Showing papers in "The New Zealand Medical Journal in 2008"

New Zealand smoking cessation guidelines.

Abstract: AIMS To summarise the key recommendations made in the 2007 New Zealand Smoking Cessation Guidelines. METHODS A comprehensive literature review of smoking cessation interventions was undertaken in November 2006. Recommendations were formulated from the findings of the literature review in line with the methods recommended by the New Zealand Guidelines Group. RESULTS The Guidelines have been structured around a new memory aid (ABC) which incorporates and replaces the 5A's (ask, advise, assess, assist, arrange). ABC prompts healthcare professionals to ask about smoking status; give brief advice to stop smoking to all smokers; and provide evidence-based Cessation support for those who wish to stop smoking. Healthcare professionals should briefly advise all people who smoke to stop smoking, regardless of whether they say they are ready to stop smoking or not. They should then offer smoking cessation support which includes both behavioural (e.g. telephone and face-to-face support) and pharmacological (e.g. nicotine replacement therapy, nortriptyline, bupropion, or varenicline) interventions. Recommendations were also formulated for priority populations of smokers: Māori, Pacific, pregnant women, and people with mental illness and other addictions. CONCLUSIONS These guidelines will assist healthcare professionals in providing evidence-based smoking cessation support to people who smoke. To be effective, the ABC model needs to be integrated into routine practice.

Ethnic and socioeconomic disparities in the prevalence of cardiovascular disease in New Zealand.

Abstract: Aim To describe the prevalence of cardiovascular disease (CVD) in New Zealand by ethnicity and socioeconomic status using NHI-linked electronic national databases. Method CVD prevalence by ethnicity and socioeconomic status in New Zealand in 2006/07 were estimated from national datasets of public hospital discharges, mortality registrations, and pharmaceutical dispensing over the period 1988-2007. Results In 2007, Maori had the highest age-standardised prevalence (7.41%) compared to non-Maori, non-Pacific, and non-Indians (4.45%). Maori males and females had the highest age-specific prevalence of CVD across virtually all age groups. There was a clear gradient of increasing CVD prevalence with increasing level of social deprivation. The corresponding age-specific CVD prevalence among the least deprived quintile of Maori were similar to the most deprived quintile of 'Other' New Zealanders. Conclusion Consistent with mortality trends, this study confirms marked ethnic and socioeconomic disparities in CVD prevalence that are (at least in part) independent of each other. Aggressive targeting of CVD risk management among these relatively easily identifiable high-risk patient groups with known CVD could be a highly cost-effective way of reducing health disparities in the short term.

Rheumatic fever diagnosis, management, and secondary prevention: A New Zealand guideline

Abstract: Aim The National Heart Foundation of New Zealand, and the Cardiac Society of Australia and New Zealand (CSANZ) recently launched an evidence-based review and guideline entitled New Zealand Guideline for Rheumatic Fever Diagnosis, Management, and Secondary Prevention . This paper is a brief summary. Method This Guideline was developed by a writing group comprising experts in the area. Relevant literature was identified and reviewed, and the Australian guideline for rheumatic fever and rheumatic heart disease was reviewed and adapted for the New Zealand context. A peer review and stakeholder consultation process followed the development of the draft document.

Epidemiology of noise-induced hearing loss in New Zealand.

Abstract: Introduction Hearing loss is a major cause of disability in the world. Occupational noise exposure is likely to contribute to a very high proportion of the cases of hearing loss in adults. Concern has been raised by the Accident Compensation Corporation (ACC) in New Zealand about the fact that the number of new cases of noise-induced hearing loss (NIHL) is not declining, despite the health and safety legislation and establishment of hearing conservation programmes in industry. To inform strategies for prevention, a review of the burden of NIHL in New Zealand was undertaken, particularly focusing on the trends in compensation claims and costs, and the associated sociodemographic patterns. Methods A review of the peer-reviewed published literature was conducted to identify national and international estimates of NIHL prevalence. The ACC claims dataset (July 1995 to June 2006) was analysed to describe annual trends in new NIHL claims, cost to ACC, and claimants’ age, gender and occupational group. Results There is currently no reliable information regarding the overall incidence and prevalence of NIHL in New Zealand. ACC data reveals a substantial increase in the number of new NIHL claims annually, rising from 2823 in July 1995–June 1996, to 5580 in July 2005–June 2006. Together with ongoing claims the overall costs of NIHL claims increased by an average of 20% each year (a six-fold increase over the decade) resulting in a total cost to ACC of $193.82M over the review period. Collectively, agriculture and fisheries workers, trades workers, machine operators, and assemblers accounted for 53% of new claims. Most claims were lodged in middle age or later, with the vast majority of claimants (95%) being men. The relationship of age with the probability of making a claim changed significantly over the study period with rates in older age groups increasing faster than in younger. Conclusions The substantial and increasing societal costs despite decades of NIHL control legislation suggests that current strategies addressing this problem are not effective, inadequately implemented, or both. Noise-induced hearing loss (NIHL) is a form of hearing loss caused by sustained and repeated exposure to excessive sound levels. While commonly attributed to prolonged employment in high-noise industries, any form of sound exposure can lead to NIHL provided there is sufficient intensity and exposure time. 1 The hearing loss occurs because of damage to the hearing organ (cochlea) of the inner ear. 2,3 Exposure to sound above a level of approximately 85dBA initially manifests as a temporary hearing loss or ‘dullness’ of hearing ( a temporary threshold shift ) which recovers within 16–24 hours of the exposure. However, with repeated or sustained

The effects of seasonal variation of 25-hydroxyvitamin D on diagnosis of vitamin D insufficiency.

Abstract: AIMS To explore the effects of seasonal variation on the diagnosis of vitamin D sufficiency and to determine whether age, gender, and ethnicity modify these effects. METHODS 21,987 adults had a measurement of serum 25-hydroxyvitamin D (25OHD) at Labplus, Auckland City Hospital, between January 2002 and September 2003, and sine curves were fitted for 25OHD versus day of year to predict the 25OHD nadir for each individual. RESULTS 48% (range: 30-63%) of individuals had 25OHD 50 nmol/L throughout the year varied substantially by season (in summer at least 60-75 nmol/L), and tended to be higher in men than women, decrease with age, and vary with ethnicity. Mean 25OHD levels were very low (<40 nmol/L) in people of Indian, Middle Eastern, and African descent. CONCLUSION Seasonal variation in 25OHD affects the diagnosis of vitamin D sufficiency. Clinicians should consider the month of sampling when interpreting the results of 25OHD measurements. In New Zealand, a summertime 25OHD <60-75 nmol/L is generally required to ensure year-round 25OHD levels <50 nmol/L.

Comparison of different markers of socioeconomic status with cardiovascular disease and diabetes risk factors in the Diabetes, Heart and Health Survey.

Abstract: Aim To compare different markers of socioeconomic status (SES) with cardiovascular disease (CVD) and diabetes risk factors. Methods Data were from 4020 participants aged 35-74 years from the Diabetes, Heart and Health Survey that was carried out in 2002 and 2003. Measures of SES were the occupation-based NZ Socioeconomic Index (NZSEI), combined household income, education, and the area-based deprivation measure NZDep2001. Results After adjusting for all other SES measures, there were relatively few independent risk factor associations with NZSEI or education. Both low income and being more deprived as measured by NZDep2001 were independently associated with higher 2-hour glucose tolerance concentrations, HbA1c levels, waist-to-hip ratio, urinary albumin concentrations, 5-year CVD risk, current cigarette smoking, lower HDL-cholesterol, and less time spent exercising compared to the highest SES strata. Low income was independently associated with a higher prevalence of total and previously diagnosed diabetes mellitus, and lower stature. More deprivation was independently associated with higher diastolic blood pressure levels, fasting glucose concentrations and BMI. Associations with height, and 2-hour glucose levels, and prevalence of total and previously diagnosed diabetes were greater with income, whereas NZDep2001 showed stronger associations with diastolic blood pressure, raised blood pressure, HDL-cholesterol, fasting glucose, BMI, waist-to-hip ratio, exercise levels, urinary albumin concentrations, 5-year risk of CVD and prevalence of smoking compared to the highest SES groups. Associations of income and NZDep2001 with HbA1c were similar. Conclusions Cardiovascular disease and diabetes risk factors were more strongly associated with the area-based NZDep2001 and household income than with the individual's occupation-based NZSEI or education. In general, the strongest associations were observed for NZDep. These findings provide support for the application of NZDep in health policy development in New Zealand, when other measures of SES are not available, and we recommend that this very accessible indicator of socioeconomic and health status continue to be updated.

Medication beliefs and adherence to antidepressants in primary care.

Abstract: positively associated with non-adherence. Where beliefs about the necessity outweighed concerns about taking the medication, significantly greater adherence was observed. Fewer depressive symptoms were also associated with greater adherence. Conclusions This study extended prior research on the role of patient beliefs in medication adherence for chronic physical health problems by showing the beliefadherence relationship in a depressed patient sample. A balance between beliefs about the costs and benefits of medication are likely to be important in understanding adherence with other medications. Major depressive disorder is the most common mental health condition seen in primary care. The MaGPIe (2003) study, 1 estimated a 12-month prevalence rate of 18.1% among primary care patients in New Zealand, with 4.4% meeting the criteria for severe depression. The economic burden of depression is heavy,² and the burden of depression experienced by the patient and their families is significant. 3–5 It is widely accepted that primary healthcare providers deliver treatment for the vast majority of patients with mental health concerns. 1,6 Antidepressant medication, such as serotonin-specific and serotonin and noradrenergic reuptake inhibitors are effective and frequently used treatments for the symptoms of depression. 7–9 Research suggests that 40–70% of depressed patients adhere to medication. 10 Recent research on the determinants of medication adherence has focused on patient beliefs or perceptions. 11 This research has stemmed from the Self-Regulatory model which proposes that adherence is based on an “active decision” by the patient in response to their interpretation of the symptoms they experience. That is, the patient balances their concerns regarding the potential adverse effects of taking the medication with the benefits in deciding whether to adhere. 12 Various theoretical models have been posited to explain patient adherence with medications, which may be understood as patient feedback or patient satisfaction with the benefits of the treatment versus the costs. 13

Fournier's gangrene: a review of 110 cases for aetiology, predisposing conditions, microorganisms, and modalities for coverage of necrosed scrotum with bare testes.

Abstract: Background The aetiology, definition, and management of Fournier's gangrene are an enigma to surgeons and urologists alike. Indeed, controversy surrounds its management. We managed 110 cases of Fournier's gangrene with different modalities and compared their outcomes along with those of contemporary studies. Aims To evaluate aetiology, predisposing factors, and causative organisms plus compare modalities of surgical management of Fournier's gangrene. Methods 110 cases of Fournier's gangrene that were admitted and treated in S.S.G. Hospital (Vadodara/Baroda, India) from January 2000 to December 2006 were evaluated. Results The average duration of symptoms was 3-5 days and the commonest presentation was scrotum swelling plus pain and fever. The most common aetiological factor was trauma and urinary tract infection. The majority (84%) of cases had bilateral scrotal involvement. In the majority (46%) of patients, a mixture of causative organisms were isolated; E. coli was isolated in 17.5% of patients. The fascicutaneous rotation thigh flap procedure gave the best cosmetic results. Conclusions Review of the cases suggests that the Fournier's gangrene is either an idiopathic condition or secondary to adjacent infection or the operation performed. The condition progresses rapidly but is usually self-limiting and most commonly confined to the genitalia. Adequate diagnosis is imperative and immediate intense and aggressive therapy is necessary. Prompt surgical debridement and administration of appropriate antibiotics (both local and systemic) are necessary to lower mortality and morbidity. Most of the defects can be closed secondarily while some need coverage by skin grafting. Fasciocutaneous rotation thigh flap is the best cosmetically acceptable repair, although it demands surgeons with considerable skill and experience and there are relatively more complications compared with other procedures as well as a longer hospital stay.

The road we travel: Māori experience of cancer.

Abstract: Aim This research explores Maori experiences of cancer. It does so to shed light on the causes of cancer inequalities for Maori. Methods The views of 44 Maori affected by cancer--including patients, survivors, and their whanau (extended families)--were gathered in five hui (focus groups) and eight interviews in the Horowhenua, Manawatu, and Tairawhiti districts of New Zealand. After initial analysis, a feedback hui was held to validate the findings. Results Maori identified effective providers of cancer services such as Maori health providers. They also identified positive and negative experiences with health professionals. The involvement of whanau in the cancer journey was viewed as highly significant as was a holistic approach to care. Participants had many suggestions for improvements to cancer services such as better resourcing of Maori providers, cultural competence training for all health workers, the use of systems 'navigators', and the inclusion of whanau in the cancer control continuum. Conclusion The research identifies a range of health system, healthcare process, and patient level factors that contribute to inequalities in cancer for Maori. It also explores the role of racism as a root cause of these inequalities and calls for urgent action.

Role of alcohol in maxillofacial fractures.

Abstract: BACKGROUND: Excessive consumption of alcohol results in impaired judgement and inappropriate behaviour, and is often a major contributor to interpersonal violence and motor vehicle accidents. This study examines the experience of a tertiary centre in alcohol-related facial fractures. METHODS: A retrospective database of patients presenting to the Oral and Maxillofacial Surgery Service at Christchurch Hospital (New Zealand) during an 11-year period was reviewed. Variables examined include demographics, type of fractures, mode of injury, and treatment delivered. RESULTS: 2581 patients presented with facial fractures during the study period, 49% of these being alcohol-related. Males accounted for 88% of alcohol-related fractures and 59% were males in the 15 to 29 year age group; 78% of alcohol-related fractures were due to interpersonal violence and 13% to motor vehicle accidents; 65% required hospital admission and 58% underwent surgery. CONCLUSION: The majority of alcohol-related facial fractures were due to interpersonal violence, with young men in the 15 to 29 year age group being predominantly affected. Alcohol-related fractures were associated with an increase in the incidence of hospitalisation and surgery. The high prevalence of alcohol as a contributing factor to facial fractures indicates a need to push for community awareness and public education on the harmful effects of alcohol. Language: en

Correlation of physician seniority with increased emergency department efficiency during a resident doctors' strike.

Abstract: AIM Physician seniority has increasingly been shown to correlate with improved clinical outcomes. However few studies examine the relationship between treating doctor experience and the efficiency of emergency care systems. We explored the hypothesis that increased seniority of emergency department (ED) medical staff would result in improved ED efficiency. METHOD This was prospective observational study conducted at the ED of Waikato Hospital, a 650-bed university-affiliated teaching hospital. All patient presentations during a 5-day resident doctors' strike when the ED was staffed by senior physicians, and the corresponding normally staffed days of the subsequent calendar week were examined. Patient waiting times, time seen to disposition, and total ED length of stay were recorded according to Australasian Triage Score (ATS). RESULTS 608 and 683 patient presentations were recorded during the strike and non-strike period respectively. Waiting times were reduced for ATS3 (43.8 vs 73.6 minutes, p<0.001) and ATS4 (53.7 vs 82.0 minutes, p<0.001) during the strike period. Time seen to disposition were reduced for ATS2 (147.9 vs 255.1 minutes, p=0.001) and ATS3 (119.9 vs 165.0 minutes, p<0.001) during the strike period. ED length of stay was reduced for ATS2 (162.6 vs 278.6 minutes, p<0.001), ATS3 (161.9 vs 238.4 minutes, p<0.001), and ATS4 (134.1 vs 179.2 minutes, p<0.001) during the strike period. No difference was observed in patient walkout, ED mortality, 48-hour mortality, or 30-day unscheduled representation rates. CONCLUSIONS Increasing seniority of front line ED staff during a period of resident doctors' strike action was associated with increased efficiency of ED patient processing. Early specialist involvement with ED patients may replicate these efficiencies during periods of normal departmental operation.

Kava hepatotoxicity: a European view.

Abstract: Kava was well tolerated and considered as devoid of major side effects only until 1998 when the first report of assumed kava hepatotoxicity appeared. Causality of hepatotoxicity for kava +/- comedicated drugs was evident after the use of predominantly ethanolic and acetonic kava extracts in Germany (n=7), Switzerland (n=2), United States (n=1), and Australia (n=1) as well as after aqueous extracts in New Caledonia (n=2). Compliance regarding the recommendation for daily kava dose and duration was ascertained in only a few patients, including 2 from Germany and Switzerland. Since 450 millions of daily doses of kava extracts equating to 15 millions of monthly doses were sold in Germany and Switzerland, hepatotoxicity by kava appeared to be rare--similar to other herbal remedies, dietary supplements, and synthetic drugs. Risk factors were found in most patients and include daily kava overdose, prolonged therapy, and comedication with up to 5 other herbal remedies, dietary supplements, and synthetic drugs. Kava hepatotoxicity was not reported until 1998, thus raising the question of inferior quality of the kava raw material at times of the kava boom later on. Insufficiently defined regulatory guidelines to produce kava extracts are of some concern. Open questions refer not only to kava cultivars, but also to analytical methods and definitions of extract media and contents. Future strategies should therefore focus on the solution of a standard methodology of ascertaining quality that can assure a high degree of reliability in conjunction with actions by regulators, physicians, manufacturers, and producers. A medical advisory is also recommended as part of the labelling.

Declining sperm quality in New Zealand over 20 years.

Abstract: AIM To investigate whether semen quality has changed in New Zealand over the last 20 years METHOD A retrospective study from 1987 to 2007 The sperm concentration, volume of seminal fluid, and the percentage of motile sperm were analysed from the first semen sample of 975 men presenting as sperm donors in Auckland and Wellington RESULTS Linear regression showed that the mean concentration of sperm decreased from 110 x 10(6) per millilitre in 1987 to 50 x 10(6) per millilitre in 2007 (p<0001); an average reduction of 25% annually The volume of semen also fell significantly from 37 ml to 33 ml (p<0001) There was no concomitant change in the duration of abstinence CONCLUSION The decline in semen volume and sperm concentration in men presenting as sperm donors may indicate a reduction in the semen quality of New Zealand men over the past 20 years

High prevalence of gout in patients with Type 2 diabetes: male sex, renal impairment, and diuretic use are major risk factors.

Abstract: AIMS Gout and hyperuricaemia are recognised features of the metabolic syndrome. The objective of this study was to determine the prevalence of gout in patients with diabetes. METHODS We studied 292 consecutive outpatients attending diabetes clinics between August and September 2005. A self-reported history of gout was obtained, and was confirmed by clinical chart review. Information regarding associated comorbidities was also recorded. Current treatments were compared with published EULAR guidelines for the management of gout. RESULTS Gout was confirmed in 0/27 (0%) patients with Type 1 diabetes and 59/265 (22%) of patients with Type 2 diabetes (p<0.01). Prevalence rates varied depending on age and sex, and were highest (41%) in men with type 2 diabetes over the age of 65 years. Multivariate analysis showed that the following variables were independent predictors for gout in patients with Type 2 diabetes: male sex (adjusted OR 4.4, 95%CI 2.1-9.6), impaired renal function (adjusted OR 1.2 for every 10 ml/min reduction in GFR, 95%CI 1.1-1.4), diuretic use (adjusted OR 3.2, 95%CI 1.6-6.6), and high triglycerides (adjusted OR 2.2, 95%CI 1.0-4.7) Only 28/59 (47%) of patients with gout were on urate-lowering therapy. A further 24/59 (41%) met recommended criteria for urate-lowering therapy but were not receiving this medication. CONCLUSION This study has demonstrated a high prevalence of gout in patients with Type 2 diabetes. Improved recognition of those at high risk of gout is needed to ensure optimal management of these patients.

Ethnic differences in cardiovascular disease risk factors and diabetes status for Pacific ethnic groups and Europeans in the Diabetes Heart and Health Survey (DHAH) 2002-2003, Auckland New Zealand

Abstract: Aim The aim of this paper is to provide levels of cardiovascular disease (CVD) risk factors and diabetes status for Pacific ethnic groups and make comparisons amongst these groups (Samoan, Tongan, Niuean, Cook Islanders) with European New Zealanders by gender from the 2002–03 DHAH Survey. Methods The DHAH was a cross-sectional population-based survey and was carried out in Auckland between 2002–03. A total of 1011 Pacific comprising of 484 Samoan, 252 Tongan, 109 Niuean, 116 Cook Islanders, and 47 Other Pacific (mainly Fijian) and 1745 European participants took part in the survey. Participants answered a self-administered questionnaire to assess whether they had previously diagnosed CVD risk factors (blood pressure, cholesterol, diabetes) and lifestyle risk factors (smoking, physical inactivity). All participants provided an early morning mid-stream urine sample, an initial blood test and full glucose tolerance test (GTT) for those not previously diagnosed with diabetes. Results In both men and women, CVD risk among the Pacific groups were all significantly higher than Europeans. Niueans had the lowest Pacific CVD risk and Samoans had the highest estimated risk. Individual risk factors differed between the groups, however; the most observable differences were the more adverse lipid profile in Tongan men and the lower total cholesterol and micro-albumin in Niuean women when compared to their Samoan counterparts. Diabetes prevalence was highest in Samoan men (26.2%) and Tongan women (35.8%). Tongan women had a diabetes prevalence over double that of their men (17.8%), whereas in the other Pacific groups, male and female prevalence was very similar. Niueans had the lowest diabetes prevalence of both sexes (men 14.9%, women 10.8%). Undiagnosed diabetes as a proportion of total diabetes was similar in Samoan, Niuean and Cook Islands groups (1/4–5) suggesting efficient screening. Cook Islanders had a ratio of one undetected diabetes case for every two known cases. Conclusion CVD risk factors, diabetes prevalence, and levels of undetected diabetes differed between the Pacific ethnic groups with Niueans having the healthiest profile. More rigorous screening of diabetes in Cook Islanders is needed if they are to experience similar detection rates as other Pacific Island communities in New Zealand. Greater attention is required to identify and manage CVD risk among all Pacific peoples to reduce the gap in CVD risk factors, morbidity and mortality when compared to European New Zealanders.

A single question reliably identifies physically inactive women in primary care.

Abstract: AIM To validate a single-item screening question for systematic use in primary health care to identify physically inactive adults, who may benefit from physical activity intervention. METHODS The single-item physical activity screening question was administered to 1171 women aged 51-74 years recruited from 10 general practices, followed by a longer validated physical activity questionnaire (the NZPAQ-LF). Sensitivity, specificity, likelihood ratios, positive and negative predictive values, and a Kappa statistic were calculated to assess validity of the screening question. RESULTS The sensitivity of the single-item question was 76.7% (95% confidence interval [CI] 73.5-79.7). It had high specificity (81.1%, 95%CI 77.2-84.4), and a high positive predictive value (86.7%, 95%CI 83.8-89.1). The positive likelihood ratio was 4.05 (3.33-4.93), and negative likelihood ratio was 0.29 (0.25-0.33). The Kappa statistic calculated for the single-item screening question when validated against the NZPAQ-LF was 0.56 (p<0.001). CONCLUSIONS The single-item screening question has good sensitivity, specificity, and concordance with a validated physical activity questionnaire. The question is easy to administer and elicits a simple yes/no response from patients. This validated tool can now be used in practice to identify women who would benefit from physical activity interventions in primary care.

Preventable medication-related events in hospitalised children in New Zealand.

Abstract: AIMS To evaluate the frequency and characteristics of preventable medication-related events in hospitalised children, to determine the yield of several methods for identifying them and to recommend priorities for prevention. METHODS A prospective observational cohort study was conducted over a 12-week period on the paediatric wards at a university-affiliated urban general hospital in New Zealand. For all admissions of greater than 24 hours, medication-related events were identified using a multifaceted approach and subsequently classified independently by three reviewers (using a standardised reviewer form) by event type, type of error, stage of the medication process, and preventability. RESULTS There were 495 eligible study patients, who had 520 admissions and 3037 patient days of admission, during which 3160 medication orders were written. Of 761 medication-related events reported during the study period, 630 (83.3%) were identified by chart review; 111 (14.6%) by a voluntary staff quality improvement reporting system; 16 (2.1%) by interview of parents; and 4 (0.53%) events via the concurrent routine hospital-incident reporting system. Excluding duplicate reports and practice-related issues, a total of 696 study patient-specific events were included in the analysis. Excluding the inconsequential events (trivial rule violation and 'other' categories), the majority [368/399 (92.2%)] of events were found to be preventable; comprising 38/67 (56.7%) ADEs, 75/77 (97.4%) potential ADEs, and all 255 (100%) harmless medication errors. Most commonly implicated in preventable ADEs and potential ADEs were, event rate (95%CI): improper dose and the prescribing stage-35 (29 to 42) and 74 (64 to 84) respectively per 1000 patient days; and antibacterial agents and the intravenous route of administration 21 (17 to 25) and 11 (10 to 13) respectively per 100 medication orders. CONCLUSIONS Preventable medication-related events occur commonly in the paediatric inpatient setting, and importantly over half of the events that caused patient harm were deemed preventable. Voluntary staff reporting in a quality improvement environment was found to be inferior to chart review for identifying events, but a vast improvement on the conventional incident reporting system. Most commonly implicated in the harmful or potentially harmful preventable events, and hence the best targets for prevention are dosing errors, particularly during the prescribing stage of the medication use process, and use of antibacterial agents, particularly when administered by the intravenous route.

Workplace bullying of junior doctors: cross-sectional questionnaire survey.

Abstract: Aim Workplace bullying is a growing concern amongst health professionals. Our aim was to explore the frequency, nature, and extent of workplace bullying in an Auckland Hospital (Auckland, New Zealand). Method A cross-sectional questionnaire survey of house officers and registrars at a tertiary hospital was conducted. Results There was an overall response rate of 33% (123/373). 50% of responders reported experiencing at least one episode of bullying behaviour. The largest source of workplace bullying was consultants and nurses in equal frequency. The most common bullying behaviour was unjustified criticism. Only 18% of respondents had made a formal complaint. Conclusion Workplace bullying is a significant issue with junior doctors. We recommend education about unacceptable behaviours and the development of improved complaint processes.

"If everyone does it, it's not a big deal." Young people talk about chlamydia testing.

Abstract: Aims This study aimed to explore young people's attitudes to chlamydia testing. Data were gathered to inform the development of a clinical trial aimed at increasing chlamydia testing among 16-24 year olds. Methods Four single sex focus groups were conducted with 16-24 year old males and females (n=28), and one with health professionals working with this age-group (n=7). A semi-structured interview schedule was used to discuss barriers to chlamydia testing, methods of accessing testing, communicating information about chlamydia and ideas about ways to encourage testing. Results Reasons for not seeking testing included fear, stigma, denial of personal risk, and a lack of knowledge about chlamydia and about testing procedures. Better education and a need to 'normalise' testing were suggested as ways to increase test-uptake. Preferences for places to seek testing varied among participants, but all groups supported routinely offered chlamydia testing when visiting the doctor for other reasons. Participants also favoured the concept of home-testing. Conclusions Young people identified a number of barriers to chlamydia testing, as well as ways to increase testing. These findings can be used to inform the development of much needed new initiatives to control chlamydia in New Zealand.

The maternal outcome in placenta accreta: the significance of antenatal diagnosis and non-separation of placenta at delivery.

Abstract: AIM: To evaluate the effects of antenatal diagnosis and subsequent placental non-separation at delivery on the maternal outcome in confirmed cases of placenta accreta. METHOD: The perinatal database and medical records for women who delivered in the period 2000-6 in a teaching hospital in New Zealand with a diagnosis of placenta accreta or postpartum haemorrhage or hysterectomy were reviewed. In confirmed placenta accreta cases, the amount of blood loss and blood transfused at delivery and subsequent emergency hysterectomy were analysed in respect to the presence/absence of antenatal diagnosis and the management at delivery. RESULTS: 16 women had placenta accreta confirmed (15 histologically and 1 visually). Antenatal diagnosis was made in 7 women, elective Caesarean delivery planned in all, hysterectomy to follow in 5 (4 elective, 1 emergency preterm), and elective placental separation in 2 women. When an antenatal diagnosis was not made (n=9), attempted placental separation led to emergency hysterectomy for all (p=0.001). Antenatal diagnosis and placental non-separation resulted in less mean blood loss (1.4 L vs 3.6 L, p=0.003; 1.0 L vs 3.4 L, p<0.001) and mean units of blood transfused (1.2 vs 5.1, p=0.005) in the latter. CONCLUSION: In placenta accreta, antenatal diagnosis and avoidance of placental separation may result in better maternal outcome.

Trends in population drug use in New Zealand: findings from national household surveying of drug use in 1998, 2001, 2003, and 2006.

Abstract: AIM To track trends in drug use in the New Zealand population over the past 8 years. METHOD National household surveys of drug use were conducted in New Zealand in 1998, 2001, 2003,and 2006 using the same Computer Assisted Telephone Interview (CATI) methodology. The age ranges of the random digit dial (RDD) samples from each survey wave were truncated to those aged 15-45 years old. The respective sample sizes for each of the survey waves were: 5475 in 1998; 5504 in 2001, 3042 in 2003, and 1902 in 2006. Statistical comparisons were made between the 2006 survey wave and the three other survey waves for 13 different drug types. RESULTS A higher proportion of the sample had tried alcohol in their lifetimes in 2006 compared to 2003 (89.5% vs 83.7%, p<0.0001) and compared to 2001 (89.5% vs 86.4%, p=0.0038). A lower proportion had tried tobacco in 2006 compared to 2001 (57.6% vs 63.9%, p<0.0001) and compared to 1998 (57.6% vs 64.4%, p<0.0001). A lower proportion had used cannabis in the past 12 months in 2006 compared to 2001 (17.9% vs 20.3%, p=0.0448). A lower proportion had used amphetamine in the past year in 2006 than in 2001 (3.4% vs 5.0%, p=0.0085). A higher proportion of the sample had used ecstasy (MDMA) in the past year in 2006 compared to 1998 (3.9% vs 1.5%, p<0.0001). There was an increase in the level of alcohol use by last year drinkers in 2006 compared to 1998 with an increase in the proportion of drinkers saying they were using 'more' alcohol and a decrease in those saying they were using 'less' alcohol. There was an increase in the level of amphetamine use by current amphetamine users in 2006 compared to 2003 with less users saying they had 'stopped' using the drug (12% vs 42%, p=0.0386). CONCLUSIONS The rise in the lifetime use and level of use of alcohol is consistent with the liberalisation of the alcohol environment in New Zealand. Conversely, the decline in the lifetime use of tobacco reflects stricter regulation and shifts in societal tolerance of smoking. The growing negative social connotations attached to smoking, as well the emergence of new synthetic stimulants, may have impacted negatively on levels of cannabis use. There has been some entrenchment of amphetamine use since a reported levelling off of its prevalence in 2003.

Allele frequency differences of cytochrome P450 polymorphisms in a sample of New Zealand Māori.

Abstract: Aims To determine the prevalence of functional alleles for drug metabolising genes in a sample of Maori and compare allele frequencies with Caucasians estimates. Procedures DNA from 60 Maori volunteers was genotyped for cytochrome P450 polymorphisms-CYP2A6, CYP2C9, CYP2C19, and CYP2D6-and allele frequencies calculated and compared with Caucasian estimates. Results Absolute allele frequency differences between Maori and Caucasian groups ranged from 1% to 16% for the polymorphisms tested. Conclusions Functional allele frequencies of drug metabolising genes differed between Maori and European groups warranting larger general population surveys. These findings may also bear thinking about when conducting pharmacogenetic studies or clinical trials in New Zealand cohorts because patients with Maori ancestry may respond differently to certain medicines based on genotype.

Paediatric inflammatory bowel disease in New Zealand.

Abstract: Aim To determine the incidence, presentation, and initial management of paediatric inflammatory bowel disease in New Zealand. Methods A prospective study in collaboration with the New Zealand Paediatric Surveillance Unit was undertaken between 2002-2003. Paediatricians and healthcare professionals working with children were surveyed monthly for cases of paediatric inflammatory bowel disease. Results There were 52 cases(30 males); 34 (66%) Crohn's disease, 9 (17%) ulcerative colitis, and 9 (17%) inflammatory bowel disease type unclassified. The estimated incidence of paediatric inflammatory bowel disease, Crohn's disease, and ulcerative colitis were 2.9, 1.9, and 0.5 per 100,000 per year respectively. Mean age at diagnosis was 11 years with a delay of 8.4 months from clinical presentation to diagnosis. 85% were European, while no Maori or Pacific Islanders had Crohn's disease or ulcerative colitis. The most common symptoms at presentation were abdominal pain (63%), rectal bleeding (57%), diarrhoea (55%), and weight loss (43%). 39% of Crohn's disease patients had perianal disease at presentation. Only 18% of the Crohn's disease patients presented with the classic triad of symptoms-abdominal pain, weight loss, and diarrhoea. Haematological laboratory abnormalities were more common in Crohn's disease. 5-aminosalicylic acid agents were the most common initial therapy followed by systemic steroids. 25% of the paediatric inflammatory bowel disease cohort received immunomodulators. Conclusions The incidence of paediatric inflammatory bowel disease in New Zealand is comparable but at the lower end relative to North America and United Kingdom. There is more Crohn's disease than ulcerative colitis and only a minority of Crohn's disease patients presented with the classic triad of abdominal pain, weight loss, and diarrhoea. 5-aminosalicylic acid preparations and steroids as first line treatment of Crohn's disease were much more common than nutritional therapy. It is rare for New Zealand Polynesian children to develop paediatric inflammatory bowel disease.

Rurality and pandemic influenza: geographic heterogeneity in the risks of infection and death in Kanagawa, Japan (1918-1919).

Abstract: Aim To characterise the impact of rurality on the spread of pandemic influenza by exploring both the numbers of cases and deaths in Kanagawa Prefecture, Japan, from October 1918 to April 1919 inclusive. Method In addition to the numbers of influenza cases and deaths, population sizes were extracted from census data, permitting estimations of morbidity, mortality, and case fatality by 199 different regions (population 1.4 million). These outcomes were compared between four groups; cities (n=6), larger towns (38), smaller towns (101), and villages (54). Results Whereas crude mortality in villages was lower than those of other population groups, the morbidity appeared to be the highest in villages, revealing significant difference compared to all cities and towns [risk ratio=0.601 (95% confidence interval: 0.600-0.602)]. Villages also yielded the lowest case fatality, the difference of which was statistically significant among four population groups (p=0.02). Conclusion Rurality did not show a predictive value of protection against pandemic influenza in Kanagawa. Lower morbidity in the towns and cities is likely explained by effective preventive measures in urban areas. High morbidity in rural areas highlights the potential importance of social distancing measures in order to minimise infections in the event of the next influenza pandemic.

Screening, diagnosis and services for women with gestational diabetes mellitus (GDM) in New Zealand: a technical report from the National GDM Technical Working Party.

Abstract: Rates of gestational diabetes mellitus (GDM) and Type 2 diabetes in pregnancy are increasing with the epidemic of obesity. GDM is associated with significant perinatal morbidity and future risk of permanent diabetes in the mother and obesity and diabetes in the offspring. The recent Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) has shown maternal and perinatal benefits of managing GDM once diagnosed. The criteria for GDM are under review following the recent completion of the Hyperglycaemia and Adverse Perinatal Outcomes study (HAPO). In New Zealand, the approach to identifying women with GDM or undiagnosed Type 2 diabetes has varied. The National GDM Technical Working Party reviewed the available data in the New Zealand context and recommend that (1) All pregnant women are offered screening for GDM backed up with relevant educational, systems and materials for health professionals and the women; (2) Criteria for GDM should remain unchanged pending further information (which should be actively sought); (3) Women at high risk of undiagnosed Type 2 diabetes in pregnancy should be screened at booking: the HbA1c was recommended as a practical initial screening test, but further research is needed; and (4) A structured, audited, population-based approach to managing women with GDM should be introduced in each district.

Men's health and the health of the nation.

Abstract: The health of the male population is a substantial contributor to the health of the nation. In general, men have a poorer health status and lower utilisation of health services than women. They have a lower life expectancy and are more likely to die from avoidable deaths than women. Men’s health is increasingly being recognised as a specialty area of health promotion and of clinical practice. Male-specific approaches may assist in maximising the positive outcome of interventions aimed at educating men about their health issues, attracting men into seeking clinical services, and establishing and maintaining a gender-orientation in health services that encourages men to engage. With appropriate training and resources, primary health care is ideally placed to provide accessible, male-friendly services with lead to reduction in gender inequalities in health. Why is health, and men’s health, so important? A person’s health is a foundation which enables or constrains his or her lifestyle, social, education, or employment choices. A decline in individuals’ health has significant ramifications for their employment status and participation in the workforce. Furthermore the idea of health as the foundation of individual wellbeing extends to the health of a nation. Health is not simply a by-product of economic development, but is a substantial driver of economic development as well. The health of the population affects a country’s productivity, labour supply, education levels, and capital formation. Healthy people learn better, live longer—and work, earn, and save more. 1 The increasing cost of health care, fuelled by new technologies and an ageing population, itself places a substantial economic burden. This highlights the importance of improving the overall health status of the population rather than simply extending the average life expectancy of the population—adding life to years, rather than years to life. If health is important then, what is it about men’s health that is worthy of attention? In New Zealand (NZ), men comprise 49% of the population and 52% of the labour force. 1 Building on the above arguments, the health of the male population is a substantial contributor to the health of the nation. However men’s health per se has received relatively little attention. While in some instances male subjects may have been assumed to be ‘generic’ for human beings, there has been little research

Doctoring New Zealand's gay men.

Abstract: Aims To investigate gay men's experiences of using general practitioner (GP) services. Methods A qualitative research methodology was used and transcripts obtained from 11 focus groups conducted in two large New Zealand cities were thematically analysed. Results The key result is concerned with how men attempt to access high quality GP services. Participants reported two main ways they achieve this. The first is through selection of a doctor; the second is through controlling disclosure of their sexuality to the doctor. We also report participants' positive and negative experiences of primary healthcare. Conclusion While many men reported good healthcare experiences, others did not. To optimise quality of care, gay men carefully managed their relationship with their doctors. Doctors play a crucial role in facilitating an environment to allow disclosure. While a minority of men have disclosed sexuality and sexual behaviours to their doctors, most men have not--arguably to the detriment of their healthcare. We argue that doctors need to be cognisant of the health needs of gay men to provide high quality care, and we conclude that medical practitioners and associations and gay men need to jointly address these issues.

The influence of steroid injections on the incidence of infection following total knee arthroplasty.

Abstract: Aim To investigate whether a relationship exists between preoperative intra-articular steroid injections and postoperative wound healing in total knee arthroplasty (TKA). Similar research studies on total hip arthroplasty (THA) have found higher rates of post surgical problems in hips that have been injected with steroids. Methods Thirty-eight patients with TKA postoperative wound infection, and 352 TKA patients without postoperative wound infection were compared against corticosteroid injected and non-injected patients. Variables measured were diabetes, cigarette smoking, knee scores, number of injections, injection administrator, and preoperative injection intervals. Results No significant difference emerged in rates of infection or between smoking rates and diabetes. Number of injections, preoperative injection interval and injection administrator did not significantly influence outcome. A significant difference exists between each group's knee scores. Conclusions Injecting knees with corticosteroids prior to TKA did not increase the incidence of postoperative wound infection.

Training effect of skills courses on confidence of junior doctors performing clinical procedures.

Abstract: Aim To determine the impact of a procedural skills course and of ongoing experience on the confidence of junior doctors undertaking procedures in clinical practice, and to identify any relationship between confidence level and amount of ongoing experience. Methods An intake of junior doctors (n=33) attended a procedural skills course and learnt six procedures, comprising exploration and debridement of a contaminated wound, nasogastric tube insertion, urethral catheterisation, lumbar puncture, pleural aspiration, and intercostal drain insertion and removal. Three questionnaires assessing their experience with the procedures and their confidence were completed before and immediately after the course, and 5 months later. Results The procedural skills course had a positive impact on the immediate confidence of junior doctors performing all of the clinical procedures as measured by a confidence survey pre- and post-course. Only nasogastric tube insertion, urethral catheterisation, and pleural aspiration demonstrated a maintained increase in confidence when comparing pre-course to five months follow-up confidence levels. Only urethral catheterisation was associated with an overall increase in confidence at 5 months’ follow-up. Overall there was a strong positive correlation between changes in experience and changes in confidence. Conclusions The procedural skills course produced a significant increase in confidence in the short term, but this decreased unless there was ongoing clinical experience with the procedure. The benefit of short courses is eroded by the lack of reinforcement through continuing experience. Junior doctors face several challenges as they embark on their professional careers, one of which is the need to perform clinical procedures competently. The Health Practitioners Competence Assurance Act 2003 (HPCAA) legislation highlights the need to ensure the lifelong competence of health practitioners. 1 Registration authorities are required to certify that a practitioner is competent within their scope of clinical practice when they issue an annual practising certificate. The Medical Council of New Zealand (MCNZ) has produced an 'indicative list of skills' for which 'a good understanding' should be achieved in the first year of postgraduate medical work.

The incidence and thickness of cutaneous malignant melanoma in New Zealand 1994-2004.

Abstract: Aim To examine the incidence of thick melanoma in New Zealand from 1994-2004 and investigate associations with melanoma thickness. Method The New Zealand Health Information Service provided information on all registrations for malignant melanoma from 1994-2004. Age-standardised registration rates were calculated. Logistic regression analysis was undertaken to identify factors associated with melanoma thickness. Results The incidence of thick melanoma did not decrease during 1994-2004. There were statistically significant associations for age, gender, ethnic group, and type of melanoma with melanoma thickness. Of those diagnosed with melanoma, the proportion with thick melanoma was greater for older than younger people, for males compared with females, for Maori compared with non-Maori (despite the lower incidence in Maori), and for those diagnosed with nodular melanoma compared with other types of melanoma. Conclusion Strategies to encourage the early detection of melanoma in New Zealand have not yet reduced the incidence of thick melanomas. This may be because it is too soon to see the impact of early detection, or because early detection strategies predominantly identify melanomas that are unlikely to progress, but miss thicker nodular melanomas.