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Objective To describe how various antimicrobials are used in commercial pig herds in Australia and for what disease conditions. Procedure Managers of large pig herds (> 200 sows) across Australia and their veterinarians participated in an internet-based survey in 2006. Questions were asked about herd management, the occurrence of bacterial diseases and the type and frequency of antimicrobial use. An antimicrobial usage index for each herd was derived as a summary of the risk of selection for antimicrobial resistance. Relationships between responses were explored with univariate and multivariate analysis. Results Responses were received for 197 herds estimated to represent at least 51% of all large pig herds in Australia. Most piggeries relied on drugs of low importance in human medicine (e.g. tetracyclines, penicillins and sulfonamides). For the two drugs of high importance in human medicine that can be legally prescribed to pigs in Australia, ceftiofur use was reported in 25% of herds and virginiamycin in none. Infections attributed to Lawsonia, Mycoplasma and Escherichia coli motivated the most use of antimicrobials. No useful association was found between management factors and the antimicrobial use index. Conclusion Most antimicrobial use in the Australian pig industry is based on drugs of low importance to public health. Enhanced control of E. coli infections without reliance on antimicrobials would further reduce the risk of selecting for antimicrobial resistance relevant to public health. The amount of variation in the usage index between herds suggests that antimicrobial use should be constantly reviewed on a herd by herd basis. [ABSTRACT FROM AUTHOR]

Abstract Background: The Heart Outcomes Prevention Evaluation (HOPE) study has demonstrated that ramipril 10 mg/day for 5 years in an at-risk population results in clinically and statistically significant reductions in the occurrence of cardiovascular death, myocardial infarction (MI), stroke and revascularization procedures. The likely impact of the intervention in Australia, in terms of the number of potential events avoided and the cost per life-year saved, has previously not been determined. Aims: To assess the clinical and economic impacts of the use of daily ramipril in the Australian at-risk popu­lation from the perspective of the public health-care budget. Methods: The clinical benefits were calculated from endpoints used in the trial, which were converted to the ‘number needed to treat’. These were then applied to the at-risk population, which was determined nationally from the relevant Australian statistics. The result of this calculation is the potential number of events avoided in Australia. The economic benefits were established by undertaking an incremental cost-effectiveness analysis. The economic model considered the clinical benefits and the costs (and cost offsets) arising from ramipril 10 mg/day therapy for 5 years. Life-years saved was determined by calculating the difference in total years survived between the ramipril and control arms of the study. Net costs divided by life-years saved is the cost per life-year saved, and this is reported in Australian dollars as the incremental cost effectiveness. Results: The clinical benefits over a 5-year period were expressed as the number of potential events avoided and comprised approximately: 9188 strokes; 14 658 MI; 14 317 revascularization procedures; and 12 534 cardiovascular-related deaths, nationally. The incremental cost-effectiveness analysis showed the estimated cost per life-year saved to be $A17 214. Conclusion: The use of ramipril 10 mg/day over a 5-year period in the at-risk Australian population could prevent many thousands of cardiovascular events, including 12 534 cardiovascular-related deaths. The cost per life-year saved compares favourably to other health care interventions. (Intern Med J 2003; 33: 414-419) [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Capnography during sedation," that was published in the previous issue.

A patient with Addison's disease required surgery have attempted suicide, by cutting his throat and wrist. He was also in an acute adrenal crisis, as a result of deliberately omitting his replacement steroid therapy. Urgent surgery was indicated and therefore anaesthesia was undertaken before the patient's adrenal crisis was fully controlled. The anaesthetic management is described.

We evaluated the correlation between destructive changes seen on hand radiographs and disability in 54 patients with definite or classic rheumatoid arthritis. No statistically significant correlation was found between radiographic findings and patient disability as determined by patient and physician assessment or by the patient's score on the Arthritis Impact Measurement Scales questionnaire. These findings call into question the appropriateness of using hand radiographs as a determinant of disability or as a criterion for disability insurance benefits.