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Introduction Counties Manukau Health Otolaryngology programme for general practitioners with special interest (GPwSI) was developed to provide a group of GPs with tools to manage low complexity, secondary otolaryngology (ORL) problems in their local communities. After clinical triaging, the medical records were retrieved to assess patient outcomes from community (GPwSI) review. This programme provides an example of how the aims of the Health NZ reforms may work in practice, by bridging primary and secondary services. Aim To assess whether the GPwSI programme provides patients with suitable specialty care in the community, compared to a specialised, hospital outpatient otolaryngology clinic (OPC). Methods This is a retrospective study of patients with an assigned priority of three (non-urgent) referred to Middlemore Hospital for a first specialist assessment (FSA) during 2018–19. Results Of the 6231 patients referred, one-fifth (22%) were directed to the GPwSI service, and the remainder (78%) were arranged to be seen in the OPC. GPwSI patients were more likely to be seen for their FSA earlier than OPC patients (RR 1.55, 95% CI 1.46–1.64, P

Tube thoracostomy (TT) in trauma is lifesaving. A previous audit at Counties Manukau District Health Board (CMDHB), New Zealand, showed a 22% complication rate for trauma TT. Subsequently CMDHB introduced a procedural guideline to reduce complications. The Health and Disability Commission published a report concerning oversights in TT removal. This led us to evaluate complications, documentation and procedural monitoring to identify ways to improve patient safety.A 30-month retrospective audit of patients presenting to CMDHB, with injuries which may require TT. Those who had a TT in situ, did not require a TT or whose presentation was not secondary to trauma were excluded.One hundred and forty-three TTs were performed in one hundred and fifteen patients. About 87% had injuries secondary to blunt mechanism. Penetrating injuries were more likely to require TT (P = 0.015). Non-accidental injuries were more likely to need TT (P = 0.025). The complication rate was 25.2%. TT prior to imaging had a 31% complication rate (P 0.03). About 23% had no TT insertion note. 40% had no TT removal note. About 9% TT insertions had no tertiary information to identify the proceduralist and a complication rate of 46%. About 22% of insertions and 4% of removals documented consent. About 2% of insertions documented anticoagulation status. Interventional radiology had the best documentation of data points assessed (P 0.0001). Post-procedural monitoring recommendations were documented in 1% insertions and 11% removals.The complication rate has not reduced despite introduction of a guideline. Procedural documentation and monitoring were inadequate, potentially impacting patient safety.

Bullous pemphigoid (BP) is an uncommon autoimmune bullous disorder, with significant morbidity and mortality. Mortality may be as high as 23.5% in the first year after diagnosis. Clear epidemiologic data across Australasia are lacking.A retrospective, multi-centred cohort study was designed to determine the incidence and mortality of bullous pemphigoid in New Zealand. Data from all histopathologically diagnosed patients with bullous pemphigoid between 2009 and 2015 from the Auckland region were obtained. Demographics, clinical characteristics and outcome 3 years from diagnosis (until 31 December 2018) were collected. Demographic data were compared against a denominator year-matched New Zealand Census population.One hundred sixty-one patients had confirmed bullous pemphigoid, with an incidence rate of 3.03/100 000 person-years [95% CI 2.58-3.54]; 70% were of European ethnicity; 12.4% were Pacific peoples; 11.2% were Asian; and 6.8% were Māori. 45.3% had associated cognitive impairment and/or stroke. In the 3-year follow-up, 25% had treatment complications mostly from prednisone therapy. The mortality rate was 40%, highest in the first year of diagnosis, with age at diagnosis a predictor.The incidence and mortality rates are comparable to the UK/Northern Europe. Knowledge of the epidemiology of bullous pemphigoid in New Zealand and within an international settling informs the provision of future care and treatments.

Objective The aim of this project was to make the case to the managers of a large urban teaching hospital in New Zealand for the introduction of systematic case-finding for pre-existing cognitive impairment/dementia in older hospital inpatients that screen positive for delirium. Method Two hundred consecutive acute admissions aged 75+ in four medical wards were assessed using the 4AT assessment tool for delirium and the Alzheimer Questionnaire (AQ) for pre-existing cognitive impairment/dementia. Length of stay and mortality at 1 year were also collected. Results Over a third of the sample screened positive for delirium and nearly two-thirds of these also screened positive for dementia. The median length of stay was 5 days for delirium without dementia and 7 days for delirium with dementia, compared to 3 days for those who screened negative for both. After adjustment for age, gender and ethnic group, people who screened positive for delirium (with or without dementia) had 50% longer length of stay ( p < 0.05) and at least double the risk of death ( p < 0.05). Conclusion Older hospital inpatients that screen positive for delirium and dementia using 4AT and AQ have longer lengths of stay and higher mortality. Identification may lead to more timely interventions that help to improve health outcomes and reduce hospital costs.

The purpose of this systematic review was to determine if in patients presenting for bariatric surgery, patients of different ethnicities, have different micronutrient deficiencies preoperatively. Databases searched were PubMed, Embase, MEDLINE and Cochrane Library. A meta-analysis of prevalence of vitamin D insufficiency (

To develop and validate a questionnaire to measure health CE at governance level.This study used qualitative and quantitative methods (including focus groups, cognitive interviews and an international survey), and consisted of two phases. In Phase 1, an initial list of items was generated and refined with feedback from health consumer representatives. In Phase 2, a draft survey was distributed to n=227 consumers from New Zealand, Australia and Canada. The benefit and relevance of using the questionnaire was explored through face-to-face interviews with five CE leaders from New Zealand healthcare organisations.The proposed questionnaire comprises 25 statements relating to CE. Respondents indicate their level of agreement with the statements on a five-point Likert-type scale. Focus group and cognitive interview participants found the questionnaire relevant and easy to understand. The questionnaire scores correlated with the PPEET, another instrument measuring consumer engagement, and showed excellent internal consistency (Cronbach's alpha=0.97), unidimensionality and test-retest reliability (r=0.84).The proposed questionnaire measures CE at governance level and can be used for international comparisons and benchmarking. It showed sound psychometric properties and its value and relevance was recognised by health consumer representatives and leaders with CE roles in New Zealand healthcare organisations.

Introduction Obesity increases the risk of pelvic floor disorders in individuals with obesity, including faecal incontinence. Faecal incontinence (FI) is a condition with important clinical and psychosocial consequences. Though it is associated with obesity, the effect of bariatric surgery on the prevalence and severity of FI is not well reported. Objective To assess the effect of bariatric surgery on the prevalence and severity of FI in adult patients with obesity. Methods This systematic review was conducted in accordance with the PRISMA statement. Two independent reviewers performed a literature search in MEDLINE, PubMed, Cochrane and Embase from 1 January 1980 to 12 January 2019. We included published English-language randomized control trials and observational studies assessing pre- and post-bariatric surgery prevalence or severity of FI. Random-effects models with DerSimonian and Laird’s variance estimator were used for meta-analysis. Results Thirteen studies were included, eight assessing prevalence (678 patients) and 11 assessing severity of FI (992 patients). There was no significant difference in prevalence post-operatively overall, though it trended towards a reduction [pooled OR=0.55; =0.075]. There was a significant reduction of FI prevalence in women post-bariatric surgery [95% CI 0.22 to 0.94, p=0.034]. There was a statistically significant reduction in FI prevalence following Roux-en-Y gastric bypass and one anastomosis gastric bypass [0.46, 95% CI 0.26 to 0.81; p=0.007]. There was no significant reduction of incontinence episodes post-operatively [pooled mean difference =−0.17, 95% CI −0.90 to 0.56; p=0.65]. Quality of life (QOL) was not significantly improved post-bariatric surgery [mean differences for the following facets of QOL: behaviour −0.35, 95% CI −0.94 to 0.24; depression 0.04, 95% CI −0.12 to 0.2; lifestyle −0.33, 95% CI −0.98 to 0.33; p values of 0.25, 0.61 and 0.33, respectively]. Discussion There was a significant reduction in FI prevalence in women and those who underwent Roux-en-Y or one anastomosis gastric bypass. Our results for FI prevalence overall, FI severity and impact on quality of life were not statistically significant. Larger studies are needed in this under-researched area to determine the true effect of bariatric surgery on FI. Graphical abstract

AIM Haemorrhoids are frequently encountered by the general or colorectal surgeon. Although a benign disease, those with symptomatic, advanced grades frequently require excisional haemorrhoidectomy for definitive management. Despite their widespread nature, the epidemiological burden of haemorrhoids and haemorrhoidectomies on populations is not well described. This study seeks to establish the incidence of both haemorrhoids diagnosed and haemorrhoidectomies performed in New Zealand. METHOD This is a population-based cross-sectional study examining the incidence of all patients who were newly diagnosed with haemorrhoids in New Zealand public hospital outpatient clinics and those who received excisional haemorrhoidectomy in New Zealand public hospitals from 2007 to 2016. Data were extracted and linked using the New Zealand National Minimum Dataset and the National Non-Admitted Patient Collection. Variables collected included age group, sex, ethnicity and geographical location. RESULTS A total of 46 095 recorded diagnoses of haemorrhoids were made, with a total of 18 739 haemorrhoidectomies in the 10-year period recorded. The incidence rate of diagnosis increased from 84.6 to 120.5 per 100 000 and the incidence rate of haemorrhoidectomies performed from 30.4 to 51.1 per 100 000, a significantly increased annual incidence. There was a unimodal peak prevalence in the fifth decade of life with women more affected. Europeans formed the largest group affected, with Asians showing the highest rate of increased incidence. CONCLUSION There is an increasing incidence of patients with symptomatic haemorrhoids presenting to the New Zealand public healthcare system, with a preponderance in working age adults, especially women.

With conflicting evidence in the literature, we hypothesised that the long-term subjective outcomes of the retropubic midurethral sling (MUS) are the same in the severely obese and non-obese populations. A retrospective matched cohort study was performed on women with a BMI ≥ 35 and

In New Zealand (NZ), Indigenous Māori and Pacific peoples experience a higher burden of obesity and obesity-related disease. Counties Manukau Health (CMH) provides the largest public bariatric service in NZ housing a higher proportion (64%) of non-European groups (Asian, Pacific and Māori). This study investigated whether ethnic disparities in the receipt of bariatric surgery exist within one of the most ethnically diverse populations in NZ. All patients accepted on to the CMH bariatric programme between 1 January 2011 and 31 December 2017 were identified through hospitalisation records. Logistic regression modelling with multivariate adjustment was utilised to assess the likelihood (odds ratio) of receipt of bariatric surgery by ethnicity. A total of 2519 referrals were received, of which 1051 proceeded to surgery. The proportion of patients referred who eventually underwent bariatric surgery was significantly higher for Other Europeans (68%) and NZ Europeans (63%) compared to Asian (42%), Māori (41%) and Pacific peoples (28%, p

BackgroundHospitalisation with severe lower respiratory tract infection (LRTI) in early childhood is associated with ongoing respiratory symptoms and possible later development of bronchiectasis. We aimed to reduce this intermediate respiratory morbidity with a community intervention programme at time of discharge.MethodsThis randomised, controlled, single-blind trial enrolled children aged Findings400 children (203 intervention, 197 control) were enrolled in 2011–2012; mean age 6.9 months, 230 boys, 87% Maori/Pasifika ethnicity and 83% from the most deprived quintile. Final assessment of 321/400 (80.3%) showed no differences in presence of wet cough (33.9% intervention, 36.5% controls, relative risk (RR) 0.93, 95% CI 0.69 to 1.25), abnormal examination (21.7% intervention, 23.9% controls, RR 0.92, 95% CI 0.61 to 1.38) or Brasfield score ≤22 (32.4% intervention, 37.9% control, RR 0.85, 95% CI 0.63 to 1.17). Twelve (all intervention) were diagnosed with bronchiectasis within this timeframe.InterpretationWe have identified children at high risk of ongoing respiratory disease following hospital admission with severe LRTI in whom this intervention programme did not change outcomes over 2 years.Trial registration numberACTRN12610001095055.

Aim To examine early adolescent physical activity and risk of later depressive symptoms at age 16 years in a prospective cohort study. Methods Participants were children and parents enrolled at birth of the child. Approximately half the children enrolled in the Auckland Birthweight Collaborative Study were small for gestational age at birth (SGA ≤10th percentile for sex and gestation) and half were appropriate for gestational age (AGA >10th percentile). Maternal demographic data were collected at birth, and children were followed through to age 16 years. Depression at 16 was assessed using the Center for Epidemiological Studies Depression Scale for Children. Accelerometer measures of physical activity and sleep were measured at 11 years of age. Results Moderate to severe depression was present in 15.6% of the 467 16-year-olds. Objectively measured physical activity and sleep at 11 years were not significantly associated with depressive symptoms at 16 years of age. Conclusion Prospectively collected objective measures of physical activity levels and sleep were not predictive of depressive symptoms later in adolescence in a healthy community cohort. While interventions to promote increased physical activity and sleep in adolescents who are depressed may be effective, physical activity and sleep in the general population of adolescents does not protect against future depression.

The aim of this study was to report on the prevalence of genital findings documented in women attending a forensic examination following an allegation of recent sexual assault. A secondary aim was to investigate for any associations between genital findings and variables related to population demographics and clinical factors.A retrospective review of clinical records was undertaken for 593 women, aged between 17 and 45 years of age, who underwent a forensic examination within 72 h following an alleged sexual assault at the Pohutukawa clinic, adult Sexual Abuse Assessment and Treatment Service (SAATS) in Auckland, New Zealand over a four-year period. Statistical analysis to examine for any associations between any documented genital findings and subject variables was performed.The key finding was that 66.4% (394/593) of the women had a normal genital examination. Of the 182 women with genital findings the presence of skin disruption and/or bruising was noted in 21.1% (125/593) and non-specific findings in 9.6% (57/593). 17 women were not included as the genital examination was incomplete. For 9.5% (56/593) of women the presence of abnormal genital skin was documented. From the adjusted odds ratios obtained by multivariate analysis there was a statistically significant association between the presence of genital findings and abnormal skin condition (OR 3.13, p = 0.0004).The study demonstrated that the majority of women seen within 72 h of an alleged sexual assault had a normal genital examination. Given the strength of the association between the presence of genital findings and skin condition, we recommend that documentation of the genital skin condition should become a routine part of a forensic examination following sexual assault. This is particularly important if genital findings are present, in order to present the full complexity of clinical examination findings to the court and provide an expert opinion regarding the limitations of attributing causation.

Antibiotics are commonly prescribed for infants. In addition to increasing concern about antibiotic resistance, there is a concern about the potential negative impact of antibiotics on the gut microbiota and health and development outcomes. The aim of this study was to investigate the association between early life antibiotic exposure and later neurocognitive outcomes. Participants were infants born to mothers enrolled in the probiotics study. The initial study was designed to evaluate the effect of two different probiotics on allergy outcomes in childhood. Antibiotic exposure was based on parent report and categorised according to the following timing of the first exposure: 0–6 months, 6–12 months, 12–24 months or not at all. At 11 years of age, children’s neurocognitive outcomes were assessed using psychologist-administered, parent-report and self-report measures. The relationship between the timing of antibiotic exposure and neurocognitive outcomes was examined using regression models. Of the 474 participants initially enrolled, 342 (72%) children had a neurocognitive assessment at 11 years of age. After adjustment for mode of delivery, probiotic treatment group assignment, income and breastfeeding, children who had received antibiotics in the first 6 months of life had significantly lower overall cognitive and verbal comprehension abilities, increased risk of problems with metacognition, executive function, impulsivity, hyperactivity, attention-deficit hyperactivity disorder, anxiety and emotional problems. These results provide further evidence that early exposure to antibiotics may be associated with detrimental neurodevelopmental outcomes.

Background Ethnic disparities in surgical care and outcomes have been previously reported in studies for other surgical procedures. In addition, it has been reported that ethnic differences in postoperative analgesia exist. We aimed to determine ethnic disparities in postoperative outcomes, total opioid analgesia use, and complication rates of all patients who underwent a laparoscopic ventral hernia repair (LVHR) at our institution over a 3-y period. Methods A retrospective review of all patients who underwent an LVHR at Counties Manukau Health from January 1, 2013, to December 31, 2015, was performed in line with the Strengthening the Reporting of Observational Studies in Epidemiology statement. Results A total of 267 ventral hernias were repaired in 254 patients at Counties Manukau Health over the study period, of which most were primary umbilical ventral hernias. The majority of patients in our cohort were New Zealand European and male. Major complications, as per the Clavien-Dindo classification grade 3 and above, were observed in six patients with no deaths (2.4%). There were no statistically significant ethnic disparities in length of stay, receipt of opioid analgesia, and rates of complication observed after linear regression modeling after adjustment for confounding factors. Conclusions Our study showed that the majority of patients who had a ventral hernia repaired at our institution were mostly New Zealand European and male. Although significant ethnic disparities in patient characteristics were observed, these were not associated with ethnic disparities in postoperative outcomes after an LVHR.

The purpose of this systematic review was to determine if in patients presenting for bariatric surgery, patients of different ethnicities, have different micronutrient deficiencies preoperatively. Databases searched were PubMed, Embase, MEDLINE and Cochrane Library. A meta-analysis of prevalence of vitamin D insufficiency (20ng/ml) was carried out using a random effects model. Twenty-eight articles were included assessing preoperative micronutrient status across different ethnic groups. The most common micronutrient assessed was vitamin D, and the most assessed ethnicity was Caucasian. African Americans had the greatest prevalence of vitamin D insufficiency when compared to other ethnicities with a pooled prevalence and 95% confidence interval of 0.80 [0.74; 0.85]. There was a significant difference in vitamin D insufficiency when compared across ethnicities (p0.01).

There are few data on pregnancy outcomes in women with pre-diabetes (HbA1c 41-49 mmol/mmol) at pregnancy booking. We aimed to (i) identify the proportion of women in Counties Manukau Health (CMH), South Auckland, New Zealand (NZ), with pre-diabetes at booking and (ii) compare outcomes between women with normal HbA1c and pre-diabetes.Using data from a multi-ethnic population of 10,869 singleton pregnancies, booked at20 weeks from January 2017 to December 2018 in CMH, we compared outcomes between those with normal HbA1c (≤40 mmol/mol) and those with pre-diabetes (HbA1c 41-49 mmol/mol). The primary outcomes were gestational diabetes mellitus (GDM) by NZ criteria and large for gestational age (LGA) defined as birthweight90th customised centile. Logistic regression determined the contribution of HbA1c 41-49 mmol/mol to the development of GDM.Among 10,869 participants, 193 (1.78%) had an HbA1c 41-49 mmol/mol at20 weeks' gestation. Those with HbA1c 41-49 mmol/mol were 11 times more likely to develop GDM (59.6 vs 7.9%; adjusted odds ratio (aOR) 11.16 (7.59, 16.41)) and were more likely to have an LGA baby (47 (24.4%) vs 1436 (13.5%) aOR 1.63 (1.10, 2.41)) versus those with normal HbA1c. They also had significantly higher rates of pre-eclampsia, caesarean sections, preterm births and perinatal deaths.Nearly two-thirds of women with a booking HbA1c of 41-49 mmol/mmol developed GDM as well as multiple other perinatal complications compared to women with HbA1c ≤40. Trials to evaluate the impact of treatment in early pregnancy on the risk of late-pregnancy complications are required.

Chronic respiratory diseases, such as chronic obstructive pulmonary disease, are a worldwide public health problem. Pulmonary rehabilitation is a gold-standard intervention for these diseases, yet attendance and completion rates are poor. Counties Manukau Health, in Auckland, New Zealand, has a high prevalence of chronic respiratory disease and a culturally diverse population, comprising large numbers of Māori and Pacific Island people, who are known to be disproportionately affected by chronic respiratory disease. The aim of this study was to investigate patient characteristics affecting engagement with the Counties Manukau Health pulmonary rehabilitation programme and identify factors predicting completion of the programme.Investigators performed a retrospective analysis using routinely collected data of 2,756 patients invited to attend the pulmonary rehabilitation programme at Counties Manukau Health. Data were analysed to compare demographic and clinical outcomes of patients who completed, did not complete or did not attend the programme, and identified factors predicting completion.Significant differences were found between groups in demographic and clinical characteristics. Increasing age, higher six-minute walk test distance at programme commencement and European ethnicity were significant predictors of completion of the PR programme.Compared to European people, Māori were 52% less likely and Pacific Island people were 40% less likely to complete the programme. These findings are significant for the Counties Manukau Health population. Further work needs to focus on determining how to make programmes more engaging to different cultures and how we can aim to reduce health inequities in these populations.

Behavioral problems are multifactorial and includes perinatal, maternal, family, parenting, socio-economic and personal risk factors, but less is known about the association of postnatal heavy metals on children&rsquo, s behavioral problems in Pacific Island children. Methods: A cohort of eligible nine-year-old children within a Pacific Island Families longitudinal study were recruited for a cross-sectional study. Child behavior problems were assessed using the child behavior checklist. Heavy metals (including Ni, Cu, Pb, Al, Cr and Cd) were determined in toenails, after acid digestion and analyzed using inductively coupled plasma mass spectrometry. Other factors such as lifestyle (smoking in pregnancy), health outcomes (obesity, health status), demographics (gender, ethnicity, parents&rsquo, marital status) and socioeconomic status (household income levels) were also collected. The statistical analysis included t-tests for independent sample and Mann&ndash, Whitney U-test, and chi-square or Fisher&rsquo, s exact tests of independence for comparisons of the proportions. Regression models tested the hypothesized risk factors for behavior outcomes. Results: This observational study enrolled 278 eligible Pacific Island children living in Auckland, New Zealand. The prevalence of behavioral problems in the clinical range was high (22%) but there was no significant association between heavy metals in toenails and adverse behavioral outcomes. Conclusion: Regular monitoring and assessments of children for environmental risk factors, as well as social and lifestyle factors for behavior problems, continues. Alternative indicators of exposure to heavy metal should be evaluated.

Aim To determine whether probiotic supplementation in early life improves neurocognitive outcomes assessed at 11 years of age. Methods A total of 474 children who were born March 2004-Aug 2005 participated in a two-centre randomised placebo-controlled trial of infants at risk of developing allergic disease. Pregnant women were randomised to take Lactobacillus rhamnosus strain HN001, Bifidobacterium animalis subsp. lactis strain HN019 or placebo daily from 35 weeks gestation until six months if breastfeeding, and their infants the same treatment from birth to two years. Intelligence, executive function, attention, depression and anxiety were assessed when the children were 11 years of age. Results A total of 342 (72.2%) children were assessed (HN001 n = 109, HN019 n = 118 and placebo n = 115). Overall, there were no significant differences in the neurocognitive outcomes between the treatment groups. Conclusion HN001 and HN019 given in early life were not associated with neurocognitive outcomes at 11 years of age in this study. However, we cannot exclude that other probiotics may have a beneficial effect. Further clinical trials are indicated.

Background/objectives Subcutaneous panniculitis-like alpha-beta T-cell lymphoma is a rare disease, which comprises less than 1% of all non-Hodgkin lymphoma. The epidemiology of this disorder has not been established in New Zealand, particularly the ethnic variation. Methods A retrospective study was conducted from 2005 to 2017 in South Auckland, New Zealand. Patients with histopathologically confirmed subcutaneous panniculitis-like alpha-beta T-cell lymphoma, according to the WHO-EORTC classification, were included. Cases were identified from multiple data sources to ensure the study population was completely surveyed. Census data were used as the denominator. Results Ten cases were identified. Five were men and five women. The median age at diagnosis was of 38.5 years (range 17-73 years). Nine were Māori/Pacific, and one was European. The ethnic relative risk of subcutaneous panniculitis-like alpha-beta T-cell lymphoma in Māori/Pacific versus European was 11.1 (95% Cl 1.83-246.1, P = 0.005). Conclusion Māori and Pacific have a higher relative risk of subcutaneous panniculitis-like alpha-beta T-cell lymphoma compared to non-Māori/Pacific.

Objective: To describe and explore 'gut instinct' that something was wrong in women who identified that they experienced gut instinct during pregnancy. Method: A case-control study utilising an international web-based questionnaire. Stillborn cases ( n = 146) and liveborn controls ( n = 234) answered the gut instinct question within 30 days of the pregnancy ending. Of those, 84 cases and 27 controls also provided qualitative comment data. Descriptive statistics were used for the question, with a fixed option and summative content analysis was used to analyse the comment data. Findings: In all, 110 (75%) of the stillborn cases answered "yes" to the gut instinct question vs only 28 (12%) of the controls who had a livebirth meaning the risk of stillbirth was 22.5 fold higher in those who experience "gut instinct" than in those who do not experience this feeling. Four themes were identified from the comment data namely: When the gut instinct occurred; How the gut instinct made the woman feel; Dreams and other related phenomena; Reassured by someone or something. Conclusions: Women who had a stillborn baby reported a "gut instinct" that something was wrong more frequently than mothers of a live born baby. Our findings may be influenced by recall negativity bias, and a prospective study is needed to confirm or refute our findings. The possibility that "maternal intuition" exists during pregnancy and responds to changes in fetal or placental health merits further exploration. Implications for practice: Maternity care providers should be alert to the woman when she expresses intuitive feelings, as well as asking her to report her concerns and act appropriately to assess and manage fetal wellbeing. Refereed/Peer-reviewed

Purpose: To investigate the clinical effect of vitamin D3 supplementation on psoriasis from a community-dwelling population.Materials and methods: Participants with psoriasis in a large randomized controlled trial examining the effect of vitamin D3 supplementation (100,000 IU monthly) in adults aged 50–84 years were invited to participate in a psoriasis sub-study over 12 months. The primary outcome was the Psoriasis Area and Severity Index (PASI) and secondary outcomes were Physicians Global Assessment (PGA), Dermatology Life Quality Index (DLQI), and Psoriasis Disability Index (PDI). Trial identification number ACTRN12611000402943.Results: Twenty-three were allocated to vitamin D and 42 to placebo. There was no significant difference at baseline between the two groups. Mean (SD) baseline 25-hydroxyvitamin D was 65.7 (25.7) nmol/L. There were no significant differences (p > .05) between the groups in all of the psoriasis outcome measures. Mean scores [95% CI] at 12 months for the Placebo versus Vi...

There is limited evidence on the distribution of heavy metals and its association with secondhand smoking (SHS) within Pacific Island children living in New Zealand. Certain heavy metals such as cadmium (Cd), lead (Pb), and aluminum (Al) bioaccumulates in the body and can deteriorate health in both children and adults. Others, such as chromium (Cr) and nickel (Ni) in trace amounts are necessary but become toxic at high levels. Exposure routes of these elements include food, water, and air. The purpose of this study was to identify the distribution of toxic metal concentrations and its possible correlation with SHS within the Pacific Island children. A sub-sample of children within Pacific Island families longitudinal study, at the nine-year phase, who were living in the New Zealand city of Auckland were invited to participate, (n = 278). Toenails were used as a biomarker to determine Cr, Pb, Cd, Cu, Ni, and Al concentration using inductively coupled plasma mass spectrometry. Reliable and validated questionnaires were used for demographics, lifestyle, and health outcome variables. Significant differences between household smoking status and ethnicity, as well as parents&rsquo, marital status, were observed (p &lt, 0.05). There was no statistical difference in heavy metal concentrations in smoking versus non-smoking households. However, Cr, Pb, Cd, Cu, and Ni concentrations were all higher than the required optimal health value in both groups. A high concentration of heavy metals was observed in these children that exceeded the value required for optimal health, although no significant difference in heavy metals with regards to secondhand smoking was observed. SHS was associated with children&rsquo, s ethnicity and parental marital status, but not with household income levels or maternal education.

Background History taking is a key component of clinical practice; however, this skill is often poorly performed by students and doctors. Objective The study aimed to determine whether Metaphoria, a 3D serious game (SG), is superior to another electronic medium (PDF text file) in learning the history-taking content of a single organ system (cardiac). Methods In 2015, a longitudinal mixed methods (quantitative and qualitative) pilot study was conducted over multiple sampling time points (10 weeks) on a group of undergraduate medical students at The University of Auckland Medical School, New Zealand. Assessors involved in the study were blinded to group allocation. From an initial sample of 83, a total of 46 medical students were recruited. Participants were assigned to either a PDF group (n=19) or a game group (n=27). In total, 1 participant left the PDF group after allocation was revealed and was excluded. A total of 24 students in the game group and 14 students in the PDF group completed follow-up 7 weeks later. Using an iterative design process for over a year, with input from a variety of clinical disciplines, a cardiac history-taking game and PDF file were designed and informed by Cognitive Load Theory. Each group completed its intervention in 40 min. A total of 3 levels of Kirkpatrick training evaluation model were examined using validated questionnaires: affective (perception and satisfaction), cognitive (knowledge gains and cognitive load), and behavioral attitudes (Objective Structured Clinical Exam) as well as qualitative assessment. A priori hypotheses were formulated before data collection. Results Compared with baseline, both groups showed significant improvement in knowledge and self-efficacy longitudinally (P Conclusions Students favored learning through utilization of an SG with regard to cardiac history taking. This may be relevant to other areas of medicine, and this highlights the importance of innovative methods of teaching the next generation of medical students.

Background As the economic impact of dementia on health and social care increases, governments require disease-specific epidemiological data that will help inform spending and policy decisions. The aim of this study is to examine predictors of mortality in dementia in consecutive referrals to a New Zealand (NZ) memory service that includes Māori, Pacific Islander, and NZ European patients. Methods Date of birth, sex, ethnicity, living situation, cognitive function, dementia subtype, dementia severity, physical comorbidity, and medication data were collected from electronic health records. The resulting data set was linked to administrative data on mortality and last hospital contact dates to allow time-dependent survival analyses. Results The risk of death in people with dementia was increased by age (adjusted HR per year 1.08, 95%CI:1.05-1.12) and lower cognitive score at baseline (adjusted HR for severe impairment:2.54, 95% CI:1.25-5.16), and was reduced by cholinesterase inhibitors (adjusted HR:0.54, 95% CI:0.34-0.88). Compared to NZ Europeans (HR:1.19, 95% CI:0.63-2.25), antipsychotics increased the risk of death three-fold in Māori (adjusted HR:3.62, 95% CI:0.79-16.7) and Pacific Islanders (adjusted HR:2.54, 95%CI:1.10-5.85). Conclusions Further research is required to elucidate the mechanisms underlying the survival rates in Māori and Pacific Islanders living with dementia in NZ,and their increased risk of death if antipsychotics are used.

Objective People with a serious mental health condition are no more likely to receive a diagnosis of cancer than the general population but fare more poorly in terms of outcomes. The current study investigated whether a background of mental health problems (measured by contact with mental health services and psychotropic medication) predicted treatment outcomes over and above demographic and medical confounds for cancer patients at Counties Manukau Health. Methods The sample consisted of 1652 patients diagnosed with cancer in the period 1 January 2016 to 31 December 2016. The sample was split into three groups: non-mental health, moderate mental health, and serious mental health. Results Patients in the serious and moderate mental health groups were more likely to have physical comorbidities. Those in the serious mental health group were also marginally more likely to have advanced cancer at diagnosis. There were no differences between groups in terms of treatment delays, but patients in the serious mental health group were more likely to be hospitalised and die in the 12 months following diagnosis. Whilst differences in mortality may be explained by greater clinical complexity (being older, having other physical comorbidities) and later stage at presentation, mental health history was independently associated with hospitalisations. Conclusions Cancer patients with a history of more serious mental health issues fare more poorly than those with moderate mental health issues or no such history. The clinical complexity of working with these patients, indexed by mental and physical comorbidities, may be a factor contributing to this disparity.

BACKGROUND History taking is a key component of clinical practice; however, this skill is often poorly performed by students and doctors. OBJECTIVE The study aimed to determine whether Metaphoria, a 3D serious game (SG), is superior to another electronic medium (PDF text file) in learning the history-taking content of a single organ system (cardiac). METHODS In 2015, a longitudinal mixed methods (quantitative and qualitative) pilot study was conducted over multiple sampling time points (10 weeks) on a group of undergraduate medical students at The University of Auckland Medical School, New Zealand. Assessors involved in the study were blinded to group allocation. From an initial sample of 83, a total of 46 medical students were recruited. Participants were assigned to either a PDF group (n=19) or a game group (n=27). In total, 1 participant left the PDF group after allocation was revealed and was excluded. A total of 24 students in the game group and 14 students in the PDF group completed follow-up 7 weeks later. Using an iterative design process for over a year, with input from a variety of clinical disciplines, a cardiac history-taking game and PDF file were designed and informed by Cognitive Load Theory. Each group completed its intervention in 40 min. A total of 3 levels of Kirkpatrick training evaluation model were examined using validated questionnaires: affective (perception and satisfaction), cognitive (knowledge gains and cognitive load), and behavioral attitudes (Objective Structured Clinical Exam) as well as qualitative assessment. A priori hypotheses were formulated before data collection. RESULTS Compared with baseline, both groups showed significant improvement in knowledge and self-efficacy longitudinally (PP CONCLUSIONS Students favored learning through utilization of an SG with regard to cardiac history taking. This may be relevant to other areas of medicine, and this highlights the importance of innovative methods of teaching the next generation of medical students.

BackgroundNative joint septic arthritis (NJSA) is poorly studied. We describe the epidemiology, treatment, and outcomes of large joint NJSA (LNJSA) and small joint NJSA (SNJSA) in adults at Middlemore Hospital, Auckland, New Zealand.MethodsThis was a coding-based retrospective study of patients ≥16 years old admitted between 2009 and 2014. Prosthetic joint infections were excluded.ResultsFive hundred forty-three NJSA episodes were included (302 LNJSA, 250 SNJSA). Only 40% had positive synovial fluid culture. Compared to SNJSA, LNJSA has higher incidence (13 vs 8/100 000 person-years [PY]), occurs in older, more comorbid patients, and is associated with greater rates of treatment failure (23% vs 12%) and mortality, despite longer antibiotic treatment. Total incidence is higher than previously reported (21/100 000 PY), with marked interethnic variation. Incidence rises with age (LNJSA only) and socioeconomic deprivation (LNJSA and SNJSA). Tobacco smokers and males are overrepresented. The most commonly involved joints were knee (21%) and hand interphalangeal (20%). Staphylococcus aureus was the most common pathogen (53%). Mean antibiotic duration was 25 days for SNJSA and 40 days for LNJSA, and the mean number of surgical procedures was 1.5 and 1.6, respectively. Treatment failure was independently associated with LNJSA, age, intra-articular nonarthroplasty prosthesis, and number of surgical procedures.ConclusionsThis is the largest contemporary series of adult NJSA. SNJSA has better outcomes than LNJSA and may be able to be safely treated with shorter antimicrobial courses. Incidence is high, with significant ethnic and socioeconomic variation. Microbiological NJSA case ascertainment underestimates case numbers as it frequently excludes SNJSA.

Background/objectives Merkel cell carcinoma is an aggressive neuroendocrine skin cancer. Australian studies report high incidence and poor survival rates compared internationally. While New Zealand has a comparable UV index and racial composition to Australia, survival outcomes are currently unknown. The role of Merkel cell polyoma virus in oncogenesis of Merkel cell carcinoma is an active area of research. We describe the incidence and survival of Merkel cell carcinoma in New Zealand with correlation to demographic and clinical factors including regional polyoma virus prevalence. Methods Retrospective study of population-based data from the New Zealand Cancer Registry. Incidence rates were directly standardised to the US standard 2000 population. Survival was investigated using Kaplan-Meier and multivariable Cox regression models. Results Six hundred and one cases were diagnosed in New Zealand between 2000 and 2015. The overall incidence rate was 0.96/100 000 population. Merkel cell carcinoma is more common in males, elderly and on sun-exposed areas. Eighteen percent of patients were diagnosed with distant metastasis at time of presentation. The overall 5-year survival rate and relative 5-year survival rate were 31% and 45%, respectively. Mortality was 1.9 and 2.5 times higher for stage III and IV disease, respectively, relative to stage I/II disease. Patients over age 80 had twice the mortality compared to those aged 60-69. Conclusions New Zealand has a high incidence of Merkel cell carcinoma and poor survival outcomes when compared internationally. We have the highest proportion of distant metastatic disease at time of diagnosis. Further research into the role of nonpolyoma-related Merkel cell carcinoma is warranted to improve Merkel cell carcinoma outcomes in New Zealand and abroad.

Background: Bronchiectasis prevalence has increased, especially in indigenous children. One evolutionary pathway follows hospitalisation with severe lower respiratory tract infection (LRTI) in early childhood. We aimed to reduce the intermediate respiratory morbidity with an intervention programme introduced at discharge. Methods: This randomised, controlled, single-blind trial enrolled children aged

Background Stillbirth after 28 weeks gestation affects between 1.3–8.8 per 1000 births in high-income countries. The majority of stillbirths in this setting occur in women without established risk factors. Identification of risk factors which could be identified and managed in pregnancy is a priority in stillbirth prevention research. This study aimed to evaluate women’s experiences of fetal movements and how these relate to stillbirth. Methods An international internet-based case–control study of women who had a stillbirth ≥28 weeks’ gestation within 30 days prior to completing the survey (n = 153) and women with an ongoing pregnancy or a live born child (n = 480). The online questionnaire was developed with parent stakeholder organizations using a mixture of categorical and open–ended responses and Likert scales. Univariate and multiple logistic regression was used to determine crude (unadjusted) and adjusted odds ratios (aOR) with 95% confidence intervals (CI). Summative content analysis was used to analyse free text responses. Results Women whose pregnancy ended in stillbirth were less likely to check fetal movements (aOR 0.54, 95% CI 0.35–0.83) and were less likely to be told to do so by a health professional (aOR 0.55, 95% CI 0.36–0.86). Pregnancies ending in stillbirth were more frequently associated with significant abnormalities in fetal movements in the preceding two weeks; this included a significant reduction in fetal activity (aOR 14.1, 95% CI 7.27–27.45) or sudden single episode of excessive fetal activity (aOR 4.30, 95% CI 2.25–8.24). Cases described their perception of changes in fetal activity differently to healthy controls e.g. vigorous activity was described as “frantic”, “wild” or “crazy” compared to “powerful” or “strong”. Conclusions Alterations in fetal activity are associated with increased risk of stillbirth. Pregnant women should be educated about awareness of fetal activity and reporting abnormal activity to health professionals. Electronic supplementary material The online version of this article (10.1186/s12884-017-1555-6) contains supplementary material, which is available to authorized users.

An intervention designed to reduce numbers of hospital-acquired pressure injuries was delivered in Counties Manukau Health hospitals. An audit of a sample of patients was carried out to estimate the cost savings that would have been acquired across the district health board (DHB) due to a reduction in pressure injuries.The pressure injury intervention was delivered from 2011 to 2015. A monthly prospective audit of patients with stages 1, 2, 3 and 4 pressure injuries was carried out. This involved a random sample of five patients per ward in all hospitals in Counties Manukau DHB.It was found that the annual estimated cost of treating pressure injuries in hospital patients was NZ$12,290,484 less in 2015 than in 2011.Implementation of strategies for managing hospital-acquired pressure injuries can lead to potentially large financial savings for hospitals, as well as reducing the burden of managing this difficult condition for patients and staff.

Endotracheal intubation requires laryngoscopy followed by passage of the endotracheal tube (ETT). Tube passage can be difficult, but there is little evidence to support which adjunct for tube passage is most effective.The four tube passage adjuncts tested were the naked ETT, stylet ETT, railroaded bougie and preloaded bougie. Participants completed pre- and post-test surveys identifying demographics, experience and method preference. After instruction, participants completed eight intubations on manikins with 'easy' and 'difficult' airways.One hundred and seventeen practitioners who were experienced emergency medicine physicians, anaesthesiologists and out-of-hospital providers completed 936 total ETT attempts. For the 'difficult' airway, the percentage first pass success (95% confidence interval [CI]) for the naked ETT was 30.8% (23.1-39.7%). This was significantly lower than the stylet ETT (95.7% [86.6-100%]), the railroaded bougie (75.2% [63.8-86.6%]), or the preloaded bougie (89.7% [79.7-99.7%]). On difficult airways, the median (interquartile range [IQR]) time-to-intubation was fastest in the stylet ETT (25.0 s [20.9-32.2 s]) with the railroaded bougie being the slowest (43.2 s [36.5-56.2 s]). Seventy-nine per cent of participants stated that they would change their practice based on participating in this study. Participants increased their preference for the preloaded bougie from 30.6% to 69.4%.The data show that tube passage with a stylet ETT or a preloaded bougie is superior in terms of higher first pass success, faster time-to-intubation and higher post-test preference. The naked ETT is clearly inferior to other methods. This research supports the recommendation to use a stylet ETT or bougie for every predicted difficult intubation.

INTRODUCTION: To evaluate the effectiveness of the levonorgestrel intrauterine system (LNG-IUS) in obese women with heavy menstrual bleeding in Counties Manukau Auckland area New Zealand. METHODS: Prospective observational study in a tertiary teaching hospital. Twenty women with heavy menstrual bleeding (HMB) who agreed to treatment with the LNG-IUS and had a body mass index (BMI) of >30 kg/m2 were recruited between May and December 2014. The women completed two validated tools (Menstrual Impact Questionnaire and the Pictorial Bleeding Assessment Chart) at recruitment 6 and 12 months follow-up. Demographic medical and laboratory variables were obtained from the relevant CMH databases. Data on side effects and satisfaction were obtained from the women at 12 months. RESULTS: The median age (range) and BMI of the 20 women were 40.5 years (27-52 years) and 40.6 kg/m2 (30-68) respectively. Three LNG-IUS were removed due to infection and pain and these women were subsequently booked for a hysterectomy. The reduction in menstrual loss was estimated at 19.7% per month (95% CI (12.5% 26.2%); P < 0.001) which translates to 73.2% per period of 6 months (95% CI (55.3% 83.9%)) and 92.8% per period of 12 months (95% CI (80.0% 97.4%)). The six items in the quality of life measure improved significantly in 14 women but only 12 women were satisfied with the treatment. CONCLUSION: The LNG-IUS was an effective treatment for 67% of obese women with heavy menstrual bleeding over a 12-month period as assessed by the reduction in menstrual bleeding and the improvement in the quality of life measures. (c) 2016 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

Refractory benign strictures of the oesophagus can present a significant clinical challenge and may require repeated attempts at dilatation. Intralesional triamcinolone injections have been used in a limited number of studies to aid in the dilatation of benign, refractory oesophageal strictures. It is hypothesised that intralesional steroid injection inhibits the scar formation, thereby reducing the need for dilatations. The purpose of this study was to assess if steroid injection reduces the need for serial endoscopic dilatations and aids in maintaining oesophageal patency.We report a case series of 25 patients with refractory oesophageal strictures. The mean age was 75 years and range between 41-95 years. The etiology of strictures consisted of peptic (68%), anastomotic (4%), radiation induced (16%) and eosinophilic oesophagitis (12%). Majority (75%) were distal in location. Triamcinolone (40-80 mg) was injected via 25-gauge sclerotherapy catheter in a four quadrantic manner in aliquots of 0.5 ml each into the proximal end of the stricture and also into the stricture itself after dilatation. Dilatation was carried out with over the guidewire Savary-Gilliard or through the scope (CRE) Balloon dilators depending upon the preference of the endoscopist. Dilatations were continued every 4-6 weeks until asymptomatic and/or endoscopic resolution of stricture. Periodic Dilatation Index (PDI) was calculated by the number of dilatations required over the duration of time in months.The number of dilatations reduced from mean of 3.12 to 1.41 in the peptic strictures but there was no decrease in the other groups. However, the triamcinolone injection resulted in reducing the periodic dilatation index in all groups except the eosinophilic oesophagitis. The rate ratio of PDI before and after intralesional triamcinolone injection use being 0.45 with 95% confidence interval [0.30 -0.68] (p=0.0005). Furthermore triamcinolone injections showed a trend to increase the maximal achieved diameter of the strictures.This study demonstrates the efficacy of triamcinolone intralesional steroids in reducing the requirement for repeated dilatations in refractory peptic strictures of oesophagus. Strictures related to eosinophilic oesophagitis failed to demonstrate similar efficacy.

The International Collaboration on Endocarditis Prospective Cohort Study (ICE-PCS) collected worldwide data on the presentation, management and outcome of infective endocarditis (IE). We present data from patients with endocarditis enrolled from New Zealand.Patients who fulfilled the Duke criteria for definite or probable endocarditis were enrolled from five district health boards: Auckland, Counties Manukau, Waitemata, Capital and Coast, and Canterbury, between June 2000 and September 2005.There were 336 New Zealand patients enrolled in the ICE-PCS. Prosthetic valve endocarditis occurred in 31%. Underlying medical conditions were present in 28% of patients, but only 4% of patients had rheumatic heart disease. Forty patients (12%) had healthcare-associated endocarditis. Viridans streptococci were the most common cause of IE (32%), followed by Staphylococcus aureus (24%). Patients with S. aureus IE were more likely to present within a week of symptom onset than those with viridans streptococcus IE (OR 4.18, 95% CI 2.36-7.42). Surgery was performed in 33% of patients. In total, 20 patients (6%) died in hospital. Those with endocarditis caused by coagulase-negative staphylococci had an increased risk of death compared with those viridans streptococcus endocarditis (RR 4.7, 95% CI 1.2-17). The risk of stroke was higher in those with endocarditis caused by S. aureus and coagulase-negative staphylococci (RR 2.7, 95% CI 1.2-6.05, and 4.9, 95% CI 1.9-13, respectively).While viridans streptococci remain the predominant causative organisms of IE in New Zealand, many 'traditional' clinical and management aspects of this disease no longer apply. This paper provides a reference for local practitioners assessing and managing IE.

Treatment of non-Hodgkin lymphoma (NHL) with cyclophosphamide, vincristine, doxorubicin and prednisone (CHOP) is known to be associated with a significant risk of febrile neutropenia (FN) of up to 50% [Osby et al. 2003 Blood 101(10): 3840-3848; Lyman and Delgado 2003 Cancer 98(11): 2402-2409]. This study sought to examine the impact of primary granulocyte colony-stimulating factor (GCSF) prophylaxis on the incidence of FN, quality of life and overall cost.In this retrospective cohort study, a group of 65 consecutive patients who received CHOP chemotherapy for NHL between December 2006 and October 2009 was studied. Patients either received filgrastim (300 mcg, average of seven doses), pegylated filgrastim (6 mg, single dose), or no GCSF prophylaxis. In addition, 19 patients were asked to complete Functional Assessment of Cancer Therapy: General quality-of-life questionnaires.Overall, patients who received primary GCSF prophylaxis had significantly fewer FN compared to those who did not (5 vs. 60%, p0.0001; numbers needed to treat of 1.8; 95% confidence interval, 1.6-2.9). Cost-benefit analysis showed that the GCSF prophylaxis was associated with only a small increase in direct financial cost ($238 NZD [US$189] more to give primary GCSF prophylaxis per patient vs. no prophylaxis). The quality of life assessment showed that the patients' quality of life scores were similar to the published data from the validation study population (466 patients with mixed cancers) for Functional Assessment of Cancer Therapy.Our study shows that primary GCSF prophylaxis is effective in preventing FN in patients receiving CHOP chemotherapy for NHL without adversely affecting their quality of life, and is cost effective.