Comparing the outcome of monitored anaesthesia care and local anaesthesia for carpal tunnel syndrome surgery by neurosurgeons.

INTRODUCTION: Carpal tunnel syndrome (CTS) is the commonest median nerve entrapment neuropathy of the hand, up to 90% of all nerve compression syndromes. The disease is often treated with conservative measures or surgery. The senior author initially intended to treat his own neurosurgical patients concurrently diagnosed with carpal tunnel syndrome in 2014, subsequently, he began to pick up more referrals from the primary healthcare group over the years. This has led to the setup of a peripheral and spine clinic to act as a hub of referrals. OBJECTIVE: Department of Neurosurgery Sarawak aimed to evaluate the surgical outcome of carpal tunnel release done over five years. METHODS: The carpal tunnel surgeries were done under local anaesthesia (LA) given by neurosurgeons (Bupivacaine 0.5% or Lignocaine 2%). Monitored anaesthesia care (MAC) was later introduced by our hospital neuroanaesthetist in the beginning of 2018 (Target-controlled infusion propofol and boluses of fentanyl). We looked into our first 17 cases and compared these to the two anaesthesia techniques (LA versus MAC + LA) in terms of patient's pain score based on visual analogue scale (VAS). RESULTS: Result showed MAC provided excellent pain control during and immediately after the surgery. None experienced anaesthesia complications. There was no difference in pain control at post-operation one month. Both techniques had equal good clinical outcome during patients' clinic follow up. CONCLUSION: Neurosurgeons provide alternative route for CTS patients to receive surgical treatment. Being a designated pain free hospital, anaesthetist collaboration in carpal tunnel surgery is an added value and improves patients overall experience and satisfaction.

Cost-effectiveness of cytochrome P450 2C19 *2 genotype-guided selection of clopidogrel or ticagrelor in Chinese patients with acute coronary syndrome.

The choice of antiplatelet therapy among Asian populations for the treatment of acute coronary syndrome (ACS) is complicated owing to the high prevalence of cytochrome P450 2C19 (CYP2C19) genetic polymorphism that has been associated with reduced efficacy of clopidogrel. Ticagrelor is a potent but more expensive alternative antiplatelet agent that is not affected by CYP2C19 polymorphism. This study aimed to evaluate the cost-effectiveness, from the Hong Kong health-care provider's perspective, of CYP2C19*2 genotype-guided selection of antiplatelet therapy compared with the universal use of clopidogrel or ticagrelor among ACS patients who undergo percutaneous coronary intervention (PCI). In the present study, a two-part model consisting of a 1-year decision tree and a lifetime Markov model was built to simulate the progress of a typical cohort of 60-year-old Chinese patients until age 85 years and compare three treatment strategies: (i) generic clopidogrel or ticagrelor based on CYP2C19*2 genotype, (ii) universal use of generic clopidogrel or (iii) universal use of ticagrelor for all patients. Incremental cost-effectiveness ratios (ICERs) of <1 gross domestic product per capita locally (US dollar (USD)42 423/quality-adjusted life year (QALY)) were considered cost-effective. Base-case results showed universal ticagrelor use was cost-effective compared with universal clopidogrel, but was dominated by genotype-guided treatment. Genotype-guided treatment was cost-effective compared with universal clopidogrel use (ICER of USD2560/QALY). Sensitivity analysis demonstrated that with the cost of genotype testing up to USD400, CYP2C19*2 genotype-guided antiplatelet treatment remained a cost-effective strategy compared with either universal use of generic clopidogrel or ticagrelor in post-PCI ACS patients in Hong Kong.

Real-world outcomes of unrestricted direct-acting antiviral treatment for hepatitis C in Australia: The South Australian statewide experience.

In March 2016, the Australian government offered unrestricted access to direct-acting antiviral (DAA) therapy for chronic hepatitis C virus (HCV) to the entire population. This included prescription by any medical practitioner in consultation with specialists until sufficient experience was attained. We sought to determine the outcomes and experience over the first twelve months for the entire state of South Australia. We performed a prospective, observational study following outcomes of all treatments associated with the state's four main tertiary centres. A total of 1909 subjects initiating DAA therapy were included, representing an estimated 90% of all treatments in the state. Overall, SVR12 was 80.4% in all subjects intended for treatment and 95.7% in those completing treatment and follow-up. 14.2% were lost to follow-up (LTFU) and did not complete SVR12 testing. LTFU was independently associated with community treatment via remote consultation (OR 1.50, 95% CI 1.04-2.18, P = .03), prison-based treatment (OR 2.02, 95% CI 1.08-3.79, P = .03) and younger age (OR 0.98, 95% CI 0.97-0.99, P = .05). Of the 1534 subjects completing treatment and follow-up, decreased likelihood of SVR12 was associated with genotype 2 (OR 0.23, 95% CI 0.07-0.74, P = .01) and genotype 3 (OR 0.23, 95% CI 0.12-0.43, P ≤ .01). A significant decrease in treatment initiation was observed over the twelve-month period in conjunction with a shift from hospital to community-based treatment. Our findings support the high responses observed in clinical trials; however, a significant gap exists in SVR12 in our real-world cohort due to LTFU. A declining treatment initiation rate and shift to community-based treatment highlight the need to explore additional strategies to identify, treat and follow-up remaining patients in order to achieve elimination targets.

Forecasting the future burden of opioids for osteoarthritis.

OBJECTIVE: To quantify the current national burden of opioids for osteoarthritis (OA) pain in Australia in terms of number of dispensed opioid prescriptions and associated costs, and to forecast the likely burden to the year 2030/31. DESIGN: Epidemiological modelling. METHODS: Published data were obtained on rates of opioid prescribing for people with OA and national OA prevalence projections. Trends in opioid dispensing from 2006 to 2016, and average costs for common opioid subtypes were obtained from the Pharmaceutical Benefits Scheme and Medicare Australia Statistics. Using these inputs, a model was developed to estimate the likely number of dispensed opioid prescriptions and costs to the public healthcare system by 2030/31. RESULTS: In 2015/16, an estimated 1.1 million opioid prescriptions were dispensed in Australia for 403,954 people with OA (of a total 2.2 million Australians with OA). Based on recent dispensing trends and OA prevalence projections, the number of dispensed opioid prescriptions is expected to nearly triple to 3,032,332 by 2030/31, for an estimated 562,610 people with OA. The estimated cost to the Australian healthcare system was $AUD25.2 million in 2015/16, rising to $AUD72.4 million by 2030/31. CONCLUSION: OA-related opioid dispensing and associated costs are set to increase substantially in Australia from 2015/16 to 2030/31. Use of opioids for OA pain is concerning given joint disease chronicity and the risk of adverse events, particularly among older people. These projections represent a conservative estimate of the full financial burden given additional costs associated with opioid-related harms and out-of-pocket costs borne by patients.

Is a biomarker-based diagnostic strategy for invasive aspergillosis cost effective in high-risk haematology patients?

Empirical antifungal therapy is frequently used in hematology patients at high risk of invasive aspergillosis (IA), with substantial cost and toxicity. Biomarkers for IA aim for earlier and more accurate diagnosis and targeted treatment. However, data on the cost-effectiveness of a biomarker-based diagnostic strategy (BDS) are limited. We evaluated the cost effectiveness of BDS using results from a randomized controlled trial (RCT) and individual patient costing data. Data inputs derived from a published RCT were used to construct a decision-analytic model to compare BDS (Aspergillus galactomannan and PCR on blood) with standard diagnostic strategy (SDS) of culture and histology in terms of total costs, length of stay, IA incidence, mortality, and years of life saved. Costs were estimated for each patient using hospital costing data to day 180 and follow-up for survival was modeled to five years using a Gompertz survival model. Treatment costs were determined for 137 adults undergoing allogeneic hematopoietic stem cell transplant or receiving chemotherapy for acute leukemia in four Australian centers (2005-2009). Median total costs at 180 days were similar between groups (US$78,774 for SDS [IQR US$50,808-123,476] and US$81,279 for BDS [IQR US$59,221-123,242], P = .49). All-cause mortality was 14.7% (10/68) for SDS and 10.1% (7/69) for BDS, (P = .573). The costs per life-year saved were US$325,448, US$81,966, and US$3,670 at 180 days, one year and five years, respectively. BDS is not cost-sparing but is cost-effective if a survival benefit is maintained over several years. An individualized institutional approach to diagnostic strategies may maximize utility and cost-effectiveness.

RESPOND: a programme to prevent secondary falls in older people presenting to the emergency department with a fall: protocol for an economic evaluation.

BACKGROUND: Falls remain common for community-dwelling older people and impose a substantial economic burden to the healthcare system. RESPOND is a novel falls prevention programme that aims to reduce secondary falls and fall injuries among older people who present to a hospital emergency department (ED) with a fall. The present protocol describes a prospective economic evaluation examining the incremental cost-effectiveness of the RESPOND programme, compared with usual care practice, from the Australian health system perspective. METHODS AND DESIGN: This economic evaluation will recruit 528 participants from two major tertiary hospital EDs in Australia and will be undertaken alongside a multisite randomised controlled trial. Outcome and costing data will be collected for all participants over the 12-month trial. It will compare the RESPOND falls prevention programme with usual care practice (current community-based falls prevention practices) to determine its incremental cost-effectiveness according to three intermediate clinical outcomes: (1) falls prevented, (2) fall injuries prevented and (3) injurious falls prevented. In addition, utilities will be derived from a generic quality-of-life measure (EQ-5D-5L) and used to calculate the 'incremental cost per quality-adjusted life years gained'. DISCUSSION: The results of this study will provide healthcare decision makers with evidence to assist with setting spending thresholds for preventive health programmes and inform selection of emergency and community service models of care. TRIAL REGISTRATION NUMBER: The protocol for this study is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12614000336684); Pre-results.

Injury trends from envenoming in Australia, 2000-2013.

BACKGROUND: Accidental injury is a major public health problem in developed countries with 20 years elapsed since a national overview of venomous bites undertaken in Australia. AIM: Provide the first contemporary epidemiological insight into venomous injuries based on demographics and geography nationally in Australia in the period 2000-2013. METHODS: An analysis of national hospitalisation and mortality data was undertaken to examine the incidence of injury and death due to envenoming in Australia. Rates were calculated using the intercensal population for all Australian age groups. RESULTS: Over the study period, deaths occurred due to an anaphylactic event (0.16 per 100 000), snake envenoming (0.13 per 100 000) or box jellyfish envenoming (0.01 per 100 000). Only 44% of cases involving anaphylaxis reached medical care prior to death, compared to 74% of those envenomed by snakes. Over half of all deaths (52%) occurred at home, and 64% of these occurred within a major city or inner regional area, with 48% of work-related anaphylaxis deaths. Hospital admission rates of 199 per 100 000 persons over the 11 years were caused by contact with wasps or bees (31%), spiders (30%) and snakes (15%), with a predominant age range of 30-44 years. CONCLUSIONS: The greatest burden of injury due to envenoming was caused by arthropods and snakes. Causes of death were led by anaphylaxis subsequent to an arthropod bite or sting, followed by death from snake envenoming. Over half the incidents resulting in death occurred at home, in areas where healthcare is accessible. Operational data routinely collected are informative, with variations of injury incidence between the States and Territories, indicating a need for a more localised approach to the management of this injury.

The cost-effectiveness of hospital-based telephone coaching for people with type 2 diabetes: a 10 year modelling analysis.

BACKGROUND: Type 2 diabetes (T2DM) is a burdensome condition for individuals to live with and an increasingly costly condition for health services to treat. Cost-effective treatment strategies are required to delay the onset and slow the progression of diabetes related complications. The Diabetes Telephone Coaching Study (DTCS) demonstrated that telephone coaching is an intervention that may improve the risk factor status and diabetes management practices of people with T2DM. Measuring the cost effectiveness of this intervention is important to inform funding decisions that may facilitate the translation of this research into clinical practice. The purpose of this study is to assess the cost-effectiveness of telephone coaching, compared to usual diabetes care, in participants with poorly controlled T2DM. METHODS: A cost utility analysis was undertaken using the United Kingdom Prospective Diabetes Study (UKPDS) Outcomes Model to extrapolate outcomes collected at 6 months in the DTCS over a 10 year time horizon. The intervention's impact on life expectancy, quality-adjusted life expectancy (QALE) and costs was estimated. Costs were reported from a health system perspective. A 5 % discount rate was applied to all future costs and effects. One-way sensitivity analyses were conducted to reflect uncertainty surrounding key input parameters. RESULTS: The intervention dominated the control condition in the base-case analysis, contributing to cost savings of $3327 per participant, along with non-significant improvements in QALE (0.2 QALE) and life expectancy (0.3 years). CONCLUSIONS: The cost of delivering the telephone coaching intervention continuously, for 10 years, was fully recovered through cost savings and a trend towards net health benefits. Findings of cost savings and net health benefits are rare and should prove attractive to decision makers who will determine whether this intervention is implemented into clinical practice. TRIAL REGISTRATION: ACTRN12609000075280.

Overview of shorthand medical glossary (OMG) study.

BACKGROUND: Shorthand is commonplace in clinical notation. While many abbreviations are standard and widely accepted, an increasing number are non-standard and/or unrecognisable. AIM: We sought to describe the frequency of inappropriate and ambiguous shorthand in discharge summaries. METHODS: Eighty electronic discharge summaries from the four General Medical Units at the Royal Melbourne Hospital were randomly extracted from the hospital's electronic records. Extraction was stratified by the four units and by the four quarters between July 2012 and June 2013. All abbreviations were assigned into one of four categories according to appropriateness: 1. 'Universally accepted and understood even without context'; 2. 'Understood when in context'; 3. 'Understood but inappropriate and/or ambiguous'; and 4. 'Unknown'. These categories were determined by the authors, which included junior and senior medical staff. RESULTS: The 80 discharge summaries contained 840 different abbreviations used on 6269 occasions. Of all words, 20.1% were abbreviations. Of the 6269 occasions of shorthand, 6.8% were categorised as 'Understood but inappropriate and/or ambiguous' or 'Unknown' (category 3 or 4), equating to 1.4% of all words, and an average of 5.4 words per discharge summary. CONCLUSION: Abbreviations are common in electronic discharge summaries, occurring at a frequency of one in five words. While the majority of shorthand used seems to be appropriate, the use of inappropriate, ambiguous or unknown shorthand is still frequent. This has implications for safe and effective patient care and highlights the need for better awareness and education regarding use of shorthand in clinical notation.

Clinical effectiveness of a silicone foam dressing for the prevention of heel pressure ulcers in critically ill patients: Border II Trial.

OBJECTIVE: Critically ill patients are at high risk of developing pressure ulcers (PU), with the sacrum and heels being highly susceptible to pressure injuries. The objective of our study was to evaluate the clinical effectiveness of a new multi-layer, self-adhesive soft silicone foam heel dressing to prevent PU development in trauma and critically ill patients in the intensive care unit (ICU). METHOD: A cohort of critically ill patients were enrolled at the Royal Melbourne Hospital. Each patient had the multi-layer soft silicone foam dressing applied to each heel on admission to the emergency department. The dressings were retained with a tubular bandage for the duration of the patients' stay in the ICU. The skin under the dressings was examined daily and the dressings were replaced every three days. The comparator for our cohort study was the control group from the recently completed Border Trial. RESULTS: Of the 191 patients in the initial cohort, excluding deaths, loss to follow-up and transfers to another ward, 150 patients were included in the final analysis. There was no difference in key demographic or physiological variables between the cohorts, apart from a longer ICU length of stay for our current cohort. No PUs developed in any of our intervention cohort patients compared with 14 patients in the control cohort (n=152; p<0.001) who developed a total of 19 heel PUs. CONCLUSION: We conclude, based on our results, that the multi-layer soft silicone foam dressing under investigation was clinically effective in reducing ICU-acquired heel PUs. The findings also support previous research on the clinical effectiveness of multi-layer soft silicone foam dressings for PU prevention in the ICU.

Traditional and Complementary Medicine (TCM) among Study Population with Cardiovascular Risk; use and Substitution for Conventional Medicine in Pahang, Malaysia.

INTRODUCTION: Cardiovascular diseases are the main cause of morbidity and mortality in Malaysia. There is evidence of high traditional and complementary medicine (TCM) use among population with cardiovascular risk and there have been anecdotal reports about substitution of conventional medicines with TCM. We investigated the prevalence of TCM use, treatment preference and substitution of conventional medicines in study population with cardiovascular risk factors in Pahang, Malaysia. METHODS: A cross-sectional survey was conducted using an interviewer-administered questionnaire in five districts of Pahang. A total of 1250 households were chosen through proportionate and systematic sampling. Respondents aged 18 years and above were selected. RESULTS: The study population with cardiovascular risk factors who used TCM was higher than the general population (31.7% versus 25.9%). There were no clear preferences in using TCM by gender, age groups, educational level and income even though other bumiputeras showed a slight inclination towards TCM use. Among the study population with cardiovascular risk factors who consumed TCM, 20-30% of them were using TCM as a substitute for their conventional medications. Respondents from the younger age group (18-40 years) (57.1%), highest educational level (43.2%), other bumiputeras (38.4%) and highest income group (31.4%) preferred the combination of both conventional and traditional medicine. CONCLUSION: TCM use among population with cardiovascular risk factors is high. The high preference for combination therapy of TCM and conventional medications among young adults and the use of TCM to substitute conventional medications show that much research is needed to provide proven TCM therapies to avoid self-mismanagement of cardiovascular risk in Malaysia.

Using periodic point-prevalence surveys to assess appropriateness of antimicrobial prescribing in Australian private hospitals.

BACKGROUND AND AIMS: Appropriateness of antimicrobial use is a measure of key importance in evaluating safety and quality of prescribing but has been difficult to define and assess on a wide scale. Published work is limited and has generally focused on tertiary public hospitals, whereas the private sector provides a significant proportion of care in many countries. Information on prescribing in the private hospital context is needed to identify where intervention might be required. An antimicrobial prescribing survey tool was utilised to assess the appropriateness of antimicrobial prescribing among large private hospitals in Australia. METHODS: 'Appropriateness' of antimicrobial therapy was evaluated by a team consisting of an infectious diseases physician and specialist infectious diseases pharmacist based on clear criteria. RESULTS: Thirteen hospital-wide point-prevalence surveys were conducted. Three thousand, four hundred and seventy-two inpatient medication charts were reviewed to identify 1125 (32.4%) inpatients on 1444 antimicrobials. An indication was documented in 911 (63.1%) of surveyed prescriptions, and overall, 757 (52.4%) of antimicrobials were assessed as appropriate. Antimicrobials prescribed for treatment had a higher proportion of appropriateness when compared with antimicrobials prescribed for surgical prophylaxis (80.4% vs 40.6%). The main reason for a treatment prescription to be considered inappropriate was incorrect selection, while prolonged duration (>24 h) was the main reason for inappropriate surgical prophylaxis prescriptions. CONCLUSIONS: This study provides important data on antimicrobial prescribing patterns in Australian private hospitals. Results can be used to target areas for improvement, with documentation of indication and surgical antibiotic prophylaxis requiring initial attention.

Brain and spinal tumour.

This study reviewed the epidemiology of brain and spinal tumours in Sarawak from January 2009 till December 2012. The crude incidence of brain tumour in Sarawak was 4.6 per 100,000 population/year with cumulative rate 0.5%. Meningioma was the most common brain tumour (32.3%) and followed by astrocytoma (19.4%). Only brain metastases showed a rising trend and cases were doubled in 4 years. This accounted for 15.4% and lung carcinoma was the commonest primary. Others tumour load were consistent. Primitive neuroectodermal tumour (PNET) and astrocytoma were common in paediatrics (60%). We encountered more primary spinal tumour rather than spinal metastases. Intradural schwannoma was the commonest and frequently located at thoracic level. The current healthcare system in Sarawak enables a more consolidate data collection to reflect accurate brain tumours incidence. This advantage allows subsequent future survival outcome research and benchmarking for healthcare resource planning.

Impact of emergency access targets on admissions to general medicine: a retrospective cohort study.

BACKGROUND: Emergency access targets have been implemented Australia-wide following recent retrospective cohort studies linking emergency department (ED) overcrowding and excess mortality. AIM: To examine the impact of ED access targets on the characteristics and health service utilisation of general medicine (GM) inpatients at the Royal Melbourne Hospital. METHODS: A retrospective cohort study was conducted on all patient episodes admitted from ED to GM units from January 2009 to December 2012 (n = 15562), compared in two cohorts for 24 months before (n = 7393) and after (n = 8169) the implementation of the '4-h rule'. The main outcome measures were age, comorbidity, clinical urgency at presentation (Australasian Triage Score), ED and inpatient length of stay, diagnosis at discharge, and in-hospital complications. RESULTS: After the implementation of the '4-h rule', there was an increased proportion of younger patients aged ≤50 years (7.7-9.1%), urgent Australasian Triage Scale 3 (45.6-49.7%) and semi-urgent Australasian Triage Scale 4 (21.8-27.6%) patients admitted to GM. On average, GM patients had fewer comorbid conditions (proportion with Charlson score ≥6 decreased from 14.2% to 11.9%), and higher proportions (21.8-24.7%) were admitted for less than 48 h. CONCLUSION: Implementation of a 4-h access target has been associated with changes to the characteristics of patients admitted to GM, including higher proportions of younger patients, with fewer comorbid conditions and lower clinical urgency at presentation, although the latter may be explained by a coincidental change in the way that ED patients were triaged, as well as a greater number of these patients presenting to ED overall.

Economic evaluation of micafungin versus caspofungin for the treatment of candidaemia and invasive candidiasis.

BACKGROUND: Micafungin demonstrated non-inferiority to caspofungin as definitive therapy for candidaemia and invasive candidiasis (IC) in a major randomised clinical trial. AIM: The aim of this study was to investigate if micafungin is a cost-saving option compared with caspofungin for treating candidaemia and IC. METHODS: A decision analytical model was constructed to capture downstream consequences of using either agent as initial therapy for candidaemia and IC. The main outcomes were treatment success and treatment failure (i.e. death, mycological persistence, emergent infection, clinical failure but microbiological success). Outcome probabilities and treatment pathways were derived from the literature. Cost inputs were from the latest Australian resources, and resource use was estimated by expert panel. The analysis was from the Australian hospital perspective. Sensitivity analyses using Monte Carlo simulation were conducted. RESULTS: Micafungin (AU$52 816) was associated with a lower total cost than caspofungin (AU$52 976), with a net cost-saving of $160 per patient. This was primarily due to the lower cost associated with alternative antifungal treatment in the micafungin arm. Hospitalisation was the main cost-driver for both arms. The model outcome was most sensitive to the proportion of treatment success in the micafungin arm. Uncertainty analysis demonstrated that micafungin had a 58% chance of being cost-saving compared with caspofungin. CONCLUSIONS: Micafungin was cost-equivalent to caspofungin in treating candidaemia and IC, with variation in drug acquisition cost the critical factor.

Most individuals with treated blood pressures above target receive only one or two antihypertensive drug classes.

BACKGROUND: A significant proportion of individuals taking antihypertensive therapies fail to achieve blood pressures <140/90 mmHg. In order to develop strategies for improved treatment of blood pressure, we examined the association of blood pressure control with antihypertensive therapies and clinical and lifestyle factors in a cohort of adults at increased cardiovascular risk. METHODS: A cross-sectional study of 3994 adults from Melbourne and Shepparton, Australia enrolled in the SCReening Evaluation of the Evolution of New Heart Failure (SCREEN-HF) study. Inclusion criteria were age ≥60 years with one or more of self-reported ischaemic or other heart disease, atrial fibrillation, cerebrovascular disease, renal impairment or treatment for hypertension or diabetes for ≥2 years. Exclusion criteria were known heart failure or cardiac abnormality on echocardiography or other imaging. The main outcome measures were the proportion of participants receiving antihypertensive therapy with blood pressures ≥140/90 mmHg and the association of blood pressure control with antihypertensive therapies and clinical and lifestyle factors. RESULTS: Of 3623 participants (1975 men and 1648 women) receiving antihypertensive therapy, 1867 (52%) had blood pressures ≥140/90 mmHg. Of these 1867 participants, 1483 (79%) were receiving only one or two antihypertensive drug classes. Blood pressures ≥140/90 mmHg were associated with increased age, male sex, waist circumference and log amino-terminal-pro-B-type natriuretic peptide levels. CONCLUSIONS: Most individuals with treated blood pressures above target receive only one or two antihypertensive drug classes. Prescribing additional antihypertensive drug classes and lifestyle modification may improve blood pressure control in this population of individuals at increased cardiovascular risk.

Care of severe head injury patients in the Sarawak General Hospital: intensive care unit versus general ward.

Intensive care for severe head injury patients is very important in the prevention and treatment of secondary brain injury. However, in a resources constraint environment and limited availability of Intensive Care Unit (ICU) beds in the hospitals, not all severe head injury patients will receive ICU care. This prospective study is aimed to evaluate the outcome of severe head injured patients who received ICU and general ward care in Sarawak General Hospital (SGH) over a 6-month period. A total of thirty five severe head injury patients were admitted. Twenty three patients (65.7%) were ventilated in general ward whereas twelve patients (34.3%) were ventilated in ICU. Overall one month mortality in this study was 25.7%. Patients who received ICU care had a lower one month mortality than those who received general ward care (16.7% vs 30.4%), although it was not statistically different. Multivariate analysis revealed only GCS on admission (OR 0.731; 95% CI 0.460 to 0.877; P=0.042) as the independent predictive factor for one month mortality in this study.

Economic implications of obesity among people with atherothrombotic disease.

OBJECTIVE: The purpose of this study was to ascertain the impact of obesity on the cost of disease management in people with or at high risk of atherothrombotic disease from a governmental perspective using a bottom-up approach to cost estimation. In addition, the aim was also to explore the causes of any differences found. METHOD: The health-care costs of obesity were estimated from 2819 participants recruited into the nationwide Australian REACH Registry with established atherothrombotic disease or at least three risk factors for atherothrombosis. Enrollment was in 2004, through primary care general practices. Information was collected on the use of cardiovascular drugs, hospitalizations and ambulatory care services. 'Bottom-up' costing was undertaken by assigning unit costs to each health-care item, based on Australian Government-reimbursed figures 2006-2007. Linear-mixed models were used to estimate associations between direct medical costs and body mass index (BMI) categories. RESULTS: Annual pharmaceutical costs per person increased with increasing BMI category, even after adjusting for gender, age, living place, formal education, smoking status, hypertension and diabetes. Adjusted annual pharmaceutical costs of overweight and obese participants were higher ($7 (P=0.004) and $144 (<0.001), respectively) than those of the normal weight participants. This was due to participants in higher BMI categories receiving more pharmaceuticals than normal weight participants. There was no significant change across the BMI categories in annual ambulatory care costs and annual hospital costs. CONCLUSION: In these participants with or at high risk of atherothrombotic disease, annual pharmaceutical costs were greater in participants of higher BMI category, but there was not such a gradient in the annual hospital or ambulatory care costs. The greater cardiovascular pharmaceutical costs for participants of higher BMI categories remained even after adjusting for a range of demographic factors and comorbidities. Our results suggest that these costs are explained by the higher number of drugs used among people with atherothrombotic disease. Further investigation is needed to understand the reasons for this level of drug use.

Lifetime risk and projected population prevalence of diabetes.

AIMS/HYPOTHESIS: With incidence rates for diabetes increasing rapidly worldwide, estimates of the magnitude of the impact on population health are required. We aimed to estimate the lifetime risk of diabetes, the number of years lived free of, and the number of years lived with diabetes for the Australian adult population from the year 2000, and to project prevalence of diabetes to the year 2025. METHODS: Multi-state life-tables were constructed to simulate the progress of a cohort of 25-year-old Australians. National mortality rates were combined with incidence rates of diabetes and the RR of mortality in people with diabetes derived from the Australian Diabetes, Obesity and Lifestyle study (a national, population-based study of 11,247 adults aged >or=25 years). RESULTS: If the rates of mortality and diabetes incidence observed over the period 2000-2005 continue, 38.0% (95% uncertainty interval 36.6-38.9) of 25-year-olds would be expected to develop diabetes at some time throughout their life. On average, a 25-year-old Australian will live a further 56 years, 48 of these free of diabetes. On average, a 45-year-old person with diabetes can expect to live 6 years less than a person free of diabetes. The prevalence of diabetes is projected to rise from 7.6% in 2000 to 11.4% by 2025. CONCLUSIONS/INTERPRETATION: If we maintain current diabetes incidence rates, more than a third of individuals will develop diabetes within their lifetime and in Australia there will an additional 1 million cases of diabetes by the year 2025.