Using electronic medical records to assess the rate of treatment for osteoporosis in Australia.

BACKGROUND: Despite available Medicare Benefits Schedule subsidies, it has been suggested that screening and treatment for osteoporosis are under-accessed in Australia, particularly in patients ≥70 years. This study describes the rate of osteoporosis treatment in those aged ≥70 years in regional New South Wales as identified in the electronic medical records (EMR) of 11 general practices. METHODS: EMR data were extracted using a Canning Tool adaptation. The prevalence of osteoporosis, fracture and bone-active medication prescriptions were described, and associations examined. RESULTS: Osteoporosis was identified in 728 patients (20.9%) - 28.6% females and 9.4% males - with 70.6% of these patients prescribed active medication. Diagnosis increased with fracture history (odds ratio [OR]: 6.65; 95% confidence interval [CI]: 5.22, 8.47), female gender (OR: 3.38; 95% CI: 2.73, 4.16) and each year older (OR: 1.04; 95% CI: 1.02, 1.05). Treatment was negatively associated with patients aged ≥90 years versus patients aged 70-79 years (OR: 0.5; 95% CI: 0.3, 0.9). DISCUSSION: This study suggests that treatment for osteoporosis is suboptimal. The use of EMR data could be used for audit or monitoring of interventions in general practice.

Improving the transition from medical school to internship - evaluation of a preparation for internship course.

BACKGROUND: This study evaluates the impact of a new 'Preparation for Internship' (PRINT) course, which was developed to facilitate the transition of University of New South Wales (UNSW) medical graduates from Medical School to Internship. METHODS: During a period of major curricular reform, the 2007 (old program) and 2009 (new program) cohorts of UNSW final year students completed the Clinical Capability Questionnaire (CCQ) prior to and after undertaking the PRINT course. Clinical supervisors' ratings and self-ratings of UNSW 2009 medical graduates were obtained from the Hospital-based Prevocational Progress Review Form. RESULTS: Prior to PRINT, students from both cohorts perceived they had good clinical skills, with lower ratings for capability in procedural skills, operational management, and administrative tasks. After completing PRINT, students from both cohorts perceived significant improvement in their capability in procedural skills, operational management, and administrative tasks. Although PRINT also improved student-perceived capability in confidence, interpersonal skills and collaboration in both cohorts, curriculum reform to a new outcomes-based program was far more influential in improving self-perceptions in these facets of preparedness for hospital practice than PRINT. CONCLUSIONS: The PRINT course was most effective in improving students' perceptions of their capability in procedural skills, operational management and administrative tasks, indicating that student-to-intern transition courses should be clinically orientated, address relevant skills, use experiential learning, and focus on practical tasks. Other aspects that are important in preparation of medical students for hospital practice cannot be addressed in a PRINT course, but major improvements are achievable by program-wide curriculum reform.

Clinical capabilities of graduates of an outcomes-based integrated medical program.

BACKGROUND: The University of New South Wales (UNSW) Faculty of Medicine replaced its old content-based curriculum with an innovative new 6-year undergraduate entry outcomes-based integrated program in 2004. This paper is an initial evaluation of the perceived and assessed clinical capabilities of recent graduates of the new outcomes-based integrated medical program compared to benchmarks from traditional content-based or process-based programs. METHOD: Self-perceived capability in a range of clinical tasks and assessment of medical education as preparation for hospital practice were evaluated in recent graduates after 3 months working as junior doctors. Responses of the 2009 graduates of the UNSW's new outcomes-based integrated medical education program were compared to those of the 2007 graduates of UNSW's previous content-based program, to published data from other Australian medical schools, and to hospital-based supervisor evaluations of their clinical competence. RESULTS: Three months into internship, graduates from UNSW's new outcomes-based integrated program rated themselves to have good clinical and procedural skills, with ratings that indicated significantly greater capability than graduates of the previous UNSW content-based program. New program graduates rated themselves significantly more prepared for hospital practice in the confidence (reflective practice), prevention (social aspects of health), interpersonal skills (communication), and collaboration (teamwork) subscales than old program students, and significantly better or equivalent to published benchmarks of graduates from other Australian medical schools. Clinical supervisors rated new program graduates highly capable for teamwork, reflective practice and communication. CONCLUSIONS: Medical students from an outcomes-based integrated program graduate with excellent self-rated and supervisor-evaluated capabilities in a range of clinically-relevant outcomes. The program-wide curriculum reform at UNSW has had a major impact in developing capabilities in new graduates that are important for 21st century medical practice.

Electronic records suggest suboptimal management of chronic kidney disease in general practice.

OBJECTIVE: To examine electronic records of GP management of chronic kidney disease. DESIGN: Cross-sectional study. SETTING: Thirteen general practices. PARTICIPANTS: Fifteen thousand four hundred and fiftteen active patients aged 50 years and over. MAIN OUTCOME MEASURE: Recorded estimated glomerular filtration rate (eGFR) and diabetes, and rate of prescribing of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACE/ARBs). RESULTS: Six thousand and fifty-nine (39%) patients had hypertension and 1859 (12%), diabetes. Two thousand six hundred and eighty-nine (17%) patients were recorded with eGFR < 60 mL min(-1) (1.73 m(2) )(-1) , while 3344 (22%) did not have an eGFR result recorded. Hypertension, diabetes and eGFR <60 mL min(-1) (1.73 m(2) )(-1 ) were shown to be significantly related to prescribing of ACE/ARBs; however, 31% of known diabetics and 23% of diabetics with an eGFR < 60 mL min(-1) (1.73 m(2) )(-1 ) are not recorded as receiving ACE or ARB therapy. Forty-two per cent of patients with eGFR < 60 mL min(-1) (1.73 m(2) )(-1) , are also not recorded as receiving ACE or ARB therapy. There was a 23% variation in the rates of prescribing of ACE/ARBs by practice for patients with diabetes and eGFR < 60 mL min(-1) (1.73 m(2) )(-1) . CONCLUSION: The overall recording of eGFR and the recorded prescribing of ACE or ARB therapy in known diabetics and patients with eGFR < 60 mL min(-1) (1.73 m(2) )(-1) appear suboptimal. Also, the variations in prescribing between practices require further investigation.

Rural student doctors top city colleagues: representation of a rural clinical school in the rural press.

OBJECTIVE: To describe the way in which the rural press portrays a rural clinical school and its staff and students. DESIGN: Textual analysis of a collection of newspapers kept by the local campuses of the University of New South Wales Rural Clinical School (UNSW RCS). THE STUDY: The UNSW established a RCS in January 2000. This study sampled a total of 225 articles from eleven rural newspapers, a collection held by the campuses of the rural clinical schools. The major themes of the articles were identified; the descriptive terms the newspaper articles used for medical students, the UNSW RCS and rural doctors were also identified. The way in which clinical schools, their staff and students, are portrayed in the rural press has the potential to influence recruitment and retention. CONCLUSIONS: The study showed that the rural press was strongly supportive of the rural clinical school in their local region. This was particularly true for medical students, the school itself and the potential impact on workforce. The newspapers provided information for future students, depicting work-experience programs and current students. They were less illustrative of current medical and academic staff, with the exception of the Head of School.

Comparing patients' perceptions of IMGs and local Australian graduates in rural general practice.

BACKGROUND: Despite criticism of the clinical performance of international medical graduates (IMGs), little is known about the views of patients within a general practice setting. METHODS: A survey was conducted to measure the responses of 1127 patients of 10 GPs, five IMGs and five Australian graduates. The General Practice Assessment Questionnaire was used to assess the attitudes of patients towards attributes of the consultation and how the patient felt in terms of understanding and coping with their problem or illness. DISCUSSION: No statistically significant differences were found in any of the reported categories, although there were some responses that approached significance and warrant further investigation. The level of patient satisfaction with, and acceptance of, received care was similar whether the GP was an IMG or not.

Ambient biomass smoke and cardio-respiratory hospital admissions in Darwin, Australia.

BACKGROUND: Increasing severe vegetation fires worldwide has been attributed to both global environmental change and land management practices. However there is little evidence concerning the population health effects of outdoor air pollution derived from biomass fires. Frequent seasonal bushfires near Darwin, Australia provide an opportunity to examine this issue. We examined the relationship between atmospheric particle loadings <10 microns in diameter (PM10), and emergency hospital admissions for cardio-respiratory conditions over the three fire seasons of 2000, 2004 and 2005. In addition we examined the differential impacts on Indigenous Australians, a high risk population subgroup. METHODS: We conducted a case-crossover analysis of emergency hospital admissions with principal ICD10 diagnosis codes J00-J99 and I00-I99. Conditional logistic regression models were used to calculate odds ratios for admission with 10 microg/m3 rises in PM10. These were adjusted for weekly influenza rates, same day mean temperature and humidity, the mean temperature and humidity of the previous three days, days with rainfall > 5 mm, public holidays and holiday periods. RESULTS: PM10 ranged from 6.4 - 70.0 microg/m3 (mean 19.1). 2466 admissions were examined of which 23% were for Indigenous people. There was a positive relationship between PM10 and admissions for all respiratory conditions (OR 1.08 95%CI 0.98-1.18) with a larger magnitude in the Indigenous subpopulation (OR1.17 95% CI 0.98-1.40). While there was no relationship between PM10 and cardiovascular admissions overall, there was a positive association with ischaemic heart disease in Indigenous people, greatest at a lag of 3 days (OR 1.71 95%CI 1.14-2.55). CONCLUSION: PM10 derived from vegetation fires was predominantly associated with respiratory rather than cardiovascular admissions. This outcome is consistent with the few available studies of ambient biomass smoke pollution. Indigenous people appear to be at higher risk of cardio-respiratory hospital admissions associated with exposure to PM10.

A cohort study of indoor nitrogen dioxide and house dust mite exposure in asthmatic children.

OBJECTIVE: The purpose of this study was to investigate dose-response relationships between asthma symptoms and indoor nitrogen dioxide (NO2) and house dust mite allergen (HDM) in children. METHODS: Asthmatic children from 18 primary schools in Adelaide, Australia, kept a daily symptoms diary over 12 weeks. Home and classroom NO2 levels were measured repeatedly in winter 2000. HDM levels were obtained from beds. Lung function tests were performed at the beginning and at the end of the study period. RESULTS: Data on exposure and respiratory outcomes were gathered for 174 children. For school exposure, the estimated relative symptom rate (RR) for a 10-ppb increase in NO2 for difficulty breathing during the day was 1.09 (95% confidence interval [CI] = 1.03-1.15), at night 1.11 (95% CI = 1.05-1.18), and for chest tightness at night 1.12 (95% CI = 1.07-1.17). Significant symptom rate increases were also found for kitchen NO2 exposure. This was supported by a negative dose-response relationship between percentage predicted forced expiratory volume in 1 second and NO2 (-0.39%; 95% CI = -0.76 to -0.02) for kitchen exposure. Significant threshold effects using a 10-microg/g cutoff point for HDM exposure were established in the sensitized children for nighttime wheeze (RR = 3.62, 95% CI = 1.49-8.77), daytime cough (RR = 1.64, 95% CI = 1.14-2.36), and daytime asthma attack (RR = 1.95, 95% CI = 1.06-3.60). CONCLUSION: This study has established reliable risk estimates for exacerbations of asthma symptoms in children based on dose-response investigations of indoor NO2 and HDM.

Cluster randomized controlled trials in primary care: an introduction.

BACKGROUND: Cluster randomized trials occur when groups or clusters of individuals, rather than the individuals themselves, are randomized to intervention and control groups and outcomes are measured on individuals within those clusters. Within primary care, between 1997 and 2000, there has been a virtual doubling in the number of published cluster randomized trials. A recent systematic review, specifically within primary care, found study quality to be both generally lower than that reported elsewhere and not to have shown any recent quality improvement. OBJECTIVE: To discuss the design, conduct and analysis of cluster randomized trials within primary care in terms of the appropriate expertise required, potential bias, ethical considerations and expense. DISCUSSION: Compared with trials that involve the randomization of individual participants, cluster randomized trials are more complex to design and analyse and, for a given sample size, have decreased power and a broadening of confidence intervals. Cluster randomized trials are specifically prone to potential bias at two levels-the cluster and individual. Regarding the former, it is recommended that cluster allocation be undertaken by a party independent to the research team and careful consideration be given to ensure minimal cluster attrition. Bias at the individual level can be overcome by identifying trial participants before randomization and at this time obtaining consent for intervention, data collection or both. A unique ethical aspect to cluster randomized trials is that cluster leaders may consent to the trial on behalf of potential cluster members. Additional costs of cluster randomized trials include the increased number of patients required, the complexity in their design and conduct and, usually, the need to recruit clusters de novo. CONCLUSION: Cluster randomized trials are a powerful and increasingly popular research tool. They are uniquely placed for the conduct of research within primary-care clusters where intracluster contamination can occur. Associated methodological issues are straightforward and surmountable and just need careful consideration and management.

Women's decision making at menopause - a focus group study.

BACKGROUND: Women are faced with a confusion of information and uncertainty when making decisions at menopause. METHODS: We conducted four focus groups of 31 women aged 40-64 years, exploring their experience and views about menopause, its management, and decision support needs. RESULTS: Focus group participants saw menopause as a natural progression rather than a medical condition, and decision making about therapies as a personal responsibility. They wanted reliable, agenda free information, and opportunities to discuss personal needs with (preferably female) health professionals. They preferred minimal intervention and found life style strategies helpful. DISCUSSION: Women's preference to make their own decisions at menopause is frustrated by conflicting information and the perceived marketing agenda of information sources. Women need unbiased, timely, menopause information backed by expert commentary in a range of media to suit their access needs.

Accuracy of Screening Tools for Pap Smears in General Practice.

BACKGROUND: Data extraction tools (DETs) are increasingly being used for research and audit of general practice, despite their limitations.Objective This study explores the accuracy of Pap smear rates obtained with a DET compared to that of the Pap smear rate obtained with a manual file audit. METHOD: A widely available DET was used to establish the rate of Pap smears in a large multi-general practice (multi-GP) in regional New South Wales followed by a manual audit of patient files. The main outcome measure was identification of possible discrepancies between the rates established. RESULTS: The DET used significantly underestimated the level of cervical screening compared to the manual audit. In some instances, the patient file contained phone/specialist record of Pap smear conducted elsewhere, which accounted for the failure of the DET to detect some smears. Those patients who had Pap smears whose pathology codes differed between time intervals, i.e. from different pathology providers or from within the same provider but using a different code, were less likely to have had their most recent Pap smear detected by the DET (p < 0.001). CONCLUSION: Data obtained from DETs should be used with caution as they may not accurately reflect the rate of Pap smears from electronic medical records.How this fits in DETs are increasingly being used for research and audit of general practice. This study explores the accuracy of Pap smear rates obtained with a DET compared to that of the Pap smear rate obtained with a manual file audit The DET tested significantly underestimated the level of cervical screening compared to manual screening. Data obtained from DETs should be used with caution as they may not accurately reflect the rate of Pap smears from electronic medical records.

Foot shape and its effect on functioning in Royal Australian Air Force recruits. Part 1: Prospective cohort study.

OBJECTIVE: To determine whether foot shape (flat, normal, or cavus feet) affects functioning among military recruits. METHODS: A total of 230 Royal Australian Air Force recruits embarking on a 10-week basic training course took part in a prospective cohort study of foot shape and its effect on functioning. Recruits were divided into three groups based on their foot shape, i.e., flat feet (n = 22), normal feet (n = 139), and cavus feet (n = 44), with the diagnosis being made from the arch index measured from their footprints. The groups were assessed at baseline and week 8. Outcome measures included pain, injury, foot health, and quality of life. RESULTS: There were no significant differences in outcome measures at baseline. At the end of the trial, foot shape was not related to injury. The flat feet group had significantly poorer subjective physical health than did the normal feet group (p = 0.001). CONCLUSION: This study provides high-level evidence that foot shape has little impact on pain, injury, and functioning among military recruits.

Foot shape and its effect on functioning in Royal Australian Air Force recruits. Part 2: Pilot, randomized, controlled trial of orthotics in recruits with flat feet.

As part of a larger study of the effect of foot shape on functioning, 47 Royal Australian Air Force recruits with flexible flat feet who were embarking on a 10-week basic training course took part in a randomized controlled trial of orthotic therapy. In particular, recruits were assigned at random to an untreated group or a group that received Australian Orthotics Laboratory, three-quarter-length, flexible, shoe inserts. The groups were assessed at baseline and week 8. Outcome measures included pain, injury, foot health, and quality of life. The untreated group (n = 22) had a greater proportion of heavier recruits than did the treated group (n = 25). There were no significant differences in outcome measures at baseline. Only one-half of the group assigned to orthotic therapy wore the orthotics most or all of the time. At the end of the trial, although the results were not statistically significant, those who were provided with orthotics and wore them had the least lower limb pain and the best general foot health and quality of life. Notably, none of the recruits who wore their orthotics most or all of the time sustained a training injury.

Tissue plasminogen activator -7351C/T enhancer polymorphism is a risk factor for lacunar stroke.

BACKGROUND AND PURPOSE: Occlusive thrombosis is an important component of small- and large-vessel ischemic stroke. Endogenous tissue plasminogen activator (TPA) is the primary mediator of intravascular fibrinolysis and is predominantly expressed by the endothelium of small vessels. The acute release of TPA is influenced by the TPA -7351C/T polymorphism and therefore may play an important role in the pathogenesis of lacunar stroke. In this study, we investigated the risk of lacunar and nonlacunar ischemic stroke associated with the TPA -7351C/T polymorphism. METHODS: We conducted a case-control study of 182 cases of ischemic stroke and 301 community controls. Participants were evaluated for known cerebrovascular risk factors, and the TPA -7351C/T genotype was established by a polymerase chain reaction (PCR) method. Logistic regression was used to determine the risk of lacunar and nonlacunar ischemic stroke associated with the TPA -7351C/T polymorphism. RESULTS: The prevalence of the TPA -7351 CC, CT, and TT genotypes were 46%, 45%, and 9% for controls and 41%, 46%, and 13% for stroke patients, respectively. After adjustment for known cerebrovascular risk factors, the TT genotype was significantly associated with ischemic stroke (OR: 1.9; 95% CI: 1.01 to 3.6). Stratification for stroke subtype showed a significant association between the TT genotype and lacunar stroke but not nonlacunar stroke (OR: 2.7; 95% CI: 1.1 to 6.7). CONCLUSIONS: The TPA -7351C/T polymorphism is an independent risk factor for lacunar stroke. The findings suggest that impaired fibrinolysis may play a role in the pathogenesis of lacunar stroke.

Randomized controlled trial of unflued gas heater replacement on respiratory health of asthmatic schoolchildren.

BACKGROUND: Previous studies do not provide a clear picture of the relationship between nitrogen dioxide (NO(2)) exposure and asthma. METHODS: Eighteen schools using unflued gas heating in winter were randomly allocated to either retain their heaters (10 control schools) or to have replacement flued gas or electric heaters installed at the beginning of winter (8 intervention schools). Fortnightly telephone interviews were used to record daily individual asthma symptoms that occurred over 12 weeks (including winter). Lung function and histamine challenge tests were performed at baseline and the end of the study. NO(2) was measured in each school classroom on 9 days and in each household on 3 days spread over the study period. RESULTS: From 199 primary school children that met the eligibility criteria, 45 intervention and 73 control children agreed to participate. Baseline characteristics were similar between groups. Difficulty breathing during the day (Relative Risk [RR] = 0.41; 95% CI: 0.07, 0.98) and night (RR = 0.32; 95% CI: 0.14, 0.69), chest tightness during the day (RR = 0.45; 95% CI: 0.25, 0.81), and daytime asthma attacks (RR = 0.39; 95% CI: 0.17, 0.93) were significantly reduced in the intervention group. Percentage predicted forced expiratory volume in one second (FEV(1)), the concentration of histamine inducing a 20% fall in FEV(1) (PD(20)), and the dose-response slope (DRS) were similar between groups at follow-up. Mean (standard deviation) NO(2) levels were 15.5 (6.6) parts per billion (ppb) and 47.0 (26.8) ppb in the intervention and control schools respectively (P < 0.001). CONCLUSIONS: Asthma symptoms were reduced following a replacement intervention that removed high exposure to NO(2). Such replacement should be considered a public health priority for schools using unflued gas heating during winter.

Acute skin irritant effects of cyanobacteria (blue-green algae) in healthy volunteers.

OBJECTIVE: To assess the skin irritant potential of a range of laboratory grown cyanobacterial species using skin-patch testing on human volunteers. METHODS: Cell suspensions and extracts of cyanobacterial cultures of Microcystis aeruginosa (non-toxic strain), Anabaena circinalis and Nodularia spumigena were applied to 64 volunteers in one trial, and Microcystis aeruginosa (toxic strain), Apanocapsa incerta and Cylindrospermopsis raciborskii were applied to 50 volunteers in a second trial. Six cell concentrations of each organism in the range from less than 5000 to greater than 200,000 cells/mL were applied in random order using adhesive skin patches (Finn Chambers). In addition, the applications included two treatments of each cyanobacterial species, involving whole and lysed cells, and positive (sodium lauryl sulphate) and negative (culture media) controls. Patches were removed after 24 hours and assessment of erythema was made by a dermatologist blinded to the species, cell type and concentration. RESULTS: On average, between 20% and 24% of individuals with 95% confidence interval +/-8% reacted across the concentration range tested for these cyanobacterial species. The reaction rates were lower (11% to 15%) among the subset of subjects not reacting to negative controls. The reaction was mostly mild, and in all cases was resolved without treatment. This was the case for both whole and lysed cells with little difference in reaction rates between these two treatments. There was also no dose-response across the concentration range for any of the cyanobacterial species tested. CONCLUSION: A small proportion of healthy people (around 20%) may develop a skin reaction to cyanobacteria in the course of normal water recreation, but the reaction is mild and resolved without treatment.

Effect of beta lactam antibiotic use in children on pneumococcal resistance to penicillin: prospective cohort study.

OBJECTIVE: To examine the relation between use of antibiotics in a cohort of preschool children and nasal carriage of resistant strains of pneumococcus. DESIGN AND PARTICIPANTS: Prospective cohort study over two years of 461 children aged under 4 years living in Canberra, Australia. MAIN OUTCOME MEASURES: Use of drugs, respiratory symptoms, and visits to doctors were documented in a daily diary by parents of the children during 25 months of observation. Isolates of pneumococci, which were cultured from nasal swabs collected approximately six monthly, were tested for antibiotic resistance. RESULTS: From the four swab collections 631 positive pneumococcal isolates from 461 children were found, of which 13.6% were resistant to penicillin. Presence of penicillin resistant pneumococci was significantly associated with children's use of a beta lactam antibiotic in the two months before each swab collection (odds ratio 2.03 (95% confidence interval 1.15 to 3.56, P=0.01)). The odds ratio of the association remained >1 (though did not reach significance at the 0.05 level) for use in the six months before swab collection. The association was seen in children who received only penicillin or only cephalosporin antibiotics in that period. The odds ratio was 4.67 (1.29 to 17.09, P=0.02) in children who had received both types of beta lactam in the two months before their nasal swab. The modelled odds of carrying penicillin resistant pneumococcus was 4% higher for each additional day of use of beta lactam antibiotics in the six months before swab collection. CONCLUSIONS: Reduction in beta lactam use could quickly reduce the carriage rates of penicillin resistant pneumococci in early childhood. In view of the propensity of these organisms to be spread among children in the community, the prevalence of penicillin resistant organisms may fall as a consequence.

Environmental exposure to organophosphorus and pyrethroid pesticides in South Australian preschool children: a cross sectional study.

Organophosphorus (OP) and pyrethroid (PYR) compounds are the most widely used insecticides. OPs and PYRs are developmental neurotoxicants. Understanding the extent of exposure in the general population and especially in young children is important for the development of public health policy on regulation and use of these chemicals. Presented here are the results of the first investigation into the extent of environmental exposure to neurotoxic insecticides in preschool children in South Australia (SA). Children were enrolled from different areas of SA and assigned into urban, periurban and rural groups according to their residential address. Residential proximity to agricultural activity, parental occupational contact to insecticides and use of insecticides within the household were investigated as potential indirect measures of exposure. We used liquid chromatography/tandem mass spectrometry to measure the following metabolites of OPs and PYRs in urine samples as direct indicators of exposure: dialkylphosphates, p-nitrophenol, 3-methyl-4-nitrophenol, 3,5,6-trichloro-2-pyridinol, cis- and trans-3-(2,2-dichlorovinyl)-2,2-dimethyl-cyclopropane-1-carboxylic acid, cis-3-(2,2-dibromovinyl)-2,2-dimethyl-cyclopropane-1-carboxylic acid, 2-methyl-3phenylbenzoic acid and 3-phenoxybenzoic acid. Results were analysed to assess factors affecting the risk and level of exposure. Results were also compared to the published data in similar age groups from US and German studies. The results of this study demonstrate that there was widespread chronic exposure to OPs and and PYRs in SA children. OP metabolites were detected more commonly than PYR. Exposure to more than one chemical and contemporaneous exposure to chemicals from both OP and PYR groups was common in the study population. There were some differences in risks and levels of exposure between the study groups. Exposure to some restricted use of chemicals, for example, fenitrothion, was higher in periurban and rural children. There was no difference among the study groups in exposure to chlorpyrifos, used commonly in agriculture and in domestic settings and most frequently found OP pesticide in food in Australia. South Australian children appear to have higher levels of exposure compared their peers in US and Germany.

Issues for clinicians training international medical graduates: a systematic review.

OBJECTIVE: To ascertain the specialised communication issues clinicians need to understand when preparing international medical graduates (IMGs) for clinical practice in Australia. STUDY DESIGN: Systematic review. DATA SOURCES: A series of searches using MEDLINE (1990-2006) was conducted with relevant keywords. Literature from countries with experience in the integration of IMGs into their medical workforces was included. All except four articles were published between 1997 and 2006. STUDY SELECTION: The initial search identified 748 articles, which reduced to 234 evidence-based English language articles for review. Of these, only articles relating to postgraduate medical training and overseas trained doctors were selected for inclusion. DATA EXTRACTION: Titles and abstracts were independently reviewed by two reviewers, with a concordance rate of 0.9. Articles were included if they addressed communication needs of IMGs in training. Any disparities between reviewers about which articles to include were discussed and resolved by consensus. DATA SYNTHESIS: Key issues that emerged were the need for IMGs to adjust to a change in status; the need for clinicians to understand the high level of English language proficiency required by IMGs; the need for clinicians to develop IMGs' skills in communicating with patients; the need for clinicians to understand IMGs' expectations about teaching and learning; and the need for IMGs to be able to interact effectively with a range of people. CONCLUSION: Training organisations need to ensure that clinicians are aware of the communication issues facing IMGs and equip them with the skills and tools to deal with the problems that may arise.