Objective: To examine mortality from all causes and from cardiovascular disease (CVD), and CVD hospitalisation rate for a decentralised Aboriginal community in the Northern Territory.Design and participants: For a community-based cohort of 296 people aged 15 years or older screened in 1995, we reviewed hospital and primary health care records and death certificates for the period up to December 2004 (2800 person-years of follow-up).Main outcome measures: Mortality from all causes and CVD, and hospitalisation with CVD coded as a primary cause of admission; comparison with prior trends (1988 to 1995) in CVD risk factor prevalence for the community, and with NT-specific Indigenous mortality and hospitalisation rates.Results: Mortality in the cohort was 964/100 000 person-years, significantly lower than that of the NT Indigenous population (standardised mortality ratio [SMR], 0.62; 95% CI, 0.42–0.89). CVD mortality was 358/100 000 person-years for people aged 25 years or older (SMR, 0.52; 95% CI, 0.23–1.02). Hospitalisation with CVD as a primary cause was 13/1000 person-years for the cohort, compared with 33/1000 person-years for the NT Indigenous population.Conclusion: Contributors to lower than expected morbidity and mortality are likely to include the nature of primary health care services, which provide regular outreach to outstation communities, as well as the decentralised mode of outstation living (with its attendant benefits for physical activity, diet and limited access to alcohol), and social factors, including connectedness to culture, family and land, and opportunities for self-determination.

Kevin G Rowley PhD · Kerin O’Dea PhD, AO · Ian Anderson MB BS, FAFPHM, PhD · Robyn McDermott FAFPHM, MPH, PhD · Karmananda Saraswati MB BS, FAMAC · Ricky Tilmouth · Iris Roberts EN · Joseph Fitz · Zaimin Wang PhD · Alicia Jenkins MD, FRACP · James D Best MD, FRACP, FRCPath · Zhiqiang Wang PhD · Alex Brown BMed, MPH, FCSANZ

Objective: To assess the outcomes for chronic dialysis patients requiring admission to an intensive care unit (ICU) or high dependency unit (HDU).Design: Retrospective audit of prospectively collected data from local and national databases.Setting: The ICU and HDU at a tertiary referral hospital.Participants: 70 chronic dialysis patients admitted between 2001 and 2006.Main outcome measures: Unit and hospital mortality, recurrent admission patterns and median survival after discharge from hospital.Results: For patients’ last admissions, mortality in the ICU or HDU was 17% and in hospital was 29%. The 12 deaths in the ICU or HDU occurred a median of 18 hours (range, 3–203 hours) after admission, reflecting the severity of their underlying illness. The independent predictors of death in hospital were age and the number of non-renal organ systems failing. Patients with pulmonary oedema had a lower risk of death than patients admitted for other reasons. Although 21 patients accounted for 55 of 104 admissions (53%), recurrent admissions to the ICU or HDU generally occurred during different hospital admissions. They were not associated with a higher risk of death in hospital. Patients discharged home had a median survival of 2.25 years, and a median survival of 3.5 years from starting dialysis. The median survival for patients on dialysis in Australia in general is 4.5 years (Australia and New Zealand Dialysis and Transplant Registry).Conclusion: Dialysis patients discharged home after an ICU or HDU admission have survival similar to that of Australian dialysis patients generally.

Sivagnanavel Senthuran FRCA, FJFICM · Hiran Bandeshe BSc, BEng(Biomed) · Dwarakanathan Ranganathan FRCP, FRACP · Robert Boots PhD, FRACP, FJFICM

Excessive reliance on intraocular pressure to detect glaucoma leaves many affected patients undiagnosed and untreated; visualisation of the optic disc is a dying art that needs to be revived Intraocular pressure (IOP) is measured by tonometry. In our community, mean IOP is around 15 mmHg, with a normal range (mean ± 2 SD) regarded as 10–21 mmHg. This information is irrelevant to the diagnosis of glaucoma. Misconceptions about the importance of IOP in diagnosing and screening for glaucoma continue to result in unnecessary blindness in Australia from glaucomatous optic neuropathy. An aggressive realignment in our thinking is required. The classic diagnostic triad for glaucoma of raised IOP, arcuate visual field loss and optic nerve head cupping has been inverted. Glaucoma may now be defined as a characteristic, progressive, optic neuropathy showing optic disc cupping as a consequence of neural rim loss. It tends to produce arcuate visual field loss. It is frequently associated with an elevated IOP, but may be diagnosed at any IOP if there is characteristic optic disc and/or visual field damage. This damage indicates susceptibility of that optic nerve to a given IOP. Early work established a population mean IOP, with an about normal distribution.1 It is regrettable that this result came to be interpreted as indicating a “normal” (ie, safe) IOP for an individual patient, particularly as that report recognised that glaucoma could occur despite an IOP of less than 21 mmHg. In the Baltimore Eye Survey, more than 50% of patients with newly diagnosed glaucoma had a “normal” IOP on a single tonometry measurement.2 The term “normal pressure glaucoma” (NPG) has been coined for such eyes, and they may comprise a third to a half of all open-angle glaucoma cases.2,3 Conversely, there is a subset of the population that has IOP elevated above normal, yet does not have glaucoma. This status is labelled ocular hypertension. Detection of elevated IOP remains important at any time. The prevalence of glaucoma at successive levels of IOP greater than 21 mmHg rises exponentially.4 IOP is the single greatest risk factor for glaucoma, and its reduction is the cornerstone of all current treatment. Screening on the basis of IOP alone, however, clearly produces a high rate of potentially disastrous false negatives. Patients continue to undergo “eye-checks” and be reassured that they do not have glaucoma solely on the basis of an IOP measurement. This represents an inadequate standard of care. Visual field loss is no longer a sine qua non of diagnosis. In recognition that up to 40% of axons may be lost from the optic nerve before visual field loss is evident on standard automated perimetry,5 the term “preperimetric glaucoma” connotes this early disease. Rather than being a distinct entity, preperimetric glaucoma really indicates the inadequate sensitivity of this standard psychophysical test in detecting early glaucoma (as compared with its invaluable role in confirming and monitoring established disease). Early detection of disease can thus depend entirely on identifying optic disc cupping, notching or rim loss, and associated retinal nerve fibre layer defects, perhaps in the absence of raised IOP or visual field loss. Newer and more sensitive tests of specific visual processing such as frequency doubling perimetry or short wavelength automated perimetry may detect glaucoma earlier, and may thus shift the boundary in defining preperimetric glaucoma.6 We must also disabuse ourselves of any convenient dichotomy between chronic open-angle glaucoma and acute angle-closure “glaucoma”. (Acute primary angle closure [APAC] causes a painful, unilateral red eye with markedly elevated IOP: patients with APAC may not have optic disc cupping or visual field loss.) It is increasingly evident that a massive and untreated burden of chronic angle-closure glaucoma exists, particularly in Chinese and South-East Asian people,7 and therefore in our immigrant populations and their families. Glaucoma, whether open-angle or closed-angle, is an insidious disease — “the sneak thief of sight”. Its prevalence increases exponentially with age; progression is slow, painless and irreversible; visual acuity is affected only late; and symptoms of peripheral vision loss with mobility difficulties do not occur until gross levels of field constriction have developed. For all these reasons, affected patients tend not to present but instead need to be found. Prevention — or at least slowing — of further vision loss is possible with an effective range of medical, laser or surgical therapies directed at lowering IOP to an individualised target level (which may be considerably lower than 21 mmHg). The limitation to our preventing blindness in Australia is not so much a lack of therapies, but inadequate case detection. Awareness of the newer concepts in glaucoma has been variable among general practitioners, optometrists and even ophthalmologists. Glaucoma has a prevalence of around 3% in the population aged over 50 years, yet 50% of cases of glaucoma in Australia today remain undiagnosed.8 The Melbourne Visual Impairment Project provides a further indictment: of the patients whose glaucoma was detected during the survey and who had seen an eye-care practitioner in the preceding 12 months, nearly half (many of whom had established visual field defects) had not had their glaucoma diagnosed.9 Highly sensitive screening programs of the general population for glaucoma are, however, not cost-effective, producing low case yields and a high number of false positives.10 Despite a panoply of technological wizardry, there remains no device that in a single or screening test can identify early glaucoma with appropriate sensitivity and specificity. Local research is progressing with international collaborators to identify genetic loci responsible for glaucoma,11 but a blood test to identify those genetically at risk is not generally available. What is to be done? Ophthalmologists diagnose and manage glaucoma, but are referral-dependent and thus see a selected sample. The aim that every Australian aged over 40 years have a general eye examination by an eye-care practitioner remains an elusive goal, but such a strategy could detect glaucoma as well as other ocular abnormalities, particularly if glaucoma sufferers could be prompted to reveal their diagnosis to first-degree relatives. “More funding” is a mantra so tired as to engender indifference, but would certainly enable more targeted, resource-intensive testing.12 While the benefit of disease detection seems self-evident, legitimate public health arguments could be mounted that, as progression of glaucoma is slow, diagnosis and treatment of early disease (particularly in older patients with preperimetric glaucoma) is not justifiable. We must also be mindful of the burden of the diagnosis and treatment for the patient.13 Screening protocols would therefore be directed not to detecting early glaucoma per se, but rather to finding those with a greater lifetime risk of loss of functional vision (ie, advanced disease, younger age or higher IOP). In the absence of such a structured program, we are dependent on “opportunistic screening”. In this issue of the Journal, Zegers and colleagues present two clinical vignettes illustrating the importance of a family history of glaucoma,14 which is an excellent starting point in case detection (→ Primary open-angle glaucoma: the importance of family history and role of intraocular pressure). Glaucoma suspects can also be identified by general practitioners and optometrists prepared to examine the optic disc. For the former, ophthalmoscopy is a dying art that needs to be rejuvenated in training programs so that visualisation of the optic disc can resume its place in the routine medical check-up. Optometrists, on the other hand, are technologically equipped and trained to detect and diagnose eye disease, are frequently primary eye-care practitioners, and are numerous. The recent move by a vanguard of optometrists into therapeutics and comanagement remains politically vexed. Nonetheless, medical practitioners must accept and encourage the major contribution to glaucoma detection that many optometrists make. Vision loss from glaucoma is most often preventable. Current therapies are effective if the diagnosis is made early enough. Many treatable patients continue to lose visual field because case-detection strategies are haphazard, incomplete, or suffer from a lingering and inappropriate fixation on elevated IOP as the sole diagnostic criterion. The two simple tasks of asking for a family history of glaucoma and assessing the optic disc (with referral onward of patients with positive findings) represent opportunities to diminish the impact of the commonest preventable cause of irreversible blindness in Australia today. To heighten awareness of glaucoma, the first-ever World Glaucoma Day has been designated for 6 March 2008 (http://www.wgday.net). Glaucoma Australia provides patient and community education and support, and can be contacted at http://www.glaucoma.org.au.

Mark J Walland MB BS, FRANZCO, FRACS

Objectives: To explore awareness of the causes of kidney disease and recollection of kidney function testing in a cohort of Australian adults.Design, setting and participants: An interviewer-administered cross-sectional survey, conducted from October to December 2004 as a nested study within the 5-year follow-up phase of the Australian Diabetes, Obesity and Lifestyle Study (AusDiab); 852 subjects who attended a testing site in New South Wales were interviewed.Main outcome measures: Responses to the questions “What sort of things do you think may lead to a person developing kidney disease?” and “Has a doctor or health care worker ever tested your kidney function, outside of the AusDiab study?”Results: Respondents most commonly believed that kidney disease was caused by alcohol misuse or poor diet, with few identifying diabetes or high blood pressure. Awareness of risk factors was no greater in respondents identified as having chronic kidney disease (CKD). A third of respondents with CKD recalled having undergone a test of kidney function within the previous 2 years, while another third replied they had never had their kidney function tested. Of participants with previously diagnosed diabetes or treated hypertension, 54.1% and 32.0%, respectively, reported having their kidney function tested within the previous 2 years.Conclusions: Knowledge of risk factors for kidney disease and recall of kidney function testing were both limited, even among subgroups of the cohort who were at greatest risk of CKD. Prevention efforts may benefit from public and patient education to improve recognition of risk factors for CKD.

Sarah L White MPH · Kevan R Polkinghorne FRACP, MClinEpi · Alan Cass FRACP, PhD · Jonathan Shaw FRACP, MD · Robert C Atkins FRACP, DSc · Steven J Chadban FRACP, PhD

Objective: To study persistence and adherence with the use of common antihypertensive (AHT) medications.Design, setting and participants: Longitudinal assessment of Pharmaceutical Benefit Scheme claim records covering the period January 2004 to December 2006. We analysed a 10% random sample of all Australian long-term health concession card holders who had been commenced on an angiotensin II receptor antagonist (A2RA), an angiotensin-converting enzyme inhibitor (ACEI) and/or a calcium channel blocker (CCB), but for whom no AHT medication had been dispensed in the previous 6 months.Main outcome measures: Proportion of patients failing to fill a second prescription; median persistence time with medication (ie, non-cessation of therapy); persistence with medication over 33 months; median medication possession ratio (MPR, defined as the proportion of prescribed medication actually consumed by patients persisting with treatment).Results: The database yielded information relating to 48 690 patients prescribed AHT medication. Nineteen per cent of patients failed to collect a second prescription. The median persistence time was 20 months. The data were little different from the population average with respect to A2RAs or ACEIs, but persistence was 57% poorer with respect to CCBs (log-rank P < 0.001) (28% of patients prescribed CCBs failed to collect a second prescription; median persistence time, 7 months). There were differences in persistence between individual drugs in the respective classes, the best outcomes being with candesartan and telmisartan (A2RAs; 10%–20% better), perindopril (ACEI; 25% better) and lercanidipine (CCB; 25% better). Median MPRs were generally around 100%, indicating that most patients who collected prescriptions also showed good adherence to treatment regimens.Conclusion: There is an ongoing problem of poor persistence with commonly used AHT medications. This may represent a diminished opportunity for cardiovascular disease prevention.

Leon A Simons MD, FRACP · Michael Ortiz BPharm, PhD · Gordon Calcino BA, GradDipMedStats

Chest pain reality check A multistate study has found that many patients admitted to Australian hospitals with chest pain do not receive optimal evidence-based management, and that management varies depending on where it occurs. The Heart Protection Partnership project (Walters et al, “Variations in the application of cardiac care in Australia”) used prospective case note review in 27 hospitals across five states to provide a snapshot of the quality of care, as assessed by adherence to existing Australian guidelines. Benchmarks for time to treatment were often not met, and indicated drugs and interventions not received. Hospitals with interventional facilities were most likely to deliver timely, appropriate care: 66% of patients in such hospitals received guidelines-based medical therapy and referral for angiography, compared with 20% in hospitals without interventional facilities. Clueless on kidney disease Most Australians are unaware that the major causes of kidney disease are diabetic nephropathy, hypertension and glomerulonephritis. White et al interviewed 852 participants in the ongoing AusDiab study in 2004, asking what sorts of things they believed caused kidney disease and whether they recalled having their kidney function tested (→ Limited knowledge of kidney disease in a survey of AusDiab study participants). People with known diabetes or hypertension were slightly more likely than others to know that their condition was a risk factor for kidney disease, but alcohol misuse, poor diet, genetic factors, medication, inadequate fluids and obesity were all mentioned ahead of the three main causes. And even among patients with known kidney disease, recall of kidney function testing was low. Teleradiology: back to basics What’s wrong with the idea of beaming diagnostic images around the world to be interpreted and reported on rapidly by qualified experts? According to Kenny and Lau, if the wrong images are sent to the wrong people for the wrong reasons, both the profession and patients will suffer (→ Clinical teleradiology — the purpose of principles). About seven out of 10 Australian radiologists use teleradiology in their daily work, mostly within their own state and almost all within Australia. But as the international market broadens, the International Radiology Quality Network has developed teleradiology guidelines which have been adapted for local use, with the underlying principle of “what is good for the patient”. One in five shun BP drugs A study based on Pharmaceutical Benefits Scheme records indicates that one in five patients who are commenced on antihypertensive therapy do not persist beyond the first script. Simons et al identified almost 50 000 patients who filled an initial antihypertensive prescription between 2004 and 2006 (→ Persistence with antihypertensive medication: Australia-wide experience, 2004–2006). Nineteen per cent did not fill a second prescription. Overall median persistence time was 20 months, with older patients more likely to persist than younger ones. Patients prescribed angiotensin II receptor antagonists or angiotensin-converting enzyme inhibitors were more likely to persist than those prescribed calcium channel blockers. Most patients who collected repeat prescriptions did so at the correct time intervals, indicating good adherence to treatment. Dubious allies Like it or not, say Pramming and Colagiuri from the Oxford Health Alliance, industry and business make our world go round (→ Can public health advocates work alongside industry?). While some might regard the Alliance’s links with some of the purported “big business” culprits in the current chronic disease epidemic with suspicion, they explain why and how they plan to persist with industry partnerships. Considering national registration Australia is almost certainly heading towards a system of national registration for medical practitioners, with a publicly available electronic register. In “A national medical register: balancing public transparency and professional privacy”, Healy et al point out that this will help registration to serve its main purpose — protecting the public — and explore, using comparisons of the eight existing state registers, what information an effective national register might contain. Correspondence corner At the MJA we value readers’ comments on the content and context of all our published material. We therefore welcome (and have contributed to) the debates in this issue’s Matters Arising and Letters about the interpretation of two figures in a research article published last year (→ Trends in hospital admissions and mortality from asthma and chronic obstructive pulmonary disease in Australia), and the MJA’s policy on sponsored supplements (→ MJA policy on sponsored supplements). Subtleties of CRC screening It’s essential for any screening test that the benefits outweigh the risks, and on the face of it, the risk-benefit profile for Australia’s National Bowel Cancer Screening Program is very favourable. Now that the program is up and running, though, say Rosenfeld and Duggan, we need to consider some of the more subtle downsides, including the psychological effects of embarking on testing, the shortage of female colonoscopists to meet women’s preferences, and participants’ understanding of the limitations of screening (→ Colorectal cancer screening: ensuring benefits outweigh the risks). Another time . . . another place No families take so little medicine as those of doctors, except those of apothecaries. Oliver Wendell Holmes Sr, 1860

Ruth Armstrong

Objective: To examine trends in preoperative clinical characteristics, risk profiles and postoperative outcomes of patients undergoing isolated coronary artery bypass graft (CABG) surgery in Victoria.Design, setting and patients: A prospective analysis of 9372 patients undergoing isolated CABG surgery between 1 July 2001 and 30 June 2006 in six Victorian public hospitals, using the Australasian Society of Cardiac and Thoracic Surgeons database.Main outcome measures: Trends in patient baseline characteristics and risk factors, postoperative morbidity and 30-day mortality rate.Results: Over the 5 years, the mean age of patients undergoing isolated CABG surgery increased, from 65.4 years in 2001–02 to 66.0 years in 2005–06 (P < 0.001). There was also an increase in the proportion of patients with hypertension (70.2% to 75.8%; P < 0.001), respiratory disease (83.2% to 89.5%; P < 0.001) and left main coronary artery disease (22.1% to 26.1%; P = 0.03), while the number of patients undergoing repeat CABG surgery decreased (4.4% to 2.6%; P = 0.002). The overall 30-day mortality rate remained unchanged (2.2% to 1.8%; P = 0.983). Rates of other major postoperative complications showed no significant change over the study period.Conclusion: Rates of 30-day mortality and postoperative morbidity after CABG surgery have remained steady, despite the surgical population being older. Short-term outcomes after CABG surgery in Victoria remain among the most favourable reported in any population undergoing this surgery.

Diem T Dinh PhD · Geraldine A Lee BSc, RGN, PGDE · Baki Billah PhD, MAS · Julian A Smith FRACS · Gilbert C Shardey FRACS · Christopher M Reid DipEd, MSc, PhD

Objective: To evaluate the use of clinical practice guidelines for the management of acute coronary syndromes published by the National Heart Foundation (NHF) of Australia and the Cardiac Society of Australia and New Zealand (CSANZ) in patients presenting with chest pain.Design: Cross-sectional study of consecutive patients admitted with chest pain.Setting: Prospective case note review was undertaken in 2380 patients admitted to 27 hospitals across five states in Australia between January 2003 and August 2005. Patients were divided into two groups: those who presented to centres with angiography and percutaneous intervention facilities (n = 1260) and those treated at centres without these facilities (n = 1120).Main outcome measures: The proportion of patients whose care met quality of care standards for diagnostic and risk-stratification procedures and management according to NHF/CSANZ treatment guidelines.Results: Significant delays were identified in performing electrocardiography, administering thrombolysis, transferring high-risk patients to tertiary centres, and performing revascularisation. Medical therapy was underused, especially glycoprotein IIb/IIIa antagonists in patients with high-risk acute coronary syndromes. Patients treated at centres without interventional facilities were less likely to receive guidelines-based medical therapy and referral for coronary angiography (20.11%) than patients treated at centres with interventional facilities (66.43%; P < 0.001).Conclusion: There are deficits in the implementation and adherence to evidence-based guidelines for managing chest pain in hospitals across Australia, and significant differences between hospitals with and without interventional facilities.

Darren L Walters MB BS, MPhil, FRACP · Constantine N Aroney MD, FRACP · Derek P Chew MPH, FRACP · Linden Bungey BSc, MSc · Steven G Coverdale MB BS, FRACP · Roger Allan MB BS, FRACP · David Brieger MB BS, FRACP

To the Editor: We report the serendipitous finding of non-Hodgkin’s lymphoma in a patient with adrenal Cushing’s syndrome. A 62-year-old previously well man (body mass index, 22 kg/m2) was referred to our institution with newly diagnosed type 2 diabetes, hypertension and dyslipidaemia. Clinical findings included oral thrush, bilateral severe pitting lower limb oedema, lower limb proximal myopathy, kyphosis, and increased abdominal girth (waist circumference, 92 cm), raising suspicion of Cushing’s syndrome (Box 1). Biochemical assessment revealed normal electrolytes, an unsuppressed early morning cortisol (following 1 mg dexamethasone), urinary free cortisol 6475 nmol/day (reference range, 0 – 250 nmol/day), and undetectable adrenocorticotropic hormone levels. Twenty-four-hour urinary catecholamine was normal. His testosterone level was 3.2 nmol/L, and dehydroepiandrosterone sulfate level was normal. Abdominal computed tomography showed a right adrenal mass that measured 3.1 × 2.8 × 3.4 cm (density, 36 Hounsfield units). Thoracic spine x-rays revealed wedge compression fractures at T-10 and T-11. Bone densitometry showed T-scores of − 3.3 at L2 – 4 and − 2.3 at the right femoral neck. Total body fat (18.5 kg; 33%) was higher than the recommended range for age and sex (13%–25%). The patient had a laparoscopic right adrenalectomy. Surgical excision was complete. Post-operatively, blood glucose and blood pressure returned to normal. Histopathology revealed an adrenal cortical tumour with atypical features, including a preponderance of eosinophilic cells, small numbers of clear cells, prominent nuclear pleomorphism, large nucleoli and occasional mitoses (Box 2A). However, the proliferation fraction (Ki67) was low and there was no necrosis. There was no large vessel invasion, although a single area of small vessel invasion was present (Box 2B). Unexpectedly, the adipose tissue adjacent to the adrenal gland was infiltrated by a diffuse large B-cell non-Hodgkin’s lymphoma (Box 2B). This was confirmed by positive CD20 immunohistochemistry. Bone marrow biopsy was normal. [18F]Fluorodeoxyglucose positron emission tomography (FDG-PET) scan showed increased uptake in the right adrenal bed only. The patient was treated with six courses of CHOP chemotherapy (cyclophosphamide, doxorubicin, vincristine and prednisolone) in combination with rituximab. A repeat FDG-PET scan 1 month after chemotherapy was clear. We speculate that lymphoma progression was suppressed by the coexistent steroid-producing adrenal tumour. The decision to treat the non-Hodgkin’s lymphoma was, in part, based on reports of progression of haematological disease following treatment of Cushing’s syndrome.1,2 Although histopathological examination of the tumour revealed some features suggestive of adrenocortical carcinoma, the distinction between adenoma and carcinoma can be difficult. In patients with recurrent or metastatic adrenocortical carcinoma, partial response has been reported using a combination of cylophosphamide, vincristine, cisplatin and teniposide.3 Two of these agents were used to treat our patient’s lymphoma. 1 Patient appearance at presentation, with obvious kyphosis and abdominal swelling 2 Immunohistochemistry A: Right adrenal tumour composed of enlarged pleomorphic cells with prominent nucleoli. B: Adrenal cortex (on right) with tumour showing focal vascular invasion (centre), plus adjacent non-Hodgkin’s lymphoma (on left).

Lai Y Wong · John Moore · Debbie Hill · Phil Brenner · Warick Delprado · Jennifer Turner · Joanne Taylor · Lesley Campbell · Jerry R Greenfield

Objective: To determine if low-ankle-pressure graduated-compression tights (GCTs) reduce flight-induced ankle oedema and subjectively rated travel symptoms of leg pain, discomfort and swelling, and improve energy levels, ability to concentrate, alertness, and post-flight sleep.Design, setting and participants: Open, randomised crossover trial comparing the effects of GCTs (5 mmHg at ankle, 17–20 mmHg at calf and falling to 10 mmHg above knee and 4 mmHg at buttocks) among 50 adults on flights of 5 hours’ or more duration between 1 May and 8 October 2006; 47 volunteers (pilots and passengers) completed the trial.Main outcome measures: Differences in right ankle circumference before and after flight with GCTs and without GCTs; travel symptoms rated on visual analogue scales.Results: Low-ankle-pressure GCTs decreased ankle swelling (mean difference, − 0.19 cm; 95% CI, − 0.33 to − 0.65 cm; P = 0.012). Participants reported their legs felt better (mean, 1.6; P < 0.001; 95% CI, 1.0 to 2.1), warmer (mean, − 1.1; P < 0.001; 95% CI, − 1.6 to − 0.6), and they had a better night’s sleep (mean, 1.2; P < 0.001; 95% CI, 0.8 to 1.7) after the flight when they wore GCTs. Shifts in rating-scale probability distributions showed improvements in the ratings of pain (60%; P < 0.001), leg discomfort (50%; P = 0.001), leg swelling (45%; P = 0.006), energy levels (18%; P = 0.016), alertness levels (13%; P = 0.031), and concentration (12%; P = 0.023) when wearing GCTs.Conclusions: Low-ankle-pressure GCTs reduce flight-induced ankle oedema and subjectively rated travel symptoms of leg pain, discomfort and swelling, and improve energy levels, ability to concentrate, alertness, and post-flight sleep.Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12606000150549.

Melissa J Hagan BSc, MEdSt · Stephen M Lambert RN, MAppSc