Search

The 2023 Australian guideline for assessing and managing cardiovascular disease riskprovides updated evidence‐based recommendations for the clinical assessment and management of cardiovascular disease (CVD) risk for primary prevention. It includes the new Australian CVD risk calculator (Aus CVD Risk Calculator), based on an equation developed from a large New Zealand cohort study, customised and recalibrated for the Australian population. The new guideline replaces the 2012 guideline that recommended CVD risk assessment using the Framingham risk equation. The new guideline recommends CVD risk assessment in people without known CVD: all people aged 45–79 years, people with diabetes from 35 years, and First Nations people from 30 years. The new Aus CVD Risk Calculator should be used to estimate and categorise CVD risk into low (< 5% risk over five years), intermediate (5% to < 10% risk over five years) or high risk (≥ 10% over five years). The following reclassification factors may be applied to recategorise calculated risk to improve accuracy of risk prediction, particularly in individuals close to a risk threshold: Indigenous status/ethnicity, estimated glomerular filtration rate, urine albumin to creatinine ratio measurements, severe mental illness, coronary artery calcium score and family history of premature CVD. A variety of communication formats is available to communicate CVD risk to help enable shared decision making. Healthy lifestyle modification, including smoking cessation, nutrition, physical activity and limiting alcohol, is encouraged for all individuals. Blood pressure‐lowering and lipid‐modifying pharmacotherapies should be prescribed for high risk and considered for intermediate risk individuals, unless contraindicated or clinically inappropriate. Reassessment of CVD risk should be considered within five years for individuals at low risk and within two years for those with intermediate risk. Reassessment of CVD risk is not recommended for individuals at high risk. The updated guideline recommends assessment over a broader age range and uses the Aus CVD Risk Calculator, which replaces the previous Framingham‐based equation. It incorporates new variables: social disadvantage, diabetes‐specific risk markers, diagnosis of atrial fibrillation and use of blood pressure‐lowering and lipid‐modifying therapies. Reclassification factors are also a new addition. Updated risk categories and thresholds are based on the new Aus CVD Risk Calculator. The proportion of the population in the high risk category (≥ 10% over five years) is likely to be broadly comparable to more than 15% risk from the Framingham‐based equation. The full guideline and Aus CVD Risk Calculator can be accessed at www.cvdcheck.org.au.

Hypertension guidelines recommend that absolute cardiovascular disease (CVD) risk guide the management of hypertensive patients. This study aimed to assess the proportion of patients with diagnosed hypertension with sufficient data to calculate absolute CVD risk and determine whether CVD risk is associated with prescribing of antihypertensive therapies. This was a cross-sectional study using a large national database of electronic medical records of patients attending general practice in 2018 (MedicineInsight). Of 571,492 patients aged 45–74 years without a history of CVD, 251,733 [40.6% (95% CI: 39.8–41.2)] had a recorded hypertension diagnosis. The proportion of patients with sufficient recorded data available to calculate CVD risk was higher for patients diagnosed with hypertension [51.0% (95% CI: 48.0–53.9)] than for patients without a diagnosis of hypertension [38.7% (95% CI: 36.5–41.0)]. Of those patients with sufficient data to calculate CVD risk, 29.3% (95% CI: 28.1–30.6) were at high risk clinically, 6.0% (95% CI: 5.8–6.3) were at high risk based on their CVD risk score, 12.8% (95% CI: 12.5–13.2) at moderate risk and 51.8% (95% CI: 50.8–52.9) at low risk. The overall prevalence of antihypertensive therapy was 60.9% (95% CI: 59.3–62.5). Prescribing was slightly lower in patients at high risk based on their CVD risk score [57.4% (95% CI: 55.4–59.4)] compared with those at low [63.3% (95% CI: 61.9–64.8)] or moderate risk [61.8% (95% CI: 60.2–63.4)] or at high risk clinically [64.1% (95% CI: 61.9–66.3)]. Guideline adherence is suboptimal, and many patients miss out on treatments that may prevent future CVD events.

Abstract Objectives To evaluate the impact of an intervention based in general practice on the incidence of repeat episodes of deliberate self harm. Design Cluster randomised controlled trial in which [...]

Introduction Acute cough and respiratory tract infection are terms used to describe a wide variety of clinical syndromes. Symptoms range from cough without sputum to an illness characterised by expectoration [...]

Late-life depression is common and often inadequately managed using existing therapies. Depression is also associated with increased markers of inflammation, suggesting a potential role for anti-inflammatory agents. ASPREE-D is a sub-study of ASPREE, a large multi-centre, population-based, double-blind, placebo-controlled trial of aspirin vs placebo in older Australian and American adults (median follow-up: 4.7 years) of whom 1879 were depressed at baseline. Participants were given 100 mg daily dose of aspirin or placebo. Depressive symptoms were assessed annually using the validated, self-rated short version of the Center for Epidemiological Studies Depression scale. There was a significant increase in depressive scores (0.6; 95% CI 0.2 to 0.9; χ2(1) = 10.37; p= 0.001) and a decreased score in the mental health component of a quality of life scale (–0.7; 95% CI –1.4 to –0.1; χ2(1) = 4.74; p= 0.029) in the aspirin group compared to the placebo group. These effects were greater in the first year of follow-up and persisted throughout the study, albeit with small to very small effect sizes. This study failed to demonstrate any benefit of aspirin in the long-term course of depression in this community-dwelling sample of older adults over a 5-year period, and identified an adverse effect of aspirin in the course of depression in those with pre-existing depressive symptoms.

An attempt is made to assess, if there are any differences in statin prescribing across Australia by socioeconomic status or sex and to relate prescribing rates to coronary heart disease (CHD) mortality rates. Findings reveal that, in men, there is either over prescribing of statins in the highest socioeconomic quintile or under prescribing in the lowest.

ABSTRACTIn Australia, pneumococcal vaccine is provided free to all adults aged ≥65 years and Indigenous people aged 15–65 years, and is subsidized for non-Indigenous adults <65 years of age with risk factors. This study aimed to explore pneumococcal vaccination uptake in older patients attending 550 Australian general practices from 2010–2017 by patient sociodemographics, presence of comorbidities and practice characteristics. Study 1: a cross-sectional analysis of ‘active’ patients aged ≥65 years in each year was performed to calculate annual pneumococcal vaccination uptake. Study 2: a cohort of 58,589 ‘every year’ patients aged 60–65 years in 2010 was analyzed to identify the number of patients immunized during the study period. Logistic regression models assessed associations between vaccination, patient and practice characteristics. Annual pneumococcal vaccine uptake varied by patient’s age (65–74 or ≥75 years), presence of comorbidities and regularity of practice visits (range 36% to 76%), and it declined slowly from 2011–2016 amongst all groups. Cohort analyses showed that 69% of those aged 60–65 years in 2010 had a recorded pneumococcal vaccination by 2017 (peak age of vaccination = 66 years), and vaccination was more likely among those with comorbidities, ex-smokers and frequent attenders to practices. Findings demonstrate that the NPS MedicineInsight database provides estimates of vaccination uptake consistent with past surveys, reproducible every year and at low cost. It has the advantage of additional clinical information compared to the Australian Immunization Register. Whilst vaccination uptake was adequate among ‘every year’ patients, interventions are needed to improve pneumococcal vaccination for all older Australians.

ABSTRACTInfluenza contributes to morbidity and mortality worldwide. Children are at a higher risk of influenza-related complications and vaccination promotes direct protection and limits transmission. This study aimed to explore influenza vaccination coverage among children in Australian general practice from 2015 to 2018, and patterns in coverage before and after the implementation of state-funded immunization programs. Data from 196,520 ‘active’ patients (3+ consultations in two consecutive years) aged <5 years from 542 Australian general practices were included (MedicineInsight database). Logistic regression models were used to identify associations between vaccination with patient and practice characteristics. The overall vaccination coverage increased more than five times from 2015 (3.9%) to 2018 (19.6%) and varied among states. Children attending practices located in the wealthiest areas were more likely to receive the vaccine and appeared to benefit most from the funding, as the increase in coverage from 2017 to 2018 was greater among them than those attending practices in the least advantaged areas (17 vs. 11 percentage points, respectively). This relationship was not evident when analyzing the patient’s socioeconomic level. In conclusion, free influenza vaccinations increase coverage in at-risk populations. Promotional campaigns may be required to maintain higher coverage and target practices located in low-income areas.

Stress can have adverse impacts on health, particularly when it is chronic or resulting from major adverse events. Our study investigated whether relatively common adverse events in older individuals were associated with an increased risk of death, as well as cause-specific death and potential gender differences.

The article examines community general practice as an attractive solution to the ever-growing problem of education of medical students and junior doctors with suggestions that will help augment this process.

A study of a rural Aboriginal community in Australia, which found that 95% of the population had chronic non-specific musculoskeletal pain, compared with 30% in the general population, is presented. It was found that muscle pain is an indicator of vitamin D deficiency in urban Aboriginal patients and general practitioners might be able to improve the lifestyle and level of function of many previously undiagnosed patients with chronic muscle pain by having a high index of suspicion for vitamin D deficiency.

Objective:Although polycystic ovary syndrome (PCOS) is considered a lifelong disorder, very little is understood about the diagnosis and impact of this condition in women outside of the peak reproductive years. We examined the frequency of diagnosed PCOS and concurrent health conditions in women across the lifespan.Methods:Data were analysed from 1509 women aged 15–95 years participating in a cross-sectional, face-to-face population survey in South Australia, 2015. We assessed the prevalence of PCOS in 10-year age groups and the frequency of comorbidities in women with and without PCOS subgrouped by age (< 45, ≥45 years). The main outcome measures were Diagnosed PCOS and other chronic conditions; lifestyle factors. Logistic regression analyses determined the risk of comorbidities in women with PCOS adjusting for age and BMI.Results:Overall prevalence of PCOS was 5.6% (95% confidence interval (CI) 4.6–6.9%), peaking in the 35–44 year age group (9.1%), and lowest in those aged 15–24 (4.1%) or ≥65 (3.7%) years. Women with PCOS and aged <45 years were more likely to report diabetes (16.7% vs. 3.8%), cardiovascular disease (15.5% vs. 7.2%) and arthritis (15.5% vs. 7.2%) than their peers; these differences were diminished in the ≥45 year age group. The odds of diabetes and cardiovascular disease were more than doubled among women with PCOS (adjOR 2.23, 95% CI 1.49–4.31; adjOR 3.18, 95% CI 1.31–7.68).Conclusion:PCOS is underdiagnosed in young and post-menopausal women. Diabetes and cardiovascular disease are key comorbidities requiring greater attention in younger women with PCOS.

To assess the factors that contributed to the successful completion of recruitment for the largest clinical trial ever conducted in Australia, the Aspirin in Reducing Events in the Elderly (ASPREE) study. Enrolment of GPs; identification of potential participants in general practice databases; screening of participants. Selected general practices across southeast Australia (Tasmania, Victoria, Australian Capital Territory, New South Wales, South Australia). Numbers of patients per GPscreened and randomised to participation; geographic and demographic factors that influenced screening and randomising of patients. 2717 of 5833 GPs approached (47%) enrolled to recruit patients for the study; 2053 (76%) recruited at least one randomised participant. The highest randomised participant rate per GPwas for Tasmania (median, 5; IQR, 1–11), driven by the high rate of participant inclusion at phone screening. GPs in inner regional (adjusted odds ratio [aOR], 1.45; 95% CI, 1.14–1.84) and outer regional areas (aOR, 1.86; 95% CI, 1.19–2.88) were more likely than GPs in major cities to recruit at least one randomised participant. GPs in areas with a high proportion of people aged 70 years or more were more likely to randomise at least one participant (per percentage point increase: aOR, 1.10; 95% CI, 1.05–1.15). The number of randomised patients declined with time from GPenrolment to first randomisation. General practice can be a rich environment for research when barriers to recruitment are overcome. Including regional GPs and focusing efforts in areas with the highest proportions of potentially eligible participants improves recruitment. The success of ASPREEattests to the clinical importance of its research question for Australian GPs.

Gout has an increasing global prevalence. Underutilization of urate-lowering therapy (ULT) is thought to be common, via both suboptimal dosing and poor medication adherence. The aims of this study were to determine the prevalence of self-reported gout and the key predictors of ULT use in those with gout in a representative population survey in South Australia. Data were obtained from the Spring 2015 South Australian Health Omnibus Survey, a multilevel, systematic, survey in a representative population sample involving face-to-face interviews (n= 3005). This study analyzed responses from respondents aged ≥ 25 years (n= 2531) about self-reported gout, ULT use, sociodemographic factors, lifestyle factors, and comorbidities, using survey weighting. Univariate and subsequent adjusted logistic regression analyses on self-reported gout were performed. ULT use was divided into three categories (never use, prior use, and current use) and these data were analyzed using a multinomial logistic regression model. Self-reported gout prevalence was 6.8% (95% CI 5.8, 7.9). The mean age of respondents with gout was 64 years (standard deviation 16) and 82% were male. As expected, older age, male gender, lower socioeconomic status (SES), and higher body mass index (BMI) were associated with gout, as were high alcohol consumption, current smoking, other forms of arthritis, and hypertension or hypercholesterolemia medication, after adjustment for sociodemographic variables. Two thirds of respondents with gout reported ULT use (36% current; 29% previous) with only 55% continuing treatment. Predictors of ULT use included male gender, low SES, and concomitant cholesterol-lowering therapy. Respondents with gout with a higher BMI were more likely to remain on ULT. Despite gout being a common, potentially disabling joint disease, only 55% of respondents with gout in this study adhered to ULT. Identification of key predictors of ULT use will provide guidance on prescribing strategy in clinical practice and on the quality of gout care in the community.

To determine the prevalence of sleep conditions (obstructive sleep apnea [OSA], insomnia symptoms, simple snoring, and restless legs) and their associated burden of chronic conditions in a community sample.

Introduction:Clinical uncertainty remains about the relationship between cholesterol levels and risk of death in older persons.Hypothesis:Lower low-density lipoprotein (LDL) cholesterol level was associated with a decreased mortality risk from cardiovascular disease (CVD) and an increased mortality risk due to non-CVD causes in primary prevention older populations.Methods:We examined the relationship between LDL cholesterol levels and mortality outcomes in a cohort of older individuals aged ≥65 years enrolled into a clinical trial. At baseline, participants had no diagnosed dementia, physical disability or CVD events, and were not taking lipid-lowering agents. Multivariable Cox proportional-hazards models were used to examine associations of LDL cholesterol with all-cause, CVD, cancer, and combined non-CVD/non-cancer mortality. Restricted cubic splines were used to depict non-linear relationships.Results:Among 12,334 participants included in this analysis [mean (SD) age: 75.2 (4.6) years; 54% females], who were followed for a median of 6.9 (5.7-8.0) years, 1250 (10%) died (24% due to CVD, 43% cancer, and 33% non-CVD/non-cancer). There was a U-shaped relation linking LDL cholesterol and all-cause mortality (nadir: 3.3mmol/L) and a curvilinear relation for other mortality outcomes. Each 1-mmol/L higher LDL cholesterol was associated with a lower risk of all-cause mortality (HR=0.91, 95% CI 0.85-0.98), cancer mortality (0.83, 0.74-0.94) and non-CVD/non-cancer mortality (0.81, 0.71-0.93), but a higher risk of CVD mortality (1.19, 1.03-1.38). Reduced risks of all-cause and non-CVD/non-cancer mortality were only significant in males and but not females (P values for sex interaction <0.05). When deaths in the five years after baseline were excluded, the HRs for all-cause, cancer, non-CVD/non-cancer and CVD mortality were 1.03, 1.05, 0. 91 and 1.21 respectively (all P>0.10).Conclusions:Higher LDL cholesterol is associated with a greater risk of CVD mortality in older adults. Reduced risks for non-CVD mortality were likely driven by reverse causality, evidenced by the absence of associations after excluding deaths that occurred within the initial five years of follow-up.

To examine protocol adherence to structured intensive management in the Valsartan Intensified Primary carE Reduction of Blood Pressure (VIPER-BP) study involving 119 primary care clinics and 1562 randomized participants.

Abstract: Our previous work on stochastic resonance (SR) in threshold based systems proved that the SR effect is dependent on the nature of the input signal distribution; more specifically, for certain types of signal distribution SR is not observed [Das A, Stocks NG, Nikitin A, Hines EL. Quantifying stochastic resonance in a single threshold detector for random aperiodic signals. Fluctuation Noise Lett 2004;4:L247–65]. Here we show that suprathreshold stochastic resonance (SSR) – a novel and distinct form of SR – removes this limitation and hence leads to the conclusion that SSR can probably enhance the transmission of signals of any distribution and amplitude. SSR effects are studied in a parallel array of identical nonlinear threshold based devices. A double exponential signal distribution is chosen because this distribution did not demonstrate conventional SR effects in a single threshold device [Das A, Stocks NG, Nikitin A., Hines EL. Quantifying Stochastic resonance in a single threshold detector for random aperiodic signals. Fluctuation and Noise Letters 2004;4:L247-L265.]. SSR as a possible mechanism for enhancing transmission of speech signals in the human ear is also discussed. [Copyright &y& Elsevier]

The article discusses the medical treatment of community-acquired pneumonia (CAP), and its background. CAP is described as pneumonia that is acquired outside hospital in a person who is not immunocompromised. Fever, cough and dysnoea are among the symptoms of the disease. Antibiotic guidelines for CAP treatment outside hospital, suggest that it will be based on amoxycillin 500-1000mg orally for one week. Several case studies related to CAP and its diagnosis is presented.

The aim of this pilot study was to assess any trends related to the timing of initiation, and duration, of hormone therapy (HT) use on cognitive function to facilitate the design and power calculations for a future large cohort study entitled Research into Memory, Brain function and Estrogen Replacement (REMEMBER).

Background and Objectives: Postal questionnaires are a frequently used method of obtaining information from general practitioners. However, getting GPs to return questionnaires or participate in research can be challenging. We wanted to ascertain reasons why GPs, identified as 'routine non-responders' to postal questionnaires, do not to participate in this type of research.Methods: Qualitative study using semi-structured interviews of 14 GPs who had returned only one or none of five questionnaires sent to them during a five-year period between 1994 and 1999.Results: Participants were classified into one of three groups-binners, filers, and fillers-according to their behaviour when faced with a questionnaire. Each group had slightly different attitudes toward research in general practice. Although standard strategies such as incentives and good design could influence the decision to complete a questionnaire, poor research experiences or a poor relationship between the participant and researchers were also very important.Conclusion: The decision not to return a postal questionnaire is multifactorial and reflects personal and professional attitudes, experiences and organisation of individual GPs as well as time pressure and interest. The development of a positive relationship with a researcher or academic department may be influential in encouraging the return of postal questionnaires and when trying to enhance response rates amongst 'routine non-responders' researchers should take into account the broader values and practices GPs bring to their work.

In England & Wales at least 140 000 people present at hospital annually following an episode of deliberate self-harm (DSH), and 12 to 16 make a repeat attempt. The time of greatest risk of repetition is within three months of an attempt. Around 50 of these patients visit their GP in the four to eight weeks after an episode of DSH. Guidelines for the aftercare of patients who have self-harmed in general practice may reduce repetition rates and could possibly have an impact on suicide rates. The aim of this study was to develop a clinical practice guideline for the aftercare of DSH patients in general practice. A modified Delphi technique was used with a consensus group consisting of GPs with an interest in mental health, psychiatrists, a psychologist, a specialist nurse, a voluntary organization and patients with a history of self-harm. The template for the guidelines was based on ICD-10 PHC. Consensus was reached on all points after two rounds of the Delphi and the guidelines were formatted to facilitate their use in the GP consultation. There is a difficulty developing guidelines for common problems where the evidence base is weak. The use of formal consensus methods can be employed but it must be acknowledged that the validity of the resulting guideline is related to the composition of the consensus group, the identification and analysis of any relevant evidence and the method of guideline dissemination. The guidelines are being evaluated in a randomized controlled trial of a general practice based intervention to reduce repeat deliberate self-harm.

OBJECTIVES: To evaluate the impact of an intervention based in general practice on the incidence of repeat episodes of deliberate self harm. DESIGN: Cluster randomised controlled trial in which 98 general practices were assigned in equal numbers to an intervention or a control group. The intervention comprised a letter from the general practitioner inviting the patient to consult, and guidelines on assessment and management of deliberate self harm for the general practitioner to use in consultations. Control patients received usual general practitioner care. SETTING: General practices within Avon, Wiltshire, and Somerset Health Authorities, whose patients lived within the catchment area of four general hospitals in Bristol and Bath. PARTICIPANTS: 1932 patients registered with the study practices who had attended accident and emergency departments at one of the four hospitals after an episode of deliberate self harm. MAIN OUTCOME MEASURES: Primary outcome was occurrence of a repeat episode of deliberate self harm in the 12 months after the index episode. Secondary outcomes were number of repeat episodes and time to first repeat. RESULTS: The incidence of repeat episodes of deliberate self harm was not significantly different for patients in the intervention group compared with the control group (odds ratio 1.2, 95% confidence interval 0.9 to 1.5). Similar findings were obtained for the number of repeat episodes and time to first repeat. Subgroup analyses indicated that there was no differential effect of the intervention according to patient's sex (P=0.51) or method used to cause deliberate self harm (P=0.64). The treatment seemed to be beneficial for people with a history of deliberate self harm, but it was associated with an adverse effect in people for whom the index episode was their first episode (interaction P=0.017). CONCLUSIONS: An invitation to consult, sent by the general practitioner of patients who have deliberately harmed themselves, and the use of management guidelines during any subsequent consultation did not reduce the incidence of repeat self harm. A subgroup analysis that indicated that patients who had previously harmed themselves benefited from the intervention was inconsistent with previous evidence and should be treated with caution. More research is needed on how to manage patients who deliberately harm themselves, to reduce the incidence of repeat episodes.

Objectives: To assess the predictive value, for subsequent mental health problems, and service use of a pre-registration card sent to all first-year students at the University of Bristol.Methods: A retrospective cohort study of all enrolling first-year students at the University of Bristol. Information was abstracted from the health records and pre-registration cards of a one-in-two systematic sample of all first-year students at the University Student Health Service (SHS) during the 1994/1995 academic year. The pre-registration card contained information about their past medical history and several questions concerning depression and anxiety. Data were entered into SPSS and regression analyses performed.Results: 1435 students had complete pre-registration and service utilisation data which were used in the analysis. Mental health problems accounted for 5.6% of all morbidity. Students with a self-reported history of depression (OR 6.87, CI 2.86-16.5), breakdown (OR 15.38 CI 0.98-241) or receipt of counselling (OR 3.93, CI 2.52-8.07) were at greatest risk of presenting with a mental health problem to the SHS. Although the sensitivity and specificity of these 'risk factors' were relatively low, they did have high negative predictive value.Conclusion: Attendance for mental health problems at a student health service can be predicted from self-completed answers to questions on a pre-registration card. The literature indicates that mental health problems contribute to withdrawal and failure at university. The pre-registration card could be used to identify an 'at risk' group and an intervention designed to prevent mental health morbidity.

Objective: To determine the prevalence of trachoma and blindness in the Aboriginal population in the Anangu Pitjantjatjara and Yalata lands of South Australia. Design and setting: A population‐based prevalence survey undertaken in conjunction with routine South Australian Aboriginal Trachoma and Eye Health Program trips during 1989 and 1990. Results: A group of 1514 individuals aged 0‐90 years, or approximately 58% of the estimated Aboriginal population in the Anangu Pitjantjatjara and Yalata lands, was examined. Active inflammatory trachoma was found in 17.6% of the group (266 individuals), cicatricial trachoma in 25.2% (382) and binocular blindness (Australian definition) in 1.5% (22). The major causes of monocular and binocular blindness were trachoma, cataracts and trauma. Two per cent of women (17 of 849) were blind, compared with 0.8% (5 of 665) of men (odds ratio, 3.22; 95% confidence interval, 1.03‐10.43). Conclusions: Although trachoma is still endemic in the “traditional” Aboriginal population of SA, its prevalence and severity appear to be less than previously recorded. However, the prevalence of blindness is comparable with that found in developing countries and the causes are still largely preventable. Further effort is required to reduce trachoma and preventable or treatable blindness in these communities.

The Greater Manchester Shopping Inquiry ran from July 1987 to February 1988, employing 3 Inspectors, 27 barristers and 90 consultants, and other expert witnesses. It deserves to be known for more than its vital statistics. It provided an insight into the current state of the art of strategic retail planning in a conurbation.This article presents a view through the eyes of a reluctant participant. Readers will judge for themselves whether and how much to allow for bias, but it should be clear that my opinions are not necessarily shared by Trafford Borough Council.I describe the events leading up to the Inquiry, the roots of which can be traced through Structure Plan documents back to 1974; the 11 major shopping applications received in and around Greater Manchester within 10 months in 1986 for a total of 6 672 000 gross ft2; and the way the planning system, including the Inquiry itself, responded to this challenge.On the basis of this case study, I suggest that the methods and data used to predict demand for shop floorspace are not equal to the problems set by a multi centred conurbation such as Greater Manchester; that the way we apply these methods of prediction tends to under-estimate rather than over-estimate; that under-estimates give rise to at least as many problems as over-estimates, not the least of which is a loss of control of the kind witnessed in Greater Manchester; and that many of our expectations about what strategic retail planning can do to regenerate our cities are unrealistic.

Abstract: The eye health of rural Aboriginal Australians is known to be poor. Over the past 20 years, Aboriginal communities in remote parts of Australia have had increasing access to eye health services through the National Trachoma and Eye Health Program (NTEHP). Using published and unpublished data, we examined trends in the prevalence of inflammatory trachoma in the Anangu Pitjantjatjara of South Australia. Comparisons using a generalised linear model of surveys in 1976, 1985 and 1990 indicate that there has been a significant reduction in the age‐standardised prevalence of inflammatory trachoma in 0‐ to 20‐year‐olds. When the 1990 survey was compared with 1976 interim report data from the NTEHP survey, the odds of inflammatory trachoma in 1990 were 0.25 (95 per cent confidence interval (CI) 0.18 to 0.35). When the comparison was with data from the NTEHP survey of the Red Centre, the odds of follicular trachoma in 1990 were 0.51 (CI 0.42 to 0.62), and in comparison with the 1985 NTEHP review data, the odds of inflammatory trachoma in 1990 were 0.28 (CI 0.20 to 0.39). In the older age groups (20 and over), an increase in the prevalence of inflammatory trachoma was found. Although significant, the increase affected a small proportion of the population and may have been because of difficulty in standardising the trachoma grading between surveys, or systematic grading error in the 1990 survey. This study therefore shows that the eye health of Aboriginal people in Central Australia may be improving. The decline in trachoma is welcome and may be caused by improvements in socioeconomic conditions, community development and increasing access to medical care.

Background: Eating disorders (ED) and disordered eating behaviours (DEB) have been found to be common in people with diabetes mellitus (DM). However, findings have been inconsistent. Objective: This study investigated the association between self-reported diabetes (Type 1 or 2) with ED/DEB (binge eating, subjective binge eating or loss of control overeating, severe dieting and purging) weight/shape overvaluation, and health-related quality of life (HRQoL) in a household survey in South Australia. Method: In 2017 2977 people aged ≥15 years, who were representative of the general population, were interviewed. Participants reported their gender, age, household income, highest educational attainment, area of residence, presence of DM, ED/DEB, level of overvaluation, current HRQoL and height and weight. For the analyses between ED/DEB, self-reported DM and HRQoL, a grouping variable was created: 1) people without ED/DEB or self-reported DM; 2) people without ED/DEB and with self-reported DM; 3) people with ED/DEB and without self-reported DM; and 4) people with ED/DEB and self-reported DM. Analyses were stratified by sex and age group. Results: Subjective binge eating prevalence was higher in people with self-reported DM (6.6% vs 2.8%, p= 0.016), and overvaluation was lower in those with DM (36% vs 43.8%, p= 0.007). In analyses stratified by sex and age group, subjective binge eating was higher in women and in people over 45 years with self-reported DM and overvaluation was lower in men and in people over 45 years with self-reported DM. However, these differences were not significant on tests of gender and age interaction. People in both DM groups scored significantly lower than people without DM groups on physical HRQoL. In contrast, people in both ED/DEB groups scored lower than people without ED/BEB on mental HRQoL. Conclusion: People with self-reported DM had a higher prevalence of subjective binge eating, a lower prevalence of overvaluation and there were no significant effects of age or gender. Furthermore, participants with self-reported DM and comorbid ED or DEB had impairments of both mental and physical HRQoL. Assessing an individual’s sense of control over eating along with other DEB is likely important for identification of these mental health problems.

It is unclear which symptoms and signs GPs use when attributing diagnostic labels to patients with acute respiratory illness (ARI).

Background: Little is known about the epidemiology and health related quality of life (HRQoL) of the new DSM-5 diagnoses, Binge Eating Disorder (BED) and Avoidant/Restrictive Food Intake Disorder (ARFID) in the Australian population. We aimed to investigate the prevalance and burden of these disorders. Methods: We conducted two sequential population-based surveys including individuals aged over 15 years who were interviewed in 2014 (n= 2732) and 2015 (n=3005). Demographic information and diagnostic features of DSM-5 eating disorders were asked including the occurrence of regular (at least weekly over the past 3 months) objective binge eating with levels of distress , extreme dietary restriction/fasting for weight/shape control, purging behaviors, overvaluation of shape and/or weight, and the presence of an avoidant/restrictive food intake without overvaluation of shape and/or weight. In 2014 functional impact or role performance was measured with the ‘days out of role’ question and in 2015, Health Related Quality of Life (HRQoL) was assessed with the Short Form −12 item questionnaire (SF-12v1). Results: The 2014 and 2015 3-month prevalence of eating disorders were: anorexia nervosa-broad 0.4% (95% CI 0.2–0.7) and 0.5% (0.3–0.9); bulimia nervosa 1.1% (0.7–1.5) and 1.2% (0.9–1.7); ARFID 0.3% (0.1–0.5) and 0.3% (0.2–0.6). The 2015 3-month prevalence rates were: BED-broad 1.5% (1.1–2.0); Other Specified Feeding or Eating Disorder (OSFED) 3.2 (2.6–3.9); and Unspecified Feeding or Eating Disorder (UFED) 10.4% (0.9–11.5). Most people with OSFED had atypical anorexia nervosa and majority with UFED were characterised by having recurrent binge eating without marked distress. Eating disorders were represented throughout sociodemographic groups and those with bulimia nervosa and BED-broad had mean weight (BMI, kg/m2) in the obese range. Mental HRQoL was poor in all eating disorder groups but particularly poor for those with BED-broad and ARFID. Individuals with bulimia nervosa, BED-broad and OSFED-Purging Disorder also had poor physical HRQoL. ARFID and bulimia nervosa groups had lower role performance than those without an eating disorder. Conclusions: Whilst full spectrum eating disorders, including ARFID, were less common than OSFED or UFED, they were associated with poor mental HRQoL and significant functional impairment. The present study supports the movement of eating disorders in to broader socio demographic groups including men, socio-economic disadvantaged groups and those with obesity.

ObjectiveTo determine the effectiveness of intensive structured care to optimise blood pressure control based on individual absolute risk targets in primary care.DesignPragmatic multicentre randomised controlled trial.SettingGeneral practices throughout Australia, except Northern Territory, 2009-11.ParticipantsOf 2185 patients from 119 general practices who were eligible for drug treatment for hypertension according to national guidelines 416 (19.0%) achieved their individual blood pressure target during a 28 day run-in period of monotherapy. After exclusions, 1562 participants not at target blood pressure (systolic 150 (SD 17) mm Hg, diastolic 88 (SD 11) mm Hg) were randomised (1:2 ratio) to usual care (n=524) or the intervention (n=1038).InterventionComputer assisted clinical profiling and risk target setting (all participants) with intensified follow-up and stepwise drug titration (initial angiotensin receptor blocker monotherapy or two forms of combination therapy using angiotensin receptor blockers) for those randomised to the intervention. The control group received usual care.Main outcome measuresThe primary outcome was individual blood pressure target achieved at 26 weeks. Secondary outcomes were change in mean sitting systolic and diastolic blood pressure, absolute risk for cardiovascular disease within five years based on the Framingham risk score, and proportion and rate of adverse events.ResultsOn an intention to treat basis, there was an 8.8% absolute difference in individual blood pressure target achieved at 26 weeks in favour of the intervention group compared with usual care group (358/988 (36.2%) v138/504 (27.4%)): adjusted relative risk 1.28 (95% confidence interval 1.10 to 1.49, P=0.0013). There was also a 9.5% absolute difference in favour of the intervention group for achieving the classic blood pressure target of ≤140/90 mm Hg (627/988 (63.5%) v272/504 (54.0%)): adjusted relative risk 1.18 (1.07 to 1.29, P<0.001). The intervention group achieved a mean adjusted reduction in systolic blood pressure of 13.2 mm Hg (95% confidence interval −12.3 to −14.2 mm Hg) and diastolic blood pressure of 7.7 mm Hg (−7.1 to −8.3 mm Hg) v10.1 mm Hg (−8.8 to 11.3 mm Hg) and 5.5 mm Hg (−4.7 to −6.2 mm Hg) in the usual care group (P<0.001). Among 1141 participants in whom five year absolute cardiovascular risk scores were calculated from baseline to the 26 week follow-up, the reduction in risk scores was greater in the intervention group than usual care group (14.7% (SD 9.3%) to 10.9% (SD 8.0%); difference −3.7% (SD 4.5%) and 15.0% (SD 10.1%) to 12.4% (SD 9.4%); −2.6% (SD 4.5%): adjusted mean difference −1.13% (95% confidence interval −0.69% to −1.63%; P<0.001). Owing to adverse events 82 (7.9%) participants in the intervention group and 10 (1.9%) in the usual care group had their drug treatment modified.ConclusionsIn a primary care setting intensive structured care resulted in higher levels of blood pressure control, with clinically lower blood pressure and absolute risk of future cardiovascular events overall and with more people achieving their target blood pressure. An important gap in treatment remains though and applying intensive management and achieving currently advocated risk based blood pressure targets is challenging.