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There is growing evidence that health and social outcomes following motor vehicle crash injury are related to cognitive and emotional responses of the injured individual, as well as relationships between the injured individual and the compensation systems with which they interact. As most of this evidence comes from other states in Australia or overseas, investigation is therefore warranted to identify the key determinants of health and social outcomes following injury in the context of the New South Wales motor accident insurance scheme. In this inception cohort study, 2400 participants, aged 17 years or more, injured in a motor vehicle crash in New South Wales will be identified though hospital emergency departments, general and physiotherapy practitioners, police records and a government insurance regulator database. Participants will be initially contacted through mail. Baseline interviews will be conducted by telephone within 28 days of the injury and participants will be followed up with interviews at 6, 12 and 24 months post-injury. Health insurance and pharmaceutical prescription data will also be collected. The study results will report short and long term health and social outcomes in the study sample. Identification of factors associated with health and social outcomes following injury, including related compensation factors will provide evidence for improved service delivery, post-injury management, and inform policy development and reforms. Australia New Zealand Clinical trial registry identification number - ACTRN12613000889752 . Available at: ANZCTR Registered FISH Study.

Self-rated health and health-related quality of life are inversely associated with increased morbidity and mortality; however, the temporal relationship with reproductive hormones is poorly understood.The objective of the study was to examine relationships between reproductive hormones, self-rated health, and quality of life in older men at baseline as well as changes over a 2-year follow-up.One thousand six hundred thirty-seven men aged 70 years and older from the Concord Health and Ageing in Men Project were assessed at baseline and 1316 men returned for the 2-year follow-up. Serum T, dihydrotestosterone, estradiol, and estrone (E1) were measured by liquid chromatography-tandem mass spectrometry and SHBG, LH, and FSH by immunoassay. Logistic regression and multivariate linear regression models were performed.Self-rated health and health-related quality of life measures (12-Item Short Form Health Survey) were determined.In the cross-sectional baseline data, univariate analyses revealed significant associations between many of the hormones and quality-of-life scores and self-rated health. In a multivariable analysis, the associations between T, E1, and calculated free T and self-rated health remained statistically significant. Compared with men in the highest T quartile, men in the lowest T quartile had an odds ratio of 1.47 (95% confidence interval 1.04-2.06) for reporting fair, poor, or very poor health vs excellent or good health. The findings for E1 and calculated free T were similar. In the longitudinal data, the only significant relationship was that between E1 and self-rated health. Compared with those in the highest E1 quartile, those in the lowest quartile experienced deterioration in self-rated health: adjusted odds ratio of 1.84 (95% confidence interval 1.10-3.06).Low serum T and E1 are associated with poorer self-rated health in older men, whereas lower serum levels of E1 are predictive of subsequent deterioration in self-rated health over time. Therefore, serum E1 is a novel potential risk factor for poor self-rated health in older men that warrants further investigation.

To describe the prevalence and correlates of alcohol consumption and tobacco smoking among older Australian men.Self-reported alcohol and tobacco use was assessed among a random sample of community-dwelling men aged ≥70 years living in Sydney (n = 1705) from 2005 to 2007. Logistic regression was used to compute odds ratios (ORs) and 95% confidence intervals (CIs) for factors associated with alcohol and tobacco use.The prevalence of heavy/excessive drinking was 19.2%, daily drinking 33.7%, and binge drinking 14.1%. Daily drinking was associated with chronic pain (OR = 1.38, 95% CI: 1.07-1.78). Binge drinking was associated with anxiety (OR = 1.93, 95% CI: 1.05-3.54) and being widowed (OR = 1.74, 95% CI: 1.11-2.73). Six per cent of men were current smokers and 56.7% were former smokers. Former smoking was associated with polypharmacy (OR = 1.47, 95% CI: 1.14-1.91) and each additional comorbid condition (OR = 1.11, 95% CI: 1.03-1.19).Nearly one-fifth of older men drank heavily or excessively. This highlights the need for public health initiatives to reduce alcohol consumption in older people.

This study reports chronic pain prevalence in a randomly selected sample of the adult Australian population. Data were collected by Computer-Assisted Telephone Interview (CATI) using randomly generated telephone numbers and a two-stage stratified sample design. Chronic pain was defined as pain experienced every day for three months in the six months prior to interview. There were 17,543 completed interviews (response rate=70.8%). Chronic pain was reported by 17.1% of males and 20.0% of females. For males, prevalence peaked at 27.0% in the 65--69 year age group and for females, prevalence peaked at 31.0% in the oldest age group (80--84 years). Having chronic pain was significantly associated with older age, female gender, lower levels of completed education, and not having private health insurance; it was also strongly associated with receiving a disability benefit (adjusted OR=3.89, P

Background: chronic knee pain is still considered a fairly benign disease by many, an ‘unavoidable’ consequence of ageing. This passive acceptance may be unnecessarily exposing older people to disability and serious co-morbidity. The aim of this study was to determine the disease burden associated with chronic knee pain and the role of knee extensor strength as a modifiable risk factor. Methods: a longitudinal cohort study with 2-year follow-up conducted among 1,587 community-dwelling men aged 70 years and over, 637 (40%) reported chronic knee pain. Of the 950 (60%) men without knee pain at baseline, 768 (81%) returned for the follow-up assessment with 150 (20%) reporting incident chronic knee pain. Results: knee pain was significantly associated with marked mobility disability [odds ratio (OR) 2.38; 95% confidence interval (CI) 1.74–3.29], falls (OR: 1.31; 95% CI: 1.01–1.70) and having four or more co-morbidity (OR: 1.63; 95% CI: 1.16–2.30) as well as reduced knee extensor strength and mass (dual X-ray absorptiometry). Men with incident knee pain at the 2-year follow-up assessment demonstrated greater increases in these measures of disease burden and greater decreases in muscle strength and mass, compared with those without incident chronic knee pain. Obesity, high co-morbidity burden, back pain, higher levels of physical activity or low knee extensor strength were all significant risk factors for incident knee pain. Conclusion: prevention of chronic knee pain may reduce a considerable burden of mobility disability and increased risk of serious co-morbidity among older men.

The interest in health outcomes has increased substantially as both the effectiveness and cost of care have increased. Others commenting on the history of the health outcomes movement%ve drawn att&&n to both these factors together with the growing concern, in relation to both cost and effectiveness, on the part of third party payers for health care. In an age where accountability has found a prominent place in the health service discourse, efforts in relation to the definition and measurement of outcomes have, understandably, intensified. It is important to recognise the origin of interest in outcomes because a common counter-argument is put by clinicians who claim ‘we have always been concerned with outcomes, and anyway, randomised controlled trials are the only method by which you can be entirely sure about an outcome -and they are our property’. Without disputing either their perennial interest in outcomes or their commitment (reasonably recently founded) to RCTs, it is possible to see outcomes from the perspective of the administrator/manager or third party payer in a rather different light. The interest in health outcomes, from within the health-care system itself, is much more focussed on what happens in routine practice than in what happens among the selected few included in an RCT. This includes, for example, what happens to women who, having developed breast cancer, enter and exit the health-care system-in terms of survival, yes, but also in terms of their quality of life, the adequacy and standard of care given to them, the choices that were made available on the basis of evidence in making therapeutic decisions, the support they

The aim of this population-based, prospective, observational study was to examine the relationship between serum levels of 25-hydroxyvitamin D (25OHD) and fracture risk in a cohort of 1662 community-dwelling men aged 70 to 97 years followed for a mean of 4.3 years. Data about mobility, muscle strength, balance, medication use, cognition, medical history, lifestyle factors, renal function, and serum 25OHD were collected at baseline. Data on radiologically verified fractures were collected every 4 months. The relationship between fractures and serum 25OHD levels was analyzed using Cox's proportional hazard regression. We accounted for bone mineral density, falls, physical activity, sun exposure, and season of blood draw, in addition to anthropometric and lifestyle factors, medical history, muscle strength, balance, and medication and supplement use. There were 123 first-incident fragility fractures. The relationship between baseline 25OHD and fracture risk was U-shaped, with increased fracture risk in men with either low or high serum 25OHD levels. In multivariate analysis, the risk of fracture was greatest in men with 25OHD levels in the lowest quintile (25OHD ≤36 nmol/L; hazard ratio [HR] = 3.5; 95% confidence interval [CI] 1.7-7.0) and in men in the highest quintile (25OHD72 nmol/L; HR = 2.7; 95% CI 1.4-5.4) compared with men in the 4th quintile (25OHD ≥60 to ≤72 nmol/L). These associations were not explained by lower BMD, increased physical activity, fall risk, or other lifestyle or anthropomorphic factors. In community-dwelling older men, there appears to be a healthy target range for serum 25OHD concentrations. Thus, serum 25OHD levels too high and too low may be harmful in regard to fracture risk.

Background: participation restriction, defined as ‘problems an individual may experience in involvement in life situations’ (e.g. work and leisure), reflects difficulty functioning at a societal level and is a key component of disability. Our objective was to describe changes in participation in older men over a 2-year period and to identify baseline variables associated with participation and change in participation over the 2-year period. Methods: one thousand and three hundred and twenty-seven community-dwelling men aged 70 years or over who completed the baseline and 2-year follow-up phases of the Concord Health and Ageing in Men Project, a population-based cohort study in Sydney, Australia, were studied. Participation restriction and a range of other variables were measured using self-report and performance measures. Regression analyses were conducted to examine factors associated with participation and change in participation. Results: over the 2-year period, participation in life roles deteriorated in 47.3% (627/1,327) of men, stayed the same in 20.7% (275/ 1,327) and improved in the remainder (32.0%). Overall, there was a significant deterioration in participation (P< 0.001). Reduced participation at 2-year follow-up was significantly associated with the following baseline factors: age, more comorbidities, mild cognitive impairment or dementia, lower mood, weakness, slower gait, worse activities of daily living performance, driving and baseline participation score. These variables explained 56% of the variance in participation at 2 years. Conclusion: participation in life roles worsened over a 2-year period in some community-dwelling older men. A number of associated factors were identified, which may provide targets for intervention to improve participation among older men.

Objectives The rate of total knee arthroplasty surgery (TKA) is rising in Australia despite varying impacts of TKA on physical function (PF) in population-based studies. There are potentially modifiable risk factors that could enhance PF after TKA, so we evaluated (1) the levels of PF in persons with TKA and the rest of the population, (2) potentially modifiable characteristics of those reporting poor PF after TKA. Design Nested case–control study. Setting Population-based cohort study in New South Wales, Australia. Participants Members of a large (n=267 151) cohort study recruited by a self-completed, mailed questionnaire from 2006 to 2008. After exclusions (for hip arthroplasty, partial TKA, missing important variables and mismatching TKA status between self-reported and hospital record data), this study included 205 148 participants. Primary and secondary outcomes Primary outcome, Medical Outcomes Study Physical Function scale (MOS-PF). Secondary outcome, dispensings of analgesics or anti-inflammatory drugs. Results We found 2916 TKA participants and 202 232 participants with no TKA (confirmed across datasets). Persons with TKA had a lower MOS-PF (59.9, 95% CI 58.5 to 60.6) than those without TKA (83.8, 95% CI 83.7 to 83.9). In the matched analysis, the TKA group had a lower MOS-PF (59.9, 95% CI 59.9 to 62.4) than those without TKA (68.4, 95% CI 67.8 to 69.0). In persons with TKA, lower levels of MOS-PF were associated with low self-rated health, high psychological distress, comorbidity, greater age, recent treatment for osteoarthritis and use of paracetamol. Women had an MOS-PF that was 11.6 points (95% CI 9.5 to 13.8) lower than men. Conclusions Several modifiable risk factors have been identified to influence PF in persons receiving TKA, with notable differences between sexes. The importance of these risk factors should be examined in incident TKA to test if early identification and intervention for individuals can improve outcomes.

Objective The aim of this analysis was to investigate the relationship of statins with institutionalisation and death in older men living in the community, accounting for frailty. Design Prospective cohort study. Setting Community-dwelling men participating in the Concord Health and Ageing in Men Project, Sydney, Australia. Participants Men aged ≥70 years (n=1665). Measurements Data collected during baseline assessments and follow-up (maximum of 6.79 years) were obtained. Information regarding statin use was captured at baseline, between 2005 and 2007. Proportional hazards regression analysis was conducted to estimate the risk of institutionalisation and death according to statin use (exposure, duration and dose) and frailty status, with adjustment for sociodemographics, medical diagnosis and other clinically relevant factors. A secondary analysis used propensity score matching to replicate covariate adjustment in regression models. Results At baseline, 43% of participants reported taking statins. Over 6.79 years of follow-up, 132 (7.9%) participants were institutionalised and 358 (21.5%) participants had died. In the adjusted models, baseline statin use was not statistically associated with increased risk of institutionalisation (HR=1.60; 95% CI 0.98 to 2.63) or death (HR=0.88; 95% CI 0.66 to 1.18). There was no significant association between duration and dose of statins used with either outcome. Propensity scoring yielded similar findings. Compared with non-frail participants not prescribed statins, the adjusted HR for institutionalisation for non-frail participants prescribed statins was 1.43 (95% CI 0.81 to 2.51); for frail participants not prescribed statins, it was 2.07 (95% CI 1.11 to 3.86) and for frail participants prescribed statins, it was 4.34 (95% CI 2.02 to 9.33). Conclusions These data suggest a lack of significant association between statin use and institutionalisation or death in older men. These findings call for real-world trials specifically designed for frail older people to examine the impact of statins on clinical outcomes.

OBJECTIVES: This study investigates utilisation patterns for prescription opioid analgesics in the Australian community and how these are associated with a framework of individual-level factors related to healthcare use. METHODS: Self-reported demographic and health information from participants in the 45 and Up Study cohort were linked to pharmaceutical claims from 2006-2009. Participants comprised 19,816 people with ≥1 opioid analgesic dispensing in the 12-months after recruitment to the cohort and 79,882 people not dispensed opioid analgesics. All participants were aged ≥45 years, were social security pharmaceutical beneficiaries, with no history of cancer. People dispensed opioid analgesics were classified as having acute (dispensing period

Introduction: Potentially preventable hospitalisation (PPH) has been adopted widely by international health systems as an indicator of the accessibility and overall effectiveness of primary care. The Assessing Preventable Hospitalisation InDicators (APHID) study will validate PPH as a measure of health system performance in Australia and Scotland. APHID will be the first large-scale study internationally to explore longitudinal relationships between primary care and PPH using detailed person-level information about health risk factors, health status and health service use. Methods and analysis: APHID will create a new longitudinal data resource by linking together data from a large-scale cohort study (the 45 and Up Study) and prospective administrative data relating to use of general practitioner (GP) services, dispensing of pharmaceuticals, emergency department presentations, hospital admissions and deaths. We will use these linked person-level data to explore relationships between frequency, volume, nature and costs of primary care services, hospital admissions for PPH diagnoses, and health outcomes, and factors that confound and mediate these relationships. Using multilevel modelling techniques, we will quantify the contributions of person-level, geographic-level and service-level factors to variation in PPH rates, including socioeconomic status, country of birth, geographic remoteness, physical and mental health status, availability of GP and other services, and hospital characteristics. Ethics and dissemination: Participants have consented to use of their questionnaire data and to data linkage. Ethical approval has been obtained for the study. Dissemination mechanisms include engagement of policy stakeholders through a reference group and policy forum, and production of summary reports for policy audiences in parallel with the scientific papers from the study.

Background Available evidence suggests that smokers have a lower propensity than others to use primary care services. But previous studies have incorporated only limited adjustment for confounding and mediating factors such as income, access to services and health status. We used data from a large prospective cohort study (the 45 and Up Study), linked to administrative claims data, to quantify the relationship between smoking status and use of primary care services, including specific preventive services, in a contemporary Australian population. Methods Baseline questionnaire data from the 45 and Up Study were linked to administrative claims (Medicare) data for the 12-month period following study entry. The main outcome measures were Medicare benefit claimed for unreferred services, out-of-pocket costs (OOPC) paid, and claims for specific preventive services (immunisations, health assessments, chronic disease management services, PSA tests and Pap smears). Rate ratios with 95% confidence intervals were estimated using a hierarchical series of models, adjusted for predisposing, access- and health-related factors. Separate hurdle (two part) regression models were constructed for Medicare benefit and OOPC. Poisson models with robust error variance were used to model use of each specific preventive service. Results Participants included 254,382 people aged 45 years and over of whom 7.3% were current smokers. After adjustment for predisposing, access- and health-related factors, current smokers were very slightly less likely to have claimed Medicare benefit than never smokers. Among those who claimed benefit, current smokers claimed similar total benefit, but recent quitters claimed significantly greater benefit, compared to never-smokers. Current smokers were around 10% less likely than never smokers to have paid any OOPC. Current smokers were 15-20% less likely than never smokers to use immunisations, Pap smears and prostate specific antigen tests. Conclusions Current smokers were less likely than others to use primary care services that incurred out of pocket costs, and specific preventive services. This was independent of a wide range of predisposing, access- and health-related factors, suggesting that smokers have a lower propensity to seek health care. Smokers may be missing out on preventive services from which they would differentially benefit.

Although pediatric functional abdominal pain (FAP) has been linked to abdominal pain later in life, childhood predictors of long-term outcomes have not been identified. This study evaluated whether distinct FAP profiles based on patterns of pain and adaptation in childhood could be identified and whether these profiles predicted differences in clinical outcomes and central sensitization (wind-up) on average 9 years later. In 843 pediatric FAP patients, cluster analysis was used to identify subgroups at initial FAP evaluation based on profiles of pain severity, gastrointestinal (GI) and non-GI symptoms, pain threat appraisal, pain coping efficacy, catastrophizing, negative affect, and activity impairment. Three profiles were identified: High Pain Dysfunctional, High Pain Adaptive, and Low Pain Adaptive. Logistic regression analyses controlling for age and sex showed that, compared to pediatric patients with the Low Pain Adaptive profile, those with the High Pain Dysfunctional profile were significantly more likely at long-term follow-up to meet criteria for pain-related functional gastrointestinal disorder (FGID) (OR: 3.45; CI: 1.95–6.11), FGID with comorbid non-abdominal chronic pain (OR: 2.6; CI:1.45–4.66), and FGID with comorbid anxiety or depressive psychiatric disorder (OR: 2.84; CI: 1.35–6.00). Pediatric patients with the High Pain Adaptive profile had baseline pain severity comparable to the High Pain Dysfunctional profile, but had outcomes as favorable as the Low Pain Adaptive profile. In laboratory pain testing at follow-up, High Pain Dysfunctional patients exhibited significantly greater thermal wind-up than Low Pain Adaptive patients, suggesting that a subgroup of FAP patients has outcomes consistent with widespread effects of heightened central sensitization.

To explore the association between psychotropic drug use and alcohol drinking in community-dwelling older Australian men.We conducted a cross-sectional population-based study using baseline data collected between 2005 and 2007 from 1705 participants in the Concord Health and Ageing in Men Project (CHAMP) conducted in Sydney, Australia. All participants were men aged ≥70 years. The prevalence of antidepressant and sedative or anxiolytic drug use was ascertained at clinical examinations and alcohol drinking was self-reported. Logistic regression models were used to compute the unadjusted and adjusted prevalence ratios and 95% confidence intervals for the association between sedative or anxiolytic use and antidepressant use with drinking patterns.In the study sample, 8.0% used an antidepressant, 5.7% used a sedative or anxiolytic, 33.7% were daily drinkers, 13.9% were binge drinkers, 19.2% were heavy drinkers and 11.0% were problem drinkers. Overall, 27.1% of antidepressant users were daily drinkers and 42.7% of sedative or anxiolytic users were daily drinkers. Sedative or anxiolytic use was associated with daily drinking (prevalence ratio = 1.42; 95% confidence intervals 1.09-1.76) but not with other drinking patterns. The associations between antidepressant use and alcohol drinking were not statistically significant.Potential psychotropic drug-alcohol interactions were common in older Australian men. Users of sedative or anxiolytic drugs were more likely to engage in daily drinking compared with non-users of sedative or anxiolytic drugs. Clinicians should monitor patients prescribed sedative or anxiolytic drugs for possible adverse events arising from concomitant use with alcohol.

We aimed to assess the relationship between Drug Burden Index (DBI), a risk assessment tool that measures anticholinergic and sedative medication exposure and cognitive performance, and cognitive impairment in older people. The study population consisted of community-dwelling older men, 70 years or older, living in Sydney, Australia. The Addenbrooke's Cognitive Examination (ACE) and the Trail Making Task (TMT) cognitive tests were performed, and participants were categorized as having intact cognition, mild cognitive impairment, or dementia using clinical diagnostic criteria. The analyses were restricted to participants with English-speaking background (n = 987) and to the subgroup whose cognition was intact (n = 887). In the study group, DBI exposure was not associated with poorer performance on the ACE (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.66-1.47) or the TMT (OR, 0.71; 95% CI, 0.40-1.24) tests, after controlling for covariates. Similarly, DBI exposure was not associated with cognitive impairment (OR, 1.34; 95% CI, 0.83-2.16). There was no association between increasing DBI scores and poorer performance on any of the outcomes. On subgroup analysis of cognitively intact subgroup, DBI exposure or increasing DBI scores were not associated with poorer performance on the ACE or the TMT tests. In this study of community-dwelling older men, DBI was not associated with limitations on objective cognitive performance measures or with a clinical diagnosis of mild cognitive impairment or dementia.

BACKGROUND: Quantification of the disease burden caused by different risks informs prevention by providing an account of health loss different to that provided by a disease-by-disease analysis. No complete revision of global disease burden caused by risk factors has been done since a comparative risk assessment in 2000, and no previous analysis has assessed changes in burden attributable to risk factors over time. METHODS: We estimated deaths and disability-adjusted life years (DALYs; sum of years lived with disability [YLD] and years of life lost [YLL]) attributable to the independent effects of 67 risk factors and clusters of risk factors for 21 regions in 1990 and 2010. We estimated exposure distributions for each year, region, sex, and age group, and relative risks per unit of exposure by systematically reviewing and synthesising published and unpublished data. We used these estimates, together with estimates of cause-specific deaths and DALYs from the Global Burden of Disease Study 2010, to calculate the burden attributable to each risk factor exposure compared with the theoretical-minimum-risk exposure. We incorporated uncertainty in disease burden, relative risks, and exposures into our estimates of attributable burden. FINDINGS: In 2010, the three leading risk factors for global disease burden were high blood pressure (7·0% [95% uncertainty interval 6·2-7·7] of global DALYs), tobacco smoking including second-hand smoke (6·3% [5·5-7·0]), and alcohol use (5·5% [5·0-5·9]). In 1990, the leading risks were childhood underweight (7·9% [6·8-9·4]), household air pollution from solid fuels (HAP; 7·0% [5·6-8·3]), and tobacco smoking including second-hand smoke (6·1% [5·4-6·8]). Dietary risk factors and physical inactivity collectively accounted for 10·0% (95% UI 9·2-10·8) of global DALYs in 2010, with the most prominent dietary risks being diets low in fruits and those high in sodium. Several risks that primarily affect childhood communicable diseases, including unimproved water and sanitation and childhood micronutrient deficiencies, fell in rank between 1990 and 2010, with unimproved water and sanitation accounting for 0·9% (0·4-1·6) of global DALYs in 2010. However, in most of sub-Saharan Africa childhood underweight, HAP, and non-exclusive and discontinued breastfeeding were the leading risks in 2010, while HAP was the leading risk in south Asia. The leading risk factor in Eastern Europe, most of Latin America, and southern sub-Saharan Africa in 2010 was alcohol use; in most of Asia, North Africa and Middle East, and central Europe it was high blood pressure. Despite declines, tobacco smoking including second-hand smoke remained the leading risk in high-income north America and western Europe. High body-mass index has increased globally and it is the leading risk in Australasia and southern Latin America, and also ranks high in other high-income regions, North Africa and Middle East, and Oceania. INTERPRETATION: Worldwide, the contribution of different risk factors to disease burden has changed substantially, with a shift away from risks for communicable diseases in children towards those for non-communicable diseases in adults. These changes are related to the ageing population, decreased mortality among children younger than 5 years, changes in cause-of-death composition, and changes in risk factor exposures. New evidence has led to changes in the magnitude of key risks including unimproved water and sanitation, vitamin A and zinc deficiencies, and ambient particulate matter pollution. The extent to which the epidemiological shift has occurred and what the leading risks currently are varies greatly across regions. In much of sub-Saharan Africa, the leading risks are still those associated with poverty and those that affect children. FUNDING: Bill and Melinda Gates Foundation.

The aim of this cross-sectional study was to investigate the association between sedative load and functional outcomes in community-dwelling older Australian men. A total of 1696 males aged 70 years, enrolled in the Concord Health and Ageing in Men Project, were studied. Participants underwent assessments during 2005-2007. Sedative load was computed using a published model. Outcomes included activities of daily living (ADL), instrumental activities of daily living (IADL), physical performance measures and a clinical diagnosis of cognitive impairment. Of the participants, 15.3% took medications with sedative properties. After adjusting for age, education, depressive symptoms and comorbidities, participants who took one medication with sedation as a prominent side effect (sedative load = 1) had odds ratio (OR) of 2.15 (95% confidence interval, CI: 1.20-3.85) for ADL disability, compared with participants with sedative load = 0. Participants who took at least one primary sedative or two medications with sedation as a prominent side effect (sedative load 2) had an OR of 1.55 (95% CI: 1.02-2.35) for IADL disability, compared with participants with sedative load = 0. The mean 6-m walking speed (P = 0.001) and grip strength (P = 0.003) were significantly different between sedative load groups in unadjusted models only. No association between sedative load and poorer performance on balance and chair stands tests or cognitive impairment was observed. Participants with sedative load of one were more likely to report ADL disability, whereas participants with sedative load of 2 were more likely to report IADL disability. Higher sedative load was not associated with poorer physical performance or cognitive impairment in older Australian men. Refereed/Peer-reviewed

In this essay, we describe two recent developments in global public health efforts in the chronic pain field and use the example of musculoskeletal pain to explore some of the implications arising from these developments. The first is the recognition of chronic pain as a condition in its own right, which has been the impetus for several national and one recent international pain summits that have translated that into a call for recognition, rights and resources for people with pain. The other development is the first comprehensive attempt to measure the global burden of musculoskeletal conditions in the current round of the Global Burden of Diseases, Injuries and Risk Factors Study (GBD 2010). In essence, the task here has been to translate epidemiological data from all countries where data are available into standardised measures of the overall burden of musculoskeletal conditions to allow comparison of the burden relative to other conditions, and to identify the proportion of the burden that is attributable to a set of common risk factors. Past rounds of the GBD have been influential in priority setting and allocation of health funding by the World Health Organisation and national governments. The current GBD 2010 Study is occurring in the context of changes in thinking about how to fund health care in a global context. These changes are away from disease-specific programmes to more ‘integrated’ approaches, and thus represent a potential challenge to the calls to consider pain-focussed funding. We explore the strategic implications of both of these developments for translating our better understanding of the problem of musculoskeletal pain into effective policy action.

The study of the descriptive epidemiology of chronic widespread pain (CWP) in several countries is of interest, as the occurrence of this condition varies among different populations. However, reports of pain prevalence are not consensual: it is clear that chronic musculoskeletal pain is frequent all over the world, varying from 4.2% to 13.3%. The reasons for the prevalence differences in CWP might include genetic and/or environmental factors. Multifactorial aetiopathogenesis of CWP and fibromyalgia syndrome (FMS) certainly includes genetic susceptibility and environmental influences. The risk factors for the occurrence and maintenance of CWP/FMS include female gender, increasing age, family history of chronic pain, several causes of distress, obesity and poorest mental and/or physical status. On the other hand, risk factors that negatively influence the outcome of CWP/FMS are: high levels of psychological distress, presence of somatisation, presence of fatigue, poor sleep, higher number of painful sites and pain intensity, poorest mental status and functional capacity, presence of co-morbid conditions and highest number of primary-care consultations. Mild alcohol consumption and individualised social support seem to have a protective effect on the outcome of CWP/FMS.

Weight loss is associated with bone loss; however, it is unclear whether loss of fat or loss of lean body mass plays the key role in this relationship. The aim of this longitudinal analysis was to clarify the relationship between hip BMD, hip BMC and whole body BMC with changes in fat and lean tissue mass in older men.The Concord Health and Aging in Men Project (CHAMP) is a population-based study in Sydney, Australia, involving 1705 men aged 70-97 years. Bone mineral density (BMD) of the total hip, and bone mineral content (BMC) of the hip and whole body (WB), lean mass and fat mass were measured with Dual X-ray Absorptiometry (DXA). Multivariate linear regression models were used to assess relationships.Over 2.2 years of follow-up, 368(33%) men lost at least 2% of their body weight, which included a mean loss of 0.8 kg/year of lean body mass and 0.9 kg/year of fat body mass. Fat loss was strongly associated with BMD loss in men who lost weight. As a group, weight losers lost 1.0% of hip BMD annually compared to 0.2% in men who gained weight, with each kilo of fat loss associated with 0.6%/year hip BMD loss (p0.0001). Lean mass was not associated with hip BMD loss in weight losers, however, lean mass change was associated with BMD change in men who gained weight (0.3% hip BMD increase per kilo increase of lean mass p0.01).Maintaining body weight is important for bone health in elderly men. Body fat plays an important role in this relationship, which may reflect the additional metabolic function of adipose tissue.

Serum uric acid (UA) is a strong endogenous antioxidant. Since oxidative stress has been linked to osteoporosis, we examined the association between serum UA levels and bone mineral density (BMD), prevalent vertebral and nonvertebral fractures, and laboratory measures such as calcitropic hormones and bone turnover marker levels. This cross-sectional analysis consisted of 1705 community-dwelling men aged 70 years or over who participated in the baseline part of the Concord Health and Ageing in Men Project (CHAMP), a population-based study of older men in Sydney, Australia. BMD at all sites was significantly higher among men with serum UA levels above the group median than among men with UA levels below the median. In multiple regression analyses adjusted for potential confounders, serum UA remained associated with BMD at all sites (β = 0.12 to 0.14, p

Objectives To provide estimates of the numbers of New South Wales children in Family Day Care who may be exposed to environmental tobacco smoke while attending day care; to describe existing smoking policies; and to analyse these policies with the aim of providing guidelines for smoking policy in Family Day Care. Setting All 109 Family Day Care schemes in NSW. Method Scheme coordinators were sent a questionnaire regarding the proportion of carers who smoked while caring for children; the nature, enforcement and experience of smoking policies; and barriers to implementation of a no-smoking policy. Results A mean of 10% of Family Day Care caregivers were reported to smoke while caring for children (range, 0-60%). An estimated 2045 children were potentially exposed to environmental tobacco smoke in the 86 schemes which provided this information. Thirty-five per cent of schemes had formal no-smoking policies. A range of advantages, disadvantages and perceived practical and legal barriers to implementation of a no-smoking policy in Family Day Care were described. Forty-four per cent of schemes with no-smoking policies reported no implementation problems. Conclusions There is considerable potential for exposure of children to environmental tobacco smoke in Family Day Care homes. There is legal support for Family Day Care caregivers not to expose children under their care to environmental tobacco smoke. A formal (and enforced) no-smoking policy should exist in every Family Day Care scheme, and a "top-down" directive is most likely to be successful. The issue of other smokers in the caregiver's household needs to be specifically addressed in any such directive.

Contributors SECTION 1: BASIC IDEAS 1. Chronic pain as a topic for epidemiology and public health 2. The global occurrence of chronic pain: an introduction 3. The demography of chronic pain: an overview Appendix to Section 1: Basic epidemiological concepts applied to pain SECTION 2: DEFINITION AND MEASUREMENT OF CHRONIC PAIN FOR POPULATION STUDIES 4. Introduction 5. Measuring chronic pain in populations 6. Measuring the impact of chronic pain on populations: a narrative review 7. Number of pain sites - a simple measure of population risk? SECTION 3: MECHANISMS 8. The genetic epidemiology of pain 9. The biological response to stress and chronic pain 10. Musculoskeletal pain complaints from a sex and gender perspective SECTION 4: COMMON PAIN SYNDROMES 11. Introduction 12. The symptom of pain in populations 13. Headache 14. Pain in children 15. Life-course influences on chronic pain in adults 16. Pain in older people SECTION 5: PAIN AND DISEASE 17. Disease-related pain: an introduction 18. Neuropathic pain 19. Post-surgical pain 20. Chronic chest pain, myocardial ischaemia and coronary artery disease phenotypes 21. Cancer and chronic pain SECTION 6: PUBLIC HEALTH AND CHRONIC PAIN 22. Introduction to chronic pain as a public health problem 23. Pharmacological treatment: the example of osteoarthritis 24. The potential for prevention: occupation 25. Can we change a population's perspective on pain? 26. The potential for prevention: overview Index

Circulating factors that have an effect on SIRT1 expression are influenced by caloric restriction. To determine the association between frailty and such circulating factors, we measured serum-induced SIRT1 expression from a nested cohort of frail (n = 77) and robust (n = 82) participants from Concord Health and Ageing in Men Project, a population-based study of community-dwelling men older than 70 years. Serum-induced SIRT1 expression was not different between frail and robust men (103.1 ± 17.0 versus 100.4 ± 19.3 μg/L). However, subsequent analyses showed that men with the lowest values (first quartile) were less likely to be frail (odds ratio = 0.5, 95% confidence interval = 0.2-1.0, p = .04) and had higher total body lean mass (p = .001) than the other participants. Serum-induced SIRT1 expression did not correlate with age, diseases, medications, albumin, fasting glucose, or lipids. Overall, there was no association between frailty and serum-induced SIRT1 expression; however, post hoc analysis suggested that there might be a paradoxical association between low serum-induced SIRT1 expression and robustness.

Objective: The prevalence of chronic pain in Australia has only been previously estimated for the state of New South Wales. The aim of this study was to focus estimates on pain severe enough to interfere markedly with daily function irrespective of contact with health services in another region, South Australia. Methods: A whole of population random face-to-face survey method (n=2,973) was used, directly standardised against the whole population for age, gender, country of birth and rurality. Respondents were asked about chronic pain and the degree to which it interfered with daily activities. Results: The prevalence of chronic pain was 17.9%, and pain that interfered extremely with activity 5.0%. Chronic pain was associated with older age, living alone, lower income, not being in full-time work and lower educational levels in bivariate analyses, however in multifactor analyses the only significant associations were not currently working (p

Back pain is common in older people and is associated with functional disability and poor self-rated health. Older persons are under-represented in back pain research, and research on back pain in older persons from ethnic minorities is particularly sparse. We investigated differences in back pain characteristics, effects and medication use in a population-based sample of 335 Italian-born immigrants and 849 Australian-born men aged 70 years and over. There were 189 (62%) Italian-born men and 507 (63%) Australian-born men who reported experiencing back pain in the past 12 months. Despite no difference in the reported prevalence of back pain between the two groups of men, Italian-born men were more likely to report that their pain was frequent, severe and chronic. Italian-born men were also more likely to report having other sites of pain and that they had limited their activities in the past 12 months due to back pain. Despite these differences, the use of analgesic medication was the same in both groups. Multivariate analyses showed that differences in pain characteristics and effects between the two groups of men were explained by socioeconomic factors such as years of education and occupation history.

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT? * Lean mass decreases with age while total body fat increases, leading to changes in the pharmacokinetics and pharmacodynamics of drugs. * Dual-energy X-ray absorptiometry (DXA) is a useful reference method to measure lean body weight but may not be readily utilized clinically. * Limited methods for measurement of lean body weight using easily obtainable participant characteristics, such as height and weight, have been validated for use in people aged > or =65 years. WHAT THIS STUDY ADDS * This study has shown that lean body weight can be estimated using three different equations from easily obtainable participant characteristics with results comparable to DXA-derived estimates. * These equations may be useful tools to estimate lean body weight in situations where DXA is not practical. AIMS Lean body weight (LBW) decreases with age while total body fat increases, altering drug pharmacokinetics. The aim of this study was to evaluate the ability of the LBW equation to predict dual-energy X-ray absorptiometry (DXA)-derived fat free mass (FFM(DXA)) in older community-dwelling males compared with that of two existing FFM equations: the Heitmann and Deurenberg equations. METHODS Data were obtained from 1655 older men enrolled in the Concord Health and Ageing in Men Project. The predictive performance of the LBW and FFM equations to predict FFM(DXA) accurately was assessed graphically using Bland-Altman plots and quantitatively for precision and bias using the method of Sheiner and Beal in all participants and in frailty and body mass index (BMI) subgroups. RESULTS The LBW and Heitmann equations consistently overestimated FFM(DXA) for all frailty and BMI subgroups with a mean difference [95% confidence interval (CI)] of 5.5 kg (-0.65, 11.63 kg) and 3.34 kg (-2.84, 9.64 kg), respectively. The Deurenberg equation overestimated FFM(DXA) for overweight participants but underestimated FFM(DXA) for not-frail participants, with a mean difference (95% CI) of 1 kg (-7.23, 5.25 kg) for all participants. CONCLUSION LBW and FFM estimated using these equations give results comparable to DXA-derived FFM. The LBW and Heitmann equations provide a more consistent estimate of FFM(DXA) in all frailty and BMI groups despite the Deurenberg equation having the smallest mean difference. Further studies to determine whether the LBW equation is a clinically useful substitute for weight when determining drug dose in older people appear warranted.

This study examined the assessment of pain intensity and pain distress with the Numerical Rating Scale (NRS) in elderly patients (age >60 years) with persistent pain. A consecutive sample of 800 elderly patients were categorized by age into 3 groups: 61 to 70 years (n = 366), 71 to 80 years (n = 308), and 81 years and over (n = 126). Participants completed 3 Numerical Rating Scales assessing current pain intensity, and both the usual level of pain and average pain distress in the preceding week. The failure rate for scale completion was low for all scales for all age groups, but was significantly higher in the oldest group compared to the youngest group for the scales assessing current pain intensity and average pain distress in the preceding week. The NRS was shown to be a reliable and valid measure of pain intensity and pain distress in all these age groups. Distress related to pain appeared to be specific to the pain experience and was only weakly related to more generalized affective distress. These findings confirm that measures of pain intensity and pain distress, like the NRS, capture only part of the pain experience in older patients and should be supplemented by other measures in the assessment process. Perspective This article confirms the utility of the Numerical Rating Scale (NRS) as a measure of pain intensity and pain distress in elderly patients with persistent pain. The use of a large sample increases confidence in the psychometric soundness of the NRS with this population.

Objectives: to establish whether review articles provide consistent conclusions on associations between workplace psychosocial factors and musculoskeletal pain and, if differences exist, to explore whether this is related to the methods used.Methods: reviews, reported up to February 2007, that included consideration of workplace psychosocial factors and upper limb, back or knee pain were identified through searches of multiple databases. The specific work-related psychosocial factors considered were job demands, support, job autonomy and job satisfaction. The conclusions of each review on one or more of the psychosocial/musculoskeletal pain associations were extracted.Results: 15 review articles were identified that considered one or more of the regional pain syndromes included in the study. For back pain, the most consistent conclusions (four reviews positive out of six) were with high job demands and low job satisfaction. The studies of upper limb pain were exclusively related to shoulder and/or neck pain, and the most consistent positive conclusions were with high and low job demands (four reviews positive out of six and two reviews positive out of three, respectively). For knee pain, only a single review was identified. For individual reviews of back and upper limb pain, there were marked differences in the number of associations concluded to be positive between reviews.Conclusions: the reasons for reviews coming to different conclusions included that they were often evaluating different bodies of evidence (according to their search criteria, the year when the review was conducted, the role that quality assessment played in whether studies contributed to evidence, and the combination of risk factors addressed in individual studies), but more important was whether the review specified explicit criteria for making conclusions on strength of evidence. These conclusions emphasise the importance of developing standardised methods for conducting such evaluations of existing evidence and the importance of new longitudinal studies for clarifying the temporal relationship between psychosocial factors and musculoskeletal pain in the workplace

Objective: To describe the prevalence of depressive symptoms in older male Italian-born Australian immigrants. Design, participants and setting: Cross-sectional study of 335 Italian-born and 849 Australian-born men aged 70 years and over who completed written questionnaires and were interviewed in the baseline phase of the Concord Health and Ageing in Men Project (CHAMP). Main outcome measures: Depressive symptoms assessed by the short (15-item) form of the Geriatric Depression Scale; associations between depressive symptoms and country of birth. Results: The prevalence of depressive symptoms in Italian-born men was 18%, almost twice the prevalence of 10% in Australian-born men (odds ratio [OR], 1.9; 95% CI, 1.2-3.0). After adjusting for socioeconomic and health factors, the relationship between country of birth and depressive symptoms was attenuated and no longer statistically significant (OR, 1.7; 95% CI, 0.9-3.0). The strongest confounders of the relationship between country of birth and depressive symptoms were source of income and satisfaction with social support. Conclusion: Male Italian-born immigrants aged over 70 years report more depressive symptoms than their Australian-born counterparts. This association appears to be explained by increased reliance on a government pension as the sole source of income and lower satisfaction with social support among Italian-born men. However, these findings need to be confirmed longitudinally.

Objectives This prospective cohort study aimed to investigate whether there are differences in health outcomes among persons with mild or moderate injuries who were hospitalised compared with those not hospitalised following a road traffic crash. Setting Sydney Metropolitan, New South Wales, Australia. Participants Persons aged ≥18 years involved in a motor vehicle crash were surveyed at baseline (n=364), and at 12 (n=284) and 24 months (n=252). A telephone-administered questionnaire obtained information on a range of socioeconomic, and preinjury and postinjury psychological and heath characteristics of all participants. Primary outcome measure Participants who reported admission to hospital for 24 h or more (but less than 7 days) after the crash were classified as being hospitalised; those admitted for less than 24 h were classified as non-hospitalised. Results Around 1 in 5 participants (19.0%) were hospitalised for ≥24 h after the crash. After adjusting for age and sex, hospitalised participants compared with those not hospitalised had approximately 2.6 units (p=0.01) lower Short Form-12 Physical Component Summary (SF-12 PCS) scores (poorer physical well-being) and approximately 4.9 units lower European Quality of Life visual analogue scale (EQ-VAS) scores (p=0.05), 12 months later. After further adjusting for education level, whiplash, fracture and injury severity score, participants who were hospitalised had approximately 3.3 units lower SF-12 PCS (p=0.04), 12 months later. The association with EQ-VAS did not persist after multivariable adjustment. No significant differences were observed between the 2 groups in health outcomes at 24-month follow-up. Conclusions These findings indicate that long-term health status is unlikely to be influenced by hospitalisation status after sustaining a mild/moderate injury in a vehicle-related crash.

Pain and falling both affect substantial segments of the older population. Despite the presence of several plausible mechanisms for pain to contribute to falling, very few studies have investigated this relationship in older people. If pain is a falls risk factor, this represents a potentially important point of intervention for falls prevention. Falls are a major cause of disability and loss of independent living status in older people. We examined the relationship between pain, pain-related interference with activities and falls in a cross-sectional analysis of 3509 people aged 49 years or more in two postal code areas in New South Wales, Australia (the Blue Mountains Eye Study). We found that subjects reporting pain with moderate to severe level of pain-related interference with activities were more likely to report any falls or multiple falls in the past 12 months than subjects not reporting pain (adjusted prevalence ratios 1.42, p=0.0001 and 1.62, p=0.0156, respectively). We also found a significant trend in the association indicating an increasing likelihood of self-reported falls associated with increasing level of pain-related interference with activities. The association was stronger for multiple falls than for any falls. Excluding subjects with recent fractures did not alter the findings. Given the high prevalence and public health importance of both conditions, further investigation of this association in prospective studies is recommended.

Cost estimates of the impact of chronic pain on work have largely focussed on absenteeism, excluding the hidden contribution of reduced work effectiveness to lost productivity. This paper aims to estimate the cost of lost productivity due to chronic pain in Australia, not only in terms of absenteeism but also reduced work effectiveness. Data on chronic pain in Australia and its impact on work were obtained from the 1997 New South Wales Health Survey ( n = 17,543) and the Northern Sydney Area Pain Study ( n = 2,092), both of which were population-based and used random-digit dialling sampling methods. This was combined with relevant Australian population and labour force data obtained from the Australian Bureau of Statistics. From this we estimated annual lost productivity costs arising from both chronic pain-related days absent and ‘reduced-effectiveness workdays’. There were estimated to be 9.9 million workdays absent due to chronic pain annually in Australia, equating to a cost of AUD 1.4 billion per annum. Under the assumption that reduced-effectiveness workdays affect productivity costs in the same way as lost work days, the total number of lost workday equivalents was 36.5 million, with the total annual cost of lost productivity due to chronic pain estimated as AUD 5.1 billion per annum. In conclusion, while the impact of reduced work effectiveness on days worked with pain on productivity is uncertain, it has the potential to account for the majority of lost productivity costs associated with chronic pain. Interventions which target working despite pain have the potential to significantly reduce lost productivity costs due to chronic pain.

Little is known about the relationship between chronic pain status and overall use of healthcare. We examined whether disabling chronic pain was associated with more frequent use of healthcare in three settings: primary care, emergency departments, and hospital admissions. We used data from Computer-Assisted Telephone Interviews (CATI) of 17,543 residents in New South Wales, Australia aged 16 and over who were randomly sampled using a population-based two-stage stratified sample and random digit dialing methods. The overall response rate was 70.8%. Compared to chronic pain respondents with no or limited pain-related disability, those with most pain-related disability reported more: primary care visits in the last 2 weeks and last 12 months (adjusted mean number of visits 0.59 vs 0.40 and 10.72 vs 4.81, both P0.005); hospital admissions (0.46 vs 0.18, P0.005); and emergency department visits (0.85 vs 0.17, P0.005). In modelling, having chronic pain per se, or having chronic pain with any level of activity interference predicted health care use after adjusting for age, gender, self-rated health, psychological distress, comorbidity and access to care. Higher levels of pain-related disability predicted health care use more than other pain status variables. There was a strong association between pain-related disability and greater use of services. Further work is needed to understand the nature of this association. Given the fluctuating course of chronic pain over time, there is a significant segment of the population that may be at risk of developing higher levels of disability associated with increased use of services.

The overall population impact of chronic pain on work performance has been underestimated as it has often been described in terms of work-related absence, excluding more subtle effects that chronic pain may have on the ability to work effectively. Additionally, most studies have focussed on occupational and/or patient cohorts and treatment seeking, rather than sampling from the general population. We undertook a population-based random digit dialling computer-assisted telephone survey with participants randomly selected within households in order to measure the impact of chronic pain on work performance. In addition, we measured the association between pain-related disability and litigation. The study took place in Northern Sydney Health Area, a geographically defined urban area of New South Wales, Australia, and included 484 adults aged 18 or over with chronic pain. The response rate was 73.4%. Working with pain was more common (on an average 83.8 days in 6 months) than lost work days due to pain (4.5 days) among chronic pain participants in full-time or part-time employment. When both lost work days and reduced-effectiveness work days were summed, an average of 16.4 lost work day equivalents occurred in a 6-month period, approximately three times the average number of lost work days. In multiple logistic regression modelling with pain-related disability as the dependent variable, past or present pain-related litigation had the strongest association (odds ratio (OR)=3.59, P=0.001). In conclusion, chronic pain had a larger impact on work performance than has previously been recognised, related to reduced performance while working with pain. A significant proportion were able to work effectively with pain, suggesting that complete relief of pain may not be an essential therapeutic target. Litigation (principally work-related) for chronic pain was strongly associated with higher levels of pain-related disability, even after taking into account other factors associated with poor functional outcomes.