Prevalence and cost of musculoskeletal disorders: a population-based, public hospital system healthcare consumption approach.

Objective: To use a population-level, public-hospital approach to compare the prevalence and cost of musculoskeletal diseases (MSD) with other clinical specialties.

Methods: A healthcare utilization survey of 4 million individual records over 4 years, from all major public hospitals in the state of Victoria (estimated population 4.8 million residents in 2000/01) from 1997/98 to 2000/01. Main outcome measures were inpatient episodes of care, bed-days, and outpatient clinic encounters. MSD was defined as the combination of orthopedics and rheumatology.

Results: After obstetrics, MSD was the most frequent outpatient service, with orthopedics accounting for 9.9% of all visits in 2000/01. The proportion of MSD outpatient encounters (on average 11.6% of the total) was constant over the study period. Among 26 medical specialties, MSD had the sixth highest number of inpatient episodes (6.2% in 2000/01), following renal dialysis (14.6%), general surgery (8.2%), obstetrics (7.6%), gastroenterology (7.1%), and general medicine (6.7%). MSD was the fifth highest consumer of bed-days, occupying on average 7.7% of all beds per annum in the period 1997/98 to 2000/01, behind psychiatry (10.1%), respiratory medicine (8.5%), rehabilitation (8.3%), and general medicine (7.8%). MSD was the third most-costly discipline in 2000/01, with total costs of over A dollars 169 million (9.7% of total inpatient costs that year), behind respiratory medicine (11.6%) and general surgery (11.5%).

Conclusion: Compared to other diseases, MSD consumes a substantial proportion of healthcare resources in Victorian public hospitals. These data have important implications for allocation of healthcare resources, clinical care pathways, and prevention strategies.

Pituitary disease - perspectives of patients and partners

Aim. To explore experiences of pituitary disease of people with pituitary disease (PD) and their partners (PT).

Background. Pituitary disease encompasses a range of hormonal abnormalities that produce a variety of signs and symptoms depending on the underlying cause.

Design. A triangulated exploratory study.

Methods. The study was conducted in three phases: (a) non-participant monitoring of an Internet pituitary chat room over four months; (b) in-depth structured interviews with PD attending a pituitary outpatient clinic (n = 8) and PT (n = 6), (c) focus groups (n = 12). Data were collected in 2005.

Results. Four themes emerged from the discussion in each phase: 'need to be normal', 'emotional merry-go-round', 'damage to the self', and 'doctor ignorance'. Symptoms of pituitary disease were often mistaken for sinusitis, 'getting old before my time', hypochondria, stress, and 'something sinister changing the way I look'. Time to diagnosis varied from four weeks to 15 years. PD felt included in decision-making but partners relied on PD for information. Body image changes were significant making PD feel like a 'freak show for medical students' and the emotional distress persisted after treatment and 'cure'. The word 'tumour' caused significant stress and anxiety and depression was common. PD and PT felt general practitioners (GP) lacked information about pituitary disease.

Conclusions. Pituitary disease has a major impact on psychological well-being. PD but not PT felt involved in decisions about their management. GPs may need more education about pituitary disease. The study adds important information about the emotional effects of pituitary disease and its treatment.

Relevance to clinical practice. Pituitary disease is a generic term encompassing a range of underlying disease processes that often produce vague symptoms, often attributed to other causes, which delays diagnosis and treatment. Pituitary disease has a significant under recognised impact on people's mental and physical wellbeing and self-concept. Although the underlying hormonal imbalances associated with pituitary disease are largely reversible (cured), emotional distress persists. Regular monitoring of emotional wellbeing as well as medical and hormone status is warranted.

Are aspects of study design associated with the reported prevalence of female sexual difficulties?

Objective: To investigate associations between the prevalence of sexual  difficulties reported in published studies and design features of those studies to determine if differences in design contribute to variation in prevalence estimates.
Design: Systematic review, multivariate analysis.
Setting: Studies published internationally in English.
Patient(s): Not applicable.
Intervention(s): None.
Main Outcome Measure(s): Prevalence estimates of difficulty with desire, arousal, orgasm, and sexual pain reported in published studies.
Result(s): Our systematic literature search identified 1,380 publications. Fifty-five studies met our inclusion criteria (reporting prevalence, sample size and response rate, sample size greater than 100, not clinic based). Reported prevalence of sexual difficulty varied across studies (up to tenfold). Eleven aspects of research conduct in these studies were included in our multivariate analysis as explanatory variables. Five aspects of study design and conduct (data collection procedures, inclusion criteria, duration of sexual difficulty recorded, sample size, and response rate) were associated with the reported prevalence of at least one type of sexual difficulty independently of likely predictors of true variation in prevalence: study location, study year, and age range of participants.
Conclusion(s): This review provides evidence that study design may influence reported prevalence estimates of female sexual difficulties and contribute to the wide variation in published estimates.

Modeling response rates in surveys of female sexual difficulty and dysfunction

INTRODUCTION: Studies that address sensitive topics, such as female sexual difficulty and dysfunction, often achieve poor response rates that can bias  results. Factors that affect response rates to studies in this area are not well characterized.
AIM: To model the response rate in studies investigating the prevalence of female sexual difficulty and dysfunction.
METHODS: Databases were searched for English-language, prevalence studies using the search terms: sexual difficulties/dysfunction, woman/women/female, prevalence, and cross-sectional. Studies that did not report response rates or were clinic-based were excluded. A multiple linear regression model was constructed.
MAIN OUTCOME MEASURES: Published response rates.
RESULTS: A total of 1,380 publications were identified, and 54 of these met our inclusion criteria. Our model explained 58% of the variance in response rates of studies investigating the prevalence of difficulty with desire, arousal, orgasm, or sexual pain (R(2) = 0.581, P = 0.027). This model was based on study design variables, study year, location, and the reported prevalence of each type of sexual difficulty. More recent studies (beta = -1.05, P = 0.037) and studies that only included women over 50 years of age (beta = -31.11, P = 0.007) had lower response rates. The use of face-to-face interviews was associated with a higher response rate (beta = 20.51, P = 0.036). Studies that did not include questions regarding desire difficulties achieved higher response rates than those that did include questions on desire difficulty (beta = 23.70, P = 0.034).
CONCLUSION: Response rates in prevalence studies addressing female sexual difficulty and dysfunction are frequently low and have decreased by an average of just over 1% per anum since the late 60s. Participation may improve by conducting interviews in person. Studies that investigate a broad range of ages may be less representative of older women, due to a poorer response in older age groups. Lower response rates in studies that investigate desire difficulty suggest that sexual desire is a particularly sensitive topic.

Cystic fibrosis in children of the eastern Arabian peninsula : a clinical, spatial and genetic study

Aim: The aim of this thesis is to describe the process by which the inherited disease, cystic fibrosis, (CF) was recognised as an important clinical entity in the United Arab Emirates (UAE) and the Sultanate of Oman (Oman). It examines the clinical presentation of the first patients and assesses their degree of severity. Further, it describes the first studies carried out to determine the underlying CF mutations associated with the disease in the UAE and Oman. An estimate is offered of the birth frequency of the condition. Overall, the cultural, geographical and historical aspect of the societies in which the disease occurs is stressed. Methods: An initial literature search was carried out using Medline of any literature pertaining to the Arab World and CF. this was read and classified into the relevance to Arabs in general, the Middle East and then specifically the Arab (Persian) Gulf societies. Thereafter, a clinic was established at Tawam Hospital, Al Ain, UAE, for children presenting With chronic respiratory disease that could serve as a national referral centre. It was run by the Author as a service of the Paediatric Department of the UAE University Medical School. I sent a letter to every Paediatrician working in the UAE informing them of our clinic and offering our services for the diagnosis and management of chronic respiratory disease in children. This was based on the author's experience as a respiratory paediatrician in Australia and New Zealand and as the Professor of Paediatrics in the UAE. No such service then existed in the UAE. Funding was sought to establish a research programme and develop a molecular genetics laboratory in the UAE Medical School. A series of successful research applications provided the grants to commence the investigations. Once a small number of children had been identified as having CF from those referred to the respiratory clinic, the initial project was to assess and report their clinical presentation. Following this an early start was made on the identification of the mutations responsible. Once these were established an attempt was made to estimate the frequency of the condition at birth. Additional clinical studies revolved around assessing the severity of the condition that was associated with the main mutations that were identified. A clinical comparison was made with those with the mutation AF508 and the other main mutation, despite the obvious limitation of small numbers then available. Radiological assessment was made to evaluate the progression of the disease. The final aspect of the study was to assess patients from Oman and compare their findings and mutations with the neighbouring UAE. Based on information gained hypotheses are proposed regarding the spread of the gene mutation by population drift. Thesis outline: A literature review is presented in the form of a critique on the disease and a resume of the relevant aspects of the genetics of CF. Additionally, facts about the two countries' geography and history are presented. Finally, knowledge about CF mutations and population origins from other areas is presented. The second main section deals with the clinical features of the disorder as it presents in the UAE. Molecular findings are then presented and details of the common mutation found in Bedouin Arabs. Hypotheses are then presented based on the information gathered. Results: CF is not a rare disease in the Arab children of the UAE and Oman. These findings refute previous reports of CF being a rare or non-existent disease in Arabs. The condition presents with a severe clinical picture, with early colonisation of the respiratory tract with staphylococcus, haemophilus and pseudomonas organisms, even with conventional CF management practices in place. The CF mutation S549R is prevalent in Arabs of Bedouin stock, while AF508 is found in those of Baluch origin. The former may be descendants of Arabs who left southern Arabia and travelled to the Trucial Coast at the time of the destruction of the great dam at Marib. The origins of this mutation may lie in the area that corresponds to the modern Republic of Yemen. The latter groups are descendants of those who came originally from Baluchistan. It is hypothesised also that the ancestral home of the AF508 mutation may be in the geographical area now known as Baluchistan, that spans three separate modern political territories. The evidence presented supports the concept that the S549R mutation may be associated with a severe, if not the severest, clinical pattern recognised. It equates with that seen with the homozygous AF508 genotype. The absence of an additional mutation in the promoter region accounts for the different clinical pattern seen in previously described patients. Conclusions: There needs to be a major awareness of the presence of CF as a severe clinical disease in the children of the Gulf States. The clinical presentation and findings support the concept of under recognition of the disease. Climatic conditions put the children at special risk of hyponatraemia and electrolyte imbalance. The absence of surviving adults with the disease suggests premature deaths have occurred, but the high fertility rates have maintained the gene pool for this recessive disorder.

Descriptive epidemiology of Australian football injuries presenting to sports medicine clinics

Sports injury prevention has been the focus of a number of recent public health initiatives due to the acknowledgement that sports injuries are a significant public health problem in Australia Whilst Australian football is one of the most popular participation sports in the country, only very limited data is available about football injuries The majority of sports injury data available for this sport is from hospital emergency departments and elite-level injury surveillance Overall there is a paucity of data from treatment settings other than hospitals In particular, there is a lack of information about the injuries sustained by community-level, junior and recreational Australian football participants. One good potential source of football injury data is sports medicine clinics. Analysis of injury presentations to sports medicine clinics was undertaken to provide a detailed description of the epidemiology of Australian football injuries that present to this treatment setting and to determine the implications for injury prevention in this sport. In addition, the data from sports medicine clinics was compared with existing sources of Australian football injury data to determine how representative sports medicine clinic data is of other football injury data sources and to provide recommendations for future injury surveillance n Australian football. The results contained in this thesis show that Australian football is the sport most associated with injury presentation at sports medicine clinics. The majority of injured Australian football players presenting to sports medicine clinics are community-level or junior participants which suggests that sports medicine clinics are a good source of information on the injuries sustained by sub-elite football participants. Competition is the most common context in which Australian football players presenting to sports medicine clinics are injured. The major causes of injuries to Australian football players are being struck by another player, collisions and overuse. Injuries to Australian football players predominantly involve the lower limb. Adult players, players who stopped participating immediately after noticing their injury and players with overuse injuries are the most likely to sustain a more severe injury (i.e. more than four weeks before a full return to football participation and a moderate/significant amount of treatment expected). The least experienced players (five or less years of participation) are more likely to require a significant amount of treatment than the more experienced players. The prevention of lower limb injuries, injuries caused by body contact and injuries caused by overuse should be a priority for injury prevention research in Australian football due to the predominance of these injury types in the pattern of Australian football injuries Additionally, adult players, as a group, should be a focus of injury prevention activities in Australian football due to the association between age and injury severity. Overall, the pattern of Australian football injuries presenting to sports medicine clinics appears to be different than reported by club-based and hospital emergency department injury surveillance activities. However, detailed comparison of sports medicine clinic Australian football data with other sources of Australian football injury data is difficult due to the variable methods of collecting and reporting injury information used by hospital emergency department and club-based injury surveillance activities. The development of a standardised method for collecting and reporting injury data in Australian football is strongly recommended to overcome the existing limitations of data collection in this sport. In summary, sports medicine clinics provide a rich source of Australian football injury data, especially from the community and junior levels of participation. The inclusion of sports medicine clinic data provides a broader epidemiological picture of Australian football injuries. This broader understanding of the pattern of Australian football injuries provides a better basis for the development of injury prevention measures in this sport.

Interrelations between ceruloplasmin and Fe status during human pregnancy

It is well established that Fe and ceruloplasmin interact in animals and in in vitro models. However, Fe-mediated regulation of ceruloplasmin has never been investigated in humans. In an observational study, 53 pregnant women aged 19-39 yr (29.8±0.7 yr, mean ± SEM) were recruited at the Aberdeen Antenatal Clinic, Aberdeen Maternity Hospital, UK. All requirements for local ethical committees were followed. Venous blood samples were taken from each woman at 34 wk gestation for measurement of Fe status and ceruloplasmin. Various parameters were used to test for Fe status. The most sensitive one appeared to be soluble transferrin receptor, which increased with parity. In the population studied, there was no relationship between hemoglobin or ferritin and serum ceruloplasmin. However, using soluble transferrin receptor (sTfR) levels, we were able to demonstrate an inverse linear relationship (r=0.37, p=0.021, n=41) between Fe status and ceruloplasmin. Fe supplementation, number of previous pregnancies, and smoking habits did not affect this relationship. Our data support in vitro results showing regulation of ceruloplasmin by Fe and also suggest that the interactions between Fe and ceruloplasmin should be considered when Fe supplementation is given.

The effects of treating male hypogonadism on couples' sexual desire and function

Introduction: Hypogonadism is a common endocrine condition characterized by low levels of testosterone (T) and marked by numerous symptoms, one of which is low sexual desire. Studies comparing T delivery systems have suggested that hypogonadal men’s partners may be at risk from exposure to T gels. Little other mention is found of the impact of hypogonadism and its treatment on a man’s partner and the couple’s sexual function.

Aim: To assess sexual desire and sexual function in hypogonadal men and their woman partners before and after treatment with T replacement therapy.

Methods: Twenty-one hypogonadal men and 18 partners were recruited from a   tertiary endocrine clinic, and were compared with a control group of 20 eugonadal age-matched men and their partners. All men had baseline blood tests to confirm their status as hypogonadal or eugonadal, and hypogonadal men repeated tests at 3-month intervals. All participants completed the Sexual Desire Inventory (SDI) and sexual function questionnaires at baseline and at 3-month intervals until the hypogonadal men attained normal T levels.

Main Outcome Measures: Pre- and post-treatment SDI and sexual function questionnaires were compared once T normalization was achieved. Between- and within-group comparisons were carried out.

Results: Pretreatment hypogonadal men recorded lower levels of sexual desire and function than controls, but significantly improved once hypogonadism was corrected. Eugonadal controls recorded no significant changes in either sexual desire or function during the study. Partners of the hypogonadal men reported no changes on the SDI, but significant improvements in sexual function as their partners recovered.

Conclusion: SDI and sexual function measures reflect sexual changes that  accompany rising serum T levels during correction of male hypogonadism. Women partners reported more satisfaction, less pain, and improved sexual function following the men’s treatment. Treatments affecting one partner potentially have important effects on the other.

Risk factors for chronic insomnia following hospitalisation

Aim. This paper reports a study whose purpose was to determine whether there is an increase in the incidence of chronic insomnia following hospitalization and, if so, to identify patients at risk.

Background. The consequences of difficulty sleeping in hospital have received scant attention from clinicians or researchers. Implicit in this lack of interest is the assumption that difficulty in sleeping is a transient reaction to hospitalization that will resolve on discharge, an assumption not empirically supported. It has been argued that in susceptible people this type of temporary disruption to sleep can be the catalyst for the development of chronic insomnia.

Method. Established sleep and depression rating instruments were used to monitor the sleep of 57 cardiac and 29 orthopaedic patients after elective surgery (n = 86), recruited through a hospital preadmission clinic.

Results. Preadmission chronic insomnia of 10% was consistent with general population prevalence estimates of 6–12%. Three months after discharge the incidence had almost doubled to 19%. Sixty-one per cent of this variance could be explained by hyperarousal, sleep hygiene issues, and dysfunctional cognitions about sleep. Depression was found to be a salient predictor but not an independent risk factor. Age, sex, and hospital-related data, such as score for difficulty sleeping in hospital, proved to be statistically insignificant.

Conclusions. The results support the role of hyperarousal and dysfunctional sleep attitudes and behaviours as stronger predictors of chronic insomnia than patient demographics or environmental issues. Given that most of the patients were ambivalent about how they slept in hospital, with high satisfaction (71%) in the presence of significant disruption (63%), preadmission sleep education given to these patients prior to admission potentially contributed to the development of more realistic expectations of the quality of in-hospital sleep.

Nurses’ utilisation of complementary therapies : a pilot study exploring scope of practice

The increasing use of complementary therapies (CTs) by the public requires nurses to be fully informed about the use and safety of these modalities. In addition, nurses need to be aware of what constitutes complementary therapy practice, its overlap with nursing practice and how to respond appropriately to patients' requests for access to and information about CTs. A pilot study that aimed to describe nurses' knowledge about, and the use of CTs was conducted in four hospitals in southeast Queensland, Australia. One hundred and twenty-nine nurses (65% response rate) of varying levels of qualification and expertise completed a questionnaire. Over 80% of the participants indicated that they engaged in some form of complementary therapy (CT) activity. The entire sample worked in acute care hospitals but 5% engaged in CTs while employed in a second job. These nurses worked in either individual private practice or a multidisciplinary clinic setting. Only 2% of the sample had formal qualifications in a specific CT. Many nurses seemed unsure about what should be defined as a CT. The most common CTs engaged in by nurses were massage, music therapy and relaxation techniques but some nurses also participated in acupuncture, acupressure, hypnotherapy and osteopathy. Some nurses were confused about the difference between CT and usual nursing care. In addition, there were knowledge deficits relating to institutional policies and professional standards. Our findings suggest that nurses require more education about the scope of CT and how it differs from nursing practice. Nurses also require access to clear policies about the safe use of CTs in specific practice settings and about appropriate referral of clients to complementary therapists with accredited qualifications.