Second opinion for degenerative spinal conditions: an option or a necessity? A prospective observational study.

BACKGROUND: Second opinions may improve quality of patient care. The primary objective of this study was to determine the concordance between first and second diagnoses and opinions regarding need for spinal surgery among patients with back or neck pain that have been recommended spinal surgery. METHODS: We performed a prospective observational study of patients who had been recommended for spinal surgery and received a second opinion between May 2011 and May 2012 at the Hospital Israelita Albert Einstein on the advice of their health insurance company. A physiatrist and orthopaedic surgeon independently performed the second assessment. If both agreed surgery was indicated, or consensus could not be reached, participants attended a spine review panel for a final recommendation. Descriptive analyses compared diagnoses and management plans of the first and second opinions. RESULTS: Of 544 referred patients, 16 (2.9%) did not meet inclusion criteria, 43 (7.9%) refused participation and 485 were included. Diagnoses differed from the first opinion for 290 (59.8%). Diagnoses of cervical and lumbar radiculopathy were concordant in 36/99 (36.4%) and 116/234 (49.6%) respectively. The second opinion was for conservative treatment for 168 (34.6%) participants, 27 (5.6%) were not considered to have a spine condition, and 290 (59.8%) were referred to the review board. 60 participants did not attend the board review and therefore did not receive a final recommendation. Board review was conservative treatment for an additional 67 participants, 20 were not considered to have a spine condition and 143 participants were recommended surgery. Overall, 33.6% received a final opinion of surgery (143/425) although only 66 (15.5%) received the same surgical recommendation, 235 (55.3%) were advised to have conservative treatment, and 47 (11.1%) were not considered to have a spinal diagnosis. CONCLUSIONS: We found a large discordance between first and second opinions regarding diagnosis and need for spinal surgery. This suggests that obtaining a second opinion could reduce potentially unnecessary surgery. TRIAL REGISTRATION: Current Controlled Trials ISRCTN07143259 . Registered 21 November 2011.

An economic evaluation of the costs of training a medical scribe to work in Emergency Medicine.

OBJECTIVE: To undertake a cost analysis of training medical scribes in an ED. METHODS: This was a pilot, observational, single-centre study at Cabrini ED, Melbourne, Australia, studying the costs of initiating a scribe programme from the perspective of the hospital and Australian Health sector. Recruitment and training occurred between August 2015 and February 2016 and comprised of a prework course (1 month), prework training sessions and clinical training shifts for scribe trainees (2-4 months, one shift per week) who were trained by emergency physicians. Costs of start-up, recruitment, administration, preclinical training, clinical training shifts and productivity changes for trainers were calculated. RESULTS: 10 trainees were recruited to the prework course, 9 finished, 6 were offered clinical training after simulation assessment, 5 achieved competency. Scribes required clinical training ranging from 68 to 118 hours to become competent after initial classroom training. Medical students (2) required 7 shifts to become competent, premedical students (3) 8-16 shifts, while a trainee from an alternative background did not achieve competency. Based on a scribe salary of US$15.91/hour (including 25% on-costs) plus shift loadings, costs were: recruitment and start-up US$3111, education US$1257, administration US$866 and clinical shift costs US$1137 (overall cost US$6317 per competent scribe). Physicians who trained the clinical trainee scribes during shifts did not lose productivity. CONCLUSIONS: Training scribes outside the USA is feasible using an on-line training course and local physicians. It makes economic sense to hire individuals who can work over a long period of time to recoup training costs. TRIAL REGISTRATION NUMBER: ACTRN12615000607572.

Unloading shoes for osteoarthritis of the knee: protocol for the SHARK randomised controlled trial.

BACKGROUND: Knee osteoarthritis (OA) is a common and disabling condition. Abnormalities in knee loading play an important role in disease pathogenesis, yet there are few non-surgical treatments for knee OA capable of reducing knee load. This two-arm randomised controlled trial is investigating the efficacy of specially-designed unloading shoes for the treatment of symptoms in people with knee OA. METHODS/DESIGN: 164 people with symptomatic medial tibiofemoral joint OA will be recruited from the community and randomly allocated to receive either unloading shoes or control shoes. Unloading shoes have a specially-designed triple-density midsole where the medial side is softer than normal and the lateral side harder as well as a lateral wedge between the sole and sock-liner. Control shoes are standard athletic shoes and do not contain these features. Participants will be blinded to shoe allocation and will be instructed to wear the shoes as much as possible every day for 6 months, for a minimum of 4 hours per day. The primary outcomes are knee pain (numerical rating scale) and self-reported physical function (Western Ontario and McMaster Universities Osteoarthritis Index) measured at baseline and 6 months. Secondary outcomes include additional measures of knee pain, knee stiffness, participant global ratings of change in symptoms, quality-of-life and physical activity. CONCLUSIONS: The findings from this study will help determine whether specially-designed unloading shoes are efficacious in the management of knee OA. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry reference: ACTRN12613000851763.

Internet-mediated physiotherapy and pain coping skills training for people with persistent knee pain (IMPACT - knee pain): a randomised controlled trial protocol.

BACKGROUND: Persistent knee pain in people over 50 years of age is often attributable to knee osteoarthritis (OA), a common joint condition that causes physical and psychological dysfunction. Exercise and pain coping skills training (PCST) can help reduce the impact of persistent knee pain, however, access to health professionals who deliver these services can be challenging. With increasing access to the Internet, remotely delivered Internet-based treatment approaches may provide alternatives for healthcare delivery. This pragmatic randomised controlled trial will investigate whether an Internet-delivered intervention that combines PCST and physiotherapist-guided exercise (PCST + Ex) is more effective than online educational material (educational control) in people with persistent knee pain. METHODS/DESIGN: We will recruit 148 people over 50 years of age with self-reported persistent knee pain consistent with knee OA from the Australian community. Following completion of baseline questionnaires, participants will be randomly allocated to access a 3-month intervention of either (i) online educational material, or (ii) the same online material plus an 8-module (once per week) Internet-based PCST program and seven Internet-delivered physiotherapy sessions with a home exercise programs to be performed 3 times per week. Outcomes will be measured at baseline, 3 months and 9 months with the primary time point at 3 months. Primary outcomes are average knee pain on walking (11-point numeric rating scale) and self-reported physical function (Western Ontario and McMaster Universities Osteoarthritis Index subscale). Secondary outcomes include additional measures of knee pain, health-related quality-of-life, perceived global change in symptoms, and potential moderators and mediators of outcomes including self-efficacy for pain management and function, pain coping attempts and pain catastrophising. Other measures of adherence, adverse events, harms, use of health services/co-interventions, and process measures including appropriateness and satisfaction of the intervention, will be collected at 3, 6 and 9 months. DISCUSSION: The findings will help determine the effectiveness and acceptability of Internet access to a combination of interventions that are known to be beneficial to people with persistent knee pain. This study has the potential to guide clinical practice towards innovative modes of healthcare provision. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry reference: ACTRN12614000243617.

A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures.

BACKGROUND: Vertebroplasty has become a common treatment for painful osteoporotic vertebral fractures, but there is limited evidence to support its use. METHODS: We performed a multicenter, randomized, double-blind, placebo-controlled trial in which participants with one or two painful osteoporotic vertebral fractures that were of less than 12 months' duration and unhealed, as confirmed by magnetic resonance imaging, were randomly assigned to undergo vertebroplasty or a sham procedure. Participants were stratified according to treatment center, sex, and duration of symptoms (< 6 weeks or > or = 6 weeks). Outcomes were assessed at 1 week and at 1, 3, and 6 months. The primary outcome was overall pain (on a scale of 0 to 10, with 10 being the maximum imaginable pain) at 3 months. RESULTS: A total of 78 participants were enrolled, and 71 (35 of 38 in the vertebroplasty group and 36 of 40 in the placebo group) completed the 6-month follow-up (91%). Vertebroplasty did not result in a significant advantage in any measured outcome at any time point. There were significant reductions in overall pain in both study groups at each follow-up assessment. At 3 months, the mean (+/-SD) reductions in the score for pain in the vertebroplasty and control groups were 2.6+/-2.9 and 1.9+/-3.3, respectively (adjusted between-group difference, 0.6; 95% confidence interval, -0.7 to 1.8). Similar improvements were seen in both groups with respect to pain at night and at rest, physical functioning, quality of life, and perceived improvement. Seven incident vertebral fractures (three in the vertebroplasty group and four in the placebo group) occurred during the 6-month follow-up period. CONCLUSIONS: We found no beneficial effect of vertebroplasty as compared with a sham procedure in patients with painful osteoporotic vertebral fractures, at 1 week or at 1, 3, or 6 months after treatment. (Australian New Zealand Clinical Trials Registry number, ACTRN012605000079640.)

Randomized clinical trial of three-layer tubular bandaging system for venous leg ulcers.

The safety and efficacy of three-layer (3L) tubular bandaging as a treatment for venous ulcer healing has not been evaluated despite its use in many clinical settings to treat people with venous leg ulcers. We evaluated the safety and efficacy of 3L tubular bandage compared with short-stretch compression bandage to heal venous ulcers in a multicenter, open-label, parallel-group, randomized controlled trial. We randomized 45 patients with venous leg ulcers of up to 20 cm(2) area and an ankle brachial pressure index of >0.8 from hospital outpatient wound clinics in Victoria and Queensland, Australia. We measured time to healing and percentage reduction of wound size from baseline to week 12. Secondary outcomes were proportion of ulcers healed, self-reported compliance of compression bandage, and health-related quality of life, costs, recurrence rates, and adverse events. A total of 27 ulcers healed, the proportion of healed ulcers was higher for the 3L group (17/23 [74%] vs. 10/22 [46%]) (p = 0.05). Reported bandage tolerance at all treatment visits was 21 (91%) in 3L group vs. 17 (73%) (p = 0.10). There was no difference between the groups in adverse events. Costs were substantially less in 3L group.

Prostate cancer segregation analyses using 4390 families from UK and Australian population-based studies.

Familial aggregation of prostate cancer is likely to be due to multiple susceptibility loci, perhaps acting in conjunction with shared lifestyle risk factors. Models that assume a single mode of inheritance may be unrealistic. We analyzed genetic models of susceptibility to prostate cancer using segregation analysis of occurrence in families ascertained through population-based series totaling 4390 incident cases. We investigated major gene models (dominant, recessive, general, X-linked), polygenic models, and mixed models of susceptibility using the pedigree analysis software MENDEL. The hypergeometric model was used to approximate polygenic inheritance. The best-fitting model for the familial aggregation of prostate cancer was the mixed recessive model. The frequency of the susceptibility allele in the population was estimated to be 0.15 (95% confidence interval (CI) 0.11-0.20), with a relative risk for homozygote carriers of 94 (95% CI 46-192), and a polygenic standard deviation of 2.01 (95% CI 1.72-2.34). These analyses suggest that one or more genes having a strong recessively inherited effect on risk, as well as a number of genes with variants having small multiplicative effects on risk, may account for the genetic susceptibility to prostate cancer. The recessive component would predict the observed higher familial risk for siblings of cases than for fathers, but this could also be due to other factors such as shared lifestyle by siblings, targeted screening effects, and/or non-additive effects of one or more genes.

Health-related quality of life and continuation rate on first-line anti-tumour necrosis factor therapy among rheumatoid arthritis patients from the Australian Rheumatology Association Database.

OBJECTIVES: To describe changes in health-related quality of life (HRQoL) up to 60 months after commencing anti-TNF therapy for RA patients enrolled in the Australian Rheumatology Association Database (ARAD), and to determine the continuation rate and predictors of discontinuation of first-line anti-TNF therapy. METHODS: Responses to the HAQ, Assessment of Quality of Life, Medical Outcomes Study Short Form-36 (SF-36) and European Quality of Life-5 Dimensions (EQ-5D) were extracted from ARAD for patients commencing anti-TNF therapy and analysed in 6-monthly intervals from the start date. Predictors of discontinuation of therapy were assessed using Cox regression. RESULTS: Since September 2001, 2601 RA patients have enrolled in ARAD; 1801 have used anti-TNF therapy. Before starting the therapy, all HRQoL scores were below the population norms, but showed improvements in the first 6 months. From 12 to 60 months, HRQoL remained stable but below population means. Data to 60 months were available for 106 patients; 47% were still on first-line therapy at 5 years, all were using concurrent DMARDs and 55% were using concurrent prednisolone. Predictors of discontinuation of therapy were poorer HRQoL scores, a more recent therapy start date, concurrent prednisolone use and self-reported severe infection. Older patients and those with longer symptom duration were more likely to remain on therapy. CONCLUSIONS: In routine practice, HRQoL scores improve rapidly within 6 months of starting anti-TNFs and then remain stable for up to 60 months. Almost half remain on first-line therapy.

Malignancy risk in Australian rheumatoid arthritis patients treated with anti-tumour necrosis factor therapy: an update from the Australian Rheumatology Association Database (ARAD) prospective cohort study.

BACKGROUND: Tumour necrosis factor inhibitor (TNFi) therapy has been available for rheumatoid arthritis (RA) patients for several decades but data on the long-term risk of malignancy associated with its use is limited. Our aims were to assess malignancy risk in a cohort of Australian RA patients relative to the Australian population and to compare cancer risk for patients exposed to TNFi therapy versus a biologic-naïve group. METHODS: Demographic data for RA participants enrolled in the Australian Rheumatology Association Database (ARAD) before 31 Dec 2012 were matched to national cancer records in May 2016 (linkage complete to 2012). Standardised incidence ratios (SIRs) were used to compare malignancy incidence in TNFi-exposed and biologic-naïve ARAD participants with the Australian general population using site-, age- and sex-specific rates by calendar year. Malignancy incidence in TNFi-exposed participants and biologic-naïve RA patients, were compared using rate ratios (RRs), adjusted for age, sex, smoking, methotrexate use and prior malignancy. RESULTS: There were 107 malignancies reported after 10,120 person-years in the TNFi-exposed group (N = 2451) and 49 malignancies after 2232 person-years in the biologic-naïve group (N = 574). Compared with the general population, biologic-naïve RA patients showed an increased risk for overall malignancy (SIR 1.52 (95% confidence interval (CI) 1.16, 2.02) prostate cancer (SIR 2.10, 95% CI 1.18, 4.12). The risk of lung cancer was increased for both biologic naïve and TNFi-exposed patients compared with the general population (SIR 2.69 (95% CI 1.43 to 5.68) and SIR 1.69 (95% CI 1.05 to 2.90) respectively). For the TNFi-exposed patients there was an increased risk of lymphoid cancers (SIR 1.82, 95% CI 1.12, 3.18). There were no differences between the exposure groups in the risk of cancer for any of the specific sites examined. CONCLUSIONS: Overall malignancy incidence was elevated for biologic-naïve RA patients but not for those exposed to TNFi. TNFi exposure did not increase malignancy risk beyond that experienced by biologic-naïve patients. Lung cancer risk was increased for both TNFi-treated and biologic-naïve RA patients compared with the general population suggesting that RA status or RA treatments other than TNFi may be responsible in some way.

Efficacy and safety of vertebroplasty for treatment of painful osteoporotic vertebral fractures: a randomised controlled trial [ACTRN012605000079640].

BACKGROUND: Vertebroplasty is a promising but as yet unproven treatment for painful osteoporotic vertebral fractures. It involves radiographic-guided injection of various types of bone cement directly into the vertebral fracture site. Uncontrolled studies and two controlled quasi-experimental before-after studies comparing volunteers who were offered treatment to those who refused it, have suggested an early benefit including rapid pain relief and improved function. Conversely, several uncontrolled studies and one of the controlled before-after studies have also suggested that vertebroplasty may increase the risk of subsequent vertebral fractures, particularly in vertebrae adjacent to treated levels or if cement leakage into the adjacent disc has occurred. As yet, there are no completed randomised controlled trials of vertebroplasty for osteoporotic vertebral fractures. The aims of this participant and outcome assessor-blinded randomised placebo-controlled trial are to i) determine the short-term efficacy and safety (3 months) of vertebroplasty for alleviating pain and improving function for painful osteoporotic vertebral fractures; and ii) determine its medium to longer-term efficacy and safety, particularly the risk of further fracture over 2 years. DESIGN: A double-blind randomised controlled trial of 200 participants with one or two recent painful osteoporotic vertebral fractures. Participants will be stratified by duration of symptoms (< and >or= 6 weeks), gender and treating radiologist and randomly allocated to either the treatment or placebo. Outcomes will be assessed at baseline, 1 week, 1, 3, 6, 12 and 24 months. Outcome measures include overall, night and rest pain on 10 cm visual analogue scales, quality of life measured by the Assessment of Quality of Life, Osteoporosis Quality of Life and EQ-5D questionnaires; participant perceived recovery on a 7-point ordinal scale ranging from 'a great deal worse' to 'a great deal better'; disability measured by the Roland-Morris Disability Questionnaire; timed 'Up and Go' test; and adverse effects. The presence of new fractures will be assessed by radiographs of the thoracic and lumbar spine performed at 12 and 24 months. DISCUSSION: The results of this trial will be of major international importance and findings will be immediately translatable into clinical practice.

Neuromuscular Exercise post Partial Medial Meniscectomy: Randomized Controlled Trial.

PURPOSE: This study aimed to evaluate the effects of a 12-wk, home-based, physiotherapist-guided neuromuscular exercise program on the knee adduction moment (an indicator of mediolateral knee load distribution) in people with a medial arthroscopic partial meniscectomy (APM) within the past 3-12 months. METHODS: An assessor-blinded, randomized controlled trial including people age 30-50 yr with no to mild pain after medial APM was conducted. Participants were randomly allocated to either a 12-wk neuromuscular exercise program that targeted neutral lower limb alignment or a control group with no exercise. The exercise program included eight individual sessions with one of seven physiotherapists in private clinics, together with home exercises. Primary outcomes were the peak external knee adduction moment during normal-paced walking and during one-leg sit-to-stand. Secondary outcomes included additional measures of knee joint load distribution, patient-reported outcomes, maximal knee and hip muscle strength, and physical function measures. RESULTS: Of 62 randomized participants, 60 (97%) completed the trial. There were no significant between-group differences in the change in peak knee adduction moment during normal-paced walking (mean difference (95% confidence interval), 0.22 (-0.11 to 0.55) N·m/body weight × height %, P =0.19) or during one-leg sit-to-stand (-0.01 (-0.33 to 0.31) N·m/body weight × height %, P = 0.95). There were also no significant between-group differences for any of the secondary outcomes. CONCLUSIONS: In patients 3-12 months after a medial APM, a neuromuscular exercise program did not alter the peak knee adduction moment, a key predictor of osteoarthritis structural disease progression. (Australia and New Zealand Clinical Trials Registry, #ACTRN12612000542897.).

Nodular melanoma. No longer as simple as ABC.

BACKGROUND: Malignant melanoma is the fourth most commonly diagnosed malignancy in Australia. Nodular melanoma (NM) comprise less than 15% of all melanoma but account for up to 70% of those thicker than 3 mm. OBJECTIVE: This article describes the clinical features of NM, its prognosis and management. DISCUSSION: Nodular melanoma presents very differently from superficial spreading melanoma, and does not meet the 'ABCD' criteria used to alert doctors and patients to the possibility of this diagnosis. Due to their rapidly developing depth of invasion, urgent referral and wide excision are advised.

General practitioner management of shoulder pain in comparison with rheumatologist expectation of care and best evidence: an Australian national survey.

OBJECTIVES: To determine whether current care for common shoulder problems in Australian general practice is in keeping with rheumatologist expectations and the best available evidence. METHODS: We performed a mailed survey of a random sample of 3500 Australian GPs and an online survey of all 270 rheumatologists in Australia in June 2009. Each survey included four vignettes (first presentation of shoulder pain due to rotator cuff tendinopathy, acute rotator cuff tear in a 45 year-old labourer and early and later presentation of adhesive capsulitis). For each vignette, GPs were asked to indicate their management, rheumatologists were asked to indicate appropriate primary care, and we determined best available evidence from relevant Cochrane and other systematic reviews and published guidelines. RESULTS: Data were available for at least one vignette for 614/3500 (17.5%) GPs and 64 (23.8%) rheumatologists. For first presentation of rotator cuff tendinopathy, 69% and 82% of GPs and 50% and 56% rheumatologists would order a shoulder X-ray and ultrasound respectively (between group comparisons P = 0.004 and P<0001). Only 66% GPs and 60% rheumatologists would refer to an orthopaedic surgeon for the acute rotator cuff tear. For adhesive capsulitis, significantly more rheumatologists recommended treatments of known benefit (e.g. glucocorticoid injection (56% versus 14%, P<0.0001), short course of oral glucocorticoids (36% versus 6%, p<0.0001) and arthrographic distension of the glenohumeral joint (41% versus 19%, P<0.0001). CONCLUSIONS: There is a mismatch between the stated management of common shoulder problems encountered in primary care by GPs, rheumatologist expectations of GP care and the available evidence.

Effectiveness of vertebroplasty using individual patient data from two randomised placebo controlled trials: meta-analysis.

OBJECTIVE: To determine whether vertebroplasty is more effective than placebo for patients with pain of recent onset (≤ 6 weeks) or severe pain (score ≥ 8 on 0-10 numerical rating scale). DESIGN: Meta-analysis of combined individual patient level data. SETTING: Two multicentred randomised controlled trials of vertebroplasty; one based in Australia, the other in the United States. PARTICIPANTS: 209 participants (Australian trial n = 78, US trial n = 131) with at least one radiographically confirmed vertebral compression fracture. 57 (27%) participants had pain of recent onset (vertebroplasty n = 25, placebo n = 32) and 99 (47%) had severe pain at baseline (vertebroplasty n = 50, placebo n = 49). INTERVENTION: Percutaneous vertebroplasty versus a placebo procedure. MAIN OUTCOME MEASURE: Scores for pain (0-10 scale) and function (modified, 23 item Roland-Morris disability questionnaire) at one month. RESULTS: For participants with pain of recent onset, between group differences in mean change scores at one month for pain and disability were 0.1 (95% confidence interval -1.4 to 1.6) and 0.2 (-3.0 to 3.4), respectively. For participants with severe pain at baseline, between group differences for pain and disability scores at one month were 0.3 (-0.8 to 1.5) and 1.4 (-1.2 to 3.9), respectively. At one month those in the vertebroplasty group were more likely to be using opioids. CONCLUSIONS: Individual patient data meta-analysis from two blinded trials of vertebroplasty, powered for subgroup analyses, failed to show an advantage of vertebroplasty over placebo for participants with recent onset fracture or severe pain. These results do not support the hypothesis that selected subgroups would benefit from vertebroplasty.

Shoulder-specific disability measures showed acceptable construct validity and responsiveness.

OBJECTIVE: To compare the construct validity and responsiveness of the Shoulder Pain and Disability Index (SPADI), Croft Index, and disabilities of the arm, shoulder, and hand (DASH) for patients with adhesive capsulitis and to compare these with pain on a visual analog scale, the Health Assessment Questionnaire, and the problem-elicitation technique. STUDY DESIGN AND SETTING: Two randomized double-blind placebo-controlled trials of interventions for adhesive capsulitis were performed. Both trials recruited patients from community-based physiotherapy practices. Responsiveness at 3 weeks postbaseline was assessed using four responsiveness parameters and three external criteria for improvement. RESULTS: Correlations between the shoulder-specific measures ranged from 0.55 to 0.65 at baseline and 0.49-0.55 for the 3-week change scores. Greater responsiveness was seen for the SPADI. The effect size for the SPADI ranged from 1.20 to 1.64, for the Croft Index from 0.87 to 1.21, and for the DASH from 0.55 to 0.83. Rankings were similar across the four responsiveness parameters and the three external criteria for improvement. Correlations between the shoulder-specific and generic measures for baseline and 3-week change scores were lower than those among the shoulder-specific measures (range: 0.17-0.60). CONCLUSION: The shoulder-specific disability measures showed acceptable construct validity and responsiveness with a small but consistent overall advantage for the SPADI.

A randomized controlled trial of extracorporeal shock wave therapy for lateral epicondylitis (tennis elbow).

OBJECTIVE: The aims of this double-blind, randomized, placebo-controlled trial were to determine whether ultrasound-guided extracorporeal shock wave therapy (ESWT) reduced pain and improved function in patients with lateral epicondylitis (tennis elbow) in the short term and intermediate term. METHODS: Sixty-eight patients from community-based referring doctors were randomized to receive 3 ESWT treatments or 3 treatments at a subtherapeutic dose given at weekly intervals. Seven outcome measures relating to pain and function were collected at followup evaluations at 6 weeks, 3 months, and 6 months after completion of the treatment. The mean changes in outcome variables from baseline to 6 weeks, 3 months, and 6 months were compared for the 2 groups. RESULTS: The groups did not differ on demographic or clinical characteristics at baseline and there were significant improvements in almost all outcome measures for both groups over the 6-month followup period, but there were no differences between the groups even after adjusting for duration of symptoms. CONCLUSION: Our study found little evidence to support the use of ESWT for the treatment of lateral epicondylitis and is in keeping with recent systematic reviews of ESWT for lateral epicondylitis that have drawn similar conclusions.

Non-melanoma skin cancer in Australia: the 2002 national survey and trends since 1985.

OBJECTIVES: To measure the incidence of treated non-melanoma skin cancer (NMSC) in Australia in 2002 and investigate trends since 1985 by histological type, sex, age group, latitude and skin type. DESIGN: Face-to-face survey between 1 January and 31 December 2002 using stratified sampling of households to identify people treated for skin cancer in the previous 12 months. Self-reported diagnoses were confirmed with treatment providers. Data from similar surveys conducted in 1985, 1990 and 1995 were used to assess trends. SETTING: Whole of Australia (population 19.6 million). PARTICIPANTS: Of 57 215 people interviewed, 4098 said they had been treated for skin cancer in the past year and 3198 gave permission for their diagnoses to be confirmed with their doctor. RESULTS: 817 people were confirmed as having at least one skin cancer treated in the past year. The age-standardised rate per 100 000 population for NMSC was 1170, for basal cell carcinoma (BCC) 884, and for squamous cell carcinoma (SCC) 387. The estimated number of NMSC cases in Australia for 2002 was 374 000. Cumulative risks to age 70 years of having at least one NMSC were 70% for men and 58% for women. Rates of BCC and SCC have increased since 1985, and the increases greatest for people aged 60 years and older; rates for those younger than 60 years have stabilised. CONCLUSIONS: The incidence of treated NMSC in Australia in 2002 was more than five times the incidence of all other cancers combined. Although the overall NMSC rates have risen since 1985, the stabilisation of rates for people younger than 60 years who were exposed to skin cancer prevention programs in their youth highlights the importance of maintaining and strengthening these programs.