Objective: To examine trends in Northern Territory Indigenous mortality from chronic diseases other than cancer.Design: A comparison of trends in rates of mortality from six chronic diseases (ischaemic heart disease [IHD], chronic obstructive pulmonary disease [COPD], cerebrovascular disease [CVD], diabetes mellitus [DM], renal failure [RF] and rheumatic heart disease [RHD]) in the NT Indigenous population with those of the total Australian population.Participants: NT Indigenous and total Australian populations, 1977–2001.Main outcome measures: Estimated average annual change in chronic disease mortality rates and in mortality rate ratios.Results: Death rates from IHD and DM among NT Indigenous peoples increased between 1977 and 2001, but this increase slowed after 1990. Death rates from COPD rose before 1990, but fell thereafter. There were non-significant declines in death rates from CVD and RHD. Mortality rates from RF rose in those aged ≥ 50 years. The ratios of mortality rates for NT Indigenous to total Australian populations from these chronic diseases increased throughout the period.Conclusions: Mortality rates from IHD and DM in the NT Indigenous population have been increasing since 1977, but there is evidence of a slower rise (or even a fall) in death rates in the 1990s. These early small changes give reason to hope that some improvements (possibly in medical care) have been putting the brakes on chronic disease mortality among Aboriginal and Torres Strait Islander peoples.

David P Thomas MMedSc, PhD, FAFPHM · John R Condon MPH, PhD, FAFPHM · Ian P Anderson MB BS, FAFPHM · Shu Q Li MB, MPH · Stephen Halpin BSc, MSc · Joan Cunningham ScD · Steven L Guthridge MB BS, MTH, FAFPHM

Objective: To establish the extent to which general practitioner age alone explains variations in patient morbidity and treatment patterns.Setting: An on-going, national survey of general practice activity in Australia.Participants: A random sample of 5013 GPs with a minimum of 375 general practice Medicare items claimed in the previous 3 months. Each GP contributed details of 100 consecutive encounters, with about 1000 GPs sampled each year between 1998 and 2003.Main outcome measures: Effect of practitioner age on GP activity after removing the influence of measured confounding factors: doctor, patient and practice characteristics; number of problems; and morbidity managed at encounters.Results: GP age played a significant role in practice style. In comparison with young GPs (< 35 years), older GPs provided more home visits (P < 0.001) and attendances at residential aged-care facilities (P = 0.044); were more likely to manage chronic problems (P < 0.001); had higher prescribing rates (P < 0.001), and lower rates of pathology ordering (P < 0.001) and non-pharmacological treatments (P < 0.001). Individual body system management rates also differed significantly between younger and older GPs.Conclusion: A GP’s age plays a significant role in determining practice style. Our results have implications in terms of the ageing GP population and in the wider context of the ageing medical labour force.

Janice Charles BA, MSc(Med) · Helena Britt BA, PhD · Lisa Valenti BEc

Objective: To assess the effect of employing Aboriginal health workers (AHWs) on delivery of diabetes care in remote community health centres, and to identify barriers related to AHWs’ involvement in diabetes and other chronic illness care.Design, setting and participants: Three-year follow-up study of 137 Aboriginal people with type 2 diabetes in seven remote community health centres in the Northern Territory.Main outcome measures: Delivery of guideline-scheduled diabetes services; intermediate outcomes (glycated haemoglobin [HbA1c] and blood pressure levels); number and sex of AHWs at health centres over time; barriers to AHWs’ involvement in chronic illness care.Results: There was a positive relationship between the number of AHWs per 1000 residents and delivery of guideline-scheduled diabetes services (but not intermediate health outcomes). Presence of male AHWs was associated with higher adherence to the guidelines. Barriers to AHWs’ involvement in chronic illness care included inadequate training, lack of clear role divisions, lack of stable relationships with non-Aboriginal staff, and high demands for acute care.Conclusions: Employing AHWs is independently associated with improved diabetes care in remote communities. AHWs have potentially important roles to play in chronic illness care, and service managers need to clearly define and support these roles.

Damin Si MMed · Ross S Bailie MB BS, MPhil(MCH), MD · Samantha J Togni MA · Peter H N d'Abbs PhD · Gary W Robinson PhD

Turning it off . . . . . . then on again Hormonal male contraceptive regimens are not only effective but also reversible, according to an extensive data re-analysis. Australia-based researcher Liu and colleagues examined data from 1549 healthy men, aged 18 to 51 years, who had taken part in a total of 30 studies of male contraception with various androgen or androgen-progestagen regimens conducted between 1990 and 2005. Routes of administration varied and included oral, intramuscular, transdermal and subcutaneous routes. Overall, the average time to recovery to a fertile threshold of 20 million sperm per mL of semen was 3.4 months; with 90% recovery within 1 year and 100% within 2 years. Liu and colleagues say their findings increase the promise of new contraceptive drugs, allowing men to share more fairly “the satisfaction and burden” of family planning. Lancet 2006; 367: 1412-1420 Further, faster, longer A small trial conducted in Melbourne has suggested that the angiotensin-converting enzyme inhibitor ramipril may substantially improve the symptoms of intermittent claudication in some patients with peripheral arterial disease. Ahimastos and colleagues compared 10 mg ramipril daily with placebo in 40 people, mainly men, with stable intermittent claudication due to superficial femoral artery stenosis or occlusion and who did not have diabetes. After 6 months of treatment, ramipril was found to have improved the pain-free and maximum walking times over placebo by about 4 minutes and 7 minutes, respectively. Distance walked, speed of walking and the ability to climb stairs also improved. The researchers said ramipril may improve blood flow to the lower extremities via vasodilatation, angiogenesis (collateral formation) and atherosclerotic regression. Ann Intern Med 2006; 144: 660-664 To wet or not to get wet? North Queensland researchers have found that, at least in their tropical climate, allowing a wound to get wet in the first day or so after a minor skin excision will make no difference to the incidence of subsequent infection. Heal and colleagues ran a randomised controlled trial involving 857 general practice patients allocated to either keep their minor wounds dry and covered for 48 hours post-suturing or to remove the dressing and wet the wound within the first 12 hours. The infection rate in both groups was around 8% to 9%. BMJ 2006; 332: 1053-1056 Choosing the dark side? Belonging to the Goth subculture — a genre of punk with a dark and sinister aesthetic — is a strong predictor of self-harm and suicide attempt in teenagers, according to a small Scottish study. The study followed 1258 youngsters from the age of 11 to 19 years, seeking information about personal characteristics, including identification with any of various youth subcultures, such as heavy metal, grunge, skater and hip-hop, as well as asking about any self-harm and suicide attempts. Identifying with the Goth culture was the single, best predictor of either self-harm or suicide attempt, and was even stronger than prior depression. Researchers said their data suggested that young Goths either modelled their behaviour on that of their peers and sub-cultural icons or, more likely, were attracted to this subculture because they already had a propensity to self-harm. BMJ 2006; 332: 1058-1061 Health and drug alert Women taking selective serotonin reuptake inhibitors (SSRIs) in the latter half of their pregnancy may have an increased risk of their offspring developing persistent pulmonary hypertension of the newborn (PPHN), warns a health and drug alert in the CMAJ.1 The alert was based on a case-control study which found a dramatic sixfold increase in relative risk;2 however, the absolute risk of having a child with PPHN still remained low, rising from 0.1% to 0.6%, an absolute increase of 0.5%. 1. CMAJ 2006; 174: 1555-15562. N Engl J Med 2006; 354: 579-587 Trimming the not-so-fat Pioneering Australian researchers have deliberately crossed one of the usual thresholds for bariatric surgery (a BMI of 35 kg/m2 or more), with sizeable results.1 In a randomised controlled trial, they compared laparoscopic adjustable gastric banding with an intensive medical program in 80 adults with only a mild-to-moderate degree of obesity, that is, a BMI of 30 to 35 kg/m2. The medical program involved the use of behavioural modification, a very-low-calorie diet and pharmacotherapy with orlistat. Although at 6 months the two interventions had led to identical weight loss (13.8% of initial weight), at 2 years the surgical group had gone on to lose a total of 21.6% of their initial weight whereas the medical group had regained some weight. Four study participants in the surgical group required laparoscopic revision for prolapse of the posterior gastric wall through the gastric band. US editorialists hoped the study would not cause doctors and their patients to overlook the positive health benefits of a 5% to 10% weight loss achieved with lifestyle modification.2 1. Ann Intern Med 2006; 144: 625-6332. Ann Intern Med 2006; 144: 689-691 Dr Ann Gregory, MJA

Ann Gregory

Objective: To investigate the short-term outcome of critically ill Indigenous patients.Design and participants: Retrospective cohort study using de-identified audit data from a tertiary intensive care unit (ICU) in Western Australia for the 11-year period 1 January 1993 to 31 December 2003.Main outcome measures: Hospital mortality (crude, and adjusted for severity of illness).Results: Of 16 757 ICU patients, 1076 (6.4%) were identified as Indigenous. The Indigenous patients were younger and more commonly had chronic liver and renal diseases. Indigenous people represented 3.2% of the population of Western Australia in 2001, but represented 3.1% and 9.5% of all elective and emergency ICU admissions, respectively. Diagnoses of sepsis, pneumonia, trauma, and cardiopulmonary arrest were common among critically ill Indigenous patients. Following emergency admission, the crude hospital mortality for Indigenous patients was higher (22.7% v 19.2%; crude odds ratio, 1.24; 95% CI, 1.04–1.47) than for non-Indigenous patients. The crude hospital mortality of critically ill Indigenous patients was lower than that predicted by the APACHE II prognostic model and was similar to that of non-Indigenous patients after adjusting for severity of illness and chronic health status.Conclusions: The pattern of critical illness affecting Indigenous Australians in Western Australia was different from that affecting non-Indigenous patients. The crude hospital mortality was high, but similar to that of non-Indigenous Australians after adjusting for severity of illness and chronic health status.

Kwok Ming Ho MRCP, FANZCA, FJFICM · Judith Finn PhD · Geoffrey J Dobb FRCA, FANZCA, FJFICM · Steven A R Webb PhD, FRACP, FJFICM

Age-related macular degeneration (AMD) is the leading cause of irreversible blindness in Australia and other Western countries. As there is no cure for AMD, and treatments to stop its progression have met with limited success, there is an interest in identifying modifiable risk factors to prevent or slow disease progression. To date, smoking is the only proven modifiable risk factor for AMD. Other factors under study include (i) cardiovascular risk factors such as hypertension, body mass index, and atherosclerosis; and (ii) dietary risk factors including fat and antioxidant intake, but so far these studies have produced conflicting results. Dietary fat in relation to AMD has recently attracted media attention. Despite very limited work supporting an association between vegetable fat and AMD, widespread publicity advocating margarine as a cause of AMD and encouraging use of butter instead has caused confusion and anxiety among sufferers of AMD and the general public, as well as concern among health professionals. The antioxidant carotenoids — lutein and zeaxanthin — found in dark green or yellow vegetables exist in high concentrations in the macula and are hypothesised to play a protective role. Of nine controlled trials of supplementation with carotenoids and other antioxidants, three suggested that various combinations of antioxidants and carotenoids were protective. While a low-fat diet rich in dark green and yellow vegetables is advocated in general, any specific recommendations regarding certain fats or antioxidant supplementation and AMD are not based on consistent findings at this stage.

Robyn H Guymer RANZCO, PhD, MB BS · Elaine Wei-Tinn Chong MB BS

Smoke in your pancreas? Cigarette smoking — whether active or passive — may play a role in the development of glucose intolerance, suggest US researchers. They followed over 4500 young adults for 15 years as part of the Coronary Artery Risk Development In young Adults (CARDIA) study, looking at the relationship between smoking and glucose intolerance. A dose-response effect was found — increasing pack-years of smoking was linked with an increased risk of developing glucose intolerance. Further, those with passive tobacco smoke exposure were at greater risk than previous smokers. The researchers said passive smoke contains similar toxins to active smoke but is produced at different temperatures and different reducing conditions; thus, some toxic substances are even more concentrated in passive smoke. Smoking has previously been linked with chronic pancreatitis and pancreatic cancer, suggesting that tobacco smoke may be directly toxic to the pancreas. BMJ Online First, 7 April 2006 Stroke by mutant gene People with a mutation in a specific gene may be predisposed, especially after environmental stress, to haemorrhagic stroke, says a group of international researchers.1 The gene, COL4A1, affects the assembly of Type IV collagen, a component of the vascular basement membrane.2 Gould and colleagues found that newborn and adult mice with a mutation in the equivalent mouse gene were at risk of trauma-associated intracerebral haemorrhage. They also identified a human family with a COL4A1 mutation — members had experienced small-vessel brain disease, including retinal arteriolar tortuosity as well as intracerebral haemorrhage. The researchers suggested that the presence of the mutation compromises the vascular basement membrane and weakens the vessel. 1. N Engl J Med 2006; 354: 1489-14962. N Engl J Med 2006; 354: 1451-1453 Was Pauling right? Three decades ago, two-time Nobel Prize winner Linus Pauling co-authored papers which reported that high-dose vitamin C (ascorbic acid) therapy prolonged survival in patients with terminal cancer.1 However, the treatment strategy was discarded when subsequent randomised clinical trials based at the Mayo Clinic did not confirm the benefit. Now, North American authors are calling for Vitamin C’s role to be reassessed.2 Padayatty and colleagues reported three cases of usually progressive, advanced malignant disease (a renal cell carcinoma, a transitional cell bladder carcinoma and a diffuse large B cell lymphoma) that were effectively treated with high-dose intravenous vitamin C therapy. Although each case had a possible alternative explanation for good outcome, both the case report authors and commentators pointed out that there is a new known biological plausibility worthy of closer study — in vitro, high levels of vitamin C are selectively toxic to various cancer cell lines but not to normal cells, by a mechanism involving hydrogen peroxide.2,3 Such high doses are achievable only with intravenous administration, as used by Pauling and in these reported cases; the Mayo Clinic studies used only oral administration. 1. Proc Natl Acad Sci USA 1976; 73: 3685-36892. CMAJ 2006; 174: 937-9423. CMAJ 2006; 174: 956-957 Upping the anti The HPV Vaccine Study Group has reported a follow-up study to their randomised controlled trial of a bivalent L1 virus-like particle vaccine against human papillomavirus types 16 and 18.1 The original trial results were published in the Lancet in 2004.2 At 4.5 years of follow-up, the story remains: “so far, so good”. The vaccine remains not only efficacious against HPV infection but also safe. Further, there is now evidence of cross-protection against infection with two other common HPV types associated with cervical cancers (HPV types 45 and 31). 1. Lancet online, 6 April 20062. Lancet 2004; 364: 1757-1765 A bit depressed? Which older patients with mild depression are most likely to benefit from close clinical monitoring? Analysis of data from the US PRevention Of Suicide in Primary care Elderly: Collaborative Trial (PROSPECT) has identified a trio of risk factors for a worse depressive outcome a year down the track — comorbidity, poor self-rated health and less social support.1,2 An editorialist said that, like diabetes, hypertension and many other chronic medical disorders, depression also fluctuates in severity and requires regular monitoring and therapeutic adjustments.2 The presence or absence of the three risk factors may help doctors target those most likely to benefit from a close eye. 1. Ann Intern Med 2006; 144: 496-5042. Ann Intern Med 2006; 144: 528-530 Dieting: the anti-ageing effect Australia-based researcher Leonie Heilbronn is first author of an original JAMA article which reports that 6 months of calorie restriction in 48 overweight but otherwise healthy adults led not only to reduced weight but also favourable changes in biomarkers of longevity, such as fasting insulin level and core body temperature. Further, there was reduced damage to DNA. JAMA 2006; 295: 1539-1548

Ann Gregory

Objective: To describe how high-cost users of inpatient care in Western Australia differ from other users in age, health problems and resource use.Design and data sources: Secondary analysis of hospital data and linked mortality data from the WA Data Linkage System for 2002, with cost data from the National Hospital Cost Data Collection (2001–02 financial year).Outcome measures: Comparison of high-cost users and other users of inpatient care in terms of age, health profile (major diagnostic category) and resource use (annualised costs, separations and bed days).Results: Older high-cost users (≥ 65 years) were not more expensive to treat than younger high-cost users (at the patient level), but were costlier as a group overall because of their disproportionate representation (n = 8466; 55.9%). Chronic stable and unstable conditions were a key feature of high-cost users, and included end stage renal disease, angina, depression and secondary malignant neoplasms. High-cost users accounted for 38% of both inpatient costs and inpatient days, and 26% of inpatient separations.Conclusion: Ageing of the population is associated with an increase in the proportion of high-cost users of inpatient care. High costs appear to be needs-driven. Constraining high-cost inpatient use requires more focus on preventing the onset and progression of chronic disease, and reducing surgical complications and injuries in vulnerable groups.

Janine Calver PhD · Kate J Brameld PhD · David B Preen PhD · Stoney J Alexia BA(Hons) · Duncan P Boldy MSc, PhD · Kieran A McCaul MPH

To the Editor: Obesity-related glomerulopathy (ORG) is a condition that is partially reversible by weight loss. A 48-year-old morbidly obese man presented with massive proteinuria (8.4 g/day; reference range[RR], < 0.03 g/day). His medical history included hypertension of 4 years, morbid obesity, gout and impaired fasting glycaemia. His hypertension had been relatively well controlled, with no known end-organ complication until the current review. His urinary protein excretion rate measured 6 months earlier had been 0.13 g/day. Longstanding medications included aspirin, lisinopril and allopurinol. The patient weighed 125 kg and was 1.77 m in height (body mass index, 40 kg/m2 [class III obesity]). His blood pressure was 130/70 mmHg, with no postural hypotension. The fundi were normal, with no evidence of hypertensive retinopathy. There was no peripheral pitting oedema and there were no tendon xanthomata. A repeat urinary protein measurement showed an excretion rate of 7.9 g/day, confirming the earlier result. Renal and liver function tests were normal. Other laboratory tests produced the following results: fasting cholesterol, 5.5 mmol/L (RR, < 4.0 mmol/L); triglycerides, 2.4 mmol/L (RR, < 1.8 mmol/L); serum creatinine, 92 μmol/L (RR, 60–110 μmol/L); albumin, 38 g/L (RR, 35–45 g/L); fasting glucose, 6.8 mmol/L (RR, < 5.5 mmol/L); serum insulin, 66 mU/L (RR, 5–25 mU/L); and C-peptide, 6.8 nmol/L (RR, 0.2–0.6 nmol/L). All relevant tests for glomerulonephritis, including serum antinuclear antibodies, antinuclear cytoplasmic antibodies, C3 and C4 levels, protein electrophoretic studies, and hepatitis B and C serology were negative, making a diagnosis of glomerulonephritis unlikely. While awaiting the renal biopsy, the patient decided to attempt rapid weight loss. He began consuming mostly one meal a day of about 5000 kJ (which included about 2000 kJ of protein). Six weeks later, his weight had fallen to 118 kg and his blood pressure was 130/80, with no oedema. His urinary protein excretion rate was 7.6 g/day. After 18 weeks, the patient weighed 110 kg and his urinary protein excretion rate had fallen to 2.1 g/day. At 6 months, his weight loss had plateaued at 102 kg and urinary protein excretion was 0.85 g/day. The renal biopsy showed features consistent with ORG1 (Box). No other abnormality was detected. A concomitant minimal change lesion with spontaneous remission would be a possible explanation, but such a lesion is exceedingly rare and difficult to exclude in the absence of electron microscopy. It is also unlikely given the patient’s age and abnormal light microscopy finding. It is apparent that class III obesity, through unknown mechanisms,2 is a major contributing factor in causing ORG and massive proteinuria — conditions that can be readily improved by weight loss. It remains to be seen in this case whether further weight reduction will further reduce the proteinuria, which, on the other hand, may also be confounded by the hypertension. Impaired fasting glycaemia is not a cause of proteinuria.3 This clinical vignette reinforces the need to check vigilantly for proteinuria and rigorously advise obese patients to attempt weight reduction, especially now that obesity has been confirmed to be an independent risk factor for end-stage renal disease.4 Histopathology of a representative glomerulus There is prominent vascular pole/perihilar sclerosis (broken circular line) and mild fibrosis of the Bowman capsule (arrow) (haematoxylin–eosin stain; original magnification, 3 40). No evidence of hypertensive diabetic nephropathy or tubular disease was detected. Other histological findings (not shown here) included glomerulomegaly, peripheral hyalinosis and mild basement membrane thickening.1 Morphologically, obesity-related glomerulopathy can be difficult to separate from idiopathic focal and segmental glomerulosclerosis.1

Huy A Tran FRACP, FRCPA

Rheumatoid arthritis is associated with an increase in cardiovascular mortality and morbidity; this increase is independent of traditional cardiovascular risk factors. Effective treatment of rheumatoid arthritis with disease-modifying antirheumatic drugs appears to reduce cardiovascular mortality. The optimal approach to prevention of cardiovascular disease in rheumatoid arthritis is evolving, but will include a combination of: cardiovascular risk factor screening and management; effective and sustained control of joint and systemic inflammation; and a high index of suspicion for silent cardiac disease.

Sharon Van Doornum FRACP, GradDipClinEpi, MD · Garry L R Jennings MD, FRCP, FRACP, FAHA · Ian P Wicks