bluuebunny/crossref_metadata_2025 huggingface dataset:
Video push enteroscopy in the investigation of small bowel disease: defining clinical indications and outcomes
Authors: Shackel N. A. , Bowen D. G. , Selby W. S.
Published: March 2008

Background: Push enteroscopy is a new technique for investigation of the small intestine. The clinical indications are still being defined. It also offers the potential for therapeutic intervention in suitable cases.

Aims: To evaluate further the role of push enteroscopy in the diagnosis and treatment of patients with suspected or known small bowel disease.

Methods: A prospective record was kept of all patients having enteroscopy at Royal Prince Alfred Hospital between March 1995 and July 1997. The procedure was performed 73 times in 68 patients. Indications and diagnoses were noted. The outcome in patients with obscure gastrointestinal bleeding or anaemia in whom a vascular lesion was treated with a heater probe was also determined.

Results: Enteroscopy was performed in 23 patients for gastrointestinal bleeding of obscure origin. An active or possible bleeding source was found in 13 (57%). The commonest of these was jejunal angiodysplasia. In the 21 patients with chronic iron deficiency anaemia a lesion was found in ten (48%). The majority of these were in the stomach, as described by others. The diagnostic yield in the 16 patients having enteroscopy for known or suspected small bowel disease was 56%. One patient underwent balloon dilatation of a postoperative jejunal stricture. Eleven patients with obscure bleeding or anaemia had ablation of a vascular lesion with a heater probe. Transfusion requirements fell after this procedure, particularly in those with active bleeding at the time of the examination. In five of the 11 no further transfusions were required in over six months of follow‐up.

Conclusions: The most common indications for enteroscopy are obscure gastrointestinal bleeding, chronic anaemia and known or suspected small bowel disease. A positive result can be expected in over 50% of patients. The treatment of vascular lesions via the enteroscope has a significant impact of subsequent transfusion requirements. (Aust NZ J Med 1998; 28: 198–203.)
Short duration therapy for Helicobacter pylori in Western Australia: the impact of metronidazole resistance
Authors: Forbes G. M. , Coombs G. W. , Collins B. J. , Robins P. D. , McCullough C. A.
Published: March 2008

Background: Limited Australian data are available on either short duration therapy for Helicobacter pylori infection, or the impact of metronidazole resistance on the outcome of treatment.

Aim: To compare the efficacy of two treatment regimens and determine the influence metronidazole resistance has on clearing H. pylori infection.

Methods: Eighty patients with H. pylori infection proven at upper gastrointestinal endoscopy, none of whom had previously received therapy for H. pylori, were randomised to one week therapy with either bismuth subcitrate one tablet qid, tetracycline 500 mg qid and metronidazole 400 mg tds (BTM), or lansoprazole 30 mg bd, amoxycillin 500 mg qid and metronidazole 400 mg tds (LAM). Effectiveness of therapy was measured by C14‐urea breath test at six weeks.

Results: On an intention‐to‐treat basis, clearance of infection was achieved in 17 of 32 (53%; 95% CI: 35–71%) evaluable patients receiving BTM and 32 of 46 (70%, 54–182%) patients receiving LAM (p=0.16). Metronidazole resistance was found in 32 of 65 (49%) patients in whom H. pylori was isolated by culture. On a per‐protocol basis, of patients who had metronidazole sensitive strains of H. pylori 23 of 24 (96%) cleared infection after therapy with either BTM or LAM, compared with 14 of 24 (58%) who were metronidazole resistant (p=0.004). Clarithromycin resistance was not found in 45 patients tested.

Conclusions: In Western Australia clearance rates H. pylori infection, after one week of BTM or LAM, are lower than in other published series. The high incidence of metronidazole resistance is the main determinant of our relatively poor eradication rates.
Long term follow‐up of CEOP in the treatment of HIV related non‐Hodgkin's lymphoma (NHL)
Authors: Davis A. J. , Goldstein D. , Milliken S.
Published: March 2008

Background: The development of non‐Hodgkin's lymphoma (NHL) in AIDS conveys a poor prognosis with less than 10% of patients surviving beyond two years. These tumours are generally aggressive and often require systemic chemotherapy to bring about effective palliation.

Aims: To report on the long term follow‐up of patients with HIV related NHL treated with CEOP chemotherapy.

Methods: This is a retrospective analysis of a group of 18 patients treated at two institutions between October 1990 and 1992 with modified CEOP chemotherapy. Doses were calculated using cyclophosphamide 750 mg/m2, epirubicin 50 mg/m2, vincristine 2 mg and prednisone 75–100 mg Xfive days, however initial doses of cyclophosphamide and epirubicin were modified to 50–75% of calculated dose.

Results: Seventeen of the 18 patients were male, one female; age range 26–79 (median 36 years); seven with immunoblastic, three Burkitt's, one Ki‐1 (anaplastic), six diffuse large cell, and one mixed large and small cell. Eight patients (44%) achieved a complete remission, with seven patients (39%) achieving a partial remission, for an overall response rate of 83% (95% CI=59–96%). Survival ranged from three‐35 months (median nine months). Interestingly, four patients (22%) survived more than two years (median 31 months), three remaining in complete remission at the time of death. Generally therapy was well tolerated and toxicity was manageable.

Conclusions: CEOP is an effective, tolerable and safe regimen and our long term follow‐up suggests that there is a small sub‐population of patients with HrV and lymphoma who may have a better prognosis and as such would clearly benefit from systemic chemotherapy as a means of prolonging survival and not simply palliation.
Identification of incident fractures: the Geelong Osteoporosis Study
Authors: Pasco J. A. , Henry M. J. , Gaudry T. M. , Nicholson G. C. , Kotowicz M. A.
Published: March 2008

Background: Complete fracture ascertainment is critical for fracture cost estimates and planning for future health care facilities. Virtually complete ascertainment is possible for hip fractures because they nearly always require hospitalisation.

Aims: To validate the use of radiological reports as a resource for ascertaining fracture cases, using hip fracture as a model.

Methods: Hip fracture rates obtained from radiological reports were compared with rates obtained from hospital discharge summaries of medical records using International Classification of Diseases‐9 (ICD‐9) codes 820.0–820.9 and 733.1 over a three‐year period.

Results: Hip fracture cases numbered 589 using radiological reports and 585 using medical records. Discharge summaries failed to identify 15 cases ascertained through radiology reports whereas 11 cases ascertained through medical records were not identified from X‐ray reports. The age‐specific incidence rates for radiological ascertainment were within the 95% confidence limits of the rates derived from medical records.

Conclusions: Among a population of patients generally admitted to hospital for treatment of their fracture, we were able to identify more cases from radiological reports than from medical records. Incidence rates for hip fracture were comparable using the two methods. Radiological reports provide a valuable resource for identifying incident fractures. This method of case ascertainment would be suitable for identifying both major and minor fractures in regions with self‐contained health services where access to all radiological reports is possible.
Osteolymphoma (primary bone lymphoma): an Australian review of 70 cases
Authors: Christie D. R. H. , Barton M. B. , Bryant G. , Cheuk R. , Gebski V. , Hornsey J. , Lonergan D. , MacLeod C. , Pratt G. , Roos D. , Shannon J. , Thornton D. , Wirth A.
Published: March 2008

Background: To examine prognostic factors, treatment outcomes and design future studies for Osteolymphoma (OL) – also known as primary bone lymphoma.

Methods: Between 1979 and 1993, 70 patients with OL were treated in nine Australian centres. The effect of patient‐, tumour‐, and treatment‐related factors on local control, distant disease‐free survival and overall survival were assessed by multivariate analysis.

Results: Most patients (94%) received radiotherapy (RT) (median dose 40 Gy) and 56% received chemotherapy. Multifocal disease was present in 20% of patients. The five year rates of overall survival and local control were 59% and 82%. Although there was a trend towards better results with the addition of chemotherapy, on multivariate analysis, there were no factors identified which appeared to impact upon overall and disease‐free survival. Among the distant recurrences, there was a high proportion in bone (33%). Six patients suffered pathological fractures after treatment.

Conclusion: High rates of local control were achieved by RT, but the overall survival remains relatively poor, worse than nodal lymphoma. The natural history of the disease suggests that OL may be a distinct entity, different to nodal lymphomas, so the results of clinical trials in nodal lymphoma may not be relevant to OL. Prospective studies could define the outcome of combined modality therapy and set a benchmark for testing further proposals, as well as improving our knowledge of the clinical features of OL.
Opinion of New Zealand physicians on management of acute ischaemic stroke: results of a national survey
Authors: Ardern‐Holmes S. L. , Raman R. , Anderson N. E. , Charleston A. J. , Bennett P.
Published: March 2008

Background: Randomised trials have evaluated various treatments for acute ischaemic stroke, but it is unclear how the results of these studies are used in everyday practice.

Aims: To obtain the opinions of physicians on the management of acute ischaemic stroke.

Methods: A questionnaire was sent to 368 New Zealand Fellows of the Royal Australasian College of Physicians. The survey included questions about the availability of hospital services for stroke patients, management of acute ischaemic stroke and opinion on the efficacy of treatments used in acute ischaemic stroke.

Results: Of the 293 physicians who responded to the questionnaire, 171 managed patients in the first week after stroke. Forty‐seven per cent of these physicians were general physicians. Ninety‐five per cent usually managed these patients in a general medical ward. Only five physicians admitted patients to an acute stroke unit and only 57% considered acute stroke units were beneficial. Aspirin was usually or sometimes used for patients with acute ischaemic stroke by 92% of physicians, intravenous heparin by 43%, low‐dose subcutaneous heparin by 41%, low‐molecular‐weight heparin by 25% and tissue‐plasminogen activator (t‐PA) by 3%. Two thirds considered that aspirin was definitely beneficial, but most were uncertain about the efficacy of intravenous heparin, low‐dose subcutaneous heparin, low‐molecular‐weight heparin and t‐PA. Sixty‐two per cent were prepared to begin aspirin and 21% subcutaneous heparin before computerised tomography (CT). Twenty‐three per cent used anti‐hypertensive treatment in the first few hours after an ischaemic stroke.

Conclusions: Several common deficiencies in the management of acute ischaemic stroke were identified. The widespread lack of stroke units, use of aspirin and heparin before CT, and lowering of blood pressure after an acute ischaemic stroke differed from accepted guidelines. Many physicians used heparin despite lack of evidence from randomised trials that it is beneficial. The development of stroke units and the appoint‐ment of physicians with a special interest in the management of stroke may improve the management of patients with acute stroke. (Aust NZ J Med 1999; 29: 324–330.)
Sympathetic activation and the role of beta‐blockers in chronic heart failure
Authors: Krum H.
Published: March 2008

Chronic heart failure (CHF) is associated with activation of the sympathetic nervous system. This activation provides short term haemodynamic support to the failing myocardium, but may be deleterious over longer periods as chronic catecholamine excess appears to contribute to disease progression and increased mortality in this condition.

Therefore, blockade of sympathetic activation represents a logical, if somewhat counter‐intuitive, approach to the management of the patient with systolic CHF. Pharmacological approaches to blockade of this system include inhibition of central sympathetic outflow (using central sympatholytics, e.g. rilmenidine, moxonidine), blockade of the catecholamine biosynthetic pathway (dopamine beta hydroxylase antagonists) and blockade of the cardiac effects of sympathetic activation (beta‐adrenoceptor blocking agents).

Beta‐blockers have now been extensively studied in patients with symptomatic CHF of the New York Heart Association (NYHA) Class II and III severity. Provided beta‐blocker therapy is carefully up‐titrated from sub‐therapeutic doses and given for at least three to four months, these agents have been associated with favourable long term haemodynamic, functional and mortality outcomes. Furthermore, beta‐blockers delay disease progression in CHF by reversing the pathological myocardial remodelling process that accompanies the disease.

Non‐selective beta‐adrenoceptor blocking drugs appear to be of particular benefit in CHF therapy. Myocardial β2 receptors are down‐regulated to a lesser extent than β1 receptors in CHF, therefore blockade of the β2 receptor sub‐type may assume greater importance in inhibiting the deleterious effects of sympathetic activation on the myocardium in this disease.

Newer agents that possess additional vasodilator properties (carvedilol, bucindolol, nebivolol) may be useful in overcoming the initial negative inotropy of the beta‐blocking component of the drug, however, it is unlikely that vasodilation contributes greatly to long term clinical benefits.

Drugs such as carvedilol are also anti‐oxidant, anti‐protiferative and have anti‐endothelin: actions; the clinical significance of these properties is yet to be determined.

Unanswered questions remain regarding the use of beta‐blockers in heart failure. Ongoing studies are further examining mechanisms underlying the clinical benefits of these agents as well as their therapeutic potential in NYHA Class IV patients, heart failure post‐myocardial infarction and patients with asymptomatic left ventricular dysfunction.
New thrombolytic drugs
Authors: Thomson A.
Published: March 2008

Thrombolytic drugs reduce mortality from myocardial infarction and research is focused on newer drugs with improved clinical efficacy. The ideal thrombolytic drug should be effective in dissolving fresh and older thrombi, be rapid in its action with complete dissolution of the thrombus, be able to be given as a bolus and be safe without hypotensive or allergic or immunogenic reactions.

The types of agents being developed fall into five broad categories:

• mutants or variants of single chain urokinase type plasminogen activator;

• mutants or variants of tissue type plasminogen activator;

• recombinant chimaeric plasminogen activators;

• conjugates of plasminogen activators and anti‐fibrin monoclonal antibodies;

• compounds derived from haemophagous animals.

Within the mutant and variant groups there may be single point mutations which increase the half life or deletion of various amino acid sequences to increase resistance to plasma protease inhibitors or cause more selective binding to fibrin. The recombinant chimaeric plasminogen activators are designer drugs where the kringle regions, the growth hormone domain region, the finger domain region and the serine protease part of the molecules are all cleaved and recombined in various ways to improve potency.

The conjugates of plasminogen activators and anti‐fibrin and monoclonal antibodies improve the targeting of the agent to fibrin clot. Monoclonal antibodies are commonly used against the seven aminoterminal residues of the beta chain of fibrin. These are cross linked and bound to plasminogen activators.

A variety of substances from haemophageous animals are currently being studied including salivary plasminogen activator from vampire bats, venom from southern copperhead snakes and staphylokinase from bacteria.

Currently available thrombolytic agents have many limitations, but the novel thrombolytic agents have yet to be tested in clinical trials. With few exceptions, they all act via the plasminogen system and it may be in the future that combinations of anti‐platelet and thrombolytic agents may prove to be more efficacious than thrombolytics and aspirin alone.
Troponin and other cardiac markers: role in management of acute coronary syndromes
Authors: Ohman E. M.
Published: March 2008

Many adjuncts to the traditional history, physical examination, and baseline ECG have been developed to improve the differential diagnosis of acute coronary syndromes in the Emergency Department (ED). These include serial ECGs, continuous ST‐segment monitoring, and serum markers of myocardial necrosis. In general, the serum markers of coronary ischaemia, particularly the troponins, provide the most information toward initial and later risk stratification. Serial marker measures not only increase the sensitivity and negative predictive value for acute infarction (thus reducing hospital costs) but also can add to prognostic ability. More importantly, a positive marker result indicates an increased risk of an early event, which could allow earlier intervention and thus a better outcome.
Treatment of metastatic breast cancer with continuous infusional 5 fluorouracil
Authors: Karapetis C. S. , Patterson W. K. , Pittman K. B. , Kotasek D. , Sage R. E.
Published: March 2008

Background: Single agent continuous infusional 5 fluorouracil (CI‐5FU) via a central venous catheter (CVC) is usually reserved for breast cancer patients who have previously failed one or more chemotherapy regimens. The patients are usually heavily pre‐treated with later stage disease. Previously published studies of CI‐5FU have reported response rates as high as 54%. It is considered an approach with an acceptable side effect profile in such patients.

Aims: To evaluate the efficacy and toxicity of CI‐5FU in previously treated metastatic breast cancer.

Methods: A retrospective review of advanced breast cancer patients treated with CI‐5FU between October 1992 and October 1996 was performed. Response to treatment, toxicity, CVC complications and patient survival were analysed.

Results: Twenty‐four patients with metastatic breast cancer were treated with CI‐5FU. All had received previous chemotherapy, including 19 patients (79%) with prior 5FU exposure and eight patients (33%) who had previous high dose chemotherapy with autologous stem cell transplantation. The median duration of CI‐5FU treatment was 3.1 months. Nineteen patients had evaluable disease, three (16%) of whom demonstrated a partial response and four patients had stable disease. There were no complete responses. All responses occurred in soft tissue sites with no objective evidence of response in liver or bone metastases. The survival rate at one year was 21% (five of 24) and the median survival of all patients was 6.1 months. Five patients (21%) stopped treatment due to treatment related morbidity (two CVC complications and three CI‐5FU side effects). Diarrhoea, nausea, and palmar‐plantar erythrodysaesthesia were the major side effects of chemotherapy. CVC complications requiring intervention, the most notable of which were infection and thrombosis, occurred in 11 patients (46%). There were no treatment related deaths.

Conclusions: Single agent CI‐5FU has modest activity in women with previously treated advanced breast cancer. The efficacy is lower than in previously published series. This may reflect patient selection factors. The toxicity was mainly related to CVC complications. Important issues relating to quality of life need to be objectively measured in future studies of CI‐5FU.
Severity of liver disease in hepatitis C infection contracted through injecting drug use
Authors: Ostapowicz G. , Bell S. J. , Desmond P. V.
Published: March 2008

Background: Injecting drug use (IDU) is currently the most common route of hepatitis C virus (HCV) transmission in Australia and many other Western countries. Most reports on the natural history of HCV have examined populations that included patients from all risk groups, but it is possible that this increasingly important subgroup is different.

Aims: To assess the severity of liver disease in individuals who acquired HCV through IDU.

Methods: Three hundred and forty‐six patients with confirmed HCV infection and a history of IDU, who had had a liver biopsy performed were recruited from a liver clinic. Demographic data, liver function tests and hepatitis B serology were obtained on all patients. A detailed drug use history and HCV viral studies were also available in a subgroup of 142 patients.

Results: Mean age of the group was 34 years and 73% were male. Mean duration of HCV infection was 14.6 years. Forty one per cent were infected with genotype 3a, 19%– 1a, 17%– 1 (nonsubtypable), 14%– 1b and 4%– 2b. Cirrhosis was present in 12% of patients. Patients with cirrhosis (38 years) were older than those with chronic hepatitis (34 years; p=0.0003) and had a longer duration of infection (17.2 vs 14.3 years; p=0.003). On multivariate analysis, however, patient age was the only factor independently associated with cirrhosis (odds ratio 4.2; 95% confidence interval 1.4‐12.6).

Conclusion: While cirrhosis is less common in this group than in other HCV infected populations, its prevalence may increase as these patients are followed over a longer period of time.
Systemic sclerosis prevalence and mortality in Sydney 1974‐88
Authors: Englert H. , Small‐McMahon J. , Davis K. , O'Connor H. , Chambers P. , Brooks P.
Published: March 2008

Background: Systemic sclerosis prevalence and mortality estimates have demonstrated wide variability. The sole Australian study published to date demonstrated high prevalence rates when compared to overseas estimates. The prevalence and mortality findings reported in this paper derive from a larger study which addressed the distribution and determinants of systemic sclerosis within Sydney.

Aims: To determine systemic sclerosis prevalence and mortality rates within Sydney over 15 years, 1974–88.

Methods: Cases were ascertained from multiple sources including death certificates, hospitals, physicians, vascular surgeons' and dermatologists' private practices, a systemic sclerosis self‐help group and private medical laboratories.

Results: Overall, 715 cases were identified. Females comprised 77% (95%CI:74–80) of cases. Disease of the limited subtype accounted for 79% (95%CI: 76–82) of all systemic sclerosis, being relatively more frequent in living than deceased cases, and in females than males. Crude prevalence estimates appeared to rise between 1975 (4.52/100,000 95%CI:3.75–5.29/100,000) and 1988 (8.62/100,000 95%CI:7.64–9.60/100,000) as did estimates of diffuse disease. However, diffuse disease prevalence, when expressed as a proportion of total disease prevalence, showed no significant temporal change. Although crude mortality rates also showed apparent temporal increases (0.24/100,000 in 1975 to 0.80/100,000 in 1988) standardised mortality rates showed less convincing trends (0.41/100,000 in 1976 and 0.40/100,000 in 1988). Death certificate‐derived mortality rates provided relatively large underestimates of total mortality. However, these underestimates were relatively constant over time.

Conclusions: This study has demonstrated systemic sclerosis prevalence and mortality rates comparable to overseas estimates, consistently higher prevalence and mortality rates in females than males, proportionally higher rates of diffuse disease in males than females and in deceased cases than living cases, a diffuse: limited disease ratio apparently
Vitamin D deficiency and secondary hyperparathyroidism: clinical and biochemical associations in older non‐institutionalised Southern Tasmanians
Authors: Inderjeeth C. A. , Nicklason F. , Al‐Lahham Y. , Greenaway T. M. , Jones G. , Parameswaran V. V. , David R.
Published: March 2008

Aim: To determine the prevalence and associations of vitamin D (25‐OHD) deficiency in a sample of older Tasmanian subjects.

Methods: A cross‐sectional survey of: 109 patients with a mean age of 79 years (range 60–101 years) consecutively admitted to a short stay geriatric rehabilitation ward; 52 community dwelling subjects with a mean age of 75 years (range 64–88 years). Subjects answered a questionnaire, had anthropometric measurements and underwent venepuncture.

Results: The main outcome measure was 25 hydroxy vitamin D (25‐OHD) level with deficiency defined as < 28 nmol/L. Vitamin D deficiency was found in 67% and secondary hyperparathyroidism in 49% of the hospitalised group. Vitamin D deficiency was also found in 17% of the community group, in particular one in three residents of Independent Living Units was deficient. Subjects who were deficient were older (80 years vs 76 years [p<0.001]), had lower body mass index (23.7 kg/m2vs 25.9 kg/m2 [p<0.001]) and had a lower serum albumin (35 gm/L vs 39 gm/L [p<0.001]). Deficient subjects had poorer physical functional status (p=0.02) and lower activity levels (p<0.001) and reported less habitual sun exposure (p<0.001). Biochemical measures such as parathyroid hormone, alkaline phosphatase and calcium were weakly predictive of vitamin D levels. By stepwise multiple regression analysis, the only significant predictors of vitamin D levels were the Frenchay Activity Index, albumin and calcium.

Conclusion: Vitamin D deficiency and secondary hyperparathyroidism is common in community living older people who are hospitalised in Southern Tasmania and is associated with increasing age, poor physical function and activity and low reported sun exposure.
Improved coronary artery flow after coronary angioplasty in patients with unstable angina
Authors: Williams M. J. A. , McCormick M. P. , Kay I. P. , Restieaux N. J.
Published: March 2008

Background: Coronary artery flow is impaired after myocardial infarction but there is limited information regarding coronary flow in unstable angina.

Aim: To assess baseline coronary artery flow and the effects of coronary angioplasty on coronary flow in patients with unstable angina.

Methods: Twenty‐one patients with unstable angina with a culprit lesion suitable for coronary angioplasty were enrolled in the study. Coronary flow was assessed with the Thrombolysis In Myocardial Infarction (TIMI) grade and the Corrected TIMI Frame Count (CTFC) pre and post angioplasty.

Results: Baseline flow was impaired in the culprit artery compared to the non culprit artery (42.0±28.1 vs 25.3±7.0 frames, p<0.02). Pre angioplasty coronary flow was TIMI grade 2 in 52% and TIMI grade 3 in 48% of patients. Post angioplasty flow improved with TIMI grade 2 flow in 5% and TIMI grade 3 in 95%. After angioplasty coronary flow improved from 42.0±28.1 frames to 21.6±16.3 (p=0.0001). The culprit coronary stenosis decreased from 74±9% pre angioplasty to 28±12% after intervention (p=0.0001).

Conclusions: Angioplasty and stenting of the culprit vessel restores normal coronary flow in most patients with unstable angina. This suggests that impaired flow in unstable angina is predominantly related to the culprit lesion residual stenosis.
The use of evidence‐based medicine in the practice of consultant physicians. Results of a questionnaire survey
Authors: Scott I. , Heyworth R. , Fairweather P.
Published: March 2008

Abstract Background: Information is lacking about the extent to which Australasian physicians apply methods of evidence‐based medicine (EBM) in routine practice.

Aims: To assess the frequency and predictors of use of EBM methods in a sample of consultant physicians in adult medicine.

Methods: Self‐administered questionnaires were distributed to a convenience sample of 545 physicians from October 1998 to January 1999.

Results: One hundred and eleven questionnaires were returned (20% response rate). Ninety‐eight (88%) respondents formulated five or less clinical questions per week; 69 (62%) undertook five or more evidence searches per week, the majority as MEDLINE searches involving therapeutic topics. Respondents identified insufficient time (74%), limited search skills (41%), and limited access to evidence (43%) as search impediments. In determining evidence quality, 37% frequently relied on global impressions, while 22% frequently applied explicit critical appraisal (p=0.008). Efficiency of literature searches was rated on average as good/very good by 18%, fair by 52% and poor by 30%. As a result of EBM, 47% frequently had confidence in pre‐existing decisions increased, 39% gained improved knowledge, and 5% altered clinical decisions. Frequently encountered inhibitors to changing practice were personal conservatism (40%), organisational constraints (40%), and interdisciplinary tensions (39%). Perceived weaknesses of EBM included: limited applicability to individual patients (26%); evidence deficiencies (25%); and too time consuming (13%). In making EBM more attractive, one third requested reliable evidence sources at the point of care.

Conclusions: The application of EBM to routine practice by physicians is constrained by deficient EBM skills, limited access to evidence, lack of time, and cognitive and environmental factors. Targeted education in EBM and systems that quickly deliver high‐quality evidence at the point of care are needed in realising the full potential of EBM to improve care.
The optimal use of allopurinol: an audit of allopurinol use in South Auckland
Authors: Stamp L. , Gow P. , Sharples K. , Raill B.
Published: March 2008

Background: Gout is a common and challenging problem in South Auckland, New Zealand. Allopurinol is widely used but urate reduction remains unsatisfactory. Allopurinol dosing guidelines and a therapeutic range for plasma oxypurinol levels have been published.

Aims: We aimed to determine the appropriateness of allopurinol dosing according to current guidelines and to assess the relationship between plasma creatinine, oxypurinol and urate. In addition, we assessed the clinical usefulness of the oxypurinol level.

Methods: Thirty‐one patients, on a stable dose of allopurinol for at least three weeks, had plasma creatinine, urate and oxypurinol measured as part of routine clinical assessment. Relationships between the various methods were examined using regression analysis. Fisher's exact test was used to test associations with categorical variables.

Results: Fifty‐five per cent of patients were on higher than recommended doses of allopurinol. There was a statistically significant relationship between calculated creatinine clearance and plasma oxypurinol level. Only 50% of patients with a plasma oxypurinol within the therapeutic range (30–100 μmol/L) had a plasma urate <0.42 mmol/L and this did not increase significantly in the patients with an oxypurinol level <100 μmol/L.

Conclusions: There is poor adherence to the current recommended dosing guidelines for allopurinol. Creatinine clearance rather than plasma creatinine needs to be used to predict the dose of allopurinol. The current role of the oxypurinol level is to identify non‐compliers with allopurinol therapy. We need further research to clarify whether increasing the dose of allopurinol outside the recommended dose range to reach an oxypurinol level of close to 100 μmol/L may be of benefit in those who have not had sufficient urate reduction.
Non‐urease producing Helicobacter pylori in chronic gastritis
Authors: Ren Z. , Pang G. , Batey R. , Routley D. , Russell A. , Musicka M. , Dunkley M. , Beagley K. , Clancy R.
Published: March 2008

Background: Helicobacter pylori infection is the commonest cause of gastritis. Different patterns of immune response to H. pylori infection and characteristics of bacteria are considered to contribute to clinical outcomes.

Aim: To determine characteristics of the host H. pylori relationship in subjects with non‐ulcer dyspepsia and a histological diagnosis of gastritis.

Methods: Thirty‐five subjects with chronic gastritis undergoing endoscopy (mean age 53 years, range 24–82, 14 male and 21 female) were studied, none of whom was on nonsteroidal anti‐inflammatory drugs or antibiotics. H. pylori infection was determined by rapid urease test (CLOtest), culture, antibody and RT‐PCR for Ure C, Cag A and 26 kDa gene and histology. Cytokine production of mucosal IL‐6 and IL‐8 were measured by ELISA.

Results: Fifteen subjects were positive by CLOtest and/or bacterial culture. In these subjects histology showed numerous helical forms of H. pylori (Group I). Nine subjects were negative by CLOtest, bacterial culture, and mRNA for urease C fragment, but positive by PCR for the 26 kDa protein encoding gene. Histology in these subjects showed the presence of either coccoid forms (four), or scant helical forms (two), or mixed coccoid/helical forms (three) (Group II). Eleven subjects were negative by all methods of detection (Group III). IgG and IgA antibody levels in serum (p<0.05) and gastric tissue culture supernatant (p<0.001) were significantly higher in Group I than those in Group II or III. There were significant differences in the IgG serum and IgA supernatant antibody levels (p<0.01 and p<0.05) when Group II was compared to Group III. Supernatant IL‐6 levels were significantly higher in Group I (p<0.01) than those from Groups II and III. EL‐8 levels were higher in Group I (p<0.01) and Group II (p<0.05) when compared to Group III.

Conclusions: ‘H. pylori‐negative’ gastritis can be associated with a non‐urease producing form of H. pylori, with a reduction in both local and systemic antibody levels and mucosal pro‐inflammatory cytokines.
A telephone call reminder to improve outpatient attendance in patients referred from the emergency department: a randomised controlled trial
Authors: Ritchie P. D. , Jenkins M. , Cameron P. A.
Published: March 2008

Background: Poor compliance with attendance at outpatient clinic appointments in patients referred from emergency departments (EDs) is a major problem in public hospitals.

Aims: To determine whether the intervention of a telephone call within three days of ED attendance would improve: 1. the proportion of patients making recommended outpatient appointments; and 2. the proportion of patients attending scheduled appointments. To characterise reasons for non‐attendance at appointments made by patients referred from the ED.

Methods: A randomised controlled trial was undertaken of 400 patients recommended to make outpatient appointments during attendance at The Royal Melbourne Hospital ED in July‐August 1999. Intervention: a telephone call one to three days after attendance to remind the patient about the appointment (and its importance for medical follow‐up) if one had been made and to offer to make an appointment if one had not been made. Outcome measures: 1. making the recommended appointment; 2. attendance at the scheduled appointment; and 3. reasons for non‐attendance at scheduled appointments.

Results: The telephone intervention improved attendance at scheduled appointments from 54.4% to 70.7% (p=0.002). The proportion of patients making appointments was not significandy affected. The commonest reasons given for non‐attendance were: attended general practitioner (13%), attended private specialist (6.6%), inpatient in hospital at time of appointment (6.6%), too busy or inconvenient (5.3%), claimed to have attended (5.3%) and did not differ by intervention.

Conclusions: A significant improvement in the proportion of patients attending outpatients appointments can be made by a simple reminder telephone call one to three days after attendance at the ED.
Does high dose ipratropium bromide added to salbutamol improve pulmonary function for patients with chronic obstructive airways disease in the emergency department?*
Authors: Koutsogiannis Z. , Kelly A.‐M.
Published: March 2008

Background: To determine the effect of high dose ipratropium bromide, both alone or in combination with standard dose salbutamol, on pulmonary function in patients presenting to the Emergency Department (ED) with acute exacerbation of chronic obstructive airways disease (COAD).

Method: The trial was a prospective, randomised, double blind trial of adult patients with COAD. All patients received nebulised salbutamol 5 mg and 500 μg ipratropium and hydrocortisone 250 mg IV at time=0, then were randomised to receive further nebulisers at time=15 minutes and time=30 minutes of salbutamol 5 mg combined with ipratropium 500 μg or salbutamol 5 mg alone or ipratropium 500 μg alone. Pulmonary function tests were conducted at time=0 and time=90 minutes. The primary endpoints were absolute and percent change in FEV1.

Results: The group randomised to receive 5 mg salbutamol and 500 μg ipratropium (n=18) showed a mean percentage change of FEV1 of 6.4% with a mean absolute change of 0.06 L (SD 0.18 L). Those who received 5 mg salbutamol (n=16) had a mean percentage change of 18.6% with a mean absolute change of 0.13 L (SD of 0.21 L). Those who received 500 μg ipratropium (n=16) had a mean percentage change of 4.8% with a mean absolute change of 0.023 L (SD of 0.07 L). There was no significant difference between the groups in FEV1 (p=0.56 for percentage change; p=0.36 for absolute change).

Conclusion: The addition of 500 μg ipratropium to 5 mg salbutamol in subsequent nebulisers adds no benefit to pulmonary function after the initial nebuliser of both bronchodilators in the treatment of COAD in the ED.
The angiotensin converting enzyme (ACE) inhibitor, perindopril, modifies the clinical features of Parkinson's disease
Authors: Reardon K. A. , Mendelsohn F. A. O. , Chai S. Y. , Horne M. K.
Published: March 2008

Background: Animal studies have demonstrated an interaction within the striatum between the angiotensin and dopaminergic systems. In rats, the angiotensin converting enzyme (ACE) inhibitor, perindopril, crosses the blood brain barrier and increases striatal dopamine synthesis and release. In humans, angiotensin type 1 receptors have been found on dopaminergic neurons in the substantia nigra and striatum. In Parkinson's disease, there is a marked reduction of these receptors associated with the nigrostriatal dopaminergic neuron loss.

Aims: We performed a double blind placebo controlled crossover pilot study in seven patients to investigate the effect of the ACE inhibitor, perindopril on the clinical features of moderately severe Parkinson's disease.

Results: After a four week treatment period with perindopril, patients had a faster onset in their motor response to L‐dopa and a reduction in ‘on phase’ peak dyskinesia, p=0.021 and p=0.014 respectively. Patients also reported more ‘on’ periods during their waking day in their movement diary, p=0.007. Perindopril was well tolerated without any significant postural hypotension or renal dysfunction.

Conclusions: These results suggest that ACE inhibitors such as perindopril may have a place in the management of motor fluctuations and dyskinesia in Parkinson's disease and justify further study.
A multivariate analysis of the association between social class of origin and current social class with self‐rated general health and psychological health among 16‐year‐old Australians
Authors: Siahpush M. , Singh G. K.
Published: March 2008

Background: A recent review of international literature concludes that there is a relative absence of social class differentials in health in early youth. There is an absence of Australian studies on the effect of social class on the health of this age group.

Aims: To examine the association between social class and health among 16‐year‐old Australians.

Methods: The data on 1048 16‐year‐olds came from the fifth wave (1993) of the Australian Youth Survey conducted by the former Department of Employment, Education and Training. Outcome measures were self‐rated general health and psychological health (GHQ‐12). Binary logistic regression was used to analyse data.

Results: Neither social class of origin nor current social class was associated with self‐rated general health or psychological health.

Conclusion: The argument that social class inequalities in health exist in childhood, disappear during early youth, and reappear later appears to hold ground within the Australian context.
Cost‐effectiveness and accuracy of exercise stress echocardiography in the non‐invasive diagnosis of coronary heart disease
Authors: Laufer E. , Wahi S. , Lim Y. L.
Published: March 2008

Background: Exercise stress echocardiography (ESE) is a more recent form of totally non‐invasive stress testing which like exercise thallium SPECT scintigraphy (ETS) was developed to overcome the known limitations of ECG stress testing, namely the limited diagnostic accuracy and the inability of ECG stress testing to site the region of coronary artery disease (CAD) induced ischaemia.

Aims: To determine the sensitivity and specificity (and overall accuracy) of ESE in a group of patients referred for ETS imaging and compare the relative costs of each technique.

Methods: One hundred and fifteen patients referred for ETS consented to a simultaneous ESE. Of this group, 59 patients underwent coronary angiography which was utilised as the gold standard.

Results: The feasibility of ESE was 97% (112 of 115 patients of the total study population and 57 of the 59 patients who underwent coronary angiography). Of the 59 patients undergoing coronary angiography, the sensitivity of ESE and ETS were not significantly different (84.1%versus 91.3% respectively). However, despite the apparent marked difference in specificity (92.3%versus 61.5% respectively), p= NS (Fisher's exact test) as there were only 13 normals in the group who underwent coronary angiography. Overall accuracy was also closely similar (86.0%versus 84.7% respectively) and therefore also not significantly different. By contrast, agreement with coronary angiography as measured by the kappa statistic (k±SEk) was good for ESE (0.66±0.11) but only moderate for ETS (0.54±0.13). Moreover, there was a cost saving of at least 594.00 per patient in favour of ESE.

Conclusion: ESE is a totally non‐invasive, sensitive, specific and cost‐effective imaging modality for the detection and localisation of CAD.
THE DIFFERENCE BETWEEN TWO POISSON EXPECTATIONS1
Authors: Best D. J.
Published: March 2008

A number of statistics have been suggested for testing the difference between two Poisson expectations. On the basis of size and power calculations a new statistic, v= (2x+ 3/4)1/2 ‐ (2y + 3/4)1/2, where x and y are the two observed Poisson values, is recommended for testing such differences. This statistic is shown to be similar in performance to the familiar u=(x‐y)f(x+y)1/2, except in the tails of the distribution where it is superior.
BIBLIOGRAPHY OF DESIGNS FOR EXPERIMENTS1IN THREE DIMENSIONS
Authors: Preece D. A.
Published: March 2008

A list is given of combinatorial and statistical publications on (a) designs for comparative experiments in three space dimensions, and (b) other related designs.
A CRITICAL REVIEW OF SEA‐LEVEL CHANGES IN EASTERN AUSTRALIA SINCE THE LAST GLACIAL
Authors: Hails J. R.
Published: March 2008

An outline of sea‐level changes is presented, based on field work, bore‐log data, radiocarbon analyses, and a review of the literature. The sequence of eustatic changes, during and since the Pleistocene Epoch, is obscure in Australia, as elsewhere. Evidence suggests that the sea rose rapidly from 17,000 until 6,000 B.P., and that some deltaic plains and coastal depositional features along parts of the New South Wales and Queensland coasts formed since approximately 5,000 B.P. In the areas studied, there is not sufficient evidence to support a lo‐foot higher sea‐level which has been reported in Australia and attributed to a post‐glacial thermal maximum. A possibility of slight epeirogenic movement is considered in attempting to explain some coastal features in southern New South Wales.
LAND EVALUATION: REVIEW
Authors: Robinson Geoffery , Joyce E. Bernard
Published: March 2008

Land Evaluation ‐ Papers of a C.S.I.R.O. Symposium Organized in Co‐Operation with UNESCO, Canbera, 26–31 August, 1968, edited by G.A. Stewart
Caesium‐137 as an indicator of geomorphic processes in a drainage basin system
Authors: CAMPBELL B. L. , LOUGHRAN R. J. , ELLIOTT G. L.
Published: March 2008

Caesium‐137 from fallout from nuclear weapons tests is adsorbed on fine sediments and becomes an effective tracer. It is hypothesised that within a drainage basin, sites undergoing little or no erosion accumulate
137
Cs in their upper layers; cultivated soils will have
137
Cs uniformly distributed within the cultivated layer; eroded soils, cultivated or not, will have relatively less
l37
Cs, depending on the severity of erosion. Accumulated sediments will have characteristic
137
Cs profiles reflecting temporal fallout variations and sedimentation history. This hypothetical model is largely confirmed by results from Maluna Creek basin, where erosion and accumulation of sediments has taken place. Soils under viticulture have about one third the
137
Cs content of soils with grass cover, indicating more severe erosion under cultivation. Caesium‐137 profiles in alluvial fan and flood plain deposits correlate with sediment layers and known cultivation history.
Managing Australia's water resources
Authors: CRABB P.
Published: March 2008

We have a great power not to destroy and in exercising that power, we will give proof of our consideration for the future, and for the first time in our history we will be recognised as custodians of the earth.

Tasmania has rivers flowing to the sea … these are great natural energy resources just crying out to be developed and developed they must be.
Models of urban change: Sydney 1820–1870
Authors: APLIN GRAEME
Published: March 2008

Established models of urban change do not adequately allow for the complex interactions between the forces and relations of production and the effects of changes in these factors on urban settlements. A proposed, extended model includes a transition stage which can best be described as the mercantile or early capitalist city which hadnot yet adopted the modern technology developed in the Industrial Revolution. Sydney and its growth and development between 1820 and 1870, a crucial period, is viewed against this suggested framework. During this period, Sydney was clearly going through such a transitional phase.
Wilderness, Nature and Society: contributions to the history of an environmental attitude
Authors: JEANS D. N.
Published: March 2008

The depth of feeling now seen in the struggle over environmental conservation can, with the aid of scholars in other disciplines, be traced to the central importance of Nature in the ideology of Western Society. The late seventeenth century is seen as the period of an ideological transformation in which Nature, at first under the tutelage of God, came to set the terms for social definition and debate. As a flexible metaconcept, Nature became a weapon of social control for a hegemonic centre and, at the same time, a vehicle of protest for the social periphery. Further ambiguity arises from the intersection of this development with the devaluation of Nature as a commodity within the capitalist system, which intensifies the element of protest in the use of Nature as a social category.
The evaluation of electoral redistributions: the case of Western Australia*
Authors: RUMLEY DENNIS
Published: March 2008

Electoral boundaries may be delimited by electoral commissioners who are explicitly non‐partisan but the consequences of their decisions are generally highly partisan. An evaluation of the State redistribution in Western Australia reveals that the Liberal Party was given a significant initial advantage for the 1983 State Election. Indicators used in the evaluation procedure include political party competition, shape, the integrity of political units, predictors of voting behaviour, as well as the re‐aggregation of the 1983 election results by the pre‐redistribution boundaries.