Research

Objective: To describe antimicrobial resistance and molecular epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) isolated in community settings in Australia.Design and setting: Survey of S. aureus isolates collected prospectively Australia-wide between July 2004 and February 2005; results were compared with those of similar surveys conducted in 2000 and 2002.Main outcome measures: Up to 100 consecutive, unique clinical isolates of S. aureus from outpatient settings were collected at each of 22 teaching hospital and five private laboratories from cities in all Australian states and territories. They were characterised by antimicrobial susceptibilities (by agar dilution methods), coagulase gene typing, pulsed-field gel electrophoresis, multilocus sequence typing, SCCmec typing and polymerase chain reaction tests for Panton–Valentine leukocidin (PVL) gene.Results: 2652 S. aureus isolates were collected, of which 395 (14.9%) were MRSA. The number of community-associated MRSA (CA-MRSA) isolates rose from 4.7% (118/2498) of S. aureus isolates in 2000 to 7.3% (194/2652) in 2004 (P = 0.001). Of the three major CA-MRSA strains, WA-1 constituted 45/257 (18%) of MRSA in 2000 and 64/395 (16%) in 2004 (P = 0.89), while the Queensland (QLD) strain increased from 13/257 (5%) to 58/395 (15%) (P = 0.0004), and the south-west Pacific (SWP) strain decreased from 33/257 (13%) to 26/395 (7%) (P = 0.01). PVL genes were detected in 90/195 (46%) of CA-MRSA strains, including 5/64 (8%) of WA-1, 56/58 (97%) of QLD, and 25/26 (96%) of SWP strains. Among health care-associated MRSA strains, all AUS-2 and AUS-3 isolates were multidrug-resistant, and UK EMRSA-15 isolates were resistant to ciprofloxacin and erythromycin (50%) or to ciprofloxacin alone (44%). Almost all (98%) of CA-MRSA strains were non-multiresistant.Conclusions: Community-onset MRSA continues to spread throughout Australia. The hypervirulence determinant PVL is often found in two of the most common CA-MRSA strains. The rapid changes in prevalence emphasise the importance of ongoing surveillance.

Graeme R Nimmo FRCPA, FASM, MPH, MSc · Geoffrey W Coombs BAppSc(Med Sc), PGDipBiomedSC · Julie C Pearson BSc(Biol) · Francis G O'Brien BAppSc, PhD · Keryn J Christiansen FRCPA · John D Turnidge FRACP, FRCPA · Iain B Gosbell MD, FRACP, FRCPA · Peter Collignon FRACP, FRCPA, FASM · Mary-Louise McLaws DPHTM, MPH, PhD

Objective: To assess obstetricians’ antenatal screening practice for blood-borne viruses (HIV, hepatitis B and C viruses [HBV and HCV]) and knowledge about management during labour and risk of transmission via breastfeeding for infected women after an educational intervention.Design: Cohort study, with surveys before and after an educational intervention.Setting and participants: Survey 1 was mailed in 2002–2003 to all 767 Fellows registered with the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), and Survey 2 was mailed in 2004 to the 743 of these Fellows who were still practising.Intervention: Multifaceted intervention with mail-out of survey results and a summary of recommended management, publication of two review articles in the RANZCOG journal, and an oral presentation at the RANZCOG annual scientific meeting.Main outcome measures: Self-reported frequency of antenatal screening for blood-borne viruses, change in practice based on a woman’s infection status, and advice given about risk of virus transmission via breastfeeding in Survey 2, compared with Survey 1.Results: Survey 2 (response rate, 68%) found increases from the previous survey in the proportion of respondents reporting they always offered antenatal screening for HIV, from 51% to 59%, and for HCV, from 60% to 69% (P = 0.001 for both). For women with HIV infection, the proportion of respondents always recommending elective caesarean section increased from 37% to 49% (P = 0.001) and always avoiding rupture of membranes increased from 33% to 49% (P < 0.001). The proportion who reported advising (incorrectly) that breastfeeding is associated with increased risk of transmission to the infant decreased from 34% to 25% for HBV (P = 0.01) and from 47% to 39% for HCV (P = 0.03).Conclusion: The frequency of antenatal testing for HIV and HCV is increasing in Australia. Knowledge about interventions to reduce mother-to-child transmission of HIV and knowledge of the risk of HBV and HCV transmission via breastfeeding improved after a relatively simple educational intervention.

Michelle L Giles FRACP · Suzanne M Garland FRCPA, FACSHP, MD, FRANZCOG · Sonia R Grover FRANZCOG · Sharon M Lewin FRACP, PhD · Margaret E Hellard FRACP, PhD

Objective: To describe how high-cost users of inpatient care in Western Australia differ from other users in age, health problems and resource use.Design and data sources: Secondary analysis of hospital data and linked mortality data from the WA Data Linkage System for 2002, with cost data from the National Hospital Cost Data Collection (2001–02 financial year).Outcome measures: Comparison of high-cost users and other users of inpatient care in terms of age, health profile (major diagnostic category) and resource use (annualised costs, separations and bed days).Results: Older high-cost users (≥ 65 years) were not more expensive to treat than younger high-cost users (at the patient level), but were costlier as a group overall because of their disproportionate representation (n = 8466; 55.9%). Chronic stable and unstable conditions were a key feature of high-cost users, and included end stage renal disease, angina, depression and secondary malignant neoplasms. High-cost users accounted for 38% of both inpatient costs and inpatient days, and 26% of inpatient separations.Conclusion: Ageing of the population is associated with an increase in the proportion of high-cost users of inpatient care. High costs appear to be needs-driven. Constraining high-cost inpatient use requires more focus on preventing the onset and progression of chronic disease, and reducing surgical complications and injuries in vulnerable groups.

Janine Calver PhD · Kate J Brameld PhD · David B Preen PhD · Stoney J Alexia BA(Hons) · Duncan P Boldy MSc, PhD · Kieran A McCaul MPH

Objective: To investigate the frequency, cause, and severity of adverse drug events (ADEs) among general practice patients.Design: Between May 2003 and February 2004, a subsample of 282 general practitioners in the BEACH (Bettering the Evaluation And Care of Health) data collection program recorded patient responses to questions about ADEs.Main outcome measures: Frequency, cause, and severity of ADEs; and frequency of hospitalisation and proportion of events that were preventable.Results: From 8215 encounters, GPs reported that 852 patients (10.4%) had experienced an ADE in the previous 6 months. Patients aged over 45 years (versus under 45 years), children aged 1–4 years (versus older children), and female patients (versus male patients) were significantly more likely to have experienced an ADE. Most patients (83.5%) had experienced only one ADE, with 10.7% and 5.8% experiencing two and three or more events, respectively. For 71.9% of patients, one reason for the most recent event was a recognised side effect, followed by drug sensitivity (12.4%) and allergy (11.0%). Over half of patients were rated as having a “mild” event, with 35.8% rated as “moderate”, and 10.0% as “severe”. GPs classified 23.2% of events as preventable, and 7.6% of events resulted in hospitalisation.Conclusion: Our study reveals the high frequency of ADEs in patients attending general practice. This level of morbidity makes ADEs one of the most significant causes of morbidity in the Australian community.

Graeme C Miller MB BS, PhD, FRACGP · Helena C Britt BA, PhD · Lisa Valenti BEc

Objective: To assess the effectiveness of the management of type 2 diabetes in an urban Australian setting.Design and setting: The Fremantle Diabetes Study (FDS), a community-based longitudinal observational study.Patients: 531 FDS participants with type 2 diabetes, with mean age, 62.4 years (95% CI, 40.9–79.3 years), 54% male, median diabetes duration 3.0 years (interquartile range [IQR], 0.7–7.0 years), with valid data from the baseline FDS assessment and five subsequent annual reviews between 1993 and 2001.Main outcome measures: Glycated haemoglobin (HbA1c) levels at annual review visits before and after change in blood glucose-lowering therapy.Results: Over 2893 patient-years of follow-up, 97 patients (18%) progressed from dietary management to therapy with oral hypoglycaemic agents (OHA), and 45 (9%) progressed from OHA to insulin therapy, after a median duration of diabetes of 4.0 years (IQR, 2.9–5.5 years) and 8.1 years (IQR, 5.5–13.0 years), respectively. Median HbA1c concentrations (IQR) at the review before OHA or insulin were started were 7.7% (6.9%–8.8%) and 9.4% (8.0%–10.7%), respectively. At the next annual review, HbA1c levels in the two groups had fallen to 7.4% (6.5%–8.1%) and 7.9% (7.2%–9.5%), respectively (P ≤ 0.001). Intensification of therapy was associated with beneficial changes in serum lipid profiles, but not with an increase in frequency of hypoglycaemia.Conclusions: Most Australian patients with type 2 diabetes may be spending most of the duration of their disease with suboptimal glycaemic control (HbA1c > 7.0%), despite the availability of a range of effective therapies, including insulin.

Timothy M E Davis BMedSc, MRCP, DPhil, FRACP · Wendy A Davis BA(Hons), MSc, MPH, PhD · David G Bruce MD, FRACP

Objective: To investigate the effectiveness of hot water immersion for the treatment of Physalia sp. (bluebottle or Portuguese Man-of-War) stings.Design: Open-label, randomised comparison trial. Primary analysis was by intention to treat, with secondary analysis of nematocyst-confirmed stings. One halfway interim analysis was planned.Setting: Surf lifesaving first aid facilities at two beaches in eastern Australia from 30 December 2003 to 5 March 2005.Participants: 96 subjects presenting after swimming in the ocean for treatment of an apparent sting by a bluebottle.Interventions: Hot water immersion (45°C) of the affected part versus ice pack application.Main outcome measures: The primary outcome was a clinically important reduction in pain as measured by the visual analogue scale (VAS). Secondary outcomes were the development of regional or radiating pain, frequency of systemic symptoms, and proportion with pruritus or rash on follow-up.Results: 49 patients received hot water immersion and 47 received ice packs. The two groups had similar baseline features, except patients treated with hot water had more severe initial pain (VAS [mean ± SD]: 54 ± 22 mm versus 42 ± 22 mm). After 10 minutes, 53% of the hot water group reported less pain versus 32% treated with ice (21%; 95% CI, 1%–39%; P = 0.039). After 20 minutes, 87% of the hot water group reported less pain versus 33% treated with ice (54%; 95% CI, 35%–69%; P = 0.002). The trial was stopped after the halfway interim analysis because hot water immersion was shown to be effective (P = 0.002). Hot water was more effective at 20 minutes in nematocyst-confirmed stings (95% versus 29%; P = 0.002). Radiating pain occurred less with hot water (10% versus 30%; P = 0.039). Systemic effects were uncommon in both groups.Conclusions: Immersion in water at 45°C for 20 minutes is an effective and practical treatment for pain from bluebottle stings.

Conrad Loten MB ChB · Barrie Stokes BSc, MMath · David Worsley BMed · Jamie E Seymour BSc, PhD · Simon Jiang · Geoffrey K Isbister BSc, MB BS, FACEM, MD

Objective: To investigate the change in pattern of discharge of patients from an intensive care unit (ICU) to hospital wards and to determine the impact of discharge time on subsequent hospital mortality.Design and participants: A retrospective cohort study of 10 903 patients discharged alive from a single ICU between 1 January 1992 and 31 December 2002.Main outcome measure: In-hospital mortality.Results: Of the 10 903 patients discharged alive from the ICU, 486 (4.5%) died in hospital wards. When discharge times were categorised according to nursing shift (morning, 07:00–14:59; afternoon, 15:00–21:59; and night, 22:00–06:59), patients were more likely to be discharged on an afternoon shift (odds ratio, 3.63; 95% CI, 3.05–4.30) or night shift (4.52; 95% CI, 3.15–6.64) in 2000–2002 compared with 1992–1994. In a multiple logistic model, hospital mortality after discharge from the ICU was increased by higher APACHE II score (1.14; 95% CI, 1.12–1.16); admission to ICU from the operating room (1.47; 95% CI, 1.11–1.95) and from the general ward (1.75; 95% CI, 1.37–2.23); and discharge during the afternoon (1.36; 95% CI, 1.08–1.70) and night shifts (1.63; 95% CI, 1.03–2.57).Conclusion: Over an 11-year period, more patients are being discharged from the ICU in the afternoon and night suggesting increasing pressure on ICU beds. Patients discharged on these shifts have an increased risk of death.

Antony E Tobin MB BS, FRACP, FJFICM · John D Santamaria MD BS, FRACP, FJFICM

Objective: To determine the psychological wellbeing of sole mothers in Australia.Design: Cross-sectional analyses of survey data from The Australian Longitudinal Study on Women’s Health.Participants: 9689 younger women (aged 22–27 years) surveyed in 2000 and 12 338 mid-age women (aged 47–52 years) surveyed in 1998.Main outcome measures: Demographic characteristics and economic status; prevalence of suicidal thoughts, self-harm, and psychoactive medication use; depression (Center for Epidemiologic Studies Depression Scale) and psychological health (the Mental Health Component Score of the Medical Outcome Short Form Health Survey [SF-36]).Results: Among the younger women, sole mothers were more likely than other women to have experienced suicidal thoughts (odds ratio [OR], 2.18; 95% CI, 1.45–3.27) and self-harm (OR, 3.25; 95% CI, 1.97–5.38). Among the younger and mid-age women, sole mothers were the group most likely to have used medication for depression (ORs, 2.75 [95% CI, 1.76–4.30] and 2.29 [95% CI, 1.56–3.37], respectively). They were more than twice as likely to have experienced depression, and had significantly poorer psychological health (P < 0.001). After adjusting for economic status, only depression and psychological health remained significantly associated with sole motherhood, and the strength of these relationships was reduced.Conclusions: Economic status partly accounts for the relatively poorer psychological health of sole mothers. Sole mothers are more likely than other women to experience debilitating psychological health problems.

Deborah Loxton PhD, BPsych(Hons) · Rosemary Mooney BA(Hons) · Anne F Young PhD, AStat

Objective: To describe the management of and outcomes in a population-based cohort of patients with newly diagnosed glioma.Design, setting and patients: Retrospective cohort study of patients with glioma newly diagnosed over the period 1998–2000 in Victoria. Patients were identified from the population-based Victorian Cancer Registry (VCR). Doctors involved in managing the patients were surveyed by a questionnaire sent out in 2003. The cohort was followed until the end of 2004 to obtain at least 4 years’ follow-up data on all patients.Main outcome measures: Reported treatment, referral patterns and survival rates.Results: Over the study period, 992 cases of glioma were identified; 828 completed surveys on eligible patients were obtained (response rate, 93%); 473 patients (57%) had glioblastoma multiforme (GBM); 105 patients (13%) diagnosed with “glioma” had had no histological confirmation. Complete macroscopic resection was performed in 209 patients (25%); 612 patients (74%) were referred for radiotherapy and 326 (54%) for chemotherapy; 39 (5%) were enrolled on a clinical trial. Median survival was 9.2 months for all patients and 7.4 months for patients with GBM.Conclusions: This is the largest reported glioma management survey in the world to date. Much of the patient demographics and approach to treatment were as expected and represent a reasonable “standard of care”. However, there are some areas for improvement, including the absence of histological diagnosis in some patients, lack of multidisciplinary care, low clinical trial enrolment and poor use of ancillary services.

Mark A Rosenthal MB BS, FRACP, PhD · Katharine J Drummond MB BS, FRACS · Michael Dally MB BS, FRANZCR · Michael Murphy MB BS, FRACS, MD · Lawrence Cher MB BS, FRACP · David Ashley MB BS, FRACP, PhD · Vicky Thursfield BSc, GradDipAppl Stats · Graham G Giles MSc, PhD

Objective: To report on strategies for, and outcomes of, evaluation of knowledge (publications), health and wealth (commercial) gains from medical research funded by the Australian Government through the National Health and Medical Research Council (NHMRC).Design and methods: End-of-grant reports submitted by researchers within 6 months of completion of NHMRC funded project grants which terminated in 2003 were used to capture self-reported publication number, health and wealth gains. Self-reported gains were also examined in retrospective surveys of grants completed in 1992 and 1997 and awards primarily supporting people (“people awards”) held between 1992 and 2002.Results: The response rate for the 1992 sample was too low for meaningful analysis. The mean number of publications per grant in the basic biomedical, clinical and health services research areas was very similar in 1997 and 2003. The publication output for population health was somewhat higher in the 2003 than in the 1997 analysis. For grants completed in 1997, 24% (31/131) affected clinical practice; 14% (18/131) public health practice; 9% (12/131) health policy; and 41% (54/131) had commercial potential with 20% (26/131) resulting in patents. Most respondents (89%) agreed that NHMRC people awards improved their career prospects. Interpretation is limited by the relatively low response rates (50% or less).Conclusions: A mechanism has been developed for ongoing assessment of NHMRC funded research. This process will improve accountability to the community and to government, and refine current funding mechanisms to most efficiently deliver health and economic returns for Australia.

for the National Health and Medical Research Council Evaluations and Outcomes Working Committee

Objective: To examine the relationship between hospital and emergency department (ED) occupancy, as indicators of hospital overcrowding, and mortality after emergency admission.Design: Retrospective analysis of 62 495 probabilistically linked emergency hospital admissions and death records.Setting: Three tertiary metropolitan hospitals between July 2000 and June 2003.Participants: All patients 18 years or older whose first ED attendance resulted in hospital admission during the study period.Main outcome measures: Deaths on days 2, 7 and 30 were evaluated against an Overcrowding Hazard Scale based on hospital and ED occupancy, after adjusting for age, diagnosis, referral source, urgency and mode of transport to hospital.Results: There was a linear relationship between the Overcrowding Hazard Scale and deaths on Day 7 (r = 0.98; 95% CI, 0.79–1.00). An Overcrowding Hazard Scale > 2 was associated with an increased Day 2, Day 7 and Day 30 hazard ratio for death of 1.3 (95% CI, 1.1–1.6), 1.3 (95% CI, 1.2–1.5) and 1.2 (95% CI, 1.1–1.3), respectively. Deaths at 30 days associated with an Overcrowding Hazard Scale > 2 compared with one of < 3 were undifferentiated with respect to age, diagnosis, urgency, transport mode, referral source or hospital length of stay, but had longer ED durations of stay (risk ratio per hour of ED stay, 1.1; 95% CI, 1.1–1.1; P < 0.001) and longer physician waiting times (risk ratio per hour of ED wait, 1.2; 95% CI, 1.1–1.3; P = 0.01).Conclusions: Hospital and ED overcrowding is associated with increased mortality. The Overcrowding Hazard Scale may be used to assess the hazard associated with hospital and ED overcrowding. Reducing overcrowding may improve outcomes for patients requiring emergency hospital admission.

Peter C Sprivulis MB BS, PhD, FACEM · Julie-Ann Da Silva BPsych · Ian G Jacobs RN, PhD · George A Jelinek MD, FACEM · Amanda R L Frazer MB BS, LLB

Objective: To quantify any relationship between emergency department (ED) overcrowding and 10-day patient mortality.Design and setting: Retrospective stratified cohort analysis of three 48-week periods in a tertiary mixed ED in 2002–2004. Mean “occupancy” (a measure of overcrowding based on number of patients receiving treatment) was calculated for 8-hour shifts and for 12-week periods. The shifts of each type in the highest quartile of occupancy were classified as overcrowded.Participants: All presentations of patients (except those arriving by interstate ambulance) during “overcrowded” (OC) shifts and during an equivalent number of “not overcrowded” (NOC) shifts (same shift, weekday and period).Main outcome measure: In-hospital death of a patient recorded within 10 days of the most recent ED presentation.Results: There were 34 377 OC and 32 231 NOC presentations (736 shifts each); the presenting patients were well matched for age and sex. Mean occupancy was 21.6 on OC shifts and 16.4 on NOC shifts. There were 144 deaths in the OC cohort and 101 in the NOC cohort (0.42% and 0.31%, respectively; P = 0.025). The relative risk of death at 10 days was 1.34 (95% CI, 1.04–1.72). Subgroup analysis showed that, in the OC cohort, there were more presentations in more urgent triage categories, decreased treatment performance by standard measures, and a higher mortality rate by triage category.Conclusions: In this hospital, presentation during high ED occupancy was associated with increased in-hospital mortality at 10 days, after controlling for seasonal, shift, and day of the week effects. The magnitude of the effect is about 13 deaths per year. Further studies are warranted.

Drew B Richardson MB BS(Hons), FACEM, GradCertHE

Objectives: To compare the injury profiles of the Indigenous population in New South Wales with that of the non-Indigenous population.Design and setting: Descriptive analysis of NSW Health data obtained from the Health Outcomes Information and Statistical Toolkit (HOIST) database. Hospitalisation data were collected for the period 1 July 1999 to 30 June 2003. Mortality data were collected for the period 1 January 1999 to 31 December 2002.Main outcome measures: Hospitalisation and death rates due to injury by age, sex, injury mechanism and Indigenous status. Rate ratios for comparison between Indigenous and non-Indigenous populations.Results: Rates of death from injury were higher for all age groups in the Indigenous population, except people older than 65 years. Indigenous people aged 25–44 years were twice as likely to be hospitalised as their non-Indigenous counterparts (rate ratio [RR], 2.09; 95% CI, 2.03–2.14), and five times as likely to be hospitalised for interpersonal violence (RR, 5.19; 95% CI, 4.98–5.40).Conclusion: The higher rates of injury-related hospitalisation and death in the Indigenous population in NSW are consistent with data reported for other parts of Australia. Of particular concern is the number of Indigenous deaths and hospitalisations due to interpersonal violence.

Kathleen F Clapham PhD · Mark R Stevenson PhD · Sing Kai Lo PhD

Objective: To determine whether pancreatic islet transplantation can control diabetes and prevent severe life-threatening hypoglycaemia.Design, setting and participants: A single-arm observation study of six patients undergoing islet transplantation. All patients had had type 1 diabetes mellitus for over 5 years and documented episodes of repeated severe hypoglycaemia. Islets were isolated from donor pancreases digested by Liberase. Separated islets were infused into the recipient’s liver via the portal vein. Patients were immunosuppressed with daclizumab, sirolimus and tacrolimus. The transplants were performed at Westmead Hospital, NSW, between October 2002 and February 2005.Main outcome measures: Normal blood glucose control without administration of exogenous insulin; demonstration of islet function and abolition of hypoglycaemia.Results: Five of the patients received two islet infusions, and the sixth was withdrawn after one infusion following a portal vein thrombosis. Three patients became insulin-independent, with excellent glycaemic control. Two had islet function with circulating C-peptide, improved glycaemic control, reduced insulin requirement and abolition of severe hypoglycaemia. However, over a 2-year period, graft function deteriorated. Recipients who were initially insulin free remained C-peptide positive but required supplemental insulin. Complications included one postoperative bleed, two portal vein thromboses (which resolved completely), presumed recurrence of tuberculosis in one patient, and deterioration in renal function in one patient.Conclusions: Islet transplantation is effective at improving glycaemic control and hypoglycaemia unawareness in the short to medium term. However, problems with long-term safety of immunosuppression, islet-induced thrombosis and early detection of loss of islet function remain to be addressed.

Philip J O’Connell MB BS, FRACP, PhD · Wayne J Hawthorne MHSc, MD · Brian J Nankivell MD, PhD, FRACP · Anita T Patel BSc · Stacey N Walters DipAppSci · Henry C C Pleass MD, FRCS, FRACS · Richard D M Allen MB BS, FRACS · Jeremy R Chapman MD, FRACP, FRCP · D Jane Holmes-Walker MB BS, FRACP, PhD · Jenny E Gunton MB BS, FRACP, PhD

Objective: To estimate the prevalence of heart failure (HF) and left ventricular (LV) systolic dysfunction in a population-based sample of older Australians.Design, setting and participants: A cross-sectional survey of 2000 randomly selected residents of Canberra, aged 60–86 years, conducted between February 2002 and June 2003. Participants were assessed by history, physical examination by a cardiologist, and echocardiography.Main outcome measures: Age- and sex-specific prevalence rates of clinical HF and LV systolic dysfunction (defined as LV ejection fraction ≤ 50%).Results: Of 1846 people eligible for our study, 1388 (75%) agreed to participate and 1275 completed all investigations (mean age, 69.4 years; 50% men). In the study sample, 72 subjects (5.6%; 95% CI, 4.4%–7.1%) had clinical HF that had been previously diagnosed and was confirmed by our assessment. A further 0.6% (95% CI, 0.3%–1.2%) had undiagnosed clinical HF (ie, evidence of structural heart disease and symptoms/signs of cardiac insufficiency without a previous diagnosis of clinical HF). Thus, the overall prevalence of clinical HF in the sample was 6.3% (95% CI, 5.0%–7.7%). Clinical HF increased in prevalence with advancing age (a 4.4-fold increase from the 60–64-years age group to the 80–86-years age group; P < 0.0001). Of the 75 subjects (5.9%; 95% CI, 4.7%–7.3%) with LV systolic dysfunction, 44 (59%) were in the preclinical stage of disease.Conclusion: Diagnosed HF cases represent the “tip of the iceberg” for the national burden of HF and LV systolic dysfunction. Clinically identifiable HF cases can remain undiagnosed, and the majority of people with LV systolic dysfunction are in a preclinical stage of the disease.

Walter P Abhayaratna MB BS, FRACP · Niels G Becker BSc, MSc, PhD · Wayne T Smith BMed, MPH, PhD · Thomas H Marwick MB BS, PhD, FRACP · Ian M Jeffery MB BS, FRACP · Darryl A McGill MB BS, PhD, FRACP

Objectives: To calculate the cost of assisted reproductive technology (ART) treatment cycles and resultant live-birth events.Design: Cost-outcome study based on a decision analysis model of significant clinical and economic outcomes of ART.Setting and participants: All non-donor ART treatments initiated in Australia in 2002. Treatment cycles, maternal age and birth outcome data were obtained from the Australian and New Zealand Assisted Reproduction Database. Direct health care costs were obtained from fertility centres, and included government, private insurer and patient costs.Main outcome measures: Average health care cost of non-donor, fresh and frozen embryo ART treatment cycles. Average and age-specific costs per live-birth event following ART treatment.Results: Average health care cost per non-donor ART live-birth event was $32 903 (range, $24 809 for women < 30 years to $97 884 for women ≥ 40 years). The cost per live birth for women aged ≥ 42 years was $182 794. The average treatment cost of a fresh cycle was $6940, compared with $1937 for a frozen embryo transfer cycle.Conclusions: Debate regarding funding for ART services has been hindered by a lack of economic studies of ART treatments and outcomes in Australia. This is the most comprehensive costing study of ART services to date in terms of resources consumed during ART treatment. It confirms that ART treatment is less cost-effective in older women. Alongside economic considerations of ART, community values, ethical judgements and clinical factors should influence policy decision-making.

Georgina M Chambers BAppSci(MLS), GradDip(Comp), MBA, Doctoral Candidate · Elizabeth A Sullivan MB BS, MPH, MMed(Sexual Health) · Maria T Ho MBBS, MHP, MD

Objective: To evaluate the efficacy of supplementation with zinc and vitamin A in Indigenous children hospitalised with acute lower respiratory infection (ALRI).Design: Randomised controlled, 2-by-2 factorial trial of supplementation with zinc and vitamin A.Setting and participants: 187 Indigenous children aged < 11 years hospitalised with 215 ALRI episodes at Alice Springs Hospital (April 2001 to July 2002).Interventions: Vitamin A was administered on Days 1 and 5 of admission at a dose of 50 000 IU (infants under 12 months), or 100 000 IU; and zinc sulfate was administered daily for 5 days at a daily dose of 20 mg (infants under 12 months) or 40 mg.Main outcome measure: Time to clinical recovery from fever and tachypnoea, duration of hospitalisation, and readmission for ALRI within 120 days.Results: There was no clinical benefit of supplementation with vitamin A, zinc or the two combined, with no significant difference between zinc and no-zinc, vitamin A and no-vitamin A or zinc + vitamin A and placebo groups in time to resolution of fever or tachypnoea, or duration of hospitalisation. Instead, we found increased morbidity; children given zinc had increased risk of readmission for ALRI within 120 days (relative risk, 2.4; 95% CI, 1.003–6.1).Conclusion: This study does not support the use of vitamin A or zinc supplementation in the management of ALRI requiring hospitalisation in Indigenous children living in remote areas. Even in populations with high rates of ALRI and poor living conditions, vitamin A and zinc therapy may not be useful. The effect of supplementation may depend on the prevalence of deficiency of these micronutrients in the population.

Anne B Chang MPHTM, FRACP, PhD · Paul J Torzillo FRACP, FFICM · Peter M Stewart FRCPA · Naomi C Boyce BNurs · Andrew V White FRACP · Gavin R Wheaton FRACP · David M Purdie BSc(Hons), PhD · John Wakerman MB BS, MPH · Patricia C Valery MD, MPH, PhD

Objective: To assess the safety and efficacy of percutaneous vertebroplasty for the treatment of acute osteoporotic vertebral fractures.Design: A prospective, non-randomised, “intention-to-treat” 2-year study.Patients and setting: 126 consecutive patients (39 men and 87 women, aged 51–95 years) with acute osteoporotic vertebral fractures presenting to St George Hospital from November 2000 to December 2002. They comprised 88 patients treated by percutaneous vertebroplasty and 38 by conservative therapy.Main outcome measures: Primary outcomes — changes in patients’ pain score and level of function recorded at 24 hours, 6 weeks, 6–12 months and 24 months after therapy. Secondary outcomes — occurrence of new clinical or radiological vertebral fractures and survival at 2 years.Results: Three minor complications (fractured pedicle and psoas muscle haemorrhage) occurred in the vertebroplasty group during the first year of the study. Outcomes in vertebroplasty-treated patients (60% reduction in visual analogue pain scores from 20 to 8; P < 0.001), a rapid return to normal function (29% improvement in physical functioning from 14 to 18; P < 0.001) and lower rates of hospitalisation (43% reduction in the mean number of hospital bed-days occupied) were better than those treated conservatively (P < 0.001 for the comparison of all variables at 24 hours). Lower pain scores persisted in the vertebroplasty-treated group at 6 weeks (P < 0.001), but no differences between the two groups were evident at 12 and 24 months. In the vertebroplasty-treated group compared with the control group, the rates of new vertebral fractures (clinically and by radiographic assessment) (hazard ratio, 1.13; 95% CI, 0.52–2.46; P = 0.76) and death (hazard ratio, 1.07; 95% CI, 0.42–2.76; P = 0.89) showed no significant difference.Conclusion: The analgesic benefit of percutaneous vertebroplasty and the low complication rates suggest that it is a useful therapy for acute painful osteoporotic vertebral fractures.

Terrence H Diamond MB BS, MB BCh, FRACP · Carl Bryant FRACR · Lois Browne PhD · William A Clark FRACR

Objective: To describe the epidemiology of invasive pneumococcal disease (IPD), and the impact of pneumococcal vaccines on IPD, in Indigenous people in north Queensland.Setting: North Queensland, 1999–2004; there are about 53 750 Indigenous people in the region, including nearly 6900 children < 5 years and nearly 5650 adults ≥ 50 years.Main outcome measures: Incidences of IPD in Indigenous children and in Indigenous adults compared between the 3 years before and after the introduction of a 7-valent pneumococcal conjugate vaccine (7vPCV) (1999–2001 versus 2002–2004).Results: Estimated annual incidence of IPD in Indigenous children < 5 years of age declined from 170 to 78 cases per 100 000 in the 3 years following the introduction of 7vPCV in 2001. The annual incidence of vaccine-preventable IPD in Indigenous adults had declined by 86% since a 23-valent pneumococcal polysaccharide vaccine (23vPPV) was introduced to the region in 1996, to 15 cases per 100 000 (95% CI, 8–25) in 2002–2004.Conclusion: Although there was a rapid decline in IPD in young Indigenous children, it is unlikely that the incidence will fall much further with the current 7-valent vaccine. There was a suggestion that vaccinating Indigenous children indirectly protected those aged 5–14 years and Indigenous adults ≥15 years of age. Incidence of IPD in Indigenous adults in 2002–2004 was the lowest on record in the region.

Jeffrey N Hanna MPH, FAFPHM · Jan L Humphreys · Denise M Murphy DipMedTech

Objective: To assess the prevalence and impact of overweight and obesity in an Australian obstetric population.Design, setting and participants: The Mater Mother’s Hospital (MMH), South Brisbane, is an urban tertiary referral maternity hospital. We reviewed data for the 18 401 women who were booked for antenatal care at the MMH, delivered between January 1998 and December 2002, and had a singleton pregnancy. Of those women, 14 230 had an estimated pre-pregnancy body mass index (BMI) noted in their record; 2978 women with BMI ≤ 20 kg/m2 were excluded from further study; the remaining 11 252 women were divided into four categories: “normal” (BMI 20.01–25 kg/m2), “overweight” (BMI 25.01–30 kg/m2), “obese” (BMI 30.01–40 kg/m2) and “morbidly obese” (BMI > 40 kg/m2).Main outcome measures: Prevalence of overweight and obesity in an obstetric population; maternal, peripartum and neonatal outcomes associated with raised BMI.Results: Of the 14 230 women, 6443 (45%) were of normal weight, and 4809 (34%) were overweight, obese or morbidly obese. Overweight, obese and morbidly obese women were at increased risk of adverse outcomes (figures represent adjusted odds ratio [AOR] [95% CI]): hypertensive disorders of pregnancy (overweight 1.74 [1.45–2.15], obese 3.00 [2.40–3.74], morbidly obese 4.87 [3.27–7.24]); gestational diabetes (overweight 1.78 [1.25–2.52], obese 2.95 [2.05–4.25], morbidly obese 7.44 [4.42–12.54]); hospital admission longer than 5 days (overweight 1.36 [1.13–1.63], obese 1.49 [1.21–1.86], morbidly obese 3.18 [2.19–4.61]); and caesarean section (overweight 1.50 [1.36–1.66], obese 2.02 [1.79–2.29], morbidly obese 2.54 [1.94–3.32]). Neonates born to obese and morbidly obese women had an increased risk of birth defects (obese 1.58 [1.02–2.46], morbidly obese 3.41 [1.67–6.94]); and hypoglycaemia (obese 2.57 [1.39–4.78], morbidly obese 7.14 [3.04–16.74]). Neonates born to morbidly obese women were at increased risk of admission to intensive care (2.77 [1.81–4.25]); premature delivery (< 34 weeks’ gestation) (2.13 [1.13–4.01]); and jaundice (1.44 [1.09–1.89]).Conclusions: Overweight and obesity are common in pregnant women. Increasing BMI is associated with maternal and neonatal outcomes that may increase the costs of obstetric care. To assist in planning health service delivery, we believe that BMI should be routinely recorded on perinatal data collection sheets.

Leonie K Callaway MB BS(Hons), FRACP · Allan M Chang PhD, FRANZCOG · H David McIntyre MB BS(Hons), FRACP · Johannes B Prins PhD, FRACP

Objective: To compare changes in autonomic nervous activity in healthy senior individuals while walking with and without a dog, and during routine activities at home and periods of interacting with the dog at home.Design: Controlled crossover study.Participants and setting: 13 healthy volunteers (3 men, 10 women; mean age, 67.5 years) who walked in a park adjacent to Gunma University, Japan, and 4 volunteers among these who underwent monitoring in their own homes.Interventions: Heart rate variability was monitored continuously by means of a palm-sized electrocardiographic monitor (which facilitated spectral analysis of the RR interval) while participants walked for 30 minutes (first with, then without, the study dog, or vice versa); three participants underwent this intervention on 3 consecutive days. Four participants underwent continuous monitoring for 6 hours in their own homes, including two 30-minute periods of free interaction with the study dog.Main outcome measures: High frequency (HF) power values of heart rate variability, which is a measure of parasympathetic neural activity.Results: During dog-walking, HF power increased significantly (P < 0.01); this increase was sustained throughout each dog walk, and was more pronounced during succeeding dog walks. At home, HF power was 1.87 times greater when the dog was present, and 1.57 times greater (P < 0.01) than in the walking experiment.Conclusions: Walking a dog has potentially greater health benefits as a buffer against stress in senior citizens than walking without a dog; and, independent of actually walking, merely patting and talking to a dog also raises parasympathetic neural activity. Power spectral analysis of heart rate variability shows promise as a non-invasive approach to quantifying clinicophysiological research on human health benefits possibly derived from interaction with companion animals.

Masahiko Motooka MMS · Nell L Kennedy PhD · Hiroto Koike MD, PhD · Tomoyuki Yokoyama MD, PhD

Objectives: To examine whether children’s television viewing may be a useful indicator of risk of obesity-promoting versus healthy eating behaviours, low-level physical activity (PA) and overweight or obesity among children of primary school entry and exit ages.Design: Cross-sectional study, stratified by area-level socioeconomic status.Participants and setting: 1560 children (613 aged 5–6 years [50% boys], and 947 aged 10–12 years [46% boys]) from 24 primary schools in Melbourne, Australia, randomly selected proportionate to school size between 1 November 2002 and 30 December 2003 .Main outcome measures: Parents’ reports of the time their child spends watching television, their participation in organised physical activities (PA), and their food intake; each child’s measured height and weight and their PA levels as assessed by accelerometry for one week.Results: After adjusting for the age and sex of child, the parents’ level of education, clustering by school, and all other health behaviour variables, children who watched television for > 2 h/day were significantly more likely than children who watched television for ≤ 2 h/day to: to have one or more serves/day of high energy drinks (adjusted odds ratio [AOR], 2.31; 95% CI, 1.61–3.32), and to have one or more serves/day of savoury snacks (AOR, 1.50; 95% CI, 1.04–2.17). They were also less likely to have two or more serves/day of fruit (AOR, 0.58; 95% CI, 0.46–0.74), or to participate in any organised PA (AOR, 0.52; 95% CI, 0.34–0.80).Conclusions: Health practitioners in the primary care setting may find that asking whether a child watches television for more than 2 hours daily can be a useful indicator of a child’s risk of poor diet and low physical activity level.

Jo Salmon PhD · Karen J Campbell MPH, PhD · David A Crawford PhD

Objective: To identify risk factors for dementia in an elderly Australian cohort.Design and setting: A longitudinal cohort study conducted in Dubbo, NSW.Participants: 2805 men and women aged 60 years and older living in the community and initially free of cognitive impairment, first assessed in 1988 and followed for 16 years.Main outcome measure: Admission to hospital or nursing home with any kind of dementia.Results: There were 115 cases of dementia in 1233 men (9.3/100) and 170 cases in 1572 women (10.8/100). In a proportional hazards model for dementia, any intake of alcohol predicted a 34% lower risk, and daily gardening a 36% lower risk. Daily walking predicted a 38% lower risk of dementia in men, but there was no significant prediction in women. The lowest tertile of peak expiratory flow predicted an 84% higher risk of dementia, the upper tertile of depression score predicted a 50% higher risk.Conclusion: While excess alcohol intake is to be avoided, it appears safe and reasonable to recommend the continuation of moderate alcohol intake in those already imbibing, as well as the maintenance of physical activity, especially daily gardening, in the hope of reducing the incidence of dementia in future years.

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

Objectives: To examine the commercial development of Australian medical patents and identify the determinants of their being used in innovations (new or improved products or production processes).Design: Cross-sectional survey with a nested case–control study.Participants and setting: 177 inventors listed as the first Australian on medical patents granted in the United States between 1 January 1984 and 30 December 1994, and surveyed in 1998–1999.Main outcome measure: A series of predictor variables (including characteristics of the patents; characteristics of the inventors; ideas, advice and funding during commercialisation; and the process of commercialisation) for whether or not a patent became an innovation.Results: Half (89/177) of the medical patents became innovations, with 34% generating a total of A $287 million (13% over $1 million) in annual sales a median of 8 years after the patent had been granted. A patent was more likely to become an innovation if the inventor was employed by industry at the time of invention (odds ratio [OR], 3.2; 95% CI, 1.1–9.2), had invested their own finances (OR, 2.8; 95% CI, 1.0–7.4), and if the patent had been licensed (OR, 4.6; 95% CI 1.7–12.7), led to further patents (OR, 3.2; 95% CI, 1.0–10.4) and involved an industry partner in its commercial development (OR, 10.1; 95% CI, 3.6–27.7). It was less likely to become an innovation if finance came from a research funding agency (OR, 0.3; 95% CI, 0.1–0.8) and if interest from Australian industry was judged by inventors as “poor” (OR, 0.6; 95% CI, 0.4–0.9).Conclusions: Medical patents in the US listing Australian inventors are more likely to become innovations if they originate from industry rather than the public sector, and if inventors are willing to invest their own finances.

Eugen Mattes MPH, PhD, FRACGP · Michael C Stacey DS, FRACS · Dora Marinova BEng, MSc, PhD

We need a vision to attract funding increases, and it must come from the research community Some time ago, a federal Health Minister met with a group of medical researchers who argued passionately for more funding of medical research. As they left, the researchers overheard the Minister say, in an aside to his adviser, “even if we give them what they ask, they will just want more”. This real political comment is indicative of an enduring tension between medical researchers and government — perhaps an enduring tension between all who seek more of the taxpayers’ funds from governments faced with a plethora of competing community demands. This tension is echoed in the outcome of a 2002 survey of health and medical researchers reported in this issue of the Journal by Shewan and colleagues.1 These authors reveal that about 90% of respondents believe that adequate funding was very or extremely important to their research role, but only about 10% felt that the current level of research funding was adequate. This accords with current campaigns by the Australian Society for Medical Research,2 Research Australia3 and the Association of Australian Medical Research Institutes4 to increase government funding. But to increase funding to what purpose? Following the Wills Report in 1999,5 the federal government doubled National Health and Medical Research Council (NHMRC) funding for medical research to almost $480 million in 2004.6 Although NHMRC funding is only a proportion of our total medical research funding, it is the major component. After this increase, the NHMRC undertook a number of new activities (eg, Public Health Capacity Building Grants, Centres of Clinical Research Excellence) and funded project grants more fully. However, the major change that the extra funds allowed was the introduction of new, large and flexible Program Grants. These are competed for on the basis of achievements over the previous 5 years, and allow teams of researchers to be much more strategic in their research plans. The new funding also allowed the NHMRC to attend to things which were unpopular in some quarters; for example, abolition of block funding of independent medical research institutes. Now, in 2005, NHMRC future funding projections are again flat, and the government shows little inclination for “more of the same”; that is, to increase the NHMRC budget for the sake of it. Researchers hoped that the recent Grant Report,7 which examined the implementation of the government’s doubling of NHMRC funding, would spark a further increase in funding from the government, but this was not to be. There is also increasing competition from countries which can either support Australia’s best researchers more lavishly (eg, the United States) or which are rapidly increasing their national funding (eg, China, Singapore, and the European Union). There is no common view on what increased Australian funding for medical research is needed for. Ask individual researchers and they will forcefully articulate their individual cases. Depending on who they are, they may point to the need to strengthen health services research to provide an evidence base for turning policy into practice in the health system. Others may call for a robust research effort in established infectious diseases (eg, Ross River fever) or in new ones that are potential threats (eg, new forms of influenza), or for research into public health measures to combat these threats. Others may advocate research into problems of chronic diseases that are sometimes seen as less urgent but, in fact, account for the overwhelming majority of the burden of disease locally and internationally, even in poorer countries. For example, it has been pointed out recently that 80% of deaths from chronic diseases involve people living in low- and middle-income countries.8 It seems that until a strong “story” emerges from the research community for the need for extra funding, nothing much will happen. The medical research leadership needs to work together to articulate what extra funding will provide for Australia. “More of the same, but better” is unlikely to succeed — the medical research community needs to come forward with a vision. One interesting finding in the study by Shewan and colleagues was a divergence in views between researchers at medical research institutes and universities.1 University researchers felt significantly more strongly that the infrastructure available for research was inadequate, and were also significantly more satisfied with the excitement of discovery in their research work. The medical research institutes enjoy some advantages in that they now receive direct infrastructure funding from the NHMRC and also from state governments; do not pay fringe benefits tax; don’t have to teach undergraduates; and often have magnificent, government-funded research labs. Now, universities are adopting an internal research institute model (eg, the University of Queensland’s Institute for Molecular Biosciences, and Monash University’s Institute of Medical Research) so that they too have a two-tiered system. Still, most health research emanates from universities, and university-based researchers need to follow the example of the independent institutes and organise themselves more effectively. To return to my original theme, the medical research community needs to develop a plan that will convince government that the pursuit of research and its translation into treatments, equipment and services contributes to a more innovative and productive economy. An important part of this plan will be to keep our most talented younger researchers working here for the good of Australia. Talented young researchers often see themselves as global citizens, able to find work easily anywhere around the world. There must be good funding methods that support the best research, from molecular genetics through to health services research, and the best young researchers, so that we are constantly adding zest and the yeast into the system! The young are much more likely to challenge orthodoxies and hunt out new approaches — Peter Doherty and Barry Marshall were both young when they made their ground-breaking discoveries that led to their Nobel prizes. New ideas and well supported arguments can work, as shown by the federal government’s response to the Wills Report in 1999, and the Victorian and Queensland governments’ responses through their innovation initiatives (the Science, Technology and Innovation Initiative for Victorian, and Smart State for Queensland). Governments need to take a long-term view, and to regard research funding as an investment, to set strategic goals and commit to the long term. They also need to develop comprehensive policies that encourage private and philanthropic investment in research in Australia, which, compared with that in the US, is but a drop in the ocean. This will keep the mobile health research workforce here, working to make Australian health research vibrant and productive, and contributing even more to national health and wealth. It is up to the research community to come up with innovative directions. The NHMRC itself will need to take a much stronger leadership role in developing exciting and innovative strategies suitable for the 21st century and justifying the community’s hopes and trust9 in health research.

Warwick P Anderson PhD