bluuebunny/crossref_metadata_2025 huggingface dataset:
Heart failure ‐ outlooks and strategies for treatment
Authors: Keogh Anne
Published: March 2008

The outlook in heart failure patients with a dilated cardiomyopathy has improved dramatically over the past ten years. The availability of many excellent drugs apart from angiotensin II converting enzyme inhibitors (ACEI) has contributed to this. The best current survival rates reported are, however, in association with deliberate optimisation of haemodynamic parameters and incorporation of functional testing to monitor disease progression. These practises could well be adopted more widely in Australia and New Zealand. Surgical options for heart failure continue to expand, but apart from heart transplantation, remain somewhat experimental.
Improving the results of coronary angioplasty
Authors: Aroney Con N.
Published: March 2008

Coronary angioplasty has changed dramatically in the past three years with major reductions in suboptimal results and restenosis rates, and improvements in safety, efficacy and cost‐effectiveness. Intracoronary stent implantation with optimisation of strut expansion and the abandonment of anticoagulants after deployment, have led to less entry‐site complications, facilitated early hospital discharge, virtually abolished subacute stent thrombosis and resulted in a 50% reduction in target vessel revascularisation. Adjuvant medical treatment with anti‐platelet agents, including glycoprotein IIb/IIIa receptor inhibitors, improves the safety of angioplasty and may further reduce the restenosis rate. Selective use ofdebulking devices has extended the indications for angioplasty. High resolution fluoroscopy, quantitative coronary angiography and intracoronary ultrasound leading to improved diagnosis, equipment selection and treatment have contributed to better outcomes. Further clinical trials will compare angioplasty and stent implantation with coronary bypass surgery in patients with multivessel coronary disease, and may extend the indications for percutaneous transluminal coronary angioplasty (PTCA) to selected patients with three vessel disease.
Seroprevalence of Helicobacter pylori in a longitudinal study of New Zealanders at ages 11 and 21
Authors: Fawcett J. P. , Shaw J. P. , Brooke M. , Walker A. , Barbezat G. O.
Published: March 2008

Background: Helicobacter pylori seroprevalence increases with age in adult life but spontaneous reversion may occur in childhood and adolescence.

Aims: To determine the seroprevalence of H. pylori in a longitudinal study of New Zealanders at ages 11 and 21.

Methods: Serum from members of the Dunedin Multidisciplinary Health and Development Study (DMHDS) at age 11 (n=561; 303 males, 258 females) and 21 (n=785; 413 males, 372 females) was tested for H. pylori antibodies. A large proportion of those tested at age 11 was retested at age 21 (n=465; 262 males, 203 females). Serological status was examined in terms of gender, socioeconomic status (SES) and self‐reported use of antibiotics.

Results: The seroprevalence of H. pylori decreased by 38% from 6.6% (37/561) at age 11 to 4.1% (32/785) at age 21. Seroprevalence at age 11 was not associated with gender or SES. For those tested at both ages, the drop in seroprevalence from 6.7% to 4.1% was statistically significant (t=2.57, ρ<0.01, paired t‐test) and was much greater in females (71%) than males (12%). Of the 31 seropositive individuals at age 11, 17 (six males, 11 females) seroreverted and self‐reported antibiotic use in the year preceeding age 21 was more common in females (eight/11) than males (zero/six). Of die 434 seronegative individuals at age 11, only five (four males, one female) had seroconverted at age 21.

Conclusions: Seroprevalence in the DMHDS declined from age 11 to 21 predominantly in females. The decline involved a greater rate of seroreversion and lower rate of seroconversion in females than males.
Australian encephalitis in the Northern Territory: clinical and epidemiological features, 1987–1996
Authors: Burrow J. N. C. , Whelan P. I. , Kilburn C. J. , Fisher D. A. , Currie B. J. , Smith D. W.
Published: March 2008

Background: The last epidemic of Australian encephalitis occurred in 1974. Since then, cases have been reported from the Kimberley of Western Australia (WA).

Aims: To describe the epidemiology and clinical features of Australian encephalitis in the Northern Territory (NT) of Australia.

Methods: Review of cases of Australian encephalitis presenting to Royal Darwin Hospital from 1987–1996 and review of sentinel chicken surveillance for Australian encephalitis viruses.

Results: Sixteen patients were identified; ten from the NT and six from WA. Cases occurred in the years 1987, 1988, 1991 and 1993. Infection was acquired throughout northern NT below latitude 20°S in the months March to July. All infections were due to Murray Valley encephalitis (MVE) virus. Eleven of the patients were children. Distinguishing features were spinal cord and brainstem involvement and the absence of seizures in adults. CT scanning was normal and EEG showed no focal activity. Five died (31%) and four (25%) have residual neurological disability. Sentinel chicken surveillance since 1992 shows yearly seroconversion to MVE virus throughout northern NT; human cases occurred simultaneously with chicken seroconversion in 1993.

Conclusions: Australian encephalitis is endemic in the NT; the areas at risk are norm of Tennant Creek. Outbreaks are seasonal and occur every few years. Young children are most at risk. Mortality and morbidity are high. Prevention of disease is by avoidance of mosquito exposure and vector control measures.
Increased survival in patients diagnosed with Hodgkin's disease in Tasmania, 1972–1992
Authors: Strickland A. H. , Arthur G. E. , Matthews J. P. , Beresford J. A. , Lowenthal R. M.
Published: March 2008

Background: It has been shown that in certain populations the prognosis of Hodgkin's disease (HD) has improved markedly since the late 1960s. This has not been formally demonstrated in an Australian population.

Aims: To review all patients in Tasmania diagnosed with HD between 1972 and 1992, and to ascertain whether variation in survival is evident in this group over this period.

Methods: Tasmanian patients with HD diagnosed from 1978 to 1992 were identified retrospectively from the Tasmanian Cancer Registry database. Identification of those diagnosed prior to 1978 was obtained from a previously published data set. To be valid for inclusion, subjects were required to have been diagnosed between January 1972 and December 1992, enabling a minimum four year follow up period. Survival was assessed by contacting patients' medical practitioners and by examining the most current electoral roll, medical records, and the register of births, deaths and marriages. Univariate and multivariate analyses were performed of the influence on prognosis of age, sex, histological subtype and epoch of diagnosis; information concerning stage of disease was not available.

Results: During the period of this study 206 patients were newly diagnosed as having HD. Comparisons of cases diagnosed in the successive seven‐year epochs 1972–8, 1979–85 and 1986–92 revealed a significant increase in survival duration (ρ=0.023), with ten year survival rates of 46%, 55% and 73% respectively. In a multivariate analysis adjusting for age, sex and histology, each successive epoch was associated with an estimated 28% reduction in the death rate relative to the preceding epoch (ρ=0.022).

Conclusions: There was a significant improvement in the survival duration of patients diagnosed with HD in Tasmania over the period 1972–92, which was possibly due to a combination of better diagnostic techniques and more effective treatments.
The effect of test duration on the sensitivity and specificity of ultra‐rapid urease test for the detection of Helicobacter pylori infection
Authors: Ho K. Y. , Kang J. Y. , Lim T. P. , Yeoh K. G. , Wee A.
Published: March 2008

Background:‘Home made’ ultra‐rapid urease tests are used extensively in the Asia Pacific region. Data on the reliability of these ‘home made’ tests are limited.

Aims: To evaluate the effect of test duration on the sensitivity and specificity of a self‐prepared biopsy urease test for the detection of Helicobacter pylori.

Methods: Using histology as the ‘gold standard’, the effect of test duration on the sensitivity and specificity of a self prepared urease test for the detection of H.pylori was evaluated in 411 consecutive patients undergoing upper gastrointestinal endoscopy.

Results: Histology was positive for H.pylori in 217 of the 411 patients (52.8%). Within 24 hours of retrieving the specimen, 189 (87.1%) of the histology positives and 174 (89.7%) of the histology negatives were correctly identified by the urease test. Of the H.pylori positives, 72.0%, 81.0%, 89.9% and 100% were detected by the urease test within one minute, five minutes, three hours and 24 hours respectively. Thus, sensitivities of the urease test at one minute, five minutes, three hours and 24 hours were 62.7%, 70.5%, 78.3% and 87.1% respectively. Corresponding figures for the specificity were 93.8%, 93.3%, 92.3% and 89.7% respectively. Using a receiver‐operating characteristic curve, an optimal combination of sensitivity and specificity was obtained when the urease test was read at 24 hours.

Conclusions: While the biopsy urease test was positive in most cases within a minute, better results could be obtained if the test continued to be read over a 24 hour period.
Characteristics and prognosis of KI‐1 positive anaplastic large cell lymphoma in Asians
Authors: Lee S. C. , Kueh Y. K. , Lehnert M. , Chong S. M. , Tan Y. O. , Wong J.
Published: March 2008

Background: Ki‐1 positive anaplastic large cell lymphoma is a rare type of non‐Hodgkin's lymphoma (NHL), and has not been extensively described in Asian patients.

Aim: To evaluate the clinical characteristics, prognostic factors and treatment outcome of Ki‐1 positive lymphoma in an Asian community.

Methods: A retrospective analysis of all patients with CD30 antigen positive anaplastic large cell lymphoma from 1987 to 1996 in a single institution.

Results: Of 218 patients with NHL, ten (5%) were identified with Ki‐1 positive anaplastic large cell lymphoma. Eight were Chinese, two Indians. The male: female ratio was 1.5:1, and the median age was 32 years. Seven patients presented with B‐symptoms, and five had stage III/IV disease. The majority (seven of ten) was low‐or low‐intermediate risk according to the International Prognostic Index (IPI). Four out of five cases immunophenotyped showed a T‐cell origin. Five out of eight patients who received first‐line combination chemotherapy achieved a complete remission. Two relapsed, with one being re‐induced into a durable second remission. One patient with recurrent cutaneous lymphoma received solely radiotherapy and was disease‐free at 20+ years from diagnosis. At analysis, two patients had died, five were disease‐free at four, 27, 78, 89 months and 20 years respectively, and three were alive with disease. The IPI appears to have prognostic significance.

Conclusion: Incidence and clinical characteristics in our Asian patients were similar to those described in Western populations. The IPI appears to have prognostic relevance. In approximately one‐third of patients, long term survival can be achieved with standard treatment.
Comorbidities and prediction of length of hospital stay
Authors: Roe C. J. , Dodich N. , Kulinskaya E. , Adam W. R.
Published: March 2008

Background: Variability in length of stay (LOS) within Australian National Diagnosis Related Groups (AN‐DRGs) reflects clinical heterogeneity in age, severity of illness, complications and comorbidities.

Aim: To develop a clinically based score which measures patient morbidity and which will better predict LOS compared to existing methods.

Methods: ICD‐9‐CM codes of diseases and procedures were allocated to one of 23 body system categories to calculate the body burden of disease (BBD) score. Evaluation of BBD in predicting LOS was performed using multiple regression and analysis of variance with a data set of 34,079 cases from 75 AN‐DRGs from three Victorian hospitals.

Results: Adding BBD and age improved prediction of LOS by 27.2% in AN‐DRG version 1.0 and by 17.5% in AN‐DRG version 3.1. When using average inlier LOS for AN‐DRG, BBD and age improved prediction of LOS by 44.6% and by 14.8% in AN‐DRG version 1.0 and version 3.1 respectively. Deaths were positively related to BBD.

Conclusions: BBD is a simple quantitative measure of extent of disease that improves current methods in accounting for variability in LOS.
Safety of plasmapheresis in the treatment of neurological disease
Authors: Vucic S. , Davies L.
Published: March 2008

Background: Plasmapheresis is used as a treatment modality in several neurological disorders. Adverse reactions relating to vascular access, replacement fluid and anticoagulant use have been reported.

Aims: To establish the incidence of complications of therapeutic plasmapheresis in the treatment of neurological diseases.

Methods: A retrospective study was performed, in which case records of patients undergoing plasmapheresis for neurological indications between 1 April 1992 and 1 September 1996 were reviewed for fatalities and adverse reactions related to vascular access, transmission of Hepatitis B or C or Human Immunodeficiency Virus (HIV), fluid imbalance, allergic or febrile reactions, haematological complications, machine failure and citrate toxicity.

Results: In the study period, 1283 plasmapheresis procedures were performed on 73 patients with neurological disease. There were no fatalities, no cases of Hepatitis B or C or HIV transmission, no allergic or febrile reactions, thrombosis, bleeding diathesis or severe citrate toxicity. Infections related to venous access occurred in 0.5 per cent of procedures with septicaemia in 0.2 per cent of procedures (4.1% of patients). Less serious complications included hypotension in 1.2 per cent of procedures (11% of patients) and citrate toxicity manifesting as nausea, vomiting, cramping or paraesthesia in 1.2 per cent of procedures. Machine failure occurred in 0.2 per cent of procedures.

Conclusions: Plasmapheresis is a safe procedure when performed for neurological indications by experienced personnel in a large pheresis unit. The most frequent adverse event is infection of the venous access site.
Neoadjuvant chemotherapy in locally advanced cervical cancer: two randomised studies
Authors: Kumar L. , Grover R. , Pokharel Y. H. , Chander S. , Kumar S. , Singh R. , Rath G. K. , Kochupillai V.
Published: March 2008

Between August 1990 and January 1992, 184 patients with squamous cell carcinoma of the cervix, FIGO stage IIBIV A were randomised (study 1) to receive either two cycles of bleomycin, ifosfamide‐mesna and cisplatin (BIP) chemotherapy (CT) followed by radiotherapy (RT) ‘CT‐RT Group’ a=94 or RT alone, RT Group n=90. In the ‘CT‐RT Group’, of evaluable 89 patients, 64 responded: complete response (CR) four (4.5%) and partial response (PR) 60 (67.5%). Of the remaining 25 patients 23 had stable disease and two progressed. Eighty of 89 patients completed RT as planned. Following RT 56 (70%) achieved CR, 19 (23.7%) had residual disease and five (6.3%) had progressed. Patients aged>45 and those with Hb >10 gm/dL had significantly better response to CT. Further, CT responders had a better response to RT; 83% (49/59) vs 33.3% (seven/21), p<0.01. In the ‘RT Group’ 88 patients were evaluable; 61 (69.3%) patients achieved CR, 25 had residual disease and two progressed. The estimated overall survival at 48 months in the ‘CT‐RT Group’ and the ‘RT Group’ is 38%+2.01 (SE) and 36%+1.85 (SE), p=0.59 respectively.

In a subsequent randomised study (study 2) 36 patients with stage III B cervical cancer received three cycles of BIP (as above) followed by RT vs 36 patients who received RT alone. In the ‘CT RT Group’ 29 patients responded; CR‐8 (22.2%>), PR‐21 (58.3%). Six patients had no response to CT and one patient died of CT toxicity. Following RT ‐ 24 of 35 (68.6%) patients achieved CR, eight had residual disease and three patients progressed while on RT. In the ‘RT Group’ ‐ 21 of 36 (58.4%) achieved CR, 12 had residual disease and three progressed. Estimated survival was 71%> in the ‘CT‐RT Group’ and 69% in the ‘RT Group’, p=ns.

Nausea/vomiting, alopecia, grade I‐II myelosuppression, diarrhoea and mucositis were the major side effects of CT. Three patients died of CT toxicity ‐ two in study 1 and one in study 2. Cystitis, proctitis and local skin reaction after RT occurred equally in the two groups in both the studies.

BIP CT prior to RT in patients with locally advanced cervical cancer results in a high response rate. Response to CT predicts response to RT. There is no increase in the toxicity to subsequent RT. Our studies have failed to demonstrate any significant difference in overall and disease‐free survival when neoadjuvant CT is added prior to the standard RT regimen.
Lung cancer and quality of life
Authors: Thongprasert S.
Published: March 2008

Quality of life (QOL) is frequently used as an endpoint of measurement in cancer treatment. Compared to other cancers, there are only a few reports of QOL in the treatment of lung cancer. Several QOL instruments have been developed and this paper reports experience with the functional Living‐Index‐Cancer and Quality of Life Index tools in Lung Cancer treatment, in a randomised controlled trial of chemotherapy.
NSAIDs and faecal blood loss in elderly patients with osteoarthritis: is plasma half‐life relevant?
Authors: Scharf S. , Kwiatek R. , Ugoni A. , Christophidis N.
Published: March 2008

Background: Nonsteroidal anti‐inflammatory drugs (NSAIDs) vary in their degree of gastrointestinal (GI) toxicity. NSAIDs with longer half‐lives are of particular concern as they may be more toxic in the elderly.

Aim: To compare the GI toxicity, by measurement of faecal blood loss, of short, intermediate and long half‐life NSAID treatments compared with control in elderly patients with osteoarthritis.

Methods: Twenty‐three patients, mean age 69 years, with osteoarthritis requiring NSAID treatment, received treatment with diclofenac 100 mg/day, naproxen 750 mg/day and piroxicam 20 mg/day, representing a short, medium and long half‐life NSAID respectively, in a double‐blind, randomised, three way, cross‐over block design. In each case, a three week washout control phase was followed by active treatment phases of two weeks each with three week washout between treatment phases.

Results: Faecal blood loss, collected over 72 hours at the end of each treatment phase, was measured by 51Cr‐labelled erythrocyte method. Comparison was made of mean 24 hour faecal blood loss with each treatment compared with control using repeated measures analysis of variance. Eighteen patients completed all phases of the study. Three patients were withdrawn due to GI bleeding; two during diclofenac treatment and one during treatment with piroxicam. Mean 24 hour faecal blood loss with diclofenac (0.53 mL±0.21) was not significantly different from control (0.28 mL±0.06), whereas it was significantly increased with naproxen (2.76 mL±2.22) and piroxicam (1.16 mL±0.62), p= 0.0013.

Conclusion: A short half‐life NSAID was associated with lower GI toxicity than a medium and long half‐life NSAID, as measured by faecal blood loss.
Continuous and intermittent infusion of coagulation factor concentrates in patients undergoing surgery: a single centre Australian experience
Authors: Campbell P. J. , Rickard K. A.
Published: March 2008

Background: Haemophilia patients require large doses of coagulation factor concentrates to optimise haemostasis at the time of surgery. The superior pharmacokinetic profile of continuous infusion over intermittent bolus administration may be more advantageous.

Aims: We report our experience using coagulation factor concentrates delivered by continuous infusion in patients undergoing surgery.

Methods: A retrospective case notes review of all patients treated by continuous infusion at Royal Prince Alfred Hospital (RPAH) over a two year period and a comparison of two cohorts of patients undergoing orthopaedic surgery using either continuous infusion or bolus factor VIII (FVIII) replacement therapy. Patients received a pre‐operative bolus of factor concentrate (AHF, Immunine or Recombinate) followed by a continuous infusion calculated according to weight, clearance and target plasma concentration.

Results: Twenty‐one (19 M, two F) with haemophilia or von Willebrand's disease underwent 26 surgical procedures between July 1995 and July 1997. The mean total consumption of concentrate per patient was 36,676 units (range 6750–82,000) infused over a mean period of 7.6 days (range one‐16). One patient experienced minor surgical bleeding on treatment and one patient developed severe bleeding into the replaced joint off infusion requiring additional boluses of treatment. In a separate analysis, ten of these patients who underwent major orthopaedic surgery were compared to a historic cohort (n=8) of patients who received bolus injections for similar types of operations.

Conclusions: Coagulation factor concentrates delivered by continuous infusion have major clinical and economic advantages in the surgical management of patients with haemophilia.
Heparin management in acute myocardial infarction (AMI)
Authors: Granger Christopher B.
Published: March 2008

Antithrombotic agents have been shown to be beneficial in the setting of acute coronary syndromes, and as an adjunct to thrombolysis for acute myocardial infarction (AMI). The optimal type and dosing of antithrombotic drug, however, remains elusive. Heparin, the agent most commonly used, has several limitations, the most important of which may be its inability to inhibit clot‐bound thrombin. Newer, direct thrombin inhibitors (such as hirudin) provide potent and predictable thrombin inhibition and are able to inhibit clot‐bound thrombin. Both heparin and hirudin can carry a substantial risk of haemorrhage, however, and thrombin activity is likely to rebound after discontinuation of either agent. Further, the relationships of antithrombotic/thrombolytic dosing, measures of anticoagulation (such as APTT), and clinical outcomes are not always clear. Nonetheless, from the data available from large, randomised trials, intravenous heparin should remain a standard adjunct to thrombolytic therapy for AMI.
Oral cyclosporin in refractory inflammatory bowel disease
Authors: Taylor A. C. F. , Connell W. R. , Elliott R. , D'Apice A. J. F.
Published: March 2008

Background: The role of cyclosporin in patients with severe, refractory inflammatory bowel disease is unclear.

Methods: A seven year retrospective review of patients treated with oral cyclosporin for inflammatory bowel disease refractory to conventional medical therapy was undertaken.

Results: Twenty‐eight patients (13 ulcerative colitis and 15 Crohn's disease) received oral cyclosporin for a mean of nine months (range 0.25–27 months). Within four weeks of starting cyclosporin, a complete clinical response occurred in 15 patients (nine with ulcerative colitis and six with Crohn's colitis), in whom conventional maintenance treatment was instituted concurrently. The clinical response was sustained during cyclosporin treatment in ten, but maintained after cyclosporin withdrawal in only five patients (18% of entire study group). Four of the five patients who relapsed after cyclosporin withdrawal had failed previously to respond to azathioprine. None of the five patients with continuing remission after cyclosporin withdrawal had received azathioprine in the past. There were three clinically significant infections and 14 cases of impaired renal function during treatment.

Conclusions: Oral cyclosporin induces remission in some patients with severe ulcerative colitis or Crohn's colitis, but its benefits in cases refractory to azathioprine are overshadowed by a high frequency of relapse after drug withdrawal. (Aust NZ J Med 1998; 28: 179–183.)
Comparison of thallium‐201 and gallium‐67 scintigraphy in the evaluation of non‐Hodgkin's lymphoma
Authors: Roach P. J. , Arthur C. K. , Cooper R. A. , Ravich R. B.
Published: March 2008

Background: Gallium‐67 (Ga‐67) is widely used in the assessment of patients with lymphoma. Although highly sensitive in Hodgkin's disease and high grade non‐Hodgkin's lymphoma (NHL), its sensitivity is reported to be reduced in lower grades of NHL. Several series have suggested that thallium‐201 (Tl‐201) may be more useful than Ga‐67 in the evaluation of low and possibly intermediate grade NHL.

Aim: To compare the sensitivity and relative avidities (uptakes) of Tl‐201 and Ga‐67 in patients with NHL.

Methods: A total of 36 pairs of studies were performed in 33 patients (14 male: 19 female; age range 16–84 years, mean 55 years). All had whole body Ga‐67 (400 MBq) and Tl‐201 (100–200 MBq) studies (interval 0‐three days) which were read by two experienced nuclear medicine physicians blinded to clinical history and results of other investigations.

Results: Tl‐201 had a higher sensitivity and avidity than Ga‐67 in patients with low grade NHL. In contrast, Ga‐67 was slightly more sensitive and had a higher avidity in patients with both intermediate and high grade NHL.

Conclusions: We conclude that Tl‐201 is more sensitive and avid for low grade NHL than Ga‐67 and that consideration should be given to its use in this condition in conjunction with Ga‐67 as it may provide complementary information. Routine use in intermediate grade NHL is less convincing as Ga‐67 was superior in most cases. Ga‐67 is more sensitive than Tl‐201 in assessment of high grade NHL.
Shared rheumatoid epitope as a risk factor in determining outcome in rheumatoid arthritis
Authors: Hedger S. C. , Macardle P. , Bond M. J. , Ahern M. J. , Smith M. D. , Roberts‐Thomson P. J.
Published: March 2008

Background: A genetic component is thought to contribute to 30–40% of the expression of rheumatoid arthritis (RA) with the HLA‐DR4, w4 (B1*0401), w14 (B1* 0404) genes (and associated shared rheumatoid epitope) constituting a substantial portion of this risk.

Aim: Our objective was to determine the presence of these risk factors in a group of patients with RA and to correlate presence with disease outcome.

Method: Forty‐three RA patients who had been regularly assessed up to a ten year period since their initial entry into two gold treatment trials were studied. DR4, w4, w14 and shared rheumatoid epitope were determined on peripheral blood lymphocytes using flow cytometry and specific monoclonal antibodies. Disease outcome was measured by Health Assessment Questionnaire (HAQ) score and C‐Reactive Protein (CRP) as a serological measure of joint inflammation.

Results: To confirm accuracy of the flow cytometric technique, DR typing and epitope status was compared with results obtained by genotyping in a subset of 14 patients. There was complete concordance between these two techniques for the rheumatoid epitope. However, concordance was not complete (both false positives and false negatives) for DR4, w4 and w14. Hence the presence of rheumatoid epitope was only evaluated further in the larger group. The presence of the shared rheumatoid epitope correlated positively with poorer outcome on serological assessment (p<0.05). No significant correlation between HAQ score and rheumatoid epitope status was observed although a weak trend was noted.

Conclusion: These studies suggest that determination of rheumatoid epitope status by flow cytometry may provide useful data concerning the long term outcome of patients with RA.
‘Mini‐allografts’ for haematological malignancies: an alternative to conventional myeloablative marrow transplantation
Authors: Grigg A. , Seymour J. F. , Roberts A. , Szer J.
Published: March 2008

Background: Considerable morbidity and mortality are consequences of the myeloablative chemoradiotherapy utilised in conventional allogeneic marrow transplantation. This has generally restricted such potentially curative treatment to patients <50–55 years with normal organ function. Recent studies suggest that purine‐analogue based non‐myeloablative regimens are sufficiently immunosuppressive to facilitate allogeneic donor cell engraftment.

Aim: To review the outcome of HLA‐compatible sibling allogeneic peripheral blood progenitor cell (PBPC) transplants using fludarabine‐based conditioning in patients ineligible for a conventional transplant, with emphasis on engraftment, graft vs host disease (GVHD) and graft vs tumour effects.

Methods: Eleven patients (nine 47 years age) with advanced haematological malignancies received one of three different fludarabine‐based chemotherapy followed by infusion of granulocyte colony‐stimulating factor mobilised PBPC. Cyclosporin‐methotrexate was used as GVHD prophylaxis.

Results: Two patients died early; minimal non‐haematological toxicity apart from mucositis occurred in the other nine. Eight of the nine evaluable patients had evidence of durable donor cell engraftment in preference to recipient cells. Acute GVHD (grade 2) occurred in seven of eight patients with donor engraftment who survived beyond two months. Four patients are alive in complete remission 8–28 months post‐transplant; another is alive in probable remission at four months.

Conclusions: Fludarabine‐based non myeloablative chemotherapy facilitates rapid engraftment of allogeneic donor cells, which produce powerful GVHD and graft vs tumour effects. This approach has the potential to extend the applicability of allogeneic stem cell transplants to patients traditionally regarded as too old or sick for conventional marrow transplants.
Cerebrovascular disease as a general medicine discharge diagnosis: assessment of diagnostic agreement on case note review
Authors: Lunt H. , Beard M. E. J. , Wilson M. A. , Kendall D. , Frampton C. M.
Published: March 2008

Background: Accurate clerical coding of discharge diagnoses is important partly because results may be used to derive a recommended costing for hospital length of stays (LOS). Some authors think that discharge coding undertaken by clinicians will result in less diagnostic misclassification than clerical coding. This presupposes a high degree of between‐observer diagnostic agreement between clinicians.

Aims: To compare discharge coding undertaken by two general physicians, for patients receiving a clerical discharge code of cerebrovascular disease. The recommended LOS was then calculated from each observer's discharge codes using the Physicians Diagnosis Related Group Working Guidebook.

Results: Eighty‐two cases were coded as stroke by the clerical coder. Both medical coders agreed with this diagnosis in 68 (83%) of these cases. The corresponding figure for cases coded by the clerical coder as transient cerebral ischaemia was 47% (32/68) agreement between all three observers. Correcting for chance agreement between medical observers using the kappa statistic, a value of 0.64 was obtained for the combined stroke and transient cerebral ischaemia discharges, suggesting moderate diagnostic agreement. Using the clerical coder's results, the mean recommended LOS for all cases of cerebrovascular disease over the study period was calculated at 6.68 days. The corresponding values for the two medical coders were 6.68 days and 6.75 days.

Conclusions: Diagnostic agreement between clinicians was moderate. Consideration of alternative diagnostic possibilities and the difficulty in determining the duration of neurological deficit were the main reasons for diagnostic disagreement. The mean recommended LOS was similar, however, when comparing results from all three observers.
Antithrombins and the importance of good control
Authors: Tideman P. A.
Published: March 2008

The generation of thrombin and the formation of platelet rich intra‐coronary thrombus in response to atherosclerotic plaque rupture is pathognomonic of acute coronary syndromes. An understanding of the process of thrombin generation and the unique relationship between the structure and function of thrombin is essential to developing more effective anti‐thrombotic strategies than the use of standard unfractionated heparin in the acute coronary syndromes. The mechanisms of action of heparin, low molecular weight heparins (LMWHs) and the newer direct anti‐thrombins, recombinant hirudin and Hirulog, are reviewed. Evidence from the currently available phase 2 and 3 trials of these drugs regarding their efficacy in the acute coronary syndromes is also reviewed.
Non‐rheumatic atrial fibrillation and stroke
Authors: Tonkin A.
Published: March 2008

The risk of systemic embolism and stroke in patients with non‐rheumatic atrial fibrillation (NRAF) should not be underestimated. The annual embolic rate is approximately 5% and in those with left atrial enlargement and/or left ventricular (LV) dysfunction, or who have already had systemic embolism, this rate may be as high as 20%. Decisions on patient management and the prophylaxis of stroke must always be individualised. The risk of bleeding related to warfarin is almost certainly greater than that encountered in the previous randomised trials. Also, clinical and echocardiographic features can further define absolute risk in an individual patient with NRAF. Clinical markers of increased risk of embolism in patients with NRAF include older age, previous cerebral embolism, recent congestive heart failure, hypertension and diabetes mellitus. Transthoracic echocardiography improves risk stratification and should be performed in the vast majority of patients. Embolic risk is greatest in those with increasing left atrial dilation, atrial dysfunction and LV dysfunction. Transoesophageal echocardiography sharpens the risk profile in selected patients.

Overall randomised trials show greater benefit with warfarin than aspirin. In general, increasing age is associated with a greater incidence of structural heart disease and probably implies greater potential benefit with warfarin. Increasing age per se may not increase the risk of warfarin‐related bleeding. When the decision is made to warfarinise patients, at the present time data suggest that the target INR should be in the range of 2.0–3.0.
Oestrogen and vascular disease
Authors: Harvey P.
Published: March 2008

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in postmenopausal women. Epidemiological studies consistently suggest that oestrogen administered to postmenopausal women confers an estimated 30–50% reduction in risk of development and progression of CVD. The long term effect on the cardiovascular system of the addition of a progestogen to the replacement regimen is currently unknown. In addition, it may be argued that it remains to be proven whether the magnitude of the oestrogen‐induced cardioprotective effect demonstrated in these observational studies is a real biological phenonumon. No prospective, randomised, controlled studies examining the effect of oestrogen on primary and secondary prevention of CVD have been completed. However, a large number of biologically plausible mechanisms have been identified which provide evidence to support the proposed oestrogen‐induced cardioprotection. These include oestrogen mediated favourable changes in metabolic profile, in particular changes in lipid metabolism, insulin resistance and the fibrinolytic system. In addition, recent data have shown that oestrogen may affect vascular structure and function by a variety of mechanisms. It has been shown that oestrogen may induce acute and chronic coronary and cerebral vasodilation through both direct (vascular smooth muscle) and indirect (endothelium dependent) mechanisms. Oestrogen also has recently been shown to have complex anti‐atherogenic and antioxidant properties. Much less is known of the vascular effects of progestogens. Progestogens currently in clinical use have androgenic properties and may attenuate the beneficial effects of oestrogen by neutralising or opposing the lipid lowering, vasodilatory and anti‐atherogenic actions of oestrogen. Thus further studies are required to elucidate the effects on arterial physiology and CVD outcome of the oestrogens and progestogens of different types, doses and routes of administration which are collectively referred to as postmenopausal ‘hormone replacement therapy’.
Review of Emergency Department thrombolytic therapy and changes in inpatient mortality of acute myocardial infarction on the NSW Central Coast 1986 to 1994–96
Authors: Hooi H.
Published: March 2008

Aims: To examine changes in inpatient mortality of acute myocardial infarction (AMI) from 1986 to 1994–96 and to review the Emergency Department (ED) use of thrombolytic therapy (TT) for AMI on the NSW Central Coast.

Method: A retrospective review of medical records of patients presenting to the EDs of Gosford and Wyong Hospitals with a discharge diagnosis of AMI (ICD9 code 410.x) from 1 January 1986 to 31 December 1986 and 1 January 1994 to 31 December 1996. Data were collected on patients' age, sex, duration of symptoms on arrival at the ED, ECG changes and presence of positive ECG criteria for thrombolysis, agent used, contraindications to TT, and inpatient mortality. The main measure of outcome was inpatient mortality.

Results: There were 423 admissions for AMI in 1986 and 1220 admissions in 1994–96. The overall inpatient mortality has declined from 18.9% in 1986 to 9% in 1994–96 (p<0.0001). The mean age of patients has increased from 67.5 years to 68.1 years (p=0.35). The proportion of patients over age 75 years has increased significantly from 24.6% to 30.3% (p<0.0001). Presentation times from onset of symptoms have not changed significantly from a median time of two hours in 1986 to 2.5 hours in 1994 to 1996 (p=0.52). The overall proportion of patients with ECG criteria for TT was 53.2% in 1994–96. TT was administered to 42.9% of patients with a mean door to needle time of 67 minutes (median 45 minutes). The Australasian College for Emergency Medicine benchmark door to needle time of 60 minutes was achieved in 71.3% of patients. Streptokinase was the predominant agent given in 78%, while recombinant tissue plasminogen activator accounted for 15.7% of patients. Patients not receiving TT due to negative ECG criteria showed a decline in mortality from 18.6% to 6.7% (p<0.0001). Patients who underwent mechanical revascularisation (by bypass graft or angioplasty) increased from 8.7% to 17.4% (p<0.0001). Inpatient mortality has declined for all age groups, for both sexes, and for all sites of AMI.

Conclusion: There have been significant declines in inpatient mortality of patients with AMI on the Central Coast. TT has had a significant impact on this decline but has an eligibility rate of less than half. Significant declines in mortality have also been seen in patients ineligible for thrombolysis. These patients have benefited from other therapies introduced or more widely used in the last decade. The results achieved on the Central Coast compare favourably with published reviews in Australia and overseas despite the lack of facilities for coronary angiography, coronary angioplasty and cardiothoracic surgery.
Use of cytokeratin fragments 19.1 and 19.21 (Cyfra 21‐1) in the differentiation of malignant and benign pleural effusions
Authors: Lee Y. C. (Gary) , Knox B. S. , Garrett J. E.
Published: March 2008

Background: Differentiation between malignant and benign pleural effusions is often difficult. Serum level of Cyfra 21‐1, a marker of cytokeratin 19 fragments, has been used in the diagnosis and monitoring of epithelial tumours, especially bronchogenic carcinomas.

Aim: This study is designed to establish the usefulness of effusion Cyfra 21‐1 level in differentiating malignant from benign effusions.

Methods: Forty‐eight malignant effusion aspirates (proven by cytology or pleural biopsy) and 34 benign samples were compared. Cyfra 21‐1 concentration was measured by a solid phase sandwich radioimmunoassay (Centocur®, USA).

Results: Cyfra 21‐1 level was significantly higher in malignant effusions (geometric mean 123.6 ng/mL, 95% confidence interval [CI] 76.6‐199.4) than in benign ones (geometric mean 14.3 ng/mL, 95% CI 8.5‐23.9), p<0.00005. By Receiver Operating Characteristics curve analysis, the sensitivity is 77% for a specificity of 79% if the cut‐off is set at 32 ng/mL. No significant difference was observed (p=0.1) in Cyfra 21‐1 concentration between adenocarcinoma and mesothelioma effusions. Cyfra 21‐1 level was not influenced by the effusion protein concentration (r=0.29), or by renal function as measured by serum creatinine (r=0.1). There was no significant difference between Cyfra 21‐1 levels in benign exudate and transudate effusions, p=0.28.

Conclusions: Cyfra 21‐1 is a useful adjunct in the workup of effusions but should not replace conventional investigations as there is considerable overlap in levels between benign and malignant groups. It is unable to differentiate between subgroups of malignancies.
Renal sarcoidosis in Christchurch, New Zealand 1970–1998
Authors: Jose M. D. , McGregor D. O. , Lynn K. L.
Published: March 2008

Aim: To identify patients presenting to a nephrologist in whom a diagnosis of sarcoidosis could be made, to assess the relevant causes of renal involvement and to review treatment and long‐term follow‐up of this group.

Method: A retrospective review of the computer database PROTONTM for patients given the diagnosis of sarcoidosis, followed by a case note review of identified patients with respect to the mode of presentation, clinical and laboratory features, treatment and subsequent follow‐up.

Results: Nineteen patients (15 males) were identified, mean age 45 years, all were Caucasian, and follow‐up was four months to 26 years (mean 9.3 years). Most common mode of presentation was acute renal failure (11) during spring/summer (14). Evidence for systemic disease was present in all patients. Mean plasma creatinine on presentation was 0.52 mmol/L and calcium 3.01 mmol/L. Hypercalcaemia was present in 60%. Kidney biopsy was performed in seven patients with the predominant findings of tubular atrophy and interstitial fibrosis; significant granulomata were present in only two. Treatment in all patients was with corticosteroids with good result. Mean long term plasma creatinine was 0.17 mmol/L at 9.3 years. Steroid withdrawal was attempted in all patients, successful in five, with the mean time to relapse of five months in the remaining 14. Mean steroid dose in this group was 7.6 mg on long term follow‐up.

Conclusions: Sarcoidosis causes renal dysfunction mainly through altered calcium metabolism. Treatment with corticosteroids is successful in improving renal function, but relapse is common on steroid withdrawal and prolonged treatment is necessary for disease control.
Cardiac surgery in octogenarians – The Green Lane Hospital Experience 1995–1998
Authors: Wong S. P. , Dixon S. R. , Ruygrok P. R. , Legget M. E.
Published: March 2008

Background: An increasing number of patients aged 80 years and over are being considered and accepted for cardiac surgery.

Aim: To review the experience of surgery in this elderly group of patients at our institution.

Methods: Hospital records of octogenarians undergoing surgery between January 1995 and September 1998 were reviewed and follow‐up was obtained by general practitioner (GP) and patient questionnaires.

Results: Thirty‐seven patients underwent cardiac surgery. The mean age was 82.8±1.4 years (range 80.8 to 86.2 years). Twenty‐three (62%) were male. All were independent pre‐operatively with severe symptoms and minor co‐existing morbidity.

All operations were urgent except two (emergency). Twenty patients (54%) had isolated coronary surgery, six (16%) aortic valve replacement alone, and 11 (30%) combined surgery. There were four (11%) early deaths and five (14%) peri‐operative neurological events. The mean duration of post‐operative intensive care stay was 2.4±3.9 days (range 0.05 to 16, median 1.0) and post‐operative hospital stay 14.0±13.9 days (range 0 to 79, median 11).

At the time of follow‐up (mean duration 20.0±11.2 months) two further patients had died (non‐cardiac). Twenty‐six of the 31 survivors were living at home (23 independently), one with relatives, and four in residential care. Their cardiac symptoms were well controlled. The GPs of all hospital survivors, and all surviving patients themselves, felt that cardiac surgery had been beneficial.

Conclusions: Cardiac surgery in the very elderly has been reserved for those with severe disease or symptoms and little co‐morbidity. Early mortality is higher than for the general population undergoing cardiac surgery, but post‐operative resource use is acceptable and the intermediate‐term outcome for survivors is good.
Are antipseudomonal antibiotics really beneficial in acute respiratory exacerbations of cystic fibrosis?
Authors: Wolter J. M. , Bowler S. D. , McCormack J. G.
Published: March 2008

Background: Although anti‐pseudomonal antibiotics are routinely used in the treatment of acute respiratory exacerbations of adult cystic fibrosis (CF), the specific efficacy of such treatment remains uncertain, the mechanism of action of these agents is not fully understood, and the role of sputum susceptibility testing in clinical decision making is controversial.

Aims: We investigated the relationship between susceptibility testing and clinical outcome in adult CF patients colonised with Pseudomonas aeruginosa.

Methods: Sputum samples were collected before, during and after respiratory exacerbations from 31 admissions (17 patients). Sputum colony counts and MIC of P. aeruginosa were performed.

Results: Sputum colony counts did not change significantly during or after intravenous (IV) antibiotic therapy. Clinical outcome parameters (lung function, 12‐minute walking distance, sputum weight and quality of life) were compared with susceptibility of P. aeruginosa colonies isolated at admission to the antibiotics used, and no correlation was evident. There was no evidence for the development of cross‐resistance and there was no change in the proportion of mucoid colonies with therapy.

Conclusions: While this study has a small patient sample size, it highlights the inconsistency of the role of antipseudomonal drugs also shown in other similar studies. The presence of P. aeruginosa in sputum of acutely ill CF patients prompts us to prescribe IV antipseudomonal drugs. If this approach was valid, we would expect to find a reduction in sputum colony counts and improvement in clinical parameters with the use of antibiotics to which the organisms were sensitive. The fact that such a relationship cannot be consistently demonstrated in this and other studies suggests that the use of antipseudomonal therapy in these patients requires more critical bacteriological and clinical evaluation.