In This Issue

Stroke care bundle

The acute care of patients presenting with suspected stroke or transient ischaemic attack has evolved rapidly over the past few years — so much so that the National Institute of Clinical Studies has developed and released an emergency department stroke and transient ischaemic attack care bundle (Weeraratne and colleagues, “The NICS care bundle: aiming to improve the initial care of patients with stroke and transient ischaemic attack”). A care bundle is a collection of best-practice recommendations (not as comprehensive as a guideline) that focuses on highlighting practice gaps and triggering other best practice activities. The bundle does not include thrombolysis and stroke unit care, but the authors say their recommendations will act as a conduit to these important interventions where they are available.

Pneumococcal herd immunity?

Age-specific pneumococcal vaccination programs appear to be benefiting people of all ages in north Queensland. In 2005, several years after their provision for the Aboriginal and Torres Strait Islander population, a 7-valent pneumococcal conjugate vaccine (7vPCV) for children and a 23-valent pneumococcal polysaccharide vaccine (23vPPV) for people aged ≥ 65 years were made freely available to non-Indigenous Australians. A before-and-after analysis by Hanna and colleagues (→ Invasive pneumococcal disease in non-Indigenous people in north Queensland, 2001-2009) shows a significant decline in the overall incidence of invasive pneumococcal disease (IPD) in north Queensland, reflecting declines in 7vPCV serotype IPD in all age groups. The 23vPPV seemed to have a direct effect in those eligible to receive it but contributed less to herd immunity: there was a non-significant decrease in 23vPPV-only serotype IPD for adults aged ≥ 65 years, and a marked increase for adults aged 15-64 years. Newer conjugate vaccines are on their way, and the authors say these could provide even more population protection.

Chameleon unmasked

The patient described by Lim and colleagues (→ Catching a chameleon: IgG4-related systemic disease) was ravaged by a nameless multi-organ inflammatory disease for 20 years, before medical science finally caught up with him. IgG4-related systemic disease (IRSD) has only recently been described but its new name comes with effective management, so it’s important to make the diagnosis.

Understanding male ageing

A Sydney-based study of men aged 70 years and older confirms that, while osteoporosis is common, it is rarely treated in this group. A quarter of the men enrolled in the Concord Health and Ageing in Men Project met one or more of the Pharmaceutical Benefits Scheme criteria for osteoporosis treatment, generally on the basis of vertebral deformities (Bleicher et al, “Prevalence and treatment of osteoporosis in older Australian men: findings from the CHAMP study”). Most were unaware of their diagnosis, and the use of bisphosphonates (10%), calcium (14%) and vitamin D (7%) was low.

Clinicians have been toying with the idea of “andropause” for years. In “Testosterone and male ageing: spinning the wheels”, Handelsman likens the recent publication of two studies in the same issue of the New England Journal of Medicine to “spinning the wheels”, by placing one foot on the accelerator and the other on the brakes for testosterone replacement: an observational study found an association between low testosterone levels and several sexual symptoms and used the term “late-onset hypogonadism”, while a clinical trial of testosterone supplementation was terminated early due to excess adverse cardiovascular effects. What do these findings mean for testosterone prescribing in Australia? While there is a danger now of confusion or, worse still, commercial opportunism, testosterone use for “andropause” should still only happen in clinical trials, says Handelsman.

Soy milk, seaweed and the food detectives

Iodine deficiency due to depleted dietary sources is a problem in a number of Australian regions, but this issue’s Notable Cases (→ Iodine toxicity from soy milk and seaweed ingestion is associated with serious thyroid dysfunction) is a reminder that patients presenting with thyroid dysfunction might actually be suffering from iodine toxicity. Crawford and colleagues saw a number of patients with abnormal thyroid function and one thing in common: the ingestion of a popular brand of soy milk whose production included fermentation in seaweed. Included in the series are also some cases of neonatal hypothyroidism related to maternal ingestion of the same soy milk, and seaweed soup.

Desperately seeking disruption

“New technologies do not automatically lead to improvements in accompanying work practices, organisational structures and models of care”, say Westbrook and Braithwaite (→ Will information and communication technology disrupt the health system and deliver on its promise?). They must be “matched by new skills and behaviours”. This view will resonate with many doctors in regard to the integration of an ever-expanding array of information and communication technologies (ICTs) into patient care. The authors believe that, in order to reach their full potential, ICTs need to be used to “disrupt” entrenched systems, revolutionising rather than supporting the way things are done. Considerable resources have been allocated to e-health in Australia. In “E-health in Australia: time to plunge into the 21st century”, Pearce and Haikerwal discuss the challenges faced by the National E-Health Transition Authority and others in creating an integrated and secure electronic network to support and enhance our health system.

Another time . . . another place

The “"Geriatric Giants"” -— immobility, incontinence, instability and intellectual deterioration.

Bernard Isaacs