Research

Objective: To determine the association between smoking in pregnant teenagers and baby birthweight.Design, setting and participants: A retrospective population-based study of women aged < 20 years who gave birth to liveborn singletons in Australia between January 2001 and December 2004. Data were drawn from the National Perinatal Data Collection.Main outcome measures: Maternal smoking, birthweight, low birthweight (LBW).Results: The prevalence of LBW in babies born to teenage smokers was 9.9%, compared with 6.0% in babies born to teenage non-smokers (odds ratio [OR], 1.72 [95% CI, 1.57–1.90]). On average, babies born to teenage smokers were 179.8 g lower in birthweight than babies born to teenage non-smokers (95% CI, 165.5 –194.1 g; t = 24.6, P < 0.001). Smoking, Indigenous status, Socio-Economic Indexes for Areas category and parity were independently associated with LBW (all ORs > 1.3; P < 0.001) after adjusting for maternal age group. Teenagers smoking > 10 cigarettes a day had babies with lower birthweight that those who smoked ≤ 10 cigarettes a day, demonstrating a dose–response relationship. The babies of teenage smokers who stopped smoking before 20 weeks’ gestation had birthweights similar to those of babies born to teenage non-smokers. One in 15 teenage smokers stopped smoking during pregnancy.Conclusion: Babies whose mothers smoked during pregnancy were more likely to have LBW than babies whose mothers did not smoke. Mothers who continue to smoke in the second half of pregnancy increase their baby’s risk of LBW. There is significant scope to improve the quitting rate, and health professionals need to target smoking cessation at all contacts with pregnant women who continue to smoke.

Denise L Chan · Elizabeth A Sullivan MB BS, MPH, MMed(Sexual Health)

Objective: To examine the relationship between child weight and vehicle booster seat usage in the context of current Australasian booster seat standards.Design, setting and participants: Questionnaire survey conducted between February and April 2005. A convenience sample of parents with children aged 4–11 years in New South Wales and Victoria completed a questionnaire, reporting on the height and weight of their children and the nature of restraint devices used in the family vehicle.Main outcome measures: Proportion of children meeting standard-specified weight and height criteria who are not restrained in booster seats; proportion of children who meet the specified height criteria but whose weight exceeds the specified weight.Results: 699 of 3959 questionnaires were returned (response rate, 18%), of which seven lacked essential details. The remaining 692 responses provided information on 1500 children. Of these children, 633 aged 4–11 years fell within the recommended height range for using booster seats, but only 29% were typically restrained in booster seats, the majority (70%) being restrained in normal seatbelts. A key finding was that 37% of the children who met the recommended height criteria exceeded the maximum weight for booster seats stipulated by the current Australasian safety standard.Conclusion: In view of increasing rates of overweight and obesity in children, it is important to reassess current Australasian standards for child restraints in vehicles. A concerted parental education campaign is also needed to raise awareness of which restraint types are appropriate for children of various heights and weights.

Michael P Fitzharris BA, BSc(Hons), PhD · Judith Charlton BEd, MSc, PhD · Megan Bohensky BA, MPH · Sjaanie Koppel BAppSc(Hons), PhD · Brian Fildes BSc(Hons), PhD

Objectives: To compare results of statistical process-control analyses of in-hospital deaths of patients with acute myocardial infarction by using either administrative or clinical data sources and prediction models, and to assess variation in results according to selected patient characteristics.Design: Retrospective, cross-sectional study comparing variable life-adjusted display (VLAD) curves derived by using administrative or clinical prediction models applied to a single patient sample.Participants and setting: Data from 467 consecutive patients admitted to a tertiary hospital in Queensland, between 1 July 2003 and 31 March 2006, with a coded discharge diagnosis of acute myocardial infarction.Main outcome measure: Statistical estimates of cumulative lives gained or lost in excess of those predicted at the end of the study period.Results: The two prediction models, when applied to all patients, generated almost identical VLAD curves, showing a steadily increasing excess mortality over the study period, culminating in an estimated 11 excess deaths. Risk estimates for individual patients from each model were significantly correlated (r = 0.46, P < 0.001). After exclusion of misclassified cases, out-of-hospital cardiac arrests and deaths within 30 minutes of presentation, replotting the curves reversed the mortality trend and yielded, depending on the model, a net gain of three or seven lives. After further exclusion of transfers in from other hospitals and patients whose care had a palliative or conservative intent, the net gain increased to seven or 10 lives.Conclusion: Appropriate patient selection is more important than choice of dataset or risk-prediction model when statistical process-control methods are used to flag unfavourable mortality trends suggestive of suboptimal hospital care.

Ian A Scott FRACP, MHA, MEd · Peter L Thomson MEngSc, MPH, MBiomedE · Seshasayee Narasimhan MB BS

Objective: To examine differences in psychostimulant prescribing between paediatricians and child/adolescent psychiatrists for treating children with attention deficit hyperactivity disorder (ADHD) in Western Australia.Design: Using whole-population prescribing data, logistic and linear regressions were used to model the number of children (aged 2–17 years) treated with psychostimulants between August 2003 and December 2004 for ADHD and medication dose prescribed by clinical specialty, controlling for age, sex, body weight, and other medication use.Main outcome measures: Mean number of patients treated by specialty; associations between prescriber specialty and patient characteristics; associations between stimulant dose and patient characteristics and prescriber specialty.Results: 54 paediatricians and 23 child/adolescent psychiatrists prescribed stimulant medications for children with ADHD. The mean number of patients treated (per prescriber) was 159.8 (range, 1–1977) for paediatricians and 34.3 (range, 1–166) for psychiatrists. Boys were 32% more likely to be treated with stimulants by paediatricians (P = 0.002). Psychiatrists were 2.9 times (95% CI, 2.4–3.3; P < 0.001) more likely than paediatricians to treat patients with multiple psychotropic medications. When controlled for all other factors, psychiatrists prescribed higher stimulant doses (4.5 mg/day greater; 95% CI, 2.0–7.0 mg/day; P < 0.001) than paediatricians.Conclusion: Treatment of children with stimulant medicines for ADHD differed between clinical specialties. Paediatricians treated more patients per prescriber, a greater proportion of boys, and a younger age demographic, but relied less on combined psychotropic pharmacotherapy and prescribed lower stimulant doses than psychiatrists.

David B Preen BSc(Hons), PhD · Janine Calver BA(Hons) PhD · Frank M Sanfilippo PGradDipPharm, PhD, FPS · Max Bulsara BSc, MSc · C D’Arcy J Holman FACE, FAFPHM, FAIM

Objectives: To investigate the relationship between admission glycaemic status and inpatient mortality in patients with and without pre-existing diabetes.Design: Prospective observational cohort study.Setting: A general medical ward in an Australian tertiary referral hospital.Participants: 903 patients admitted to the general medical ward between February 2003 and July 2004.Main outcome measure: Inpatient death.Results: The overall inpatient mortality was 5.4% (n = 49). In the total cohort, age > 75 years and admission fasting plasma glucose (FPG) levels ≥ 5.6 mmol/L were independent predictors of mortality. For patients without a known history of diabetes, each 1 mmol/L rise in admission FPG was associated with a 33% increase in mortality. In these patients, elevated (> 6.0%) and normal glycated haemoglobin (HbA1c) levels were associated with mortalities of 11.3% and 4.4%, respectively (odds ratio, 2.47; 95% CI, 1.16–5.26). In contrast, in patients with known diabetes, there was no association between admission FPG levels, HbA1c and mortality. Length of stay was not independently associated with FPG, HbA1c, or diabetes status.Conclusions: In patients without known diabetes, the risk of death was increased for admission FPG levels ≥ 5.6 mmol/L. However, pre-existing abnormal glucose metabolism, reflected by elevated HbA1c levels, appeared a more important predictor of inpatient mortality than glucose levels in patients without known diabetes.

Scott T Baker MB BS, BMedSc, FRACP · Cherie Y Chiang MB BS · Jeffrey D Zajac MB BS, PhD, FRACP · Leon A Bach MB BS, PhD, FRACP · George Jerums MB BS, MD, FRACP · Richard J MacIsaac MB BS, PhD, FRACP

Objective: To study the clinical contexts contributing to harmful medication errors.Design, setting and participants: A qualitative study using semi-structured interviews was conducted between March and August 2005 at Fremantle Hospital, a 450-bed metropolitan teaching hospital. Twenty-six of 46 staff members (57%) identified by pharmacy staff as having contributed to a significant medication error were interviewed. Interviews were recorded and transcribed for thematic analysis.Results: Most errors were due to slips in attention that occurred during routine prescribing, dispensing or drug administration. Knowledge-based mistakes (eg, failure to follow a protocol) also contributed to prescribing errors. Errors were more likely to occur during tasks being carried out after hours by busy, distracted staff, often in relation to unfamiliar patients. Communication problems with senior staff and difficulty accessing appropriate drug dosing information contributed to knowledge-based prescribing errors. Several medical staff were unaware they had committed an error until their involvement with our study.Conclusions: Contextual factors that contributed to slips, lapses and knowledge-based mistakes in our sample are likely to be widespread in hospitals, and their impact on medication error may be substantial. Staff need training in how to recognise and deal with error-prone clinical situations. Safe prescribing practices (eg, the absolute requirement to acquire information before prescribing unfamiliar drugs) must be emphasised. Improved access to drug information at the point of prescribing, attention to communication barriers, and increasing staffing levels in particular areas are other potential strategies for reducing error.

Pamela Nichols PhD · Tandy-Sue Copeland DipPharm · Ian A Craib MB ChB, MRCP, FRACP · Paul Hopkins · David G Bruce BSc, MD, FRACP

Objective: To audit the accuracy of dose administration aid (DAA) packaging in regional aged care facilities (RACFs) within the boundaries of the Hunter Urban Division of General Practice.Design, participants and setting: Each participating RACF audited one DAA for each resident receiving medication between May and August 2006. Registered nurses compared the contents with the medication chart prepared by the general practitioner and recorded any discrepancies as incidents.Main outcome measures: Number of medication incidents in the provision of DAAs.Results: 297 incidents were detected from 6972 packs for 2480 residents (incident rate of 4.3% of packs and 12% of residents) from 42 participating RACFs. Reasons for incidents included medications missing from a pack (99 occasions), wrong medication dispensed (12), supply of the wrong strength (32), incorrect labelling (7), pharmacies supplying medication that had been ceased by the GP (37), incorrect dosage instructions (32), medications not delivered to the RACF (13).Conclusion: The rate of incidents in DAA packaging in RACFs was high. The error types included incorrect packaging, correct packaging but the DAA was no longer required, and operational problems. Recommendations for improvement include: continuing audit and analysis by RACFs; streamlining of communications among GPs, pharmacists and RACF staff; using electronic methods to chart, order and dispense medications; use of generic names as much as possible; development of guidelines for the supply of medication in DAAs.

Annette Carruthers MB BS(Hons), FRACGP, FAICD · Kialie Naughton · Gordon Mallarkey PhD

Objective: To examine mortality from all causes and from cardiovascular disease (CVD), and CVD hospitalisation rate for a decentralised Aboriginal community in the Northern Territory.Design and participants: For a community-based cohort of 296 people aged 15 years or older screened in 1995, we reviewed hospital and primary health care records and death certificates for the period up to December 2004 (2800 person-years of follow-up).Main outcome measures: Mortality from all causes and CVD, and hospitalisation with CVD coded as a primary cause of admission; comparison with prior trends (1988 to 1995) in CVD risk factor prevalence for the community, and with NT-specific Indigenous mortality and hospitalisation rates.Results: Mortality in the cohort was 964/100 000 person-years, significantly lower than that of the NT Indigenous population (standardised mortality ratio [SMR], 0.62; 95% CI, 0.42–0.89). CVD mortality was 358/100 000 person-years for people aged 25 years or older (SMR, 0.52; 95% CI, 0.23–1.02). Hospitalisation with CVD as a primary cause was 13/1000 person-years for the cohort, compared with 33/1000 person-years for the NT Indigenous population.Conclusion: Contributors to lower than expected morbidity and mortality are likely to include the nature of primary health care services, which provide regular outreach to outstation communities, as well as the decentralised mode of outstation living (with its attendant benefits for physical activity, diet and limited access to alcohol), and social factors, including connectedness to culture, family and land, and opportunities for self-determination.

Kevin G Rowley PhD · Kerin O’Dea PhD, AO · Ian Anderson MB BS, FAFPHM, PhD · Robyn McDermott FAFPHM, MPH, PhD · Karmananda Saraswati MB BS, FAMAC · Ricky Tilmouth · Iris Roberts EN · Joseph Fitz · Zaimin Wang PhD · Alicia Jenkins MD, FRACP · James D Best MD, FRACP, FRCPath · Zhiqiang Wang PhD · Alex Brown BMed, MPH, FCSANZ

Objectives: To explore awareness of the causes of kidney disease and recollection of kidney function testing in a cohort of Australian adults.Design, setting and participants: An interviewer-administered cross-sectional survey, conducted from October to December 2004 as a nested study within the 5-year follow-up phase of the Australian Diabetes, Obesity and Lifestyle Study (AusDiab); 852 subjects who attended a testing site in New South Wales were interviewed.Main outcome measures: Responses to the questions “What sort of things do you think may lead to a person developing kidney disease?” and “Has a doctor or health care worker ever tested your kidney function, outside of the AusDiab study?”Results: Respondents most commonly believed that kidney disease was caused by alcohol misuse or poor diet, with few identifying diabetes or high blood pressure. Awareness of risk factors was no greater in respondents identified as having chronic kidney disease (CKD). A third of respondents with CKD recalled having undergone a test of kidney function within the previous 2 years, while another third replied they had never had their kidney function tested. Of participants with previously diagnosed diabetes or treated hypertension, 54.1% and 32.0%, respectively, reported having their kidney function tested within the previous 2 years.Conclusions: Knowledge of risk factors for kidney disease and recall of kidney function testing were both limited, even among subgroups of the cohort who were at greatest risk of CKD. Prevention efforts may benefit from public and patient education to improve recognition of risk factors for CKD.

Sarah L White MPH · Kevan R Polkinghorne FRACP, MClinEpi · Alan Cass FRACP, PhD · Jonathan Shaw FRACP, MD · Robert C Atkins FRACP, DSc · Steven J Chadban FRACP, PhD

Objective: To determine the population incidence and clinical features of Escherichia coli bacteraemia in Canberra, Australia.Design, setting and participants: Canberra (including the nearby local government areas of Queanbeyan and Yarrowlumla) has a geographically isolated population of about 366 000 people. Its six hospitals also provide tertiary medical services for the surrounding region. Confining our analysis (by residential postcodes) to Canberra residents only, we used microbiology laboratory records and population statistics to calculate the population incidence of E. coli bacteraemia from January 2000 to December 2004. Clinical data were also collected prospectively on episodes occurring within three of the hospitals.Main outcome measures: Population incidence of E. coli bacteraemia; place of acquisition of infection; focus of infection within body; recovery, new morbidity or death at 7 days.Results: During the 5-year period, 515 episodes of E. coli bacteraemia occurred in Canberra residents, an incidence of 28 per 100 000 population per year. The highest rate was in men aged ≥ 80 years (463 per 100 000). Overall, E. coli bacteraemia occurred in equal numbers in males and females, but incidence was higher in males aged < 1 year and ≥ 60 years. Most episodes occurred in people aged ≥ 60 years (316/511 [62%]) and most were community-associated (347/511 [68%]). Half the infections (257/511) had a genitourinary focus and 28% (141/511) a gastrointestinal focus. The 7-day case-fatality rate was 5%. Prostate biopsies and urinary catheters were notable preventable foci of health care-associated bacteraemia. Resistance of isolates to gentamicin (2.1%), ciprofloxacin (1.8%) and cefotaxime (0.4%) was low.Conclusions: E. coli is the most common cause of bacteraemia in Canberra, and incidence increases with age. Most cases have a community onset, but many episodes are related to health care procedures. Ongoing surveillance is important for identifying risk factors that may be modified to reduce disease.

Karina J Kennedy MB BS · Jan L Roberts RN · Peter J Collignon MB BS, FRACP, FRCPA

Objective: To examine trends in preoperative clinical characteristics, risk profiles and postoperative outcomes of patients undergoing isolated coronary artery bypass graft (CABG) surgery in Victoria.Design, setting and patients: A prospective analysis of 9372 patients undergoing isolated CABG surgery between 1 July 2001 and 30 June 2006 in six Victorian public hospitals, using the Australasian Society of Cardiac and Thoracic Surgeons database.Main outcome measures: Trends in patient baseline characteristics and risk factors, postoperative morbidity and 30-day mortality rate.Results: Over the 5 years, the mean age of patients undergoing isolated CABG surgery increased, from 65.4 years in 2001–02 to 66.0 years in 2005–06 (P < 0.001). There was also an increase in the proportion of patients with hypertension (70.2% to 75.8%; P < 0.001), respiratory disease (83.2% to 89.5%; P < 0.001) and left main coronary artery disease (22.1% to 26.1%; P = 0.03), while the number of patients undergoing repeat CABG surgery decreased (4.4% to 2.6%; P = 0.002). The overall 30-day mortality rate remained unchanged (2.2% to 1.8%; P = 0.983). Rates of other major postoperative complications showed no significant change over the study period.Conclusion: Rates of 30-day mortality and postoperative morbidity after CABG surgery have remained steady, despite the surgical population being older. Short-term outcomes after CABG surgery in Victoria remain among the most favourable reported in any population undergoing this surgery.

Diem T Dinh PhD · Geraldine A Lee BSc, RGN, PGDE · Baki Billah PhD, MAS · Julian A Smith FRACS · Gilbert C Shardey FRACS · Christopher M Reid DipEd, MSc, PhD

Objective: To evaluate the use of clinical practice guidelines for the management of acute coronary syndromes published by the National Heart Foundation (NHF) of Australia and the Cardiac Society of Australia and New Zealand (CSANZ) in patients presenting with chest pain.Design: Cross-sectional study of consecutive patients admitted with chest pain.Setting: Prospective case note review was undertaken in 2380 patients admitted to 27 hospitals across five states in Australia between January 2003 and August 2005. Patients were divided into two groups: those who presented to centres with angiography and percutaneous intervention facilities (n = 1260) and those treated at centres without these facilities (n = 1120).Main outcome measures: The proportion of patients whose care met quality of care standards for diagnostic and risk-stratification procedures and management according to NHF/CSANZ treatment guidelines.Results: Significant delays were identified in performing electrocardiography, administering thrombolysis, transferring high-risk patients to tertiary centres, and performing revascularisation. Medical therapy was underused, especially glycoprotein IIb/IIIa antagonists in patients with high-risk acute coronary syndromes. Patients treated at centres without interventional facilities were less likely to receive guidelines-based medical therapy and referral for coronary angiography (20.11%) than patients treated at centres with interventional facilities (66.43%; P < 0.001).Conclusion: There are deficits in the implementation and adherence to evidence-based guidelines for managing chest pain in hospitals across Australia, and significant differences between hospitals with and without interventional facilities.

Darren L Walters MB BS, MPhil, FRACP · Constantine N Aroney MD, FRACP · Derek P Chew MPH, FRACP · Linden Bungey BSc, MSc · Steven G Coverdale MB BS, FRACP · Roger Allan MB BS, FRACP · David Brieger MB BS, FRACP

Objective: To evaluate and compare the clinical outcomes of children with cystic fibrosis (CF) managed primarily at a tertiary cystic fibrosis centre (CFC) with those treated at regional centres by local health care professionals and the cystic fibrosis outreach service (CFOS).Design, setting and patients: Retrospective study of 273 children with CF born between 19 October 1982 and 19 February 2002 and with clinical data available between 1 January 2000 and 31 December 2002. Patients were grouped into CFC (n = 131) or CFOS (n = 142), with CFOS then further categorised into three groups depending on the level of care they received.Main outcome measures: Pulmonary function, Pseudomonas aeruginosa status, height and weight z scores, and hospital admission rates.Results: There were no significant differences in pulmonary function, P. aeruginosa status, or height and weight z scores between children managed by CFC or by CFOS. Children receiving more care at the CFC (level of care [LOC] 1 and 2) were more likely to have multiple hospital admissions than children receiving more care in regional areas (LOC 3 and 4) (P < 0.001).Conclusion: The CFOS model provides effective delivery of specialised multidisciplinary care to children and adolescents living in rural and regional Queensland.

Clare L Thomas MB BS, FRACP · Peter K O’Rourke BSc, BA, PhD · Claire E Wainwright MB BS, MD

Objective: To describe the incidence and risk of suicide in cancer patients in Western Australia from 1981 to 2002.Design, setting and patients: Retrospective cohort study of patients diagnosed with cancer in WA from 1981 to 2002, using data from the WA Linked Database.Main outcome measure: Age-standardised mortality ratios (SMRs).Results: A total of 121 533 patients were diagnosed with cancer, corresponding to a total of 543 696 person-years at risk. There were 129 suicides in this group (108 in men). The SMR for suicide in cancer patients was 1.61 (95% CI, 1.36–1.92). An initial period of peak risk was seen in the first 3 months after cancer diagnosis (SMR, 5.75; 95% CI, 3.89–8.51), mainly in patients with a poor prognosis. A second peak period of risk was found to occur 12–14 months after diagnosis (SMR, 2.33; 95% CI, 1.11–4.89) in those with a good or moderate prognosis.Conclusion: The rate of suicide in cancer patients in WA is low and represents an excess of two to three suicides per year, or 0.3% of all cancer deaths, comparable to studies in other Western countries. The risk is highest in the first 3 months after diagnosis, and a second period of increased risk 12–14 months after diagnosis may occur in response to cancer recurrence or treatment failure.

Nigel R C Dormer MB BS, MRCGP, DRCOG · Kieran A McCaul MPH · Linda J Kristjanson RN, BN, PhD

Objective: To evaluate the management, clinical outcomes and adherence to chelation therapy in adult transfusion-dependent patients with thalassaemia major.Design, setting and participants: We reviewed all transfusion-dependent adults with thalassaemia major (n = 44) attending the Haematology Department at the Prince of Wales Hospital, Sydney, in 2005. Data were collected retrospectively (2000–2005) and prospectively (2005) for cross-sectional clinical audit from clinical reviews, patient questionnaires, pharmacy dispensing records and routine laboratory investigations.Main outcome measures: Iron overload and its complications; complications of transfusion; adherence to subcutaneous and oral chelation therapy (expressed as a percentage based on the ratio of the amount dispensed to the prescribed dose).Results: The prevalence of diabetes mellitus was 18%; hypothyroidism, 16%; hypogonadism, 32%; cardiomyopathy, 9%; and osteopenia/osteoporosis, 83%. Serological evidence of exposure to hepatitis C and hepatitis B was present in 41% and 14% of patients, respectively, and 23% of patients had active hepatitis C infection. Predictors of complications included increasing number of years of transfusion, increasing age, coprescription of desferrioxamine and deferiprone, and poor adherence to desferrioxamine treatment. There was a wide range of adherence to therapy with desferrioxamine (0–100% of prescribed dose; mean, 46%; median, 49%) and deferiprone (29%–214% of prescribed dose; mean, 117%; median 112.5%).Conclusion: The health outcomes in our patients were similar to or better than those of patients in other cohorts, but, despite the availability of effective chelating agents, our patients had marked iron overload and a high incidence of complications.

Giselle L Kidson-Gerber MB BS, BSc · Sally Francis DipAppSc(Nursing) · Robert Lindeman FRACP, FRCPA, PhD

Objective: To determine whether asking general practitioners to offer chlamydia screening at the same time as Pap screening increases chlamydia screening rates.Design: A pragmatic cluster randomised controlled trial.Participants and setting: Doctors from 31 general practices in the Australian Capital Territory performing more than 15 Pap smear screens per year, and all women aged 16–39 years attending those practitioners between 1 November 2004 and 31 October 2005.Intervention: Doctors in the intervention practices were asked to routinely offer combined chlamydia and Pap screening to eligible women; doctors in the control practices were asked to implement screening guidelines based on a risk assessment of the individual patient (ie, usual practice).Main outcome measure: Chlamydia screening rate per visit.Results: There were 26 876 visits by eligible women during the study period: 16 082 to intervention practices and 10 794 to control practices. Chlamydia screening occurred during 6.9% (95% CI, 6.5%–7.3%) of visits to intervention practices and 4.5% (95% CI, 4.1%–4.9%) of visits to control practices. After controlling for clustering and potential confounders, there were twofold greater odds of chlamydia screening occurring during a visit by an eligible woman to an intervention practice than to a control practice (adjusted odds ratio, 2.1 [95% CI, 1.3–3.4]).Conclusion: Combining chlamydia and Pap screening increases the rate of chlamydia screening in general practice. Implementing this approach would require little additional infrastructure support in settings where a cervical screening program already exists.

Francis J Bowden FRACP, FAChSHM, MD · Marian J Currie RN, RM, PhD · Helen Toyne MB BS, DipRACOG · Clare McGuiness MB BS, PhD · Lynette L Lim MSc, PhD · James R Butler MPolEcon, PhD · Nicholas J Glasgow MB ChB

Objective: To determine if low-ankle-pressure graduated-compression tights (GCTs) reduce flight-induced ankle oedema and subjectively rated travel symptoms of leg pain, discomfort and swelling, and improve energy levels, ability to concentrate, alertness, and post-flight sleep.Design, setting and participants: Open, randomised crossover trial comparing the effects of GCTs (5 mmHg at ankle, 17–20 mmHg at calf and falling to 10 mmHg above knee and 4 mmHg at buttocks) among 50 adults on flights of 5 hours’ or more duration between 1 May and 8 October 2006; 47 volunteers (pilots and passengers) completed the trial.Main outcome measures: Differences in right ankle circumference before and after flight with GCTs and without GCTs; travel symptoms rated on visual analogue scales.Results: Low-ankle-pressure GCTs decreased ankle swelling (mean difference, − 0.19 cm; 95% CI, − 0.33 to − 0.65 cm; P = 0.012). Participants reported their legs felt better (mean, 1.6; P < 0.001; 95% CI, 1.0 to 2.1), warmer (mean, − 1.1; P < 0.001; 95% CI, − 1.6 to − 0.6), and they had a better night’s sleep (mean, 1.2; P < 0.001; 95% CI, 0.8 to 1.7) after the flight when they wore GCTs. Shifts in rating-scale probability distributions showed improvements in the ratings of pain (60%; P < 0.001), leg discomfort (50%; P = 0.001), leg swelling (45%; P = 0.006), energy levels (18%; P = 0.016), alertness levels (13%; P = 0.031), and concentration (12%; P = 0.023) when wearing GCTs.Conclusions: Low-ankle-pressure GCTs reduce flight-induced ankle oedema and subjectively rated travel symptoms of leg pain, discomfort and swelling, and improve energy levels, ability to concentrate, alertness, and post-flight sleep.Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12606000150549.

Melissa J Hagan BSc, MEdSt · Stephen M Lambert RN, MAppSc

Objective: To determine whether identity badges and lanyards worn by health care workers (HCWs) are capable of harbouring potentially pathogenic bacteria.Design, setting and participants: Cross-sectional study of 71 HCWs (59 clinical ward staff and 12 infection control staff) at Monash Medical Centre, a university teaching hospital. Samples from lanyards, identity badge surfaces and connections (eg, clips, keys, pens) were cultured. The study was conducted from July to August 2006.Main outcome measures: Presence of pathogenic bacteria on identity badges and lanyards; differences in bacterial counts on items carried by nurses and doctors.Results: A total of 27 lanyards were identified with pathogenic bacteria, compared with 18 badges. Analysing lanyards and badges as a combined group, seven had methicillin-resistant Staphylococcus aureus, 29 had methicillin-sensitive S. aureus (MSSA), four had Enterococcus spp and five had aerobic gram-negative bacilli. Lanyards were found to be contaminated with 10 times the median bacterial load per area sampled compared with identity badges. There were no significant differences between nurses and doctors in total median bacterial counts on items carried, but doctors had 4.41 times the risk of carrying MSSA on lanyards (95% CI, 1.14–13.75).Conclusion: Identity badges and lanyards worn by HCWs may be contaminated with pathogenic bacteria, which could be transmitted to patients. In view of this finding we suggest appropriate infection control interventions.

Despina Kotsanas BSc(Hons), MClinEpi · Carmel Scott BN · Elizabeth E Gillespie BN, MPubHealth · Tony M Korman MB BS, FRACP, FRCPA · Rhonda L Stuart MB BS, FRACP, PhD

Objective: To measure the safety and acceptability of providing written advice (WA) for selected patients referred to a haematology service, as an alternative to inpatient or outpatient assessment.Design, setting and participants: Review of the initial management and subsequent course of patients newly referred to a tertiary referral hospital in Christchurch, New Zealand, between 16 October 2003 and 8 June 2006. Structured questionnaires were sent to all referring doctors and patients recently managed with WA.Main outcome measures: Numbers and diagnoses of patients managed with WA, early assessment or delayed assessment; re-referral and treatment details; characteristics of WA letters; and opinions of referring doctors and their patients on the WA process.Results: 26% of new referrals (714/2785) were managed with prompt WA, while 16% (455/2785) received the alternative of delayed assessment. After a median follow-up of 23 months (range, 8–40 months), 13% of those managed with WA (91/714) were re-referred back to the same haematologists; 7% (52/714) were assessed in hospital and 2% (15/714) eventually required treatment. There were no deaths due to haematological causes. Over 90% of responding referring doctors said the WA process was rapid and effective, and 77% of recently managed patients were pleased to be treated by their own doctors.Conclusions: Using WA to manage a substantial minority of patients referred to haematologists can be rapid and safe. It is widely accepted by referring doctors.

Peter S Ganly PhD, FRACP, FRCPA · Helen Keeman · Ruth L Spearing FRACP, FRCPA · Mark P Smith FRACP, FRCPA · Nigel Patton MD, FRACP, FRCPA · Eileen G Merriman MB ChB, BMLSc · Steve S Gibbons FRACP, FRCPA

Have you ever wondered what makes a good research paper? Since 1995, the best original research paper published each year in the Medical Journal of Australia (MJA), as judged by the Journal’s Content Review Committee, has been awarded the MJA/Wyeth Research Award. To date, 12 papers have won the award ($10 000 and a commemorative trophy), representing a diverse range of research methodologies, practice settings, professional disciplines, and subsequent citation rates (Box 1). We recently interviewed key researchers associated with this distinguished dozen, inviting them to tell us the behind-the-scenes stories of their papers and the impact their work has had since publication. In the course of our discussions, we heard 12 very different but often strikingly similar stories — stories of curiosity, innovation, purpose, determination and teamwork, as well as some significant concerns about the future of medical research in Australia. 1995: Gastric emptying is not needed after acute oral overdose in adultsAs you administered a particularly unpleasant medical intervention, have you ever wondered whether it was really necessary? Susan Pond, an Australian medical graduate, found herself working in the United States as a Fellow in Clinical Pharmacology at San Francisco General Hospital in the 1970s. Following on from the Haight-Ashbury hippie days of the previous decade, drug overdose was a major problem in the city. At that time, the treatment of overdose was quite empirical, and Pond set about collecting evidence for the ways in which charcoal could be used to remove poisons. Adapting the well known tradition of self-experimentation, Pond co-opted a couple of her six children to test out “easy” formulations of activated charcoal (Box 2). “One of them was game enough to swallow this awful black stuff, and he threw up within minutes ... the mess was just terrible”, Pond said. Referring to standard treatment, she added: “Not only were we making overdose patients vomit with ipecac, but we were also giving them activated charcoal, after which they promptly vomited again. It seemed to me to be very pointless”. Pond returned to Australia in the 1980s, where the opportunity arose, at Princess Alexandra Hospital in Brisbane, to challenge the long-established routine care for poisoning through a prospective, randomised controlled trial, comparing activated charcoal with a combination regimen of gastric emptying plus charcoal. In designing the study, Pond spent a long time talking with an American toxicologist, Ken Kulig, who had reported that acutely poisoned patients could be effectively treated without gastric emptying. Pond wanted to build on Kulig’s earlier research but without running into the same pitfalls: insufficient patient numbers and allocation bias.1 The Australian trial involved 876 eligible patients who presented to the emergency department at Princess Alexandra Hospital between January 1988 and June 1990. No significant differences were detected between the two treatment arms, and Pond and colleagues concluded that gastric emptying could be omitted from the treatment regimen for adults after acute oral overdose. Published in the MJA in October 1995, it did not take long for the study results to filter through to clinical practice — in 1997, the American Academy of Clinical Toxicology issued a position statement on ipecac syrup, which concluded that gastric emptying by ipecac should not be administered routinely in the management of poisoned patients.2 “The field was ready for a big study and it [our study] served to crystallise the thinking”, Pond said. “Very rapidly, the issue became whether or not charcoal needed to be administered, and the field moved on quite rapidly to suggest that even that’s not necessary in many cases of poisoning.” In 1997, Pond joined Johnson & Johnson Research Pty Ltd in Sydney to pursue the application of the genomics revolution to therapeutics. Her current research involves discovery and development of RNA and DNA molecules that regulate gene function and expression. The most advanced product, currently in clinical trial, is an anti-HIV RNA molecule inserted into bone marrow stem cells of patients infected with HIV. 1996: A public health investigation detects Japanese encephalitis virus in AustraliaHow would you go about investigating the mysterious deaths of two members of a small island community? When such a tragedy occurred on the outer Torres Strait island of Badu in March–April 1995, the residents welcomed a wide range of investigators from the Australian mainland, led by public health physician Jeffrey Hanna. Scott Ritchie, medical entomologist on the project, told us that Murray Valley encephalitis was initially thought to be the most likely culprit but, before long, virological studies on samples from the encephalitis cases, and serological surveys of other asymptomatic residents revealed evidence of Japanese encephalitis (JE) virus infection. The researchers found themselves investigating an outbreak of a virus that had never been found in Australia before — a classic, emerging, infectious disease. Ritchie said the various teams — medical, public health, entomological, veterinary, and laboratory — worked away for days at a time, applying known “shoe-leather” epidemiological methods to get the information they needed. When not working, they watched late-night test cricket and slept on mattresses at the health centre. The whole investigation took about a month. In addition to infection in the residents, the investigators also identified recent JE virus infection among domestic pigs (one of the viral hosts) on the outer islands of the Torres Strait. Virus isolations and mosquito surveys on Badu Island implicated the mosquito Culex annulirostris as the major vector in the outbreak. The researchers speculated that migratory birds and/or windblown mosquitoes had imported the virus into the Torres Strait, possibly from Papua New Guinea, and that a combination of environmental factors — including large numbers of domestic pigs kept in “wet” pigpens close to human dwellings and mosquito-breeding sites (Box 3) — had facilitated the outbreak. “It fit the pattern of JE virus overseas. In South-East Asia, you have rice paddies and people with pigpens in the backyard. In the Torres Strait, it’s quite low and swampy, and pigs are abundant”, Ritchie said. Ritchie is certain that lives were saved as a result of the public health response to this research. After the Badu Island outbreak, an inactivated JE vaccine was offered to the inhabitants of the outer Torres Strait islands. On Badu Island, pigs were moved from backyards to a piggery out of town, and swamps were drained. “JE virus is now detected nearly every summer in sentinel pigs on Badu Island, but there haven’t been any other human cases since a second outbreak in 1998. If we hadn’t vaccinated, I think we would have definitely seen more human cases”, Ritchie said. Hanna and colleagues have continued to publish papers on disease outbreaks, including the 1998 JE outbreak and the Noah Beach malaria outbreak in Far North Queensland;3,4 the cross-agency collaboration continues to this day. 1997: Photographic surveillance can effectively detect melanoma in patients with multiple dysplastic naeviHow you would respond if you were questioned about your everyday clinical practice because it was different from that of your peers? In the 1980s, when Melbourne dermatologist John Kelly was asked why he was using total body photographic surveillance to follow a group of melanoma-prone patients with multiple dysplastic naevi (MDN), instead of undertaking the then widely used practice of prophylactic excision, he decided to conduct a study to determine the value, including cost-effectiveness, of his approach. Several years earlier, while working in a melanoma clinic in San Francisco, Kelly had been involved in a case–control study that found that MDN were a strong and independent risk factor for the development of melanoma.5 “It seemed logical that if these people were most at risk for melanoma, then they were the people to put into a follow-up program to find the melanoma in the future”, Kelly said. But what if the case–control study had been flawed? He wanted to reassure himself as well as others. Kelly enlisted the assistance of several colleagues and his sister-in-law (a clinical photographer) and followed a high-risk cohort of 278 patients with MDN, using photographic surveillance, for an average of 42 months. All the patients had presented at his private dermatological practice between March 1985 and November 1992. Over the course of the study, 20 new melanomas were detected in 16 patients, corresponding to an age-adjusted incidence of melanoma in these patients that was 46 times that of the general population. “The use of the photographs enabled earlier diagnosis because we were able to detect new and changed lesions that were early melanomas but that were not yet showing typical clinical features. The median tumour thickness was much lower than for tumours reported to the State Cancer Registry at the time”, Kelly said. Further, more than 60% of the melanomas were de-novo, rather than arising from dysplastic naevi, suggesting that prophylactic excision of dysplastic naevi was not a satisfactory alternative to follow-up. This study, along with others, helped to confirm the very high rates of melanoma in patients with dysplastic naevi and to “guide guidelines” for the use of total body photography, said Kelly. With others, Kelly has conducted further research along similar lines with a new cohort of patients, confirming the previous findings and showing that a new or changed pigmented lesion is more likely to be a melanoma in patients older, rather than younger, than 50 years of age.6 Internationally, photographic surveillance is now the standard practice in managing people with MDN. 1998: Outdoor air pollution is linked to night-time cough and chest colds in childrenHow would you go about assessing the effects of the environment on child health in an industrial city? Ongoing community concern about a possible link between childhood asthma and air pollution in the steel cities of New South Wales — Newcastle and Wollongong — helped Peter Lewis and Michael Hensley and their colleagues achieve high participation rates in their 1993 cross-sectional survey of children’s respiratory symptoms and home environment. The existing body of work had been done primarily in the US and Europe, but there were some significant differences in aspects of air quality and air-quality basins in Australia. “We had some lower levels of pollution, in particular, particulate pollution”, said Hensley. The researchers consulted widely and often with the community. They surveyed primary school children living in suburbs close to the steelworks, as well as children from surrounding suburbs further away, who acted as “normals” exposed to “background” levels of pollution. The study found that particulate pollution was associated with respiratory symptoms such as head cold and coughs but not with asthma. They also found that the effects on health were seen at lower levels of particulate pollution than had previously been thought. In 1999, the Newcastle steelworks closed, principally for economic reasons, said Lewis. “However, this paper was one of several studies that contributed to how air quality guidelines should be set in Australia”, he said. “It certainly strengthened the case that the levels of air pollution we were experiencing are not without their potential side effects.” Hensley, with co-researchers, has gone on to publish related papers about indoor air quality, including the effects of environmental tobacco smoke and bronchial reactivity among children,7,8 and is now Dean of Medicine at the University of Newcastle. Lewis has taken his environmental epidemiological research approach to public health work on the Central Coast of NSW and is now involved with measuring the impact on health of such diverse entities as bushfires, fluoridation of the water supply, and retirement village living. 1999: Comprehensive screening and treatment program reduces prevalence of STIs in remote Aboriginal communitiesWho do you think has made a contribution to the control of sexually transmitted infections (STIs) in Aboriginal Australia that is greater than the sum of everyone else’s? For this accolade, Paul Torzillo would not hesitate to pick Penny Miller, a primary care doctor who created a program in the mid 1990s that aimed to improve access to and delivery of STI services in remote Aboriginal communities on the expansive Anangu Pitjantjatjara (AP) Lands in the far north-west of South Australia, with a view to reducing transmission not only of STIs but also HIV. “At the time, it was widely touted that community-wide STI screening would be virtually impossible, let alone unethical, because the Aboriginal communities would not want it; and, if it did occur, it would be ineffective”, Torzillo said. But the Aboriginal communities did want it. Nganampa Health Council is the independent, Aboriginal-controlled health service that provides primary health care to nearly 3000 Aboriginal people living on the AP Lands. The Council’s Aboriginal board of management, which is also the ethics committee, approved Miller’s project. Annual community-wide screening for syphilis was already well established in the AP Lands, and community participation in the new program was voluntary and high. Miller’s community-based program took full advantage of technological advances in screening for gonorrhoea and chlamydial infections, with urine polymerase chain reaction tests replacing diagnosis by urethral swab in men and by vaginal and cervical swabs in women. The urine testing made mass screening both more acceptable and more feasible. The program also involved more than a dozen further interventions, including presumptive treatment (before diagnosis was confirmed by pathology results), single-dose rather than multidose therapy, and reporting back to the community. The program was effective. Coauthored with Torzillo and Wayne Hateley, an Aboriginal health worker who until recently lived and worked in the communities, Miller’s paper reported that, in the short period of 2 years, the prevalence of gonorrhoea in people aged 12–40 years was significantly reduced — in fact, almost halved — from 14.3% in 1996 to 7.7% in 1998. The service also achieved reductions in chlamydia and syphilis. The paper weakened a general resistance at the time to applying public health principles to Aboriginal health. “In retrospect, the resistance was clearly because inadequate screening and treatment isn’t effective, but comprehensive screening and treatment can be”, Torzillo said. Miller now works in the field of international HIV research. Torzillo continues to work for the Nganampa Health Council, as he has done since it was first established in 1983. He also maintains an appointment as a respiratory and intensive care consultant at Sydney’s Royal Prince Alfred Hospital. Today, aggressive public health approaches to STIs are considered the “norm” in Aboriginal communities. On the AP Lands, this program and others, like women’s health and child immunisation programs, continue to operate. New STI program initiatives continue to emerge, like Ushma Scales’ song about condom use, Take your shield to town, with lyrics in Pitjantjatjara.9 2000: Systematic chronic disease treatment program reduces rates of renal failure and death in Aboriginal communitiesWhat would you do if your research revealed a whole community with untreated early disease whose progression could be slowed by a simple intervention? When working in New Mexico in the US, Wendy Hoy, with co-researchers, demonstrated that end-stage renal disease was a significant problem in Native American tribes. On her return to Australia, she investigated a burgeoning epidemic of renal failure in Aboriginal people in the Northern Territory and found probably the world’s highest recorded rates of renal failure in the communities of the Tiwi Islands, north of Darwin. There was also a great reservoir of early disease, including hypertension and albuminuria. Hoy said: “I knew from existing literature that the progression of renal disease could be reduced by treatment with angiotensin-converting enzyme inhibitors. This treatment needed to be widely applied in the Tiwi community, but the health services were very scantily resourced at that time and couldn’t do it”. Another barrier was a prevailing attitude that if you gave Aboriginal people a pill, they wouldn’t take it; and that if they did take it, it wouldn’t have an effect because their biology was different. “You’ve got people with a deadly disease for which treatment guidelines are out there in the international literature, with known very beneficial outcomes. It would have been wrong to allow it to go unattended”, Hoy said. So the research team delivered a service offshoot that was embraced by the community — a systematic chronic disease treatment program to modify renal and cardiovascular disease, involving antihypertensive agents to achieve blood pressure goals and attempts to improve the control of blood glucose and lipid levels. After 2 years of treatment, Hoy and colleagues were able to report a rapid, dramatic improvement in clinical profiles and a fall in death rates. Their paper declared: “These results show that Aboriginal people are interested in health issues and receptive to health messages, and will take medications over the long term to protect against future health risk, with excellent response”. Over the past decade, there has been increasing acceptance and practice of the principles of chronic disease surveillance and rigorous management in Aboriginal communities. “Endorsement, intellectually, of chronic preventable disease strategies is no longer the issue; now, it’s resources and staffing to execute them in remote areas where the people have disastrous disease profiles”, said Hoy. After handover of the treatment program to the local health board in the Tiwi Islands, the intensity of the program declined and compliance with medicines use fell for a time, due to inadequate resources.10 However, Hoy is optimistic about the future of Indigenous health. “The spotlight on Aboriginal health here is becoming brighter, and dialogue encouraging government to be, one, more receptive; and, two, more accountable in terms of delivering good services is only going to intensify.” 2001: Quality improvement project reduces inhospital deaths in patients with acute myocardial infarctionHow would you respond to the suggestion that patients hospitalised with acute myocardial infarction (AMI) at your hospital might have a higher mortality rate than similar patients at peer hospitals? In the mid 1990s, Ian Scott, then Director of Medicine at Queensland’s Ipswich Hospital, responded by initiating a quality improvement project that aimed to achieve, among other things, a reduced time to thrombolysis and an increased number of patients who were taking lipid-lowering agents when they left the hospital. He wrote local guidelines for coronary care practice, started an echocardiography service, and got together with the local Division of General Practice to set up a cardiac rehabilitation program, as well as providing sequential feedback to health care providers. A before–after time-series study suggested that quality of care at the hospital did improve as a result of the project.11 This evidence was soon bolstered when hard outcomes data on inhospital deaths, from the Queensland Hospitals Admitted Patient Data Collection, came to Scott’s attention. Using this state-based data, Scott and colleagues were able to demonstrate a significant reduction in the mortality rate for AMI at Ipswich Hospital, from 12.5% in 1994–1995 (pre-intervention) to 8.8% in 1996–1999 (post-intervention). The rates at a group of control hospitals in Queensland showed no significant change (remaining at about 12.8%) over the same period of time. “The study has given a higher profile to quality improvement science by showing that we can improve and evaluate practice on a reasonable scientific footing, with real data to support what we are saying”, said Scott. The quality improvement interventions have now been rolled out, with beneficial effects, across more Queensland hospitals.12 “I think it’s been a real success story. We’ve gone from a small community hospital to a collaborative of about 21 hospitals across the state, accounting for close to 80% of all AMI admissions.” Now based at Brisbane’s Princess Alexandra Hospital, Scott has continued to pursue further quality improvements in relation to the management of AMI and heart failure. Recently, together with colleagues, he reported on “risk–treatment mismatching”, where much more treatment goes to lower- or moderate-risk patients than high-risk patients.13 2002: Serious doctor–patient and health care worker–patient miscommunication may be compromising Indigenous health outcomesHave you ever struggled to communicate with a patient? What if the patient didn’t speak much English — what would you do? Working in Darwin with Indigenous patients who had kidney disease, Alan Cass and colleagues found themselves operating across what seemed to be a significant cultural and, often, linguistic divide. At the same time, people working as linguists and community researchers in Arnhem Land were also becoming aware that, despite everyone’s best intentions, there were communication problems they didn’t understand. “It was a somewhat fortuitous coming together of people from very different backgrounds, including some of the patients themselves, who wanted to think about how we could work together in undertaking some cross-cultural research to try to understand the issues”, Cass said. The group considered various possible methodologies before settling on the qualitative approach of participatory action research — using video to capture interactions, then analysing them to identify issues. They also conducted post-interaction interviews in the health care workers’ and patients’ first language to clarify what each person had understood to be communicated. In the setting of a satellite dialysis unit, where many of the carers were fairly well known to the patients and vice versa, the researchers videotaped five clinical interactions concerning diagnosis, treatment and management in diverse individual patients from the Yolngu language group of north-east Arnhem Land. In their “Sharing the true stories” study, the researchers found that miscommunication was pervasive, even when both the health care worker and the patient perceived the communication to be effective. Multiple issues were identified — beyond the limited use of interpreters — including “gratuitous concurrence” (when patients tell the health care worker what they think the worker wants to hear); problems with culturally specific understanding and ways of explaining health and illness (eg, health professionals would frequently describe health states using quantification such as percentages of kidney function, which had little meaning for most Yolngu people); and a lack of staff training in cross-cultural communication. Cass said the paper has engendered a powerful response from people working in all kinds of cross-cultural health settings. “So, I think communication — or miscommunication — issues talk very broadly”, he said. The study has been presented and cited not only nationally but internationally, leading to ongoing relationships with doctors and educational videomakers in the US. A “Sharing the true stories” website has been developed, with links to further education resources (Box 4). There is also now greater systematic use of interpreters in Indigenous health settings. Cass is currently involved in several research programs related to Indigenous health. He remains committed to developing and fostering universally available, high-quality education and training in cross-cultural care. 2003: Non-toxic treatment is effective for chronic suppurative otitis mediaWhat would you do if the only treatment your community could access for a particular condition was a product that was potentially toxic in your circumstances? Until recently, Aboriginal health services were faced with treating chronic suppurative otitis media (CSOM) in patients who had a perforated tympanic membrane with aminoglycoside ear drops, which are potentially ototoxic. In 2001–2002, Sophie Couzos, a public health physician with the National Aboriginal Community Controlled Health Organisation (NACCHO), led the NACCHO Ear Trial, which set out to assess the effectiveness of non-toxic fluoroquinolone ear drops compared with the usual treatment. Couzos said Dr Puggy Hunter, then NACCHO Chair, had wanted the organisation to instigate and undertake a research project to benefit the Aboriginal community. “Hearing issues were a big priority, and particularly runny ears due to chronic otitis media. The community needed a non-toxic alternative for treating the condition”, she said. The methodology was to be that of a double-blind randomised controlled trial, so that it would be scientifically meaningful. But the study also had to be community-based, designed in such a way that the Aboriginal organisations had leadership. At the time, Hunter coined the phrase, “We are not just participants, we are in charge”. As well as providing “real-world” results, the trial was designed to build capacity in the communities so that the intervention would be sustainable and transferable. Thus, the researchers opted for a challenging multicentre approach rather than putting all their investment into only one or two sites. Aboriginal health workers, rather than research assistants, were trained to undertake the trial protocol as part of core primary health care. Far from resisting the research project, health services were eager to be part of it. “Some services had to be turned away, because of the limited study budget or because they could not meet explicit criteria, such as having a doctor employed within the service”, Couzos said. Hunter died soon after the NACCHO Ear Trial was underway, but the trial went on to show that non-ototoxic fluoroquinolone drops were more effective than aminoglycoside drops in achieving cure for CSOM. The paper has had an impact in several key areas. Firstly, thanks to NACCHO’s advocacy role, said Couzos, remote area Aboriginal health services can now provide non-ototoxic ear drops to their clients for free, under Section 100 of the National Health Act 1953 (Cwlth). Secondly, the trial was pivotal to the listing of ototopical fluoroquinolone drops on the Pharmaceutical Benefits Schedule, which means that health care providers in non-remote areas can also provide subsidised medicine. Australian prescribing recommendations have also endorsed the use of fluoroquinolone ear drops in the presence of tympanic membrane perforation.14,15 Finally, in terms of research policy, the NACCHO Ear Trial has provided a real-world example of successful, community-based participatory research.16 2004: The Australian Medical Sheepskin halves incidence of pressure ulcers in lower-risk patientsIf you had a product you thought would benefit patients in hospital, how would you get the attention of hospital managers and clinicians? Having developed a sheepskin that they were confident would reduce the incidence of pressure ulcers in low- to moderate-risk patients, staff of the Commonwealth Scientific and Industrial Research Organisation (CSIRO) Leather Research Centre approached Don Campbell at the Royal Melbourne Hospital (RMH) about generating some clinical evidence of efficacy. “Here was an Australian industry initiative; here was a large public health problem and an opportunity to collaborate. It was a very attractive proposition”, said Campbell. After gaining some initial data from a small trial conducted in a high-risk group setting in Western Australia,17 the research partnership was granted National Health and Medical Research Council (NHMRC) funding for an open-label randomised controlled trial, conducted at the RMH in 2000. The Australian Medical Sheepskin was designed with a fibre length and density sufficient to perform a pressure distribution function, to minimise shear and friction, and to withstand high-temperature cleansing. In the trial, the sheepskins were used without covering as a partial mattress overlay, in accordance with their design. Sheepskin elbow and heel protectors were also used, as necessary. Of the 441 patients enrolled in the trial, 58 developed pressure ulcers. However, patients randomly assigned to the sheepskin group were less than half as likely to develop pressure ulcers as those in the usual care group. “Our evidence showed that we had a piece of technology that was clearly of demonstrable benefit. But the sheepskin hasn’t been widely taken up into practice. The real tragedy is that it hasn’t been capitalised on from an Australian perspective”, Campbell said. Sales of the sheepskin have mostly been incidental, for use in non-clinical environments and for people who are bed-bound or in wheelchairs. In retrospect, Campbell and the study’s first author, medical statistician Damien Jolley, would have liked the trial to have had sufficient funding to incorporate two further features: a third treatment arm, comparing the sheepskin “head to head” with pressure mattresses; and a proper cost-effectiveness analysis, including effects on hospital length of stay. However, what was missing and is still needed for real translation of their study findings into clinical hospital practice, they said, is an industry partner of sufficient size to manage advertising, sales and distribution requirements. But there is good news too. Recognising that pressure ulcers are a clinical indicator of quality of care, the Victorian Quality Council identified their reduction as a key objective for health care services in Victoria. Since state-wide surveys of the prevalence of pressure ulcers within Victoria’s acute and subacute health services began in 2003, progress has been made in implementing elements of a comprehensive program of pressure ulcer prevention and management. There has been a 33% reduction in the proportion of patients with pressure ulcers, from 26.5% in 2003 to 17.6% in 2006.18 2005: Hand hygiene program reduces nosocomial MRSA ratesHave you ever said you’d like to embark on an ambitious project, not really expecting to be given the opportunity? After an unexpected change in Victorian state government, the infection control team at a Melbourne hospital, Austin Health, suddenly found themselves the recipients of new infection control staff and an opportunity to apply for a state government Quality Improvement Fund grant. Their plan was to try to cut nosocomial methicillin-resistant Staphylococcus aureus infection (MRSA) at Austin Health by 30% over a 3-year period. The only hitch was that they had no real idea how to achieve their grand goal. “It was kind of exciting and scary at the same time”, said Paul Johnson, one of the study authors. Around the same time, while in Geneva at a World Health Organization meeting, Johnson arranged to meet Didier Pittet, who had recently published a landmark Swiss study in the Lancet showing that when staff regularly used a hand hygiene solution before and after every patient, contact rates of hospital infections, including MRSA, could be substantially cut.19 The “secret” of encouraging staff to use the solution was to include, along with the antibacterial alcohol and chlorhexidine, an emollient to protect the skin. “The other insight they had, partly I think because of their French culture, was that you have to engage people at an emotional level as well as cognitive, and one of the ways they set out to do this was by using art — they had these posters that were created as works of art by the staff of each ward to introduce the program ... they called them ‘talking walls’ in Geneva”, said Johnson. Pittet encouraged the Austin Health group to develop a similar program, and so they did — the multifaceted Operation Clean Start (OCS) program — developing their own hand hygiene solution (DeBugTM) and even adapting the concept of the “talking walls” (Box 5). The hospital staff and, in particular, nurses in infection control were incredibly supportive of OCS. “After we’d introduced it [the program] in one area, there was a real demand to introduce it into the next area, and so on. It just took off like wildfire”, said Johnson. Run over 3 years, OCS showed that staff’s compliance with hand hygiene improved. The Australian researchers also added an innovation of their own to the project design: by analysing large datasets in the hospital using interrupted time-series analysis, they were able to show a significant reduction in hospital rates of MRSA infections. After their paper was published, the OCS researchers were approached by the Victorian Quality Council, who were keen to replicate the reduction in MRSA infections state-wide. An alcohol-chlorhexidine hand hygiene program was rolled out initially in six major hospitals and then across the whole of Victoria. At the time of our interview with Johnson, coauthor Lindsay Grayson was in Geneva with Pittet, working with the WHO on aspects of hygiene policy for the world. 2006: Hot water immersion for 20 minutes can relieve the pain of a bluebottle stingHave you ever imagined conducting your research on a beach in summer? More importantly, what if that research were to turn a time-honoured treatment on its head? It might sound ideal, but Geoff Isbister and colleagues in the coastal NSW city of Newcastle weathered several difficulties in conducting their randomised controlled trial comparing hot water immersion with ice packs for relieving the pain of bluebottle stings. For example, in addition to the usual ethics committee approval, there was the not-so-small matter of local council approval, particularly in an era when public liability has become a major issue. Then there was the sporadic nature of bluebottle stings — 35 subjects were recruited in a day; 4 weeks went by with no one stung. And what about beach user behaviour — once a sting had eased with treatment, why sit around for the full 20 minutes required by the study protocol? Although it was organisationally challenging, the actual study was very simple and successfully challenged the existing belief that ice was the best way to relieve pain in this situation. The researchers suggested that the mechanism of reducing pain with heat treatment was the inactivation of venom. It is still early days since publication. Although local practice has changed on the beaches where the study was conducted, national changes in clinical practice as a result of this study are yet to be fully implemented. However, Isbister hopes that the Australian Resuscitation Council’s recent adoption of the new evidence in their treatment recommendations will mean hot water immersion becomes more widely available, and that cost and safety issues related to installing hot-water plumbing at surf lifesaving clubs around Australia can be resolved. And, after all, people can control the way they choose to treat their own jellyfish stings.20 Isbister is actively involved in much more “bites and stings” research. He said, “Within medicine, there are so many myths and, particularly in my area of research, so little research, that for just about anything you do in clinical practice, you can ask the research question and do it [the research]”. Twelve winners, one voiceEach year in the MJA we publish over a hundred research papers. Each one has a story: a reason for being, a unique setting, colourful protagonists, a narrative, a resolution and, in many cases, the possibility of development and continuation. As we spoke to the authors of each of the MJA/Wyeth Research Award-winning papers, however, it often seemed as though they were speaking with one voice — the engaged, thoughtful tones of a focused, committed, intelligent and passionate individual, working in the interests of both science and humanity. None had set out to win an award in doing their work; they had all simply wanted to answer a real question in a real area of need. So what did we learn about what makes a good research paper? Having a question whose answer will have a real impact on public health or clinical practice would seem to be a good start, as would using appropriate, pragmatic methodology. Our MJA/Wyeth winners’ research was also well planned, and each came to embrace the power of collaborative teamwork in conducting their research, not only across medical disciplines but across a diverse range of fields, and often, critically, with study participants. Accessing funding for good clinical research was not easy for many of our winners, several of whom suggested that Australia needs a formal mechanism within the health and medical research environment to specifically fund applied clinical research. Publication was also often a thorny issue — when the time came to submit their papers, many award winners reported pressure from their institutions or funding bodies to publish in “high impact” journals, preferably overseas. In the long run, however, they had considered that the MJA was the right journal with the right readership for communicating messages of relevance to Australian clinicians, particularly when local or national health policy needed to be “influenced”. Several interviewees said, in almost precisely the same definite way, that the intent of their research had been to benefit people and patients rather than to further their careers. Nearly all the award winners were gratified with the impact their work has made since publication. Several were concerned that the long-term sustainability of successful programs was at risk due to funding inadequacies or health service management restructuring beyond their control. Can a single piece of research change the world? There are a few spectacular examples where this may have been the case but, in the end, as many of our winners acknowledged, most research papers contribute only a fragment to the “big picture” of health and health care. As a powerful example, we leave you with Sophie Couzos’ perspective after completing the NACCHO Ear Trial, the first double-blind randomised controlled trial conducted in, and controlled by, Aboriginal communities: While healing the tympanic membrane will improve hearing, if you have recurrent infections because your living circumstances aren’t right, then using ear drops will not totally solve the problem. It will create an environment where healing can occur, but the solution to Aboriginal health problems is not just medicines. Although improved access to medicines is vital, the solutions are holistic. 1 The Medical Journal of Australia/Wyeth Research Award-winning articles, 1995–2006, with ISI citations to date* Year Article and authors Citations 1995 Gastric emptying in acute overdose: a prospective randomised controlled trial. Susan M Pond, David J Lewis-Driver, Gail M Williams, Adèle C Green, Noel W Stevenson. Med J Aust 1995; 163: 345-349. 89 1996 An outbreak of Japanese encephalitis in the Torres Strait, Australia, 1995. Jeffrey N Hanna, Scott A Ritchie, Debra A Phillips, Jack Shield, M Clare Bailey, John S Mackenzie, Michael Poidinger, Bradley J McCall, Phillip J Mills. Med J Aust 1996; 165: 256-260. <eMJA full text> 86 1997 A high incidence of melanoma found in patients with multiple dysplastic naevi by photographic surveillance. John W Kelly, Josephine M Yeatman, Cheryl Regalia, Grahame Mason, Amanda P Henham. Med J Aust 1997; 167: 191-194. <eMJA full text> 53 1998 Outdoor air pollution and children’s respiratory symptoms in the steel cities of New South Wales. Peter R Lewis, Michael J Hensley, John Wlodarczyk, Ruth C Toneguzzi, Victoria J Westley-Wise, Trevor Dunn, Dennis Calvert. Med J Aust 1998; 169: 459-463. <eMJA full text> 13 1999 Impact of improved diagnosis and treatment on prevalence of gonorrhoea and chlamydial infection in remote Aboriginal communities on Anangu Pitjantjatjara Lands. Penny J Miller, Paul J Torzillo, Wayne Hateley. Med J Aust 1999; 170: 429-432. 19 2000 Reducing premature death and renal failure in Australian Aboriginals: a community-based cardiovascular and renal protective program. Wendy E Hoy, Philip R Baker, Angela M Kelly, Zhiqiang Wang. Med J Aust 2000; 172: 473-478. <eMJA full text> 40 2001 The effects of quality improvement interventions on inhospital mortality after acute myocardial infarction. Ian A Scott, Michael D Coory, Catherine M Harper. Med J Aust 2001; 175: 465-470. 10 2002 Sharing the true stories: improving communication between Aboriginal patients and healthcare workers. Alan Cass, Anne Lowell, Michael Christie, Paul L Snelling, Melinda Flack, Betty Marrnganyin, Isaac Brown. Med J Aust 2002; 176: 466-470. <eMJA full text> 17 2003 Effectiveness of ototopical antibiotics for chronic suppurative otitis media in Aboriginal children: a community-based, multicentre, double-blind randomised controlled trial. Sophie Couzos, Traven Lea, Reinhold Mueller, Richard Murray, Margaret Culbong. Med J Aust 2003; 179: 185-190. <eMJA full text> 13 2004 Preventing pressure ulcers with the Australian Medical Sheepskin: an open-label randomised controlled trial. Damien J Jolley, Robyn Wright, Sunita McGowan, Mark B Hickey, Don A Campbell, Rodney D Sinclair, Kenneth C Montgomery. Med J Aust 2004; 180: 324-327. <eMJA full text> 2 2005 Efficacy of an alcohol/chlorhexidine hand hygiene program in a hospital with high rates of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection. Paul D R Johnson, Rhea Martin, Laurelle J Burrell, Elizabeth A Grabsch, Susan W Kirsa, Jason O’Keeffe, Barrie C Mayall, Deidre Edmonds, Wendy Barr, Christopher Bolger, Humsha Naidoo, M Lindsay Grayson. Med J Aust 2005; 183: 509-514. <eMJA full text> 18 2006 A randomised controlled trial of hot water (45°C) immersion versus ice packs for pain relief in bluebottle stings. Conrad Loten, Barrie Stokes, David Worsley, Jamie E Seymour, Simon Jiang, Geoffrey K Isbister. Med J Aust 2006; 184: 329-333. <eMJA full text> 3 * As of August 2007. ISI = Institute for Scientific Information (now Thomson Scientific). 2 A little black mouth A “volunteer” tests samples of activated charcoal. 3 Backyard pigpens on the outer Torres Strait islands Pigpens (A) adjacent to swampy conditions or (B) situated over standing water were found to breed Culex annulirostris mosquitoes. 4 Artwork from the “Sharing the true stories” website Courtesy: Phyllis Batumbil, Matamata, Northern Territory. http://www.sharingtruestories.com. 5 Hand hygiene poster DeBugTM — an alcohol/chlorhexidine hand hygiene solution — was featured on a “talking walls” poster as part of Operation Clean Start at Austin Health, Melbourne.

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

Charles Halliley Kellaway (1889–1952) was one of the first Australians to make a full-time career of medical research. He built his scientific reputation on studies of snake venoms and anaphylaxis. Under Kellaway’s directorship, the Walter and Eliza Hall Institute gained worldwide acclaim, and he played a critical role in its success between the world wars. His administrative and financial strategies in the era before the National Health and Medical Research Council (NHMRC) helped local medical research weather the Depression and gain a strong foothold by World War II.

Peter G Hobbins BA, BSc(Hons) · Kenneth D Winkel MB BS, PhD, FACTM

Objective: To evaluate a hospital-wide surveillance and intervention program introduced to reduce the incidence of bloodstream infections (BSIs) caused by intravascular (IV) catheters.Design, setting and participants: Prospective surveillance of all inpatients and outpatient attendees with positive blood cultures (both hospital-onset and community-onset) at a 500-bed tertiary referral hospital from 1998 to 2005.Interventions: Prompt review of all positive blood cultures with identification of BSIs due to IV catheters and associated preventable factors; weekly team meetings and regular reports to clinical areas, with assistance to implement targeted interventions.Main outcome measure: Number of BSI episodes due to IV catheters per year.Results: There were 491 BSI episodes due to IV catheters, mainly central venous catheters. Episodes per year fell from 110 in 1998 to 48 in 2005 (from 32% of all BSI episodes to 14%; a > 50% reduction). From 1998 to 2005, the rate per 1000 discharges fell from 2.3 to 0.9 (P for trend < 0.0005) and the rate per 1000 patient-days fell from 0.6 to 0.3 (P for trend < 0.0005).Conclusions: Our program was associated with a profound drop in the number of IV catheter-related BSIs per year. Active surveillance and intervention programs can lead to substantial and sustained reductions in these common life-threatening infections.

Peter J Collignon FASM, FRCPA, FRACP · Dianne E Dreimanis BHSc(Nursing), MN · Wendy D Beckingham RN, BHSc(Nursing) · Jan L Roberts RN, BHSc(Nursing) · Anne Gardner BA, PhD

Objective: To determine the intentions that young people have for seeking help if they were to develop a mental disorder.Design, participants and setting: National telephone survey of 3746 Australians aged 12–25 years and 2005 co-resident parents, which asked questions about vignettes portraying either depression, depression with alcohol misuse, social phobia or psychosis.Main outcome measures: Where participating young people or co-resident parents would seek help if they (or their child) had one of the problems portrayed in the vignettes; barriers to seeking help.Results: For adolescents, family was the main source of intended help, mentioned by 45%–60% (depending on the vignette), while general practitioners were mentioned by only a small minority (4%–13%). For young adults, family was relatively less important (21%–31%) and GPs relatively more so (19%–34%). By contrast, parents frequently mentioned GPs as an intended source of help for their children (by 40%–72% of parents of adolescents and 61%–76% of parents of young adults). For young people, the main barriers to seeking help were embarrassment or concern about what others might think, while the main barrier for parents was resistance from the child.Conclusions: Recent initiatives to extend the uptake of treatment for mental disorders have been centred around GPs as the initial point of help-seeking. Few young people see GPs as a preferred source of help, and action is needed to alter this perception or to reform mental health services to be more attractive to this age group.

Anthony F Jorm MPsychol, PhD, DSc · Annemarie Wright BAppSc(OT), MMedSc(HProm) · Amy J Morgan BASc, BAppSci(Psychol)(Hons)

Objective: To document the epidemiology, clinical characteristics and diagnosis of an outbreak of Mycobacterium ulcerans infection (Bairnsdale or Buruli ulcer [BU]) during the period 1998–2006, and compare delays in diagnosis between residents of endemic and non-endemic regions.Design and setting: Retrospective case study of patients identified through infectious disease physicians on the Bellarine Peninsula and the Victorian Department of Human Services notifiable diseases database.Main outcome measures: Description of events leading to diagnosis of BU.Results: Eighty-five BU patients recalled their experience. Fifty-three patients were older than 60 years, and 61 permanently resided on the Bellarine Peninsula. The onset of symptoms occurred most frequently in mid winter. Twenty-eight patients had lesions on the arm and 51 on the leg. The median time between onset of symptoms and first medical contact was shorter for those living in the endemic area (3.0 weeks; interquartile range [IQR], 1.0–5.0 weeks) compared with non-endemic areas (5.3 weeks; IQR, 2.0–9.5 weeks) (P = 0.05). Patients who resided in the endemic area had a shorter median time from their first medical appointment to diagnosis (1.0 week; IQR, 0.0–3.9 weeks) than those who resided in non-endemic areas (5.0 weeks; IQR, 1.3–8.0 weeks) (P = 0.001).Conclusion: Delay in presentation and time to diagnosis of BU are longer in non-endemic than endemic areas. Measures should be taken to raise awareness of the disease in non-endemic areas.

Tricia Y J Quek BSc(Hons) · Margaret J Henry BSc(Hons), PhD · Julie A Pasco BSc(Hons), PhD · Daniel P O’Brien MB BS, FRACP · Paul D R Johnson PhD, FRACP · Andrew Hughes MB BS(Hons), FRACP · Allen C Cheng FRACP, PhD · Jane Redden-Hoare BN(Hons), PhD · Eugene Athan MB BS, FRACP

Objective: To compare demographic and clinical characteristics of methamphetamine users and patients with other toxicology-related problems requiring medical intervention in a hospital emergency department (ED).Design and setting: Prospective observational study of toxicology-related presentations to the ED of St Vincent’s Hospital (SVH), Sydney, an inner-city tertiary hospital, between 1 October and 31 December 2006.Main outcome measures: Differences between methamphetamine-related and other toxicology-related presentations to the ED in relation to behaviour, mode of arrival, accompaniment, need for scheduling, location of drug use, intravenous drug use history, psychiatric history and demographic characteristics.Results: During the study period there were 10 305 patient presentations to SVH ED; 449 (4%) were toxicology-related presentations, of which 100 (1% of total) were methamphetamine-related. Methamphetamine users were significantly more agitated, violent and aggressive than patients with other toxicology-related presentations and significantly less alert, communicative and cooperative (P < 0.001); 24% of methamphetamine users (24/100) arrived with police accompaniment versus 9% of other toxicology patients (33/349) (P < 0.001). Methamphetamine users were more likely to have a history of intravenous drug use and mental health problems (P < 0.001); 39% of methamphetamine presentations (39/100) required scheduling under the Mental Health Act 1990 (NSW) compared with 19% of other toxicology-related presentations (67/349) (P < 0.001); 43% of methamphetamine-related presentations (43/100) involved drug use on the street compared with 24% of other toxicology-related presentations (83/349) (P < 0.001). Two-thirds of all methamphetamine users were male, and the most common age group for both male and female users was 26–30 years. The mean age and sex distribution of patients with other toxicology-related presentations were not significantly different. Among methamphetamine users, 27% of women (9/33) were in the 21–25-year age group compared with 10% (7/67) of men (P < 0.001).Conclusion: There were significant differences between methamphetamine-related and other toxicology-related presentations to SVH ED. Methamphetamine users were more aggressive, violent and dangerous, and thus more likely to pose a risk to health personnel and others. Methamphetamine appeared to be used consistently, rather than as an episodic “party drug”.

Philippa J Bunting BBus, CA · Gordian W O Fulde MB BS, FRACS, FACEM · S Lesley Forster MB BS, FRACMA, FAFPHM