Research

Objective: To determine the feasibility, safety and effectiveness of a structured clinical pathway for stratification and management of patients presenting with chest pain and classified as having intermediate risk of adverse cardiac outcomes in the subsequent six months.Design: Prospective clinical audit.Participants and setting: 630 consecutive patients who presented to the emergency department of a metropolitan tertiary care hospital between January 2000 and June 2001 with chest pain and intermediate-risk features.Intervention: Use of the Accelerated Chest Pain Assessment Protocol (ACPAP), as advocated by the Management of unstable angina guidelines — 2000 from the National Heart Foundation and the Cardiac Society of Australia and New Zealand.Main outcome measure: Adverse cardiac events during six-month follow-up.Results: 409 patients (65%) were reclassified as low risk and discharged at a mean of 14 hours after assessment in the chest pain unit. None had missed myocardial infarctions, while three (1%) had cardiac events at six months (all elective revascularisation procedures, with no readmissions with acute coronary syndromes). Another 110 patients (17%) were reclassified as high risk, and 21 (19%) of these had cardiac events (mainly revascularisations) by six months. Patients who were unable to exercise or had non-diagnostic exercise stress test results (equivocal risk) had an intermediate cardiac event rate (8%).Conclusions: This study validates use of ACPAP. The protocol eliminated missed myocardial infarction; allowed early, safe discharge of low-risk patients; and led to early identification and management of high-risk patients.

Con N Aroney MD, FRACP · Heather L Dunlevie BHlthScN · JH Nicholas Bett FRACP

Objective: To evaluate the impact of a chest-pain guideline on clinical decision-making and medium-term outcomes of patients presenting to a hospital emergency department (ED) with non-traumatic chest pain.Design: Before-and-after guideline implementation study.Setting: Bankstown–Lidcombe Hospital, Sydney, NSW (454-bed metropolitan teaching hospital), in the six-month periods before and after guideline implementation in February 2001.Participants: Patients presenting to the ED with non-traumatic chest pain who had chest-pain assessment forms completed by ED doctors, comprising 422/768 (54.9%) of those presenting before and 461/691 (66.7%) after guideline implementation.Main outcome measures: Appropriateness of admission/discharge decisions compared with decision of senior cardiologist based on guideline; death, recurrent chest pain, ED re-presentation and hospital readmission in the ensuing three months.Results: After guideline implementation, appropriate admission/discharge decisions increased significantly from 180/265 (68%) to 261/324 (81%) (difference, 13%; 95% CI, 6%–20%). The largest increase was for patients at moderate risk of death or acute myocardial infarction within six months, from 39/96 (38%) to 57/103 (55%) (difference, 18%; 95% CI, 4%–31%). Increases were seen for both junior doctors (interns and resident medical officers) (18%; 95% CI, 7%–30%) and senior doctors (11%; 95% CI, 2%–19%). Logistic regression showed that implementation of the guideline, seniority of assessing doctor and patient history of coronary disease were independent predictors of appropriate decisions. There was a significant decline in re-presentations to ED with recurrent chest pain in patients previously presenting with cardiac or possibly cardiac pain, from 46/201 (23%) before implementation to 32/247 (13%) after (difference, 210%; 95% CI, 217% to 23%).Conclusions: The chest-pain guideline resulted in a significant improvement in clinical decision-making in the ED and reduced re-presentations with cardiac/possibly cardiac chest pain.

Soufiane Boufous MPH(Hons) · Bin B Jalaludin PhD, FAFPHM · Charles H Pain FAFHPM · Susan Ieraci FACEM · Anne-Louise Gray BAppSc, PGCertMgt · Susan E Harris B Phty, MPH · Craig P Juergens FRACP · Peter W Kelleher FRACP · Linda M Dann FANZCA, FACEM

Objective: To determine the proportion of patients in Victoria treated within the British Heart Foundation 90-minute call-to-needle (CTN) time benchmark for thrombolysis of ST-elevation myocardial infarction (STEMI), and to validate the British Heart Foundation 90-minute benchmark with respect to mortality.Design: Cohort study.Setting: 20 hospitals and two ambulance services in the State of Victoria, Australia.Participants: 1147 patients with STEMI transported to hospital by ambulance and eligible for thrombolysis.Main outcome measures: CTN time, and in-hospital mortality.Results: Median CTN time was 83 minutes (mean, 93.2 min; range, 29–894 min). Median door-to-needle (DTN) time was 37 minutes (mean, 46.5 min; range, 0–853 min). 61% of patients received thrombolysis within the 90-minute benchmark. Patients with CTN times > 90 minutes had an increased risk of dying (relative risk, 1.8; 95% CI, 1.3–2.7). Factors associated with CTN time < 90 minutes were lower DTN time, prior notification of the receiving hospital and transport time less than 20 minutes.Conclusion: The British Heart Foundation CTN time benchmark is being met for 61% of eligible STEMI patients in Victoria. Strategies to reduce CTN time should be region-specific, and should include attempts to reduce DTN and to enhance ambulance–hospital communication. Prehospital thrombolysis may be appropriate for some regions.

Anne-Maree Kelly MD, FACEM · Debra Kerr BN, MBL · Ian Patrick BParamedStud, MICAcert · Tony Walker BParamedStud, GDipEd

Objective: To achieve sustained improvement in use of cefotaxime and ceftriaxone (CEFX) in a major teaching hospital, as measured against national antibiotic guidelines.Design and setting: Pre- and post-intervention survey of CEFX use in the Royal Melbourne Hospital, a tertiary hospital in Melbourne, Victoria.Intervention: Web-based antimicrobial approval system linked to national antibiotic guidelines was developed by a multidisciplinary team and implemented in March 2001.Main outcome measures: Change in rate of CEFX use (defined daily doses [DDDs] per 1000 acute occupied bed days) over 8 months pre- and 15 months post-intervention; concordance of indication for CEFX with national antibiotic guidelines pre- and post-intervention.Results: CEFX use decreased from a mean of 38.3 DDDs/1000 bed days pre-intervention to 15.9, 18.7 and 21.2 DDDs/1000 bed days at 1, 4 and 15 months post-intervention. Concordance with national antibiotic guidelines rose from 25% of courses pre-intervention to 51% within 5 months post-intervention (P < 0.002). Gentamicin use also increased, from a mean of 30.0 to 48.3 DDDs/1000 bed days (P = 0.0001).Conclusion: The web-based antimicrobial approval system achieved a sustained reduction in CEFX use over 15 months as well as increased prescribing concordance with antibiotic guidelines. It has potential for linking to electronic prescribing and for wider use for other drugs, as well as for research into the epidemiology of antibiotic use.

Michael J Richards FRACP · Lyn-Li Lim MB BS · Marion B Robertson BPharm, MSc · Nicholas R Jones BPharm, Grad Dip Clinical Pharmacy · Simone E Taylor PharmD, Grad Cert CRM · Margarida M Duarte BA (CompSci), BEng (partial) · Dale A Kerr BBus (Information Systems) · Graham J Stanton · Peter D Ritchie MPubHlth, FACEM · Jonathan G A Dartnell BPharm, PhD

Objective: To determine the chance of at least one live birth from one round of in-vitro fertilisation (IVF) treatment and the effect of the woman's age on that likelihood.Design: Retrospective analysis of outcomes from IVF treatment that did not involve donated gametes, but which included embryos cryopreserved in the retrieval cycle.Setting and patients: All IVF patients (median age, 36 years; range, 22–48 years) who attended a private IVF clinic in Sydney for an egg retrieval between 1 January 1998 and 31 December 1998, and had embryo placements (fresh and cryostored) performed up to 30 June 2001.Main outcome measure: Independently audited live births surviving the neonatal period.Results: 565 women had 648 egg retrievals during the period. The age of peak utilisation of IVF was 39 years. For women aged 34 years or less, the chance of a live birth from one round of egg retrieval and IVF treatment was 52.4% (95% CI, 47%–59%). For women aged 35–44 years, there was a linear decline in the live birth rate, and no babies were born from retrievals at age 45 years and over. There was an age-dependent rise in the frequency of miscarriages, from 10.5% (95% CI, 5%–18%) for women under 35 years, to 16.1% (95% CI, 9%–25%) for those 35–39 years, and 42.9% [95% CI, 24%–63%] for those over 40 years (P < 0.001). A third of the first births resulted from embryo transfers performed after a period of cryostorage.Conclusion: As fertility with IVF falls from the age of 34 years, and the age of peak IVF utilisation is 39 years, many Australian women are seeking IVF at an age when the likelihood of a live birth is reduced.

Robert P S Jansen MD, FRACP, FRANZCOG, CREI

Objective: To evaluate the benefits of coordinating community services through the Post-Acute Care (PAC) program in older patients after discharge from hospital.Design: Prospective multicentre, randomised controlled trial with six months of follow-up with blinded outcome measurement.Setting: Four university-affiliated metropolitan general hospitals in Victoria.Participants: All patients aged 65 years and over who were discharged between August 1998 and October 1999 and required community services after discharge.Interventions: Participants were randomly allocated to receive services of a Post-Acute Care (PAC) coordinator (intervention) versus usual discharge planning (control).Main outcome measures: Comparison of quality of life and carer stress at one-month post-discharge, mortality, hospital readmissions, use of community services and community and hospital costs over the six months post-discharge.Results: 654 patients were randomised, and 598 were included in the analysis (311 in the PAC group and 287 in the control group). There was no difference in mortality between the groups (both 6%), but significantly greater overall quality-of-life scores at one-month follow-up in the PAC group. There was no difference in unplanned readmissions, but PAC patients used significantly fewer hospital bed-days in the six months after discharge (mean, 3.0 days; 95% CI, 2.1–3.9) than control patients (5.2 days; 95% CI, 3.8–6.7). Total costs (including hospitalisation, community services and the intervention) were lower in the PAC than the control group (mean difference, $1545; 95% CI, $11–$3078).Conclusions: The PAC program is beneficial in the transition from hospital to the community in older patients.

Wen K Lim FRACP · Sue F Lambert PhD, BEcons · Len C Gray PhD, FRACP

Aim: To determine effectiveness of treatment for hepatitis C outside clinical trials, by testing the hypothesis that apparent effectiveness and tolerability of interferon alfa-2b/ribavirin combination therapy would be less in a hospital liver clinic setting.Design: Retrospective analysis of all patients in one centre commencing interferon alfa-2b/ribavirin therapy, but not in clinical trials, between 1998 and 2000.Main outcome measures: Effectiveness as sustained virological response (SVR); tolerability as premature discontinuation of treatment.Results: The 121 patients had similar demographic and viral characteristics as those in Australian trials (age, 44 ± 10 years; males, 66%; genotype 1, 44%; genotype 3, 36%), but 38% had advanced fibrosis, including 17% with cirrhosis. Sixty (50%) were previously untreated, 38 (31%) had relapsed after initial response (response relapse) and 23 (19%) were non-responders to interferon monotherapy. Sustained viral response (SVR) was achieved in 53% of patients overall: 47% of patients with genotype 1 HCV, 71% of patients with genotype 3. For patients with genotype 1 HCV, SVR was 43% in those previously untreated, 63% in response relapsers, and 38% in non-responders. Corresponding SVRs for genotype 3 were 65%, 87% and 33%. These results are similar to those obtained in published trials. Only 7% of our patients discontinued treatment because of adverse effects, fewer than reported in most clinical trials. Dose reduction was required in 18% of patients.Conclusions: In a hospital clinic setting the effectiveness of interferon alfa-2b/ribavirin combination therapy appears equivalent to published results from clinical trials.

Dinesh Kumar* MD, DM · Craig Wallington-Beddoe* BSc, MB BS · Jacob George PhD, FRACP · Rita Lin PhD, FRACP · Dev Samarasinghe PhD, FRACP · Chris Liddle PhD, FRACP · Geoffrey C Farrell MD, FRACP

Objective: To examine doctors' perceptions and attitudes to prescribing within the Authority Prescribing System (APS).Design and setting: Questionnaire survey of Australian doctors' responses to a number of statements and factorial vignettes, conducted between 1 May and 30 June 2001.Participants: A national random sample of 1200 doctors, stratified according to specialist/generalist, rural/urban and high/low prescriber: 669 (56%) responded.Main outcome measures: Self-reported perceptions of the APS and attitudes to prescribing within the APS.Results: 72% of doctors agreed that the APS makes effective medications available to the socioeconomically disadvantaged members of the Australian public and 50% agreed that it compromises patient privacy. Fewer agreed that authority indicators were based on the highest quality of evidence quality (40%) or medication safety (12%). Doctors placed more emphasis on the doctor–patient relationship than on the criteria for authority prescribing in their decisions about prescribing APS medications. Doctors who used computers to prescribe were more likely to agree that computers can improve the authority prescribing process.Conclusions: This study suggests that authority-required prescribing is not achieving the stated aims of the National Medicines Policy in reducing variability in prescribing. Strategies to improve the quality of prescribing must consider the professional and ethical conundrum associated with prescribing outside of PBS/APS approved use for clinical and patient-centred reasons.

Siaw-Teng Liaw PhD, FRACGP · Christopher M Pearce FRACGP, FACRRM, MFM · Patty Chondros MSc · Leone Piggford MB BS, FRACGP · Kay Jones MSW, PhD · Barry P McGrath PhD, MB BS

Objective: To evaluate changes in prescribing behaviour after distribution of antibiotic guidelines printed on a 9 × 6 cm laminated card suitable for clipping to a hospital identification badge.Intervention: Guidelines for appropriate antibiotic prescribing for 20 common and important paediatric infections were printed on a laminated 9 × 6 cm card suitable to clip to a hospital identification badge and distributed to all medical staff.Design: We collected data from medical records for three marker conditions (tonsillitis, pneumonia, and orbital/periorbital cellulitis) on samples of patients from the six-month periods either side of the month in which the cards were distributed. Prescribers were unaware of the study and investigators analysed the prescriptions without knowledge of the period in which they were written. Prescriptions were rated for appropriate choice of antibiotic and appropriate dose. Data were also collected on antibiotic costs.Main outcome measures: Proportion of cases in which antibiotic choice was appropriate; proportion of cases in which antibiotic dose was appropriate; annualised costs of third-generation cephalosporins.Results: For tonsillitis there was little change in prescribing practice after the cards were introduced. For pneumonia, cases with appropriate choice increased from 77% to 92% (P = 0.028) and cases with appropriate dose increased from 48% to 81% (P = 0.001). For orbital/periorbital cellulitis, cases with appropriate choice increased from 19% to 78% (P < 0.001) and cases with appropriate dose increased from 30% to 51% (P = 0.11). Annualised costs of third-generation cephalosporins were $193 245 pre-cards and $89 814 post-cards.Conclusion: The cards appeared to have a beneficial effect on prescribing practice for the three marker conditions. This simple intervention is likely to be cost-effective and useful in reducing inappropriate use of antibiotics.

Michael South FRACP, MD · Jenny Royle FRACP, MD · Michael Starr FRACP

Objectives: To examine whether the use of current prescribing software systems might raise rates of repeat prescribing, with a consequent increase in use of antibiotics in the community.Design and setting: A prospective audit of consecutive prescriptions for amoxycillin, cefaclor, roxithromycin and amoxycillin/clavulanate presented to community pharmacies in the Hunter region of New South Wales and a follow-up survey of people who received a repeat prescription, October to November 2000.Main outcome measures: The frequency of repeat prescription ordering on computer-generated and handwritten prescriptions; the proportion of people who filled their repeat prescription.Results: Data were collected for 1667 prescriptions presented to 35 pharmacies; 126 people who received repeat prescriptions completed the survey. The rate of repeat prescription ordering on computer-generated prescriptions was 69%, compared with 40% for handwritten prescriptions (odds ratio, 3.3; 95% CI, 2.6–4.2). Computer-generated repeat prescriptions were as likely to be filled as hand-written prescriptions (61% and 69%, respectively).Conclusions: The default settings on computerised prescribing packages result in a significant increase in the use of antibiotics. We estimate these settings result in about 500 000 additional prescriptions being filled annually in Australia for the four antibiotics in the study.

David A Newby BPharm, PhD · Jayne L Fryer BMath, GradDipMedStats · David A Henry MB ChB, FRCP

Objective: To investigate the incidence rate of circumcision for phimosis and other medically indicated reasons in Western Australian boys from 1 January 1981 to 31 December 1999.Design and setting: A population-based incidence study using hospital discharge data of all circumcisions performed in all WA hospitals during the study period.Main outcome measures: Changes in the incidence rate of circumcision for medically indicated reasons.Results: The rate of medically indicated circumcisions increased in boys aged less than 15 years during the study period. Phimosis was the most common medical indication for circumcision in all age groups. The rate of circumcision associated with phimosis was eight times that associated with balanoposthitis and 21 times that of balanitis xerotica obliterans. Boys aged less than five years had the highest rate of circumcision to treat phimosis, at 4.6 per 1000 person-years, representing about 300 circumcisions per year. Boys aged less than five years living in country areas were 1.5 times more likely to be circumcised for phimosis than boys living in metropolitan Perth.Conclusion: The rate of circumcision to treat phimosis in boys aged less than 15 years is seven times the expected incidence rate for phimosis. Many boys are circumcised before reaching five years of age, despite phimosis being rare in this age group.

Katrina Spilsbury BSc, PhD · James B Semmens MSc, PhD · C D'Arcy J Holman MB BS, MPH, PhD · Z Stan Wisniewski MB BS, FRACS

Objective: To assess iodine status and goitre prevalence in a sample of schoolchildren in Melbourne.Design: Cross-sectional study of urinary iodine excretion and presence of goitre in a sample of schoolchildren from Years 5–12 attending two urban schools.Participants: 607 children aged 11–18 years consented to thyroid gland palpation and 577 provided a urine sample on the day of examination in August 2001.Outcome measure: Iodine status of the study population, based on median urinary iodine values categorised as normal (≥ 100 μg/L), mild (50–99 μg/L) or moderate–severe (< 50 μg/L), and classified according to sex, school year and presence of goitre.Results: 76% (439/577) of students had abnormal urinary iodine values, with 27% (156/577) having values consistent with moderate–severe deficiency. The median urinary iodine excretion for the total group was 70μg/L, with values for school years 5–12 ranging from 62 μg/L (Year 12) to 76 μg/L (Year 9). The median urinary iodine value in girls was lower than that in boys (64μg/L v 82 μg/L), and girls had significantly lower urinary iodine values overall (P < 0.002). There was no association between goitre grade and moderate–severe (< 50 μg/L; P = 0.39) or mild (50–99 μg/L; P = 0.07) urinary iodine deficiency.Conclusions: We found mild iodine deficiency in a cohort of schoolchildren in Melbourne. Our results support other data showing mild iodine deficiency in Sydney and Tasmania and the argument for a national study of iodine nutrition.

Ciara M McDonnell MB, MRCPI · Mark Harris MD BS, FRACP · Margaret R Zacharin MB BS, FRACP

Objectives: To evaluate a Framingham risk function for coronary heart disease in an elderly Australian cohort and to derive a risk function for cardiovascular disease (CVD) in elderly Australians.Design and setting: Analysis of data from a prospective cohort study (the Dubbo Study) in a semi-urban town (population, 34 000).Participants: 2805 men and women 60 years and older living in the community, first assessed in 1988, and a subcohort of 2102 free of CVD at study entry.Main outcome measures: Incidence of CVD (myocardial infarction, coronary death or stroke) over 5 and 10 years.Results: A Framingham risk function assessing "hard" coronary heart disease (ie, myocardial infarction or coronary death) accurately predicted 10-year incidence in men and women aged 60–79 years who were free of prevalent CVD or diabetes at study entry. In a multiple logistic model, CVD incidence was significantly predicted by age, sex, taking antihypertensive medication, blood pressure, smoking, total cholesterol level and diabetes. For a given age and cholesterol level, CVD risk over 5 years was doubled in the presence of antihypertensive medication or diabetes, increased by 50% with cigarette smoking, and halved in women compared with men.Conclusions: We have derived a simple CVD risk function specifically for elderly Australians that employs risk factors readily accessible to all medical practitioners.

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

Objectives: To estimate the appropriateness of transfusions of platelets, fresh frozen plasma (FFP) and cryoprecipitate using National Health and Medical Research Council and Australasian Society for Blood Transfusion guidelines (NHMRC/ASBT 2002).Design and setting: Three separate retrospective surveys of medical records from 1 January to 31 August 2000 (1147 transfused patients) from 14 hospitals selected randomly from all public hospitals that use these blood products in New South Wales: five tertiary referral, five major metropolitan, and four major rural (base) hospitals.Main outcome measures: Proportion of potentially inappropriate transfusions.Results: 33% (136/414) of platelet, 37% (248/669) of FFP and 62% (37/60) of cryoprecipitate transfusions were assessed as inappropriate. By hospital type, 29% (75/259) of platelet transfusions were inappropriate at tertiary referral hospitals, 51% (40/78) at major urban hospitals, and 27% (21/79) at major rural hospitals. For FFP, 36% (112/313), 37% (80/216) and 39% (55/140) were inappropriate for referral, urban and rural hospitals, respectively. Cryoprecipitate was used almost exclusively at tertiary referral hospitals.Conclusions: In terms of the NHMRC/ASBT guidelines on use of blood products, there is considerable inappropriate transfusion of platelets, FFP and cryoprecipitate in NSW public hospitals.

William N Schofield MA, DipEdPsych · George L Rubin FAFPHM, FACR · Mark G Dean FRACP, FRCPA

Objectives: To describe the prevalence of markers of growth, chronic and infectious disease in peripubertal Aboriginal children living in the Darwin Health Region in the "Top End" of the Northern Territory, and to compare prevalence between children living in urban and remote areas.Design: Cross-sectional survey nested in a prospective birth cohort.Subjects: 482 children living in the region who were recruited at birth (Jan 1987 to Mar 1990) and were followed up between 1998 and 2001, when aged 8–14 years.Main outcome measures: Selected parameters of growth and nutrition, infectious disease and potential markers of chronic adult disease were compared between children living at follow-up in suburban situations in Darwin–Palmerston (urban) and those living in rural communities with an Aboriginal council (remote).Results: Remote children were shorter than urban children (mean height, 141.7 v 146.3 cm; P < 0.001), lighter (median weight, 30.3 v 37.1 kg; P < 0.001) and had lower body mass index (median, 15.3 v 17.9 kg/m2; P < 0.001) and haemoglobin level (mean, 125.1 v 130.9 g/L; P < 0.001). Some potential markers of adult chronic disease were higher in urban than remote children: systolic blood pressure (mean, 109.6 v 106.2 mmHg; P = 0.004), and levels of total cholesterol (4.3 v 4.0 mmol/L; P < 0.001), high-density lipoprotein cholesterol (mean, 1.4 v 1.2 mmol/L; P < 0.001) and insulin (median, 7 v 4 mU/L; P = 0.007). Diastolic blood pressure, levels of red cell folate, serum glucose and low-density lipoprotein cholesterol, and urinary albumin–creatinine ratio did not differ by location. The prevalence of visible infections was also higher in remote than urban children (P < 0.05).Conclusion: As some markers of health differ between peripubertal Aboriginal children living in urban areas and those in remote areas, results of surveys in remote areas cannot be generalised to urban Aboriginal populations.

Dorothy E M Mackerras MPH, PhD · Alison Reid MSc · Susan M Sayers FRACP, PhD · Gurmeet R Singh MD · Kathryn A Flynn BNurs · Ingrid K Bucens FRACP

Objective: To investigate the toxicity of bupropion hydrochloride in deliberate self-poisoning in adults and accidental ingestion by children.Design and setting: Prospective study of cases identified from calls to the New South Wales Poisons Information Centre (NSW PIC), with follow-up through hospital medical records.Participants: Patients with bupropion poisoning managed in hospital, about whom the NSW PIC was contacted for advice, from 1 November 2000 to 31 July 2001 (59 adults and 10 children).Main outcome measures: Clinical effects, adverse outcomes (including seizures and death) and treatment.Results: 45 of the 59 adults were followed up (76%), 19 of whom had taken bupropion alone. Major clinical effects of bupropion included sinus tachycardia (83%), hypertension (56%), seizures (37%), gastrointestinal symptoms (37%) and agitation (32%). Seizures were dose-dependent, with those having seizures ingesting a significantly higher median dose (P = 0.02). All seizures were brief and self-limiting. 29 patients received decontamination therapy. 10 patients required pharmacological sedation, 10 were admitted to intensive care and six were intubated. None died. Eight of 10 accidental ingestions by children were followed up (80%); one child had symptoms (vomiting and hallucinations).Conclusions: Bupropion overdose caused significant clinical effects in adults, but few in children.

Corrine R Balit BPharm · Christa N Lynch BPharm · Geoffrey K Isbister BSc, MB BS FACEM

Objectives: To evaluate the effectiveness of a trachoma control program in a remote community before and after major environmental health improvements.Design: Before-and-after cross-sectional design. The control program was in three rounds — each consisting of community census, screening of children < 13 years, health promotion activities and antibiotic treatment. There were two housing and infrastructure surveys.Interventions: Treatment of affected children and their households with azithromycin at baseline, 7 and 21 months, and health promotions. Housing and sewerage infrastructure improvements were completed at 12 months.Setting: Large, remote Central Australian Aboriginal community, 1998–2000.Participants: All community residents.Main outcome measures: Prevalence of active trachoma among children under 13 years; community population changes; and adequacy of housing facilities for healthy living practices.Results: The prevalence of trachoma among children was 40% (95% CI, 32%–46%) at baseline, 33% (95% CI, 26%–40%) at 7 months' follow-up and 37% (95% CI, 29%–46%) at 21 months. These proportions were neither clinically nor statistically significantly different. There was a high degree of population mobility over the study period, with only 32% of residents appearing in all three censuses. The proportion of houses with completely adequate facilities increased from 0 to 16%.Conclusions: Population mobility (both within and between communities), inadequate housing and continued crowding (despite improvements), as well as uncertainty about compliance with antibiotic treatment, are the likely factors contributing to the lack of effect of this trachoma control program. Because of high population mobility, a region-wide approach is needed for effective trachoma control.

Dan P Ewald MAppEpid, FAFPHM · Gillian V Hall MB BS, PhD · Christine C Franks GradDipIndHealth, MAppEpid

Objective: To investigate possible routes for human infection by the dog hookworm (Ancylostoma caninum).Design, setting and participant: Relatively small numbers of infective larvae were administered orally and percutaneously to an informed healthy volunteer (J K L) under medical supervision, at intervals between May 1998 and May 1999.Main outcome measures: Symptoms; weekly blood eosinophil counts; faecal microscopy.Results: A marked blood eosinophilia followed a single oral exposure to 100 infective larvae, while faecal examination remained negative. Eosinophil counts then declined gradually, although a rapid, spontaneous rise several months later, at the beginning of spring, possibly indicated reactivation of dormant larvae. Blood eosinophil numbers did not rise significantly after percutaneous infection with 200 larvae. A subsequent, smaller, oral inoculum of 20 larvae provoked an eosinophil response similar to that of the first experiment.Conclusions: Our findings suggest that, following ingestion, some infective larvae of A. caninum develop directly into adult worms in the human gut (as they do in dogs). While the percutaneous route might be the most common means of human exposure to canine hookworm larvae, leading generally to subclinical infection, oral infection may be more likely to provoke symptomatic eosinophilic enteritis.

Juergen K Landmann BSc(Hons) · Paul Prociv MB BS, PhD, FRACP, FRCPA

Objectives: To examine trends in the licit consumption of the psychostimulants dexamphetamine and methylphenidate in Australia and nine other countries from 1994 to 2000 and in each State and Territory of Australia from 1984 to 2000.Design: Annual rates of consumption of psychostimulants were compared using Poisson regression models. All drug consumption was standardised to defined daily doses per 1000 population per day.Main outcome measures: Rates of consumption of each psychostimulant in each country and in each Australian State and Territory.Results: For the 10 countries from 1994 to 2000, total psychostimulant consumption increased by an average 12% per year, with the highest increase from 1998 to 2000. Australia and New Zealand ranked third in total psychostimulant use after the United States and Canada. Australia consumed significantly more than the United Kingdom, Sweden, Spain, the Netherlands, France or Denmark. In Australia, from 1984 to 2000, the rate of consumption of licit psychostimulants increased by 26% per year, with an 8.46-fold increase from 1994 to 2000. Western Australia ranked first, with nearly twice the consumption rate of total psychostimulants as New South Wales, which ranked second. Methylphenidate is the main psychostimulant consumed in the US and Canada, and dexamphetamine in Australia.Conclusions: The consumption of psychostimulants in Australia is high internationally and varies significantly between States and Territories. The results imply varied jurisdictional prescribing determinants and supply processes throughout Australia, which may require new national prescribing standards and access to online patient data for prescribers and dispensers.

Constantine G Berbatis BSc, MSc · V Bruce Sunderland PhD, FPS · Max Bulsara BSc(Hons), MSc

Objective: To investigate the extent of participation in cervical cancer screening among women who live in discrete rural and remote Indigenous communities in Queensland.Design: Descriptive analysis of data from the Queensland Health Pap Smear Registry for the period March 1999 to February 2001.Subjects: Women aged 20–69 years who had given their address of usual residence as one of 13 discrete rural and remote Indigenous communities in Queensland.Main outcome measures: Proportion of women who participated in cervical screening over a two-year period ("biennial participation percentage") and variation in participation across the 13 communities.Results: Overall, the biennial participation percentage in the Indigenous communities was 41.1%. This was 30% lower (risk ratio, 0.70; 95% CI, 0.67–0.72) than that for the rest of Queensland. There was statistically significant variation among communities, with biennial participation percentage ranging from 19.9% to 63.5%.Conclusions: The variation in participation across the communities suggests that the problem of low participation among Indigenous women is not intractable. Achieving participation rates similar to the highest rates found in our study would be of major benefit to Indigenous women.

Michael D Coory MB BS, PhD · Jennifer M Muller MEnvCommHealth, GradDipHealthProm · Nathan A M Dunn BSc(Hons) · Patricia S Fagan MB BS, FAFPHM

Objective: To determine the incidence and appropriateness of use of allogenic packed red blood cell (RBC) transfusion in Australian and New Zealand intensive care practice.Setting: Intensive care units of 18 Australian and New Zealand hospitals: March 2001.Design: Prospective, observational, multicentre study.Methods: All admissions to participating intensive care units were screened and all patients who received a transfusion of RBC were enrolled. The indications for transfusion were recorded and compared with Australian National Health and Medical Research Council guidelines. Transfusions conforming to these guidelines were deemed appropriate.Main outcome measures: RBC transfusion in intensive care and transfusion appropriateness.Results: 1808 admissions to intensive care units were screened: 357 (19.8%) admissions (350 patients) received an RBC transfusion while in intensive care. Overall, 1464 RBC units were administered in intensive care on 576 transfusion days. The most common indications for transfusion were acute bleeding (60.1%; 880/1464) and diminished physiological reserve (28.9%; 423/1464). The rate of inappropriate transfusion was 3.0% (44/1464). Diminished physiological reserve with haemogloblin level ≥ 100 g/L was the indication in 50% (22/44) of inappropriate transfusions; no indication was provided for 31% (15/44).Conclusion: The rate of inappropriate transfusion in Australian and New Zealand intensive care units in 2001 was remarkably low.

and the ANZICS Clinical Trials Group*

Objectives: To determine whether routine urinalysis in the antenatal period facilitates diagnosis of pre-eclampsia. Can routine urinalysis during pregnancy be discontinued in women with normal results of dipstick urinalysis and microscopy at the first antenatal visit?Design: Prospective observational study.Setting: A metropolitan public hospital and a private hospital in Sydney (NSW).Participants: One thousand women were enrolled at their first antenatal visit (March to November 1999), and 913 completed the study.Outcome measures: The primary outcome was a diagnosis of de novo hypertension (gestational hypertension, pre-eclampsia, or pre-eclampsia superimposed on chronic hypertension).Results: Thirty-five women had dipstick proteinuria at their first antenatal visit. In 25 (71%) of these women, further dipstick proteinuria was detected during pregnancy, and two (6%) were diagnosed with pre-eclampsia. Of the 867 without dipstick proteinuria at the first visit, 338 (39%) had dipstick proteinuria (> 1+) at some time during pregnancy. There were no statistically significant differences in the proportion of women with and without dipstick proteinuria at their first visit who developed hypertension during pregnancy. Only six women developed proteinuria before the onset of hypertension. Women who had an abnormal result of a midstream urine test at their first visit, compared with women with a normal result, were more likely to have a urinary tract infection diagnosed during pregnancy; however, the numbers were small.Conclusion: In the absence of hypertension, routine urinalysis during pregnancy is a poor predictor of pre-eclampsia. Therefore, after an initial screening urinalysis, routine urinalysis could be eliminated from antenatal care without adverse outcomes for women.

Noreen Murray RM, BN · Caroline S E Homer RM, PhD · Gregory K Davis MD, FRACOG · Julie Curtis RN, RM · George Mangos MD, FRACP · Mark A Brown MD, FRACP

Objectives: To evaluate the effectiveness of coordinated care for chronic respiratory disease.Design and setting: Community-based geographical control study, in western (intervention) and northern (comparison) metropolitan Adelaide (SA).Participants: 377 adults (223 intervention; 154 comparison) with chronic obstructive pulmonary disease, asthma or other chronic respiratory condition, July 1997 to December 1999.Intervention: Coordinated care (includes care coordinator, care guidelines, service coordinator and care mentor).Main outcome measures: Hospital admissions (any, unplanned and respiratory), functionality (activities of daily living) and quality of life (SF-36 and Dartmouth COOP).Results: At entry to the study, intervention and comparison subjects were dissimilar. The intervention group was 10 years older (P < 0.001), less likely to smoke (P = 0.014), had higher rates of hospitalisation in the previous 12 months (P < 0.001) and had worse self-reported quality of life (SF-36 physical component summary score [P < 0.001] and four of nine COOP domains [P = 0.002–0.013]). After adjustment for relevant baseline characteristics, coordinated care was not associated with any difference in hospitalisation, but was associated with some improvements in quality of life (SF-36 mental component summary score [P = 0.023] and three of nine COOP domains [P = 0.008–0.031]) compared with the comparison group.Conclusions: Coordinated care given to patients with chronic respiratory disease did not affect hospitalisation, but it was associated with an improvement in some quality-of-life measures.

Brian J Smith MB BS, PhD · Heather J McElroy BSc(Hons) · Richard E Ruffin MD, FRACP · Adrian R Heard MPH, BSocAdmin · Peter A Frith MD, FRACP · Malcolm W Battersby MB BS, PhD · Adrian J Esterman BSc(Hons), MSc · Peter Del Fante MB BS(Hons), MSc(Public Health) · Peter J McDonald MB BS, FRACP

Objectives: To describe the epidemiology of gestational diabetes mellitus (GDM) in Victoria.Study design: Population study of all women having singleton births in Victoria in 1996.Methods: Probabilistic record linkage of routinely collected data and capture–recapture techniques to provide an estimate of the incidence of GDM.Main outcome measures: Risk factors for and the adverse outcomes associated with GDM compared with the non-diabetic population by univariate and multivariate analysis.Results: The estimated incidence of GDM was 3.6% (95% confidence interval [CI], 3.60%–3.64%). GDM is associated with women who are older, Aboriginal, non-Australian born, or who give birth in a larger hospital. The adverse outcomes associated with GDM pregnancies were hypertension/pre-eclampsia (adjusted odds ratio [OR], 1.6; 95% CI, 1.4–1.9), hyaline membrane disease (1.6; 1.2–2.2), neonatal jaundice (1.4; 1.2–1.7) and macrosomia (2.0; 1.8–2.3). Interventions during childbirth were also associated with GDM — for example, induction of labour (3.0; 2.7–3.4) and caesarean section (1.7; 1.6–1.9).Conclusion: Women with GDM had increased rates of hypertension, pre-eclampsia, induced labour, and interventional delivery. Their offspring had a higher risk of macrosomia, neonatal jaundice and hyaline membrane disease.

Christine A Stone GradDipEpidBiostat, MPH, MHSc(PHP) · Kylie A McLachlan MB BS, FRACP · Jane L Halliday PhD · Peter Wein MB BS, FRANZCOG, GradDipEpidBiostat · Christine Tippett MB BS, FRANZCOG, MRCOG

Objective: To investigate family members' experiences of involvement in a previous study (conducted August 1995 to June 1997) following their child's diagnosis with Ewing's sarcoma.Design: Retrospective survey, conducted between 1 November and 30 November 1997, using a postal questionnaire.Participants: Eighty-one of 97 families who had previously completed an in-depth interview as part of a national case–control study of Ewing's sarcoma.Main outcome measures: Participants' views on how participation in the previous study had affected them and what motivated them to participate.Results: Most study participants indicated that taking part in the previous study had been a positive experience. Most (n = 79 [97.5%]) believed their involvement would benefit others and were glad to have participated, despite expecting and finding some parts of the interview to be painful. Parents whose child was still alive at the time of the interview recalled participation as more painful than those whose child had died before the interview. Parents who had completed the interview less than a year before our study recalled it as being more painful than those who had completed it more than a year before.Conclusions: That people suffering bereavement are generally eager to participate in research and may indeed find it a positive experience is useful information for members of ethics review boards and other "gatekeepers", who frequently need to determine whether studies into sensitive areas should be approved. Such information may also help members of the community to make an informed decision regarding participation in such research.

Debbie A Scott DipNurse, MPH · Frances M Boyle BA(Psych)(Hons), PhD · Christopher J Bain MBBS MPH · Patricia C Valery MD, MPH, PhD