Research

Objective: To assess the prevalence of metabolic syndrome and its association with sociodemographic, clinical and lifestyle variables among Australian patients with a variety of psychiatric disorders.Design and setting: Cross-sectional study of patients attending a public mental health service in Western Australia between July 2005 and September 2006.Participants: Patients who were aged 18–65 years; diagnosed with schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder with psychotic symptoms, drug-induced psychosis or borderline personality disorder; and currently taking at least one antipsychotic drug for a minimum of 2 weeks.Main outcome measures: Prevalence of metabolic syndrome diagnosed with International Diabetes Federation criteria; fasting blood glucose and lipid levels; sociodemographic and lifestyle characteristics.Results: Of 219 patients invited to participate, 203 agreed and had complete data. Prevalence of metabolic syndrome was 54% overall, and highest among patients with bipolar disorder or schizoaffective disorder (both 67%), followed by schizophrenia (51%). Sociodemographic variables, including age and ethnic background, were not significantly associated with metabolic syndrome, but a strong association was seen with mean body mass index. Other cardiovascular risk factors, such as smoking and substance misuse, were common among participants.Conclusions: Prevalence of metabolic syndrome in this population was almost double that in the general Australian population, and patients with schizophrenia had a prevalence among the highest in the developed world. Prevalence was also high in patients with a variety of other psychiatric disorders.

Alexander P John MB BS, MD, FRANZCP · Radhakrishnan Koloth MB BS, DPM · Milan Dragovic PhD · Stephen C B Lim PhD

Objective: To assess the performance of the Framingham and United Kingdom Prospective Diabetes Study (UKPDS) cardiovascular risk equations in Australian patients with type 2 diabetes who were initially free of cardiovascular disease (CVD).Design and setting: The Fremantle Diabetes Study (FDS), a community-based longitudinal observational study; data for the period 1993–2006 were used.Patients: Of the 815 FDS participants with type 2 diabetes who were initially CVD-free, 791 (97%) were eligible for assessment using the UKPDS equations, and 697 (86%) using the Framingham equation.Main outcome measures: CVD endpoints during 5 years of follow-up. For the UKPDS equations, these were fatal myocardial infarction (MI) or sudden death (fatal coronary heart disease [CHD]); hospitalisation for/with or death from MI or sudden death (all CHD); fatal stroke; and all stroke. For the Framingham equation, they were all MI, sudden death or angina pectoris (CHD).Results: During follow-up to first CVD event, death or 5 years, there were 38 MIs (11 fatal) and 23 strokes (13 fatal) in the UKPDS-assessable cohort of FDS participants. The UKPDS risk equations for all CHD, fatal CHD, and all stroke overestimated the number of events by 6.5, 2.8 and 1.8 times, respectively. The risk equation for fatal stroke underestimated the number of events by 38%. The UKPDS CHD risk equations showed modest discrimination and poor calibration, while the stroke risk equations showed good discrimination and calibration. The Framingham equation predicted 28% fewer CHD events than occurred (93 v 130), and discrimination and calibration were poor.Conclusions: While the UKPDS stroke risk equations performed relatively well, the UKPDS and Framingham CHD risk equations are not suitable for predicting risk in Australians with type 2 diabetes.

Wendy A Davis MPH, PhD · Stephen Colagiuri FRACP · Timothy M E Davis DPhil, FRACP

Objective: To estimate costs of retrieval, transport and acute medical services associated with road crashes in northern Queensland from March 2004 to June 2007.Design, setting and participants: Case study of 696 people aged 16 years or older who had been involved in a road crash in the study area (all areas north and west of Bowen, excluding the urban areas of Townsville and Cairns) and had been admitted to hospital for a minimum of 24 hours after the crash. Data on mode of retrieval, acute care provided and total costs were obtained for each patient.Main outcome measures: Method of retrieval or transport; length of stay in intensive care unit (ICU) and/or hospital for each patient; costs of retrieval, transport and inhospital care.Results: Retrieval data were collected for 614 of the 696 study participants (88%). Most primary retrievals (446; 73%) occurred by road. More than half of interhospital transfers were undertaken by fixed or rotary wing services. Casualties in the study occupied a total of 6360 bed-days, of which 734 were ICU bed-days. The total retrieval, transport and acute hospital care costs of road crash victims in northern Queensland over the study period were calculated to be approximately $10.4 million.Conclusion: The costs associated with rural and remote road crashes in northern Queensland represent a considerable economic burden.

Teresa M O’Connor DPhSt, MPH · Heather A Hanks BMedSc(Hons) · Mark S Elcock MB ChB, FACEM, FCEM · Richard C Turner MB BS, BMedSc, FRACS · Craig Veitch DipAppSc(RT), BA(Hons), PhD

Objective: To explore the experiences of families with a baby with Down syndrome at the time of diagnosis, and their preferences for information and support in the early period after diagnosis.Design, setting and participants: A qualitative, interview-based study of 18 families living in Victoria with a child with Down syndrome born between 2002 and 2004 who had not been diagnosed with the syndrome before birth. Interviews were transcribed verbatim and interpretive content analysis was undertaken.Results: Parental coping with the unexpected diagnosis of Down syndrome in their infant was influenced by the time interval between birth and disclosure of clinical suspicion of Down syndrome, the level of certainty of the attending physician at the time of disclosure, and the time interval between disclosure of clinical suspicion and confirmation of karyotype. Initial uncertainty and a delay in the diagnosis were detrimental to parental coping, as was premature communication of the news. Perinatal complications increased parental anxiety regarding their child’s condition and future. Individual communication style of midwives and physicians was a powerful predictor of parental adaptation. Parental needs for support and information were facilitated through normalising postnatal care, ensuring privacy, and providing early access to peer support and up-to-date written information. Many parents would have appreciated access to a liaison worker.Conclusion: The experiences of parents in this study provide practice points for improving postnatal care with minimal changes to formal service systems.

Evelyne E Muggli MPH · Veronica R Collins PhD · Catherine Marraffa FRACP, FRCPCH

Objective: To examine the circumstances of homicides of children in New South Wales from 1991 to 2005.Design and setting: Retrospective analysis of all identified child homicides in NSW from 1991 to 2005, based on data on offenders and victims obtained from crime statistics, documents located by systematic searches of legal databases and media reports, and medicolegal reports of offenders who committed child homicides during psychotic illness.Main outcome measures: Demographic characteristics of homicides and a history of prior psychiatric treatment among offenders with psychosis.Results: We located documents describing 165 homicides by 157 offenders. Fifty-nine deaths were a consequence of child abuse, including those of five children who died from methadone overdoses. Both the offenders and the victims in fatal child abuse were significantly younger than in other forms of child homicide. The courts found that 27 child homicides had been committed by 26 offenders during the acute phase of psychotic illness, and 15 of these offenders had never been treated with antipsychotic medication.Conclusions: Earlier identification and treatment of psychotic illness in mothers, and changes in the way methadone is provided to opiate-dependent parents, might result in a small overall reduction in the number of child deaths. More lives could be saved by measures that reduce the incidence of child abuse, including the prohibition of corporal punishment of children.

Olav B Nielssen MB BS, MCrim, FRANZCP · Matthew M Large BSc(Med), MB BS, FRANZCP · Bruce D Westmore MB BS, MCrim, FRANZCP · Steven M Lackersteen BPsych(Hons)

Objective: To document general baseline data on the patterns of childhood malignant tumours at a teaching hospital in south-western Nigeria.Design, setting and participants: A retrospective study of childhood malignancy at Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria, during an 11-year period, from January 1996 to December 2006.Results: 77 children were diagnosed with malignant tumours (an average of seven diagnoses per year); 46 were boys (60%), giving a male-to-female ratio of 1.5 : 1. The age distribution of patients was 1–18 years. There were 42 diagnoses (55%) in the 1–5-year age group and 68 malignancies (88%) were diagnosed at ages of 12 years or younger. Lymphomas were the most prevalent malignancy identified, accounting for 31 diagnoses (40%). Burkitt’s lymphoma constituted the majority of malignancies (28 cases; 36%), followed by retinoblastoma (16 cases; 21%) and nephroblastoma (11 cases; 14%). Other malignancies included germ cell tumours (6), neuroblastomas (4), osteosarcomas (3), rhabdomyosarcomas (3) and non-Hodgkin’s lymphomas (3). One case each of medullary thyroid carcinoma, adenocarcinoma of the rectum, invasive mucinous carcinoma of the colon were also identified.Conclusion: These data suggest that Burkitt’s lymphoma is the most common childhood malignant tumour in our geographic area of south-western Nigeria. With the rising incidence of childhood malignancy in resource-poor countries, measuring the baseline occurrence of such tumours is imperative to provide much-needed resource allocation.

Ayodeji O J Agboola MB ChB, MSc · Folashade A Adekanmbi MB BS, FWACP · Adewale A Musa MB BS, FWACS · Adetoun S Sotimehin MB BS, FWACP · Anotu M Deji-Agboola BSc, MSc, PhD · Aderibigbe M O Shonubi MB BS, FWACS · Temitope Y Oyebadejo MB BS, FMCPath · Adekunbi A F Banjo MB BS, FMCPath

Objective: To investigate National Health and Medical Research Council (NHMRC) support over the decade to 2006 for researchers studying Indigenous health and researchers who self-identified as Indigenous.Design and setting: Review of data on all recipients of People Support awards and Capacity Building Grants in Population Health Research who were researching Indigenous health or who self-identified as Indigenous between 1996 and 2006.Main outcome measures: Annual People Support and Capacity Building grants and expenditure, by broad research area, state or territory, administering institution, and Indigenous status (as self-identified by award recipients in their applications).Results: Between 1996 and 2006, 134 People Support awards were made to researchers studying Indigenous health; of these, 27 (20%) were to researchers who self-identified as Aboriginal or Torres Strait Islander. In 2006, about 2.9% of the annual expenditure on all People Support funding was for Indigenous health research, representing a doubling in the proportion of funds since 2001. There was no increase in the number of self-identified Indigenous researchers funded under People Support, but Capacity Building Grants increased the number of people from Indigenous backgrounds supported by the NHMRC, with funds allocated to 36 Indigenous researchers from 2002 to 2006, compared with 14 funded by People Support during the same period.Conclusions: Funding to support Indigenous health research through the People Support scheme has increased since the NHMRC adopted policy changes in 2002, but it has not reached the targeted expenditure of at least 5% of agency allocations. The Capacity Building Grants have been a more effective vehicle for funding researchers from Indigenous backgrounds.

Sophia Leon de la Barra BA, MPH, MPhilPH · Sally Redman BA(Hons)(Psych), PhD · Sandra Eades BMed, PhD · Carey Lonsdale BSc, GradDip(Zool), MApplSci

The association between smoking and lung cancer is now an accepted fact. Every day, doctors base management decisions on cardiovascular risk calculated using the Framingham equation. It is because of such findings and practical implications that the British doctors study and the Framingham Heart Study from the United States are among the world’s best known longitudinal studies. The stories of these landmark studies in the fields of epidemiology and public health have already been told;1,2 but longitudinal researchers have also been at work in Australia, with implications for our particular population and the wider world. We selected just a few of these (Box 1) — studies that have already demonstrated some longevity and which we judged would be of particular interest to our readership — and interviewed some of their key investigators. What are their stories? How will they make their mark in medicine? The Australian Diabetes, Obesity and Lifestyle Study (AusDiab)Interviewee: Professor Paul Zimmet“How many Australians suffer from diabetes? How many new cases are diagnosed annually? ... How many people have complications of diabetes that are threatening to their vision or even to their life? ... These are not questions from ‘Trivial Pursuit’ nor is the answer to each of these questions readily available”, wrote Professor Paul Zimmet in the Medical Journal of Australia in 1985.3 At that time, Zimmet was frustrated that there had been little research into the growing problem of diabetes in Australia. Even Papua New Guinea, then one of the poorest countries in the world, had better diabetes data. Zimmet’s involvement in the epidemiology of diabetes had begun a decade earlier when, in 1975, he had gained funding from the US National Institutes of Health (NIH) to conduct a diabetes prevalence survey on Nauru, a Central Pacific island. The President of Nauru, Hammer DeRoburt, had invited Pincus Taft — his Australian physician and a colleague of Zimmet’s — to the island because he thought diabetes was a problem on Nauru; he was right! Zimmet and Taft’s survey found the highest prevalence of diabetes in the world — about a third of the adult population were affected.4 With further NIH funding, Zimmet and his team were able to survey other Pacific countries and Mauritius, and also, in 1985, to set up the International Diabetes Institute (IDI) in Melbourne as a World Health Organization collaborating centre for the epidemiology of diabetes. “It was really that NIH funding which allowed me to create the institute and establish the framework and the infrastructure that was then able to do AusDiab”, said Zimmet. In 1996, Australia’s health ministers agreed that diabetes would become one of the national health priorities. Spearheaded by Dr Michael Wooldridge, the then federal Minister for Health and Aged Care, the National Diabetes Strategy was launched in 1998. Arising from (but only partly funded by) the Strategy, the Australian Diabetes, Obesity and Lifestyle Study (AusDiab) was commissioned, with Zimmet and Professor Timothy Welborn as the lead investigators. AusDiab was a population-based, cross-sectional survey of the national prevalence of diabetes and associated risk factors in people aged 25 years or older. The study involved an initial household interview, followed by a biomedical examination that included an oral glucose tolerance test, and questionnaires. It was conducted between May 1999 and December 2000 in 42 randomly selected districts in the six states and the Northern Territory of Australia. “It was akin to an army exercise”, said Zimmet. Team members would go in advance to work out logistics of transport, motels and meals, as well as to identify suitable study centres, which might be schools, town halls or local bowling clubs. Blood sugar-level tests were done immediately on site at a mini-lab, and blood samples were then sent by car or plane to the main lab for other testing and storage. In the initial cohort, 11 247 people attended the biomedical examination. The most alarming finding was that almost a million Australian adults had diabetes — equating to 7.4% of the adult population and a 300% increase since 1981.5 A further 16.3% had pre-diabetes, and there was a 60% prevalence of overweight and obesity and a high prevalence of untreated hypertension. Further funding, now with Professor Jonathan Shaw from Melbourne as co-investigator, allowed a 5-year follow-up study of 6537 participants in 2004–2005. This determined, among other things, that about 100 000 adults in Australia develop diabetes each year; that is, about 275 people every day. AusDiab is the largest national study of diabetes in the world. To ease ongoing funding concerns and to provide critical infrastructure, the IDI has recently merged with the Baker Heart Research Institute in Melbourne. There is no longer any argument that diabetes is a global epidemic with devastating human and socioeconomic effects. However, Zimmet says other questions related to diabetes now need answers, such as “Will preventing type 2 diabetes prevent cardiovascular disease?” Bettering the Evaluation And Care of Health (BEACH)Interviewees: Associate Professor Helena Britt, Associate Professor Graeme MillerEach year in Australia, more than 100 million general practice services are provided to about 85% of the population — to the tune of about $4 billion in Medicare payments.6 What really happens in these consultations? What is being diagnosed? In whom? And how is it being treated? Although Medicare statistics can provide some information about general practice services, it is data from the Bettering the Evaluation And Care of Health (BEACH) program that have been able to inform health care policy and clinical practice by answering these questions. Now in its 11th year, the BEACH program is a continuous national study of general practice activity in Australia — the only such study in the world — conducted by the Australian General Practice Statistics and Classifications Centre, a collaborating unit of the University of Sydney and the Australian Institute of Health and Welfare. Since its inception in 1998, 100 000 encounters between general practitioners and patients from a random, changing sample of 1000 GPs have been added to the BEACH database each year. The database now includes details of more than a million encounters. The BEACH program has provided independent data about a range of often controversial topics, including consultation length, payment structures, doctors’ prescribing practices, and adverse drug events, to various stakeholders, including researchers, educators, government departments and agencies, pharmaceutical companies and health care professional organisations. The program has produced 23 books (freely available for download from the BEACH website) and about 100 articles published in recognised journals. Most recently, the group has reported on the prevalence and patterns of chronic disease in Australia, finding that one in four Australians suffer from two or more chronic conditions.7 When asked to comment on the program’s impressive productivity, Associate Professor Helena Britt was quick to point out that: “What makes the productivity level so high is a fantastic team of excellent health services researchers”. There were also many years of methodological development and validation before BEACH was launched. “We didn’t land on the BEACH without preparation. It did take 20 years to get to that point ... and some more from [Emeritus Professor] Charles Bridges-Webb before that.” Between 1978 and 1990, Britt, a research psychologist by training, worked in the University of Sydney’s teaching and research general practice. The practice, run by Bridges-Webb, used a continually evolving data collection system that was based on his work in the 1960s and 70s with patient-based data collection from all general practices in the Victorian town of Traralgon. In 1990, the team successfully secured funding from the National Health and Medical Research Council (NHMRC) and the General Practice Evaluation Program for the first national study of general practice for more than two decades, and for a comparative study of rural and metropolitan general practice. These studies were reported in supplements to the MJA. Thanks to their distinctive covers, they became known as the purple report (Morbidity and treatment in general practice in Australia 1990–1991) and the green report (A comparison of country and metropolitan general practice).8,9 Some very lean years followed these two studies, with the team only managing to stay together by taking on smaller jobs from different groups, such as doing quality research for clinical trials for pharmaceutical companies, and, from 1993, by offering (for a fee) the method they’d developed as a quality assurance option to about 4000 GPs, thus gaining further evidence for and experience in using their method. Then, in 1997, with growing interest in how new drugs were being used in clinical practice, the team managed to “stitch together” sufficient funds from government and other sources, including the pharmaceutical industry, to launch the BEACH program the following year. Since the launch of BEACH, funding has remained mixed and uncertain, being renegotiated with all involved parties on an annual or biennial basis. In 2004, the government contribution to funding was withdrawn and, in 2006, there was a real concern that the program would be forced to close. However, this fear was not realised, as the government’s contribution to the program was re-established in mid 2007.6 Why does the BEACH team keep persisting in its efforts despite the ongoing funding challenges? According to the Centre’s Medical Director, Associate Professor Graeme Miller: “It’s a commitment to the importance of general practice, and of reliably describing general practice to justify what it’s doing and its place in the health care system”. The Blue Mountains Eye Study (BMES)Interviewee: Professor Paul MitchellDoes smoking cause blindness? What effect does visual impairment have on daily living? Observing the impact of eye disease on individual patients might explain why a clinical ophthalmologist would develop an interest in epidemiological research. The notion becomes even less surprising when one learns that Australian legend Professor Fred Hollows is one of two mentors whom ophthalmologist Professor Paul Mitchell credits with inspiring him to develop the Blue Mountains Eye Study (BMES) — the first large Australian population-based study of eye disease. Mitchell says that it was Hollows who talked him into doing an MD in Newcastle, New South Wales, in the 1980s, to research the prevalence of and risk factors for diabetic retinopathy. His other mentor is US-based Professor Ron Klein, who began (and still runs) the Wisconsin Epidemiologic Study of Diabetic Retinopathy in 1979 and the Beaver Dam Eye Study in 1987. When the two met at a diabetes conference in Australia, Klein invited Mitchell to the US to see how the Beaver Dam Eye Study had been done. It was after being appointed to the University of Sydney’s Department of Ophthalmology in 1990 that Mitchell designed the initial BMES to study visual impairment and common eye diseases in a representative older Australian community sample, and obtained NHMRC funding. Study participants were identified in two postcode areas in the Blue Mountains region, west of Sydney. The area was ideal because of the residents’ demographic similarity to the overall Australian population (for most characteristics); and its geographical separation from Sydney meant that publicity could be well targeted. In the first wave of the study (BMES-1), 3654 residents aged 49–97 years were examined during 1992–1994, with Mitchell personally conducting the eye examination for all participants. There have since been 5-year and 10-year follow-up studies, and an extension study in 1999–2000 of further residents who became eligible to participate (BMES-E). A 15-year follow-up study is currently underway. Since 2001, the BMES has been incorporated into the research activities of the Westmead Millennium Institute’s Centre for Vision Research in Sydney. When asked about the study’s highlights, Mitchell nominates the finding that visual impairment has an impact on quality of life that is similar to that from most major systemic conditions, and doubles the need for earlier institutionalised care; it is also associated with about an 80% risk of increased mortality. Further, the BMES was among the first studies in the world to demonstrate the link between smoking and blindness (now a warning on cigarette packets sold in Australia and elsewhere) (Box 2).10 Among the most important of more than 300 papers published from the study, Mitchell includes a New England Journal of Medicine report of the link between using inhaled steroids and developing cataracts.11 According to Mitchell, one of the core strengths of the BMES is the collection of objective data. All eye photographs are graded using standard protocols developed for the Beaver Dam Eye Study, which allows for the independent assessment and pooling of data from the BMES with data from other national and international cohorts. A further strength is that, right from the start, the BMES was designed to be much bigger than “just an eye study”. A wide array of data was collected and then expanded upon in the follow-up studies, including fasting blood tests, various detailed questionnaires, and hearing assessments, with the project also extending into genetic studies. Ever looking forward, Mitchell believes that a valuable area for future investigation is a possible link between basic vascular signs in the eye and systemic events, particularly cardiovascular events, stroke and mortality. “The eye is the only place you can see vessels — microvascular vessels — naked”, said Mitchell. “These microvascular signs are quite important for a whole range of diseases, and can now be imaged very easily without dilating the pupil and assessed automatically with computer programs.” The Busselton Health StudyInterviewees: Dr Digby Cullen, Associate Professor Alan James, Professor Bill MuskWho should benefit from a community-based study? Most obviously, “the general population”, but Busselton-based GP Dr Kevin Cullen, who founded the Busselton Health Study in 1966, nominated the community itself. One of the study’s five original aims specified that the study should “provide a community service in the detection, treatment and prevention of disease and in the education of a population”. For more than 40 years, and persisting beyond Dr Cullen’s death in 1994, the study’s dedication to the people of Busselton, a picturesque coastal town in the south-west of Western Australia (Box 3), has been returned in kind. This has not only been in terms of study participation, but also in enthusiastic ongoing support, fund-raising and volunteering. As an example — at one time, the local milkman was delivering bottles of glucose solution for the recipients to drink before blood testing for diabetes on the same day.12 The Busselton Health Study is now one of the longest running epidemiological research programs in the world. The predominantly Anglo-Saxon adult community of Busselton Shire took part in cross-sectional health surveys every 3 years from 1966 to 1981, with surveys of all schoolchildren each following year. A “hiatus” for a few years was followed by several surveys of special groups; and, in 1992, a specific family-based genetic study was conducted. In 1994–1995, 5500 surviving participants from the early surveys were successfully recalled. In 2005–2007, an NHMRC project grant enabled a further study of a randomised sex- and age-stratified sample of adults and of all schoolchildren, followed by studies of chronic airflow obstruction and sleep apnoea, with ongoing studies of diabetes and healthy ageing in “baby boomers”. So far, a total of around 16 000 people have been studied at least once. The earliest descriptive reports in Australia of the prevalence of common diseases including asthma and other lung problems (the study has always had an emphasis on respiratory disease), diabetes and coronary heart disease are those from the “population laboratory” of Busselton. Numerous papers have been published: interviewees Professor Bill Musk, Associate Professor Alan James and Dr Digby Cullen (son of Kevin) nominated research describing the decline in lung function related to asthma and cigarette smoking,13 and genetic studies into asthma14,15 and haemochromatosis16 as their recent favourites. From the community perspective, there has always been a policy of providing feedback to survey participants, with recommendations made to seek medical advice from the family doctor if indicated. Dr Digby Cullen said, “We have made an attempt to create a therapeutic community in Busselton and to a significant extent I think we have been successful ... certainly, when you look at the health statistics of Busselton, there is good evidence for a creation of a therapeutic community with, for instance, very low rates of smoking in the population — about 12% in our most recent survey”. In addition, the prevalence of coronary artery disease has been shown to be lower in Busselton than in the nearby state capital, Perth. What of the future? Since 1966, Busselton has grown sixfold from a small town with a population of about 5000 to one of around 30 000, as people, particularly retirees, have moved into the area. However, the population has remained relatively stable, ethnically and socioeconomically speaking, and wine growing, tourism and farming remain the main industries. The Busselton genetic resource is in international demand. Associate Professor James said, “We’re now matching the phenotypes that we have collected in Busselton with genotyping in our own studies and with an expanding number of international collaborators; there’s plenty of scope for genetic epidemiology to go from strength to strength in Busselton”. Regardless of how the study develops, the community focus will persist. Professor Musk said, “We very much feel the community around us and behind us. All of us worked with Kevin Cullen briefly or for various times before he died. He instilled in me, and I’m sure in plenty of other people, that our first duty was to the community. We plan to keep that, as a mantra, if you like, into the future”. The Dubbo StudyInterviewee: Professor Leon SimonsWho among us will live to a ripe old age, physically well and mentally able? In the 1980s, when Associate Professor Leon Simons of St Vincent’s Hospital, Sydney, decided to conduct a longitudinal study, he was aware that older age groups had been relatively neglected in research studies up to that time. He also realised that by studying “survivors”, some characteristics of healthy “long-livers” might be identified. The decision to embark on the Dubbo Study of the Health of the Elderly — now known more simply as the Dubbo Study — was preceded by a raft of other decisions. Initially a neurophysiologist, then a lipid clinician–researcher, Simons followed the 1980s evolution in his field by retraining as an epidemiologist while on sabbatical in Jerusalem. Simons’ Israeli mentor, Professor Yechiel Friedlander, remains a collaborator to this day. A key decision was where to locate the study. Simons said, “We selected Dubbo [a major regional centre in NSW, home of the renowned Western Plains Zoo] in reverse, after working out the size of the town we needed — a community of 35 000 to 40 000 people”. Another decision was what data to collect. At the time, there was much data available in the form of aggregated health statistics — how many people each year go to hospital, how many go home, how many die — but not much was known about the people themselves. “We decided to study what is loosely called ‘healthy ageing’ but with a focus on cardiovascular disease risk factors, because they were a little bit more controversial — did what we knew in middle-aged people also apply to senior citizens?” said Simons. “And when you study the elderly, you open up a Pandora’s box of sociology.” Thus, the Dubbo Study came into being as a prospective, longitudinal community study of the health of all non-institutionalised residents of the Dubbo local government area who were born before 1 January 1930. The cohort, first examined in 1988, was composed of 2805 residents (1233 men and 1572 women) aged 60 years or older. Initial study aims included identifying patterns and predictors of mortality, hospitalisation and the need for residential care. As well as extensive biomedical investigation, including a resting electrocardiograph, peak expiratory flow measurement, and blood testing for lipid and glucose levels, there was also to be a social science investigation of healthy ageing and health service use. Cardiovascular diseases and dementia were conditions of special interest. Subsequent data collections were made in 2000 and 2002–2003 as part of the Study of Assets and Health Dynamics Among the Oldest Old (AHEAD) investigation; and there has been continuing “cold pursuit” of death, hospitalisation and residential care data. Pragmatically, Simons’ favourite reports are those most recently published17 or currently in preparation. Our favourite may be the 2005 article which reported that having a “green thumb” (daily gardening) can guard against dementia.18 Less than half of those in the original cohort are still living, making further active data collection unlikely. Nevertheless, more papers are on the way to add to the 50 already published. Today, as the shape of Australia’s population pyramid changes to reflect our ageing population, there is heightened interest in healthy ageing and the provision of health care and other services to our older citizens. Over the next 10 to 15 years, as the most resilient of the cohort retire to their gardens, Simons anticipates that the Dubbo Study’s database will continue to be accessed and continue to contribute to our knowledge of ageing. Tasmanian Longitudinal Health Study (TAHS)Interviewees: Associate Professor Shyamali Dharmage, Professor John Hopper, Professor E Haydn WaltersHow do childhood factors affect adult-onset asthma? How do issues around the time of puberty influence the risk of breast cancer? When a disease “runs in the family”, is it because of environmental or genetic reasons? Today, the Tasmanian Longitudinal Health Study (TAHS) is attempting to answer these questions and more. However, very different questions were at the forefront when the study began in the late 1960s. The study, originally known as the Tasmanian Asthma Survey, was the brainchild of Dr Heather Gibson, a pioneering doctor working with the school medical service in Tasmania. Professor Haydn Walters, one of the current TAHS team, said: “At that time, the main interest was in how much asthma and how much other respiratory morbidity there was in young children, and what the risk factors were”. The baseline study in 1968 surveyed all 8500 schoolchildren in Tasmania who were born in 1961 and were then 7 years old. Particularly novel for the time were the lung function tests performed on all of these schoolchildren, known as probands. The probands’ brothers, sisters and parents were also surveyed, taking the total number of participants at the time of original survey to 45 900. Follow-up studies were conducted in 1974, 1979, 1992 and 1996, often involving a specific subset of the original participants. The first time that blood samples were collected from participants in the TAHS was in 1996, from a relatively small sample of families. The aim of the current and next phases of the study is to investigate the total original cohort of 45 900. Ninety per cent of the probands have now been traced, with 80% of them participating in a recently completed follow-up study. The sibling follow-up is underway, with 70% traced so far, and 60% of them participating in the study. The TAHS researchers are seeking to collect blood samples from all probands and siblings for genetic testing, to tease out the different effects of “nature” versus “nurture”. Today, the original probands are around 47 years of age, and include such prominent figures as a Deputy Lord Mayor and leading medical researchers. The TAHS researchers say their most cited article to date is one published in the BMJ in 1994. It reported that only one in four probands who had asthma in childhood continued to have asthma at age 32, and that one in 10 probands who didn’t have asthma as a child developed it later on.19 Among more recent interesting findings, the TAHS found that, for girls, being overweight at 7 years of age triples the risk of developing adult-onset asthma.20 The TAHS is unique internationally because it is the world’s largest and longest running respiratory health study. However, because of the population-complete nature of the cohort, the length of follow-up and the opportunities for a general health study, research is now extending to other areas such as breast cancer, eye disease and social science. As TAHS team members say, on the one hand, “It’s now a very rich dataset in terms of early life exposure ... and the original questionnaires asked about symptoms rather than diagnosis — a real strength from a research point of view”. On the other hand, “In terms of a cohort, the group are now starting to get very interesting because they’re getting older. They’ve gone through the healthy part of their life and now the major diseases are starting to emerge”. In keeping with the study’s original respiratory focus, the TAHS will enable the study of lung ageing. Although the TAHS was originally (and, essentially, still is) a Tasmanian study, 30% of the original probands now live outside Tasmania — mostly on the eastern Australian mainland in Victoria, NSW and Queensland — and, as current TAHS team leader Associate Professor Shyamali Dharmage explained, the study now involves a national collaborative family of researchers. But the TAHS has always been a family study. As Professor John Hopper, a long-standing TAHS team member, said, “The thing that differentiates this from a lot of other longitudinal studies is that it involves families, and its strength is that Australian families tend to know where each other are. The next stage will be to study the offspring”. Wittenoom cohort studiesInterviewees: Professor Nick de Klerk, Associate Professor Lenore Layman, Professor Michael Hobbs, Professor Bill MuskWhat would you do if you could see an accident waiting to happen that would hasten the deaths of hundreds of people? In 1948, Dr (later, Professor) Eric Saint, who had emigrated from the United Kingdom to Australia, was horrified by dust levels in the crocidolite (blue asbestos) mine and mill at Wittenoom in the Pilbara region of Western Australia, more than 1000 km north of Perth (Box 4). Saint wrote to the head of the WA Health Department advising that the mine would produce the greatest crop of asbestosis the world had ever seen. Unfortunately, responsibility for any decision to halt mining in the area rested with the Department of Mines, and the Health Department could only stand on the sidelines in frustration. Tragically, in time it became clear that there was another even more lethal health risk to the workers and residents of Wittenoom. The first Wittenoom-related case of mesothelioma was diagnosed in 1960,21 shortly after the initial suggestion of a link between exposure to crocidolite and mesothelioma.22 However, the Wittenoom mine continued to operate until 1966 when, ironically, it was closed for economic rather than health reasons. The mine may have been losing money then; today, the loss in life continues. In the mid 1970s, when it became apparent that an epidemic of asbestos-related disease was emerging in Wittenoom workers, Australian researchers began a cohort study. Mine workers’ employment records, giving detailed information about the identity of the workers, their length of employment and the duties they performed, were made available to the research team. Although only several hundred people were employed at any time, about 7000 workers (mostly men) had passed through the mine or mill over the years. Most worked for only a few months; many were post-war migrants, several hundred of whom returned (and were traced) to Italy. Resulting studies have reported that asbestos-related diseases, particularly malignant mesothelioma, lung cancer and pneumoconiosis, continue to be the main causes of excess mortality in the former blue asbestos miners and millers of Wittenoom. Further, mesothelioma appeared much earlier in these people than had been seen after exposure to other types of asbestos in UK industrial studies. By the early 1980s, people who had lived in the town of Wittenoom without working in the mine or mill were also developing asbestos-related disease at an alarming rate. In the 1950s and 60s, crocidolite tailings had been spread around the town as a cheap gravel and sand substitute. Professor Bill Musk said, “They brought the crocidolite in from the gorges and laid it around the township to counter the dust or the mud, depending on whether it was raining or not. So everybody living in town was exposed”. Professor Michael Hobbs continued, “The school playground had been layered with asbestos tailings as a better surface for children to be running about on, rather than hard dirt”. Thus, a residents cohort study involving more than 4500 former residents of Wittenoom, including Indigenous residents, was embarked upon. Intervention and other studies have continued in that group to this day, giving, as Associate Professor Lenore Layman said, “some support and comfort to people who live with this terrible fear about their children getting mesothelioma”. Together, the Wittenoom studies have provided evidence that (unlike with smoking) the risks of mesothelioma do not diminish with increasing time since exposure. Most importantly, Professor Nick de Klerk says that dose–response curves were able to determine, once and for all, that, “When it comes to blue asbestos, there is no such thing as a ‘safe’ level of exposure”. The evidence from these studies has influenced asbestos policy in Australia, assisted in legal deliberations, inspired a hit song by Australian rock band Midnight Oil (“Blue sky mine”), and even led to Wittenoom becoming a designated contaminated site that has been literally wiped off the map. However, asbestos is still being used in developing countries around the world. Hobbs said: “The first world has sort of recognised the dangers of asbestos and stopped using it. I think we have a moral obligation to go on pushing this barrow to make sure that our colleagues in China and India are equally armed with the information they need to try and stop things happening there. Because, if not, whereas we’ve seen hundreds of cases of mesothelioma, they will see thousands”. Women’s Health Australia (WHA)Interviewees: Professor Julie Byles, Professor Annette Dobson“I am woman, hear me roar; in numbers too big to ignore ...” proclaimed the lyrics of Australian-born Helen Reddy’s song “I am woman”. The song won Reddy a Grammy Award in 1973 and is now famous as the anthem of the Women’s Movement. But how much did we really know then about ordinary women’s lives and the influences on their health? In 1985, after much lobbying, Prime Minister Bob Hawke’s government committed to forming a National Women’s Health Policy. The Policy, which would provide a framework and planned strategy to improve the health of women in Australia, was to incorporate a wide perspective — recognising that women’s health was much more than just reproductive and sexual health. In the early 1990s, a tender was put out by the federal government for a national longitudinal study on women’s health — one that could collect scientifically valid information relevant to the development of health policy and practice, and that would enable women to gain greater power over shaping the nature of health care. On seeing the advertisement for the tender, a group of researchers from different academic disciplines (including medicine, sociology, psychology and statistics) met over coffee in Newcastle, NSW, and decided to put in a submission. Thus began Women’s Health Australia (WHA), also known as the Australian Longitudinal Study on Women’s Health. The study’s overall goal was (and still is) to clarify relationships between women’s health and a range of biological, psychological, social and lifestyle factors. Professor Annette Dobson said: “We’ve never claimed to have just one clear hypothesis. Rather, what we felt was needed was enough power in the study to be able to address new questions as they emerged. We did have some concrete examples of the sorts of hypotheses that could be answered, but we didn’t say this was a study to address this or that question. We were saying it’s a study to look generally at factors that influence the health of women”. Extensive surveys have been mailed at regular intervals to a national sample of thousands of women in three different age cohorts (18–23, 45–50 and 70–75 years at baseline in 1996). These age groups were chosen because they represented times before which major changes could be expected in women’s lives; so, for example, there would be baseline data for young women before most of them had babies. Further, the women were recruited from the national Medicare database, allowing a link to health services data. More than 41 000 women (14 792 young women, 14 200 middle-aged women and 12 624 older women) responded to the baseline surveys in 1996;23 and now, about 10 000 completed questionnaires are received each year. Over time, themes explored have included health-related behaviour (eg, diet and exercise), time use (eg, paid and unpaid work, and leisure), life stages and key events (eg, childbirth, divorce and widowhood), violence against women, and chronic disease. Because WHA does not focus on a specific exposure, disease outcome or social problem, publications are highly diverse (http://www.alswh.org.au/public.html). Dobson said, “We’re contributing to the story of the health of Australian women”. There is sustained work on overweight, obesity and physical activity, and in the unfashionable area of incontinence. Professor Julie Byles said, “We’re dispelling the myth that incontinence is just a condition for older people”. WHA is also one of the significant studies of ageing in Australia. In addition, there are add-on studies and collaborations. WHA has passed the 10-year mark and is currently funded to last the desired 20 years. However, the researchers see possibilities for expansion and extension. Byles said, “We have found that the cohorts’ experiences are likely to be different as they age, so we have put a suggestion to the Department [of Health and Ageing] that we recruit a new young cohort — precisely because of those differences”. The WHA study has certainly fulfilled Reddy’s command that women not be ignored. And, to make sure of it, Byles would like the study to “hang around” at least until the older women reach the milestone age of 100. Australians advancingThese eight longitudinal studies, all conducted “on our selection” (to borrow an Australianism from Steele Rudd), have already contributed much to our knowledge of diseases in Australia. Although they cover disparate topics and range in cohort size from several thousand to many tens of thousands of participants, there are some common elements to their stories: committed investigators who are capable of thinking into the future; dedicated and often longstanding research teams; sustained support and enthusiastic participation from the community; and the need to endure and persist through periods of extreme funding uncertainty. A striking feature of these longitudinal studies is their capacity to produce valuable results with relatively little funding overall — many of those interviewed said that their work had been conducted on “the smell of an oily rag”. Reports from the studies have been published in prestigious high-impact journals, such as Nature, the New England Journal of Medicine and the BMJ, as well as high audience-impact journals, such as the MJA, thus influencing discourse, attitudes and policy. These Aussie battlers are rightfully proud of their achievements, as are we. Despite some successes, none of the researchers are content to rest on their laurels. All are eyeing a future for their studies, carefully watching the emergent literature for new ideas that may be a natural fit for their study populations. Many are actively engaging productive collaborators in cutting-edge areas, like genetics, and seeking a greater international contribution through the integration and comparison of their data with those of others. Both of these advances are enabled by making their data available online. Does a longitudinal study have a natural lifespan? Maybe, but all our interviewees are more concerned that it will be a lack of funding rather than relevance or researcher interest that sounds the death-knell for their study. If these studies are stopped too soon, we will all miss out on “the gold coins at the end of the rainbow”. As Miller (from BEACH) said, “Enough of the past must be seen before we can begin to predict the future with any certainty”. To achieve sustainability, many argue that a different kind of funding is needed than that usually available to epidemiological researchers. Hopper (TAHS) said, “The work is generally funded by project grants, scientific project grants, but what is needed is core funding”. Several interviewees said there needed to be some sort of formal research policy providing long-term support to cohort studies. Whatever the lifespan of their own study turns out to be, most of the researchers want a future that is better for all longitudinal study investigators. WHA has published a practical guide to conducting longitudinal studies — how to store data, track people, manage collaborators and more.24 Dharmage (TAHS) dreams of establishing a supportive collaboration of longitudinal researchers, all helping each other forward. What will be the next great Australian longitudinal study? Zimmet (AusDiab) says the time is ripe for Australia to establish a comprehensive longitudinal national health survey, conducted every 5 years, which would give an idea of the burden of disease and the opportunity to monitor interventions. Hopper sees a future where the historically fostered culture of institutionalised non-cooperative research groups is turned on its head. “Even now, the concept of having national cohorts that are run as resources for the general scientific community is becoming more and more established. The general thinking is growing — not just in Australia but internationally — that these resources are precious, that they need to be open and accessible to a wide range of research; and that people who do research using these resources need to put that data back into the resource so that others can build on it.” Australian longitudinal research is making its mark in medicine at home and beyond. With renewed commitment, vision and adequate ongoing resources, we hope that these stories, and others like them, will continue. 1 On our selection: characteristics of some Australian longitudinal studies Study title Location Year of initiation No. in baseline cohort(s) Funding* No. of publications† Study website Initial funding Total funding The Australian Diabetes, Obesity and Lifestyle Study (AusDiab) National 1999 11 247 $1 500 000 $2 600 000 80 http://www.diabetes.com.au/research.php?regionID=181 Bettering the Evaluation And Care of Health (BEACH) National 1998 na $1 200 000 $11 000 000 53 http://www.fmrc.org.au/beach.htm The Blue Mountains Eye Study (BMES) Blue Mountains, NSW 1992 3654 $163 819 $7 255 400 332 http://www.cvr.org.au/bmes.htm The Busselton Health Study Busselton, WA 1966 5008 £6000 > $7 600 000 > 250 http://www.busseltonhealthstudy.com The Dubbo Study Dubbo, NSW 1988 2805 $250 000 $400 000 51 http://www.dubbostudy.org Tasmanian Longitudinal Health Study (TAHS) National 1968 45 900 nd $4 000 000‡ 30 — Wittenoom cohort studies Wittenoom, WA 1974 11 684 $50 000 > $4 000 000 100 http://www.sph.uwa.edu.au/go/research-programs/oee/schools-and-centres/schools/school-of-population-health/projects#asb Women’s Health Australia (WHA) National 1995 41 616 $3 500 000 > $18 000 000 252 http://www.alswh.org.au na = not applicable. nd = data not available. NSW = New South Wales. WA = Western Australia. * Amounts shown are estimates and may not include institutional funding for costs such as investigator salaries or postgraduate students, and may comprise a mix of federal funding, support from trusts and industry, and in-kind support from various states and territories. Total funding is an estimate of funding received so far. † Number of published (or in press) articles in peer-reviewed journals only. See study websites for details of other publications. ‡ TAHS funding information is only available since 1992. 2 Macular degeneration Neovascular macular degeneration in the right eye of a 71-year-old woman who smoked heavily. 3 Busselton, Western Australia At nearly 2 km, Busselton’s iconic jetty is the longest in the southern hemisphere. 4 Wittenoom miners Underground Wittenoom miners having a lunch break in a dusty crypt room.

Ann T Gregory MB BS, GradDipPopHealth · Ruth M Armstrong BMed · Tanya D Grassi MB BS(Hons), BSc(Vet)(Hons) · Bronwyn Gaut MB BS, DCH, DA · Martin B Van Der Weyden MD, FRACP, FRCPA

Objective: To determine whether the statewide system of trauma care introduced in 2000 has resulted in improved survival for all major trauma patients in Victoria.Design, setting and participants: Population-based cohort study using data from the Victorian State Trauma Registry (VSTR), a registry of all hospitalised major trauma patients in Victoria. The study included major trauma patients with an Injury Severity Score > 15 captured by the VSTR between July 2001 and June 2006.Main outcome measure: In-hospital mortality.Results: The number of major trauma cases captured by the registry rose from 1153 in 2001–02 to 1737 in 2005–06. Adjusting for key predictors of mortality, there was a significant overall reduction between 2001–02 and 2005–06 in the risk of death for patients treated in the trauma system (adjusted odds ratio [AOR], 0.62 [95% CI, 0.48–0.80]). The reduced risk of death was also significant when road trauma cases (AOR, 0.56 [95% CI, 0.39–0.80]) and serious head injury cases (AOR, 0.62 [95% CI, 0.46–0.83]) were analysed separately. The proportion of road trauma patients definitively treated at one of the three major trauma service (MTS) hospitals in Victoria rose by 7% over the 5-year period. Direct transfers from the scene of injury to MTS hospitals rose by 8% for all cases and 13% for road trauma cases over the same period.Conclusions: Introduction of a statewide trauma system was associated with a significant reduction in risk-adjusted mortality. Such inclusive systems of trauma care should be regarded as a minimum standard for health jurisdictions.

Peter A Cameron MB BS, FACEM · Belinda J Gabbe PhD · D James Cooper MB BS, MD, FJICM · Tony Walker BParamedStud, GDipEmergHth, MEd · Rodney Judson FRACS · John McNeil MB BS, FRACP, PhD

Objectives: To examine the characteristics of adult patient attendances to emergency departments (EDs) in Perth hospitals by patients’ frequency of attendance.Design, setting and participants: A linked-data population study of adults (aged ≥ 15 years) attending all nine Perth hospital EDs between 1 July 2000 and 31 December 2006.Main outcome measures: Proportion of frequent attenders (FAs; those attending five or more times annually); and demographic characteristics, mode of arrival at the ED, disposition (admission, transfer, discharge or death), urgency and clinical conditions by frequency of attendance.Results: There was a mean of 1.5 attendances per individual per year, resulting in 1 583 924 attendances by 663 309 individuals over the 6.5 years of the study. Most patients (97.6%) attended Perth EDs fewer than five times a year. The more frequently patients attended, the more likely they were to be male, middle-aged and late-middle-aged, have self-referred, have mental and behavioural disorders and alcohol intoxication, to not wait to be assessed, and to arrive by ambulance. The groups of patients attending between 5–9 and 10–19 times per year (97.4% of FAs) had more urgent conditions, more circulatory system disease and higher admission rates than all other patients.Conclusion: Most FAs at Perth EDs present fewer than 20 times a year and have more serious and urgent illness than other patients, more often requiring inpatient services. A very small minority of patients (around 100 patients/year) attends 20 or more times a year, many with mental and behavioural disorders and alcohol intoxication not requiring hospital admission.

George A Jelinek MD, FACEM, DipDHM · Moyez Jiwa MD, MRCGP, FRACGP · Nicholas P Gibson PhD, RN, FRCNA · Ann-Maree Lynch BSc (Hons), PhD

Objective: To measure long-term survival following combined chemotherapy and radiotherapy for inoperable non-small cell lung cancer.Design and setting: Two prospective Phase I/II studies in the multidisciplinary Lung Service of a dedicated cancer hospital in Victoria, commencing in 1996 and 1997–1998.Patients: 33 patients referred for treatment of histologically or cytologically proven inoperable non-small cell lung cancer, who had no evidence of distant metastases, Karnofsky performance status > 70%, weight loss < 10%, and no prior treatment for lung cancer. Patients were followed until death or for a minimum of 9 years.Interventions: Patients in both studies were treated concomitantly with chemotherapy and radiotherapy 60 Gy in 30 fractions over 6 weeks. Chemotherapy in the first study (LURTCE) consisted of cisplatin and etoposide; in the second study (LURTCF), chemotherapy consisted of escalating doses of carboplatin and fluorouracil.Main outcome measure: Overall survival.Results: Six of 33 patients were still alive 9 years after commencement of treatment. Median survival for the whole group was 2.1 years (95% CI, 1.3–3.1 years), with 18% (95% CI, 8%–35%) of patients still alive at 5 years (plateau).Conclusion: Long-term survival can be achieved in some patients with inoperable non-small cell lung cancer treated by radical chemoradiation alone, suggesting the possibility of cure.

Nikki M Plumridge FRANZCR · Michael J Millward MBioethics, FRACP · Danny Rischin MD, FRACP · Michael P MacManus MD, FRCR, FRANZCR · Andrew Wirth FRACP, FRANZCR · Michael Michael FRACP · Kally Yuen MSc, AStat · David L Ball MB BS, MD, FRANZCR

Objective: To measure the prevalence of somatisation (multiple somatic symptoms and hypochondriasis) among Australian general practice attendees, its recognition by general practitioners, and its relationship with symptoms of depression and anxiety.Design, setting and participants: Self-reported questionnaires completed by 10 507 consecutive patients aged ≥18 years attending 340 GPs enrolled in a 6-hour national mental health program of continuing professional development who accepted invitations to participate; audit form completed by GPs for each patient during the period March 2004 to December 2006.Main outcome measures: Somatic symptom severity (measured with the 15-item Patient Health Questionnaire [PHQ-15]); hypochondriasis (measured with the Whiteley Index [Whiteley-7]; depression and anxiety (measured by the Kessler Psychological Distress scale [K10]); prevalence of “somatisers” (defined by medium to severe somatic symptom severity and hypochondriasis); GP recognition of somatisation (determined by their responses on audit forms to questions on whether patient’s complaints were most likely to have a physical or psychological explanation).Results: 18.5% of patients were classified as somatisers and 9.5% as probable cases of depression or anxiety. While 29.6% of somatisers had high anxiety or depression scores, 57.9% of people with anxiety or depression were also somatisers. Sex and age asserted significant but weak effects on psychometric scores. GPs identified somatic complaints as “mostly explained by a psychological disturbance” in 25.1% of somatisers.Conclusions: Somatisation is common in general practice, and more prevalent than depression or anxiety. While a minority of somatisers have significant anxiety and depression, most patients with depression and anxiety have a significant degree of somatisation. Recognition of depression and anxiety can be hindered by a somatic presentation and attribution. On the other hand, managing somatisation does not just involve recognising depression and anxiety, but also dealing with the health anxieties that underpin hypochondriasis.

David M Clarke PhD, FRACGP, FRANZCP · Leon Piterman MMed, FRACGP, FRCP · Claire J Byrne BSc(Behav)(Hons) · David W Austin PhD

Objectives: To examine self-reported patterns of alcohol consumption and experience of alcohol-related harms among professional Australian Football League (AFL) players.Design, setting and participants: Cross-sectional survey of player alcohol consumption and self-reported alcohol-related harms among members of all 16 professional AFL clubs. Data relating to the 2006 football year were collected between 25 July and 30 August 2006 at regular football training sessions using a self-administered structured questionnaire.Main outcome measures: Risky/high-risk drinking for long- and short-term harm at different times of the year; Alcohol Use Disorders Identification Test (AUDIT) score.Results: 582 AFL players completed the questionnaire (an 83% response rate). Alcohol consumption varied at different times of the year. During the playing season (approximately 22 weeks), the level of risky/high-risk consumption for long-term harm in AFL players (11/564 [2%]) was typically lower than in age-matched Australian men in the general population (15%). However, risky/high-risk consumption for long-term harm was higher in AFL players during the end-of-season period (approximately 2 weeks) (303/561 [54%]) and vacation period (6–8 weeks) (231/559 [41%]) than in age-matched Australian men. Risky/high-risk drinking for short-term harm on a monthly basis was frequent at all times of the year (eg, 395/560 [71%] in the pre-season period). The mean AUDIT score was 8.8 (95% CI, 8.4 to 9.1; range, 0 to 36). Reports of harmful effects of drinking and negative consequences, such as getting involved in a fight (physical or verbal) while drinking (146/556 [26%]), were common. Risky/high-risk consumption for short-term harm on a monthly basis was associated with a variety of player characteristics, such as usually drinking in public locations (odds ratio, 1.55 [95% CI, 1.02 to 2.35]). AUDIT score was associated with variables such as marital status, with married players scoring more than two points lower (95% CI, – 3.58 to – 0.58) than single players. Formal club rules on alcohol consumption had little effect on outcome measures.Conclusions: Drinking among AFL players is intricately related to time of year. This seasonal drinking pattern requires the development of specific club and league strategies to minimise drinking-related harms to players.

Paul M Dietze PhD · John L Fitzgerald PhD · Rebecca A Jenkinson MEpid, GradDipEpiBiostat

Objective: To evaluate the immune status and vaccination needs of first-year medical students in relation to bloodborne viruses and common vaccine-preventable diseases.Design, setting and participants: Survey of first-year medical students at the University of New South Wales, Sydney, NSW, attending a mandatory screening and vaccination clinic, 2002–2005.Main outcome measures: Self-reported history of vaccination or natural infection; serological evidence of immunity to measles, mumps, rubella and varicella (presence of specific IgG) and hepatitis B (presence of hepatitis B virus surface antibodies) or infection with hepatitis B and C viruses and HIV; and Mantoux test results.Results: 733 students attended the clinic (85% of those enrolled). Four students were positive for HBsAg and four had hepatitis C antibodies. None were HIV-positive. Twenty-nine per cent (216/733) were not immune to hepatitis B, 33% (238/724) to mumps, 26% (190/724) to measles, 13% (91/724) to rubella and 10% (75/724) to varicella. About 23% (91/237) needed further testing for tuberculosis. Immunity corresponded poorly with self-reported history of vaccination. More students reported vaccination against rubella (96%), measles (81%) and mumps (80%) than were immune, and fewer reported vaccination against hepatitis B (44%).Conclusions: Many students were not immune to vaccine-preventable diseases, and a small number had a previously undiagnosed bloodborne virus infection (hepatitis B or C). The level of immunity to vaccine-preventable infections was unacceptable and justified the provision of an easily accessible program for screening and vaccination.

Adrienne J Torda FRACP, GradDipBioethics, PhD

Objective: To estimate the percentage of preterm (< 37 weeks) and full-term low-birthweight (37–41 weeks, < 2500 g) babies born to mothers who smoke, stratified by Indigenous status and statistically adjusted for the potential confounding effects of social and demographic factors, medical conditions and pregnancy complications.Design, setting and participants: Population-based study of singleton babies born to mothers resident in Queensland who gave birth in Queensland from 1 July 2005 to 31 December 2006.Main outcome measures: Adjusted percentages of preterm birth and full-term low birthweight for babies born to Indigenous and non-Indigenous mothers.Results: Of the 79 803 babies studied, 4228 (5.3%) were born to Indigenous mothers and 16 395 (20.5%) were born to mothers who smoked during pregnancy. The percentage of Indigenous mothers who smoked (54%) was almost triple that for non-Indigenous mothers (risk ratio, 2.90; 95% CI, 2.81–2.99). The adjusted outcomes for babies born to Indigenous non-smokers were similar to those for non-Indigenous non-smokers (preterm, 7.1% v 6.1%; full-term low birthweight, 1.6% v 1.1%). The adjusted percentages for smokers were high regardless of Indigenous status (preterm, Indigenous v non-Indigenous, 8.3% v 7.8%; full-term low birthweight, Indigenous v non-Indigenous, 5.3% v 3.7%).Conclusions: Antenatal smoking remains an important cause of poor health among both Indigenous and non-Indigenous newborn babies. Most pregnant smokers receive their antenatal care in the public sector. State and federal governments, who directly fund this sector, have a particular responsibility to ensure that interventions are offered to all pregnant smokers to help them quit smoking.

Rachael-Anne Wills BAppSc(Hons) · Michael D Coory PhD, FAFPHM, AStat

Objectives: To explore the role of socioeconomic status and Aboriginality on birthweight at an urban hospital.Design, participants and setting: Extraction of data on the demographic characteristics (socioeconomic status, mothers’ single-parent status, age and smoking status) and infants’ birthweight from a clinical record system. Infants delivered at an outer urban hospital to mothers residing in the local government area during 2002 were included. Infants were identified and results interpreted in consultation with Indigenous health workers.Main outcome measure: Infant birthweight.Results: Indigenous infants had a lower mean birthweight than non-Indigenous infants (difference, 127 g), and were more likely to weigh < 2500 g. Mothers of Indigenous infants were more likely to be single, aged < 20 years and to smoke during pregnancy. Lower birthweight was associated with lower socioeconomic status for Indigenous and non-Indigenous infants. Indigenous infants in the most socioeconomically disadvantaged quintile in this study were at higher risk and had a mean birthweight 204 g less than non-Indigenous infants in the same quintile. In multivariate analysis, differences in birthweight were associated with socioeconomic status and smoking during pregnancy.Conclusions: For both Indigenous and non-Indigenous infants, birthweights were associated with socioeconomic status. Differences between Indigenous and non-Indigenous infants were largely explained by low socioeconomic status and smoking during pregnancy.

Angela T Titmuss BSci(Med)(Hons), MB BS, MPH · Elizabeth Harris BA, DipSocWork, MPH · Elizabeth J Comino BVSc, MPH, PhD

Objectives: To explore the understanding of both Indigenous and non-Indigenous Australians with end-stage kidney disease (ESKD) about the cause of their disease, and how this understanding could affect patients’ engagement with their treatment.Design, setting and participants: Qualitative study conducted in 2005–2006 in nine hospital renal units and 17 associated dialysis centres in four states and the Northern Territory as part of the IMPAKT (Improving Access to Kidney Transplants) study. In-depth interviews were conducted with 146 Indigenous and 95 non-Indigenous Australians with ESKD, covering personal history of illness, social and psychosocial context, attitudes to treatments including transplantation, adequacy of information and communication, and satisfaction with services.Results: Indigenous Australians were less certain about the cause of their illness and reported feeling uninformed but eager for information. They commonly reported lifestyle factors as potentially causal, with profound confusion about the role of alcohol. Indigenous Australians had considerable ambivalence towards biomedical explanations.Conclusions: Indigenous Australians are confused, frustrated and feel poorly informed about their illness. This study confirms the need to develop shared understandings about chronic kidney disease and to put in place the high-quality and appropriate educational resources that patients need.

Kate Anderson BSc(Psych)(Hons), BA · Jeannie Devitt PhD · Joan Cunningham ScD · Cilla Preece BAppSci(IPHC) · Alan Cass MB BS, FRACP, PhD

Objective: To examine short- and medium-term outcomes of percutaneous coronary interventions (PCIs), with a focus on comparing drug-eluting stents (DESs) with bare-metal stents (BMSs).Design, setting and participants: Retrospective analysis of data from the Melbourne Interventional Group (MIG) registry, a large multicentre Australian registry. The study cohort consisted of 6364 consecutive patients undergoing 7167 PCIs between April 2004 and August 2007.Main outcome measures: Clinical events including death, myocardial infarction (MI), target lesion revascularisation (TLR), target vessel revascularisation (TVR) and major adverse cardiac events (MACE) (a composite of death, MI and TVR), at 30 days and at 12 months.Results: The cohort was predominantly male (74%), with a mean age of 64.7 years (SD, 12.0 years). DESs were used in 3482 (51.4%) of PCIs. In the overall cohort, rates of clinical events were low at 30 days: mortality (1.9%), MI (2.4%), TLR (2.0%), TVR (2.4%) and MACE (5.7%). At 12 months, event rates were: mortality (5.2%), MI (6.0%), TLR (5.8%), TVR (8.2%) and MACE (16.2%). Patients receiving DESs had similar mortality rates to those receiving BMSs (4.0% v 6.0%; P = 0.62 [propensity score-adjusted]); late thrombosis rates were also similar in the two groups (0.8% v 1.1%; P = 0.38). The proportion of patients receiving DESs fell significantly over time, from 54.9% in the first 24 months to 44.7% in the last 15 months of the study period (P < 0.01). Independent predictors of 12-month mortality included diabetes, renal failure, ST-segment-elevation MI and cardiogenic shock.Conclusion: Our clinical event rates were comparable with international registry outcomes. Rates of mortality and stent thrombosis were no higher in patients with DESs than those with BMSs. Although DESs were used in about half the procedures (preferentially for higher-risk lesions), recent trends suggest their use is in decline.

Andrew E Ajani MD, FRACP, FJFICM · Christopher M Reid BA, MSc, PhD · Stephen J Duffy FRACP, MRCP, PhD · Nick Andrianopoulos MB BS, MBiostat · Jeffrey Lefkovits MB BS, FRACP · Alexander Black MB BS, FRACP · Gishel New FRACP, FACC, PhD · Robert Lew MB BS, FRACP, PhD · James A Shaw MB BS, FRACP, PhD · Bryan P Yan MB BS, FRACP · Ronen Gurvitch MB BS · Ali Al-Fiadh MB BS · Angela L Brennan RN, CCRN · David J Clark MB BS, FRACP

Objective: To assess the effectiveness of the PAST (Pre-hospital Acute Stroke Triage) protocol in reducing pre-hospital and emergency department (ED) delays to patients receiving organised acute stroke care, thereby increasing access to thrombolytic therapy.Design: Prospective cohort study using historical controls.Setting: Hunter Region of New South Wales, September 2005 to March 2006 (pre-intervention) and September 2006 to March 2007 (post-intervention).Participants: Consecutive patients presenting with acute stroke to a regional, tertiary referral hospital.Intervention: PAST protocol, comprising a pre-hospital stroke assessment tool for ambulance officers, an ambulance protocol for hospital bypass for potentially thrombolysis-eligible patients, and pre-hospital notification of the acute stroke team.Main outcome measures: Proportion of patients who received intravenous tissue plasminogen activator (tPA), process of care time points (symptom onset to ED arrival, ED arrival to tPA treatment, and ED transit time), and clinical outcomes of patients treated with tPA.Results: The proportion of ischaemic stroke patients treated with tPA increased from 4.7% (pre-intervention) to 21.4% (post-intervention) (P < 0.001). Time point outcomes also improved, with a reduction in median times from symptom onset to ED arrival from 150 to 90.5 min (P = 0.004) and from ED arrival to stroke unit admission from 361 to 232.5 minutes (P < 0.001). Of those treated with tPA, 43% had minimal or no disability at 3 months.Conclusions: Organised pre-hospital and ED acute stroke care increases patient access to tPA treatment, which is proven to reduce stroke-related disability.

Debbie A Quain BA(Nursing) · Mark W Parsons PhD, FRACP · Allan R Loudfoot MBA · Neil J Spratt PhD, FRACP · Malcolm K Evans RN, BA(HealthManagement) · Michelle L Russell RN, CM · Angela T Royan BNursing · Andrea G Moore BNursing · Ferdinand Miteff MB ChB · Carolyn J Hullick FACEM · John Attia MD, PhD, FRCPC, FRACP · Patrick McElduff BMath, PhD · Christopher R Levi BMedSci, FRACP

Objective: To assess the quality of Australian clinical guidelines for chronic diseases and their relevance to older people with multiple comorbid conditions. Design: Selection and assessment of national clinical guidelines for chronic conditions listed as National Health Priority Areas: cardiovascular health, diabetes mellitus, mental health, asthma, arthritis and musculoskeletal conditions, and cancer. Main outcome measures: Standardised mean scores obtained with the Appraisal of Guidelines Research and Evaluation (AGREE) instrument (criteria grouped into six domains: scope and purpose; stakeholder involvement; rigour of development; clarity and presentation; applicability; and editorial independence). Relevance of guidelines for older people with multiple comorbid conditions. Results: 17 guidelines were included in the study. Guidelines approved by the National Health and Medical Research Council (NHMRC) scored significantly better than those not approved by the NHMRC in all domains except for editorial independence and clarity and presentation. The mean quality of guidelines not approved by the NHMRC was below 50% in all domains except clarity and presentation. Half of the guidelines addressed treatment for older patients or for patients with one comorbid condition, but only one addressed treatment for older patients with multiple comorbid conditions. Conclusions: Professional societies and charities should be encouraged and supported to develop clinical guidelines in compliance with NHMRC requirements. Future guidelines should place more emphasis on the management of older people with multiple comorbid conditions.

Agnes I Vitry PhD · Ying Zhang MB BS, PhD

Objective: To determine whether Helicobacter pylori eradication is an effective treatment for Australian patients with chronic immune thrombocytopenic purpura (ITP).Design, setting and patients: Retrospective analysis of clinical records of a consecutive series of ITP patients referred to a gastrointestinal surgeon in a tertiary referral hospital for laparoscopic splenectomy between August 2005 and November 2007.Main outcome measures: Platelet response (measured at least 3-monthly) following successful H. pylori eradication therapy (confirmed by urea breath test 4 weeks later).Results: Of 16 patients, seven were H. pylori-negative and underwent laparoscopic splenectomy. Nine were H. pylori-positive and successfully underwent H. pylori eradication therapy; five of the nine had an initial platelet response. Four patients had platelet counts > 100 × 109/L (reference range, 140–450 × 109/L) and were off all immunosuppression at 9 months; three had a sustained response beyond 12 months. One patient had an initial response at 3 months (15 × 109/L to 208 × 109/L), but relapsed 4 months after H. pylori eradication and underwent splenectomy with platelet count recovery. The remaining four patients showed no platelet response and subsequently underwent splenectomy.Conclusion: Larger prospective studies are needed to fully ascertain the role of H. pylori in Australian patients with ITP. However, H. pylori eradication is simple and safe. H. pylori screening and eradication should be considered before immunosuppression or splenectomy.

Vanaja Sivapathasingam BSc(Med), MB BS(Hons) · Michael P Harvey PhD, FRACP, FRCPA · Robert B Wilson BSc, MB BS(Hons), FRACS

Objective: To determine whether a 5-day course of oral prednisolone is superior to a 3-day course in reducing the 2-week morbidity of children with asthma exacerbations who are not hospitalised.Design, setting and participants: Double-blind randomised controlled trial of asthma outcomes following a 5-day course of oral prednisolone (1 mg/kg) compared with a 3-day course of prednisolone plus placebo for 2 days. Participants were children aged 2–15 years who presented to the emergency departments of three Queensland hospitals between March 2004 and February 2007 with an acute exacerbation of asthma, but were not hospitalised. Sample size was defined a priori for a study power of 90%.Main outcome measures: Difference in proportion of children who were symptom-free at Day 7, as measured by intention-to-treat (ITT) and per-protocol analysis; quality of life (QOL) on Days 7 and 14.Results: 201 children were enrolled, and there was an 82% completion rate. There was no difference between groups in the proportion of children who were symptom-free (observed difference, 0.04 [95% CI, − 0.09 to 0.18] by ITT analysis; 0.04 [95% CI, − 0.17 to 0.09] by per-protocol analysis). There was also no difference between groups in QOL (P = 0.42). The difference between groups for the primary outcome was within the equivalence range calculated post priori.Conclusion: A 5-day course of oral prednisolone confers no advantage over a 3-day course for children with asthma exacerbations who are not hospitalised.Trial registration: Australian Clinical Trials Registry ACTRN012605000305628.

Anne B Chang MPHTM, PhD, FRACP · Ronald Clark PhD, FRACP · Theo P Sloots BSc, PhD · David G Stone FRACP · Helen L Petsky BN · Donna Thearle BN · Anita A Champion BPharm · Coralie Wheeler BN · Jason P Acworth FRACP

Objective: To ascertain the current level of understanding among older men about prostate cancer, including treatment options and their potential side effects.Design and setting: Questionnaires administered by general practitioners in five general practices in the Perth metropolitan and regional areas of Western Australia.Participants: Convenience sample of 503 men aged 40–80 years, with or without prostate cancer, presenting for routine consultations between January and August 2006.Main outcome measure: Knowledge and attitudes of men about prostate cancer, and predictors of knowledge.Results: Eighty per cent of men did not know the function of the prostate, and 48% failed to identify prostate cancer as the most common internal cancer in men. Thirty-five per cent had no knowledge of the treatments for prostate cancer and 53% had no knowledge of the side effects of treatments. Asked how they would arrive at a decision about treatment, 70% said they would ask the GP or specialist for information on all their options and then decide themselves.Conclusion: There is a deficit in knowledge about prostate cancer among men in the at-risk age group, encompassing areas that could delay diagnosis and treatment. Overall, the men preferred some GP or specialist involvement in treatment decision making.

Diane E Arnold-Reed BSc(Hons), PhD · Dana A Hince BSc(Hons), PhD · Max K Bulsara MSc · Hanh Ngo BSc(Hons) · Michael Eaton MB BS, FACRRM · Alan R Wright MB BS, MFM, FRACGP · Frank R Jones MB BCh, FACRRM, FRACGP · Walter Kaczmarczyk MB BS, FRACGP · Andreas G Marangou MB BS, FRACGP · Thomas D Brett MD, FRACGP, MRCGP

Objective: To describe trends in prostate-specific antigen (PSA) testing, prostate cancer incidence and mortality in New South Wales.Design and setting: Descriptive analysis using routinely collected data of observed trends in PSA testing from 1989 to 2006, and prostate cancer cases and deaths from 1972 to 2005 in NSW.Main outcome measures: Age-standardised and age-specific rates and joinpoint regression to identify changes in trends; projected trends observed before the introduction of PSA testing to quantify its impact on incidence and mortality rates.Results: The number of PSA tests per year more than doubled between 1994 and 2006. Age-standardised incidence of prostate cancer peaked in 1994, fell by 10.0% per year to 1998 and then increased by 4.9% per year from 2001 to 2005. An estimated 19 602 (43%) more men than expected from preceding trends were diagnosed with prostate cancer between 1989 and 2005 after PSA testing was introduced. The incidence of recorded advanced prostate cancer at diagnosis fell from 13.0 per 100 000 men in 1987–1991 to 7.0 per 100 000 men in 2002–2005. The age-standardised mortality from prostate cancer increased by 3.6% per year between 1984 and 1990 and then fell by 2.0% per year to 2005.Conclusions: There was a sustained increase in prostate cancer incidence in NSW after PSA testing was introduced. While falls in the incidence of advanced disease at diagnosis and mortality from prostate cancer after 1993 are consistent with a benefit from PSA testing, other explanations cannot be excluded.

David P Smith BA, MPH · Rajah Supramaniam MSc, MPH(Hons) · Villis R Marshall MD, FRACS · Bruce K Armstrong MB BS, DPhil, FRACP

Objective: To determine how well the current Pharmaceutical Benefits Scheme (PBS) eligibility criteria for subsidy of lipid-lowering drugs compare with current national guidelines for determining the population at high risk of developing cardiovascular disease (CVD).Design and participants: Analyses of the population-based, cross-sectional Australian Diabetes, Obesity and Lifestyle (AusDiab) study, conducted in 1999–2000. The 1991 Framingham risk prediction equation was used to compute 5-year risk of developing first-time CVD in 8286 participants aged 30–74 years with neither CVD nor diabetes. Based on the National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand guidelines, people with either 5-year CVD risk ≥ 15% or with 5-year CVD risk of 10%–< 15% and the metabolic syndrome were defined as having estimated high absolute CVD risk.Main outcome measures: 5-year CVD risk; estimated population with high CVD risk.Results: Among participants without prevalent CVD or diabetes, 7.9% of men and 1.5% of women had a 5-year CVD risk ≥ 15%. Of the estimated residential Australian population in 2000 aged 30–74 years without CVD or diabetes, 717 000 people were considered to be at high absolute CVD risk. Among the high-risk AusDiab participants without CVD or diabetes, only 16.9% of men and 15.4% of women were being treated with lipid-lowering drugs. Of the 9.6% of participants free of CVD and diabetes who were untreated but eligible for subsidy under PBS criteria, only 27.4% had an estimated high absolute CVD risk.Conclusion: Strategies for CVD prevention using lipid-lowering medications can be improved by adoption of the absolute-risk approach.

Lei Chen MD, MMed · Sophie L Rogers MEpi · Stephen Colagiuri MD, FRACP · Dominique A Cadilhac MPubHlth, PhD · Timothy H Mathew MB BS, FRACP · Andrew N Boyden BM BS(Hons), MPH, FRACGP · Anna Peeters BSc(Hons), PhD · Dianna J Magliano MPH, PhD · Jonathan E Shaw MD, MRCP, FRACP · Paul Z Zimmet MD, PhD, FRACP · Andrew M Tonkin MB BS, MD, FRACP