Alastair H. MacLennan

Prevalence and cost of alternative medicine in Australia

BACKGROUND To determine the prevalence and cost of alternative medicines and alternative practitioner use in an Australian population. METHODS We conducted a representative population survey of persons aged 15 or older living in South Australia, which required 3004 personal interviews. We assessed the rates of use and types of alternative medicine and therapists used by this population in 1993, and correlations with other demographic and medical variables. FINDINGS The overall use of at least one non-medically prescribed alternative medicine (excluding calcium, iron and prescribed vitamins) was 48.5%. The users were more likely to be perimenopausal females, better educated, have a higher alcohol intake, be of normal weight and more likely to be employed than non-users. 20.3% of respondents had visited at least one alternative practitioner, most commonly chiropractors (15%). The users of alternative practitioners were more likely to be younger, live in the country and be overweight. Women were more likely to consult naturopaths, iridiologists, and reflexologists than men. INTERPRETATION Extrapolation of the costs to the Australian population gives a natural expenditure in 1993, for alternative medicines, of

The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery

621 million (Australian dollars) and for alternative therapists of

A template for defining a causal relation between acute intrapartum events and cerebral palsy: international consensus statement

AU309 million per annum. This compares to the

Effectiveness and safety of the oxytocin antagonist atosiban versus beta-adrenergic agonists in the treatment of preterm labour

AU360 million of patient contributions for all classes of pharmaceutical drugs purchased in Australia in 1992/93. The public health and economic ramifications of these huge costs are questioned in view of the paucity of sound safety and efficacy data for many of the therapies and products of the alternative medicine industry.

Main morbidities recorded in the women's international study of long duration oestrogen after menopause (WISDOM): a randomised controlled trial of hormone replacement therapy in postmenopausal women

Objectives To define the prevalence of pelvic floor disorders in a non‐institutionalised community and to determine the relationship to gender, age, parity and mode of delivery.

Lumbar epidural analgesia in labour: relation to fetal malposition and instrumental delivery.

In 1997 the research committee of the Perinatal Society of Australia and New Zealand competitively funded a special initiative to bring together the modern literature on the causation of cerebral palsy, and to try to define an objective template of evidence to better identify cases of cerebral palsy where the neuropathology began or became established around labour and birth. Recently there have been many advances in a wide variety of scientific areas associated with cerebral palsy, and thus this multidisciplinary review may benefit research into the causation and prevention of cerebral palsy and may also help those who offer expert opinion when counselling in this area or giving such opinion in court. The corresponding task force was open to anyone who could make a scientific contribution to understanding in this area. The task force had representation from a wide range of clinical and scientific specialties. Submissions were sought from the societys 1000 members, which include scientists, pathologists, obstetricians, neonatalogists, midwives, neonatal nurses, and epidemiologists. International contributions were sought from those identified from the current literature as contributing to this area through peer reviewed research. They were not preselected for their views, and they were invited to join the corresponding task force Some international members joined later in the discussion process as word of this open debate reached them. During 1997 and 1998 multiple online electronic conferences were held, and in March 1998 many of the task force members were able to participate in a workshop in Alice Springs, Australia to discuss the fourth draft of the statement. Drafts of the statement were circulated and debated, with the sixth draft being discussed at an international telephone conference in October 1998. The paper continued to be redrafted eight times until consensus was reached. No opinion was excluded from the debate, but the …

Health related quality of life after combined hormone replacement therapy: randomised controlled trial

Objective To compare the effectiveness and safety of the oxytocin antagonist atosiban with conventional beta‐adrenergic agonist (beta‐agonist) therapy in the treatment of preterm labour.

Hormone therapy, timing of initiation, and cognition in women aged older than 60 years: the REMEMBER pilot study.

Objective To assess the long term risks and benefits of hormone replacement therapy (combined hormone therapy versus placebo, and oestrogen alone versus combined hormone therapy). Design Multicentre, randomised, placebo controlled, double blind trial. Setting General practices in UK (384), Australia (91), and New Zealand (24). Participants Postmenopausal women aged 50-69 years at randomisation. At early closure of the trial, 56 583 had been screened, 8980 entered run-in, and 5692 (26% of target of 22 300) started treatment. Interventions Oestrogen only therapy (conjugated equine oestrogens 0.625 mg orally daily) or combined hormone therapy (conjugated equine oestrogens plus medroxyprogesterone acetate 2.5/5.0 mg orally daily). Ten years of treatment planned. Main outcome measures Primary outcomes: major cardiovascular disease, osteoporotic fractures, and breast cancer. Secondary outcomes: other cancers, death from all causes, venous thromboembolism, cerebrovascular disease, dementia, and quality of life. Results The trial was prematurely closed during recruitment, after a median follow-up of 11.9 months (interquartile range 7.1-19.6, total 6498 women years) in those enrolled, after the publication of early results from the womens health initiative study. The mean age of randomised women was 62.8 (SD 4.8) years. When combined hormone therapy (n=2196) was compared with placebo (n=2189), there was a significant increase in the number of major cardiovascular events (7 v 0, P=0.016) and venous thromboembolisms (22 v 3, hazard ratio 7.36 (95% CI 2.20 to 24.60)). There were no statistically significant differences in numbers of breast or other cancers (22 v 25, hazard ratio 0.88 (0.49 to 1.56)), cerebrovascular events (14 v 19, 0.73 (0.37 to 1.46)), fractures (40 v 58, 0.69 (0.46 to 1.03)), and overall deaths (8 v 5, 1.60 (0.52 to 4.89)). Comparison of combined hormone therapy (n=815) versus oestrogen therapy (n=826) outcomes revealed no significant differences. Conclusions Hormone replacement therapy increases cardiovascular and thromboembolic risk when started many years after the menopause. The results are consistent with the findings of the womens health initiative study and secondary prevention studies. Research is needed to assess the long term risks and benefits of starting hormone replacement therapy near the menopause, when the effect may be different. Trial registration Current Controlled Trials ISRCTN 63718836

Cerebral palsy: causes, pathways, and the role of genetic variants

The incidence of instrumental delivery and malposition immediately before delivery was compared in patients who were given lumbar epidural analgesia and those who were not. Instrumental delivery was five times more common and a malposition of the fetal head was more than three times as common in the epidural group as in women who did not receive regional analgesia. Similar incidences were found even when the epidural was electively chosen before labour in the absence of medical indications. The instrumental delivery rate was affected by parity, the length of the second stage of labour, and the return of sensation by the second stage but not by other factors studied. The high incidence (20%) of malposition associated with epidural analgesia was not affected by any of the factors studied. The psychological and physical disadvantages of malposition and instrumental delivery have yet to be assessed. In the meantime, when there are no medical indications for epidural analgesia, the advantages of pain relief should be weighed against those of a normal spontaneous delivery.

Menopausal hot flushes and night sweats: where are we now?

Objective To assess the effect of combined hormone replacement therapy (HRT) on health related quality of life. Design Randomised placebo controlled double blind trial. Setting General practices in United Kingdom (384), Australia (94), and New Zealand (24). Participants Postmenopausal women aged 50-69 at randomisation; 3721 women with a uterus were randomised to combined oestrogen and progestogen (n=1862) or placebo (n=1859). Data on health related quality of life at one year were available from 1043 and 1087 women, respectively. Interventions Conjugated equine oestrogen 0.625 mg plus medroxyprogesterone acetate 2.5/5.0 mg or matched placebo orally daily for one year. Main outcome measures Health related quality of life and psychological wellbeing as measured by the women’s health questionnaire. Changes in emotional and physical menopausal symptoms as measured by a symptoms questionnaire and depression by the Centre for Epidemiological Studies depression scale (CES-D). Overall health related quality of life and overall quality of life as measured by the European quality of life instrument (EuroQol) and visual analogue scale, respectively. Results After one year small but significant improvements were observed in three of nine components of the women’s health questionnaire for those taking combined HRT compared with those taking placebo: vasomotor symptoms (P<0.001), sexual functioning (P<0.001), and sleep problems (P<0.001). Significantly fewer women in the combined HRT group reported hot flushes (P<0.001), night sweats (P<0.001), aching joints and muscles (P=0.001), insomnia (P<0.001), and vaginal dryness (P<0.001) than in the placebo group, but greater proportions reported breast tenderness (P<0.001) or vaginal discharge (P<0.001). Hot flushes were experienced in the combined HRT and placebo groups by 30% and 29% at trial entry and 9% and 25% at one year, respectively. No significant differences in other menopausal symptoms, depression, or overall quality of life were observed at one year. Conclusions Combined HRT started many years after the menopause can improve health related quality of life. Trial registration ISRCTN 63718836.