Geoffrey P. Sayer

Relative Toxicity of Beta Blockers in Overdose

OBJECTIVE To compare the toxicity of beta blockers in overdose and to identify clinical features predictive of serious toxicity. DESIGN Comparison of clinical data collected prospectively on a relational database of subjects presenting to hospital with self-poisoning, coroners data and prescription data. SETTING Newcastle and Lake Macquarie, Australia, 1987-1995. MAIN OUTCOME MEASURES Death, seizure, cardiovascular collapse, hypoglycemia, coma and respiratory depression. SUBJECTS Fifty-eight self-poisonings with beta blockers and two deaths investigated by the coroner with evidence of propranolol poisoning. RESULTS All patients who developed toxicity did so within six hours of ingestion. The use of ipecac was temporally associated with cardiorespiratory arrest in one patient. Propranolol was the only beta blocker associated with seizure; of those who ingested more than 2 g of propranolol, two thirds had a seizure. There was a significant association between a QRS duration of > 100 ms and risk of seizures. Propranolol was over represented in beta blocker poisoning when prescription data were also examined. Propranolol was the only beta blocker associated with death. Propranolol was taken by a younger age group. CONCLUSIONS Propranolol should be avoided in patients at risk of self-poisoning. Propranolol poisonings should be observed closely for the first six hours post ingestion. Syrup of ipecac should not be used to decontaminate the gastrointestinal tract after beta blocker overdose.

Sex differences in morbidity: A case of discrimination in general practice

Several factors influence sex differences in morbidity and general practice utilization rates. These factors are of a biological, social and behavioural nature and have differential effects on varying morbidity types. Secondary analysis of data from the Australian Morbidity and Treatment Survey 1990-91, was conducted using multiple logistic regression to discriminate female from male patient encounters in general practice. This approach considered possible confounding influences of GP and patient characteristics. The results showed there was a tendency for larger differences in the types of problems managed than in the types of reasons for encounter presented. Morbidity related to the reproductive, genitourinary and neurological systems, the blood, and of a psychological and social nature were significant contributors to female poor health and service utilization. Females were also more likely to present with digestive, cardiovascular and respiratory problems, while males were more likely to have digestive and cardiovascular problems managed. Furthermore, males were more likely to present skin complaints and have them managed. The potentially higher rates for males in cardiovascular, digestive, skin and respiratory morbidity not only reflect biological differences, but suggest differences in health reporting, utilisation and illness preventive attitudes.

Sex differences in prescribed medications: Another case of discrimination in general practice

Biological, social and behavioural factors influence doctors to prescribe different types of medications to male and female patients. Secondary analysis of data from the Australian Morbidity and Treatment Survey 1990-1991 was conducted using multiple logistic regression to discriminate male and female patient encounters in general practice. The approach used considered possible confounding influences of GP and patient characteristics. The results showed that females were significantly more likely than males to receive prescriptions for: antibiotics; hormones; drugs affecting the central nervous, cardiovascular and urogenital systems; drugs for allergy and immune disorders; ear and nose topical preparations, and skin preparations, even after taking into account morbidity differences. If males and females were treated according to their presenting problems, differences in morbidity patterns would account for the management differences. However, the present investigation would suggest that GP and patient behaviours are also important factors that lead to differences in the prescriptions received by male and female patients in general practice.

Co-morbidity in general practice.

Background: Co-morbidity, or the presence of more than one clinical condition, is gaining increased attention in epidemiological and health services research. However, the clinical relevance of co-morbidity has yet to be defined. In general practice, few studies have been conducted into co-morbidity, either at a single health care encounter, an episode of care, or for a defined time period. Aims: To describe the major co-morbidity cluster profiles recorded by general practitioners. Another aim of this study is to describe the common clusters of co-prescribing. Methods and results: Twelve month data from patients attending 156 GPs from 95 practices around a six month period of January to June 2003 were analysed. This represented 840 961 encounters from about 200 000 individual patients at these participating practices. Co-morbidity and co-prescribing cluster profiles are represented by problems managed and reasons for prescribing for the top 10 presentations and top 10 prescribed drugs in the study period. Conclusions: By analysing the 10 most prevalent problems and 10 most prevalent drugs prescribed in consultations in a community sample, other co-morbidities that are particular to general practice, for example hypertension and lipid disorders, can be uncovered. Whether these clusters are causally related or occur by chance requires further analysis.

Do very sick neonates born at term have antenatal risks

Aims. 1. Ascertain antenatal and intrapartum risk factors for term neonates ventilated primarily for respiratory problems. 2. Describe the neonatal morbidity and mortality.

Score of neonatal acute physiology as a measure of illness severity in mechanically ventilated term babies.

The objectives of this population‐based, case‐control cohort study were to describe the use of the score of neonatal acute physiology (SNAP) as a measure of illness severity in mechanically ventilated term infants, to compare the SNAP scores of the different diagnostic groups, to assess the contribution of the individual SNAP items to the overall SNAP severity category, and to assess SNAP as a predictor of mortality and neonatal intensive care unit (NICU) resource utilization (length of stay (LOS) and duration of ventilation (LOV)). The study was carried out in Sydney and four large rural/urban health areas in New South Wales, Australia. The subjects—182 singleton term infants with no major congenital anomalies—were admitted to a tertiary NICU for mechanical ventilation. Highest mean (SD) SNAP scores occurred in infants ventilated for meconium aspiration (18 (9)), and perinatal asphyxia (17 (9)), compared with pulmonary hypertension (14 (6)) and respiratory distress syndrome (13 (5)). The individual SNAP items that contributed most to SNAP moderate and severe categories were blood gas items, creatinine, urine output, blood glucose, and seizures. Predictors of death included total SNAP score, individual SNAP items (urine output, pH, Oxygenation Index (OI)), 5‐min Apgar, gestational age >40 wk, growth restriction, and ventilation for asphyxia/apnoea. SNAP alone was not a good predictor of NICU resource utilization (LOS, LOV) in term infants. The best predictors were LOV for LOS, and a combination of SNAP and the reason for ventilation for LOV.

Do very sick neonates born at term have antenatal risks? 1. Infants ventilated primarily for problems of adaptation to extra-uterine life.

Aims. 1. Ascertain antenatal and intrapartum risk factors for term neonates ventilated primarily for ‘perinatal asphyxia’. 2. Describe the neonatal morbidity and mortality.