Abstracts - Adult Medicine

In program order:

Urinary Incontinence  Monday 7.30-8.30
Glenise Berry

Urinary incontinence is the involuntary loss of urine so severe as to have social and/or hygiene consequences. This major problematic symptom affects a broad range of people but has most impact to the very elderly living in the community and in nursing homes. The prevalence is thought to affect about 800,000 Australians, 10% of men, 15% of women but there is significant under reporting. There is a high incidence in hospitalised patients and an even greater incidence in nursing home residents. If pre-morbid continence is normal, incontinence is likely to be reversible. If incontinence is established it can be classified as functional stress, urge and overflow with overlap. The most common cause of incontinence in the elderly population produces a symptom of urge incontinence and is associated with detrusor hyperreflexia. Stress incontinence occurs when dysfunction of the bladder outlet leads to leakage of urine, as intra-abdominal pressure is raised above urethral resistance. Overflow incontinence occurs when intravesical pressure exceeds uretheral pressure only at high bladder volumes greater than 400mls, with high residual urines greater than 50mls. Mixed incontinence combines symptoms of these entities, typically stress and urge in females and urge with outlet obstruction in males.

Core evaluation in a patient with incontinence requires documentation of full post history, and present complaints followed by a full physical examination. Investigation includes core measures which are mostly sufficient for diagnostic formulation. Specialised investigations include cystoseopy, IVP, transrectal prostatic biopsy, simple urodynamics and multichannel urodynamics. Multichannel urodynamics is the gold standard for documentation of bladder and sphincter function.

Management of urinary incontinence is complex and is based on an accurate diagnosis facilitated through the multidisciplinary continence clinic in selected cases. The role of the continence advisor especially in hospitals and nursing homes, should not be underestimated. Cases will be presented to facilitate discussion of specific complex incontinence problems.

In-between Illness and the HDU  Monday 7.30-8.30
Robert Boots

Seriously ill, "at risk" or complicated patients not admitted to the ICU are traditionally cared for close to the nursing station. Older and sicker patients are managed in hospital with increasingly complex managements. Clinical care is increasingly organised with patients grouped together depending upon care needs rather than traditional factors such as medical or surgical specialty. Establishing a high dependency care unit (HDU) is common where intensive care admission is constrained. The establishment of a new HDU service requires attention to the change management of the infrastructure and care delivery. Casemix and service delivery specifications need to be defined and agreed upon within the institution. Defined working relationships with the ICU and primary care teams are essential. This review aims to examine the issues to be considered in establishing new or extending existing services.

Management of Overdoses  Monday 7.30-8.30
Kevin Humphrey

One of the great challenges in clinical toxicology currently is staying one step ahead of that bright young animal, the street pharmacologist. It is a mistake to believe that all people that use chemicals in order to experience the effects and side effects for pleasure are unintelligent. Many young and not so young people explore aspects of pharmacology either during university study or out of interest. They discover what they believe to be unique potential interactions that may extend or increase the activity of their chosen recreational agent. Unfortunately this information is then made available by word of mouth or by the Internet. Less intelligent or more damaged recreational users who do not understand the potential for these interactions to result in toxicological emergencies gain access to this information. And so comes trouble!

Some examples of the information available on the Internet and the ease of access will be presented and then some example cases. The cases will demonstrate the similarities and differences between a standard toxicological overdose presentation, and an injudicious recreational event producing the same outcome. This will be followed with a brief discussion of the current management suggestions for this increasingly common toxicological presentation.

Finally, a brief discussion of other interesting drug combinations that are coming to notice overseas, and their potential to spread into the Australian illicit and recreational drug scene.

Stresses of Medical Practice  Wednesday 7.30-8.30
Brian Kelly and Frank Varghese

This session will focus on the emotional demands of medical practice with particular emphasis on the common dilemmas encountered in the doctor-patient relationship using case vignettes. The psychological problems experienced by clinicians will also be reviewed, identifying the contributing factors and common obstacles to the recognition and appropriate care of doctors when these occur.

Respiratory Update: Non-invasive Ventilation  Monday 11.00-12.30
Robert Boots

Non-invasive ventilation has been increasingly used in the management of acute and chronic respiratory failure. It represents ventilatory support using various modes using a facemask. From beginnings in the intensive care unit, it has been applied to an increasing number of high dependency and general ward managements. This review is aimed to define the indications for non-invasive ventilation in acute and chronic respiratory disease, what modes are available and how they differ, the practicalities of how it is done, and resource and intensive care unit liaison implications.

Respiratory Update: Respiratory function tests  Monday 11.00-12.30
Paul Zimmerman

There is now a sound physiological basis for tests of forced expiration reflecting the mechanical properties of the lungs. When graphically displayed as volume-time or flow-volume curves, the quality of the record can be assessed as well as the pattern of impairment. Flow-volume loops can demonstrate airflow obstruction and whether it is intrathoracic, extrathoracic, variable or fixed. For example, an obstruction to a major airway may be suspected and differentiated from asthma.

Although a >15% increase in FEV_1.0 with bronchodilator traditionally has signified reversibility, functionally significant reversibility in chronic airflow obstruction may, in some patients, only be recognised via improvements in inspiratory capacity measured in a body plethysmograph.

The magnitude of changes in spirometry, which are clinically significant, depends upon the pattern and severity of impairment as well as the intervals between repeated measurements.

The presence of a normal ventilatory capacity does not exclude other causes of dyspnoea.
Bronchoprovocation testing may indicate the severity of asthma, is useful in screening individual's for underwater diving and can aid in elucidating the causes of a chronic cough or intermittent dyspnoea.

The diffusing capacity, a measure of the rate of uptake of trace amounts of carbon monoxide, reflects the amount of accessible haemoglobin in the pulmonary capillary bed. When used in conjunction with alveolar volume, it can differentiate areas of non-ventilated lung from ventilated areas containing diffuse abnormalities, such as emphysema or an interstitial process. Conditions that affect the pulmonary vascular bed, such as pulmonary hypertension, thromboemboli or chronic cardiac failure can cause reduced values. Anaemia, recent smoking and small alveolar volumes may also confound the results.

In patients with orthopnea, without evidence of cardiac failure, a difference between supine and erect vital capacity exceeding 20% suggests diaphragm weakness. This may be confirmed by reduced maximal inspiratory and transdiaphragmatic pressures.

Genetics Update: Basic Genetics  Monday 2.00-3.30
Stephen Withers

Most clinicians are familiar with autosomal and X-linked dominant and recessive inheritance, including variability due to reduced penetrance and variable expression. Since Mendel's initial studies were performed on peas, it is not surprising that genetics in humans has proven more complex. Molecular genetics has been particularly useful in explaining non-Mendelian forms of genetics. Concepts such as children being born with autosomal recessive disorders when only one parent is a carrier, fathers passing X-linked disorders onto their sons, parents having two children with the same autosomal dominant disorder even though neither parent is affected or carries the gene in their blood can all now be explained by uniparental disomy and gonadal mosaicism rather than non-paternity. The variation in severity of some disorders, depending on which parent passes the gene on, is now known to be due to imprinting. Some genes are unstable and may change size when passed to the offspring, often with the sex of the transmitting parent being important, and this is the explanation for the phenomenon of anticipation. Mitochondria have their own set of genes which are inherited from the mother and can cause disease. The mitochondrial genes can vary between mitochondria within the one cell, in adjacent cells and between tissues, which makes diagnosis and interpretation of results difficult. Molecular genetics is also useful in Mendelian disorders and can be used to identify carriers of genetic disorders, non-penetrant individuals and can be used for prenatal or preimplantation diagnoses. The Human Genome project offers the potential for further understanding of genetic disorders and new approaches to therapy via pharmacogenetics.

Genetics Update: Common Genetic Diseases in Adults
 Monday 2.00-3.30
John MacMillan

The distinction between genetic (inherited) and acquired disease continues to become more questionable as we identify inherited genetic variations which increase our susceptibility to developing a number of disorders. In conventional thinking, a 'common' genetic disease in adults might be neurofibromatosis type I which has a population prevalence of 1 in 4000. The prevalence of hereditary hemochromatosis by clinical or pathological criteria is only 1 in 20,000 hospital admissions, but 1 in 250 males if based on transferrin saturation and ferritin levels. 1 in 30 of the population are heterozygous for the Factor V Leiden mutation which increases susceptibility (relative risk 3-4) to venous thrombosis. But is it correct to define Factor V Leiden as a genetic disease in its own right? I would argue not, just as I would argue that the presence of homozygous C282Y in the absence of clinical iron overload does not constitute hemochromatosis. As a 'model disease' on which population screening programs may be developed it is important to realise that 50% of C282Y homozygotes are not symptomatic and 17% do not meet the diagnostic criteria for hemochromatosis. Individuals who are H63D homozygotes or C282Y+/- with H63D-/+ (compound heterozygotes) are rarely affected with clinical disease (1%). If we reconsider these changes in the HFE gene as markers of increased susceptibility to iron overload then targeted therapeutic intervention takes on a new meaning. Rather than just advocating venesection for those with documented iron overload we should consider health education strategies designed to reduce alcohol consumption, dietary and supplemental iron intake and modify vitamin-C intake. Long term studies will be needed however to assess the utility of such measures in reducing the disease burden from hemochromatosis.

Genetics Update: Genetics of Cancer  Monday 2.00-3.30
Barbara Leggett

Cancer is always a genetic disease at the level of the single cell and sometimes at the level of the whole individual. Cells behave in a malignant manner because of genetic alterations and sometimes some of these alterations are inherited. It is estimated that at least 4 to 6 individual genetic changes are required for an invasive malignancy to develop. This process occurs through clonal evolution where genetic changes giving a selective growth advantage in a particular microenvironment are cause the progeny of this cell to expand and take over the tumour. An increased level of genetic instability favours the development of genetic changes and increases the pace of tumour development.

Genetic changes consist of activating mutations or increased expression of oncogenes and inactivation of tumour supressor genes by combinations of deletion, mutation and methylation. Particular tumour types have a favoured set of oncogenes and tumour suppressor genes which tend to be altered in that tumour type. However each tumour is individual and has a characteristic genetic "signature" which is related to its biological behaviour and response to treatment. Characterisation of tumours using microarrays may become an efficient and clinically useful tool in the future.

Most inherited cancer syndromes are due to inherited mutations in tumour suppressor genes. The only known exception is MEN 2 which is due to an activating mutation in the RET oncogene. Much progress has been made in understanding the genes mutated in common hereditary cancer syndromes such as Familial Adenomatous Polyposis, Hereditary Non-polyposis Colorectal Cancer and inherited breast cancer. Testing of blood samples from affected patients is now clinically available and can be used to confirm the diagnosis of inherited cancer and then to predict whether young "at risk" members of the family have inherited the disease.

Endocrinology Update: Abnormal endocrine tests  Monday 4.00-5.00
Robin Mortimer

The feedback relationships between hormones secreted by target glands and their control systems offers a useful framework for analysis and elucidation of incongruous results of endocrine investigations. The hypothalamo-pituitary-thyroid system presents a good example. This session will explore the interpretation of inappropriate thyroid function tests.

Female Health  Tuesday 7.30-8.30
Clare Boothroyd

Clinicians caring for female patients are mindful of unique aspects of women's health including the preservation of fertility, the possibility of unplanned, future and/or current pregnancy and the increased longevity of women with the implications of today's management on geriatric health in the future. Issues to be covered in this session include newer contraceptive choices for women, the preservation of fertility in 2002 and the proactive management of oestrogen deficiency premature or otherwise. All these situations may be encountered in the care of women with medical disorders.

New contraceptive choices include the subdermal progestin implant, (Implanon™) or progestin releasing intrauterine device (Mirena™) and permanent contraception with minimal surgical risk (Essure™).

Survival after chemotherapeutic agents has resulted in an increasing number of women of young age with premature ovarian failure of varying degrees. Issues include preservation of fertility, predicting ovarian reserve and treatment of complications of oestrogen deficiency. Proactive management of reduced bone mass would seem prudent but longitudinal studies are lacking.

The increased prevalence of thrombosis with increased age poses challenges if the use of potentially thrombogenic agents such as oestrogens and selective oestrogen modulators is advocated and this will also be discussed.

Naltrexone and other strategies for addiction  Tuesday 7.30-8.30
John Saunders

Pharmacotherapies have an established place in the treatment of drug dependence and with the rapid developments in our understanding of the neuroscience of addiction, are likely to have a far greater role in the future. Naltrexone, often preceded by rapid opiate detoxification, has achieved great prominence as a treatment for opiate dependence, but remains highly controversial. The 6 - and 12 - month outcome results of a randomised controlled trial of naltrexone versus methadone maintenance will be presented. In essence, it is an effective treatment for those with good motivation to succeed in an abstinence-oriented treatment program, but fewer opiate users are engaged satisfactorily in treatment than with agonist maintenance. Methadone maintenance remains the benchmark treatment for most patients. It reduces deaths, major morbidity, social problems and criminal behaviour by 75%. Buprenorphine, a partial opioid agonist, is a welcome addition to maintenance therapies. There is a huge research effort currently to develop effective pharmacotherapies for pyschostimulant dependence. Pilot studies of amphetamine substitution offer some encouragement but the place of such an approach is far from established. Cannabis antagonists are also undergoing trial, and cannabis maintenance strategies are being considered. Pharmacotherapies should never be applied as the sole form of treatment for drug dependence. Psychosocial support, an empathic approach by staff, and management of comorbid mental health disorders all contribute importantly to achieving good outcomes.

Principles of pain control  Tuesday 7.30-8.30
Bruce Stafford

Control of pain in the setting of cancer related illness is always challenging particularly for patients whose pain is severe enough to warrant admission to hospital. The vast majority of pain problems can be solved in the ambulatory setting with careful titration of opioids and the use of adjuvant analgesics. It should be remembered that therapeutics is but one arm of pain control and that pain management in cancer, as in chronic non-malignant pain is often delivered by a team approach. In cancer related pain, radiotherapy and interventional therapy (spinal opioids and neurolytic procedures) provide significant relief in cases which do not respond easily to systemic drug therapy. The presentation will include a case history as well as a review of currently used opioids (morphine, oxycodone, fentanyl, and hydromorphone) and tramadol. It will also look briefly at the use of some adjuvant drugs in pain management.

Male Health  Tuesday 7.30-8.30
Chris Strakosch

Efforts to restore the vitality of aging males are rooted deep in history and mythology. Use of extract of rooster testes more than 100 years ago predated the use thyroid extract.
During this session several cases will be presented to illustrate the uses and controversies associated with androgen replacement therapy in males. This treatment is now primarily used in symptomatic hypogonadal men, eg patients with congenital hypogonadism such as that of Klinefelter's Syndrome or persons rendered hypogonadal due to pituitary disorders or testicular disease. The use of androgens in otherwise normal, but aging, men continues to attract a lot of interest since many of the hormonal changes found in aged men resemble those of younger men with hypogonadism. Androgens are under investigation for use as male contraception. The endocrinology of male sexual dysfunction will be discussed. More controversial is the use of androgens in patients who have low testosterone levels due to other problems such as Post Traumatic Stress Disorder, depression, obesity or chronic fatigue syndrome. Is there a place for the use of androgens in patients with ischemic heart disease or in patients with hypogonadism and minimal cancer of the prostate? Male athletes who overtrain tend to have a decline in testosterone levels, should they be treated as well?

The HIC criteria for the use of androgens will be discussed as will the various preparations available in Australia.

Screening the Central Nervous System in 5 minutes  Tues 7.30-8.30
Dan McLaughlin

The potential for the neurological examination to be both exhaustive and exhausting is appreciated by most physicians. This presentation will discuss the approaches to the neurological examination based on patient history to limit this procedure to its essential elements. Clinical vignettes will be utilised to highlight the importance of a directed search for clinical signs. Where the neurological examination is undertaken to coplete the general examination, a description of a concise technique will be presented.

Nephrology Update: Renal artery stenosis  Tuesday 9.00-10.30
Richard Gordon

Questions for the practising physician:

1. Why should I bother to look for renal artery stenosis (RAS) in my patients?
2. How do I look for RAS and is my looking "cost effective" and safe?
3. If I find that my patient has RAS, how do I decide whether the risks associated with an intervention outweigh the possible benefits? How do I decide between different interventional techniques such as angioplasty, stenting, vascular surgery and nephrectomy?
4. Can I be comforted by clear-cut evidence on the incidence of RAS in my patients, and benefits and risks of investigating and treating "medically" versus "intervention"?
5. Is long term follow-up of my patient in terms of renal function and hypertension essential?
6. All this is rather daunting. Are there any straight-forward patient s with RAS, who have a stunningly successful outcome?
   

Nephrology Update: Problems in patients on dialysis
 Tuesday 9.00-10.30
Carmel Hawley

Dialysis therapies have been available for over three decades and major advances in the management of patients with End Stage Renal Failure (ESRD) have occurred in this time. Renal failure is associated with a number of difficult management problems, and the dialysis process itself is associated with specific management issues.

We have seen improvements in dialysis including major advances in haemodialysis membranes (more efficient solute clearance and more biocompatable), technological machine advances and greatly improved water purification treatments. There is a growing trend towards more frequent haemodialysis than the conventional three times a week approach in an attempt to improve dialysis survival and complications. Peritoneal dialysis has changed enormously in recent years with a move towards automated cyclers to increase dialysis prescription and new dialysate solutions to overcome specific problems such as ultrafiltration failure.

Which Antibiotic?  Tuesday 11.00-12.30
Wendy Munckhof and Christopher Coulter

This interactive keypad session will be moderated by two infectious disease physicians / microbiologists who are active in clinical practice. It will be a Cook's tour of new, controversial and topical aspects of antimicrobial therapeutics.

Topics to be covered may include antimicrobial therapy of bacterial meningitis and community-acquired pneumonia, the role of the new quinolones particularly in respiratory infections, oral therapy of methicillin-resistant Staphylococcus aureus infection including community-acquired strains, management of vancomycin-resistant enterococcal infections, treatment of infection caused by Stenotrophomonas (Xanthomonas), choice of antibiotics for home intravenous antibiotic therapy, and the role of the new antifungal drugs.

Neurology Update: Cognitive impairment  Tuesday 11.00-12.30
Christopher Davis

The Australian population is increasingly surviving in to old age but much of this achievement is being eroded by the increasing emergence of significant deficits in higher cortical function. Diagnosis may be relatively straightforward in advanced dementia although good management is seldom simple. It is however becoming increasingly important to recognize and diagnose early cognitive impairment because of the potential impact on issues such as driving skills, legal capacity, social relationships and general morbidity. There is also evidence that early diagnosis may allow specific interventions that contribute to better outcomes in a number of domains. In order to do so, it essential for clinicians to accurately differentiate the various syndromes that may present as cognitive impairment.
This presentation will endeavour to provide a concise overview of current knowledge and controversy in this complex and dynamic field, and provide pathway-based guidelines for the prevention, recognition, diagnosis and treatment of brain failure.

Neurology Update: Neurology in the elderly  Tuesday 11.00-12.30
Paul Varghese

The past decade has seen major advances in our knowledge of the basic molecular biology of the dementias and other degenerative disorders such as Parkinson's Disease which are prevalent in the elderly. While much of this knowledge has yet to translate into clinical practice there have been important developments in the pharmacological management of these disorders. Changes in the clinical presentation of these diseases in the elderly and the subtle changes in the neurologic examination of older persons will be discussed. In response to the important ideal of developing objective outcome measures in rehabilitation there has been a push to further develop clinical tools to quantify changes in gait and mobility and thus guide treatment. Some of these measures and their importance in clinical practice will be discussed.

South-East Asian Medicine: Sudden cardiac death  Tuesday 2.00-3.30
Pyatat Tatsunavivat

The sudden death in apparently healthy young males in their sleep has been known as Laitai or Non-Laitai locally in the northeast of Thailand and Laos.

The classical descriptions of this syndrome consists of:

1. Majority of the victims is 20 - 50 years of age.
2. The event commonly associates with sleep mostly happen at the beginning few hours of sleep.
3. Previously healthy victim.
4. There is agonal respiration before the victim succumb.

Awakening is difficult or unsuccessful; some may experience recurrence and eventually leading to death shortly after he has survived the first episode. Necropsy yields no explainable cause of death.

Recommendations: Every sudden death victim must undergo extensive investigation to exclude structural heart disease including programmed electrical stimulation (PES). For those without definite cause, but has inducible ventricular fibrillation (VF), an AICD should be implanted.
ECG Brugada sign should be searched on the victims and relatives, particularly male siblings, using both standard 12 lead surface ECG and higher intercostal chest leads with and wtihout sodium channel blockers provocative test. If the test is positive they should be advised of the risk of having arrhythmic event. Since current data do not allow us to define the prevalence of asymptomatic Brugada sign carriers to draw conclusion about their treatment, the choices of further investigation and management should be clarified among these carriers. However, further research in this locally prevalence syndrome is clearly needed and this message is to be delivered positively to potential research subjects in order to increase the research participation and enable researchers to make major advances to solve one of the major local health problems.

Cardiology Update: Pacemakers  Tuesday 4.00-5.30
Wayne Stafford

Major advances in cardiac pacing over the past five years have included both significantly extended indications for pacemaker implantation, and in technological aspects of pacing. Symptomatic high grade AV block and sick sinus syndrome have been recognised as common clinical problems resulting often in significant symptoms, and are major indications for pacemaker implantation. Atrial tachyarrhythmias may in some cases be treated by pacing, both for termination and prevention of further episodes, or for rate control for refractory atrial tachyarrhythmias when combined with AV node catheter ablation. Other newer indications include hypertrophic cardiomyopathy, medically refractory vasovagal syncope, and recently biventricular pacing has been shown to be effective symptomatic therapy for left ventricular dysfunction with significant intraventricular conduction abnormalities, due to either dilated cardiomyopathy or ischaemic heart disease.

In most institutions in Australia, dual-chamber pacing is now the dominant modality, having significant advantages in retaining chronotropic response to exercise, maintaining AV synchrony, and preventing pacemaker syndrome. Pacing leads may be unipolar or bipolar, and either tined or screw-in (active fixation). The majority of leads are steroid eluting, which helps to maintain low pacing thresholds. Bipolar pacing leads are favoured in most institutions because of the absence of muscle stimulation, avoidance of myopotential inhibition, and lower susceptibility to electromagnetic interference. Pacemaker pulse generators have undergone a progressive reduction in size with improved technology in micro-circuitry and battery technology. Modern pulse generators have significantly improved memory capacity, which has proved extremely useful in diagnostic functions such as documentation of atrial and ventricular arrhythmias using stored electrograms, assessment of ongoing pacemaker function such as lead impedance monitoring, rate response, and automatic threshold testing and adjustment of pacing output. These functions are also extremely useful in troubleshooting pacemaker problems or persisting patient symptoms.

In patients with sinus node dysfunction and associated chronotropic incompetence, rate adaptive pacing is available based on a number of sensor types, most commonly activity sensing or accelerometer, and/or respiration minute volume monitoring. Automatic mode switching has been a major advance in preventing tracking of atrial tachyarrhythmias by dual-chamber pacemakers, thereby maintaining a controlled ventricular pacing rate during atrial arrhythmias.

Cardiac pacing continues to evolve using an exciting combination of evidenced-based therapies and technological advances, which have resulted in major benefits for patients with both brady and tachyarrhythmias.

Cardiology Update: Mineralocorticoid forms of hypertension
 Tuesday 4.00-5.30
Michael Stowasser

The past decade has witnessed major advances in our understanding of the pathogenesis of mineralocorticoid excess (ME) and its prevalence among patients with hypertension. Primary ME, which occurs in the absence of increased levels of renin/angiotensin II or ACTH, may be caused by autonomous adrenal overproduction of aldosterone (in primary aldosteronism, PAL) or rarely deoxycorticosterone (DOC; in DOC-secreting adrenal tumors). In other low-renin hypertensive ME-like states, adrenal mineralocorticoid production is reduced, but excessive mineralocorticoid-like activity occurs because cortisol inappropriately gains access to the mineralocorticoid receptor due to inherited or acquired 11Beta-hydroxysteroid dehydrogenase deficiency, or because of genetically-determined constitutive activation of the epithelial sodium channel (Liddle's syndrome) or of the mineralocorticoid receptor in the distal nephron.
At the Greenslopes Hospital Hypertension Unit (GHHU), adoption of the policy in 1991 to screen all hypertensives (and not just those with hypokalemia or resistant hypertension) by aldosterone/renin ratio testing led to a tenfold increase in detection rate of PAL (only 22% hypokalemic) and a fourfold increase in rate of removal of aldosterone-producing adenomas (APAs). The GHHU reported a prevalence of PAL of 8.5% among 199 consecutively referred normokalemic hypertensives and 12.5% among 52 antihypertensive drug trial volunteers. The combined GHHU/Princess Alexandra Hospital Hypertension Unit PAL series stands at over 900 patients.

Reliable detection requires that:
(1) the diagnosis is considered in all hypertensives,
(2) samples are collected under standardised conditions of diet, posture and time of day,
(3) medications known to alter the ratio are avoided or their effects taken into account, and
(4) reliable methods (such as fludrocortisone suppression testing) are used to confirm PAL.

Adrenal venous sampling is the only dependable way to differentiate APA from bilateral adrenal hyperplasia. The availability of laparoscopic adrenalectomy and a new selective aldosterone receptor antagonist (eplerenone) represent important advances in management. Elucidation of the genetic mutation responsible for a familial, glucocorticoid-remediable form of PAL and development by the GHHU of a PCR-based diagnostic test has greatly facilitated detection and led to a fuller appreciation of phenotypic diversity and aldosterone regulation in that subtype. The identification of mutations causing another, more common familial variety described by the GHHU in 1991 should further aid in the detection of PAL and potentially curable hypertension.

Infectious diseases in the tropics and subtropics: Leptospirosis  
Tuesday 4.00-5.30
Visith Sitprija

Leptospirosis is an important zoonosis in the tropics. The incidence of leptospirosis in Thailand has strikingly increased during the past few years. The peak of the outbreak was around the end of the rainy season. As expected, the patients affected were those working in the farm, fishermen and those wading in the water. The clinical picture has changed with more presentations of hypotension and pulmonary involvement including pulmonary hemorrhage, edema and acute respiratory distress syndrome. Nevertheless, fever with chills, headache, conjunctival suffusion, myalgia, jaundice and renal failure were still the major symtoms. Significant hypotension upon admission with the mean arterial pressure below 70 was observed in over 60% of the patients. Hypokalemia was observed in 40% of the patients. The overall mortality in the general hospitals varied from 3% to 12%, and the mortality among complicated cases ranged from 12% to 30%. The patients with poor prognosis usually manifested with persistent hypotension, jaundice with rapid rise in serum bilirubin, diarrhea, renal failure and pulmonary hemorrhage. The platelet count was often less than 50,000/MM3. Twenty two percent of leptospirosis patients had associated infections. Besides antibiotic therapy and dialysis for renal failure, blood exchange, plasmapheresis or continuous venovenous hemofiltration offered beneficial results in severe cases with oliguria and rapid increase in serum bilirubin and pulmonary complications. Prompt correction of hypotension prevented the development of renal failure and Pulmonary complication.

Infectious diseases in the tropics and subtropics: Melioidosis
 Tuesday 4.00-5.30
Vipada Chaowakul

Melioidosis is a potentially lethal bacterial infection caused by the environmental saprophyte Burkholderial psuedomallei. It is endemic in East Asia and Northern Australasia. In Thailand, the majority cases occur in the northeast of the country. Melioidosis is a rainy season disease affecting predominantly rice farmers. The majority of patients have an underlying predisposition to infection, most commonly diabetes mellitus or chronic renal disease. Although almost any organ can be involved, the lung is the most commonly affected. Systemic infection is often, associated with abscess formation, particularly in the liver and spleen. Septicaemia is common. Children may present with a unique local form of the disease; suppurative parotitis which has an excellent prognosis. B.pseudomallei is readily isolated from routine blood cultures. Use of selective media improves isolation from sputum, urine, and open abscesses. Direct immunofluorescence is positive in 70% of culture positive specimens enabling rapid diagnosis. Before the introduction of specific treatment with ceftazidime, the mortality of severe melioidosis was approximately 80%. It is now 40%. The carbapenems are probably as good as ceftazidime, and amoxycillin-clavulanic is also effective. Other third generation cephalosporins are inferior to ceftazidime. Systemic infection requires at least two weeks high dose parenteral treatment followed by oral maintenance treatment with chloramphenicol (for 8 weeks) and doxycycline+trimethoprim+sulphamethoxazole to complete a total of 20 weeks treatment. Approximately 8% of patients will relapse. Lifelong follow-up is needed.

Medical Education  Wednesday 7.30-8.30
Ken Donald

Medical Schools worldwide are introducing many changes to medical education. A number of issues are driving the need for those changes and among them are:-

• The knowledge explosion:- Nobody can know it all or keep up with knowledge production without skills that include self-directed lifelong learning, critical appraisal of evidence, and I.T. capacity.
• The complexity of modern medical practice:- Systematic and integrated problem solving capacity (i.e. clinical reasoning) in an incredibly broad range of situations confronts doctors before they have to choose from increasingly complex (and double edged) interventions at either individual or population levels.
• Community expectations and knowledge:- The profession no longer owns its "body of knowledge" nor decides alone on the services needed by the community. Doctors are as much facilitators and communicators as they are decision-makers.
• Medico-Legal and ethical debates about medicine:- These issues are "public property" and the medical profession is often a respondent to developments as much (or more than) it is a leader.

Of course doctors who graduated over the last 50 years have often coped well with changes in knowledge, practice and community expectations. Many have suffered serious personal costs in doing so and too many have not coped well in the eyes of the community and governments. Therefore, Medical Schools worldwide have been asking "How can our admission policies, learning models and assessment processes better equip future doctors to deal with the challenges they will face"? Accreditation Bodies (such as the Australian Medical Council) in most countries are requiring Medical Schools to address these issues to retain their accreditation so that their graduates can be licensed to practice. These Accreditation Bodies are made up of mostly medical graduates so that it remains a self-governing professional activity. The elements of hostility found towards these changes in some individuals and some institutions is expected and understood given human history, but as cohorts are beginning to appear in the workforce, there are encouraging data that suggest a beneficial change is occurring - not "better doctors" but doctors "better equipped" to deal with the challenging times ahead. The profession has a long history of trying to make the next generation better - thank goodness

Cancer Of The Prostate  Wednesday 7.30-8.30
Frank Gardiner

An overview of prostate cancer with particular reference to current practice and, where available, the evidence for many of the decisions made in managing this disease

Obstetric Medicine  Wednesday 7.30-8.30
David McIntyre

Medical disorders, either pre - existing or specifically related to pregnancy, are an important cause of maternal and neonatal morbidity in modern obstetric practice. With a reducing list of "absolute" contra - indications to pregnancy, an increase in maternal age at the time of child - bearing and more effective therapy for chronic illness, women are becoming pregnant with a broader range of underlying pathologies.

Clinical custom, rather than evidence, continues to guide many therapeutic decisions before, during and after pregnancy. Dogma, rather than fact, often prevails and the "absolutely correct" method of managing problems varies markedly between different centres.

This presentation will cover two broad areas of medical disease in pregnancy - thyroid disease (in particular hyperthyroidism) and hypertension.

Two illustrative cases will be discussed, with key diagnostic and therapeutic decisions related to the available evidence. In each case, the format for discussion will be:

• Care in preparation for pregnancy
  
• Care during each trimester of pregnancy
  
• Complications during pregnancy and their medical management
  
• Post partum follow - up

Audience participation will be encouraged, so please come armed with opinionated enthusiasm and remember "In God We Trust - All Others Bring Data".

Telemedicine  Wednesday 7.30-8.30
Richard Wootton

The delivery of specialist health care services to remote areas of Queensland has always been challenging. The geography of Queensland and the congregation of tertiary level services in the SE corner of the state, are two major factors. When a specialist opinion is required, patients are normally transferred directly to the tertiary centre. Alternatively, if the matter is non-urgent, the patient will be scheduled an appointment to see a specialist during a periodic outreach site visit. Both options are time-consuming and costly.

Traditionally, referring a patient directly to a specialist has been the 'easiest' option for the referring doctor. Until now, telehealth has been seen as a less convenient option that requires 'more effort' and 'takes too much time'. Negative perceptions include that the equipment 'didn't always work', 'or was too complicated'.

In a research project conducted by the Centre for Online Health and the Royal Children's Hospital in Queensland, this suspected barrier is being overcome. A convenient 'telereferral' service is being trialed to two specific intervention sites (regional hospitals in Queensland). Results show that telehealth activity has increased, interest has grown and changes are occurring in the planning, design and delivery of outreach services.

In twelve months, clinical activity via videoconference has increased significantly, from almost zero activity to an average 10 hours per month. The Royal Children's Hospital Telehealth service received 201 referrals in total, resulting in a total of 315 individual patient consultations (direct/indirect clinical care) via videoconference. Preliminary results show savings made - through the prevention of direct transfer to Brisbane (travel and accommodation) of an estimated $89,000.

New Diagnostic Tests in Haematology   Wednesday 9.00-10.30
Beverley Rowbotham

Developments in flow cytometry and molecular genetics have resulted in a plethora of new tests - some useful, some that raise more questions than they answer. New tests in the following areas will be discussed; thrombophilia, hyperhomocysteinemia, bleeding disorders, paroxysmal nocturnal haemoglobinemia, haematological malignancies. Tests in development will also be discussed.

Infectious Diseases Update: Infection control for physicians
Wednesday 11.00-12.30
David Looke

Healthcare acquired infections (HAI) are still a significant cause of morbidity and mortality.

In the USA they have been ranked amongst the top 10 causes of death with a similar estimate in the UK. In Australia, there has been no formal national prevalence study since 1985, but data abstracted from recent surveillance studies indicates that HAI are of a similar magnitude. Blood stream infections from intra-vascular devices, surgical site infections, nosocomial pneumonia and urinary tract infections form the largest proportion. It has been estimated that up to 30% of events are preventable. Understanding the factors that underlie the pathogenesis of these infections forms the key to their prevention.

The rise of antibiotic resistance and spread of organisms such as MRSA, VISA, VRE, ESBL producing Gram-negatives and Multi-drug resistant Acinetobacter is a major challenge for all institutions. Physicians need to know how to manage patients with infections caused by these organisms as well as ensure that prevention programs are in place and operating.

Surveillance with statistical analysis using control chart methods is an important tool in preventing infections that occur commonly. Less frequent events or "signal infections" prompt a different way of responding. Antibiotic use has a significant impact upon the occurrence of HAI. Ensuring the appropriate use of these drugs is an important part of minimising resistance.

Examples of HAI, their management and prevention will be discussed.

EMB - Ischaemic hear disease / Congestive cardiac failure Wednesday 2.00-3.30
Ian Scott, Alison Mudge, John Bennet and Daniel Stowasser

Clinical trials have yielded many effective management modalities for patients with heart disease. This workshop features six 15 minute presentations which focus on strategies for optimising the management of patients hospitalised with acute coronary syndromes and congestive heart failure. Studies performed in Australia and overseas suggest opportunities for improving quality of care of such patients, both in-hospital and post-discharge. A number of quality improvement interventions have been evaluated in controlled trials, and many of those shown to be effective have been adopted by the Brisbane Cardiac Consortium Achieving Better Care (ABC) Program involving three hospitals (two tertiary; one community) and 4 Divisions of General Practice in the greater Brisbane area. This workshop will showcase results of what this action research program has achieved over the last 2 years and highlight examples of evidence-practice gaps. The workshop aims to assist fellows who may wish to undertake similar initiatives in their own institutions or clinics.

Screening for Chronic Liver Disease  Wednesday 2.00-3.30
Lawrie Powell

Patients with compensated chronic liver disease usually manifest with lethargy and abnormal liver function tests. Laboratory screening is required to establish or exclude the common causes. These are: viral hepatitis (serological markers for HBV and HCV), haemochromatosis (serum ferritin and transferrin saturation and genetic testing of the C282Y and H63D mutations), autoimmune hepatitis (autoantibodies), alpha-1-antitrypsin deficiency, cystic fibrosis and Wilson's disease (see below).

The common and important hereditary liver diseases are discussed in more detail since there is increasing interest in population screening particularly for haemochromatosis.

Hereditary haemochromatosis: The disease frequency (1:200-1:300 homozygous) together with the known natural history of the disease and easy therapy has led many to advocate population screening. However, at the present time screening is confined to families of individual patients (cascade screening).

Cystic fibrosis: Screening for this disorder is usually carried out on an individual family basis particularly when a member has been identified. Because of the large number of mutations genetic studies are expensive and cumbersome and the diagnosis usually rests on sweat chloride concentration. However, in some countries screening of newborns is performed at day five as part of the Guthrie card.

Alpha-1-antitrypsin deficiency: The condition should be considered in any patient with cirrhosis whatever the age particularly with a past history of infantile liver disease or with associated chest infection. Diagnosis involves measuring serum alpha-1-antitrypsin levels and PiZZ phenotype.

Wilson's disease: Because of the large number of mutations, mutation analysis is not a practical method of diagnosis in individual patients. A diagnosis depends on a high index of suspicion, the detection of low serum copper and ceruloplasmin levels with increased 24-hr urinary copper excretion and increased copper concentration on liver biopsy. Family screening can be performed by the use of flanking markers, i.e., DNA microsatellite markers on either side of the gene and comparison of the affected patient with siblings and parents.