The New Zealand medical journal

Published by New Zealand Medical Association
Publications
To investigate the extent of current problem gambling in New Zealand, and the risk factors, addictive behaviours, and self-rated health status associated with problem gambling. Analysis of the gambling questions from the 2002/03 New Zealand Health Survey, which interviewed 12,529 people aged 15 years and over, and included increased sampling of Maori, Pacific, and Asian people. Approximately 1.2% (95% confidence interval: 1.0-1.5) of the New Zealand adult population were found to be current problem gamblers, representing an estimated 32,800 (26,200-39,400) people. Risk factors for problem gambling included being of Maori or Pacific ethnicity, being aged 25-34 years, living alone, being employed, and being less qualified. Problem gambling was significantly associated with potentially hazardous drinking behaviour, daily cigarette smoking, and worse self-rated health, as measured on several SF-36 health domains. Maori and Pacific peoples were at significantly greater risk of being problem gamblers than other people, particularly among those people who gambled. Associations between gambling problems and health problems and/or risk behaviours suggest compounded problems from comorbidity. This evidence may be useful in informing policy and public health programmes to reduce the harmful impact of problem gambling on individuals and communities, and in addressing the inequalities evident in gambling-related harm.
 
To provide an update for the assessment of discrepancies in ethnicity counts in the 2001 census and mortality data for the 2004-2006 period. 2001 census anonymously and probabilistically linked to 5 years of subsequent mortality data (135,849 eligible mortality records), allowing a comparison of ethnicity recording for the years 2001-2004 and 2004-2006. Using a total definition of ethnicity, census and mortality counts agree reasonably well in 2004-06 and resemble comparisons in 2001-04, except at younger ages where counts for Pacific and Asian ethnicities are up to a third less for mortality data. Due to multiple ethnicities being more commonly recorded on census data, sole ethnicity counts are generally greater on mortality than census data, particularly for Maori ethnicity. Similar to 2001-2004, there is little bias in ethnic group counts between census and mortality data when using total ethnicity. Calculations of mortality rates by ethnicity using unlinked census and mortality data and a total definition of ethnicity should be unbiased. These results support ongoing use of the census definition of ethnicity on all health datasets.
 
Numerical differences in script counts for Māori compared with non-Māori, adjusted for age and historical disease burden, disaggregated by access and persistence  
To describe variations in dispensing of specific medication groups by ethnicity in New Zealand, adjusting for health need. Preliminary linkage of dispensings of prescription medicines in 2006/07 to age/disease burden proxies of health need for Maori, Pacific peoples (Pasifika)--who are mostly of Samoan, Tongan, Niuean, or Cook Islands descent--in New Zealand, and non-Maori/non-Pasifika. These disease burden proxies combine differences in prevalence, age, morbidity, and mortality. Variations were disaggregated by patients being first dispensed medicines ('access') versus subsequent dispensings ('persistence'). Initially, overall age-adjusted incidence of 'scripts' (prescriptions dispensed) to Maori was similar to that of non-Maori. There were differences in therapeutic coverage between Maori and Pasifika, for example greater use of asthma medicines in Maori. However, further adjustments linking with disease burden showed marked variance for a number of diseases. Differences in dispensing included areas of high health need such as heart disease, infections, diabetes, mental health and respiratory disease. Maori had 19-37% lower dispensings overall than non-Maori, with a net difference of nearly 1 million scripts. Maori were both less likely to access medicines, and then after first dispensing had fewer subsequent scripts. Patterns for Pasifika appeared similar, although needs-adjusted analysis is awaited for this population. Once adjusting for need, there was variable but sizeable differences in medicines dispensed to Maori compared with non-Maori, and likely differences for Pasifika populations. There are however important limitations to this preliminary analysis. Crude and age-standardised metrics may be poor predictors of needs-adjusted gaps in medicines use. In this analysis, solely age-standardised rates tended to underestimate differences once adjusting for burden of disease; future analyses of prescribing patterns should consider better adjusting for disease burden.
 
To audit medical activity at Christchurch Hospital New Zealand between 2230 and 0800 hours; specifically, to measure the volumes of tasks requiring completion overnight and to identify the competencies required for this as well as the level of teamwork that existed. After a pilot study tested possible methods, Resident Medical Officers (RMOs) responsible for the care of adult patients at night were linked by a shift coordinator to recorders (mostly nursing students) trained to register the tasks performed, together with task urgency (as judged by the RMO) and duration. This information, checked each morning for completeness, was entered immediately into a database and analysed later. Telephonists logged all outbound calls through the hospital switchboard to on-call medical staff; theatre and admission records were recorded as usual. Anaesthetic and Radiology Registrar activity was self-recorded. Christchurch Hospital is a 650 bed tertiary centre, which covers most specialties. In the absence of leadership, the RMOs were not working as a team. Consequently some were overextended while others were inactive. House officer tasks were largely generic--not specialty specific; there was no formal handover from the afternoon or day shifts and the level of hospital medical staffing did not reflect the activity levels over the time period studied. A review of the beep policy is urgently needed. A third of the admissions were to General Medicine, and basic medical activities (including admitting, reviewing, and prescribing drugs and fluids) for patients admitted under all specialties represented the majority of the night workload. Medical registrars had reduced some of the traditional multiple clerking by admitting patients themselves. The workload and its distribution over time was remarkably similar to that found at the 17 pilot sites in the United Kingdom, where Out of Hours Multidisciplinary Teams (OoHMT) were introduced. We recommend that Christchurch Hospital use these data to plan the composition and leadership of an OoHMT.
 
To report the blood pressure results from the 2008/09 New Zealand Adult Nutrition Survey (2008/09NZANS). Blood pressure measurements were available for 4,407 adults who were part of a survey involving face-to-face interviews with 4,721 New Zealanders aged 15 years and over. Three measurements were taken one minute apart, and the mean of the second and third readings has been used for this analysis. Hypertension was defined as systolic blood pressure (SBP) greater than and equal to 140 mmHg or diastolic blood pressure (DBP) greater than and equal to 90 mmHg or self reported use of antihypertensive medications. Comparisons were made with previously published New Zealand population blood pressure estimates. Mean SBP for the New Zealand adult population was 126 mmHg. The prevalence of hypertension was 31%, with 15% reporting taking antihypertensive medication. Mean SBP has increased since 2002/03 for New Zealand European and others (NZEO) aged 35-54 years and Maori aged 35-74 years, reversing a downward trend observed in NZEO between 1982 and 2002. The increasing blood pressure levels are concerning. Given the importance of elevated blood pressure as a risk factor for cardiovascular disease, intensive screening, public health measures aimed at lowering population blood pressure, and further population monitoring are warranted.
 
The 2006/07 New Zealand Health Survey, 2008/09 New Zealand Adult Nutrition Survey and the Virtual Diabetes Register age-specific diagnosed diabetes rates, by 10-year age groups for men aged 15 years and over 
The 2006/07 New Zealand Health Survey, 2008/09 New Zealand Adult Nutrition Survey and the Virtual Diabetes Register age-specific diagnosed diabetes rates, by 10-year age groups for women aged 15 years and over. 
The age-specific rates for self-reported doctor diagnosed diabetes, undiagnosed diabetes and prediabetes by age group for
Reported prevalence of diagnosed diabetes for different regional and national studies in New Zealand, 1967-2009
Reported prevalence of new diabetes for different regional and national studies in New Zealand, 1967-2009
To describe the prevalence of diagnosed and undiagnosed diabetes and prediabetes for New Zealand adults. The 2008/09 New Zealand Adult Nutrition Survey was a nationally representative, cross-sectional survey of 4,721 New Zealanders aged 15 years and above. Self-reported diabetes and the 2010 American Diabetes Association cutoffs for HbA1c were used to define diagnosed diabetes, undiagnosed diabetes and prediabetes. Prevalence rates were calculated and age-specific diagnosed diabetes rates were compared with those from the Virtual Diabetes Register. Overall, prevalence of diabetes was 7.0%, and prevalence of prediabetes 18.6%. Prevalence of diabetes was higher in men (8.3%, 95% CI: 6.4, 10.1) than in women (5.8%, 95% CI: 4.7, 7.0), and was higher among the obese (14.2%, 95% CI: 11.6, 16.9) compared with the normal weight group (2.4%, 95% CI: 1.4, 3.6). Prevalence of undiagnosed diabetes was highest among Pacific people (6.4%, 95% CI: 3.8, 9.1) compared with Maori (2.2%, 95% CI: 1.2, 3.1) and New Zealand European and Others (1.5%, 95% CI: 0.9, 2.1). The high prevalence of prediabetes indicates the prevalence of diabetes will continue to increase in New Zealand. Implementation of effective evidence-based prevention strategies is required to reduce the increasing costs of the diabetes epidemic.
 
Sodium fluoroacetate (1080) is used for control of vertebrate pests in New Zealand. Little is known about chronic effects in humans, but animal studies demonstrate potential for adverse fetal, male fertility, and cardiac effects. We aimed to employ analyses of 1080 to help assess the degree of exposure of bait formulators and distributors, and identify specific tasks where exposure reduction appeared most indicated. We also aimed to utilise the (limited) 1080 toxicity data to assess the significance of the analytical results. Exposures during various activities were assessed by monitoring air levels and blood and urine concentrations. To help evaluate the results, a provisional "biological exposure index" (BEI) was later derived, by extrapolating from experimental data. Early monitoring indicated exposures were highest in relation to (cereal) bait manufacturing and aerial carrot baiting procedures. A provisional BEI of 15 microg/L for 1080 in urine was proposed. Further protective measures and ongoing workplace monitoring are required, particularly in the above situations. Compliance with the current BEI cannot guarantee complete safety. Any information regarding chronic adverse effects in humans, along with the associated urine levels, would assist risk assessment. Further investigation of the human kinetics of fluoroacetate would be helpful.
 
To describe vascular trauma in New Zealand: its management and early outcomes. Patients suffering vascular trauma between January 1993 and December 2003 were analysed using data collected prospectively by the New Zealand Society of Vascular Surgeons' database (NZVASC). There were 549 cases of vascular trauma amongst 45,759 vascular admissions collected by the database in the 11-year period. This study confirmed the findings in international studies that younger adult males were more likely to suffer vascular trauma. Elderly patients, especially females, were most at risk of iatrogenic vascular injury, which accounted for 22% of cases in this study. Complication rates reported by rural vascular surgeons in New Zealand were comparable to results in the main centres and to international reports. While programmes to slow down and sober up road users help reduce injuries in the younger age groups, it lies in the hands of our own profession to reduce the iatrogenic injuries in the older patients.
 
Absolute 5-year CVD risk in Pacific and European men and women by age group 
presents the distribution of the PREDICT Pacific cohort in their respective
To investigate the differences in the baseline cardiovascular disease (CVD) risk profiles of Pacific peoples and Europeans assessed in routine primary care practice by PREDICT, a web-based clinical decision support programme for assessing and managing CVD risk. PREDICT has been implemented in primary care practices from nine consenting PHOs in Auckland and Northland. Between 2002 and January 2009, over 70,000 CVD risk assessments were conducted. These analyses compare CVD risk factors for Pacific and European patients. Baseline risk assessments were completed for 39,835 Europeans and 10,301 Pacific peoples aged 35-74 years. Over 85% of the Pacific cohort was comprised of the four main Pacific ethnic groups in New Zealand (Samoan, Tongan, Cook Island Maori and Niuean). Fijians (n=1341) were excluded from the analyses because of a likely misclassification error with Indian Fijians. On average, Pacific peoples in the PREDICT cohort were 4 years younger at the time of risk assessment than Europeans, and were overrepresented in areas of high socioeconomic deprivation. At risk assessment, Pacific men were 1.5 times as likely to be current smokers as European men, whereas similar or lower proportions of Pacific women smoked compared with European women. Pacific peoples were approximately three times more likely to have diabetes as Europeans. Pacific peoples had higher diastolic blood pressures and Pacific women had higher total cholesterol/HDL ratios. Both Pacific men and women had a significantly higher predicted risk of CVD in the next 5 years than Europeans, based on the Framingham risk score. The PREDICT programme has already generated the largest cohort of Pacific peoples ever to be studied in New Zealand. This comparative analysis of patients who have been screened highlights significant disparities in CVD risk factors for Pacific peoples particularly for diabetes in both sexes and for smoking in men. Targeting these modifiable risk factors will be important in addressing the widening inequalities in CVD outcomes between Pacific peoples and Europeans.
 
To determine vaccination coverage, by ethnicity, for the routine publicly funded vaccinations for 11 year olds, from school-based vaccination data in South Auckland, New Zealand. De-identified aggregate data were obtained with permission from the Counties Manukau District Health Board (CMDHB) Public Health Nurses Database on the 11-year-old tetanus and polio vaccinations from 2005, and analysed to determine percentages of form return, consent and vaccination receipt by ethnicity, including relative risks for Maori compared to non-Maori students. Reasons for vaccination refusal were also analysed. Overall, 48% of Maori and 56% of non-Maori in Year 7 in CMDHB in 2005 (n=8642) were immunised through the school-based programme. Assuming that parents who stated their child had already received these vaccinations were all correct, the estimated overall coverage in this population for the recommended Year 7 tetanus vaccination was 67% (53% for Maori, and 71% for non-Maori). Vaccination coverage amongst 11 year olds in this population was lower than coverage for other childhood vaccinations in New Zealand, and there was a large Maori:non-Maori disparity.
 
The aetiology, definition, and management of Fournier's gangrene are an enigma to surgeons and urologists alike. Indeed, controversy surrounds its management. We managed 110 cases of Fournier's gangrene with different modalities and compared their outcomes along with those of contemporary studies. To evaluate aetiology, predisposing factors, and causative organisms plus compare modalities of surgical management of Fournier's gangrene. 110 cases of Fournier's gangrene that were admitted and treated in S.S.G. Hospital (Vadodara/Baroda, India) from January 2000 to December 2006 were evaluated. The average duration of symptoms was 3-5 days and the commonest presentation was scrotum swelling plus pain and fever. The most common aetiological factor was trauma and urinary tract infection. The majority (84%) of cases had bilateral scrotal involvement. In the majority (46%) of patients, a mixture of causative organisms were isolated; E. coli was isolated in 17.5% of patients. The fascicutaneous rotation thigh flap procedure gave the best cosmetic results. Review of the cases suggests that the Fournier's gangrene is either an idiopathic condition or secondary to adjacent infection or the operation performed. The condition progresses rapidly but is usually self-limiting and most commonly confined to the genitalia. Adequate diagnosis is imperative and immediate intense and aggressive therapy is necessary. Prompt surgical debridement and administration of appropriate antibiotics (both local and systemic) are necessary to lower mortality and morbidity. Most of the defects can be closed secondarily while some need coverage by skin grafting. Fasciocutaneous rotation thigh flap is the best cosmetically acceptable repair, although it demands surgeons with considerable skill and experience and there are relatively more complications compared with other procedures as well as a longer hospital stay.
 
The aim of this study was to evaluate the economic cost of community-acquired pneumonia (CAP) in New Zealand adults. Although this is an important illness, there is little published information on the national costs of treatment. Without such information, new treatment options cannot be evaluated in economic terms. Costs were estimated from a societal perspective for the adult population (aged 15 years and over) using New Zealand age-specific hospital admission rates (average of 2000-2002), population data (2003), and unit costs (2003) in combination with international data on the proportion of pneumonia cases hospitalised. Univariate and multivariate sensitivity analyses were used to determine the major cost drivers and evaluate uncertainty in the estimates. It was estimated that in 2003 there were 26,826 episodes of pneumonia in adults; a rate of 859 per 100,000 people. The annual cost was estimated to be 63 million dollars, (direct medical costs of 29 million dollars; direct non-medical costs of 1 million dollars; lost productivity of 33 million dollars). The major generators of costs for community-acquired pneumonia are the number of hospitalisations (particularly for the group aged 65 years and over) and loss of productivity. Intensified prevention and effective community treatment programmes focussing on the 65 years and older age groups should be investigated (as they have the greatest potential to reduce healthcare costs).
 
Small bowel capsule endoscopy (CE) has been introduced in New Zealand (NZ) in all of the tertiary and some secondary centres over the last few years. We describe our experience with CE from a single centre in NZ. In this 2-year, retrospective, study of 122 consecutive patients, data was collected on multiple variables from the patient clinical, laboratory, and radiology records. Pillcam of Given Imaging Diagnostic System (Given Imaging Ltd, Yogneam, Israel) was used to image the small bowel. Descriptive statistics were used to analyse the data. Good preparation was noted in 69% of the cases. The most common indication for referral was obscure GI bleeding (70%). The overall diagnostic yield for relevant findings was 52%, with angioectasia as the most common specific finding (37%). The diagnostic yield in those with overt bleeds improved with inpatient status (74%). Incomplete examinations were noted in 12% and were significantly more common in the male gender. Preliminary imaging (barium, CT/MR) was noted to have a lower diagnostic yield. Enteroscopies were considered in 25% of the patients post CE procedure. CONCLSION: Apart from a lower diagnostic yield in patients with overt bleeds, our data is consistent with that reported in literature and support the role of CE as the minimally invasive gold standard investigation for small bowel imaging.
 
Baseline demographic characteristics of people in Pacific ethnic groups in the PREDICT cohort 
Data on the cardiovascular disease risk profiles of Pacific peoples in New Zealand is usually aggregated and treated as a single entity. Little is known about the comparability or otherwise of cardiovascular disease (CVD) risk between different Pacific groups. To compare CVD risk profiles for the main Pacific ethnic groups assessed in New Zealand primary care practice to determine if it is reasonable to aggregate these data, or if significant differences exist. A web-based clinical decision support system for CVD risk assessment and management (PREDICT) has been implemented in primary care practices in nine PHOs throughout Auckland and Northland since 2002, covering approximately 65% of the population of these regions. Between 2002 and January 2009, baseline CVD risk assessments were carried out on 11,642 patients aged 35-74 years identifying with one or more Pacific ethnic groups (4933 Samoans, 1724 Tongans, 1366 Cook Island Maori, 880 Niueans, 1341 Fijians and 1398 people identified as Other Pacific or Pacific Not Further Defined). Fijians were subsequently excluded from the analyses because of a probable misclassification error that appears to combine Fijian Indians with ethnic Fijians. Prevalences of smoking, diabetes and prior history of CVD, as well as mean total cholesterol/HDL ratio, systolic and diastolic blood pressures, and Framingham 5-year CVD risk were calculated for each Pacific group. Age-adjusted risk ratios and mean differences stratified by gender were calculated using Samoans as the reference group. Cook Island women were almost 60% more likely to smoke than Samoan women. While Tongan men had the highest proportion of smoking (29%) among Pacific men, Tongan women had the lowest smoking proportion (10%) among Pacific women. Tongan women and Niuean men and women had a higher burden of diabetes than other Pacific ethnic groups, which were 20-30% higher than their Samoan counterparts. Niuean men and women had lower blood pressure levels than all other Pacific groups while Tongan men and women had the highest total cholesterol to HDL ratios. Tongan men and women had higher absolute 5-year CVD risk scores, as estimated by the Framingham equation, than their Samoan counterparts (Age-adjusted mean differences 0.71% [95% CI 0.36% to 1.06%] for Tongan men and 0.52% [95% CI 0.17% to 0.86%] for Tongan women) although these risk differences were only about 10% higher in relative terms. The validity of the analyses depend on the assumption that the selection of participants for CVD risk assessment in primary care is similar between Pacific groups. The ethnic-specific CVD risk profiles presented do not represent estimates of population prevalence. Almost all previous Pacific data has been aggregated with Pacific peoples treated as a single entity because of small sample sizes. We have analysed data from the largest study to date measuring CVD risk factors in Pacific peoples living in New Zealand. Our findings suggest that aggregating Pacific population data appears to be reasonable in terms of assessing absolute CVD risk, however there are differences for specific CVD risk factors between Pacific ethnic groups that may be important for targeting community level interventions.
 
Graph showing results of multiple correspondence analysis of the responses to the six statements about the tobacco industry 
New Zealand has been at the forefront of tobacco control and can boast an impressive range of tobacco control intervention. To date, tobacco control policy and interventions have directed very little attention to the tobacco industry because they concentrate on reducing demand for tobacco. In addition, the tobacco industry does not have a bold profile in the mass media. Given this low profile of the tobacco industry and the predominance of measures to reduce demand we were interested in teenage perceptions of the tobacco industry in New Zealand. A cross-sectional sample of 31,459 Year 10 students was obtained in 2006. Attitudes towards the tobacco industry and smoking outcomes were analysed using multivariate logistic regression. Thirty-six percent of students disagreed that tobacco companies are responsible for people starting to smoke and 34% agreed that tobacco companies have equal right to sell cigarettes as other companies to sell their products. Female, Māori and students from low decile schools, who are all more likely to be smoking or have tried smoking, were more likely to show greater acceptance of the tobacco industry. Intention to smoke was associated with the belief that tobacco industry is not responsible for smoking initiation (odds ratio 1.7, p<0.001), and that the tobacco industry is legitimate and credible (odds ratio 2.9, p<0.001). Tolerant attitudes towards the tobacco industry were strongly associated with intentions to smoke and current smoking amongst teenagers.
 
The number of students' publications in the NZMJ each year (1999–2013) 
Numbers of students’ publications published by month of NZMJ edition (1999–2013) 
Little is known about students' contribution to mainstream New Zealand (NZ) medical literature. This study aimed to analyse the pattern of students' contributions to the New Zealand Medical Journal (NZMJ). A retrospective review of all articles authored or co-authored by students, and published in the NZMJ from November 1999 to December 2013. Author and article related information were collected and analysed. There were 288 issues and 4205 articles published between November 1999 and December 2013. Students authored or co-authored 376 (8.9%) articles during this time period. There is an increased trend in the number of articles published during the study period in that students published three times more in 2013 when compared to 2000. Senior medical students and postgraduate students contributed the most with 41.2% and 40.3% of the total student publications respectively. Original articles constituted the most common type of students' publications (67.6%). Students contributed substantially to mainstream published NZ medical literature. Students' contribution continues to increase and this reflects the increased participation in research activities. Academic institutions should harness this potential and encourage students to publish their research findings.
 
In December 2001, nursing industrial action occurred at Christchurch Hospital. This study assesses the effect industrial action had on relatives of those Intensive Care Unit (ICU) patients involved. A written questionnaire was sent to the relatives of the 17 patients on Intensive Care around the time of the strike; 11 of these patients had needed to be transferred to out of region hospitals for continuing care, whilst the others remained in the intensive care unit. Comparisons were made with a control group of 26 next-of-kin. Compared with relatives of patients not involved in the strike, relatives involved during the strike were significantly more angry (p<0.007) and less trusting that the patients had received the best possible care (p<0.05). Compared to the control group, they were also more negative in their continuing view of the healthcare system (p<0.05). Those relatives involved in air transfers were more distressed (p<0.05), angry (p<0.001), and less trusting than those not involved in a transfer (p<0.005). The study shows that industrial action caused measurable distress and anxiety to the relatives involved some 16 months after the strike, especially in patients who were transferred. A persistent negative perception of the healthcare system in New Zealand could be demonstrated in this group.
 
An 18-year-old woman with primary amenorrhoea and pubertal delay was investigated for mild labile hypertension and secondary hypogonadism. Low renin and normal aldosterone levels combined with evidence of primary adrenal insufficiency suggested partial 17-alpha hydroxylase enzyme deficiency. The diagnosis was confirmed by measurement of 24-hour urine steroid metabolites and whole gene sequencing of CYP17A1 that demonstrated c.160_162delTTC (p.Phe54del) homozygous mutation. Ultrasound showed bilateral small ovaries with multiple cysts. The serum anti-mullerian hormone concentration was unremarkable at 6.6 (normal <12.6 ng/ml) but the outlook for her future ovulatory potential is uncertain. Dexamethasone 0.25 mg pre-bed and hydrocortisone 5 mg on waking normalised her hormonal profile and her blood pressure without side-effects.
 
To study pre-hospital delay, its components and determinants, in patients with acute coronary syndromes (ACS) admitted to Middlemore Hospital Coronary Care Unit. Consecutive ACS patients admitted between January 2009 and July 2010 were included. Pre-hospital delay was defined as the time from onset of worst symptom(s) to defibrillator availability: either ambulance arrival at the scene or time of hospital arrival (non-ambulance patients). For 805 patients the median delay from symptom onset to defibrillator availability was 174 minutes. Half the cohort had a delay to defibrillator availability of >3 hours. The median delay was an hour longer for patients from areas of greatest deprivation compared with less deprived areas, [208 vs 149 min, respectively (p=0.015)], and 7 hours longer for non-ambulance vs ambulance patients, [553 vs 130 min (p<0.001)]. Māori, Pacific, Indian and those from areas of higher deprivation were less likely to travel to hospital by ambulance. Of ST-elevation myocardial infarction patients eligible for reperfusion, over two-thirds of the total delay between symptom onset and reperfusion occurred pre-hospital. Community intervention targeted at more disadvantaged communities and higher risk ethnic groups should be considered as part of an overall strategy to reduce disparity and improve cardiac outcomes.
 
A Difficult Hypertension Clinic was established at Whangarei Hospital (Whangarei, Northland, New Zealand) in March 2006 in response to a perceived need amongst general practitioners. The experience with the first 150 patients is reviewed. Mean BP at referral was 162/89 mmHg, and mean number of antihypertensive drugs was 2.49. Mean BP at discharge from the Difficult Hypertension Clinic was 138/78 mmHg and mean number of antihypertensive drugs 3.16. The commonest cause of hypertension resistance was underprescription of diuretics. Secondary or contributory causes of hypertension were identified in 28 (19%) of patients, and white coat hypertension in three (2%). The Difficult Hypertension Clinic established in our hospital is an effective model for achieving clinical targets and care recommended in evidence-based guidelines.
 
To investigate the characteristics of under-18 year old callers to New Zealand's Quitline (smoking-cessation telephone counselling service). Analysis of routinely collected demographic and smoking history characteristics of under-18 year old Quitline callers in 2004 and 2005. In the 24 months of 2004-2005, 2371 under-18s called Quitline (for the first time) seeking smoking cessation support. Females (58.9%) and teens in their older teen years called most often. Compared with adult callers, there were significantly higher proportions of Maori (32.9% vs 19.6%) and Pacific (5% vs 3.6%) under-18 callers, and fewer European (64.0% vs 74.6%) and 'Other' (6.0% vs 7.1%) callers. Despite similar levels of nicotine dependence in under-18 and adult callers (70.1% vs 71.4% reported smoking within 30 minutes of waking), under-18s were issued nicotine replacement therapy (NRT) half as often (RR=0.51). Under-18s were more likely than adults to register a mobile phone number (48.9% vs 44.4%). Under-18 year old smokers are under-represented in the Quitline calling population. Maori and Pacific under-18s require further cessation support to avoid exacerbating existing disparities in smoking. Awareness that under-18 nicotine dependence is equivalent to that of adults should lead to improved provision of NRT for adolescents. Initiatives involving mobile phone technology are particularly appropriate for improving access to information and treatment for under-18s. Adolescent tobacco cessation should be accorded greater priority in tobacco control policy, practice, and research.
 
Demographic characteristics and CVD risk factors in men (proportions and means with standard deviation) 
Percentage of ProCare population assessed, by age and gender
Demographic characteristics and CVD risk factors in women (proportions and means with standard deviations) 
Age and gender distribution of PREDICT-CVD patient population over 35 years compared with ProCare and Auckland population 
To describe the cardiovascular disease (CVD) risk factor status of approximately 18,000 patients profiled in routine primary care practice by PREDICT-CVD, a web-based clinical decision support program for assessing and managing CVD risk. Between 2002 and 2005, 31,241 CVD risk assessments of 18,260 patients were undertaken in ProCare, a large primary care organisation in Auckland. Baseline risk assessments were completed for 10,374 (57%) men and 7886 (43%) women. The mean age was 56 years (range 17 to 94 years), Of those assessed, 11% were of Pacific and 7% of Maori ethnicity. Risk assessment was more likely in men under the age of 65 years. In the over 65 year age group, women were more likely to be risk assessed. The overall prevalence of diabetes and smoking in this cohort was 14% and 13% respectively. A history of a previous CVD event increased with age in both men and women. Above the age of 75 years, 36% reported a previous cardiovascular event, most commonly ischaemic heart disease. The patients assessed represented 6% of men and 4% of women in the enrolled ProCare population over 35 years of age. General practitioners and practice nurses using PREDICT-CVD targeted patients according to national guideline age and gender recommendations. PREDICT-CVD is a practical and effective tool for systematically generating standardised patient CVD risk factor profiles during routine primary care practice. When implemented widely, PREDICT will enable primary care organisations to monitor the CVD risk burden and management in their practice populations using a nationally standardised evidence-based approach.
 
Taken from a patient, aged 35, who had suffered for some time past from a melanotic degeneration of the right eye ball: this was removed about six weeks before his death some improvement took place upon the removal of the tumour, but this was only temporary. He gradually relapsed, and suffered from severe pains in the head: coma slowly supervened, and he died in that condition. During the last year he had occasionally suffered from severe pain in the epigastric region, and had been at tacked with paroxysms not unlike those of angina pectoris. On post mortem examination, the brain was found very firm, and much congested. There was considerable effusion of fluid in the ventricles, but no abnormal deposit of any kind in the substance. Two round masses about the size of a garden pea was situated on the third nerves at their region; in fact the nerves appeared to have there origin from these masses . On looking at the heart, a black mass, about the size of a chestnut, was seen in the substance of the left ventricle. Several small tumours, the size of pears, were scattered about in the vicinity of the larger one. On opening the abdomen, several tumours were found connected with peritoneum; a black mass larger than that in the heart existed in the right lobe of the liver. Both kidneys were much diseased, but the right presented a rare and beautiful specimen of malignant disease. A large mass of the size of an orange involved more than one-third of the organ, situated chiefly towards its convexity. Two others of the size of pigeon' eggs were seen; one situated just
 
Daily Mail (London): ANZACS in France. Off to the trenches (circa 1916) Alexander Turnbull Library. Official war pictures, no. 153. [Postcard. ca 1916]. Reference Number: Eph-POSTCARD-WWI-01. 2012 [cited January 2013]; Available from:  
Pandemic Influenza deaths amongst NZEF personnel (1918–1919) 
Pandemic influenza mortality rates amongst NZEF personnel at different locations 
The impact of pandemic influenza on the New Zealand Expeditionary Force (NZEF) in 1918-19 has never been studied using modern epidemiological methods. Therefore we analysed mortality and descriptive data from various sources for these military personnel. An estimated 930 NZEF personnel deaths from pandemic influenza occurred in 1918-19, making it the main cause of disease deaths, and representing 5.1% of all NZEF deaths from World War One (WW1). The epidemic curve was much more drawn out in the Northern Hemisphere compared with the Southern Hemisphere. Mortality rates varied markedly by setting (e.g. in military camps, by country and by hemisphere). Significantly higher mortality rates were found amongst NZEF personnel: aged 30-34 years, those of Maori ethnicity, those with a rural background, and those who left New Zealand for Europe in 1918. In conclusion, this work documents the heavy mortality burden from pandemic influenza amongst this national military force and highlights the large variations in mortality rates through host and environmental factors.
 
Amongst New Zealand soldiers in Gallipoli in 1915 there were reports of poor food quality and cases of scurvy. But no modern analysis of the military food rations has ever been conducted to better understand potential nutritional problems in this group. We analysed the foods in the military rations for 1915 using food composition data on the closest equivalents for modern foods. We compared these results with other plausible diets and various optimised ones using linear programming. Historical accounts provide evidence for poor food quality supplied to these soldiers. The nutrient analysis suggested that the military rations were below modern requirements for vitamins A, C and E; potassium; selenium; and dietary fibre. If military planners had used modest amounts of the canned vegetables and fruit available in 1915, this would probably have eliminated four of these six deficits. The results from the uncertainty analyses for vitamin C (e.g., 95% uncertainty interval [UI]: 5.5 to 6.7 mg per day), was compatible with the range known to cause scurvy, but the UI for vitamin A intake was only partly in the range for causing night blindness. To indicate the gap with the ideal, an optimised diet (using foods available in 1915), could have achieved all nutrient requirements for under half the estimated purchase cost of the 1915 military rations. There is now both historical and analytic evidence that the military rations provided to these soldiers were nutritionally inadequate in vitamin C, and probably other nutrients such as vitamin A. These deficits are likely to have caused cases of scurvy and may have contributed to the high rates of other illnesses experienced at Gallipoli. Such problems could have been readily prevented by providing rations that included some canned fruit or vegetables (e.g., as manufactured by New Zealand at the time).
 
This study aimed to examine the impact of rurality on mortality rates from pandemic influenza in New Zealand in 1918. Mortality data was obtained from death certificates (in a published source) and denominator population data from the 1916 census (for the European population only). Analyses were conducted on cities (n = 4), towns (n = 111), counties (n = 97). The influenza mortality rate for the towns and cities was more than twice that of the counties that represented rural settings (rate ratio (RR) = 2.13, 95% CI = 2.00-2.27). However, larger towns (population >2000 people) had a significantly lower mortality rate than smaller towns (RR = 0.81, 95%CI = 0.74-0.88). Similarly, cities had a lower mortality rate than larger towns (RR = 0.89, 95%CI = 0.83-0.95). These results are suggestive that rurality may have provided some protection from mortality during this influenza pandemic. This may have been due to a mix of remoteness and greater social distancing among rural residents. However, the differences in mortality rates between towns and cities may have reflected other factors such as the more organised provision of community care in the larger towns and cities, when compared to smaller towns.
 
Epidemic curve for pandemic influenza mortality for Europeans in Iceland and NZ, 1918 
Total pandemic influenza mortality rates in 1918 by age-group for Europeans in Iceland and NZ 
Nations varied in their experience of, and response to, the 1918-19 influenza pandemic. Island communities can provide unique opportunities to study the epidemiology of infectious diseases. We aimed to compare the epidemiology and public health response to this pandemic in two remote island nations, on opposite sides of the globe: Iceland and New Zealand (NZ). Historical accounts in both nations were reviewed, along with recent analysis of the pandemics impact and course. Marked similarities were noted in epidemic timing, failure of border control, shape of epidemic curves, and delayed use of public health interventions. However, amongst the exposed European populations, Iceland experienced a significantly higher mortality rate (830 vs 550 per 100,000) compared to NZ (rate ratio: 1.5, 95%CI: 1.4-1.6). There is evidence that some public health measures in specific areas of both nations resulted in lower mortality rates. In particular, Iceland's use of travel restrictions and ship quarantining, appeared to protect 36% of the population. The epidemiology of the 1918-19 influenza pandemic was fairly similar for the exposed European populations of Iceland and NZ. Nevertheless, major differences were the significantly higher overall mortality rate in Iceland and the success of Iceland's use of travel restrictions.
 
To characterise the impact of rurality on the spread of pandemic influenza by exploring both the numbers of cases and deaths in Kanagawa Prefecture, Japan, from October 1918 to April 1919 inclusive. In addition to the numbers of influenza cases and deaths, population sizes were extracted from census data, permitting estimations of morbidity, mortality, and case fatality by 199 different regions (population 1.4 million). These outcomes were compared between four groups; cities (n=6), larger towns (38), smaller towns (101), and villages (54). Whereas crude mortality in villages was lower than those of other population groups, the morbidity appeared to be the highest in villages, revealing significant difference compared to all cities and towns [risk ratio=0.601 (95% confidence interval: 0.600-0.602)]. Villages also yielded the lowest case fatality, the difference of which was statistically significant among four population groups (p=0.02). Rurality did not show a predictive value of protection against pandemic influenza in Kanagawa. Lower morbidity in the towns and cities is likely explained by effective preventive measures in urban areas. High morbidity in rural areas highlights the potential importance of social distancing measures in order to minimise infections in the event of the next influenza pandemic.
 
Top-cited authors
Rod Jackson
  • University of Auckland
Peter Davis
  • University of Auckland
Richard Edwards
  • University of Otago
Tony Blakely
  • University of Otago
Wasan Ali
  • University of Auckland