Gender differences in presentation and outcome of nonfunctioning pituitary macroadenomas.

OBJECTIVES: Few data exist regarding gender differences in hormonal outcomes in nonfunctioning pituitary macroadenomas (NFPMA). The aim was to assess whether there are gender differences in hormonal outcomes in NFPMA following pituitary surgery at a single centre. DESIGN AND METHODS: Retrospective review of cases undergoing a first surgical procedure for NFPMA. Preoperative hormonal function was available for 122 cases at presentation and 94 cases 6 months postoperatively. Multiple hormone deficiency was defined as ≥2 hormonal axis losses. Tumour size and invasion on MRI scan were assessed independently by a single neuroradiologist. RESULTS: At presentation, men were more likely than women to have multiple hormonal deficiency (47% vs 28%, P = 0·038). Premenopausal women tended to have smaller adenomas than men, but neither adenoma size nor invasion was associated with multiple hormonal deficiency at presentation. Postoperatively, differences were observed with only 14% of premenopausal women exhibiting multiple hormone deficiency, compared with 36% of postmenopausal women and 46% of men (P = 0·03). Overall, postoperative hormonal recovery was observed in over one-third of cases. Greatest recovery occurred in the gonadal axis of 60% (6/10) premenopausal women compared with 19% (8/43) of other groups combined (P = 0·007). CONCLUSIONS: Premenopausal women with NFPMA appear to have favourable hormonal outcomes. This may be due to a complex interplay between smaller tumour size and shorter disease duration. There should be no hesitation in offering pituitary surgery to premenopausal women with NFPMA, who have the most to gain in terms of restoration of hormonal function.

Are extra-labral MR findings useful in the diagnosis of a labral tear?

OBJECTIVE: To determine diagnostic performance statistics of extra-labral magnetic resonance (MR) findings for detection of labral tears in a population of patients with clinical suspicion of this diagnosis. MATERIALS AND METHODS: Seventy-nine patients clinically suspected of having a labral tear (who underwent arthroscopy) had their MR studies retrospectively reviewed to determine the presence of lateral acetabular oedema-like marrow signal, ganglia, dysplastic femoral bumps, synovial herniation pits and geodes. These findings were then correlated with the arthroscopic presence (or absence) of a labral tear. RESULTS: All findings (lateral acetabular oedema-like marrow signal, ganglia, dysplastic femoral bumps, synovial herniation pits and geodes) had a specificity and positive predictive value (PPV) of 100%. Lateral acetabular oedema-like marrow signal had a sensitivity of 35% and 20% negative predictive value (NPV). This was the only statistically significant finding (P < 0.05). The sensitivity and NPV of ganglia were 12% and 16%, dysplastic femoral bumps (12%, 16%), synovial herniation pits (4%, 14%) and geodes (6%, 15%) respectively, (P > 0.05). CONCLUSION: Lateral acetabular oedema-like marrow signal is a useful sign (100% PPV) in the MR diagnosis of a labral tear, if one is clinically suspected. The other findings (ganglia, dysplastic femoral bumps, synovial herniation pits and geodes) were not statistically significant. Further studies are required to evaluate these.

Relative efficacy of different MRI signs in diagnosing active Crohn's disease, compared against a histological gold standard.

INTRODUCTION: There has been growing interest in the use of MRI in assessing Crohn's disease because of its lack of ionising radiation. Many MRI signs have been described in the literature, but their relative utility is unknown. METHODS: The MRIs of the bowel performed at 1.5 Tesla were blindly reviewed on 26 patients with recent histology (surgery and/or colonoscopy and their associated reports) according to a dedicated pro forma. Each patient's bowel was divided into nine segments. Each segment was assessed as to the presence or absence of 15 MRI signs described in the literature: abnormal gadolinium enhancement (both subjective and objective), wall oedema, fat oedema, fat proliferation, nodal enlargement, free fluid, wall nodularity, serosal blurring, mural thickening >4 mm, stricture, multi-segmental disease, fistula, abscess and layered contrast enhancement. The results were compared against a histological gold standard with a six-point scale of disease severity. RESULTS AND CONCLUSIONS: MRI correctly identified all 15 patients with at least established mucosal disease, and three of eight with only mild mucosal disease. Combining these results, a positive MRI correlated highly with at least early mucosal disease (positive predictive value 95%), while the presence of established mucosal disease was unlikely if MRI was negative (negative predictive value 100%). The MRI signs found to be the most sensitive for detecting active Crohn's disease were those related to the bowel wall, namely, wall thickening, nodularity, contrast enhancement and oedema. The most specific signs were the presence of multi-segmental disease, layered contrast enhancement and complications (fistula and abscess).

A mandatory intercalated degree programme: revitalising and enhancing academic and evidence-based medicine.

BACKGROUND: Recruitment of medical graduates to research careers is declining. Expansion of medical knowledge necessitates all graduates be equipped to critically evaluate new information. To address these challenges, a mandatory intercalated degree programme was introduced as part of curriculum reform. AIMS: To review the place on intercalated degrees, the methods available for learning about research and to analyse experience with a new university programme focusing on research. METHODS: A literature review followed by the analysis of experience with eight cohorts of students who had completed the new programme. RESULTS: A total of 1599 students completed the programme. Laboratory-based research was the most common choice followed by clinical research, population health, epidemiology, medical humanities and mental health. Also, 93% of students spent over 75% of their time undertaking research. Sixty-three students published their research, half as first authors. Students and coordinators support the programme. Learning about research during the postgraduate phase is variable and frequently left to individual choice. CONCLUSION: Intercalating an additional degree focusing on research can achieve a number of learning objectives but demands a level of maturity, autonomy and preparedness, not uniformly present in students undertaking a mandatory intercalated programme. A more realistic goal is the development of 'research-mindedness' amongst all students.

Barriers to continuing medical education in Australian prevocational doctors.

To determine perceived barriers to continuing education for Australian hospital-based prevocational doctors, a cross sectional cohort survey was distributed to medical administrators for secondary redistribution to 2607 prevocational doctors from August 2003 to October 2004. Four hundred and seventy valid questionnaires (18.1%) were returned. Only seven per cent (33/470) did not identify any barriers to continuing education. Barriers identified the most were lack of time (85% [371/437]), clinical commitment (65% [284/437]), resistance from registrars (13% [57/437]) and resistance from consultant staff (10% [44/437]). Other barriers included workload issues (27% [27/98]), teaching program inadequacies (26% [25/98]), lack of protected time for education (17% [17/98]), motivational issues (11% [10/98]) and geographic remoteness (10% [10/98]). Australian graduates (87%) identified lack of time more frequently than international medical graduates (77%) (P = 0.036). Perceived barriers did not differ significantly between doctors of differing postgraduate years.

Reduction of proteinuria by rosiglitazone in non-diabetic renal disease.

AIM: To investigate the effect of a thiazolidinedione on proteinuria in patients with non-diabetic renal disease. METHODS: In an open-label randomized cross-over study, 40 adults with chronic non-diabetic renal disease completed the study. In a random fashion, one group was treated for 4 months with 4 mg of rosiglitazone first followed by a 4-month period of standard treatment. The opposite order was used for the second group. RESULTS: Baseline urinary protein excretion rate was 1.45 g/24 h. On rosiglitazone, there was a drop of urinary protein level of 0.24 g/24 h (P=0.045). In contrast, there was a trend for proteinuria to increase during the control period (0.12 g/24 h, P=0.18). The urine protein level on rosiglitazone was lower than on usual treatment (0.36 g/24 h, P=0.002, 95% CI 0.15-0.58). There was a similar beneficial effect on systolic blood pressure which was reduced by rosiglitazone by 7.8 mmHg (P=0.006, 95% CI 2.6-13.1). Although average fasting glucose was only 5.8 mmol/L, there was a significant Spearman correlation between fasting glucose and a reduction in urinary protein levels (r=0.34, P=0.045). CONCLUSION: It is concluded that thiazolidinediones may have a role in the management of non-diabetic proteinuria of various aetiologies. In this study the average body mass index was 28.9 kg/m2. It will be important to repeat these studies in non-overweight subjects with non-diabetic proteinuria and in addition to trial maximal therapeutic doses of the thiazolidenedione.

Learning opportunities for Australian prevocational hospital doctors: exposure, perceived quality and desired methods of learning.

OBJECTIVE: To survey prevocational doctors working in Australian hospitals on aspects of postgraduate learning. PARTICIPANTS AND SETTING: 470 prevocational doctors in 36 health services in Australia, August 2003 to October 2004. DESIGN: Cross-sectional cohort survey with a mix of ordinal multicategory questions and free text. MAIN OUTCOME MEASURES: Perceived preparedness for aspects of clinical practice; perceptions of the quantity and usefulness of current teaching and learning methods and desired future exposure to learning methods. RESULTS: 64% (299/467) of responding doctors felt generally prepared for their job, 91% (425/469) felt prepared for dealing with patients, and 70% (325/467) for dealing with relatives. A minority felt prepared for medicolegal problems (23%, 106/468), clinical emergencies (31%, 146/469), choosing a career (40%, 188/468), or performing procedures (45%, 213/469). Adequate contact with registrars was reported by 90% (418/465) and adequate contact with consultants by 56% (257/466); 20% (94/467) reported exposure to clinical skills training and 11% (38/356) to high-fidelity simulation. Informal registrar contact was described as useful or very useful by 94% (433/463), and high-fidelity simulation by 83% (179/216). Most prevocational doctors would prefer more formal instruction from their registrars (84%, 383/456) and consultants (81%, 362/447); 84% (265/316) want increased exposure to high-fidelity simulation and 81% (283/350) to professional college tutorials. CONCLUSION: Our findings should assist planning and development of training programs for prevocational doctors in Australian hospitals.

Patient perceptions of privacy infringements in an emergency department.

OBJECTIVE: To identify the nature, severity, impact, frequency and risk factors for patient perceived privacy infringements in the ED of St Vincent's Health Melbourne with 32,000 emergency attendances per annum. METHODS: Patients 18 years and older attending emergency over a 2-week period were offered a nine-item questionnaire using a Likert scale. A privacy incident was defined as: (i) overhearing medical or personal information; (ii) being overheard; (iii) having private body parts exposed or (iv) seeing others' body parts. Differences between demographic, emergency environment, length of stay and other factors suspected of affecting patient privacy were quantified. RESULTS: From 1169 emergency presentations, 235 patients returned questionnaires, with 105 of these (45%) reporting a total of 159 privacy incidents. Seventy-eight patients (33%, 95% CI 28-36%) reported a definite privacy incident and 81 (35%, 95% CI 29-37%) reported a probable privacy incident. Ninety-six patients (41%, 95% CI 35-47%) reported overhearing other patient's conversations with the staff whereas 36 (15%, 95% CI 11-21%) felt their conversations with staff were overheard by others. Twenty-seven patients (11%, 95% CI 6-14%) experienced or observed inappropriate exposure of private body parts. Ten patients (4%, 95% CI 2-7%) changed or withheld information from staff because they felt others may overhear it and two refused part of their physical examination because they felt they may be seen by inappropriate people. Twenty-four patients (10%, 95% CI 6-14%) did not have their expectations of privacy met. The longer a patient was in emergency the greater the number of privacy incidents they experienced (Spearman correlation P < 0.01). Patients in walled cubicles experienced fewer privacy incidents than those in curtained cubicles (P < 0.05). CONCLUSIONS: Patient privacy incidents occur frequently in an ED, risk factors being length of stay and absence of a walled cubicle. Patients who have their conversations overheard are more likely to withhold information from staff and less likely to have had their expectations of privacy met.

Clustering effects of chronic obstructive pulmonary disease specific quality of life in hospitalized patients.

OBJECTIVES: The primary aim of treatments for COPD is to improve health-related quality of life. However, little is known of the clustering effects related to health-related quality of life as an outcome measure. If clustering effects are observed, these have important implications for sample size estimates when cluster randomization is used in interventional studies. This study aimed to determine the intracluster correlation coefficient (ICC) of the quality of life, between hospitals for COPD patients. METHODOLOGY: The Dyspnoea Impact and Symptoms Questionnaire was administered to 100 COPD inpatients from four public hospitals (25 from each) around metropolitan Melbourne, selected on the basis that they had not had any major programs implemented within the last 2 years that aimed to improve the management of COPD. Data were collected concerning demographic and socioeconomic variables and comorbidities. RESULTS: The highest ICC value for a health-related quality of life subscale was 0.02 (psychological score), while the highest for a symptom-based subscale was 0.04. CONCLUSIONS: There is minimal clustering effect of quality of life in COPD patients between the hospitals studied. Despite this, when using a cluster randomised design the sample size needed to detect the same effect as a study using simple randomisation could be inflated by up to 183%. If cluster randomization is required, the average cluster size should be kept as small as possible to negate this effect.

Creutzfeldt-Jakob disease cluster in an Australian rural city.

Through the Australian National Creutzfeldt-Jakob Disease Registry, 6 pathologically confirmed sporadic cases were recognized over a 13-year period in persons who had been long-term residents of a moderate-sized rural city, whereas the expected number was 0.923. An extensive investigation could not find any point-source or case-to-case transmission links. This occurrence is highly statistically significant (p = 0.0027) when viewed in isolation and remains significant (p < 0.02) when only the cases that arose after the cluster was recognized were taken into account. However, a more conservative statistical analysis suggests that such a grouping could have arisen by chance in at least one population group of this size when the whole country is taken into consideration.

A meta-analysis of effectiveness of influenza vaccine in persons aged 65 years and over living in the community.

AIM: To estimate the effectiveness of inactivated influenza vaccine in persons aged 65 years and over living in the community. SCOPE: A meta-analysis of studies selected using predetermined criteria without language restriction. CONCLUSION: Influenza vaccine was effective in reducing influenza-like illness by 35% (95% confidence interval (CI) 19-47%), hospitalization for pneumonia and influenza by 33% (CI 27-38%), mortality following hospitalization for pneumonia and influenza by 47% (CI 25-62%); and mortality from all causes by 50% (CI 45-56%).

Characteristics of Victorian general practitioners who practise complementary therapies.

BACKGROUND: To compare the characteristics of Victorian general practitioners who practise and do not practise complementary therapies. METHOD: A self administered postal survey sent to 800 Victorian GPs. RESULTS: The response rate was 64%. There were no statistically significant differences between complementary therapy practitioners and nonpractitioners in the number of patients seen per week, urban versus rural location, solo versus group practice or Fellowship of the Royal Australian College of General Practitioners. In some complementary therapies, practising GPs tended to be male, full time and older. DISCUSSION: Victorian GPs who practise complementary therapies are on the whole not from the fringes of the medical community. The reasons why GPs include complementary therapies in their practice cannot be answered by this study.