Research

Objective: To determine the relationship between compensable status in a “no-fault” compensation scheme and long-term outcomes after orthopaedic trauma.Design and setting: Prospective cohort study within two adult Level 1 trauma centres in Victoria, Australia.Participants: Blunt trauma patients aged 18–64 years, admitted between September 2003 and August 2004 with orthopaedic injuries and funded by the no-fault compensation scheme for transport-related injury, or deemed non-compensable.Main outcome measures: 12-item Short Form Health Survey (SF-12) and return to work or study at 12 months after injury.Results: Of 1033 eligible patients, 707 (68.8%) provided follow-up data; 450 compensable and 247 non-compensable patients completed the study. After adjusting for differences across the groups (age, injury severity, head injury status, injury group, and discharge destination) using multivariate analyses, compensable patients were more likely than non-compensable patients to report moderate to severe disability at follow-up for the physical (adjusted odds ratio [AOR], 2.0; 95% CI, 1.3–2.9), and mental (AOR, 1.6; 95% CI, 1.1–2.5) summary scores of the SF-12. Compensable patients were less likely than non-compensable patients to have returned to work or study, even after adjusting for injury severity, age, head injury status and discharge destination (AOR, 0.6; 95% CI, 0.3–0.9).Conclusions: Patients covered by the no-fault compensation system for transport-related injuries in Victoria had worse outcomes than non-compensable patients.

Belinda J Gabbe BPhysio(Hons), MAppSc, PhD · Peter A Cameron MB BS, FACEM · Owen D Williamson GradDipEpi, FRACS, FAOrtho · Elton R Edwards MB BS, FRACS, FAOrthA · Stephen E Graves DPhil, FRACS, FAOrthA · Martin D Richardson MS, FRACS, FAOrthA

Objective: To evaluate the impact of a sustained, community-based collaborative approach to antenatal care services for Indigenous women.Design: Prospective quality improvement intervention, the Mums and Babies program, in a cohort of women attending Townsville Aboriginal and Islanders Health Service, 1 January 2000 – 31 December 2005 (MB group), compared with a historical control group (PreMB group), 1 January 1998 – 30 June 1999.Main outcome measures: Proportion of women having inadequate antenatal care and screening; perinatal indicators.Results: The number of antenatal visits per pregnancy increased from three (interquartile range [IQR], two to six) in the PreMB group to six (IQR, four to ten) in the MB group (P < 0.001). There were significant improvements in care planning, completion of cycle-of-care, and antenatal education activities throughout the study period. About 90% of all women attending for antenatal care were screened for sexually transmitted diseases, 89% had measurement of haemoglobin level, and serological tests for hepatitis B and syphilis (minimum antenatal screening). There was increased attendance for dating and morphology scans. In the MB group compared with the PreMB group, there was a significant reduction in perinatal mortality (14 v 60 per 1000 births; P = 0.014).Conclusion: Sustained access to a community-based, integrated, shared antenatal service has improved perinatal outcomes among Indigenous women in Townsville.

Kathryn S Panaretto MB BS, MPH, FAFPHM · Melvina R Mitchell · Lynette Anderson · Sarah L Larkins MPH, MPH · Vivienne Manessis MB BS, FRACGP · Petra G Buettner PhD · David Watson FRANZCOG

Objective: To investigate the effectiveness of an educational Quality Use of Medicines program, delivered at the level of general practice, on medicines use, falls and quality of life in people aged ≥ 65 years.Design: Cluster randomised controlled trial conducted in 2002.Setting: General practices in the Hunter Region, New South Wales, Australia.Participants: Twenty general practitioners recruited 849 patients to participate in the study.Intervention: Education (academic detailing, provision of prescribing information and feedback); medication risk assessment; facilitation of medication review; financial incentives.Main outcome measures: Primary measures: a composite score reflecting use of benzodiazepines, non-steroidal anti-inflammatory drugs (NSAIDs) and thiazide diuretics; secondary measures: use of medication reviews, occurrence of falls, quality of life (as assessed by SF-12 and EQ-5D survey scores.Results: Compared with the control group, participants in the intervention group had increased odds of having an improved medication use composite score (odds ratio [OR], 1.86; 95% CI, 1.21–2.85) at 4-month follow-up but not at 12 months. At 4-month follow-up, the intervention group had reduced odds of using NSAIDs (OR, 0.62; 95% CI, 0.39–0.99) and showed a non-significant reduction in use of benzodiazepines (OR, 0.51; 95% CI, 0.20–1.30) and thiazide diuretics (OR, 0.70; 95% CI, 0.48–1.01). Changes in drug use were not significant at 12-month follow-up. At 12 months, intervention-group participants had lower adjusted ORs (AORs) for having a fall (AOR, 0.61; 95% CI, 0.41–0.91), injury (AOR, 0.56; 95% CI, 0.32–0.96), and injury requiring medical attention (AOR, 0.46; 95% CI, 0.30–0.70). Quality-of-life scores were unaffected by the intervention.Conclusion: Education and systems for medication review conducted by GPs can be used to improve use of medicines. These interventions are associated with a reduction in falls among older people, without adverse effects on quality of life.

Sabrina W Pit MSc, PhD · Julie E Byles BMed, PhD · David A Henry MB ChB, FRCP · Lucy Holt BPharm · Vibeke Hansen BA(Psych)(Hons) · Deborah A Bowman BA

Objective: To examine changing demand for specialist food allergy services for children aged 0–5 years over the 12 years from 1995 to 2006 as an index of changing prevalence.Design, setting and participants: Retrospective analysis of the records of 1489 children aged 0–5 years referred to a community-based specialist allergy practice in the Australian Capital Territory (population, about 0.33 million).Main outcome measures: Trends in demand for assessment for food allergy, dietary triggers and severity over 12 years, compared with Australian hospital morbidity data.Results: 47% (697/1489) of 0–5 year-old children seen in private practice had food allergy (175 with food-associated anaphylaxis), most commonly to peanut, egg, cows milk and cashew. Over 12 years, the number of children in this age group evaluated each year increased more than fourfold, from 55 cases in 1995 to 240 in 2006. There was no change in the proportion diagnosed with allergic rhinitis in 1995 and 2006 (14.5% and 13.3%, respectively), urticaria (14.5% and 12.9%) or atopic eczema (54.5% and 57.0%). By contrast, the proportion with asthma dropped from 33.7% in 1995 to 12.5% in 2006 and the number with food allergy increased 12-fold, from 11 to 138 patients (and from 20.0% to 57.5% of children seen) The number with food anaphylaxis increased from five to 37 children (9.0% to 15.4%) over the same period. There were similar trends in age-adjusted Australian hospital admission rates for anaphylaxis in children aged 0–4 years, which increased from 39.3 to 193.8 per million population between the financial years 1993–94 and 2004–05, a substantially greater increase than for older age groups, or for the population as a whole (36.2 to 80.3 per million population).Conclusions: There is an urgent need for coordinated systematic studies of the epidemiology of food allergy in Australia, to ascertain risk factors and guide public health policy. An increased prevalence of food allergy has implications for public health and medical workforce planning and availability of allergy services in Australia.

Raymond J Mullins PhD, FRACP, FRCPA

Objective: To assess the management of patients with type 2 diabetes mellitus in the primary care setting, with respect to risk factors associated with coronary heart disease.Design: Retrospective cross-sectional audit.Setting: Specialised diabetes assessment clinic in a tertiary referral teaching hospital.Participants: 328 patients with type 2 diabetes mellitus (mean age, 58.3 years [95% CI, 57.5–59.1]) and no existing coronary heart disease (CHD) referred to the clinic by general practitioners during 2004–2005.Main outcome measures: Comparison of glycated haemoglobin (HbA1c), systolic blood pressure and total cholesterol levels and smoking frequency with current RACGP (Royal Australian College of General Practitioners) targets (< 7.0%; < 130/80 mmHg; < 4 mmol/L; and smoking cessation, respectively). Estimation of patients’ 10-year absolute risk of CHD events using the United Kingdom Prospective Diabetes Study risk engine, and its relation to primary prevention of CHD.Results: 42%, 61% and 43% of patients were receiving medication to treat hyperglycaemia, hypertension and hypercholesterolaemia, respectively; 46%, 29% and 15% of patients, respectively, had achieved the recommended RACGP target values for HbA1c, blood pressure, and total cholesterol; and 22% of patients were current smokers. The mean 10-year absolute risk of CHD was 16.8% (95% CI, 15.7%–17.9%), and 48% of patients were classified as “high risk” (absolute risk, > 15%). Based on the 10-year absolute risk, there was no difference between high- and low-risk groups with respect to prescription of aspirin, statins or angiotensin-converting enzyme inhibitors. If all the recommended RACGP goals were achieved, the mean 10-year absolute risk would decrease to 12.6% (95% CI, 11.8%–13.4%).Conclusions: Recommended treatment targets are not being uniformly achieved. Medication for primary CHD prevention is not being preferentially directed at those patients at highest risk, based on the estimated 10-year absolute risk of CHD events. Our findings suggest new initiatives are required in the way target goals and primary CHD prevention measures are set for patients with type 2 diabetes mellitus.

Tuck Y Yong MB BS · George Phillipov BSc(Hons), MSc, PhD · Patrick J Phillips MB BS, MA, FRACP

Objective: To describe the outcome of valve surgery, for rheumatic heart disease (RHD) and non-RHD, in residents of Cape York Peninsula and the Torres Strait Islands referred to the Cairns Base Hospital specialist outreach service.Design and participants: Retrospective review of medical records on all patients residing in the outreach area who had surgery for valvular heart disease between 1 January 1992 and 31 December 2004.Main outcome measures: Operation type and perioperative characteristics; 5- and 10-year survival rates; reoperation rates; complications.Results: Forty-seven patients met the selection criteria; the median age was 40 years (range, 4–76 years); and 39 patients were Indigenous. RHD was the predominant cause of valve dysfunction (30/47 patients). Thirty-seven patients had valve replacements, six had valve repair and four had balloon valvotomy as the initial procedure. There were three bleeding complications, two episodes of operated valve endocarditis, and six embolic complications. There were nine valve-related deaths (six in the first 5 years). At 5 years, all seven patients who had had valve repair or balloon valvotomy were alive. Seven of the 47 patients required reoperation. Survival analysis showed freedom from valve-related deaths to be 83% (95% CI, 66%–92%) at 5 years and 61% (95% CI, 33%–80%) at 10 years. Freedom from reoperation at 5 years was 88% (95% CI, 71%–95%). Among the 30 patients with RHD, freedom from valve-related death was 80% (95% CI, 60%–92%) at 5 years and 52% (95% CI, 21%–75%) at 10 years. In patients with RHD, freedom from reoperation at 5 years was 87% (95% CI, 65%–96%).Conclusion: Valvular heart disease results in substantial morbidity and mortality, despite intervention. Efforts need to focus on prevention of rheumatic fever and closer follow-up.

Anna McLean MB BS · Michael Waters MB BS(Hons) · Emma Spencer MB BS · Clive Hadfield MB BS

Objective: To estimate the incidence and severity of invasive group A streptococcal infection in Victoria, Australia.Design: Prospective active surveillance study.Setting: Public and private laboratories, hospitals and general practitioners throughout Victoria.Patients: People in Victoria diagnosed with group A streptococcal disease notified to the surveillance system between 1 March 2002 and 31 August 2004.Main outcome measure: Confirmed invasive group A streptococcal disease.Results: We identified 333 confirmed cases: an average annualised incidence rate of 2.7 (95% CI, 2.3–3.2) per 100 000 population per year. Rates were highest in people aged 65 years and older and those younger than 5 years. The case-fatality rate was 7.8%. Streptococcal toxic shock syndrome occurred in 48 patients (14.4%), with a case-fatality rate of 23%. Thirty cases of necrotising fasciitis were reported; five (17%) of these patients died. Type 1 (23%) was the most frequently identified emm sequence type in all age groups. All tested isolates were susceptible to penicillin and clindamycin. Two isolates (4%) were resistant to erythromycin.Conclusion: The incidence of invasive group A streptococcal disease in temperate Australia is greater than previously appreciated and warrants greater public health attention, including its designation as a notifiable disease.

Kerry-Ann F O’Grady BScN, GDipPH, MAppEpid · Loraine Kelpie BNurs · Ross M Andrews PhD · Nigel Curtis MB BS, PhD · Terence M Nolan MB BS, PhD · Gowri Selvaraj BSc(Hons) · Jonathan W Passmore BSc, MPH · Frances Oppedisano BAppSc · John A Carnie MB BS, FAFPHM · Jonathan R Carapetis MB BS, PhD

Objective: To study the work satisfaction of general practice staff, the differences between types of staff, and the individual and organisational factors associated with work satisfaction.Design, setting and participants: Cross-sectional multipractice study based on a self-completed job satisfaction survey of 626 practice staff in 96 general practices in Australia between 16 December 2003 and 8 October 2004.Main outcome measures: Job satisfaction scores for all staff and for general practitioners alone; relationship between job satisfaction and the team climate, practice size, particular jobs within practices, demographic characteristics of participants, and geographical location of practices.Results: The response rate was 65%. Job satisfaction was high, with a mean score of 5.66 (95% CI, 5.60–5.72). Multilevel analysis showed that all general practice staff were highly satisfied if they worked in a practice with a good team climate. Practice managers reported the highest satisfaction with their work. Practice size and individual characteristics such as the sex of the participant were unrelated to job satisfaction. GPs tended to have lower satisfaction than other staff in relation to income, recognition for good work and hours of work. Rural GPs were more satisfied.Conclusions: Most general practice staff are satisfied with their work. Facilitating teamwork may be a key strategy for both recruitment and retention of the general practice workforce, especially staff who are not GPs.

Mark F Harris MD, FRACGP · Judy G Proudfoot BEd(Hons), PhD · Upali W Jayasinghe MSc, PhD · Christine H Holton BA(Acc), GDPH · Gawaine P Powell Davies BA, MHP · Cheryl L Amoroso BSc, MPH · Tanya K Bubner GDPH · Justin J Beilby MD, FRACGP

Objective: To assess the impact of iodine fortification of bread on the iodine status of pregnant women, and to determine if studies of iodine levels in school-age children were indicative of women’s gestational iodine status.Design: Urinary iodine surveys of pregnant Tasmanian women before and after bread was fortified with iodine in October 2001.Participants and setting: 285 women attending the Royal Hobart Hospital (RHH) antenatal clinic from 1 October 2000 to 30 September 2001 and 517 women attending the RHH antenatal clinic or primary health care centres in 2003–2006.Main outcome measures: Median urinary iodine concentration (UIC) for comparison against the World Health Organization recommendation of of 150–249 μg/L for pregnant women.Results: Before supplementation, the median UIC of the 285 women attending the RHH antenatal clinic was 76 μg/L. After supplementation, median UICs were 81 μg/L for 288 women attending primary health care centres and 86 μg/L for 229 women attending the RHH antenatal clinic. Differences in mean UIC were not significant for either the antenatal clinic group (P = 0.237) or the primary health care group (P = 0.809) compared with the pre-supplementation group.Conclusions: Iodine deficiency in pregnancy persists despite being corrected in Tasmanian children. Successful iodine supplementation must target reproductive-age and pregnant women and be substantiated by ongoing monitoring during pregnancy and lactation. A robust national program for correcting iodine deficiency is urgently needed. Mandatory universal salt iodisation has international endorsement, and should be considered the preferred strategy for eliminating iodine deficiency in Australia.

John R Burgess BMedSc, MD, FRACP · Judy A Seal MPH, AdvAPD · Georgina M Stilwell MB BS · Peter J Reynolds MB BS, FRACOG · E Roscoe Taylor GradDipEpid, MRNZCGP, FAFPHM · Venkat Parameswaran PhD

Objective: To investigate whether hospital utilisation and health outcomes in Victoria differ between people born in refugee-source countries and those born in Australia.Design and setting: Analysis of a statewide hospital discharge dataset for the 6 financial years from 1 July 1998 to 30 June 2004. Hospital admissions of people born in eight countries for which the majority of entrants to Australia arrived as refugees were included in the analysis.Main outcome measures: Age-standardised rates and rate ratios for: total hospital admissions; emergency admissions; surgical admissions; total days in hospital; discharge at own risk; hospital deaths; admissions due to infectious and parasitic diseases; and admissions due to mental and behavioural disorders.Results: In 2003–04, compared with the Australia-born Victorian population, people born in refugee-source countries had lower rates of surgical admission (rate ratio [RR], 0.85; 95% CI, 0.81–0.88), total days in hospital (RR, 0.74; 95% CI, 0.73–0.75), and admission due to mental and behavioural disorders (RR, 0.70; 95% CI, 0.65–0.76). Over the 6-year period, rates of total days in hospital and rates of admission due to mental and behavioural disorders for people born in refugee-source countries increased towards Australian-born averages, while rates of total admissions, emergency admissions, and admissions due to infectious and parasitic diseases increased above the Australian-born averages.Conclusions: Use of hospital services among people born in refugee-source countries is not higher than that of the Australian-born population and shows a trend towards Australian-born averages. Our findings indicate that the Refugee and Humanitarian Program does not currently place a burden on the Australian hospital system.

Ignacio Correa-Velez MD, PhD · Vijaya Sundararajan MD, MPH · Kaye Brown PhD · Sandra M Gifford MPH, PhD

Objective: To determine whether primary care management of chronic heart failure (CHF) differed between rural and urban areas in Australia.Design: A cross-sectional survey stratified by Rural, Remote and Metropolitan Areas (RRMA) classification. The primary source of data was the Cardiac Awareness Survey and Evaluation (CASE) study.Setting: Secondary analysis of data obtained from 341 Australian general practitioners and 23 845 adults aged 60 years or more in 1998.Main outcome measures: CHF determined by criteria recommended by the World Health Organization, diagnostic practices, use of pharmacotherapy, and CHF-related hospital admissions in the 12 months before the study.Results: There was a significantly higher prevalence of CHF among general practice patients in large and small rural towns (16.1%) compared with capital city and metropolitan areas (12.4%) (P < 0.001). Echocardiography was used less often for diagnosis in rural towns compared with metropolitan areas (52.0% v 67.3%, P < 0.001). Rates of specialist referral were also significantly lower in rural towns than in metropolitan areas (59.1% v 69.6%, P < 0.001), as were prescribing rates of angiotensin-converting enzyme inhibitors (51.4% v 60.1%, P < 0.001). There was no geographical variation in prescribing rates of β-blockers (12.6% [rural] v 11.8% [metropolitan], P = 0.32). Overall, few survey participants received recommended “evidence-based practice” diagnosis and management for CHF (metropolitan, 4.6%; rural, 3.9%; and remote areas, 3.7%).Conclusions: This study found a higher prevalence of CHF, and significantly lower use of recommended diagnostic methods and pharmacological treatment among patients in rural areas.

Robyn A Clark MEd, FRCNA · Kerena A Eckert MPH · Simon Stewart PhD, FCSA · Susan M Phillips DPhil · Julie J Yallop NZRN · Andrew M Tonkin MD, MRACP, FRACP · Henry Krum PhD, FRACP

Objective: To determine the incidence of postoperative complications, including 30-day mortality rate, and need for intensive care unit (ICU) admission in older patients after non-cardiac surgery.Design and setting: Prospective observational study of all patients aged 70 years or older having elective and non-elective, non-cardiac surgery, and staying at least 1 night after surgery in one of three Melbourne teaching hospitals, June to September 2004.Main outcome measures: Postoperative complications and 30-day mortality rate.Results: 1102 consecutive patients were audited in mid 2004; 70% had pre-existing comorbidities. The 30-day mortality rate was 6%; 19% had postoperative complications; and 20% of patients spent at least 1 night in ICU. On multivariate analysis, preoperative factors associated with 30-day mortality included age (odds ratio [OR], 1.09 per year over 70 years; 95% CI, 1.04–1.13; P < 0.001); increasing severity of systemic disease (American Society of Anesthesiologists physical status classification) (OR, 2.53; 95% CI, 1.65–3.86; P < 0.001); and albumin level < 30 g/L (OR, 2.23; 95% CI, 1.09–4.57; P = 0.03). Postoperative factors associated with 30-day mortality were unplanned ICU admission (OR, 3.95; 95% CI, 1.63–9.55; P = 0.003); sepsis (OR, 2.75; 95% CI, 1.17–6.47; P = 0.02); and acute renal impairment (OR, 2.40; 95% CI, 1.06–5.41; P = 0.04). Thoracic surgery was the only surgical specialty significantly associated with mortality (OR, 3.96; 95% CI, 1.44–9.10; P = 0.008) in the multivariate analysis.Conclusion: Older patients having surgery had high rates of comorbidities and postoperative complications, placing considerable demands on critical care services. Patient factors were often stronger predictors of mortality than the type of surgery.

Larry McNicol MB BS, FRCA, FANZCA · David A Story MD, BMedSci, FANZCA · Kate Leslie MEpi, MD, FANZCA · Paul S Myles MD, FCARCSI, FANZCA · Michael Fink MB BS, FRACS · Andrew C Shelton BN, GradCertCritCare · Ornella Clavisi BSc(Hons), MPH · Stephanie J Poustie BN, CritCareCert, MPH

Objective: To determine whether eating Lactobacillus rhamnosus GG (LGG) in the form of commercially available yoghurt improves clearance of vancomycin-resistant enterococci (VRE).Design: Double-blind, randomised, placebo-controlled trial.Setting: Renal ward of Austin Health, a tertiary hospital, Feb–Oct 2005.Participants: 27 VRE-positive patients, 14 receiving active treatment and 13 controls.Interventions: Subjects were randomly assigned to either a treatment group (receiving 100 g daily of yoghurt containing LGG for 4 weeks) or a control group (receiving standard pasteurised yoghurt). Faecal samples were obtained three times at about weekly intervals. Treated patients were tested for VRE again at 8 weeks. Patients in the control group who had failed to clear VRE after 4 weeks were then given LGG-containing yoghurt for 4 weeks, as an open continuation.Main outcome measure: Number of faecal specimens clear of VRE.Results: Of the 27 patients enrolled, 23 completed the study. Two patients were lost to follow-up, one died and one withdrew. All 11 patients in the treatment group who completed the study cleared VRE. Three subjects reverted to VRE positivity after using antibiotics to which LGG is sensitive, while all others remained negative for at least 4 weeks after trial completion. Twelve control subjects completed the study, of whom one cleared VRE and 11 remained VRE-positive. Eight of these 11 patients were subsequently crossed over to receive LGG yoghurt, and all cleared VRE within 4 weeks.Conclusion: To our knowledge, this is the first description of a probiotic therapy to successfully treat gastrointestinal carriage of VRE in renal patients. Further investigation of the use of LGG in VRE-positive patients is warranted.

Karen J Manley BSc, MHumNutr, GradDipDiet · Margaret B Fraenkel BM BS, PhD, FRACP · Barrie C Mayall MB BS, FRACP, FRCPA · David A Power BM BS, PhD, FRACP

Objective: To examine overweight and obesity in Australian children followed through to adulthood.Design and participants: A cohort study of 8498 children aged 7–15 years who participated in the 1985 Australian Schools Health and Fitness Survey; of these, 2208 men and 2363 women completed a follow-up questionnaire at age 24–34 years in 2001–2005.Main outcome measures: Height and weight were measured in 1985, and self-reported at follow-up. The accuracy of self-reported data was checked in 1185 participants. Overweight and obesity in childhood were defined according to international standard definitions for body mass index (BMI), and, in adulthood, as a BMI of 25–29.9 and ≥ 30 kg/m2, respectively, after correcting for self-report error.Results: In those with baseline and follow-up data, the prevalence of overweight and obesity in childhood was 8.3% and 1.5% in boys and 9.7% and 1.4% in girls, respectively. At follow-up, the prevalence was 40.1% and 13.0% in men and 19.7% and 11.7% in women. The relative risk (RR) of becoming an obese adult was significantly greater for those who had been obese as children compared with those who had been a healthy weight (RR = 4.7; 95% CI, 3.0–7.2 for boys and RR = 9.2; 95% CI, 6.9–12.3 for girls). The proportion of adult obesity attributable to childhood obesity was 6.4% in males and 12.6% in females.Conclusion: Obesity in childhood was strongly predictive of obesity in early adulthood, but most obese young adults were a healthy weight as children.

Alison J Venn BSc(Hons), PhD · Russell J Thomson BSc(Hons), PhD · Michael D Schmidt BS, MS, PhD · Verity J Cleland BAppSci(Hons) · Beverley A Curry BSc, MSc · Hanni C Gennat BSc, PhD · Terence Dwyer MB BS, MPH, MD

Objectives: To measure physical assets in Australasian hospitals required for the management of mass casualties as a result of terrorism or natural disasters.Design and setting: A cross-sectional survey of Australian and New Zealand hospitals.Participants: All emergency department directors of Australasian College for Emergency Medicine (ACEM)-accredited hospitals, as well as private and non-ACEM accredited emergency departments staffed by ACEM Fellows in metropolitan Sydney.Main outcome measures: Numbers of operating theatres, intensive care unit (ICU) beds and x-ray machines; state of preparedness using benchmarks defined by the Centers for Disease Control and Prevention in the United States.Results: We found that 61%–82% of critically injured patients would not have immediate access to operative care, 34%–70% would have delayed access to an ICU bed, and 42% of the less critically injured would have delayed access to x-ray facilities.Conclusions: Our study demonstrates that physical assets in Australasian public hospitals do not meet US hospital preparedness benchmarks for mass casualty incidents. We recommend national agreement on disaster preparedness benchmarks and periodic publication of hospital performance indicators to enhance disaster preparedness.

Matthias Traub MD, FRACS · David A Bradt MD, FACEM, FAFPHM · Anthony P Joseph MB BS, FACEM

Objective: To assess whether a diagnosis of the metabolic syndrome (MetS) improves the prediction of cardiovascular disease or total mortality beyond that already provided by conventional risk factors.Design and setting: A longitudinal cohort study conducted in Dubbo, New South Wales.Participants: 2805 men and women aged 60 years and older living in the community, first assessed in 1988–1989 and followed for 16 years.Main outcome measures: Coronary heart disease (CHD) events, ischaemic stroke events, and total mortality.Results: MetS was present in 31% of men and 34% of women. Crude CHD, ischaemic stroke, and total mortality rates were higher in the presence of MetS in men and women. In proportional hazards models that included conventional risk factors, but excluded variables used to define the presence of MetS, MetS was a significant predictor of CHD, stroke and total mortality. In men, the respective hazard ratios were 1.64 (95% CI, 1.37–1.96), 1.31 (95% CI, 0.97–1.77), and 1.53 (95% CI, 1.30–1.79). In women, the respective hazard ratios were 1.70 (95% CI, 1.43–2.02), 1.37 (95% CI, 1.04–1.82), and 1.35 (95% CI, 1.15–1.59). The use of MetS variables on an ordinal scale produced broadly similar conclusions.Conclusions: A diagnosis of MetS provides additional prediction of CHD events, stroke events, and total mortality beyond that provided by other conventional risk factors.

Leon A Simons MD, FRACP · Judith Simons MACS · Yechiel Friedlander PhD · John McCallum DPhil

Objectives: To describe the self-reported use of prostate specific antigen (PSA) tests, faecal occult blood tests (FOBTs), and whole-body skin examinations among Queensland men, reasons for use, and the personal characteristics of men undergoing the tests for cancer screening.Setting and design: Data were obtained from the Queensland Cancer Risk Study (QCRS), a population-based telephone survey conducted in 2004, which used random sampling stratified by age, sex, and geographic location.Participants: All men aged 50–75 years who participated in the QCRS (n = 2336).Main outcome measures: Use of PSA test, FOBT, or whole-body skin examination, specifically as a screening procedure; the probability of being screened; and associations with sociodemographic factors, risk behaviour, and cancer experience.Results: More than a third of men reported never having been screened for prostate, colorectal, or skin cancer. Of those who had been screened, the odds of PSA testing being reported were more than two times greater than the odds of whole-body skin examination (adjusted odds ratio [OR], 2.54; 95% CI, 1.49–4.32), and the odds of reporting an FOBT were less (adjusted OR, 0.48; 95% CI, 0.22–1.04). Men who participated in cancer screening tended to be older, white, living with a partner, and to have private health insurance. Smokers were less likely to be screened with any of the three screening tests.Conclusions: Of these three cancer screening tests, the FOBT has the best evidence for reducing mortality and yet is the least frequently used by Queensland men. There are disparities in reported screening prevalence between the specific tests and across certain population subgroups.

Philippe Carrière MD, MSc · Peter Baade PhD, AStat · Beth Newman PhD · Joanne Aitken PhD · Monika Janda PhD

Objective: To examine evolving changes in asthma and chronic obstructive pulmonary disease (COPD) in South Australia and Australia as a whole from the perspective of hospital admissions, ventilatory support and mortality data.Design: Retrospective analyses, for the period 1993–2003, of hospital separations data from the Australian Institute of Health and Welfare and the Integrated South Australian Activity Collection, and mortality data from the Australian Bureau of Statistics and South Australian hospital morbidity collection.Main outcome measures: Hospital separations, ventilatory support episodes, mortality rates, burden-of-disease rankings.Results: Between 1993 and 2003, in SA and nationally, hospital separations for asthma declined but separations for COPD increased significantly. Falling mortality rates from asthma in both men and women, and from COPD in men, contrast with increasing rates of COPD-related hospitalisation and mortality in women.Conclusions: Hospital admissions and mortality associated with asthma have fallen. Admission rates for COPD are declining for men, but there is no indication that admission rates for women have reached a peak. There is a need for higher prioritisation of COPD, including policies to reduce smoking in women, and medical practice initiatives to support primary and secondary prevention, pulmonary rehabilitation and appropriate drug therapies.

David H Wilson PhD, MPH, BEd · Graeme Tucker BSc · Peter Frith MD · Sarah Appleton BA · Richard E Ruffin MD · Robert J Adams MD

Objective: To describe the prevalence, characteristics and outcomes of amphetamine-related presentations to a tertiary hospital emergency department (ED).Design, setting and participants: Prospective observational study of amphetamine-related presentations to the ED of the Royal Perth Hospital (RPH), an adult, inner-city, tertiary referral hospital, between 3 August and 2 November 2005. For all patients presenting to the ED, the treating doctors were automatically prompted by the computerised data entry system to consider amphetamine use.Main outcome measures: Proportion of ED presentations related to amphetamine use; demographic features and usage practices of amphetamine users; characteristics of presentations and admissions; associated psychiatric illnesses and use of other drugs.Results: Over the study period, there were 13 125 presentations, of which 156 (1.2%) were judged to be causally related to amphetamine use. Of those 156 patients, over half were habitual drug users (89 [57.1%] used amphetamines at least weekly), and the majority were men (111 [71.2%]). The mean age was 28 years (range, 16–55 years). Presentations were of high acuity: 104 patients [66.7%] were rated 1, 2 or 3 on the Australasian Triage Scale; 50 (32.1%) arrived by ambulance; and 25 (16.0%) arrived with police. The mean time spent in the ED was 6 h (range, 0.5–24 h). Fifty patients (32.1%) required sedation, and the likelihood of requiring sedation increased almost threefold if the heart rate was over 100 beats/min on presentation. Sixty-two patients (39.7%) were admitted and 58 (37.2%) required psychiatric evaluation. Repeat attendance was common, with 71 patients (45.5%) having previous amphetamine-related presentations to the RPH ED.Conclusions: Amphetamine-related presentations comprise 1.2% of all ED attendances and have a major impact on hospital EDs. Patients are often agitated and aggressive, require extensive resources, and frequently re-attend. The burden of amphetamine-related illnesses on EDs is likely to increase in the future.

Suzanne D Gray MB BS · Daniel M Fatovich MB BS, FACEM · David L McCoubrie MB BS, FACEM · Frank F Daly MB BS, FACEM

Objective: To examine trends in hospital separations related to “drug-induced” psychosis for cannabis and methamphetamine, in the context of patterns of cannabis and methamphetamine use in the Australian population.Design and setting: Analysis of prospectively collected data from the National Hospital Morbidity Database on hospital separations primarily attributed to drug-induced psychosis (July 1993 – June 2004), and specifically for cannabis and amphetamines (1999–2004). Calculation of Australian population-adjusted rates of drug-induced psychosis hospital separations using estimated resident population data from the Australian Bureau of Statistics (at 30 June each year) and data on cannabis and methamphetamine use from the 2004 National Drug Strategy Household Survey.Main outcome measures: Number of hospital separations due to drug-induced psychosis, and standardised (age-specific) rates per million population and per million users.Results: There have been notable increases in hospital separations due to drug-induced psychosis, which appear to have been driven by amphetamine-related rather than cannabis-related episodes. The rate of hospital separations was higher for amphetamine users than for cannabis users in all age groups, and the rate increased among older amphetamine users.Conclusions: The risk of hospitalisation for a drug-induced psychotic episode associated with amphetamine use appears to be greater than that for cannabis use in all age groups.

Louisa Degenhardt PhD, MPsych(Clinical) · Amanda Roxburgh BA(Hons)Psych, MCrim · Rebecca McKetin PhD

Objective: To examine pre-registration junior doctors’ perceptions of the value of a general practice term in their training program.Design, setting and participants: Semi-structured interviews, in five teaching hospitals in South Australia in 2005, with 20 pre-registration junior doctors (interns) who had completed a general practice term and at least one core term of intern training.Main outcome measure: Comparisons between general practice and teaching hospital core training terms with respect to the domains of junior doctor education.Results: Interns perceived general practice and teaching hospital terms to be complementary in their overall training program. The general practice term provided them with knowledge and skills they would not have acquired in the teaching hospital terms alone. One-on-one consulting, initiating patient management, and the opportunity to practise a range of practical and procedural skills were seen to be of particular value.Conclusions: The general practice and teaching hospital terms both contribute to the training of interns, offering contrasting environments and experiences which enhance interns’ professional and personal growth. General practice terms should be considered for inclusion in intern training programs across Australia.

Anne A Martin BSc(Hons), PhD · Caroline O Laurence BA(Hons), MHlthServMt · Linda E Black BA(Psych), DipApplPsych, MAPS · Bruce V Mugford BM BS, FRACGP, FACRRM

Objective: To assess the prevalence of obesity in patients undergoing coronary artery bypass grafting, heart valve surgery, or both procedures, and its association with postoperative outcomes.Design and setting: Retrospective analysis of data, collected by the Australasian Society of Cardiac and Thoracic Surgeons Victorian Cardiac Surgery Database Project, on patients undergoing coronary artery bypass grafting, heart valve surgery, or both procedures, between 1 June 2001 and 31 January 2006.Participants: 11 736 patients divided into four groups: underweight (body mass index [BMI], < 20), normal weight (BMI, 20–30), obese (BMI, > 30 to < 40), and morbidly obese (BMI, ≥ 40).Main outcome measures: Prevalence of obesity (compared with the age- and sex-matched adult Australian population); associations between obesity and morbid obesity in cardiac patients and adverse postoperative outcomes.Results: 30.4% of patients had a BMI > 30 (28.6% obese, 1.8% morbidly obese) compared with an expected prevalence of 21.2%. Morbid obesity was associated with prolonged ventilation (adjusted odds ratio [OR], 2.4; 95% CI, 1.6–3.7), readmission to intensive care (adjusted OR, 2.2; 95% CI, 1.2–4.1), and length of stay > 14 days (adjusted OR, 2.1; 95% CI, 1.4–3.3). Both obesity and morbid obesity were associated with renal failure (adjusted ORs, 1.4 [95% CI, 1.1–1.7] and 2.9 [95% CI, 1.7–4.9], respectively) and deep sternal wound infection (adjusted ORs, 2.4 [95% CI, 1.5–3.8] and 7.2 [95% CI, 2.8–18.7], respectively).Conclusions: Obesity is 1.4 times more prevalent in patients having coronary artery bypass grafting or heart valve surgery in Victoria compared with the general adult Australian population. Both obesity and morbid obesity are associated with early morbidity, but not mortality, after operation.

Cheng-Hon Yap MB BS, MS · Morteza Mohajeri FRACS · Michael Yii FRACS, MS

Objective: To review homicides committed during psychotic illness in New South Wales over 10 years from 1993 to 2002.Design and setting: Case series of all known homicides committed during psychotic illness in NSW, taken from reports of psychiatrists submitted in proceedings in the Supreme Court of NSW.Main outcome measures: Demographic and clinical features of perpetrators; estimated frequency of homicide during psychotic illness.Results: In the 10 years from 1993 to 2002, there were at least 88 people charged with 93 homicide offences committed during the acute phase of mental illness. High rates of drug misuse, especially of drugs known to induce psychotic illness and brain injury, were reported. Evolving auditory hallucinations and delusional beliefs that led the person to believe they were in danger were the symptoms strongly associated with lethal assault. The victims were mostly family members or close associates. Only nine of the victims were strangers, including three fellow patients. Most lethal assaults (69%) occurred during the first year of illness, and the first episode of psychotic illness was found to carry the greatest risk of committing homicide.Conclusions: People in their first episodes of mental illness should be considered to be at greater risk of committing serious violence than those in subsequent episodes. Illicit drug use, a history of brain injury, auditory hallucinations and delusional beliefs of immediate danger were particularly associated with lethal assault.

Olav B Nielssen MB BS, MCrim, FRANZCP · Bruce D Westmore MCrim, FACLM, FRANZCP · Matthew M B Large BSc(Med), MB BS, FRANZCP · Robert A Hayes LLB, PhD

Objective: To explore the ways that patients and health professionals communicate about intimate and sexual changes in cancer and palliative care settings.Design: A qualitative study using a three-stage reflexive-inquiry approach, with semi-structured, participant interviews (n = 82); textual analysis of national and international cancer and palliative care clinical practice guidelines (n = 33); and participant feedback at 15 educational forums for cancer patients or health professionals.Setting: A large Australian public teaching hospital between 2002 and 2005.Participants: 50 patients diagnosed with cancer, and 32 health professionals who had worked in cancer and/or palliative care for a minimum of 12 months.Main outcome measures: Communication about intimacy and sexuality: patients’ needs and experiences and health professionals’ attitudes and experiences.Results: There were mismatched expectations between patients and health professionals and unmet patient needs in communication about sexuality and intimacy. Most patients sought information, support and practical strategies about how to live with intimate and sexual changes after treatment for cancer, even if their cancer type did not affect fertility or sexual performance. In contrast, many health professionals assumed that patients shared their professional focus on combating the disease, irrespective of the emotional and physical costs to the patient. Health professionals overwhelmingly limited their understanding of patient sexuality to fertility, contraception, menopausal or erectile status. Many stereotypical assumptions were made about patient sexuality, based on age, sex, diagnosis, culture, and partnership status. There was a relationship between providing patient-centred communication about intimacy and sexuality and health professionals’ understanding of their own attitudes and beliefs.Conclusion: Resources are needed to help health professionals engage in an exploration of their own definitions of intimacy and sexuality and understand how these affect interactions with patients with cancer.

Amanda J Hordern PhD · Annette F Street PhD

Objective: To assess whether the rates of Down syndrome births in Queensland vary according to rurality (ie, whether the mother lives in a rural or urban area) and type of antenatal care provider, and to consider any implications for antenatal care.Design and setting: Population-based study of Down syndrome births in Queensland between 1990 and 2004, stratified by rurality and type of antenatal care provider (private obstetrician, public hospital or shared care).Results: Since 2000, there has been a large fall in maternal-age-adjusted rates of Down syndrome births among mothers living in urban areas (−14.3% per year; 95% CI, −22.7%, −5.0%) and among mothers receiving their antenatal care from private obstetricians (−27.5% per year; 95% CI, −37.6%, −15.8%). Similar decreases have not occurred among mothers living in rural areas (0.0%; 95% CI, −11.7%, 13.1%) or among mothers receiving antenatal care from public hospitals (+2.9%, 95% CI, −10.3%, 17.9%).Conclusion: Possible reasons for the observed trends include unequal access to antenatal screening; confusion about screening guidelines and protocols; late presentation for antenatal care; and differences in attitudes to screening and termination of pregnancy among expectant parents, such that they may choose not to have screening or not to act on a positive screening test result.

Michael D Coory FAFPHM, PhD, AStat · Timothy Roselli BAppSc, BSc(Hons) · Heidi J Carroll MB BS, MPH