Inflammatory bowel disease: the view of the surgeon

Despite advances in medical therapy, surgery is required in approximately 30-40% of patients with ulcerative colitis (UC) and 70-80% of patients with Crohn's disease (CD) at some point during their lifetime. For patients with UC, surgery may be curative, whereas recurrence of CD following surgery is common due to the potentially pan-enteric distribution of the disease. As a result, the indications and surgical management of the disease may be quite different. For UC, the surgeon is involved in the identification of new cases, management of severe disease, recognition of dysplasia and restorative proctocolectomy. Most of the advances in surgery for UC have been in novel techniques relating to the ileal pouch-anal anastomosis, which can now be performed safely for UC with a 10% pouch failure rate long term. For CD, the surgeon is involved in the management of small bowel and ileo-colonic disease, Crohn's colitis and perianal disease. Advances in the surgical management of CD include strictureplasty for extensive small bowel disease, laparoscopic ileo-caecal resection and a combined medical and surgical approach to perianal disease. For both CD and UC close liaison between the gastroenterologist and colorectal surgeon is essential.

The intention to hasten death: a survey of attitudes and practices of surgeons in Australia

OBJECTIVE

To determine attitudes among surgeons in Australia to assisted death, and the proportion of surgeons who have intentionally hastened death with or without an explicit request.

DESIGN

Anonymous, cross-sectional, mail-out survey between August and November 1999

PARTICIPANTS

683 out of 992 eligible general surgeons (68.9% response rate).

MAIN OUTCOME MEASURES

Proportion of respondents answering affirmatively to questions about administering excessive doses of medication with an intention to hasten death.

RESULTS

247 respondents (36.2%; 95% CI, 32.6%-39.9%) reported that, for the purpose of relieving a patient's suffering, they have given drugs in doses that they perceived to be greater than those required to relieve symptoms with the intention of hastening death. More than half of these (139 respondents; 20.4% of all respondents; 95% CI, 17.4%-23.6%) reported that they had never received an unambiguous request for a lethal dose of medication. Of all respondents, only 36 (5.3%; 95% CI, 2.9%-6.1%) reported that they had given a bolus lethal injection, or had provided the means to commit suicide, in response to an unambiguous request.

CONCLUSIONS

More than a third of surgeons surveyed reported giving drugs with an intention to hasten death, often in the absence of an explicit request. However, in many instances, this may involve the use of an infusion of analgesics or sedatives, and such actions may be difficult to distinguish from accepted palliative care, except on the basis of the doctor's self-reported intention. Legal and moral distinctions based solely on a doctor's intention are problematic.

"A little encouragement": health services and domestic violence

The aim of this study was to identify those elements of health care which women who have experienced domestic violence consider to represent quality care and explore opportunities for an area health service to improve its service delivery to these women. To do this nine focus groups were conducted with six urban and three rural groups, recruited from Women's Support Services and Refuges, and 65 women participated. A trained facilitator conducted the focus groups with a representative from each participating organisation. Audiotapes were transcribed then coded using a thematic analysis approach. Analysis of the tapes revealed six opportunities for improvement of health services. Improve services to Aboriginal women; increase access to services; promote available services; improve the health service environment; educate service providers; and provide specialist health services. A major theme to emerge was the importance of a supportive environment where women were supported to make choices for their future.

The effect of a community action intervention on adolescent smoking rates in rural australian towns: the CART project. Cancer Action in Rural Towns

BACKGROUND

This paper describes one outcome of a randomized controlled trial of community action for cancer prevention, Cancer Action in Rural Towns. The aims are to [1] explore the effectiveness of community action in decreasing adolescent smoking in rural Australian towns; and [2] describe the relationship between adolescent smoking rates and demographic variables.

METHODS

In 1992, 20 rural Australian towns were selected. Community action involved formation of community committees and utilization of access-point networks to initiate and maintain intervention strategies. Cross-sectional surveys of smoking behaviors for all Year 9 and Year 10 students (13-16 years) in each town were conducted pre- and posttest. The main outcome measure was self-reported smoking in the past 4 weeks. SUDAAN software was used to look at differences between treatment.

RESULTS

The results showed strong secular trends toward increased adolescent smoking, regardless of treatment group, particularly for females. There was no significant intervention effect.

CONCLUSIONS

Increasing adolescent smoking rates found in this and other studies highlight that the definitive strategy to stem the adolescent smoking epidemic has not been found. Hope may remain for recent legislative strategies, but rigorous evaluation is essential, and compliance with legislation should be carefully monitored.

Effect of a community action program on adult quit smoking rates in rural australian towns: the CART project

BACKGROUND

This article describes one outcome of a randomized controlled trial of community action for cancer prevention. The aims of this article were to (a) explore the effectiveness of a community action program in decreasing community smoking rates in rural Australian towns and (b) describe the relationship between adult smoking quit and uptake rates and demographic variables.

METHODS

In 1992, 20 towns were selected for randomization. Community action involved formation of community committees and utilization of access point networks to initiate and maintain intervention strategies. At post-test, outcomes were proportion of "quitters" from a cohort of self-described smokers, proportion of "uptakers" from a cohort of self-described nonsmokers, and "net effect."

RESULTS

Differences in quit rate, uptake rate, and net effect for intervention compared to control condition favored the intervention in all cases, although mainly nonsignificant. Significantly more male smokers quit in intervention towns than in control towns [7.0% (95% CI: 0.6, 13.5)].

CONCLUSIONS

Given that CART utilized and improved upon strategies argued as effective in the literature, the limited success of the project in reducing adult smoking, considered in combination with COMMIT findings, suggests the need for further innovation in the field.

Effect of a community action intervention on cervical cancer screening rates in rural Australian towns: the CART project

BACKGROUND

The effect of community action on cervical cancer screening rates was explored in 20 rural Australian towns.

METHODS

Town quarterly Pap test counts, from the Australian Health Insurance Commission, were converted to town rates using Census populations. Pap test rates for 12 quarters before and after mobilization were examined.

RESULTS

Wilcoxon-Mann-Whitney tests demonstrated significantly higher per capita Pap test rates pre- to postmobilization for intervention towns compared to matched control towns for women whose last Pap test was more than 2 years ago (P=0.008). Maximum efficiency robust tests examining the equality of mean differences (intervention-control) of per capita rates between pre- and post-mobilization periods also found significant differences for Pap tests where last procedure was between 1 and 2 years ago (R = 13.9, P = 0.039) and near significance for Pap tests where last procedure was less than one year ago (R = 10.6, P = 0.087).

CONCLUSIONS

It appeared that underscreened women were more likely and overscreened women were less likely to have a Pap test in response to the intervention. The results indicate that a community action program can positively impact cervical cancer screening rates.

Analysis of dichotomous outcome data for community intervention studies

Community intervention trials are becoming increasingly popular as a tool for evaluating the effectiveness of health education and intervention strategies. Typically, units such as households, schools, towns, counties, are randomized to receive either intervention or control, then outcomes are measured on individuals within each of the units of randomization. It is well recognized that the design and analysis of such studies must account for the clustering of subjects within the units of randomization. Furthermore, there are usually both subject level and cluster level covariates that must be considered in the modelling process. While suitable methods are available for continuous outcomes, data analysis is more complicated when dichotomous outcomes are measured on each subject. This paper will compare and contrast several of the available methods that can be applied in such settings, including random effects models, generalized estimating equations and methods based on the calculation of 'design effects', as implemented in the computer package SUDAAN. For completeness, the paper will also compare these methods of analysis with more simplistic approaches based on the summary statistics. All the methods will be applied to a case study based on an adolescent anti-smoking intervention in Australia. The paper concludes with some general discussion and recommendations for routine design and analysis.

Cell-microcarrier adhesion to gas-liquid interfaces and foam

The interaction of microcarriers, both with and without cells attached, with gas bubbles was studied. These studies consisted of qualitative microscopic observations of microcarriers with bubbles, quantitative measurements of microcarrier entrapment in foam, and quantitative measurements of the effect of bubble rupture at gas-medium interfaces. Ten different "protective additives" were evaluated for their ability to change the dynamic surface tension of the culture media and to prevent microcarrier adhesion to air bubbles during gas sparging and to prevent entrapment in the foam layer. These studies indicate that microcarriers, with and without cells, readily attach to gas-medium interfaces; yet unlike suspended cells, cells attached to microcarriers are not damaged by bubble ruptures at gas-medium interfaces. Only one surfactant was found to substantially prevent microcarrier entrapment in the foam layer; however, this surfactant was toxic to cells. No correlation was observed between surface tension and the prevention of microcarrier adhesion to gas-liquid interfaces. It is suggested that cell damage as a result of sparging in microcarrier cultures is the result of cells, attached to microcarriers, attaching to rising bubbles and then detaching from the microcarrier as this combination rises through the medium. It is further suggested that the hydrodynamic drag force of the rising microcarrier is sufficiently high to remove the bubble-attached cell from the microcarrier.

Satisfaction with the process of lead remediation in an urban Australian community

OBJECTIVE

To assess householders' satisfaction with the process of residential lead abatement in an urban Australian population.

METHOD

The study area consisted of suburbs immediately surrounding a lead-related industry on Australia's east coast. Nineteen of 20 remediated households in the study area agreed to participate in the survey. One trained interviewer conducted semi-structured qualitative interviews with one 'key' person from each remediated household. Participants were asked for their personal views as well as general household views about the rationale for, process and results of lead remediation.

RESULTS

The 19 households varied from three to seven people and contained 1-5 children (16 years or under). The opinions of residents of remediated households were polarised, with the majority being either greatly satisfied or greatly dissatisfied with the process. Level of satisfaction was clearly linked to perceived quality of the remediation works.

CONCLUSIONS

Satisfaction with household lead remediation could be improved by ensuring effective communication between all parties; providing clear, simple, but detailed information about the remediation works to be undertaken on each household; providing timely support for householders when problems arise; and ensuring that all contractors are skilled, reputable and have acceptable communication skills.

Comparison of the upper gastrointestinal safety of Arthrotec 75 and nabumetone in osteoarthritis patients at high risk for developing nonsteroidal anti-inflammatory drug-induced gastrointestinal ulcers

A 6-week, multicenter, double-masked, placebo-controlled, parallel-group study compared the upper gastrointestinal (UGI) safety of Arthrotec 75 (diclofenac sodium 75 mg-misoprostol 200 microg; G.D. Searle & Co., Skokie, Illinois) administered twice daily with that of nabumetone 1500 mg administered once daily in 1203 patients with symptomatic osteoarthritis (OA) of the hip or knee. All patients had a documented clinical history of endoscopically confirmed gastric, pyloric-channel, or duodenal ulcer or > or = 10 erosions in the stomach or duodenum. UGI endoscopy was performed at baseline and again at week 6 or early withdrawal. Treatment with Arthrotec 75 resulted in a significantly lower combined incidence of endoscopically confirmed gastric and duodenal ulcers compared with nabumetone (4% vs 11%), and its rate of endoscopically confirmed ulceration was equivalent to that of placebo. The incidence of gastric ulcers alone was also significantly lower with Arthrotec 75 than with nabumetone (1% vs 9%). The incidence of duodenal ulcer with Arthrotec 75 was not significantly different from that with nabumetone (4% vs 3%). Types of adverse events were similar for all treatment groups, with GI adverse events predominating. Arthrotec 75 was well tolerated by the majority of patients. The results of this study demonstrate that Arthrotec 75 has a superior UGI safety profile, causing significantly fewer UGI ulcers, in comparison with nabumetone in patients with symptomatic OA and a documented history of ulcers or > or = 10 erosions.

Cervical cancer screening in rural NSW: Health Insurance Commission data compared to self-report

There are several sources of data for estimates of community Pap test rates, including self-report, pathology laboratory records and Health Insurance Commission (HIC) data. Estimates of screening rates can vary considerably according to the sampling frame and data source. This study aimed to compare the self-reported estimates of cervical cancer screening with HIC estimates for women in rural NSW towns. Self-report of a Pap test in the past two years from 2,498 women in 19 rural towns of NSW was compared to HIC-provided Pap test rates. Self-report levels were adjusted for non-HIC providers and HIC levels included data from the Victorian Cytology Register. Self-report estimates were significantly higher than HIC estimates in 18 of the 19 towns, with discrepancies ranging from 13% to 29%. HIC-recorded providers accounted for between 65% and 100% of Pap tests per town, according to self-report. The highest Pap test rate by self-report was 70.1%, the highest by HIC was 49.2%. The lowest Pap test rate by self-report was 45.2%, the lowest by HIC was 26.1%. There was significant variation in Pap test rates between towns for adjusted self-report estimates, but not for the crude self-report estimates. Researchers should always be aware of both the possible variations according to data source and the inherent biases for whichever data source is used. An extra caution is given to consider the public/private provider profile when exploring possible geographical differences in Pap test rates.

Community action for health promotion: a review of methods and outcomes 1990-1995

OBJECTIVE

Our objective was to explore the effectiveness of community action as a strategy for health promotion, through a critical review of five years of community action evaluation literature.

METHODS

Community action was defined as a health promotion, program that involved the community in implementation and control of the process of the program. Criteria for scientific evaluation of programs were proposed for sampling and control procedures, reliability and validity of instruments, analysis techniques, and specification of details of the intervention. A critical review of the literature, located by an on-line and related reference search, was undertaken for community action aimed at reducing cancer and cardiovascular disease, between January 1990 and May 1995.

RESULTS

None of seven community action studies (17 articles) that examined cancer risk factors fulfilled all the criteria for rigorous scientific evaluation. The most methodologically adequate cancer study, the COMMIT intervention, had only a moderate degree of success in reducing community smoking rates. Similarly, none of the six studies (25 articles) on cardiovascular disease fulfilled all the criteria. The results for the most methodologically adequate study, the Minnesota Heart Health Program, were disappointing, with strong secular trends preventing adequate assessment of the intervention effect.

CONCLUSIONS

The finding that none of the reviewed studies met all evaluation criteria was due to several factors, including political considerations, feasibility, and the continued evolution of the science of evaluation in health promotion. Some important questions are posed for researchers by the failure of methodologically superior projects, such as COMMIT, to show major gains in reducing health risk behaviors.

Knowledge of cancer risk reduction practices in rural towns of New South Wales

The Australian Cancer Society has published guidelines for recommended risk reduction strategies for breast, cervical, smoking-related and skin cancer. While knowledge may not be sufficient for change, it is argued to be necessary for change to occur. A measure of the level of health knowledge in the community can be useful for health promotion practitioners, identifying where health messages are not reaching their proposed targets. Our aims were to examine the level of knowledge about risk reduction practices for breast, cervical, smoking-related and skin cancers, for a rural New South Wales sample, and to examine sex and age effects on knowledge levels. A survey of 2846 women and 1732 men from rural New South Wales, which used an unprompted recall strategy, revealed some notable deficits in recall of cancer risk reduction practices: only 26 per cent of women identified mammograms as a risk reduction strategy for breast cancer; only 5 per cent of women knew at which ages mammograms should start and stop; only 6 per cent of women could identify when Pap tests should be discontinued; less than half of the sample could identify common solar protection strategies; and less than one-third of people identified passive smoking as a lung cancer risk.

Analysis of a second bacteriophage hyaluronidase gene from Streptococcus pyogenes: evidence for a third hyaluronidase involved in extracellular enzymatic activity

The hyaluronidase gene (hylP2) from a second group A streptococcal bacteriophage was isolated from ATCC T-type-22 hyaluronidase-producing strain 10403, a strain known to produce increased amounts of extracellular hyaluronidase. Sequence analysis of hylP2 and alignment with the previously described bacteriophage hyaluronidase gene (hylP) showed a high degree of similarity; however, hylP2 had deletions of regions specifying 34 amino acids. Twenty-eight of the deleted amino acids were in a region of HylP containing a series of collagen-like Gly-X-Y repeating units. By employing primers for both hylP and hylP2, PCR amplification resulted in fragments of appropriate sizes in 97% of the strains tested, with some strains producing two fragments, indicating the presence of at least two phages. When the hylP2 gene was introduced via a plasmid vector into a non-hyaluronidase-producing Streptococcus pyogenes strain, this strain was still unable to produce extracellular hyaluronidase, although intracellular hyaluronidase was present. These results, along with the absence of a typical N-terminal signal peptide, indicate that HylP2 is unable to be secreted into the extracellular milieu. Examination of more than 100 strains for production of hyaluronidase showed that only 23% of the strains produced extracellular hyaluronidase. One of these strains (strain 10403) contains a single bacteriophage hyaluronidase gene (hylP2) which, when inactivated by allelic replacement, still produces large amounts of extracellular hyaluronidase. These results suggest the presence of a different hyaluronidase gene encoding a protein that is actively secreted into the extracellular milieu.

Domestic violence experienced by women attending an accident and emergency department

The aim of the study was to establish the extent and severity of domestic violence experienced by women attending the accident and emergency department of a large teaching hospital in Newcastle. The data were collected over a five-week period in 1992. All women between 17 and 80 years, attending the emergency or ambulatory areas between 8 a.m. and midnight, were asked to complete a confidential structured interview. A total of 401 women participated in the study, representing 82 per cent of eligible women approached. Each participant was asked if she had ever been physically hurt by someone close to her. Questions were asked to determine the relationship to the perpetrator, the type and cause of injury, treatment necessary and help sought. Seven (1.7 per cent, 95 per cent confidence interval (CI) 0.46 to 3.02) of the women surveyed were attending the hospital as a direct result of an incident of domestic violence, and 100 women (25 per cent, CI 21 to 29) had experienced domestic violence at some time. Bruising, fractures and cuts were the most common forms of injury, with the most common locations being the head, face and chest. Weapons, such as guns and knives, were used in 20 per cent of the incidents. A considerable number of the women (68 per cent) did not seek help at the time of their injuries. As a substantial proportion of women have experienced domestic violence in their lives, accident and emergency workers should receive training in recognising and assisting victims of domestic violence.

Drug use in Australia: a community prevalence study

OBJECTIVE

To estimate the prevalence of drug use in a representative Australian community.

DESIGN

Using a Census district sampling framework supplied by the Australian Bureau of Statistics, we randomly selected dwellings for our survey. A household was defined as all those people living permanently at the postal address. All eligible members of each household, 15 years and older, were asked to participate.

SETTING

The data were collected in the context of a large scale general population survey of health practices and attitudes, conducted in the Greater Newcastle area of New South Wales, during 1987 and 1988.

PARTICIPANTS

Seventy-two per cent of eligible individuals approached (2623) agreed to participate in the survey.

MAIN OUTCOME MEASURES

Participants were asked about their use of a number of drug types: medically prescribed drugs, non-prescription drugs, tobacco, alcohol and illicit drugs. For alcohol, only the results for use at a hazardous level according to the National Health and Medical Research Council guidelines are reported here.

RESULTS

Seventy-eight per cent (95% confidence interval, 76%-80%) of the community sample reported having recently consumed at least one of these drug types. There were significant age and sex differences in drug use. A greater proportion of women and the older age groups (over 45 years) reported the use of both non-prescription and prescription medications than did men and the younger age groups. Conversely, a significantly greater proportion of men and the younger age groups reported the use of social and illicit drugs.

CONCLUSION

The importance of regular, representative, methodologically comparable community studies of drug use is stressed, particularly in view of the inadequacy of the current routine sources of epidemiological data on drug use.

Aspirin use in children: heeding the warning?

In 1986, the Australian Government issued warnings about the use of aspirin for children and adolescents after the link had been established between aspirin use and Reye's syndrome in America. This study questioned a representative community sample of parents in Newcastle, New South Wales, about their awareness of this caution, and their recent aspirin use for children under 18 years. While 65% of women and 47% of men reported that they were aware of the Government recommendations, only 8% of women and 9% of men reported obtaining this information from the printed warning on the medicine container or packet. Despite awareness of the warnings, almost one third of parents reported administering aspirin to their children. When it is necessary to caution patients about the use of over-the-counter medications, it is not sufficient to use package labelling as the main site of information.

Agreement between two measures of drug use in a low-prevalence population

The present study examined the agreement between two measures of prevalence of drug use in the community: self-report and specific pharmacological analyses of urine samples. The data were collected in the context of a random community survey of health practices and attitudes. A random 20% of the households participating in the health study were targeted for biochemical assay. Compliance with urine delivery was relatively high at 79%. Urine samples were screened qualitatively for cannabinoids and benzodiazepines using the enzyme multiplied immunoassay technique (EMIT) (Syva Diagnostics, Palo Alto, CA). Screening for pharmaceuticals used a standard thin-layer chromatography (TLC) technique. Agreement between the self-report and biochemical assay estimates of prevalence was statistically significant (p less than .05). While self-report of substance use is not a perfect measure of consumption, it remains a relatively economical and reasonably accurate method of obtaining estimates of substance use in community samples.