Australia's university courses: are they meeting the educational expectations of the National Environmental Health Strategy?

Australia has developed a national strategy to encourage an intersectoral approach to environmental health and the creation of an environment that promotes good health and prevents problems. This strategy has implications for the education and training of the workforce. Therefore, the authors conducted a survey of courses in environmental health and other courses highly relevant to the environment offered by Australian universities in 2000. The purpose was to determine the extent to which those courses meet the educational expectations of the National Environmental Health Strategy. Results of the survey showed that Australia's universities are not meeting all the educational expectations of the national strategy. These findings might prompt other countries that agree with the thrust of the strategy to review their own educational offerings.

Critical review of epidemiological studies of the association between smoking and non-Hodgkin's lymphoma.

Smoking has been suggested to increase the risk of non-Hodgkin's lymphoma (NHL) but the results of epidemiological studies have been inconsistent. The aim of this work was to assess whether the findings of individual studies might have arisen by chance, bias or confounding and whether any associations found between smoking and NHL represent cause-and-effect. Reports of the association between smoking and NHL were identified from Medline. Confidence intervals on relative risks and odds ratios, use of multiple comparisons, and information on source, direction, actual existence and size of potential biases and confounding and features of any associations were abstracted. Four out of five cohort studies found no association between current smoking and NHL but three may have been biased against doing so. One found an association with follicular lymphoma but without a convincing exposure-risk gradient. The fifth found a strong association and an exposure-response gradient with ever smoking but excluded living cases from the end-point. Only one study found an association with past smoking which lacked features of causality. Eight out of 14 case-control studies found no association between current and/or past smoking and NHL but five may have been biased against doing so. Of six positive studies, three involved multiple comparisons, the association of one became non-significant after eliminating bias, four did not explore features of causality and one found an association only in heavy smokers, particularly under 45 years old. There are no grounds to reject the null hypothesis but associations should continue to be sought particularly in subgroups of smokers and with NHL subtypes.

Helicobacter pylori infection and fasting plasma glucose concentration.

BACKGROUND: Helicobacter pylori infection raises basal and meal stimulated serum gastrin concentrations and lowers iron stores, which may in turn reduce fasting plasma glucose concentrations in the population. AIM: To determine whether H pylori infection leads to lower fasting plasma glucose concentrations in the population. METHODS: One hundred and seventy three women and 165 men, randomly selected from the electoral rolls of an Australian city, participated in a cardiovascular risk factor survey. Plasma glucose concentrations and H pylori IgG antibody titres were measured. Non-fasting subjects and pregnant women were excluded, as were known diabetics, whose plasma glucose concentrations would be affected by diet and/or medications. Fasting plasma glucose concentrations were logarithmically transformed and the relation with H pylori infection, adjusting for age and other confounding factors, was determined for men and women separately by analyses of variance. RESULTS: Helicobacter pylori infection was significantly associated with fasting plasma glucose concentration among women. Infected women had a lower mean fasting plasma glucose concentration (5.2 mmol/litre; range, 3.9-8.2) than did non-infected women (5.4 mmol/litre; range, 3.9-11.1). CONCLUSIONS: Helicobacter pylori infection may lead to lower fasting plasma glucose concentrations among women and should be considered when interpreting concentrations bordering on diabetes.

Determinants of basal plasma gastrin levels in the general population.

BACKGROUND: There is considerable variation in basal plasma gastrin levels in healthy subjects. Although high plasma gastrin levels may be causally associated with duodenal ulcer and colorectal cancer, there has been little research to identify the factors that determine basal gastrin levels in the general population. METHODS: Helicobacter pylori IgG antibodies and fasting basal gastrin concentrations were measured in 134 males and 137 females who had participated in a cardiovascular disease risk factor prevalence survey and for whom frozen plasma was available. Stepwise multiple linear regression analysis was used to identify the determinants of basal plasma gastrin concentration. RESULTS: The determinants of basal plasma gastrin concentration were H. pylori infection (B=0.12+/-0.03; P=0.0001), age in deciles (B=0.02+/-0.01; P=0.03), hazardous drinking (B=0.10+/-0.05; P= 0.07) and gender (B=0.05+/-0.03; P=0.06), but not education, neighborhood socioeconomic index, smoking, body mass index, vigorous exercise or medication known to affect basal plasma gastrin concentration. Ten percent (+/-3) of seropositive subjects had a high basal plasma gastrin concentration > 90 pg/mL compared with only 2% (+/-1) of seronegative subjects. CONCLUSIONS: Helicobacter pylori infection is one of the few modifiable determinants of basal plasma gastrin levels in the general population.

Comparison of rural and non-rural students undertaking a voluntary rural placement in the early years of a medical course.

OBJECTIVE: The experiences of rural and non-rural students undertaking a voluntary rural placement in the early years of a medical course were compared. METHOD: Eighty percent (28) of the rural and 70% (114) of the non-rural students completed a post-placement questionnaire. RESULT: The two groups did not differ on their overall rating of the placement, whether they felt welcome, adequacy of the time with doctors or their rating of the accommodation provided. However, 46% (13) of the rural students reported the placement had changed their feelings towards rural practice to the maximum/almost maximum extent compared with only 24% (27) of the non-rural students.

The establishment of an industry-based education program in public health.

Commonwealth reforms have led to staff of the Department of Health and Aged Care needing a greater knowledge of public health, to more effectively evaluate evidence and to quickly acquire competence in new emerging areas. The department's requirements of a training program could not be met by existing university-based public health courses. A consortium of five universities and the department worked together to develop an industry-based course that would meet the Commonwealth's needs. The course was constituted within university regulations; had an incremental and articulated structure with exit points at certificate, diploma and Masters levels; was relevant to the work of staff; offered subjects which complemented the staff's existing skills, training and career aspirations; drew upon expertise across the universities; and was flexible in its delivery. The Commonwealth's and universities' experience has been sufficiently positive to conclude that a corporate public health postgraduate program has a place alongside university-based programs.

Preventing fractures in large rural centres: sociodemographic sub-groups at risk of osteoporosis from their lifestyle.

Middle-aged people living in non-metropolitan Victoria have higher hospitalisation rates from osteoporotic fractures than those in metropolitan areas. This may reflect a higher prevalence of lifestyle risk factors for osteoporosis. One-fifth of Victoria's non-metropolitan population live in 'large rural centres'. The aim of the present study was to identify the sociodemographic sub-groups in a 'large rural centre' at risk of osteoporosis because of their lifestyle. Adults on Ballarat's electoral rolls were invited to complete a questionnaire and have their height and weight measured. A total of 335 eligible people participated in the present study (67% response). The sub-groups at risk of osteoporosis were identified using logistic regression analyses. Among women, being single/separated/divorced/widowed was associated with being underweight and having low dietary calcium. A lack of exercise was associated with not completing high school and smoking with being aged 25-44 years. Among men, low dietary calcium was associated with not completing high school and smoking was associated with being employed in a non-professional/non-managerial occupation. These sub-groups must be considered when planning preventative strategies for people in 'large rural centres'.

Hospital separation rates from osteoporotic and non-osteoporotic fractures in metropolitan and rural Australia.

Rural populations of the United Kingdom and Scandinavia have lower hospital discharge and incidence rates for hip fractures than urban ones. We compared hospital separations from fractures in rural health regions of Victoria, Australia, with those in metropolitan regions. Fractures were grouped into those commonly (1A), often (1B) or not often (2) associated with osteoporosis. For group 1A fractures, we found rural separation rates were significantly higher among both men and women who were aged either 20-24 or 45-64. The rural separation rates for group 1B fractures were also significantly higher in these age groups but only among men. For group 2 fractures, rural separation rates were significantly higher among young adults. Fractures of the neck, trunk, radius and ulna, but not neck of the femur, contributed to the rural excess of group 1A fractures. If rural adults are not hospitalised more often, risk factors for group 1 and group 2 fractures, which in the middle aged includes osteoporosis, may be more prevalent in rural Victoria. Our findings suggest that international studies of rural-urban differences in fracture rates are needed which include a range of anatomical sites.

Prevalence and sociodemographic determinants of cardiovascular risk in a rural area.

Non-metropolitan areas have a higher mortality from cardiovascular disease than metropolitan areas. The study's aim was to establish the prevalence of cardiovascular disease risk factors in a rural area and identify their sociodemographic determinants. Adults, randomly selected from Ballarat's electoral rolls, were invited to complete a questionnaire and have their height, weight, blood pressure and fasting lipids measured. Three hundred and thirty-eight eligible persons participated (67% response). The data were analysed using logistic and multiple regression analyses. Increasing age was associated with hypertension, high plasma cholesterol, overweight/obesity, high plasma triglyceride levels and increasing plasma fibrinogen. Women were less likely to be overweight/obese and have a high plasma triglyceride. Not having completed high school was associated with hypertension, high plasma cholesterol and triglyceride levels and physical inactivity. Smoking was associated with employment and being in a non-professional/managerial occupation. Rural health promotion initiatives should take account of the needs of these population subgroups.

Helicobacter pylori infection is not a correlate of plasma fibrinogen in the Australian population.

Plasma fibrinogen concentration is an important independent risk factor for cardiovascular disease. Studies into whether Helicobacter pylori infection and fibrinogen are associated have yielded inconsistent results. Despite the geographical variation in fibrinogen and prevalence of H. pylori infection, all studies to date have been undertaken in the United Kingdom or Italy. The association between H. pylori infection and fibrinogen was investigated in 324 adults, 65% of a random sample, in an Australian regional city. The mean plasma fibrinogen concentration in 98 infected participants (2.52 g/l) was similar to that in 226 non-infected subjects (2.58 g/l, P = 0.51); 95% confidence interval on the difference was -0.23-0.11 g/l. After including all potential confounding factors in a backward multiple linear regression analysis, H. pylori was still not associated with fibrinogen (P = 0.084). Any association between H. pylori and cardiovascular disease in Australia is not mediated through fibrinogen.

Post-test probability that men in the community with raised plasma ferritin concentrations are hazardous drinkers.

BACKGROUND: Raised plasma ferritin concentrations occur unexpectedly during iron studies done by primary care physicians. Plasma ferritin concentration has been positively associated with alcohol use among men. AIM: To determine the post-test probability that men in the community with raised plasma ferritin concentrations are hazardous drinkers. METHODS: The subjects were 152 men, randomly selected from a city's electoral roll. Nineteen (12.5 (2.7)%, mean (SEM)) admitted to drinking hazardously. The pretest probability of a man being a hazardous drinker was 0.125. This was converted to pretest odds of 0.14. The likelihood ratio (the ratio of the probability of obtaining a raised plasma ferritin concentration in a hazardous drinker (sensitivity) to the probability of obtaining a raised plasma ferritin concentration in a non-hazardous drinker (1-specificity)) was calculated for different plasma ferritin cut off points. RESULTS: A plasma ferritin level of > 652 micrograms/l gave the largest likelihood ratio, 4.16. Post-test odds were obtained by multiplying the pretest odds (0.14) by the likelihood ratio (4.16). A plasma ferritin level of > 652 micrograms/l had a post-test odds for a man being a hazardous drinker of 0.58. This was converted to a post-test probability of 0.37. CONCLUSIONS: Inquiries could usefully be made into the alcohol consumption of men with a plasma ferritin concentration > 652 micrograms/l, as approximately one in three would admit to drinking hazardously.

Helicobacter pylori infection: an added stressor on iron status of women in the community.

OBJECTIVE: To explore a possible association between Helicobacter pylori infection and iron status. DESIGN: Cross-sectional study. SETTING: Ballarat (a major regional city in Victoria), population 78000, October November 1997. PARTICIPANTS: 160 women and 152 men, a subsample of participants in a cardiovascular disease risk factor prevalence survey for whom frozen plasma was available. MAIN OUTCOME MEASURES: H. pylori IgG antibody status by enzyme immunoassay; iron intake; plasma iron, transferrin and ferritin concentrations. RESULTS: 28% of women and 33% of men were infected with H. pylori. The mean (SEM) plasma ferritin concentration of infected women (59.3 [7.6] microg/L) was significantly lower than for non-infected women (88.8 [7.9] microg/L; P=0.002), after adjusting for age. Mean daily dietary iron intakes were similar in infected and non-infected women. CONCLUSIONS: H. pylori infection appears to be an additional stressor on women's iron status, but the mechanism remains to be determined.

Age-standardised mortality and proportional mortality analyses of aboriginal and non-aboriginal deaths in metropolitan, rural and remote areas.

The study's aim was to assess how much of the variation in disease-specific mortality between metropolitan, rural and remote areas is specific to those diseases or reflects the all-cause mortality pattern. The ranges and variances of disease-specific standardised proportional mortality ratios between geographical areas were compared to those of the corresponding standardised mortality ratios. For most chapters in the International Classification of Diseases, the ranges and variances of the standardised proportional mortality ratios were less than 40% of those of the corresponding standardised mortality ratios. Only a small proportion of the variation in mortality can therefore be attributed to a specific disease component; the remainder must be attributed to an underlying 'force of mortality'. Research, programs and policies addressing the socio-economic disadvantages of living in remote areas may lead to a greater improvement in mortality than those targeting specific diseases.

Death certification by doctors in non-metropolitan Victoria.

OBJECTIVE: To examine the completeness and accuracy of death certification by general practitioners, specialists and resident medical officers (RMOs) in non-metropolitan Victoria. DESIGN: An examination of the death certificates written by a representative sample of community and hospital doctors and comparison with the clinical history. SETTING: The Ballarat statistical district. RESULTS: Eighteen percent of the death certificates at initial assessment, were unsatisfactory (the percentage for those written by RMOs were significantly higher). After review of the clinical record, 27% of certificates were found to inaccurately represent the cause of death, (again the percentage for RMOs was higher) Eighteen percent of certificates required a change of code. CONCLUSION: Monitoring the health of the public relies in part on information gained from death certificates. It is thus of concern that such a high percentage of death certificates are inaccurate to the extent that they are incorrectly coded. Consideration should be given to new educational initiatives and to the promotion of the existing toll free telephone advice service to doctors.

Comparison of unsafe drinking between a rural and metropolitan area.

Factors associated with unsafe drinking in a rural area were identified and the prevalence of unsafe drinking and alcohol related mortality compared with a metropolitan area. Alcohol consumption data were collected from a random sample of adults in Greater Ballarat. Odds ratios of demographic factors associated with unsafe drinking were estimated by logistic regression. Compared with males and 20-29-year-olds, females and 30-59-year-olds had a significantly lower prevalence of 'intermediate' or higher risk drinking and binge-only drinking. Rural-metropolitan ratios for the prevalence of unsafe drinking and alcohol related mortality were also greatest in young adults. Young adults must adopt safer drinking habits if the rural excess in mortality is to be reduced.

Helicobacter pylori infection in an Australian regional city: prevalence and risk factors.

OBJECTIVE: To investigate the prevalence of Helicobacter pylori infection and potential risk factors for infection in an adult Australian population. DESIGN: Cross-sectional study. SETTING: Ballarat, a major regional city in Victoria (population, 78,000; 92% bom in Australia), November 1994 to July 1995. PARTICIPANTS: 217 adults randomly selected from the electoral roll. MAIN OUTCOME MEASURES: H. pylori IgG antibody status by enzyme immunoassay; amount of dental plaque; sociodemographic and other potential risk factors; odds ratios for risk factors determined by logistic regression analysis. RESULTS: Age-standardised prevalence of H. pylori infection was 30.6%. After adjustment for age, sex and socioeconomic index, positive H. pylori status was significantly associated with increasing number of tooth surfaces with a high plaque score (odds ratio [OR], 1.7; 95% confidence interval [CI], 1.1-2.7), increasing number of years in a job with public contact (OR, 1.7; 95% CI, 1.3-2.3), blood group B antigen (OR, 3.1; 95% CI, 1.1-9.1), and having lived in a household with more than six members during childhood (OR, 2.5; 95% CI, 1.1-5.5). Negative H. pylori status was significantly associated with increasing education, having ever lived on a farm, and having teeth scaled less than once a year. CONCLUSIONS: H. pylori infection is common. Dental plaque may be a reservoir for H. pylori, which is probably transmitted by person-to-person contact, and blood group B antigen may predispose to infection. Community education about effective oral hygiene and adoption of good hygiene practices by those with regular public contact may be important to prevent acquisition and transmission of H. pylori.

Predictive value of MCV for hazardous drinking in the community.

A recent study suggested that general practitioners (GPs) do not see the necessity of investigating MCVs which unexpectedly and only slightly exceed the reference limit, despite the association between MCV and alcohol abuse. Because a literature search could not find a study of the predictive value of the MCV for hazardous drinking in the community, such a study was undertaken among a random sample of 338 adults living in a regional Australian city. Twenty-nine of the adults admitted drinking hazardously. The MCV with the optimum sensitivity and specificity for identifying the hazardous drinkers was determined. An MCV of > 94 fl identified as many as 35% of the hazardous drinkers whilst misclassifying only 6% of the non-hazardous drinkers. The predictive value was even greater among males, 67%. We conclude that inquiring into MCVs > 94 fl will lead to GPs identifying a significant proportion of adults in the community admitting to hazardous drinking.

Helicobacter pylori antibody titres in serum, plasma and successively thawed specimens: implications for epidemiological and clinical studies.

Agreement between Helicobacter pylori IgG antibodies measured using the Pylori-set EIA-G kit in serum, plasma and successively thawed specimens was studied and the implications for epidemiological and clinical studies assessed. Plasma titres may differ from serum titres by -6% to +8% and therefore may be substituted for serum. The change in titre around the cut off value was -0.31 (se = 5.7, p = 0.96) per thaw. The estimated maximum drop after three thawings, 34.5, would result in only a small decrease in sensitivity (1.3%). For qualitative epidemiological studies, this additional misclassification rate is relatively small. However, positive titres did reduce over successive thawings, with the estimated maximum drop being 11.4% per thaw. Therefore, thawing does need to be considered as a contributing factor when interpreting titre drops in eradication trials. Baseline and follow up specimens from clinical studies should be thawed once only and tested concurrently.