Chronic heart failure (CHF) is found in 1.5%–2.0% of Australians. Considered rare in people aged less than 45 years, its prevalence increases to over 10% in people aged ≥ 65 years. CHF is one of the most common reasons for hospital admission and general practitioner consultation in the elderly (≥ 70 years). Common causes of CHF are ischaemic heart disease (present in > 50% of new cases), hypertension (about two-thirds of cases) and idiopathic dilated cardiomyopathy (around 5%–10% of cases). Diagnosis is based on clinical features, chest x-ray and objective measurement of ventricular function (eg, echocardiography). Plasma levels of B-type natriuretic peptide (BNP) may have a role in diagnosis, primarily as a test for exclusion. Diagnosis may be strengthened by a beneficial clinical response to treatment(s) directed towards amelioration of symptoms. Management involves prevention, early detection, amelioration of disease progression, relief of symptoms, minimisation of exacerbations, and prolongation of survival.

on behalf of the CHF Guidelines Core Writers

Weigh by day Daily self-weighing has been linked with a decreased risk of regaining lost weight in a US trial. In a group of 314 participants who had recently lost at least 10% (and about 20 kg) of their body weight, the Study to Prevent Regain (STOP Regain) trial compared the weight regained during an 18-month face-to-face intervention or an Internet-based intervention with that regained by a control group. Both intervention groups received a similar program that stressed daily self-weighing and self-regulation. Although the face-to-face group regained the least weight overall, fewer participants in both intervention groups who weighed themselves daily regained 2.3 kg or more in weight, compared with those who weighed themselves less often. N Engl J Med 2006; 355: 1563-1571 Getting older? If you or your patients are seeking an anti-ageing hormone supplement, be advised that the adrenal sex steroid dehydro-epiandrosterone (DHEA) is unlikely to be effective. Mayo Clinic researchers led a 2-year study in which 56 elderly men and women with low baseline levels of sulfated DHEA were randomised to receive DHEA supplementation. Although plasma DHEA levels increased to values in the high-normal range for young adults, there was no detectable effect on physical performance, insulin sensitivity or quality of life. There was a small effect on bone mineral density. N Engl J Med 2006; 355: 1647-1659 From on high Researching high-altitude pulmonary oedema may help us to better understand and treat some common lowland pulmonary oedemas, suggests a US expert.1 Swenson was commenting on a small European study conducted at high altitude which has unexpectedly found that prophylactic dexamethasone prevented not only acute mountain sickness but also high-altitude pulmonary oedema (HAPE) in HAPE-susceptible individuals.2 Taken as 8 mg twice daily, dexamethasone was commenced the day before a rapid ascent from about 1100 m to 4559 m and continued throughout the duration of the study. This prolonged intake seemed critical to its effectiveness in reducing pulmonary arterial pressure, which had not been notable previously. Swenson said it was intriguing to speculate that the pulmonary vascular hyperreactivity of HAPE-susceptible persons may account for the severe secondary hypertensions sometimes seen with sleep apnoea, heart failure or lung disease. 1. Ann Intern Med 2006; 145: 550-552 2. Ann Intern Med 2006; 145: 497-506 Psoriasis and the heart Patients with psoriasis have an increased risk of myocardial infarction, according to UK researchers. In a prospective study using data collected over an average of 5 years by general practitioners, they compared outcomes in 127 139 patients with mild psoriasis, 3 837 patients with severe psoriasis and 556 995 control patients. The risk of myocardial infarction was greater for patients with psoriasis; it was greatest in young patients with severe psoriasis. The findings add to the growing evidence linking T-helper cell type 1 immunological diseases, like psoriasis and rheumatoid arthritis, to atherosclerosis and coronary artery disease. JAMA 2006; 296: 1735-1741 Making no bones about it Tasmanian researchers have determined that calcium supplementation in childhood is unlikely to reduce the risk of fracture to a degree which would be of major public health importance. They conducted a meta-analysis of 19 randomised controlled trials, involving 2859 children aged 3 to 18 years, that compared calcium supplementation, taken for at least 3 months, with placebo. After at least 6 months of follow-up, calcium supplementation was found to have no effect on bone mineral density (BMD) at the femoral neck or lumbar spine. However, there was a small effect on total body bone mineral content and upper limb BMD. Although the upper limb effect persisted after supplementation ended, the size of effect was thought to be clinically insignificant. The researchers suggested that it may be appropriate to explore possible alternative nutritional interventions, such as increasing vitamin D concentrations and the intake of fruit and vegetables. BMJ 2006; 333: 775-780 I apologise . . . Apology is an emerging clinical skill in medical practice, according to a US expert. Lazare believes that an effective apology is one of the most profound healing processes between individuals and groups. Effective apologies are characterised by up to four parts — acknowledgement of an offence; an explanation for committing the offence; an expression of remorse; and reparation. As well as restoring damaged relationships, effective apologies can strengthen existing good relationships, for example, between doctors and their patients and colleagues. As with other activities that have the power to heal, Lazare says that it is essential for physicians to develop skills and ethical principles to allow them to use apologies effectively and honestly in practice. JAMA 2006; 296: 1401-1404

Ann Gregory

Objective: To investigate whether responses to a previously validated four-item medication adherence questionnaire were associated with adverse cardiovascular events.Design: Survey conducted among a cohort of participants in the Second Australian National Blood Pressure Study.Setting: Australian general practice.Participants: 4039 older people with hypertension.Main outcome measures: All major cardiovascular events or death; first specific cardiovascular event.Results: Subjects who adhered to their medication regimen (compared with non-adherent subjects) were significantly less likely to experience a first cardiovascular event or a first non-fatal cardiovascular event (hazard ratio [HR] for both, 0.81; 95% CI, 0.67–0.98; P = 0.03); a fatal other cardiovascular event (HR, 0.68; 95% CI, 0.48–0.99; P = 0.04); or a first occurrence of heart failure (HR, 0.58; 95% CI, 0.37–0.90; P = 0.02). Those who answered yes to “Did you ever forget to take your medication?” were significantly more likely to experience a cardiovascular event or death (HR, 1.28; 95% CI, 1.04–1.57; P = 0.02); a first cardiovascular event or death (HR, 1.31; 95% CI, 1.07–1.60; P = 0.01); a first cardiovascular event (HR, 1.34; 95% CI, 1.09–1.65; P = 0.01); or a first non-fatal cardiovascular event (HR, 1.35; 95% CI, 1.09–1.66; P = 0.01). Those who answered yes to “Sometimes, if you felt worse when you took your medicine, did you stop taking it?” were significantly more likely to experience a first occurrence of heart failure (HR, 2.06; 95% CI, 1.16–3.64; P = 0.01).Conclusions: Subjects who adhered to their medication regimen were less likely to experience major cardiovascular events or death. The question relating to forgetting to take medication identified non-adherent subjects likely to experience a cardiovascular event or death. Clinicians could use this question to identify patients with hypertension who are likely to benefit from medication adherence strategies.

Mark R Nelson MFM, FRACGP, PhD · Christopher M Reid MSc, PhD · Philip Ryan MB BS, FAFPHM · Kristyn Willson BSc(Hons) · Lisa Yelland BMa

Metabolic syndrome (MS) refers to the clustering of cardiometabolic risk factors — including abdominal obesity, hyperglycaemia, dyslipidaemia and elevated blood pressure — that are thought to be linked to insulin resistance. MS is associated with increased risk of cardiovascular disease and type 2 diabetes. MS is common, affecting a quarter to a third of adults, and its prevalence is rising, in parallel with increasing obesity and population ageing. Operational definitions of MS have been proposed by the World Health Organization and the National Cholesterol Education Program. Recently, the International Diabetes Federation proposed a global definition that emphasised the importance of central adiposity. In cardiovascular risk assessment, MS encapsulates the contribution of non-traditional risk factors and provides a clinically useful framework for early identification of people at increased long-term risk. It should be used in conjunction with standard algorithms based on conventional risk factors, which better predict short-term risk. Management of MS should emphasise lifestyle interventions (eg, physical activity, healthy diet and weight reduction) to reduce long-term risk of cardiovascular disease and diabetes. Those at increased short-term risk should also have individual risk factors treated according to established guidelines.

Gerard T Chew MB BS(Hons), FRACP · Seng Khee Gan MB BS, FRACP, PhD · Gerald F Watts DSc, MD, FRACP

Men are at highest risk of cardiovascular disease, chronic lung disease, some cancers, suicide and transport-related injury. An anticipatory approach to men's health in general practice should assess risk for these conditions and offer effective interventions, either to prevent them or manage them early. This requires attention to the barriers, not only to men accessing general practice, but also to appropriate assessment and management, especially among disadvantaged groups.

Mark F Harris DRACOG, FRACGP, MD · Suzanne McKenzie MB BS, FRACGP, MMedSci(Clin Epi)

Dispelling the belief that men are not interested in their health Despite the well known shorter life span of men compared with women,1 strategies to raise awareness of the burden of disease in men — such as social population health approaches2 — have only recently emerged. While men’s increased risk of disorders such as atherosclerotic vascular disease is well known, there has been little focus on male reproductive health — the emerging specialty of andrology. In particular, the prevalence of disorders such as prostate disease, lower urinary tract symptoms (LUTS), erectile dysfunction, androgen deficiency and male infertility have been poorly defined. The Men in Australia Telephone Survey (MATeS) conducted in 2003 is the first whole-of-nation, population-based study focusing on the reproductive health and other problems of middle-aged and older Australian men3 (Box). As the first accurate picture of reproductive health in Australian men over the age of 40 years, it provides prevalence data not previously available, stratified by age and state. The depth of questioning provides a unique snapshot, not only of reproductive health, but also of issues relating to general health, lifestyle and sexual behaviour.3,4 Ongoing data-mining of this comprehensive dataset may help identify risk factors and potential areas of preventive health. For example, in this issue of the Journal, Holden and colleagues explore the sociodemographic factors that affect help-seeking behaviour of men aged over 40 years with reproductive health disorders.5 But, beyond biomedical outcomes, the MATeS study uniquely challenges several general misconceptions about men’s health. MATeS differs from most other reported population studies in that it covers a broader demographic group; previous studies have been confined to geographic areas, such as Massachusetts in the United States,6 and South Australia,7 or to particular population groups, such as men recruited from general practice.8 The results of MATeS are thus better able to be extrapolated to the entire Australian population of men. In addition, studies on male reproductive health tend to be restricted to single components (eg, erectile dysfunction, LUTS or prostate disease), while MATeS provides prevalence rates for a range of conditions and allows interactions to be explored. Similarly, while the large Australian Study of Health and Relationships (Sex in Australia)9 has provided the cornerstone of research and understanding in Australia on sexual health, behaviour and relationships in a younger population (aged 16 to 59 years),10 its findings cannot be directly extrapolated to an older population. MATeS is thus unique in allowing us to challenge existing men’s health constructs for this older age group. Firstly, MATeS demonstrates that significant numbers of men are affected by reproductive health disorders, with one in three men over the age of 40 years reporting erectile dysfunction, prostate disease and/or LUTS. Prevalence rates in the over-40-years age group are: erectile dysfunction, 21%; LUTS, 16%; prostate disease, 14%; and infertility, 8%. The rates of the first three conditions increase sharply with age. While these conditions are not considered life-threatening, the significant numbers of men affected and the potential link with other chronic diseases, such as cardiovascular disease, hypertension, diabetes and depression,6,11 highlight the need to educate both the community and health professions to ensure reproductive health disorders are not overlooked or dismissed. They may be early warning signs of more serious disease. Secondly, the study challenges the belief that men are not interested in or concerned about their health.1 Almost 90% of men aged over 40 years had visited a doctor in the 12 months before interview, and men expressed high levels of concern about developing reproductive health problems as they age: 80% were concerned about developing erectile dysfunction, and 57% about developing prostate cancer.3 However, the study suggests that men are selective about the issues they will discuss openly, and the social, cultural and environmental influences that modulate such health behaviours need to be better understood. In a clinical setting, these barriers need to be overcome by allowing men, particularly older men, opportunities to disclose reproductive health concerns that may otherwise remain unspoken. Health promotion strategies that address men’s health concerns may assist in overcoming barriers to help-seeking behaviour.5 Examples include targeted health education sessions and promotional displays as part of other social events, such as community men’s health nights,12 and workplace or local community events.13 Thirdly, MATeS achieved a high response rate of 78%. Not only does this response rate ensure the validity of the dataset, but it also demonstrates the acceptance of this research by the target group, which is commonly considered to be more difficult to recruit and is often excluded from studies on sexual health.14 Finally, MATeS also challenges the widely accepted notion that older couples are sexually inactive (37% of men aged over 70 years were sexually active4), thereby implicitly dismissing their sexual health needs in many settings. The inclusion of older couples in sexual health studies needs to be considered as part of the healthy ageing research agenda, as relationships and sexual expression are a key component of ongoing good health across the life span. In addition, medical practitioners and allied health professionals need to consider that sexual relationships remain important for many couples as they age, and should not be overlooked or dismissed on the basis of patient age. A progressive decline in male reproductive health with advancing age is well recognised.3,6 However, the physiological causes of this decline may be multifaceted and influenced by lifestyle, social, cultural and environmental issues. Population-based studies of the incidence and progression of disease and related health issues are necessary components of public health and health outcomes research to allow the development of strategies for promotion, prevention and intervention. This was recognised in 1995 when the Commonwealth Department of Health and Aged Care commissioned the Australian Longitudinal Study of Women’s Health to assess a wide range of women’s health and health-related issues.15 Although longitudinal studies of men’s health issues have been conducted overseas,6 there is no similar study in Australia. With Australia’s increasingly ageing population, MATeS provides the impetus for a formal longitudinal study to help us understand the impact of social and biomedical determinants on the health of middle-aged and older Australian men. This would help us to lessen the burden of disease and ensure that quality of life and wellbeing are maintained as far as possible in later life. Outcomes from such a longitudinal study would potentially help the development of better clinical management options for men as they approach their middle years. An effective men’s health research agenda should be implemented in Australia to coordinate the research effort, involve the many and varied stakeholders, address the prevailing assumptions in men’s health, and develop a sound evidence base for future policy and practice. However, any development of men’s health research should not be used to argue for a diminution of the existing emphasis on women’s health. Instead, it should be recognised that biological and sociocultural factors can profoundly affect the behavioural responses of both sexes to disease, the environment and the stresses of life.1,16 Overview of MATeS (Men in Australia Telephone Survey)3-5 Design A representative sample of men aged 40 years and over was contacted from 7636 households which had been randomly selected from the Electronic White Pages. Unbiased sampling stratified by age (40–49, 50–59, 60–69 and 70 + years) and across all states and territories. All men participated in a 20-minute computer-assisted telephone interview exploring general and reproductive health, including related knowledge and beliefs, and sociodemographic and lifestyle factors. Participants 5990 men participated from 7636 randomly selected households, with an individual response rate of 78%. Outcomes High rates of reproductive health disorders and related concerns. A low level of specific enquiry and treatment for reproductive health disorders. This suggests that opportunities to talk to general practitioners about reproductive health problems are being missed. A strong link between reproductive health disorders and age. This suggests that more men will seek help in the future.

David M de Kretser MB BS, PhD · Megan Cock PhD · Carol Holden PhD

Objective: We aimed to assess the pattern of use of drug-eluting stents (DESs) in patients undergoing percutaneous coronary interventions (PCIs) in Victorian public hospitals.Design, setting and patients: Prospective study comparing the use of one or more DESs versus bare-metal stents (BMSs) only, in consecutive patients undergoing 2428 PCIs with stent implantation from 1 April 2004 to 31 December 2005 at seven Victorian public hospitals.Main outcome measures: Adherence to current Victorian Department of Human Services guidelines which recommend DES use in patients with high-risk features for restenosis (diabetes, small vessels, long lesions, in-stent restenotic lesions, chronic total occlusions and bifurcation lesions).Results: Of the 2428 PCIs performed, at least one DES was implanted in 1101 (45.3%) and BMSs only were implanted in 1327 (54.7%). In 87.7% (966/1101) of PCI with DESs, there was at least one criterion for high risk of restenosis. DESs were more likely to be used in patients with diabetes (risk ratio [RR], 2.45; 95% CI, 2.02–2.97), small vessels (RR, 3.35; 95%CI, 2.35–4.76), long lesions (RR, 3.87; 95% CI, 3.23–4.65), in-stent restenotic lesions (RR, 3.98; 95%CI, 2.67–6.06), chronic total occlusions (RR, 1.30; 95% CI, 0.51–2.88) and bifurcation lesions (RR, 2.23; 95%CI, 1.57–3.17). However, 66.2% (1608/2428) of all PCIs were in patients eligible for DESs according to Victorian guidelines, and in 39.9% (642/1608) of these PCIs, a BMS was used.Conclusion: In Victorian public hospitals, DESs have been largely reserved for patients at high risk of restenosis in accordance with Department of Human Services guidelines. However, many patients with high-risk criteria for restenosis did not receive DESs. Greater use of DESs in these patients may improve outcomes by reducing the need for repeat revascularisation.

on behalf of the Melbourne Interventional Group (MIG) investigators

Objective: To review the management of glycaemia, blood pressure and serum lipids in a hospital outpatient diabetes clinic, the director of which co-authored the current national diabetes management guidelines.Design: Retrospective audit.Setting: Outpatient diabetes clinic in a tertiary referral teaching hospital, Sydney, NSW.Study population: 96 patients with type 1 diabetes (mean age, 44.4 [SD, 12.8] years) and 509 patients with type 2 diabetes (mean age, 64.4 [SD, 12.0] years) attending the clinic in 2003, who had undergone formal review of complications.Main outcome measures: Weight, height, control and treatment of glycaemia, blood pressure and serum lipids, and prevalence of diabetic microvascular complications.Results: Glycated haemoglobin (HbA1c) was < 7% in 13% of type 1 and 30% of type 2 diabetes patients, and > 8% in 47% and 34%, respectively. 35% of patients with type 1 diabetes and 71% of patients with type 2 diabetes were treated with antihypertensive agents. Of these patients, 29% and 24%, respectively, had blood pressure readings ≤ 130/80 mmHg. Among patients not treated with hypertensive agents, blood pressure readings were ≤ 130/80 mmHg in 60% of type 1 and 38% of type 2 diabetes patients. About 30% of patients with type 1 diabetes and 50% of those with type 2 diabetes were being treated with lipid-lowering agents; of these, about 60% had low-density lipoprotein (LDL) cholesterol levels < 2.6 mmol/L. Among patients not treated with lipid-lowering agents, about 40% had LDL cholesterol levels < 2.6 mmol/L. Retinopathy was documented in 52% and 18%, and nephropathy in 9% and 36% of type 1 and type 2 diabetes patients, respectively.Conclusions: Despite the demonstrated benefits of tight glucose, blood pressure and lipid control in reducing the risk of macrovascular and microvascular complications in type 1 and type 2 diabetes, our results suggest that treatment targets are not being met in a large proportion of patients attending a tertiary referral hospital. Responsible practice suggests that treatment targets and the current means to achieve them should both be examined.

Wendy Bryant,* RN, CDE, GradDipDiabetesEdManagement · Jerry R Greenfield,* PhD, FRACP · Donald J Chisholm FRACP · Lesley V Campbell FRCP, FRACP

Clinical record A 15-year-old boy developed recurrent, severe occipital headache, with vomiting, lethargy and blurred vision, after a minor head injury without loss of consciousness. The headache was dull and tense, exacerbated by activity and ameliorated by sleep, but unaffected by a change of posture. A week after the head injury, his general practitioner found him to be neurologically normal. The results of a non-contrast cerebral computed tomography scan were also normal. Based on a history of reversible wheeze and cough, the patient had been diagnosed with asthma at 12 years of age. He was strictly compliant with his prescription of inhaled fluticasone propionate (1000 μg/day via accuhaler) and rinsed his mouth after use. As instructed, he doubled the dose of inhaled corticosteroids during acute attacks, which occurred twice a year. There were no interval symptoms. Nonetheless, his dose of inhaled corticosteroids was never reduced. Before being prescribed inhaled corticosteroids, he had been prescribed nasal steroids for allergic rhinitis and nasal polyps, but rarely required this after a successful surgical intervention. He was not taking any other medications or vitamins. A year before presentation, he had had an episode of witnessed collapse with spontaneous recovery. This was attributed to a vasovagal attack at the time. Paediatric assessment 1 month after the head injury showed that he was lean and healthy. His weight (49 kg) and height (160.2 cm) were on the 25th centiles, and his body mass index (19 kg/m2) was on the 30th centile. His head circumference (56.8 cm) was on the 75th centile. Neurological examination gave normal results. A Mini-Mental State Examination identified a short-term memory deficit (2/3 objects recalled). The results of a cardiovascular examination were normal except for hypertension (140/70 mmHg; > 97th centile). There were no renal bruits. Urinalysis gave normal results. He was clinically euthyroid, and had no cutaneous hypo- or hyperpigmentation or signs of Cushing syndrome. He was diagnosed with postconcussion syndrome and reactive hypertension. An ophthalmological assessment identified normal visual fields and acuity and no papilloedema. The fluticasone propionate dose was reduced to 500 μg/day with a view to gradually stopping it altogether. Over the following 2 weeks, his headache worsened in intensity and frequency. An electroencephalogram and cerebral magnetic resonance scan were normal. Amitriptyline (25 mg/day) was prescribed for the headache, without effect. Two months after the paediatric assessment, lumbar puncture, performed under chloral hydrate sedation when relaxed with the back fully extended, showed an elevated cerebrospinal fluid (CSF) opening pressure of 24 cmH2O (reference range, 10–20 cmH2O).1,2 The procedure resulted in immediate headache relief. Examination of the CSF showed no abnormalities. Benign intracranial hypertension was diagnosed and he was prescribed oral acetazolamide (250 mg four times daily). His inhaled corticosteroid therapy was discontinued. Persistent mild hypertension (130/70 mmHg; 97th centile) was again noted on repeated occasions. The results of investigations (including renal function, urinalysis, renal ultrasound, full blood count, inflammatory markers, complement factors, antinuclear antibody, electrocardiography, chest x-ray, thyroid function, plasma renin activity, and urinary catecholamines) were normal and did not reveal a secondary cause of the hypertension. However, the morning cortisol level was undetectable (< 6 nmol/L). A morning short Synacthen test (250 μg) confirmed adrenal suppression, with a suboptimal cortisol rise from baseline of 175 nmol/L to a 1-hour peak of 275 nmol/L (reference, > 600 nmol/L). A paired adrenocorticotropic hormone (ACTH) level was 15 pmol/L, not consistent with primary adrenal disease. In view of the adrenal suppression, he was prescribed oral hydrocortisone (20 mg three times daily) for periods of acute physiological stress. Over the ensuing months, he required multiple therapeutic lumbar punctures, with immediate headache relief on each occasion. The acetazolamide dose was ceased 2 months after initiation. His hypertension resolved 4 months after presentation and the headaches resolved after 9 months. During recovery, he used “stress” hydrocortisone for two episodes of fever and lethargy. Serial (3-monthly) morning short Synacthen tests (250 μg) were performed. By 12 months, he had a normal peak cortisol response (657 nmol/L) and a baseline ACTH level of 7.3 pmol/L. Steroid precautions were then discontinued. Ophthalmological review now identified a cotton-wool spot on the inferotemporal edge of the right optic disc, suggestive of a past axoplasmic blood flow impediment caused by raised intracranial pressure. The temporal association between his headache severity, CSF opening pressures and cortisol levels is shown in the Box. Benign intracranial hypertension has an incidence of 1 per 100 000 children.3 As “benign” belies the potentially debilitating nature of this disorder, including the risk of irreversible blindness,4 the synonyms “pseudotumor cerebri” and “idiopathic intracranial hypertension” are sometimes preferred. Although the pathophysiological basis has not been determined, benign intracranial hypertension has been associated with vitamin deficiencies and toxicities, obesity, head injury,5 adrenal insufficiency,6 and medications, including topical and systemic steroids.7-9 To the best of our knowledge, this is the first reported association between benign intracranial hypertension and inhaled corticosteroids (we conducted a MEDLINE search, using multiple search terms, of English language publications from 1966 to June 2005). The diagnosis of benign intracranial hypertension in our case was based on modified Dandy’s criteria, an elevated cerebrospinal fluid (CSF) opening pressure (using the paediatric reference range),1,2 and repeated instances of immediate headache relief with lumbar puncture. The ophthalmological findings were non-specific but supported the diagnosis. Magnetic resonance venography would have excluded venous sinus thrombosis (an important cause of benign intracranial hypertension), but there was no reason to suspect a hypercoagulable tendency. As the CSF opening pressure was first measured 2 months after the patient sustained a minor head injury, we cannot determine whether this injury was the trigger for benign intracranial hypertension or incidental to it. However, the injury alone cannot explain the benign intracranial hypertension in this patient, given its mild nature and the absence of any radiological evidence of parenchymal brain injury. The adrenal suppression was most likely secondary to inhaled corticosteroid therapy. This is supported by the gradual adrenal recovery after withdrawal of inhaled corticosteroids. The past history of collapse suggests the onset of the adrenal suppression may have occurred 1 year before presentation. Given the absence of papilloedema at presentation, and the fact that the headache and elevated CSF opening pressure were clearly temporally associated with the withdrawal of inhaled corticosteroids, we suggest that the benign intracranial hypertension was related to the withdrawal of the steroid dose. Benign intracranial hypertension has previously only been reported in cases of primary adrenal insufficiency (Addison disease),6 or in association with the use or withdrawal of topical, oral or intranasal corticosteroids.7-9 Clinicians should be mindful of benign intracranial hypertension as a potential side effect when prescribing inhaled corticosteroids. Our case emphasises the importance of using appropriate inhaled corticosteroid dosage and “back titration”. Patients receiving inhaled corticosteroids require regular review. Dosages should be monitored to achieve the minimal dose for symptom control.10 Temporal association between headache severity, cortisol levels, and cerebrospinal fluid opening pressure Medication: F = fluticasone propionate (initially 1000 μg/day); A = acetazolamide (initially 1000 mg/day). CSF = cerebrospinal fluid.

Patrick Patradoon-Ho FRACP · Hasantha Gunasekera MIPH(Hons), FRACP · Monique M Ryan MMed, FRACP · Geoffrey R Ambler MD, FRACP

Objective: To examine factors influencing the identification of kidney impairment in patients with type 2 diabetes in Australian primary care.Design, setting and participants: 348 general practitioner investigators were asked to estimate kidney function and its severity in 10–15 consecutively presenting patients with type 2 diabetes (n = 3893). They were then asked, for each patient, whether they routinely estimated kidney function. No instruction was provided on how kidney function should be estimated or categorised. Data were collected between April and September 2005.Main outcome measures: Kidney function estimated by the Cockcroft–Gault equation using clinical and laboratory data provided by the GP; estimates of kidney function made by the GP.Results: In 24% of the patients with type 2 diabetes, their GP routinely estimated kidney function. However, few of these patients had impaired kidney function or risk factors for kidney disease. There was a good statistical correlation between the estimates made by GPs and the data-derived estimates (R2 = 0.72). GPs identified patients with data-derived estimates of kidney function < 60 mL/min in over 83% of cases, with a specificity of 90%. Impaired kidney function was reported by GPs in 34.4% of men and 36.4% of women. These figures were discordant with function categorisation using both GP estimates and data-derived values, overlapping in half of the patients. Despite GPs’ ability to assess creatinine clearance, “raw” (unstandardised) serum creatinine levels inappropriately influenced the perception of impairment of kidney function.Conclusion: GPs can accurately assess kidney function, without reporting of estimated glomerular filtration rate (eGFR). However, even in patients at increased risk of chronic kidney disease, routine estimates are seldom made. Our findings underline the value of the recent initiative recommending automatic reporting of eGFR in Australia.

Merlin C Thomas PhD, FRACP · Andrew J Weekes MD · Olivia J Broadley BSc, BCA · Mark E Cooper PhD, FRACP