone were the primary or other drugs of concern; (iii) the National Coronial Information System on deaths where oxycodone was the underlying cause of death or a contributory factor.Main outcome measures: Population-adjusted numbers of (i) prescriptions for morphine and oxycodone by 10-year age group, (ii) hospital separations for “other opioid” poisoning, and (iii) treatment episodes related to morphine or oxycodone; and (iv) number of oxycodone-related deaths.Results: Prescriptions for morphine declined, while those for oxycodone increased. Prescriptions for both were highest among older Australians. Hospital separations for “other opioid” poisoning doubled between the financial years 2005–06 and 2006–07. Treatment episodes for morphine remained stable, while those for oxycodone increased. There were 465 oxycodone-related deaths recorded during 2001–2009.Conclusions: Oxycodone prescriptions in Australia have increased, particularly among older Australians. The increase may, in part, reflect appropriate prescribing for pain among an ageing population. However we are unable to differentiate non-medical use from appropriate prescribing from this data. In comparison to heroin, the morbidity and mortality associated with oxycodone is relatively low in Australia. There is a continued need for comprehensive training of general practitioners in assessing patients with chronic non-malignant pain and prescribing of opioids for these patients, to minimise the potential for harms associated with use of these medications.

Amanda Roxburgh MCrim, MPsych(Clin), MAPS · Raimondo Bruno BSc(Hons), PhD, MAPS · Briony Larance BSc(Psych)(Hons) · Lucy Burns MPH, GradDipHealthPolicy, PhD

Objectives: To describe temporal trends in the use of evidence-based medical therapies and management of patients with acute coronary syndromes (ACS) in Australia and New Zealand.Design, setting and participants: Our analysis of the Australian and New Zealand cohort of the Global Registry of Acute Coronary Events (GRACE) included patients with ST-segment-elevation myocardial infarction (STEMI) and non-ST-segment-elevation ACS (NSTEACS) enrolled continuously between January 2000 and December 2007 from 11 metropolitan and rural centres in Australia and New Zealand.Results: 5615 patients were included in this analysis (1723 with STEMI; 3892 with NSTEACS). During 2000–2007 there was an increase in the use of statin therapy, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and thienopyridines (P < 0.0001 for each). Among patients with STEMI, there was an increase in emergency revascularisation with PCI (from 11% to 27% [P < 0.0001]), and inhospital coronary angiography (from 61% to 76% [P < 0.0001]). Among patients with NSTEACS, there was an increase in revascularisation with PCI (from 20% to 25% [P = 0.004]). Heart failure rates declined substantially among STEMI and NSTEACS patients (from 21% to 12% [P = 0.0002], and from 13% to 4% [P < 0.0001], respectively) as did rates of hospital readmission for ischaemic heart disease at 6 months (from 23% to 9% [P = 0.0001], and from 24% to 15% [P = 0.0001], respectively).Conclusions: From 2000 to 2007 in Australia and New Zealand, there was a fall in inhospital events and 6-month readmissions among patients admitted with ACS. This showed an association with improved uptake of guideline-recommended medical and interventional therapies. These data suggest an overall improvement in the quality of care offered to contemporary ACS patients in Australia and New Zealand.

Bernadette Aliprandi-Costa RN · Isuru Ranasinghe MB BS, MMed · Vincent Chow MB BS · Shruti Kapila MB BS · Craig Juergens MB BS, FRACP, FCSANZ · Gerard Devlin MBChB, FRACP, FCSANZ · John Elliott MBChB, FRACP, FCSANZ · Jeff Lefkowitz MB BS, FRACP, FCSANZ · David B Brieger MB BS, PhD, FRACP

Objective: To evaluate percutaneous coronary intervention (PCI) practice trends and 12-month outcomes in Australia in the era of drug-eluting stents (DES).Design, setting and patients: Prospective study of consecutive patients undergoing 9204 PCIs between 1 April 2004 and 31 March 2008 at seven Victorian public hospitals.Main outcome measures: Temporal trends in baseline characteristics and in-hospital and 12-month clinical outcomes including death, myocardial infarction (MI), target vessel revascularisation (TVR) and composite major adverse cardiac events (MACE), from year to year.Results: Between 2004–2005 and 2007–2008, the mean age of patients undergoing PCI was stable (65 ± 12 years), and comorbidities such as hypertension, hyperlipidaemia, peripheral arterial disease and stroke increased (P < 0.05). There were fewer elective and more urgent PCIs, especially for MI < 24 hours (17.6% in 2004–2005 to 27.2% in 2007–2008, P < 0.01). Overall stent use remained high (mean, 94.6%), but use of DES declined steadily (53.9% in 2004–2005 to 32.0% in 2007–2008, P < 0.01), despite increases in complex lesions. Planned clopidogrel therapy of ≥ 12 months after insertion of DES increased from 54.7% in 2004–2005 to 98.0% in 2007–2008 (P < 0.01). The overall procedural success rate was high (mean, 95.9%), and 12-month rates of mortality (3.8%), MI (4.8%), TVR (6.8%) and stent thrombosis (1.8%) remained low. Selective use of DES was an independent predictor of freedom from MACE at 12 months (odds ratio, 0.68; 95% CI, 0.56–0.81).Conclusions: Use of DES declined steadily from 2004–2005 to 2007–2008, despite increasing patient risk profile and lesion complexity. Procedural success remained high and 12-month adverse outcomes remained low, with increasing use of prolonged dual antiplatelet therapy.

Bryan P Yan MB BS, FRACP, FACC · Andrew E Ajani MB BS, FRACP, MD · David J Clark MB BS, FRACP · Stephen J Duffy MB BS, PhD, FRACP · Nick Andrianopoulos MB BS, MBiostat · Angela L Brennan RN, CCRN · Philippa Loane BSc · Christopher M Reid BA, MSc, PhD

Objective: To assess the relationship between dietary sodium intake, as measured by urinary electrolyte excretion, and blood pressure within a population of older Australian adults.Design, setting and participants: A cross-sectional study of adults enrolled in the Melbourne Collaborative Cohort Study, stratified by sex, country of birth (Italy, Greece, Australia/New Zealand) and age (50–59 and 60–75 years). Blood pressure measurements were taken in 2003–2007 and 24-hour urine collections in 2007–2008.Main outcome measures: 24-hour urinary excretion of sodium and potassium, urinary sodium-to-potassium ratio, and clinic blood pressure measurement.Results: The mean ± SD age of 783 participants was 64.0 ± 6.3 years. Mean ± SD urinary sodium was 155.1 ± 63.1 mmol/day (8.9 ± 3.6 g salt/day), urinary potassium was 82.3 ± 27.9 mmol/day, and urinary sodium-to-potassium ratio was 1.99 ± 0.83. In the 587 participants with blood pressure measurements, urinary sodium and the sodium-to-potassium ratio were both associated with systolic blood pressure in all adjusted and unadjusted models (mmHg change per 100 mmol/day increase in sodium: regression coefficient, 2.3, 95% CI, 0.1–4.6; P = 0.049, adjusted for age, sex, body mass index, country of birth and antihypertensive medication use).Conclusion: This study has demonstrated, for the first time within an Australian population sample of older adults, that sodium intake is positively associated with blood pressure. These results suggest that a population-wide reduction in sodium intake could be effective in reducing blood pressure in adults in Australia.

Catherine E Huggins BSc(Hons), PhD · Sharleen O’Reilly BSc(Hons), PhD, CertHEd · Maree Brinkman BSc(Nutrition), MND · Allison Hodge BSc, GradDipDiet, PhD · Graham G Giles BSc, MSc, PhD · Dallas R English BSC, PhD · Caryl A Nowson PhD, DipNutDiet

Objective: To study patient persistence on therapy for hypertension and dyslipidaemia using a single-pill combination compared with a two-pill approach.Design and setting: Post-hoc observational assessment of Pharmaceutical Benefits Scheme claim records covering the period April 2005 to March 2010.Participants: A 10% random sample of Australian long-term concession card holders was analysed. The patients studied had commenced on either amlodipine and atorvastatin as two individual pills, or a single pill containing both amlodipine and atorvastatin (AA), with neither combined approach having been dispensed to them in the previous 6 months.Main outcome measures: The proportions of patients failing to fill their first repeat prescription after 1 month or failing to persist with treatment at 12 months, and the median persistence time (MPT) were measured.Results: Of 4146 patients prescribed the AA single pill, 11% failed to fill the first repeat prescription and 33% had ceased treatment by 12 months (MPT, 35 months). Of 6204 patients prescribed amlodipine and atorvastatin as two pills, 23% failed to fill the first repeat prescriptions and 59% had ceased treatment by 12 months (MPT, 7 months). In a multivariate model, cessation of single-pill therapy increased by 165% if there was no prior therapy, but only increased by 48%–55% if there was no prior therapy with a calcium channel blocker or statin. MPT on the single pill was 8 months in those without prior antihypertensive therapy, but was ≥ 37 months in those with any prior antihypertensive therapy.Conclusion: A single-pill combination drug is associated with superior long-term persistence compared with two-pill therapy in the management of hypertension and dyslipidaemia.

Leon A Simons MD, FRACP · Michael Ortiz BPharm, PhD · Gordon Calcino BA, GradDipMedStats

Objective: To estimate the number of deaths among people released from prison in Australia in the 2007–08 financial year, within 4 weeks and 1 year of release.Design, participants and setting: Application of crude mortality rates for ex-prisoners (obtained from two independent, state-based record-linkage studies [New South Wales and Western Australia]) to a national estimate of the number and characteristics of people released from prison in 2007–08.Main outcome measures: Estimated number of deaths among adults released from Australian prisons in 2007–08, within 4 weeks and 1 year of release, classified by age, sex, Indigenous status and cause of death.Results: It was estimated that among people released from prison in 2007–08, between 449 (95% CI, 380–527) and 472 (95% CI, 438–507) died within 1 year of release. Of these, between 68 (95% CI, 56–82) and 138 (95% CI, 101–183) died within 4 weeks of release. Most of these deaths were not drug-related.Conclusion: The estimated annual number of deaths among recently released prisoners in Australia is considerably greater than the annual number of deaths in custody, highlighting the extreme vulnerability of this population on return to the community. There is an urgent need to establish a national system for routine monitoring of ex-prisoner mortality and to continue the duty of care beyond the prison walls.

Stuart A Kinner PhD · David B Preen BSc(Hons), PhD · Azar Kariminia BSc, MSc, PhD · Tony Butler PhD, MSc · Jessica Y Andrews BHSci/Comm(Hons) · Mark Stoové PhD · Matthew Law MA, MSc, PhD

Objective: To determine the Australian native ant species associated with ant sting anaphylaxis, geographical distribution of allergic reactions, and feasibility of diagnostic venom-specific IgE (sIgE) testing.Design, setting and participants: Descriptive clinical, entomological and immunological study of Australians with a history of ant sting anaphylaxis, recruited in 2006–2007 through media exposure and referrals from allergy practices and emergency physicians nationwide. We interviewed participants, collected entomological specimens, prepared reference venom extracts, and conducted serum sIgE testing against ant venom panels relevant to the species found in each geographical region.Main outcome measures: Reaction causation attributed using a combination of ant identification and sIgE testing.Results: 376 participants reported 735 systemic reactions. Of 299 participants for whom a cause was determined, 265 (89%; 95% CI, 84%–92%) had reacted clinically to Myrmecia species and 34 (11%; 95% CI, 8%–16%) to green-head ant (Rhytidoponera metallica). Of those with reactions to Myrmecia species, 176 reacted to jack jumper ant (Myrmecia pilosula species complex), 18 to other jumper ants (15 to Myrmecia nigrocincta, three to Myrmecia ludlowi) and 56 to a variety of bulldog ants, with some participants reacting to more than one type of bulldog ant. Variable serological cross-reactivity between bulldog ant species was observed, and sera from patients with bulldog ant allergy were all positive to one or more venoms extracted from Myrmecia forficata, Myrmecia pyriformis and Myrmecia nigriceps.Conclusion: Four main groups of Australian ants cause anaphylaxis. Serum sIgE testing enhances the accuracy of diagnosis and is a prerequisite for administering species-specific venom immunotherapy.

Simon G A Brown MB BS, PhD, FACEM · Pauline van Eeden BAppSci(MLS), PhD · Michael D Wiese BPharm, MClinPharm, PhD · Raymond J Mullins PhD, FRACP, FRCPA · Graham O Solley MB BS, FACP · Robert Puy MB BS, FRACP · Robert W Taylor PhD · Robert J Heddle PhD, FRACP, FRCPA

Objectives: To determine issues that affect newly resettled refugees in accessing an emergency department (ED).Design, setting and participants: We conducted a descriptive community survey using a semistructured questionnaire. Newly resettled refugees from the Middle East and Africa were interviewed, statistical analysis was performed, and standard content analysis methods were applied to free-text responses.Main outcome measures: Emergency health-seeking behaviour, sociocultural barriers and beliefs about Australia’s emergency health services.Results: Half the African refugees (53/106) (50%), compared with only 15/49 (31%) of the Middle Eastern refugees, preferred an ED service over other forms of care for an urgent medical condition (P = 0.024). Qualitative data revealed that most newly resettled refugees understand how to use the emergency health services. However, while most indicated that they were able to make a call for emergency medical help, a substantial number of our respondents revealed that they were afraid to make such a call for fear of security implications, on the basis of experiences from their home countries.Conclusion: Reasons for differences in preferences of health care access, and determining how best to educate the community on the use of ED services, warrant further investigation. From a policy perspective, the increasing health care needs of refugees need re-examination when planning health care provision to refugees.

Mohamud Sheikh DrPH, MHSc, MIPH · Peter I Nugus PhD · Zhanhai Gao PhD · Anna Holdgate MB BS, MMed, FACEM · Alison E Short PhD · Ayman Al Haboub BPharm, MIPH · C Raina MacIntyre FRACP, MAppEpid, PhD

Amanda Leach (centre), coauthor of the winning article and recipient of the 2010 MJA/Pfizer Research Award, with Bill Ketelby, Country Medical Director of Pfizer (left), and Annette Katelaris, Editor of the MJA (right). I am pleased to announce the winner of the Medical Journal of Australia/Pfizer Australia Research Award for 2010. This $10 000 award recognises and rewards the best original research published each year in the Journal, and was presented at the annual Australian Medical Association National Conference in May this year. This year, the Journal’s Content Review Committee awarded the 2010 prize to Peter Morris and his colleagues from the Menzies School of Health Research, Charles Darwin University and the Northern Territory Clinical School of Flinders University in Darwin and Royal Prince Alfred Hospital in Sydney for their article, “Single-dose azithromycin versus seven days of amoxycillin in the treatment of acute otitis media in Aboriginal children (AATAAC): a double blind, randomised controlled trial”. This trial was funded by the National Health and Medical Research Council and the report was published in the Medical Journal of Australia on 4 January 2010. Acute otitis media, particularly perforation of the tympanic membrane, is a major public health problem among Aboriginal children. Only one in 10 children has bilaterally normal ears and hearing. This research group has previously found that long-term antibiotic treatment resolves middle ear effusion and prevents perforation. Because of often poor compliance with treatment regimens over several days, this trial compared a one-off intervention with a standard 7-day regimen. They found that single-dose azithromycin was more effective than a 7-day course of amoxycillin at eliminating the bacterial pathogens, but it was not more effective at curing acute otitis media in this population. Disturbingly, both treatments failed in half the cases treated. The group is now evaluating a double-dose regimen of azithromycin. This was the first randomised controlled trial of antibiotic treatment of acute otitis media in a population with high rates of acute and chronic tympanic membrane perforation. Because single-dose therapy virtually ensures treatment compliance, the findings of this study are potentially practice changing. This award has been sponsored by Wyeth Australia since 1995. We are grateful for their support over the years, and now welcome Pfizer, who acquired Wyeth in 2009, as our cosponsor. The award was presented by Dr Bill Ketelby, Country Medical Director of Pfizer. Pfizer had no role in the study or in the choice of a winner, and it was purely coincidental that a drug that is manufactured by the company was used in the study.

Annette Katelaris MB BS, MPH, FRACGP

Objective: To assess the influence of area-level socioeconomic status (SES) on incidence and case-fatality rates for stroke.Design, setting and participants: Analysis of pooled data for 3077 patients with incident stroke from three population-based studies in Perth, Melbourne, and Auckland between 1995 and 2003.Main outcome measures: Incidence and 12-month case-fatality rates for stroke.Results: Annual age-standardised stroke incidence rates ranged from 77 per 100 000 person-years (95% CI, 72–83) in the least deprived areas to 131 per 100 000 person-years (95% CI, 120–141) in the most deprived areas (rate ratio, 1.70; 95% CI, 1.47–1.95; P < 0.001). The population attributable risk of stroke was 19% (95% CI, 12%–27%) for those living in the most deprived areas compared with the least deprived areas. Compared with people in the least deprived areas, those in the most deprived areas tended to be younger (mean age, 68 v 77 years; P < 0.001), had more comorbidities such as hypertension (58% v 51%; P < 0.001) and diabetes (22% v 12%; P < 0.001), and were more likely to smoke (23% v 8%; P < 0.001). After adjustment for age, area-level SES was not associated with 12-month case-fatality rate.Conclusions: Our analysis provides evidence that people living in areas that are relatively more deprived in socioeconomic terms experience higher rates of stroke. This may be explained by a higher prevalence of risk factors among these populations, such as hypertension, diabetes and cigarette smoking. Effective preventive measures in the more deprived areas of the community could substantially reduce rates of stroke.

Emma L Heeley MSc, PhD · Jade W Wei BPharm · Kristie Carter PhD · Md Shaheenul Islam MB BS, MPH, MSc · Amanda G Thrift PhD · Graeme J Hankey MD · Alan Cass PhD · Craig S Anderson MD, PhD

Objective: This study examined the knowledge of stroke warning signs and risk factors among the general public, including what they would do if they were to develop such symptoms.Design, setting and participants: Population study of randomly selected members of the general public in Adelaide, South Australia. A simple survey assessed knowledge of stroke warning signs and gave four options for management. The survey was conducted on three separate occasions: before, immediately after and 3 months after the National Stroke Foundation’s National Stroke Week in 2009.Main outcome measures: The outcome measures were the public perception of risk factors and warning signs of stroke and what the members of the public would do if presented with a range of warning signs. They were also asked about their knowledge of the Face, Arms, Speech, Time (FAST) test.Results: The three surveys were completed by 251 members of the public. Hypertension and smoking were recognised as risk factors for stroke by 71% and 53% of respondents respectively. Before National Stroke Week, slurred speech was identified by 51% and both slurred speech and upper limb sensory loss was identified by 62% as warning signs to provoke presentation to an emergency department (ED). Amaurosis, upper limb sensory loss, upper limb numbness and upper limb weakness were correctly identified individually as warning signs to attend an ED by fewer than one-third of respondents. There was no significant difference in the survey results following National Stroke Week. Conclusions: Public awareness of the symptoms of stroke, and what to do about them, is limited. There was little improvement after the national week-long awareness campaign. The lack of public awareness about stroke warning signs must be addressed to reduce mortality and morbidity from stroke.

J Ian Spark MD, FRCS, FRACS · Nadia Blest MB BS · Sheralee Sandison RN, MN · Phillip J Puckridge MB BS, FRACS · Hafees A Saleem MB BS, MRCSEd · David A Russell MB ChB, MD, FRCS

Objective: To assess the impact of the quick-service restaurant industry (QSRI) self-regulatory initiative on fast-food advertising to children on Australian commercial television.Design and setting: Analysis of advertisements for foods on the three main free-to-air commercial television channels (channels 7, 9 and 10) in Sydney, Australia, over 4 days in both May 2009 and April 2010 in terms of: number of advertisements; types of food (coded core [healthy] foods, non-core [unhealthy] foods, miscellaneous foods; or fast foods); whether advertised meals were intended for children; whether advertisements were broadcast during children’s peak viewing times; and whether the company in question was a signatory to the QSRI initiative.Main outcome measures: Change in the mean frequency and rate of food advertisements per hour from 2009 to 2010; change in the types of fast-food meals (healthier alternatives [at least one nutrient-dense, low-energy food considered part of a healthy diet for children], non-core [high in undesirable nutrients and not considered part of a healthy diet for children], and other) being advertised; and proportion of children’s energy requirements provided by fast-food meals.Results: From 2009 to 2010, the mean frequency of fast-food advertisements increased from 1.1 to 1.5 per hour. While non-core fast foods comprised a lesser share of fast-food advertising in 2010 than 2009, the mean frequency at which they were advertised during times when the largest numbers of children were watching television remained the same (1.3 per hour in both 2009 and 2010). Family meals advertised for children’s consumption in 2010 provided energy far in excess of children’s requirements.Conclusions: Children’s exposure to unhealthy fast-food advertising has not changed following the introduction of self-regulation, and some fast foods advertised for children’s consumption contain excessive energy. The limited impact of self-regulation suggests that governments should define the policy framework for regulating fast-food advertising to children.

Lana A Hebden BND · Lesley King MPsych(Hons) · Anne Grunseit PhD · Bridget Kelly MPH, BSc(Nutr)(Hons) · Kathy Chapman MNutrDiet, BSc

Objective: To identify characteristics of doctors who are repeated subjects of complaints by patients.Design and setting: Case–control study of doctors about whom patients had complained to the Victorian Health Services Commissioner between 1 January 2000 and 31 December 2009.Participants: 384 doctors in private practice; cases comprised 96 doctors who were the subject of four or more separate complaints; and the control group comprised 288 doctors who were the subject of a single complaint over the study period.Results: Among doctors in private practice in Victoria, 20.5% (95% CI, 19.7%–21.3%) experienced at least one complaint over the decade. Among doctors who were the subject of a complaint, 4.5% (95% CI, 3.6%–5.4%) had four or more complaints, and this group accounted for 17.6% (95% CI, 16.3%–19.0%) of all complaints to the Victorian Health Services Commissioner. Multivariate analyses showed that surgeons (odds ratio [OR], 8.90; 95% CI, 3.69–21.50) and psychiatrists (OR, 4.59; 95% CI, 1.46–14.43) had higher odds of being in the complaint-prone group than general practitioners. Doctors trained overseas had lower odds of being complaint-prone than those trained in Australia (OR, 0.31; 95% CI, 0.13–0.72).Conclusions: A small group of doctors in private practice in Victoria account for nearly 18% of complaints. Interventions to improve patient satisfaction and public confidence in health services should target complaint-prone subgroups of practitioners.

Marie M Bismark MB ChB, LLB, MBHL · Matthew J Spittal BSc(Hon), PhD · David M Studdert LLB, ScD, MPH

Objectives: To report on the burden of disease in Australian infants with congenital cytomegalovirus (cCMV) infection in the era of neonatal hearing screening and improved diagnostic techniques.Design, setting and participants: National data were collected from across Australia via the Australian Paediatric Surveillance Unit (APSU) with monthly reporting by > 1000 clinicians between January 1999 and February 2009. For each reported case, data on investigations and epidemiological and clinical features were analysed. Detailed clinical reviews were performed on 42 infants in two Sydney tertiary paediatric infectious diseases clinics.Results: There were 195 infants with cCMV identified, including 126 definite and 69 probable cases. Of these, 175 (90%) were symptomatic and only 15 were treated with antiviral agents. Identification was delayed beyond 60 days of age in 30 cases (15%). During the period of study, neonatal hearing screening was introduced for most Australian infants. Detection of hearing loss increased from 19% of cCMV cases in 1999–2003 to 31% in 2004–2009. Of 42 infants whose cases were reviewed in detail, 33 (79%) had symptomatic disease. DNA detection of CMV, using polymerase chain reaction testing of newborn screening cards, was useful in retrospective identification, and was strongly correlated with the presence of clinical sequelae (15/18; 83%).Conclusions: Congenital CMV is underdiagnosed, infrequently treated, and often manifests as isolated hearing loss. Delayed diagnoses both before and after the introduction of neonatal hearing screening represent missed treatment and management opportunities and are likely to lead to poorer, life-long outcomes for these children. Retrospective analysis of newborn screening cards for CMV should be undertaken for infants with sensorineural hearing loss, to identify unrecognised cCMV.

Brendan J McMullan BMed(Hons), DTMH, DCH · Pamela Palasanthiran MB BS, FRACP, MD · Cheryl A Jones MB BS, FRACP, PhD · Beverley M Hall RN, RM, MPH · Peter W Robertson PhD · Jonathan Howard BSc(Hons), PhD · William D Rawlinson PhD, FRACP, FRCPA

Objective: The development of an effective therapeutic equivalence program (TEP) through the collaborative support of medical staff, using the principles of disinvestment.Design and setting: A TEP was introduced at Southern Health, a metropolitan health service in Melbourne, in the 2006–07 financial year. Therapeutic classes were selected for the TEP by stakeholder consensus, and a preferred medication for each class was selected on the basis of cost considerations and therapeutic equivalence. New patients were commenced on preferred medicines, but patients receiving another medicine from a therapeutic class included in the program were not automatically switched to the preferred medicine. For the first 4 years of the program, prescribing patterns were monitored, and savings achieved (due to lower prices for and increased use of preferred medicines) were calculated on a monthly basis.Main outcome measures: Prescribing trends for preferred medicines, as a measure of acceptance of the TEP, and savings produced by the program.Results: Over the 4-year study period, 11 therapeutic classes were targeted. The use of all preferred medicines increased once they become part of the TEP and a total of $3.16 million was saved. The annual savings increased each year, and the rate of increase was six times that of the increase in patient separations.Conclusions: The TEP at Southern Health resulted in significant savings. It showed that, by using a collaborative and evidence-based approach, the principles of disinvestment can be applied to use of medicines.

Ian Larmour BPharm, FSHP, MSc · Silvana Pignataro BPharm(Hons) · Kerryn L Barned BPharm(Hons) · Stav Mantas BPharm(Hons) · Melvyn G Korman MB BS, PhD, FRACP

Objectives: To describe hospital and emergency department use in the last year of life by people for whom death from cancer or one of another nine conditions was an expected outcome.Design, participants and setting: Retrospective cross-sectional study based on death registrations and morbidity data for 1071 Western Australians who died between 1 August 2005 and 30 June 2006. Decedents had an informal primary carer, did not live in residential aged care and died of a condition amenable to palliative care.Main outcome measures: Total number of hospital admissions; emergency presentations (with and without hospital admission); days spent in hospital by age group at death, sex, metropolitan or rural place of residence and cancer versus non-cancer diagnosis; proportion in hospital on any day in the last 365 days of life; time points of change in the last 365 days of life at which there was an increasing proportion of hospital admissions for those with cancer and non-cancer conditions.Results: All but 4% of the decedents spent time in hospital with a marked increase in hospitalisations in the last 108 days of life for people who died of cancer and the last 83 days of life for people who died of non-cancer conditions. Those with cancer spent less time in hospital than those with other diagnoses. Seventy per cent of the cohort had at least one emergency presentation. On the last day of life, 61.5% of people were in hospital and 4.0% had been seen in emergency departments.Conclusions: Western Australian hospitals currently provide extensive and progressively greater care at the end of life. Identifying patterns of emergency and inpatient use for various disease trajectories will assist in the planning of appropriate services for people where death is an expected outcome.

Lorna K Rosenwax BAppSc(OT), MSc, PhD · Beverley A McNamara BA(Hons), Dip(Teach), PhD · Kevin Murray BSc(Hons), MSc · Rebecca J McCabe BBus, GradCertBus, MCom(Bus Admin) · Samar M Aoun BSc(Hons), PhD, MPH · David C Currow BMed, FRACP, MPH