Suicide among psychiatric patients : a case-control study

Objective: To examine patient- and treatment-based differences between psychiatric patients who do and do not die by suicide. Method: By linking databases of deaths and psychiatric service use in Victoria, we compared 597 cases who suicided over 5 years with individually matched controls. Results: Cases and controls could not be distinguished on the majority of patient- or treatment- based characteristics. The exceptions were that cases were more likely to be male, less likely to be outside the labour force, more likely to have recent contact with inpatient and community services, and more likely to have a registration as their last contact. Conclusions: Patients who suicide 'look' similar to those who do not, suggesting prevention approaches should ensure that all psychiatric patients receive optimal care, including appropriate detection, diagnosis, assessment and treatment of mental health problems, and careful, individualised assessment of suicide risk.

Integrating cost-effectiveness evidence into clincal practice guidelines in Australia for acute myocardial infarction

 A teaching hospital is working with the Victorian State Government and universities, integrating cost-effectiveness evidence into clinical practice guidelines (CPGs), protocols and pathways for respiratory and cardiology interventions. Acute myocardial infarction (AMI) findings are reported. Results will stimulate cost-effective practice and inform medical associations, federal and state governments and international organisations developing CPGs. Published CPGs by the American College of Cardiology/American Heart Foundation for AMI in 1999 are reviewed by a large interdis- ciplinary hospital-based committee given cost-effectiveness evidence. Levels of evi- dence criteria rating on methodological rigor for effectiveness and costs are applied. National Health and Medical Research Council (NHMRC) grades of recommendation criteria for combinations of relative effectiveness versus relative costs and cut-off points are used. Extrapolating results between countries was addressed by applying the OECD's health purchasing power parity series. Recommendations for revisions to United States guidelines and for local application are formulated. United States Guide- lines require updating: Regarding angioplasty, percutaneous transluminal coronary angioplasty (PTCA) is cost-effective for men aged 60 years relative to recombinant tissue plasminogen activator (tPA),with additional cost per life year saved of 274 ecu. PTCA with discharge after 3 days is cost-effective in low-risk AMI. Regarding GP llb/Illa drugs, Abciximab during intervention incurred equal mean hospital costs for placebabciximab bolus, and abciximab bolus+ infusion with incremental 6-month cost for the latter treatment costing US$ 293 per patient. Agent recouped almost all initial therapy costs with significant benefits. Incre- mental cost of abciximab per event prevent- ed is US$ 3,258.Tirofiban was compared to placebo after high-risk angioplasty for AMI or unstable angina.Tirofiban decreased the rate of hospital deaths, myocardial infarc- tion, revascularisation at 2 days by 36% relative to placebo (8% vs. 12%) without increased cost. Clinical benefits were similar at 30 days.Tirofiban+heparin+aspirin was compared to heparin+aspirin.Tirofiban arm resulted in net savings of 33,418 ecu per 100 patients for the first 7 days of treatment. Regarding thrombolytics,tPA is more cost- effective than streptokinase. Incremental costs for each life saved when streptokinase is substituted by recombinant tissue plasmi- nogen are 31%,45%, 97% higher in Germa- ny, Italy and the United States than in the United Kingdom. Regarding anticoagulants, enoxaparin is a promising alternative to unfractionated heparin for hospitalised patients with non-Q-wave myocardiai infarc- tion or unstable angina, saving C$ 1,485 per patient over 12 months with 10% reduction in 1 year risk of death, myocardial infarction or recurrent angina. Regarding anti- arrhymics, the cost-effectiveness of no amiodarone, amiodarone for patients with depressed heart rate variability (DHRV),and amiodarone for patients with DHRV plus positive programmed ventricular stimula- tion (PPVS) for high-risk post-AMI was investigated. Amiodarone for DHRV+PPVS patients was dominated by a blend of the two alternatives. Compared to no amioda- rone, the incremental cost-effectiveness of amiodarone for DHRV patients was US$ 39,422 per quality adjusted life year gained. Amiodarone for DHRV is the most appropriate. Other CPG updates concern serum markers, for example, cardiac troponin I assay (c-Tnl), cost advantages of ad hoc angioplasty and secondary prevention through antioxidants and pravastatin. Australian costs are reported later in the paper.

Do socioeconomic gradients in women's health widen over time and with age?

A population-based study was conducted to investigate changes over time in women's well-being and health service use by socio-economic status and whether these varied by age. Data from 12,328 mid-age women (aged 45–50 years in 1996) and 10,430 older women (aged 70–75 years) from the Australian Longitudinal Study on Women's Health were analysed. The main outcome measures were changes in the eight dimensions of the Short Form General Health Survey (SF-36) adjusted for baseline scores, lifestyle and behavioural factors; health care utilisation at Survey 2; and rate of deaths (older cohort only). Cross-sectional analyses showed clear socioeconomic differentials in well-being for both cohorts. Differential changes in health across tertiles of socioeconomic status (SES) were more evident in the mid-age cohort than in the older cohort. For the mid-aged women in the low SES tertile, declines in physical functioning (adjusted mean change of –2.4, standard error (SE) 1.1) and general health perceptions (−1.5, SE 1.1) were larger than the high SES group (physical functioning –0.8 SE 1.1, general health perceptions –0.8 SE 1.2). In the older cohort, changes in SF-36 scores over time were similar for all SES groups but women in the high SES group had lower death rates than women in the low SES group (relative risk: 0.79, 95% confidence interval 0.64–0.98). Findings suggest that SES differentials in physical health seem to widen during women's mid-adult years but narrow in older age. Nevertheless, SES remains an important predictor of health, health service use and mortality in older Australian women.

Injury profiles of Indigenous and non-Indigenous people in New South Wales

Objectives:
To compare the injury profiles of the Indigenous population in New South Wales with that of the non-Indigenous population.
Design and setting:
Descriptive analysis of NSW Health data obtained from the Health Outcomes Information and Statistical Toolkit (HOIST) database. Hospitalisation data were collected for the period 1 July 1999 to 30 June 2003. Mortality data were collected for the period 1 January 1999 to 31 December 2002.
Main outcome measures:
Hospitalisation and death rates due to injury by age, sex, injury mechanism and Indigenous status. Rate ratios for comparison between Indigenous and non-Indigenous populations.
Results:
Rates of death from injury were higher for all age groups in the Indigenous population, except people older than 65 years. Indigenous people aged 25–44 years were twice as likely to be hospitalised as their non-Indigenous counterparts (rate ratio [RR], 2.09; 95% CI, 2.03–2.14), and five times as likely to be hospitalised for interpersonal violence (RR, 5.19; 95% CI, 4.98–5.40).
Conclusion:
The higher rates of injury-related hospitalisation and death in the Indigenous population in NSW are consistent with data reported for other parts of Australia. Of particular concern is the number of Indigenous deaths and hospitalisations due to interpersonal violence.

Consequences of youth tobacco use: a review of prospective behavioural studies

Background Cigarette smoking represents a significant health problem and tobacco has been identified as causing more preventable diseases and premature deaths than any other drug. Although health consequences from smoking have been documented, there has been a surprising lack of research into behavioural consequences.

Aims To review what is known of the long-term relationship between patterns of tobacco use prior to age 18 years and behavioural consequences in adulthood.

Method A literature search of electronic abstraction services from 1980 to September 2005 was conducted. To be included in the review, studies had to have large, representative samples, be longitudinal studies with baseline age under 18 years and follow-up age 18 years or older and clarify effects due to attrition, leaving 16 articles that met the inclusion criteria. Two reviewers evaluated each paper.

Findings Adolescent tobacco use predicts a range of early adult social and health problems. Surprisingly few studies met the inclusion criteria. The limited evidence available suggests that adolescent tobacco smoking increases the likelihood of early adult tobacco use and the initiation of alcohol use or the development of alcohol-related problems. The link between adolescent tobacco use and subsequent cannabis use was not resolved convincingly from the studies summarized. The effects of tobacco use on later illicit drug use tended to fall away when adjusting for underlying risk factors. Existing studies of the effects of tobacco use on later mental health have many limitations. Nevertheless, a finding that youth tobacco use may predict subsequent mental health problems deserves further investigation. The possible effects of tobacco use on academic/social problems and sleep problems also warrant further investigation.

Conclusion This review highlights links between youth tobacco use and subsequent behavioural and mental health problems. It provides health care professionals with evidence of the possible harmful effects of youth tobacco smoking on later social, emotional, and behavioural well-being.

Action on climate change : the health risks of procrastinating

Objective: The world's climate will continue to change because of human influence. This is expected to affect health, mostly adversely. We need to compare the projected health effects in Australia arising from differing climate change scenarios to inform greenhouse gas emission (mitigation) policy.

Methods: We estimated health effects in Australia (heatwave mortality, dengue transmission regions) around 2100 under various greenhouse gas scenarios: "strong policy action" (efforts made now to reduce emissions) and "no policy action" (emissions continue at present high levels with no climate change-specific policies).

Results: Compared with no policy action, mitigation could reduce the number of deaths caused by hot temperatures among older Australians by 4,000–7,000 a year (range reflects likely population size at 2100). Under a scenario of "no action", the zone of potential transmission of dengue fever expands 1,800 kilometres (km) south, as far as Sydney. In contrast, by markedly constraining greenhouse gas emissions now, this southward extension could be limited to 600 km (to Rockhampton). The number of displaced people within the Asia-Pacific region could increase (by orders of magnitude) under the "no action" scenario because of adverse socioecological circumstances aggravated by climate change.

Conclusions: Additional health effects will accrue as a result of the projected climate change throughout this century, and individuals and health systems should be prepared for some level of adaptation. However, timely and strong policy action to reduce greenhouse gas emissions would diminish the extent and severity of estimated future health effects.

Colorectal cancer screening in Australia: an economic evaluation of a potential biennial screening program using faecal occult blood tests

Objective: To evaluate whether the introduction of a national, co-ordinated screening program using the faecal occult blood test represents 'value-for-money' from the perspective of the Australian Government as third-party funder.  Methods: The annual equivalent costs and consequences of a   biennial screening program in 'steady-state' operation were estimated for the Australian population using 1996 as the reference year. Disability-adjusted life years (DALYs) and the years of life lost (YLLs) averted, and the health service costs were modelled, based on the epidemiology and the costs of colorectal cancer in Australia together with the mortality reduction achieved in randomised controlled trials. Uncertainty in the model was examined using Monte Carlo simulation methods. Results: We estimate a minimum or 'base program' of screening those aged 55 to 69 years could avert 250 deaths per annum (95% uncertainty interval 99–400), at a gross cost of $A55 million (95% UI $A46 million to $A96 million) and a gross incremental cost-effectiveness ratio of $A17,000/DALY (95% UI $A13,000/DALY to $A52,000/DALY). Extending the program to include 70 to 74-year-olds is a more effective option (cheaper and higher health gain) than including the 50 to 54-year-olds. Conclusions: The findings of this study support the case for a national program directed at the 55 to 69-year-old age group with extension to 70 to 74-year-olds if there are sufficient resources. The pilot tests recently announced in Australia provide an important opportunity to consider the age range for screening and the sources of uncertainty, identified in the modelled evaluation, to assist decisions on implementing a full national program.

Hepatitis B Virus transmission and hepatocarcinogenesis: a 9 year retropective cohort of 13676 relatives with hepatocellular carcinoma

Background/Aims
Familial clustering of hepatitis B virus (HBV) infection is related to perinatal transmission, and is the main cause of familial-type hepatocellular carcinoma (HCC). The route of HBV transmission differs between the children and siblings of patients with HCC. This study examined the differences in HBV carrier rates and HCC-related mortality between two generations in HCC families.
Methods
From 1992 to 1997, relatives of individuals with HCC were screened prospectively with ultrasonography, alpha-fetoprotein, liver biochemistry tests and viral markers. Total HCC-related deaths during a 9-year period were compared between the generations of index patients and their children.
Results
The study included a total of 13 676 relatives in two generations. More HCC-related deaths occurred in the index patient generation than in the child generation. Furthermore, children of female index patients had higher rates of liver cancer related mortality than children of male index patients. The same was true when the analysis was limited to male HBV carriers. The prevalence of HBsAg in the offspring of HBsAg positive mothers was 66% in the child generation and 72% in the index patient generation. These high prevalences indicated high maternal HBV replication status.
Conclusions
Perinatal transmission and maternal viral load are important risk factors in hepatocarcinogenesis.

Plant pathogens causing vegetation dieback: a serious threat to the conservation of small mammals in Australia

The soil-borne plant pathogen Phytophthora cinnamomi occurs in most Australian states. It is pathogenic to many Australian species, particularly the Proteaceae, Fabaceae, Dillineaceae and Epacridaceae. In Western Australia, c. 2000 of the 9000 endemic plant species are directly affected by the disease. The epidemic of plant deaths caused by P. cinnamomi is recognised as one of 11 Key Threatening Processes to the Australian Environment, and is now also acknowledged as a potential threat fauna in a range of communities. The implications of landscape modification due to the effects of P. cinnamomi dieback prompted our research, designed to measure the distribution and abundance of small mammals in disease-affected ecosystems. This study was in the Jarrah (Eucalyptus marginata) forests in the Darling Range, Western Australia and measured the distribution and abundance of one small mammal species, the Mardo (Antechinus flavipes) by Elliott trapping in forests with (1) high, (2) mixed and (3) no evidence of Phytophthora dieback. Trap success was highest in sites with no effect of Phytophthora (7.3 animals per 100 trap nights), whereas the lowest trap success was recorded at the high impact sites (0.67 animals per 100 trap night). There was a significant difference in trap success of Mardos in Elliott trapping over 1800 trap nights (x²= 23.19, d.f = 5, p < 0.001). An examination of the distribution of individuals and sexes suggests that Phytophthora-affected sites act as sinks for Mardos, while source areas are healthy, unaffected Jarrah forest.

Traffic fatalities: does income inequity create an externality?

Responsible for 20 million severe injuries and/or deaths annually, few epidemics receive less attention than traffic accidents. Going beyond confirming an inverted U-shaped relationship between mean income and fatalities, we show theoretically that income inequality can positively affect fatalities in two ways. Each operates through heterogeneity between road users, and while the direct effect can be expected to evaporate with rising income, the indirect effect may prove to be an externality in that the relationship remains regardless of the level of income. Our model is supported by evidence from 79 countries between 1970 and 2000.

Moral panic : the old and the new

The theory of moral panics has been prominent in the sociology of deviance since the 1970s. This article uses this theory to trace the rise of the moral panic around the high number of heroin overdose deaths in Australian in the mid to late 1990s. It argues, however, that much of the panic was generated by groups not traditionally associated with moral panics, but by political progressives in the field of illicit drugs as well as victims, parent groups, and those who work with illicit drug users. In this way it was not a conventional right-wing moral crusade, but it was no less a moral panic.

A randomized trial of protocol-directed sedation management for mechanical ventilation in an Australian intensive care unit

Objective: To compare protocol-directed sedation management with traditional non-protocol-directed practice in mechanically ventilated patients. Design: Randomized, controlled trial. Setting: General intensive care unit (24 beds) in an Australian metropolitan teaching hospital. Patients: Adult, mechanically ventilated patients (n = 312). Interventions: Patients were randomly assigned to receive sedation directed by formal guidelines (protocol group, n = 153) or usual local clinical practice (control, n = 159). Measurements and Main Results: The median (95% confidence interval) duration of ventilation was 79 hrs (56-93 hrs) for patients in the protocol group compared with 58 hrs (44-78 hrs) for patients who received control care (p = .20). Lengths of stay (median [range]) in the intensive care unit (94 [2-1106] hrs vs. 88 (14-962) hrs, p = .58) and hospital (13 [1-113] days vs. 13 (1-365) days, p = .97) were similar, as were the proportions of subjects receiving a tracheostomy (17% vs. 15%, p = .64) or undergoing unplanned self-extubation (1.3% vs. 0.6%, p = .61). Death in the intensive care unit occurred in 32 (21%) patients in the protocol group and 32 (20%) control subjects (p = .89), with a similar overall proportion of deaths in hospital (25% vs. 22%, p = .51). A Cox proportional hazards model, after adjustment for age, gender, Acute Physiology and Chronic Health Evaluation II score, diagnostic category, and doses of commonly used drugs, estimated that protocol sedation management was associated with a 22% decrease (95% confidence interval 40% decrease to 2% increase, p = .07) in the occurrence of successful weaning from mechanical ventilation. Conclusions: This randomized trial provided no evidence of a substantial reduction in the duration of mechanical ventilation or length of stay, in either the intensive care unit or the hospital, with the use of protocol-directed sedation compared with usual local management. Qualified high-intensity nurse staffing and routine Australian intensive care unit nursing responsibility for many aspects of ventilatory practice may explain the contrast between these findings and some recent North American studies. (C) 2008 Lippincott Williams & Wilkins, Inc.

Dyslipidaemia in rural Australia : the evidence treatment gaps

Aims & rationale/Objectives : Hypercholesterolaemia accounts for 11.6% of total deaths and 6.2% of the disability burden for the Australian population.1 This paper reports population lipid profiles for three rural Australian populations, and assesses evidence-treatment gaps against the most recent (2005-2007) Australian guidelines.

Methods : Three population surveys were undertaken in the Greater Green Triangle. 3,320 adults aged 25-74 yrs were randomly selected using age/gender stratified electoral roll samples and of these 1563 subjects participated in the survey. Anthropometric, clinical and self-administered questionnaire data relating to chronic disease risk were collected in accordance with the WHO MONICA protocol.2 A detailed investigation of dyslipidaemia was included.

Principal findings : All required data was available for 1255 participants. Age-standardised mean total cholesterol (TC), triglycerides, LDL cholesterol and HDL cholesterol concentrations were 5.36 mmol/l, 1.42 mmol/l, 3.23 mmol/l and 1.48 mmol/l, respectively. Amongst those taking lipid-lowering medication, just 11% categorised as secondary prevention/diabetes, and 39% as primary prevention, achieved all lipid targets. In the 20% of untreated participants at high risk of a primary cardiovascular event, 26% were aware of their hypercholesterolaemia and just 2% achieved all lipid targets (2.8% achieved TC?5.5 mmol, 8.5% achieved LDL<3.5 mmol/l). 11.2% of the overall population used lipid-lowering medication (95% was statin monotherapy).

Implications : Most adults do not achieve their target lipid profile. This paper identifies the subpopulations and lipid components which need to be targeted for future interventions. It also identifies substantial evidence-treatment gaps which should be addressed to help improve lipid profiles at a population level.

The burden of smoking related ill health in the UK

Background: Smoking is one of the biggest avoidable causes of morbidity and mortality in the United Kingdom. This paper quantifies the current health and economic burden of smoking in the UK. It provides comparisons with previous studies of the burden of smoking in the UK and with the costs for other chronic disease risk factors.

Methods: A systematic literature review to identify previous estimates of National Health Service costs attributable to smoking was undertaken. Information from the World Health Organization’s Global Burden of Disease Project and routinely collected mortality data were used to calculate mortality due to smoking in the UK. Population-attributable fractions for smoking-related diseases from the Global Burden of Disease Project were applied to NHS cost data to estimate direct financial costs.

Results: Previous studies estimated that smoking costs the NHS about £1.4 billion to £1.7 billion in 1991 and has been responsible for about 100 000 deaths per annum over the past 10 years. This paper estimates that the number of deaths attributable to smoking in 2005 was 109 164 (19% of all deaths, 27% deaths in men and 11% of deaths in women). Smoking was directly responsible for 12% of disability adjusted life years lost in 2002 (15.4% in men; 8.5% in women) and the direct cost to the NHS was £5.2 billion in 2005–6.

Conclusion: Smoking is still a considerable public health burden in the UK. Accurately establishing the burden in terms of death, disability and financial costs is important for informing national public health policy.

Patterns of coronary heart disease mortality over the 20th century in England and Wales : possible plateaus in the rate of decline

Background
Coronary heart disease (CHD) rates in England and Wales between 1950 and 2005 were high and reasonably steady until the mid 1970s, when they began to fall. Recent work suggests that the rate of change in some groups has begun to decrease and may be starting to plateau or even reverse.

Methods
Data for all deaths between 1931 and 2005 in England and Wales were grouped by year, sex, age at death and contemporaneous ICD code for CHD as cause of death. CHD mortality rates by calendar year and birth cohort were produced for both sexes and rates of change were examined.

Results
The pattern of increased burden of CHD mortality within older age groups has only recently emerged in men, whereas it has been established in women for far longer. CHD mortality rates among younger people showed little variation by birth cohort. For younger women (49 and under), the rate of change in CHD mortality has reversed in the last 20 years, indicating a future plateau and possible reversal of previous improvement in CHD mortality rates. Among younger men the rate of change in CHD mortality has been consistent for the past 15 years indicating that rates in this group have continued to fall steadily.

Conclusion
Although CHD mortality rates continue to drop in older age groups the actual burden of coronary heart disease is increasing due to the ageing of the population. The rate of improvement in CHD mortality appears to be beginning to decline and may even be reversing among younger women.