Research

Objective: To assess the degree to which men considered it appropriate for general practitioners to order prostate-specific antigen (PSA) testing if the testing was either “disclosed” or “undisclosed” to the patient.Design: Telephone-administered survey conducted in June to October 2000.Participants: 514 men aged 50–70 years, identified by random selection of households from the Sydney Electronic White Pages phone directory.Methods: We developed two hypothetical scenarios. Each scenario described a GP ordering a PSA test for a male patient at the same time as other pathology tests were ordered. In Scenario 1, the GP’s intention to order a PSA test was disclosed to the patient (“disclosed”). In Scenario 2, the GP did not tell the patient a PSA test was being ordered (“undisclosed”). For each scenario, men reported the degree to which they perceived screening to be “appropriate”. We also recorded demographic characteristics, health status and health locus of control, and administered a 14-question knowledge test about prostate cancer and PSA screening.Results: Over 90% of men stated that “disclosed” PSA screening was either “appropriate” or “very appropriate”. Significantly fewer (44.9%) rated “undisclosed” screening as appropriate/very appropriate (P < 0.001). While the skewed distribution of responses to Scenario 1 precluded multivariate analysis to determine predictors, men rejecting “undisclosed” PSA screening (Scenario 2) were more likely to be younger (adjusted odds ratio [AOR], 0.97; 95% CI, 0.94–1.00; P = 0.03); to have better knowledge of the issues (AOR, 1.01; 95% CI, 1.00–1.03; P = 0.02); and to be single (AOR, 0.62; 95% CI, 0.41–0.94; P = 0.02).Conclusions: Many men consider that inclusion of PSA screening within a battery of pathology tests without disclosure to the patient is unacceptable. Educating men about the pros and cons of screening may alter their support of opportunistic screening and thus enhance community expectations of “informed participation”.

Melina Gattellari BSc(Hons), PhD · Jeanette E Ward MB BS, PhD, FAFPHM

Objective: To identify variation in the rates of use of key evidence-based therapies and in clinical outcomes among patients hospitalised with acute coronary syndromes (ACS).Design: Retrospective analysis of data on care processes and clinical outcomes of representative patient samples recorded by the Queensland Health Cardiac Collaborative registry.Setting: 18 public hospitals (3 tertiary, 15 non-tertiary) in Queensland, August 2001 to December 2003.Study population: 2156 patients who died or were discharged after troponin-positive ACS.Main outcome measures: Comparison of proportions of highly eligible patients receiving indicated care and in-hospital mortality between subgroups categorised by age, sex, comorbidities (diabetes, renal failure, chronic obstructive pulmonary disease and mental disorder), type of admitting hospital (tertiary or non-tertiary), and cardiologist involvement (transfer or non-transfer to cardiology unit).Results: Patients aged ≥ 65 years were less likely than younger patients to receive heparin (79% v 87%), β-blockers (79% v 87%), lipid-lowering agents (78% v 87%), coronary angiography (51% v 66%), and referral to cardiac rehabilitation (17% v 33%). Patients with diabetes were less likely than others to receive coronary angiography (50% v 63%), while those with moderate to severe renal failure were less likely to receive thrombolysis (52% v 84%), heparin (71% v 83%), β-blockers (69% v 84%), lipid-lowering agents (61% v 84%), in-hospital cardiac counselling (46% v 64%) and referral to cardiac rehabilitation (9% v 25%). Patients admitted to tertiary hospitals were more likely than those admitted to non-tertiary hospitals to receive coronary angiography (85% v 55%) and referral to cardiac rehabilitation (36% v 21%). Risk-adjusted mortality was highest in patients with moderate to severe renal failure (15% v 3%) and older patients (6% v 2%).Conclusions: Variations exist in the provision of indicated care to patients with ACS according to age, diabetic status, renal function and type of admitting hospital. Excess mortality in elderly patients and in those with advanced renal disease may be partially attributable to failure to use key therapies.

Ian A Scott FRACP, MHA, MEd · Mark A Jones BSc(Hons) · Andy B Duke · Irene C Darwin BSpThy, GradCertManagement · Kathy H Harvey GradCertManagement

Objectives: To determine population-based rates and outcomes of hypertensive disorders in pregnancy.Design: Cross-sectional study using linked population databases.Setting and participants: All women, and their babies, discharged from hospital following birth in New South Wales, between 1 January 2000 and 31 December 2002.Main outcome measures: Rates of hypertensive disorders in pregnancy, maternal and infant morbidity and mortality, and level of hospital care for the birth admission.Results: 250 173 women and their 255 931 infants were included in the study. Overall, 24 517 women (9.8%) had a hypertensive disorder in pregnancy, including 1411 (0.6%) with chronic hypertension, 10 379 (4.2%) with pre-eclampsia, 731 (0.3%) with chronic hypertension with superimposed pre-eclampsia, and 10 864 (4.3%) with gestational hypertension. Women with, and infants exposed to, hypertension were more likely to suffer death or major morbidity than those without hypertension. Infants of mothers with hypertension were more likely to be to born preterm and small for gestational age. Just over half the women with major morbidity or mortality delivered in hospitals with a high level of medical care. In contrast, most infants with major morbidity or mortality were delivered in hospitals with neonatal intensive care units.Conclusions: Hypertension is a common complication of pregnancy, and adverse outcomes are increased among hypertensive women and their babies. Clinicians appear to be better at identifying and seeking an appropriate level of care for pregnancies where the infant is at risk of a poor outcome than when the mother is at risk. More specific antenatal indicators of poor maternal outcome would help guide the referral of hypertensive women to higher levels of care.

Christine L Roberts MB BS, DrPH · Jane B Ford BA(Hons), PhD · David J Henderson-Smart FRACP, PhD · Charles S Algert BSc, MPH · Jonathan M Morris FRANZCOG, PhD

Objective: To examine trends in adverse drug reactions (ADRs) in people aged 60 years or over causing admission to or an extended stay in Western Australian hospitals between 1981 and 2002.Design and setting: Secondary data analysis of case series.Patients: 43 380 patients admitted to WA public and private hospitals with an (International Classification of Diseases) ICD external cause code for an ADR, identified by the population-based WA Hospital Morbidity Data System.Main outcome measures: Age-specific, age-standardised and drug-specific rates of ADR-related hospital stays.Results: The age-standardised rate of ADR-related hospital stays increased from 2.5 per 1000 person-years (py) in 1981 to 12.9 per 1000 py in 2002. The largest increases occurred in those aged 80 + years (tenfold in men and sevenfold in women). The most common drug group involved was cardiovascular agents (17.5%), while anticoagulants (7.5%), cytotoxics (7.4%) and antirheumatics (6.8%) were the more specific drug classes most often implicated. ADRs from the last three classes of drugs were still rising at the end of the study, whereas ADRs from corticosteroids and antihypertensives peaked in 1996 and from opioids in 2000.Conclusions: Increases in hospital admissions or extended lengths of stay due to ADRs in WA have continued despite programs to promote rational and safer use of medicines. The sharp increase in ADRs from anticoagulants warrants attention to revised clinical guidelines.

Christel L Burgess BHlthSc(Hons) · C D’Arcy J Holman MB BS, MPH, PhD · Anthony G Satti BEd

Objective: To evaluate the effect on depressive symptoms in cardiac patients of patient-specific advice to general practitioners regarding management of comorbid depression.Design and setting: A randomised controlled trial in four general hospitals in Adelaide, South Australia.Participants: Patients (n = 669) admitted to cardiology units for a range of cardiovascular conditions who were screened and assessed as being depressed according to the Center for Epidemiological Studies Depression Scale (CES-D).Intervention: Inpatient psychiatric review, followed by telephone case conferencing between specialist hospital staff and GPs to provide patient-specific information about the patient’s depression and its management, educational material, and ongoing clinical support.Main outcome measures: Level of depression severity at 12 months post-hospitalisation.Results: On the basis of intention to treat, intervention patients had lower rates of moderate to severe depression (CES-D ≥ 27) after 12 months (25% v 35%, relative risk, 0.72; 95% CI, 0.54–0.96, number needed to treat for benefit, 11). The intervention was most effective in preventing progression from mild depression to moderate to severe depression. The multidisciplinary telephone case conferencing was difficult to implement and, in a post hoc analysis, brief phone advice from a psychiatrist was found to be effective.Conclusions: Screening hospitalised cardiac patients for depression and providing targeted advice to their GPs reduces depression severity 12 months after hospitalisation.

Geoff Schrader PhD, FRANZCP · Frida Cheok PhD · Ann-Louise Hordacre PhD · Julie Marker GDPH · Victoria Wade FRANCGP, MPsych

Objective: To investigate whether Indigenous Australians with cancer have more advanced disease at diagnosis than other Australians, and whether late diagnosis explains lower Indigenous cancer survival rates.Design: Retrospective cohort study.Setting and participants: Indigenous and non-Indigenous people diagnosed with cancers of the colon and rectum, lung, breast or cervix and non-Hodgkin lymphoma in the Northern Territory of Australia in 1991–2000.Main outcome measures: SEER summary stage of cancer at diagnosis (local, regional or distant spread), cause-specific cancer survival rates and relative risk of cancer death.Results: Diagnosis with advanced disease (regional or distant spread) was more common for Indigenous people (70%; 95% CI, 62%–78%) than for non-Indigenous people (51%; 95% CI, 53%–59%) with cancers of the colon and rectum, breast, cervix and non-Hodgkin lymphoma, but for lung cancer the opposite was found (Indigenous, 56% [95% CI, 46%–65%] v non-Indigenous, 69% [95% CI, 64%–75%]). Stage-adjusted survival rates were lower for Indigenous people for each cancer site. With few exceptions, the relative risk of cancer death was higher for Indigenous people for each category of stage at diagnosis for each cancer site.Conclusions: Health services apparently could, and should, be performing better for Indigenous people with cancer in the Northern Territory, and probably elsewhere in Australia. This study has demonstrated that data from cancer registers, enhanced with data on stage at diagnosis, can be used to monitor health service performance for Indigenous Australians in the Northern Territory; similar data is available in other States, and could be used to monitor health service performance for Indigenous people throughout Australia.

John R Condon MPH, FAFPHM · Tony Barnes MSc · Bruce K Armstrong DPhil · Sid Selva-Nayagam FRACP · J Mark Elwood MD

Objectives: To determine and compare the prevalence of Helicobacter pylori in an urban and a remote rural Western Australian Indigenous community.Design: Cross-sectional study of Helicobacter pylori status determined by urea breath tests between mid-January 2003 and the end of June 2004.Participants: 520 self-selected fasting participants, comprising 270 members of the Martu community at Jigalong, Punmu and Parnngurr in the East Pilbara region (129 men, 141 women; age range, 2–90 years) and 250 people from the Perth Indigenous community (96 men, 154 women; age range, 3–75 years.Results: The overall prevalence of H. pylori was 76%, but the prevalence in the remote rural community was 91%, compared with 60% in the urban community. The odds of having H. pylori were six times greater for rural than for urban participants (odds ratio [OR], 6.34; 95% CI, 3.89–10.33). Further, the overall odds of H. pylori infection in males (rural and urban combined) were greater than for females (OR, 1.61; 95% CI, 1.02–2.54). In both communities, the prevalence of infection remained relatively constant after the age of 10.Conclusions: The prevalence of H. pylori in the two Indigenous communities was two to three times higher than that in the non-Indigenous Australian population and higher than that shown in previous studies in Indigenous Australians.

Helen M Windsor PhD · Susan D Morrow BA · Barry J Marshall FRACP · Emmanuel A Abioye-Kuteyi MB BS · Jacqueline M Leber RN · Max K Bulsara MSc

Objective: To evaluate the effect of a behaviour modification program, taught to parents in a single visit to a trained nurse, in improving sleep performance in newborn infants.Design: Randomised controlled trial.Setting and participants: 268 families with normal newborn infants in the community, recruited between October 1996 and March 1997 from birth notices published in a South Australian daily newspaper.Intervention: A 45-minute consultation with a nurse 2–3 weeks after the birth, including a tutorial discussion on normal sleep patterns in newborn infants, supported by retained written material and, for infants with weight gain < 30 g daily, referral to their usual postnatal care provider.Main outcome measures: Hours of daytime sleep (0600–1800), night sleep (1800–0600) and total sleep per 24 h; and number of daily records with total sleep ≥ 15 h per 24 h, assessed by 7-day sleep diary at ages 6 and 12 weeks.Results: 268 families returned at least one sleep diary (137/171 intervention, 131/175 control), recording 3273 days. Two intervention infants were referred for low weight gain. Total sleep time was 15 h or more per 24 h on 62% of recorded days in the intervention group, compared with 36% in the control group (P < 0.001). At 6 weeks of age, intervention infants slept a mean 1.3 h per day more than control infants (95% CI, 0.95–1.65), comprising a mean 0.5 h more night sleep (95% CI, 0.32–0.69) and 0.8 h more daytime sleep (95% CI, 0.56–1.07). At 12 weeks, intervention infants slept a mean 1.2 h per day more (95% CI, 0.94–2.14), comprising 0.64 h more night sleep (95% CI, 0.19–0.89) and 0.58 h more daytime sleep (95% CI, 0.39–1.03). There was no significant difference in crying time between the groups.Conclusions: A single consultation supported by written material in the first 3 weeks of a child’s life improves sleep performance at 6 weeks of age. This improvement is maintained at 3 months.

Brian G Symon MD · John E Marley MD · A James Martin MD · Emily R Norman MB BS

Objective: To study the impact of various risk factors on survival time in a cohort of elderly Australians.Design, setting and participants: A longitudinal, prospective cohort study conducted in Dubbo, NSW. Participants were men and women aged 60 years or over living in the community, first assessed in 1988–1989 and followed for 15 years.Main outcome measures: Mortality rates; risk factors; survival times.Results: There were 668 deaths in 1233 men (54%) and 625 deaths in 1572 women (40%). Coronary heart disease was the major cause of death, rates being higher in men than women until age group 80+ years; stroke death rates were similar in both sexes; cancer and respiratory death rates were higher in men than women across all ages. In a proportional hazards model, the independent predictors of mortality were cigarette smoking, diabetes, very high blood pressure (BP), impaired peak expiratory flow (PEF), physical disability, and zero intake of alcohol. Over 15 years, the average reductions in survival time associated with various risk factors, in men and women respectively, were smoking, 22 and 15 months; diabetes, 18 and 18 months; very high BP, 16 and 9 months; impaired PEF, 14 and 17 months; physical disability, 16 and 12 months; zero alcohol intake, 9 and 5 months. Combinations of selected risk factors were associated with a multiplier effect.Conclusion: The reduction in survival time in elderly citizens demonstrated in the presence of smoking, diabetes and hypertension highlights a potential benefit to healthy ageing to be gained from prevention and intervention.

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

Objective: To determine the prevalence of venous thromboembolism (VTE) after total hip replacement (THR), total knee replacement (TKR) or bilateral TKR in a large sample of patients in a major hospital orthopaedic unit.Design, setting and patients: The Mater Misericordiae Hospital, North Sydney, NSW, a 195-bed private hospital. All patients who had THR, TKR or bilateral TKR at the hospital between 1 April 1995 and 31 December 2001 had physical prophylaxis (graduated compression elastic stockings or intermittent pneumatic compression, or both) and chemical prophylaxis (anticoagulant) against VTE. All underwent ultrasonography of both legs before discharge, with a small, symptomatic group also undergoing a ventilation/perfusion lung scan (V/Q scan) and computed tomographic pulmonary angiography.Main outcome measures: Prevalence of deep-vein thrombosis (DVT) and symptomatic pulmonary embolism (PE) before discharge.Results: Among a total of 5999 patients, the pre-discharge prevalence of DVT after THR, TKR or bilateral TKR was 8.9%, 25.6% and 36.9%, respectively. The prevalence of symptomatic non-fatal in-hospital PE was 1.9%, while the prevalence of fatal in-hospital PE was 0.05%.Conclusions: Despite short-term chemical and physical thromboprophylaxis, the prevalence of DVT after lower-limb joint replacement, measured by pre-discharge ultrasonography, was high. The rate of symptomatic non-fatal in-hospital PE was moderate, but fatal in-hospital PE was rare.

Richard F O’Reilly MB BS, FRACP · Ian A Burgess MB BS, FRANZCR · Bernard Zicat MD, FRCSC, FRACS

Objective: An Australian stroke services study (SCOPES) has developed a framework to compare different forms of acute stroke services, the gold standard being localised stroke units. We aimed to use this framework to assess changes in the quality of stroke care over time as a sequential audit process.Design and setting: A retrospective medical record audit comparing 100 sequential stroke admissions (July 2002 to June 2003) two years after institution of a mobile stroke service (MSS) with 100 historical controls (September 1998 to October 1999) at a 260-bed hospital in Melbourne. The MSS results were also compared with stroke units in SCOPES.Main outcome measures: Adherence to quality indicators and standard measures of outcome (complications, length of stay and discharge disability) after implementing the MSS.Results: Significant improvements were seen in prophylaxis for deep-vein thrombosis, incontinence management, premorbid function documentation, frequent neurological observations and early occupational therapy. The MSS demonstrated fewer severe complications (9% versus 24%; P = 0.004), reduced median length of stay (discharged patients: 12.0 days versus 18.5 days; P = 0.003) and more patients were independent at discharge (32% versus 9%; P < 0.001). Comparison with SCOPES stroke units showed our MSS could improve in incontinence management and appropriate use of antiplatelet therapy.Conclusion: Institution of the MSS was associated with improvements in the quality of stroke care. This study demonstrates application of an audit procedure for quality improvement in hospital stroke management and the potential to improve stroke services in smaller centres.

Anneke van der Walt MB ChB · Amanda K Gilligan MB BS, FRACP · Amy G Brodtmann MB BS, FRACP · Dominique A Cadilhac MPubHlth · Dora C Pearce MIT · Geoffrey A Donnan MD

Aim: To ascertain the incidence of autism spectrum disorders in Australian children.Setting: New South Wales (NSW) and Western Australia (WA), July 1999 to December 2000.Design: Data were obtained for WA from a prospective register and for NSW by active surveillance.Main outcome measures: Newly recognised cases of autism spectrum disorders (defined as autistic disorder, Asperger disorder and pervasive developmental disorder not otherwise specified [PDD-NOS]) in children aged 0–14 years; incidence was estimated in 5-year age bands (0–4 years, 5–9 years, 10–14 years).Results: In WA, 252 children aged 0–14 years were identified with autism spectrum disorder (169 with autistic disorder and 83 with Asperger disorder or PDD-NOS). Comparable figures in NSW were 532, 400 and 132, respectively. Most children were recognised with autistic disorder before school age (median age, 4 years in WA and 3 years in NSW). Incidence of autistic disorder in the 0–4-years age group was 5.5 per 10 000 in WA (95% CI, 4.5–6.7) and 4.3 per 10 000 in NSW (95% CI, 3.8–4.8). Incidence was lower in older age groups. The ratio of all autism spectrum disorders to autistic disorder alone was 1.5:1 in WA and 1.3:1 in NSW, and rose with age (1.8:1 and 2.9:1 in 10–14-year-olds in WA and NSW, respectively).Conclusions: These are the first reported incidence rates for autism for a large Australian population and are similar to rates reported from the United Kingdom. Ongoing information gathering in WA and repeat active surveillance in NSW will help to monitor any future changes.

Katrina Williams PhD, FRACP, FAFPHM · Megan Helmer MHlthSc(CDM) · Craig M Mellis MPH, MD, FRACP · Marshall Tuck MPH · Emma J Glasson PhD · Carol I Bower MSc, PhD, FAFPHM · John Wray FRACP

Objective: To assess differences in trends for prostate cancer mortality, radical prostatectomy and prostate-specific antigen (PSA) testing for Australian men aged 50–79 years living in capital cities compared with regional and rural areas.Design: Descriptive, population-based study based on data from official sources from 1985 to the 2002/03 financial year (depending on data availability).Main outcome measures: Age-standardised rates per 100 000 men aged 50–79 years of mortality from prostate cancer, incidence of prostate cancer, PSA tests and radical prostatectomy.Results: We found a statistically significant and increasing (age-standardised) mortality excess for prostate cancer in regional and rural areas. In 2000–2002 the excess (compared with capital cities) was 21% (95% CI, 14%–29%). Rates of radical prostatectomy in rural and regional Australia were 29% lower (95% CI, 23% lower to 35% lower) than in capital cities. Although PSA testing is common across the whole of Australia, age-standardised rates in 2002/03 were 16% lower (95% CI, 15% lower to 17% lower) in regional and rural areas than in capital cities.Conclusions: Our results show that the probability of a man having a PSA test and the management of his prostate cancer depend on where he lives. The cause or causes of the prostate cancer mortality excess in regional/rural areas cannot be established in a descriptive study, but fewer radical prostatectomies in regional and rural areas, perhaps associated with less PSA screening, remain among the several competing hypotheses. Other possibilities are related to other differences in management, perhaps associated with access to urologists. Governments and other budget holders need good evidence about the effectiveness of prostate cancer screening and early treatment, but also about the best strategies for providing equitable access to cancer services in both urban and rural areas.

Michael D Coory MB BS, PhD, FAFPHM · Peter D Baade BSc, MMedSc, PhD

Objectives: To assess whether healthcare professionals correctly incorporate the relevance of a favourable test outcome in a close relative when determining the level of risk for individuals at risk for Huntington’s disease.Design and setting: Survey of clinical geneticists and genetic counsellors from 12 centres of clinical genetics (United Kingdom, 6; The Netherlands, 4; Italy, 1; Australia, 1) in May–June 2002. Participants were asked to assess risk of specific individuals in 10 pedigrees, three of which required use of Bayes’ theorem.Participants: 71 clinical geneticists and 41 other healthcare professionals involved in genetic counselling.Main outcome measures: Proportion of respondents correctly assessing risk in the three target pedigrees; proportion of respondents who were confident of their estimate.Results: 50%–64% of respondents (for the three targets separately) did not include the favourable test information and incorrectly estimated the risks as being about equal to the prior risks; 77%–91% of these respondents were “sure” or “completely sure” that their estimations were correct. Twenty of the 112 respondents correctly estimated the risks for all three target pedigrees.Conclusions: Clinical geneticists and genetic counsellors frequently use prior risks in situations where Bayes’ theorem should be applied, leading to overestimations of the risk for an individual.

Benno Bonke PhD · Theo Stijnen PhD · Aad Tibben PhD · Dick Lindhout MD · Angus J Clarke MD

Objective: To compare attitudes of Australian physicians and paediatricians about treatment and randomised controlled trial (RCT) participation.Design and participants: A cross-sectional survey using the validated “Physician Orientation Profile” (POP), with 250 physicians and 250 paediatricians surveyed.Outcome measures: Five indices — primary allegiance, decision making under uncertainty, professional activities, perceived rewards, and peer-group influence — with scores for each participant ranging along a continuum from clinician-oriented to research-oriented and expressed as a number between 0 and 1.Results: Overall response rate was 60%, with 135 physicians (54%) and 165 paediatricians (66%) responding. Paediatricians and physicians were similar in their attitudes to RCT participation, being generally clinician-oriented rather than research-oriented and less inclined to participate in RCTs when there is uncertainty about the best treatment. Most assign limited time to research, with 26.9% not currently involved in research and 31.5% having no experience of RCT participation. Doctors perceive few rewards and little peer-group influence regarding trial participation. Independent predictors of favourable attitudes to trial participation (based on POP scores) were the presence of allocated research time (0.37 for no allocated research time v 0.61 for > 70% research time; P < 0.0001), previous experience enrolling a patient in an RCT (0.40 for no experience v 0.46 for experience; P < 0.0001), and articles published in the past 12 months (0.40 for no publications v 0.55 for > 3 publications; P < 0.0001).Conclusions: This study highlights the minor importance of research for most Australian physicians. Research plays only a small role in their professional activities, and the importance of research participation is not recognised. They are clinician-oriented in their attitudes to RCT participation. To encourage greater involvement in trials among physicians in Australia, clinical research needs to be restructured in a primarily clinically oriented setting with dedicated research time.

Patrina H Y Caldwell FRACP, PhD · Jonathan C Craig FRACP, PhD · Phyllis N Butow MClinPsych, PhD

Objective: To determine the extent to which the Framingham function predicts the risk of coronary heart disease (CHD) in Aboriginal people.Design and setting: Cohort study in an Aboriginal community in the Northern Territory.Participants: 687 Aboriginal people aged 20–74 years were followed up from a baseline examination in 1992–1995 through to 31 December 2003.Main outcome measure: First CHD events were identified through hospital and death records during the follow-up period.Methods: An original Framingham function was used to predict CHD risk according to the duration of follow-up and the values of traditional risk factors, which included age, sex, total cholesterol level, high-density lipoprotein (HDL) cholesterol level, blood pressure, the presence of diabetes, and smoking status. The predicted CHD incidence using the Framingham function was 4.4 per 1000 person-years, while the observed incidence was 11.0 (95% CI, 8.7–13.9) per 1000 person-years. The observed number of CHD events (68) was 2.5 times the number predicted (27) using the Framingham function. The observed incidence was about four and three times the predicted incidence for age groups < 35 and 35–44 years, respectively, and about twice the predicted incidence for those over 45 years of age. The Framingham function was a particularly unreliable predictor for women, especially younger women, in whom the observed CHD rate was 30 times the predicted rate.Conclusions: The Framingham function substantially underestimates the actual risk of CHD observed in Aboriginal people in a remote community, especially for women and younger adults. This implies that traditional risk factors have different degrees of impact and/or that other factors are contributing to risk. A population-specific risk function is needed.

Zhiqiang Wang PhD, MSc, MB · Wendy E Hoy MB BS, BScMed, FRACP

Objective: To identify and explore behavioural characteristics of registrars that interns find helpful in their working relationships and workplace learning.Design, setting and participants: Semistructured interviews with 18 interns at Nepean Hospital, Penrith, NSW, at the end of their first working year as doctors. The survey was conducted between December 2003 and February 2004.Main outcome measure: Desirable and undesirable behavioural characteristics in registrars, as reported by interns.Results: Overall, interns’ opinions of registrars were positive. Desirable characteristics in registrars included approachability, availability, good communication skills, and a willingness to teach. Undesirable characteristics included an unwillingness to listen, unreasonably high expectations, a condescending attitude, apathy and rudeness.Conclusion: The behavioural characteristics of registrars that interns find helpful are identifiable, and there is significant room for improvement in the quality of clinical mentoring by registrars. The next step is to facilitate regular feedback from interns on registrars’ performance, and to develop ways to encourage desirable behaviours in registrars while actively discouraging undesirable behaviours.

Christopher S Lack BA, BM · John A Cartmill MB BS, BSc(Med), FRACS

Objectives: To determine the accident rate for Australian helicopter emergency medical services (HEMS) per 100 000 flying hours and to determine the patient mortality risk per mission from a HEMS accident.Method: Retrospective observational study of Australian HEMS flying hours and accidents from 1992–2002.Results: The calculated accident rate for Australian HEMS is 4.38 per 100 000 flying hours. One patient died as a direct result of helicopter accident in 50 164 missions. Overall, one accident occurred every 16 721 missions.Conclusions: The overall Australian HEMS accident rate is similar to that reported from other countries, with all accidents occurring in Queensland community HEMS. Helicopters flown at night under Visual Flight Rules (VFR) appear to represent a high-risk subgroup. HEMS flights do not appear to present significant mortality risk to patients being transported.

Jim Holland MB BS · David G Cooksley MB ChB, FACEM

Objective: To examine the impact of a sudden and dramatic decrease in heroin availability, concomitant with increases in price and decreases in purity, on fatal and non-fatal drug overdoses in New South Wales, Australia.Design and setting: Time-series analysis was conducted where possible on data on overdoses collected from NSW hospital emergency departments, the NSW Ambulance Service, and all suspected drug-related deaths referred to the NSW Coroner’s court.Main outcome measures: The number of suspected drug-related deaths where heroin and other drugs were mentioned; ambulance calls to suspected opioid overdoses; and emergency department admissions for overdoses on heroin and other drugs.Results: Both fatal and non-fatal heroin overdoses decreased significantly after heroin supply reduced; the reductions were greater among younger age groups than older age groups. There were no clear increases in non-fatal overdoses with cocaine, methamphetamines or benzodiazepines recorded at hospital emergency departments after the reduction in heroin supply. Data on drug-related deaths suggested that heroin use was the predominant driver of drug-related deaths in NSW, and that when heroin supply was reduced overdose deaths were more likely to involve a wider combination of drugs.Conclusion: A reduction in heroin supply reduced heroin-related deaths, and did not result in a concomitant increase, to the same degree, in deaths relating to other drugs. Younger people were more affected by the reduction in supply.

Louisa J Degenhardt PhD, MPsych(Clinical) · Elizabeth Conroy BA · Stuart Gilmour BSc · Wayne D Hall PhD

Objective: To determine the effectiveness of intranasal (IN) naloxone compared with intramuscular (IM) naloxone for treatment of respiratory depression due to suspected opiate overdose in the prehospital setting.Design: Prospective, randomised, unblinded trial of either 2 mg naloxone injected intramuscularly or 2 mg naloxone delivered intranasally with a mucosal atomiser.Participants and setting: 155 patients (71 IM and 84 IN) requiring treatment for suspected opiate overdose and attended by paramedics of the Metropolitan Ambulance Service (MAS) and Rural Ambulance Victoria (RAV) in Victoria.Main outcome measures: Response time to regain a respiratory rate greater than 10 per minute. Secondary outcome measures were proportion of patients with respiratory rate greater than 10 per minute at 8 minutes and/or a GCS score over 11 at 8 minutes; proportion requiring rescue naloxone; rate of adverse events; proportion of the IN group for whom IN naloxone alone was sufficient treatment.Results: The IM group had more rapid response than the IN group, and were more likely to have more than 10 spontaneous respirations per minute within 8 minutes (82% v 63%; P = 0.0173). There was no statistically significant difference between the IM and IN groups for needing rescue naloxone (13% [IM group] v 26% [IN group]; P = 0.0558). There were no major adverse events. For patients treated with IN naloxone, this was sufficient to reverse opiate toxicity in 74%.Conclusion: IN naloxone is effective in treating opiate-induced respiratory depression, but is not as effective as IM naloxone. IN delivery of naxolone could reduce the risk of needlestick injury to ambulance officers and, being relatively safe to make more widely available, could increase access to life-saving treatment in the community.

Anne-Maree Kelly MD, MClinEd, FACEM · Debra Kerr RN, MBL · Zeff Koutsogiannis MB BS, FACEM · Paul Dietze PhD · Ian Patrick · Tony Walker

Objective: To assess effectiveness and side effects of thiazolidinediones (TZDs) as adjunctive therapy in suboptimally controlled patients with type 2 diabetes.Design and setting: Review of a prospectively recorded database at the Royal Melbourne Hospital diabetes clinic.Participants: 203 patients with type 2 diabetes who received pioglitazone or rosiglitazone between 1 May 2000 and 31 October 2002.Outcome measures: Response in glycohaemoglobin (HbA1c) level, lipid profile changes and side effects, including hypoglycaemia, weight gain, oedema and precipitation of cardiac failure.Results: Both pioglitazone and rosiglitazone improved glycaemic control, with a reduction in the HbA1c level of 1.02% (range, 0.85%–1.19%) and 0.96% (range, 0.81%–1.11%), respectively, in the first 6 months of therapy. Rosiglitazone was associated with a 0.45 mmol (range, 0.31–0.59 mmol) increase in cholesterol level and 0.99 mmol (range, 0.60–1.38 mmol) increase in triglyceride level, while pioglitazone was associated with insignificant declines in cholesterol and triglyceride levels. There was reduced requirement for insulin, but not for oral hypoglycaemic agent (OHA), in most patients who used these agents. Pioglitazone and rosiglitazone were associated with increased rates of hypoglycaemia (17% and 11% of patients, respectively), significant weight gain (48% and 58%) and oedema (33% and 21%). There were four cases of acute left ventricular failure and two cases of reversible liver dysfunction in patients treated with TZDs.Conclusions: Adding pioglitazone or rosiglitazone therapy to OHA or insulin in patients with type 2 diabetes significantly improved glycaemic control. However, the use of these drugs in routine clinical practice was associated with more frequent adverse events than previously reported in clinical trials.

Zanariah Hussein MB BS · John M Wentworth MB BS, PhD · Alison J Nankervis MD, FRACP · Joseph Proietto FRACP, PhD · Peter G Colman FRACP, MD

Objective: To determine whether mental illness is associated with accessibility and remoteness.Design: A cross-sectional, population-based, computer-assisted telephone interview survey, stratified by Accessibility and Remoteness Index of Australia (ARIA) categories.Setting: Secondary analysis of data collected from 2545 South Australian adults in October and November 2000.Outcome measures: Psychological distress and depression as determined by the Kessler 10 Psychological Distress Scale, the SF-12 measure of health status, and self-reported mental illness diagnosed by a doctor in the previous 12 months.Results: Overall, mental illness prevalence estimates were similar using the three measures of psychological distress (10.5%), clinical depression (12.9%) and self-reported mental health problem (12.7%). For each measure, there was no statistically significant variation in prevalence across ARIA categories, except for a lower than expected prevalence of depression (7.7%) in the “accessible” category. There was no trend suggesting higher levels of mental illness among residents of rural and remote regions.Conclusions: The prevalence rates of psychological distress, depression and self-reported mental illness are high. However, we found no evidence that the prevalence of these conditions varies substantially across ARIA categories in South Australia. This finding may challenge existing stereotypes about higher levels of mental illness outside metropolitan Australia.

Kerena A Eckert MPH · Anne W Taylor BA, MPH · Graeme R Tucker BSc · David D Wilkinson MB ChB, DSc

Objective: To examine predictors of death in young offenders who have received a custodial sentence using data routinely collected by juvenile justice services.Design: A retrospective cohort of 2849 (2625 male) 11–20-year-olds receiving their first custodial sentence between 1 January 1988 and 31 December 1999 was identified.Main outcome measures: Deaths, date and primary cause of death ascertained from study commencement to 1 March 2003 by data-matching with the National Death Index; measures comprising year of and age at admission, sex, offence profile, any drug offence, multiple admissions and ethnic and Indigenous status, obtained from departmental records.Results: The overall mortality rate was 7.2 deaths per 1000 person-years of observation. Younger admission age (hazard ratio [HR], 1.4; 95% CI, 1.0–1.9), repeat admissions (HR, 1.8; 95% CI, 1.1–2.9) and drug offences (HR, 1.5; 95% CI, 1.0–2.1) predicted early death. The role of ethnicity/Aboriginality could only be assessed in cohort entrants from 1996 to 1999. The Asian subcohort showed higher risk of death from drug-related causes (HR, 2.5; 95% CI, 1.1–5.5), more drug offences (relative risk ratio [RRR], 13; 95% CI, 8.5–20.0) and older admission age (oldest group v youngest: RRR, 9.3; 95% CI, 1.3–68.0) than non-Indigenous Australians. Although higher mortality was not identified in Indigenous Australians, this group was more likely to be admitted younger (oldest v youngest: RRR, 0.31; 95% CI, 0.15–0.63) and experience repeat admissions (RRR, 1.6; 95% CI, 1.0–2.4).Conclusions: Young offenders have a much higher death rate than other young Victorians. Early detention, multiple detentions and drug-related offences are indicators of high mortality risk. For these offenders, targeted healthcare while in custody and further mental healthcare and social support after release appear essential if we are to reduce the mortality rate in this group.

Carolyn Coffey BSc, GradDipEpi · Andrew W Lovett FRACP · Eileen Cini BSc(Hons) · George C Patton MD, FRANZCP · Rory Wolfe PhD · Paul Moran MD, MRCPsych

Objective: To determine trends in use of Australian acute hospital inpatient services by older patients.Design and data sources: Secondary analysis of hospital data from the Australian Institute of Health and Welfare in the period 1993–94 to 2001–02, with population data for this period from the Australian Bureau of Statistics.Outcome measures: Population-based rates of hospital separations and bed utilisation.Results: The Australian aged population (65 years and older) increased by 18% compared with total population growth of 10%, yet the proportion of hospital beds occupied by older patients remained stable at 47%. The most substantial changes were observed in the population aged 75 years and older, with separations increasing by 89%, length of stay reducing by 35% and bed utilisation increasing by 23%. However, rates of bed utilisation (in relation to population) declined among older groups (10% decline in per capita use in population 75 years and older), but increased in the younger population (1% increase in per capita use in people younger than 65 years).Conclusion: Important trends in use of inpatient services were identified in this study. These trends are contrary to common perception. Ageing of the Australian population was not associated with an increase in the proportion of hospital beds used by older patients.

Len C Gray PhD, FRACP · Margaret A Yeo MPH, BSc(Hons) · Stephen J Duckett PhD, FCHSE

Objectives: To analyse temporal trends and geographical variations in testosterone prescribing in Australia.Design and setting: An analysis of testosterone prescribing over the past 11 years according to products and region, determined by Pharmaceutical Benefits Scheme (PBS) expenditure in Australian states and territories.Main outcome measure: Patterns of monthly PBS expenditure on injectable, oral and implantable testosterone products from 1 January 1991 to 30 December 2001, classified by state or territory.Results: There were two periods (1993–1994 and 1998–1999) of striking upsurge followed by declines in national total prescribing of testosterone. These changes were more prominent for oral than injectable testosterone products, and patterns were similar in all regions, apart from a disproportionately higher peak in Western Australia in 1998. On a per-capita basis, Western Australia showed a dramatic increase in prescribing of oral and implantable, but not injectable, testosterone coinciding with the opening of a franchised men’s sexual health clinic in Perth.Conclusion: The two striking upsurges in testosterone prescribing despite no convincing new evidence to justify them appear to reflect promotional activity to prescribe testosterone for older men, rather than overcoming the underdiagnosis of androgen deficiency related to pituitary or testicular disease in younger men. The curtailments after the introduced restrictions to PBS prescribing for older men without overt androgen deficiency were partial and temporary, suggesting that such regulatory barriers are only partly successful in counteracting the commercial and populist pressure driving excessive testosterone prescribing. Professional and community education is needed for appropriate diagnosis of genuine androgen deficiency in younger men, while discouraging unproven testosterone treatment for ageing men.

David J Handelsman FRACP, PhD