The safety and cost-effectiveness of low osmolar contrast media. Can economic analysis determine the real worth of a new technology?

OBJECTIVES: To estimate the reduction in mortality associated with a reduced adverse reaction rate following the substitution of older high osmolar radiocontrast media (HOCM) by the newer and more expensive low osmolar contrast media (LOCM), and to assess the cost-effectiveness of switching from HOCM to LOCM in patients with and without underlying risk factors for adverse reactions from radiocontrast agents. DATA SOURCES: Data from large prospective studies of adverse reactions to HOCM and LOCM were used to estimate the expected number of deaths and severe non-fatal reactions in a hypothetical population receiving one million intravenous radiocontrast injections with HOCM, and the expected reduction in the frequency of these outcomes after substitution by LOCM in high-risk and low-risk groups respectively. Life-years lost with each radiocontrast-related death were estimated from an audit of fatal adverse reaction reports submitted to the Adverse Drug Reactions Advisory Committee. The direct costs considered in the study were the increased costs of LOCM and the hospital costs of treating radiocontrast reactions which were estimated from an audit of cases admitted to public hospitals in Newcastle. STUDY SELECTION: The literature search included Medline (1966-1989) and bibliographies of original and review articles. We included only studies which were prospective, monitored patients in a formal way, described a mechanism for the recording of adverse events and were of sufficient size to have been capable of detecting severe reactions to radiocontrast agents. DATA EXTRACTION: Data were extracted independently by two investigators, unblinded, with disagreements resolved by consensus. DATA SYNTHESIS: Mortality data from individual reports were pooled and exact confidence intervals were calculated on the assumption of a Poisson distribution. In the case of comparative studies the relative risks of severe reactions in low-risk versus high-risk patients and with LOCM compared with HOCM were treated for homogeneity, and pooled odds ratios and 95% confidence intervals (CI) were calculated by combining the logarithms of the odds ratios weighted by their variances. RESULTS: The mortality after intravenous administration of HOCM was estimated from all studies to be 23.3 (95% CI, 2.4-33.1) per million injections. However, the mortality was 11.7 per million (95% CI, 2.4-34.1) in studies published since 1986. The mortality after the use of LOCM was estimated as 3.9 per million (95% CI, 0.1-21.7).(ABSTRACT TRUNCATED AT 400 WORDS)     

Congenital heart defects in Central Australia

OBJECTIVE: To determine the incidence of congenital heart defects (CHD) in Aboriginal and non-Aboriginal infants in Central Australia and to compare this with the incidence elsewhere in Australia. DESIGN AND SETTING: Data on cases were obtained from patient records of the Alice Springs Hospital, Central Australia, the sole referral centre for paediatric and initial cardiac diagnostic services for the region. PARTICIPANTS: Patients with CHD proven by echocardiography reported between 1 January 1993 and 30 June 2000. MAIN OUTCOME MEASURES: Incidence of CHD using all live births in Central Australia as the denominator. RESULTS: 108 patients with CHD were detected among 6156 live births (incidence, 17.5 per 1000; 95% CI, 14.9-21.7 per 1000); 57 of 2991 were Aboriginal (19.0 per 1000; 95% CI, 14.4-24.6 per 1000) and 51 of 3165 were non-Aboriginal (16.1 per 1000; 95% CI, 12.0-21.1 per 1000). The difference between the two groups was not statistically significant (relative risk, 1.18; 95% CI, 0.81-1.72). CHD incidence in Central Australia was significantly higher than that reported for other parts of Australia (4.3 per 1000 live births in New South Wales and the Australian Capital Territory, 1981-1984; 7.65 and 12 per 1000 total births in Western Australia, 1980-1989, and South Australia, 1993-2000, respectively). CONCLUSIONS: The high rates of CHD in Central Australia may partly reflect the high utilisation of echocardiography for assessing minor lesions. However, the incidence of both major and minor types of CHD was significantly higher than previously reported from other regions of Australia. The role of socioenvironmental factors in this high incidence should be explored.     

Trends in licit opioid use in Australia, 1984-1998: comparative analysis of international and jurisdictional data

OBJECTIVES: To examine trends from 1984 to 1998 in licit opioids used in Australia compared with nine other developed countries, and in New South Wales compared with other Australian jurisdictions. DESIGN: Poisson regression analysis of annual rates of national and jurisdictional consumption of methadone, morphine and pethidine. MAIN OUTCOME MEASURES: All drug data were standardised to defined daily doses per 1000 population per day. RESULTS: Methadone consumption increased by, on average, 12% per year (RR, 1.12; 95% CI, 1.08-1.17), with Australia in the first rank of countries. Morphine use increased by 5% per year (RR, 1.05; 95% CI, 1.02-1.09), with Australia ranking equal second with three other countries behind Denmark. Consumption of pethidine in all 10 countries was unchanged (RR, 0.99; 95% CI, 0.97-1.00), with Australia equal first. In Australia, use of methadone syrup increased by 17% per year (RR, 1.17; 95% CI, 1.16-1.17) and by 11% per year for methadone tablets (RR, 1.11; 95% CI, 1.10-1.12). Consumption of methadone syrup in NSW was more than double that of any other jurisdiction. Consumption of methadone tablets was 2.4 times higher in South Australia (RR, 2.35; 95% CI, 2.09-2.65) than NSW. The Northern Territory, Tasmania and Queensland also had significantly higher consumption than NSW. From 1991 to 1998, controlled-release morphine consumption increased by 27% per year nationally (RR, 1.27; 95% CI, 1.24-1.30). The NT had 2.6 times more supply of morphine (RR, 2.63; 95% CI, 1.71-4.03) and Tasmania 58% more supply than NSW (RR, 1.58; 95% CI, 1.11-2.25). CONCLUSIONS: Australia's consumption of licit opioids ranked high internationally. There were diverse trends in the supply of licit opioids to Australia's jurisdictions, resulting in a heterogeneous pattern throughout the country.     

Predictors of glycaemic control and hypoglycaemia in children and adolescents with type 1 diabetes from NSW and the ACT

OBJECTIVES: To audit glycaemic control and incidence of severe hypoglycaemia in children and adolescents with type 1 diabetes in New South Wales (NSW) and the Australian Capital Territory (ACT). DESIGN: A multicentre, population-based, cross-sectional study from 1 September to 31 December, 1999. PARTICIPANTS: 1190 children and adolescents aged 1.2-15.8 years with type 1 diabetes, identified from three hospital-based paediatric diabetes units, four private city-based paediatric practices and 18 regional outreach clinics in NSW and the ACT. MAIN OUTCOME MEASURES: HbA(1c) level and incidence of severe hypoglycaemia (defined by unconsciousness or seizures). RESULTS: The response rate was 67% (1190 of a target group of 1765). The median HbA(1c) level was 8.2% (interquartile range, 7.6%-9.1%). Significant predictors of HbA1c level in a multiple regression model were duration (b = 0.05; 95% CI, 0.02-0.07) and insulin dose/kg (b = 0.46; 95% CI, 0.27-0.66). At least one episode of severe hypoglycaemia in the previous three months was reported in 6.7%, and the rate of severe hypoglycaemia was 36/100 patient-years. Significant predictors of hypoglycaemia in a Poisson regression model were younger age (P = 0.03), male sex (P = 0.04), longer diabetes duration (P = 0.02), and > 3 daily insulin injections (P = 0.02), but not HbA(1c) level. Children with diabetes had higher BMI standard deviation scores compared with population standards, and those in the highest quartile of BMI standard deviation score were younger, had shorter diabetes duration and had higher HbA(1c) level. CONCLUSIONS: Many children and adolescents with type 1 diabetes have suboptimal glycaemic control, placing them at high risk of developing microvascular complications. Those with longer diabetes duration are at increased risk of suboptimal glycaemic control and severe hypoglycaemia and should be targeted for interventional strategies.     

An evaluation of poor pregnancy outcomes among Burundian refugees in Tanzania

CONTEXT: Little is known about pregnancy outcomes among the approximately 11 million refugees worldwide, 25% of whom are women of reproductive age. OBJECTIVE: To estimate incidence of and determine risk factors for poor pregnancy outcomes and to calculate the contribution of mortality from neonatal and maternal deaths to overall mortality in a refugee camp. DESIGN: Cross-sectional review of records and survey, conducted in February and March 1998. SETTING: Mtendeli refugee camp, Tanzania. PARTICIPANTS: For the overall assessment, 664 Burundi women who had a pregnancy outcome during a recent 5-month period (September 1, 1997-January 31, 1998) and their 679 infants; 538 women (81%) completed the survey. MAIN OUTCOME MEASURES: Incidence of fetal death (fetus born > or =500 g or > or =22 weeks' gestation with no signs of life), low birth weight (<2500 g), neonatal death (death <28 days of life), and maternal death (deaths during or within 42 days of pregnancy from any cause related to or aggravated by the pregnancy or its management). RESULTS: The fetal death rate was 45.6 per 1000 births, the neonatal mortality rate was 29.3 per 1000 live births, and 22.4% of all live births were low birth weight. Compared with women without poor pregnancy outcome, those with poor pregnancy outcome were more likely to report prior high socioeconomic status (adjusted odds ratio [OR], 1.6; 95% confidence interval [CI], 1.1-2.4), having a first or second pregnancy (OR, 2.2; 95% CI, 1.4-3.4), and having 3 or more episodes of malaria during pregnancy (OR, 2.0; 95% CI, 1.4-3.1). Neonatal and maternal deaths accounted for 16% of all deaths during the period studied. CONCLUSIONS: Poor pregnancy outcomes were common in this refugee setting, and neonatal and maternal deaths, 2 important components of reproductive health-related deaths, contributed substantially to overall mortality.     

Screening for Chlamydia trachomatis at the time of routine Pap smear in general practice: a cluster randomised controlled trial

OBJECTIVE: To determine whether asking general practitioners to offer chlamydia screening at the same time as Pap screening increases chlamydia screening rates. DESIGN: A pragmatic cluster randomised controlled trial. PARTICIPANTS AND SETTING: Doctors from 31 general practices in the Australian Capital Territory performing more than 15 Pap smear screens per year, and all women aged 16-39 years attending those practitioners between 1 November 2004 and 31 October 2005. INTERVENTION: Doctors in the intervention practices were asked to routinely offer combined chlamydia and Pap screening to eligible women; doctors in the control practices were asked to implement screening guidelines based on a risk assessment of the individual patient (ie, usual practice). MAIN OUTCOME MEASURE: Chlamydia screening rate per visit. RESULTS: There were 26 876 visits by eligible women during the study period: 16 082 to intervention practices and 10 794 to control practices. Chlamydia screening occurred during 6.9% (95% CI, 6.5%-7.3%) of visits to intervention practices and 4.5% (95% CI, 4.1%-4.9%) of visits to control practices. After controlling for clustering and potential confounders, there were twofold greater odds of chlamydia screening occurring during a visit by an eligible woman to an intervention practice than to a control practice (adjusted odds ratio, 2.1 [95% CI, 1.3-3.4]). CONCLUSION: Combining chlamydia and Pap screening increases the rate of chlamydia screening in general practice. Implementing this approach would require little additional infrastructure support in settings where a cervical screening program already exists.     

Hepatitis A epidemiology in Australia: national seroprevalence and notifications

OBJECTIVES: To determine hepatitis A seroprevalence and notification rates in Australia in order to inform vaccination policy. DESIGN: Seroprevalence was determined by cross-sectional survey of opportunistically collected sera; notifications were extracted from the National Notifiable Diseases Surveillance System. PARTICIPANTS: 3,043 serum samples collected in 1998 were obtained from 46 laboratories around Australia. Sample size in each age group was based on expected seroprevalence, and States and Territories were sampled proportionally to their population size. Males and females were equally represented. Notifications were extracted for cases with onset between 1 January 1991 and 31 December 1998. MAIN OUTCOME MEASURES: Seroprevalence and notifications were analysed by age, sex and State/Territory. RESULTS: 41.1% of serum samples were seropositive for hepatitis A (95% CI, 39.4%-42.9%) (population-weighted seroprevalence, 38.3%). Seroprevalence was significantly associated with increasing age (P<0.001), but did not differ between the sexes (male:female ratio, 1.04:1; 95% CI, 0.95-1.14). However, significantly more notifications were recorded for males than females (male:female ratio, 1.65:1; 95% CI, 1.60-1.70). The Northern Territory had the highest seroprevalence (68.8%; 95% CI, 52.7%-84.8%) and annual notification rates (48.7 per 100,000 population; 95% CI, 45.0-52.4 per 100,000). CONCLUSIONS: These data show that about half the Australian population has not been exposed to hepatitis A and is therefore susceptible to infection. However, any decision on national routine childhood hepatitis A vaccination requires a cost-benefit analysis. Routine vaccination of high-incidence communities remains controversial.     

Asthma screening as part of a routine school health assessment in the Australian Capital Territory

OBJECTIVE: To determine the feasibility and performance of a routine screen for childhood asthma in new entrants to primary school relative to diagnosis by a paediatrician. DESIGN: Cross-sectional study with a validation substudy. PARTICIPANTS AND SETTING: All 4539 new primary school entrants (mean age, 5.72 years; 95% CI, 5.71-5.74) in the Australian Capital Territory (ACT) in 1999; 180 of these children (73% of the 248 contacted) participated in the validation substudy. MAIN OUTCOME MEASURE: Performance of the screening test relative to a paediatrician's diagnosis of current asthma (defined as a history of wheeze suggestive of a clinical diagnosis of asthma within the past 12 months) based on history and examination. RESULTS: 3748 of the 4539 new primary school entrants (83%) returned completed asthma and respiratory questions. The screening test was positive in 38% of children. Estimated sensitivity was 92% (95% CI, 75%-99%); specificity, 76% (95% CI, 72%-80%); positive predictive value, 51% (95% CI, 41%-63%); negative predictive value, 98% (95% CI, 90%-100%); positive likelihood ratio, 3.8 (95% CI, 2.8-4.8); and negative likelihood ratio, 0.14 (95% CI, 0.02-0.33). CONCLUSIONS: It is feasible to conduct population screens for asthma that have good diagnostic test performance against a specialist paediatrician's diagnosis through school health programs. This approach could facilitate monitoring changes in asthma prevalence over time.     

Malnutrition, measles, mortality, and the humanitarian response during a famine in Ehiopia

CONTEXT: The World Food Programme estimated that 10 million people were at risk of starvation in Ethiopia in 2000 but later reported that a famine had been averted. However, no population-based data on mortality or nutrition existed for Gode district, at the epicenter of the famine in the Somali region of Ethiopia. OBJECTIVES: To estimate mortality rates, determine the major causes of death, and estimate the prevalence of malnutrition among children and adults for the population of Gode district. DESIGN AND SETTING: Two-stage cluster survey conducted from July 27 through August 1, 2000, which included anthropometric measures and 8-month retrospective mortality data collection. PARTICIPANTS: A total of 595 households comprising 4032 people living in Gode district of Ethiopia. MAIN OUTCOME MEASURES: Crude mortality rates and mortality rates for children younger than 5 years, causes of death, weight for height of less than -2 z scores among children aged 6 months to 5 years, and body mass index of less than 18.5 kg/m(2) among adults and older persons. RESULTS: Of the 595 households, 346 (58.2%) were displaced from their usual places of residence. From December 1999 through July 2000, a total of 293 deaths occurred in the sample population; 159 (54.3%) deaths were among children younger than 5 years and 72 (24.6%) were among children aged 5 to 14 years. The crude mortality rate was 3.2/10 000 per day (95% confidence interval [CI], 2.4-3.8/10 000 per day), which is 3 times the cutoff used to define an emergency. The mortality rate for children younger than 5 years was 6.8/10 000 per day (95% CI, 5.4-8.2/10 000 per day). Approximately 77% of deaths occurred before major relief interventions began in April/May 2000. Wasting contributed to 72.3% of all deaths among children younger than 5 years. Measles alone or in combination with wasting accounted for 35 (22.0%) of 159 deaths among children younger than 5 years and for 12 (16.7%) of 72 deaths among children aged 5 to 14 years. The prevalence rate for wasting (weight for height of <-2 z score) among children aged 6 months to 5 years was 29.1% (95% CI, 24.7%-33.4%). Using a method to adjust body mass index for body shape, the prevalence of undernutrition (body mass index <18.5 kg/m(2)) among adults aged 18 to 59 years was 22.7% (95% CI, 17.9%-27.5%). CONCLUSIONS: To prevent unnecessary deaths, the humanitarian response to famine needs to be rapid, well coordinated, and based on sound epidemiological evidence. Public health interventions, such as mass measles vaccination campaigns with coverage extended to children aged 12 to 15 years should be implemented as the first priority. The prevalence of wasting and undernutrition among children and adults, respectively, should be assessed in all prolonged, severe famines.     

Trends in ischaemic heart disease in the Hunter Region of New South Wales 1985-1989

OBJECTIVE: To find out whether trends in rates of non-fatal myocardial infarction (MI) parallel trends in rates of coronary death. DESIGN: A population-based observational study involving continuous surveillance of all suspected heart attacks or coronary deaths from 1985 to 1989. STUDY POPULATION: Residents of the Hunter Region of New South Wales aged under 70 years. MAIN OUTCOME MEASURES: Rates of non-fatal definite or possible MI or fatal MI or coronary death, as defined by the diagnostic criteria of the WHO MONICA Project. RESULTS: For men, mortality rates declined by an average of 16.2 per 100,000 per year (95% confidence interval [CI]: -23.8, -8.7); rates of non-fatal definite MI declined by 16.2 per 100,000 (95% CI: -27.8, -4.6); rates of non-fatal possible MI increased initially and then stabilised. For women smaller changes occurred in the same directions. CONCLUSION: In this population trends in rates for non-fatal definite MI paralleled the declines in mortality rates. Rates for less severe non-fatal possible MI did not follow this pattern, perhaps reflecting increased medical attention to chest pain.     

Moderate alcohol intake is associated with survival in the elderly: the Dubbo Study

OBJECTIVE: To examine the relationship between alcohol intake and survival in elderly people. DESIGN AND SETTING: A prospective study over 116 months of non-institutionalised subjects living in Dubbo, a rural town (population, 34,000) in New South Wales. PARTICIPANTS: 1235 men and 1570 women aged 60 years and over who were first examined in 1988-89. MAIN OUTCOME MEASURES: All-causes mortality; gross cost of alcohol per life-year gained. RESULTS: Death occurred in 450 men and 392 women. Intake of alcohol was generally moderate (i.e., less than 14 drinks/week). Any intake of alcohol was associated with reduced mortality in men up to 75 years and in women over 64 years. In a proportional hazards model, the hazard ratio for mortality in men taking any alcohol was 0.63 (95% CI, 0.47-0.84) and in women was 0.75 (95% CI, 0.60-0.94). Cardiovascular deaths in men were reduced from 20/100 (95% CI, 14-26) to 11/100 (95% CI, 9-13) and in women from 16/100 (95% CI, 13-19) to 8/100 (95% CI, 6-10). The reduction in mortality occurred in men and women taking only 1-7 drinks/week--hazard ratios, 0.68 (95% CI, 0.49-0.94) and 0.78 (95% CI, 0.61-0.99), respectively, with a similar protective effect from intake of beer or other forms of alcohol. After almost 10 years' follow-up, men taking any alcohol lived on average 7.6 months longer, and women on average 2.7 months longer, compared with non-drinkers. The gross cost for alcohol per life-year gained if consuming 1-7 drinks/week was $5700 in men, and $19,000 in women. CONCLUSIONS: Moderate alcohol intake in the elderly appears to be associated with significantly longer survival in men 60-74 years and in all elderly women.     

Paediatric food allergy trends in a community-based specialist allergy practice, 1995-2006

OBJECTIVE: To examine changing demand for specialist food allergy services for children aged 0-5 years over the 12 years from 1995 to 2006 as an index of changing prevalence. DESIGN, SETTING AND PARTICIPANTS: Retrospective analysis of the records of 1489 children aged 0-5 years referred to a community-based specialist allergy practice in the Australian Capital Territory (population, about 0.33 million). MAIN OUTCOME MEASURES: Trends in demand for assessment for food allergy, dietary triggers and severity over 12 years, compared with Australian hospital morbidity data. RESULTS: 47% (697/1489) of 0-5 year-old children seen in private practice had food allergy (175 with food-associated anaphylaxis), most commonly to peanut, egg, cows milk and cashew. Over 12 years, the number of children in this age group evaluated each year increased more than fourfold, from 55 cases in 1995 to 240 in 2006. There was no change in the proportion diagnosed with allergic rhinitis in 1995 and 2006 (14.5% and 13.3%, respectively), urticaria (14.5% and 12.9%) or atopic eczema (54.5% and 57.0%). By contrast, the proportion with asthma dropped from 33.7% in 1995 to 12.5% in 2006 and the number with food allergy increased 12-fold, from 11 to 138 patients (and from 20.0% to 57.5% of children seen) The number with food anaphylaxis increased from five to 37 children (9.0% to 15.4%) over the same period. There were similar trends in age-adjusted Australian hospital admission rates for anaphylaxis in children aged 0-4 years, which increased from 39.3 to 193.8 per million population between the financial years 1993-94 and 2004-05, a substantially greater increase than for older age groups, or for the population as a whole (36.2 to 80.3 per million population). CONCLUSIONS: There is an urgent need for coordinated systematic studies of the epidemiology of food allergy in Australia, to ascertain risk factors and guide public health policy. An increased prevalence of food allergy has implications for public health and medical workforce planning and availability of allergy services in Australia.     

The effect of socioeconomic status on outcomes for seriously ill patients: a linked data cohort study

OBJECTIVE: To investigate the association between socioeconomic status (SES) and outcomes for seriously ill patients. DESIGN AND SETTING: A retrospective cohort study based on data from an intensive care unit clinical database linked with data from the Western Australian hospital morbidity and mortality databases over a 16-year period (1987-2002). MAIN OUTCOME MEASURES: In-hospital and long-term mortality. RESULTS: Data on 15,619 seriously ill patients were analysed. The in-hospital mortality rate for all seriously ill patients was 14.8%, and the incidence of death after critical illness was 7.4 per 100 person-years (4.8 per 100 person-years after hospital discharge). Patients from the most socioeconomically disadvantaged areas were more likely to be younger, to be Indigenous, to live in a remote area, to be admitted non-electively, and to have more severe acute disease and comorbidities. SES was not significantly associated with in-hospital mortality, but long-term mortality was significantly higher in patients from the lowest SES group than in those from the highest SES group, after adjusting for age, ethnicity, comorbidities, severity of acute illness, and geographical accessibility to essential services (hazard ratio for death in lowest SES group v highest SES group was 1.21 [95% CI, 1.04-1.41]; P = 0.014). The attributable incidence of death after hospital discharge between patients from the lowest and highest SES groups was 1.0 per 100 person-years (95% CI, 0.3-1.6 per 100 person-years). CONCLUSION: Lower SES was associated with worse long-term survival after critical illness over and above the background effects of age, acuity of acute illness, comorbidities, Indigenous status and geographical access to essential services.     

Colonoscopy screening for colorectal cancer: the outcomes of two recruitment methods

OBJECTIVES: To determine the response to colorectal cancer (CRC) screening by colonoscopy, through direct invitation or through invitation by general practitioners. DESIGN AND SETTING: Two-way comparison of randomised population sampling versus cluster sampling of a representative general practice population in the Australian Capital Territory, May 2002 to January 2004. INTERVENTION: Invitation to screen, assessment for eligibility, interview, and colonoscopy. SUBJECTS: 881 subjects aged 55-74 years were invited to screen: 520 from the electoral roll (ER) sample and 361 from the general practice (GP) cluster sample. MAIN OUTCOME MEASURES: Response rate, participation rate, and rate of adenomatous polyps in the screened group. RESULTS: Participation was similar in the ER arm (35.1%; 95% CI, 30.2%-40.3%) and the GP arm (40.1%; 95% CI, 29.2%-51.0%) after correcting for ineligibility, which was higher in the ER arm. Superior eligibility in the GP arm was offset by the labour of manual record review. Response rates after two invitations were similar for the two groups (ER arm: 78.8%; 95% CI, 75.1%-82.1%; GP arm: 81.7%; 95% CI, 73.8%-89.6%). Overall, 53.4% ineligibility arose from having a colonoscopy in the past 10 years (ER arm, 98/178; GP arm, 42/84). Of 231 colonoscopies performed, 229 were complete, with 32% of subjects screened having adenomatous polyps. CONCLUSIONS: Colonoscopy-based CRC screening yields similar response and participation rates with either random population sampling or general practice cluster sampling, with population sampling through the electoral roll providing greater ease of recruitment.     

Racial disparities in infection-related mortality at Alice Springs Hospital, Central Australia, 2000--2005

OBJECTIVE: To compare infection-related mortality rates and pathogens isolated for Indigenous and non-Indigenous adult patients at Alice Springs Hospital (ASH). DESIGN, PARTICIPANTS AND SETTING: Retrospective study of inhospital deaths of adults (patients aged > or = 15 years) associated with an infection during a medical or renal admission to ASH between 1 January 2000 and 31 December 2005. MAIN OUTCOME MEASURES: Admission- and population-based infection-related mortality rates and mortality rate ratios (MRRs) for Indigenous versus non-Indigenous adults. RESULTS: There were 513 deaths, of 351 Indigenous and 162 non-Indigenous patients. For Indigenous patients, 60% of deaths were infection-related, compared with 25% for non-Indigenous patients (P < 0.001). The admission-based infection-related MRR for Indigenous versus non-Indigenous adults was 2.2 (95% CI, 1.6-3.1) (15.3 v 6.8 deaths per 1000 admissions; P < 0.001). After adjusting for age and year of death, the population-based infection-related MRR was 11.3 (95% CI, 8.0-15.8) overall (351 v 35 deaths per 100,000 population; P < 0.001) and 31.5 (95% CI, 16.1-61.8) for patients aged < 60 years. The median age of patients who died with an infection was 49 (interquartile range [IQR], 38-67) years for Indigenous and 73 (IQR, 58-80) years for non-Indigenous patients (P < 0.001). For Indigenous patients, 56% of infection-related deaths were associated with bacterial sepsis, with half of these due to enteric organisms. Other deaths followed chronic hepatitis B infection, invasive fungal infections and complications of strongyloidiasis. CONCLUSION: Indigenous patients at ASH are 11 times more likely than non-Indigenous patients to die with an infectious disease. This racial disparity reflects the ongoing socioeconomic disadvantage experienced by Indigenous Australians.     

The rising incidence of childhood type 1 diabetes in New South Wales, 1990-2002

OBJECTIVES: To determine the incidence of childhood type 1 diabetes mellitus (T1DM) in New South Wales from 1997 to 2002; to compare with previously published rates (1990-1996); and to analyse trends in incidence from 1990 to 2002. DESIGN, SETTING AND PARTICIPANTS: Prospective population-based incidence study. Primary ascertainment of incident cases aged < 15 years was from the Australasian Paediatric Endocrine Group NSW children's diabetes register. Secondary ascertainment was from the National Diabetes Supply Scheme until 1999 and from the Australian Institute of Health and Welfare thereafter. Childhood population data were obtained from the Australian Bureau of Statistics. MAIN OUTCOME MEASURES: Age-standardised incidence; trends in incidence by calendar year, and sex and age at diagnosis. RESULTS: There were 3260 incident cases (1629 boys, 1631 girls) in the 13 years. Case ascertainment was 99.7% complete using the capture-recapture method. Mean age-standardised incidence per 100 000 person-years was 20.9 (95% CI, 19.9 to 21.9) from 1997 to 2002 compared with 17.8 (95% CI, 17.0 to 18.7) from 1990 to 1996; there was a plateau in incidence between 1997 and 2002. Overall, the incidence increased on average by 2.8% per year (95% CI, 1.9% to 3.8%, P < 0.001) and increased with age, being 12.2 (95% CI, 11.3 to 13.1) in 0-4 year olds; 18.9 (95% CI, 17.8 to 20.0) in 5-9 year olds and 26.7 (95% CI, 25.4 to 28.1) in 10-14 year olds. The increase per year in 0-4 year olds (3.9%) was not significantly higher than in older children. The mean incidence of T1DM was 19.8 (95% CI, 18.8 to 20.7) in girls and 18.8 (95% CI, 17.9 to 19.7) in boys (P = 0.02). CONCLUSIONS: The incidence of childhood-onset T1DM has increased significantly in all age groups in NSW since 1990. Resource planning in the management of childhood diabetes in NSW should take these findings into account.     

End-stage renal disease in aboriginals in New South Wales: a very different picture to the Northern Territory

OBJECTIVES: To compare the incidence of end-stage renal disease (ESRD) among Aboriginals in New South Wales with the incidence among Aboriginals in the Northern Territory, and to compare the patterns of ESRD among Aboriginals and non-Aboriginals in NSW. DESIGN: Secondary data analysis of information from unpublished and published Australia and New Zealand Dialysis and Transplant Registry reports. MAIN OUTCOME MEASURES: Average annual incidence of ESRD (persons per million); form of renal replacement therapy; mortality at 31 March 1998; patient and graft survival one and five years after transplant. RESULTS: Each year in NSW, 5-17 new Aboriginal patients are treated for ESRD. There was no increase in the average annual incidence of ESRD among NSW Aboriginals (118 per million in 1988-1989 and 111 per million in 1996-1997), whereas incidence in the NT increased from 255 per million to 800 per million. In NSW, ESRD was attributed to diabetes in 32% of Aboriginal patients, compared with 13% of non-Aboriginal patients (P < 0.001). In NSW, Aboriginal patients were younger and more likely to be female, a pattern similar to that in the NT. The outcome of ESRD treatment is not significantly different between Aboriginals and non-Aboriginals in NSW. CONCLUSION: There is a different pattern of incidence of ESRD and of outcomes with treatment among Aboriginals in NSW compared with those in the NT. A possible explanation is that the lower incidence in NSW reflects less profound socioeconomic disadvantage and better access to primary and specialist care.