[Show abstract][Hide abstract] ABSTRACT: Midwives providing care as lead maternity caregivers in New Zealand provide continuity of care to women who may give birth in a variety of settings, including home, primary units, and secondary and tertiary level hospitals. The purpose of this study was to compare mode of birth and intrapartum intervention rates for low-risk women planning to give birth in these settings under the care of midwives.
Data for a cohort of low-risk women giving birth in 2006 and 2007 were extracted from the Midwifery Maternity Provider Organisation database. Mode of birth, intrapartum interventions, and neonatal outcomes were compared with results adjusted for age, parity, ethnicity, and smoking.
Women planning to give birth in secondary and tertiary hospitals had a higher risk of cesarean section, assisted modes of birth, and intrapartum interventions than similar women planning to give birth at home and in primary units. The risk of emergency cesarean section for women planning to give birth in a tertiary unit was 4.62 (95% CI: 3.66-5.84) times that of a woman planning to give birth in a primary unit. Newborns of women planning to give birth in secondary and tertiary hospitals also had a higher risk of admission to a neonatal intensive care unit (RR: 1.40, 95% CI: 1.05-1.87; RR: 1.78, 95% CI: 1.31-2.42) than women planning to give birth in a primary unit.
Planned place of birth has a significant influence on mode of birth and rates of intrapartum intervention in childbirth.
[Show abstract][Hide abstract] ABSTRACT: Although antibiotic use in the community is a significant contributor to resistance, little is known about social patterns of use. This study aimed to explore the use of antibiotics by age, gender, ethnicity, socio-economic status and rurality.
Data were obtained on all medicines dispensed to ambulatory patients in one isolated town for a year, and data on antibiotics are presented in this paper. Demographic details were obtained from pharmacy records or by matching to a national patient dataset.
During the study year, 51% of the population received a prescription for one or more antibiotics, and on average people in the region received 10.15 defined daily doses (DDDs). Prevalence of use was higher for females (ratio, 1.18), and for young people (under 25) and the elderly (75 and over), and the amount in DDDs/person/year broadly followed this pattern. Māori (indigenous New Zealanders) were less likely to receive a prescription (48% of the population) than non-Māori (55%) and received smaller quantities on average. Rural Māori, including rural Māori children, received few prescriptions and low quantities of antibiotics compared with other population groups.
The level of antibiotic use in the general population is high, despite campaigns to try to reduce unnecessary use. The prevalence of acute rheumatic fever is high amongst rural Māori, and consequently treatment guidelines recommend prophylactic use of antibiotics for sore throat in this population. This makes the comparatively very low level of use of antibiotics amongst rural Māori children very concerning.
Journal of Antimicrobial Chemotherapy 05/2011; 66(8):1921-6. · 5.34 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Graduates from a new, 3-year Bachelor of Midwifery program joined those educated through the 1 year, postgraduate route (for those already qualified as nurses) for the first time in New South Wales (NSW) Australia in 2007. Many hospitals offer transition support programs for new graduates during their first year of practice though there is little evidence available to inform these programs.
To establish the new midwife's confidence in working to the 14 "National Competency Standards for the Midwife"(1) and the International Confederation of Midwives (ICM) Definition of a Midwife and to explore whether the new midwife's confidence changed over the new graduate year. In particular the study set out to determine whether there were any differences in the confidence of new graduates from undergraduate or postgraduate programs.
Pre and post survey with comparisons longitudinally and within undergraduate and postgraduate cohorts.
Three Area Health Services in Sydney and surrounding areas, Australia.
A convenience sample of all new graduate midwives employed in the three Area Health Services in the early months of 2008.
New graduate midwives rated their level of confidence (1-10) in working to the 14 National Competency Standards for the Midwife and the ICM Definition of a Midwife during their first weeks of employment and after the completion of their first year of practice.
Midwives prepared through the undergraduate and postgraduate routes commenced their first year of practice with similar levels of confidence. The confidence of these midwives increased modestly over the first year of practice. Those from postgraduate programs were significantly more confident than those from undergraduate programs on four competencies after the first year of practice. Participant's self reported confidence in working to the ICM Definition of a Midwife was low.
Our profession and community need strong, confident midwives and it is in all our interests to look to ways we can best achieve this. While the findings of this study should be treated with caution, this study suggests that there is room for improvement in the way we support newly graduated midwives to build their confidence over their first year of practice. Further research is needed to identify the needs of newly graduated midwives and how best we can support them to develop as strong and confident practitioners through their first year of practice.
[Show abstract][Hide abstract] ABSTRACT: Insecure hiding of the treatment allocation in randomized trials is associated with bias. It is less certain how much bias is associated with different methods of treatment allocation.
Meta-epidemiological study of 389 randomized trials from 19 systematic reviews and 65 meta-analyses with differing methods of treatment allocation. Pooled ratios of odds ratios (RORs) and 95% confidence intervals (95% CI) were calculated from trials with different methods of treatment allocation. An ROR less than one shows exaggeration of treatment effect.
There is no evidence that the use of sealed envelopes with enhancement was different from central randomization (ROR 1.02, 95% CI: 0.85-1.23). Sealed envelopes without enhancement were associated with an exaggeration of the estimate of effect (ROR 0.87, 95% CI: 0.76-1.00). Where allocation concealment for double-blind trials was unclear, the ROR is 0.86 (95% CI: 0.78-0.96) and if not hidden, the ROR is 0.89 (95% CI: 0.70-1.15).
Sealed envelopes with some form of enhancement (opaque, sequentially numbered, and so forth) may give adequate concealment. Description of a study as "double blind" does not imply a lack of bias when concealment of allocation is unclear.
Journal of clinical epidemiology 04/2011; 64(10):1070-5. · 5.48 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To obtain pharmacists' views on proposals for electronic transmission of dispensing data to the New Zealand Intensive Medicines Monitoring Programme (IMMP).
Consultation with a randomly selected group of 100 community pharmacists and all 28 hospital pharmacies in New Zealand was conducted by postal survey. A specific questionnaire was designed to obtain pharmacists' views on several aspects of electronic data transmission including willingness to co-operate with a new system, awareness of other electronic systems and views on security.
Survey response rates were 95% for community pharmacists and 73% for hospital pharmacists. Ninety (95%) of the community pharmacists and 18 (95%) of the hospital pharmacists who responded stated they would use the IMMP proposed method of electronic data transmission. Some 91% of community pharmacists and 100% of hospital pharmacists considered the proposed new method would be equally or more secure than the present hard-copy system of posting dispensing records.
There is a high level of support from New Zealand pharmacists for electronic capture of prescription dispensing data for medicines monitored by the IMMP. This electronic method will now be implemented. Development of such systems is important for enhancing patient safety and pharmacovigilance programmes worldwide.
International Journal of Pharmacy Practice 04/2011; 19(2):136-9.
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to conduct a prospective randomized controlled clinical trial to evaluate the rate of space closure and tooth angulation during maxillary canine retraction using preactivated T-loops made from titanium-molybdenum alloy (TMA) and nickel-titanium (NiTi). Twelve patients (six males and six females) aged between 13 and 20 years who had upper premolar extractions were included, and each acted as their own control, with a NiTi T-loop allocated to one quadrant and TMA to the other using a split mouth block randomization design. The loops were activated 3 mm at each visit to deliver a load of approximately 150 g to the upper canine teeth. Maxillary dental casts, taken at the first and each subsequent monthly visit, were used to evaluate changes in extraction space and canine angulation. All used T-loops were compared with unused loops in order to assess distortion. Mixed model statistical analysis was used to adjust for confounding variables. The mean rate of canine retraction using preactivated NiTi and TMA T-loops was 0.91 mm/month (±0.46) and 0.87 mm/month (±0.34), respectively. The canine tipping rates were 0.71 degrees/month (±2.34) for NiTi and 1.15 degrees/month (±2.86) for TMA. Both the rate of space closure and the tipping were not significantly different between the two wire types. The average percentage distortion of the TMA T-loop was 10 times greater than that of the NiTi loops when all other variables were matched. There was no difference in the rate of space closure or tooth angulation between preactivated TMA or NiTi T-loops when used to retract upper canines. The NiTi loops possessed a greater ability to retain and return to their original shapes following cyclical activation.
The European Journal of Orthodontics 03/2011; 34(1):33-8. · 1.08 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The objective of this systematic review was to identify trial design and patient characteristics associated with symptom improvement in acute mania clinical trials.
Drug trials in acute mania that used the Young Mania Rating Scale (YMRS) score as the primary endpoint were identified using a systematic search strategy. Details of the trial, patient population, and treatment assignment were recorded. Covariates associated with change in YMRS were analyzed using a multiple regression model.
A total of 41 studies, comprising 89 treatment arms and 10,471 patients, were selected for this analysis. Three variables were statistically significantly associated with change in YMRS score: treatment assignment, baseline mania score, and study location. Compared with placebo, greater mean (95% confidence interval) reductions in YMRS score were noted for all three active treatment arms [-4.7 (-6.4 to -3.0) for mood stabilizers; -5.9 (-7.6 to -4.2) for antipsychotics; and -8.3 (-10.2 to -6.4) for combined mood stabilizer/antipsychotics; all comparisons p < 0.0001]. Greater changes in YMRS score were associated with higher baseline YMRS scores (p = 0.002) and with studies performed outside of the USA (p= 0.02). Year of study publication was not associated with YMRS score change. Study size, number of study sites, YMRS score required for study entry, inclusion of patients with mixed mania or treatment resistance, and enrollment of inpatients versus outpatients had no significant influence on change in YMRS score.
These findings may assist in the design of future drug trials for acute mania.
[Show abstract][Hide abstract] ABSTRACT: Knowledge regarding the possible health benefits of probiotic preparations has been increasing, but clinical trials have largely produced non-significant results. In contrast, the open market for probiotics is expanding worldwide despite little research of consumer characteristics.
We aimed to survey the availability of probiotic preparations, the recommendation patterns of general practitioners (GP) and the characteristics of consumers.
Pharmacies were visited and the types of probiotic supplements were reviewed. A telephone survey was conducted to identify and characterise users and non-users. A questionnaire was sent to GPs.
We found 31 probiotic products containing 16 different strains of bacteria. The majority of GPs were unable to clearly define a probiotic. Of 1512 random phone numbers called, 873 were answered. The prevalence of probiotic use was 25.4% of respondents. More females than males had ever used probiotics (30.6% vs 17.2%; p<0.0001). The highest rate of use was found in those with tertiary qualifications (34.2%; p<0.001). Of users, 75.2% said they had used probiotics on a recommendation, 80.5% of non-users said they would consider taking a probiotic if it was recommended by the GP. Probiotics were mainly used alongside antibiotic treatment (23%) and gastrointestinal disorders (27.5%). Significantly more users than non-users believed in the benefits of probiotic without concern for possible side effects.
The majority of participants would consider taking a probiotic if it was recommended by their GP, but GPs exhibited a lack of knowledge in the use and indications for probiotic therapy. There was a general lack of concern regarding potential side-effects.
The New Zealand medical journal 02/2011; 124(1329):36-43.
[Show abstract][Hide abstract] ABSTRACT: Background Knowledge regarding the possible health benefits of probiotic preparations has been increasing, but clinical trials have largely produced non-significant results. In contrast, the open market for probiotics is expanding worldwide despite little research of consumer characteristics.
THE NEW ZEALAND MEDICAL JOURNAL Journal of the New Zealand Medical Association NZMJ ISSN. 02/2011; 11(1175):8716-36.
[Show abstract][Hide abstract] ABSTRACT: Many systematic reviews include only a few studies. It is unclear whether recommendations based on these will be correct in the longer term; hence, this article explores whether meta-analyses give reliable results after only a few studies.
Cumulative meta-analysis of data from 65 meta-analyses from 18 Cochrane systematic reviews was carried out. Various measures of closeness to the pooled estimate from all trials after three and five trials were included. Changes during the accumulation of evidence were noted.
The 95% confidence interval included the final estimate in 72% of meta-analyses after three studies and in 83% after five studies. It took a median of four (interquartile range: 1.25-6) studies to get within 10% of the final point estimate. Agreement between the results at three and five studies and the final estimate was not predicted by the number of participants, the number of events, τ(2), or I(2). Estimates could still change substantially after many trials were included.
Many of the conclusions drawn from systematic reviews with small numbers of included studies will be correct in the long run, but it is not possible to predict which ones.
Journal of clinical epidemiology 02/2011; 64(2):145-53. · 5.48 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Randomised controlled trials have investigated aspects of postal survey design yet cannot elaborate on reasons behind participants' decision making and survey behaviour. This paper reports participants' perspectives of the design of, and participation in, a longitudinal postal cohort survey. It describes strengths and weaknesses in study design from the perspectives of study participants and aims to contribute to the: 1) design of future cohort surveys and questionnaires generally and, 2) design of cohort surveys for people with musculoskeletal disorders (MSDs) specifically.
In-depth interviews explored the design of postal surveys previously completed by participants. Interviews used open ended questioning with a topic guide for prompts if areas of interest were not covered spontaneously. Thematic data analysis was undertaken based on the framework method. A second researcher verified all coding.
Data from fourteen interviews were analysed within three main themes; participation, survey design and survey content. One of the main findings was the importance of clear communication aimed at the correct audience both when inviting potential participants to take part and within the survey itself. Providing enough information about the study, having a topic of interest and an explanation of likely benefits of the study were important when inviting people to participate. The neutrality of the survey and origination from a reputable source were both important; as was an explanation about why information was being collected within the survey itself. Study findings included participants' impressions when invited to take part, why they participated, the acceptability of follow-up of non-responders and why participants completed the follow-up postal survey. Also discussed were participants' first impression of the survey, its length, presentation and participants' views about specific questions within the survey.
Ideas generated in this study provide an insight into participants' decision making and survey behaviour and may enhance the acceptability of future surveys to potential participants. As well as clear communication, participants valued incentives and survey questions that were relevant to them. However, opinions varied as to the preferred format for responses with some advising more opportunity for open-ended feedback. We also found that some standard format questions can raise quandaries for individual participants.
BMC Medical Research Methodology 01/2011; 11(1):8. · 2.21 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Spirituality is increasingly understood to be important in healthcare provision, as seen in policy, guidelines and practice across many Western healthcare systems. Definitions of spirituality remain controversial, despite their importance for consistency in research and practice. This paper reports on the definition findings of a nation-wide New Zealand (NZ) study (2006–2008) that examined understandings, experiences and ways to improve spiritual care, primarily focused in hospices. A mixed methods approach included 52 semi-structured interviews and a survey of 642 patients, family members and staff from 25 (78%) of NZ's hospices. A generic qualitative design and analysis was used to capture the experiences and understandings of participants' spirituality and spiritual care and a cross-sectional survey gave sample-based information about the study's questions. Across both studies the majority view held that spirituality is a useful, important, inclusive and broadly defined concept. NZ is a secular country, yet there is clear evidence that spirituality is important at the end of life. These findings add weight to the international trend for spirituality to be further investigated and attended to in healthcare.
[Show abstract][Hide abstract] ABSTRACT: All treatment guidelines for acute mania recommend monotherapy with either mood stabilizers (MS) or antipsychotics. The objective of this analysis was to compare the efficacy and acceptability of both drug classes in an expanded set of clinical trials in acute mania.
Randomized double-blind trials comparing MS vs second generation antipsychotics (SGA) in acute mania were identified in a systematic literature search. Change in mania rating scale, responder rates and dropout rates were compared by treatment assignment using Review Manager version 5.0.
Nine studies totaling 1631 patients that compared the MS lithium or valproate against a number of SGAs, and which reported one or more analysis endpoints were identified. Statistically significant advantages were noted in favour of SGA over MS for standardized mean difference (SMD) for change in mania scores (-0.22 [95% CI -0.33 to -0.11]; p < 0.0001), responder rate risk difference (7% [95% CI 1% to 13%]; p = 0.02), and dropout risk difference (-5% [95% CI -10% to -1%]; p = 0.02). This change in SMD for mania scores is equivalent to a 2.5-3 point difference in Young Mania Rating Scale score. Similar trends for SMD were noted when comparing subgroups of lithium and valproate studies against SGAs.
Over half the included studies included olanzapine, and the applicability of these findings, especially to first generation antipsychotic drugs, requires confirmation. This analysis could not assess the relative efficacy of combined MS/SGA vs individual monotherapies.
In acute mania, monotherapy with SGAs demonstrates statistically significant advantages over MS in terms of both efficacy and acceptability, and may be preferable for initial choice of treatment.
Journal of affective disorders 12/2010; 134(1-3):14-9. · 3.76 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Pharmacy dispensing databases provide a comprehensive source of data on medicines use free from many of the biases inherent in administrative databases. There are challenges associated with using pharmacy databases however. This paper describes the methods we used, and their performance, so that other researchers considering using pharmacy databases may benefit from our experiences.
Data were collected from all nine pharmacy dispensing databases in an isolated New Zealand town for the period October 2005-September 2006. Probabilistic record matching was used to link individuals across pharmacies. Patient addresses from the pharmacy data were geo-located to small areas so an area measure of socioeconomic deprivation could be assigned. Medicines were coded according to the ATC-DDD drug classification system.
Data on 619,264 dispensings were collected. Record matching reduced an initial pool of individuals from 54,484 to 38,027. Socioeconomic deprivation ranks were assigned for 30,972 (93%) of the 33,375 unique addresses identified, or 36,048 (95%) of individuals. ATC codes were assigned to 613,490 (99%) of the dispensings, with DDDs assigned to 561,223 (91%). Overall, 93% of dispensing records had complete demographic and drug information.
The methods described in this paper generated a rich dataset for medicines use research. These methods, while initially resource-intensive, can to a great extent be automated and applied to other locations, and will hopefully prove useful to other researchers facing similar challenges with using pharmacy databases. However, it is difficult to envisage these methods being viable on a long-term or national scale.
Journal of Biomedical Informatics 12/2010; 43(6):982-7. · 2.13 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We perform a systematic review to discern if ST resolution achieved via percutaneous coronary intervention (PCI) has a different meaning to that achieved via fibrinolysis.
Resolution of ST-segment elevation in acute myocardial infarction has been widely used as a surrogate for treatment success. A recent randomized study suggested that after primary PCI, the prognostic significance of ST resolution may have been overemphasized.
Using the MEDLINE, COCHRANE, EMBASE, and PUBMED databases to search for the relevant papers, we analyze the data with a new ST-resolution score. ST-resolution groups of <30%, 30% to < 70%, and ≥ 70% are given scores of 1, 2, and 3 respectively, whereas ST-resolution groups reported as < 50% are scored as 1.5, and ≥ 50% scored as 2.5.
We identify 18 fibrinolysis cohorts (32,341 patients) and 5 PCI cohorts (1,913 patients). The mean ST-resolution score weighted for the number of patients in each cohort is 1.87 ± 0.15 for PCI and 1.66 ± 0.20 for fibrinolysis (P < .001). The raw combined 30-day mortality is 4.9% with fibrinolysis and 4.3% with PCI (P = .452 by Poisson regression). There is a linear relationship with lower 30-day mortality associated with higher ST-resolution score. The regression line for the PCI cohorts almost overlaps with that from the fibrinolysis cohorts. On multivariate regression, only ST-resolution score is significant in predicting 30-day mortality. When tested, the interaction term (treatment group × ST resolution score) is never a significant predictor (P > .25 in all models).
ST resolution after different reperfusion therapies has similar prognostic meaning.
American heart journal 11/2010; 160(5):842-848.e1-2. · 4.65 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To investigate mandibular motion in six degrees of freedom before, during and after twin block treatment in one individual.
The appliance was worn for eight months, and motion recordings, using a 12-camera opto-electric system, were captured prior to placement of a twin block appliance and 2, 4, 14 and 52 weeks after insertion.
The wide variations in mandibular motion that accompany twin block wear disappeared post-treatment, except for an increase in anteroposterior movement of the mandible.
Twin block therapy appears to affect mandibular motion temporarily.
Australian orthodontic journal 11/2010; 26(2):189-94. · 0.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To investigate the effect of an orally administered probiotic on disease activity, fatigue, quality of life, and intestinal symptoms in patients with active spondyloarthritis.
Patients with active spondyloarthritis [defined as Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) ≥ 3, Bath Ankylosing Spondylitis Functional Index (BASFI) ≥ 3, Maastricht Ankylosing Spondylitis Enthesitis Score (MASES) ≥ 2, or peripheral joint count ≥ 2] were randomized to oral probiotic or placebo for 12 weeks. Patients and assessors were blinded to treatment allocation. The primary outcome measure was 10% improvement in the BASFI. Additional outcome measures were improvements in the ASsessments in Ankylosing Spondylitis (ASAS)-endorsed core domains: pain, spinal mobility, patient global, peripheral joint and entheseal scores, stiffness, C-reactive protein, and fatigue. The ASAS20 criteria, a composite measure of response, were also applied. Quality of life and bowel symptoms were quantified using the Ankylosing Spondylitis Quality of Life Questionnaire (ASQoL) and Dudley Inflammatory Bowel Symptom Questionnaire (DISQ).
Sixty-three patients were randomized to oral probiotic (n = 32) or placebo (n = 31). All patients completed the trial. No significant difference was noted between groups in any of the core domains. The mean BASFI fell from 3.5 ± 2.0 to 2.9 ± 1.9 in the probiotic group and from 3.6 ± 1.9 to 3.1 ± 2.2 in the placebo group (p = 0.839). The mean BASDAI fell from 4.2 ± 2.2 to 3.2 ± 2.1 in the probiotic group and 4.5 ± 2.0 to 3.9 ± 2.2 in the placebo group (p = 0.182). No significant adverse events were recorded in the probiotic-treated group.
In this randomized controlled trial, the probiotic combination administered did not demonstrate significant benefit over placebo, despite a theoretical rationale for this therapy.
The Journal of Rheumatology 10/2010; 37(10):2118-25. · 3.26 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study compared the moments produced by V-bends placed in rectangular nickel titanium (NiTi) orthodontic wire to those produced in titanium-molybdenum alloy (TMA). V-bends that included angles of 135, 150, and 165 degrees were heat set into 0.017×0.025 and 0.016×0.025 inch NiTi alloy wires and identical bends bent into TMA wires with a dimension of 0.018×0.025 and 0.016×0.022 inch. There were five specimens per group (N=60). The moments produced by each specimen were tested on a custom jig that aligned two lower incisor brackets with zero tip or torque at an interbracket distance of 15 mm. The upper bracket was connected to a moment transducer. The V-bend position for each specimen was varied in 1 mm increments towards the moment transducer. The moments produced by TMA wires were linear, which increased as the V-bend approached the transducer, while NiTi exhibited a non-linear curve characterized by a flattening of the moment value. The point of dissociation (where the moment experienced by the bracket became zero) was estimated for both wire types using linear mixed model analysis. For TMA wires, this point was similar to that reported in the literature but was significantly less for NiTi wire when compared with TMA. The moments produced by TMA generally increased with the magnitude of the V-bend, whereas this was not the case for NiTi.
The European Journal of Orthodontics 10/2010; 33(4):457-60. · 1.08 Impact Factor