Hot Summers and Heart Failure: Seasonal Variations in Morbidity and Mortality in Australian Heart Failure Patients (1994-2005)

Background There are minimal reports of seasonal variations in chronic heart failure (CHF)-related morbidity and mortality beyond the northern hemisphere. Aims and methods We examined potential seasonal variations with respect to morbidity and all-cause mortality over more than a decade in a cohort of 2961 patients with CHF from a tertiary referral hospital in South Australia subject to mild winters and hot summers. Results Seasonal variation across all event-types was observed. CHF-related morbidity peaked in winter (July) and was lowest in summer (February): 70 (95% CI: 65 to 76) vs. 33 (95% CI: 30 to 37) admissions/1000 at risk (p<0.005). All-cause admissions (113 (95% CI: 107 to 120) vs. 73 (95% CI 68 to 79) admissions/1000 at risk, p<0.001) and concurrent respiratory disease (21% vs. 12%,p<0.001) were consistently higher in winter. 2010 patients died, mortality was highest in August relative to February: 23 (95% CI: 20 to 27) vs. 12 (95% CI: 10 to 15) deaths per 1000 at risk, p<0.001. Those aged 75 years or older were most at risk of seasonal variations in morbidity and mortality. Conclusion Seasonal variations in CHF-related morbidity and mortality occur in the hot climate of South Australia, suggesting that relative (rather than absolute) changes in temperature drive this global phenomenon.

Nitrone [2]rotaxanes: Simultaneous chemical protection and electrochemical activation of a functional group

We report on the use of the hydrogen bond accepting properties of neutral nitrone moieties to prepare benzylic-amide-macrocycle-containing [2]rotaxanes in yields as high as 70 %. X-Ray crystallography shows the presence of up to four intercomponent hydrogen bonds between the amide groups of the macrocycle and the two nitrone groups of the thread. Dynamic 1H NMR studies of the rates of macrocycle pirouetting in nonpolar solutions indicate that amide-nitrone hydrogen bonds are particularly strong, ~1.3 and ~0.2 kcal mol-1 stronger than similar amide-ester and amide-amide interactions, respectively. In addition to polarizing the N-O bond through hydrogen bonding, the rotaxane structure affects the chemistry of the nitrone groups in two significant ways: The intercomponent hydrogen bonding activates the nitrone groups to electrochemical reduction, a one electron reduction of the rotaxane being stablized by a remarkable 400 mV (8.1 kcal mol-1) with respect to the same process in the thread; encapsulation, however, protects the same functional groups from chemical reduction with an external reagent (and slows down electron transfer to and from the electroactive groups in cyclicvoltammetry experiments). Mechanical interlocking with a hydrogen bonding molecular sheath thus provides a route to an encapsulated polarized functional group and radical anions of significant kinetic and thermodynamic stability.

Rural and Urban Differentials in Primary Care Management of Chronic Heart Failure: New Data from the CASE Study

Objective: To determine whether primary care management of chronic heart failure (CHF) differed between rural and urban areas in Australia. Design: A cross-sectional survey stratified by Rural, Remote and Metropolitan Areas (RRMA) classification. The primary source of data was the Cardiac Awareness Survey and Evaluation (CASE) study. Setting: Secondary analysis of data obtained from 341 Australian general practitioners and 23 845 adults aged 60 years or more in 1998. Main outcome measures: CHF determined by criteria recommended by the World Health Organization, diagnostic practices, use of pharmacotherapy, and CHF-related hospital admissions in the 12 months before the study. Results: There was a significantly higher prevalence of CHF among general practice patients in large and small rural towns (16.1%) compared with capital city and metropolitan areas (12.4%) (P < 0.001). Echocardiography was used less often for diagnosis in rural towns compared with metropolitan areas (52.0% v 67.3%, P < 0.001). Rates of specialist referral were also significantly lower in rural towns than in metropolitan areas (59.1% v 69.6%, P < 0.001), as were prescribing rates of angiotensin-converting enzyme inhibitors (51.4% v 60.1%, P < 0.001). There was no geographical variation in prescribing rates of β-blockers (12.6% [rural] v 11.8% [metropolitan], P = 0.32). Overall, few survey participants received recommended “evidence-based practice” diagnosis and management for CHF (metropolitan, 4.6%; rural, 3.9%; and remote areas, 3.7%). Conclusions: This study found a higher prevalence of CHF, and significantly lower use of recommended diagnostic methods and pharmacological treatment among patients in rural areas.

The limits of competition : reasserting a role for consumer protection and fair trading regulation in competitive markets

In this paper we advocate for the continued need for consumer protection and fair trading regulation, even in competitive markets. For the purposes of this paper a ‘competitive market’ is defined as one that has low barriers to entry and exit, with homogenous products and services and numerous suppliers. Whilst competition is an important tool for providing consumer benefits, it will not be sufficient to protect at least some consumers, particularly vulnerable, low income consumers. For this reason, we argue, setting competition as the ‘end goal’ and assuming that consumer protection and consumer benefits will always follow, is a flawed regulatory approach. The ‘end goal’ should surely be consumer protection and fair markets, and a combination of competition law and consumer protection law should be applied in order to achieve those goals.

Interest rate caps : protection or paternalism

In a context where over-indebtedness and financial exclusion have been recognised as problems in Australia, it is undesirable that those who can least afford it, pay a high cost for short-term consumer credit. Evidence points to an increase in consumer debt in Australia and consequential over-indebtedness which has been shown to lead to a wide range of social problems.2 There is also evidence of financial exclusion, where consumers suffer a lack of access to mainstream financial services, and in Australia this is particularly the case with regard to access to safe and affordable credit.3 Financial exclusion can only exacerbate over-indebtedness, given that financially excluded, predominantly low income consumers , have been shown to turn to high cost credit to meet their short term credit needs. This is a problem that has been explored most recently in the Victorian Consumer Credit Review...