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Objective: To identify factors associated with antenatal smoking and explore characteristics of smoking behaviour among pregnant Aboriginal and Torres Strait Islander women., Design and Setting: Cross-sectional study using interviewer-administered questionnaires of 145 pregnant Aboriginal and Torres Strait Islander women attending a health service in Far North Queensland between November 2005 and December 2006., Main Outcome Measures: Prevalence of self-reported smoking; predictors and patterns of smoking in early pregnancy; and relationships between smoking and the prevalence of predisposing, enabling and reinforcing factors, including women's knowledge about and attitudes towards smoking and the risks involved., Results: Of 145 women, 41% (n = 60) reported being daily or occasional smokers. Knowledge about harms of smoking was generally high. Women who were smokers had a significantly higher rate of smoking partners (n = 36) than women who were non-smokers (n = 31) (77% v 41%, P < 0.001). Level of daily stress was significantly higher among smokers than non-smokers (P = 0.001)., Conclusion: Shifted population norms among Aboriginal and Torres Strait Islanders are accompanied by a shift in the factors that can effectively differentiate between smokers and non-smokers within this population. Rather than the traditional, mainstream predictors of antenatal smoking, interventions with Aboriginal and Torres Strait Islander women should focus on the social environment, and the influences of social networks and partners on the behaviour of individuals.

Background: Hyperglycaemia, fever, and swallowing dysfunction are poorly managed in the admission phase of acute stroke, and patient outcomes are compromised. Use of evidence-based guidelines could improve care but have not been effectively implemented. Our study aims to develop and trial an intervention based on multidisciplinary team-building to improve management of fever, hyperglycaemia, and swallowing dysfunction in patients following acute stroke., Methods and Design: Metropolitan acute stroke units (ASUs) located in New South Wales, Australia will be stratified by service category (A or B) and, within strata, by baseline patient recruitment numbers (high or low) in this prospective, multicentre, single-blind, cluster randomised controlled trial (CRCT). ASUs then will be randomised independently to either intervention or control groups. ASUs allocated to the intervention group will receive: unit-based workshops to identify local barriers and enablers; a standardised core education program; evidence-based clinical treatment protocols; and ongoing engagement of local staff. Control group ASUs will receive only an abridged version of the National Clinical Guidelines for Acute Stroke Management. The following outcome measures will be collected at 90 days post-hospital admission: patient death, disability (modified Rankin Score); dependency (Barthel Index) and Health Status (SF-36). Additional measures include: performance of swallowing screening within 24 hours of admission; glycaemic control and temperature control., Discussion: This is a unique study of research transfer in acute stroke. Providing optimal inpatient care during the admission phase is essential if we are to combat the rising incidence of debilitating stroke. Our CRCT will also allow us to test interventions focussed on multidisciplinary ASU teams rather than individual disciplines, an imperative of modern hospital services., Trial Registration: Australia New Zealand Clinical Trial Registry (ANZCTR) No: ACTRN12608000563369.

Background: We sought to determine whether inter-patient variations in pattern of PSA changes after radiation exist and, if so, are they prognostically significant., Methods: In the Trans-Tasman Radiation Oncology Group (TROG) 96.01 randomized controlled trial, patients with T2b,c,3,4 N0 prostate cancer (PC) were randomised to 0, 3 or 6months maximal androgen deprivation prior to 66Gy to the prostate and seminal vesicles (XRT). Patterns of anatomical site of failure were one of the trial endpoints. Serial serum PSA's were mandated at all follow-up visits. Pattern recognition software was developed to characterize PSA response "signatures" (PRS) after therapy in individual patients., Results: By 2000, 270 eligible patients were randomised to radiation alone. Individual patient PSA values were observed to descend after radiation according to one of two characteristic "signatures": single exponential (PRS Type 1), non-exponential (PRS Type 2). Compared to PRS Type 1, men with PRS Type 2 (50% of the group) had lower PSA nadir (nPSA) levels (p<.0001), longer doubling times on relapse (p=.006) and significantly lower rates of local (hazard ratio [HR]: 0.47, 95% confidence interval [0.30-0.75], p=.0014) and distant failure (HR: 0.25[0.13-0.46], p<.0001), death due to PC (HR: 0.20[0.10-0.42], p<.0001) and death due to any cause (HR: 0.37 [0.23-0.60], p<.0001). PRS retained its powerful prognostic significance in Cox models that incorporated all key pre-treatment covariates and nPSA., Conclusions: PRS reflect the presence of tumor phenotypes that vary substantially in their clinical behavior and response to XRT. Molecular characterization is now necessary.

The study was conducted to assess the prevalence of and factors associated with haemoglobin (Hb) concentrations among children aged 6-59 months in Timor-Leste. The 2003 Demographic and Health Survey was a multi-stage cluster survey of 4,320 households from four different geographic regions in Timor-Leste. In total, 4,514 children aged 6-59 months were included in the analysis. The prevalence of anaemia (Hb concentration <11.0g/dL) was 38.2% (638/1,668) for children aged 6-23 months and 22.6% (644/2,846) for older children (p<0.001). Girls had a higher mean Hb concentration than boys (11.9g/dL vs 11.7g/ dL, p<0.006) and children who had diarrhoea in the previous two weeks had a lower Hb concentration than children without diarrhoea (11.5g/dL vs 11.9g/dL, p<0.001). Children from the richest and middle-class households had a lower average Hb concentration than those from the poorest households (11.8g/ dL, 11.7g/dL vs 12.0g/dL, p<0.001). Children of mothers with some secondary or more education had a lower mean Hb concentration than children of mothers with completed primary, some primary and no education (11.7 g/dL vs 11.9 g/dL, 11.8 g/dL, and 11.9 g/dL, p=0.002). Children from severely-anaemic mothers had a lower mean Hb concentration than children from moderately-, mild and not anaemic mothers (10.5 g/dL vs 11.1 g/dL, 11.6 g/dL, 12.0 g/dL, p<0.001). After backward stepwise hierarchical multiple regression, wasting, male sex, recent diarrhoea, household wealth index (richest and middle-class), maternal educational status (some secondary or more and some primary), and maternal anaemic status were significantly associated with a lower Hb concentration in children and increased age of child and duration of breastfeeding (6 months) with a higher Hb concentration. Anaemia-prevention programmes among children in Timor-Leste should focus on those children aged less than two years, children with recent diarrhoea, wasted children, high socioeconomic status, and anaemic mothers.

Purpose: Psychological morbidity in cancer patients is common, but often undetected and untreated. We developed a communication skills training (CST) program targeting this issue, and evaluated its impact on doctor behaviour., Patients and Methods: Thirty of 35 oncologists from six teaching hospitals in six Australian cities, participated. The CST was a 1.5-day intensive face-to-face workshop incorporating presentation of principles, a DVD modelling ideal behaviour and role-play practice, followed by four 1.5 h monthly video-conferences incorporating role-play of doctor-generated scenarios. Doctors were randomized to receive the CST or not. Simulated patient interviews were videotaped and coded at baseline, after CST and 6 months later. Doctors completed questionnaires assessing stress and burnout at the same time points., Results: Doctors in the intervention group displayed more creating environment and fewer blocking behaviours at both follow-ups; however, these differences did not reach statistical significance. Intervention doctors valued the training highly, but did not report substantial reductions in stress and burnout., Conclusions: This short training programme demonstrated a positive effect on aspects of doctor behaviour. Video-conferencing after a short training course may be an effective strategy for delivering CST., ((c) 2007 John Wiley & Sons, Ltd)

Background: A cancer incidence and mortality study was conducted in response to health concerns raised by workers from F-111 aircraft deseal/reseal fuel tank maintenance programs, to determine whether personnel exposed to deseal/reseal had an excess of cancers and mortality., Methods: Number of deaths and cancers for individuals involved in F-111 DSRS activities were matched against two Air Force comparison groups. Analyses were weighted to adjust for differences in age, exposure period and rank., Results: Eight hundred seventy-three exposed, 7,577 comparison group one, and 9,408 comparison group two individuals were matched against death and cancer data, with 431 cancers and 431 deaths. Cancer incidence was higher in the exposed group, with marginally significant increases of 40-50% (cancer incidence rate ratio range 1.45-1.62). Exposed group mortality was significantly lower than both comparison groups, likely due to survivor bias in the exposed group (mortality rate ratio range 0.33-0.44)., Conclusions: On the balance of probabilities, there is an increased risk of cancer associated with participation in F-111 deseal/reseal activities., (2007 Wiley-Liss, Inc)

Background: Repetition of self-poisoning is common., Aims: To report the 24-month outcomes of a non-obligatory postcard intervention (plus treatment as usual) compared with treatment as usual., Method: In a randomised-controlled trial (Zelen design) conducted in Newcastle, Australia, eight postcards were sent to participants over a 12-month period. The principal outcomes were the proportion of participants with one or more repeat episodes of self-poisoning and the number of repeat episodes per person., Results: No significant reduction was observed in the proportion of people repeating self-poisoning in the intervention group (21.2%, 95% CI 17.0-25.3) compared with the control group (22.8%, 95% CI 18.7-27.0; chi(2)=0.32, d.f.=1, P=0.57); the difference between groups was -1.7% (95% CI -7.5 to 4.2). There was a significant reduction in the rate of repetition, with an incidence risk ratio of 0.49 (95% CI 0.33-0.73)., Conclusions: A postcard intervention maintained the halving of the rate of repetition of hospital-treated self-poisoning events over a 2-year period, although it did not significantly reduce the proportion of individuals who repeated self-poisoning.

There is a need for pragmatic and rigorous research designs to evaluate the effectiveness of population-based health interventions. The randomized controlled trial (RCT) has limitations in its practicality, ethical appropriateness, and cost when evaluating population-based interventions. Like RCTs, the multiple baseline design can demonstrate that a change in behavior has occurred, the change is a result of the intervention, and the change is significant. Especially important practical advantages over the RCT are that this design requires fewer population groups and communities may act as their own controls. Advantages and methodologic limitations of the multiple baseline design are discussed, and where feasible, strategies to minimize the impact of its limitations are suggested. Recommendations for future research are included.

Population- and systems-based interventions need evaluation, but the randomized controlled trial (RCT) research design has significant limitations when applied to their complexity. After some years of being largely dismissed in the ranking of evidence in medicine, alternatives to the RCT have been debated recently in public health and related population and social service fields to identify the trade-offs in their use when randomization is impractical or unethical. This review summarizes recent debates and considers the pragmatic and economic issues associated with evaluating whole-population interventions while maintaining scientific validity and credibility.

Atherosclerosis is an inflammatory response, probably to a range of initiating causes. Chronic infection with Chlamydia pneumoniae (C.pn) has been suggested as one cause, but the nature of the association is controversial, in large part due to lack of an identified mechanism to link infection with the atherosclerotic process in man. This study examined 139 consecutive subjects with stable chest pain, with the aim of correlating the serological status of C.pn infection with the pattern of secretion of cytokines from CD4(+) T lymphocytes. C.pn seropositive subjects secreted significantly more interleukin (IL)-4 than did those who were C.pn seronegative (P = 0.02). No significant difference was noted for secreted interferon (IFN)-gamma. The amount of secreted IL-4, but not of secreted IFN-gamma, correlated positively with the extent of coronary artery disease (P = 0.006). A similar correlation with secreted IL-4 was not identified with Helicobacter pylori infection. These results support the hypothesis that C.pn infection contributes to the inflammatory process responsible for coronary artery atherosclerosis. The method used to detect cytokine secretion involves ligation of CD40L on blood CD4(+) T cells, which may have relevance to tissue events.

Objective: To contrast subjective and objective measures of neuropsychological health in F-111 aircraft Deseal/Reseal maintenance personnel, against two appropriate comparison groups., Methods: Exposed and comparison participants completed a postal questionnaire which included a validated memory questionnaire and additional questions relating to possible cognitive symptoms. They also underwent a comprehensive neuropsychological assessment and screening for a past or current disturbance of mood. Multiple linear or logistic regression was conducted for each outcome using exposure group and potential confounders as explanatory variables., Results: There was a strong and consistent excess of self-reported cognitive problems among the exposed group relative to the comparison groups including a 2.8-4.3-fold increase in self-reported symptoms of forgetfulness, loss of concentration and difficulty finding the right word. On detailed neuropsychological testing, the exposed group performed significantly worse than comparisons on tests of psychomotor speed, executive functioning, and new learning/memory. These findings could not be accounted for by disturbances of mood or other potential confounders., Conclusions: There was a strong and consistent increase in self-reported cognitive problems among the exposed, and small but significant exposure-specific differences on objective tests of cognitive functioning. The findings are consistent with the development of adverse neuropsychiatric changes related to occupational exposure to solvents.

Background: Fatigue and impaired performance in athletes is well recognised and has been loosely linked to "overtraining". Reduced concentration of IgA in the saliva and increased shedding of Epstein Barr virus (EBV) have been associated with intense training in elite athletes., Objective: To determine whether athletes presenting with fatigue and impaired performance had an immune defect relevant to defective containment of EBV infection, and whether a probiotic preparation (Lactobacillus acidophilus) shown to enhance mucosal immunity in animal models could reverse any detected abnormality., Results: The fatigued athletes had clinical characteristics consistent with re-activation of EBV infection and significantly (p = 0.02) less secretion of interferon (IFN) gamma from blood CD4 positive T cells. After one month of daily capsules containing 2 x 10(10) colony forming units of L acidophilus, secretion of IFNgamma from T cells had increased significantly (p = 0.01) to levels found in healthy control athletes. A significant (p = 0.03) increase in salivary IFNgamma concentrations in healthy control athletes after the one month course of L acidophilus demonstrated in man the capacity for this probiotic to enhance the mucosal IFNgamma concentration., Conclusion: This is the first evidence of a T cell defect in fatigued athletes, and of its reversal following probiotic therapy.

Objective: To determine if self-reported data recalling at least one fall over a six-month recall period could be used as a reliable measure of falls by comparing retrospective self-report with a 'gold standard' method of reporting these events using a prospective calendar-reported method., Design: Prospective study., Setting: Community-dwelling older people living in New South Wales (NSW) and Queensland in Australia., Subjects: A stratified sample of 264 randomly selected participants from a concurrent randomized controlled trial (RCT) of preventive health assessment for people over the age of 70 years., Interventions: Intervention and control group participants in the RCT kept a calendar of fall events for a six-month validation substudy. At the end of six months, participants were asked to retrospectively report their falls over the six-month period., Main Results: Results indicated that percentage agreement between retrospective self-report and the calendar report of falls was 84%, however, sensitivity was 56% (95% confidence interval (CI) 44.1-67.5). Ten participants (4%) gave false positive self-reports of falls, and 33 (13%) participants gave false negative self-reports of falls. Therefore, retrospective self-reported fall rates were likely to involve under-reporting of falls. Significant differences were found in the sensitivity of retrospectively self-reported falls reported by the intervention group participants (sensitivity = 71%; 95% CI 56.6-85.5) compared with the control group (sensitivity = 40.5%; 95% CI 24.7-56.4, P = 0.008). Validity of self-reported injuries as a result of a fall was less accurate (71% agreement; sensitivity 24% (95% CI 16.0-33.6)., Conclusions: As recall of falls was more accurate in the intervention group than in the control group, it could appear that the intervention had the effect of increasing falls compared to the control group. Using these results, a method was devised to weight self-reported retrospective data to compensate for the poorer recall demonstrated in the control group, so that a more accurate estimate of falls could be derived from the self-reported data.

Background and Purpose: To identify contributing factors to delayed rectal and urinary symptoms in a randomised trial comparing different durations of maximal androgen deprivation (MAD), given prior to radiotherapy, for locally advanced prostate cancer., Patients and Methods: Between 1996 and 2000, 818 patients with stages T2b,c, 3 and 4 prostate cancer were entered into a trial comparing 0, 3 and 6 months of MAD prior to and during radiotherapy. Their delayed normal tissue effects were recorded by their treating doctors using standardised scales and by the patients using a self-assessment questionnaire regularly. Time to occurrence and prevalence data were analysed., Results: Rectal and urinary symptom levels were observed to vary markedly over time in at least 80% of patients, with some indicating lasting resolution of symptoms. Prevalence rates were found to be substantially lower than actuarial probability rates. Baseline symptom levels and greatest acute symptom levels were both very powerful predictors. Obstructive lower urinary tract symptoms were noted to improve during the first 4 years after radiotherapy in approximately 60% of cases in each treatment arm. However, the treatment arm itself was not shown to influence these improvements in other univariate or multivariate analyses. MAD was shown to reduce both time to occurrence and prevalence of delayed proctopathic symptoms, but this effect was confirmed statistically in the 3 month treatment arm only. Multivariate models indicated that higher levels of haemoglobin prior to any treatment may in some way protect against delayed proctopathic symptoms., Conclusions: Prevalence data provide more clinically meaningful estimates of risk of delayed effects in normal tissues where assessment relies substantially on reported symptom levels. In these tissues consideration of the impact of baseline symptom levels and pathologies, and greatest acute symptom levels in analyses of delayed effects appears mandatory. Obstructive lower urinary symptoms improve over several years in the majority of patients treated for locally advanced prostate cancer by radiotherapy. Future research could address whether rectal toxicity is affected by initial haemoglobin levels and declines in it due to MAD.

Background and Objectives: Measurement of multimorbidity and comorbidity is important in epidemiologic and health services research. The aim of this research was to derive a generic multimorbidity index based on patient self-report, incorporating severity, for predicting a range of outcomes., Methods: The dataset was obtained from a trial including 1,541 Veterans and war widows aged 70 years and over. The survey included sociodemographics, hospital admissions, SF-36, and information on deaths was obtained. The methods of Charlson were used to derive Multimorbidity Indices., Results: All indices predicted quality of life, with decreasing quality of life for each increase in multimorbidity category. Multimorbidity scores incorporating severity significantly contributed to the prediction of mortality, hospital admission, and follow-up quality of life, regardless of adjustment for baseline quality of life., Conclusions: Our results indicate that a single index cannot predict a variety of relevant outcomes. Consequently, research undertaken to assess the impact of intervention or illness on health outcomes should use an index that is valid for predicting the specific outcome of interest.

Background and Objective: This article aims to address two issues: first, whether risk scores derived from Caucasian cohorts can accurately predict coronary heart disease (CHD) in a Chinese population; second, derivation and validation of a new risk prediction score for cardiovascular disease (CVD) from a Chinese cohort., Methods: A cohort of 4,400 male steelworkers (18-74 years old) recruited between 1974-1980 was followed up for an average 13.5 years. A Cox model was used to predict 10 year risk of CHD, ischemic, and hemorrhagic stroke based on blood pressure, age, total cholesterol, body mass index, and smoking status., Results: The prediction rule from the European Recommendations greatly overestimates the risk of CHD in Orientals. The new models had good predictive ability, with the area under receiver operating characteristic curves (AUCs area) in the derivation set being 0.76, 0.72, and 0.82 for CHD, ischemic, and hemorrhagic stroke separately; AUCs in the validation set were equally good, at 0.76, 0.78, and 0.82, respectively., Conclusion: The risk stratification rules derived from Caucasian cohorts overestimates the CHD risk in Orientals, and we derive a specific risk stratification rule for CHD, ischemic and hemorrhagic stroke for Chinese men.

Although population-based molecular association studies are becoming increasingly popular, methodology for the meta-analysis of these studies has been neglected, particularly with regard to two issues: testing Hardy-Weinberg equilibrium (HWE), and pooling results in a manner that reflects a biological model of gene effect. We propose a process for pooling results from population-based molecular association studies which consists of the following steps: (1) checking HWE using chi-square goodness of fit; we suggest performing sensitivity analysis with and without studies that are in HWE. (2) Heterogeneity is then checked, and if present, possible causes are explored. (3) If no heterogeneity is present, regression analysis is used to pool data and to determine the gene effect. (4) If there is a significant gene effect, pairwise group differences are analysed and these data are allowed to 'dictate' the best genetic model. (5) Data may then be pooled using this model. This method is easily performed using standard software, and has the advantage of not assuming an a priori genetic model., (Copyright 2004 John Wiley & Sons, Ltd.)

Introduction: The seven-year experience of elective abdominal aortic aneurysm (AAA) repair of a vascular surgical unit in a teaching hospital was reviewed to determine the factors associated with in-hospital mortality., Methods: All patients who underwent elective open repair of an AAA between July 1, 1991, and June 30, 1998, were identified using International Classification of Diseases Ninth Revision (ICD-9) codes. Twenty-four variables were selected for investigation by reviewing the published literature and by discussion with local vascular surgeons. Data were obtained by retrospective medical record review. Variables were first analysed by univariate analysis, and those with a p-value up to 0.25 were included in multivariate analysis., Results: Of the 219 patients reviewed, 8 (3.7%, 95% confidence interval, 1.6%, 7.1%) died during the admission. The mean age of patients was 69.9 years, and 81% of them were male. Univariate analysis found that female sex, renal artery involvement in the aneurysm, and aortic cross-clamp duration of 90 min or greater were significantly associated with mortality. Multivariate analysis found that female sex, use of a bifurcated graft, and performance of an additional procedure at the time of operation were the only variables independently associated with mortality., Discussion: Use of a bifurcated graft was a significant prognostic variable on logistic regression analysis confirming that the technical difficulty of the operation and the morphology of the aneurysm are important factors in determining mortality. Why women may be at higher risk for death is unclear. This study also highlights that caution is required when interpreting raw audit data.

Aim: To estimate agreement between measurement of intraocular pressure (IOP) by the Tono-Pen and by the Goldmann tonometer. The hypothesis tested was that the mean difference in measurements would be <-2 mmHg., Methods: A prospective, single-centre, comparison study was carried out. The Tono-Pen was compared to the Goldmann tonometer in 138 patients systematically selected from two glaucoma clinics and among selected patients known to have high pressures (n = 22). For both groups the investigators were masked to the value of the Goldmann readings, the instruments were used in random order, and duplicated readings were taken with both tonometers., Results: In the systematically selected group, for right eyes, the mean difference in measurement between the Tono-Pen and Goldmann tonometer was -0.41 mmHg (SD: 2.59). The 95% limits of agreement were -5.5 to 4.7 mmHg, and the intraclass correlation coefficient (ICC) was 0.90. Results for left eyes were very similar. For patients with high pressures (> or =25 mmHg), the mean difference between instruments (Tono-Pen reading minus Goldmann reading): was -4.2 mmHg (P = 0.0004), SD: 4.6, 95% limits of agreement: -13.2 to 4.8 mmHg and ICC = 0.76. Combining the analysis for both groups, the Tono-Pen significantly underestimated the IOP when the pressure was >20 mmHg., Conclusions: The Tono-Pen cannot replace the Goldmann tonometer in the sense that it will give the same readings of IOP. The accuracy of the Tono-Pen is increased, if at least two measurements are taken per eye and then averaged.

Objective: To assess the performance of low BMI, and define optimal BMI cut-off values in order to detect fever-associated adult morbidity., Design: A cohort study of adults between 18 and 60 y in rural Vietnam, whose BMI and health status were assessed at baseline, and who were then monitored for illness events for 4 months. Nonparametric receiver operating characteristic (ROC) analysis was used to evaluate the performance of low BMI to detect the average number of restricted-days due to illness and to determine optimal cut-off values., Setting: A rural commune in the Red River Delta, northern Vietnam., Subjects: The study included 693 men and 739 women aged 18-60-y., Results: At baseline, 21% of the study participants had a BMI<18.5 kg/m(2). As BMI progressively decreased, the percentage of participants experiencing morbidity with fever increased. The areas under the ROC curves for BMI were significantly greater than 0.5 for all levels of monthly average restricted-days of illness (MARDI) with fever, with best performance for >5 days/month. Excluding participants with acute or chronic disease at baseline improved the performance of BMI to detect MARDI with fever of >5 days (area under ROC curve 0.95; 95% CI 0.92, 0.99). With increasing levels of MARDI with fever, BMI cut-offs fell to 17.9 kg/m(2) when MARDI with fever was >5 days., Conclusions: The ROC analysis demonstrates that low BMI performs well as a risk indicator of MARDI with fever of >5 days with an optimal BMI cut-off value of 17.9 kg/m(2).

Background: Young adults represent a high-risk group for sexually transmissible infections (STIs). No randomized controlled trials of interventions in family practice to reduce sexual risk have been reported., Objectives: We evaluated the impact of brief advice initiated in routine consultations in 20 family practices to modify young adults' risk perception and self-reported risk behaviour for STIs, particularly human immunodeficiency virus (HIV) and hepatitis., Methods: Patients aged 18-25 years completed self-administered confidential questionnaires in the waiting-room before seeing participating family physicians (FPs). Patients were unobtrusively randomized to receive advice about safe sex and complementary resources from their FP (INT group) or usual care (CONTROL group). Three months later, patients completed mailed follow-up questionnaires to assess changes in risk perception and behaviour., Results: Three hundred and twelve patients completed baseline questionnaires. Of 237 who agreed to follow-up, 156 (68%) returned self-administered follow-up questionnaires. At post-test, we found equivalent self-reported use of questions to assess any new sexual partner's risk (33 versus 36%) and equivalent self-reported use of condoms on first occasion of sex with a new partner (73 versus 77%). While self-reported behaviour did not change significantly, we demonstrated significant change from pre- to post-test for knowledge of hepatitis risk, for both intervention and control groups. Multiple regression showed that the odds of risk perceptions were significantly higher at post-test than at pre-test for the CONTROL group but not the INT group., Conclusion: FPs remain to be convinced that allocation of time within consultations to opportunistic health promotion is worthwhile. Indeed, there are many competing demands for such time. Our results do not yet provide compelling evidence for the impact of a brief intervention about STI risk by FPs. As primary prevention efforts for young adults remain important, randomized controlled trials of larger scope are needed.

Introduction: Although many studies have addressed the relationship between multiple individual polymorphisms in the vitamin D receptor (VDR) gene and bone health, few have analyzed this data in terms of haplotypes. We performed a meta-analysis of studies with data on the BsmI, ApaI, and TaqI polymorphisms in order to (a) estimate haplotype frequencies, (b) determine linkage disequilibrium (LD), and (c) estimate the magnitude of the association between haplotypes and osteoporosis/bone mineral density (BMD)., Methods: Haplotypes were inferred using the expectation-maximization algorithm (EM); log-linear models were used to determine association with osteoporosis; and regression analysis with variance components was used to determine association with BMD., Results: Our results indicate that the most common haplotype for the VDR gene, regardless of ethnicity, is baT, followed by BAt and bAT in Caucasians, and bAT and BaT in Asians. This indicates strong LD between the BsmI and TaqI polymorphisms. We demonstrate a gain in power when considering the haplotypes rather than the individual polymorphisms separately, i.e., although BsmI, ApaI, and TaqI were not significantly associated with osteoporosis on their own, the haplotypes Bat and BAt were significantly associated, with an OR of approximately 4., Conclusion: We have applied haplotype analysis to the VDR polymorphisms and bone measures. We also highlight a number of methodologic issues, including linkage disequilibrium, the robustness of the EM algorithm in this context, and the potential for exploring effect modification.

Unlabelled: With the rise of molecular and genetic epidemiology, molecular association studies are increasingly common; however, meta-analysis of these studies has been a neglected area. This study performed a meta-analysis of the association of the vitamin D receptor (VDR) gene polymorphisms and BMD. We also highlight methodological issues that need to be resolved., Introduction: With the rise of molecular and genetic epidemiology, molecular association studies are increasingly common; however, meta-analysis of these studies has been a neglected area. This study performed a meta-analysis of the association of vitamin D receptor (VDR) gene polymorphisms and BMD/osteoporosis and highlights methodological issues., Materials and Methods: Studies published from 1994 to 2001 were identified through Medline using PubMed software. The reference lists of the articles retrieved were also reviewed. Where eligible papers had insufficient information, we contacted authors by mail (up to three mailings) for additional information. Any observational study, which tested the association between VDR BsmI genotypes and either BMD or osteoporosis at the femoral neck or spine in adult women, was included in the review. Data were extracted independently by two reviewers (AT and JA) using a standardized data extraction form., Results: The B allele was significantly associated with BMD at the spine; it seemed to follow a recessive model, with the BB genotype having lower BMD than Bb/bb genotypes at baseline, which led to greater bone mineral loss over time. Highlighted methodological lessons included the need to check Hardy-Weinberg equilibrium and the importance of exploring heterogeneity, pooling data in a manner that is sensitive to genetic models, and avoiding multiple comparisons., Conclusion: With the proliferation of molecular association studies, there will be an increased need to quantify the magnitude of the risk associated with genetic polymorphisms. This will likely entail meta-analytic methods, and this meta-analysis highlights some of the methodological issues that will need to be resolved.

Chloro complexes [RuCl(N-N)P3]BPh4 (1-3) [N-N = 2,2'-bipyridine, bpy; 1,10-phenanthroline, phen; 5,5'-dimethyl-2,2'-bipyridine, 5,5'-Me2bpy; P = P(OEt)3, PPh(OEt)2 and PPh2OEt] were prepared by allowing the [RuCl4(N-N)].H2O compounds to react with an excess of phosphite in ethanol. The bis(bipyridine) [RuCl(bpy)2[P(OEt)3]]BPh4 (7) complex was also prepared by reacting RuCl2(bpy)2.2H2O with phosphite and ethanol. Treatment of the chloro complexes 1-3 and 7 with NaBH4 yielded the hydride [RuH(N-N)P3]BPh4 (4-6) and [RuH(bpy)2P]BPh4 (8) derivatives, which were characterized spectroscopically and by the X-ray crystal structure determination of [RuH(bpy)[P(OEt)3]3]BPh4 (4a). Protonation reaction of the new hydrides with Brønsted acid was studied and led to dicationic [Ru(eta2-H2)(N-N)P3]2+ (9, 10) and [Ru(eta(2-H2)(bpy)2P]2+ (11) dihydrogen derivatives. The presence of the eta2-H2 ligand was indicated by a short T(1 min) value and by the measurements of the J(HD) in the [Ru](eta2-HD) isotopomers. From T(1 min) and J(HD) values the H-H distances of the dihydrogen complexes were also calculated. A series of ruthenium complexes, [RuL(N-N)P3](BPh4)2 and [RuL(bpy)2P](BPh4)2 (P = P(OEt)3; L = H2O, CO, 4-CH3C6H4NC, CH3CN, 4-CH3C6H4CN, PPh(OEt)2], was prepared by substituting the labile eta2-H2 ligand in the 9, 10, 11 derivatives. The reactions of the new hydrides 4-6 and 8 with both mono- and bis(aryldiazonium) cations were studied and led to aryldiazene [Ru(C6H5N=NH)(N-N)P3](BPh4)2 (19, 21), [[Ru(N-N)P3]2(mu-4,4'-NH=NC6H4-C6H4N=NH)](BPh4)4 (20), and [Ru(C6H5N=NH)(bpy)2P](BPh4)2 (22) derivatives. Also the heteroallenes CO2 and CS2 reacted with [RuH(bpy)2P]BPh4, yielding the formato [Ru[eta1-OC(H)=O](bpy)2P]BPh4 and dithioformato [Ru[eta1-SC(H)=S](bpy)2P]BPh4 derivatives.

Background: The likelihood of genital injury following sexual assault remains unclear. Genital injury related to sexual assault is often an issue in court proceedings, with the expectation that injuries will be found in 'genuine' cases. Conviction rates are higher when the complainant has genital injuries., Objectives: To determine the type, frequency and severity of genital and non-genital injuries of women following alleged sexual assault and, in addition, to determine factors associated with the presence of injuries., Methods: The assault records and forensic examination findings of 153 consecutive women who attended a sexual assault service in Newcastle, Australia, between 1997 and 1999 were reviewed. All of the women were examined within 72 h of the assault. Associations were sought between victim and reported assault variables and the presence of injury using multiple logistic regression analysis., Results: Of the women, 111 (73%) were aged under 30 years and only 4% were over 50 years. Penile-vaginal penetration was the most common type of sexual assault (86%). Non-genital injuries were found in 46% of the women examined (mostly minor) and genital injury in only 22%. Genital injury in the absence of non-genital injury was rare (3%). Independent risk factors for the detection of non-genital injuries were reported threats of violence (OR 5.7, 95% CI; 2.2-14.6). Risk factors for genital injury were the presence of non-genital injury (OR 19, 95% CI; 6.0-63.0), threats of violence (OR 3.7, 95% CI; 1.5-8.9) and being over the age of 40 years (OR 5.6, 95% CI; 1.6-20.3). If the alleged assailant was known to the woman this was protective for both non-genital (OR 0.3, 95% CI; 0.1-0.5) and genital (OR 0.4, 95% CI; 0.2-0.9) injury., Conclusions: The presence of genital injury should not be required to validate an allegation of sexual assault, particularly in the absence of non-genital injuries.

Meta-analyses of population-based molecular association studies have become increasingly common over the last 10 years, but little attention has been paid to methodology. In addition to the traditional considerations pertinent to any meta-analysis, there are genetic issues particular to molecular association studies: checking Hardy-Weinberg equilibrium, handling data from more than two groups while avoiding multiple comparisons, and pooling data in a way that is sensitive to genetic models. We systematically reviewed all meta-analyses of molecular association studies identified via MEDLINE. Of a total of 37 studies, eight (22%) described the search terms. Nineteen (51%) did not state inclusion or exclusion criteria. Heterogeneity was assessed in 28 (76%), but only 7 of 37 (19%) studies checked for publication bias. Nine (24%) studies assessed the goodness-of-fit of Hardy-Weinberg equilibrium, and eight (22%) gave any biological rationale to justify the choice of genetic model used for pooling. There is a need for greater communication between epidemiologists and geneticists to develop methods appropriate to this area.

Background: Family physicians (FPs) in Australia underutilize effective strategies to help patients stop smoking. We conducted a cluster randomization trial to evaluate a multifaceted, practice-based intervention involving audit, feedback, and academic detailing to improve FP smoking cessation advice., Methods: Sixty FPs in 39 practices participated. FPs' provision of smoking cessation advice was measured by patient recall, medical record audit, and FP self-report. Logistic regression analysis using generalized estimating equations was performed to assess improvements in practice, after adjustment for clustering by practice., Results: Improvements between baseline and posttest in patient recall of FP advice about nicotine replacement patches and gum were significantly greater in the intervention than in the control group (P = 0.0056 and P = 0.0002, respectively). While there were substantial increases in patient recall of assessment of smoking status and FP use of "quit dates," behavioral advice, and written materials in the intervention group, these changes were not significantly greater than those in the control group. Notation of patients' smoking status and smoking cessation advice in medical records remained suboptimal in both groups., Conclusions: This multifaceted intervention was successful only in promoting FPs' use of nicotine replacement therapy. While the use of other effective cessation strategies appeared to increase, a larger trial is needed for further evaluation.

Objectives: We have previously shown that photographs assist in detection of change in skin lesions and designed the present randomised population based trial to assess the feasibility of photographs as an aid to management of skin cancers in older men., Setting: 1899 men over fifty, identified from the electoral roll in two regions in New South Wales (NSW), Australia, were invited by mail to participate., Methods: A total of 973 of 1037 respondents were photographed and randomised into intervention (participants given their photographs) or control groups (photographs withheld by investigators). At one and two years from the time of photography, all participants were advised to see their primary care practitioner for a skin examination. Those in the intervention group were examined with their photographs and those in the control group without their photographs., Results: The results indicated that the practitioners were more likely to leave suspicious lesions in place for follow up observation (37% v 29%) (p=0.006) and less likely to excise benign non pigmented lesions (20 v 32%). There was little difference in excision rates for benign pigmented lesions (21% v 23%). Lesions excised were more likely to be non-melanoma skin cancer (58% v 42%) from patients who had photographs compared to those without photographs (p=0.005). The use of skin photography resulted in a substantial savings due to the reduced excision of benign lesions., Conclusions: These results suggest that it would be feasible to conduct a large scale randomised trial to evaluate the value of photography in early detection of melanoma and that such a trial could be cost effective due to the reduced excision of benign skin lesions.

Tuberculosis (TB) has made a comeback. It has become a resurgent public health problem in developing countries in the tropics and is the leading cause of death from any single infectious agent. Non-compliance to anti-tuberculosis treatment is the most serious problem in TB control. A cross-sectional study was conducted to investigate the determinants of poor compliance with anti-tuberculosis treatment among tuberculosis patients in Kota Bharu, Kelantan, Malaysia in 1999. A total of 390 patients were included in the study of which 130 were tuberculosis patients who defaulted treatment and 260 were those compliant to treatment. Data collection was done by interviewing the patients and collecting clinical and laboratory data from their medical records. Using multiple logistic regression analysis, patients who were not on direct observed therapy (DOT) lived distant to the health facility, were non-intravenous drug users (IVDU) and were HIV positive had statistically significant higher odds of being non-compliant. Patients should be given treatment under direct supervision with special attention to IVDU and HIV positive groups. Anti-TB treatment should be accessible to patients at the nearest health center from their residence. Interventions with health education programs emphasizing the benefits of treatment compliance should be implemented by further large-scale multicentered studies.

Objectives: To examine the benefits of a guideline-based educational program to improve management of unstable angina pectoris (UAP) in hospital patients., Design: Randomised controlled trial., Setting: 37 public hospitals across New South Wales., Patients: 1,872 patients admitted with a diagnosis of UAP between 1 February and 30 June 1996 (baseline survey), and 1,368 patients with the same diagnosis admitted between 1 July and 31 December 1998 (follow-up survey)., Intervention: Educational sessions run by local opinion leaders, presenting guidelines on management of UAP from the National Health and Medical Research Council and feedback on local practice using data from the baseline survey. Sessions were run between March and June 1998., Main Outcome Measures: Use of evidence-based practice, identified by review of medical records., Results: Use of beta-blockers increased in intervention and control hospitals, although the increase was significant only in the former. Use of calcium-channel blockers decreased significantly in both intervention and control hospitals. However, the change in drug use between baseline and follow-up did not differ significantly between intervention and control hospitals., Conclusions: Despite some appropriate changes in drug use for UAP management between 1996 and 1998, there was no evidence that a guideline-based educational program was of benefit in changing management. This reaffirms the difficulty of changing doctors' behaviour through practice guidelines. Alternative methods of encouraging evidence-based practice should be considered.

An observational cohort study examined the difference in use of cardiac procedures during and after hospital admission for acute chest pain in 47 metropolitan or non-metropolitan hospitals across New South Wales (NSW). There were 3836 patients, represented by 4151 admissions to hospital after acute myocardial infarction (AMI), unstable angina or other angina. Follow up at 22 months was completed on 1695 patients. Patients admitted to metropolitan hospitals had higher rates of most cardiac procedures while in-patients than did patients in non-metropolitan hospitals. Odds ratios (95% confidence intervals) for the use of exercise stress tests, echocardiograms, nuclear studies and coronary angiography were 3.30 (1.38, 7.90), 9.34 (4.07, 21.44), 4.87 (2.08, 11.39) and 68.64 (17.29, 272.49), respectively, for patients with AMI and 1.93 (0.91, 4.12), 5.60 (1.60, 19.57), 3.51 (1.48, 8.33) and 38.57 (9.36, 158.94), respectively, for patients with unstable angina. Rates were similar between hospital types during the 22 months after discharge. The appropriateness of this large variation in resource use between metropolitan and non-metropolitan hospitals requires examination.

Objective: To examine the acceptability of photography as an aid to skin examinations in men over 50 years of age., Methods: A randomised trial of men selected from the electoral roll. All participants were photographed, but only half received their photographs. Skin examinations by GPs at years one and two., Results: 55% of men consented to have photographs taken and 51% did so. 86% of respondents had risk factors for melanoma (compared to 68% of non-responders) and 47% had two or more risk factors (compared to 23% of non-responders). At year one, 91% of participants remaining in study regions had been examined. Photographs were lost by only six participants., Conclusions: Men over 50 years of age respond to personalised health messages about melanoma and respondents include a high proportion of males with risk factors for melanoma., Implications: These initial results suggest that photography may be a logistically acceptable approach for assisting in the early detection of melanoma.

Objective: To determine whether a screening recruitment strategy for first degree relatives of people with colorectal cancer is effective in enabling eligible relatives to request screening from their general practitioner (GP) and to assess acceptability to GPs and patients., Methods: Thirty GPs, from 26 practices, and 303 of their patients aged over 50 who were first degree relatives of a person with colorectal cancer, participated in a randomised controlled trial of a GP-based recruitment strategy, in the Newcastle Area of New South Wales, Australia., Results: The proportion of relatives requesting screening was statistically significantly higher in the intervention group than in the control group (18% compared to 4%, respectively; p = 0.01)., Conclusions: Interest in the study by GPs was low, however for GPs who were involved, the recruitment strategy did prompt first degree relatives to discuss screening. The strategy may be even more effective when combined with other interventions such as a media campaign. The results may be generalizable to feasibility studies of general population screening for colorectal cancer in Australia., Implications: The results of this work are potentially informative to public health practice in Australia given the ensuing pilot programs of colorectal cancer screening.

Objectives: To compare outcomes one year after hospital admission for patients initially discharged with a diagnosis of acute myocardial infarction (AMI), other ischaemic heart disease (other IHD), congestive heart failure (CHF) or stroke., Design: Cohort study., Setting: Hunter Area Heart and Stroke Register, which registers all patients admitted with heart disease or stroke to any of the 22 hospitals in the Hunter Area Health Service in New South Wales., Patients: 4981 patients with AMI, other IHD, CHF or stroke admitted to hospital as an emergency between 1 July 1995 and 30 June 1997 and followed for at least one year., Main Outcome Measures: Death from any cause or emergency hospital readmission for cardiovascular disease., Results: In-hospital mortality varied from 1% of those with other IHD to 22% of those with stroke. Almost a third of all patients discharged alive (and 38% of those aged 70 or more) had died or been readmitted within one year. This varied from 22% of those with stroke to 49% of those with CHF. The causes of death and readmission were from a spectrum of cardiovascular disease, regardless of the cause of the original hospital admission., Conclusions: Data from this population register show the poor outcome, especially with increasing age, among patients admitted to hospital with cardiovascular disease. This should alert us to determine whether optimal secondary prevention strategies are being adopted among such patients.

Objective: To examine whether presentation of older people with thick melanoma is a result of the site and histological type or of their reduced ability to identify melanoma., Design and Setting: Retrospective analysis of the Newcastle Melanoma Unit patient database., Patients: 2154 patients with melanoma for whom complete data (histological type, thickness and site of melanoma) were available and who presented from February 1981 to April 1997., Main Outcome Measures: Histological type and site of melanoma in older (> or = 50 years) versus younger men and women; frequency with which these groups identified melanoma and the first changes of melanoma that were noticed., Results: Patients aged > or = 50 years, particularly men, were more likely to present with thicker lesions. Older men and, to a lesser extent, older women were more likely to present with nodular melanoma, which were more frequent on the scalp and face in older, compared with younger, men, and scalp and back in older men compared with older women. Failure to identify melanoma was associated with older age, sites on the scalp and back and histological type of the lesion, but was independent of sex once histological type, age, site and thickness were taken into account. Multivariate analysis indicated that the association of older age of patients with failure to identify melanoma applied irrespective of the site, type and thickness of their melanoma., Conclusion: The higher frequency of thick melanoma in older people is accounted for by an increased proportion of nodular melanoma and decreased ability to recognise the changes of melanoma. These findings have important implications for examination of older patients by doctors and for design of strategies for early detection of melanoma in this age group.

Objectives: To examine whether older people were less able to distinguish changes of melanoma than younger people, and to test whether an educational brochure illustrating changes of melanoma would increase their ability to detect the changes., Design: Photographic images of pigmented skin lesions were altered using computer graphics software. Images of typical changes of melanoma were shown to groups of volunteers younger than 30 years (n = 52) and older than 45 years (n = 41). Short intervals (seconds) between viewing of the original and changed lesions were used to test ability to distinguish the changes, and longer intervals (29 and 60 days) were used to test their ability over more realistic intervals. All participants were randomized to receive an educational brochure (designed using the same technology) to evaluate whether this would assist in identifying early changes of melanoma., Setting: A cross section of volunteers employed in a large semigovernment utility., Intervention: An educational brochure that illustrated typical changes of melanoma., Main Outcome Measure: Score of correct or incorrect detection of changed or unchanged skin lesions., Results: Tests at short intervals showed that both age groups were able to detect early changes of melanoma but had poor ability to detect changes of melanoma at longer intervals. Repeated viewing of the original lesions enabled the participants to once more recognize the changes. Both groups had low ability to detect the appearance of new pigmented lesions. The educational brochure improved the ability of participants to detect change., Conclusions: The main difficulty people have in self-detection of melanoma is limited ability to recall the appearance of their skin. This ability did not differ between the age groups. Educational material that focused on change was effective in increasing the ability to detect changes over short intervals. Photographic records may be the most effective aid for detection of changes at longer intervals.

We conducted a randomised trial to determine the differential effectiveness of a telephone prompt by a medical researcher compared with a nonmedical research assistant in improving response rates of general practitioners to a survey and to compare personnel costs. A national random sample of Australian general practitioners was allocated randomly to two intervention groups. In advance of a self-administered questionnaire, Group A (n = 184) received a telephone prompt by a medical researcher and Group B (n = 189) a prompt by an experienced nonmedical research assistant. Other aspects of survey administration were identical for both groups. The five-month cumulative response rate obtained by the medical researcher (81 per cent) was not significantly different from that of 72 percent obtained by the research assistant (chi 2 = 3.3, 1 df, P = 0.07). For Group A, 279 telephone calls, consuming 23 hours 15 minutes, were made. Group B required more calls (384) and more time (32 hours). Using the relevant award pay scales, the estimated personnel costs for each group were $631 and $601 respectively. We conclude that an experienced nonmedical research assistant is as effective as a medical practitioner in administering telephone prompts to enhance survey response rates, although savings are not necessarily made.

Background: An opportunistic reminder for a Pap smear is effective and acceptable in general practice. Women's views of strategies to promote ongoing attendance for Pap smears were unknown at the time of this study., Objective: To determine women's perceptions of strategies to help them attend for their next Pap smear., Setting and Patients: Randomly selected male general practitioners in urban Sydney and 174 of their female patients., Results: Seventy-eight per cent response rate to a questionnaire sent after a consultation in which opportunistic screening was offered. A reminder letter from the GP was nominated as likely to help 'a lot' by at least 50 per cent of respondents. Free Pap smears and child-minding were nominated by at least 50 per cent of respondents as making 'no difference'., Conclusion: This survey has explored women's perceptions of potential strategies to promote continuing Pap smear screening. Given the disappointing results when these strategies have been implemented in individual general practices, however, the authors recommend prospective controlled evaluation before widespread adoption.