In This Issue

A dangerous crowd

Access block, where emergency departments become overcrowded due to an inability to move admitted patients into the wards, has been the bane of public hospitals for some time. We also know that, in times of access block, admitted patients are likely to have longer hospital stays, but new research from two different Australian hospitals (Richardson, “Increase in patient mortality at 10 days associated with emergency department overcrowding” and Sprivulis et al, “The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments”) raises the stakes even further. Using different methods both studies reveal that hospital overcrowding is associated with an increase in mortality for admitted patients. To ease the squeeze, Cameron suggests strategies to reduce hospital demand and optimise bed capacity (→ Hospital overcrowding: a threat to patient safety?).

Islets in the stream

Pancreatic islet cell transplantation has been in the pipeline for about 40 years, with reports of moderate success from overseas in the past decade. O’Connell et al have conducted the first Australian trial, performing transplants on six patients between October 2002 and February 2005. They report their results in “Clinical islet transplantation in type 1 diabetes mellitus: results of Australia’s first trial”.

My syphilitic heart

In post-penicillin Australia, syphilis is not the usual diagnosis that springs to mind when assessing a patient with coronary artery or valvular heart disease. In this issue’s Lesson from practice, “A pox on the heart: five cases of cardiovascular syphilis”, Tong et al reveal that syphilitic heart disease is not that rare, as illustrated by several recent cases.

Pragmatic paradigms

We all have patients whose medical management lies outside accepted guidelines — obese patients who love their food too much, or lifelong, addicted smokers with heart disease. In practice we do our best to work with these people within the limits of the lifestyle changes they are willing or able to make, but, in the cold light of evidence-based practice guidelines, we know we have failed. Hayhow and Lowe say it shouldn’t be like this. Harm reduction is standard practice when dealing with patients with drug and alcohol problems, so why not apply it to the lifestyle factors that contribute to chronic disease (→ Addicted to the good life: harm reduction in chronic disease management)?

Hallmarks of hereditary

Of the two main familial syndromes associated with bowel cancer, hereditary non-polyposis colorectal cancer has been the most difficult to detect. As the importance of family history in young patients with bowel cancer has become better understood, family cancer clinics and genetic testing are playing a role in identifying people at risk. Along with this, as described by Kirk, Australian researchers are leading the field in observing, and testing for, specific tumour characteristics that are associated with the syndrome (→ How can we best detect hereditary non-polyposis colorectal cancer?).

New approaches to breast cancer

Do you know anything about the use of magnetic resonance imaging in breast cancer detection, or the relative merits of core needle biopsy and fine needle aspiration biopsy for histological diagnosis? What about the latest on adjuvant therapies and reconstruction? After reading Houssami et al’s article “The prevention, detection, and management of breast cancer”, you will be ready to advise your patients on the use of these modalities.

Redefining the doctor

Recently, a working party of the Royal College of Physicians of London produced a report entitled: Doctors in society: medical professionalism in a changing world, which sought a rethink of what medical professionals should strive to be and do. In “New ideas about medical professionalism”, Sir Donald Irvine, past chairman of the UK’s General Medical Council explains why redefining the ideal doctor is so important, but cautions that the report’s recommendations do not go far enough towards protecting patients’ interests.

Counting the wounded

One of the areas of health disadvantage for Indigenous people is known to be high rates of injury, but difficulties with Indigenous status identification have precluded large scale quantification of the problem. In “Injury profiles of Indigenous and non-Indigenous people in New South Wales”, Clapham et al use NSW Health data to show that, between 1999 and 2003, Indigenous people had higher rates of hospitalisation and death from injury in all but the eldest age-group, peaking at double the rate for 25-44-year-olds. This group was also five times more likely to be hospitalised or to die from interpersonal violence. Now the statistics are on the record, it’s time for remediation to begin.

More than a spectator

In a 1999 Australian study, 5% of people who participated in sporting activities over a two week period sustained an injury, about a quarter of whom required treatment. Not surprisingly then, in this issue’s MJA Practice Essentials — Sports Medicine article, "6. Doctor on the sidelines", Verrall et al report that there are plenty of jobs for doctors who wish to cover sports events in Australia. If you decide to volunteer, you might want to take their comprehensive guide along with you.

Another time . . . another place

The climate of a hospital always has within it some wafts of fear.