Derrick Lopez

Medical career choice and practice location: early factors predicting course completion, career choice and practice location

Aims  The overall aim of the study was to identify the factors that best predict medical career choice and practice location.

Physical activity and all-cause mortality in older women and men

Background Regular physical activity is associated with reduced risk of mortality in middle-aged adults; however, associations between physical activity and mortality in older people have been less well studied. The objective of this study was to compare relationships between physical activity and mortality in older women and men. Methods The prospective cohort design involved 7080 women aged 70–75 years and 11 668 men aged 65–83 years at baseline, from two Australian cohorts – the Australian Longitudinal Study on Womens Health and the Health in Men Study. Self-reported low, moderate and vigorous intensity physical activity, socio-demographic, behavioural and health characteristics were assessed in relation to all-cause mortality from the National Death Index from 1996 to 2009; the median follow-up of 10.4 (women) and 11.5 (men) years. Results There were 1807 (25.5%) and 4705 (40.3%) deaths in women and men, respectively. After adjustment for behavioural risk factors, demographic variables and self-reported health at baseline, there was an inverse dose – response relationship between physical activity and all-cause mortality. Compared with women and men who reported no activity, there were statistically significant lower hazard ratios for women who reported any activity and for men who reported activities equivalent to at least 300 metabolic equivalent.min/week. Risk reductions were 30–50% greater in women than in men in every physical activity category. Conclusions Physical activity is inversely associated with all-cause mortality in older men and women. The relationship is stronger in women than in men, and there are benefits from even low levels of activity.

Falls, injuries from falls, health related quality of life and mortality in older adults with vision and hearing impairment—Is there a gender difference?

BACKGROUND Vision and hearing decline with age. Loss of these senses is associated with increased risk of falls, injuries from falls, mortality and decreased health-related quality of life (HRQOL). Our objective was to determine if there are gender differences in the associations between visual and hearing impairment and these outcomes. METHODS 2340 men and 3014 women aged 76-81 years from the Health in Men Study and the Australian Longitudinal Study on Womens Health were followed for an average of 6.36 years. Dependent variables were self-reported vision and hearing impairment. Outcome variables were falls, injuries from falls, physical and mental components of HRQOL (SF-36 PCS and MCS) and all-cause mortality. RESULTS Vision impairment was more common in women and hearing impairment was more common in men. Vision impairment was associated with increased falls risk (odds ratio (OR)=1.77, 95% CI=1.35-2.32 in men; OR=1.82, 95% CI=1.44-2.30 in women), injuries from falls (OR=1.69, 95% CI=1.23-2.34 in men, OR=1.79, 95% CI=1.38-2.33 in women), and mortality (hazard ratio (HR)=1.44; 95% CI=1.17-1.77 in men; HR=1.50, 95% CI=1.24-1.82 in women) and declines in SF-36 PCS and MCS. Hearing impairment was associated with increased falls risk (OR=1.38, 95% CI=1.08-1.78 in men; OR=1.45, 95% CI=1.08-1.93 in women) and declines in SF-36 PCS and MCS. Overall there were no gender differences in the association between vision and hearing impairment and the outcomes. CONCLUSION In men and women aged 76-81 years, there were no gender differences in the association between self-reported vision and hearing impairment and the outcomes of falls, mortality and HRQOL.

Validation of the FRAIL Scale in a Cohort of Older Australian Women

To the Editor: Assessment of frailty has generally been operationalized in one of three ways. Using the phenotypicbased approach, individuals are considered to be frail if they meet a number of specific criteria. One approach used by Fried and colleagues defined frailty according to the occurrence of at least three of the following five deficits: unintentional weight loss, exhaustion, measured grip strength, slow walking speed, and low level of physical activity. A second approach used a method of counting an individual’s illnesses and disabilities and is highly reproducible and predictive of mortality and other deleterious outcomes. As a third approach, frailty may be based on the clinician’s subjective opinion from clinical examination and history taking. The first approach is simple but relies on a small set of criteria that may not be relevant to every case, the second has good predictive ability but is time consuming and not practical in a clinical setting, and the third approach is not feasible in large-scale epidemiological studies. The Geriatric Advisory Panel of the International Academy of Nutrition, Health, and Aging task force on frailty assessment of older people in clinical practice proposed a simple screening tool, the FRAIL scale, based on elements in both of the first two approaches. The FRAIL scale is a simple five-point scale based on items from the Medical Outcomes Study 36-item Short Form Survey (SF36) and questions about illnesses and loss of weight. This scale was recently validated in a cohort of older Australian men. The aims of the current study were to validate the FRAIL scale in a cohort of older Australian women and to determine whether a score of greater than 2 on the FRAIL scale is predictive of frailty.

Associations of insulin‐like growth factor‐I and its binding proteins and testosterone with frailty in older men

Ageing is associated with frailty and decreased anabolic hormones, insulin‐like growth factor‐I (IGF‐I) and testo;?>sterone. We hypothesized that components of the IGF‐I system, in conjunction with testosterone, modulate frailty risk in the elderly. We examined associations between IGF‐I, its binding proteins IGFBP1 and IGFBP3 and testosterone with frailty in men.

Laser acupuncture for chronic non-specific low back pain: a controlled clinical trial

Objective The primary aim was to determine if laser acupuncture (LA) is more effective than sham laser in reducing pain and disability in adults with chronic non-specific low back pain. Methods The design was a double blind, two-group parallel randomised controlled trial. The active intervention was an 830 nm (infrared), 10 mW, Ga-Al-As laser diode laser for acupuncture and a sham control. The primary outcome measures were changes in pain (visual analogue scale) and disability (Oswestry Disability Index) at the end of 5–10 treatment sessions. Secondary outcomes were patient global assessment, psychological distress (Depression Anxiety Stress Scale) and subjective wellbeing (Personal Wellbeing Index). Follow up was performed at 6 weeks and 6 months after completion of treatment. Results 100 participants were enrolled and treated in a general practice setting. Per protocol analysis of the primary outcome measures using ANOVA suggested that although there was a significant overall improvement in pain and disability after the course of treatments (p<0.01), there was no significant difference between the intervention and control group in both the primary and most secondary outcome measures. Conclusion This study did not show a specific effect for LA using infrared laser at 0.2 Joules per point for chronic low back pain. The overall intervention appeared effective because of placebo and other factors. As there was some concern about baseline inequality between the groups further research using tighter inclusion criteria should attempt to replicate the result and examine if a dose response may exist.

Initial hospitalisation for atrial fibrillation in Aboriginal and non-Aboriginal populations in Western Australia

Objective The epidemiology of atrial fibrillation (AF) among Aboriginal Australians is poorly described. We compared risk factors, incidence rates and mortality outcomes for first-ever hospitalised AF among Aboriginal and non-Aboriginal Western Australians 20–84 years. Methods This retrospective cohort study used whole-of-state person-based linked hospital and deaths data. Incident hospital AF admissions (previous AF admission-free for 15 years) were identified and subsequent mortality determined. Disease-specific comorbidity histories were ascertained by 10-year look-back. Age-standardised incidence rates were estimated and the adjusted risk of 30-day and 1-year mortality calculated using regression methods. Results Aboriginal patients accounted for 923 (2.5%) of 37 097 incident AF admissions during 2000–2009. Aboriginal patients were younger (mean age 54.8 vs 69.3 years), had lower proportions of primary field AF diagnoses and higher comorbidities than non-Aboriginal patients. The Aboriginal and non-Aboriginal age-standardised incidence rates per 100 000 for men 20–54 years were 197 and 55 (ratio=3.6), for women 20–54 years were 122 and 19 (ratio=6.4), for men 55–84 years were 1151 and 888 (ratio=1.3), and for women 55–84 years were 1050 and 571 (ratio=1.8). While 30-day mortality was similar, crude 1-year mortality risks in Aboriginal and non-Aboriginal patients were 20.6% and 16.3% (adjusted HR=1.24) and 14.4% and 9.9% in 30-day survivors (adjusted HR=1.58). Conclusions The incidence (particularly at young ages) and long-term mortality following hospitalised AF is significantly higher in Aboriginal people. Better control of the antecedent risk factors for AF, improved detection and management of AF itself and prevention of its complications are needed.

Early Trauma Management Skills in Australian General Practitioners

Background:  General practitioners (GPs) have a role in the early management of major trauma in rural Australia. The Early Management of Severe Trauma (EMST) course fulfils their educational needs by providing skills for the systematic management of the seriously injured patient. However, with any skill there is a natural loss over time. This study surveyed GPs who have completed the EMST course to determine their confidence in trauma management.

Transfers to metropolitan hospitals and coronary angiography for rural Aboriginal and non‐Aboriginal patients with acute ischaemic heart disease in Western Australia

BackgroundAboriginal people have a disproportionately higher incidence rate of ischaemic heart disease (IHD) than non-Aboriginal people. The findings on Aboriginal disparity in receiving coronary artery procedures are inconclusive. We describe the profile and transfers of IHD patients admitted to rural hospitals as emergency admissions and investigate determinants of transfers and coronary angiography.MethodsPerson-linked hospital and mortality records were used to identify 28-day survivors of IHD events commencing at rural hospitals in Western Australia. Outcome measures were receipt of coronary angiography, transfer to a metropolitan hospital, and coronary angiography if transferred to a metropolitan hospital.ResultsCompared to non-Aboriginal patients, Aboriginal patients with IHD were more likely to be younger, have more co-morbidities, reside remotely, but less likely to have private insurance. After adjusting for demographic characteristics, Aboriginal people with MI were less likely to be transferred to a metropolitan hospital, and if transferred were less likely to receive coronary angiography. These disparities were not significant after adjusting for comorbidities and private insurance. In the full multivariate model age, comorbidities and private insurance were adversely associated with transfer to a metropolitan hospital and coronary angiography.ConclusionDisparity in receiving coronary angiography following emergency admission for IHD to rural hospitals is mediated through the lower likelihood of being transferred to metropolitan hospitals where this procedure is performed. The likelihood of a transfer is increased if the patient has private insurance, however, rural Aboriginal people have a lower rate of private insurance than their non-Aboriginal counterparts. Health practitioners and policy makers can continue to claim that they treat Aboriginal and non-Aboriginal people alike based upon clinical indications, as private insurance is acting as a filter to reduce rural residents accessing interventional cardiology. If health practitioners and policy makers are truly committed to reducing health disparities, they must reflect upon the broader systems in which disparity is perpetuated and work towards a systems improvement.

Impact of behavioural risk factors on death within 10 years for women and men in their 70s: absolute risk charts

BackgroundEstimates of the absolute risk of death based on the combined effects of sex, age and health behaviours are scarce for elderly people. The aim of this paper is to calculate population based estimates and display them using simple charts that may be useful communication tools for public health authorities, health care providers and policy makers.MethodsData were drawn from two concurrent prospective observational cohort studies of community-based older Australian women (N = 7,438) and men (N = 6,053) aged 71 to 79. The outcome measure was death within ten years. The predictor variables were: sex, age, smoking status, alcohol consumption, body mass index and physical activity.ResultsPatterns of risks were similar in men and women but absolute risk of death was between 9 percentage points higher in men (17 %) than in women (8 %) in the lowest risk group (aged 71–73 years, never smoked, overweight, physically active and consumed alcohol weekly) and 21 % higher in men (73-74 %) than women (51-52 %) in the highest risk group (aged 77–79 years, normal weight or obese, current smoker, physically inactive and drink alcohol less than weekly).ConclusionsThese absolute risk charts provide a tool for understanding the combined effects of behavioural risk factors for death among older people.