bluuebunny/crossref_metadata_2025 huggingface dataset:
Assessment of coronary artery disease by dobutamine stress echocardiography (DSE)
Authors: Chan R. K. M. , Tonkin A. M. , Byrgiotis S. , Calafiore P.
Published: March 2008

Background: Dobutamine stress echocardiography (DSE) is a new non‐invasive imaging modality which combines two‐dimensional echocardiography with cardiovascular stress induced by dobutamine infusion. Its use in patients with suspected or documented coronary artery disease (CAD) is currently under extensive investigation.

Aims: To illustrate the clinical utility, safety and diagnostic value of DSE.

Methods: One hundred and thirty‐seven consecutive patients referred for DSE were studied. Eighty‐four patients also underwent coronary angiography.

Results: Eleven patients (8%) did not undergo DSE because of poor image quality. Of the remaining 126 patients, 110 (87%) achieved their target heart rate or reached a pre‐determined end point during DSE. Eight patients (6%) developed non‐cardiac side effects during DSE, none of which required premature termination of the procedure. Cardiac arrhythmias were documented in 15 patients (12%) but only one required intervention. In 84 patients who underwent coronary angiography, DSE showed a sensitivity and specificity of 88% and 83%, respectively, in detecting the presence of, and 75% and 75%o, respectively, in localising significant CAD. In 35 patients who underwent DSE after uncomplicated myocardial infarction, the positive and negative predictive values for cardiac events following infarction in a six‐month follow up period were 74% and 62%, respectively.

Conclusions: DSE is a well tolerated, safe and useful test in detecting and localising significant CAD. It can also provide useful post‐infarctional prognostic information. (Aust NZ J Med 1995; 25: 707‐715.) Key words: Echocardiography, dobutamine, coronary artery disease.
Developmental regulation of the human β‐globin cluster
Authors: Jane STEPHEN M. , Amrolia PERSIS , Cunningham JOHN M.
Published: March 2008

Expression of the genes of the human β‐globin cluster is subject to stringent developmental regulation. An integral component of this control is competition between the γ‐ and β‐promoters for the upstream regulatory sequences of the Locus Control Region (LCR). We have defined two stage selector elements (SSE and SSE‐2), located in the proximal γ‐promoter and y‐gene 5′UTR which mediate the preferential interaction of the γ‐gene with the L CR in the foetal developmental stage. The activity of both elements is dependent upon the binding of foetal and erythroid‐specific proteins. We have purified the protein binding the proximal SSE and characterised it as a complex between the ubiquitous transcription factor CP2 and a 40 kD partner protein. Comparative studies between human CP2 and the chicken stage selector protein, NF‐E4, demonstrate homology between the protein complexes. These findings demonstrate that competitive silencing of globin genes mediated by developmentally‐specific protein complexes is conserved in evolution.
Comparison of optimised planar scintigraphy with SPECT thallium, exercise ECG and angiography in the detection of coronary artery disease
Authors: Roach P. J. , Hansen P. S. , Scott A. M. , Cooper R. A. , Hoschl R. , Wiseman J. C. , Bernar A. , Edwards A. C.
Published: March 2008

Background: Thallium SPECT has been shown to be more sensitive than planar imaging in the detection of coronary heart disease (CAD) in a number of reported series. Early (< 10 minutes) redistribution on planar imaging has been demonstrated in clinical studies and this may partly contribute to its lower sensitivity.

Aim: To determine whether thallium SPECT is superior to planar scintigraphy (with the timing of imaging performed optimally so that it was commenced within five minutes of injection) in the detection of CAD.

Methods: Planar and SPECT studies were performed in 44 patients with significant (>70% stenosis) CAD, seven patients with borderline stenoses (50–69%) and in 18 patients with no significant CAD.

Results: The sensitivity of planar imaging was 66% which was higher than exercise ECG 54% (ns) but significantly lower than SPECT 86% (ρ<0.005). The specificity of planar thallium scintigraphy was 100% which was higher than SPECT (83%) and significantly higher than exercise ECG 72% (ρ<0.05). SPECT had a significantly higher sensitivity for LAD and single vessel disease than planar imaging and this was unrelated to a history of prior myocardial infarction.

Conclusion: Even when planar imaging is timed optimally to minimise the impact of early redistribution, SPECT is more sensitive than either planar imaging or exercise ECG in the detection of CAD, but its specificity is lower.
Scleroderma and silicone gel breast prostheses — the Sydney study revisited
Authors: Englert H. , Morris D. , March L.
Published: March 2008

Background: Silicone augmentation mammoplasty has been postulated as a cause of environmentally‐induced scleroderma. While representing a small proportion of all alleged causes of scleroderma, the issue has huge social, ethical and medicolegal ramifications. The hypothesis, however, has been recently questioned in results of comparative studies.

We have previously reported no association between augmentation mammoplasty and scleroderma. However, all information was self‐reported including augmentation mammoplasty status, and the prosthesis type was not identified. In addition, data were not available from untraceable cases. The current study addresses these issues.

Aims: To validate self‐reported augmentation mammoplasty status, re‐analyse rates of exposure to silicone gel breast prostheses in 556 scleroderma patients and 289 general practice controls and evaluate whether silicone gel breast prostheses are causally linked to scleroderma.

Methods: Study design ‐ population‐based case‐control study; Cases ‐ scleroderma patients resident in Sydney for at least six consecutive months between 1974–1988; Controls ‐patients from 29 randomly selected Sydney general practices, age‐ and gender‐group‐matched with cases.

Validation of augmentation mammoplasty exposure was ascertained from the general medical practitioner of each interviewed case and control, or from the medical records of each deceased or untraceable case. Validation of the date of surgery and prosthesis type was from the relevant plastic surgeon. For each augmentation mammoplasty‐positive case, validation of both the date and nature of the scleroderma onset was from the patient's medical records. Controls were given a ‘control date’ for disease onset to adjust for duration of potential exposure.

Results: Validation of augmentation mammoplasty status was possible in 252 (87.2%) living controls, and 532 (95.7%) cases, of whom 287 were living. Self‐reported augmentation mammoplasty status was highly reliable in living non‐senile cases (kappa=l), and living validated controls (kappa=0.86).

No association was identified between silicone gel augmentation mammoplasty and scleroderma with unadjusted odds ratios of 1.33 (95% CI:0.26–6.71), and 1.00 (95% CI:=0.16–6.16) following adjustment for potential confounders of age, socioeconomic status and ethnicity.

Conclusions: This validates the self‐reported augmentation mammoplasty status previously reported and does not support the hypothesis that silicone gel augmentation mammoplasty is an environmental inducer of scleroderma in females.
Near‐fatal asthma in South Australia:descriptive features and medication use
Authors: Campbell D. A. , Luke C. G. , McLennan G. , Coates J. R. , Frith P. A. , Gluyas P. A. , Latimer K. M. , Martin A. J. , Ruffin R. E. , Yellowlees P. M. , Roder D. M.
Published: March 2008

Background: Self‐reported prior morbidity levels and medication use among survivors of a near‐fatal asthma attack (NFA) were studied.

Aims: To identify deficiencies in asthma management and opportunities for intervention.

Methods: A hundred and twenty‐seven consecutive patients aged 15 years or more presenting with a NFA to accident and emergency departments of teaching hospitals were interviewed.

Results: High levels of morbidity due to asthma were reported. Most cases (79%) reported symptoms occurring at least weekly in the three months before their NFA. A mean of 20.8 days was reportedly lost from work, school or other usual daily activity in the 12 months before these events. Regular use of beta agonist as nebuliser solution was reported by 27% of cases, increasing to 34.5% in response to increased symptoms, while 41% reported use of nebulised beta agonist in response to the NFA event. Less than half of all cases (46%) reported using an inhaled corticosteroid on a regular basis. Oral corticosteroids were used by 33% of cases at times of increased symptoms in the preceding 12 months. However, only 7% of cases reported initiating or increasing oral corticosteroids at the time of the NFA.

Conclusions: Despite high levels of prior asthma morbidity, regular preventive inhaled corticosteroid use was not widespread in this series of NFA asthmatics. By comparison, over‐reliance on regular beta agonist medication was common. Oral corticosteroids were rarely commenced in response to the NFA.
Cost‐effectiveness of coronary angioplasty versus medical treatment: the impact of cost‐shifting
Authors: Kinlay S.
Published: March 2008

Background: Coronary angioplasty (PTCA) offers improved symptom control over medical treatment in patients with stable angina and single‐vessel disease. However, it is uncertain if PTCA is more cost‐effective. Cost‐shifting could also influence the provision of PTCA.

Methods: Data from the only randomised trial comparing PTCA to medical therapy (ACME study) were used with costs from an Australian teaching hospital to estimate the costs and freedom from angina in 100 patients over three years. The incremental cost‐effectiveness of PTCA, and the potential for cost‐shifting were also examined.

Results: Although the total cost of treating 100 patients over three years with PTCA ($678,978) was higher than a medical strategy ($631,078), PTCA was more cost‐effective ($10,930 versus$12,682 per patient free of angina). The incremental cost‐effectiveness of PTCA ($3875 per extra patient free of angina) was also substantially less than the cost of the medical strategy. These should be considered crude estimates as they were based on limited data on resource use. The hospital could reduce costs by pursuing a medical strategy, but 54% of the savings would result from shifting the cost of treating patients to the Federal Government and patients. By performing PTCA on privately insured rather than Medicare patients, die hospital could shift $29,876 per 100 patients to the Federal government and private insurance funds.

Conclusions: From society's perspective, PTCA may be more cost‐effective than a medical strategy. However, the financial interests of the hospital are best served by limiting PTCA or restricting PTCA to privately insured patients. Cost‐shifting may have a major impact on the provision of PTCA. The costs of providing medical services need to be weighed against the cost of not providing them.
Predictors of mortality in the prospective Dubbo study of Australian elderly
Authors: Simons L. A. , McCallum J. , Friedlander Y. , Simons J.
Published: March 2008

Background: A prospective study in non‐institutionalised Australian elderly 60 years and over commenced in Dubbo, NSW in 1988.

Aim: To examine clinical and socio‐demographic predictors of all‐causes mortality

Methods: The data were derived from a community‐based sample comprising 1236 men and 1569 women followed for a median period of 62 months.

Results: Two hundred and thirty five men (19%) and 184 women (12%) died, 46% of male and 53% of female deaths respectively related to cardiovascular disease. In a proportional hazards model, the significant predictors of mortality were: older age, being married (relative risk [RR]=0.71 for men, 0.74 for women), current smoking for men (RR=3.11), taking more than three alcoholic drinks per day for men (RR=0.37), prior coronary heart disease for men (RR=1.36), severe hypertension for women (RR=1.99), use of anti‐hypertensive medication for men (RR=1.74), diabetes for men (RR=1.62), poor‐fair self‐rated health for women (RR=1.74) and physical disability for men (RR=1.72). Serum cholesterol was associated with mortality in a ‘J‐shaped’ relationship in men and in a reciprocal relationship in women. Blood pressure predicted mortality in an incremental fashion below 75 years, but in older subjects lower pressure was associated with excess mortality.

Conclusion: Some predictors of mortality in the well elderly have been identified and a more extended period of follow‐up will possibly resolve contradictory findings in some areas.
Anti‐streptokinase antibodies and streptokinase resistance in an Aboriginal population in northern Australia
Authors: Urdahl K. B. , Mathews J. D. , Currie B.
Published: March 2008

Background: Thrombolytic treatment with streptokinase in acute myocardial infarction has proven to be safe and effective in Caucasian populations with relatively low levels of anti‐streptokinase IgG and streptokinase resistance. Higher levels of antibodies, as seen in previous recipients of streptokinase therapy, cause more adverse reactions and may result in lower efficacy.

Aims: To examine the levels of anti‐streptokinase IgG and streptokinase resistance in a population subjected to endemic streptococcal infections.

Methods and Results: Thirty Aboriginal adults from a remote community in Northern Australia with endemic streptococcal infections and 15 non‐Aboriginal adults from an urban community without endemic infections participated in this study. Aboriginal adults exhibited levels of anti‐streptokinase IgG and streptokinase resistance that, respectively, were almost 20 and 15 times greater than the values of non‐Aboriginal adults. At least 23% of Aboriginal adults had sufficiently high levels of streptokinase resistance to neutralise a standard 1.5 million unit dose of streptokinase.

Conclusions: Aboriginal adults from a remote community had dramatically elevated levels of anti‐streptokinase IgG and in vitro streptokinase resistance. Prospective studies are needed to assess the clinical relevance of streptokinase resistance in populations from areas with endemic streptococcal infection.
Video assisted thoracoscopic surgery (VATS) in Asia ‐ its impact and implications
Authors: Yim A. P. C.
Published: March 2008

Abstract Background: Within a short period of time, video assisted thoracoscopic surgery (VATS) has revolutionised the practice of thoracic surgery. Most of the existing literature, however, is concentrated on the technical aspects.

Aims: We examined the impact of VATS on our practice and its implications.

Methods: We reviewed our thoracic case load two years before and two years after the introduction of VATS in our hospital.

Results: We have witnessed a rapid and progressive increase in our thoracic case load since the introduction of VATS. With increased experience, proportionally more cases were performed using VATS compared to conventional surgical access. The increased case load covered a wide range of thoracic diseases with the majority for spontaneous pneumothorax and pleural diseases.

Conclusion: The higher case load is due to increased referrals which at least partly reflect earlier acceptance by both the patients and their physicians for surgical intervention. The changing indications for surgery and the high cost associated with VATS, however, could place extra demand on the healthcare, especially for some countries in Asia. Cost containment is therefore a high priority here. More research is greatly needed in this area.
Prevalence of IgE‐mediated allergy to latex in hospital nursing staff
Authors: Douglas R. , Czarny D. , Morton J. , O'Hehir R. E.
Published: March 2008

Abstract Background: IgE‐mediated hypersensitivity to latex proteins has become a significant clinical problem over the last decade. Nursing and medical staff are at risk because of their occupational exposure to latex.

Aims: To determine the prevalence of type I hypersensitivity to latex allergens in the nursing staff of an Australian hospital.

Methods: A questionnaire which asked about symptoms associated with the use of latex gloves was completed by 140 nurses working in the Alfred Hospital (72 in general medical wards, 68 in intensive care units). Skin prick tests with eluates of five different types of latex glove as well as common aeroallergens (rye pollen and house dust mite) and banana extract were performed.

Results: Thirty‐one nurses (22%) were skin prick test positive to at least one of the five latex glove eluates. All of these nurses were atopic, having positive skin prick tests to rye pollen or house dust mite. Symptoms of local dryness, itch and erythema associated with glove use were reported by more than half the study group, but not more frequently by those who were skin prick test positive to latex. Urticaria associated with glove use was reported more frequently by those with positive latex skin prick tests (13%vs 4%, p=0.05). Eighty‐seven per cent of the nurses who were latex skin test positive were also positive to banana extract.

Conclusions: IgE‐mediated hypersensitivity to latex is common in nurses working in an Australian hospital. Glove associated symptoms were frequently reported, but in most cases the symptoms were more typical of irritant or contact dermatitis rather than type I hypersensitivity reactions. However, the extent of subclinical sensitisation to latex found in this study suggests that symptomatic latex allergy is likely to emerge as an increasing problem for nursing staff in this country.
Early prediction of risk in patients with suspected unstable angina using serum troponin T
Authors: Kerr G. D. , Dunt D. R.
Published: March 2008

Abstract Background: One‐third of patients with rest angina are reported to have detectable cardiac troponin T in the serum and may be at increased risk of serious cardiac events.

Aim: To investigate whether a single early estimation of serum troponin T was an independent predictor of serious cardiovascular complications in patients with suspected unstable angina.

Methods: A prospective cohort study in which patients with suspected rest angina had a serum troponin T estimation 14 hours after symptom onset and were classified using discriminator levels of serum troponin T of 0.05 and 0.1 μg/L as well as a number of other variables. All patients were followed for six months to document any cardiac complications and a stepwise logistic regression analysis was conducted to determine independent risk factors of complications.

Results: One hundred and sixty‐four patients were evaluated. Using a discriminator level of 0.05 (μg/L 54 patients (33%) had detectable troponin T. The admission ECG was the only independent predictor of cardiac events in hospital ‐ odds ratio 4.0 (95% CI 1.7–9.6). Detectable troponin T did not appear to be an independent predictor of serious complications. During the six‐month follow‐up period, detectable troponin T using a discriminator of 0.05 (μg/L was an independent predictor of serious complications ‐ odds ratio 3.7 (95% CI 1.8–7.6).

Conclusions: In patients with suspected rest angina, detectable serum troponin T >0.05 (μg/L is an independent predictor of serious cardiac events during the six‐month follow‐up period although not during hospitalisation. Using a single, early serum troponin T estimation and other variables available at the time of admission, a high risk subgroup who may benefit from early investigation and revascularisation can be identified.
The Family Atherosclerosis Risk Intervention Study (FARIS): risk factor profiles of patients and their relatives following an acute cardiac event
Authors: Goble A. , Race E. , Jackson B. , Oliver R. G. , Phillips P. , Worcester M. C
Published: March 2008

Abstract Background: Relatives of patients with coronary heart disease have a heightened risk of cardiovascular disease. Attendance at a family‐based screening clinic after an acute cardiac event could motivate patients and relatives to modify their lifestyles.

Aims: The Family Atherosclerosis Risk Intervention Study (FARIS) aimed to determine (i) whether a high proportion of patients and relatives would attend a special screening and prevention programme; (ii) whether the risk factor profiles of relatives would be worse than those in the general community; and (iii) whether ongoing management of patients and families together in a special clinic would improve risk factor profiles.

Methods: Consecutive patients, together with spouse, siblings and offspring, aged 18 to 69 years, were randomly allocated three months after an acute cardiac event to attend a special outpatient clinic, a screening and advice group, or a control group. Risk factor measures were total cholesterol, HDL cholesterol (HDLC), systolic blood pressure (SBP), body mass index (BMI) and smoking behaviour. This paper presents the risk factor profiles of all FARIS attenders and compares those of family members, age adjusted, with risk factors measured in a multicentre urban cross‐sectional survey conducted in die same period. Differences between groups were compared using t‐tests for numerical variables and ANOVA and chi‐square for categorical variables.

Results: Six hundred and twenty‐eight patients and 1723 family members were enrolled, representing 85.9% and 82.7% of eligible patients and relatives respectively. Risk factors were significantly worse amongst family members than among those in the population survey.

Conclusion: FARIS has achieved high attendance rates of high risk subjects who are well motivated for secondary and primary prevention of cardiovascular disease.
Interferon therapy for acute hepatitis C viral infection ‐ a review by meta‐analysis
Authors: Quin J. W.
Published: March 2008

Abstract Background: Hepatitis C viral (HCV) infection poses a major health problem for Australia. Currently interferon therapy is approved only for people with chronic infection, yet the literature contains a number of studies that show that there is a better response to interferon in symptomatic acute HCV.

Aim: To review the response to interferon therapy in acute HCV by way of meta‐analysis.

Methods: This study was a retrospective review of the data on the use of interferon therapy in acute HCV. The meta‐analysis was performed using the methods of DerSimonian and Laird. Data were presented by calculating the risk difference which estimated efficacy by calculating the proportion of patients in treatment groups who responded better (0 to +1.0) or worse (0 to −1.0) than untreated control groups.

Results: A meta‐analysis of six studies on the use of 3MU of interferon alpha 2b (IFN‐a2b) three times a week for six to 24 weeks showed a significant response as measured by long term (>12 months) normalisation of alanine aminotransferase (ALT) and clearance of HCV RNA (as measured by polymerase chain reaction). The risk of difference was +0.31 (95% CI of +0.19 to +0.43,p<0.01) and +0.33 (95% CI of +0.08 to +0.58, p<0.001) respectively.

Slightly better results were seen with daily doses of 3MU of interferon beta (IFN‐p) given intravenously over four to seven weeks. This produced a risk difference of +0.57 (95% CI of +0.26 to +0.88, p<0.02) for normalisation of ALT and +0.83 (95% CI of +0.61 to 1.00,p<0.001) for clearance of HCV.

Results for higher daily doses of both IFN α and β were limited to a few studies and most were uncontrolled. 6MU of IFN‐a2b three times a week for 16 to 24 weeks produced a risk difference of +0.53 (95% CI +0.17 to +0.89, p<0.05) for normalisation of ALT and +0.44 (95% CI +0.06 to +0.82) for clearance of HCV RNA. Results with 6MU daily for eight weeks of IFN‐β in an uncontrolled study, showed up to 90% patients cleared HCV long term. Preliminary results with 10MU of IFN‐a2b daily for four to six weeks also showed long term clearance of HCV RNA and normalisation of ALT in 90%o of treated patients.

Conclusion: Short term (six weeks to six months) treatment of symptomatic acute HCV with interferon (both a and (3) produced a better long term response rate than prolonged therapy (> 12 months) in chronic HCV. Daily doses of 6MU and 10MU produced better responses than 3MU but more studies are needed to determine the optimum regime.
Radiofrequency ablation for cure of atrial flutter
Authors: Kalman J. M. , Vohra J. K. , Jayaprakash S. , Sparks P. B.
Published: March 2008

Abstract Background: Atrial flutter is a common arrhythmia which frequently recurs after cardioversion and is relatively difficult to control with antiarrhythmic agents.

Aims: To evaluate the success rate, recurrence rate and safety of radiofrequency (RF) ablation for atrial flutter in a consecutive series of patients with drug refractory chronic or paroxysmal forms of the arrhythmia.

Methods: Electrophysiologic evaluation of atrial flutter included activation mapping with a 20 electrode halo cadieter placed around the tricuspid annulus and entrainment mapping from within the low right atrial isthmus. After confirmation of the arrhythmia mechanism with these techniques, an anatomic approach was used to create a linear lesion between the inferior tricuspid annulus and the eustachian ridge at the anterior margin of the inferior vena cava. In order to demonstrate successful ablation, mapping techniques were employed to show that bi‐directional conduction block was present in the low right atrial isthmus.

Results: Successful ablation was achieved in 26/27 patients (96%). In one patient with a grossly enlarged right atrium, isthmus block could not be achieved. Of the 26 patients with successful ablation, mere has been one recurrence of typical flutter (4%) during a mean follow‐up period of 5.5±2.7 months. This patient underwent a successful repeat ablation procedure. Of eight patients with documented clinical atrial fibrillation (in addition to atrial flutter) prior to the procedure, five continued to have atrial fibrillation following the ablation. There were no procedural complications and all patients had normal AV conduction at the completion of the ablation.

Conclusions: RF ablation is a highly effective and safe procedure for cure of atrial flutter. In patients with chronic or recurrent forms of atrial flutter RF ablation should be considered as a first line therapeutic option.
Rehospitalisation for asthma within 12 months: unequal rates on the basis of gender at two hospitals
Authors: Heard A. R. , Campbell D. A. , Ruffin R. E. , Smith B. , Luke C. G. , Roder D. M.
Published: March 2008

Abstract Background: High asthma morbidity has been reported in certain demographic groups in geographical areas of low socioeconomic status (SES).

Aim and Methods: We tested for an ecological association between the gender of people being frequently hospitalised for asthma and the SES of the area in which they lived,

Results: Women represented 75% of the readmission population at The Queen Elizabeth Hospital (TQEH ‐ low SES hospital) and 55% at Modbury Hospital (moderate‐high SES hospital). Women at TQEH were significantly more likely to have one readmission within 12 months and over 30 times more likely to have two or more readmissions than women at Modbury Hospital.

Conclusion: The ecological association observed in this study needs to be confirmed elsewhere in Australia.
A PCR‐based method of screening individuals of all ages, from neonates to the elderly, for familial hyperaldosteronism type I
Authors: Stowasser M. , Gartside M. G. , Gordon R. D.
Published: March 2008

Abstract Aim: Unless specifically treated (glucocorticoids in low doses), Familial Hyperaldosteronism Type I (FH‐I) may result in early death from stroke. We report the successful application of a rapid, polymerase chain reaction (PCR)‐based method of detecting the ‘hybrid’ 11β‐hydroxylase (11β‐OHase)/aldosterone synthase (AS) gene as a screening test for FH‐I.

Methods:‘Long‐PCR’ was used to amplify, concurrently, a 4 kb fragment of AS gene (both primers AS‐specific) and a 4 kb fragment of the hybrid gene (5' primer 11β‐OHase‐specific, 3' primer AS‐specific) from DNA extracted from blood either collected locally or transported from elsewhere. Sample collection and transport were straightforward. This 4 kb fragment contains all the currently recognised hybrid gene ‘crossover’ points.

Results: Within a single family, long‐PCR identified all 21 individuals known to have FH‐I. Hypertension was corrected in all 11 treated with glucocorticoids. Nine with normal blood pressure are being closely followed for development of hypertension. Long‐PCR cord blood analysis excluded FH‐I in three neonates born to affected individuals.

Long‐PCR newly identified two other affected families: (1) a female (60 years) with a personal and family history of stroke and her normotensive daughter (40 years), and (2) a female (51 years) previously treated for primary aldosteronism with amiloride, her two hypertensive sons (14 and 16 years) and her hypertensive mother (78 years).

No false negative or false positive results have yet been encountered. At least seven other centres have successfully performed this test.

Conclusion: Long‐PCR is a reliable method of screening individuals of all ages for FH‐I.
Socio‐economic disadvantage, quality of medical care and admission for acute severe asthma
Authors: Kolbe J. , Vamos M. , Fergusson W.
Published: March 2008

Background: In asthma, socio‐economic and health care factors may operate by a number of mechanisms to influence asthma morbidity and mortality.

Aim: To determine the quality of medical care including the patient perception of the doctor‐patient relationship, and the level of socio‐economic disadvantage in patients admitted to hospital with acute severe asthma.

Methods: One hundred and thirty‐eight patients (15–50 years) admitted to hospital (general ward or intensive care unit) with acute asthma were prospectively assessed using a number of previously validated instruments.

Results: The initial subjects had severe asthma on admission (pH=7.3±0.2, PaCO2=7.1 ±5.0 kPa, n=90) but short hospital stay (3.7±2.6 days). Although having high morbidity (40% had hospital admission in the last year and 60% had moderate/severe interference with sleep and/or ability to exercise), they had indicators of good ongoing medical care (96% had a regular GP, 80% were prescribed inhaled steroids, 84% had a peak flow meter, GP measured peak flow routinely in 80%, 52% had a written crisis plan and 44% had a supply of steroids at home). However, they were severely economically disadvantaged (53% had experienced financial difficulties in the last year, and for 35% of households the only income was a social security benefit). In the last year 39% had delayed or put off GP visit because of cost. Management of the index attack was compromised by concern about medical costs in 16% and time off work in 20%.

Conclusion: Patients admitted to hospital with acute asthma have evidence of good quality on‐going medical care, but are economically disadvantaged. If issues such as financial barriers to health care are not acknowledged and addressed, the health care services for asthmatics will not be effectively utilised and the current reductions in morbidity and mortality may not be maintained.
Adult acute leukaemia ‐ a retrospective study of 66 consecutive patients
Authors: Shapiro J. , Brown S. , Briggs P. , Stanley R. , Griffiths J. , Brodie G. , Richardson G.
Published: March 2008

Background: Advances in therapy and supportive care have improved the outlook for many patients with acute leukaemia, however elderly patients have increased treatment‐related toxicity and shorter survival. Most clinical trials have selected patient populations with young median ages and it is therefore difficult to apply results to the general population where the majority of patients presenting with acute leukaemia are over 60 years. There is little information in the literature guiding appropriate treatment of these patients.

Aims: To determine the relationship between age, treatment received, and outcome in patients presenting with acute leukaemia.

Methods: A retrospective analysis was performed on all patients presenting to Prince Henry's Hospital and Monash Medical Centre with acute myeloid leukaemia (AML) or acute lymphocytic leukaemia (ALL) during a five year period.

Results: Sixty‐six patients (51 ‐ AML, 15 ‐ ALL) presented with acute leukaemia between March 1989 and April 1994. Median patient age was 63 years; 32% of patients received supportive therapy only; 86% of patients with ALT, and 58% of patients with AML commencing remission‐induction chemotherapy entered a complete remission. Median survival for patients receiving only supportive therapy was three months. Median survival in patients under 55 years was almost twice as long as patients over 55 years receiving similar treatment (AML ‐ eight vs four months p=0.023; ALL ‐ 3.5 vs seven months p=0.029).

Conclusions: Median survival for acute leukaemia is inversely proportional to age. Applying results from selected series to elderly patients with acute leukaemia is inappropriate.
Exercise vascular responses in health and disease
Authors: Thomson Helen
Published: March 2008

In normal subjects during exercise, there is vasoconstriction of non‐exercise resistance vessels and an increase in blood pressure. We have investigated patients with vasovagal syncope with structurally normal hearts and patients with hypertrophic cardiomyopathy compared with normal controls and found a failure of vasoconstriction in both patients with vasovagal syncope and hypertrophic cardiomyopathy compared with normals and this has been associated with exercise hypotension. An association between exercise hypotension and sudden death has previously been reported in hypertrophic cardiomyopathy. We speculate that in patients with vasovagal syncope and structurally and electrically normal hearts, exercise hypotension is well tolerated, but in patients with structurally abnormal hearts, exercise hypotension can have catastrophic consequences.
The importance of the autonomic nervous system in health and disease*
Authors: Sleight Peter
Published: March 2008

Baroreceptor control of the circulation is now generally thought to be concerned only with short term buffering of changes in arterial pressure, rather than with long term setting of pressure levels. This paper reviews evidence to the contrary, which suggests that impairment of the baroreflex, either by local changes in the carotid sinus or by environmental or genetic influences working through cortical modulation of the reflex gain, may have an important influence on long term arterial pressure.

Further interest in the baroreflex has been revived by the demonstration in several large studies that autonomic control, measured either by baroreflex sensitivity (BRS) or heart rate variability (HRV), is a powerful independent prognostic factor, which adds to other clinical measures of risk stratification in patients with left ventricular damage, or who have survived a myocardial infarction.

The inter‐relationships are complex, poorly understood, and subject to many confounding factors. Nevertheless, BRS and HRV are promising techniques. Further understanding holds out the hope of new therapeutic approaches to these patients.
Interventional management of acute myocardial infarction (AMI)
Authors: Bett John H. Nicholas
Published: March 2008

The best way to limit infarct size and improve survival in patients with early heart attacks is to restore as quickly as possible patency in the infarct‐related artery and blood flow to the threatened myocardium. The value of thrombolytic therapy and aspirin has been shown in large clinical trials. A regimen of accelerated recombinant tissue plasminogen activator is more effective than those using streptokinase. In older patients, there is a greater risk of haemorrhagic stroke; nevertheless, thrombolytic treatment saves more lives because the mortality of myocardial infarction (MI) is higher.

Thrombolytic therapy fails to restore blood flow sufficiently rapidly or completely in nearly one‐fifth of patients. Its efficacy, therefore, has been compared with immediate or direct angioplasty (PTCA). If it can be done promptly enough, PTCA is superior in preventing recurrent ischaemia and the combined outcome of death or non‐fatal reinfarction, and is associated with a lesser risk of intracranial haemorrhage. It may also be cheaper because patients spend less time in hospital and fewer of them require late revascularisation. PTCA should be considered for patients with cardiogenic shock or for those in whom there is a contraindication to thrombolytic therapy.

The benefits of prompt treatment have been reduced by excessive delay in reaching hospital and door‐to‐needle time.

After fibrinolysis, coronary angiography and PTCA may be reserved for those with spontaneous angina or exercise‐induced ischaemia.
Diabetic ketoacidosis in adults at Auckland Hospital, 1988–1996
Authors: Bagg W. , Sathu A. , Streat S. , Braatvedt G. D.
Published: March 2008

Background: Diabetic ketoacidosis (DKA) is associated with significant morbidity and mortality. Recent evidence suggests that patients with both type 1 and type 2 diabetes can develop DKA.

Aim: To review the experience in managing patients admitted to Auckland Hospital with DKA over an eight year period.

Methods: A retrospective chart review was undertaken to identify patients with a discharge code of DKA admitted to Auckland Hospital between May 1988 and October 1996.

Results: One hundred and twenty‐five patients were identified who met the defined criteria for DKA. The in‐patient mortality for the group was 2.4%. Thirteen patients (10.4%) probably had type 2 diabetes. Thirty‐eight (30.4%) patients were admitted to the Department of Critical Care Medicine (DCCM) ‐ these patients had a significantly lower systolic blood pressure and arterial pH, together with a significantly higher admission blood glucose and longer duration of insulin infusion than those not admitted to DCCM. Following their index admission 25% of patients were readmitted to hospital with DKA during the study period. Errors in insulin self‐administration that contributed to admission to hospital with DKA were identified in 61% of the patients with known diabetes.

Conclusions: Patients with DKA in this study spent about a week in hospital and a significant proportion were admitted to the DCCM. In spite of this the overall mortality was low. Many of these patients were readmitted to hospital with DKA. A small number of patients with DKA may have type 2 diabetes and may not need long term insulin therapy. More effort on patient education regarding insulin use with illness, may prevent admission to hospital with DKA.
A phase II study of liposomal doxorubicin in the treatment of HIV‐related Kaposi's sarcoma
Authors: Newell M. , Milliken S. , Goldstein D. , Lewis C. , Boyle M. , Dolan G. , Ryan S. , Cooper D. A.
Published: March 2008

Objectives: To evaluate the toxicity and clinical efficacy of liposomal encapsulated doxorubicin (DOX‐SL) in the treatment of HIV‐related Kaposi's sarcoma (KS).

Methods: DOX‐SL 20–40mg/m2 was administered by intravenous infusion over 30–60 minutes every two weeks. Toxicity was assessed in all patients and response assessed in patients who completed two or more cycles of therapy.

Results: Twenty‐five patients with KS were enrolled. Nine had received previous KS chemotherapy but only one prior anthracycline therapy. Eighteen patients had CD4 counts <50/mm3. Eight had pulmonary and/or visceral KS. A total of 191 cycles were given, median 6, range 1–33. Twenty patients completed two or more cycles and were considered evaluable for efficacy. A defined response occurred in 11 patients, nine achieving a partial response and two a complete response. The median duration of response was 120 days and the median time to disease progression was 187 days. Acute toxicity was minimal, except in one patient who had generalised erythema, hypotension and diaphoresis within ten minutes of starting DOX‐SL infusion. Grade 3 or 4 neutropenia occurred in 13.6 and 3.7% of cycles respectively. Neutropenic sepsis secondary to drug therapy was not reported. Alopecia and gastrointestinal symptoms were mild and infrequent. No cardiac toxicity was seen. Nine/25 patients developed HIV‐associated illnesses while on study (three Pneumocystis carinii pneumonia, two systemic Cytomegalovirus infection, three cryptosporidiosis, one Mycobacterium avium intracellulare‐(MAC) infection). Median survival in the evaluable patients was 219 days.

Conclusions: DOX‐SL is an effective and well tolerated palliative therapy in AIDS‐related KS.
Percutaneous transseptal mitral valvotomy‐progress report
Authors: McCredie R. M. , Hill A. T. , Allan R. M. , Black I. W.
Published: March 2008

Background: Percutaneous transseptal mitral valvotomy (PTMV) has been established as an alternative to surgery in the treatment of mitral stenosis.

Aim: To review our experience in the first 200 attempted PTMV procedures in patients with mitral stenosis, and the short and medium term follow‐up.

Methods: PTMV was attempted on 200 occasions in 189 patients with significant mitral stenosis between May 1988 and May 1994. There were 156 females and 33 males, mean age 53.5 years (range 14 to 83 years). Six patients were pregnant at the time of the procedure.

Results: Valve split was achieved at the initial attempt in 183/189 procedures (97%). Clinical improvement of at least one New York Heart Association (NYHA) functional class was achieved in 172/189 patients (91%). The mean mitral valve gradient (mean±SD) decreased from 11.5±5.1 mmHg to 4.9±4.1 mmHg, mean cardiac output rose from 3.9±1.1 L/minute to 4.4±1.4 L/minute and mean calculated mitral valve area increased from 1.0±0.3 cm2 to 2.1±0.9 cm2. Ten patients developed clinically significant mitral incompetence requiring surgical mitral valve replacement. There were two transient cerebral embolic events. Small atrial septal defects were detected echocardio‐graphically in 42 patients, but none has been a clinical problem. There were no early deaths; there were 11 late deaths, four of which were non‐cardiac. Twenty patients have had repeat PTMV for re‐stenosis, four to 67 months after the first.

Conclusions: PTMV provides significant haemodynamic and clinical improvement with low risk and should be considered the treatment of choice in patients with mitral stenosis.
Plasma leptin in relation to regional body fat in older New Zealand women
Authors: Taylor R. W. , Goulding A.
Published: March 2008

Background: Leptin is the protein product of the obesity (ob) gene and is produced in adipose tissue. Plasma leptin values are highly correlated with total body fat mass but less is known concerning relationships of leptin with regional adiposity.

Aim: To investigate associations between leptin and dual energy X‐ray absorptiometry (DEXA) measures of regional body fat deposition in older New Zealand women.

Methods: Body composition was measured in 80 women aged 40 to 79 years (20 in each decade) using DEXA. Height and weight were measured by conventional anthropometry. Plasma leptin concentrations were assayed by radioimmunoassay.

Results: Leptin was strongly correlated (p<0.001) with weight (r=0.751), body mass index (r=0.782), total fat mass (r=0.854) and % fat mass (r=0.813). A statistical model with trunk fat (kg) and leg fat (kg) as the independent variables showed that trunk fat accounted for 72.1% of the variance in plasma leptin with leg fat explaining only a further 1.6% of the variance. No relationships were found between leptin and age, height, lean tissue mass or menopausal status (p>0.05).

Conclusions: We conclude that trunk fat explains more of the variance in circulating leptin concentrations than leg fat, suggesting that the propensity to leptin resistance may be increased in women with higher central adiposity.
Management of patients with diabetes after heart attack: A population‐based study of 1982 patients from a heart disease register
Authors: Lim L. L‐Y. , Tesfay G. M. , Heller R. F.
Published: March 2008

Background: Previous studies examining the management of patients with diabetes after acute myocardial infarction (AMI) have been based on clinical studies under experimental conditions. We used data from a population‐based heart disease register to document differences in the management after AMI between patients with and without diabetes.

Hypothesis: There were no differences in the prescription rates of aspirin, beta blockers, streptokinase, ACE inhibitors and calcium channel blockers between patients with and without diabetes admitted to hospital with AMI.

Methods: A retrospective study of 268 patients with, and 1714 patients without, diabetes discharged from hospital with ‘definite’ AMI between August 1988 and March 1994.

Results: The prescription rates of all five drug classes increased between 1988 and 1994 both for patients with and without diabetes. Patients with diabetes were significantly less likely to have been prescribed aspirin (76%vs 85%), beta blockers (41%vs 53%) and streptokinase (25%vs 43%) but more likely to have been prescribed ACE inhibitors (47%vs 29%) and calcium channel blockers (50%vs 40%). The differences in prescription rates were statistically significant after controlling for age, sex, history of ischaemic heart disease, smoking status, educational level and disease severity.

Conclusion: Patients with diabetes were less likely to have been prescribed three of the five drug classes where evidence points to a beneficial effect after AMI. Further work is needed to identify the reasons for the disparity between management of patients with and without diabetes, and to develop effective strategies to increase the implementation of best practice guidelines in the management of patients with diabetes after AMI.
Can we improve on front‐loaded alteplase (r‐TPA)?
Authors: Aylvoard Philip
Published: March 2008

The method of administration of alteplase has evolved since its introduction to clinical practice in the late 1980s. The initial dosage regimen of a graded administration of 100 mg was replaced by the front‐loaded weight adjusted regimen, the efficacy of which was demonstrated in the GUSTO 1 trial.

Double bolus administration was shown to achieve superior TIMI 3 patency of the infarct related artery in a small angiographic study, but the COBALT trial failed to show equivalence and indeed showed a slightly higher mortality and incidence of stroke, so cannot be recommended.

Reteplase, a deletion mutant of alteplase, also showed superior efficacy in achieving coronary patency but no clinical superiority in outcomes in the 15,000 patient GUSTO 3 trial. The case of administration of reteplase, however, has some attraction as an alternative to alteplase. Trials of newer agents based on further modifications of alteplase are ongoing, but at present the front‐loaded alteplase regimen remains the standard for clinical practice.