The differential effect of socio-economic status, birth weight and gender on body mass index in Australian Aboriginal Children.

BACKGROUND: Adult Aboriginal Australians have 1.5-fold higher risk of obesity, but the trajectory of body mass index (BMI) through childhood and adolescence and the contribution of socio-economic factors remain unclear. Our objective was to determine the changes in BMI in Australian Aboriginal children relative to non-Aboriginal children as they move through adolescence into young adulthood, and to identify risk factors for higher BMI. METHODS: A prospective cohort study of Aboriginal and non-Aboriginal school children commenced in 2002 across 15 different screening areas across urban, regional and remote New South Wales, Australia. Socio-economic status was recorded at study enrolment and participants' BMI was measured every 2 years. We fitted a series of mixed linear regression models adjusting for age, birth weight and socio-economic status for boys and girls. RESULTS: In all, 3418 (1949 Aboriginal) participants were screened over a total of 11 387 participant years of follow-up. The prevalence of obesity was higher among Aboriginal children from mean age 11 years at baseline (11.6 vs 7.6%) to 16 years at 8 years follow-up (18.6 vs 12.3%). The mean BMI increased with age and was significantly higher among Aboriginal girls compared with non-Aboriginal girls (P<0.01). Girls born of low birth weight had a lower BMI than girls born of normal birth weight (P<0.001). Socio-economic status and low birth weight had a differential effect on BMI for Aboriginal boys compared with non-Aboriginal boys (P for interaction=0.01). Aboriginal boys of highest socio-economic status, unlike those of lower socio-economic status, had a higher BMI compared with non-Aboriginal boys. Non-Aboriginal boys of low birth weight were heavier than Aboriginal boys. CONCLUSIONS: Socio-economic status and birth weight have differential effects on BMI among Aboriginal boys, and Aboriginal girls had a higher mean BMI than non-Aboriginal girls through childhood and adolescence. Intervention programs need to recognise the differential risk for obesity for Aboriginal and non-Aboriginal boys and girls to maximise their impact.

Dealing with lead in Broken Hill--trends in blood lead levels in young children 1991-2003.

The objective of the study was to investigate trends in blood lead concentrations in preschool children between 1991 and 2003, as part of the evaluation strategy of a public health lead management program in Broken Hill, Australia. Since 1991, all Broken Hill children aged 1-4 years have been offered at least annual blood lead screening as part of a community-wide lead management program. Recruitment of children was promoted throughout the period using local media and distribution of promotional material from health care centres and preschool, childcare, and educational facilities around the city. Venous blood samples were collected using standard procedures and analyses were subjected to internal and external quality control programs. Because the frequency distribution of blood lead levels are skewed, geometric rather than arithmetic means were used for comparative purposes. Trend analysis was based on age and sex standardised mean blood lead levels. The number of 1- to 4-year-old children screened ranged between 496 and 948 in any one year and response rates varied between 39% and 73%. The age-sex standardised mean blood lead level decreased from 16.3 microg/dL to 7.1 microg/dL between 1991 and 2003. Overall, blood lead levels declined by 56% over 13 years. These reductions were consistently observed irrespective of age or where a child lived in the town. The rate of decline has slowed since 1997. We conclude that substantial progress has been made in dealing with the lead problem in Broken Hill children, although the rate of decline of blood lead levels has slowed. Continued public health action is still needed to bring the proportion of young children with significantly elevated blood lead levels (>15 microg/dL) down from the 2003 figure of 12% to the NHMRC community-based target for lead in young Australians of 5%.

Ageing of the baby boomer generation: how demographic change will impact on city and rural GP and nursing workforce.

OBJECTIVE: To compare the impact of ageing on the GP and nursing rural and city workforce. METHOD: Cohort analysis of Australian Bureau of Statistics census data. The data was used to examine the age distribution of the city and rural GP and nursing workforce; patterns of attrition for those 50 years and over; and the impact of changes in working hours. RESULTS: The rural GP and nursing workforce is significantly older than their city counterparts (p<0.001) with the 'baby boomer' generation making up 52% of city GPs but 59% of rural GPs in 2001. While a large proportion of city and rural GPs continued to work past the age of 65 years, rural GPs left the workforce at a significantly younger age than city doctors (p<0.001). Rural nurses are older than their city peers (p<0.001) but retire at an older age than city nurses (p<0.001). In 1986, a significantly higher proportion of rural GPs in all age cohorts worked more than 41 hours per week compared with their city counterparts (p<0.001). By 2001, rural 'generation X' GPs were no more likely to work long hours than those in the city (p<0.001). However, significantly more rural than city 'baby boomers' continued to work long hours. CONCLUSIONS: Rural GPs are retiring faster than city GPs and strategies to attract rural GPs and nurses will be critical to ensure adequate rural health care and that current rural workforce shortage do not worsen.

Cost effectiveness of accelerated rehabilitation after proximal femoral fracture.

A randomised controlled trial comparing an accelerated rehabilitation program after proximal femoral fracture with conventional care and rehabilitation was conducted with 252 elderly patients treated at an Australian general hospital in 1989/1990. This paper presents a cost-effectiveness analysis of the accelerated rehabilitation program. The measure of cost was all direct costs of treatment and subsequent care (medical and non-medical) incurred during the 4 months after fracture. Effectiveness was defined as whether the patient returned to semi-independent living; or if moderately or severely disabled prior to the fracture to the premorbid level of physical independence. The cost for treatment up to 4 months after fracture was estimated at A$ 10,600 per accelerated rehabilitation patient and A$ 12,800 per conventional care patient (1990 Australian dollars, A$). Thus, accelerated rehabilitation releases resources equivalent to approximately 17% of costs for treatment per patient. When cost effectiveness is considered, the potential cost savings rise to 38% per recovered patient.

Clinical course and outcome of severe head injury in Australia.

The records of 159 severely head-injured patients (all in coma for longer than 6 hours) from Sydney, Australia, were studied. The clinical course, charted over a 2-week period, indicated that 60% of deaths occur by Day 3 and that 12% of patients remain in coma (Glagow Coma Scale (GCS) score less than 7) for more than 2 weeks. Overall, at long-term follow-up review more than 2 years after injury, 51% of patients were dead, 7% were severely disabled or vegetative, and 42% had a good to moderate recovery. Outcome of the patients in prolonged coma was assessed separately, with only one-third making a good or moderate recovery; two-thirds of the severely disabled patients came from this group. The high proportion of poor outcomes associated with prolonged coma suggests that this group of patients should be specifically targeted in research. One appropriate intervention with this group would be the restructuring and intensification of early rehabilitation. However, the GCS score lacks the precision needed for this type of study, and a better measure of recovery should be developed.

Lead dust in broken hill homes--a potential hazard for young children?

OBJECTIVE: To determine the potential hazard posed by indoor lead dust to young children in Broken Hill, a silver-lead-zinc mining town in outback Australia, and the degree to which lead flux is influenced by factors such as geographical location, house construction type and condition. METHODS: 116 homes were selected and 93 (80%) studied from 10 localities in Broken Hill during the spring of 1995. Lead flux was measured using 85 mm diameter polystyrene petri dishes. Dishes were placed in four rooms of each house to collect dust over a six-to-eight-week period. Data on the location, condition and construction type of each house were recorded. Multiple linear regression was used to determine predictors of lead flux. Flux data were log transformed for the analysis. RESULTS: Average household lead flux varied nearly seven-fold across districts from a low of 166 (distant from the mines), to a high of 1,104 microg/m2/30-day period (adjacent to the mines). Houses that were 'adequately sealed' had 2.9 times the lead flux, and 'poorly sealed' houses 4.3 times the flux, of 'very well sealed' houses. Construction material did not significantly affect these flux levels, and no statistically significant interactions were found between house condition and location or house type. CONCLUSIONS: Many Broken Hill homes have high levels of lead flux that pose a potential risk to young children. Quantification of this hazard provides useful information for the community that can help focus efforts on actions required to minimise lead dust in the home. IMPLICATIONS: Household dust is a potential source of lead for young children in at-risk communities. Information on lead flux in homes can assist these communities and public health agencies to better understand and deal more effectively with the problem.

Accelerated rehabilitation after proximal femoral fracture: a randomized controlled trial.

This randomized controlled trial compared accelerated rehabilitation after surgical treatment of proximal femoral fracture with conventional care and was conducted in a general hospital in an outer urban area. Participating were 261 sequentially admitted patients over the age of 50 years who met predetermined inclusion criteria and all were followed up until death or 4 months after fracture. Patients who were treated with the accelerated rehabilitation programme had a 20% reduction in length of hospital stay. Improved physical independence (as measured by Barthel Index) was observed after fracture in accelerated rehabilitation programme patients with limited pre-existing disability. Non-nursing-home patients receiving accelerated rehabilitation were also less likely to be discharged to nursing-home care or die in hospital. Accelerated rehabilitation led to a substantial reduction in length of hospital stay with a modest short-term improvement in level of physical independence and accommodation status after discharge.

Periodontal maintenance following scaling and root planing. A randomized single-center study comparing minocycline treatment and daily oral irrigation with water.

Objective: Trying to limit the use of antimicrobial drugs in periodontitis is a general trend. Thus, the aim of the present study was to assess the efficacy of daily water irrigation in comparison with subgingival minocycline in periodontal maintenance, in subjects with moderate to severe periodontitis. This was done by evaluating probing pocket depth (the primary outcome), other clinical parameters such as clinical attachment level, plaque index and bleeding on probing, and bacterial flora changes inside periodontal pockets. Materials and Methods: In this single-center, parallel, single blind, randomized clinical study, thirty subjects (12 men, mean age 56 ± 2.2 years) with moderate to severe periodontitis were randomized 1:1 into a minocycline-treated group (M-group, n=15) and a water-treated group (W-group, n=15). Clinical and microbiological parameters were measured at baseline. Scaling and root planing were carried out on all subjects, then to M-group patients minocycline was administered inside the pockets. W-group subjects had instead to daily apply oral irrigation with water. Clinical and microbiological measurements were repeated after 30 days. Results: Both water irrigation and minocycline treatment led to a significant reduction of all the clinical parameters tested at t=30 days with respect to baseline. Moreover, both procedures appeared to be able to maintain a low bacterial load inside periodontal pockets, for most of the microorganisms tested. No statistically significant differences were observed between M-group and W-group at t=30 days, concerning both clinical and microbiological parameters. However, further studies are needed to assess the long-term effect. Conclusion: Daily oral irrigation with water showed comparable efficacy to a single administration of minocycline in periodontal maintenance subjects.

Lead dust in Broken Hill homes: effect of remediation on indoor lead levels.

This study was undertaken to determine whether home remediation effectively reduced indoor lead levels in Broken Hill, a long-established silver-lead-zinc mining town in outback Australia. A before-after study of the effect of home remediation on indoor lead levels was embedded into a randomized controlled trial of the effectiveness of remediation for reducing elevated blood lead levels in young children. Moist towelettes were used to measure lead loading (microg/m2) on internal windowsills and internal and entry floors of 98 homes; samples were collected before, immediately after, and 2, 4, 6, 8, and 10 months after remediation. Data were log(10) transformed for the analysis. Remediation reduced average indoor lead levels by approximately 50%, and lead levels remained low for the duration of the follow-up period (10 months). The greatest gains were made in homes with the highest initial lead levels; homes with low preremediation lead levels showed little or no benefit. Before remediation, homes located in areas with high soil lead levels or with "poor" dust proofing had higher lead levels than those in areas with lower soil lead levels or with "medium" or "good" dust proofing; these relative differences remained after remediation. There was no evidence that lead loading was reduced by an increased opportunity to become aware of lead issues. We conclude that remediation is an effective strategy for reducing the lead exposure of children living in homes with high indoor lead levels.

Incidence and prevalence of insulin-dependent diabetes mellitus in the zero- to 19-years' age-group in Sydney.

A population-based register of cases of insulin-dependent diabetes mellitus in the zero- to 19-years' age-group was established in the Southern Metropolitan Health Region of Sydney. The aims of the register were to provide accurate incidence and prevalence data for comparison with those of studies from elsewhere in the world and to evaluate diabetes services, morbidity and compliance with self-care regimens. This article presents the incidence and prevalence data. In the Southern Metropolitan Health Region, the annual incidence of insulin-dependent diabetes mellitus per 100,000 population who were aged zero to 19 years, rose from 10.3 cases in 1984 to 14.8 cases in 1987, and in the zero- to 14-years' age-group, it rose from 13.6 cases per 100,000 population in 1984 to 19.4 cases per 100,000 population in 1987; the increases were not statistically significant. The prevalence in the zero- to 19-years' age-group was 0.80 cases per 1000 population, and in the zero- to 14-years' age-group, it was 0.74 cases per 1000 population on February 1, 1986. Age-specific incidence rates were calculated for the years 1984-1987. Incidence peaks occurred at the ages of six years, 10 years and 12-13 years.

Services and cost of hospitalization for children and adolescents with insulin-dependent diabetes mellitus in New South Wales.

Data on services for Australian children and adolescents with diabetes are limited. The purpose of the present study was to examine the availability, utilization and some of the costs of services for persons of less than 20 years of age with insulin-dependent diabetes mellitus in New South Wales, and to make recommendations for future services. The numbers of prevalent and incident cases of insulin-dependent diabetes mellitus in the zero- to 19-years' age-group in each of the health regions of the State were estimated using data from the insulin-dependent diabetes mellitus register of the Southern Metropolitan Health Region. Information on the available services for young persons with diabetes was obtained from doctors and diabetes educators around the State, and on the utilization of services in the Southern Metropolitan Health Region from interviewing the families of persons whose names are listed in the diabetes register. An estimated range of the annual direct cost of hospital admissions for diabetes in the zero- to 19-years' age-group in New South Wales was calculated by use of the data collected from the diabetes register, the hospital separation data from the NSW Department of Health, the NSW Department of Health estimated bed-day cost and the estimated average cost of a bed day for diabetic patients at The Children's Hospital Camperdown. Services for children and adolescents with insulin-dependent diabetes mellitus in this State are most comprehensive in central Sydney. However, even these excellent services are not utilized fully by the children and their families. The annual cost of hospitalization for diabetes in the zero- to 19-years' age-group in New South Wales is estimated to be approximately +1.5 million. There needs to be an equally high standard of care for all diabetic children in the State; however, the utilization of services, as well as the services themselves, need to be improved and the cost-effectiveness of new services needs to be evaluated.

Relatives as lay-therapists for the severely head-injured.

Although the need for an integrated approach to the management of the head-injured patient has been recognized, and the concept of incorporating the family in the rehabilitation treatment programme suggested, there is minimal documentation of how the services of family members can be utilized to optimal effect. At a large university teaching hospital in Sydney, Australia, an early intensive rehabilitation programme was pretested on 37 patients during 1984-85. The pretest was to identify the extent to which relatives could contribute input as lay-therapists to such a programme. The findings indicate that relatives can make a major time commitment to providing therapy, but that to avoid harm to both patients and relatives certain safeguards need to be enforced. These experiences and resultant recommendations may have a bearing on the organization of rehabilitation programmes for other categories of patient.

Implementing an innovative rehabilitation programme in an acute care hospital.

There have been various proponents of the advantages of early intensive rehabilitation programmes for improved patient outcome. This suggests that rehabilitation should commence whilst patients are in standard wards of acute care hospitals, rather than the usual practice of waiting until they are transferred to a rehabilitation unit or rehabilitation hospital. For effective implementation of such programmes it is important to consider the organization of personnel required and the implications for efficient delivery of services. This paper reports the experiences of implementing such a programme.

Outcome following physical trauma: a comparative approach.

This study aimed to examine physical and psychosocial changes after injury in a range of trauma patients. Three groups were selected for comparison purposes: severely head-injured patients, patients with major trauma, and those with minor trauma (n = 102). Outcomes were assessed by questionnaires and inventories administered to a family member or friend of the trauma survivor, approximately 1 year post-injury. Severely head-injured patients were reported to have the greatest degree of difficulty in self-care and mobility, and in community living skills, followed by other major trauma patients and then minor trauma patients. Severely head-injured patients also had relatively more frequent reports of behavioural changes than the other two groups. None the less, more than half of the major trauma group were reported to act differently after the accident. The relative frequency of adverse outcomes in the major trauma group was greater than expected and should be the focus of further research.

Mass media-led antismoking campaign can remove the education gap in quitting behavior.

This study investigated whether the effective mass media-led antismoking campaigns in Australia had the traditional differential effect across educational levels. Our population surveys included random samples of 12,851 people before the campaign and 11,609 several years after the campaign had started. No statistically significant differences were found in quitting across education levels in three of the four subgroups. Mass media-led antismoking campaigns may play an important role in getting the antismoking message to the less educated.

Regionalization of trauma services in western Sydney: predicted effect on ambulance and hospital utilization rates.

A previous study has demonstrated the effectiveness of ambulance staff in identifying the majority of trauma victims who warrant admission to a Level 3 Hospital. This paper applied the results of that study in order to estimate the likely effect of a system of bypass whereby these identified patients are transported to a Level 3 hospital rather than the nearest Level 1 or 2 Hospital. Under the proposed plan whereby both Westmead and Liverpool Hospitals would be granted Level 3 status, the effect of Westmead would be negligible. However, Liverpool's caseload would increase (25% for total admissions, 136% for serious admissions) and, consequently, its level of resources would need to be upgraded before this plan can be put into action. Meanwhile, Level 1 and 2 hospitals would see little change to total patient admissions, although there would be a substantial drop in serious admissions (-63%). Under the proposed system, the effects on the Ambulance Service would also be negligible in terms of both the number of transports and total transport hours. However, the nature of these transports would change. More time would be required in bypass cases, although this would be compensated for by a corresponding fall off in interhospital transfers (28% decline in time spent on transfers). Ultimately, this means that patients would be getting to the hospital of definitive care much sooner. These results have implications for the development of trauma services in other sectors.

Trauma triage in western Sydney: results of a pilot study.

A pilot study of the effectiveness of prehospital triage of trauma patients was carried out in a western Sydney between February and July 1988. Triage guidelines were developed to identify seriously injured persons at the incident site who might warrant admission to a Level 3 Trauma Service Hospital (Trauma Centre), as part of the NSW Department of Health trauma services plan. The study results were based on 64% of ambulance trauma transports for which a triage decision was provided. Of trauma transports studied, 3.7% had injuries serious enough to warrant admission to Level 3 Trauma Service Hospital. Ambulance officers correctly triaged 77% of these cases in the field. However, 62% of trauma transports triaged 'severe' or 'critical' did not have injuries serious enough to warrant admission to a Level 3 Trauma Service Hospital. Nevertheless, the triage guidelines compared favourably with similar instruments used elsewhere. Based on the performance of the triage guidelines it was concluded that the introduction of a regionalized trauma service in metropolitan NSW with local bypass is possible.

Counting heads: estimating traumatic brain injury in New South Wales.

The public health problem of head injuries contributes to considerable morbidity in the community and is the commonest cause of death in young adult Australians. However, estimating the incidence of head injury has been difficult, and has varied between countries and over time. This paper critically appraises the methodological issues contributing to head injury/brain injury incidence estimates, in particular case definition, differing data sources, and methods of case ascertainment. The most appropriate definition from a methodological service provider perspective is one which clearly distinguishes between potential and actual brain injury. The results from a study which used the most accurate methods have been extrapolated to NSW, and reduce the estimated brain injury incidence in NSW from a reported 392 to 180 per 100,000 incident cases per year. This revised estimate implies that in 1990 there will be about 10,500 new cases of traumatic brain injury, of which an estimated 400 will result in serious physical or mental disability. These estimates were originally calculated to enable the development of an appropriate level of health service provision for brain-injured persons through the NSW Brain Injury Program.

Medical care of doctors.

AIM: To describe doctors' attitudes towards their own medical care. METHODS: Postal survey asking 2564 doctors about their access to, and use of, medical services. The sample, 14% of all New South Wales doctors, was randomly selected from the NSW Register of Medical Practitioners. To ensure anonymity, non-respondents were not followed up. RESULTS: The response rate was 44%. Only 42% of respondents had a general practitioner and most had self-prescribed medication. Nineteen per cent reported marital disturbances, 18% emotional disorders, 3% alcohol problems and 1% drug abuse, but not many had discussed these problems with their doctor. Twenty-six per cent had a condition warranting a medical consultation but felt inhibited about consulting a doctor. CONCLUSION: Many doctors lack adequate medical care. RECOMMENDATIONS: We recommend that doctors have their own general practitioner, avoid "corridor consultations" and not self-prescribe drugs that affect mental function. Teaching of appropriate help-seeking responses should be part of medical education.

The effectiveness of coma arousal intervention.

Thirty-one patients who were in coma or persistent vegetative state two weeks after sustaining a severe head injury were entered into a coma arousal programme. The coma arousal protocol called for a sequence of vigorous multisensory stimulations to be applied to the patient by a relative for up to eight hours a day for seven days a week. An independent study team monitored two patient outcomes, the time taken to obey a simple command on two consecutive occasions 24 hours apart and patients' score on the Glasgow Outcome Scale 10-12 months post-injury. Outcomes were compared with an historical reference group chosen from the literature, consisting of 135 similarly classified patients. Differences between the pilot study and the reference group patients on initial characteristics suggested that the pilot study patients might have the more favourable outcomes, independent of treatment effect. The sample size was sufficient to detect a 40% improvement in recovery rate. No significant improvements were noted in either the time to obey a simple command (p greater than 0.2) or in the Glasgow Outcome Scale (p greater than 0.25), although the observed difference in the latter group was 11% in favour of the pilot study patients. This study was unable to find any evidence that coma arousal, for all its arduous patient contact, had a markedly better outcome compared with conventional treatment.