The geography of melanoma in South Australia.

OBJECTIVE: We sought to determine the distribution of melanoma in South Australia with respect to the relative incidence and mortality in coastal/river versus inland areas and metropolitan versus regional/remote areas, and to outline the public health implications of this distribution. METHODS: All melanoma cases and deaths for the period 1985-2004 for Adelaide and 11 regional centres were geo-coded and then allocated to ABS collection districts. Collection districts with a centroid within 2 km of the coast or River Murray were determined using mapping software. RESULTS: Melanoma incidence is higher in coastal South Australia (OR=1.19) and near the River Murray (OR=1.25) than in inland South Australia. This geographical effect remains after adjustment for age and socio-economic status. Incidence is also higher in metropolitan Adelaide than in regional areas (OR=1.10). For melanoma mortality there is no significant effect of living near the coast or river, and no effect of living in regional areas. CONCLUSION: Living near the coast or River Murray in South Australia is associated with an increased risk of being diagnosed with melanoma. IMPLICATIONS: Melanoma prevention and acute care programs can be usefully targeted at persons living in coastal and riverine areas, where there is a significant excess of melanoma incidence. This target population is older than inland populations and will require interventions appropriate for aged communities.

Risk factors for intrauterine growth restriction in a socio-economically disadvantaged region.

BACKGROUND: Risk factors for pregnancies being complicated by the birth of a small-for-gestational age (SGA) infant were analysed in a socio-economically disadvantaged area, with separate analysis for population-based and customized-based birth weight percentiles. METHODS: A retrospective case-controlled study of all singleton pregnancies resulting in the birth of an infant with a birth weight < 10 population-based centile, born in the Northern suburbs of metropolitan Adelaide, between 1998 and 2003. Significant risk factors in the univariate analysis were subsequently checked with multivariate analysis. RESULTS: The analyses confirm marked differences between population-based and customized-birth weight centiles. Patterns of risk factors show clear differences in risk factors for these two different SGA groups. Univariate analyses of all (nulliparous and multiparous women) customized SGA infants shows us the following odds ratio's (OR); unemployment OR 2.06, 95% confidence interval (CI) 1.46-2.92, being a single mother OR 1.90, CI 1.76-2.05, smoking OR 3.24, CI 2.32 - 4.54, recreational drug use OR 2.40, CI 1.55-3.70, mental health problems OR 1.52, CI 1.04-2.23, domestic violence OR 3.42, CI 1.26-9.29, being healthy OR 0.43, CI 0.30-0.61, preeclampsia OR 1.73, CI 1.01-2.97, and BMI < 30 OR 0.63 CI 0.43-0.93. Length of pregnancy interval had no relationship whatsoever with the risk of being delivered of an SGA infant. Multivariate analyses for customized SGA showed five factors with an OR > 2 (95% CI not crossing 1), including unemployment, smoking, maternal age > 34 years, not being healthy and preeclampsia, while different paternity, age 25-34 compared to age < 25 were also found to be significant risk factors. Higher systolic blood pressure was found to convey significant protection. CONCLUSION: When studying risk factors for pregnancies complicated by the birth of an SGA infant, both population-derived and customized growth centiles should be utilized. This study confirms the importance of smoking as a major risk factor, our data also show major protection being conveyed by having a regular job and being generally healthy. Pregnancy interval did not have any relationship with the birth of SGA infants, while paternity change was identified as a clear risk factor. Although genuine preeclampsia persists as a clear risk factor, higher systolic blood pressure appears to convey protection.

Avoidable risk factors in perinatal deaths: a perinatal audit in South Australia.

OBJECTIVES: To analyse risk factors of perinatal death, with an emphasis on potentially avoidable risk factors, and differences in the frequency of suboptimal care factors between maternity units with different levels of care. METHODS: Six hundred and eight pregnancies (2001-2005) in South Australia resulting in perinatal death were described and compared to 86 623 live birth pregnancies. RESULTS: Two hundred and seventy cases (44.4%) were found to have one or more avoidable maternal risk factors, 31 cases (5.1%) had a risk factor relating access to care, while 68 cases (11.2%) were associated with deficiencies in professional care. One hundred and four women (17.1% of cases) presented too late for timely medical care: 85% of these did have a sufficient number of antenatal visits. The following independent maternal risk factors for perinatal death were found: assisted reproductive technology (adjusted odds ratio (AOR) 3.16), preterm labour (AOR 22.05), antepartum haemorrhage (APH) abruption (AOR 6.40), APH other/unknown cause (AOR 2.19), intrauterine growth restriction (AOR 3.94), cervical incompetence (AOR 8.89), threatened miscarriage (AOR 1.89), pre-existing hypertension (AOR 1.72), psychiatric disorder (AOR 1.85) and minimal antenatal care (AOR 2.89). The most commonly found professional care deficiency in cases was the failure to act on or recognise high-risk pregnancies/complications, found in 49 cases (8.1%). CONCLUSION: Further improvements in perinatal mortality may be achieved by greater emphasis on the importance of antenatal care and educating women to recognise signs and symptoms that require professional assessment. Education of maternity care providers may benefit from a further focus on how to recognise and/or manage high-risk pregnancies.

Endometrial cells as a predictor of uterine cancer.

BACKGROUND: With the recent cervix screening national guidelines recommending against reporting of benign endometrial cells, we examined South Australian data to see what impact this would have on detecting uterine cancers. AIMS: To test whether benign endometrial cells detected in cervical cytology testing confer an increased risk of uterine cancer, and to ascertain what percentage of uterine cancers will be missed in cervical screening programs if these cells are not reported. METHODS: The study was a retrospective cohort design of 1585 women with shed endometrial cells, each matched with three women without shed cells. All were linked with cancer registry data to check for uterine cancer diagnosis. Cox proportional hazards regression was used to check for any increase in cancer risk with shed endometrial cells. Using the calculated relative risks for uterine cancer diagnosis, we estimated the number of uterine cancers in South Australia associated with benign endometrial cells. RESULTS: The presence of benign endometrial cells in a cervical cytology test increases the risk of uterine cancer sixfold. However, screening women with benign cells would involve a major increase in pathology work for only an 18% increase in uterine cancers detected. CONCLUSIONS: Until cytology systems have a higher sensitivity in detecting which benign endometrial cells are associated with uterine cancer, pathology laboratories are unlikely to be required to report these cells on tests. Inability to adjust for symptomatic status may have reduced the relevance of the results in this study.

Risk factors for hypertension during pregnancy in South Australia.

OBJECTIVE: To identify risk factors for hypertension in pregnancy among South Australian women. DESIGN: A population-based retrospective analysis using the South Australian perinatal data collection for 1998-2001. METHODS: Three groups of women with hypertension (pre-existing hypertension, pregnancy hypertension, and superimposed pre-eclampsia) were compared with normotensive women using unconditional logistic regression analysis on 70,386 singleton births to identify sociodemographic and clinical risk factors for hypertension in pregnancy. RESULTS: Nulliparity, Aboriginal race and Caucasian race (compared with Asian) and pre-existing and gestational diabetes were demonstrated to be risk factors for all hypertensive disorders, as was increasing maternal age for pre-existing hypertension and superimposed pre-eclampsia. Risk was increased for pregnancy hypertension and superimposed pre-eclampsia among women who gave their occupation as 'home duties' and also for superimposed pre-eclampsia among unemployed women. Women with hypertension were more likely to give birth in teaching hospitals. Urinary tract infections were not found to be a risk factor for any type of hypertension. Smoking during pregnancy was protective for all types of hypertension. CONCLUSIONS: The present study used a statewide population perinatal database and has confirmed that Aboriginal race, Caucasians, nulliparity, and pre-existing and gestational diabetes are independent risk factors for all types of hypertension in pregnancy. Increasing maternal age increased the risk for pre-existing hypertension and superimposed pre-eclampsia. There appeared to be appropriate referral of women with hypertensive disorders to teaching hospitals. A new finding is the increased risk among unemployed women and women engaged in home duties.

Trial of nurse-run asthma clinics based in general practice versus usual medical care.

OBJECTIVE: The aim of this study was to assess the ability of nurse-run asthma clinics based in general practice compared with usual medical care to produce at least a moderate improvement in the quality of life of adults with asthma. METHODOLOGY: A randomized controlled trial involving 80 asthma clinic and 90 usual medical care asthma participants, aged 18 years and older was conducted in 11 general practices in Adelaide. The main outcome measure was the St George's respiratory questionnaire (SGRQ), from which quality-of-life scores were used to assess therapeutic benefit. Lung function measurements and health services utilization data were also collected. RESULTS: One hundred and fifty-three participants (90%) were reviewed at follow up after 6-9 months. There was little difference between groups in baseline measures or for the 6-month follow-up outcomes, including the mean difference in total SGRQ scores (-0.5, 95% confidence interval (CI) -4.0, 2.9) and the mean difference in percentage predicted FEV(1) (2.3%, 95% CI -0.7, 5.3 pre-bronchodilator; 0.4%, 95% CI -5.1, 5.9 post-bronchodilator). Trends in health services utilization were noted. CONCLUSIONS: Nurse-run asthma clinics based in general practice and usual medical care were similar in their effects on quality of life and lung function in adults. These findings cannot be generalized to hospital outpatients and other clinics that manage more severe asthmatic patients.

Hypertension during pregnancy in South Australia, part 1: pregnancy outcomes.

BACKGROUND: There have been conflicting reports about pregnancy outcome in the hypertensive disorders of pregnancy. The present study was undertaken to examine outcomes using a population database. AIMS: To examine for differences in a range of pregnancy outcomes between three different groups of hypertensive women and normotensive women in South Australia. METHODS: Nine pregnancy outcomes were compared for 70,386 singleton pregnancies in the South Australian perinatal data collection in 1998-2001, consisting of 639 women with pre-existing hypertension, 5356 women with pregnancy hypertension, 448 women with superimposed pre-eclampsia and 63 943 normotensive women. Means for the four groups were calculated for birthweight, gestational age, the baby's and mother's length of stay. The groups were also compared for perinatal deaths with an earlier period, 1991-1997. RESULTS: While all three hypertensive groups had high incidences of induction of labour and emergency Caesarean, only pre-existing hypertension and superimposed pre-eclampsia were significantly associated with elective Caesarean section. All hypertensive groups had increased risks for low birthweight and preterm birth and special and neonatal intensive care. Uncomplicated pre-existing hypertension was not associated with small for gestational age infants, but with preterm delivery between 32 and 36 weeks' gestation. Superimposed pre-eclampsia had the worst prognosis for perinatal and maternal morbidity. While pregnancy hypertension held the intermediate position, it was not associated with an increase in perinatal mortality. The perinatal mortality rate for women with hypertensive disorders in 1998-2001 was significantly lower than that of an earlier period and equivalent to that for normotensive women. CONCLUSIONS: Superimposed pre-eclampsia occurs in approximately 40% of pregnancies of women with pre-existing hypertension and has the most severe outcomes. The hypertensive disorders are associated with high levels of morbidity and intervention, but the high perinatal mortality associated with these disorders has fallen significantly.

Hypertension during pregnancy in South Australia, part 2: risk factors for adverse maternal and/or perinatal outcome - results of multivariable analysis.

OBJECTIVE: To identify factors associated with adverse pregnancy outcomes among women with hypertension during pregnancy. DESIGN: A population-based retrospective multivariable analysis using the South Australian perinatal data collection. METHODS: Perinatal data on 70,386 singleton births in 1998-2001 were used in multivariable analyses on three groups: all women combined, all hypertensive women and women with pregnancy hypertension only, in order to identify independent risk factors for requirement for level II/III care, preterm birth, small for gestational age (SGA) birth and maternal length of stay greater than 7 days. RESULTS: The risks for the four morbidities were all increased among women with hypertension compared with normotensive women. Those with pre-existing hypertension had the lowest risk (with odds ratios (OR) 1.26-2.90). Pregnancy hypertension held the intermediate position (OR 1.52-5.70), while superimposed pre-eclampsia was associated with the highest risk (OR 2.00-8.75). Among women with hypertension, Aboriginality, older maternal age, nulliparity and pre-existing or gestational diabetes increased the risk for level II/III nursery care, preterm birth and prolonged hospital stay. Smokers had shorter stays, which may be related to their decreased risk of having a Caesarean section or operative vaginal delivery. Asian women, Aboriginal women, smokers and unemployed women had an increased risk for having an SGA baby, while women with pre-existing or gestational diabetes had a reduced risk. CONCLUSIONS: Among hypertensive pregnant women, nulliparity, older maternal age, Aboriginality, unemployment and diabetes are independent risk factors for one or more major adverse pregnancy outcomes. Smoking does not always worsen the outcome for hypertensive women except for SGA births.

Hospital attendance prediction tool also identifies impaired quality of life in adults with asthma in general practice.

STUDY OBJECTIVE: To assess the ability of an adult risk screening questionnaire (RSQ), previously shown to predict attendance at hospital emergency departments, to identify impaired quality of life in adult patients with asthma in general practice. DESIGN: Baseline data from an RCT of asthma clinics in general practice, using the St. George Respiratory Questionnaire (SGRQ) to measure quality of life. SETTING: Twelve general practices in Adelaide, Australia. RESULTS: A total of 184 adult asthmatics were recruited, with a mean (standard deviation) age of 50.3 years (16.6 years). Age, gender, weight, number of comorbidities, smoking status, FEV1 and percent predicted FEV1 (pre-and post-bronchodilator), peak flow (pre and post), and RSQ were independently related to SGRQ scores. After adjusting for potential confounders, an RSQ score predictive of hospital attendance was also associated with an average increase (worsening) in SGRQ total score of 11.9 (95% CI: 7.6, 16.3), an average increase in activity score of 9.0 (2.5, 15.5), symptom score of 14.8 (8.6, 21.0), and impact score of 13.1 (8.6, 17.6). These represent clinically significant differences. CONCLUSION: An RSQ score predictive of hospital attendance should alert the general practitioner to explore and address symptom, activity, and impact domains associated with impaired quality of life in adult asthma.

The effectiveness of coordinated care for people with chronic respiratory disease.

OBJECTIVES: To evaluate the effectiveness of coordinated care for chronic respiratory disease. DESIGN AND SETTING: Community-based geographical control study, in western (intervention) and northern (comparison) metropolitan Adelaide (SA). PARTICIPANTS: 377 adults (223 intervention; 154 comparison) with chronic obstructive pulmonary disease, asthma or other chronic respiratory condition, July 1997 to December 1999. INTERVENTION: Coordinated care (includes care coordinator, care guidelines, service coordinator and care mentor). MAIN OUTCOME MEASURES: Hospital admissions (any, unplanned and respiratory), functionality (activities of daily living) and quality of life (SF-36 and Dartmouth COOP). RESULTS: At entry to the study, intervention and comparison subjects were dissimilar. The intervention group was 10 years older (P < 0.001), less likely to smoke (P = 0.014), had higher rates of hospitalisation in the previous 12 months (P < 0.001) and had worse self-reported quality of life (SF-36 physical component summary score [P < 0.001] and four of nine COOP domains [P = 0.002-0.013]). After adjustment for relevant baseline characteristics, coordinated care was not associated with any difference in hospitalisation, but was associated with some improvements in quality of life (SF-36 mental component summary score [P = 0.023] and three of nine COOP domains [P = 0.008-0.031]) compared with the comparison group. CONCLUSIONS: Coordinated care given to patients with chronic respiratory disease did not affect hospitalisation, but it was associated with an improvement in some quality-of-life measures.