admission. This proportion could already be greater in some parts of the country and may increase if referrals of cases of self-poisoning increase faster than the facilities for their assessment and management. The provision of social work and psychiatric expertise in casualty departments may be one means of preventing unnecessary medical admissions without risk to the patients. Dr Blake's and Dr Bramble's figures do not demonstrate, however, that any advantage would attach to medical teams taking over assessment from psychiatrists except that, by implication, assessments would be completed sooner by staff working on the ward full time. What the figures actually suggest is that if assessment of overdoses were left to house doctors there would be an increase in admissions to psychiatric units (by 19°U), outpatients (by 5O°'), and referrals to social services (by 140o). So for house doctors to assess overdoses would provide no economy for the psychiatric or social services. The study does not tell us what the consequences would have been for the six patients who the psychiatrists would have admitted but to whom the house doctors would have offered outpatient appointments. E J SALTER

Vitamin D deficiency.

Infectious Diseases Society of America.

The AUDIT Alcohol Consumption Questions (AUDIT-C) An Effective Brief Screening Test for Problem Drinking

Childhood obesity and adult morbidities

The guideline is intended for use by healthcare providers who care for adult and pediatric patients with group A streptococcal pharyngitis. The guideline updates the 2002 Infectious Diseases Society of America guideline and discusses diagnosis and management, and recommendations are provided regarding antibiotic choices and dosing. Penicillin or amoxicillin remain the treatments of choice, and recommendations are made for the penicillin-allergic patient, which now include clindamycin.

/pdf/clinical-practice-guideline-for-the-diagnosis-and-management-51g80uc39j.pdf

Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America.

Low serum 25 hydroxyvitamin D3 (vitamin D3) is known to perturb cellular function in many tissues, including the endocrine pancreas, which are involved in obesity and type II diabetes mellitus (TIIDM). Vitamin D3 insufficiency has been linked to obesity, whether obesity is assessed by body mass index (BMI) or waist circumference (waist). Central obesity, using waist as the surrogate, is associated with the metabolic syndrome (MetSyn), insulin resistance, TIIDM and atherosclerotic cardiovascular disease (CVD). We tested how vitamin D3 was related to measures of fat mass, MetSyn markers, haemoglobin A1c (HbA1c) and MetSyn in a cross-sectional sample of 250 overweight and obese adults of different ethnicities. There were modest inverse associations of vitamin D3 with body weight (weight) (r = -0.21, p = 0.0009), BMI (r = -0.18, p = 0.005), waist (r = -0.14, p = 0.03), [but not body fat % (r = -0.08, p = 0.24)], and HbA1c (r = -0.16, p = 0.01). Multivariable regression carried out separately for BMI and waist showed a decrease of 0.74 nmol/L (p = 0.002) in vitamin D3 per 1 kg/m2 increase in BMI and a decrease of 0.29 nmol/L (p = 0.01) per 1 cm increase in waist, with each explaining approximately 3% of the variation in vitamin D3 over and above gender, age, ethnicity and season. The similar relationships of BMI and waist with vitamin D3 may have been due to associations between BMI and waist, or coincidental, where different mechanisms relating hypovitaminosis D3 to obesity occur concurrently. Previously reviewed mechanisms include that 1) low vitamin D3, may impair insulin action, glucose metabolism and various other metabolic processes in adipose and lean tissue 2) fat soluble-vitamin D3 is sequestered in the large adipose compartment, and low in serum, 3) obese people may be sensitive about their body shape, minimising their skin exposure to view and sunlight (not tested). We showed evidence for the first theory but no evidence to support the second. In the current study, serum vitamin D3 was inversely related to weight, BMI and markers of TIIDM (large waist, raised HbA1c) but not to adipose mass nor to MetSyn per se.

/pdf/relationships-of-low-serum-vitamin-d3-with-anthropometry-and-22t010enp8.pdf

Relationships of low serum vitamin D3 with anthropometry and markers of the metabolic syndrome and diabetes in overweight and obesity.

Aim: To estimate acute rheumatic fever (ARF) incidence rates for New Zealand children and youth by ethnicity, socioeconomic deprivation and region

Methods:  National hospital admissions with a principal diagnosis of ARF (ICD9_AM 390-392; ICD10-AM I00-I02) were obtained from routine statistics and stratified by age, ethnicity, socioeconomic deprivation index (NZDep2006) and District Health Board (DHB)

Results:  The mean incidence rate for ARF in 2000–2009 peaked at 9 to 12 years of age Incidence rates for children 5 to 14 years of age for Māori were 402 (95% confidence interval 368, 438), Pacific 812 (734, 896), non-Māori/Pacific 21 (16, 26) and all children 172 (161, 183) per 100 000 Māori and Pacific incidence rates increased by 79% and 73% in 1993–2009, while non-Māori/Pacific rates declined by 71% Overall rates increased by 59%

In 2000–2009, Māori and Pacific children comprised 30% of children 5–14 years of age but accounted for 95% of new cases Almost 90% of index cases of ARF were in the highest five deciles of socioeconomic deprivation and 70% were in the most deprived quintile A child living in the most deprived decile has about one in 150 risk of being admitted to the hospital for ARF by 15 years of age Ten DHBs containing 76% of the population 5 to 14 years of age accounted for 94% of index cases of ARF

Conclusions:  ARF with its attendant rheumatic heart disease is an increasing public health issue for disadvantaged North Island communities with high concentrations of Māori and/or Pacific families

Incidence of acute rheumatic fever in New Zealand children and youth.

Objectives The aim of this project was to evaluate the perceptions, knowledge and attitudes regarding generic medicines. Methods A cross-sectional study, with self administered questionnaires, was conducted to survey consumers visiting pharmacies in four regions of Auckland (North Shore, Waitakere, Central Auckland and South Auckland). Through stratified random sampling, approximately 10% of pharmacies from each region were selected, which turn out to be 30 pharmacies. Every alternate customer coming to the pharmacy, who was eligible to participate in the study, was asked by the researchers to complete the questionnaire. Results A total of 441 questionnaires were included in the analysis. Different response rates were obtained in different regions of Auckland. Of all respondents, 51.6% had previous knowledge of generic medicines. Pharmacists were the main source of information regarding generic medicines followed by doctors and media. A higher level of education had a direct relationship with having correct knowledge of generics (P = .002). Attitude of participants toward the use of generic medicines was determined by their knowledge of generics, whether it was recommended by a pharmacist and their type of illness. Participants were more prepared to change to a generic for a minor illness (79%) than for a major illness (58.7%). Those who had better knowledge were more likely than those with poor knowledge to say they would to use a generic in major illness (P = .001) as well as minor illness (P < .0001). Previous positive experiences with generics also determined consumers’ willingness to use generics. Conclusion Many consumers have misconceptions regarding generic medicines. Having knowledge about generics and the advice by doctors and pharmacists are key indicators to improve the quality use of generic medicines.

An evaluation of consumers’ knowledge, perceptions and attitudes regarding generic medicines in Auckland

Background: Rheumatic fever is a preventable chronic disease preceded by group A β-haemolytic streptococcal (GABHS) pharyngitis. Objective: To test the non-inferiority of once-daily (QD) oral amoxicillin to the recommended twice-daily (BID) oral penicillin V in GABHS pharyngitis. Methods: This was a randomised non-inferiority trial carried out in a school-based clinic in New Zealand. Children presenting with GABHS pharyngitis were randomised to oral amoxicillin 1500 mg QD (or 750 mg if bodyweight was ⩽30 kg) or to oral penicillin V 500 mg BID (or 250 mg if bodyweight was ⩽20 kg) for 10 days. Observed medication and weekend diary cards were used to monitor adherence. Outcome: Eradication of GABHS, determined with follow-up throat cultures on days 3–6, 12–16 and 26–36. GABHS isolates were serotyped to distinguish bacteriological treatment failures (and relapses) from new acquisitions. Non-inferiority was defined as an upper 95% confidence limit (CL) for the difference in success of eradication in the amoxicillin and penicillin V treatment groups of ⩽10%. Results: 353 children with positive throat swabs for GABHS were randomised to amoxicillin (n = 177) or penicillin V (n = 176). The upper 95% CL for the differences in positive cultures between the antibiotics was 4.9% at days 3–6, 6.5% at days 12–16 and 8.5% at days 26–36. Treatment failures (including relapses) occurred at each visit in 5.8%, 12.7% and 10.7% of amoxicillin recipients and 6.2%, 11.9% and 11.3% of penicillin V recipients, respectively. No significant differences in resolution of symptoms were noted between treatment groups. One case of unsubstantiated acute rheumatic fever occurred after 7 days of amoxicillin. Conclusion: In this adequately powered study, once-daily oral amoxicillin is not inferior to twice-daily penicillin V for the treatment and eradication of GABHS in children with pharyngitis.

Once-daily amoxicillin versus twice-daily penicillin V in group A beta-haemolytic streptococcal pharyngitis.

Background: To identify the concerns of experienced artificial eye wearers and investigate whether these had changed since they lost their eye.

Design:  A retrospective study of private practice patients.

Participants:  Sixty-three experienced artificial eye wearers.

Methods:  An anonymous questionnaire was posted to participants. Paired Wilcoxon tests were used to investigate changes to concern levels over time. Ordinal logistic regression was used to investigate associations of demographic variables with concern levels.

Main Outcome Measures:  Changes in level of concern over time.

Results:  At the time of initial eye loss, participants were mainly concerned about the health of their remaining eye, coping with monocularity and receiving good advice. Between initial eye loss and the present, reductions in concern occurred with judging distance, peripheral vision, appearance, receiving good advice, comfort, retention, colour and movement of the artificial eye, fullness of orbit, loss of balance and postoperative pain. Patients whose jobs involved the public were more concerned about appearance and reduced visual range than those in other occupations. Participants' chief present-day concerns were health of the remaining eye and watering, crusting and discharge. All results above had a probability <0.05.

Conclusions:  The study emphasized patients' concerns about the health of their remaining eye and their need for good advice at time of eye loss. Knowledge that their initial concerns about judging distance, reduced peripheral vision and appearance all decrease over time may help clinicians in counselling these patients. Watering, crusting and discharge was the chief present-day concern after health of the remaining eye.

Joanna Stewart

Papers

Relationships of low serum vitamin D3 with anthropometry and markers of the metabolic syndrome and diabetes in overweight and obesity.

Incidence of acute rheumatic fever in New Zealand children and youth.

An evaluation of consumers’ knowledge, perceptions and attitudes regarding generic medicines in Auckland

Once-daily amoxicillin versus twice-daily penicillin V in group A beta-haemolytic streptococcal pharyngitis.

Concerns of anophthalmic patients wearing artificial eyes.