Colchicine in Patients with Chronic Coronary Disease.

BACKGROUND: Evidence from a recent trial has shown that the antiinflammatory effects of colchicine reduce the risk of cardiovascular events in patients with recent myocardial infarction, but evidence of such a risk reduction in patients with chronic coronary disease is limited. METHODS: In a randomized, controlled, double-blind trial, we assigned patients with chronic coronary disease to receive 0.5 mg of colchicine once daily or matching placebo. The primary end point was a composite of cardiovascular death, spontaneous (nonprocedural) myocardial infarction, ischemic stroke, or ischemia-driven coronary revascularization. The key secondary end point was a composite of cardiovascular death, spontaneous myocardial infarction, or ischemic stroke. RESULTS: A total of 5522 patients underwent randomization; 2762 were assigned to the colchicine group and 2760 to the placebo group. The median duration of follow-up was 28.6 months. A primary end-point event occurred in 187 patients (6.8%) in the colchicine group and in 264 patients (9.6%) in the placebo group (incidence, 2.5 vs. 3.6 events per 100 person-years; hazard ratio, 0.69; 95% confidence interval [CI], 0.57 to 0.83; P<0.001). A key secondary end-point event occurred in 115 patients (4.2%) in the colchicine group and in 157 patients (5.7%) in the placebo group (incidence, 1.5 vs. 2.1 events per 100 person-years; hazard ratio, 0.72; 95% CI, 0.57 to 0.92; P = 0.007). The incidence rates of spontaneous myocardial infarction or ischemia-driven coronary revascularization (composite end point), cardiovascular death or spontaneous myocardial infarction (composite end point), ischemia-driven coronary revascularization, and spontaneous myocardial infarction were also significantly lower with colchicine than with placebo. The incidence of death from noncardiovascular causes was higher in the colchicine group than in the placebo group (incidence, 0.7 vs. 0.5 events per 100 person-years; hazard ratio, 1.51; 95% CI, 0.99 to 2.31). CONCLUSIONS: In a randomized trial involving patients with chronic coronary disease, the risk of cardiovascular events was significantly lower among those who received 0.5 mg of colchicine once daily than among those who received placebo. (Funded by the National Health Medical Research Council of Australia and others; LoDoCo2 Australian New Zealand Clinical Trials Registry number, ACTRN12614000093684.).

Measures of mental health and addictions conditions show a U-shaped relationship with self-rated worker performance.

BACKGROUND: Reports of a meaningful relationship between mental health-related conditions and work productivity measures are relatively common. These, however, are frequently examined for their linearity while ignoring untapped, and potentially rich, non-linear associations. METHODS: Following a serendipitous finding of a curvilinear relationship between workplace presenteeism (lowered productivity while at work) and depression, an investigation was undertaken of the association between worklife prevalence measures of presenteeism (measured by the W.H.O. Health & Work Performance Questionnaire) and lifetime prevalence of twelve psychosocial vulnerabilities, encompassing mental health, mental health-related, and addictive conditions. Linear and quadratic (U-shaped) functions were calculated across the "relative" presenteeism measure (self vs. other workers) for each of the 12 conditions. RESULTS: A visual analysis revealed a U-shaped graphic function in all conditions, and excepting anxiety all were statistically significant. In general, increases beyond the lowest ("poorest") level of self-reported comparative productivity were associated with increases in psychosocial stability, but only as far as deemed equality. Beyond that, increases in self-confidence resulted in a reversal, thus returning to a higher level of vulnerability for the condition in question. A cursory scan of five relevant journals indicated that non-linear analyses were often possible, but rarely carried out. CONCLUSIONS: This has informative value for our conceptualization of overconfidence, and it begs the question of whether an over-reliance on linear measures has caused us to overlook important curvilinear human relationships. The inclusion of analyses of non-linear functions is suggested as a matter of course for future studies.

Shifts in coralline algae, macroalgae, and coral juveniles in the Great Barrier Reef associated with present-day ocean acidification.

Seawater acidification from increasing CO2 is often enhanced in coastal waters due to elevated nutrients and sedimentation. Our understanding of the effects of ocean and coastal acidification on present-day ecosystems is limited. Here we use data from three independent large-scale reef monitoring programs to assess coral reef responses associated with changes in mean aragonite saturation state (Ωar ) in the Great Barrier Reef World Heritage Area (GBR). Spatial declines in mean Ωar are associated with monotonic declines in crustose coralline algae (up to 3.1-fold) and coral juvenile densities (1.3-fold), while non-calcifying macroalgae greatly increase (up to 3.2-fold), additionally to their natural changes across and along the GBR. These three key groups of organisms are important proxies for coral reef health. Our data suggest a tipping point at Ωar 3.5-3.6 for these coral reef health indicators. Suspended sediments acted as an additive stressor. The latter suggests that effective water quality management to reduce suspended sediments might locally and temporarily reduce the pressure from ocean acidification on these organisms.

Development of the coral index, a summary of coral reef resilience as a guide for management.

Coral reef management is increasingly focused on supporting the resilience of coral communities to increasing and cumulative pressures. The coral index provides a concise summary of coral community resilience that can be efficiently communicated to a range of management and policy stakeholders. We detail the development of the index both as a technical reference for users but also as an example of an approach that could be more generally applied to the reporting of ecosystem resilience. The index is sensitive to acute impacts that are expected when coral communities are exposed to disturbances such as cyclones, bleaching events or crown-of-thorns outbreaks. Importantly, spatial and temporal trends in the index enable the identification of areas and periods of reduced resilience that suggest chronic environmental pressure imposed by runoff. The ability to summarise complex ecological processes into a single index provides an efficient and intuitive tool for the communication of where, when and which pressures are impacting ecosystem resilience.

Spatial resilience of the Great Barrier Reef under cumulative disturbance impacts.

In the face of increasing cumulative effects from human and natural disturbances, sustaining coral reefs will require a deeper understanding of the drivers of coral resilience in space and time. Here we develop a high-resolution, spatially explicit model of coral dynamics on Australia's Great Barrier Reef (GBR). Our model accounts for biological, ecological and environmental processes, as well as spatial variation in water quality and the cumulative effects of coral diseases, bleaching, outbreaks of crown-of-thorns starfish (Acanthaster cf. solaris), and tropical cyclones. Our projections reconstruct coral cover trajectories between 1996 and 2017 over a total reef area of 14,780 km2 , predicting a mean annual coral loss of -0.67%/year mostly due to the impact of cyclones, followed by starfish outbreaks and coral bleaching. Coral growth rate was the highest for outer shelf coral communities characterized by digitate and tabulate Acropora spp. and exposed to low seasonal variations in salinity and sea surface temperature, and the lowest for inner-shelf communities exposed to reduced water quality. We show that coral resilience (defined as the net effect of resistance and recovery following disturbance) was negatively related to the frequency of river plume conditions, and to reef accessibility to a lesser extent. Surprisingly, reef resilience was substantially lower within no-take marine protected areas, however this difference was mostly driven by the effect of water quality. Our model provides a new validated, spatially explicit platform for identifying the reefs that face the greatest risk of biodiversity loss, and those that have the highest chances to persist under increasing disturbance regimes.

Concordance with antibiotic guidelines in Australian primary care: A retrospective study of prior-to-hospital therapy.

Background Appropriate antibiotic prescribing improves patient outcomes and mitigates antimicrobial resistance. As the majority of antibiotics are used in the community, rational prescribing in this setting is of paramount importance. Objectives We aimed to (1) evaluate the concordance of community antibiotic prescribing with guidelines for three common infection types among patients who presented to hospital, and (2) identify relationships between guideline concordance and patient-related factors. Methods Medical records were evaluated from the Royal Hobart Hospital (Tasmania, Australia) for patients presenting with respiratory tract, urinary tract or skin and soft tissue infections within a 12-month period. Prior-to-hospital antibiotic therapy was assessed for concordance with prescribing guidelines based on presenting diagnosis. Concordance was assessed against first-line recommendations in the Australian Therapeutic Guidelines - Antibiotic, based on drug choice, dose, frequency and patient factors. Descriptive statistics were performed to address Objective 1. Multivariate logistic regressions were conducted to address Objective 2 with the following independent variables: infection type, age, allergies, diabetes status, gender and residential setting. Results A total of 285 patient records were eligible for data analysis; 28.8% (n = 82) were fully guideline concordant. The most common reason for non-concordance was inappropriate drug choice (n = 143, 50.2%). Patients with the following characteristics were less likely to receive concordant therapy: diabetes (OR = 0.3, 95% CI 0.1-0.8, P = .02) and increasing age (OR = 0.99, 95% CI 0.98-1.00, P = .04). Conclusions Almost three-quarters of patients received community-initiated antibiotic therapy that was not fully guideline concordant. Antimicrobial stewardship interventions are urgently needed to improve guideline concordance for community-initiated antibiotic therapy.

Acute drivers influence recent inshore Great Barrier Reef dynamics.

Understanding the dynamics of habitat-forming organisms is fundamental to managing natural ecosystems. Most studies of coral reef dynamics have focused on clear-water systems though corals inhabit many turbid regions. Here, we illustrate the key drivers of an inshore coral reef ecosystem using 10 years of biological, environmental, and disturbance data. Tropical cyclones, crown-of-thorns starfish, and coral bleaching are recognized as the major drivers of coral loss at mid- and offshore reefs along the Great Barrier Reef (GBR). In comparison, little is known about what drives temporal trends at inshore reefs closer to major anthropogenic stress. We assessed coral cover dynamics using state-space models within six major inshore GBR catchments. An overall decline was detected in nearly half (46%) of the 15 reefs at two depths (30 sites), while the rest exhibited fluctuating (23%), static (17%), or positive (13%) trends. Inshore reefs responded similarly to their offshore counterparts, where contemporary trends were predominantly influenced by acute disturbance events. Storms emerged as the major driver affecting the inshore GBR, with the effects of other drivers such as disease, juvenile coral density, and macroalgal and turf per cent cover varying from one catchment to another. Flooding was also associated with negative trends in live coral cover in two southern catchments, but the mechanism remains unclear as it is not reflected in available metrics of water quality and may act through indirect pathways.

Agreement among the Productivity Components of Eight Presenteeism Tests in a Sample of Health Care Workers.

BACKGROUND: Presenteeism (reduced productivity at work) is thought to be responsible for large economic costs. Nevertheless, much of the research supporting this is based on self-report questionnaires that have not been adequately evaluated. OBJECTIVES: To examine the level of agreement among leading tests of presenteeism and to determine the inter-relationship of the two productivity subcategories, amount and quality, within the context of construct validity and method variance. METHODS: Just under 500 health care workers from an urban health area were asked to complete a questionnaire containing the productivity items from eight presenteeism instruments. The analysis included an examination of test intercorrelations, separately for amount and quality, supplemented by principal-component analyses to determine whether either construct could be described by a single factor. A multitest, multiconstruct analysis was performed on the four tests that assessed both amount and quality to test for the relative contributions of construct and method variance. RESULTS: A total of 137 questionnaires were completed. Agreement among tests was positive, but modest. Pearson r ranges were 0 to 0.64 (mean = 0.32) for Amount and 0.03 to 0.38 (mean = 0.25) for Quality. Further analysis suggested that agreement was influenced more by method variance than by the productivity constructs the tests were designed to measure. CONCLUSIONS: The results suggest that presenteeism tests do not accurately assess work performance. Given their importance in the determination of policy-relevant conclusions, attention needs to be given to test improvement in the context of criterion validity assessment.

Barriers to Optimal Pain Management in Aged Care Facilities: An Australian Qualitative Study.

Up to 80% of residents in aged care facilities (ACFs) experience pain, which is often suboptimally managed. The purpose of this study was to characterize pain management in ACFs and identify the barriers to optimal pain management. This exploratory descriptive qualitative study used semistructured interviews in five Southern Tasmania, Australian ACFs. Interviewees included 23 staff members (18 nurses and 5 facility managers) and were conducted from September to November 2015. Interviews included questions about how pain was measured or assessed, what happened if pain was identified, barriers to pain management, and potential ways to overcome these barriers. Interviewees noted that there were no formal requirements regarding pain assessment at the ACFs reviewed; however, pain was often informally assessed. Staff noted the importance of adequate pain management for the residents' quality of life and employed both nonpharmacologic and pharmacologic techniques to reduce pain when identified. The barriers to optimal pain management included difficulty identifying and assessing pain, residents' resistance to reporting pain and/or taking medications, and communication barriers between the nursing staff and GPs. Staff interviewed were dedicated to managing residents' pain effectively; however, actions in a number of areas could improve resident outcomes. These include a more consistent approach to documenting pain in residents' progress notes and improving nurse-GP communications to ensure that new or escalating pain is identified and expedient changes can be made to the resident's management. Additionally, resident, family, nurse, and carer education, conducted within the facilities on a regular basis, could help improve the pain management of residents.

Delayed coral recovery in a warming ocean.

Climate change threatens coral reefs across the world. Intense bleaching has caused dramatic coral mortality in many tropical regions in recent decades, but less obvious chronic effects of temperature and other stressors can be equally threatening to the long-term persistence of diverse coral-dominated reef systems. Coral reefs persist if coral recovery rates equal or exceed average rates of mortality. While mortality from acute destructive events is often obvious and easy to measure, estimating recovery rates and investigating the factors that influence them requires long-term commitment. Coastal development is increasing in many regions, and sea surface temperatures are also rising. The resulting chronic stresses have predictable, adverse effects on coral recovery, but the lack of consistent long-term data sets has prevented measurement of how much coral recovery rates are actually changing. Using long-term monitoring data from 47 reefs spread over 10 degrees of latitude on Australia's Great Barrier Reef (GBR), we used a modified Gompertz equation to estimate coral recovery rates following disturbance. We compared coral recovery rates in two periods: 7 years before and 7 years after an acute and widespread heat stress event on the GBR in 2002. From 2003 to 2009, there were few acute disturbances in the region, allowing us to attribute the observed shortfall in coral recovery rates to residual effects of acute heat stress plus other chronic stressors. Compared with the period before 2002, the recovery of fast-growing Acroporidae and of "Other" slower growing hard corals slowed after 2002, doubling the time taken for modest levels of recovery. If this persists, recovery times will be increasing at a time when acute disturbances are predicted to become more frequent and intense. Our study supports the need for management actions to protect reefs from locally generated stresses, as well as urgent global action to mitigate climate change.

Temporal Trends in the Prevalence and Incidence of Diagnosed ADHD in Children and Young Adults between 1999 and 2012 in Canada: A Data Linkage Study.

OBJECTIVE: There is a need for the routine monitoring of treated attention-deficit hyperactivity disorder (ADHD) for timely policy making. The objective is to report and assess over a decade the prevalence and incidence of diagnosed ADHD in Canada. METHODS: Administrative linked patient data from the provinces of Manitoba, Ontario, Quebec, and Nova Scotia were obtained from the same sources as the Canadian Chronic Diseases Surveillance Systems to assess the prevalence and incidence of a primary physician diagnosis of ADHD ( ICD-9 and ICD-10 codes: 314, F90.x) for consultations in outpatient and inpatient settings (Med-Echo in Quebec, the Canadian Institute of Health Information Discharge Abstract Database in the 3 other provinces, plus the Ontario Mental Health Reporting System). Dates of service, diagnosis, and physician specialty were retained. The estimates were presented in yearly brackets between 1999-2000 and 2011-2012 by age and sex groups. RESULTS: The prevalence of ADHD between 1999 and 2012 increased in all provinces and for all groups. The prevalence was approximately 3 times higher in boys than in girls, and the highest prevalence was observed in the 10- to 14-year age group. The incidence increased between 1999 and 2012 in Manitoba, Quebec, and Nova Scotia but remained stable in Ontario. Incident cases were more frequently diagnosed by general practitioners followed by either psychiatrists or paediatricians depending on the province. CONCLUSION: The prevalence and incidence of diagnosed ADHD did not increase similarly across all provinces in Canada between 1999 and 2012. Over half of cases were diagnosed by a general practitioner.

Pain and Functionality Following Sternotomy: A Prospective 12-Month Observational Study.

OBJECTIVE: To document pain levels, functionality, and analgesic use in the 12 months following a sternotomy to identify factors associated with the development of persistent post-sternotomy pain. DESIGN: Prospective observational study. SETTINGS: Royal Hobart Hospital, Australia. SUBJECTS: Patients undergoing a sternotomy between January and November 2013. METHODS: One hundred and ten patients were recruited and followed for 12 months, with telephone calls at 10 days, 6 weeks, 3 months, and 12 months. An initial survey was completed at the point of recruitment including patient history, depression and anxiety scales, self-rated health, and pain catastrophizing scale. RESULTS: The mean age of participants was 69.6 years, with the majority of participants being male (84.5%). The proportion of patients reporting pain in the early post-discharge period was high, with 30% of patients experiencing on average moderate-severe pain in the 10 days following discharge and 11% experiencing on average moderate-severe pain at 6 weeks. At 12 months, 15.5% of participants reported on average mild pain and 0.9% an average of moderate-severe pain in the preceding week at their sternotomy site. Pain of neuropathic origin was reported by 41.2% of those with on average daily pain at 12 months. CONCLUSION: This study highlights the need for further research to investigate whether more intensive pain management in the post-discharge period following sternotomy as well as the early identification of patients with neuropathic pain symptoms can reduce the incidence of persistent post-operative pain at 12 months.

Assessing the uptake and effectiveness of a quick reference guide to antibiotic prescribing in Australian general practice.

Prescribing guidelines are an essential component of antimicrobial stewardship programs in Australian hospitals. Nonetheless, the majority of antibiotic prescribing occurs in the community and the effectiveness of guidelines developed specifically to meet the needs of Australian general practice is unknown. This study aims to assess the uptake and effectiveness of a quick reference guide to antibiotic prescribing among primary care prescribers. A quick reference guide to antibiotic prescribing was developed and prescribers in five Tasmanian practices were surveyed regarding use of this guide. Thirty-three surveys were returned and, of those answering specific sections, 75% were aware of the guide and 71% had used it within the last month. The guide affected the antibiotic prescribing practice of 74% of responding prescribers; most often on choice of antibiotic; but also on duration of treatment, dose and dosing frequency. A quick reference guide to antibiotic prescribing was well received by prescribers and may usefully support efforts to improve antimicrobial stewardship in the community.

Use of Opioid Analgesics in Older Australians.

OBJECTIVE: To identify potential medication management issues associated with opioid use in older Australians. DESIGN: Retrospective cross-sectional review of the utilization of analgesics in 19,581 people who underwent a medication review in Australia between 2010 and 2012. SUBJECTS: Australian residents living in the community deemed at risk for adverse medication outcomes or any resident living fulltime in an aged care facility. METHODS: Patient characteristics in those taking regularly dosed opioids and not and those taking opioid doses >120 mg and ≤120 mg MEQ/day were compared. Multivariable binary logistic regression was used to analyze the association between regular opioid and high dose opioid usage and key variables. Additionally, medication management issues associated with opioids were identified. RESULTS: Opioids were taken by 31.8% of patients, with 22.1% taking them regularly. Several major medication management issues were identified. There was suboptimal use of multimodal analgesia, particularly a low use of non-opioid analgesics, in patients taking regular opioids. There was extensive use (45%) of concurrent anxiolytics/hypnotics among those taking regular opioid analgesics. Laxative use in those prescribed opioids regularly was low (60%). Additionally, almost 12% of patients were taking doses of opioid that exceeded Australian recommendations. CONCLUSIONS: A significant evidence to practice gap exists regarding the use of opioids amongst older Australians. These findings highlight the need for a quick reference guide to support prescribers in making appropriate decisions regarding pain management in older patients with persistent pain. This should also be combined with patient and caregiver education about the importance of regular acetaminophen to manage persistent pain.

Sex-based prognostic implications of nonobstructive coronary artery disease: results from the international multicenter CONFIRM study.

PURPOSE: To determine the clinical outcomes of women and men with nonobstructive coronary artery disease ( CAD coronary artery disease ) with coronary computed tomographic (CT) angiography data in patients who were similar in terms of CAD coronary artery disease risk factors, angina typicality, and CAD coronary artery disease extent and distribution. MATERIALS AND METHODS: Institutional review board approval was obtained for all participating sites, with either informed consent or waiver of informed consent. In a prospective international multicenter cohort study of 27 125 patients undergoing coronary CT angiography at 12 centers, 18 158 patients with no CAD coronary artery disease or nonobstructive (<50% stenosis) CAD coronary artery disease were examined. Men and women were propensity matched for age, CAD coronary artery disease risk factors, angina typicality, and CAD coronary artery disease extent and distribution, which resulted in a final cohort of 11 462 subjects. Nonobstructive CAD coronary artery disease presence and extent were related to incident major adverse cardiovascular events ( MACE major adverse cardiovascular events ), which were inclusive of death and myocardial infarction and were estimated by using multivariable Cox proportional hazards models. RESULTS: At a mean follow-up ± standard deviation of 2.3 years ± 1.1, MACE major adverse cardiovascular events occurred in 164 patients (0.6% annual event rate). After matching, women and men experienced identical annualized rates of myocardial infarction (0.2% vs 0.2%, P = .72), death (0.5% vs 0.5%, P = .98), and MACE major adverse cardiovascular events (0.6% vs 0.6%, P = .94). In multivariable analysis, nonobstructive CAD coronary artery disease was associated with similarly increased MACE major adverse cardiovascular events for both women (hazard ratio: 1.96 [95% confidence interval { CI confidence interval }: 1.17, 3.28], P = .01) and men (hazard ratio: 1.77 [95% CI confidence interval : 1.07, 2.93], P = .03). CONCLUSION: When matched for age, CAD coronary artery disease risk factors, angina typicality, and nonobstructive CAD coronary artery disease extent, women and men experience comparable rates of incident mortality and myocardial infarction.

CT angiography (CTA) and diagnostic performance of noninvasive fractional flow reserve: results from the Determination of Fractional Flow Reserve by Anatomic CTA (DeFACTO) study.

OBJECTIVE: Fractional flow reserve (FFR) computed from standard coronary CT scans (FFRCT) is a novel noninvasive method for determining the functional significance of coronary artery lesions. Compared with CT alone, FFRCT significantly improves diagnostic accuracy and discrimination for patients with and without hemodynamically significant coronary artery stenoses. To date, the impact of CT image quality on diagnostic performance of FFRCT is unknown. We evaluated the impact of patient preparation, CT scan protocol, and factors related to image quality on the diagnostic accuracy of FFRCT. SUBJECTS AND METHODS: We studied stable patients with suspected coronary artery disease (CAD), enrolled from 17 centers, who underwent CT, invasive coronary angiography, FFR, and FFRCT. The accuracy of CT and FFRCT for diagnosis of ischemia was compared against an invasive FFR reference standard. Anatomically obstructive CAD was defined by a stenosis value of at least 50 by CT or invasive coronary angiography, whereas ischemia was defined by an FFR or FFRCT of up to 0.80. Ischemia was assessed at the per-patient and per-vessel levels. Diagnostic performance of FFRCT was then evaluated in relation to patient preparation, including administration before CT of a ß-blocker or nitroglycerin, as well as in relation to imaging characteristics, including misalignment, noise, motion, and coronary artery calcium. RESULTS: Among 252 study participants, 137 (54.0%) had an abnormal FFR. Administration of a ß-blocker increased FFRCT specificity (51.0% vs 66.0%; p = 0.03) with lower bias (-0.084 vs -0.048; p = 0.008), whereas nitroglycerin pretreatment within 30 minutes of CT was associated with improved specificity (54.0% vs 75.0%; p = 0.013). Misalignment artifacts resulted in impaired sensitivity (43.0% vs 86.0%; p = 0.001) with resultant reductions in overall accuracy (56.0% vs 71.0%; p = 0.03). No differences in diagnostic performance of FFRCT were noted in the presence of coronary motion or increasing coronary artery calcium score. CONCLUSION: Use of ß-blockade and nitroglycerin administration before CT improve diagnostic performance of FFRCT. Diagnostic accuracy of FFRCT is significantly reduced in the setting of misalignment artifacts.

Optimising pharmacotherapy for secondary prevention of non-invasively managed acute coronary syndrome.

About half of all patients who experience an acute coronary syndrome (ACS) in Australia have their conditions managed non-invasively - that is, they do not undergo coronary angiography and revascularisation in hospital. ACS patients whose conditions are managed non-invasively may not receive the same level of evidence-based care as those who receive coronary revascularisation. This article reviews the optimal pharmacological management of ACS managed non-invasively. There is strong evidence to support the prescription of dual antiplatelet therapy (DAPT; aspirin with a P2Y12 inhibitor). DAPT should continue for 12 months after an ACS, then aspirin should be continued indefinitely. Anticoagulation with warfarin or a novel oral anticoagulant may be needed if atrial fibrillation occurs; the combination with DAPT increases the risk of bleeding. Unless contraindicated, high-intensity statin therapy should be prescribed for all post-ACS patients irrespective of their cholesterol level. Non-statin lipid therapy has not been shown to improve outcomes. Use of ß-adrenergic blockers is recommended in most guidelines, but the clinical trials to support this recommendation were performed more than 30 years ago, and routine long-term use may not be relevant to modern treatment, except when there is cardiac failure or left ventricular dysfunction. Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers are also widely recommended, but the evidence for benefit is stronger when there is left ventricular dysfunction. Calcium-channel blockers, nitrates, antiarrhythmic drugs, digoxin and diuretics do not improve outcomes in post-ACS patients.

Pharmacological management of pain in Australian Aged Care Facilities.

BACKGROUND: up to 80% of residents in aged care facilities (ACFs) experience pain, and previous studies have found that older patients with pain are often undertreated. Few studies have been conducted in Australia evaluating the use of analgesic therapy in ACF residents. OBJECTIVE: to explore the use of analgesics among ACF residents, including independent predictors of analgesic use, evaluate analgesic use against pain management guidelines and identify potential medication management issues. METHODS: a retrospective analysis of 7,309 medicines reviews conducted on Australian ACF residents was undertaken. Medication use was compared with published guidelines relating to the management of pain in elderly patients or ACF residents. Multiple variable logistic regression was used to identify independent predictors of analgesic use. RESULTS: nearly 91% of residents were prescribed analgesics. Of those, 2,057 residents were taking regular opioids (28.1%). Only 50% of those taking regular opioids received regular paracetamol at doses of 3-4 g/day. The concurrent use of sedatives was high, with 48.4% of those taking regular opioids also taking an anxiolytic/hypnotic. CONCLUSION: there is a need to optimise the prescribing and administration of regular paracetamol as a first line and continuing therapy for pain management in ACF residents, to potentially improve pain management and reduce opioid requirements. Furthermore, with the risk of falls and fractures increased by concurrent use of opioids and sedatives, the widespread use of these drugs in a population already at high risk was concerning, indicating a need for better education of health professionals in this area.

Stress and development of depression and heavy drinking in adulthood: moderating effects of childhood trauma.

PURPOSE: Studies suggest that childhood trauma is linked to both depression and heavy drinking in adulthood, and may create a lifelong vulnerability to stress. Few studies have explored the effects of stress sensitization on the development of depression or heavy drinking among those who have experienced traumatic childhood events. This study aimed to determine the effect of childhood trauma on the odds of experiencing depression or heavy drinking in the face of an adult life stressor, using a large population-based Canadian cohort. METHODS: A total of 3,930 participants were included from the National Population Health Survey. The associations among childhood trauma, recent stress and depression/heavy drinking from 1994/1995 to 2008/2009 were explored using logistic regression, as were interactions between childhood trauma and recent stress. A generalized linear mixed model was used to determine the effects of childhood trauma and stressful events on depression/heavy drinking. Analyses were stratified by sex. RESULTS: Childhood trauma significantly increased the odds of becoming depressed (following 1 event: OR = 1.66; 95%CI 1.01, 2.71; 2+ events, OR = 3.89; 95%CI 2.44, 6.22) and drinking heavily (2+ events: OR = 1.79; 95%CI 1.03, 3.13). Recent stressful events were associated with depression, but not heavy drinking. While most interaction terms were not significant, in 2004/2005 the association between recent stress and depression was stronger in those who reported childhood trauma compared to those with no childhood trauma. CONCLUSIONS: Childhood trauma increases risk for both depression and heavy drinking. Trauma may moderate the effect of stress on depression; the relationship among trauma, stress and heavy drinking is less clear.

Off-label use of medicines in paediatric inpatients at an Australian teaching hospital.

AIM: The study aims to investigate the prevalence of off-label prescribing in the general paediatric ward at a major teaching hospital in Tasmania, Australia. METHOD: The drug charts and medical records from two groups of 150 consecutive paediatric patients, admitted 6 months apart in July 2009 and January 2010, were studied retrospectively. Patients were required to spend at least one night in hospital and be aged less than 12 years. Each prescribed drug was compared with the approved product information to determine if the usage was off-label. Data concerning documented informed consent and adverse drug reactions were also recorded. RESULTS: Three hundred patients were prescribed a total of 887 medicines. Of these, 31.8% were off-label and 57.3% of children received an off-label medication. There was no significant seasonal variation in patient characteristics or prescriptions. Drugs were most commonly off-label due to their dosage or frequency of administration. Of the 106 different drugs used, the use of 51 was off-label on at least one occasion, and for 30 drugs their use was off-label on more than 75% of occasions. The drugs most commonly used off-label were oxycodone, salbutamol and paracetamol. No informed consent documentation was identified, and two of five recorded adverse drug reactions were associated with off-label drug use. CONCLUSION: Off-label use of medicines occurred frequently in paediatric inpatients. The available evidence often supported off-label medication use. An improved system for the revision of approved drug information and an Australian guideline for paediatric prescribing are needed.