Research

Objective: To report the rate of thrombolysis for treating acute stroke in South Australia from October 2007 to September 2009. We hypothesised that the rate of thrombolytic therapy would be related to distance from an acute stroke unit.Design, setting and patients: An observational, population-based, retrospective review of case notes and imaging, using multiple case-ascertainment methods. Patients administered a thrombolytic agent by any method for suspected ischaemic stroke in urban, rural, public and private hospitals in SA (covering a population of 1.5 million people) were included.Main outcome measures: Absolute and relative contraindications for thrombolysis administration in each case, according to the 2007 National Stroke Foundation guidelines; incidence of haemorrhage; and population thrombolysis rates according to distance from an acute stroke unit.Results: A total of 158 cases of thrombolytic therapy for suspected acute ischaemic stroke were identified in 157 patients. Fifteen patients (10%) had symptomatic intracranial haemorrhage, of whom eight (5%) died within 3 months. Seven patients had symptomatic extracranial haemorrhage. Five patients (3%) received thrombolysis despite absolute contraindications. Patients living closer to stroke units were more likely to receive thrombolysis.Conclusions: Rates of symptomatic haemorrhage after thrombolysis were similar to those in voluntary registries. A large proportion of South Australians are currently missing out on acute stroke therapy as a result of poor access to acute stroke units in both urban and rural settings. It is estimated that fewer than 2% of ischaemic stroke patients are administered thrombolysis in SA.

James M Leyden MB BS, FRACP · Woon K Chong MB BS, FRANZCR · Tim Kleinig MB BS(Hons), FRACP, PhD · Andrew Lee MB BS, MPH, FRACP · John B Field PhD, AStat · Jim Jannes BM BS, FRACP, PhD

Objective: To evaluate trends in the incidence and serotype profile of invasive pneumococcal disease (IPD) in Australian children under 2 years of age after the introduction of the 7-valent pneumococcal conjugate vaccine (7vPCV).Design and setting: Analysis of incidence rates calculated using IPD surveillance data (including age, Indigenous status and serotype of the pneumococcal isolate) from 2002 to 2007 obtained from the National Notifiable Diseases Surveillance System and population estimates obtained from the Australian Bureau of Statistics.Main outcome measures: Trends in IPD incidence among Indigenous and non-Indigenous children between 2002 and 2007; change in the serotype profile of IPD in non-Indigenous children after the introduction of universal 7vPCV vaccination in 2005.Results: Overall incidence of IPD decreased by 74% in all children < 2 years of age between 2002 and 2007 (P < 0.001). While the incidence of IPD caused by 7vPCV serotypes decreased significantly among both Indigenous and non-Indigenous children, the incidence of non-7vPCV serotype IPD increased significantly in non-Indigenous children (from 9.7 to 15.7 per 100 000, P < 0.001). Compared with a pre-vaccination period (2002–2004), the 2007 incidence of serotype 19A IPD in non-Indigenous children increased significantly (from 2.7 to 8.6 per 100 000, P < 0.001). In 2007, 19A was the predominant serotype causing IPD (37.7%) in all children aged < 2 years.Conclusions: The overall incidence of IPD decreased from 2002 to 2007, primarily driven by a reduction in IPD caused by 7vPCV serotypes. However, this was partially offset by a significant increase in the incidence of IPD caused by non-7vPCV serotypes, particularly 19A, in non-Indigenous children.

Scott R Williams BSc(Hons), MB BS · Paul J Mernagh BEc(Hons), MCom · Michael H T Lee BA, MB BCh BAO · Jonathan T Tan BSc(Hons), PhD

Objective: To examine the adequacy of policies at Australian medical schools for managing potential conflicts of interest with the pharmaceutical industry.Design, setting and participants: National survey of 20 Australian medical schools to assess their policies regarding disclosure and management of conflict of interest, undertaken in October 2009, using the American Medical Student Association’s PharmFree Scorecard.Main outcome measures: Policy scores and grades for Australian medical schools.Results: Compared with United States medical schools, Australian medical schools performed better in only the curriculum domain and had a lower mean score overall (44% v 58%; P < 0.001).Conclusion: Our results indicate a need for improved self-regulation of conflicts of interest in Australian medical schools.

Paul R Mason MB BS, BPhysio · Martin H N Tattersall MD, MSc, FRACP

Objective: To determine the impact that mandatory fortification with folic acid of wheat flour used in breadmaking has had on the blood folate levels of an Australian population since it was introduced in September 2009.Design, setting and patients: A retrospective analysis of serum and red blood cell (RBC) folate levels of 20 592 blood samples collected between April 2007 and April 2010 from a wide variety of inpatients and outpatients and analysed in a large public hospital diagnostic pathology laboratory.Main outcome measures: Prevalences of low levels of serum and RBC folate and monthly mean levels before and after introduction of mandatory fortification.Results: Between April 2009 and April 2010, there was a 77% reduction in the prevalence of low serum folate levels (from 9.3% to 2.1%) in all samples tested and an 85% reduction in the prevalence of low RBC folate levels (from 3.4% to 0.5%). In April 2010, the prevalence of low RBC folate levels for females of childbearing age was 0.16% for all samples. There was a 31% increase in mean serum folate level (from 17.7 nmol/L to 23.1 nmol/L; t = 9.3, P < 0.01), and a 22% increase in mean RBC folate level (from 881 nmol/L to 1071 nmol/L). The greatest increment in mean serum folate levels occurred in September 2009, the month that mandatory fortification was introduced, although there was evidence of a gradual change during the preceding months.Conclusion: The introduction of mandatory fortification with folic acid has significantly reduced the prevalence of folate deficiency in Australia, including in women of childbearing age.

Ross D Brown PhD, MBA, FAIMS · Mark R Langshaw BAppSci, GradDipIT · Elaine J Uhr MSc(BiolSc) · John N Gibson PhD, FRACP, FRCPA · Douglas E Joshua DPhil, FRACP, FRCPA

Objective: To determine antibody levels and estimate incidence of infection with pandemic (H1N1) 2009 influenza in children and pregnant women during the 2009 winter in Western Australia.Design, setting and participants: Two cross-sectional serosurveys using stored specimens collected for unrelated pathology testing, from before and after (3 August to 30 November 2009) circulation of the pandemic virus, and before commencement of the pandemic vaccination program. Specimens were from three groups: children aged 1–4 years, older children and teenagers aged 5–19 years, and pregnant women aged 21–45 years. The groups were geographically representative of the WA population.Main outcome measures: Reactivity against pandemic (H1N1) 2009 and seasonal A(H1N1) influenza viruses measured using haemagglutination inhibition (HI) assays.Results: Antibody titres were determined for 648 individuals in the prepandemic period and 736 in the postpandemic period. In the prepandemic period, HI titres ≥ 40 against the pandemic virus were found in 0 (95% CI, 0.0%–1.6%) children aged 1–4 years, 8.3% (95% CI, 5.3%–12.7%) of older children and teenagers, and 4.5% (95% CI, 2.4%–8.3%) of pregnant women. In postpandemic specimens collected from 1 September 2009 (when influenza activity had declined to near-baseline levels), estimated infection rates (subtracting prepandemic levels) were 25.4% (95% CI for difference, 18.6%–33.4%) in 1–4-year-old children, 39.4% (95% CI, 29.8%–48.5%) in older children and teenagers, and 10.2% (95% CI, 4.1%–17.1%) in pregnant women.Conclusions: A quarter of preschool children and about 40% of school-aged children and older teenagers had serological evidence of pandemic influenza infection during winter 2009, indicating high levels of mild or asymptomatic infection. The infection rate in pregnant women was much lower. The high infection rates in children help explain the reduced impact of the pandemic virus during the 2010 winter. Augmented by vaccination, there should be sufficiently high levels of immunity in the Australian population to significantly reduce the impact of the virus in future influenza seasons.

Gary K Dowse MB BS, MSc, FAFPHM · David W Smith BMedSc, MB BS, FRCPA · Heath Kelly MB BS, MPH · Ian Barr PhD · Karen L Laurie BSc(Hons), PhD · Anthony R Jones BSc, MASM · Anthony D Keil MB BS, FRCPA · Paul Effler MD, FAFPHM

Objective: To report the latest conditional survival estimates for patients with cancer in Queensland, Australia.Design, setting and participants: Descriptive study of state-wide population-based data from the Queensland Cancer Registry on patients aged 15–89 years who were diagnosed with invasive cancer between 1982 and 2007.Main outcome measure: Conditional 5-year relative survival for the 13 most common types of invasive cancer, and all cancers combined.Results: The prognosis for patients with cancer generally improves with each additional year that they survive. A significant excess in mortality compared with the general population ceases to occur within 10 years after diagnosis for survivors of stomach, colorectal, cervical and thyroid cancer and melanoma, with these groups having a conditional 5-year relative survival of at least 95% after 10 years. For the remaining cancers we studied (pancreatic, lung, breast, prostate, kidney, and bladder cancer, non-Hodgkin lymphoma, and leukaemia), conditional 5-year relative survival estimates (at 10 years after diagnosis) ranged from 82% to 94%, suggesting that patients in these cohorts continue to have poorer survival compared with the age-matched general population.Conclusions: Estimates of conditional survival have the potential to provide useful information for cancer clinicians, patients and their carers as they are confronted by personal and surveillance-related decisions. This knowledge may be effective in building realistic hope and helping people manage uncertainty about the future. We suggest that measures of conditional survival be incorporated into routine statistical reporting in Australia.

Peter D Baade PhD · Danny R Youlden BSc · Suzanne K Chambers PhD

Objective: To model the impact of both population and high-risk strategies on cardiovascular disease (CVD) outcomes.Design, setting and participants: A CVD risk-factor survey was carried out in rural south-eastern Australia from 2004 to 2006. Using a stratified random sample, data for 1116 participants aged 35–74 years were analysed. Applying the Framingham risk equations to risk-factor data, 5-year probabilities of a coronary heart disease event, stroke and cardiovascular event were calculated. The effect of different changes in risk factors were modelled to assess the extent to which cardiovascular diseases can be prevented by changing the risk factors at a population level (population strategy), among the high-risk individuals (high-risk strategy) or both.Results: Among men, a population strategy could reduce cardiovascular events by 19.3% (193 per 1000 per 5 years), the high-risk strategy by 12.6% (126 per 1000) and a combined strategy by 24.1% (241 per 1000); and among women, by 21.9% (219 per 1000), 19.0% (190 per 1000) and 28.7% (287 per 1000), respectively.Conclusions: For prevention of CVD in Australia, it is important both to treat high-risk individuals and to reduce the mean risk-factor levels in the population. We show how risk-factor survey data can be used to set targets for prevention and to monitor progress in line with the recommendations of the National Preventative Health Taskforce.

Erkki A Vartiainen MD, PhD · Tiina Laatikainen MD, PhD · Benjamin Philpot BSc · Edward D Janus MD, PhD · Nathalie Davis-Lameloise PhD · James A Dunbar MD, FRACGP

Objective: To quantify and characterise the reports of syncope and seizures following quadrivalent (4v) human papillomavirus (HPV) vaccination.Design and setting: Retrospective case series of notifications to SAEFVIC (Surveillance of Adverse Events Following Vaccination In the Community), May 2007 – April 2009.Main outcome measures: Incidence of syncope and seizure following 4vHPV vaccination; clinical outcomes.Results: 97/1653 SAEFVIC reports met the study criteria: afebrile seizures (3), syncopal seizures (31) and syncope alone (63). Median age at vaccination was 15 years (range, 8–26 years). Injuries were reported in seven cases, including one vertebral fracture. A SAEFVIC clinic review was undertaken in 41% (40/97) and 22 patients received further 4vHPV vaccine doses administered supine, with no recurrences. The reporting rate after 4vHPV vaccine for syncope and syncopal seizures was 7.8/100 000 and 2.6/100 000 doses distributed, respectively.Conclusion: Syncope and syncopal seizures occurred after 4vHPV vaccination in Victoria at rates similar to those seen internationally. Clinical review allowed clarification of the diagnosis and management, including safe administration of further doses under supervision.

Nigel W Crawford · Hazel J Clothier MEpid · Sonja Elia RN · Teresa Lazzaro MB BS · Jenny Royle MB BS, MD · Jim P Buttery MB BS, MSc

Objective: To assess background pre-pandemic cross-reacting antibodies to the pandemic (H1N1) 2009 virus in older populations in Australia.Design, setting and participants: Data were opportunistically generated from three cross-sectional pre-pandemic studies involving people aged 60 years or older: a 3-year (2006–2008) study of influenza outbreaks in aged care facilities (ACFs) in Sydney; an investigation of a respiratory virus outbreak in an ACF in rural New South Wales in June 2009; and a non-influenza serosurvey undertaken in NSW in 2007 and 2008.Main outcome measure: Prevalence of pandemic (H1N1) 2009 haemagglutination inhibition (HAI) antibody titres ≥ 1:40 (putative protective level) in pre-pandemic sera.Results: In total, 259 serum samples from individuals aged 60 years or older (range, 60–101 years) were tested. More than half of the individuals tested were women (151/259; 58.3%). About a third of individuals (37.5%) had cross-reacting HAI antibody titres ≥ 1:40. The prevalence of cross-reacting antibodies was highest in the oldest age groups (≥ 85 years), with more than 60% of these people having HAI antibody titres ≥ 1:40. The proportion of subjects with HAI antibody titres ≥ 1:40 decreased significantly and successively in younger groups to only 12% of those aged 60–64 years.Conclusions: Our study suggests a pre-existing influenza A antibody reserve in most of the oldest group of people that was cross-reactive to the new pandemic (H1N1) 2009 virus; this is likely to be lifelong and to have provided them with clinical protection against the first wave of the pandemic. Pandemic influenza control measures need to focus more on younger adults naive to the pandemic virus and at increased risk of severe disease.

Robert Booy MD, FRACP, FRCPCH · Gulam Khandaker MB BS, MPH, DCH · Leon G Heron MB ChB, FRCPA, FAFPHM · Jiehui Yin MB BS, MPH(Hons) · Bridget Doyle BAppSci, GradDipEd · Katherine K Tudo BMedSci · Linda Hueston BSc, MSc · Gwendolyn L Gilbert MD, FRACP, FRCPA · C Raina MacIntyre MB BS(Hons), PhD, FRACP · Dominic E Dwyer MD, FRACP, FRCPA

Objective: To determine the prevalence and diagnosis rates of Klinefelter syndrome (KS) in Victoria, Australia, and compare these to previous international findings.Design, setting and participants: A Victorian population-based descriptive study of all cytogenetic examinations resulting in a diagnosis of KS, including prenatal diagnoses from 1986 to 2006 and postnatal diagnoses from 1991 to 2006.Main outcome measures: Birth prevalence and diagnosis rates of KS.Results: The birth prevalence of KS in Victoria is estimated to be 223 per 100 000 males (95% CI, 195–254), with about 50% of cases remaining undiagnosed.Conclusions: KS may be occurring more frequently than has been reported previously, yet many cases remain undiagnosed. Our results highlight the need for increased awareness leading to timely detection.

Amy S Herlihy BSc, GradDipGenCounsel · Jane L Halliday BSc(Hons), PhD · Megan L Cock BSc(Hons), PhD · Robert I McLachlan MB BS, PhD

Objective: To compare the level and determinants of job satisfaction between four groups of Australian doctors: general practitioners, specialists, specialists-in-training, and hospital non-specialists.Design, participants and setting: National cross-sectional questionnaire survey as part of the baseline cohort of a longitudinal survey of Australian doctors in clinical practice (Medicine in Australia — Balancing Employment and Life [MABEL]), undertaken between June and November 2008, including 5193 Australian doctors (2223 GPs, 2011 specialists, 351 hospital non-specialists, and 608 specialists-in-training).Main outcome measures: Job satisfaction scores for each group of doctors; the association between job satisfaction and doctor, job and geographical characteristics.Results: 85.7% of doctors were moderately or very satisfied with their jobs. There were no differences in job satisfaction between GPs, specialists and specialists-in-training. Hospital non-specialists were the least satisfied compared with GPs (odds ratio [OR], 0.56 [95% CI, 0.39–0.81]). For all doctors, factors associated with high job satisfaction were a good support network (OR, 1.72 [95% CI, 1.41–2.10]), patients not having unrealistic expectations (OR, 1.48 [95% CI, 1.25–1.75]), and having no difficulty in taking time off work (OR,1.48 [95% CI, 1.20–1.84]). These associations did not vary across doctor types. Compared with GPs, on-call work was associated with lower job satisfaction for specialists (OR, 0.48 [95% CI, 0.23–0.98]) and hospital non-specialists (OR, 0.25 [95% CI, 0.08–0.83]).Conclusion: This is the first national survey of job satisfaction for doctors in Australia. It provides an important baseline to examine the impact of future health care reforms and other policy changes on the job satisfaction of doctors.

Catherine M Joyce BA(Hons), MPsych, PhD · Stefanie Schurer MSc, PhD · Anthony Scott BA, MSc, PhD · John Humphreys BA(Hons), DipEd, PhD · Guyonne Kalb MEc, PhD

Objective: To document presenting symptoms, investigations and management for Australian patients with oesophageal adenocarcinoma (OAC), gastro-oesophageal junction adenocarcinoma (GOJAC) and oesophageal squamous cell carcinoma (OSCC).Design, setting and participants: Cross-sectional study of a population-based sample of 1100 Australian patients aged 18–79 years with histologically confirmed oesophageal cancer diagnosed in 2002–2005, using data from cancer registries and treatment centres, supplemented with clinical information collected through medical record review in 2006–2007 and mortality information collected in 2008.Main outcome measures: Prevalence of primary symptoms, and staging investigations and treatment modalities used.Results: The primary presenting symptom was dysphagia, which was self-reported by 41%, 39% and 48% of patients with OAC, GOJAC and OSCC, respectively. Less common symptoms were reflux, chest pain, bleeding and weight loss. All patients underwent endoscopy, most had a staging computed tomography scan (OAC 93%, GOJAC 95% and OSCC 93%), and about half had positron emission tomography scans (OAC 51%, GOJAC 44% and OSCC 42%). Pretreatment tumour stage was reported in 25% of records, and could be derived from results of investigations in a further 23%, but the remaining half lacked sufficient information to ascribe a pretreatment stage. Curative treatments were attempted for 60% of OAC, 88% of GOJAC and 65% of OSCC patients. Surgery was performed on 52% of OAC, 83% of GOJAC and 41% of OSCC patients. About two-thirds of surgical patients received additional therapies.Conclusions: With anticipated increases in oesophageal cancer incidence, the resources required to diagnose and manage patients with oesphageal cancer are also likely to rise. Our data provide a baseline from which to plan for the future care of patients with cancers of the oesophagus.

Bernard M Smithers MB BS, FRACS, FRCS · Paul P Fahey BSc, MMedStat · Tracie Corish RN · David C Gotley MD, FRACS · Gregory L Falk FRACS, FACS · Garett S Smith MS, FRACS · George K Kiroff MB BS, MS, FRACS · Andrew D Clouston MB BS, PhD, FRCPA · David I Watson MD, FRACS · David C Whiteman MB BS,PhD, FAFPHM

Objectives: To explore the perceived impact of medicolegal concerns on how Australian doctors practise medicine and to compare doctors who have experienced a medicolegal matter with those who have not.Design and setting: Cross-sectional survey (posted in September 2007, with reminder 4 weeks later) of Australian doctors from all major specialty groups, trainees and a sample of general practitioners who were insured with a medical insurance company.Participants: 2999 respondents of 8360 who were sent the survey.Main outcome measures: Perceived practice changes due to concerns about medicolegal issues, beliefs about medicolegal issues, and the influence of medicolegal issues on both career choices and how doctors relate to their patients.Results: Respondents reported changes in practice behaviour due to medicolegal concerns, with 43% of doctors stating that they referred patients more than usual, 55% stating that they ordered tests more than usual, and 11% stating that they prescribed medications more than usual. Respondents also reported improved communication of risk (66%), increased disclosure of uncertainty (44%), developed better systems for tracking results (48%) and better methods for identifying non-attenders (39%) and for auditing clinical practice (35%). Concerns about medicolegal issues led to 33% considering giving up medicine, 32% considering reducing their working hours and 40% considering retiring early. These proportions were all significantly greater for doctors who had previously experienced a medicolegal matter compared with those who had not.Conclusions: This Australian study, like international studies, confirms that doctors’ concerns about medicolegal issues impact on their practice in a variety of ways. There is a greater perceived impact on those doctors who have previously experienced a medicolegal matter.

Louise M Nash MB BS(Hons), BA, FRANZCP · Merrilyn M Walton BA, MSW, PhD · Michele G Daly BSc(Hons), MSc · Patrick J Kelly BMath(Hons), PhD · Garry Walter BMedSc, PhD, FRANZCP · Elizabeth H van Ekert BA, DipEd, MMedHum · Simon M Willcock MB BS, PhD · Christopher C Tennant MD, MPH, FRANZCP

Objectives: To compare survival among the subgroup of children with acute lymphoblastic leukaemia (ALL) who were treated at Princess Margaret Hospital for Children (PMH) in Perth, Western Australia, over 25 years under 15 consecutive protocols of the Children’s Cancer Group (CCG) with survival for the entire cohort of children in multiple centres treated under CCG protocols in that period; and to highlight the benefits of membership of a large cooperative research group conducting multicentre randomised controlled trials.Design, participants and setting: Retrospective review of the outcomes of all 311 children with newly diagnosed ALL treated at PMH between 1983 and 2008.Main outcome measures: 4-year event-free survival; and 10-year overall survival.Results: Four-year event-free survival for the entire PMH cohort increased from 66% (SE, 6%) for 1983–1987 to 88% (SE, 6%) for 2002–2005, while overall survival over the same period improved from 78% (SE, 5%) to 94% (SE, 4%). Comparisons of outcomes of children treated at PMH with those of the entire CCG cohort, protocol by protocol, revealed similar outcomes.Conclusion: Outcomes of children treated at PMH over the 25-year period are equivalent to those of the larger CCG cohort.

Hannah Forward MB BS(Hons) · Guicheng C Zheng PhD · Catherine H Cole MB BS, FRACP, FRCPA

Objective: To examine cancer incidence and mortality in Indigenous Queenslanders.Design, setting and patients: Assessment of indirectly standardised incidence and mortality ratios for Indigenous Australians in Queensland diagnosed with cancer from 1997 to 2006, compared with the total Queensland population.Main outcome measures: Standardised incidence and mortality ratios.Results: Compared with the total Queensland population, Indigenous Queenslanders had a lower overall incidence of cancer (standardised incidence ratio, 0.79; 95% CI, 0.75–0.82), but a higher incidence of some of the more fatal cancer types. Overall cancer mortality was higher (standardised mortality ratio, 1.36; 95% CI, 1.28–1.45) and similar to rates for Indigenous people in other Australian states.Conclusion: Cancer rates for Indigenous Queenslanders, a mostly urbanised population, are similar to rates for Indigenous Australians mostly living in remote areas.

Suzanne P Moore BHSc(Nursing), MPH, PhD · Peter K O’Rourke BSc(Hons) BA(Hons), PhD · Kylie-Ann Mallitt BSc(Hons) · Gail Garvey BEd, MEd · Adèle C Green MB BS, MSc, PhD · Michael D Coory MB BS, PhD, FAFPHM · Patricia C Valery MD, MPH, PhD

Objective: To describe the contemporary management and outcomes of patients presenting with ST-segment-elevation myocardial infarction (STEMI) in Australia.Design, participants and setting: Observational analysis of data for patients who presented with suspected STEMI and enrolled in the Australian Acute Coronary Syndrome Prospective Audit from 1 November 2005 to 31 July 2007.Main outcome measures: Factors associated with use of reperfusion therapy and timely use of reperfusion therapy, and the effects of reperfusion on mortality.Results: In total, 755 patients had suspected STEMI. Median time to presentation was 105 minutes (IQR, 60–235 minutes). Reperfusion therapy was used in 66.9% of patients (505/755), and timely reperfusion therapy in 23.1% (174/755). Thombolysis was administered in 39.2% of those who received reperfusion therapy (198/505), while 60.8% (307/505) received primary percutaneous intervention. Cardiac arrest (OR, 2.83; P = 0.001) and treatment under the auspices of a cardiology unit (OR, 2.14; P = 0.02) were associated with use of reperfusion therapy. A normal electrocardiogram on presentation (OR, 0.42; P = 0.01), left bundle branch block (OR, 0.18; P = 0.001), acute pulmonary oedema (OR, 0.34; P < 0.01), history of diabetes (OR, 0.54; P < 0.01), and previous lesion on angiogram of > 50% (OR, 0.51; P = 0.001) were associated with not using reperfusion. Inhospital mortality was 4.0% (30/755), mortality at 30 days was 4.8% (36/755), and mortality at 1 year was 7.8% (59/755). Receiving reperfusion therapy of any kind was associated with decreased 12-month mortality (hazard ratio [HR], 0.44; 95% CI, 0.25–0.78; P < 0.01). Timely reperfusion was associated with a reduction in mortality of 78% (HR, 0.22; P = 0.04). There were no significant differences in early and late mortality in rural patients compared with metropolitan patients (P = 0.66).Conclusion: Timely reperfusion, not the modality of reperfusion, was associated with significant outcome benefits. Australian use of timely or any reperfusion remains poor and incomplete.

Luan T Huynh MB BS, FRACP · Jamie M Rankin MB BS, FRACP · Phil Tideman FRACP · David B Brieger MB BS, PhD, FRACP · Matthew Erickson BM BS, FRACP · Andrew J Markwick MB BS · Carolyn Astley RB, BN · David J Kelaher BPharm, MSc · Derek P B Chew MB BS, MPH, FRACP

Objective: To use neonatal thyroid-stimulating hormone (TSH) concentration data to measure the iodine status of the population of the Australian state of Victoria.Design, participants and setting: Retrospective analysis of the results of 368 552 neonatal heel-prick blood tests for TSH concentration in Victoria in the years 2001–2006.Main outcome measures: Iodine deficiency as indicated by a mean percentage of neonatal TSH concentrations > 5 mIU/L of over 3% in accordance with World Health Organization, United Nations Children’s Fund and International Council for the Control of Iodine Deficiency Disorder criteria; comparison of findings for the nine Department of Human Services health regions in Victoria.Results: The mean percentage of neonatal TSH concentrations > 5 mIU/L ranged from 4.07% in 2001 to 9.65% in 2006, and this increase was statistically significant (P < 0.001). The populations of all nine Victorian health regions showed increasing iodine deficiency over the study period. Metropolitan populations had higher iodine deficiency than non-metropolitan populations, and this difference was also statistically significant (P < 0.05). These results are consistent with urinary iodine excretion research in Victoria.Conclusions: The high percentage of elevated TSH concentrations among newborns is of concern and requires ongoing monitoring. Neonatal TSH assay is part of routine screening in Australia, and thus offers an effective and economical method of monitoring population iodine status.

Ashequr Rahman MB BS, MSc, MPH · Gayle S Savige PhD · Nicholas J Deacon PhD · Ivan Francis BSc, GradDipCompSci · Janice E Chesters PhD

Objective: To understand self-injury and its correlates in the Australian population.Design, participants and setting: Cross-sectional survey, using computer-assisted telephone interview, of a representative sample of 12 006 Australians from randomly selected households.Main outcome measures: Data on demographics, self-injury, psychiatric morbidity, substance use, suicidality, disclosure and help-seeking.Results: In the 4 weeks before the survey, 1.1% of the sample self-injured. For females, self-injury peaked in 15–24-year-olds; for males, it peaked in 10–19-year-olds. The youngest self-injurers were nine boys and three girls in the 10–14-year age group, and the oldest were one female and one male in the 75–84-year age group. Mean age of onset was 17 years, but the oldest age of onset was 44 years for males and 60 years for females. No statistically significant differences existed between those who did and did not self-injure on sex, socioeconomic status or Indigenous status. Most common self-injury method was cutting; most common motivation was to manage emotions. Frequency of self-injury during the 4-week period ranged from 1 to 50 instances (mean, 7). Self-injurers were significantly more psychologically distressed, and also more likely to use substances. Adults who self-injured were more likely to have received a psychiatric diagnosis. Self-injurers were more likely to have experienced recent suicidal ideation (OR, 11.56; 95% CI, 8.14–16.41), and have ever attempted suicide (OR, 8.51; 95% CI, 5.70–12.69). Most respondents told someone about their self-injury but fewer than half sought help.Conclusion: The prevalence of self-injury in Australia in the 4 weeks before the survey was substantial and self-injury may begin at older ages than previously reported. Self-injurers are more likely to have mental health problems and are at higher risk of suicidal thoughts and behaviour than non-self-injurers, and many self-injurers do not seek help.

Graham Martin MD, FRANZCP, DPM · Sarah V Swannell BPsych(Hons), GradCertBiostat · Philip L Hazell MB ChB, PhD, FRANZCP · James E Harrison MB BS, MPH, FAFPHM · Anne W Taylor BA, MPH, PhD

Objective: To determine whether changes in 24-hour average background ozone (O3), nitrogen dioxide (NO2), carbon monoxide (CO) and particulates < 10 μm (PM10) increase the risk of hospital emergency department (ED) presentations for asthma among children.Design, setting and subjects: A time-stratified case-crossover method was used to analyse data of 603 children and young adults aged 0–19 years who were resident in a south-west metropolitan area of Perth, Western Australia, and who had presented with asthma at any public ED within Perth between 1 January 2002 and 31 December 2006. Effect sizes were assessed in relation to age group, sex and season of exposure. City-wide background air pollution was estimated from air monitoring network data.Main outcome measures: ED presentation with asthma.Results: Patients 0–4 years with 1-day lagged exposure to NO2 and CO showed the most significant risk of ED presentation for asthma. An interquartile range (IQR) increase in NO2 resulted in an odds ratio (OR) of 1.70 (95% CI, 1.08–2.69). An IQR increase in CO resulted in an OR of 1.40 (95% CI, 1.06–1.84).Conclusions: The effect sizes observed in this study were higher than those of past studies, and indicated that children aged 0–4 years were the most vulnerable to the effects of air pollution. The period of exposure most clinically relevant is the day before ED presentation.

Gavin Pereira MAppStats, BCM, GCResCom · Angus Cook MB ChB, PhD · Annemarie J B M De Vos PhD, MPH, RN · C D’Arcy J Holman MB BS, MPH, PhD

Objective: We reviewed resources for researchers interested in privacy issues surrounding secondary use of health data for research. These included applicable privacy regulations and available information on privacy perception in Australia. The review is timely because the current Australian Population Health Research Network infrastructure investments are likely to attract new researchers to the field.Data sources: We used Australian federal, state and territory regulations and programs, polls and surveys, public speeches and academic literature, and some international resources.Data synthesis: We identify four themes (de-identification, consent, bias and participation) emerging as areas of concern from the review, and discuss issues relevant to these themes. We provide arguments that excessive privacy regulation has a negative effect on public health research.Conclusions: There is little evidence of privacy complaints or breaches in health research, but significant concerns about consent and de-identification appear to persist in the community. New researchers need to take account of privacy regulation and may wish to take account of privacy perception when designing study and consent processes.

Christine M O'Keefe PhD, MBA, BSc(Hons) · Chris J Connolly LLB

Objective: To report Australian outcomes from the Safe Implementation of Thrombolysis in Stroke International Stroke Thrombolysis Register (SITS-ISTR).Design: Observational study using data collected prospectively from December 2002 to December 2008.Setting: Centres administering thrombolysis for acute stroke in Australia and worldwide.Patients: All patients treated with recombinant tissue plasminogen activator for acute stroke in participating centres, regardless of stroke severity, time of treatment and other clinical factors.Intervention: Thrombolysis for acute stroke, administered according to local protocol.Main outcome measures: Functional outcome as 3-month modified Rankin score (mRS), and frequency of symptomatic intracerebral haemorrhage (ICH).Results: During the study period, a total of 32 countries participated, and confirmed baseline data were available for 581 Australian patients and 20 953 patients in the rest of the world. Australian patients were older (median age, 73 v 69 years; P < 0.001), were less independent before stroke (premorbid mRS of 0–1, 87.5% v 91.2%; P < 0.005), and had more comorbidities and more severe strokes. Comparing the Australian cohort with the rest of the world, the odds ratio of 3-month mRS of 0–2 was 0.98 (95% CI, 0.88–1.08; P = 0.63), the odds ratio of symptomatic ICH was 0.98 (95% CI, 0.83–1.16; P = 0.85 [by the definition used by the National Institute of Neurological Disorders]) and the odds ratio of death was 1.04 (95% CI, 0.91–1.19; P = 0.54). Good outcome in the Australian cohort was predicted by younger age, presence of hyperlipidaemia, lower premorbid mRS, absence of infarct on early brain imaging, less severe stroke, and lower baseline blood glucose level.Conclusion: Clinical outcomes after thrombolysis in Australia were similar to those worldwide.

Marion A Simpson BSc, MB ChB(Hons), MRCP · Helen M Dewey PhD, FRACP, FAFRM(RACP) · Leonid Churilov PhD · Niaz Ahmed MD, PhD · Christopher F Bladin MB BS, MD, FRACP · David Schultz BM BS, FRACP · Romesh Markus MB ChB(Hons), PhD, FRACP · Jonathan W Sturm MB ChB, PhD · Christopher R Levi BMedSci, MB BS, FRACP · David J Blacker MB BS, FRACP · Jim Jannes BM BS, FRACP, PhD · Richard I Lindley MD, FRCP, FRACP · Mark W Parsons PhD, FRACP

Objective: To document diabetes health services use and indices of glycaemic management of young people with type 1 diabetes from the time of their first contact with adult services, for those living in regional areas compared with those using city and state capital services, and compared with clinical guideline targets.Design, setting and subjects: Case note audit of 239 young adults aged 18–28 years with type 1 diabetes accessing five adult diabetes services before 30 June 2008 in three geographical regions of New South Wales: the capital (86), a city (79) and a regional area (74).Main outcome measures: Planned (routine monitoring) and unplanned (hospital admissions and emergency department attendance for hypoglycaemia or hyperglycaemia) service contacts; recorded measures of glycated haemoglobin (HbA1c), body mass index (BMI), and blood pressure (BP).Results: Routine preventive service uptake during the first year of contact with adult services was significantly higher in the capital and city. Fewer regional area patients had records of complications assessment and measurements of HbA1c, BMI and BP across all audited years of contact (HbA1c: 73% v 94% city, 97% capital; P < 0.001). Across all years, regional area patients had the highest proportion of HbA1c values > 8.0% (79% v 62% city, 56% capital) and lowest proportion < 7% (4% v 7%, 22%) (both P < 0.001). Fewer young people made unplanned use of acute services for diabetes crisis management in the capital (24% v 49% city, 50% regional area; P < 0.001). In the regional area, routine review did not occur reliably even annually, with marked attrition of patients from adult services after the first year of contact.Conclusion: Inadequate routine specialist care, poor diabetes self-management and frequent use of acute services for crisis management, particularly in regional areas, suggest service redesign is needed to encourage young people’s engagement.

Lin Perry PhD, MSc, RN · Katharine S Steinbeck MB BS, FRACP, PhD · Janet S Dunbabin BAg(Sc), PhD · Julia M Lowe MB ChB, FRCP, MMedSci

Objective: To assess emergency department (ED) doctors’ knowledge of radiation doses associated with diagnostic imaging and to describe their practice with regard to informing patients of risk.Design, participants and setting: Prospective, questionnaire-based observational study in May 2009 among all 110 doctors in the EDs of a 570-bed teaching hospital and a 200-bed district hospital.Main outcome measures: Percentage knowledge score; and frequency of discussing radiation risk with patients, based on responses to three scenarios rated on a visual analogue scale (VAS), where a score of 100 indicates doctors would always discuss it.Results: 96 doctors (87%) completed the questionnaire. The overall mean knowledge score was 40% (95% CI, 38%–43%). Senior doctors scored somewhat higher than junior doctors, but not significantly (42% v 39%; P = 0.75). Over three-quarters of doctors (78%) underestimated the lifetime risk of fatal cancer attributable to a single computed tomography scan of the abdomen. Most doctors (76%) reported never having had any formal training on risks to patients from radiation exposure. The frequency at which doctors would inform patients of the risk of radiation varied greatly depending on the clinical scenario (mean VAS scores, between 38 and 90).Conclusion: Emergency doctors in our sample had a varied knowledge of the risks from radiation exposure, but overall knowledge was poor. Staff should receive education, and the diagnostic imaging request process may need to include information on radiation doses and risks.

Gerben B Keijzers MB BS, MSc(Epid), FACEM · Charles J Britton MB ChB

Objective: To evaluate the impact of psychiatric inpatient bed closures, accompanied by a training program aimed at enhancing team effectiveness and incorporating data-driven practices, in a mental health service.Design and setting: Retrospective comparison of the changes in services within three consecutive financial years: baseline period — before bed reduction (2006–07); observation period — after bed reduction (2007–08); and intervention period — second year after bed reduction (2008–09). The study was conducted at Cramond Clinic, Queen Elizabeth Hospital, Adelaide.Main outcome measures: Length of stay, 28-day readmission rates, discharges, bed occupancy rates, emergency department (ED) presentations, ED waiting time, seclusions, locality of treatment, and follow-up in the community within 7 days.Results: Reduced bed numbers were associated with reduced length of stay, fewer referrals from the community and subsequently shorter waiting times in the ED, without significant change in readmission rates. A higher proportion of patients was treated in the local catchment area, with improved community follow-up and a significant reduction in inpatient seclusions.Conclusion: Our findings should reassure clinicians concerned about psychiatric bed numbers that service redesign with planned bed reductions will not necessarily affect clinical care, provided data literacy and team training programs are in place to ensure smooth transition of patients across ED, inpatient and community services.

Tarun J Bastiampillai MB BS, BMedSc, FRANZCP · Niranjan P Bidargaddi BE(CompSc), PhD · Rohan S Dhillon MB BS, FRANZCP, MClinSc · Geoffrey D Schrader FRANZCP, PhD · Jörg E Strobel MD, FRANZCP · Philip J Galley RMN, DipCPC, BA(Hons)

Objective: To determine the proportion of older Australian men who meet the Pharmaceutical Benefits Scheme (PBS) criteria for osteoporosis treatment and are receiving effective treatment.Design and setting: A population-based, cross-sectional analysis of the baseline phase of the Concord Health and Ageing in Men Project (CHAMP), a large epidemiological study focusing on the health of older men. Data were collected through questionnaires and clinical assessments. Bone mineral density (BMD) of the hip and spine was measured by dual x-ray absorptiometry (DXA). Vertebral deformities were identified from DXA lateral vertebral fracture assessment images. The study was conducted at Concord Hospital, Sydney, between January 2005 and May 2007.Participants: 1705 community-dwelling men aged 70 years or over from a defined geographical region around Concord Hospital.Main outcome measures: Prevalence of vertebral deformities; previous minimal trauma fractures; BMD T-scores ≤ – 3; falls in the previous 12 months; use of bisphosphonates and calcium and vitamin D supplements.Results: Of the 1705 men seen at baseline, 1626 completed all DXA scans and 401 (25%) met one or more of the PBS criteria for osteoporosis treatment. Ninety per cent of the men who met the PBS criteria were unaware they had osteoporosis. Of the men eligible for PBS-subsidised treatment, 39 (10%) reported use of a bisphosphonate, 56 (14%) had taken calcium supplements, and 28 (7%) had taken vitamin D supplements. Only three men had taken calcium, vitamin D and bisphosphonates in combination.Conclusions: Despite a high prevalence of osteoporosis in elderly Australian men, awareness, diagnosis and treatment of the condition remain very low.

Kerrin Bleicher BSc, PostGradDipPhysio · Vasi Naganathan MB BS, FRACP, PhD · Robert G Cumming MB BS, MPH, PhD · Markus J Seibel MD, FRACP, PhD · Philip N Sambrook MD, LLB, FRACP · Fiona M Blyth MPH, FAFPHM, PhD · David G Le Couteur FRACP, GradCertEd, PhD · David J Handelsman MB BS, FRACP, PhD · Louise M Waite MB BS, FRACP, PhD · Helen M Creasey MB BS, FRACP