Making sense of polarities in health organizations for policy and leadership

Making sense of complex adaptive clinical practice and health systems is a pressing challenge as health services continue to struggle to adapt to changing internal and external constraints. In this Forum, we begin with Dervin's Sense‐Making theories and research in communications. This provides a conceptual and theoretical context for this editions research on comparative complexity of family medicine consultations in the USA, models for adaptive leadership in clinical care and social networking to make sense of health promotion challenges for young people. Finally, a Sense‐Making schema is proposed.     

Obstetric Training for Rural General Practice

In the current debate on the problems faced by rural doctors, lack of training in procedural disciplines such as obstetrics has emerged as a priority issue. With specialist obstetric services concentrated in metropolitan and major provincial cities, general practitioners will continue to provide rural communities with obstetric care. Postgraduate obstetric training programmes for general practitioners must provide procedural skills training for intending rural practitioners or risk being regarded as irrelevant to the needs of rural communities.     

Dysfunctional uterine bleeding in adolescence

This paper assesses the basic steps of management and treatment of dysfunctional uterine bleeding (DUB) - the irregular bleeding arising from anovulation. After menarche, the hypothalamic-pituitary-ovarian axis can take several years to mature resulting in anovulatory and therefore irregular cycles. During an anovulatory cycle, the corpus luteum fails to form, causing failure of normal cyclical progesterone secretion. This results in continuous unopposed production of estradiol, stimulating overgrowth of the endometrium. Without progesterone, the endometrium grows thicker and thicker eventually outgrowing its blood supply, leading to necrosis. The end result is very heavy bleeding.     

Ergotamine Use in Pregnancy

EDITORIAL COMMENT: We accepted this short report for publication to warn readers that ergotamine may cause acute fetal hypoxia. Although prescribing information lists pregnancy as a contraindication, there is still a belief that ergotamine can be used in pregnancy. The mechanism of injury of the fetus is not clear-cut. The use of ergotamine was associated with more than just the fetal brain becoming hypoxic: the cardiotocograph shows features of myocardial ischaemia as well. The fact that the infant was stillborn also suggests myocardial injury, so that isolated cerebral vasospasm seems unlikely. It is of interest that meconium was not passed. Both this case and that described in reference 4 indicate that ergotamine may cause uterine contractions as well as vasospasm.     

Do Internet interventions for consumers cause more harm than good? A systematic review

Objective  To systematically review the effect of consumer use of online health information on decision-making, attitudes, knowledge, satisfaction and health outcomes and utilization.
Search strategy  Electronic databases searched included the Cochrane Controlled Trials Register, MEDLINE, PREMEDLINE (to 14 March 2001), CINAHL, Australian Medical Index, Health and Society, National Institutes of Health Clinical Trials Database and CenterWatch.
Inclusion criteria  All post-1995 comparative studies (including controlled studies, before and after studies, and interrupted time series analyses) of Internet users vs. non-Internet users and other communications mediums, and Internet characteristics such as e-mail vs. other communication mediums, were included. Outcomes included consumer decision-making, attitudes, knowledge, satisfaction and measurable changes in health status or health utilization.
Data extraction and synthesis  One reviewer screened all papers then two reviewers independently assessed studies against the selection criteria and any discrepancies were resolved by discussion with a third reviewer. No attempt was made to combine the data for further statistical analysis.
Main results  We identified 10 comparative studies. Studies evaluated the effectiveness of using the Internet to deliver a smoking cessation programme, cardiac and nutrition educational programmes, behavioural interventions for headache and weight loss, and pharmacy and augmentative services. All studies showed some positive effects on health outcomes, although the methodological quality of many studies was poor.
Conclusions  Despite widespread consumer Internet use to obtain health-care information, there is almost a complete lack of evidence of any effects this may have on health outcomes.     

TOPICAL TRETINOIN IMPROVES THE APPEARANCE OF PHOTO DAMAGED SKIN

A multicentre clinical trial has been conducted to assess the efficacy and safety of tretinoin 0.05% cream (Retin-A®) in the treatment of photodamaged Australian skin. Subjects with cutaneous facial photodamage were randomised to treatment with tretinoin (62) or vehicle (63) cream. After an initial two week run-in, all subjects applied the cream to the face, neck and left forearm/hand, once nightly for 24 weeks. Changes in clinical signs of photodamage and parameters of cutaneous irritation were assessed by investigators using a 7 point scale, whilst changes in signs of photodamage were rated by subjects using a 5 point scale. Changes in skin biopsies and silicone skin surface replicas were also assessed. Significant improvements in skin wrinkles, mottled hyperpigmentation, laxity, lentigines and roughness of tretinoin treated subjects were noted by investigators. Subjects receiving tretinoin noted significant improvements in skin wrinkles, tightness, colour and pores. Improvement in overall severity of photodamage was significantly greater for tretinoin treated subjects and was progressive over the study period. Histological findings included a significant increase in mean epidermal thickness. Significant topographical changes were not detected in skin surface replica sets. Cutaneous irritation, the most common side effect, was usually mild and transient. We conclude that tretinoin 0.05% cream significantly improved the appearance of photodamaged skin.     

Visual acuity in an Australian Aboriginal population

Background: Australia is a developed country, However; Aboriginal Australians have rates of blindness comparable to Third World countries. There have been well-funded eye health programs for 15 years in Central Australia. This paper examines if there has been an improvement in visual disability of one traditional group of Aboriginal Australians. Methods: Results from an eye health survey of the Anangu Pitjantjatjara of South Australia in 1990 are presented. These data are compared with results for ‘blindness’ and ‘poor vision’ from a national survey undertaken in 1976. The two surveys were comparable in design, both were cross-sectional population-based prevalence surveys. Prevalence rates were adjusted for the size of the source population. Results: Young rural Aboriginal Australians have good visual acuity. Low vision and blindness (WHO definitions) occur in 19.6% and 10.4% of 60+ year olds, respectively. Women were more likely than men to be blind or have low vision (OR= 1.93; 1.06-3.58). There was a decline in ‘poor vision’ between surveys (OR=2.86; 1.86-4.75) but not in ‘blindness’. Conclusion: Although there has been a reduction in the prevalence of visual disability in rural Aboriginal Australians, improvements in the provision of eye care for the elderly need to occur.