Rodentolepis straminea (Cestoda: Hymenolepididae) in an urban population of Apodemus sylvaticus in the UK.

The presence of the cyclophyllidean cestode Rodentolepis straminea (Cestoda: Hymenolepididae), was confirmed by molecular DNA analysis from a wood mouse (Apodemus sylvaticus) population inhabiting urban woodland in Salford, Greater Manchester (UK) with a prevalence of 27.8%. It would appear that the only previously published record of this species in A. sylvaticus in the British Isles is that from south-west Ireland, where 24% of the wood mice examined were infected with R. straminea. This species has been recorded in studies on A. sylvaticus in continental Europe. The current report represents a new record for R. straminea on mainland Britain and a first study of helminth parasites in an urban wood mouse population.

Modern Hydrocortisone Replacement Regimens in Adrenal Insufficiency Patients and the Risk of Adrenal Crisis.

The aim of this study was to examine the incidence of adrenal crises (AC) and the prescription of short-acting glucocorticoids (GC) in different geographic areas. To do this we conducted a descriptive study of AC hospitalisations and prescriptions for two GCs (hydrocortisone (HC) and cortisone acetate (CA)), and fludrocortisone acetate (FA), in different geographic areas of Australia between 1999/2000 and 2011/2012, using government databases.There were 2,584 hospital admissions for AC in Australia between 1999/00 and 2011/12 and the corresponding admission rates increased significantly from 7.4 to 11.1/10(6)/year (p<0.001). AC admission rates increased in 5 out of 6 geographic areas. Prescription rates for the combined GCs (HC/CA) increased at an annual rate of between 0.2-2.0% in all areas. All areas had significant (p<0.01) increases in HC prescription rates (4.5% to 13.7% annually) and CA prescription rates decreased in 5 out of the 6 regions (3.5% annual decrease to a 0.5% annual increase). When the geographic areas were combined, there was a significant correlation between the AC admission rates and HC/CA prescription rates (r=0.30, p<0.01). Admissions for AC and GC prescriptions increased significantly in Australia after 1999 and these varied significantly by geographic area. These results suggest that modern recommendations for lower dose, short-acting GC replacement may be of concern and further investigation is warranted.

Adrenal Insufficiency in Australia: Is it Possible that the Use of Lower Dose, Short-Acting Glucocorticoids has Increased the Risk of Adrenal Crises?

Morbidity from adrenal insufficiency (AI) in Australia is poorly described. The objective of this study was to evaluate AI morbidity patterns in adults between 1999/2000 and 2011/2012 using national databases. A descriptive study of hospitalisations for AI and adrenal crises (AC) in adults and trends in prescriptions for 2 short-acting glucocorticoids (GC) was designed. The setting was the Australian healthcare system. Main outcome measures are the trends in hospitalisation and prescription rates. There were 7,378 hospital admissions for treatment of AI in adults between 1999/00 and 2011/12. Of these, 29.5% were for an AC. Admission rates for AC increased from 9.5 to 12.4 admissions/10(6)/year (p < 0.05). There was a 5.8% decrease in admission rates for AI (excluding AC), from 27.0 to 25.5/10(6)/year (p = ns). Short-acting GC [hydrocortisone (HCT) and cortisone acetate (CA)] prescription rates increased significantly (p < 0.001) from 3,176.1/10(6) to 3,463.8/10(6). Prescription rates for CA decreased by 22.4% (p < 0.001) but HCT prescription rates increased to 77.1% (p < 0.001). The increase in AC admission rates was positively correlated with the rise in both the total GC prescription rate (r = 0.63, p < 0.05) and the HCT prescription rate (r = 0.74, p< 0.01). Over the 13-year study period, there was a 30.8% increase in hospitalisation rates for ACs and a concomitant 77.1% increase in prescribing of HCT. The association between AC events and HCT use and/or reduced effective GC dose is plausibly causal, but confirmatory studies are required before suggesting any change to GC replacement in AI.

Incidence of pulmonary embolism: a comparison of two Australian hospitals.

In this retrospective observational study, we noted that there were significantly more admissions at the public than the private hospital due to both a principal (1.87 vs 0.83 per 1000, P < 0.001) and secondary diagnosis of pulmonary embolism (PE) (3.10 vs 2.01 per 1000, P = 0.002), with no difference in mortality. There was a highly significant increase in secondary PE diagnoses at the private hospital (R(2) = 0.68, ß = 0.14, P = 0.003) over the study period. Despite disparate rates of PE between the two hospitals, there was no difference in mortality, suggesting there may be an element of overdiagnosis.

Incidence of deep venous thrombosis: a comparison of two Australian hospitals.

In this retrospective observational study, we observed that principal and comorbid diagnoses of deep venous thrombosis (DVT) occurred at a rate of 1.02 and 4.86 per 1000 admissions. Principal DVT diagnosis admissions were more common in the public hospital (1.29 vs 0.57 per 1000; P < 0.001), while the private hospital had nearly three times the admissions with comorbid DVT (2.99 vs 8.23 per 1000; P < 0.001). In-hospital mortality was uncommon (0.2% and 1.6% for principal and comorbid DVT diagnoses, respectively), and this did not differ significantly between the two hospitals.

Increased rates of ENT surgery among young children: have clinical guidelines made a difference?

OBJECTIVES: To examine the association between introduction of paediatric ear, nose and throat (ENT) surgery guidelines and population procedure rates. To determine changes in children's risk of undergoing ENT surgery. METHODS: Trend analysis of incidence of myringotomy, tonsillectomy and adenoidectomy among New South Wales (NSW) children aged 0-14 between 1981 and mid 1999. Poisson regression models were used to estimate annual rates of change pre and postguidelines introduction and age/gender specific rates, and lifetable methods to determine risk of undergoing an ENT procedure by age 15. RESULTS: ENT surgery rates increased by 21% over the study period. Children's risk of surgery increased from 17.9% in 1981 to 20.2% in 1998/99. Guideline introduction was associated with moderate short-term decreases in rates. For tonsillectomy, rates decreased between 1981 and 1983, but then rose continually until the introduction of myringotomy guidelines in 1993, when they fell, only to recommence rising until the end of the study period. For myringotomy, rates rose annually from 1981 to 1992/93 and fell in the 3 years following guideline introduction, after which they rose again. Increases were almost exclusively restricted to children aged 0-4 and correspond with increased use of formal childcare. The prevalence of myringotomy by the age of 5 years rose from 5.6% of children born in 1988/89 to 6.4% of those born in 1994/95, and the prevalence of tonsillectomy from 2.4% to 2.7%. CONCLUSIONS: The risk of young Australian children undergoing ENT surgery increased significantly over the last two decades despite the introduction of guidelines and no evidence of an increase in otitis media, one condition prompting surgery. Surgery increased most among the very young. We hypothesize this is related to increasing use of childcare.

Where the data are deficient: a field evaluation of the effectiveness of pneumococcal vaccination in remote Australia.

The aims of the study were to: (i) determine whether a field evaluation of a pneumococcal vaccination program conducted in 1991-1993 could show whether the program was effective; and (ii) to describe the epidemiology of invasive pneumococcal disease using laboratory surveillance data. As part of quality assurance, we undertook a retrospective cohort study to compare the hospitalisation and mortality rates of a pneumococcal-vaccine-vaccinated and an unvaccinated group and a correlational study to compare the before- and after-vaccination hospitalisation rates for the vaccinated and unvaccinated groups. We used laboratory data to describe the epidemiology of invasive pneumococcal disease. The cohort study consisted of 815 subjects (306 vaccinated, 509 comparison). No significant differences were observed in the admission rates for pneumonia and lower respiratory tract infection between the two groups. By using a correlational study, we examined before- and after-vaccination hospitalisation rates and this also failed to reveal any differences, except for persons aged 50 years and older. Laboratory surveillance of invasive disease demonstrated that children younger than 6 years and adults younger than 50 years with alcohol-related problems accounted for most of the cases. Despite the study's limitations, it supports the use of pneumococcal vaccine in persons aged older than 50 years, while at the same time highlighting the ongoing need for better vaccines, especially for children and those aged younger than 50 years with medical conditions predisposing to pneumococcal disease.

Foot orthosis prescription habits of Australian and New Zealand podiatric physicians.

This research project investigated the orthotic prescription habits of podiatric physicians in Australia and New Zealand. A 23-item questionnaire was distributed to all members of the Australian Podiatry Association and the New Zealand Society of Podiatrists. When asked what type of foot orthoses they prescribe most often, 72% of respondents reported functional foot orthoses; the next most common response was prefabricated orthoses (12%). A typical prescription for functional foot orthoses consisted of a modified Root style orthosis, balanced to the neutral calcaneal stance position, with the shell made from polypropylene and an ethyl vinyl acetate (EVA) rearfoot post applied. The majority of podiatric physicians surveyed used a commercial orthotic laboratory to fabricate their orthoses. However, New Zealand respondents were three times more likely to prescribe prefabricated foot orthoses, and males were twice as likely as females to manufacture the orthoses themselves rather than use a commercial orthotic laboratory.

The impact of new technology on cholecystectomy rates in New South Wales.

This study examined the impact of the introduction of laparoscopic cholecystectomy (LC) on the rate and pattern of cholecystectomy in New South Wales, Australia. An analysis of the hospital data for the period 1981-94/95 was performed, which encompassed patients of both public and private hospitals. Cholecystectomy rates in the years after the introduction of LC in mid-1990 were 24% higher on average than rates in the prior years and rose from an average 1.68-2.09 per 1000. In the 5-year period of the study after the introduction of LC, the average age of private hospital patients increased from 50.6 to 53.4 years, while that of public hospital patients declined slightly from 53.5 to 52.4 years. Laparoscopic cholecystectomy was introduced more rapidly in private than public hospitals. By June 1995, 96% of private compared with 71% of public hospitals had introduced LC, and cholecystectomy patients in private hospitals were more likely to have laparoscopic surgery than patients in public hospitals (92% compared with 80%). The introduction of LC has been accompanied by a marked and sustained increase in the cholecystectomy rate. While the unit cost for the laparoscopic procedure is lower because of a shorter length of stay, the increase in the number of procedures means that there have been no net savings for the health system from the increased efficiency. While the new procedure offers superior advantages to patients with symptomatic gallbladder disease, the effect of the apparent lower threshold for surgery needs investigation.

"Death by proxy": ethics and classification in epidemiology.

Epidemiology is reductionist in that it usually relies on creating categories of people or risk factors. Classification must be undertaken as part of any study, however by the act of choosing groups, individuals are (potentially) consigned to either a higher or lower risk group. We discuss this from an ethical perspective and consider: (a) whether the groupings commonly chosen genuinely represent the risk factor of interest, (b) the implications for individuals when consigned to groups and (c) the implications for epidemiology.

Agreement between medical record data and patients' accounts of their medical history and treatment for dyspepsia.

We examined agreement between data abstracted from medical records and interview data for patients with dyspepsia admitted to hospital for endoscopy, to determine the extent to which health records could be used to validate self-reports of dyspepsia and the management of this condition. Results from the sample of 220 patients showed that there was poor agreement between data sources for information about duration of dyspepsia (k=0.34) and previous barium meal examination (k=0.34). Patients reported significantly longer dyspepsia histories (Wilcoxon sign test Z=4.13, p<0.0001) and significantly more barium meals (sign test Z=8.43, p<0.0001) than were documented in their records. There was also disagreement between data sources regarding the number of drugs taken before and after endoscopy (k=0.28 and k=0.31, respectively). Where there was disagreement for number of drugs there was no significant difference in the direction of the disagreement. There was moderate agreement regarding the name of pre-endoscopy medication (k=0.55) and substantial agreement for the name of medication used post-endoscopy (k=0.62). There was very poor agreement regarding diagnosis. The medical record was the gold standard for this information. Choice of data source, medical records or self-reports, will in many instances provide significantly different results and it is likely that this may also be true for other variables of interest to researchers. Thus in the case where no gold standards are available researchers need to consider carefully the implication of choice of data source on their results.

Hysterectomy fractions in New South Wales, 1971-2006.

Hysterectomy fractions by age group for particular periods are of interest for: estimating proper population denominators for calculation of disease and procedure rates affecting the cervix and uterus; estimating the target population for Pap test programs, and response rates; and as a way of displaying the cumulative consequences of hysterectomies in a population. Hysterectomy fractions for populations can be determined by direct inquiry via a representative sample survey, or, as in this study, from prior hysterectomy rates of the cohorts of women which compose each age bracket. Hysterectomy data 1979-93 were obtained from the hospital In-patients Statistics Collection (ISC) which covers both public and private hospitals in NSW. Annual population denominators of women were obtained from Census data. Data were modelled by Poisson regression, using five-year age group (15- > or = 85 years), annual period, and five-year birth cohort (APC model). Forward- and back-projection of the period effects were undertaken. The resultant NSW hysterectomy fractions by age and period are consistent with fractions obtained from modelled hysterectomy rates for Western Australia (1980-84), and fractions from national representative sample surveys (1989/90 and 1995) for younger women, but not for women aged > or = 70 years in 1995, which revealed higher hysterectomy fractions than modelled hysterectomy data would suggest. Hysterectomy fractions for NSW women by five-year age group for quinquennia centred on 1971 to 2006 are provided.

Health outcomes and infectious disease control.

With the development of improved health systems, antibiotics and vaccines throughout the 20th century, the prospects of control of infectious diseases improved. During the same time-frame, an approach to disease control was developed which used the health outcomes resulting from various interventions to choose, guide and modify those interventions. Despite these major advances in the control of diseases, infectious diseases have (with occasional exceptions) not only continued to occur but in many instances the situation had deteriorated with the emergence and re-emergence in recent years of a range of infectious diseases. In this paper we consider why infectious disease control has not benefited from the move towards a health outcomes approach, why infectious disease control might benefit from such a move, and the differences between infectious and non-infectious diseases when considering health outcomes. We follow-up with some practical approaches to the use of health outcomes. We argue that appropriate use of health outcomes when planning and evaluating infectious disease control programs will improve human health.

Readmissions to hospital: the contribution of morbidity data to the evaluation of asthma management.

We evaluated hospital readmission as an indicator of the quality of management of asthma patients, between July 1989 and June 1990. Using hospital separation data, we constructed a matched data set to identify early (within two weeks of discharge) readmissions. Of over 14,000 admissions for asthma in the 1-to-44-year age group, 2.8 per cent were classified as early readmissions. Admissions and readmissions were more common in rural than metropolitan areas. Admissions were most common during autumn, but early readmissions occurred most often during spring. Patients staying more than one day were 0.5 times (95 per cent confidence interval (CI) 0.37 to 0.68) as likely to have an early readmission than patients staying less than one day. Using the same data set, we identified patients who had the potential for readmission within a six-month period. Of the 5052 patients, 17.8 per cent were readmitted at least once during the period; 3.7 per cent had at least one early readmission, and 15.8 per cent had at least one late readmission (more than two weeks following discharge). A length of stay of more than one day was associated with 0.41 times (CI 0.24 to 0.70) the risk of early readmission in this cohort. A length of stay of more than one day was associated with a higher risk of late readmission (1.52, CI 1.09 to 2.12), which was less likely to occur in rural than metropolitan areas (0.45, CI 0.37 to 0.55).(ABSTRACT TRUNCATED AT 250 WORDS)

Paediatric appendicectomy in NSW: changes in practice over time and between groups.

The present study examined patterns of appendicectomy among 0- to 14-year-old children in New South Wales between 1986 and 1989/90. The study, which used routinely collected hospital separation data, showed that the overall rate of appendicectomy in this age group in 1989/90 was 2.5 per 1000 which was a significant (P < 0.01) reduction on the 1986 rate. The rate of appendicectomy with histologically confirmed appendicitis was 1.8 per 1000 in 1989/90 which was significantly (P < 0.01) lower than the corresponding rate for 1986. The proportions of appendicectomies with perforation (10% in 1989/90) and without acute appendicitis ('negative' appendicectomy; 28% in 1989/90) were comparable to previous Australian and overseas reports and changed little during the study period. Differences in the rates of appendicectomy and of perforated appendices were found between geographic areas. However, the area-specific rates of perforation were not systematically associated with the corresponding rates of negative appendicectomy. The proportion of negative appendicectomies was higher among female than male children (35% of females compared with 25% of males in 1989/90). The youngest age group (0-4 years) had the highest proportion of perforations: 27% compared with 13% in the 5-9 year and 8% in the 10-14 year age groups. We conclude that appendicectomy is now performed less frequently in NSW than in previous years. Surgical practice in relation to appendicectomy in NSW provides outcomes that compare favourably with previous Australian and overseas experience. Although the proportion of perforations is relatively low, the comparatively high proportion of perforations in the youngest age group is of concern.(ABSTRACT TRUNCATED AT 250 WORDS)