bluuebunny/crossref_metadata_2025 huggingface dataset:
New antiplatelet agents
Authors: White Harvey D. , French John K. , Ellis Christopher J.
Published: March 2008

Aspirin is an established therapy for the management of acute myocardial infarction (AMI) and unstable angina. Secondary prevention with chronic aspirin therapy is also indicated for patients with stable angina.

Aspirin inhibits cyclo‐oxygenase‐I, a key enzyme in the biosynthetic pathway leading to the production of thromboxane A2. It therefore inhibits only one of the many activation pathways leading to platelet aggregation. Other antiplatelet agents that have also been evaluated in clinical trials include ticlopidine and clopidogrel, which inhibit adenosine diphosphate‐mediated platelet aggregation, but these agents are known to be effective against only one of the 90 known agonists that stimulate platelet aggregation.

The final common pathway for platelet aggregation involves the glycoprotein IIb/IIIa receptor combining with fibrinogen. Several inhibitors of the glycoprotein IIb/IIIa receptor have been developed and have an important role as adjunctive therapy in angioplasty. Recent trials have been performed in patients with unstable angina, and trials of adjunctive therapy are currently underway in patients receiving thrombolysis for AMI, and for secondary prevention.

These drugs have various different features, including specificity for blockade of the glycoprotein IIb/IIIa receptor, half life, duration of the haemostatic effect and potential for antigenicity. Recently concluded and ongoing trials of both intravenous and oral agents are expected to provide further support for the introduction of these agents into clinical management of patients with acute coronary syndromes.
Issues in extrapolating from clinical trials to clinical practice and outcomes
Authors: Tonkin Andrew M.
Published: March 2008

Extrapolation of clinical trial results to clinical practice requires consideration of whether the trial patients were representative of clinical practice, whether the trial therapy studied was optimal, whether the sample size was adequate, and the impact of adjunctive treatments.

In thrombolytic trials in particular, regional variations in attitudes to coronary angiography may have affected outcomes. Clinical trial results need to be interpreted in the light of the cost effectiveness of the application.

The assessment of clinical outcomes depends on interplay between the structure and process of care, patient factors and chance. Large standardised databases are necessary to assess clinical practice and outcomes.
Staphylococcal bacteraemia: the hospital or the home? A review of Staphylococcus aureus bacteraemia at Concord Hospital in 1993
Authors: O'Kane G. M. , Gottlieb T. , Bradbury R.
Published: March 2008

Aims: To examine the risk factors for, and the complications and mortality of, Staphylococcus aureus bacteraemia.

Methods: A retrospective case review of patients with S. aureus bacteraemia in 1993 diagnosed at the Concord Repatriation General Hospital, Sydney.

Results: Of 104 cases reviewed, 32 were due to methicillin resistant S. aureus (MRSA), 73 were due to methicillin sensitive S. aureus (MSSA) and one was a dual infection. Twenty‐eight of the bacteraemias were community‐acquired, including one case of MRSA, and 76 were hospital‐acquired; 38% had an implanted prosthetic device or graft. The average age (68 years), incidence of underlying diseases and hospitalisation in the past month (26%) did not differ between MRSA and MSSA groups. MRSA was more likely in patients with recent broad‐spectrum antibiotic use (53%vs 0, p<.01). Vascular access was the commonest source of sepsis (61 %) but in community‐acquired cases the source was unknown in 50%. Use of central line access was more predictive of MRSA infection (75%vs 49%, p=.018). In hospital‐acquired infection, MRSA sepsis occurred later in the course of the admission (26 days vs eight days, p<.01). Directly attributable mortality was highest in MRSA and community‐acquired MSSA infection (9% and 11%) compared with hospital‐acquired MSSA infection (1%).

Conclusions: Nosocomial S. aureus bacteraemia, particularly MRSA, is a major source of preventable morbidity, which could be addressed by improved infection control of MRSA, antibiotic use and attention to central line catheter use.
Risk factors for osteoporosis and fracture in patients attending rheumatology outpatient clinics
Authors: Brand C. A. , Jolley D. , Tellus M. , Muirden K. D. , Wark J. D.
Published: March 2008

Background: Bone mineral density (BMD) using dual energy X‐ray absorptiometry (DXA) scanning is the best predictor of osteoporotic fracture but may not be cost effective for all patient groups. Risk factors (RF) other than BMD may be useful for fracture prediction.

Aim: To assess the prevalence of RF for osteoporosis (OP) and fracture in patients attending a public hospital rheumatology clinic and to document physician awareness of these RF.

Methods: Two hundred and twenty rheumatology outpatients completed a self‐administered questionnaire pertaining to known RF for OP and fracture. Initiatives were documented by the treating rheumatologist.

Results: One hundred and fifty‐four females and 66 males completed questionnaires: 57% had an inflammatory disorder and 32% had received significant glucocorticoid therapy. Forty‐five (68%) males and 126 (82%) females had three or more RF for OP and fracture. Diagnosis of rheumatoid arthritis or connective tissue disorder (CTD) was the variable most significantly associated with increasing numbers of RF. Anti‐osteoporotic medication (AOM) use at assessment (64/219, 29.2%) was accounted for primarily by the use of hormone replacement therapy in females between 45–54 years. Prednisolone use predicted intervention in 103 (48%) patients.

Conclusion: Many rheumatology outpatients have multiple RF for OP and fracture. Infrequent AOM use could be explained by inadequate awareness of high risk patients and the lack of an ideal long term agent. With restricted outpatient resources, the feasibility of identifying high risk patients for OP and fracture would increase if the hierarchical status of RF was better understood.
Attitudes and information needs of Chinese migrant cancer patients and their relatives
Authors: Huang X. , Butow P. , Meiser B. , Goldstein D.
Published: March 2008

Background: The information needs of ethnic minorities often differ from that of the dominant culture, leading to dissatisfaction among both patients and health professionals.

Aims: This research project aims to identify attitudes towards cancer and associated information and communication needs of Chinese patients and their relatives in Sydney, thereby providing a framework for the provision of culturally appropriate cancer care for Chinese‐Australians.

Methods: A qualitative data collection strategy was selected as the most appropriate method, because no validated measures are available and no previous research has examined attitudes and needs of Chinese‐Australian cancer patients. Patients were recruited from three major teaching hospitals in Sydney and from a Chinese cancer support organisation. Sampling was discontinued when informational redundancy was achieved. Four focus groups and 26 individual telephone interviews were conducted with a total of 36 cancer patients and 12 relatives born in China, Singapore and Malaysia.

Results: While individual differences were observed, a majority view was expressed on a range of issues. Non‐disclosure of a poor prognosis was favoured, and the role of the family in liaising between health professionals and the patient was emphasised. Patients preferred a confident and clear diagnosis and treatment recommendation. Most patients wished to incorporate Chinese culture‐specific treatments into their care. The need for interpreters and psychological and spiritual support was emphasised.

Conclusions: Providing information in a culturally sensitive manner will assist doctors in providing optimum care and support for ethnic minority groups in this country.
Uncovering a multitude of sins: medication management in the home post acute hospitalisation among the chronically ill
Authors: Stewart S. , Pearson S.
Published: March 2008

Background: Sub‐optimal use of prescribed medication is often associated with unplanned hospitalisation among the chronically ill.

Aims: To examine the extent of sub‐optimal use of prescribed medication in a ‘high risk’ patient cohort recently discharged from acute hospital care.

Methods: Chronically ill patients discharged from acute hospital care (n=342) were studied. At one week post discharge a home visit was performed by a nurse and a pharmacist during which medication management (including compliance and medication—related knowledge) was assessed.

Results: During the majority of home visits at least one medication‐related problem was detected: approximately half of the cohort subject to a ‘reliable’ pill‐count were found to be mal‐compliant and almost all demonstrated inadequate medication‐related knowledge. Mal‐compliance was correlated with ≥ five prescribed medications (Odds ratio [OR] 2.6: p <0.002). Comparatively, lower medication‐related knowledge was correlated with age >75 years (OR 2.2: p <0.001), exacerbation of a pre‐existing chronic illness (OR 2.7: p=0.044) and six years formal education (OR 1.9: p≥0.004). Neither were modulated by extent of in‐hospital counselling. Other previously unknown problems detected during the home visit included hoarding of previously prescribed medication (35%) and reducing medication intake to minimise costs (21%).

Conclusions: Management of prescribed medications among chronically ill patients recently discharged from acute hospital care is often sub‐optimal. Assessment of medication management in the home provides an invaluable opportunity to detect and address problems likely to result in poorer health outcomes.
Anti‐transglutaminase antibodies and coeliac disease
Authors: Miller A. , Paspaliaris W. , Elliott P. R. , D'Apice A.
Published: March 2008

Background: Anti‐endomysial antibodies have high specificity for coeliac disease but measurements are limited by the requirement for monkey oesophagus, a substrate that is expensive, and of limited availability and ethical acceptance. Tissue transglutaminase has recently been identified as the endomysial autoantigen in coeliac disease.

Aims: To examine the validity of serum tissue transglutaminase antibody levels in patients with coeliac disease and to assess their sensitivity and specificity against standard serological tests.

Methods: Serum IgA anti‐tissue transglutaminase antibody titres (measured by ELISA), IgA anti‐gliadin antibody litres (measured by a commercial ELISA) and anti‐endomysial antibody titres (measured by indirect immunofluorescence) were determined in 46 untreated and 14 treated patients biopsy‐proven coeliac disease and 145 disease and healthy controls.

Results: All patients with untreated coeliac disease were positive for anti‐endomysial and anti‐tissue transglutaminase antibodies (sensitivity 100%). Seventy‐one per cent of treated coeliac patients were anti‐tissue transglutaminase antibody negative. Five of 145 disease and healthy controls had low titres of anti‐tissue transglutaminase antibody (specificity 97%); no controls were anti‐endomysial antibody positive.

Conclusions: Our results demonstrated the sensitivity and specificity of IgA anti‐tissue transglutaminase antibodies to correlate highly with anti‐endomysial antibodies in the diagnosis of coeliac disease. The ELISA for IgA anti‐tissue transglutaminase antibodies is quantitative and easy to perform and is a valid alternative to indirect immunofluorescence for anti‐endomysial antibodies in screening for suspected coeliac disease.
Impact of an aggressive stenting strategy on initial and one‐year follow‐up costs in patients undergoing coronary angioplasty
Authors: Farshid A. , Leong B. , Pitney M. , McCredie R. M. , Allan R.
Published: March 2008

Background: Although stents have been shown in randomised trials to reduce restenosis rates compared with balloon angioplasty, there are concerns regarding the cost‐effectiveness of an aggressive stenting strategy. Stents were shown to increase medical costs over 12 months in the early trials.

Aim: Our aim was to determine the economic impact of an aggressive stenting strategy using current stenting techniques compared with a conservative stenting strategy.

Methods: Initial and one year follow‐up costs were determined in all patients who underwent successful revascularisation during June to December 1996 (aggressive stenting, n=401), and compared to all patients treated in the corresponding months in 1995 (conservative stenting, n=347). All patients had clinical follow‐up for one year.

Results: The proportion of patients receiving a stent increased from 22.5% in 1995 to 66.1% in 1996 (p<0.0001). Requirement for repeat procedures in the 1995 group compared with 1996 was coronary angiography in 31%vs 16%(p<0.0001), coronary angioplasty in 11%vs 6%(p=0.0044) and bypass surgery in 4.8%vs 2.5%(p=0.054). The mean initial cost of the procedure was higher in the aggressive stenting group ($4319±1276 in 1995 vs$5131±1491 in 1996, p<0.0001), but after 12 months follow‐up, total medical costs were equivalent ($5975±4143 in 1995 vs$5994±3476 in 1996, p=NS).

Conclusion: An aggressive coronary stenting strategy is associated with higher initial costs compared with a conservative strategy, but lower costs during follow‐up due to reduced need for repeat procedures, resulting in equivalent one year total medical costs.
Risk factors for development of hepatocellular carcinoma among Australians with hepatitis C: a case‐control study
Authors: Dutta U. , Byth K. , Kench J. , Khan M. H. , Coverdale S. A. , Weltman M. , Lin R. , Liddle C. , Farrell G. C.
Published: March 2008

Background: Older patients with cirrhosis due to hepatitis C are at risk of developing hepatocellular carcinoma (HCC), but additional risk factors may vary between countries.

Aim: In the present study, we sought to identify additional risk factors for HCC among a cohort of Australian patients with chronic hepatitis C.

Methods: Case‐control study of patients with advanced fibrosis stage hepatitis C who developed HCC during five‐year follow up at a referral liver clinic. Cases were compared to twice the number of age‐matched patients with chronic hepatitis C of similar fibrotic severity who did not develop HCC over a similar interval, using conditional logistic regression analysis (CLRA) and multivariate analysis. The main outcome measures were demographic and disease‐related variables at first presentation in relation to the development of HCC.

Results: HCC developed in 17 cases, an annual incidence among those considered to be at risk of 2%. The duration of follow up since first assessment was comparable among the cases and 34 selected age‐matched controls (4.1 and 5.2 years respectively, p=0.5). Cases were more often male (p=0.03), born in Asia (p=0.05), and had poorer liver function as indicated by serum albumin concentration (p=0.02). Anti‐hepatitis B core antibody (anti‐HBc) was detected in 59% (ten/17) of cases, compared to 21% (seven/34) of the controls (p=0.01). No patient with a sustained response to interferon developed HCC during follow up. There were no significant differences in the mode of HCV transmission, HCV genotype, alcohol exposure, serum bilirubin level or prothrombin time between the cases and the controls. Although the data set was small, multivariate CLR analysis identified serum albumin 35 g/L and anti‐HBc positivity to be independent risk factors for development of HCC.

Conclusions: Among older Australian patients (over the age of 40 years) with advanced fibrosis stage hepatitis C, the annual incidence of HCC is about 2%. Those who have low serum albumin and evidence of previous exposure to hepatitis B virus (anti‐HBc positivity) appear to have the highest risk of developing HCC during follow up, but males and those born in Asia could also be at increased risk.
Platelet adhesion receptors: novel targets for anti‐thrombotic therapy
Authors: Williamson D. , Giuliano S. , Jackson S. P.
Published: March 2008

The critical role of platelets in the development of the acute coronary syndromes is now well recognised, and a great deal of effort has therefore focused on elucidating the key adhesion receptors mediating platelet‐vessel wall and platelet‐platelet interactions. The vascular adhesion protein von Willebrand factor (vWf) plays a key role in supporting platelet adhesion to the damaged vessel wall and binds to two adhesion receptors on the platelet surface, the glycoprotein (GP) lb‐ V‐IX complex and glycoprotein IIb‐IIIa. The GP IIb‐V‐IX complex is a unique adhesion receptor which enables platelets to roll on a vWf matrix under conditions of rapid blood flow as well as transducing signals leading to the activation of GP IIb‐IIIa. This latter receptor binds to a distinct site on vWf and is essential for stabilising platelet adhesion to the site of vessel wall injury. In addition to supporting platelet adhesion, GP IIb‐IIIa plays a key role in a number of other platelet responses including platelet spreading, aggregation, the release of procoagulant‐rich microvesicles, and clot retraction. Given its central role in platelet function GP IIb‐IIIa has become an attractive target for the development of novel anti‐thrombotic agents. In this paper, we consider the advantages of inhibitors of GP IIb‐IIIa compared with other established anti‐platelet drugs including aspirin and ticlopidine, and also discuss some potential problems associated with the inhibition of GP IIb‐IIIa and other platelet adhesion receptors.
The addition of allogeneic peripheral blood‐derived progenitor cells to bone marrow for transplantation: results of a randomised clinical trial
Authors: Szer J. , Curtis D. J. , Bardy P. G. , Grigg A. P.
Published: March 2008

Background: The use of cytokine‐mobilised peripheral‐blood‐derived progenitor cells (PBPC) has resulted in a significant improvement in the safety of autologous transplantation. Collections of PBPC contain large numbers of haemopoietic progenitors and T‐lymphocytes when compared with bone marrow (BM).

Aims: To assess the clinical effects and safety of filgrastim‐mobilised allogeneic PBPC, in particular whether PBPC would alter the kinetics of engraftment or the incidence and severity of graft‐versus‐host disease (GVHD).

Methods: Twenty‐seven patients undergoing allogeneic transplantation were randomised to receive BM or BM supplemented by PBPC. Patients were conditioned with busulphan 16 mg/kg and cyclophosphamide 120 mg/kg. GVHD prophylaxis was with methotrexate and cyclosporin. Ganciclovir prophylaxis was administered to all cytomegalovirus seropositive patients. No haemopoietic growth factor was used after BMT. Donors of PBPC underwent a single, seven litre apheresis after four days of filgrastim, 10 μg/kg/day by subcutaneous injection.

Results: Donor toxicity was mild, with the most frequently reported being bone pain in the cytokine‐treated donors. The patients transplanted with BM+PBPC received an eight‐fold increase in CD3+ T‐lymphocytes (1.65X108kg vs 0.22×108/kg, p=0.04) and the cytokine product contained a median of 5×106 CD34+ cells/kg. BM+PBPC patients had more rapid engraftment of neutrophils to 0.5×109/L (17 days vs 19 days, p=0.02) and platelets to 50×109/L (22 days vs 35 days, p=0.04). BM megakaryocyte numbers were significantly enhanced at days 14 and 28 after BMT (both p=0.04), however platelet transfusions were not significantly different. The incidence, organ distribution, severity and time to onset of acute and chronic GVHD were not different between the treatment groups and there was no difference in overall survival or event‐free survival.

Conclusions: Allogeneic PBPC from HLA‐identical siblings may speed engraftment of neutrophils and platelets without detrimental effects on GVHD or survival.
Profile of people referred to an emergency department from residential care
Authors: Finucane P. M. , Wundke R. , Whitehead C. , Williamson L. , Baggoley C. J.
Published: March 2008

Background: Elderly people in residential care are among the most infirm in society and are at high risk of developing acute medical problems. There are no Australian data on the use of acute hospital emergency services by this group.

Aim: To determine patterns of use of a major public hospital's Emergency Department (ED) by elderly people living in residential care, their presenting problems and the outcome of attendance.

Methods: Prospective study of 300 consecutive referrals to a teaching hospital's ED involving people aged over 65 years and living in residential care in southern Adelaide, South Australia. Case records were examined and residential care staff were interviewed by telephone when information required clarification. This occurred in 25% of referrals.

Results: The 300 referrals were seen over a three month period and accounted for 2.43% of the 12,371 ED attendances during this period. During this time, at least 4.9% of people in residential care in the region were referred to the ED. The referrals involved 239 residents, 196 (82%) who were referred once only, 32 (13%) twice and 11 (5%) three or more times. Residents had a mean age of 84 years and 70% were female. A broad range of acute medical problems precipitated referral and 61% of people referred were immediately hospitalised. There was no general practitioner (GP) involvement in the management of the presenting illness in 58% of all referrals and in 45% of those where symptoms had been present for over three days.

Conclusions: People living in residential care are frequently referred to an ED service, often bypassing their GP in the process. They present with a wide range of acute medical problems for which most are hospitalised. Strategies that anticipate, prevent and manage health breakdown in residential care and so minimise the need for ED referral should be trialed.
Helicobacter pylori treatment and antibiotic susceptibility: results of a five‐year audit
Authors: Fraser A. G. , Moore L. , Hackett M. , Hollis B.
Published: March 2008

Background: Helicobacter pylori eradication treatment has been a rapidly evolving field. Audit of treatment results provides reassurance that trial data can be translated into routine clinical practice.

Methods: Data were collected prospectively over five years. Patients were given four different treatment regimens over the audit period ‘standard’ triple therapy, two types of clarithromycin‐based treatment or ranitidine, amoxycillin and metronidazole. Eradication was proven by a urea breath test at least four weeks after completing treatment.

Results: Eradication treatment for H. pylori was given to 665 patients; 89% had follow‐up data. H. pylori eradication was significantly associated with treatment type (p<0.0001) and smoking (p=0.04) by univariate analysis, but was not associated with sex, age, alcohol consumption, endoscopic diagnosis, recent treatment with anti‐secretory drugs or NSAIDs. By logistic regression analysis, only treatment type was significant (p=0.0001). H. pylori culture and sensitivities were available for 255 patients. Metronidazole resistance was shown for 84 isolates (32%) and clarithromycin resistance for 18 isolates (6.8%). Metronidazole resistance was significantly associated with younger age (p=0.02), ethnicity (p=0.02), female sex (p=0.02), and year of endoscopy (p=0.04), but was not associated with clarithromycin resistance. Clarithromycin resistance was not associated with age, sex, or ethnicity. Metronidazole resistance significantly affected H. pylori eradication for regimens containing metronidazole without clarithromycin. Eradication with metronidazole without clarithromycin was achieved in 90% of sensitive strains but only 55% of resistant strains (p<0.001). Metronidazole resistance was not significantly associated with treatment failure when metronidazole was combined with clarithromycin. Eradication with metronidazole and clarithromycin was achieved in 86% of sensitive strains and 78% of resistant strains (p=0.42).

Conclusion: Treatment type and antibiotic susceptibility are the most important determinants of treatment success.
The effect of parental smoking on presence of wheeze or airway hyper‐responsiveness in New South Wales school children
Authors: Belousova E. G. , Toelle B. G. , Xuan W. , Peat J. K.
Published: March 2008

Background and Aims: To assess accurately the effect of parental smoking on the respiratory health of New South Wales (NSW) school children, we obtained a large data set by pooling data from seven cross‐sectional studies conducted in NSW between 1991 and 1993.

Methods: A random sample of 6394 children age eight to 11 years was studied. Respiratory symptoms, family history of asthma and parental smoking history were measured by questionnaire, atopy by skin prick test and airway hyper‐responsiveness (AHR) by histamine inhalation test.

Results: In total, 58.3% of children had at least one parent who smoked; 38.5% were exposed to maternal smoking. After adjusting for potential confounders, such as atopy, parental history of asthma and bronchitis in the first two years, children who were exposed to maternal smoking had a significantly increased risk of recent wheeze but not of AHR (odds ratios 1.33; 95% CI: 1.2‐1.5 and 1.00; 95% CI: 0.9‐1.2).

Conclusions: The positive association with wheeze and the lack of an association with AHR suggests that exposure to parental smoking leads to wheezing, but does not increase airway responsiveness.
Atrial fibrillation: prevalence and management in an acute general medical unit
Authors: Stewart F. M. , Singh Y. , Persson S. , Gamble G. D. , Braatvedt G. D.
Published: March 2008

Background: Atrial fibrillation (AF) is a common comorbid condition in patients admitted to hospital. In managing patients with AF, recent research has highlighted the importance of heart rate control, cardioversion, maintenance of sinus rhythm and anticoagulation for the prevention of thromboembolism.

Aim: To determine the prevalence of AF in patients admitted acutely to the general medical service at Auckland Hospital and to assess the adequacy of heart rate control, the number cardioverted and the use of warfarin to prevent thromboembolism.

Methods: Prospective review of all acute admissions to the general medical service over a 12 week period. Information was collected from hospital notes on the patients' present and past medical conditions, admission and discharge cardiac medication and the use of investigations, particularly thyroid function tests and echocardiography. The heart rate on discharge, number cardioverted either during the admission or after discharge and the number given warfarin and aspirin were recorded.

Results: One hundred and forty‐seven patients (aged 38–96, mean age 76 years and 52% male) were admitted in AF 165 times out of the 1637 admissions over the study period (a prevalence of 10.4%, 95% CI 8.6–11.5%). The main causes of admission were heart failure (23%), pneumonia or sepsis (17%), cerebrovascular accident (CVA) or transient ischaemic attack (TIA) (14%) and ischaemic heart disease (11%). Past medical history included hypertension (46%), ischaemic heart disease (39%), congestive heart failure (58%), valvular heart disease (12%), chronic obstructive airways disease (24%), CVA, TIA or thromboembolic event (24%) and diabetes (17%).

Thyroid function tests were performed in 50% of patients and echocardiograms in 38%. Heart rate control at discharge could not be assessed, as this was not recorded prior to any patient's discharge. Seventy‐eight per cent of patients were discharged on digoxin but only 29% on drugs that control the heart rate with exercise. Five patients out of 11 considered for cardioversion had a successful cardioversion in hospital and two were later cardioverted as outpatients. Twenty‐eight per cent were discharged on warfarin, 33% on aspirin and one patient on both. Fifty‐two per cent were considered to have contraindications to warfarin therapy. Prescribing rates for warfarin did not vary according to the patients' clinical risk for thromboembolism.

Conclusion: AF is a common comorbid condition in the acute general medical ward. Standard investigations were under‐utilised. Attention needs to be paid to the recording and control of heart rate at rest and on exercise. Cardioversion is considered infrequently. This patient group had a high risk for thromboembolism and after excluding the large group in whom warfarin was contraindicated, warfarin was still under‐utilised.
Implementation of nationally developed guidelines in cardiology: a survey of NSW cardiologists and cardiothoracic surgeons
Authors: Shah S. , Ward J. , Tonkin A. , Harris P.
Published: March 2008

Background: In July 1996, the National Health and Medical Research Council (NHMRC) published clinical practice guidelines for ‘The Procedural and Surgical Management of Coronary Heart Disease’. Despite increasing interest in dissemination and implementation of guidelines, initial reactions to these specific Guidelines and factors critical to their successful implementation had not been determined until our study.

Aims: To determine views of New South Wales (NSW) clinicians towards these NHMRC Guidelines; to identify perceptions about local relevance, usefulness and likely impact and to elicit preferred implementation strategies.

Methods: A postal survey in November 1997 of all cardiologists and cardiothoracic surgeons in NSW.

Results: One hundred and ten of 174 clinicians returned the questionnaire (63% response rate). Forty‐eight per cent indicated that they were aware of the Guidelines before receiving a copy with the questionnaire while 26% had commented on the draft version of the Guidelines when distributed in November 1995. More than half of respondents ‘agreed’ or ‘strongly agreed’ with six of nine statements about potential strengths of the Guidelines. While at least 25%‘disagreed’ or ‘strongly disagreed’ on 11 out of the 13 statements about potential criticisms of the Guidelines, more than half agreed or ‘strongly’ agreed that the Guidelines did not tell them ‘anything they didn’t already know’. Fifty‐two per cent ‘agreed’ or ‘strongly agreed’ that guidelines will be misinterpreted by lawyers. At least 30% rated nine out of 11 implementation strategies as important. Local audits of care and regular feedback, reports from colleagues at conferences and hospital workshops outranked other implementation strategies in encouraging uptake of the Guidelines.

Conclusions: Clinicians in NSW have generally positive views about the Guidelines, however, medicolegal concerns are apparent. To strengthen evidence‐based decisionmaking as exemplified by the Guidelines, audits, presentations by opinion leaders and hospital‐based workshops are recommended.
Survey of blood cultures from five community hospitals in south‐western Sydney, Australia, 1993–1994
Authors: Gosbell I. B. , Newton P. J. , Sullivan E. A.
Published: March 2008

Background: Blood culture results have profound implications for patients. Comprehensive overviews of blood cultures have been uncommon, and focused on tertiary referral hospitals.

Aim: To present a review of blood culture results from a laboratory servicing community hospitals in Sydney, Australia.

Methods: Retrospective chart review of patients with positive blood cultures from 1 June 1993 to 31 May 1994.

Results: During the survey period there were 107,382 hospital admissions; 12,109 blood culture sets from 9292 patients were processed. Of these 1197 sets were positive, representing 974 febrile episodes in 923 patients. There were 476 episodes of contamination. Of the episodes of true bacteraemia, Escherichia coli was isolated in 139, Staphylococcus aureus in 91 (22 methicillin‐resistant), other enterobacteriaceae in 60, and Streptococcus pneumoniae in 51. The diagnoses attributable to bacteraemia included intravenous catheter‐related sepsis (122 episodes), urinary tract infection (88), bacteraemia from unknown source (79), intra‐abdominal and biliary sepsis (91), pneumonia (35), and meningitis (21). Sixty‐eight patients died directly due to bacteraemia. Multivariate analysis showed underlying disease (OR 3.97) or shock (OR 28.1) predicted death. Blood cultures confirmed clinical diagnoses in 258 episodes, but made a de novo diagnosis in 205 episodes.

Conclusions: This study describes the clinical and laboratory features of bacteraemias occurring in smaller public hospitals, as distinct from tertiary referral centres. It demonstrated that intravenous catheter‐related sepsis was very common in smaller hospitals. The clinical diagnosis was frequently confirmed, and a de novo diagnosis was often established by a positive blood culture. Unfortunately nearly half the positive blood cultures represented contamination.
Hip fracture outcomes: quality of life and functional status in older adults living in the community
Authors: Hall S. E. , Williams J. A. , Senior J. A. , Goldswain P. R. T. , Criddle R. A.
Published: March 2008

Abstract Background: People who return to living in the community after a hip fracture are considered to have the best outcome. However, their quality of life (QOL) and its relationship with function over the longer term have not been fully assessed.

Aims: This case control study of community dwelling subjects six to 12 months post hip fracture aims to investigate their QOL and functional independence.

Method: The Short Form‐36 (SF‐36) was utilised to measure QOL. The Modified Barthel Index (MBI), the Frenchay Activities of Daily Living Index (FAI), the Timed `Up & Go' (TUG), and the Berg Balance Scale (Berg) were used to measure functionality.

Results: Ninety‐two subjects and 92 controls were recruited. Despite being age and gender matched, the hip fracture subjects scored significantly (p<0.05) worse than the controls in all measures of function. The fracture group was slower on the TUG (19 vs 10.5 seconds), had more difficulties with balance (46 vs 54 out of 56), and was less active and more dependant than the control group (FAI 24 vs 31 out of 42). The SF‐36 has eight domains: physical function, role physical, bodily pain, mental health, role emotional, social function, general health and vitality. The control group had a higher (p<0.05) perception of their QOL in all domains.

Conclusion: The effects of impaired balance and mobility along with reduced functional and social independence are reflected in the diminished QOL perceived by the fracture group. This indicates that many do not return to their pre‐fracture lifestyle.
Lp(a) and conventional risk profiles predict the severity of coronary stenosis in high‐risk hospital‐based patients
Authors: Wang X. Li , Cranney G. , Wilcken D. E. L.
Published: March 2008

Abstract Aims: To explore predictive power of Lp(a), of conventional lipoprotein profiles and their carrier proteins, and of biometric measurements, for the presence and severity of angiographically documented coronary disease in high‐risk patients, and to compare risk profiles in men and women.

Methods: We determined coronary artery disease (CAD) risk factors in 1308 Australian Caucasian patients (313 women and 995 men) aged 65 years who consecutively underwent coronary angiography.

Results: In univariate analyses of the risk factors, lipid profiles, Lp(a), cigarette smoking, diabetes, hypertension and obesity were all higher in men and women with CAD and changed significantly with the number of significantly diseased vessels (50% luminal obstruction). When stepwise logistic regression analysis was applied, age (OR 1.06, 95% CI: 1.04–1.09), TC/HDL–C (OR 1.29, 95% CI: 1.15–1.45), male gender (OR 2.64, 95% CI: 1.67–4.16), hyperLp(a) (300 mg/L) (OR 2.09, 95% CI: 1.42–3.07), lifetime smoking dose (OR 1.02, 95% CI: 1.01–1.03), diabetes (OR 2.19, 95% CI: 1.14–4.18) and waist/hip ratio (OR 14.53, 95% CI: 1.21–174.90) were predictive of the disease. Both Lp(a) levels and percentage of hyperLp(a) increased linearly with the number of significantly diseased vessels. When the analyses were conducted in men and women separately, hyperLp(a), TC/HDL–C, lifetime smoking dose and age remained as significant predictors in both groups but the waist/hip ratio was only predictive in women.

Conclusions: As Lp(a) is an independent predictor of the occurrence and extent of coronary stenosis and relevant to treatment options, we suggest that it should be measured routinely in the coronary risk profile assessment of high–risk patients.
Advance care planning in residential care
Authors: Nair B. , Kerridgey I. , Dobson A. , McPhee J. , Saul P.
Published: March 2008

Abstract Background: To provide optimal care for our ageing population, some form of advance care planning (ACP) is essential. Overseas data suggest that the process of ACP and the use of advance care directives (ACD) is suboptimal in residential care institutions. By comparison there are few Australian data.

Aim: To study the process of ACP and the prevalence of ACD in residential care.

Methods: Cross‐sectional study using a questionnaire in the Hunter area, NSW, Australia.

Results: Very low levels of formal advance directives were found (available for only 0.2%). Only 1.1% of residents had no‐CPR' orders documented in the medical record, while 5.6% had a formal guardian and 2.8% had an enduring guardian.

Informal processes of advance planning were much more prevalent. Sixty‐five per cent had a `person responsible' recorded to make decisions for them while in 13% of cases, there was `staff consensus' as to the optimal care for the patient. However, in 10.6% there was no clear process for medical decision making identified.

Conclusions: Advanced directives are infrequently used in residential care. Further qualitative and quantitative studies are warranted to explore current processes of decision making.
HLA‐B27 expression and reactive arthritis susceptibility in two patient cohorts infected with Salmonella Typhimurium
Authors: McColl G. J. , Diviney M. B. , Holdsworth R. F. , McNair P. D. , Carnie J. , Hart W. , McCluskey J.
Published: March 2008

Background: Reactive arthritis (ReA) is an inflammatory arthritis triggered by certain gastrointestinal and genitourinary infections. Single source outbreaks of triggering infections provide an opportunity to elucidate host susceptibility factors in this disease.

Aim: To determine the role of Major Histocompatibility Complex (MHC) Class I alleles in ReA susceptibility after two large single source outbreaks of Salmonella Typhimurium gastroenteritis.

Methods: A questionnaire screening for features of ReA and a request for HLA class I typing were sent to all patients affected by two single source outbreaks of S. Typhimurium gastroenteritis. Individuals with arthritis of recent onset were interviewed, examined and diagnostic criteria for ReA applied.

Results: Nineteen cases of reactive arthritis, 11 female, were diagnosed in the 424 respondents with S. Typhimurium gastroenteritis from both outbreaks. Clinical features of the arthritis were similar to those described after other large single source outbreaks of Salmonella infection. HLA‐B27 was expressed by only two of the 19 ReA patients and therefore did not predict susceptibility to this form of arthritis. Caucasians were, however, more likely to develop reactive arthritis than Asians.

Conclusions: In this study, susceptibility to ReA was not increased in HLA‐B27 positive individuals or males but was greater in those of Caucasian descent.
The ethics of cloning and creating embryonic stem cells as a source of tissue for transplantation: time to change the law in Australia
Authors: Savulescu J.
Published: March 2008

Every day, people die because there are insufficient tissues available for transplantation. The development of cloning and embryonic stem (ES) cell line technologies offers real hope for developing better sources of tissues for transplantation. Moreover, these new technologies may mean that damaged tissue (for example, after a stroke or heart attack) can be replaced with normal functioning tissue rather than scar tissue. Research into ‘therapeutic cloning’ and the development of ES cell lines is illegal in several States in Australia. It is time to review that legislation in order to allow destructive embryo research. My argument is that at least research should be allowed on spare embryos from assisted reproduction; that it is only one moral view (of several plausible ones) of the status of the embryo which precludes producing embryos for research; that this view is mistaken and so it is morally permissible to produce embryos for research into therapeutic cloning.
ESTIMATION OF A DENSITY FUNCTION USING ORDER STATISTICS1
Authors: Bofingeb Eve
Published: March 2008

A non‐parametric estimator of a density at a particular quantile is based on sample quantiles. The optimal (to minimize M.S.E.) choice of these quantiles is considered and a method of removing the bias is suggested.
Gentrification in inner Melbourne: problems of analysis
Authors: LOGAN W. S.
Published: March 2008

Measurement and analysis of survey data for the period 1961–76 show that the concept of ‘gentrification’, borrowed from the British inner housing scene by local media and social scientists, does not capture the most salient features of the recent inner Melbourne experience. Serious inadequacies are revealed in the census data and alternative data sources are tapped. Positivist methods say nothing about the ‘meaning’ of inner city social changes, leaving room for interpretation based on the socio‐political stance of the observer. This is seen in the attribution of motives for the ‘gentry's’ entry into inner Melbourne and for their environmental and political activities.
The use of wind direction data to predict pollution dispersal around the Port Kembla industrial area, New South Wales
Authors: CRISP P.T. , ARCHIBOLD O.W. , CRISP E.A.
Published: March 2008

Wind direction data were used to calculate the percentage time during which winds blew over the principal sources of air pollution at Port Kembla into each of the surrounding residential suburbs for each month of 1980. The percentage wind frequencies (PWFs) correlated well with measured concentrations of airborne metals in the suburbs and with measured rates of metal deposition in moss bags located in suburbs adjoining the air pollution sources. PWFs for all suburbs exhibited winter minima and spring‐summer maxima, with the highest PWFs being calculated for suburbs south to south‐west of the industrial area and the lowest for suburbs lying to the west. Where experimental data are not available, PWFs could provide an indication of air quality for land‐use planning and zoning.
Fiction and the small town in the United States: a contribution to the study of urbanisation
Authors: JEANS D. N.
Published: March 2008

In recent years human geographers have turned to creative writing as a source of insights, and it is suggested that data can be derived to shed light on Facts, Experiences and Meanings. A large group of United States novels reveals two shifts in opinion of the small town compared with the city. Up to 1880 the small town was seen favourably, but from 1880 to about 1935 it was seen as vicious and repellent. A return to a favourable image then took place and continues. Using the approach of Raymond Williams to literature as ‘production’, these novels can be seen as a signifying system reinforcing public opinion as an integral part of the process of urbanisation.
Variation in suspended sediment concentration during storms in five small catchments in southeast New South Wales
Authors: OLIVE L.J. , RIEGER W.A.
Published: March 2008

Suspended sediment concentrations were determined during storm events for five small catchments in the Wallagaraugh River in southeast New South Wales between July 1977 and June 1978. A total of thirty‐nine storm responses were analysed and both storm hydrographs and hysteresis loops were produced. The behaviour of suspended sediment concentration was extremely variable and seven different types of response were recognised. In these catchments there is no simple single constant relationship between discharge and suspended sediment concentration. The free availability of suspendable material appears to be an important limiting control on sediment concentration and this appears to be related to the soil moisture conditions
From equalisation to rationalisation: public health care provision in New South Wales
Authors: EYLES JOHN
Published: March 2008

This article examines the changing nature of the resource allocation formula for health care provision in New South Wales. It looks at the technical changes to the formula reviewing its problems and limitations and subsequent modifications. The impact of the formula on actual resource provision is established and this provision is placed in the context of health policy and public expenditure debates in Australia. Finally, the formula and its use as a rationalisation device are examined in relation to economic crisis and state practice with the suggestion being made that certain features of the Australian state may lead to a review of aspects of the theory of the state.
Office location in Australian metropolitan areas: centralisation or dispersal?
Authors: DANIELS P. W.
Published: March 2008

As office activities have become even more centralised in A ustralia's largest cities they have also become more suburbanised. Taking account of the recent expansion of intermediate (mostly office‐based) services and their locational requirements, this article examines the existing and potential strategic planning policies for achieving a better organised, more equitable, and efficient distribution of office activities in Sydney, Brisbane, Adelaide, Melbourne and Perth. Preference for policies based on suburban office centres represents a convergence of ideas. Some of the factors which make it difficult to implement these policies are examined. The role of the CBD and adjacent office areas, however, should not be underrated given the established patterns of office location behaviour and the changing structure and origin of demand for non‐local market metropolitan offices.
A Sydney and Melbourne comparison of intra‐urban differentials in unemployment rates
Authors: VIPOND JOAN , BEED CLIVE
Published: March 2008

This article reports on multiple regression analyses of unemployment rates in the local government areas of Sydney and Melbourne which show that the spatial inequalities in unemployment risks may be greater in Sydney than in Melbourne. It explores the reasons for the difference and their implications for future trends in spatial inequalities.
Integrating Landsat and Land Systems for Cover Maps in Southern Inland Queensland
Authors: HILL GREG J. E. , KELLY GAIL D.
Published: March 2008

Digital analysis of Landsat data is applied to up‐dating land cover maps for the Goondiwindi district of southern, inland Queensland.

The imagery was paired with climax cover maps obtained from land systems reports with analysis conducted separately for each of three climax cover types (open forest, woodland and open woodland). Computer classification using this approach produced readily interpreted and reliable results.

This work demonstrates that Landsat can be used in conjunction with existing, land systems derived maps to produce data that combine the advantages of two approaches to environmental survey, the former being based on current land cover/land use and the latter on the original environment and its land use potential.
Patterns of Forest Settlement in Western Thailand
Authors: HIRSCH PHILIP
Published: March 2008

Most studies of land settlement are concerned with planned schemes. This is despite the fact that unplanned settlement has more often been the major process by which agricultural land is settled in many countries. In this local study of spontaneous forest settlement in western Thailand, the recent history of two communities is traced in order to shed light on the process of settlement Common assumptions about frontier communities are examined critically. It is suggested that many aspects of the post‐settlement community, in particular social differentiation, can best be understood in light of the process of settlement