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Objective: To determine diagnostic performance statistics of extra-labral magnetic resonance (MR) findings for detection of labral tears in a population of patients with clinical suspicion of this diagnosis. Materials and Methods: Seventy-nine patients clinically suspected of having a labral tear (who underwent arthroscopy) had their MR studies retrospectively reviewed to determine the presence of lateral acetabular oedema-like marrow signal, ganglia, dysplastic femoral bumps, synovial herniation pits and geodes. These findings were then correlated with the arthroscopic presence (or absence) of a labral tear. Results: All findings (lateral acetabular oedema-like marrow signal, ganglia, dysplastic femoral bumps, synovial herniation pits and geodes) had a specificity and positive predictive value (PPV) of 100%. Lateral acetabular oedema-like marrow signal had a sensitivity of 35% and 20% negative predictive value (NPV). This was the only statistically significant finding (P 0.05). Conclusion: Lateral acetabular oedema-like marrow signal is a useful sign (100% PPV) in the MR diagnosis of a labral tear, if one is clinically suspected. The other findings (ganglia, dysplastic femoral bumps, synovial herniation pits and geodes) were not statistically significant. Further studies are required to evaluate these.

Introduction: There has been growing interest in the use of MRI in assessing Crohn's disease because of its lack of ionising radiation. Many MRI signs have been described in the literature, but their relative utility is unknown. Methods: The MRIs of the bowel performed at 1.5 Tesla were blindly reviewed on 26 patients with recent histology (surgery and/or colonoscopy and their associated reports) according to a dedicated pro forma. Each patient's bowel was divided into nine segments. Each segment was assessed as to the presence or absence of 15 MRI signs described in the literature: abnormal gadolinium enhancement (both subjective and objective), wall oedema, fat oedema, fat proliferation, nodal enlargement, free fluid, wall nodularity, serosal blurring, mural thickening >4 mm, stricture, multi-segmental disease, fistula, abscess and layered contrast enhancement. The results were compared against a histological gold standard with a six-point scale of disease severity. Results and conclusions: MRI correctly identified all 15 patients with at least established mucosal disease, and three of eight with only mild mucosal disease. Combining these results, a positive MRI correlated highly with at least early mucosal disease (positive predictive value 95%), while the presence of established mucosal disease was unlikely if MRI was negative (negative predictive value 100%). The MRI signs found to be the most sensitive for detecting active Crohn's disease were those related to the bowel wall, namely, wall thickening, nodularity, contrast enhancement and oedema. The most specific signs were the presence of multi-segmental disease, layered contrast enhancement and complications (fistula and abscess).

Objective To investigate the clinical utility of current-generation dipole modelling of scalp EEG in focal epilepsies seen commonly in clinical practice. Methods Scalp EEG recordings from 10 patients with focal epilepsy, five with Benign Focal Epilepsy of Childhood (BFEC) and five with Mesial Temporal Lobe Epilepsy (MTLE), were used for interictal spike dipole modelling using Scan 4.3 and CURRY 5.0 . Optimum modelling parameters for EEG source localisation (ESL) were sought by the step-wise application of various volume conductor (forward) and dipole (inverse) models. Best-fit ESL solutions (highest explained forward-fit to measured data variance) were used to characterise best-fit forward and inverse models, regularisation effect, additional electrode effect, single-to-single spike and single-to-averaged spike variability, and intra- and inter-operator concordance. Inter-parameter relationships were examined. Computation times and interface problems were recorded. Results For both BFEC and MTLE, the best-fit forward model was the finite element method interpolated (FEMi) model, while the best-fit single dipole models were the rotating non-regularised and the moving regularised models. When combined, these forward–inverse models appeared to offer clinically meaningful ESL results when referenced to an averaged cortex overlay, best-fit dipoles localising to the central fissure region in BFEC and to the basolateral temporal region in MTLE. Single-to-single spike and single-to-averaged spike measures of concordance for dipole location and orientation were stronger for BFEC versus MTLE. The use of an additional pair of inferior temporal electrodes in MTLE directed best-fit dipoles towards the basomesial temporal region. Inverse correlations were noted between unexplained variance (RD) and dipole strength (Amp), RD and signal to noise ratio (SNR), and SNR and confidence ellipsoid (CE) volume. Intra- and inter-operator levels of agreement were relatively robust for dipole location and orientation. Technical problems were infrequent and modelling operations were performed within 5min. Conclusions The optimal forward–inverse single dipole modelling set-up for BFEC and MTLE interictal spike analysis is the FEMi model using the combination of rotating non-regularised and moving regularised dipoles. Dipole modelling of single spikes characterises best-fit dipole location and orientation more reliably in BFEC than in MTLE for which spike averaging is recommended. Significance The clinical utility of dipole modelling in two common forms of focal epilepsy strengthens the case for its place in the routine clinical work-up of patients with localisation-related epilepsy syndromes.

Rheumatoid arthritis (RA) is associated with increased cardiovascular disease (CVD) risk that has been attributed to endothelial dysfunction and inflammation. Non-steroidal anti-inflammatory drugs (NSAIDs) and cyclo-oxygenase (COX)-2 inhibitors have been shown in some studies to improve endothelial function in subjects without RA. The aim of this study was to investigate the effects of COX inhibition on endothelial function in patients with RA.Patients with RA (n = 37) were randomized to receive a 2-week course of either indomethacin (75 mg bd), rofecoxib (12.5 mg bd), or placebo in a double-blind study. Endothelial function was measured using flow-mediated dilation (FMD) of the brachial artery in response to reactive hyperaemia. Arterial stiffness was also assessed using pulse wave analysis (PWA) through the measurement of the aortic augmentation index (AIx). Measurements of vascular function and inflammatory markers were taken before and at the end of the treatment period.There were no significant differences in changes in FMD, AIx, blood pressure (BP), serum creatinine, erythrocyte sedimentation rate (ESR), or high-sensitivity C-reactive protein (hsCRP) between groups. However, compared with the other treatment groups, there was a tendency for systolic BP to decrease in the placebo group (p = 0.063) and for creatinine to increase in the indomethacin and rofecoxib groups after treatment (p = 0.054).This study suggests that COX inhibition by indomethacin or rofecoxib do not improve endothelial function in patients with RA.

Objectives: The primary aim of treatments for COPD is to improve health-related quality of life. However, little is known of the clustering effects related to health-related quality of life as an outcome measure. If clustering effects are observed, these have important implications for sample size estimates when cluster randomization is used in interventional studies. This study aimed to determine the intracluster correlation coefficient (ICC) of the quality of life, between hospitals for COPD patients. Methodology: The Dyspnoea Impact and Symptoms Questionnaire was administered to 100 COPD inpatients from four public hospitals (25 from each) around metropolitan Melbourne, selected on the basis that they had not had any major programs implemented within the last 2 years that aimed to improve the management of COPD. Data were collected concerning demographic and socioeconomic variables and comorbidities. Results: The highest ICC value for a health-related quality of life subscale was 0.02 (psychological score), while the highest for a symptom-based subscale was 0.04. Conclusions: There is minimal clustering effect of quality of life in COPD patients between the hospitals studied. Despite this, when using a cluster randomised design the sample size needed to detect the same effect as a study using simple randomisation could be inflated by up to 183%. If cluster randomization is required, the average cluster size should be kept as small as possible to negate this effect.

Through the Australian National Creutzfeldt-Jakob Disease Registry, 6 pathologically confirmed sporadic cases were recognized over a 13-year period in persons who had been long-term residents of a moderate-sized rural city, whereas the expected number was 0.923. An extensive investigation could not find any point-source or case-to-case transmission links. This occurrence is highly statistically significant (p = 0.0027) when viewed in isolation and remains significant (p < 0.02) when only the cases that arose after the cluster was recognized were taken into account. However, a more conservative statistical analysis suggests that such a grouping could have arisen by chance in at least one population group of this size when the whole country is taken into consideration.

BACKGROUND The development of prostate carcinoma is androgen-dependent. The coding sequence of the androgen receptor (AR) gene contains a CAG repeat polymorphism that has been shown to influence AR activity in vitro. Studies of this polymorphism as a prostate carcinoma risk factor have been conflicting. METHODS A matched case–control design was used in a clinic-based multicenter study of Australian prostate carcinoma subjects. Cancer subjects were matched by age and locality with controls, all of whom had a serum prostate specific antigen (PSA) level of less than 4 mg/L. Conditional logistic regression was used to determine the relative risk of prostate carcinoma dependent on AR gene CAG number. The association of disease characteristics at diagnosis with the polymorphism also was assessed. RESULTS Five hundred forty-five cases of prostate carcinoma and 456 matched case–control pairs were recruited. Association studies of disease characteristics at diagnosis showed age at diagnosis to be associated with AR CAG number by univariate (P = 0.004) and multivariate (adjusting for PSA, stage, and grade) linear regression (P = 0.018). No association was observed between the polymorphism and disease stage (TNM-based categories; P = 0.277), histologic grade (P = 0.41), or PSA level at diagnosis (P = 0.48). In the pairwise case–control analysis, the odds ratio of prostate carcinoma for a change of 5 CAG repeats gave an odds ratio of 0.9821 (95% confidence interval, 0.84–1.15). CONCLUSIONS In this Australian study population, the AR CAG repeat polymorphism was not a risk factor for prostate carcinoma, but a shorter repeat sequence was associated with earlier age at diagnosis. Cancer 2001;92:941–9. © 2001 American Cancer Society.

Objectives To describe Victorian general practitioners' attitudes towards and use of a range of complementary therapies. Design A self-administered postal survey sent to a random sample of 800 general practitioners (GPs) in Victoria in July 1997. Participants 488 GPs (response rate, 64%). Main outcome measures GPs' knowledge; opinions about harmfulness and effectiveness; appropriateness for GPs to practise; perceived patient demand; need for undergraduate education; referral rates to complementary practitioners; and training in and practice of each therapy. Results Acupuncture, hypnosis and meditation are well accepted by the surveyed GPs, as over 80% have referred patients patients to practitioners of these therapies and nearly half have considered using them. General practitioners have trained in various therapies--meditation (34%), acupuncture (23%), vitamin and mineral therapy (23%), hypnosis (20%), herbal medicine (12%), chiropractic (8%), naturopathy (6%), homoeopathy (5%), spiritual healing (5%), osteopathy (4%), aroma-therapy (4%), and reflexology (2%). A quarter to a third were interested in training in chiropractic, herbal medicine, naturopathy and vitamin and mineral therapy. General practitioners appear to underestimate their patients' use of complementary therapies. Conclusions There is evidence in Australia of widespread acceptance of acupuncture, meditation, hypnosis and chiropractic by GPs and lesser acceptance of the other therapies. These findings generate an urgent need for evidence of these therapies' effectiveness.

Objective: Dilated cardiomyopathy (DCM) is associated with a progressive deterioration in cardiac function. We hypothesised that some of the deleterious effects of DCM could be reduced by mechanically limiting the degree of cardiac dilatation. Methods: A Transonic 20A cardiac output (CO) flow-probe was implanted in the pulmonary artery of 12 adult (52±4 kg) sheep. Early heart failure was created by rapid right ventricular (RV) pacing for 21 days at a rate which resulted in an initial 10% decrease in CO (to a maximum of 190 bpm). A custom polyester jacket (Acorn Cardiovascular, St Paul, MN) was then placed, via a partial lower sternotomy, on the ventricular epicardium of all sheep. Animals were randomised either to jacket retention (wrap) or removal (sham). Pacing was recommenced at a higher rate (that initiated a further 10% decrease in CO) for 28 days. Haemodynamic and echocardiographic parameters were determined at baseline, implant and at termination. Results: At termination, the left ventricular fractional shortening was significantly higher ( p =0.03), the degree of mitral valve regurgitation lower (scaled 0–3) ( p =0.03) and the left ventricular long axis area smaller ( p =0.02) in the wrap animals compared with sham. Conclusions: In this model of heart failure, ventricular constraint with a polyester jacket diminished the deterioration in cardiac function associated with progressive dilated cardiomyopathy. These results suggest that maintainance of a more normal cardiac size and shape may be beneficial in patients with dilated cardiomyopathy.

Plasma fibrinogen concentration is an important independent risk factor for cardiovascular disease. Studies into whether Helicobacter pylori infection and fibrinogen are associated have yielded inconsistent results. Despite the geographical variation in fibrinogen and prevalence of H. pylori infection, all studies to date have been undertaken in the United Kingdom or Italy. The association between H. pylori infection and fibrinogen was investigated in 324 adults, 65% of a random sample, in an Australian regional city. The mean plasma fibrinogen concentration in 98 infected participants (2.52 g/l) was similar to that in 226 non-infected subjects (2.58 g/l, P = 0.51); 95% confidence interval on the difference was - 0.23-0.11 g/l. After including all potential confounding factors in a backward multiple linear regression analysis, H. pylori was still not associated with fibrinogen (P = 0.084). Any association between H. pylori and cardiovascular disease in Australia is not mediated through fibrinogen.

INTRODUCTION: The development of susceptibility to atrial fibrillation (AF) is a common consequence of many forms of cardiovascular disease, especially heart failure. In this study we used a sheep model of pacing-induced stable early heart failure to describe, quantify, and relate the level of susceptibility to AF to changes in structural and electrophysiologic parameters. METHODS AND RESULTS: Epicardial electrodes were implanted on the atria and right ventricles of nine sheep. The AF threshold, atrial vulnerability period, atrial effective refractory period (ERP), and interatrial conduction time were examined during control and over a 6-week period of ventricular pacing at 190 beats/min. Left atrial (LA) area and left ventricular (LV) fractional shortening were monitored using echocardiography. There were significant increases in LA susceptibility to AF (P < 0.0003), LA area (P < 0.0002), and LA ERP400 (P < 0.0002). Rate of increase in LA area was related positively to AF susceptibility (P = 0.02) and inversely to LA ERP400 (P = 0.002). LV fractional shortening decreased to approximately 50% of control value (P < 0.00001). No changes were observed in right atrial electrophysiology. CONCLUSION: In this study, susceptibility (the ability of an extrastimulus to induce AF) was rigorously measured within a predetermined format. Significant relationships were found to exist between susceptibility, certain of the observed changes in atrial electrophysiology and structure.

Factors associated with unsafe drinking in a rural area were identified and the prevalence of unsafe drinking and alcohol related mortality compared with a metropolitan area. Alcohol consumption data were collected from a random sample of adults in Greater Ballarat. Odds ratios of demographic factors associated with unsafe drinking were estimated by logistic regression. Compared with males and 20-29-year-olds, females and 30-59-year-olds had a significantly lower prevalence of 'intermediate' or higher risk drinking and binge-only drinking. Rural-metropolitan ratios for the prevalence of unsafe drinking and alcohol related mortality were also greatest in young adults. Young adults must adopt safer drinking habits if the rural excess in mortality is to be reduced.

Purpose: The purpose of the study is to analyze the effectiveness and side effects of botulinum toxin using four different treatment site applications to determine the most successful treatment regime with the least side effects. Methods: In a prospective trial, 92 patients (50 blepharospasm and 42 hemifacial spasm) were assigned randomly to 1 of 4 different treatment groups (standard [S], brow [B], inner orbital [10], or outer orbital [00]). Each treatment group had a different pattern of injection sites in the orbicularis. A total of 285 treatments were given, and the mean follow-up time was 16.4 months. Results: In the blepharospasm group, patients assigned to the standard group had a significantly longer duration of effect than for those in the brow, inner orbital, and outer orbital groups (8.1 weeks compared with 4.5, 4.2, and 3.1 weeks, respectively; P P Conclusions: The position of the injection sites around the orbicularis influences the effectiveness and side effects of botulinum toxin treatment for patients with blepharospasm and hemifacial spasm. The further the treatment is away from the eyelid margin, the lower the risk of ocular side effects. The standard treatment produces the longest duration of effect in the blepharospasm group but with the most transient ocular irritation and epiphora. In the hemifacial spasm group, the brow treatment has an equally long duration of effect as that of the standard treatment with fewer side effects.

Objective: Recently we described the establishment and first 6 months of a psychiatric consultation-liaison service to a Melbourne obstetric-gynaecology teaching hospital. The follow-up report evaluates the service in two ways: first, it compares referral data for the 12 months of 1992 with that of the first 6 months of operation in 1990; and second, it reports on results of a survey of referrer and patient satisfaction with the service. Method: Referral data were collected for the data comparison from the consultation-liaison referral book and patients' files. Referrer and patient satisfaction was evaluated by questionnaires sent to 45 medical staff, 7 charge nurses, and 100 consecutive patients. Result: A fairly constant referral rate for inpatients has emerged at 0.8%, this very low referral rate being some cause for concern. An internal shift in the type of referrals over time has developed, with an increase in obstetric and a decrease in gynaecology referrals. High referrer satisfaction, with 86% of the doctors finding the consultation(s) “very” or “quite” helpful, and high patient satisfaction, with 83% of respondents having found the consul tat ion(s) “very” or “quite” helpful, was found. Conclusions: Despite high referrer and consumer satisfaction, and objective evidence of need, this pioneering consultation-liaison service in obstetric-gynaecology continues to be grossly under-utilised. Increasing the referral rate will be one of the greatest challenges in the future of this service.

Persistent nipple pain in lactating women, burning in nature, and associated with radiating breast pain, has been claimed by some authorities to be due to 'thrush' (candida) infection. Yet, scientific proof has been lacking. This study compared microbiological assessment of 61 women with nipple pain, 64 women without nipple pain, and 31 non-lactating women. Swabs of the nipple and baby's mouth, and expressed breast milk were collected for culture. Growth of Candida albicans (nipple and milk) was found more often in the women with nipple pain (19%) than in the control group (3%, p0.01). In addition, Staphylococcus aureus was also associated with nipple pain (p0.0001), and independently associated with nipple fissures (p0.0001). Neither C. albicans nor S. aureus was found on the nipples of the non-lactating group.

The aim of the study was to assess the psychological impact of nipple pain in lactating women. Forty-eight lactating women with nipple pain completed mood scales at their first visit and following resolution of their pain, and 65 lactating women without nipple pain completed one set of mood scales. At the first visit, the mean score on the Edinburgh Postnatal Depression Scale (EPDS) in the nipple pain group was 12.4 and the control group was 7.6 (p0.0001). Eighteen women (38%) scored above the threshold for depression (12), compared to nine in the control group (14%): p0.01. Following pain resolution, the mean score on the EPDS decreased to 7.3 (p0.001); and six women (16%) scored 13 or over on the EPDS, significantly less than initially (p0.05). Similarly, on the Profile of Mood States (POMS), the nipple pain group scored significantly higher than control group on all mood factors (Tension, Depression, Fatigue, Confusion, Vigor [lower]), except Anger which did not reach a level of significance. After pain resolution, POMS scores returned to similar levels as the control group. In conclusion, both the EPDS and POMS indicated women with nipple pain were experiencing high levels of emotional distress. However, once the pain had resolved their distress also resolved.

Summary Objectives Few data exist regarding gender differences in hormonal outcomes in nonfunctioning pituitary macroadenomas (NFPMA). The aim was to assess whether there are gender differences in hormonal outcomes in NFPMA following pituitary surgery at a single centre. Design and methods Retrospective review of cases undergoing a first surgical procedure for NFPMA. Preoperative hormonal function was available for 122 cases at presentation and 94 cases 6 months postoperatively. Multiple hormone deficiency was defined as 2 hormonal axis losses. Tumour size and invasion on MRI scan were assessed independently by a single neuroradiologist. Results At presentation, men were more likely than women to have multiple hormonal deficiency (47% vs 28%, P = 0038). Premenopausal women tended to have smaller adenomas than men, but neither adenoma size nor invasion was associated with multiple hormonal deficiency at presentation. Postoperatively, differences were observed with only 14% of premenopausal women exhibiting multiple hormone deficiency, compared with 36% of postmenopausal women and 46% of men (P = 003). Overall, postoperative hormonal recovery was observed in over one-third of cases. Greatest recovery occurred in the gonadal axis of 60% (6/10) premenopausal women compared with 19% (8/43) of other groups combined (P = 0007). Conclusions Premenopausal women with NFPMA appear to have favourable hormonal outcomes. This may be due to a complex interplay between smaller tumour size and shorter disease duration. There should be no hesitation in offering pituitary surgery to premenopausal women with NFPMA, who have the most to gain in terms of restoration of hormonal function.

Recruitment of medical graduates to research careers is declining. Expansion of medical knowledge necessitates all graduates be equipped to critically evaluate new information. To address these challenges, a mandatory intercalated degree programme was introduced as part of curriculum reform.To review the place on intercalated degrees, the methods available for learning about research and to analyse experience with a new university programme focusing on research.A literature review followed by the analysis of experience with eight cohorts of students who had completed the new programme.A total of 1599 students completed the programme. Laboratory-based research was the most common choice followed by clinical research, population health, epidemiology, medical humanities and mental health. Also, 93% of students spent over 75% of their time undertaking research. Sixty-three students published their research, half as first authors. Students and coordinators support the programme. Learning about research during the postgraduate phase is variable and frequently left to individual choice.Intercalating an additional degree focusing on research can achieve a number of learning objectives but demands a level of maturity, autonomy and preparedness, not uniformly present in students undertaking a mandatory intercalated programme. A more realistic goal is the development of 'research-mindedness' amongst all students.

To determine perceived barriers to continuing education for Australian hospital-based prevocational doctors, a cross sectional cohort survey was distributed to medical administrators for secondary redistribution to 2607 prevocational doctors from August 2003 to October 2004. Four hundred and seventy valid questionnaires (18.1%) were returned. Only seven per cent (33/470) did not identify any barriers to continuing education. Barriers identified the most were lack of time (85% [371/ 437]), clinical commitment (65% [284/437]), resistance from registrars (13% [57/437]) and resistance from consultant staff (10% [44/ 437]). Other barriers included workload issues (27% [27/98]), teaching program inadequacies (26% [25/98]), lack of protected time for education (17% [17/98]), motivational issues (11% [10/98]) and geographic remoteness (10% [10/98]). Australian graduates (87%) identified lack of time more frequently than international medical graduates (77%) (P = 0.036). Perceived barriers did not differ significantly between doctors of differing postgraduate years.

OBJECTIVE To explore a possible association between Helicobacter pylori infection and iron status. DESIGN Cross-sectional study. SETTING Ballarat (a major regional city in Victoria), population 78000, October November 1997. PARTICIPANTS 160 women and 152 men, a subsample of participants in a cardiovascular disease risk factor prevalence survey for whom frozen plasma was available. MAIN OUTCOME MEASURES H. pylori IgG antibody status by enzyme immunoassay; iron intake; plasma iron, transferrin and ferritin concentrations. RESULTS 28% of women and 33% of men were infected with H. pylori. The mean (SEM) plasma ferritin concentration of infected women (59.3 [7.6] microg/L) was significantly lower than for non-infected women (88.8 [7.9] microg/L; P=0.002), after adjusting for age. Mean daily dietary iron intakes were similar in infected and non-infected women. CONCLUSIONS H. pylori infection appears to be an additional stressor on women's iron status, but the mechanism remains to be determined.

A recent study suggested that general practitioners (GPs) do not see the necessity of investigating MCVs which unexpectedly and only slightly exceed the reference limit, despite the association between MCV and alcohol abuse. Because a literature search could not find a study of the predictive value of the MCV for hazardous drinking in the community, such a study was undertaken among a random sample of 338 adults living in a regional Australian city. Twenty-nine of the adults admitted drinking hazardously. The MCV with the optimum sensitivity and specificity for identifying the hazardous drinkers was determined. An MCV of > 94 fl identified as many as 35% of the hazardous drinkers whilst misclassifying only 6% of the non-hazardous drinkers. The predictive value was even greater among males, 67%. We conclude that inquiring into MCVs > 94 fl will lead to GPs identifying a significant proportion of adults in the community admitting to hazardous drinking. Language: en

OBJECTIVE: To survey prevocational doctors working in Australian hospitals on aspects of postgraduate learning. PARTICIPANTS AND SETTING: 470 prevocational doctors in 36 health services in Australia, August 2003 to October 2004. DESIGN: Cross-sectional cohort survey with a mix of ordinal multicategory questions and free text. MAIN OUTCOME MEASURES: Perceived preparedness for aspects of clinical practice; perceptions of the quantity and usefulness of current teaching and learning methods and desired future exposure to learning methods. RESULTS: 64% (299/467) of responding doctors felt generally prepared for their job, 91% (425/469) felt prepared for dealing with patients, and 70% (325/467) for dealing with relatives. A minority felt prepared for medicolegal problems (23%, 106/468), clinical emergencies (31%, 146/469), choosing a career (40%, 188/468), or performing procedures (45%, 213/469). Adequate contact with registrars was reported by 90% (418/465) and adequate contact with consultants by 56% (257/466); 20% (94/467) reported exposure to clinical skills training and 11% (38/356) to high-fidelity simulation. Informal registrar contact was described as useful or very useful by 94% (433/463), and high-fidelity simulation by 83% (179/216). Most prevocational doctors would prefer more formal instruction from their registrars (84%, 383/456) and consultants (81%, 362/447); 84% (265/316) want increased exposure to high-fidelity simulation and 81% (283/350) to professional college tutorials. CONCLUSION: Our findings should assist planning and development of training programs for prevocational doctors in Australian hospitals.

Objective: To identify the nature, severity, impact, frequency and risk factors for patient perceived privacy infringements in the ED of St Vincent's Health Melbourne with 32 000 emergency attendances per annum. Methods: Patients 18 years and older attending emergency over a 2-week period were offered a nine-item questionnaire using a Likert scale. A privacy incident was defined as: (i) overhearing medical or personal information; (ii) being overheard; (iii) having private body parts exposed or (iv) seeing others’ body parts. Differences between demographic, emergency environment, length of stay and other factors suspected of affecting patient privacy were quantified. Results: From 1169 emergency presentations, 235 patients returned questionnaires, with 105 of these (45%) reporting a total of 159 privacy incidents. Seventy-eight patients (33%, 95% CI 28–36%) reported a definite privacy incident and 81 (35%, 95% CI 29–37%) reported a probable privacy incident. Ninety-six patients (41%, 95% CI 35–47%) reported overhearing other patient's conversations with the staff whereas 36 (15%, 95% CI 11–21%) felt their conversations with staff were overheard by others. Twenty-seven patients (11%, 95% CI 6–14%) experienced or observed inappropriate exposure of private body parts. Ten patients (4%, 95% CI 2–7%) changed or withheld information from staff because they felt others may overhear it and two refused part of their physical examination because they felt they may be seen by inappropriate people. Twenty-four patients (10%, 95% CI 6–14%) did not have their expectations of privacy met. The longer a patient was in emergency the greater the number of privacy incidents they experienced (Spearman correlation P

Agreement between Helicobacter pylori IgG antibodies measured using the Pylori-set EIA-G kit in serum, plasma and successively thawed specimens was studied and the implications for epidemiological and clinical studies assessed. Plasma titres may differ from serum titres by -6% to +8% and therefore may be substituted for serum. The change in titre around the cut off value was -0.31 (se = 5.7, p = 0.96) per thaw. The estimated maximum drop after three thawings, 34.5, would result in only a small decrease in sensitivity (1.3%). For qualitative epidemiological studies, this additional misclassification rate is relatively small. However, positive titres did reduce over successive thawings, with the estimated maximum drop being 11.4% per thaw. Therefore, thawing does need to be considered as a contributing factor when interpreting titre drops in eradication trials. Baseline and follow up specimens from clinical studies should be thawed once only and tested concurrently.

To compare the characteristics of Victorian general practitioners who practise and do not practise complementary therapies.A self administered postal survey sent to 800 Victorian GPs.The response rate was 64%. There were no statistically significant differences between complementary therapy practitioners and nonpractitioners in the number of patients seen per week, urban versus rural location, solo versus group practice or Fellowship of the Royal Australian College of General Practitioners. In some complementary therapies, practising GPs tended to be male, full time and older.Victorian GPs who practise complementary therapies are on the whole not from the fringes of the medical community. The reasons why GPs include complementary therapies in their practice cannot be answered by this study.

AIM: To estimate the effectiveness of inactivated influenza vaccine in persons aged 65 years and over living in the community. SCOPE: A meta-analysis of studies selected using predetermined criteria without language restriction. CONCLUSION: Influenza vaccine was effective in reducing influenza-like illness by 35% (95% confidence interval (CI) 19-47%), hospitalization for pneumonia and influenza by 33% (CI 27-38%), mortality following hospitalization for pneumonia and influenza by 47% (CI 25-62%); and mortality from all causes by 50% (CI 45-56%).

Left atrial (LA) dilation is a common finding in patients with chronic atrial fibrillation (AF). Progressive dilatation may alter the atrial defibrillation threshold (ADFT). In our study, epicardial electrodes were implanted on the LA free wall and right ventricular apex of eight adult sheep. Large surface area, coiled endocardial electrodes were positioned in the coronary sinus and right atrium (RA). LA dilatation was induced by rapid ventricular pacing (190 beats/min) for 6 weeks and echocardiographically assessed weekly along with the ADFT (under propofol anesthesia). LA effective refractory period (ERP) was measured every 2-3 days using a standard extra stimulus technique and 400 ms drive. The AF cycle length (AFCL) was assessed from LA electrograms. During the 6 weeks of pacing the mean LA area increased from 6.1 +/- 1.5 to 21.3 +/- 2.4 cm2. There were no significant changes in the mean ADFT (122 +/- 15 V), circuit impedance (46 +/- 5 omega), or LA AFCL (136 +/- 23 ms). There was a significant increase in the mean LA ERP (106 +/- 10 ms at day 0, and 120 +/- 13 ms at day 42 of pacing). In this study, using chronically implanted defibrillation leads, the minimal energy requirements for successful AF were not significantly altered by ongoing left atrial dilatation. This finding is a further endorsement of the efficiency of the coronary sinus/RA shock vector. Furthermore, the apparent stability of the AF present may be a further indication of a link between the type of AF and the ADFT.

The study's aim was to assess how much of the variation in disease-specific mortality between metropolitan, rural and remote areas is specific to those diseases or reflects the all-cause mortality pattern. The ranges and variances of disease-specific standardised proportional mortality ratios between geographical areas were compared to those of the corresponding standardised mortality ratios. For most chapters in the International Classification of Diseases, the ranges and variances of the standardised proportional mortality ratios were less than 40% of those of the corresponding standardised mortality ratios. Only a small proportion of the variation in mortality can therefore be attributed to a specific disease component; the remainder must be attributed to an underlying force of mortality. Research, programs and policies addressing the socio-economic disadvantages of living in remote areas may lead to a greater improvement in mortality than those targeting specific diseases.

OBJECTIVE To investigate the prevalence of Helicobacter pylori infection and potential risk factors for infection in an adult Australian population. DESIGN Cross-sectional study. SETTING Ballarat, a major regional city in Victoria (population, 78,000; 92% bom in Australia), November 1994 to July 1995. PARTICIPANTS 217 adults randomly selected from the electoral roll. MAIN OUTCOME MEASURES H. pylori IgG antibody status by enzyme immunoassay; amount of dental plaque; sociodemographic and other potential risk factors; odds ratios for risk factors determined by logistic regression analysis. RESULTS Age-standardised prevalence of H. pylori infection was 30.6%. After adjustment for age, sex and socioeconomic index, positive H. pylori status was significantly associated with increasing number of tooth surfaces with a high plaque score (odds ratio [OR], 1.7; 95% confidence interval [CI], 1.1-2.7), increasing number of years in a job with public contact (OR, 1.7; 95% CI, 1.3-2.3), blood group B antigen (OR, 3.1; 95% CI, 1.1-9.1), and having lived in a household with more than six members during childhood (OR, 2.5; 95% CI, 1.1-5.5). Negative H. pylori status was significantly associated with increasing education, having ever lived on a farm, and having teeth scaled less than once a year. CONCLUSIONS H. pylori infection is common. Dental plaque may be a reservoir for H. pylori, which is probably transmitted by person-to-person contact, and blood group B antigen may predispose to infection. Community education about effective oral hygiene and adoption of good hygiene practices by those with regular public contact may be important to prevent acquisition and transmission of H. pylori.

OBJECTIVES: To examine the reliability of relative work value assessment in general practice consultations and to determine whether different methods of assessing work produce consistent rankings. DESIGN: Cross-sectional observational assessment of general practice consulations. SETTING: General practices in Victoria between October 1991 and October 1992. PARTICIPANTS: 686 patients attending one of 58 general practitioners (GPs) drawn from a random, stratified sample. METHODS: Each participating GP had one day of consultations videotaped. They rated the work value of each consultation by using a magnitude estimation scale relative to a reference vignette. Three GP observers independently applied the same scale to the videotaped consultations. After three months, the observers applied a second measurement of work value, a compensation scale (also relative to the reference vignette), to the videotaped consultations. Duration of consultation was the third rating method. MAIN OUTCOME MEASURES: The reliability of work value assessment for each scale. Consultation rank order correlation coefficients among all rating methods. RESULTS: Observer reliability was high for both scales. Practising GPs showed lower levels of reliability in assessing the work value of their consultations. Strong positive correlations were found for consultation rankings among the observer scales and duration of the consultation. The duration of the consultation emerged as an important predictor of consultation work value. CONCLUSIONS: Scaling methods appear to be of little value to the practising GP in reliably assessing the relative work value of their consultations; training in the use of these scales may improve their reliability. However, the duration of consultation may be a reasonable proxy for relative work value assessment in general practice consultations.

Objective: The present study set out to determine general levels of distress, anxiety and depression in an obstetric-gynaecology inpatient population and to ascertain levels of patient satisfaction with services. Method: 200 English-speaking consecutive admissions to the hospital filled out a package of questionnaires consisting of a demographic data form, the 30-item General Health Questionnaire, the Speilberger State-Trait Anxiety Inventory, the Inventory to Diagnose Depression and a Patient Satisfaction with Services Questionnaire. 134 packages were fully completed. Results: The most significant findings were: first, that high levels of anxiety prevailed, with approximately 1/3 of patients at or above the 75th percentile for anxiety levels; and second, that those patients born in non-English speaking countries were significantly more dissatisfied with their care. Conclusions: The results of this study suggest that there is a need for increased awareness of and further research into the psychological needs of obstetric-gynaecology patients.

Objectives. We assessed the feasibility of low energy endocardial defibrillation in a canine model of atrial fibrillation, comparing catheters with large surface area electrodes and standard electrode catheters, and evaluated the effects of lead configuration and circuit impedance on defibrillation energy requirements.Background. Although recent animal studies have demonstrated the feasibility of low energy endocardial atrial defibrillation, their results have been conflicting with regard to important methodologie aspects.Methods. In 14 anesthetized greyhounds, atrial fibrillation was induced by rapid atrial pacing and maintained by vagal stimulation. Two large surface area braided electrode catheters and two standard electrode catheters were introduced percutaneously, one of each, in the right atrial appendage and right ventricular apex. A cutaneous patch electrode was placed on the left thorax. Biphasic shocks synchronized to the ventricular electrogram were used to terminate atrial fibrillation. Seven configurations were evaluated. Three used standard electrodes: proximal atrial cathode to distal atrial, ventricular or cutaneous anode. Four used braided electrodes: three with atrial cathode to ventricular, cutaneous or combined anode; one with ventricular cathode to atrial anode.Results. Defibrillation with standard electrode catheters was associated with high impedance (576 ± 112 Ω) and low success rates for all configurations (28% success at ≤40 J, no successes at 10 J). Low energy defibrillation was readily achieved with the braided electrodes with significantly lower impedance (75 ± 13 Ω, p < 0.0001). Ventricular fibrillation did not occur. The success rate of cardioversion increased in a dose-response manner, allowing fitting of a sigmoid curve and calculation of energy associated with 50% (ED50) and 90% (ED90) success. The most successful configuration was ventricular cathode/atrial anode (ED501.5 ±0.4 J), and the least successful was atrial anode/cutaneous patch (ED506.5 ± 3.2 J, p = 0.0001).Conclusions. Low energy atrial defibrillation is feasible using large surface area electrodes but not with standard electrode catheters owing to high impedance. An intracardiac anode provides lower impedance and higher success rates than are provided by a cutaneous anode.

Objective To examine the characteristics of all individuals assessed as requiring nursing home care arising from a population living within a defined geographical region and to study the manner in which they presented for assessment. Design Clinical assessment by a physician in geriatric medicine with the assistance of other disciplines. Setting Regional Geriatric Assessment Service. Subjects All persons recommended for nursing home care within the study period. Results The major diseases contributing to the need for nursing home care were organic brain disorders (60%) and stroke (32%). Dementia was present in 64% of cases; significant behavioral disturbance in 18%; severe communication disorders were frequent. The majority (86%) had been ill for greater than 1 year. The mode of presentation was acute in 9%, acute-on-chronic in 46%, and chronic in 45%. It was associated with significant differences in case characteristics including the location at the time of assessment, diagnoses, duration of illness, physical dependency, communication disorders, behavioral disturbance, and skilled nursing care requirements. Conclusions These observations suggest that progression to nursing home care varies considerably. Strategies directed toward the prevention of institutionalization should be organized in recognition of these variations.

Investigations into seasonal trends for the onset of leukemia have produced conflicting results. The majority of studies demonstrating seasonal variation have done so for childhood ALL and have suggested a role for an infectious agent. Few investigations have studied adult AML and none have looked at the potential differences between various AML subtypes. An infectious etiology for adult AML will more likely be reflected by cases that are truly de novo and that have not arisen by transformation from a pre-leukemic phase or from prior exposure to a carcinogenic agent. The Victorian Cancer Cytogenetics Service is the central reference laboratory for cytogenetic analysis of all new adult leukemias in the state of Victoria. We have investigated seasonal trends in the diagnosis of 635 cases of new adult AML (≥15 yrs) received for cytogenetic analysis during a five-year period, March 1999 – Feb 2004. Cases of new AML that were secondary in nature were excluded. Cases were subdivided into three recognised prognostic risk groups (favourable, intermediate and adverse) based on cytogenetic findings according to the published criteria of the UK Medical Research Council. The favourable risk group (FR) consisted of t(15;17), inv(16)/t(16;16) and t(8;21) (n = 95). The adverse risk group (AR) included complex karyotypes, abnormalities of 3q, monosomy 7 and loss of chromosome 5 or part of 5q (n = 118). The intermediate risk group (IR) consisted of all other cytogenetic findings including normal results (n = 422). The cytogenetic abnormalities comprising the FR group are rarely associated with secondary AML whereas the converse is true of the AR group. Initial descriptive statistics demonstrated that the greatest trend towards seasonal variation was in the FR group with a peak occurrence in Spring. Spectral analysis was subsequently performed on the data in order to detect if any underlying pattern was genuinely present for the three prognostic groups. The outcome of this analysis supported the possibility of an approximately 12 month cycle for the FR group with the potential peak around the month of October, the middle month of a southern hemisphere Spring. The relatively short time frame of only 5 years limited the interpretation of the analysis. However, these results suggest a possible seasonal trend in the incidence of new adult AML presenting with cytogenetic abnormalities associated with a favourable prognosis. Analysis of data covering a greater time period is proposed to further investigate these preliminary findings.

Objective: This study measures the effect of an intervention to improve mailed survey response rates. Method: A randomised controlled trial of a ‘primer’ postcard was performed as part of a large survey in Victoria in 1997 Prior to the survey mailout, half the sample of 800 general practitioners supplied by the Health Insurance Commission was sent, at random, a primer card to request prompt return of the survey. Results: The intervention resulted in a more rapid return of the survey and improved overall response rates from 60% to 66%. The increased cost per returned survey (40°) was largely offset by fewer non-responders requiring follow-up. Conclusions: A primer postcard is a time and cost-efficient method to increase response rates in general practitioner surveys. Implications: Public health researchers should consider implementing this intervention to improve response rates to postal surveys. Reports of other response maximising strategies should report the cost per returned survey to allow better comparison.