Research

Objective: To document the risk-factor profile and risk-factor knowledge of patients with an acute coronary syndrome (ACS) not attending standard cardiac rehabilitation.Design and setting: Cross-sectional comparison in a tertiary hospital.Participants: Patients admitted to hospital with an ACS, residing within 20 km of the hospital, and without severe comorbidity who did not access cardiac rehabilitation (NCR) were compared with a group about to commence standard cardiac rehabilitation (SCR).Main outcome measures: Risk-factor profile, knowledge of risk factors via face-to-face assessment, quality of life.Results: Of the 446 patients eligible for cardiac rehabilitation, 208 attended for assessment (NCR: n = 144; SCR: n = 64). The NCR group had higher mean (± SEM) low-density lipoprotein (LDL) cholesterol levels (2.6 ± 0.1 v 2.3 ± 0.1; P = 0.02), and were more likely than the SCR group to have a total cholesterol level of > 4.0 mmol/L (78% v 53%; P < 0.001) and an LDL cholesterol level > 2.5 mmol/L (47% v 25%; P = 0.01). They were more likely than the SCR group to be physically inactive (77% v 22%; P < 0.001); obese (46% v 33%; P = 0.04); depressed (21% v 5%; P < 0.001); or current smokers (21% v 1%; P < 0.001). Compared with the SCR group, the NCR group also had higher risk scores (LIPID risk score) (4.5 v 2.1; P < 0.001); lower quality of life (Medical Outcome Short Form [SF-36] Health Survey); and significantly poorer knowledge of risk factors. Among patients with at least two modifiable cardiac risk factors, the NCR group were less likely than the SCR group to be able to state at least one risk factor (24% v 38%; P < 0.001).Conclusions: Patients not participating in cardiac rehabilitation after an ACS have more adverse risk profiles and poorer knowledge of risk factors compared with those about to commence cardiac rehabilitation. Alternate models for secondary prevention are required to improve health outcomes in patients not attending cardiac rehabilitation.

Julie Redfern BAppSc, BSc · Elizabeth R Ellis MHealthLaw, MSc, PhD · Tom Briffa BPhysEd, MPhysEd, PhD · S Ben Freedman MB BS,PhD, FRACP

Objective: To provide a contemporary picture of the general practitioner and specialist obstetric workforce in Victoria.Design, participants and setting: Postal census by questionnaire of all 317 Fellows and 961 Diplomates on the Victorian database of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists in September 2003.Main outcome measures: Sex, age and geographical distributions and patterns of retirement from and recruitment to the GP and specialist obstetric workforce in Victoria.Results: 244 Fellows (77.0%) and 652 Diplomates (67.8%) participated. The average age of Diplomates was 42 years; only 20% were involved in procedural obstetrics. Of GPs practising procedural obstetrics, 56% intended to cease within 7 years. Two-thirds of specialist obstetricians continued to practise obstetrics. Among those ceasing obstetrics, almost half had done so since 2000. Among Fellows ceasing obstetric practice, there is a peak in the 50–60-years age group, but cessation of obstetric practice occurred across all age groups.Conclusion: The proportion of GPs involved in procedural obstetrics has fallen markedly over the past decade, with half of those ceasing practice in the 40–50-years age group. New GPs entering the workforce with the Diploma and overseas doctors are unlikely to meet the procedural workforce shortfall. Attracting the large cohort of doctors aged 40–50 years back to obstetric practice must be a priority. Given the pattern of retirements from obstetrics, there will be insufficient numbers of specialists to maintain current levels of service. The reasons include non-participation in obstetrics by new graduates and international medical graduates, the inadequate number of new graduates, and the predominance of women among specialists aged under 40 years, whose work output tends to be affected by family commitments.

Cameron S Loy FRACGP, DCH, DRANZCOG · R Bruce Warton FRCOG, FRANZCOG, FRACMA · James A Dunbar MD, FRCPEdin, FRACGP

Objective: To describe the epidemiology of falls from ladders in a state-wide population.Design and setting: Retrospective review of data from the the Victorian State Trauma Registry and the Victorian Emergency Minimum Dataset on patients presenting to public hospital emergency departments (EDs) with injuries due to a fall while climbing a ladder, from 1 July 2001 to 30 June 2005.Main outcome measures: Overall trends in the incidence of ladder-related ED presentations, and in cases of major trauma, trends according to age, and trends according to activity at the time of the fall.Results: 4553 patients presented to EDs after falls from ladders in Victoria during the study period; 160 patients had injuries classified as major trauma. There has been a significant rise in the number of presentations to EDs following falls from ladders in Victoria, with a marked increase in the number of cases involving patients aged over 50 years and those climbing ladders outside of paid working conditions. Deaths occurred predominantly in the elderly after falls from heights above 1 metre.Conclusions: Despite knowledge of the dangers of falls from ladders, there has been a significant increase in the number of patients presenting to hospitals after ladder falls. Middle-aged to elderly patients undertaking unpaid work account for this increase. A targeted public health initiative is required to curb this trend.

Biswadev Mitra MB BS · Peter A Cameron MB BS, MD, FACEM · Belinda J Gabbe BPhysio(Hons), MAppSc, PhD

The National Health and Medical Research Council Act 1992 (Cwlth) was amended in 2006 to streamline governance arrangements and help the National Health and Medical Research Council (NHMRC) to become a more responsive organisation and more effective at both acquisition and implementation of new knowledge. As part of the NHMRC’s plans for the future, we will implement the recommendations of the Investment Review of Health and Medical Research on policy- and practice-focused research, commercialisation, and recruitment of health and research professionals to the NHMRC. The NHMRC is also improving its process for selecting and supporting the best research across biomedical, clinical, public health and health services disciplines; and will develop, trial and introduce new forms of communicating evidence-based information.

Warwick P Anderson BSc, PhD

Research and publication misconduct is commoner than many believe, hard to detect and difficult to investigate, with institutions often being reluctant to take action. The first countries to set up formal systems for policing research misconduct were the United States and some Scandinavian countries. The US Office of Research Integrity (ORI) is a useful model for other countries; rather than conduct investigations, the ORI supervises the investigation by the respondent’s institution. The United Kingdom has taken more than 10 years to set up a national supervisory body — the UK Panel for Research Integrity in Health and Biomedical Sciences. Unlike the ORI, it has no statutory basis. It is too early to tell whether the procedures set up in the UK will work. The present trend for governments to encourage universities to link up with industry may lead to a culture of secrecy and confused accountability. In any country, including Australia, intent on policing research, it is only possible for editors, reviewers or readers to initiate investigations, not undertake them, as power lies in the hands of employers, research funders and regulatory bodies.

Harvey Marcovitch FRCPCH

Institutions investigating allegations of research misconduct are vulnerable to claims that their processes are inadequate or that they have an institutional conflict of interest. The Office of Research Integrity in the United States sets down standards for and reviews the adequacy of investigations of research misconduct by institutions; recognises that internal politics and the involvement of non-experts can lead to honest mistakes being regarded as serious misconduct; requires complainants and investigators to act “in good faith”; and reduces damaging publicity when complaints are misconceived or false. Australia needs an office of academic integrity to ensure that all complaints are thoroughly investigated; the investigative procedures meet international standards; fair processes are provided for complainants and respondents; and institutions are protected from claims of “cover-up” and institutional conflict of interest.

Bruce M Hall MB BS, FRACP, PhD

Research conduct in Australia and worldwide is mostly unaudited. The purpose of good research governance is to ensure integrity in research through accountability, transparency and responsibility. Institutional responsibility for research governance has been adopted by Monash University’s Department of Epidemiology and Preventive Medicine, providing clear lines of accountability for researchers as well as support and guidance. A research audit tool has been developed, identifying areas where practice could be improved especially among less experienced researchers; the most common adverse findings concerned research protocols and procedure manuals. The need for participant confidentiality, privacy and data security was found to be understood, and adhered to widely by all researchers. An evaluation of the effect of audit on researchers found that the process was well accepted.

Stephanie J Poustie MPH, CertCritCare, BN · David McD Taylor MD, FACEM · Andrew B Forbes BSc(Hons), MSc, PhD · Marina A Skiba BEd · Mark R Nelson MFM, FRACGP, PhD · John J McNeil MB BS, PhD, FRACP

Objective: To compare cervical screening policy, screening uptake, and changes in cervical cancer incidence and mortality between Australia and the United Kingdom.Design: Analysis of screening registry data and national cancer statistics.Setting: In Australia, organised cervical screening was initiated in 1991 for sexually active women aged 18–69 years, with a recommended 2-yearly interval. In the UK, organised screening began in 1988 for women aged 20–64 years, with a recommended 3-yearly interval in most regions.Results: Estimated lifetime screening participation rates in 2001 were similar in the two countries, at 88% in Australia and 90% in the UK. For women who were screened and had a negative result, the median time to the next screen was 27 months in Australia and 38 months in the UK. At 39 months, equivalent proportions (74%) had been re-screened in the two countries, and by 60 months the re-screened proportions were 81% in Australia and 94% in the UK. From 1991–1993 to 1998–2000, the incidence of cervical cancer in women aged 20–69 years fell by 33% in Australia and 33% in the UK, and mortality from cervical cancer fell by 36% in both countries.Conclusions: After the introduction of organised screening, similar reductions in cervical cancer incidence and mortality were achieved in Australia and the UK. Therefore, the 2-yearly screening policy in Australia and the predominantly 3-yearly screening policy in the UK appear to have been of broadly similar effectiveness.

Karen Canfell DPhil · Freddy Sitas MSc(Med), MSc(Epi), DPhil · Valerie Beral FRS

Objective: To investigate whether responses to a previously validated four-item medication adherence questionnaire were associated with adverse cardiovascular events.Design: Survey conducted among a cohort of participants in the Second Australian National Blood Pressure Study.Setting: Australian general practice.Participants: 4039 older people with hypertension.Main outcome measures: All major cardiovascular events or death; first specific cardiovascular event.Results: Subjects who adhered to their medication regimen (compared with non-adherent subjects) were significantly less likely to experience a first cardiovascular event or a first non-fatal cardiovascular event (hazard ratio [HR] for both, 0.81; 95% CI, 0.67–0.98; P = 0.03); a fatal other cardiovascular event (HR, 0.68; 95% CI, 0.48–0.99; P = 0.04); or a first occurrence of heart failure (HR, 0.58; 95% CI, 0.37–0.90; P = 0.02). Those who answered yes to “Did you ever forget to take your medication?” were significantly more likely to experience a cardiovascular event or death (HR, 1.28; 95% CI, 1.04–1.57; P = 0.02); a first cardiovascular event or death (HR, 1.31; 95% CI, 1.07–1.60; P = 0.01); a first cardiovascular event (HR, 1.34; 95% CI, 1.09–1.65; P = 0.01); or a first non-fatal cardiovascular event (HR, 1.35; 95% CI, 1.09–1.66; P = 0.01). Those who answered yes to “Sometimes, if you felt worse when you took your medicine, did you stop taking it?” were significantly more likely to experience a first occurrence of heart failure (HR, 2.06; 95% CI, 1.16–3.64; P = 0.01).Conclusions: Subjects who adhered to their medication regimen were less likely to experience major cardiovascular events or death. The question relating to forgetting to take medication identified non-adherent subjects likely to experience a cardiovascular event or death. Clinicians could use this question to identify patients with hypertension who are likely to benefit from medication adherence strategies.

Mark R Nelson MFM, FRACGP, PhD · Christopher M Reid MSc, PhD · Philip Ryan MB BS, FAFPHM · Kristyn Willson BSc(Hons) · Lisa Yelland BMa

Objective: To investigate the effectiveness of the Northern Territory Women’s Cancer Prevention Program in improving cervical screening participation for Indigenous women.Design: Descriptive longitudinal period prevalence study.Participants: All NT resident women aged 20–69 years who had at least one Pap smear recorded on the NT Pap Smear Register between 1997 and 2004.Main outcome measures: Indirectly estimated percentage of NT Indigenous women in rural and remote areas with a predominantly Indigenous population (accounting for 55% of the NT Indigenous population) who participated in screening, in biennial periods between 1997 and 2004. Participation by all eligible NT women (both Indigenous and non-Indigenous) is also reported by region for the same period.Results: In 1997–1998, estimated participation for Indigenous women was about half the national rate (33.9% [95% CI, 32.6%–35.2%] v 63.9% [95% CI, 63.8%–63.9%]). Participation increased to 44.0% (95% CI, 42.7%–45.4%) in 1999–2000, and changed little thereafter; participation was higher in the Top End compared with Central Australia, and varied from 16.6% to 75.0% between remote areas. Participation rates for all women living in rural/remote regions were lower than those in urban regions.Conclusions: Recruitment of Indigenous women for cervical screening has improved since 1999. This may have partly contributed to the fall in their cervical cancer incidence and mortality in recent years. Although in most areas Indigenous participation is lower than national levels, in one area it was considerably higher. Improvements can be achieved by learning from these communities, to further close the gap in morbidity and mortality between Indigenous and non-Indigenous women.

Philippa L Binns FRACGP, MAppEpid · John R Condon FAFPHM, PhD

Objective: To identify sociodemographic factors associated with help-seeking behaviour for reproductive health disorders in middle-aged and older Australian men.Design: A cross-sectional, population-based, computer-assisted telephone interview exploring sociodemographic factors and general and reproductive health.Participants and setting: Analysis of data from the Men in Australia Telephone Survey (MATeS) of 5990 Australian men aged 40 years and older interviewed between September and December 2003.Main outcome measures: Self-reported diagnosis of prostate disease and erectile dysfunction (ED), help-seeking behaviour (including visiting a doctor, prostate-specific antigen testing, treatment of prostate disease, speaking to a health professional about ED and treatment of ED).Results: Age was a significant predictor of all help-seeking behaviour studied, other than treatment for ED. Controlling for all predictor variables, never-married status predicted a lower likelihood of visiting a doctor (odds ratio [OR], 0.68 [95% CI, 0.48–0.97]) or speaking to a health professional about ED (OR, 0.44 [95% CI, 0.21–0.93]), while divorced/separated status predicted lower likelihood of having a prostate-specific antigen test (OR, 0.63 [95% CI, 0.50–0.79]). Living in a regional or remote area or being from a non-English-speaking background predicted lower likelihood of receiving treatment for ED (ORs, 0.62 [95% CI, 0.42–0.92] and 0.41 [95% CI, 0.24–0.72], respectively), but did not influence screening for prostate disease.Conclusion: Seeking advice or treatment for male reproductive health disorders is predicted by sociodemographic factors specific to different reproductive health problems. As middle-aged and older men do attend doctors, opportunities exist for health professionals to optimise their consultations by routinely discussing reproductive health with all men, to identify under-reported male reproductive health disorders.

Carol A Holden PhD · Damien J Jolley MSc(Epidemiol), AStat · Robert I McLachlan MB BS, PhD · Marian Pitts PhD · Robert Cumming PhD · Gary Wittert MB BCh, PhD · David J Handelsman MB BS, PhD · David M de Kretser MB BS, PhD

Objective: To determine the influence of obesity on the diagnosis of age-related androgen deficiency (AD) in symptomatic men according to current Australian guidelines.Design, setting and participants: A community-based cohort of healthy ageing men with symptoms suggestive of AD was studied between May 2001 and February 2003. Men were classified as obese or non-obese according to body mass index (BMI) or waist circumference (WC).Main outcome measure: Diagnosis of AD according to Endocrine Society of Australia (ESA) guidelines.Results: 223 men aged 54–86 years with mean BMI 27.3 ± 0.2 kg/m2 (range 20.5–36.2 kg/m2) were recruited; 99 men were obese (BMI ≥ 30.0 kg/m2 or WC ≥ 102 cm) and 124 men were non-obese. Obese men had lower total testosterone (TT) (12.7 ± 0.4 v 15.0 ± 0.4 nmol/L); P < 0.001) and calculated free testosterone (275.7 ± 7.8 v 299.3 ± 7.4 pmol/L); P = 0.03) levels than non-obese men. TT levels < 8 nmol/L were recorded in 12% of obese men and 1% of non-obese men. Applying the ESA guidelines for the diagnosis of age-related AD, 15 obese men (15%) and 4 non-obese men (3%) were classified as being eligible for androgen therapy supported by the Pharmaceutical Benefits Scheme (PBS); the relative risk in obese men was 1.92 (95% CI, 1.44–2.55; P < 0.001).Conclusion: Obesity is an important determinant of serum TT levels in ageing men. Almost one in seven obese men but only one in 30 non-obese men in our study were eligible for PBS-supported androgen therapy according to Australian guidelines. Although obese men are more likely to have biochemical hypoandrogenism, the clinical implications of this remain uncertain. Studies of testosterone therapy in this group of ageing men are needed to determine whether androgen replacement is beneficial.

Carolyn A Allan PhD, FRACP · Boyd J Strauss PhD, FRACP · Henry G Burger MD, FRACP · Elise A Forbes RN · Robert I McLachlan PhD, FRACP

Objective: To assess the psychosocial impact of the diagnosis of either localised or metastatic prostate cancer (PCA) on patients and their female partners.Design: Observational, prospective study at Time 1 and 6 months later at Time 2 of two groups of couples facing PCA. Time 1 was when patients were first diagnosed with histologically confirmed localised (potentially curable) PCA or metastatic (incurable) PCA.Main outcome measures: Depression and anxiety disorders according to the Diagnostic and statistical manual of mental disorders 4th edition (DSM-IV); psychological distress; marital satisfaction.Results: At Time 1, partners had rates of DSM-IV major depression and generalised anxiety disorder twice those of women in the Australian community, and considerably higher than the patients’ rates. At Time 2, psychological distress in partners had lessened but that in patients had increased. On the other hand, at Time 2, partners’ marital satisfaction had deteriorated.Conclusions: To be fully effective, interventions aimed at reducing the psychosocial morbidity of PCA must involve both patient and partner, rather than the patient alone.

Jeremy W Couper MB BS, MMed(Psych) · Sidney Bloch MB ChB, PhD · Anthony Love PhD · Gillian Duchesne BSc(Hons), MB ChB, MD · Michelle Macvean PhD · David W Kissane MB BS, MPM, MD

Objective: To present data on rotavirus notifications in the Northern Territory to provide knowledge about the local epidemiology of rotavirus gastroenteritis that can be used to inform the use and funding of rotavirus vaccines.Design: Retrospective analysis of data from the Northern Territory Notifiable Diseases Database.Participants and setting: Patients with cases of rotavirus infection notified to the NT Centre for Disease Control from 1 January 1995 to 31 December 2004.Main outcome measures: Patterns of rotavirus notifications over time; infection rates in Indigenous versus non-Indigenous children aged 0–5 years; age groups infected with rotavirus.Results: Numbers of rotavirus notifications over the period 1995–2004 show annual, monthly and regional variability. The rotavirus notification rate for Indigenous children aged 0–5 years was 2.75 per 100 per year, compared with 0.98 for non-Indigenous children, with a relative risk for Indigenous children of 2.17 (95% CI, 1.97–2.39) over the 10 years. Indigenous children infected with rotavirus were younger than non-Indigenous children, with median ages of 11 months and 16 months, respectively. Rotavirus gastroenteritis occurred in outbreaks, transmitted over months throughout the NT.Conclusion: Large numbers of cases of rotavirus gastroenteritis affecting Indigenous and non-Indigenous children in the NT are notified every year. The rate in Indigenous children may be decreasing relative to non-Indigenous children. An effective rotavirus vaccine could prevent significant morbidity.

Rosalie Schultz MB BS, MPH

Objectives: To determine the impact of the Australian provisions for temporary rather than permanent protection for asylum seekers found to be genuine refugees.Design and setting: A comparison of the mental health of Persian-speaking refugees with temporary (n = 49) versus permanent (n = 67) protection visas attending an early intervention program in Sydney, New South Wales, 2002–03.Measures: Standard measures were used to assess past trauma, detention experiences, postmigration stresses, symptoms of post-traumatic stress disorder (PTSD), anxiety, depression and functional impairment.Results: The two groups had experienced similar levels of past trauma and persecution. Nevertheless, holders of temporary protection visas (TPVs) returned higher scores on three psychiatric symptom measures (P < 0.001). Multivariate analyses showed that TPV status was the strongest predictor of anxiety, depression and particularly PTSD. Further analyses suggested that, for TPV holders, experience of past stresses in detention in Australia and ongoing living difficulties after release contributed to adverse psychiatric outcomes.Conclusions: The sequence of postmigration stresses experienced by TPV holders appears to impact adversely on their mental health.

Shakeh Momartin PhD, BA(Hons) · Zachary Steel MPsych(Clinical), BA(Hons) · Marianio Coello MPsych(Clinical) · Jorge Aroche MPsych(Clinical) · Derrick M Silove MD, FRANZCP · Robert Brooks PhD, BA(Hons)

Objective: To review the management of glycaemia, blood pressure and serum lipids in a hospital outpatient diabetes clinic, the director of which co-authored the current national diabetes management guidelines.Design: Retrospective audit.Setting: Outpatient diabetes clinic in a tertiary referral teaching hospital, Sydney, NSW.Study population: 96 patients with type 1 diabetes (mean age, 44.4 [SD, 12.8] years) and 509 patients with type 2 diabetes (mean age, 64.4 [SD, 12.0] years) attending the clinic in 2003, who had undergone formal review of complications.Main outcome measures: Weight, height, control and treatment of glycaemia, blood pressure and serum lipids, and prevalence of diabetic microvascular complications.Results: Glycated haemoglobin (HbA1c) was < 7% in 13% of type 1 and 30% of type 2 diabetes patients, and > 8% in 47% and 34%, respectively. 35% of patients with type 1 diabetes and 71% of patients with type 2 diabetes were treated with antihypertensive agents. Of these patients, 29% and 24%, respectively, had blood pressure readings ≤ 130/80 mmHg. Among patients not treated with hypertensive agents, blood pressure readings were ≤ 130/80 mmHg in 60% of type 1 and 38% of type 2 diabetes patients. About 30% of patients with type 1 diabetes and 50% of those with type 2 diabetes were being treated with lipid-lowering agents; of these, about 60% had low-density lipoprotein (LDL) cholesterol levels < 2.6 mmol/L. Among patients not treated with lipid-lowering agents, about 40% had LDL cholesterol levels < 2.6 mmol/L. Retinopathy was documented in 52% and 18%, and nephropathy in 9% and 36% of type 1 and type 2 diabetes patients, respectively.Conclusions: Despite the demonstrated benefits of tight glucose, blood pressure and lipid control in reducing the risk of macrovascular and microvascular complications in type 1 and type 2 diabetes, our results suggest that treatment targets are not being met in a large proportion of patients attending a tertiary referral hospital. Responsible practice suggests that treatment targets and the current means to achieve them should both be examined.

Wendy Bryant,* RN, CDE, GradDipDiabetesEdManagement · Jerry R Greenfield,* PhD, FRACP · Donald J Chisholm FRACP · Lesley V Campbell FRCP, FRACP

Objective: To evaluate the outcomes of and barriers to implementing standard guidelines (Caring for Australasians with renal impairment [CARI]), using iron management in patients having dialysis as an example.Design and setting: On-site review of iron management processes at six Australian dialysis units varying in size and locality. Patients’ iron indices and haemoglobin levels were obtained from the Australian and New Zealand Dialysis and Transplant Registry.Participants: Patients with chronic kidney disease who were dependent on dialysis.Main outcome measures: Processes for assessing indices of iron stores and iron supplementation; comparison with target indices in the CARI guidelines.Results: There was considerable variability among the units in achievement of haemoglobin and iron targets, with 25%–32% of patients achieving haemoglobin targets of 110–120 g/L, 30%–68% achieving ferritin targets of 300–800 μg/L, and 65%–73% achieving transferrin saturation targets of 20%–50%. Implementation barriers included lack of knowledge, lack of awareness of or trust in the CARI guideline, inability to implement the guideline, and inability to agree on a uniform unit protocol. Factors associated with achieving the CARI guideline targets included nurse-driven iron management protocols, use of an iron management decision aid, fewer nephrologists per dialysis unit, and a “proactive” (actively keeping iron levels within target range) rather than “reactive” (only reacting if iron levels are out of the range) protocol.Conclusions: Variability in achievement of iron targets, despite the availability of a clinical practice guideline, may be explained by variability in processes of care for achieving and maintaining adequate iron parameters.

Michelle J Irving MHSciEd · Jonathan C Craig MMed, PhD, FRACP · Martin Gallagher MB BS, MMEpi, FRACP · Stephen McDonald MB BS(Hons), PhD, FRACP · Kevan R Polkinghorne MB ChB, FRACP, MClinEpi · Rowan G Walker MD, MB BS, FRACP · Simon D Roger MD, FRACP

Objective: To examine trends in suicide in the Northern Territory between 1981 and 2002, and demographic and other characteristics of people completing suicide in the Top End region in 2000–2002.Design: Retrospective descriptive analysis of Australian Bureau of Statistics death registration data and data from the NT Coroner’s Office.Setting and participants: All residents of the NT who completed suicide between 1981 and 2002.Main outcome measures: Changes in the age-adjusted and age- and sex-specific rates of suicide in Indigenous and non-Indigenous NT residents over time; prior diagnosis of mental illness and use of alcohol or other drugs by those completing suicide.Results: The age-adjusted suicide rate in the NT increased significantly between 1981 and 2002 (P < 0.001). Over this period, the rates among the Indigenous and non-Indigenous male populations increased by 800% (P < 0.05) and 30% (P > 0.05), respectively. Indigenous males aged under 45 years and non-Indigenous males aged 65 years and over were most at risk. In the Top End, a history of diagnosed mental illness was present in 49% of suicide cases, and misuse of alcohol or other drugs around the time of death was associated with 72% of suicide cases.Conclusion: Our study highlights the rising rate of suicide in the NT and suggests that suicide prevention initiatives need to specifically target Indigenous and non-Indigenous males in the age groups most at risk.

Mary-Anne L Measey MPH · Shu Qin Li MPH · Robert Parker FRANZCP · Zhiqiang Wang PhD

Objective: To determine the potential for organ donation in 12 Victorian hospitals.Design and setting: Prospective audit of all deaths in 12 major public hospitals in the state of Victoria between January 2002 and October 2004.Main outcome measures: Number of organ donors and potential organ donors (patients with brain death or likely to progress to brain death within 24 hours if supportive treatment continued), requests for organ donation and consents. Unrealised potential donors (organ donation not requested) were categorised by an independent panel of intensivists as category A (brain death formally diagnosed); B (brain death not formally diagnosed but criteria likely to be fulfilled); and C (potential to progress to brain death within 24 hours).Results: There were 17 230 deaths, 280 potential organ donors and 220 requests for organ donation. The 60 unrealised potential organ donors were classified as category A (3), B (17) and C (40). Consent rate was 53% to 65%, depending on the definition of potential donor (categories A, B and C or category A only). Consent rate was lower when discussions about organ donation were held by trainees or registrars (21%) than when specialists were present (57%) (P = 0.004). A maximum practically achievable organ donation rate for Victoria was estimated to be 15 to 17 donors per million population (current rate, 9 per million population).Conclusions: The potential for organ donation in Victoria is limited by a small organ donor pool. There is potential to increase the number of organ donors by increasing the consent rate (lower than expected from public surveys), the identification of potential organ donors (particularly those likely to progress to brain death if supportive treatment is continued), and requests for organ donation.

Helen I Opdam MB BS, FJFICM · William Silvester MB BS, FJFICM

Objective: To determine the incidence of and risk factors for surgical site infections in general practice.Design: Prospective, observational study of patients presenting for minor excisions.Setting: Primary care in a regional centre, Queensland, October 2004 to May 2005.Participants: 857 patients were assessed for infection.Results: The overall incidence of infection was 8.6% (95% CI, 3.5%–13.8%). Excisions from lower legs and feet (P = 0.009) or thighs (P = 0.005), excisions of basal cell carcinoma (P = 0.006) or squamous cell carcinoma (P = 0.002), and diabetes (P < 0.001) were independent risk factors for wound infection.Conclusion: Our results indicate the high-risk groups for surgery in a general practice setting, such as people with diabetes and those undergoing excision of a non-melanocytic skin cancer or excision from a lower limb. Recognition of these groups could encourage more judicial use of prophylactic antibiotics and use of other interventions aimed at reducing infection rates.

Clare Heal MB ChB, DRACOG, FRACGP · Petra Buettner MSc, PhD · Sheldon Browning DRACOG, DipDerm, FRACGP

Objective: To examine factors influencing the identification of kidney impairment in patients with type 2 diabetes in Australian primary care.Design, setting and participants: 348 general practitioner investigators were asked to estimate kidney function and its severity in 10–15 consecutively presenting patients with type 2 diabetes (n = 3893). They were then asked, for each patient, whether they routinely estimated kidney function. No instruction was provided on how kidney function should be estimated or categorised. Data were collected between April and September 2005.Main outcome measures: Kidney function estimated by the Cockcroft–Gault equation using clinical and laboratory data provided by the GP; estimates of kidney function made by the GP.Results: In 24% of the patients with type 2 diabetes, their GP routinely estimated kidney function. However, few of these patients had impaired kidney function or risk factors for kidney disease. There was a good statistical correlation between the estimates made by GPs and the data-derived estimates (R2 = 0.72). GPs identified patients with data-derived estimates of kidney function < 60 mL/min in over 83% of cases, with a specificity of 90%. Impaired kidney function was reported by GPs in 34.4% of men and 36.4% of women. These figures were discordant with function categorisation using both GP estimates and data-derived values, overlapping in half of the patients. Despite GPs’ ability to assess creatinine clearance, “raw” (unstandardised) serum creatinine levels inappropriately influenced the perception of impairment of kidney function.Conclusion: GPs can accurately assess kidney function, without reporting of estimated glomerular filtration rate (eGFR). However, even in patients at increased risk of chronic kidney disease, routine estimates are seldom made. Our findings underline the value of the recent initiative recommending automatic reporting of eGFR in Australia.

Merlin C Thomas PhD, FRACP · Andrew J Weekes MD · Olivia J Broadley BSc, BCA · Mark E Cooper PhD, FRACP

Objective: To evaluate the use of cardiovascular medications in patients with and without heart failure after myocardial infarction (MI).Design and setting: Multicentre study of drug therapy for patients with MI in 16 major metropolitan teaching hospitals in Australia over a 1-month period at each hospital in the period November 2004 – March 2005.Participants: 479 patients admitted consecutively to the individual hospitals.Main outcome measures: Proportion of patients with and without heart failure who were prescribed key cardiovascular medications after MI.Results: 116 of the 479 patients admitted for MI (24.2%) had heart failure at some point during their hospitalisation. Patients with heart failure were older (68 v 63 years; P < 0.05), more likely to be women (34% v 24%; P < 0.05) and a higher proportion had diabetes (26% v 21%). There was significantly reduced prescribing of β-blockers, clopidogrel and statins for patients with heart failure compared with those without heart failure. Mineralocorticoid receptor antagonist use was low (< 10%) in the former group.Conclusions: We found reduced prescribing of some prognostically relevant medications for patients with heart failure. For β-blockers, this may be explained by the greater clinical instability in patients with heart failure. Given the absolute benefit of drug therapy in patients with heart failure after MI, our findings suggest suboptimal prescribing in Australian teaching hospital practice.

Henry Krum MB BS, PhD, FRACP · Adam Meehan · John Varigos BSc(Hons) · Philippa R Loane BBiomedSc · Baki Billah PhD

Objective: To assess the feasibility of administering an inexpensive preparation of vitamin D3 100 000 IU orally 3 monthly to aged-care residents.Design: Prospective, controlled open-label implementation trial.Setting: Residential aged care, November 2003 to May 2004 (primary study).Participants: 137 ambulant residents: 107 treated (mean age, 85 years; 79 were women), 30 untreated controls (mean age, 87 years; 22 were women).Interventions: Lactose microencapsulated vitamin D3 100 000 IU orally at baseline, then 3 monthly (three or more doses); untreated subjects were observed contemporaneously.Main outcome measures: Serum levels of 25-hydroxyvitamin D [25(OH)D] at 6 months compared with baseline; acceptability of the program to residents and staff.Results: At baseline, 95% of residents assessed (n = 137) had serum 25(OH)D levels below the desirable range of 60–160 nmol/L. At 6 months, all treated residents (n = 98) achieved desired levels, with the mean (± SD) 25(OH)D level increasing from 36.4 ± 12.6 nmol/L (range, 12–75 nmol/L) at baseline to 124.0 ± 27.9 nmol/L (range, 68–244 nmol/L). In no resident did 25(OH)D approach toxic levels. The mean serum 25(OH)D level remained low in the control group (n = 27): 42.8 ± 18.3 nmol/L (range, 18–98 nmol/L). The difference between the mean 25(OH)D levels of treatment and control groups at 6 months was 81.2 nmol/L (95% CI, 69.7–92.0 nmol/L). The cost of the supplement was $4 per resident per annum. Substudies showed mean trough serum 25(OH)D levels in the desired range at 3 months (n = 31), but below the desired range at 6 months (n = 50). Subjects given 3-monthly doses for up to 2 years maintained serum 25(OH)D levels within the desired range, with no trend toward undesirable accumulation (n = 11).Conclusions: Vitamin D3 100 000 IU given orally 3 monthly is a practical, safe, effective and inexpensive way to meet the vitamin D3 requirements of aged-care residents.

Alison E R Wigg BAppScPhysio, MAppScPhysio, MBA · Caroline Prest RN · Peter Slobodian BPharm, MClinPharm · Allan G Need MD, FRACP, FRCPA · Leslie G Cleland MD, FRACP

Objective: To assess the efficacy of endovenous laser therapy (EVLT) for treating varicose veins with saphenous reflux.Design: A trial of treatment, with results assessed by ultrasound surveillance.Setting: Outpatient clinics with sonographer and nursing support.Main outcome measures: Control of reflux; occlusion or obliteration of the saphenous veins assessed by ultrasound.Results: EVLT was used to treat 404 veins in 308 patients. Univariate life table analysis showed primary success in 80% (95% CI, 69%–87%) and secondary success after further treatment of recurrent saphenous vein reflux by ultrasound-guided sclerotherapy in 88% (95% CI, 78%–95%) at 3 years. On multivariate Cox regression analysis, none of the covariates studied were associated with ultrasound failure.Conclusions: Early results indicate that EVLT effectively controlled saphenous reflux. Its advantages are that it is performed as an outpatient procedure under local anaesthesia with immediate mobilisation, causes minimal disruption of activities, and avoids surgical trauma.

Kenneth Myers MS, FRACS, FACS · Robert Fris FRACS, FACS · Damien Jolley MSc(Epidemiol)

Objective: To evaluate the outcomes of the research investment of the National Heart Foundation of Australia (NHF).Design and setting: The NHF Research Evaluation Working Group was established in 2002 to oversee evaluation of research funding and outcomes data collected over a 5-year period. The evaluation included a bibliometric analysis conducted by the Research Evaluation and Policy Project at the Australian National University.Outcome measures: Level and leverage of research funding; funding levels across the disciplines of biomedical, clinical, and public health research; and visibility and knowledge impact of NHF-supported research in international cardiovascular journals.Results: The NHF’s investment in research increased by 27% from 2001 to 2005. This increase resulted from leveraged support for fellowships and scholarships of $1.5 million over this period, and $2.2 million from the pharmaceutical industry. There was an increase in fellowship and scholarship funding from 26% in 2001 to 46% in 2005. There was a 75% increase in the funding allocated to public health research from 2002 to 2004. NHF-funded research publications were found in high impact journals at levels above Australian and world averages, but received fewer citations than expected based on citation rates for all similar articles.Conclusions: The NHF has been successful in implementing a policy to allocate 50% of its research funding to people and 50% to projects. This strategy has led to an increase in funding support for public health research. NHF-funded research has performed very well in terms of knowledge impact. The NHF is now well placed to strategically fund relevant research in the future.

Moira A Clay PhD · Claire Donovan PhD · Linda Butler BEcon · Brian F Oldenburg PhD