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Background Spontaneous pneumothorax can be managed initially by observation, aspiration or chest drain insertion. Aims To determine the clinical features of spontaneous pneumothorax in patients presenting to the emergency department ( ED), interventions, outcomes and potential risk factors for poor outcomes after treatment. Methods Retrospective chart review from ED of three major referral and two general hospitals in Australia of presentations with primary spontaneous pneumothorax ( PSP) or secondary spontaneous pneumothorax ( SSP). Main outcomes were prolonged air leak (>5 days) and pneumothorax recurrence within 1 year. Results We identified 225 people with PSP and 98 with SSP. There were no clinical tension pneumothoraces with hypotension. Hypoxaemia (haemoglobin oxygen saturation measured by pulse oximetry ≤92%) occurred only in SSP and in older patients (age >50 years) with PSP. Drainage was performed in 150 (67%) PSP and 82 (84%) SSP. Prolonged air leak occurred in 16% (95% confidence interval 10-23%) of PSP and 31% (21-42%) of SSP. Independent risk factors for prolonged drainage were non-asthma SSP and pneumothorax size >50%. Complications were recorded in 11% (7.5-16%) of those having drains inserted. Recurrences occurred in 5/91 (5%, 1.8-12%) of those treated without drainage versus 40/232 (17%, 13-23%) of those treated by drainage, of which half occurred in the first month after drainage. Conclusion Pneumothorax drainage is associated with substantial morbidity including prolonged air leak. As PSP appears to be well tolerated in younger people even with large pneumothoraces, conservative treatment in this subgroup may be a viable option to improve patient outcomes, but this needs to be confirmed in a clinical trial. [ABSTRACT FROM AUTHOR]

Prior to changes in the Western Australian legislation in 1993 an injured worker could sue his or her employer for damages at common law irrespective of the seriousness of injury or size of damages. A common law action is conditional on the personal injury being sustained during the course of employment, and caused by the negligence or breach of statutory duty of the employer. In recent years there has been concern expressed about the efficacy of the common law process in providing injured workers with awards that match their pecuniary and non-pecuniary losses. We address this issue by developing a model of the determination of common law awards in which we assume pre-trial settlement. We find that the economic mechanisms which bring plaintiff and defendant to a pre-trial settlement will not necessarily produce an award settlement consistent with the size of pecuniary and nonpecuniary losses. The model is subjected to an empirical examination using a sample of 384 plaintiffs whose cases were closed in Western Australia in 1990. Our results indicate that in practice the common law process fails to determine an individual assessment of injured workers' losses. In particular, awards represent an inadequate compensation for the losses suffered by severely incapacitated plainttffs. [ABSTRACT FROM AUTHOR]

ACEM has endorsed the proposal for an Aboriginal Voice to Parliament in Australia as a means of delivering its objectives to provide culturally safe care in EDs and to improve health outcomes for Aboriginal and Torres Strait Islander people. Unfortunately the Voice proposal has become a politically conentious issue. There is currently insufficient detail about how the Voice would operate and whether it will achieve the outcomes its proponents intend. This article argues that the claims in the ACEM statement are speculative rather than based on facts. In addition, by taking a position on this complex and controversial political matter ACEM is operating beyond its remit and risks distracting attention from its core mission., (© 2023 Australasian College for Emergency Medicine.)

Alcohol is a modifiable breast cancer risk, increasing risk in a dose-dependent manner. Mid-life women (aged 45-64 years) consume alcohol at higher rates than younger women and this, combined with age, make them a high-risk group for breast cancer. This critical public health problem has a seemingly obvious solution (reduce drinking); however, women do not necessarily know alcohol causes breast cancer, and if they do, reducing consumption is not always possible, or desirable. To innovate public health responses, we employ an interpretative sociological framework 'candidacy' to understand women's perspectives on breast cancer risk relative to alcohol consumption and their social class. Drawing on 50 interviews with Australian mid-life women, our findings reveal the socio-structural determinants of 'candidacy', that mean modifying alcohol consumption for breast cancer prevention is impacted by social class. Utilising Bourdieu's relational capitals, our interpretations show how social class shapes women's ascriptions and enactments of breast cancer candidacy. We offer an important theoretical extension to 'candidacy' by demonstrating more or less fluidity in women's assessment of breast cancer risk according to their agency to adopt breast cancer prevention messages. Understanding the social class possibilities and limitations in women's perceptions of breast cancer risk provides a new opportunity to reduce inequities in breast cancer incidence., (© 2023 Foundation for the Sociology of Health & Illness.)

Silicosis in artificial stone workers has become increasingly recognised in Australia over the last two years, with a large proportion of screened workers showing imaging features of the disease. The spectrum of findings has differed from the classical silicosis previously described, with many features of accelerated disease, including ground-glass opacities and progressive massive fibrosis. This cohort of patients presents after exposure to a unique product high in silica and other binding agents, and the patterns of disease on imaging in this cohort are not previously described. This article reviews the radiological features seen in different forms of silicosis seen to date in this Australian cohort., (© 2020 The Royal Australian and New Zealand College of Radiologists.)

Introduction: To describe the utilization of vasopressors (VP) in patients enrolled in the Australasian Resuscitation In Sepsis Evaluation (ARISE) trial, and to explore the association between time to VP and 90-day mortality., Methods: The primary exposure variable was VP use after arrival in the emergency department (ED). Vasoactive agents considered as VP included: norepinephrine, epinephrine, metaraminol, or vasopressin. Time-to-event analysis, multivariable logistic regression, and propensity-matched treatment effects modeling were used to assess the association between time to VP and 90-day mortality., Results: In total 1,102 of 1,588 patients (69%) in ARISE received VP at any point. The median [interquartile range (IQR)] time from ED presentation to commencing VP was 4.4 [2.7, 7.1] h, and 38% did so prior to central venous access. The median [IQR] volume of intravenous (i.v.) fluid administered prior to commencing VP was 3.1 [2.3, 4.3] L. Increasing age and volume of i.v. fluid therapy were associated with a lower likelihood of commencing VP early (within 4 h of ED presentation), while greater illness severity was associated with a higher likelihood, P < 0.001, respectively. In those who subsequently died within 90 days, the sub-hazard ratio (95% confidence interval) for commencing VP was 1.4 (1.20, 1.68), P < 0.001, adjusted for age, acute physiology and chronic health evaluation II score, study group, inclusion criteria, plasma lactate, i.v. fluid prior to VP, study institution, and site of infection., Discussion: 50% of the ARISE cohort commenced VP within 4.4 h of ED presentation, and many did so prior to central venous access. Earlier initiation of VP was associated with greater crude and adjusted 90-day mortality.

We report results of a retrospective review of intra-aortic balloon pump (IABP) use in two Australasian centres and evaluate the effect of final IABP tip position on outcome. Indications for counterpulsation, patient demographics and in-hospital outcomes and complications were retrospectively collected. The chest X-ray reports provided the 'final' position of the IABP tip. The position was defined as acceptable (tip was seen just below the aortic arch, at T2-T5 vertebrae), malpositioned (tip > 5 cm below aortic arch or at T5-T6) or severely malpositioned (tip > 10 cm below aortic arch or at T7 or below).?Major complications were considered a composite of death secondary to IABP, major limb ischaemia, major IABP malfunction, balloon rupture or haemorrhage, severe renal dysfunction (rise in creatinine > 200 µmol/l), stroke and mesenteric ischaemia. Six hundred and forty-five cases were reviewed. The overall major complication rate was 26.2% and 24.3%. Severe renal impairment was the most common complication (16.6%), and second, severe catheter dysfunction (5.4%). ?Final IABP position was acceptable in 39.9%, malpositioned in 11.1%,?severely malpositioned in 6.7% and unavailable for 42.4%. Logistic regression analysis showed IABP tip malposition (compared with satisfactory position odds ratio=3.9 [95% confidence interval=2.0-7.6, P < 0.001] and severely malpositioned odds ratio=13.0 [95% confidence interval 5.3-31.7, P < 0.001]) was associated with major complications more than the presence of shock (odds ratio=3.8, confidence interval=2.1-6.8 P < 0.001). The acceptance of a less-than-ideal final position was highly predictive of morbidity directly related to IABP device therapy.

Many patients with musculoskeletal pain also suffer from a depressed mood. Catastrophizing is one process that may link depression and pain since it is a key concept in models of both problems. Earlier research has suggested that catastrophizing measures something above and beyond depression. This study tests the idea that if depressed mood and catastrophizing are separate entities then when one is absent the other should still contribute to poor outcome, and, when both are present there should be an additional adverse effect. To this end, a prospective design, with a built-in replication from two clinical samples of patients with sub-acute pain (one from Sweden, N=373; one from Australasia, N=259), was employed. Participants were classified as to having high/low scores on measures of depression and catastrophizing. Subsequently, these classifications were studied in relation to outcome variables cross-sectionally and at follow-up. Results showed a small to moderate correlation between catastrophizing and depression and that there are individuals with one, but not the other problem. Further, having one or the other of the entities was associated with current pain problems and outcome, while having both increased the associations substantially. The replication showed very similar results Our data demonstrate that pain catastrophizing and heightened depressed mood have an additive and adverse effect on the impact of pain, relative to either alone. It suggests that each should be assessed in the clinic and that future research should focus on treatments specifically designed to tackle both depressed mood and catastrophizing., (Copyright © 2010 European Federation of International Association for the Study of Pain Chapters. Published by Elsevier Ltd. All rights reserved.)

In this review evidence on the impact of introducing or lowering legal blood alcohol limits on traffic safety measures is examined. There is substantial variability in the types and rigour of methods used to evaluate these legislative measures, and thus not surprisingly there is variability in the results observed. In most but not all cases where an evaluation of an introduced or lowered legal limit has been conducted, some beneficial effect on traffic safety measures has been reported. These effects are in some cases relatively small, and in other cases may be temporary. In some jurisdictions, lasting reductions in collision rates have been reported. Available evidence suggests that where beneficial effects are observed they are due to general deterrence, and not restricted only to drivers at blood alcohol concentrations (BAC) specifically affected by the legal change.

An epidemic of cardiovascular disease (CVD) and end stage renal disease (ESRD) has developed among Aborigines in the Northern Territory; CVD deaths increased over the 1980s (tripling among women!), and are now more than five times those of non-Aboriginal people, while ESRD rates are increasing more than 20-fold and are doubling every three to four years. Dialysis costs (>$75,000 per person/year) pose a crisis for health care budgets, but premature mortality is the greater human catastrophe. Health services are not meeting the challenge of timely diagnosis, prevention and containment. We screened 90% of adults (20+ years) in one community, with CVD mortality among the highest in Australia, and ESRD rates increased 60-fold. Seventy-five per cent of persons were smokers. Central obesity was common, but BMIs only modestly increased by Caucasian standards, 23% had hypertension (>140/90), 29% had diabetes or impaired glucose tolerance (IGT) (peaking at 65% of persons aged 40-49 years), high triglyceride and insulin levels were common, and 55% had albuminuria (albumin/creatinine ratio (ACR), >3.4 gm/moL). Progressive albuminuria predicted renal failure. ACR was correlated with age, BMI, blood pressure, lipid, glucose and insulin levels, heavy drinking and past and current skin infections, and, inversely with birth weight. ACR correlated strongly with a composite CV risk score, and in a two to five year follow-up, microalbuminuria (ACR 3.4-33) and overt albuminuria (ACR 34+) have both predicted increased rate of premature death from natural causes of lower ACRs. Thus albuminuria marks CV risk/disease. This implies that renal and CV disease share common risk factors, and should respond to the same interventions, and that this response might be monitored through ACR levels. Robust public health programmes could reduce all these reversible risk factors, lowering disease rates over the intermediate term, however, few such programmes are in place. Modification of disease in persons already afflicted is a parallel responsibility. To this end, in November 1995, we introduced a treatment programme with Coversyl (perindopril, Servier) for all persons in the study community with hypertension (>140/90), for all diabetics with ACR 3.4+ and for all nondiabetic, non-hypertensive persons with progressive overt albuminuria (ACR 34+). One-quarter of all adults, or 224 persons have enrolled; 162 have reached one year of treatment and 100 have passed two years. Compliance is reasonable and enthusiasm high. Average SBP has fallen 12 mmHg (24 mmHg in hypertensive persons), while average ACR and estimated glomerular filtration rate (GFR) have stabilised. This contrasts favourably with the pretreatment course (average 2.7 years) in the same persons, when SBP had increased by 3 mmHg, ACR had increased by 15% and GFR had decreased by 3.5 mL/min each year. Cautious estimates suggest a >50% fall in ESRD, and a reduction in all-cause and CV deaths, even at this early stage, although more extended observation is needed. These data predict a dramatic and rapid fall in morbidity, premature deaths and health care costs if these basic principles of medical care are extended to all Aboriginal people. A national, concerted, multi-disciplinary effort to implement a coherent, effective strategy to this end is of great urgency.

Objectives: To examine health practitioner and community concerns, priorities and preferred options regarding patient self-determination in terminal care., Method: A postal questionnaire was sent to 229 general practitioners in two areas of Queensland (Brisbane and Wide Bay) and to 1100 community members throughout Queensland. Questions covered a range of end of life decision making issues, including where people wish to die, the use of advance directives and proxy decision makers, and possible barriers to such options., Results: GPs and community members held very different opinions on most issues: community members were divided between home, hospital and hospice as a preferred place to die, while GPs strongly favoured home as their preferred place to die. Both groups supported the use of advance directives and proxies, but differed significantly with respect to barriers preventing the use of such options., Conclusion: Clarifying differences in perceptions and preferred options between the two groups on end of life decision making should not only improve communication and interactions between GPs and their patients but also allow both groups to become full participants in current policy and practice debates on end of life decisions.

Objective: To examine current attitudes and knowledge of the community and medical practitioners in Queensland to end-of-life decisions., Design: Cross-sectional survey by postal questionnaire., Participants: 387 general practitioners and medical specialists and 910 community members from the Queensland electoral roll., Main Outcome Measures: Responses to five questions about end-of-life decision-making, and to legislative changes relating to such decisions., Results: The overall response rate for medical practitioners was 67% and for community members was 53%. 78% of community members (age adjusted) and 54% of doctors thought that a doctor should comply with a patient's request to turn off a life-support system; 68% of doctors through people would still ask to have their life ended even if pain were controlled, compared with 54% of community members; 70% of community members thought the law should be changed to allow active voluntary euthanasia, compared with 33% of doctors; and 65% of community members thought that a doctor should be allowed by law to assist a terminally ill person to die, but only 36% of doctors agreed. 79% of doctors and 75% of community members agreed that people would still ask for assistance to end their lives even if optimal palliative care were freely available., Conclusion: Community members supported greater choice and control over end-of-life decisions, while doctors were less supportive of some of the options canvassed. In a climate of community participation in health care decisions, it is important to better understand the basis and meaning of these different views. Further detailed research is recommended.