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This paper outlines the benefits and problems which both students and staff supervisors encounter in undertaking a major project as part of the degree program in the Department of Management Studies at the University of Waikato. (Author/JEG)

Evaluative reporting provides a balanced approach to evidence interpretation. The use of evaluative reporting in forensic DNA analysis is common practice and well understood in Australia and New Zealand. However, it is less common and perhaps less understood in the pattern and trace evidence areas. Recent publications, such as the 2015 'European Network of Forensic Science Institutes (ENFSI) Guideline for Evaluative Reporting in Forensic Science', have prompted discussion in Australia and New Zealand about the benefits and risks of expanding its application in forensic science. To aid discussions and build a common understanding of evaluative reporting, the Australia New Zealand Policing Advisory Agency National Institute of Forensic Science (ANZPAA NIFS) convened a project working group to create 'An introductory guide to evaluative reporting'. The guide covers terminology and uses examples to illustrate the concepts. It also provides advice on the implementation of evaluative reporting in forensic science disciplines. This article provides an overview of the project, and the methodology and thinking behind the development of the guide and its associated fact sheet and process poster. [ABSTRACT FROM AUTHOR]

Background: Anti-glomerular basement membrane (GBM) antibody-mediated disease is rare and classically presents with the syndrome of glomerulonephritis and pulmonary haemorrhage. Aim: This aim of this report was to determine the incidence, clinical features, management and outcomes of anti-GBM disease in Auckland between 1998 and 2008. Methods: Potential patients were identified by a search for positive anti-GBM antibody serology, diagnostic renal biopsy, or in-hospital admissions using International Classification of Diseases 9 and 10 codes between 1998 and 2008. A retrospective case notes review of all potential cases was performed with data censored at 31 December 2010. Results: Twenty-three cases were identified. The rate of anti-GBM disease was estimated at 1.79 per million person-years. There were 12 men and 11 women. The median age was 45 years, range 12-74 years. Sixteen patients were European, three were Pacific peoples, three were NZ Maori and one was Chinese. Eleven were regular smokers and eight ex-smokers, significantly higher proportions than the population ( P≤ 0.001). Smokers were significantly more likely to have respiratory disease ( P= 0.03). The mean creatinine at presentation was 474 µmol/L. All patients had a renal biopsy; 20 had crescentic glomerulonephritis. One patient recovered renal function without treatment. Twenty-two were immunosuppressed with cyclophosphamide and corticosteroids. Seventeen received plasmapheresis. Eighteen were alive, eight with end-stage renal disease, two with chronic kidney disease and eight with normal renal function. Conclusions: Anti-GBM disease is a rare condition, which is not overrepresented among indigenous people. With aggressive therapy the prognosis has improved; however, the morbidity and mortality of this condition remain significant. [ABSTRACT FROM AUTHOR]

Background: There is conflicting information about the relationship between asthma and socioeconomic status, with different studies reporting no, positive, or inverse associations. Most of these studies have been cross sectional in design and have relied on subjective markers of asthma such as symptoms of wheeze. Many have been unable to control adequately for potential confounding factors.Methods: We report a prospective cohort study of approximately 1000 individuals born in Dunedin, New Zealand in 1972-3. This sample has been assessed regularly throughout childhood and into adulthood, with detailed information collected on asthma symptoms, lung function, airway responsiveness, and atopy. The prevalence of these in relation to measures of socioeconomic status were analysed with and without controls for potential confounding influences including parental history of asthma, smoking, breast feeding, and birth order using cross sectional time series models.Results: No consistent association was found between childhood or adult socioeconomic status and asthma prevalence, lung function, or airway responsiveness at any age. Having asthma made no difference to educational attainment or socioeconomic status by age 26. There were trends to increased atopy in children from higher socioeconomic status families consistent with previous reports.Conclusions: Socioeconomic status in childhood had no significant impact on the prevalence of asthma in this New Zealand born cohort. Generalisation of these results to other societies should be done with caution, but our results suggest that the previously reported associations may be due to confounding. [ABSTRACT FROM AUTHOR]

Aim To assess the possible effects of tobacco and cannabis smoking on lung function in young adults between the ages of 18 and 26. Setting and participants A group of over 900 young adults derived from a birth cohort of 1037 subjects born in Dunedin, New Zealand in 1972/73 were studied at age 18, 21 and 26 years. Measurements Cannabis and tobacco smoking were documented at each age using a standardized interview. Lung function, as measured by the forced expiratory volume in one second/vital capacity (FEV[sub 1]/VC) ratio, was obtained by simple spirometry. A fixed effects regression model was used to analyse the data to take account of confounding factors. Findings When the sample was stratified for cumulative use, there was evidence of a linear relationship between cannabis use and FEV[sub 1]/VC (P < 0.05). In the absence of adjusting for other variables, increasing cannabis use over time was associated with a decline in FEV[sub 1]/VC with time: the mean FEV[sub 1]/VC among subjects using cannabis on 900 or more occasions was 7.2%, 2.6% and 5.0% less than non-users at ages 18, 21 and 26, respectively. After controlling for potential confounding factors (age, tobacco smoking and weight) the negative effect of cumulative cannabis use on mean FEV[sub 1]/VC was only marginally significant (P < 0.09). Age (P < 0.001), cigarette smoking (P < 0.05) and weight (P < 0.001) were all significant predictors of FEV[sub 1]/VC. Cannabis use and daily cigarette smoking acted additively to influence FEV[sub 1]/VC. Conclusions Longitudinal observations over 8 years in young adults revealed a dose-dependent relationship between cumulative cannabis consumption and decline in FEV[sub 1]/VC. However, when confounders were accounted for the effect was reduced and was only marginally significant, but given the limited time frame over which observations were made, the trend suggests that continued cannabis smoking has the potential to result in clinically important impairment of lung... [ABSTRACT FROM AUTHOR]

Aim. To evaluate the relationship between cannabis dependence and respiratory symptoms and lung function in young adults, while controlling for the effects of tobacco smoking. Setting and participants. Nine hundred and forty-three young adults from a birth cohort of 1037 subjects born in Dunedin, New Zealand in 1972/1973 were studied at age 21. Measurements. Standardized respiratory symptom questionnaires were administered. Spirometry and methacholine challenge tests were undertaken. Cannabis dependence was determined using DSM-III-R criteria. Descriptive analyses and comparisons between cannabis-dependent, tobacco-smoking and non-smoking groups were undertaken. Adjusted odds ratios for respiratory symptoms, lung function and airway hyper-responsiveness (PC[sub 20]) were measured. Findings. Ninety-one subjects (9.7%) were cannabis-dependent and 264 (28.1%) were current tobacco smokers. After controlling for tobacco use, respiratory symptoms associated with cannabis dependence included: wheezing apart from colds, exercise-induced shortness of breath, nocturnal wakening with chest tightness and early morning sputum production. These were increased by 61%, 65%, 72% (all p < 0.05) and 144% (p < 0.01) respectively, compared to non-tobacco smokers. The frequency of respiratory symptoms in cannabis-dependent subjects was similar to tobacco smokers of 1-10 cigarettes/day. The proportion of cannabis-dependent study members with an FEV[sub 1]/FVC ratio of < 80% was 36% compared to 20% for non-smokers (p = 0.04). These outcomes occurred independently of co-existing bronchial asthma. Conclusion. Significant respiratory symptoms and changes in spirometry occur in cannabis-dependent individuals at age 21 years, even although the cannabis smoking history is of relatively short duration. [ABSTRACT FROM AUTHOR]

Introduction: Breast cancer surgery aims to excise lesions with clear margins and provide optimal cosmesis with a low re-excision rates. These aims are aided by accurate lesion localisation and a surgical choice of incision site with minimal removal of healthy tissue. Problems associated with hookwires have led to adoption of non-wire methods including radioguided occult lesion localisation using iodine-125 (ROLLIS). This paper outlines the problems encountered and lessons learnt during the largest RCT involving 659 participants, conducted at eight sites (seven Australian, one New Zealand centres) between September 2013 and April 2018.* METHODS: Data, along with substantive comments, regarding each ROLLIS procedure, documenting each step from the seed insertion, ease of operative retrieval, to return of the seed to medical physics, from a shared on-line secure database and a separate site email survey, were synthesised and categorised., Results: The Australian and New Zealand ROLLIS RCT experience highlights several important issues. Lessons learned were related to licencing the seed and tracking protocols. A Designated Team Lead, who is a good communicator, ensuring the Tracking Protocols were accurately followed and updated, subspecialty leads and a Co-ordinator, responsible for training, logbook maintenance and seed ordering, enhanced the success and acceptance of the programme. Addressing radiation issues, fears, education of staff and seed loss was imperative., Conclusion: The Australian and New Zealand ROLLIS RCT experience highlights the need for adherence to local licencing laws and protocols, appointing a dedicated ROLLIS Designated Team Lead with good communication and a ROLLIS Co-ordinator. These facilitate the adoption of a successful ROLLIS programme., (© 2022 The Authors. Journal of Medical Imaging and Radiation Oncology published by John Wiley & Sons Australia, Ltd on behalf of Royal Australian and New Zealand College of Radiologists.)

Aim: The primary aim of this survey was to develop an understanding of current pulmonary rehabilitation practices in New Zealand. The onset of a COVID-19 lockdown in New Zealand in March 2020, shortly after completion of the initial survey, enabled a follow-up survey to determine how services had adapted in response to the global pandemic., Methods: A cross-sectional observational design using two sequential purpose designed online surveys administered before (Survey 1) and after COVID-19 lockdowns (Survey 2) in New Zealand., Results: Survey 1 was completed by 36 PR services across New Zealand and showed homogeneity in the content and structure of services provided. PR was primarily funded by district health boards, run by a multi-disciplinary team of health professionals and included participants with a range of chronic respiratory conditions. All programmes completed pre- and post-PR assessments, were a minimum of eight weeks in duration and included exercise and education. Survey 2 showed that, during level 4 and level 3 COVID-19 restrictions, 11 (40.7%) of services paused PR programmes, with 16 (59%) adapting the service to provide home-based rehabilitation via telephone or teleconference facilities., Conclusion: PR programmes in New Zealand report following Australian and New Zealand PR best practice guidelines and are homogenous in content and structure, but COVID-19 restrictions highlighted the need for services to provide more diverse options for service delivery. Future service development should focus on providing a range of delivery options allowing increased access to PR, tailoring therapy to meet individual needs and ensuring services are engaging for all participants to optimise participation., Competing Interests: Nil.

Spirometry has been established as an essential test for diagnosing and monitoring respiratory disease, particularly asthma and COPD, as well as in occupational health surveillance. In Australia and New Zealand, there is currently no pathway for spirometry operators in community-based healthcare settings to demonstrate spirometry competence. The Australia and New Zealand Society of Respiratory Science (ANZSRS) has identified a need for developing a pathway for operators working in community-based practices in Australia and New Zealand to demonstrate spirometry competence and certification. Spirometry certification provides evidence to patients, clients, employers and organizations that an individual has participated in an assessment process that qualifies them to perform spirometry to current international spirometry standards set out by the American Thoracic Society and the European Respiratory Society (ATS/ERS). This document describes a competence assessment pathway that incorporates a portfolio and practical assessment. The completion of this pathway and the award of certification confer an individual is competent to perform spirometry for 3 years, after which re-certification is required. The adoption of this competency assessment and certification process by specialist organizations, and the commitment of operators performing spirometry to undergo this process, will enhance spirometry quality and practice in community-based healthcare settings., (© 2020 The Authors. Respirology published by John Wiley & Sons Australia, Ltd on behalf of Asian Pacific Society of Respirology.)

Introduction: Most exercise studies for older adults have been university- or hospital-based. Little is known about the benefits and factors influencing long-term participation in community-based exercise programmes, especially in New Zealand., Aim: To quantify the objective benefits, participant perceptions and retention rates of a New Zealand community-based exercise programme for adults (60 years or older)., Methods: Study 1 involved assessing the benefits of 12 weeks' training on a convenience sample of 62 older adults commencing the never2old Active Ageing programme. Study 2 assessed the perceptions of 150 current participants on a variety of programme components that could act as barriers or facilitators to continued engagement. Study 3 assessed the retention rates of 264 participants in the programme over a two-year period., Results: Significant improvements in many physical functional scores were observed in Study 1 (5-30 percentile points; p<0.05). Questionnaire responses from participants in Study 2 indicated many perceived benefits (positive responses from 67-95% on various questions) and that core components of the programme were rated very highly (64-99% on various components). Retention rates were high, with Study 3 finding 57% of participants still engaging in the programme at the end of the two-year period., Discussion: A community-based exercise programme for older adults can improve many objective and subjective measures of physical fitness and functional performance and have good retention rates. General practitioners and other allied health professionals in New Zealand should consider promoting programmes, such as the never2old Active Ageing programme, to their older patients.

High concentrations of tetrodotoxin (TTX) have been detected in some New Zealand populations of Pleurobranchaea maculata (grey side-gilled sea slug). Within toxic populations there is significant variability in TTX concentrations among individuals, with up to 60-fold differences measured. This variability has led to challenges when conducting controlled laboratory experiments. The current method for assessing TTX concentrations within P. maculata is lethal, thus multiple individuals must be harvested at each sampling point to produce statistically meaningful data. In this study a method was developed for taking approximately 200 mg tissue biopsies using a TemnoEvolution(®) 18G × 11 cm Biopsy Needle inserted transversely into the foot. Correlation between the TTX concentrations in the biopsy sample and total TTX levels and in individual tissues were assessed. Six P. maculata were biopsied twice (nine days apart) and each individual was frozen immediately following the second sampling. Tetrodotoxin concentrations in biopsy samples and in the gonad, stomach, mantle and the remaining combined tissues and fluids were measured using liquid chromatography-mass spectrometry. Based on the proportional weight of the organs/tissues a total TTX concentration for each individual was calculated. There were strong correlations between biopsy TTX concentrations and the total (r(2) = 0.88), stomach (r(2) = 0.92) and gonad (r(2) = 0.83) TTX concentrations. This technique will enable more robust laboratory studies to be undertaken, thereby assisting in understanding TTX kinetics, ecological function and origin within P. maculata., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Aims: To assess the effectiveness of a new hypertension clinic (in Auckland, New Zealand) using clinical nurse specialist appointments for drug titration., Methods: A new hypertension clinic was established at Waitemata District Health Board (DHB) in August 2010 using an initial registrar clinic appointment followed by fortnightly clinical nurse specialist appointments for drug titration. 50 GP-referred patients were prospectively audited and their outcomes compared to 50 patients seen in the physician hypertension clinic., Results: The comorbidities of the two groups were similar. 52-66% had the metabolic syndrome by IDF criteria. The mean number of clinic visits to discharge was not significantly different. The mean number of antihypertensive drugs at discharge was the same (2.8) for both clinics. There were significant reductions in systolic and diastolic blood pressures in both clinics, with a mean discharge blood pressure of 131/78 in the nurse clinic group., Conclusions: Nurse titration clinics are as effective as physician-only appointments in rapidly achieving target blood pressures.

Aims: Goodpasture's syndrome, glomerulonephritis and pulmonary haemorrhage, may be due to a variety of causes. Rarely, patients with Goodpasture's syndrome present with both anti-glomerular basement membrane (GBM) and antineutrophil cytoplasmic antibody (ANCA). The aim of this report was to determine the incidence, clinical features, management and outcomes of patients presenting with concurrent ANCA and anti-GBM disease in Auckland., Methods: Potential patients were identified by an electronic search of serology for ANCA and anti-GBM antibody, diagnostic renal biopsy, or in-hospital admissions using ICD9 and ICD10 codes between 1998 and 2008. A retrospective case-note review of all potential cases was performed., Results: Six cases were identified: two women and four men. The incidence was estimated at 0.47 cases per million people per year. The mean age of presentation was 59 years (range 25-85 years). One patient was a smoker and two patients were ex-smokers. All subjects were anaemic, had haemoptysis and an abnormal chest X-ray at presentation. The mean creatinine at presentation was 225 µmol/L (range 126-406 µmol/L); all patients had haematuria and proteinuria. All patients received corticosteroids and cyclophosphamide. Two patients were not plasma exchanged and died. Four patients received plasma exchange and are alive. One patient had a clinical relapse 6 years after their initial presentation and is on renal replacement therapy., Conclusion: Concurrent ANCA and anti-GBM disease is rare. The mortality rate is high. Aggressive immunosuppression with steroids, cyclophosphamide and plasma exchange can induce remission and preserve renal function. Long-term monitoring for relapses should occur., (© 2011 The Authors. Nephrology © 2011 Asian Pacific Society of Nephrology.)

Purpose: To explore the barriers and facilitators to engagement in physical activity from the perspective of people with multiple sclerosis (MS)., Method: This study adopted a qualitative descriptive design, using semi-structured interviews. Participants were recruited through local MS Societies and one District Health Board as part of a larger study. Ten people with a definite diagnosis of MS were purposefully selected aiming for diversity on a range of characteristics., Results: A number of factors were identified that seemed to interact and work to tip the decisional balance regarding physical activity engagement for people with MS. The most prominent themes included beliefs about physical activity; related emotional responses; and the role of fatigue in the decision to take part in physical activity. One of the most striking findings was the apparent tension surrounding the decision to take part in physical activity which seemed to be related to the co-existence of conflicting beliefs., Conclusions: For people with MS, the decision to engage in physical activity (or not) is complex, fluid and individual; made more complex by the unpredictable nature of MS. Rehabilitation professionals attempting to engage people with MS in a physical activity programme should consider adopting an individualised approach to barrier management which takes into account personal beliefs and perceptions regarding physical activity engagement.

Background: Activity Monitors give an objective measure of usual walking performance. This study aimed to examine the test-retest reliability of the StepWatch Activity Monitor outputs (mean steps/day; peak activity index; sustained activity indices of 1, 5, 20, 30, 60 minutes; steps at high, medium, and low stepping rates)., Methods: Thirty healthy adults age 18 to 49 years wore the StepWatch for 2 3-day periods at least 1 week apart., Results: The intraclass correlation coefficients of the StepWatch outputs ranged from 0.44 to 0.91 over 3 days. The coefficient of variation ranged from 3.0% to 51.3% over the monitoring periods, with higher variation shown for shorter monitoring periods. The most reliable 5 outputs had 95% limits of agreement between 3-day periods that were less than 40%. These were mean steps/day ( ± 39.1%), highest step rate in 1 ( ± 17.3%) and 5 ( ± 37.4%) minutes, peak activity index ( ± 25.6%), and percentage of inactive time ( ± 9.52%)., Conclusions: Mean steps/day, highest step rate in 1 and 5 minutes, peak activity index, and percentage of inactive time have good test-retest reliability over a 3-day monitoring period, with lower reliability shown by the other StepWatch outputs. Monitoring over 1 or 2 days is less reliable.

Background: Exhaled nitric oxide (FENO) measurements may help to highlight when inhaled corticosteroid (ICS) therapy should or should not be adjusted in asthma. This is often difficult to judge. Our aim was to evaluate a decision-support algorithm incorporating FENO measurements in a nurse-led asthma clinic., Methods: Asthma management was guided by an algorithm based on high (>45ppb), intermediate (30-45ppb), or low (<30ppb) FENO levels and asthma control status. This provided for one of eight possible treatment options, including diagnosis review and ICS dose adjustment., Results: Well controlled asthma increased from 41% at visit 1 to 68% at visit 5 (p=0.001). The mean fluticasone dose decreased from 312 mcg/day at visit 2 to 211mcg/day at visit 5 (p=0.022). There was a high level of protocol deviations (25%), often related to concerns about reducing the ICS dose. The % fall in FENO associated with a change in asthma status from poor control to good control was 35%., Conclusion: An FENO-based algorithm provided for a reduction in ICS doses without compromising asthma control. However, the results may have been influenced by the education and support which patients received. Reluctance to reduce ICS dose was an issue which may have influenced the overall results., Trial Registration: Australian Clinical Trials Registry # 012605000354684.

Background: Exposure to cats and dogs during childhood has been linked to a lower risk of developing allergies. It remains unclear whether this is due to selective avoidance of pets by families with a history of allergies. The effects of pet ownership in adulthood are unknown., Objectives: We sought to assess the association between cat and dog ownership in childhood and early adulthood and the development of atopy in a population-based birth cohort of 1037 subjects., Methods: Ownership of cats or dogs between birth and age 9 years and between the ages of 18 and 32 years was reported. Skin prick tests to common allergens were performed at 13 and 32 years., Results: There was no evidence that families with a history of atopy avoided owning pets. There were significant cat-by-dog interactions for the development of atopy in both childhood and adulthood. Children who had owned both a cat and a dog were less likely to be atopic at age 13 years. Living with only one of these animals was not protective against atopy. Among those who were not atopic by age 13 years, having both a cat and a dog in adulthood was associated with a lower risk of new atopy by age 32 years. This association was only significant among those with a parental history of atopy. These effects were independent of a range of potential confounding factors., Conclusions: There is a synergistic interaction between cat and dog exposure that is associated with a lower risk of developing atopy in childhood and young adulthood.

Objective: To revise the Physical Activity Disability Scale (PADS) and to explore the acceptability and test-retest reliability of the revised measure, the PADS-R, in people with multiple sclerosis., Design: This study was conducted over three phases: (1) PADS-R questionnaire development including modification to the original PADS, field testing and refinement; (2) PADS-R scoring; (3) PADS-R acceptability and reliability assessment, where participants completed the PADS-R twice over the telephone, three days apart, and then answered a series of semi-structured questions on the instrument's acceptability., Subjects: Participants were recruited from the local Multiple Sclerosis Society, Stroke Foundation and Auckland District Health Board depending on the purpose of each phase: (1) PADS-R questionnaire development (n = 30, multiple sclerosis); (2) PADS-R scoring (n = 293, multiple sclerosis; and n = 83, stroke); and (3) PADS-R acceptability and reliability assessment (n = 29, multiple sclerosis)., Main Measures: Physical Activity Disability Scale-Revised (PADS-R) RESULTS: The PADS-R took approximately 20 minutes to administer and most (n = 25; 86%) participants reported it to be easy to understand and complete. All participants reported that it enabled them to give an accurate picture of their physical activities. In terms of test-retest reliability, the intraclass correlation coefficient was high (0.87 (95% confidence intervals (CI) 0.78, 0.96)), but the 95% limits of agreement were wide (+/-1.13). When observations which potentially represented important changes in activity were excluded, these limits narrowed considerably (+/-0.89)., Conclusions: The PADS-R appears to be a conceptually and psychometrically sound measure of physical activity for people with chronic neurological conditions.

Pseudomonas aeruginosa is an important pathogen in cystic fibrosis (CF). Although most patients harbour unique P. aeruginosa isolates, some clinics report patients sharing common strains. The overall importance of person-to-person transmission in P. aeruginosa acquisition and whether routine patient segregation is necessary remains uncertain. The present authors therefore investigated the extent of P. aeruginosa transmission in New Zealand CF clinics. New Zealand's seven major CF centres were assessed, combining epidemiological data with computer-assisted SalI DNA fingerprinting of 496 isolates from 102 patients. One cluster of related isolates was significantly more prevalent in the largest clinic than expected by chance. The seven patients with isolates belonging to this cluster had more contact with each other than the remaining patients attending this centre. No other convincing evidence of transmission was found in any of the other smaller clinics. Three P. aeruginosa strains believed to be transmissible between patients in Australian and British CF clinics are present in New Zealand, but there was no definite evidence they had spread. Pseudomonas aeruginosa transmission is currently infrequent in New Zealand cystic fibrosis clinics. This situation could change rapidly and ongoing surveillance is required. The current results confirm that computer-assisted SalI DNA fingerprinting is ideally suited for such surveillance.

Rationale: Both obesity and asthma are common conditions, and both are characterized by the presence of inflammation. Animal studies suggest that the development of airway hyperresponsiveness with antigen challenge is exaggerated with obesity. However, clear evidence for either an additive or a synergistic pathologic interaction between obesity and asthma is lacking in humans., Objectives: To identify whether an interaction between systemic and local inflammation occurs in obese subjects with asthma in a controlled observational study., Methods: We studied 79 women: obese patients with asthma (n = 20), normal-weight patients with asthma (n = 19), obese patients without asthma (n = 20), and normal-weight patients without asthma (n = 20). After corticosteroid withdrawal, between-group differences in spirometric values, lung volumes, exhaled nitric oxide, induced sputum cell counts, and biomarkers of inflammation in sputum supernatant and blood were measured, and interactions explored., Measurements and Main Results: Markers of systemic inflammation were increased with obesity, and Th2 cytokines were increased with asthma, but no important interactions were identified. Obesity adversely affected lung function with increases in functional residual capacity and residual volume in obese but not normal-weight patients with asthma, with a significant obesity by asthma interaction., Conclusions: The link between obesity and asthma is unlikely to be explained by enhancement of the "classical" forms of airway inflammation resulting from the systemic inflammatory effects of obesity itself. Other mechanisms, possibly related to innate immunity, may explain the relationship between obesity and asthma.

Background: Several studies have reported an association between asthma and gastro-oesophageal reflux, but it is unclear which condition develops first. The role of obesity in mediating this association is also unclear. We explored the associations between respiratory symptoms, lung function, and gastro-oesophageal reflux symptoms in a birth cohort of approximately 1000 individuals., Methods: Information on respiratory symptoms, asthma, atopy, lung function and airway responsiveness was obtained at multiple assessments from childhood to adulthood in an unselected birth cohort of 1037 individuals followed to age 26. Symptoms of gastro-oesophageal reflux and irritable bowel syndrome were recorded at age 26., Results: Heartburn and acid regurgitation symptoms that were at least "moderately bothersome" at age 26 were significantly associated with asthma (odds ratio = 3.2; 95% confidence interval = 1.6-6.4), wheeze (OR = 3.5; 95% CI = 1.7-7.2), and nocturnal cough (OR = 4.3; 95% CI = 2.1-8.7) independently of body mass index. In women reflux symptoms were also associated with airflow obstruction and a bronchodilator response to salbutamol. Persistent wheezing since childhood, persistence of asthma since teenage years, and airway hyperresponsiveness since age 11 were associated with a significantly increased risk of heartburn and acid regurgitation at age 26. There was no association between irritable bowel syndrome and respiratory symptoms., Conclusion: Reflux symptoms are associated with respiratory symptoms in young adults independently of body mass index. The mechanism of these associations remains unclear.

Rationale: Factors predicting the development of wheeze may differ between sexes and between childhood and adolescence., Methods: A New Zealand birth cohort of 1,037 children was followed to age 26. For this analysis, those reporting recurrent wheezing at two or more assessments were classified as "wheezers." We examined risk factors for development of wheeze before age 10 (childhood) and subsequently (adolescent-onset) for males and for females separately using Cox regression modeling., Results: Males more often developed childhood wheeze (p = 0.002) and females adolescent-onset wheeze (p < 0.001). Maternal atopy (asthma or hay fever) was a risk factor for childhood wheeze in both sexes (hazard ratio [HR], 1.48, p < 0.05 for males; HR, 2.37, p < 0.001 for females). Paternal atopy also influenced childhood wheeze, significantly for males (HR, 1.72; p = 0.01), and similarly but not significantly for females (HR, 1.70; p = 0.08). For adolescent-onset wheeze, neither maternal (HR, 1.41; p = 0.19) nor paternal history (HR, 0.73; p = 0.42) was a risk factor in males, but maternal history (HR, 2.08; p < 0.01) was a significant risk factor for females. When both age ranges were combined, providing greater power for analysis, paternal history was a stronger risk factor for wheeze in females (HR, 1.62; p = 0.02) than in males (HR, 1.35; p = 0.12)., Conclusion: The influence of parental atopy on the development for wheeze differs between males and females and between childhood- and adolescent-onset wheeze.

Rationale: Several studies have identified an association between asthma and obesity in women. It remains unclear if this association is due to genuine asthma or to symptoms caused by overweight, at what age the association develops, and whether it is confined to females., Objective: To explore the relations between body mass index, asthma, and atopy in a birth cohort of approximately 1,000 individuals., Methods: Information on asthma and measurements of lung function, airway responsiveness, and atopy were obtained on multiple occasions between ages 9 and 26. Associations between these outcomes and body mass index were analyzed using generalized mixed linear regression models. Further analyses adjusted for potential covariates including breastfeeding, birth order, parental asthma, and personal and family smoking history., Main Results: Body mass index was positively associated with asthma, wheeze, asthma treatment, atopy, immunoglobulin E, and inversely with the FEV(1)/FVC ratio in females. There was no significant association with airway responsiveness to methacholine or salbutamol. There was little evidence of an association between body mass index and asthma or atopy in males. Analyses adjusting for potential covariates showed similar findings. Asthma was not associated with a raised body mass index in childhood and childhood asthma did not lead to being overweight as an adult., Conclusions: A raised body mass index is associated with asthma and atopy in women but not men. Population attributable fraction calculations estimate that 28% (95% confidence interval 7-45) of asthma developing in women after age 9 is due to overweight.

Background: The outcome of childhood asthma in adults has been described in high-risk cohorts, but few population-based studies have reported the risk factors for persistence and relapse., Methods: We assessed children born from April 1972 through March 1973 in Dunedin, New Zealand, repeatedly from 9 to 26 years of age with questionnaires, pulmonary-function tests, bronchial-challenge testing, and allergy testing., Results: By the age of 26 years, 51.4 percent of 613 study members with complete respiratory data had reported wheezing at more than one assessment. Eighty-nine study members (14.5 percent) had wheezing that persisted from childhood to 26 years of age, whereas 168 (27.4 percent) had remission, but 76 (12.4 percent) subsequently relapsed by the age of 26. Sensitization to house dust mites predicted the persistence of wheezing (odds ratio, 2.41; P=0.001) and relapse (odds ratio, 2.18; P=0.01), as did airway hyperresponsiveness (odds ratio for persistence, 3.00; P<0.001; odds ratio for relapse, 3.03; P<0.001). Female sex predicted the persistence of wheezing (odds ratio, 1.71; P=0.03), as did smoking at the age of 21 years (odds ratio, 1.84; P=0.01). The earlier the age at onset, the greater the risk of relapse (odds ratio, 0.89 per year of increase in the age at onset; P<0.001). Pulmonary function was consistently lower in those with persistent wheezing than in those without persistent wheezing., Conclusions: In an unselected birth cohort, more than one in four children had wheezing that persisted from childhood to adulthood or that relapsed after remission. The factors predicting persistence or relapse were sensitization to house dust mites, airway hyperresponsiveness, female sex, smoking, and early age at onset. These findings, together with persistently low lung function, suggest that outcomes in adult asthma may be determined primarily in early childhood., (Copyright 2003 Massachusetts Medical Society)

Background: Breastfeeding is widely advocated to reduce risk of atopy and asthma, but the evidence for such an effect is conflicting. We aimed to assess long-term outcomes of asthma and atopy related to breastfeeding in a New Zealand birth cohort., Methods: Our cohort consisted of 1037 of 1139 children born in Dunedin, New Zealand, between April, 1972, and March, 1973, and residing in Otago province at age 3 years. Children were assessed every 2-5 years from ages 9 to 26 years with respiratory questionnaires, pulmonary function, bronchial challenge, and allergy skin tests. History of breastfeeding had been independently recorded in early childhood., Findings: 504 (49%) of 1037 eligible children were breastfed (4 weeks or longer) and 533 (51%) were not. More children who were breastfed were atopic at all ages from 13 to 21 years to cats (p=0.0001), house dust mites (p=0.0010), and grass pollen (p<0.0001) than those who were not. More children who were breastfed reported current asthma at each assessment between age 9 (p=0.0008) and 26 years (p=0.0008) than those who were not. Breastfeeding effects were not affected by parental history of hayfever or asthma. Multifactor analysis controlling for socioeconomic status, parental smoking, birth order, and use of sheepskin bedding in infancy, showed odds ratios of 1.94 (95% CI 1.42-2.65, p<0.0001) for any allergen positive at age 13 years, 2.40 (1.36-4.26, p=0.0003) for current asthma at 9 years, and 1.83 (1.35-2.47, p<0.0001) for current asthma at 9-26 years by repeated-measures analysis., Interpretation: Breastfeeding does not protect children against atopy and asthma and may even increase the risk.

Background: Predictors of hospital admissions for asthma in children and young adults in a general population are not well defined, because most studies have used selected subpopulations., Objective: The purpose of this investigation was to determine risk factors for single and multiple hospital admissions for asthma., Methods: The members of a population-based, unselected birth cohort of 1037 New Zealanders answered questionnaires and underwent lung function, airway responsiveness, and allergy testing on 7 occasions to the age of 26 years., Results: Among the 766 study members (74% of the cohort) who reported wheezing symptoms ever by the age of 26 years, 136 hospitalizations were reported by 62 individuals (8.3% of those at risk, 6.2% of the total cohort). Only 55 of these 136 admissions involved children less than 9 years of age; admissions continued to occur between the ages of 9 and 18 years (40 admissions) and at >18 years (41 admissions). Those admitted were predominantly male, had earlier ages of onset of symptoms, were more atopic, and had more airway hyperresponsiveness to methacholine than those not admitted. Frequent symptoms and low lung function were evident among the 45 study members with single admissions and even more evident among the 17 study members with multiple (2-10) admissions., Conclusions: A surprisingly large fraction of this unselected population experienced hospitalization for asthma during the 26-year follow-up, many being admitted in later childhood, adolescence, and early adulthood. Clinical characteristics and markers of severity, including frequent respiratory symptoms, airway hyperresponsiveness, atopy, and low lung function, identify those at high risk for hospitalization for asthma, particularly with respect to multiple admissions.

Study Objectives: This aim of this study was to determine the relative contributions of craniofacial form and anthropometric factors to obstructive sleep apnea (OSA) in two different racial groups, both markedly obese and with a similar mean respiratory disturbance index (RDI)., Design: A cross-sectional study of New Zealand Maori (Polynesian) and European (Caucasian) men with RDI> or =15, using lateral and postero-anterior cephalometric radiography., Setting: N/A., Patients or Participants: N/A., Measurements and Results: Measurements of facial and cranial width, length and height, airway size, stature, weight, body mass index (BMI), neck circumference, RDI, and age were obtained. The Polynesian men had, on average, a greater neck circumference than the Caucasian men. There were no significant differences in age, weight, BMI or RDI between the two groups. The Polynesian men also had broader craniofacial skeletons, larger and more prognathic mandibles, greater neck extension, and some larger airway dimensions than the Caucasian men. In the Polynesian men, the width of the bony nasal aperture was positively associated with RDI, and mandibular prognathism was negatively associated with RDI. In contrast, in the Caucasian men only neck circumference was positively associated with RDI, while the retropalatal airway was negatively associated with RDI., Conclusions: The results indicate that OSA in these two racially distinct groups is due to different etiological factors. Small reductions in mandibular prognathism and a wider bony nasal aperture were major factors associated with OSA in Polynesians. On the other hand, in the Caucasian group OSA was associated with a larger neck circumference and a reduced retropalatal airway size.

Objectives: All patients discharged from the emergency department (ED) should be given discharge instructions (DIs). This study aimed to describe the DI practices of EDs in Australasia and to examine the differences between public and private EDs., Methods: A voluntary, questionnaire-based survey of public and private EDs throughout Australia and New Zealand., Results: 58 of 74 (78.4%) EDs provided instruction notes upon discharge although 51 (68.9%) gave them to only "some" patients. There were no significant differences between the public and private EDs (p>0.05). Thirty seven (50%) EDs provided pre-formatted instruction sheets although 22 (29.7%) EDs gave them to only "some" patients. There were no significant differences between the public and private EDs (p>0.05). Only five (6.8%) EDs retained a copy of the instruction sheets and no (O%) ED provided sheets that included all recommended features. Sixty six (89.2%) EDs provided information sheets although 44 (59.5%) EDs gave them to only "some" patients. Private EDs gave information sheets to significantly more patients than public EDs (p=0.04)., Conclusions: The DI practices of individual EDs varied and the rates of DI provision were low. EDs should improve their DI practices. Pre-formatted instruction sheets, containing all recommended features, should be provided to all patients with a copy kept in the medical record. Consideration should be given to the use of DI practices as an ED performance indicator.

Helicobacter pylori strains may be either cagA+ or cagA-, and in logitudinal studies, infection with a cagA+ strain has been associated with increased risk for the development of atrophic gastritis and cancer of the distal stomach. We sought to determine the relative proportion of strains producing CagA in different geographic locales, and the extent to which CagA seroprevalence varied in countries with different gastric and esophageal cancer rates. Using an enzyme-linked immunosorbent assay (ELISA) to detect serum IgG to CagA, we examined sera from 468 asymptomatic H. pylori-infected adults from Canada, Peru, China, Thailand, The Netherlands and 3 different ethnic groups in New Zealand. The CagA seroprevalence in Peru and Thailand (82.2% and 78.8%, respectively) were each substantially higher than for the Chinese (37.9%), Canadian (41.9%), Dutch (39.0%) and New Zealand (28.2%) subjects, but within each population, rates were relatively constant across gender and age groups. Reported gastric but not esophageal cancer rates for the 8 studied populations were significantly associated with H. pylori seroprevalence. Variation in CagA positivity rates was not significantly associated with variation in either gastric or esophageal cancer rates. Our data suggest that CagA seroprevalence is not the major factor influencing gastric cancer rates.

Aims: The aims of this study were to describe the prescribing of nonsteroidal antiinflammatory drugs (NSAIDs) by some general practitioners and to assess the information recorded on computer records on their use in individual patients so that techniques could be developed for a broader investigation of the topic in general practice., Methods: All prescribing and consulting data from five Dunedin practices was reviewed for a 6 month period. From all consultations generating a prescription for NSAIDs, data was collected relating to the name of the drug, dosage, strength and length of treatment and patient demographic and morbidity details. Recorded adverse drug reactions were classified into six groups and four age groups were used for the analysis., Results: Prescriptions for NSAIDs accounted for 2.6% of all items prescribed. Diclofenac was the most commonly prescribed NSAID, for most conditions, but menstrual problems were more likely to be treated with mefenamic acid. Coprescription of possibly contraindicated medications (usually antihypertensive medicines) occurred for 20.8% of patients. Gastric adverse reactions were reported in 3% of cases while 0.9% of prescriptions resulted in no change in condition, leading to a change in therapy. Aspirin, fenbufen, ketoprofen, sulindac and flurbiprofen were never prescribed for patients under 20 years old., Conclusion: Routinely recorded patient and prescribing information from general practice permits an assessment of the use of NSAIDs which includes the conditions for which they are prescribed, the total numbers prescribed, concurrent medications prescribed and their recorded adverse effects. This is not possible from any other source. Data from clinical trials provides an incomplete assessment of the use of these medications in general practice.

Aims: to evaluate attitudes and preferred mechanisms in the establishment of specialist recertification for pathologists., Methods: a national survey was conducted amongst the membership of the New Zealand Society of Pathologists., Results: responses were received from 54 (62%) financial members of the society. The majority of respondents agreed with the concept of compulsory periodic recertification. The ideal recertification period should be 10 years and the system should be supervised by the New Zealand Society of Pathologists. The favoured recertification mechanism was by continuing medical education which should be funded by the individual candidate. The majority of respondents supported the establishment of voluntary recertification on a trial basis., Conclusions: the survey suggested a favourable attribute amongst pathologists to the introduction of continuing education based periodic recertification.

Following the diagnosis of a case of miliary tuberculosis in a ward of 30 psychogeriatric patients, a further seven patients required treatment for active tuberculosis, and an additional four received prophylactic therapy. Tuberculosis contributed significantly to the deaths of three patients during the outbreak. This report highlights the particular risks of both reactivation and primary tuberculosis among geriatric patients receiving long term residential care. Late diagnosis contributed to the extent of the outbreak. Previous studies indicate that occult transmission of tuberculosis is relatively common in this group. An active policy of screening and prophylactic treatment is advised.

The case history and identification of the aetiological agent of a case of primary amoebic meningoencephalitis contracted from a natural thermal steam is presented. The diagnosis and treatment of suspected cases is discussed.

A total of 1158 sera were tested by an enzyme linked immunosorbent assay (ELISA) for IgG and IgA antibodies to Campylobacter pyloridis. When used to test sera from gastroendoscopy patients this method had a sensitivity of 91% and a specificity of 75%. Ninety-eight of 108 infected patients (91%) were seropositive whereas only 23 of 92 (25%) uninfected patients were seropositive (p less than 0.001). Positive serology was also associated with histological gastritis (p less than 0.001). When sera from occupational groups were compared to random blood donor sera, meat workers, freezing works veterinary surgeons and pest control officers had significantly higher seropositivity. Cook Island (33 of 85 (39%)), Samoan (57 of 129 (44%)) and Tongan (39 of 56 (70%)) blood donors also had greater seropositivity than random blood donors (15 of 102 (15%)), (p less than 0.001 for all three ethnic groups). Seropositivity increased with age. The results indicate that C pyloridis infection is common among certain groups within New Zealand. The implication of this finding with respect to the hypothesis that C pyloridis is aetiologically related to dyspepsia and peptic ulcer disease is discussed.