In This Issue

Work with Heart

The World Heart Federation’s World Heart Day is 27 September 2009. This year, as part of a “Work with Heart” campaign, adults will be encouraged to visit a health care professional to find out their risk of coronary heart disease. In this issue, Tonkin and colleagues (→ Maximising the effectiveness and cost-effectiveness of cardiovascular disease prevention in the general population) introduce us to Australia’s National Vascular Disease Prevention Alliance’s recently released evidence-based guidelines for assessing absolute cardiovascular risk; and Peiris and colleagues (→ Cardiovascular disease risk management for Aboriginal and Torres Strait Islander peoples in primary health care settings: findings from the Kanyini Audit) and Webster and colleagues (→ Gaps in cardiovascular disease risk management in Australian general practice) show us the gaps we need to close to achieve ideal screening, prescribing and treatment for cardiovascular risk factors in our Indigenous and general populations, respectively.

Targeting glycated haemoglobin

A new position statement from the Australian Diabetes Society offers guidance to clinicians who want to individualise a patient’s glycaemic targets. For example, in a patient who suffers from recurrent severe hypoglycaemia, the glycated haemoglobin (HbA1c) target could be set at ≤ 8.0% (ie, above the general target of ≤ 7.0%) (→ Position statement of the Australian Diabetes Society: individualisation of glycated haemoglobin targets for adults with diabetes mellitus). In a Diagnostic Dilemma, Dimeski and colleagues remind us of some of the caveats associated with measuring glycaemic control; in particular, that the presence of an abnormal haemoglobin variant can lead to an unusually low or high HbA1c level that is discordant with a patient’s clinical status (→ A case of discordant HbA1c: a method-dependent error) .

Coming to Australia

Cases of multidrug-resistant tuberculosis are on the increase, according to Lavender and colleagues. Between 1998 and 2007, 31 patients in Victoria were diagnosed with multidrug-resistant tuberculosis, with more cases detected towards the end of the study period; 27 were born in countries with a high risk of TB occurrence. Of the 20 patients with pulmonary disease, 12 had smear-positive sputum and were therefore likely to be highly infectious. Lavender and colleagues outline a number of approaches that Australia could consider in addressing this issue (→ Multidrug-resistant tuberculosis in Victoria: a 10-year review).

Not your everyday analogy

What could our health care system have in common with an old-growth forest ecosystem? According to Dietz, who cites the work of retired ecologist Crawford Holling, both systems started out small and simple, increasing in complexity over time in response to changing conditions. Having reached their peak in efficiency and interconnectedness, any further increase in complexity becomes a negative. Systems lose their resilience, becoming “brittle” instead. Contrary to recommendations made in the recent Garling report, Dietz says it’s now time for us to opt for less regulation in health care delivery and smaller, more resilient systems. “It’s time to dismantle area health services and hand back responsibilities to those at the coalface, not for a federal takeover and another bout of increasingly desperate centralisation.” (→ Our public health system: an accident waiting to happen?)

Under close observation

In young women at high risk of developing breast cancer, magnetic resonance imaging (MRI) of the breast can detect more lesions than mammographic x-ray or high-resolution ultrasound examination, say Saunders and colleagues. In a pilot study, they used all three screening modalities in a special 2-year surveillance program offered to 72 women in Western Australia aged 50 years or younger who were at high risk of breast cancer. Of the 15 lesions detected during the program, all were visible on MRI and four were only detected by MRI; only three of the lesions detected were clinically significant. Some Medicare benefits have been available for breast MRI since 1 February 2009 (→ A pilot study of trimodality breast imaging surveillance in young women at high risk of breast cancer in Western Australia).

Who will pay?

Even with Australia’s subsidised Pharmaceutical Benefits Scheme in place, economic forces are having a profound effect on whether medications are purchased, say Ampon and colleagues. In a 4-year study, they found that concession card holders were about 2.5 times more likely to be dispensed a prescription for inhaled corticosteroids than general beneficiaries (ie, those who do not have a concession card). The patient copayment per prescription for general beneficiaries is over six times higher than that for concession card holders ($23.10–$29.50 versus $3.70–$4.70 at the time of the study). The researchers say their findings imply that cost is a barrier to the purchase of inhaled corticosteroids for managing obstructive lung disease, independent of socioeconomic status (→ Cost is a major barrier to the use of inhaled corticosteroids for obstructive lung disease).

Another time . . . another place

The tubercule bacillus bore cheerfully a degree of medication which proved fatal to its host!

Edward Livingston Trudeau, 1916