bluuebunny/crossref_metadata_2025 huggingface dataset:
Risk factors for death in patients admitted to hospital with asthma: a follow‐up study
Authors: Ryan G. , Stock H. , Musk A. W. , Knight J. L. , Perera D. M. , Hobbs M. S. T.
Published: March 2008

Abstract Hospital records of patients with asthma admitted to teaching hospitals in Perth, Western Australia between 1976 and 1980 were examined retrospectively to identify characteristics of the illness which were associated with subsequent death. From 5722 admissions there were 195 deaths to December 1982, 186 of whom had records available (cases); 452 of the surviving subjects were used for comparison (controls). There was no difference in age of onset of asthma or cigarette smoking habits between the two groups, but ischaemic heart disease as an associated condition was significantly more frequent in cases. On admission to hospital an arterial Pco2<45 mmHg was more frequent in those who died, but there were no differences in arterial Po2, lowest pH, highest or lowest FEVi and FVC. Cases more frequently used home nebulisers and were more frequently prescribed corticosteroids, antibiotics and sedatives or tranquillisers prior to admission, corticosteroids and sedatives or tranquillisers during admission and sedatives or tranquillisers on discharge. These results suggest that cases had more severe asthma in that they were more often treated with home nebulisers, corticosteroids and antibiotics, but with the exception of PaCO2 the commonly used measurements of severity of asthma did not identify those at risk of death. The prescription of sedatives or tranquillisers appears to be associated with an increased risk of death in subjects with asthma.
Low dose erythropoietin in maintenance haemodialysis: improvement in quality of life and reduction in true cost of haemodialysis
Authors: Harris D. C. H. , Lawrence S. , Chapman J. R. , Roger S. D. , Stewart J. H.
Published: March 2008

Abstract Human recombinant erythropoietin (r‐HuEPO) improves quality of life in patients on maintenance haemodialysis, but the haemoglobin (Hb) level necessary to achieve this improvement is unknown. In this study, quality of life, functional capacity and symptoms of 28 haemodialysis patients with an initial Hb of 67 ±2 (mean ± SEM) g/L were assessed after 0, 6 and 12 months of r‐HuEPO, the dose of which was titrated to achieve a stable Hb of between 90 and 100 g/L.

At six and 12 months Hb was 97 ± 2 and 93+2 g/L, and mean r‐HuEPO dose between three and six, and between nine and 12 months was 88 ± 6 and 62 ± 9 U/kg/week intravenously respectively. There was a significant improvement in level of activity and satisfaction with various aspects of life, and a reduction in fatigue, weakness, dyspnoea, angina and restless legs. Patients were able to walk 50% further in six minutes. The improvement in quality of life and function was similar to that reported from other centres whose target Hb was between 100 and 120 g/L, and where the r‐HuEPO dose was 75% higher than in this study.

Costs of r‐HuEPO therapy were assessed. The drug itself costs $A3681/yr/patient, to which was added the estimated cost of additional dialyses and medications, bringing the total to $A5177/yr/patient. There was, however, a reduction in both hospitalisation by 8.3 days/yr/patient and medical consultation by 3.9 hours/yr/patient. Five patients commenced full‐time work, one took up full‐time study aimed at finding work, three transferred to home haemodialysis and six fewer patients drew social security benefits. The net cost saving from using low dose r‐HuEPO was more than $A1,000/yr/patient.
Metformin increases insulin sensitivity and basal glucose clearance in Type 2 (non‐insulin dependent) diabetes mellitus
Authors: Mclntyre H. D. , Paterson C. A. , Ma A. , Ravenscroft P. J. , Bird D. M. , Cameron D. P.
Published: March 2008

Abstract The effects of metformin on glycaemia, insulin and c‐peptide levels, hepatic glucose production and insulin sensitivity (using the euglycaemic, hyperinsulinaemic clamp) were evaluated at fortnightly intervals in 9 Type 2 diabetic patients using a stepwise dosing protocol: Stage 1 ‐ no metformin for four weeks; stage 2 ‐ metformin 500mg mane; stage 3 ‐ metformin 500mg thrice daily; stage 4 – metformin 1000mg thrice daily. Results are expressed as Mean ± SEM. Fasting blood glucose decreased from basal values (9.7 ±1.0 mmol/L) by 13% at stage 2, 34% at stage 3 and 41% at stage 4 (p<0.02 vs basal for all stages; p<0.02 stage 2 vs stage 3). Post‐prandial glycaemia was significantly improved only with metformin 3000mg/day (p<0.05). Fasting, meal‐stimulated and total insulin and c‐peptide levels showed no change. Hepatic glucose output did not change significantly with metformin. Insulin sensitivity, measured as total glucose utilisation during hyperinsulinaemia, increased from stage 1 (10.3 ± 2.1 μmoL/kg/min) by 23% at stage 3 (p < 0.05) and by 29% at stage 4 (p < 0.02). Basal metabolic clearance of glucose increased compared to stage 1 (1.69 ±0.16 mL/kg/min) by 30% at stage 2, 53% at stage 3 and 44% at stage 4 (all p <0.02). This study demonstrates that improved efficiency of glucose utilisation, both basally and under conditions of euglycaemic hyperinsulinaemia, is the basis of metformin's antihyperglycaemic action.
Adult T‐cell leukaemia lymphoma in an Aborigine
Authors: Kirkland M. A. , Frasca J. , Bastian I.
Published: March 2008

Abstract A 44‐year‐old Aborigine with Adult T‐cell Leukaemia/Lymphoma (ATLL) due to HTLV‐I is reported. He presented with transverse myelitis of subacute onset, and subsequently developed frank T‐cell leukaemia complicated by splenomegaly and hypercalcaemia. Cell surface marker studies showed a phenotype of CD3 + CD4 + CD8‐CD25 +, and serological and molecular studies confirmed HTLV‐I infection. This is the first report of ATLL in an Australian Aborigine.
A randomised double‐blind trial of cyclosporin and azathioprine in refractory rheumatoid arthritis
Authors: Ahern M. J. , Harrison W. , Hollingsworth P. , Bradley J. , Laing B. , Bayliss C.
Published: March 2008

Abstract :Fifty‐two patients with severe rheumatoid arthritis (RA) from four Australian centres were randomised to receive cyclosporin A (CSA) (n = 25) or azathioprine (AZA) (n = 27) for six months. Initial mean doses of CSA and AZA were 4.2 mg/kg and 1.7 mg/kg respectively. The mean doses of CSA and AZA at six months were 3.4 mg/kg and 1.9 mg/kg. Assessments of side‐effects and outcomes of benefit were made monthly by independent, blinded observers. Both treatment groups exhibited statistically significant improvement in standard outcome parameters when compared with baseline values. However, there were no statistically significant differences in these parameters between the two groups.

There was a mean increase in serum creatinine concentration associated with CSA; no persons were withdrawn from the study for this reason. Seven CSA recipients (three gastrointestinal symptoms, two neurological symptoms, two other) and 12 AZA recipients (six gastrointestinal symptoms, four inefficacy, two other) withdrew from treatment prematurely. Seven CSA recipients became hypertensive and four required anti‐hypertensive therapy. Adverse events not requiring cessation of therapy were more commonly seen among CSA patients.

In this group of severely affected patients with RA both cyclosporin and azathioprine were effective therapies. CSA toxicities were predictable and manageable but required close monitoring. (Aust NZ J Med 1991; 21: 844–849.)
Circulating anti‐glomerular basement membrane antibodies in coeliac disease and epidermolysis bullosa acquisita
Authors: Savige J. A. , Baker C. , Gallicchio M. , Varigos G.
Published: March 2008

Abstract The demonstration of circulating anti‐glomerular basement membrane (GBM) antibodies is almost diagnostic for anti‐GBM disease and Goodpasture's syndrome. These antibodies are, however, occasionally present in SLE and diabetes, in association with IgA disease and membranous nephropathy and after transplantation in Alport's syndrome. In addition, we describe circulating anti‐GBM antibodies in a research worker who handled GBM and in whom coeliec disease later developed, and in an individual with epidermolysis bullosa acquisita. Neither patient had impaired renal function nor an abnormal urinary sediment, suggesting either that these antibodies were of low affinity, or that additional factors are required for the pathogenesis of an aggressive glomerular lesion when circulating anti‐GBM antibodies are present. In at least one of these individuals anti‐GBM antibodies may have developed after the exposure of basement membrane collagen type IV to activated immunological mediators and cells. (Aust NZ J Med 1991; 21: 867–870.)
Complete external ophthalmoplegia and asterixis with carbamazepine toxicity
Authors: Ng K. , Silbert P. L. , Edis R. H.
Published: March 2008

Abstract Ophthalmoplegia is a rarely observed sign in carbamazepine and other anticonvulsant overdoses. We present a patient who developed transient complete external ophthalmoplegia and asterixis with relative preservation of consciousness, in association with carbamazepine toxicity. Previously reported cases and proposed mechanisms are reviewed. (Aust NZ J Med 1991; 21: 886–887.)
Hepatitis C virus infection in haemodialysis patients
Authors: Roger S. D. , Crewe E. , Cunningham A. , Harris D. C. H.
Published: March 2008

Antibody to hepatitis C has been variously detected in 1‐20% of haemodialysis patients in recent studies from overseas. To determine the frequency of antibodies to the C100‐3 protein of the hepatitis C virus (anti‐HCV) a cross‐sectional study was performed in 60 patients on maintenance haemodialysis in Western Sydney. Six patients (10%) were anti‐HCV seropositive. Four of the six anti‐HCV positive patients were also hepatitis B core antibody positive, compared with nine of 54 anti‐HCV negative patients (p < 0.05). All anti‐HCV positive patients had received multiple blood transfusions. Serum alanine aminotransferase (ALT) was not useful as a screening test. Recent evidence suggests that anti‐HCV seropositivity underestimates infectivity.
Oesophageal intramural pseudodiverticulosis—always benign?
Authors: Evans P. R.
Published: March 2008

Oesophageal intramural pseudodiverticulosis is a rare condition that presents with dysphagia. The diagnosis is usually not apparent endoscopically and careful radiological evaluation is required. Previous reports suggest a benign course with good response of dysphagia to oesophageal dilatation and complications have not been described. Two cases are reported, one in whom life threatening haemorrhage developed following dilatation, and one complicated by a retro‐oesophageal collection. It is possible that oesophageal intramural pseudodiverticulosis results in an increased propensity to trauma and even perforation.
Intermittent subcutaneous apomorphine injection treatment for Parkinsonian motor oscillations
Authors: Kempster P. A. , Iansek R. , Larmour I.
Published: March 2008

Eight patients with severe Parkinsonian motor oscillations have been treated with the dopamine receptor agonist apomorphine by intermittent subcutaneous self‐injection as an adjunct to oral anti‐Parkinsonian medication. The dopamine receptor antagonist domperidone was also given by mouth to prevent nausea. Six patients remain on chronic treatment (mean period 6.5 months) with improved control of motor function in each case. Four have had major enhancement of their quality of life. Benefits of this treatment stem from the training of patients to use intelligent behaviour to administer a promptly acting and effective pharmacological agent, thereby exercising a degree of direct control over previously unpredictable variations in motor performance.
The early diagnosis of acute myocardial infarction
Authors: Foy S. G. , Kennedy I. C. S. , Ikram H. , Low C. J. S. , Shirlaw T. M. , Crozier I. G.
Published: March 2008

Latex agglutination for serum myoglobin (Rapitex™) was compared with the initial ECG for the early diagnosis of acute myocardial infarction. Forty patients suspected of myocardial infarction were prospectively evaluated by initial electrocardiogram and Rapitex™ serum myoglobin. The initial ECG was categorised into one of three groups: Group 1 had ST segment elevation of at least 1 mm in a limb lead or 2 mm in a precordial lead (with or without Q waves); Group 2 had abnormalities other than those seen in Group 1; and Group 3 had no particular abnormalities present that is, a normal ECG. Myocardial infarction was confirmed by a rise in creatine kinase to greater than or equal to twice the upper limit of normal for our laboratory range and with a CKMB fraction of greater than 6%. Nineteen of 40 patients sustained myocardial infarction; nine ECG group 1, six ECG group 2, and four ECG group 3. Eleven of the 19 patients with myocardial infarction had positive serum myoglobin agglutination. The initial ECG was the most predictive of a subsequent rise in CK (p = 0.003), while Rapitex™ serum myoglobin determination was the least predictive (p= 0.8517). We conclude that the Rapitex™ serum myoglobin test offers little diagnostic or economic advantage over the initial electrocardiogram.
Phenelzine associated peripheral neuropathy—clinical and electrophysiologic findings
Authors: Goodheart R. S. , Dunne J. W. , Edis R. H.
Published: March 2008

Phenelzine associated sensorimotor peripheral neuropathy is reported in two patients. Symptoms were predominantly sensory, and improvement occurred after withdrawal of phenelzine. Electrophysiologic findings were consistent with an axonal process.
Alpha 1‐antitrypsin deficiency and pancreatitis in a juvenile
Authors: Edmunds S. E. J. , Wilkinson M. L.
Published: March 2008

An 18‐year‐old female with PiSZ phenotype alpha 1‐antitrypsin deficiency presented with pancreatitis and a pancreatic pseudocyst. There were no other causative factors. Deficiency of alpha 1‐antitrypsin may predispose to pancreatitis or exacerbate existing pancreatic disease.
Medical informatics—an Australian perspective
Authors: Hannan T.
Published: March 2008

Computers, like the X‐ray and stethoscope1can be seen as clinical tools, that provide physicians with improved expertise in solving patient management problems. As tools they enable us to extend our clinical information base, and they also provide facilities that improve the delivery of the health care we provide.

Automation (computerisation) in the health domain will cause the computer to become a more integral part of health care management and delivery before the start of the next century. To understand how the computer assists those who deliver and manage health care, it is important to be aware of its functional capabilities and how we can use them in medical practice.

The rapid technological advances in computers over the last two decades2–4has had both beneficial and counterproductive effects on the implementation of effective computer applications in the delivery of health care. For example, in the 1990s the computer hobbyist is able to make an investment of less than $ 10,000 on computer hardware that will match or exceed the technological capacities of machines of the 1960s. These rapid technological advances, which have produced a quantum leap in our ability to store and process information, have tended to make us overlook the need for effective computer programmes which will meet the needs of patient care.

As the 1990s begin, those delivering health care (eg, physicians, nurses, pharmacists, administrators.) need to become more involved in directing the effective implementation of computer applications that will provide the tools for improved information management, knowledge processing, and ultimately better patient care.
Genes, gender and geometry and the prolapsing mitral valve
Authors: Wilcken David E. L.
Published: March 2008

Mitral Valve Prolapse (MVP) is usually a variant of normal occurring in about 4% of the population. Complications are relatively uncommon, but false associations due to ascertainment bias have had a potential for iatrogenic harm. Adverse outcomes which do occur in a subset of MVP subjects are considered here in relation to the contributions of genes, gender and geometry.

There are definite associations between MVP and several dominantly inherited connective tissue abnormalities; it occurs in 85% of adults with Marfan syndrome. All these contribute to a very small proportion of the MVP population. A larger less easily characterised group with dominant inheritance and some features of a connective tissue disorder awaits DNA studies for identification. For most MVP subjects our data define significant family aggregation consistent with polygenic inheritance; the likelihood of a first degree relative having MVP is about two and a half times the population average.

There is a higher prevalence in young women than in men—5% versus 3%; this has also been demonstrated for floppy mitral valve (MV) at autopsy. MVP complications of chordal rupture, severe mitral regurgitation and infective endocarditis are, however, two to three times more common in men, are age related and evident after the age of 50 years. Higher blood pressure in men may contribute to this in accordance with a response‐to‐injury hypothesis to explain progressive valve changes.

Leaflet, annulus and left ventricular size differences and septal changes are geometric variants with a potential for increasing tension‐related valve injury. Changes in excised floppy valves are consistent with ongoing repair in response to repetitive leaflet and chordal injury involving enhanced type III collagen gene expression and proteoglycan synthesis. This myxomatous change constitutes the final common pathway to serious mitral regurgitation and the rare occurrence of sudden death. The response‐to‐injury concept has implications for treatment to minimise progressive changes.
The APO A, B, a of coronary risk: back to kindergarten
Authors: Wilcken David E. L. , Wang Xing Li L. , Dudman Nicholas P. B.
Published: March 2008

Approximately 1% of the population have a dominantly inherited lipid disorder predisposing to premature vascular disease. Apolipoproteins (Apo) B, and Al, the carrier proteins for the atherogenic low density lipoprotein (LDL) and the protective high density lipoprotein (HDL) cholesterol respectively are markers for these disorders, as is Apo(a), the unique carrier protein for lipoprotein(a). We assessed changes in these apolipoproteins during the first 12 years of life, aiming to detect young families with inherited dyslipidaemia and implement early prevention. Among 1032 consecutively born babies in whom levels were measured within their first week and at a mean age of 8.5 months, the Apo B/Al ratio and Apo(a) both tracked closely (p<0.01 and <0.0001). High B/Al ratios (>95 percentile) identified two families with familial hypercholesterolaemia, and infants with high Apo B identified two families with hyperapolipoprotein B. Apo(a) levels increased twofold between the first week and 8.5 months and were highly correlated (r = 0.73, p < 0.0001). Levels at 8.5 months were not different from parental values and were closely correlated with them. We then assessed school children aged eight to 12 years. In a pilot study (n—1400) we have established normal apolipoprotein values and distribution patterns and defined the 95th percentile for each. This study is continuing and parents of children with high levels are being recalled (with their children) for lipid measurements. Our findings indicate that our approach is feasible and has wide acceptance, and that measuring Apo B/A 1 and Apo(a) in childhood identifies families at increased cardiovascular risk. We have yet to assess the efficacy of our family‐based coronary prevention programme.
Trials and tribulations: the ISIS experience
Authors: Sleight Peter
Published: March 2008

The ISIS trials group has grown slowly over the last ten years and now includes about 1000 collaborating hospitals worldwide.

The original stimulus came from the thesis of a research student, Salim Yusuf, a newly qualified Rhodes Scholar from India. Yusuf s thesis (begun in 1976) examined methods of measuring infarct size quantitatively and paved the way to a preliminary trial of i.v. atenolol in 477 patients in Manchester and Oxford.

Richard Peto was consulted about the statistical aspects of a trial design and pointed out that most clinical trials at that time were hopelessly inadequate in size to have the power reliably to ascertain the value of moderate but medically worthwhile treatments in many common conditions. We thus developed much larger collaboration, which still continues to grow.

Dr Rory Collins joined the Oxford Cardiac Department and the CTSU in 1981 and now is the coordinator of the ISIS trials, and co‐director with Richard Peto of the CTSU.

Simple trials answer the questions rapidly and effectively. The mechanics of the trial do not hinder patient entry by participating doctors and nurses.

The trials are mainly funded by industry, with ‘priming’ grants from the British Heart Foundation. Once the protocol is agreed the funding companies have no further input. The trials are planned and supervised by an international steering committee. Sir Richard Doll chairs the data monitoring committees.

A brief overview of the three completed trials will be given, together with some peeps behind the scenes!
The push, the pull and the periphery
Authors: Oakley Celia M.
Published: March 2008

If the failing left ventricle could be given an effective push, other approaches to the treatment of heart failure would not be needed. We have inotropes only for short‐term parenteral use. We have no safe inotrope for chronic oral use. The effect of digitalis is only feeble and the phosphodiesterase inhibitors seem to increase mortality from sudden death.

Diuretics are dramatic for acute pulmonary oedema and the mainstay for chronic fluid retention but do not improve the pump and by reducing blood volume stimulate the renin angiotensin system leading to vasoconstriction, further fluid retention and hypokalaemia. Nitrates drop pre‐load without reducing blood volume but tolerance is a problem and stroke volume does not increase.

Reduction of afterload helps the failing ventricle to empty, the pull and output increases. The angiotensin converting enzyme inhibitors (ACEI) are now the cornerstone of heart failure treatment, reducing mortality in severe heart failure (CONSENSUS) and superior to standard vasodilator therapy (V‐HeFT‐2) at improving the survival of patients with mild to moderate heart failure. ACEI can reduce the incidence of ventricular ectopy and probably do this through improving left ventricular function, from decreasing sympathetic tone, reducing myocardial oxygen demand or increasing serum potassium but ACEI did not dimmish the incidence of sudden death in the SOLVD trial despite reducing mortality.

Disappointingly little improvement in exercise tolerance and persistence of chronic fatigue in heart failure concentrated attention on the periphery. That the changes found in skeletal muscles are consequent upon the combination of inability to increase perfusion on exercise together with the effects of chronic inactivity are beyond question (though it has been suggested otherwise). Retraining by suitable daily exercise has been shown to improve exercise tolerance in chronic stable heart failure with restoration of lost oxidative fast muscle fibres and capillary network. Rest is no longer the order of the day.
Exercise testing? not at all
Authors: Jelinek Michael
Published: March 2008

The traditional approach to the ambulatory patient with suspected or definite coronary disease is to evaluate the clinical features, to perform non‐invasive tests for myocardial ischaemia, and to proceed, if necessary, to coronary angiography and coronary revascularisation. However, when the results of the exercise tests are discordant with the clinical classifications they are usually misleading as diagnostic tools. When the exercise lest is used to assist prognostication, the information provided overlaps with that available to the clinician and only the presence of ST segment depression is an independent prognosticator. The amount of ST segment shift has been found to be an inferior prognosticator to the severity of disease seen on a coronary angiogram and the latter allows for appropriate decisions to be made regarding coronary angioplasty or bypass surgery. A more appropriate use of exercise testing is as a gate for coronary angiography if there is real doubt or the nature of the chest pain or as an aid in therapeutic decisions if the coronary angiography interpretation is difficult.
Accuracy of a portable interpretive ECG machine in diagnosis of acute evolving myocardial infarction
Authors: O'Rourke M. F. , Cook A. , Carroll G. , Gallagher D. , Hall J.
Published: March 2008

From a study of 526 patients having automatic ECG analysis, criteria were established which diagnosed acute evolving Q wave myocardial infarction with 71% sensitivity and 98% specificity. Specificity was 100% when patients with known previous Q wave infarction were excluded. In pre‐hospital practice the high sensitivity and specificity were maintained. This method appears appropriate, when other criteria are met, for paramedic‐initiated pre‐hospital thrombolysis with remote supervision of a cardiologist by telephone. (Aust NZ J Med 1992; 22: 9–13.)
Acute stroke outcome: effects of stroke type and risk factors
Authors: Lefkovits J. , Davis S. M. , Rossiter S. C. , Kilpatrick C. J. , Hopper J. L. , Green R. , Tress B. M.
Published: March 2008

We studied 925 consecutive patients hospitalised with acute stroke to determine how stroke type, age, gender and risk factors influence acute, in‐hospital outcome. Stroke types included carotid territory cortical or large subcortical infarction (52%), vertebrobasilar infarction (12%), lacunar infarction (11%), intracerebral haemorrhage (16%), and subarachnoid haemorrhage (9%). Mean age (mean ± 1 SD) was 66 ± 15 years, but patients with cerebral infarction were older than those with cerebral haemorrhage. The prevalence of hypertension, diabetes mellitus and cardiac disease increased with age across all stroke types, while the prevalence of smoking decreased with age. Mortality was 19% overall, but varied significantly between stroke types, highest in intracerebral haemorrhage (34%), and lowest in lacunar infarction (1%). Age had a marked adverse effect on mortality, independent of stroke type, the probability of death increasing by 3 ± 0.5% per year from 20–92 years, whereas gender had no effect. Cardiac disease and diabetes were independent adverse prognostic factors (Odds Ratios 1.6 and 1.5 respectively). Cerebral haemorrhage, age, cardiac disease and diabetes all independently worsen acute stroke outcome. (Aust NZ J Med 1992; 22: 30–35.)
Extranodal Ki‐1 lymphoma in a renal transplant patient
Authors: Ng K. , Trotter J. , Metcalf C. , Thatcher G. , Marshall E.
Published: March 2008

The Ki‐1 (CD 30) antigen has been identified as a marker of a subset of large cell anaplastic non‐Hodgkin's lymphoma that may have a more favourable prognosis. We describe an immunosuppressed renal transplant patient who developed primary extranodal large cell anaplastic Ki‐1 lymphoma of T‐cell phenotype confined to the sigmoid colon. The patient was treated with local resection of the sigmoid colon and reduction of immunosuppression and at two year follow‐up remains free of recurrence. It is recognised that long term immunosuppression in post transplant patients increases the risk of certain malignancies. Localised gut lymphoma may be amenable to local resection as a curative procedure. (Aust NZ J Med 1992; 22: 51–53.)
Monoclonal large granular lymphocyte proliferation in SLE with HTLV‐I seroreactivity
Authors: Marlton P. , Taylor K. , Elliott S. , McCormack J.
Published: March 2008

A 60‐year‐old part Aboriginal woman was observed to develop severe neutropenia and a large granular lymphocyte (LGL) proliferation five years after the diagnosis of systemic lupus erythematosus (SLE). Monoclonality of the CD3 +, CD4 ‐, CD8 + LGL population was confirmed using the novel approach of X‐linked restriction fragment length polymorphism (RFLP) analysis. Indeterminate HTLV‐I serology was present. The patient responded to steroid therapy. LGL proliferation in the setting of SLE and the use of X‐linked RFLP analysis to define LGL clonality have not previously been reported. (Aust NZ J Med 1992; 22: 54–55.)
Trabecular spacing in post‐menspausal Australian women with and without vertebral fractures
Authors: Moore R. J. , Durbridge T. C. , McNcil P. J. , Parkinson I. H. , Need A. G. , Vernon‐Roberts B.
Published: March 2008

Histomorphometric measurements were made from iliac crest biopsies of 32 women with vertebral fractures and 37 women without fracture. All were post‐menopausal Australian women who had presented with back pain to a hospital out‐patient endocrinology clinic Bone from the fracture cases was characterised by loss of individual trabccular elements, with the remaining trabeculac being spaced further apart than those in the non‐fracture women (p <0.0001). This resulted in a significant decrease in trabecular bone volume (p <0.01). In addition osteoid surface was reduced (p <0.01). Dynamic parameters of bone turnover were not significantly different between the two groups. These data should be useful for the assessment of iliac bone histomorphometry in Australian post‐menopausal women suspected of having osteoporosis. (Aust NZ J Med 1992; 22: 269–273.)
Health service utilisation in the public and private sector by patients with diabetes rnellitus aged less than 40 years
Authors: Griffiths R. , Moses R.
Published: March 2008

This paper uses the Illawarra 0–39 years diabetes register to provide a data base of health suvice utilisation in tbc public and private sectors. Eligible patients from the register were divided into a ‘stable group’ comprising children and adults who had had diabetes for more than one year prior to review and a ‘newly diagnosed’ group who were followed for one year after diagnosis. The records of inpatient and selected autpatbt services at public hospitals as well as visits to general practitioners, paediatricians and physicians were considered. Less than balf of all ‘newly diagnosed’ patients were admitted to hospital faf stabilisation and none required readmission in the 12 month review period. Less than one fifth of all ‘stable’ patients were admitted to hospital during the year. General practitioners were the most frequently used health used health resource being attended by 31/38(82%) ‘stable children’, 122/133 (92%) ‘stable adults’ and 25/25 (100%) ‘newly diagnosed patients’. Public hospital Accident and Emergency Services were the least used health facility being frequented by only 9/38 (24%), 23/133 (17%) and 7/25 (28%) rrspecrivtly. (AWR NZ J Med 1992; 22:274–277.)
Semi‐quantitative determination of microalbuminuri by urinary dipstick
Authors: Gilbert R. E. , Akdeniz A. , Jerums G.
Published: March 2008

Microalbuminuria predicts subsequent clinical nephropathy and mortality in diabetic patients. This study was undertaken to determine the usefulness of a new immunochemical urinary dipstick test (Micral‐Test, Boehringer Mannheim, GmbH Mannheim, Germany) in identifying urinary albumin concentrations within the microalbuminuric range (urinary albumin concentration 20–200 mg/L). Twenty‐four hour urine specimens were collected from 298 consecutive diabetic outpatients. Micral‐Test was performed by two laboratory scientists blinded to each other's results and those of radioimmunoassay (RIA) and immunoturbidimetry on the same specimen. When compared with RIA, Micral‐Test had an overall sensitivity of 92.2%, specificity of 92.3% and positive predictive value of 86.4%. However, at the threshold value of 20 mg/l Micral‐Test showed false positive results in 37.8% of samples when compared with RIA. Similar results were obtained when Micral‐Test was compared with immunoturbidimetry. We conclude that Micral‐Test is a useful screening method for the detection of microalbuminuria. We suggest that positive tests be confirmed by a timed urine collection using established methodology and that patients whose Micral‐Test is negative be subjected to annual retesting.
The prevalence of asthma in Victorian adults
Authors: Abramson M. , Kutin J. , Bowes G.
Published: March 2008

To determine the prevalence of asthma in Victorian adults, we carried out a cross‐sectional postal survey utilising a new screening questionnaire which gathered data on self reported respiratory symptoms, whether asthma had been diagnosed and, if so, how it had been treated. Questionnaires were returned by 2198 (72%) of 3095 adults selected randomly from the Victorian electoral roll, an adequate response rate. The reported prevalences of individual asthmatic symptoms in the last 12 months ranged from 8% for nocturnal wheeze to 22% for current wheeze. Thirteen per cent of respondents had ever had asthma, 7% had experienced an attack within the last 12 months and 6% were currently taking medication.

The high prevalence of asthma revealed by our study has major implications for the planning of health services.
Effect of the revised CDC case definition of AIDS on the number of AIDS cases in the Sydney AIDS Prospective Study
Authors: Tindall B. , Sharkey T. , Kaldor J. , Cooper D. A.
Published: March 2008

We sought to evaluate the potential impact of a proposed revision in the case definition of acquired immunodeficiency syndrome (AIDS) (from a clinical case definition to one also including subjects with HIV infection who have an absolute number of peripheral CD4 + cells of less than 200 times 106/L) among 512 HIV‐seropositive homosexual/bisexual who were reviewed between 1984 and 1991. According to the current case definition, 151 (30%) of 512 at‐risk subjects developed AIDS between 1984 and August 1, 1991. Of the 361 at‐risk subjects who were not classified as AIDS by the current definition, 47 (13%; 95% CI 9 – 17%) were classified as AIDS according to the revised definition. The median time to development of AIDS according to the revised definition was 288 weeks and that according to the current definition was 338 weeks. Data on clinical status were available for 34 of the new cases at the time of their diagnosis according to the proposed case definition: 16 (47%) of these were asymptomatic, 10 (29%) had persistent generalised lymphadenopathy and eight had minor infectious diseases. Of the 151 cases diagnosed according to the current definition, 78 (52%) had an antecedent CD4 + cell count that met the criteria for AIDS under the revised definition a median of 59 weeks before their diagnosis according to the current definition. These data indicate an appreciable increase in the number of cases of AIDS in this cohort when the revised case definition was applied. These findings have important implications for the surveillance, and for the clinical monitoring and treatment, of patients with HIV disease in Australia.
Failure of intensive chemotherapy in poor prognosis non‐Hodgkin's lymphoma
Authors: Matthews J. R. D. , Cooper I. A. , Matthews J. P. , Ding J. CHONG
Published: March 2008

In an attempt to improve response and survival rates in patients with non‐Hodgkin's lymphoma, a relatively intense six drug regimen MATCOP was developed comprising four‐weekly cycles of methotrexate (100mg/m2, IVY day 8), Adriamycin (30mg/m2, IVY days 1,2), teniposide (75 mg/rn2, IV, day 1), cyclophophamide (300 mg/m2, po, days one to five), Oncovin (1.4 mg/m2, IV: maximum 2 mg, days 8,15) and prednisolone (100 mg, po, days one to five). A randomised trial was conducted comparing MATCOP with the standard CHOP regimen, comprising three‐weekly cycles of cyclophosphamide (750 mg/m2, IV, day 1), Adriamycin (50 mg/m2, IV, day 1), Oncovin (1.4 mg/m2 IV: maximum 2 mg, day 1) and prednisolone (100 mg, PO, days two to six). Eighty patients with large cell lymphoma, diffuse mixed small cleaved and large cell lymphoma or diffuse small cleaved cell lymphoma were randomised, 47 to MATCOP and 33 to CHOP. MATCOP patients experienced increased granulocytopenia, thrombocytopenia (p 0.0001), mucositis (p= 0.002) and infections (p= 0.01) compared to CHOP patients. Complete response rates were similar: 66% for MATCOP patients and 61% for CHOP patients. There were no apparent differences in the time to relapse for patients achieving CR, the time to treatment failure or the overall survival time. Thus despite an increase in toxicity, the more intense regimen MATCOP failed to confer any therapeutic benefit compared with the standard CHOP regimen.

Survival was not influenced but toxicity was increased by dose intensification. (Aust NZ J Med 1992; 22: 123–128.)
Streptokinase morbidity — more common than previously recognised
Authors: Siebert W. J. , Ayres R. W. , Bulling M. T. , Thomas C. M. , Minson R. B. , Aylward P. E.
Published: March 2008

Streptokinase is the thrombolytic agent most commonly used for the treatment of acute myocardial infarction. We report eight patients who developed late uncommon adverse reactions to streptokinase probably due to immune complex disease. The clinical manifestations included vasculitic rashes, abnormal renal and liver function tests and a syndrome resembling adult respiratory distress syndrome, Major adverse events with streptokinase such as stroke, bleeding and othet allergic reactions, have been previously documented but the morbidity related to delayed reactions has not been widely recognised. These reactions produced significant morbidity resulting in prolonged hospital stay and may need to be considered in the decision to use streptokinase. (Aust NZ J Med 1992; 22: 129–133.)
Fulminant hepatic failure in a young mother
Authors: Gane E. J. , Zwi L. J. , Lane M. R.
Published: March 2008

We report the case of a mother who developed hlminant hepatic failure with hypoglycaemia, coagulopathy, Grade III hepatic encephalopathy, two days after the delivery of her fourth child. She had complained of pruritus for the final two weeks of pregnancy. She received supportive medical management within a critical care unit, and the hepatic failure resolved completely within 48 hours. Liver biopsy confirmed the diagnosis of acute fatty liver of pregnancy. This case is unusual in that this patient deteriorated markedly following delivery, at a time when spontaneous recovery is normally expected. (Aust NZ J Med 1992; 22: 142–143.)
Pharmacological treatment of alcoholism
Authors: Monteiro MARISTELA G.
Published: March 2008

This paper presents an overview on pharmacologic treatment of alcoholism. A wide range of drugs have been tested over the years, some showing a reduction of alcohol drinking in alcoholics. However, at present, there is little evidence that phnrmacotherapy is effective in the rehabilitation of alcoholics. Although research in this area still has several methodological problems and much needs to be done, a greater understanding of the neuropharmacoiogy and neurobiology of alcohol use and abuse will certainly open new avenues for investigation and drug development. Patient‐treatment matching and the combination of two or more modalities of intervention may also help increase overall effectiveness of alcohol treatment. (Aust NZ J Med 1992; 22: 220–223.)
New approaches to the management of poor prognosis non‐seminomatous germ cell tumours
Authors: Grigg A. , McKendrick J. , Fox R.
Published: March 2008

While most patients with disseminated non‐seminomatous germ cell tumours (NSGCT) are cured by treatment with cisplatinum‐based chemotherapy, a subset die from refractory or relapsing disease. Poor prognostic factors at diagnosis include bulky disease, visceral involvement, high serum marker levels and an inadequate rate of fall in these markers in response to treatment.

There are a number of approaches to poorer risk patients. One is to use conventional induction chemotherapy followed by second‐line salvage regimens in those who fail induction. Results with this approach have been disappointing. A second approach is to use more intensive induction regimens, in some cases with growth factor support; whether these are superior to standard treatment has yet to be established by randomised studies. A third approach, based on the chemotherapy‐dose responsiveness of NSGCT, consists of the administration of very high dose chemotherapy followed by haematological rescue with autologous marrow to patients failing initial therapy. Review of autograft studies suggest that durable remissions can be obtained in most patients with responsive disease, but not if the disease is chemotherapy‐refractory. A new approach may be elective early autografting in patients identified at diagnosis to have very poor prognosis disease. (Aust NZ J Med 1992; 22: 679ndash;684.)
Culture‐positive tuberculosis at St Vincent's Hospital, Melbourne, 1962–1989
Authors: Hurley J. C. , Uren E. M. , Andrew J. H. , Burdon J.
Published: March 2008

The disease types and demography of patients with culture confirmed tuberculosis (TB) diagnosed at St Vincent's Hospital, Melbourne between the years 1962 to 1989 were reviewed. Four hundred and eighty‐two patients with culture‐positive TB were identified whose origins were as follows: Australia 194; Northern Europe 38; The Mediterranean 98; Asia 60 and other or unknown 92. Patients whose country of birth was in Asia or the Mediterranean area accounted for 57% of patients in the 1980s; they presented at a younger age, with a higher proportion of extrapulmonary disease and a more equal sex distribution than did Australian born patients. The main types of extrapulmonary disease also differed for the various ethnic groups. The overall proportion of patients with an isolate resistant to at least one of the anti‐TB drugs was 10.0% but in the Asian born was 21.7%. This survey, the longest series of bacteriologically confirmed cases of TB reported from a single institution in Australasia, has identified several changes in how TB is presenting for diagnosis. (Aust NZ J Med 1993; 23: 7–11.)
Continuous hepatic artery infusion of 5‐fluorouracil for metastatic colorectal cancer localised to the liver
Authors: Boyle F. M. , Smith R. C. , Levi J. A.
Published: March 2008

Continuous regional delivery of chemotherapeutic agents offers the prospect of maximising dose intensity at the site of localised disease, while minimising systemic toxicity. This prospective phase II study evaluates the efficacy and toxicity of hepatic arterial infusion of 5‐Fluorouracil (5‐FU) via an implantable Infusaid™ pump in previously untreated patients with localised but unresectable hepatic metastases from colorectal cancer. In 25 patients the response rate was 56% and median survival was 15 months, comparable to previous reports utilising fluorodeoxy‐uridine (FUDR). Twenty per cent of patients (all responders) survived longer than three years. Systemic toxicity was trivial, and the practice of reducing the intensity of therapy when nausea or a rise in alkaline phosphatase occurred avoided the previously described local toxicity of biliary sclerosis seen frequently with FUDR. In selected patients, particularly those with more limited disease, this form of therapy is effective and well tolerated and warrants further evaluation as an alternative to FUDR. (Aust NZ J Med 1993; 23: 32–34.)
Intravenous aminophylline confers no benefit in acute asthma treated with intravenous steroids and inhaled bronchodilators
Authors: Coleridge J. , Epstein J. , Cameron P. , Teichtahl H.
Published: March 2008

Abstract Background: The role of intravenous aminophylline in acute asthma is unclear despite meta‐analysis of many studies comparing aminophylline with other bronchodilator therapies.

Aims: The aim of this study is to determine whether continuous aminophylline infusion confers any benefit in acute severe asthmatics treated with intravenous steroids and inhaled bronchodilators.

Methods: The study was randomised, double‐blind and placebo‐controlled. All patients received nebulised salbutamol (1 mL of 0.5%) and ipratropium bromide (1 mL of 0.025%) with glycol diluent (1 mL) at 0, two, four, six, eight and 12 hours, and six‐hourly thereafter. In addition all patients were given intravenous hydrocortisone 250 mg six‐hourly and oxygen to maintain normoxia. Aminophylline infusions were adjusted to maintain therapeutic levels. Peak expiratory flow rate (PEFR) was measured before and after nebulised bronchodilator on a two‐hourly basis in the Emergency Department (ED) and six‐hourly on the inpatient wards.

Results: Thirty‐one patients were clinically sufficiently improved within 12 hours to be discharged home from the ED. The remaining 28 patients were admitted to the inpatient ward for a total trial duration of 48 hours.

No significant difference was found between the placebo and treatment groups for measurements of PEFR, or for the duration of stay of the patients in hospital. The power of the study was 80% for a 25% to 33% difference at a 5% level of significance. Presentation values of PEFR and arterial blood gases did not predict which patients would require inpatient admission and which could be safely discharged home from the ED.
Treating hypercholesterolaemia with HMG CoA reductase inhibitors: a direct comparison of simvastatin and pravastatin
Authors: Lintott C. J. , Sutherland W. H. F. , Scott R. S. , Bremer J.
Published: March 2008

Abstract Background: Simvastatin and pravastatin are both competitive inhibitors of the rate limiting enzyme for cholesterol biosynthesis (HMG CoA) reductase, but data from individual clinical trials suggest significant differences in potency for cholesterol reduction between the two drugs.

Aim: To assess any differences in efficacy and safety between simvastatin and pravastatin in a direct, comparative study.

Methods: A double‐blind, double‐dummy, randomised study design was used, involving 48 patients with primary hypercholesterolaemia. Following a 6 week placebo baseline period, patients were randomly allocated to treatment with either simvastatin or pravastatin, commencing at a dose of 10 mg daily. The dose levels were titrated up to the recommended maximum effective dose of 40 mg daily at 6 weekly intervals if LDL cholesterol levels remained 3.4 mmol/L. After 18 weeks of therapy, all patients were transferred to simvastatin therapy for a further 6 weeks, continuing at their week 18 dose level. Patients complied with a standard lipid lowering diet (containing < 30% of energy as total fat) throughout the study period.

Results: Over the 18 week direct comparison of the two drugs, there was a significant difference (p< 0.001) in response between simvastatin and pravastatin for reduction in levels of total cholesterol (32%vs21% respectively), LDL cholesterol (38%vs27%) and apolipoprotein B levels (34%vs23%). No significant difference in drug effect was seen for the small reduction in levels of apolipoprotein AI (5%vs6% respectively), nor for the increased levels of apolipoprotein All (14%vsll%) and HDL cholesterol (1 l%vs7%). Lp(a) levels remained unchanged.

When pravastatin was replaced with simvastatin for the final 6 weeks of the study in the 23 patients initially randomised to pravastatin, there were further reductions (p < 0.01) in total and LDL cholesterol, and apolipoprotein B.

These results establish the advantage of simvastatin over pravastatin in terms of efficacy, for the treatment of primary hypercholesterolaemia.
Book Reviews
Authors: Baume Peter
Published: March 2008

Book reviewed in this article:

ABORIGINAL HEALTH AND HISTORY (Power and Prejudice in Remote Australia)By E. Hunter.

HEALING THE SCHISM (Epidemiology, Medicine and the Public's Health)By K. L. White.

COELIAC DISEASE Edited by M. N. Marsh.

AUSTRALIA'S HEALTH 1992 By the Australian Institute of Health & Welfare.