A prospective multicentre study of barriers to discharge from inpatient rehabilitation.

OBJECTIVES: To assess the prevalence of and reasons for barriers to discharge from inpatient rehabilitation, to measure the resulting additional days in hospital, and to determine if these were predicted by key demographic or clinical variables. DESIGN, SETTING AND PARTICIPANTS: Prospective open cohort study of 360 patients admitted into two inpatient rehabilitation units in Melbourne over an 8-02 and a 10-02 period in 2008. MAIN OUTCOME MEASURES: Occurrence of discharge barriers, their causes and the duration of unnecessary hospitalisation. RESULTS: There were 360 patients in the study sample, 186 were female (51.7%), and mean age was 58.4 years. Fifty-nine (16.4%) patients had a discharge barrier. The most frequent causes of discharge barriers were patients being non-weight bearing after lower limb fracture, family deliberations about discharge planning, waiting for home modifications and waiting for accommodation. Patients with acquired brain damage and lower limb fracture were the impairment groups most likely to experience a discharge barrier. Over the study period, 21.0% (3152/14 976) of all bed-days were occupied by patients deemed to have a discharge barrier. Regression analysis showed that age, sex, impairment group and dependency level on admission all influenced the occurrence of a discharge barrier. Although regression analysis showed that dependency on admission and age group were significant predictors of additional days in hospital resulting from discharge barriers (P = 0.006), these variables explained only 11% of the additional bed-days. CONCLUSION: Barriers to discharge from inpatient rehabilitation are common and substantial, and they represent an important opportunity for improvement.

Monash transient ischemic attack triaging treatment: safety of a transient ischemic attack mechanism-based outpatient model of care.

BACKGROUND AND PURPOSE: Controversy surrounds the need for routine hospital admission for transient ischemic attack. The Monash Transient Ischemic Attack Triaging Treatment (M3T) model adopts rapid management in the emergency department followed by outpatient management prioritized by stroke mechanism. We compared safety and processes of care between M3T and the previous model of routine admission. METHODS: Study cohorts consisted of patients managed with M3T (2004-2007) and the previous model (2003-2004). We determined 90-day stroke outcome using clinical and medical record review and data linkage to the population level state-wide hospital discharge morbidity database. We compared models of care using risk difference analysis, followed by logistic regression to adjust for previous indicators of risk. Secondary outcomes were proportions admitted, proportions undergoing carotid ultrasound, times to ultrasound and revascularization, and medication prescription. RESULTS: In M3T (mean age, 64.7±14.7) 85/488 (17.4%) patients were admitted compared with 117/169 (62.9%) in the previous model (mean age, 72.5±13.9). With near-complete follow-up, 90-day stroke outcome was 1.50% (95% confidence interval, 0.73%-3.05%) in M3T and 4.67% (95% confidence interval, 2.28%-9.32%) in the previous model (P=0.03). Compared with the previous model, the adjusted odds ratio of stroke for M3T was 0.46 (95% confidence interval, 0.12-1.68; P=0.24). M3T was associated with greater proportions undergoing carotid ultrasound (P<0.001) and receiving antiplatelet therapy (P=0.005). CONCLUSIONS: The M3T system was associated with low 90-day stroke outcome in transient ischemic attack patients, providing proof of concept that these patients may be managed safely without routine hospital admission using a closely supervised protocol in the emergency department.

Which patients have missing data? An analysis of missingness in a trauma registry.

BACKGROUND: Trauma registry data are almost always incomplete. Multiple imputation can reduce bias in registry analyses but the ideal approach would be to improve data capture. The aim of this study was to identify, using multiple imputation, which type of patients were most likely to have incomplete data. METHODS: An analysis of prospectively collected regional trauma registry data over one year was performed. Analyses were conducted following complete data estimation using multiple imputation. Variables necessary for TRISS analysis and with incomplete data were analysed. For each variable, logistic regression analyses were performed to identify predictors of missingness. A p-value of less than 0.05 was considered to be statistically significant. RESULTS: There were 2520 cases. The variables with the greatest proportion of missing observations were respiratory rate, GCS, Qualifier (of GCS and respiratory rate) and systolic blood pressure. The Qualifier variable described whether or not the patient was intubated and mechanically ventilated at the time the first hospital GCS and respiratory rate were recorded. GCS and respiratory rate were more likely to be missing (imputed) when abnormal (unadjusted ORs: 8.6 (p<0.001) and 2.1 (p=0.02), respectively). The most important determinant of a valid GCS or respiratory rate was the Qualifier. There was no association between whether the systolic blood pressure and Qualifier were missing (imputed) and whether they were estimated to be abnormal. Following multivariable analysis, data for all four variables were more likely to be missing when the patient died in hospital. Additional independent predictors of a missing GCS or respiratory rate were an abnormal pre-hospital GCS and severe chest injury. The Qualifier and systolic blood pressure were more likely to be missing where the patient was transferred from the primary hospital. CONCLUSION: The major independent predictor of missing primary hospital physiological variables was death in hospital. An abnormal GCS was more likely to be missing from the regional trauma registry dataset. Predictors of a missing GCS or respiratory rate included whether the patient was intubated, an abnormal pre-hospital GCS and severe chest injury. Augmenting resources to record the initial observations of the more severely injured patients would improve data quality. Multiple imputation can be used to inform data capture.

Performance of the ABCD2 score for stroke risk post TIA: meta-analysis and probability modeling.

OBJECTIVE: To study the accuracy of the ABCD2 score in predicting early stroke risk following TIA and to model post-test probability of stroke for varying cutoff scores and baseline stroke risk. METHODS: Medline, PubMed, Embase, conference proceedings, and manuscript references up to October 2010 were searched for studies reporting ABCD2 score and stroke outcome after TIA. Additional data were requested from authors. Meta-analysis, meta-regression, and post-test probability modeling were undertaken to assess prediction of stroke at 2, 7, and 90 days. RESULTS: Of 44 eligible studies, data were available for 33 (16,070 patients): 26/33 reported stroke at 2 days (533 strokes), 32/33 at 7 days (781 strokes), and 28/33 at 90 days (1,028 strokes) after TIA. Using scores 0-3 ("low risk") and 4-7 ("high risk") for stroke at 7 days, pooled measures were sensitivity 0.89 (0.87-0.91), specificity 0.34 (0.33-0.35), positive predictive value 0.08 (0.07-0.09), negative predictive value 0.98 (0.98-0.98), positive likelihood ratio (PLR) 1.43 (1.33-1.54), negative likelihood ratio (NLR) 0.40 (0.33-0.50), and area under the curve (AUC) 0.70 (0.62-0.78). Results were similar at days 2 and 90. There was moderate heterogeneity while pooling PLR (p < 0.01, I(2) >50%), with stroke specialist TIA diagnosis associated with slightly higher PLR. At 5% baseline stroke risk, ABCD2 >3 indicated an absolute increase in 7-day stroke risk of only 2.0% while a score ≤3 indicated a 2.9% decrease in risk. Changes in risk were very small when baseline stroke risk was lower. CONCLUSIONS: The ABCD2 score leads to only small revisions of baseline stroke risk particularly in settings of very low baseline risk and when used by nonspecialists.

Demand at the emergency department front door: 10-year trends in presentations.

OBJECTIVES: To measure the increase in volume and age-specific rates of presentations to public hospital emergency departments (EDs), as well as any changes in ED length of stay (LOS); and to describe trends in ED utilisation. DESIGN, PATIENTS AND SETTING: Population-based retrospective analysis of Department of Health public hospital ED data for metropolitan Melbourne for 1999-00 to 2008-09. MAIN OUTCOME MEASURES: Presentation numbers; presentation rates per 1000 person-years; ED LOS. RESULTS: ED presentations increased from 550,662 in 1999-00 to 853,940 in 2008-09. This corresponded to a 32% rise in rate of presentation (95% CI, 29%-35%), an average annual increase of 3.6% (95% CI, 3.4%-3.8%) after adjustment for population changes. Almost 40% of all patients remained in the ED for ≥4 hours in 2008-09, with LOS increasing over time for patients who were more acutely unwell. The likelihood of presentation rose with increasing age, with people aged≥85 years being 3.9 times as likely to present as those aged 35-59 years (95% CI, 3.8-4.0). The volume of older people presenting more than doubled over the decade. They were more likely to arrive by emergency ambulance and were more acutely unwell than 35-59 year olds, with 75% having an LOS≥4 hours and 61% requiring admission in 2008-09. CONCLUSION: The rise in presentation numbers and presentation rates per 1000 person-years over 10 years was beyond that expected from demographic changes. Current models of emergency and primary care are failing to meet community needs at times of acute illness. Given these trends, the proposed 4-hour targets in 2012 may be unachievable unless there is significant redesign of the whole system.

"Death in low-mortality diagnosis-related groups": frequency, and the impact of patient and hospital characteristics.

OBJECTIVE: To examine the frequency of deaths in low-mortality diagnosis-related groups (LM-DRGs) and the patient and hospital characteristics associated with them. DESIGN, SETTING AND PATIENTS: Retrospective cohort study of 2,400,089 discharge episodes for adults (> 18 years) from 122 Victorian public hospitals from 1 July 2006 to 30 June 2008. MAIN OUTCOME MEASURES: Frequency of episodes of death in LM-DRGs (defined as DRGs with mortality < 0.5% over the previous 3 years or < 0.5% in any of the previous 3 years); associations between characteristics of patients and hospitals with deaths in LM-DRGs. RESULTS: There were 1,008, 816 LM-DRG episodes with 0-15 LM-DRG deaths per hospital in the 2006-07 financial year and 0-20 deaths per hospital in the 2007-08 financial year. Increased age, level of comorbidity, being male, admission from a residential aged care facility, interhospital transfer, emergency admission and lower hospital volume were associated with an increased risk of death in LM-DRG episodes in both years. Metropolitan location and teaching/major provider status were not associated with LM-DRG deaths (P > 0.10). More than 40% of LM-DRG deaths were among patients aged 83 years or over, who had a length of stay of less than 1 day and had a medical DRG classification. Standardised mortality ratios (SMRs) that adjusted for the patient and hospital characteristics identified nine outlier hospitals with high frequencies of deaths in LM-DRGs in the 2006-07 and six in the 2007-08 financial year compared with 59 hospitals flagged by the death-in-LM-DRG indicator. CONCLUSIONS: The use of the LM-DRG indicator requires further investigation to test its validity. LM-DRG deaths are infrequent, making it difficult to identify temporal changes and outlier hospitals. Patient characteristics unrelated to quality of care increase the likelihood of death among LM-DRG patients. The SMR analysis showed that failure to adjust for these characteristics may result in unfair and inaccurate identification of outlier hospitals. The increased risk of death associated with interhospital transfer patients and low-volume hospitals requires further investigation.

The challenges of population ageing: accelerating demand for emergency ambulance services by older patients, 1995-2015.

OBJECTIVE: To measure the growth in emergency ambulance use across metropolitan Melbourne since 1995, to measure the impact of population growth and ageing on these services, and to forecast demand for these services in 2015. DESIGN AND SETTING: A population-based retrospective analysis of Ambulance Victoria's metropolitan emergency ambulance transportation data for the period from financial year 1994-95 to 2007-08, and modelling of demand in the financial year 2014-15. MAIN OUTCOME MEASURES: Numbers and rates of emergency ambulance transportations. RESULTS: The crude annual rate of emergency transportations across all age groups increased from 32 per 1000 people in 1994-95 to 58 per 1000 people in 2007-08. The rate of transportation for all ages increased by 75% (95% CI, 62%-89%) over the 14-year study period, representing an average annual growth rate of 4.8% (95% CI, 4.3%-5.3%) beyond that explained by demographic changes. Patients aged ≥ 85 years were eight times (incident rate ratio, 7.9 [95% CI, 7.6-8.3]) as likely to be transported than those aged 45-69 years over this period. Forecast models suggest that the number of transportations will increase by 46%-69% between 2007-08 and 2014-15, disproportionately driven by increasing usage by patients aged ≥ 85 years. CONCLUSIONS: These findings confirm a dramatic rise in emergency transportations over the study period, beyond that expected from demographic changes. Rates increased across all age groups, but more so in older patients. In the future, such acceleration is likely to have major effects on ambulance services and acute hospital capacity. This calls for further investigation of underlying causes and alternative models of care.

[Australian Medical Sheepskin for prevention of pressure ulcers: individual patient data meta-analysis shows effectiveness]. / 'Australische medische schapenvacht' ter preventie van decubitus: meta-analyse met individuele patiëntendata toont effectiviteit.

OBJECTIVE: To assess the effectiveness of the Australian Medical Sheepskin (AMS) on the prevention of sacral pressure ulcers based on combined data from 3 previously published trials. DESIGN: Meta-analysis of randomised clinical trials (RCTs). METHOD: The effectiveness of these specially treated sheepskins from the Merino sheep was studied in three RCT's (2 involving Australian hospital patients and 1 involving Dutch nursing-home patients). In all 3 trials patients were randomized to 1 of 2 groups: a control group, who received standard care, and an intervention group, who, in addition to standard care, had at least one AMS placed under the sacral area when in bed. The total research population consisted of 1,281 patients from 11 institutions with 45 nursing wards. Data from the 3 RCT's were pooled and analysed: (a) with conventional meta-analysis based on the published effect sizes and (b) with multilevel logistic regression analysis based on the combined individual patient data for each trial separately and for the combined dataset. The primary outcome measure was the incidence of sacral pressure ulcers. RESULTS: The incidence of sacral pressure ulcers was 12.2% in the control group versus 5.4% in the intervention group. The odds-ratio was 0.37 (95% CI: 0.17-0.77) with conventional meta-analysis, and 0.35 (95% CI: 0.23-0.55) with multilevel logistic regression analysis on the combined individual patient data. CONCLUSION: Both analysis methods confirm that the AMS is effective in preventing sacral pressure ulcers. The confidence interval in the multilevel logistic regression analysis on individual patient data was almost 50% smaller than in the conventional meta-analysis, and gave a more reliable picture of the actual effect.

Identifying and improving unreliable items in registries through data auditing.

OBJECTIVE: Assessing the reliability of clinical registries is important for ensuring the availability of credible data. Therefore, this study aimed to investigate the reliability of data collected by the Australian and New Zealand Haemostasis Registry (the registry). DESIGN: Data from 5% of randomly selected registry cases were re-abstracted by an independent data auditor who was blinded to the results of the original data abstraction. Categorical data were investigated for agreement between original and re-abstracted data. The mean difference and standard deviations (SD) of differences were calculated for continuous variables. We estimated a 'prediction interval' as the mean difference ± twice the SD of differences. We computed a coefficient of variation as the SD of differences. SETTING: The registry records all cases of off-licence use of recombinant activated factor VII (rFVIIa) at participating institutions (on-licence use of rFVIIa is not recorded). RESULTS: Data on 76 registry cases (6% of registry) were re-abstracted. Various parameters demonstrated high levels of inter-rater reliability, including age, gender and intensive care unit admission (88, 99 and 99% agreement, respectively). Other variables were highly unreliable, including crystalloid infusion volumes (coefficient of variation 123.01%), red blood cell units (92.05%) and time from bleeding onset to administration of rFVIIa (153.06%). CONCLUSIONS: Registry audits are useful for identifying variables with poor reliability. Repeated audits will not improve data reliability; however, they can assist in identifying and evaluating the impact of modified data collection processes on improving data reliability.

A multilevel analysis of three randomised controlled trials of the Australian Medical Sheepskin in the prevention of sacral pressure ulcers.

OBJECTIVE: To assess the effectiveness of the Australian Medical Sheepskin in preventing sacral pressure ulcers (PUs), based on combined data from existing published trials. DESIGN AND SETTING: Data from two randomised controlled trials (RCTs) among Australian hospital patients and one RCT among Dutch nursing home patients were pooled, comprising a total population of 1281 patients from 45 nursing wards in 11 institutions. These data were analysed in two ways: with conventional meta-analysis based on the published effect sizes; and with multilevel binary logistic regression based on the combined individual patient data. In the multilevel analysis, patient, nursing ward and institution were used as levels and we controlled for sex, age, PU risk and number of days of observation. MAIN OUTCOME MEASURE: Incidence of sacral PUs. RESULTS: Overall, the incidence of sacral PUs was 12.2% in the control group versus 5.4% in the intervention group with an Australian Medical Sheepskin. Conventional meta-analysis showed significantly reduced odds of developing a PU while using the sheepskin (odds ratio [OR], 0.37 [95% CI, 0.17-0.77]). Multilevel analysis gave an OR of 0.35 and narrowed the confidence interval by almost 50% (95% CI, 0.23-0.55). CONCLUSIONS: These analyses of pooled data confirm that the Australian Medical Sheepskin is effective in preventing sacral PUs. Multilevel analysis of individual patient data gives a more precise effect estimate than conventional meta-analysis.

Missing in action: a case study of the application of methods for dealing with missing data to trauma system benchmarking.

BACKGROUND: Trauma registry data are usually incomplete. Various methods for dealing with missing data have been used, some of which lead to biased results. One method that reduces bias, multiple imputation (MI), has not been widely adopted. There is no standardization of the approach to missing data across trauma registries. OBJECTIVES: This study examined the effect of using selected methods for handling missing data on a recognized trauma outcome measure. METHODS: Data from the Victorian State Trauma Registry (VSTR) were used for the period July 2003 to June 2008. Three methods for handling missing data were investigated: complete case analysis, single imputation, and MI. The latter was applied using five distinct models, each with a different combination of variables (Trauma and Injury Severity score [TRISS] variables; prehospital Glasgow Coma Scale [GCS], respiratory rate, and systolic blood pressure; arrival by ambulance; transfer to a second hospital; and whether the GCS was "legitimate" according to the TRISS definition). For each method, TRISS analysis (comparing actual and expected deaths) was performed; the W-score and Z-statistic were derived. A Z-statistic greater than 1.96 in absolute value was considered statistically significant. RESULTS: Of 10,180 cases, 2,398 (24%) were missing at least one of the component variables necessary for TRISS analysis. With the use of complete case analysis, the W-score was 0.54 unexpected survivors for every 100 cases, with a Z-statistic of -1.96. Using two approaches to single imputation, the W-scores were -1.41, with Z-statistics of -5.19 and -5.30. Applying four of the five combinations of variables used for MI, there was a statistically significant number of unexpected survivors (W = -0.60, Z = -2.23; W = -0.52, Z = -1.97; W = -0.53, Z = -1.97; W = -0.63, Z = -2.24). However, using MI confined to TRISS variables only, there was a statistically significant number of unexpected deaths (W = +0.52, Z = +1.98). CONCLUSIONS: Missing data methods can influence the assessment of trauma care performance and need to be reported in all analyses. It is important that validated standardized approaches to dealing with missing data are universally adopted and reported.

Assessment of the urgency and deferability of transfusion to inform emergency blood planning and triage: the Bloodhound prospective audit of red blood cell use.

BACKGROUND: Careful planning is essential to ensure blood availability during shortages. Triaging supply is one proposed strategy; however, few data concerning the urgency of transfusion are available to inform planning. This study sought to determine the proportion of red blood cells (RBCs) used for clinically urgent indications. STUDY DESIGN AND METHODS: A total of 5132 RBC units were randomly selected at point of production and distributed into general statewide inventory over a 9-month period. These selected units carried case report forms, for completion at the point of hospital issue for transfusion. Completed forms were returned to the blood service for collation and analysis, capturing information on indication and clinical urgency of supply, including use for potentially deferrable elective surgery. RESULTS: Data from 5052 RBC units indicated that 95.6% were transfused. Approximately one-third of transfused units were used to support surgery, one-third for hematology/oncology, and one-third for other medical and miscellaneous indications. Where used for surgery, 25.7% (95% confidence interval [CI], 23.4%-28.0%) were for elective procedures, although urgency of surgery was unknown in 17.1% (95% CI, 15.2%-19.2%) of cases. Supply for nonurgent medical indications and elective surgery only accounted for 9.8% (95% CI, 9.0%-10.6%) of use, with 53.4% (95% CI, 52.0%-54.8%) of RBCs required within 24 hours. CONCLUSIONS: The majority of RBCs are transfused with a high degree of clinical urgency, with only a minor proportion required to support elective surgery.

Income inequality and alcohol attributable harm in Australia.

BACKGROUND: There is little research on the relationship between key socioeconomic variables and alcohol related harms in Australia. The aim of this research was to examine the relationship between income inequality and the rates of alcohol-attributable hospitalisation and death at a local-area level in Australia. METHOD: We conducted a cross sectional ecological analysis at a Local Government Area (LGA) level of associations between data on alcohol caused harms and income inequality data after adjusting for socioeconomic disadvantage and remoteness of LGAs.The main outcome measures used were matched rate ratios for four measures of alcohol caused harm; acute (primarily related to the short term consequences of drinking) and chronic (primarily related to the long term consequences of drinking) alcohol-attributable hospitalisation and acute and chronic alcohol-attributable death. Matching was undertaken using control conditions (non-alcohol-attributable) at an LGA level. RESULTS: A total of 885 alcohol-attributable deaths and 19467 alcohol-attributable hospitalisations across all LGAs were available for analysis. After weighting by the total number of cases in each LGA, the matched rate ratios of acute and chronic alcohol-attributable hospitalisation and chronic alcohol-attributable death were associated with the squared centred Gini coefficients of LGAs. This relationship was evident after adjusting for socioeconomic disadvantage and remoteness of LGAs. For both measures of hospitalisation the relationship was curvilinear; increases in income inequality were initially associated with declining rates of hospitalisation followed by large increases as the Gini coefficient increased beyond 0.15. The pattern for chronic alcohol-attributable death was similar, but without the initial decrease. There was no association between income inequality and acute alcohol-attributable death, probably due to the relatively small number of these types of death. CONCLUSION: We found a curvilinear relationship between income inequality and the rates of some types of alcohol-attributable hospitalisation and death at a local area level in Australia. While alcohol-attributable harms generally increased with increasing income inequality, alcohol-attributable hospitalisations actually showed the reverse relationship at low levels of income inequality. The curvilinear patterns we observed are inconsistent with monotonic trends found in previous research making our findings incompatible with previous explanations of the relationship between income inequality and health related harms.

Solar UV forecasts: a randomized trial assessing their impact on adults' sun-protection behavior.

This study examined the effectiveness of solar UV forecasts and supporting communications in assisting adults to protect themselves from excessive weekend sun exposure. The study was conducted in Australia, where 557 adult participants with workplace e-mail and Internet access were randomly allocated to one of three weather forecast conditions: standard forecast (no UV), standard forecast + UV, standard forecast + UV + sun-protection messages. From late spring through summer and early autumn, they were e-mailed weekend weather forecasts late in the working week. Each Monday they were e-mailed a prompt to complete a Web-based questionnaire to report sun-related behavior and any sunburn experienced during the previous weekend. There were no significant differences between weather forecast conditions in reported hat use, sunscreen use, sun avoidance, or sunburn. Results indicate that provision of solar-UV forecasts in weather forecasts did not promote markedly enhanced personal sun-protection practices among the adults surveyed.

Men in Australia Telephone Survey (MATeS): predictors of men's help-seeking behaviour for reproductive health disorders.

OBJECTIVE: To identify sociodemographic factors associated with help-seeking behaviour for reproductive health disorders in middle-aged and older Australian men. DESIGN: A cross-sectional, population-based, computer-assisted telephone interview exploring sociodemographic factors and general and reproductive health. PARTICIPANTS AND SETTING: Analysis of data from the Men in Australia Telephone Survey (MATeS) of 5990 Australian men aged 40 years and older interviewed between September and December 2003. MAIN OUTCOME MEASURES: Self-reported diagnosis of prostate disease and erectile dysfunction (ED), help-seeking behaviour (including visiting a doctor, prostate-specific antigen testing, treatment of prostate disease, speaking to a health professional about ED and treatment of ED). RESULTS: Age was a significant predictor of all help-seeking behaviour studied, other than treatment for ED. Controlling for all predictor variables, never-married status predicted a lower likelihood of visiting a doctor (odds ratio [OR], 0.68 [95% CI, 0.48-0.97]) or speaking to a health professional about ED (OR, 0.44 [95% CI, 0.21-0.93]), while divorced/separated status predicted lower likelihood of having a prostate-specific antigen test (OR, 0.63 [95% CI, 0.50-0.79]). Living in a regional or remote area or being from a non-English-speaking background predicted lower likelihood of receiving treatment for ED (ORs, 0.62 [95% CI, 0.42-0.92] and 0.41 [95% CI, 0.24-0.72], respectively), but did not influence screening for prostate disease. CONCLUSION: Seeking advice or treatment for male reproductive health disorders is predicted by sociodemographic factors specific to different reproductive health problems. As middle-aged and older men do attend doctors, opportunities exist for health professionals to optimise their consultations by routinely discussing reproductive health with all men, to identify under-reported male reproductive health disorders.

The health watch case-control study of leukemia and benzene: the story so far.

A case-control study nested in the Health Watch cohort of petroleum industry workers, investigated whether the excess of lymphohematopoetic cancers, identified among male members of the Health Watch cohort, was associated with benzene exposure. Cases of non-Hodgkin's lymphoma (n = 31), multiple myeloma (n = 15), and leukemia (n = 33) were identified between 1981 and 1999. Cases were age-matched to five controls. Exposure was retrospectively estimated for each occupational history using an algorithm in a relational database. Benzene exposure measurements, supplied by Australian petroleum companies, were used to estimate exposure for specific tasks. The tasks carried out within the job, the products handled, and the technology used, were identified from interviews with contemporary colleagues. More than half of the subjects started work after 1965 and had an average exposure period of 20 years. Exposure was low, 85% of the cumulative exposure estimates were <10 ppm years. Matched analyses showed that non-Hodgkin's lymphoma and multiple myeloma were not associated with benzene exposure. Leukemia risk, however, was significantly increased for the subjects with greater than 16 ppm years cumulative exposure, odds ratio (OR) 51.9 (5.6-477) or with greater than 0.8 ppm intensity of highest exposed job. Cumulative exposures were similar to those found in comparable studies. The inclusion of occasional high exposures, for example, as a result of spillages, reduced the ORs, when the exposure was treated as either a continuous or a categorical variable. Our data demonstrate a strong association between leukemia and modest benzene exposure. The choice of cut-point and reference group has a marked effect on the ORs, but does not change the overall conclusions.

The relationship between media reporting of suicide and actual suicide in Australia.

This study aimed to determine whether media items about suicide were associated with differential increases in actual suicides. Data were available on 4,635 suicide-related items appearing in Australian newspapers and on radio and television news and current affairs shows between March 2000 and February 2001. These data were combined with national data on completed suicides occurring during the same period, by a process that involved identifying the date and geographical reach of the media items and determining the number of suicides occurring in the same location in selected weeks pre- and post-item. Regression analyses were conducted to determine whether the likelihood of an increase in post-item suicides could be explained by particular item characteristics. We found that 39% of media items were followed by an increase in male suicides, and 31% by an increase in female suicides. Media items were more likely to be associated with increases in both male and female suicides if they occurred in the context of multiple other reports on suicide (versus occurring in isolation), if they were broadcast on television (versus other media), and if they were about completed suicide (versus attempted suicide or suicidal ideation). Different item content appeared to be influential for males and females, with an increase in male suicides being associated with items about an individual's experience of suicide and opinion pieces, and an increase in female suicides being associated with items about mass- or murder-suicide. Item prominence and quality were not differentially associated with increases in male or female suicides. Further research on this topic is required, but in the meantime there is a need to remain vigilant about how suicide news is reported. Mental health professionals and suicide experts should collaborate with media professionals to try to balance 'public interest' against the risk of harm.

The outcome of cardiac surgery in dialysis-dependent patients.

BACKGROUND: Patients on dialysis for end-stage renal failure (ESRF) are undergoing cardiac surgery with increasing frequency. Furthermore, ESRF is known to be an important risk factor for complications of cardiac operations performed with cardiopulmonary bypass. AIMS: To evaluate the outcome of dialysis-dependent patients undergoing cardiac surgery at one institution. METHODS: A retrospective analysis was performed on consecutive patients with ESRF dependent upon maintenance haemodialysis or peritoneal dialysis who underwent cardiac surgery from January 1998 to August 2002. RESULTS: Thirty-eight patients on dialysis underwent cardiac surgery during this time period (1.5% of total cases). The most common cause for ESRF was diabetic nephropathy (n = 12). Operations performed included isolated coronary artery bypass grafting (CABG, n = 22), CABG and valve surgery (n = 8), and valve surgery alone (n = 6). When allowing for age, sex, surgeon and operative category, the odds ratio for mortality risk of dialysis patients, compared with all others, was 4.9 (95% confidence interval (CI): 1.7-13.9, p = 0.003), and for morbidity risk, was 2.8 (95% CI: 1.4-5.4, p = 0.003). CONCLUSIONS: Patients on dialysis have an increased morbidity and mortality following cardiac surgery, however we believe ESRF should not be regarded as an absolute contraindication to cardiac surgery or cardiopulmonary bypass.

Preventing pressure ulcers with the Australian Medical Sheepskin: an open-label randomised controlled trial.

OBJECTIVE: To estimate the effectiveness of a new high-performance Australian medical sheepskin (meeting Australian Standard 4480.1-1998) in preventing pressure ulcers in a general hospital population at low to moderate risk of these ulcers. DESIGN: Open-label randomised controlled clinical trial. SETTING: A large metropolitan teaching hospital in Melbourne, Victoria, in 2000. PARTICIPANTS: 441 patients aged over 18 years admitted between 12 June and 30 November 2000, with expected length of stay over 2 days and assessed as at low to moderate risk of developing pressure ulcers. INTERVENTION: Patients were randomly allocated to receive a sheepskin mattress overlay for the duration of their hospital stay (218 patients) or usual treatment, as determined by ward staff (referent group, 223 patients). MAIN OUTCOME MEASURES: Incidence rate and cumulative incidence of pressure ulcers, assessed daily throughout hospital stay. RESULTS: 58 patients developed pressure ulcers (sheepskin group, 21; referent group, 37). Cumulative incidence risk was 9.6% in the sheepskin group (95% CI, 6.1%-14.3%) versus 16.6% in the referent group (95% CI, 12.0%-22.1%). Patients in the sheepskin group developed new pressure ulcers at a rate less than half that of referent patients (rate ratio, 0.42; 95% CI, 0.26-0.67). CONCLUSIONS: The Australian Medical Sheepskin is effective in reducing the incidence of pressure ulcers in general hospital inpatients at low to moderate risk of these ulcers.