Research

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

Objective: To determine the prevalence of psychiatric disorders among Vietnamese children and adolescents living in Perth, Western Australia.Design, participants and setting: A list of Vietnamese households was drawn from Perth telephone directories. A computer program generated a systematic probability sample of households. All children and adolescents aged 9–17 in these households were invited to participate in the study. Children and their parents were interviewed in their home using the Diagnostic Interview Schedule for Children, version 2.3 (DISC-2.3). The child version (DISC-C) was used for children and the parent version (DISC-P) for adults. The study was conducted between July and December 1997.Main outcome measures: The prevalence of psychiatric disorders in children and adolescents, based on DISC-C and DISC-P data.Results: Results were based on the 519 children (89.2%) for whom complete data were available. Twenty-three parents (4.4%) reported that their child had one or more disorders on the DISC-P, 82 children (15.8%) reported one or more disorders on the DISC-C, and 18.3% of children were reported to have a disorder on either the DISC-C or the DISC-P. Parent–child concordance on specific diagnoses was very low (0.6%). The great majority of disorders reported were anxiety disorders, especially simple and social phobias.Conclusions: The combined prevalence of psychiatric disorders among Vietnamese children aged 9–17 was similar to that found among children in Western Australia's general population. Vietnamese children in our study were much more likely to report symptoms of a psychiatric disorder than were their parents.

Robert S McKelvey MD, FRANZCP · David L Sang PhD · Loretta Baldassar PhD · Lisa Davies PhD · Lynne Roberts PhD · Neil Cutler BA

Objective: To describe the frequency, cause and potential cost of prevention of hollow-bore dirty needlestick injury (NSI) sustained by healthcare workers.Design and participants: Ten-year prospective surveillance study, 1990–1999, with triennial anonymous questionnaire surveys of nursing staff.Setting: 800-bed university tertiary referral hospital in Brisbane, Australia.Main outcome measures: Rates and circumstances of NSI in medical, nursing and non-clinical staff; knowledge of NSI consequences in nurses; and minimum costs of safety devices.Results: Between 1990 and 1999, there was a significant increase (P < 0.001) in the trend of the reported rate of NSI. Of the 1836 "dirty" NSIs reported, most were sustained in nursing (66.2%) and medical (16.8%) staff, with 62.7% sustained before disposal. Hollow-bore injuries from hypodermic needles (83.3%) and winged butterfly needles (9.8%) were over-represented. Knowledge among nursing staff of some of the risks and outcomes of NSI improved over the decade. A trend (χ2 = 9.89; df = 9; P = 0.0016) with increasing rate of reported injuries in this group was detected. The estimated cost of consumables only, associated with the introduction of self-retracting safety syringes with concomitant elimination of butterfly needles, where practicable, would be about $365 000 per year. Conclusion: More than one NSI occurs for every two days of hospital operation. Introduction of self-retracting safety syringes and elimination of butterfly needles should reduce the current hollow-bore NSI by more than 70% and almost halve the total incidence of NSI.

R Michael Whitby FRACP, FRCPA · Mary-Louise McLaws MPH, PhD

Objectives: To investigate whether pantoprazole (20 mg/d) produces significantly greater symptom control than ranitidine (300 mg/d) in patients with gastro-oesophageal reflux disease (GORD).Design: Multicentre, randomised, double-blind, parallel-group comparison.Setting: 76 general practices in north-west Sydney and Newcastle, New South Wales (Australia), from 19 January 1999 to 22 September 2000.Patients: 307 patients aged 18 years or over presenting with symptomatic GORD.Interventions: Pantoprazole (20 mg once daily) or ranitidine (150 mg twice daily).Main outcome measures: Patient-assessed frequency and severity of heartburn using the Gastrointestinal Symptom Rating Scale (GSRS) and a patient heartburn diary.Results: Pantoprazole was associated with significantly higher rates of complete control of GORD symptoms than ranitidine at four weeks (40% v 19%; P < 0.001), eight weeks (55% v 33%; P < 0.001), six months (71% v 56%; P = 0.007) and 12 months (77% v 59%; P = 0.001).Conclusions: Low-dose pantoprazole is an effective alternative to standard-dose ranitidine for initial and maintenance treatment of patients with symptomatic GORD.

Nicholas J Talley MD, FRACP · Michael G Moore FRACGP, GradDipPublicHealth · Arn Sprogis MB BS, FRACGP, GradDipClinEpid · Peter Katelaris MD, FRACP

Objective: To measure the cost-effectiveness of cholesterol-lowering therapy with pravastatin in patients with established ischaemic heart disease and average baseline cholesterol levels.Design: Prospective economic evaluation within a double-blind randomised trial (Long-Term Intervention with Pravastatin in Ischaemic Disease [LIPID]), in which patients with a history of unstable angina or previous myocardial infarction were randomised to receive 40 mg of pravastatin daily or matching placebo.Patients and setting: 9014 patients aged 35–75 years from 85 centres in Australia and New Zealand, recruited from June 1990 to December 1992.Main outcome measures: Cost per death averted, cost per life-year gained, and cost per quality-adjusted life-year gained, calculated from measures of hospitalisations, medication use, outpatient visits, and quality of life.Results: The LIPID trial showed a 22% relative reduction in all-cause mortality (P < 0.001). Over a mean follow-up of 6 years, hospital admissions for coronary heart disease and coronary revascularisation were reduced by about 20%. Over this period, pravastatin cost $A4913 per patient, but reduced total hospitalisation costs by $A1385 per patient and other long-term medication costs by $A360 per patient. In a subsample of patients, average quality of life was 0.98 (where 0 = dead and 1 = normal good health); the treatment groups were not significantly different. The absolute reduction in all-cause mortality was 3.0% (95% CI, 1.6%–4.4%), and the incremental cost was $3246 per patient, resulting in a cost per life saved of $107 730 (95% CI, $68 626–$209 881) within the study period. Extrapolating long-term survival from the placebo group, the undiscounted cost per life-year saved was $7695 (and $10 938 with costs and life-years discounted at an annual rate of 5%).Conclusions: Pravastatin therapy for patients with a history of myocardial infarction or unstable angina and average cholesterol levels reduces all-cause mortality and appears cost effective compared with accepted treatments in high-income countries.

Paul P Glasziou FRACGP, PhD · Simon D Eckermann BEc(Hons), BSc(Ma · Sarah E Mulray BA · R John Simes FRACP, MD · Andrew J Martin MA, PhD · Adrienne C Kirby BSc(Hons), MSc · Susan Caleo BPharm, GradDipSci · Jane P Hall BA, PhD · Harvey D White DSc, FRACP · Andrew M Tonkin MD, FRACP

Objective: To determine whether hormone replacement therapy (HRT) after treatment for breast cancer is associated with increased risk of recurrence and mortality.Design: Retrospective observational study.Participants and setting: Postmenopausal women diagnosed with breast cancer and treated by five Sydney doctors between 1964 and 1999.Outcome measures: Times from diagnosis to cancer recurrence or new breast cancer, to death from all causes and to death from primary tumour were compared between women who used HRT for menopausal symptoms after diagnosis and those who did not. Relative risks (RRs) were determined from Cox regression analyses, adjusted for patient and tumour characteristics.Results: 1122 women were followed up for 0–36 years (median, 6.08 years); 154 were lost to follow-up. 286 women used HRT for menopausal symptoms for up to 26 years (median, 1.75 years). Compared with non-users, HRT users had reduced risk of cancer recurrence (adjusted relative risk [RR], 0.62; 95% CI, 0.43–0.87), all-cause mortality (RR, 0.34; 95% CI, 0.19–0.59) and death from primary tumour (RR, 0.40; 95% CI, 0.22–0.72). Continuous combined HRT was associated with a reduced risk of death from primary tumour (RR, 0.32; 95% CI, 0.12–0.88) and all-cause mortality (RR, 0.27; 95% CI, 0.10–0.73).Conclusion: HRT use for menopausal symptoms by women treated for primary invasive breast cancer is not associated with an increased risk of breast cancer recurrence or shortened life expectancy.

Eva M Durna MBioeth · Leo R Leader MD, FRANZCOG · Peter Sjoblom PhD · John A Eden MD, FRANZCOG · Barry G Wren MD, FRANZCOG · Gillian Z Heller PhD

Objective: To describe the natural history of rheumatic manifestations of Ross River virus (RRV) disease.Design: Prospective longitudinal clinical review.Setting: North Queensland local government areas of Cairns, Douglas, Mareeba and Atherton during January to May 1998.Participants: General practice patients diagnosed with RRV disease on the basis of symptoms and a positive RRV IgM result.Main outcome measures: Rheumatic symptoms and signs assessed as soon as possible after disease onset and on two subsequent occasions (up to 6.5 months after onset).Results: 57 patients were recruited, 47 of whom were reviewed three times (at means of 1.1, 2.4 and 3.6 months after disease onset). Results are reported for these 47: 46 (98%) complained of joint pain at first review, with the ankles, wrists, fingers, knees and metacarpophalangeal joints (II–IV) most commonly involved. Prevalence of joint pain decreased progressively on second and third reviews, both overall (92% and 68% of patients, respectively), and in the five joints most commonly affected. The prevalence of other common rheumatic symptoms and signs, and use of non-steroidal anti-inflammatory drugs, also progressively declined over the three reviews.Conclusions: Earlier studies may have overestimated the prevalence and duration of symptoms in RRV disease. Progressive resolution over 3–6 months appears usual.

David Harley PhD, FAFPHM · David Bossingham FRCP, FRACP · David M Purdie MMedSc, PhD · Nirmala Pandeya BSc, MMedSc · Adrian C Sleigh MD, MPH, FRCP

Objective: To describe the natural history, treatment and cost of Ross River virus-induced epidemic polyarthritis (RRV disease).Design: Questionnaire-based longitudinal prospective study.Participants and setting: Patients in the greater Brisbane area, Queensland, diagnosed with RRV disease by their general practitioners based on clinical symptoms and paired serological tests between November 1997 and April 1999.Main outcome measures: Scores on two validated quality-of-life questionnaires (Clinical Health Assessment Questionnaire and Medical Outcomes Study Short Form 36) were obtained soon after diagnosis and one, two, three, six and 12 months thereafter. Scores were compared between patients diagnosed with RRV disease alone and those with RRV disease plus other conditions.Results: 67 patients were enrolled. Most patients with RRV disease alone had severe acute symptoms, but followed a consistent path to recovery within three to six months. Other conditions, often chronic rheumatic diseases or depression, were identified in half the cohort; their quality-of-life scores suggested stable chronic illness between six and 12 months after diagnosis. Non-steroidal anti-inflammatory drugs (NSAIDs) were taken by 58% of patients (average use, 7.6 weeks; range, 2–22 weeks). Time off work averaged 1.9 days, and direct cost to the community was estimated as $A1018 per patient.Conclusions: Symptom duration and frequency of long-term symptoms may have been overestimated by previous studies of RRV disease. Disease persisting six to 12 months after RRV diagnosis was largely attributable to other conditions, highlighting the need to seek other diagnoses in RRV patients with persistent symptoms.

Andrea D Mylonas BA, RN · Allison M Brown RN, Grad Cert CDM · Tracy L Carthew RN, BN · David M Purdie MMedSc, PhD · Nirmala Pandeya GradDipAppSc, MMedSc · Louisa G Collins BEc, MPH · Andreas Suhrbier MA, PhD · Barry McGrath MB BS, PhD · Elizabeth J Reymond FRACGP, PhD · Philip C Vecchio FRACP, MBA · Ian D Gardner PhD, FACTM · Ferdinandus J de Looze MB BS, MSc

The United States will invest nearly US$70 billion (US$260 per capita) on medical research this year, more than half of which will be sponsored by the biopharmaceutical industry. This investment has been shown to provide major gains in basic, disease-oriented and patient-oriented research. It also provides a huge economic return on investment — whether measured in terms of jobs created, health costs saved, or the dollar value of lives saved. Australia, whose investment in medical research is less than 10% that of the United States, should increase its national commitment.

Leon E Rosenberg MD

Objective: To determine the quality of claims in advertisements published in Australian medical publications, describe how benefits and harms are presented, and examine the level of underpinning evidence.Design and setting: Audit of a consecutive three-month sample of advertisements appearing in six popular Australian medical publications.Main outcome measures: Proportion of advertisements with quantitative information; proportion of claims conveying clinical outcomes; where retrievable, level of underpinning evidence.Results: Of 1504 claims, 855 could be substantiated quantitatively. Of these, 45% were supported by compelling evidence (randomised controlled trials or better). Of 13 claims explicitly reporting quantitative outcomes, none provided the absolute risk reduction or the number needed to treat.Conclusions: Our audit invites greater diligence by pharmaceutical companies in substantiating their claims and greater vigilance among clinicians when reading them.

Tim W Loke MB BS(Hons) · Fong Chee Koh MB BS(Hons) · Jeanette E Ward PhD, FAFPHM