Journal of the New Zealand Medical Association Vol 129 | No 1441 | 9 September 2016 Socioeconomic correlates of quality of life for non-Māori in advanced age: Te Puāwaitanga o Nga Tapuwae Kia ora Tonu. Life and Living in Advanced Age

Protecting New Zealand children from exposure to the marketing of unhealthy foods and drinks: a comparison of three nutrient profiling systems to classify foods Clinical ethics support services in New Zealand—tailoring services to meet the needs of doctors

What’s new with the flu? Reflections The Uses of Mental Improved compliance with regarding the management and Health Telephone the World Health Organization prevention of influenza from Counselling Service Surgical Safety Checklist is the 2nd New Zealand Influenza for Chinese speaking associated with reduced surgical Symposium, November 2015 people in New Zealand specimen labelling errors Publication Information published by the New Zealand Medical Association

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NZMJ 9 September 2016, Vol 129 No 1441 ISSN 1175-8716 © NZMA DRAFT www.nzma.org.nz/journal CONTENTS

EDITORIAL 54 8 What’s new with the flu? What are clinical ethics advisory Reflections regarding the groups for? management and prevention John McMillan of influenza from the 2nd New Zealand Influenza Symposium, ARTICLES November 2015 Nadia A Charania, Osman D Mansoor, 10 Diana Murfitt, Nikki M Turner Clinical ethics support services in New Zealand—tailoring services to 63 meet the needs of doctors Improved compliance with Elizabeth Dai, Angela Ballantyne the World Health Organization 18 Surgical Safety Checklist is Socioeconomic correlates of associated with reduced surgical quality of life for non-Māori in specimen labelling errors Walston Martis, Jacqueline A Hannam, advanced age: Te Puāwaitanga o Tracey Lee, Alan Merry, Simon Mitchell Nga Tapuwae Kia ora Tonu. Life and Living in Advanced Age: a 68 Cohort Study in New Zealand The uses of mental health (LiLACS NZ) telephone counselling service Ngaire Kerse, Ruth Teh, Simon A Moyes, for Chinese speaking people in Lorna Dyall, Janine L Wiles, Mere Kepa, New Zealand: demographics, Carol Wham, Karen J Hayman, Martin presenting problems and Connolly, Tim Wilkinson, Valerie Wright- evaluation of the calls St Clair, Sally Keeling, Joanna B Broad, Christine Yang Dong Santosh Jatrana, Thomas Lumley 78 33 Overview of the 2015 American Adherence to the current Thyroid Association guidelines guidelines for bradycardic for managing thyroid nodules and pacing in the octogenarian and differentiated thyroid cancer nonagenarian populations Bashar Matti, Ruben Cohen-Hallaleh Vivienne Kim, James Pemberton, Fiona Riddell, Khang-Li Looi CLINICAL CORRESPONDENCE 41 87 Protecting New Zealand children Amniotic fluid embolism after from exposure to the marketing intrauterine fetal demise of unhealthy foods and drinks: Karl Kristensen, Fali Langdana, Howard a comparison of three nutrient Clentworth, Chu Hansby, Paul Dalley profiling systems to classify foods Cliona Ni Mhurchu, Tara Mackenzie, Stefanie Vandevijvere

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LETTER 101 89 Does smoking cessation prior to Stroke Family/Whānau pilot elective spinal surgery lead to project long-term smoking abstinence Roslyne McKechnie, Sylvia Hach, Bruce Hodgson, Chris Hanrahan, Vivian Dianne Roy, Allanah Harrington, Victoria Cuthbertson Andersen METHUSELAH 91 Riding in cars with boys, and girls, 104 Long-term aromatase-inhibitor while smoking...in New Zealand therapy in breast cancer Frank Houghton, Bruce Duncan, Diane O'Doherty 100 YEARS AGO 94 105 A continuation of 10% annual The therapeutics of cancer tobacco tax increases until 2020: August 1916 Modelling results for smoking prevalence by sex and ethnicity PROCEEDINGS Frederieke Sanne van der Deen, Nick Wilson, Tony Blakely 107 Proceedings of the 233rd Otago 98 Medical School Research Society, Perspectives of New Zealand Summer Research studentship health professionals and smokers meeting on e-cigarettes 2016 Trish Fraser, Nigel Chee, Murray Laugesen

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Clinical ethics support services in New Zealand – tailoring services to meet the needs of doctors Elizabeth Dai, Angela Ballantyne The New Zealand Health and Disability Commissioner and the courts recommend doctors engage in “broad consultation in difficult clinical situations”, but do not specify mechanisms by which this should occur. Clinical ethics support services (CESS) aim to assist doctors in complicated ethical decision-making. This formal ethics support is well established overseas but relatively new to New Zealand. We did a qualitative study interviewing senior doctors at CCDHB to better understand their needs in regards to ethical support at work and their views of the new CESS at CCDHB. We found some misconceptions about the role of the CESS and wariness regarding abdicating responsibility for ethical decision-making for their patients. Allowing referring doctors to be present for the CESS deliberation would make the process more acceptable to doctors. Socioeconomic correlates of quality of life for non-Māori in advanced age: Te Puāwaitanga o Nga Tapuwae Kia ora Tonu. Life and Living in Advanced Age: a Cohort Study in New Zealand (LiLACS NZ) Ngaire Kerse, Ruth Teh, Simon A Moyes, Lorna Dyall, Janine L Wiles, Mere Kepa, Carol Wham, Karen J Hayman, Martin Connolly, Tim Wilkinson, Valerie Wright-St Clair, Sally Keeling, Joanna B Broad, Santosh Jatrana, Thomas Lumley The demographic ageing of the New Zealand population is most marked for those 85 years and over—a cohort predicted to increase six-fold by 2050. Older people contribute to society in many ways and valued contributions continue into advanced age. Those in advanced age also utilise the highest per capita public expenditure, mostly on health and disability support. Knowing more about the health, cultural profile and social status of those in advanced age will help health planners, society, families and older people prepare for the projected increase in those of advanced age. This paper focuses on quality of life (QoL) and presents the demo- graphic, social and cultural characteristics, and aims to identify correlates of health-related QOL, for the non-Māori cohort of Te Puāwaitanga o Nga Tapuwae Kia ora Tonu, Life and Living in Advanced Age: a Cohort Study in New Zealand, (LiLACS NZ). Adherence to the current guidelines for bradycardic pacing in the octogenarian and nonagenarian populations Vivienne Kim, James Pemberton, Fiona Riddell, Khang-Li Looi In New Zealand, there is increasing aging population that require bradycardia-support device implantation. Our study showed that there was underutilisation of dual chamber pacemakers in this population. Presence of cognitive impairment and multiple comorbidities influence the device of implanting single-chamber device in this population.

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Protecting New Zealand children from exposure to the marketing of unhealthy foods and drinks: a comparison of three nutrient profiling systems to classify foods Cliona Ni Mhurchu, Tara Mackenzie, Stefanie Vandevijvere Marketing of unhealthy foods and drinks to children is an important, changeable risk-factor for child obesity and development of diet-related diseases. An accepted food classification system is necessary to classify foods as suitable/unsuitable for marketing to children and to implement restrictions. We compared three accepted systems to identify the best one to protect New Zealand children from exposure to the marketing of unhealthy foods and drinks. Under any of the three systems, only about one-third of New Zealand packaged foods would be permitted to be marketed to children. The World Health Organization Europe Model restricts marketing of unhealthy foods more effectively than the other two systems, and should underpin the Advertising Standards Authority revised Children’s Code for Advertising Food. What’s new with the flu? Reflections regarding the management and prevention of influenza from the 2nd New Zealand Influenza Symposium, November 2015 Nadia A Charania, Osman D Mansoor, Diana Murfitt, Nikki M Turner Seasonal outbreaks of influenza cause substantial morbidity and mortality that burdens healthcare services every year; thus, focused discussions on improving management and prevention efforts is warranted. The Immunisation Advisory Centre (IMAC) hosted the 2nd New Zealand Influenza Symposium (NZiS) in November 2015. International and national participants discussed current issues in influenza management and prevention. Experts in the field presented data from recent studies and discussed the ecology of influenza viruses, epide- miology of influenza, methods of prevention and minimisation, and experiences from the 2015 seasonal influenza immunisation campaign. The symposium concluded that although much progress in this field has been made, many areas for future research remain. Improved compliance with the World Health Organization Surgical Safety Checklist is associated with reduced surgical specimen labelling errors Walston R Martis, Jacqueline A Hannam, Tracey Lee, Alan F Merry, Simon J Mitchell If used properly the World Health Organisation Surgical Safety Checklist has been shown to reduce deaths and complications in patients undergoing surgery. Currently, the biggest related challenge is facilitating optimal use of the checklist by operating room teams. A recent study conducted at Auckland City Hospital found that several strategic process changes resulted in a marked improvement in compliance and team engagement in checklist use. Following on from that, the present study demonstrated that this improvement in checklist use was associated with a reduction in surgical specimen labelling errors to less than half the rate occurring prior to the process changes. This is important because errors in the labelling of specimens sent to the laboratory for analysis can result in misguidance of patient care. The Health Quality and Safety Commission is currently advocating the adoption of the Auckland checklist process changes at hospitals throughout New Zealand.

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The uses of mental health telephone counselling service for Chinese speaking people in New Zealand: demographics, presenting problems and evaluation of the calls Christine Yang Dong This study aimed to investigate the call profiles of a Chinese-speaking mental health coun- selling helpline service in New Zealand (Chinese Lifeline provided by Lifeline Aotearoa) and to evaluate the calls and explore the possible factors influencing the outcome of the calls. A random sample of 151 answered calls was involved. The results showed that the service receives calls from callers with a wide range of demographics and with a large variety of presenting issues. This study identified several important factors which influenced coun- sellors' satisfaction of the calls and the length of the calls. Overview of the 2015 American Thyroid Association guidelines for managing thyroid nodules and differentiated thyroid cancer Bashar Matti, Ruben Cohen-Hallaleh Thyroid nodules/lumps require clinical assessment to determine whether they are cancerous or not. The American thyroid association has published a multi-level, step-by-step clinical assessment guidelines to help clinicians, generalists and specialists in the assessment and management process. These guidelines however are somewhat long and hence in this paper we attempted to provide a succinct summary.

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What are clinical ethics advisory groups for? John McMillan

Calls for greater ethical support for clini- This implies that an essential skill is to cians have been reinvigorated over recent be able to see the ethical issues in clinical years.1 However, it is worth bearing in practice. While this might appear to be mind that New Zealand, via the research obvious and something that we all do, there ethics committees established under the is a risk when talking to peers that they see Regional Health Authorities, used to have the same issues as us. But when a clinical a national network that could give clinical situation is discussed with colleagues from ethics advice. This might mean that the a range of specialties, as would be the case indifference to clinical ethics that Dai and with a CEAG, it’s likely that any ethical Ballantyne identify2 is not a new issue and issues are more fully identified and under- it also seems relevant to note that calls for stood in a better way. It could also be that clinical ethics support have waxed and engaging with other specialties will help to waned in other countries.3 clarify any unconscious bias that may have Dai and Ballantyne point out the impor- entered into identifying the relevant issues. tance of clarifying for clinicians what Likewise, some expertise in the law or Clinical Ethics Advisory Groups (CEAGs) policy will result in a more complete range can do.2 Whether or not CEAGs offer some- of issues being identified than might be the thing valuable, over and above discussion case via a peer discussion. with peers, depends upon the nature of the Analysing the issues identified can be discussion with that peer. It might be that a done in a number of ways and there are colleague asks critical questions that chal- some useful resources available for clini- lenge assumptions, that they have a good cians and medical students that explore knowledge of the legal context or that they this further.5 All other things being equal, are particularly experienced with this kind a CEAG is more likely to have a structured of presentation. On the other hand, there is approach for working through the issues a risk when seeking the advice of a colleague in a complex scenario than would be the that their thinking is too close to yours to case with a peer discussion. Following offer more than reassurance, that there are through the likely and possible conse- issues that someone from another specialty quences of various courses of action is or health profession would notice or that you part of analysing issues, and clinicians are share a blind spot with respect to the law or likely to find the assistance of a CEAG a policy. So whether or not a CEAG offers clini- valuable supplement to the advice of peers cians ethical advice that is better, depends when they are faced with ethically complex upon whether or not that peer offers good situations. advice and also what constitutes good While a structured approach to clinical clinical ethics advice. A number of ethicists ethics won’t always ‘resolve’ ethically have considered what constitutes ‘clinical challenging situations, Jonsen and Siegler ethics’ and suggested structures for how we are correct that ‘assisting’ clinicians in can improve ethical deliberation. working toward this should be the core What is clinical ethics? aim. Others have suggested that the final Jonsen and Siegler claim that "Clinical step in a structure approached to a chal- ethics is a practical discipline that provides lenging ethical case should be to make a a structured approach to assist physicians justified decision, which is the decision a in identifying, analysing and resolving clinician makes after weighing alternate ethical issues in clinical medicine".4 course of action and being clear about why they are choosing a specific course of

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action.5 So a key thing that a CEAG should them with a structured approach to clinical be able to do well is assist a clinician to ethics rather than ethical approval. weigh the relevant considerations so as to The majority of ethically tricky situations justify a decision when there might not be a will continue to be handled well by experi- consensus about the best way forward. enced clinicians after discussion with their What Clinical Ethics Advisory peers. The extra time that will unavoidably Groups can do be added by involving a CEAG is likely to It might be that a common misconception mean that it is cases which are ethically is that a CEAG fulfils a similar function novel, already complicated and contested, or to a research ethics committee: a group involve innovative therapy where additional of people outside of your area deliberate support is requested. about something you are planning on doing Where to next? and then tell you whether or not you have Clarifying what a CEAG can do will help, ethical approval to proceed. There might but they also require support from senior be instances where CEAGs have operated clinicians in the relevant institution. in this fashion, but that should not be their Without that leadership, the trust and rela- central function and is likely to detract tionships that are required in order for a from the more useful contributions to good clinician or DHB to openly discuss a situ- clinical ethics a CEAG can make. Supporting ation where things have not gone as well clinicians to take an evidence based, struc- as they might, are much harder to create. A tured and well justified approach to clinical first step for institutions that wish to build ethics is where a CEAG can be the most their network of clinical ethics support useful and it is usually built into their terms could be to review events that have not of reference. For example the Capital and gone well, to learn from them and prepare Coast DHB CEAG says it aims “To provide for similar ethically challenging events a consultative, advisory and supportive in the future. That too requires trust, and mechanism to assist healthcare profes- DHBs are (understandably) cautious in the sionals to make informed ethical decisions current environment, yet it seems a way in their management of patients".2 The that the value of discussions of this kind can emphasis here is clearly upon supporting be nurtured after the event and without the and enabling clinicians to make the best pressure that results from the need for a decisions they can, which implies providing decision to be made.

Author information: John McMillan, Bioethics Centre, University of Otago, New Zealand. Corresponding author: John McMillan, Bioethics Centre, University of Otago, New Zealand. [email protected] URL: https://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2016/vol-129-no- 1441-9-september-2016/6993

REFERENCES: 1. MacDonald A, Worth- 2. Dai E, Ballantyne A. (2016) 4. Clinical Ethics: A Practical ington R. (2012) The role Clinical ethics support Approach to Ethical Deci- of clinical ethics in the services in New Zealand: sions in Clinical Medicine, health system of New tailoring services to meet 4th Edition by Albert R. Zealand Capital and Coast the needs of doctors NZMJ Jonsen, Mark Siegler, and District Health Board, New 3. Slowther A, Hill D, William J. Winslade (1998) Zealand, in association McMillan J. (2002) “Clin- 5. Wendy Rogers and with the Health Quality ical ethics committees: Braunack-Mayer Prac- and Safety Commission opportunity or threat?” tical Ethics for General in Health Ethics Commit- Practice. OUP (2008) tee Forum Vol14 N1

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Clinical ethics support services in New Zealand— tailoring services to meet the needs of doctors Elizabeth Dai, Angela Ballantyne

ABSTRACT: Aims: To better understand senior doctors’ attitudes to clinical ethics support services at Capital and Coast District Health Board (CCDHB), in order to better tailor clinical ethics support services in New Zealand to the needs of doctors. Methods: We conducted in-depth semi-structured interviews with 14 senior doctors at CCDHB in 2011 and 2012. Data analysis was inductive and iterative. Results: Doctors primarily rely on informal avenues of peer consultation for support when making difficult ethical decisions. Many participants saw a potential role for formal ethics support, but expressed concern about how ethics support services would fit into their clinical practice. Primary concerns included the accessibility of support services and moral responsibility for ethical decision making in clinical settings. Conclusions: Doctors are more willing to engage in ethics support services where they are able to participate in, or at least observe, the decision-making process.

Ethical challenges are an inevitable part not have adequate support structures to of the practice of medicine, a vocation that help them process ethical concerns.7 serves people when they are vulnerable. The New Zealand Health and Disability Clinical ethics support services (CESS) aim Commissioner and the courts recommend to assist doctors in complicated ethical doctors engage in “broad consultation in 1 decision-making. In New Zealand, CESS difficult clinical situations”, but do not are relatively new and have emerged as a specify mechanisms by which this should clinician-led initiative. In North America occur.8 In New Zealand there are eight CESS, and Europe CESS have become increasingly some serving more than one District Health prevalent in and integrated into healthcare Board (DHB), and the majority of these delivery. Several models have emerged for have been established since 2008. The most the delivery of this support, ranging from prevalent model is that of a committee-style formally trained clinical ethicists who work advisory group composed predominantly of as professional consultants to hospital ethics clinicians. In July 2012, the Health Quality committees comprising both clinical and lay and Safety Commission (HQSC) offered a members. A growing literature is contrib- grant to support the establishment of a New uting to principles of best practice in clinical Zealand Clinical Ethics Network to support 2–6 ethics support. existing Clinical Ethics Advisory Groups Appropriate training in ethical reasoning (CEAGs) and facilitate the establishment of for clinicians and ongoing access to support new services around the country. The HQSC in ethical decision-making across the span grant highlights a turning point in New of a clinical career improves doctors’ well- Zealand where CESS are being increasingly being and enhances patient care. A study recognised as critical to safe and reflective by Kӓlvemark et al conducted in 2003 found medical practice. As such, it is an important that moral distress was experienced at time to take stock and reflect on how CESS higher rates by clinicians who felt they did can be designed to best meet the needs of

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clinicians. Our study was independently behaviours in a team is often shaped by funded and not part of the HQSC grant. the most senior clinician and senior clini- There is a surprising lack of literature cians are more likely to have experience of on the role, function and effectiveness of ethical dilemmas to draw on because they emerging CESS in New Zealand. In 2004, have more years of clinical practice. We Pinnock and Crosthwaite published survey ensured our sample included surgeons and results regarding health professionals’ paediatricians for the following reasons. views of the Auckland Hospital’s Clinical Previous research showed that surgeons Ethics Advisory Group (Auckland CEAG).9 were much less likely than other clini- 12 However, to date there has been no previous cians to use CESS. Paediatric clinical qualitative study of CESS in New Zealand. ethics typically require a different deci- Qualitative methods generate nuanced sion-making framework to that used in 13 data that allows in-depth exploration of adult medicine; as a result, some larger complex themes. We use the CEAG estab- centres overseas have developed separate 14 lished at Capital and Coast District Health paediatric clinical ethics committees. Board (CCDHB) in 2010 as a case study for an Within these parameters, we wanted in-depth qualitative investigation of the role heterogeneity, therefore recruitment was CESS can play in supporting ethical deci- limited to the first three volunteers from sion-making in New Zealand hospitals. The each sub-specialty. Interviews were guided CCDHB CEAG Terms of Reference identify by an 18-point questionnaire, with ques- two central purposes: tions grouped under four general headings: clinicians processes for ethical decisions • to provide a consultative, advisory making, ethical decision making in the and supportive mechanism to assist hospital, services provided by the CEAG, the healthcare professionals to make clinical ethics environment in New Zealand. informed ethical decisions in their Interviews were recorded and transcribed management of patients verbatim. ED coded the transcripts and ED • to facilitate education in the area of and AB analysed the results. We conducted ethics and to foster a culture of ethical an iterative inductive thematic analysis, awareness at CC DHB so as to equip whereby some emerging themes were inte- healthcare professionals with the grated into the interview template. The New means to approach ethical problems Zealand Central Regional Ethics Committee 10 and conflicts in clinical practice. approved the study (CEN/11/EXP/073). When a case is referred to the CEAG it is considered at their regularly scheduled Results monthly meeting or, in urgent cases, can Between 2011 and 2012 ED conducted be reviewed within 24 hours. The referring 14 interviews, ranging from 40 minutes–2 clinician provides relevant clinical and hours duration. All participants gave ethical details of the case. Patients and their written informed consent. Recruitment families are not informed that the case finished when data saturation was has been referred and are not involved reached. This is when no new broad over- with CEAG processes. The CEAG then has a arching themes were being revealed by closed session in which they discuss possible each subsequent interview set.15 Partic- approaches to managing the ethical issues. ipants’ clinical specialties are listed in CEAG members have access to patient Table 1. The four main themes relate to medical records if necessary. The CEAG awareness of the role of CCBDH CEAG, provides a formal non-binding opinion in comparison of informal ethics support to writing to the referring clinician. formal CESS, clinician involvement in CESS ethical deliberation and ethical deliber- Methods ation as a clinical responsibility. These We recruited participants by emailing are the key themes arising from the data, invitations to senior doctors. All senior and do not correlate exactly to the topic doctors at CCDHB were invited. We chose sections of the questionnaire. senior doctors because the culture of ethical

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Table 1: Specialties of participants (in alphabetical order). corridor consult; it requires a greater Endocrinology investment of time and energy on the Endocrinology and older adult medicine part of both the clinicians accessing the service and those volunteering to General medicine and infectious disease provide it. Participant 5 stated “[An Intensive care ethics committee is] a slow bloody organisation. For individuals it’s too Paediatrics slow...Where you’re dealing with Paediatrics/neonatology (2) policy and larger picture things, I think that’s where it works really well.” Neurosurgery (2) • the training of CEAG members in ethics Obstetrics and gynaecology is not necessarily greater than the senior colleagues that the doctor might Older adult medicine and palliative care otherwise consult, at least at present. Orthopaedic surgery • despite their diverse clinical back- Psychiatry grounds, members of the CEAG may not necessarily have the specific Renal medicine clinical expertise necessary to grasp the intricacies of the cases referred Awareness to them. Many participants were unaware or Participants described a range of barriers misinformed of the purpose of the CCDHB to accessing ethics support (whether CEAG. Two of the participants had referred informal or formal), which included a case to the CEAG (3 and 14) and four others isolation and a medical culture inhib- had been peripherally involved in such iting both help-seeking behaviours and cases (2, 6, 7 and 13). Participant 12 sits on constructive criticism. Interestingly, it the CEAG as a clinical representative. Most was common for participants to describe of the remaining participants had not heard their own team or specialty as supporting of the CEAG. Even among the clinicians who open non-judgmental ethical debate, but were aware of the CEAG, most did not have to assert that other specialties were less a clear understanding of its functions or receptive. Many clinicians emphasised how to access it, including clinicians who that the culture of medicine makes it very had already referred cases to the service. difficult to raise concerns about the practice Common misconceptions included whether of peers—particularly senior peers—and the advice provided by the CEAG was legally that this can be a barrier to dialogue about binding or whether accessing it obviated ethical issues. “In medicine we’re not the need for seeking medicolegal advice in very good at criticising people…The more instances where there were legal quandaries senior the person gets, the harder it is…” in addition to ethical ones. (11) Several participants reflected that they Comparing informal ethics support found seeking ethical advice as a junior to formal CESS doctor more challenging, and expressed Participants reported that the primary concern that the same barriers may exist source of ethical support available to for their junior colleagues today. Partici- doctors is informal, such as seeking the pants noted that junior staff, in addition to opinions of senior colleagues. Most partici- facing the inherent disadvantage of being pants reported feeling well-supported and less experienced, came up against cultural comfortable about seeking ethics support and systemic barriers to being able to seek from peers. Study participants raised three adequate support in managing ethical specific concerns about CEAG, reflecting concerns. “…going cap in hand to your boss their views that it would not provide and asking for advice on things like this is superior ethical support compared to their often perceived as a sign of weakness.” (9) existing informal mechanisms: Some participants felt that having formal • referring a case for consultation to the services might provide an additional avenue CEAG is more laborious than a quick for staff seeking ethics support.

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For participants, one of the most signif- sised that any model for ethics support must icant differences between ad-hoc support involve clinicians in the process if it was systems and using a formal ethics support to be accepted by the hospital community. service was that formal support is external Participant 1 pointed out that when clinicians to the group of people involved in patient were not involved, they did not learn from care. Several participants felt that the value the consultation process. “I think discussions, of the CEAG was that it could provide an which are iterative, would be a lot better.” objective sounding board in challenging Ethical decision-making as a cases, noting that at times maintaining perspective was difficult when one was clinical responsibility Some argued that ethical decision-making immersed in a case. Participant 4 argued is a clinical responsibility that should not be that seeking an independent ethical opinion abrogated. Others contended that accessing was a sign of appropriate, reflective ethics support has the potential to enhance practice. Participant 3 noted “My experience ethical decision-making and thus is a mark of it was it actually helped me to see the situ- of responsible practice. These views influ- ation from a slightly different perspective...I enced participants’ perspectives of the value found it empowering...rather than stripping of clinical ethics support. me of my clinical autonomy.” Conversely, other participants expressed concern that All clinicians expressed the view that an external ethics advisory group would clinical ethics is a core competency for any be out-of-touch with the specific clinical doctor. Some felt that to “outsource” ethical realities that contextualise ethical decisions decision-making to a CESS is to remove the in medicine. Participant 5 stated that “if decision-making role from the individual you’re working in a very specialised area of who a) has a professional obligation to practice, the ethics of what you’re dealing fulfil that role and b) is in the best position with rotates extremely strongly around to make that decision, by virtue of their knowledge of the topic or the clinical area expertise in the given field of practice. Some with which you’re grappling.” participants expressed concern that a CESS may be making unreasonable claims to Many participants believed an ethics moral authority by offering to solve clinical support service should enhance ethical ethical problems. Participant 8 stated that capacity of the clinical workforce. These there was no reason the CEAG should be participants felt that services should help any better at making ethical decisions clinicians attain a degree of ethical compe- than a well-trained, experienced group of tence such that external ethical consultation health care professionals from a range of was required only in exceptional circum- backgrounds. “…If we cannot come to the stances. Participants offered their conclusion altogether, who else could come perspectives on the role a CESS might play back and tell us, “Oh, this is exactly the way in providing or supporting ethics education. to go?” However, participant 2 suggested Key ideas were that ethics education needed that the role of the doctor as the ultimate to be practical and integrated into the decision-maker did not preclude the workplace and that it needed to break down involvement of a CESS, but rather imposed cultural barriers to open ethical discourse. parameters on it. “An ethicist…can help Clinician involvement in CESS define the problem but at the end of the day ethical deliberation it’s still going to be a clinician’s decision.” (2) Many participants were concerned that Summary referring clinicians are shut out from the Clinicians held a broad spectrum of views process of ethical deliberation at CEAG. about the value of clinical ethic support Participant 7 said he felt concerned with the services. There was, however, consensus lack of transparency when he was involved on the importance of clinical ethics to the in referring a case to the CEAG. “I presented medical profession, which has been further my case, but then the rest of the stuff was reinforced by the HQSC backing efforts held behind closed doors. And you want to to ensure CESS are available to clinicians be involved in that discussion...it shouldn’t nationwide. The practical considerations be secretive—which it isn’t—but that’s what in the provision of clinical ethics support it feels like.” Several participants empha-

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are indicative of the environment in which Only a handful of participants had direct doctors have to make ethical decisions: they experience with the CESS, but all partic- are often under stress and time pressure ipants had at some stage used informal and they know that they will bear respon- mechanisms, such as peer consultation, to sibility for clinical outcomes. Participants help resolve ethical issues. Some partici- took their ethical responsibilities as doctors pants seemed to assume that formal CESS seriously and wanted to feel better equipped were intended to serve as a substitute for to manage them. these and found this problematic, arguing that the mechanisms of a formal CESS were Discussion too unwieldy to be used for the multitude of day-to-day ethical issues faced. This echoes Our key findings were that within CCDHB the findings of DuVal et al and Førde et al we found some common misconceptions that doctors perceive the time consumed by about the role of CESS, that clinicians were accessing formal ethics support to be a major wary of giving up decision making capacity barrier to accessing services.17,20 However, in difficult ethical cases and that clinicians CESS are not a substitute for clinician compe- wanted CESS to improve general ethical tence in managing ethical issues. There are reasoning capacity among staff. Our study two things that a CESS should be able to offer suggests that support services should work clinicians that informal systems cannot. within the pace and complexity of clinical The first is a just, independent process of realities if they are to be accepted by resolving ethical dilemmas that uses a trans- doctors as a useful tool for medical practice parent and systematic approach to ethical in New Zealand. deliberation. The second is an opportunity International literature reveals that for education and professional development clinician perceptions of what CESS can offer in managing ethical issues. determine how likely they are to engage Some clinicians were reluctant to refer with services.12,16–18 Much of the wariness cases because they felt this amounted expressed about the CEAG by participants in to relinquishing autonomy over deci- this study was fuelled by misunderstandings sion-making while retaining accountability about what the CEAG does or claims to do. for patient outcomes. Even participants who Our research suggests that efforts to dissem- recognised that the clinical ethics consul- inate accurate information about the role tation is advisory in nature, stated that they and procedures of CESS may lead to wider would feel compelled to follow CEAG advice. uptake of their services. However, we also Our research shows this is a major barrier note that some DHBs in New Zealand do to accessing clinical ethics consultation. This not have access to a CESS, and that at other corroborates studies from other jurisdic- DHBs a CESSs may exist on paper but may tions. Davies and Hudson identified that not be currently active. Some misunder- among clinicians who were most resistant standing is to be expected given that the to accessing ethics support services, their formal ethics support service had only been main concern was that they felt devolving in place at CCDHB for two years at the time decision-making to a third party was an of the research. Some clinicians’ misgivings unacceptable abdication of clinical responsi- stemmed from the fact that in New Zealand bility.16 Conversely, Orlowski et al found that CESS are in their infancy, largely being doctors most likely to refer cases for ethics composed of volunteers, many of whom lack consultation were also most likely to be the formal qualifications or training in ethics. In clinicians who perceived ethical decision addition, many CESS are still in the process making to be a shared responsibility.12 Clini- of establishing formal procedural guidelines cians in our study recognised that they are even as they begin to accept and consult accountable for their clinical decisions irre- on their first clinical cases. The dearth of spective of how the decision was made. formal curricula to train and accredit CESS has been identified internationally as a Clinician involvement in CESS processes problem and research and funding has been would have three advantages. The first is increasingly devoted to developing quality that clinician participation would improve assurance mechanisms such as formal quali- the transparency of ethical deliberation, fications and evaluation processes.19 promoting clinician trust in the procedures

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and, as such, their buy-in to the outcomes. to manage ethical issues. Not all doctors felt The second benefit is that where clinicians equally able to access informal support and are given the opportunity to be involved in junior doctors may face additional barriers. deliberation, it becomes an educative expe- Many participants were unaware that rience that equips them with the knowledge formal clinical ethics support was available and skills to better address ethical issues to them at CCDHB and most did not know arising in the future. An ethics support how formal ethics support worked. Some model that offers ethical reasoning skills participants felt that to seek case consul- to referring clinicians could enhance the tation was to abrogate clinical responsibility ethical culture of the institution as a whole. and thought that doctors should be able Third, involving doctors in deliberation to manage ethical issues themselves. The quells concerns that the ethics committee concerns identified through our research may not understand the clinical nuances of do not present immutable obstacles to CESS. the cases concerned, by providing a forum Rather, this feedback gives fledgling support in which the referrer brings that expertise services the chance to optimise services to the table. This would be in line with to maximise their utility to clinicians. research ethics review in New Zealand Emerging CESS in New Zealand should: where researchers are invited to listen to the 1. actively disseminate information committee’s discussion of their protocol. about their aims and processes to There are several limitations to the study. clinicians to enhance transparency We interviewed only senior doctors. Future and to clarify misunderstandings research should investigate the views of about their role junior doctors, who face a unique set of 2. involve clinicians in the process of challenges in managing ethical issues, in case consultation to increase user particular shaped by hierarchical medical trust and to take advantage of the culture, and the pressure of juggling educative value of case consultation training requirements and strenuous on-call 3. conduct monitoring and evaluation of demands. Future research should also the service to ensure that it achieves investigate the needs and views of other and maintains clinical relevance. health professionals at the hospital such as nurses. A second limitation is the relatively At a time when CESS in New Zealand are small pool of participants from a single DHB. in their infancy, this study offers a unique Given New Zealand’s small and close-knit insight into the culture of clinical ethical medical community, it may well be the decision making in CCDHB. Given the case that similar cultures of ethical deci- close-knit nature of the New Zealand medical sion-making exist in other regions. Further community and the movement of staff research is needed to establish this, but our between District Health Boards, the findings study suggests some potential challenges are likely to have relevance to emerging CESS that may exist for newly established CESS in throughout New Zealand. Our study indicates other areas of the country. key areas of perceived strengths and weak- nesses of the existing clinical support services that could inform ongoing evaluation and Conclusion restructuring of the services to better tailor Doctors in our study reported primarily them to clinician needs. using ad hoc strategies of peer consultation

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Competing interests: Dr Dai reports a grant from Maurice and Phyllis Paykel Trust during the conduct of the study. Acknowledgements: We would like to thank all the doctors who shared their time and their views; Mr Alastair Macdonald (Founding Chair of the CCDHB CEAG) whose input and advice during the course of the research has been most valuable; Dr Maria Stubbe for her excellent advice on qual- itative research methods; and Prof Wendy Rogers, Dr Lynn McBain and the anonymous BMedSci thesis examiners for their constructive comments on previous versions. Author information: Angela Ballantyne, Department of Primary Health Care and General Practice, University of Otago Wellington, Wellington; Elizabeth Dai, Department of Paediatrics, Whangarei Hospi- tal, New Zealand. Corresponding author: Dr Angela Ballantyne, Department of Primary Health Care and General Practice, University of Otago Wellington, Mein St, Wellington. [email protected] URL: https://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2016/vol-129-no- 1441-9-september-2016/6995

REFERENCES: 1. Slowther A, Johnston C, 4. Reiter-Theil, Stella, Agich 8. Dare T. (2010). Clinical Goodall J, Hope T. (2004). A GJ (2008). Research Ethics Committees. Practical Guide for Clinical on clinical ethics and Health Research Council Ethics Support. Oxford: UK consultation. Introduction of New Zealand: Ethics Clinical Ethics Network. to the theme. Medicine, Notes, (August). Available Retrieved from http:// Health Care and Philoso- at http://www.adhb. www.ukcen.net/index. phy, 11; 3–5. doi:10.1007/ govt.nz/ceag/articles/ php/education_resources/ s11019007-9095-x Ethics%20Notes%20-%20 support_guide 5. Slowther A, Johnston August%20201038.pdf 2. Dubler NN, Webber MP, C, Goodall J, Hope T. 9. Pinnock R, Crosthwaite Swiderski DM (2009). (2004). Development of J. (2004). The Auckland Charting the future. clinical ethics commit- Hospital Ethics Committee: Credentialing, privileging, tees. British Medical The first 7 years. The quality, and evaluation Journal, 328; 950–952. New Zealand Medical in clinical ethics consul- Retrieved from http:// Journal, 117(1205). tation. Hastings Center www.ncbi.nlm.nih.gov/ 10. Terms of Reference - Report, 39(6); 23–33. pmc/articles/PMC390221 Capital and Coast District Retrieved from http:// 6. Terry LM, Sanders K. Health Board Clinical ovidsp.ovid.com/ovidweb. (2011). Best practices in Ethics Advisory Group. cgi?T=JS&CSC=Y&NEWS= clinical ethics consultation (2011). The Terms of N&PAGE=fulltext&D= and decision making: Reference were updated in medl&AN=2005 0368 conference report. Clinical 2014 and CEAG policy now 3. Godkin MD, Faith K, Ethics, 6(2); 103–108. includes an expectation Upshur REG, Macrae SK, 7. Kälvemark S, Höglund that the referring clinician Tracy CS (2005). Project AT, Hansson MG, Wester- will have advised the examining effectiveness holm P, Arnetz B. (2004). patient that ethics advice in clinical ethics (PEECE): Living with conflicts is being sought. Actual phase 1-- descriptive -ethical dilemmas and contact between CEAG analysis of nine clinical moral distress in the and patients may happen ethics services. Journal health care system. Social on a case by-case basis. of Medical Ethics, 31(9), Science & Medicine, 58; (Personal communica- 505–12. doi:10.1136/ 1075–1084. doi:10.1016/ tion Hazel Irvine, Chair jme.2004.010595 S0277-9536(03)00279-X. CEAG, CCDHB, 2016).

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11. Patton MQ (2002). Qualita- the newborn intensive 18. Kadioğlu FG, Can R, tive Research & Evaluation care unit. Journal of Okuyaz S, Oner Yalçin Methods (3rd ed., p. 598). Perinatology, 31; 1–9. S, Kadioğlu NS (2011). Thousand Oaks, California: 15. Guest G, Bunce A, Physicians’ attitudes Sage Publications Inc. Johnson L. (2006). How toward clinical ethics 12. Orlowski JP, Hein S, Many Interviews Are consultation: a research Christensen JA, Meinke Enough? An Experiment study from Turkey Turk J R, Sincich T. (2006). Why with Data Saturation Med Sci. 41 (6): 1081–1090. doctors use or do not and Variability. Field 19. Dubler NN, Webber MP, use ethics consultation. Methods, 18(1); 59–82. Swiderski DM. (2009) Journal of Medical Ethics, doi:10.1177/1525822X Charting the future. 32; 499–502. doi:10.1136/ 05279903 Credentialing, pt priv- jme.2005.014464 16. Davies L, Hudson ileging, quality, and 13. Lyren A, Ford PJ (2007). LD. (1999) Why don’t evaluation in clinical Special considerations physicians use ethics ethics consultation. for clinical ethics consul- consultation? J Clin Hastings Center Report. tation in pediatrics: Ethics. 10(2):116–25. 39 (6) 23–33 pediatric care provider 17. Førde R, Pedersen R, 20. DuVal G, Sartorius L, as advocate. Clinical Akre V. (2008). Clinicians’ Clarridge B, Gensler G, pediatrics, 46(9); 771–776. evaluation of clinical Danis M. (2001) What doi:10.1177/0009922 ethics consultations in triggers requests for ethics 807304148 Norway: a qualitative consultations? J Med 14. Mercurio MR (2011). study. Med Health Care Ethics. 27 Suppl1:i24–9. The role of a pediatric Philos. 11(1):17–25. ethics committee in

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Socioeconomic correlates of quality of life for non- Māori in advanced age: Te Puāwaitanga o Nga Tapuwae Kia ora Tonu. Life and Living in Advanced Age: a Cohort Study in New Zealand (LiLACS NZ) Ngaire Kerse, Ruth Teh, Simon A Moyes, Lorna Dyall, Janine L Wiles, Mere Kepa, Carol Wham, Karen J Hayman, Martin Connolly, Tim Wilkinson, Valerie Wright-St Clair, Sally Keeling, Joanna B Broad, Santosh Jatrana, Thomas Lumley

ABSTRACT Aim: To establish socioeconomic and cultural profiles and correlates of quality of life (QoL) in non-Māori of advanced age. Method: A cross sectional analysis of the baseline data of a cohort study of 516 non-Māori aged 85 years living in the Bay of Plenty and Rotorua areas of New Zealand. Socioeconomic and cultural characteristics were established by face-to-face interviews in 2010. Health-related QoL (HRQoL) was assessed with the SF-12. Results: Of the 516 non-Māori participants enrolled in the study, 89% identified as New Zealand European, 10% other European, 1% were of Pacific, Asian or Middle Eastern ethnicity; 20% were born overseas and half of these identified as ‘New Zealand European.’ More men were married (59%) and more women lived alone (63%). While 89% owned their own home, 30% received only the New Zealand Superannuation as income and 22% reported that they had ‘just enough to get along on’. More than 85% reported that they had sufficient practical and emotional support; 11% and 6% reported unmet need for practical and emotional support respectively. Multivariate analyses showed that those with unmet needs for practical and emotional support had lower mental HR QoL (p<0.005). Reporting that family were important to wellbeing was associated with higher mental HR QoL (p=0.038). Those that did not need practical help (p=0.047) and those that reported feeling comfortable with their money situation (0.0191) had higher physical HRQoL. High functional status was strongly associated with both high mental and high physical HR QoL (p<0.001). Conclusion: Among our sample of non-Māori people of advanced age, those with unmet support needs reported low HRQoL. Functional status was most strongly associated with mental and physical HRQoL.

The demographic ageing of the New capita public expenditure mostly on health Zealand population is most marked for those and disability support.8 Knowing more in advanced age (85 years and over) as this about the health, cultural profile and social population group will increase six-fold by status of those in advanced age will help 2050.1 Older people contribute to society health planners, society, families and older in many ways and valued contributions people prepare for the projected increase in continue into advanced age.2–7 Those in those of advanced age. advanced age also utilise the highest per

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The life in years (quality of life), rather elsewhere.24,25 Eligibility included living than years of life (quantity of life), may in the geographic boundaries of the Bay be particularly relevant for older people, of Plenty District Health Board and Lakes thus quality of life (QoL) is the topic of this District Health Board (excluding Taupo paper. Those in advanced age may have region) of the North Island of New Zealand, higher life satisfaction than the younger and being born in the calendar year of old9 and certain factors including social 1925. A comprehensive list of all persons in support are more important to QoL for the the age group was compiled from the New very old than for younger age groups.10 Zealand General Electoral Roll, primary Economic resources,11 cannot be ignored health care databases, residential care and there is a complex interaction between lists and word of mouth. Participants were economic hardships and social supports.12 recruited by personal invitation from their In New Zealand the material wellbeing general practitioner, a person known to of older people has been examined13 and them or by a letter from The University of qualitative research has outlined contribu- Auckland. Those interested were visited tions to QoL.14,15 Stephens et al described or telephoned by a researcher and they or associations between more and stronger a family member gave written informed age-related social networks and higher consent. Ethical approval for this study was wellbeing16 in those aged 55–70 than was given by the Northern X Regional Ethics found for younger cohorts. Other research Committee NXT09/09/88. explores the social context of ageing in A comprehensive baseline assessment New Zealand,17,18 but there is a lack of was undertaken to assess the health, social, specific information about the octoge- economic, cultural and physical status of narian population. Culture, beliefs and participants25 and is briefly summarised religion also influence successful ageing.19 here. In this paper socio-demographic infor- It is known that social relationships mation, family contact and support, and sustain wellbeing, prevent depression,20 cultural practices are reported along with aid longevity,21 and interconnect with the main outcome of HRQoL. economic wellbeing in complex ways. Demographic information: age, gender, A better understanding of the current marital status, type of house, home amount and type of social support for ownership, education, living arrangement, those in advanced age is needed. main lifetime occupation of participant and Te Puāwaitanga o Nga Tapuwae Kia ora partner, religion and income data were Tonu, Life and Living in Advanced Age: gathered using standardised questions. a Cohort Study in New Zealand, (LiLACS Self-perceived economic wellbeing was NZ) was funded to describe the health, assessed with the question: social and cultural status and to identify • Thinking of your money situation predictors of successful advanced ageing of right now, would you say: I can’t Māori and non-Māori. In acknowledgement make ends meet, I have just enough 22 of the disparity in longevity for Māori and to get along on, or I am comfortable? the need for equal explanatory power to Socioeconomic deprivation related to establish predictors, two inception cohorts their residential address at the time of were recruited in 2010; Māori aged 80–90 interview was achieved by the geocoded years (a birth decade) and non-Māori aged New Zealand Deprivation Index (NZDep).26 85 years (a single year birth cohort). Ethnicity was self-identified using the This paper presents the demographic, 2001 NZ census question27 and where social and cultural characteristics and aims several ethnicities were identified New to identify correlates of health-related Zealand European was prioritised over QOL (HRQoL) for the non-Māori cohort. A ‘other European’. Where very small companion paper reports the Māori data.23 numbers were reported they were grouped for analysis. Methods Size of family, number of living children The detail of LiLACS NZ recruitment and and number of grandchildren was recorded. assessment schedule has been described

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Social support was assessed using the • Satisfaction with those roles approach from the MacArthur studies28 (extremely to not at all) with these questions with a yes or no • The importance of family to well- response: being (extremely to not at all) • When you need extra help, can you • Importance of faith to wellbeing count on anyone to help with daily (extremely to not at all) tasks like grocery shopping, cooking, All participants were asked about discrim- house cleaning, telephoning, give you ination using standard questions from the a ride? 2006/2007 New Zealand Health Survey30 • In the last year who has been the • Have you ever been the victim of an most helpful with these daily tasks? ethnically motivated attack in New • Could you have used more help with Zealand? (verbal or physical; further daily tasks than you received? ago or within 12 months) • Can you count on anyone to provide • Have you ever been treated unfairly you with emotional support? by a service agency (eg WINZ) • In the last year who has been most because of your ethnicity in New helpful in providing you with Zealand? emotional support? • Have you ever been treated unfairly • Could you have used more emotional when renting or buying housing support than you received? because of your ethnicity in New Questions about culture asked of all Zealand? participants were based on a measure • Have you ever been treated unfairly developed in New Zealand29 and by by a health professional because of Te RōpūKaitiaki o ngā tikanga Māori your ethnicity in New Zealand? (Protectors of principles of conduct in Māori Discrimination questions were collapsed research in LiLACS NZ), a cultural guidance into 'ever' vs 'never experienced' and governance group gathered together discrimination. for LiLACS NZ: HRQoL was assessed with the SF-12 • Do you live in the same area as your Version 2® including the summary scores Hapū (Māori term for extended for physical and mental HRQoL.31 Scores family)/extended family/where you vary between 0 (worst health/QoL) and 100 come from? (best health/QoL) with a mean score of 50. • Have you ever been to a marae The Nottingham Extended Activities of Daily (sacred Māori meeting place) at all? Living (NEADL) was used to assess func- 32 • How often in the last year have you tional status. Scores range from 0 to 22 been to a marae? with higher being better. • In general, would you say that your The questionnaire was undertaken with contacts are with: mainly Māori, the participant by trained lay and nurse some Māori, few Māori, no Māori? interviewers using standardised tech- niques and took a minimum of two hours. • Could you have a conversation about For some participants two or more visits a lot of everyday things in Māori or were required for full completion. Each another language? completed questionnaire was quality • How important is your language and checked by two different coordinators, and culture to your wellbeing? any queries referred back to the inter- Questions about life roles and the viewer for rectification and contact with the importance of aspects of life to wellbeing participant if required. were asked: Analyses. Descriptive statistics showed • Roles within the whānau and family status of participants on demographic, (Yes, No) social, economic and cultural variables. • Role within the community and Generalised linear models or the Cochran- neighbourhood (Yes, No) Mantel-Haenszel test were used to compare status by gender as appropriate.

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Functional status was a priori selected Socio-demographic and economic as being known to be highly correlated characteristics with HRQoL, and HRQoL differed Table 1 provides an overview of the between genders. Gender and functional socio-demographic and economic charac- status (NEADL score) were considered teristics of the sample. About 80% were confounding variables. Each variable in born in New Zealand and half of those Tables 1, 2 and 3 was tested against mental born overseas identified as New Zealand HRQoL and physical HRQoL adjusting for European. Other countries of birth included: gender and functional status in a ‘brief Australia (4), England (including northern model’. For those variables showing a Ireland, 58), Scotland (12), Ireland or significance of p<0.1 models were further Wales (3), Netherlands (7), Other Central or adjusted for the early life socioeconomic Western European countries (6), Indonesia status (SES) marker of highest education (3), Sri Lanka, Japan, Fiji, Canada or Brazil level, midlife marker of main family (6). Self-identified ethnicity for non-Māori occupation ascertained by the higher occu- consists of those who identified as New pational status of participant or lifetime Zealand European (89%), other European partner, and current SES marker reflected (10%), and ‘other’ being Pacific (3), Asian, by perceived economic wellbeing in a ‘full Middle Eastern or South African (4). model’. Adjusted means are presented for the models. Interactions between gender More men were married (59% cf 24% of and marital status and gender and living women, p<0.001) and more women were arrangement were explored. living alone (63% cf 32% of men, p<0.001) with 32 (15%) women living with others and 12 (6%) women living in residential aged Results care. Overall, 4% had never married and Of all eligible non-Māori available in 5% had no children. the study area, 59% (516 participants) Most (89%) owned their own home and agreed to participate. All completed a income from non-New Zealand Super- core set of questions (shown in Tables annuation (NZS) sources included other 1 & 2 with shading) and 404 completed superannuation (eg workplace schemes) the full questionnaire with additional 11%, other pensions 12%, investments questions expanding on the core set, one 50%, with less than 5% receiving income participant did not complete the question- from salary and wages, tribal land trusts or naire because of change of mind. Those inheritance. completing the full questionnaire differed from those completing only the core. Table 2 shows social support, impor- Firstly core questionnaire participants tance of faith, QoL and functional status. were more likely to be living in residential Religious affiliation was recorded with 68 care 24/111 (22%) of core respondents (17%) reporting no religion (not in Table) were in residential care and 23/404 (3%) and 13% reporting that faith was not at all of those completing the full question- important to their wellbeing. No non-Māori naire were in residential care) (p<0.001). participated in Māori faith. ‘Other’ religions Secondly core questionnaire respondents included Baptist (11), Christian (8), open were more likely to have the question- Brethren (3), Salvation army (4), Seventh naire completed by a proxy 17/111 (15%) of Day Adventist, Jehovah’s Witness, Prot- those completing the core questions were estant and Pentecostal (2 each). Four did not represented by a proxy and 16/404 (4%) answer the question about religion and one of those completing the full questionnaire each reported religion as: all encompassing, were represented by a proxy) (p<0.0001). belief in the creator, interdenomina- Thirdly, core respondents were more tional, Liberal Christian, non-conformist, likely to be dependent in personal care, non-denominational, Spiritual Church, and toileting, getting in and out of bed, making Theosophical Society. a hot drink, doing shopping and using the Social support was reported as present by phone (p<0.001 on each). most with 20% of men reporting that they

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Table 1: Socio-demographic, economic and family makeup characteristics of non-Māori aged 85 years in LiLACS NZ.

Men Women Total

All participants—core interview 237 (46%) 278 (54%) 515 Full interview completed 190 (47%) 214 (53%) 404

Age, mean (sd) 84.6 (0.5) 84.6 (0.5) 84.6 (0.5)

Country of birth, n (%) Born in NZ 185 (78) 229 (82) 414 (80) Born Overseas 52 (22) 49 (18) 101 (20)

Ethnicity, n (%) NZ European 213 (89) 251 (90) 462 (89) Other European 23 (10) 22 (8) 45 (10) Other (Pacific, Asian, Middle Eastern) 2 (1) 5 (2) 7 (1)

Childhood family size, mean (sd) Total family size 4.6 (2.8) 4.3 (2.6) 4.4 (2.7) Sisters 1.7 (1.6) 1.6 (1.7) 1.7 (1.7) Brothers 1.8 (1.8) 1.7 (1.6) 1.8 (1.7) Sisters still living 0.8 (1.0) 0.6 (0.8) 0.7 (0.9) Brothers still living 0.6 (0.9) 0.5 (0.9) 0.6 (0.9)

Marital status, n (%) Never married 10 (4) 8 (3) 18 (4) Widowed 73 (31) 184 (67) 257 (50) Divorced 14 (6) 17 (6) 31 (6) Married/ partnered 137 (59) 67 (24) 204 (40)*

Number living children, n (%) None 11 (6) 9 (4) 20 (5) 1–3 115 (61) 135 (63) 250 (62) 4–6 62 (33) 69 (32) 131 (33) Number grandchildren, mean (sd) 7 (6.3) 7.2 (5.3) 7.1 (5.8)

Living arrangement, n (%) Alone 61 (32) 134 (63) 195 (48)* With spouse 106 (56) 48 (22) 154 (38) With other 23 (12) 32 (15) 55 (14) If with other average number in house, mean (sd) 2.4 (1.0) 2.9 (1.2) 2.7 (1.2)

Type of house, n (%) Stand alone house 115 (61) 121 (57) 236 (59) Unit/apt 26 (14) 33 (15) 60 (15) Retirement village 35 (19) 39 (18) 74 (18) Residential care 9 (4) 15 (6) 23 (5) Other 5 (3) 6 (4) 11 (4)

Home ownership, n (%) Owns own home outright 155 (89) 170 (90) 325 (89) Rental 20 (11) 20 (11) 40 (11)

Deprivation, NZDep area score, n (%) 1–4 Low 34 (14) 41 (15) 75 (15) 5–7 Med 123 (52) 146 (53) 269 (52) 8–10 High 80 (34) 91 (33) 171 (33)

Income, n (%) NZ Superannuation (NZS) only 49 (26) 69 (32) 118 (30) Other income as well as NZS 137 (74) 144 (68) 281 (70)

Main family occupation§, n (%) Professionals 93 (39) 107 (38) 200 (39) Technicians 38 (16) 49 (18) 87 (17) Clerks 106 (45) 122 (44) 228 (44)

Thinking for your money situation right now—(%) Can’t make ends meet 2 (1) 0 2 (.5) Just enough 38 (20) 49 (23) 87 (22) I am comfortable 149 (79) 163 (77) 312 (78)

Education, n (%) Tertiary 38 (16) 30 (11) 68 (13) Trade 26 (11) 34 (13) 60 (12) Any secondary 125 (54) 170 (62) 295 (58) Primary only or none 44 (19) 39 (14) 83 (16)

Shaded items show core questions included in the core interview answered by all and unshaded are questions in the full interview. Childhood family size is siblings only, not including parents. §Professional: -Legislators, Administrators, Professionals, Agricultural and Fishery Workers Technicians:- technicians, Associate Professionals and Trades Workers Non-technical :- Clerks, Service Workers, Sales Workers, Plant/Machine Operators, Assemblers, Elementary Workers. * significant difference between men and women p<0.05

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Table 2: Social support, importance of faith, QoL and functional status of LiLACS NZ non-Māori participants.

Men Women Total

Full interview completed 190 (47%) 214 (53%) 404

Religion, n (%) Anglican 59 (41) 78 (42) 137 (41) Catholic 14 (10) 19 (10) 33 (10) Presbyterian 43 (30) 53 (28) 96 (29) Methodist 6 (4) 12 (6) 18 (5) Other 22 (15) 26 (14) 48 (15)

Importance of faith to your wellbeing, n (%) Not at all 33 (18) 19 (9) 52 (13) A little 13 (7) 16 (8) 29 (7) Moderately 39 (21) 40 (19) 79 (20) Very 67 (36) 86 (41) 153 (39) Extremely 32 (17) 51 (24) 83 (21)

Anyone to help with daily tasks? n (%) Yes 145 (77) 175 (83) 320 (80) No 6 (3) 11 (5) 17 (4) I don’t need help 37 (20) 25 (12) 62 (16)

Who has been the most helpful? n (%) Spouse 65 (43) 34 (19) 99 (30) Daughter 23 (15) 61 (35) 84 (26) Son 10 (7) 22 (13) 32 (10) Other relative 7 (5) 7 (4) 14 (4) Other 48 (31) 51 (29) 99 (30)

Could have used more practical help? n (%) Yes 14 (8) 28 (14) 42 (11)

Count on anyone to provide emotional support? n (%) No 7 (4) 14 (7) 21 (5) Yes 142 (76) 177 (85) 319 (81) I don’t need emotional support 37 (20) 17 (8) 54 (14)

Who most helpful? n (%) Spouse 78 (55) 30 (18) 108 (35) Daughter 22 (16) 68 (40) 90 (29) Son 15 (11) 24 (14) 39 (13) Other relative 5 (4) 10 (6) 15 (5) Other 21 (15) 39 (23) 60 (19)

Could have used more emotional support? n (%) Yes 7 (4) 15 (7) 22 (6)

*** difference between men and women p<0.001 NEADL Nottingham Extended Activity of Daily Living scale. QoL = quality of life.—a higher score means better QoL, range 0–100.

did not need help. A daughter was the main men (p=0.005). Mental HRQoL was slightly support for women and the spouse for men higher than physical HRQoL, and was for both practical and emotional support. similar in men and women. Thirty and 19% of non-Māori received prac- Functional status was similar between tical and emotional support, respectively, men and women and varied according from ‘others’ which included formal paid to living arrangement. Those living with support workers, 14% of women and 8% of others, including those in residential care, men (p=0.051) reported an unmet need for had the lowest NEADL scores with a mean practical help. of 13.1 (sd 7.0) compared with means of Function and QoL 17.9 (sd 3.0) for those living with their Table 2 shows a mean score of 41 for spouse and 18.7 (sd 2.6) for those living physical HRQoL which indicates that HRQoL alone (p<0.001). Neither physical HRQoL nor is below the mean for a standard older mental HRQoL varied by living arrangement population33 and was higher (better) in when adjusted for SES and functional status.

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Table 3: Socio-cultural characteristics of LiLACS NZ non-Māori participants.

Men Women Total All participants—core interview, n (%) 237 (46%) 278 (54%) 515 Full interview completed, n (%) 190 (47%) 214 (53%) 404

Do you live in the same area as your hāpu/ extended family/ No 219 (93) 247 (89) 466 (91) where you come from? Yes 16 (7) 29 (11) 45 (9)

Have you ever been to a marae at all? No 51 (27) 74 (35) 125 (31) Yes 139 (73) 138 (65) 277 (69)

How often in the last 12 months have you been to a marae? Less than yearly* 156 (82) 193 (91) 349 (87) Once 26 (14) 15 (7) 41 (10) A few times 5 (3) 3 (1) 8 (2) Several times, more 3 (2) 1 (0) 4 (1) than monthly

Are your contacts with Mainly Māori 1 (1) 2 (1) 3 (1) Some Māori 51 (27) 71 (33) 122 (30) Few/no Māori 137 (72) 140 (66) 277 (69)

Importance of language and culture to wellbeing Not at all/moderately 64 (35) 70 (33) 134 (34) Very 103 (56) 120 (56) 223 (56) Extremely 17 (9) 23 (11) 40 (10)

Importance of family to wellbeing Not at all/moderately 27 (15) 13 (6) 40 (10) Very 105 (56) 105 (49) 210 (53) Extremely 54 (29) 95 (45) 149 (37)

Specific role in local community/ neighbourhood No 160 (85) 177 (83) 337 (84) Yes 29 (15) 35 (17) 64 (16)

How satisfied with role in local Not at all/moderately 9 (29) 7 (20) 16 (24) community/neighbourhood? Very 18 (58) 25 (71) 43 (65) Extremely 4 (13) 3 (9) 7 (11)

Do you have a specific role in your family? No 75 (40) 69 (33) 144 (36) Yes 113 (60) 141 (67) 254 (64)

Satisfaction with role in your family? Not at all/moderately 11 (10) 14 (10) 25 (10) Very 88 (77) 100 (70) 188 (73) Extremely 15 (13) 29 (20) 44 (17)

Discriminated against ever, combined1 No 176 (93) 190 (90) 366 (91) Yes 13 (7) 22 (10) 35 (9)

Physical health-related QoL (SF-12®), mean (sd) 43.0 (11.9) 39.7 (12.0) 41.3 (12.0)*** Mental helath-related QoL (SF-12®), mean (sd) 55.2 (7.9) 54.9 (8.7) 55.1 (8.3) Functional status (NEADL, higher is better), mean (sd) 17.7 (3.7) 17.6 (4.3) 17.6 (4.0) The 15 question Geriatric Depression Scale, (GDS-15, higher 2.26 (2.1) 2.13 (1.8) 2.19 (2.0) is worse), mean (sd)

1 Any positive response to any of the discrimination questions. QoL—Quality of Life * includes never been to a marae *** significant difference between men and women, p<0.001 Just under a third of non-Māori in More women reported that family were advanced age had mainly or some Māori extremely important to their wellbeing contacts (Table 3). While the majority (69%) (45%) than men (29%, p=0.001) and two had been to a marae, few (14%) had been thirds of the cohort reported that language once or more in the last year. and culture were very or extremely Only 9% lived in the area of their important to their wellbeing. extended family where they had grown up.

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Table 4: Characteristics of socioeconomic status associated with physical HRQoL.

Full interview completed n=404 Adj mean Brief model* Adj mean Full model** Independent variable of interest Physical HRQoL (CI) F-test (p) Physical HRQoL (CI) F-test (p)

1. Living arrangement Alone 40.1 (38.5–41.7) 3.08 (0.047) 37.1 (30–44.2) 2.39 (0.093) With spouse 42.1 (40.4–43.9) 38.6 (31.2–45.9) With other 44.5 (41.2–47.8) 41.2 (33.2–49.1)

2. Residence Type House 41.7 (40.4–43.1) 3.52 (0.008) 35.3 (27.9–42.8) 3.56 (0.007) Unit/ Apartment 41.1 (38.4–43.9) 35 (27.2–42.7) Retirement Village 40.1 (37.7–42.5) 33.5 (25.9–41.1) Residential care 50 (43.2–56.9) 44.6 (36–53.2) Other 34.5 (28.9–40) 28.9 (19.9–37.9)

3. NZ deprivation index Low 1–4 42.7 (40.6–44.9) 2.36 (0.096) 38.4 (31–45.8) 1.82 (0.163) Mod 5–7 41.9 (40.2–43.5) 38 (30.8–45.2) Hi 8–10 39.8 (37.9–41.6) 35.9 (28.8–43.1)

4. Main family occupation Professionals 42.8 (41.3–44.3) 3.41 (0.034) 38.9 (31.8–46) 1.88 (0.155) Technicians 39.8 (37.5–42.1) 36.7 (29.2–44.1) Clerks 40.1 (38.2–42.1) 36.8 (29.4–44.1)

5. Thinking of your money Can't make ends 30.2 (9.3–51.1) 4.60 (0.011) 31.3 (10.4–52.2) 4.00 situation, would you say? meet 38.5 (36.3–40.8) 38.7 (36.3–41.2) (0.019) Just enough 42.2 (41–43.4) 42.3 (40.8–43.8) Comfortable

6. Anyone to help with daily No 38.8 (33.7–43.9) 2.83 (0.060) 35.1 (26.5–43.7) 3.08 (0.047) tasks? Yes 41 (39.8–42.2) 37.3 (30.2–44.4) I don’t need help 44.2 (41.5–47) 40.7 (33.1–48.3)

7. Importance of family to Not at all/moderately 45 (41.6–48.5) 2.82 (0.062) 41.7 (33.8–49.5) 2.95 (0.054) wellbeing Very 40.6 (39.1–42) 37.1 (30–44.2) Extremely 41.8 (40–43.5) 37.9 (30.6–45.2)

8. Satisfaction with role in Not at all/moderately 37.2 (31.6–42.7) 4.09 (0.048) 35.2 (29.2–41.3) 5.65 (0.021) community Very/extremely 43.6 (40.5–46.7) 43.3 (38.6–48.1)

9. Satisfaction with role in Not at all/moderately 38.7 (34.3–43.1) 2.52 (0.083) 35.5 (26.8–44.2) 2.13 (0.122) family Very 40.3 (38.7–41.9) 37 (29.6–44.5) Extremely 44 (40.7–47.3) 40.5 (32.4–48.6)

HRQoL- SF-12® physical health summary score, CI 95%-confidence interval Each numbered section is a separate analysis. * Brief model adjusted for functional status (NEADL) and gender **Full models adjusted for gender, functional status, education (early life) main family occupation (midlife), NZdep and perceived economic wellbeing (current state), (except for models 2 and 3 where the covariate became the variable of interest) Interactions between: gender and marital status; and gender and living arrangement were not significant and were dropped.

A minority (16%) reported a specific role against ever. Those born overseas were in their local community; those who had a no more or less likely to have experienced role were highly satisfied with it. Sixty-four discrimination, however those identifying percent reported a role in their family and as New Zealand European were less likely to satisfaction was high with this role. have experienced discrimination (25/465, 5%) Reports of discrimination were rare. No compared with those not identifying as New one reported being treated unfairly by a Zealand European (10/51, 19%; p=0.001). The health professional in the last 12 months reported discrimination was experienced and 1% more than 12 months ago. When by ‘other Europeans’, not by those of Pacific, aggregated, 9% reported being discriminated Asian, Middle Eastern, or African ethnicity.

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Table 5: Characteristics of socioeconomic status associated with mental HRQoL.

Full interview completed n=404 Adj mean Brief model* Adj mean Full model** Independent variable of interest Mental HRQoL (CI) F-test (p) Mental HRQoL (CI) F-test (p)

1.Living arrangement Alone 54.2 (53–55.4) 2.79 (0.063) 52.6 (47.2–58.1) 2.37 (0.095) With spouse 56.3 (55–57.7) 54.6 (48.9–60.3) With other 54.3 (51.7–56.8) 52.6 (46.4–58.7)

2.Could have used more practi- Yes 51.8 (49.3–54.3) 6.75 50.9 (45.2–56.6) 7.00 cal support than received Not at all 55.4 (54.5–56.2) (0.010) 54.6 (49–60.3) (0.009) 3. Anyone to provide emotional No 49.6 (46.1–53.2) 4.84 47.4 (41–53.9) 5.14 support? Yes 55.3 (54.4–56.2) (0.008) 53.4 (47.9–58.9) (0.006) I don’t need help 55.7 (53.5–57.9) 53.7 (48–59.3)

4.Could have used more emo- Yes 45 (41.8–48.3) 38.53 42.5 (36.3–48.7) 41.33 tional support than received Not at all 55.7 (54.9–56.5) (<.0001) 53.6 (48.3–58.8) (<.0001) 5.Importance of language and Not at all/moderately 53.8 (52.4–55.3) 2.4 (0.092) 51.5 (45.9–57.1) 2.42 culture to wellbeing Very 55.8 (54.8–56.9) 53.5 (48.1–59) (0.091) Extremely 55.3 (52.7–57.8) 52.7 (46.7–58.8)

6.Importance of family to not at all/moderately 52.1 (49.5–54.7) 2.74 49.9 (43.8–55.9) 3.29 wellbeing Very 55.3 (54.2–56.4) (0.066) 53.3 (47.8–58.8) (0.038) Extremely 55.5 (54.2–56.9) 53.7 (48.1–59.3)

7.Do you have a specific role in No 54.1 (52.7–55.5) 3.08 51.8 (46.1–57.4) 3.47 your family Yes 55.6 (54.6–56.6) (0.080) 53.4 (47.9–58.9) (0.064)

8.Experienced any discrimina- No 54.8 (54–55.7) 3.43 52.9 (47.5–58.4) 3.98 tion Yes 57.5 (54.8–60.2) (0.065) 55.9 (49.7–62) (0.047)

HRQoL-SF-12® mental health summary score, CI 95%-confidence interval Unmet need for emotional support = Could have used more emotional support than received Unmet need for practical support = Could have used more practical support than received Each numbered section is a separate analysis. *Brief model adjusted for functional status (NEADL score) and gender. **Full models adjusted for gender, functional status, education (early life) main family occupation (midlife), NZdep and perceived economic wellbeing (current state). Interactions between: gender and marital status; and gender and living arrangement were not significant and were dropped.

Correlates of HRQoL with physical HRQOL. Those living with Regression models were used to examine others had higher physical HRQOL. the association between QoL and the socio- Full models added lifetime SES markers economic and cultural factors in Tables 1, to each of these seven regression models. 2 and 3, controlling for functional status 'Type of residence' was independently and gender, completing analyses for both associated with Physical HRQoL with those physical HRQoL and mental HRQoL. living in other situations having the lowest Physical HRQoL HRQoL. 'Economic wellbeing' and 'satis- faction with role in community' were also The brief models in Table 4 show the independently associated with physical variables that were associated with physical HRQoL. 'Not needing help with practical HRQoL to the level of significance of p<0.1 tasks' was independently associated with with those reaching p<0.05 bolded adjusting higher physical HRQoL. for age and functional status; functional status was strongly associated with physical Mental HRQoL HRQoL. After adjusting for gender and Mental HRQoL was examined in a similar functional status in the brief models, living way with the brief models controlled for arrangement, type of residence, family gender and functional status. The brief occupation, and satisfaction with role in model in Table 5 shows variables that were community were significantly associated associated with mental HRQoL to the level

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of significance of p<0.1 with those reaching may have differed) despite a national p<0.05 bolded. The table shows that unmet decline in mortgage-free home ownership need for practical and emotional support rates in older age groups New Zealand since and having no one to provide emotional 2001.36,37 Home ownership is also notably support were associated with lower mental higher than that reported in other longitu- HRQoL. Those who reported that family dinal studies; in 1988, 68% of the 80+ group were very or extremely important to well- of the Dubbo longitudinal study in Australia being had higher mental HRQoL when fully owned their own home.38 adjusted for SES. The perceptions of unmet Individual socioeconomic status in need for practical and/or emotional support the UK predicts health outcomes such as were independently associated with lower frailty.39 Here we demonstrate that main mental HRQoL. Those who had experienced family occupation during the working life discrimination reported higher mental and perceived economic wellbeing were HRQoL when fully adjusted for SES. Inter- associated with physical HRQoL. This actions between: gender and marital status; association was attenuated when other and gender and living arrangement were lifetime SES factors were adjusted for, not significant. unlike self-perceived economic wellbeing which was independently associated with Discussion HRQoL after all adjustment. Education and This study describes the socioeco- deprivation status, in our analysis, were not nomic and cultural status and social strongly associated with HRQoL. Jatrana support factors associated with HRQoL of and Blakely found that while disparities non-Māori aged 85 years in one region of in mortality related to ethnicity persist New Zealand in 2010. Participants mainly into old age, the impact of socioeconomic lived in moderately deprived areas and gradients on mortality appear to be less HRQoL for mental health was good. HRQoL in the 85+ age group compared with the 40,41 for physical health was modest. 65+ age group. Our analyses examined HRQoL, not mortality, and this may in Women may be less well off financially part be why there is not apparently such a and are more likely to live alone. Despite strong association between education and these challenges, a higher proportion of deprivation and HRQoL. Rather, self-per- women reported they can count on someone ceived economic wellbeing was important. to help with daily task (83% vs 77% in men) Potentially self-perceived economic but they also have higher unmet needs well-being may represent the adequacy for practical support (14% vs 8% in men). of money for day-to day living while Women and men traditionally have different education and deprivation does not tell us roles in household tasks, and as more men adequacy of resource availability. than women lived with a spouse, their participation in the practical tasks probably For women, a daughter was seen as differed, thus partially explaining their the most common provider of support different perceived unmet need for practical concurring with English research where it support. Women are more likely to outlive was not so much the size of the family but men and thus will need more support for the presence of a daughter that was asso- the tasks done by their husbands. The unmet ciated with higher social contact and better 42 need for practical support may also be outcome. The main supporter for men in related to house maintenance which might LiLACS NZ was their spouse. Social support not be fulfilled by the daughter (the main is gender dependent. support for women). The prevalence of living alone varies NZS, the universal retirement pension, is around the world. Fewer non-Māori partic- the main source of income for the majority ipants in LiLACS NZ (85 years old) lived of non-Māori in this study, in accordance alone (48%) than in the Newcastle 85+ with nationally reported economic data.34 study, where 61% lived alone, predomi- 43 Home ownership of 89% is higher than the nantly women. These two studies had average New Zealand home ownership rate similar eligibility criteria and thus this of 66.9%35 (although the denominators comparison is fair.

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Correlates of HRQoL sented group (eg, those in residential care), Women more often reported unmet need hence interpretation should be cautious. for practical help and had lower physical The response rate was 59%, and 78% of HRQoL than men. Living alone requires these answered all the questions (overall more resources, and reported unmet need 46%). Although the demographic profile for practical and emotional support is is similar to that of the total population, 24 associated with lower QoL. Social support response bias may be operating as those may mediate the association between lower less able to answer are not as well repre- physical HRQoL and poor outcomes,21 as sented. Our response rate is similar to the 43 there was no gender interaction for unmet Newcastle 85+ study. The proportion of our need. The importance of support for sample living in long-term residential aged emotional and practical needs is emphasised care is within the estimated range of 3.4% by these results, confirming other research.44 and 9.2%, though lower than an age group comparison which reported 22% and 15% It is interesting that reported discrim- for women and men respectively in care in ination among those identifying as 2008.46 Third, although we have adjusted for ‘other-European’ was associated with higher many confounding variables, it is possible mental HRQoL. When Māori of all ages45 that the differences we found in outcome and the Māori cohort of those in advanced23 and exposure variables could be the result report discrimination, it is associated with of other factors associated with outcome worse outcomes. Further work is needed to variable that we did not measure. understand this finding in non-Māori. It is also intriguing that living in resi- Implications for practice and policy dential aged care was associated with higher These findings support the need for main- physical HRQoL both in the brief and in the taining and improving financial resources full models. Those in residential care had for those in advanced age, particularly for the lowest functional status and both models those living alone. Support for those living are adjusted for this. One interpretation alone is needed, but this report does not is that as functional status is the strongest specify exactly the best combination of predictor, the relative difference in HRQoL supports. More work is needed. Supportive between the living arrangements is driven care appears helpful, both for practical and by function. For those in advanced age with emotional support. Potentially finding ways low function, those in residential care have to buttress informal support with access the highest physical HRQOL. Demand for to formal support, respite care, training physical support may be reduced when for informal caregivers, adaptations to taken care of by paid care providers, and environment, supply of equipment, may this relief may improve HRQOL. facilitate maintenance of QoL. Functional status is reinforced here as a key component of physical and mental Concluding statements HRQoL and will be a key outcome to be At age 85 years, non-Māori in New followed in the longitudinal study. Zealand on average, are reasonably able in activities of daily living and have a Strengths and weaknesses moderate socioeconomic status. Those with This study is the first to engage a large more social support (both practical and number of people aged 85 years old in New emotional support); who have a perception Zealand. However, the findings are subject that family and roles in the community to some limitations. First, this study reports are important to their wellbeing and cross-sectional analyses which prohibit those with perceived comfort with their drawing causal conclusions. Follow-up money situation also have high HRQoL. data will allow conclusions regarding the Those who report unmet needs have poor direction of effects, allowing causal infer- mental HRQoL. This information can be ences to be drawn more confidently. used for development of strategies to Second, although the population-based improve health and QoL for people living in sampling is a strength, selection bias might advanced age in New Zealand. arise in our analyses for the poorly repre-

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Competing interests: Dr Hayman and Dr Kerse report grants from the Health Research Council of New Zealand and the Ministry of Health during the conduct of the study; Dr Wiles reports grants from HRC during the conduct of the study. Acknowledgements: We acknowledge the expertise of our subcontractors: the Western Bay of Plenty Primary Health Organisation, Ngā Matāpuna Oranga Kaupapa Māori Primary Health Organisation, Te Korowai Aroha Trust, Te Rūnanga o Ngati Pikiao, Rotorua Area Primary Health Services, Ngati Awa Research & Archives Trust, Te Rūnanga o Ngati Irapuaia and Te Whanau a Apanui Communi- ty Health Centre in conducting the study through the Bay of Plenty and Rotorua. We thank all participants and their Whānau for participation, and the local organisations that promoted the study. We thank the RōpuKaitiaki: Hone and Florence Kameta, Betty McPherson, Paea Smith, Leiana Reynolds and Waiora Port for their guidance. Funding for this study was from a pro- gramme grant from the Health Research Council of New Zealand, a project grant from Ngā Pae o te Māramatanga. The Rotorua Energy Charitable Trust supported meetings and activities in Rotorua. The Ministry of Health provides funds for ongoing data collection and we acknowl- edge their support for manuscript production. Newcastle University provided academic accom- modation for NK during finalisation of the manuscript. Author information: Ngaire Kerse, Professor and Head, School of Population Health, Tāmaki, University of Auckland; Ruth Teh, Senior Lecturer, Department of General Practice and Primary Health Care, School of Population Health, Tāmaki, University of Auckland; Simon A Moyes, Statistician, Department of General Practice and Primary Health Care, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland; Lorna Dyall, Senior Lecturer, Department of General Practice and Primary Health Care, School of Population Health, Tāmaki, University of Auckland; Janine L Wiles, Senior Lecturer, Social and Community Health, School of Population Health, Tāmaki Campus, University of Auckland; Mere Kēpa, Honorary Senior Research Fellow, Department of General Practice and Primary Health Care, School of Population Health, Tāmaki Campus, University of Auckland; Carol Wham, Senior Lecturer, Institute of Food, Nutrition and Human Health, Massey University, Auckland; Karen Hayman, Research Fellow, Department of General Practice and Primary Health Care, School of Population Health, Tāmaki Campus, University of Auckland; Martin Connolly, Freemasons’ Professor of Geriatric Medicine, Freema- son’s Department of Geriatric Medicine, University of Auckland and Waitemata District Health Board; Tim Wilkinson, Professor of Medicine, Department of Medicine, University of Otago, Christchurch, New Zealand; Valerie Wright St Clair, Associate Professor, School of Occupational Science and Therapy, and Co-Director Active Ageing Research Group Auckland University of Technology, New Zealand; Sally Keeling, Senior Lecturer, Department of Medicine, University of Otago, Christchurch, New Zealand; Joanna Broad, Senior Research Fellow, Freemason’s Depart- ment of Geriatric Medicine, North Shore, University of Auckland; Santosh Jatrana, Associate Professor, Alfred Deakin Institute for Citizenship & Globalisation, Deakin University Waterfront Campus, Geelong, Victoria, Australia. Honorary Senior Research Fellow, University of Otago, Wellington; Thomas Lumley, Professor of Biostatistics, Department of Statistics, University of Auckland. Corresponding author: Ngaire Kerse, University of Auckland, School of Population Health, Private Bag 92019, Auckland. [email protected] URL: https://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2016/vol-129-no-1441-9- september-2016/6996

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REFERENCES: 1. Statistics New ealand. the Health and Retire- 17. Wiles JL, Allen RE, Palmer Demographic Trends: ment Study. J Aging Res. AJ, Hayman KJ, Keeling S, 2012. Wellington, New 2011;2011:530534. Kerse N. Older people and Zealand: Statistics 10. Chou KL, Chi I. Success- their social spaces: a study New Zealand, 2012. ful aging among the of well-being and attach- 2. Wiles J. Age cannot wither young-old, old-old, and ment to place in Aotearoa her, nor custom stale her oldest-old Chinese. Int New Zealand. Soc Sci Med. infinite variety. Elder Care. J Aging Human Dev. 2009 Feb;68(4):664–71. 1999 Jul-Aug;11(5):10–4. 2002;54(1):1–14. 18. Allen R, Wiles J. A type of 3. Bondevik M. Historical, 11. Kondo N, Suzuki K, Minai lady’s corset? support for cross-cultural, biological J, Yamagata Z. Positive and older people. J Prim Health and psychosocial perspec- negative effects of finance- Care. 2009 Jun;1(2):156–7. tives of ageing and the based social capital on 19. McCann Mortimer aged person. Scand J incident functional disabil- P, Ward L, Winefield Caring Sci. 1994;8(2):67–74. ity and mortality: an H. Successful ageing 4. King DA, Wynne LC. 8-year prospective study of by whose definition? The emergence of elderly Japanese. J Epide- Views of older, spiritu- “family integrity” in miol. 2012;22(6):543–50. ally affiliated women. later life. Fam Process. 12. Ahnquist J, Wamala SP, Australas J Ageing. 2004 Mar;43(1):7–21. Lindstrom M. Social 2008 Dec;27(4):200–4. 5. Lloyd-Sherlock P, McKee determinants of health- 20. Conroy RM, Golden J, M, Ebrahim S, Mark -a question of social Jeffares I, O’Neill D, McGee Gorman M, Greengross or economic capital? H. Boredom-proneness, S, Prince M, Pruchno R, Interaction effects of socio- loneliness, social engage- Gutman G, Kirkwood economic factors on health ment and depression and T, O’Neill D, Ferrucci L, outcomes. Soc Sci Med. their association with Kritchevsky SB, Vellas 2012 Mar;74(6):930–9. cognitive function in B. Population ageing 13. Perry B. The material older people: a population and health. Lancet wellbeing of older New study. Psychol Health Med. 2012;379:1295 doi:10.016/ Zealanders: background 2010 Aug;15(4):463–73. S0140-6736(12)60519–4. paper for the Retirement 21. Bowling A. Social support 6. United Nations. Strength- Commissioner’s 2010 and social networks: ening older people’s review. Wellington: their relationship to rights: Towards a UN Ministry of Social the successful and Convention: A resource Development, 2010. unsuccessful survival for promoting dialogue 14. Lowe P, McBride-Henry of elderly people in the on creating a new UN K. What factors impact community. An analysis Convention on the Rights upon the quality of life of concepts and a review of Older Persons. New of elderly women with of the evidence. Fam York: United Nations, 2012. chronic illnesses: three Pract. 1991;8(1):68–83. 7. Wiles J, Jayasinha R. Care women’s perspectives. 22. Carter KN, Blakely T, for place: The contribu- Contemp Nurse. 2012 Soeberg M. Trends tions older people make Apr;41(1):18–27. in survival and life to their communities. 15. Foster P, Neville S. Women expectancy by ethnicity, J Aging Studies, (), . over the age of 85 years income and smoking in 2013;27(1):93–101. who live alone: a descrip- New Zealand: 1980s to 2000s. NZ Med J. 2010 8. Ministry of Health. Health tive study. Nurs Prax N Aug 13;123(1320):13–24. of older people strategy: Z. 2010 Mar;26(1):4–13. health sector action to 16. Stephens C, Alpass F, 23. Dyall L, Kepa M, Teh 2010 to support positive Towers A, Stevenson R, Mules R, Moyes SA, ageing. Wellington: B. The effects of types Wham C, Hayman K, Ministry of Health, 2002. of social networks, Connolly M, Wilkinson T, Keeling S, Loughlin 9. Ailshire JA, Crimmins perceived social support, H, Jatrana S, Kerse N. EM. Psychosocial Factors and loneliness on the Cultural and social factors Associated with Longevity health of older people: and quality of life of in the United States: Age accounting for the social Maori in advanced Differences between the context. J Aging Health. age. Te puawaitanga Old and Oldest-Old in 2011 Sep;23(6):887–911. o nga tapuwae kia ora

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benefits of having more 44. Blazer DG. How do you 46. Broad JB, Boyd M, Kerse children? J Gerontol feel about...? Health N, Whitehead N, Chelimo Psych Sci Soc Sci. 2012 outcomes in late life C, Lay-Lee R, von Randow Nov;67(6):742–54. and self-perceptions of M, Foster S, Connolly 43. Collerton J, Davies K, health and well-being. MJ. Residential aged Jagger C, Kingston A, Bond Gerontologist. 2008 care in Auckland, New J, Eccles MP, Robinson LA, Aug;48(4):415–22. Zealand 1988–2008; do Martin-Ruiz C, von Zglinic- 45. Cormack DM, Harris RB, real trends over time ki T, James OF, Kirkwood Stanley J. Investigating match predictions? Age TB. Health and disease the Relationship between Ageing. 2011;40:487–94. in 85 year olds: baseline Socially-Assigned Ethnic- findings from the Newcas- ity, Racial Discrimination tle 85+ cohort study. and Health Advantage BMJ. 2009;339:b4904. in New Zealand. PLoS ONE. 2013;8(12):e84039.

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Adherence to the current guidelines for bradycardic pacing in the octogenarian and nonagenarian populations Vivienne Kim, James Pemberton, Fiona Riddell, Khang-Li Looi

ABSTRACT Aim: A significant proportion of single-chamber ventricular pacemakers are implanted in octogenarian and nonagenarian patients. We aimed to assess whether the current pacing guideline is adhered for these populations. Methods: We retrospectively identified patients ≥80 years of age, who received their first pacemaker from July 2010 to June 2013. Results: A total of 356 patients were identified. Mean age was 86.1 years and 82.6 years for single and dual-chamber pacemakers respectively (p<0.05). Total procedure-related complications occurred in 9.5% and were comparable between both groups (p=0.08). At the time of implantation, 185 patients who received single-chamber pacemaker were in sinus rhythm (52%). They were older (86.2±4.3 vs 82.6±2.9, p<0.05), more likely to have ischaemic and valvular heart disease (68 vs 27, p= 0.02 and 22 vs 13, p=0.01, respectively), and cognitive impairment (34 vs 0, p= 0.001). They were also more likely to be discharged to a residential care facility (17 vs 1, p<0.01). Conclusion: The utility of dual-chamber pacemaker in this age group remains below expectation and did not comply with current cardiac pacing guidelines. The presence of older age, multiple co-morbidities, cognitive impairment and residential care on discharge likely influenced the type of device implanted.

However, there is still a significant Background proportion of single-chamber pacemakers With improved life expectancy and being implanted in the octogenarian and advances in medical care, the number of nonagenarian patients perhaps because of pacemakers implanted in people ≥80 years the paucity of data and evidence specifically of age has been steadily increasing. Current addressing this in the very elderly group.5–7 pacing guidelines favour implantation of In clinical practice, the specific determi- dual-chamber pacemakers for brady-ar- nants of pacing mode selection in patients rhythmias including sinus node disease remain unspecified even if there are guide- and higher degree atrioventricular (AV) lines to assist the implanting physicians. block except in patients with chronic atrial The objective of this study was to assess fibrillation (AF).1,2 Dual-chamber pacing our local practice of dual-chamber pace- resembles more closely to the normal makers vs single-chamber ventricular cardiac physiology and maintains the AV pacemakers’ implantation rate in octo- synchrony. Therefore, dual-chamber pace- genarian and nonagenarian patients maker is thought to be potentially more at Auckland City Hospital. We aimed to advantageous in older adults who have assess whether the current cardiac pacing increased contribution of atrial contraction guideline is adhered in this population to ventricular filling with their haemody- and aimed to identify whether there are namic changes of ageing.3,4 any variables between the two groups

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that affected the decision of pacing mode selection. We also aimed to assess whether Statistical Analysis there were any differences in their clinical Statistical comparisons for continuous outcome and complication rate. data were performed using ANOVAs single factor, unpaired t-tests and chi-squared Methods tests and Fisher’s exact test were used for categorical data. Continuous variables are This is a retrospective observation study presented as mean ± SD, and categorical involving octogenarian and nonagenarian data as counts or percentages. Ethics patients who required pacemaker implan- approval was obtained from the Auckland tation. We identifi ed patients aged 80 years DHB Research Review Committee. or older, who received their fi rst pace- maker at Auckland City Hospital (ACH) for a conventional reason for long-term Results pacing for the three-year period (July A total of 357 patients ≥80 years of 2010 to June 2013) from a centralised ACH age who received their fi rst pacemaker pacing database. We identifi ed the patient implantation were identifi ed for the study demographics, medical co-morbidities, period. We excluded one patient who indications for pacing, type of pacemaker had an atrial pacemaker (AAI) and left implanted, acute (within 24 hours of with 356 patients for the analysis. Figure implant), early (from >24 hours to two 1 showed the number of dual and single- weeks) and late (from two weeks to three chamber pacemakers implanted in these months after pacemaker implantation) populations throughout the study period. complications and patients’ discharge Only 50 patients ≥80 years of age received destinations from the local hospital elec- dual-chamber pacemakers. Mean age of tronic medical records. Most octogenarian the patients at the time of fi rst implant and nonagenarian patients are expected was 86.1±4.3 years (range 80 to 99 years) to have some degree of valvular heart and 82.6±2.9 years (range 80 to 90 years) disease and chronic kidney disease. For the for single and dual-chamber pacemakers purpose of our review we included only respectively (p<0.05). 54% of the patients severe symptomatic valvular heart disease were male. that will be otherwise considered for The indication for pacemaker implantation surgery or patients with post valve surgery was showed in Table 1. The most common as medical co-morbidity. For chronic indication for pacing was high-grade AV kidney disease, only stage 4 or more block (43.5%) followed by AF/fl utter with advanced kidney disease were included as slow ventricular rate/pauses (35.9%). their medical co-morbidity.

Figure 1: Number of dual and single-chamber pacemakers implanted in those ≥80 years of age for three-year period.

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Table 1: Indications for pacemaker implantation.

Indications Number Atrioventricular (AV) Block 155 (43.5%)

Sinus node disease 28 (8%)

Mixed AV block and sinus node disease 41 (11.5%)

Atrial fibrillation (AF)/flutter with slow ventricular response 128 (35.9%)

Ventricular tachycardia and empiric pacing for recurrent syncope 4 (1%)

Table 2 showed the demographic data of valvular heart disease (p<0.05) and cognitive the patients who received single and dual- impairment (p<0.05). However, there were chamber pacemakers. Those who received no differences in terms of the procedure-re- single-chamber pacemaker were older (86.1 lated complications or discharge status vs 82.6 years, p<0.05), more likely to have between the two groups.

Table 2: Baseline characteristics of the patients who received single and dual-chamber pacemakers.

Single-chamber (n=306) Dual-chamber (n=50) P Value

Mean age 86.1 ± 4.3 82.6 ± 2.9 <0.05 Median age 86 82

Gender 0.13 Male (%) 161 32 Female 145 18

Previous IHD 123 27 0.07

Valvular heart disease 35 13 <0.05

Congestive heart failure 58 10 0.86

Previous stroke 66 9 0.57

CKD 51 9 0.82

Active malignancy 21 2 0.44

Cognitive impairment/dementia 53 0 <0.05

Procedural complications Acute complications 16 3 0.82

Pneumothorax 8 0 0.25

Lead remanipulation 6 1 0.97

Early complications 10 4 0.12

Late complications 0 1 0.14

Discharge status Death 4 0 1.0

Home 275 49 0.06

Residential care 27 1 1.0

Rest home 23 1 0.15

Private hospital 4 0 1.0

Abbreviation: IHD: ischaemic heart disease CKD: chronic kidney disease

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Within three months’ follow-up, a total 2 to 2.5. Another patient with moderate of 9.5% of procedure-related compli- pocket haematoma had exacerbation of cations occurred in 34 patients. Most chronic idiopathic thrombocytopenia (ITP) common complications were lead-related and was re-admitted with platelet count problems (11/34) and pocket haematomas <10 and was managed with prednisone (11/34). Most patients were on at least one and plasmapheresis. All the patients with antiplatelet therapy due to co-existing haematoma were managed conservatively ischaemic heart disease (IHD) or history with pressure dressing. of transient ischaemic attack (TIA)/stroke. Less than 50% of all patients with compli- Four patients with pocket haematomas cations required another procedure to were also taking warfarin with their inter- manage their complications: 11 (3%) national normalised ratio (INR) between required lead re-manipulation and 4 (1%)

Table 3: Baseline characteristics of non-AF patients who received single-chamber pacemakers vs pa- tients who received dual-chamber pacemakers.

Non-AF single-chamber Dual-chamber pacemakers patients pacemaker patients (n=185) (n=50) Mean age 86.2±4.3 82.6±2.9 <0.05 Median age 86 82

Gender 0.28 Male 78 18 Female 107 32

Previous IHD 68 27 0.02

Valvular heart disease 22 13 0.01

Congestive heart failure 27 10 0.35

Previous stroke 35 9 0.88

CKD 33 9 0.98

Active malignancy 16 2 0.27

Cognitive impairment/dementia 34 0 0.001

Complications Acute complications 9 3 0.72

Pneumothorax 4 0 0.58

Lead remanipulation 5 1 1.00

Early complications 4 4 0.07

Late complications 0 1 1.00

Discharge status Death 2 0 1.00

Home 166 49 0.06

Residential care 17 1 <0.01

Rest home 14 1 <0.05

Private hospital 3 0 1.00

Abbreviation: AF: Atrial fibrillation IHD: ischaemic heart disease CKD: chronic kidney disease

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patients required chest drain for pneumo- sinus node disease. In 2000, The Canadian thorax. Complication rates between the Trial of Physiologic Pacing (CTOPP) was two groups were comparable (Table 2). the first large randomised study (N=2,568) At the end of three-month follow up, four to investigate the effects of dual-chamber patients were deceased and there was no versus single-chamber ventricular pacing pacemaker-related death. on the risk of stroke or death due to cardio- 9 At the time of implantation, 185 patients vascular causes. After a mean of three-year who received a single-chamber pace- follow-up, there was no significant benefit maker were in sinus rhythm (52%). The of dual-chamber over single-chamber baseline characteristics of these patients ventricular pacing in reducing stroke or compared with those who received dual- cardiovascular death (4.9% vs 5.5%, p=0.33). chamber pacemakers were shown in Table The mean age of the patients in the CTOPP 3. Patients who received single-chamber was 73+/-10 years and was much younger pacemaker tended to be older (86.2 +/- than our study population. There was no 4.3 years vs 82.6 +/- 2.9 years, p<0.05), difference in the incidence of heart failure 9 more likely to have IHD (68 vs 27, p=0.02), hospitalisation. However, the study showed significant valvular heart disease (22 vs 13, a modest benefit of dual-chamber pacing p=0.01) and cognitive impairment (34 vs 0, on the development of AF and similarly, the p=0.001). They were also more likely to be Mode Selection Trial (MOST) in 2002 also discharged to a long term residential care demonstrated a beneficial effect of dual- facility (17 vs 1, p<0.01). chamber pacing on progression to chronic AF.10 In our study, 52% of the patients who received a single-chamber pacemaker were Discussion actually in sinus rhythm at the time of Our study showed that utilisation of dual- implantation. AF is a common arrhythmia chamber pacemakers in the octogenarian in the elderly population.12 Having a dual- and nonagenarian populations remained chamber pacemaker potentially can reduce low and did not comply with the current the incidence of AF in this group. Because of cardiac pacing guidelines. The important the age and underlying comorbidities, these predictor that determines the choice of patients were preferentially given a single- pacing mode was presence of cognitive chamber pacemaker despite the current impairment. Furthermore, those patients cardiac pacing guidelines. who received single-chamber pacemakers There were more perioperative compli- who were in sinus rhythm were older, more cations reported in CTOPP study, mainly likely to have significant co-morbidities and lead-related problems.9 This was different more likely to be discharged to a residential from our study where there was no care which might imply poorer baseline difference in the complication rates functional status before implantation. between the two groups. New Zealand, like many developed coun- Although dual-chamber pacing does tries, has an ageing population and the not provide survival benefit on published number of people aged 85 years and over is studies, the mortality endpoint is probably expected to increase from 67,000 in 2009 to not the crucial determinant for mode over a quarter of a million by 2051.8 Those selection in the majority of octogenarian who aged >85 years have been the most and nonagenarian patients. Pacing is rapidly expanding segment of our popu- generally considered primarily as a lation over the past decades and they will means of improving quality of day-to-day make up 22% of all New Zealanders aged 65 life. Expectations, values and needs are years and over, compared with 9% in 1996.8 different from patients who are younger. To date, there is no published prospective Small improvement in cardiac output and and randomised trial on the choice of exercise tolerance with dual-chamber pace- pacing mode specifically assessing those makers may be a crucial factor in allowing octogenarian and nonagenarian patients. continued independence and improving There is evidence of superiority of dual- quality of life in our octogenarian and chamber pacing over ventricular pacing nonagenarian populations. alone in patients, especially in patients with

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Pacemaker syndrome consists of a outcome. At the start of the study, our constellation of signs and symptoms that hospital did have a policy that all octoge- occur in response to loss of AV synchrony narian and nonagenarian patients should and might have significant impact on older receive only single-chamber pacemaker as person’s quality of life.14,15 Octogenarians the published data suggested no mortality and nonagenarians belong to a highly benefit of dual-chamber pacing over heterogeneous group with regards to the single pacing. The local policy regarding presence and severity of medical co-mor- our conservative approach to pacing in bidities and functional capabilities. Older the elderly was not published anywhere people with pacemaker syndrome might and the final decision to implant type of have recurrent presentations to general or pacemaker in this group of population geriatric service with vague and nonspecific has always been at operators’ discretion. illness and over time recurrent admis- Co-morbidities/frailty and cost were factors sions might exert substantial increase on considered in our centre as well as the health care expenditure as well as negative lack of resources to offer dual-chamber impact on their quality of life until proper pacemaker for the growing population of diagnosis is made. Interestingly in MOST octogenarians and nonagenarians. There study, there was high rate of crossover from were no national guidelines that we were single-chamber pacing to dual-chamber aware at that point and there is none pacing due to pacemaker syndrome still at present. Given the large number (18.3%).13 At the last follow-up, 313 patients of potential candidates (growing elderly (31.4%) assigned to ventricular pacing alone populations) and the practical constraints of were receiving dual-chamber pacing. In the limited implanting specialist resource and Pacemaker Selection in the Elderly (PASE) funding in New Zealand, our local policy of trial, the pacemaker syndrome occurred in implanting single-chamber pacemaker in 26% of patients during an average follow-up octogenarian and nonagenarian represent of 18 months.16 In contrast, CTOPP reported a conservative but pragmatic prioriti- very low (2.7%) crossover rate.9 Currently sation from the available trial evidence. We there are no clear diagnostic criteria for acknowledge this as one of the limitations pacemaker syndrome and different studies of our study. With increasing availability have different clinical thresholds for the of resources, the number of dual-chamber diagnosis of such a subjective condition. pacemaker implantation in the octoge- In the CTOPP, re-operation was required to narian and nonagenarian patients slowly change from ventricular to dual-chamber increased but remained low as showed in pacing whereas only re-programming Figure 1. This may be reviewed as part of was necessary in the MOST and PASE clinical practice in the future. trial so likely the two studies had lower A number of clinical studies have 9,10,16 threshold for the crossover. None of shown that, unnecessary chronic right our patients were upgraded to physiological ventricular pacing can cause a variety of pacing during the study period for pace- detrimental effects, including AF and heart maker syndrome and we acknowledge the failure.17–19 With the advance in the pace- limitation of our retrospective study and the maker technology, new pacing algorithms need for upgrade to a dual-chamber system have influenced our clinical practice in due to intolerable pacemaker syndrome implanting dual-chamber pacemakers to must be weighed against the increased risk allow a more physiological pacemaker yet of complication and cost with dual-chamber minimise ventricular pacing. Previously we pacemaker. At current stage we have no may have put a single-chamber ventricular means of determining who will be more lead back-up (ie VVI) to minimise pacing in susceptible to pacemaker syndrome. patients with sick sinus syndrome, but new Our review highlights the need for further dual-chamber pacing mode such as Managed research in this area. Risk stratification of Ventricular Pacing (MVP) allows a func- octogenarian and nonagenarian patients tional single-chamber atrial pacing (ie AAI) meeting current pacing guidelines for dual- with ventricular monitoring and automatic chamber pacemakers should be improved switch from AAI to dual-chamber pacing and standardised to achieve optimal patient (DDD) during episodes of AV block.18,19

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Unfortunately, there is very limited data would potentially have any cost-saving in on the cost-effectiveness analysis of dual these populations. Our main strength is our versus single ventricular pacemakers in results are a representation of 'real-world' this age group and further research is practice. It provides a useful perspective required in this area to help the clinicians for both clinicians and implanting physi- to make informed decision. Multidisci- cians on the selection of pacing mode based plinary comprehensive geriatric assessment on an individual patient clinical status. A including assessment of cognition and frailty multidisciplinary approach involving the score prior to pacemaker implantation geriatrician and implanting cardiologist to might assist in pacing mode selection by provide a comprehensive assessment prior having more accurate information on their to implantation should be considered. functional and cognitive status. Much work remains to be done with regard to the devel- Conclusion opment of new algorithm. Utility of dual-chamber PM in the octo- genarian and nonagenarian populations Limitations remains below expectations and did not A number of limitations should be comply with current pacing guidelines. considered in interpreting the results of our The presence of cognitive impairment study. Our study is a single-centre retro- was the strongest independent predictor spective observational study, the selection for receiving single-chamber pacemaker. of pacing mode ie device prescription is In addition, patients who received single- not randomised. The local policy regarding chamber pacemaker with sinus rhythm our conservative approach to pacing in the were noted to be older and more likely elderly might have influenced the oper- to have IHD, significant valvular heart ators’ decision on the choice of devices disease and more likely to be discharged implanted. Information on patients’ frailty to residential care which might imply and functional status were not available. poorer baseline functional status. Those Patients with poor functional status and factors likely influenced the decision limited expected survival were likely to of type of device implanted. Balancing be implanted preferentially with single- patients’ comorbidities and the potential chamber pacemakers. This opens the door for device-related complications against for bias. Our study did not have cost-ef- the potential benefit is recommended on a fective analysis; therefore, we do not know case-by-case basis. whether single vs dual-chamber pacemakers

Competing interests: Nil. Author information: Vivienne Kim, General Medicine & Health of Older People Services, North Shore Hospital, Auckland; James Pemberton, Green Lane Cardiovascular Services, Auckland City Hospital, Auckland; Fiona Riddell, Green Lane Cardiovascular Services, Auckland City Hospital, Auck- land; Khang-Li Looi, Green Lane Cardiovascular Services, Auckland City Hospital, Auckland. Corresponding author: Khang-Li Looi, Green Lane Cardiovascular Services, Auckland City Hospital, Level 3, Park Road, Grafton, Auckland. [email protected] URL: https://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2016/vol-129-no- 1441-9-september-2016/6997

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REFERENCES: 1. Brignole M, Auricchio 8. Statistic New Zealand. International Conference A, Baron-Esquivias G, et Population ageing in New on Medical and Biolog- al. 2013 ESC Guidelines Zealand http://www.stats. ical Engineering; 1969; on cardiac pacing and govt.nz/browse_for_stats/ Chicago, Ill: Association cardiac resynchronization people_and_communities/ for the Advancement therapy: The Task Force older_people/pop-ageing- of Medical Instrumen- on cardiac pacing and in-nz.aspx. In; 2000. tation; 1969. p. 29–33. resynchronization therapy 9. Connolly SJ, Kerr CR, 15. Lamas GA, Ellenbogen of the European Society of Gent M, et al. Effects of KA. Evidence base for Cardiology (ESC). Devel- physiologic pacing versus pacemaker mode selec- oped in collaboration ventricular pacing on the tion: from physiology to with the European Heart risk of stroke and death randomized trials. Circu- Rhythm Association due to cardiovascular lation 2004;109:443–51. (EHRA). Eur Heart J 2013. causes. Canadian Trial 16. Lamas GA, Orav EJ, Stam- 2. Epstein AE, Dimarco JP, of Physiologic Pacing bler BS, et al. Quality of Ellenbogen KA, et al. ACC/ Investigators. N Engl J life and clinical outcomes AHA/HRS 2008 Guidelines Med 2000;342:1385–91. in elderly patients treated for device-based ther- 10. Lamas GA, Lee K, Swee- with ventricular pacing as apy of cardiac rhythm ney M, et al. The mode compared with dual-cham- abnormalities. Heart selection trial (MOST) in ber pacing. Pacemaker Rhythm 2008;5:e1–62. sinus node dysfunction: Selection in the Elderly 3. Bush DE, Finucane TE. design, rationale, and Investigators. N Engl J Permanent cardiac baseline characteristics of Med 1998;338:1097–104. pacemakers in the the first 1000 patients. Am 17. Nielsen JC, Kristensen L, elderly. J Am Geriatr Heart J 2000;140:541–51. Andersen HR, Mortensen Soc 1994;42:326–34. 11. Toff WD, Camm AJ, Skehan PT, Pedersen OL, Peder- 4. Gregoratos G. Permanent JD. Single-chamber versus sen AK. A randomized pacemakers in older dual-chamber pacing comparison of atrial and persons. J Am Geriatr for high-grade atrioven- dual-chamber pacing in Soc 1999;47:1125–35. tricular block. N Engl J 177 consecutive patients 5. Mond HG, Crozier I. The Med 2005;353:145–55. with sick sinus syndrome: Australian and New 12. January CT, Wann LS, echocardiographic and Zealand Cardiac Pace- Alpert JS, et al. 2014 clinical outcome. J Am Coll maker and Implantable AHA/ACC/HRS Guideline Cardiol 2003;42:614–23. Cardioverter-Defibrillator for the Management 18. Sweeney MO, Hellkamp Survey: Calendar Year of Patients With Atrial AS, Ellenbogen KA, et 2013. Heart, Lung and FibrillationA Report of al. Adverse effect of Circulation 2015;24:291–7. the American College ventricular pacing on 6. Shen WK, Hayes DL, of Cardiology/Ameri- heart failure and atrial Hammill SC, Bailey can Heart Association fibrillation among KR, Ballard DJ, Gersh Task Force on Practice patients with normal BJ. Survival and func- Guidelines and the Heart baseline QRS duration in a tional independence Rhythm Society. Journal clinical trial of pacemaker after implantation of a of the American College of therapy for sinus node permanent pacemaker Cardiology 2014;64:e1–e76. dysfunction. Circulation in octogenarians and 13. Lamas GA, Lee KL, Swee- 2003;107:2932–7. nonagenarians. A ney MO, et al. Ventricular 19. Gillis AM, PÜRerfellner H, population-based study. Pacing or Dual-Chamber Israel CW, et al. Reduc- Ann Intern Med Pacing for Sinus-Node ing Unnecessary Right 1996;125:476–80. Dysfunction. New England Ventricular Pacing with 7. Udo EO, van Hemel Journal of Medicine the Managed Ventricular NM, Zuithoff NP, et al. 2002;346:1854–62. Pacing Mode in Patients Long-term outcome 14. Mitsui T, Hori M, Suma with Sinus Node Disease of cardiac pacing in K. The pacemaker and AV Block. Pacing and octogenarians and syndrome. In: Mitsui Clinical Electrophysiol- nonagenarians. Europace T, editor. Proceedings ogy 2006;29:697–705. 2012;14:502–8. of the Eighth Annual

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Protecting New Zealand children from exposure to the marketing of unhealthy foods and drinks: a comparison of three nutrient profiling systems to classify foods Cliona Ni Mhurchu, Tara Mackenzie, Stefanie Vandevijvere

ABSTRACT Aim: Promotion of unhealthy foods and drinks is a significant, modifiable risk factor for child obesity and diet-related non-communicable diseases. We compared three accepted nutrient profiling systems: the Health Star Rating (HSR), the Ministry of Health Food and Beverage Classification System (FBCS) and the World Health Organization (WHO) Regional Office for Europe Nutrient Profiling Model, to identify the best system to protect New Zealand children from exposure to the marketing of unhealthy foods and beverages. Methods: 13,066 packaged foods from the 2014 New Zealand Nutritrack database were classified as ‘restricted’ or ‘not restricted’ as per the WHO model; ‘everyday/sometimes’ or ‘occasional’ as per the FBCS model; and ‘<3.5 stars’ or ‘≥3.5 stars’ as per the HSR model. The proportion and types of packaged foods that met the criteria for all three systems or none of the systems, and the types of food products classified as ‘restricted’ under the WHO model but classified as ‘everyday/sometimes’ (FBCS model) or as having >3.5 stars, were determined. Results: Under any of the three nutrient profiling systems, approximately one-third (29–39%) of New Zealand packaged foods would be permitted to be marketed to children. The WHO Model would permit marketing of 29% of products; the HSR system would permit 36%; and the FBCS system would permit 39%. The WHO Model restricts marketing of unhealthy foods more effectively than the other two systems. The HSR and FBCS systems would permit marketing of a number of food products of concern, particularly high-sugar breakfast cereals, fruit juices and ready meals. Conclusion: The WHO Regional Office for Europe Nutrient Profiling Model should underpin the Advertising Standards Authority revised Children’s Code for Advertising Food. The effectiveness of the new Code in reducing New Zealand children’s exposure to marketing of unhealthy foods and drinks should be subject to evaluation by an independent body.

Promotion of unhealthy foods and Current marketing practices in New beverages to children is a significant, Zealand predominantly promote unhealthy modifiable risk factor for child obesity foods and drinks to children.5 The most and development of diet-related non-com- common categories of food products municable diseases.1 Comprehensive, promoted to children are pre-sugared independent reviews of the evidence consis- breakfast cereals, soft drinks, savoury tently find that commercial food marketing snacks, confectionery and fast foods.3 has a direct effect on children’s food pref- Estimates of the proportion of food erences, purchase requests, consumption marketing promoting these product cate- patterns and diet-related health.2-4 gories to children vary from 60% to 90%.3

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A US federal Trade Commission survey codes across all food companies, differences of industry expenditure reported 63% of in audience definitions (times children are the marketing spend directed to children likely to be watching television versus ‘chil- was for carbonated drinks, fast food and dren’s programming’ times), and different breakfast cereals.6 Analysis of UK tele- systems to classify foods as unhealthy or vision channels popular with young people ‘non-core’. Adherence to voluntary codes found six of the 10 most frequently adver- may therefore not sufficiently reduce the tised food items were fast food, high sugar/ advertising of unhealthy foods or children’s low fibre breakfast cereals, confectionery exposure to such advertising.9 7 and snack foods. A similar study in New An accepted food classification or nutrient Zealand reported that 66% of food adver- profiling system is necessary to classify tisements on a free-to-air channel popular foods as suitable/unsuitable for marketing with children were for foods high in fat, to children and to implement restrictions. 8 salt or sugar. Examples of systems used for this purpose Several national governments and food are the UK Ofcom model, the Scandinavian and beverage manufacturers have acted Keyhole model, the US Interagency Working to restrict unhealthy food marketing to Group proposals13 and the World Health children or to allow the promotion of Organization (WHO) Regional Office for healthier choices only. Countries such Europe Nutrient Profiling Model.14 as Norway, Sweden and the province In February 2016, the Advertising Stan- of Quebec, Canada have statutory regu- dards Authority (ASA) announced a review lation (a formal legislative requirement of the ASA Children’s Codes (Code for by government) restricting the advertising Advertising to Children and Children’s Code of any product to children, and Ireland, for Advertising Food).15 The consultation UK and South Korea have regulations to document contained a specific question restrict advertising of specified foods and on the role of nutrient profiling systems in beverages during children’s programming the Children’s Codes, Is there a role for a 9 or peak viewing times. A number of nutrient profiling system such as the health food and beverage companies have also star rating system in the Children’s Codes? responded with voluntary pledges (non-leg- If yes, in what way and which system would islatively required commitments) to you suggest? change their marketing activities directed To inform our response to this question, to children, and the mix of foods adver- we compared three accepted nutrient tised to children.10,11 New Zealand does not profiling systems: the Health Star Rating have statutory legislation on the adver- (HSR), the Ministry of Health Food and tising of foods to children but 67% of the Beverage Classification System (FBCS) and major packaged food manufacturers and the World Health Organization (WHO) 20% of the biggest fast food restaurants Regional Office for Europe Nutrient have a voluntary policy on food marketing Profiling Model (WHO Model) to identify to children on their company website. the best system to protect New Zealand However, none of those include an accepted children from exposure to the marketing of nutrient profiling model.12 unhealthy foods and beverages. A systematic review of the impact of statutory and voluntary codes to limit the advertising of foods to children Methods found a sharp division in the evidence Selection of Nutrient Profiling however, with scientific peer-reviewed Systems evidence showing small or no reductions Three nutrient profiling systems were in promotion of less healthy foods and selected for comparison. Two were estab- children’s exposure to food marketing, lished New Zealand systems: the HSR and except in response to statutory regulation. the Ministry of Health FBCS, and one was an 9 In contrast, industry-sponsored reports international system: the WHO Model. Table indicate high adherence to voluntary 1 provides an overview of each system. 9 codes. Discrepancies are likely to be due HSR is an interpretive, front-of-pack to lack of complete coverage of voluntary nutrition labelling scheme adopted by New

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Zealand in 2014.16 HSR rates the nutrition and Mediaworks ThinkTV children’s food content of packaged foods in half-star incre- advertising guidelines.20 ments from half a star (least healthy) to 5 The WHO Model was specifically designed stars (most healthy) and is designed to help for the purpose of restricting the marketing consumers compare foods within categories. of foods to children and was published in The number of stars is calculated based 2015.14 It was developed following extensive on the nutritional profile of the food. To consultation with European member calculate the HSR score, a product is placed states, and is based on three nutrient in one of six HSR food categories; baseline profile models currently in use in Europe points are calculated based on energy, satu- for restricting marketing to children. It rated fat, total sugar and sodium content encompasses 17 food categories including per 100g; modifying points are calculated fruit, vegetables and ready-made meals. based on the amount of fruits, vegetables, Certain food categories are not permitted nuts and legumes (V points) and in some to be marketed to children under any instances, protein (P points) and fibre (F circumstances. These include chocolate and points). The final HSR score = Baseline confectionery, cakes and sweet biscuits, points – (V points) – (P points) – (F points). juices and energy drinks. Conversely, Lower scores indicate a better (healthier) unprocessed meat and fish, and fresh/ nutrient profile. HSR is a continuous scoring frozen fruit and vegetables can be marked system with scores ranging from approxi- without restriction. Maximum nutrient mately -24 to +45 (unpublished analysis of a level cut points are applied to determine the 2012 database of approximately 17,000 New eligibility of foods in all other categories to Zealand packaged products), and a cut point be marketed to children. to dichotomise foods as healthy/unhealthy A key difference between HSR and has not yet been widely agreed. However, the other two systems is that HSR is for work commissioned by the New South packaged foods only while the FBCS and the Wales Ministry of Health on the alignment WHO Model also incorporate fresh, mixed of HSR with existing Traffic Light schemes and cooked meals. and the 2013 Australian Dietary Guidelines reported that “healthy core foods with a Database of New Zealand HSR of ≥3.5 can be confidently promoted packaged foods in public settings as healthier choices”.17 In order to compare nutrient profiling This cut point has been proposed for use schemes, a common set of products were in New Zealand as a means of identifying classified using each scheme and compared. packaged foods consistent with District The 2014 New Zealand Nutritrack packaged Health Boards’ Healthy Food Policy and food database was used for this purpose. suitable for sale in hospitals. Nutritrack food composition data are The FBCS was developed by the Ministry collected directly from labels of all packaged of Health in 2007 to support healthy eating foods and non-alcoholic beverages available environments in New Zealand schools in four Auckland supermarkets during field and identify healthy foods suitable for surveys undertaken between February and provision in schools.18 The FBCS classifies May each year. Standardised data collection foods and beverages as ‘everyday’, ‘some- methods were developed for an interna- times’ or ‘occasional’ foods based on the tional collaborative project to compare Food and Nutrition Guidelines for Healthy and monitor the nutritional composition of Children and Adolescents. ‘Everyday’ foods packaged foods.21 Supermarkets chosen for are from the four core food groups, while data collection represent the biggest retail ‘sometimes’ foods are mostly processed brands of the main supermarket retailers foods with some added fat and/or salt and/ in New Zealand (Foodstuffs (54% grocery or sugar, and ‘occasional’ foods are high market share) and Progressive Enterprises in saturated fat and/or salt and/or added (38% market share) 22 and stores were sugar (eg confectionery, deep-fried foods selected for their large product ranges. and sugar-sweetened drinks). The FBCS Nutrition information is recorded for all is the basis for the Heart Foundation’s packaged products displaying a Nutrition Fuelled4Life programme19 and the TVNZ Information Panel. Alcohol and products

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Table 1: Summary of criteria used under each nutrient profiling scheme.

Nutrient pro- Purpose Scoring Nutrients to limit Nutrients or com- Examples filing system ponents to promote HSR16 Front-of-pack nutri- Products receive a Health Energy, saturated Protein, fibre, per- Sugar sweetened soft tion labels Star Rating between ½ star fat, total sugars, centage of food that drinks = 100% of prod- on packaged foods and 5 stars from an overall sodium is fruits vegetables ucts receive <3.5 stars to assist consumers score based on food com- nuts and legumes in discriminating and ponents with positive or Frozen vegetables comparing foods negative associations with = 100% of products within categories chronic disease. receive >3.5 stars

FBCS18 Guidelines for Foods are either ‘everyday’ Added fat, added Sugar sweetened soft schools to identify ‘sometimes’ or ‘occasion- salt, added sugar drinks = ‘occasional’ healthy food and al’ foods depending on drink options for alignment with food and Frozen vegetables = sale on campus nutrition guidelines ‘everyday’

WHO Model14 Restriction of mar- Foods are either ‘permitted’ Total fat, saturated Sugar sweetened soft keting of unhealthy or ‘not permitted’ accord- fat, total sugars, drinks = ‘not permitted’ foods to children ing to nutrient thresholds added sugars, for different food categories non-sugar sweet- Frozen vegetables = eners, salt, energy ‘permitted’

that do not carry a Nutrition Information nut and legume (V Points) value, based on Panel, eg fresh produce, bakery and delica- expected content within food category, in tessen items are excluded. order to calculate HSR scores. For each packaged product with a Analysis Nutrition Information Panel, the brand A total of 13,066 packaged food products name, product name, ingredient list and across 14 broad food categories were content of energy, protein, total fat, satu- analysed after exclusions were made. Food rated fat, total carbohydrate, sugars, fibre categories in the Nutritrack database not (where available) and sodium per 100 g or included in the analysis were: alcoholic mL are recorded in a searchable web-based beverages, herbs and spices, coffee and tea, database. Nutritional information recorded sugars and baking ingredients, coatings/ is for products ‘as sold’ (ie not ‘as prepared’) breadcrumbs, baby food and supplements, in order to maximise within-category as these were not covered by the three product comparability (since preparation nutrient profiling systems. instructions vary and can have a significant The remaining 13,066 packaged impact on final composition) and different foods were classified as ‘restricted’ or pack sizes of the same product are recorded ‘not restricted’ as per the WHO model; as separate items. All data are checked and ‘everyday/sometimes’ or ‘occasional’ as per cleaned before analysis. Any data entry the FBCS model; and ‘<3.5 stars’ or ‘≥3.5 errors identified by value range checks and stars’ as per the HSR model. The FBCS does random checks are corrected using source not apply to certain food groups, including data (product photographs). Each product is cooking oils, sauces and spreads, jam and assigned to a basic food group (Level 1, 13 marmalade, honey, butter and margarine, groups) and a specific food category (Level pickled vegetables, so these were excluded 2, 41 categories).21 Level 4, the most finely (N/A) for that model. The proportion and grained food grouping in the system, has types of packaged foods that met the criteria 428 categories. Where fibre content is not for all three systems or none of the systems listed on a product Nutrition Information and the types of food products classified as Panel (it is not mandatory), we apply the restricted under the WHO model but clas- food category average. We also apply a stan- sified as ‘everyday/sometimes’ (FBCS model) dardised category-specific fruit, vegetable, or as having >3.5 stars, were determined.

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Figure 1: Proportion of New Zealand packaged foods (n=13,066) within each Health Star Rating category.

While 87–88% of packaged foods restricted Results under the HSR system (<3.5 stars) and the There was a fairly even distribution of FBCS system (occasional foods) would also New Zealand packaged foods across the 10 be restricted under the WHO Model, 42% HSR categories from 0.5 to 5 stars, although of those permitted under the HSR system proportions of packaged foods with 4.5 stars and 47% permitted under the FBCS system (5%) or 5 stars (5%) were noticeably lower would be restricted under the WHO Model than those in other HSR categories (range (Table 3). 8–14%, mean 10%) (Figure 1). The most common packaged foods The three nutrient profi ling systems restricted under the WHO Model but were broadly similar in their proportional receiving 3.5 stars or more were fruit and classifi cation of permitted foods overall vegetable products (22%, of which 27% were with approximately one-third (29–39%) fruit in juice or syrup, 17% dried fruit and of packaged foods meeting the eligibility 14% frozen potato products), dairy products criteria for each system: 29% under the (19%, of which 25% were cheese and 23% WHO model, 36% under the HSR system yoghurt and yoghurt drinks), convenience (>3.5 stars), and 39% under the FBCS system foods (14%, of which 66% were ready meals (everyday or sometimes foods) (Table 2). and 18% soups), cereals and cereal products In general, the WHO Model applies stricter (14%, of which 61% were breakfast cereals eligibility criteria and fewer foods would be and 16% cereal bars) and non-alcoholic permitted to be marketed to children under beverages (11%, of which 99% were fruit or this system. However, there were important vegetable juices) (Figure 2). differences between the three systems in The most common types of products their classifi cation of specifi c food cate- restricted under the WHO Model but clas- gories. Notably, the WHO Model would only sifi ed as ‘everyday/sometimes’ by the FBCS permit marketing of 33.5% of New Zealand system were dairy (34%, of which 62% breakfast cereals included in this analysis, were cheese and 17% yoghurt and yoghurt whereas the HSR and FBCS would permit drinks), fruit and vegetable products (21%, marketing of 77% and 75% of breakfast of which 28% were dried fruit, 26% fruit cereals respectively. The HSR system would in juice or syrup and 12% frozen potato also permit marketing of substantially more products), convenience foods (15%, of which fruit bars and fruit/vegetable juices (57% 59% were ready meals) and cereals and and 62% respectively) compared with the cereal products (11%, of which 66% were WHO Model (0% for both) and the FBCS breakfast cereals) (Figure 3). (0% and 12%). In contrast, the FBCS would In total 17% of all New Zealand packaged permit marketing of substantially more foods met the criteria for all three nutrient convenience foods and dairy products (83% profi ling systems and would be eligible to and 61% respectively) compared with the be marketed to children under any selected WHO Model (34% and 14%) and HSR (56% system. Table 4 lists the top 10 food cate- and 33%) (Table 2).

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Table 2: Classification of New Zealand packaged foods (n=13,066) by each nutrient profiling system.

Food category and key sub-categories HSR WHO Model FBCS

<3.5 stars ≥3.5 stars R NR O E/S N/A All foods 13,066 63.7 36.3 70.9 29.1 41.4 39.3 19.2

Bread and bakery products 1,603 73.1 26.9 74.3 25.7 63.6 36.4 0.0

Biscuits 736 88.5 11.5 99.7 0.3 89.1 10.9 0.0

Bread 484 30.6 69.4 15.3 84.7 7.0 93.0 0.0

Cakes, muffins and pastries 383 97.4 2.6 100.0 0.0 85.9 14.1 0.0

Cereal and cereal products 1,264 38.8 61.2 50.4 49.6 34.7 65.3 0.0

Breakfast cereals 358 22.9 77.1 66.5 33.5 24.6 75.4 0.0

Cereal bars 221 80.5 19.5 100.0 0.0 92.8 7.2 0.0

Confectionery 804 89.2 10.8 100.0 0.0 94.7 5.3 0.0

Convenience foods 726 44.2 55.8 66.3 33.7 16.7 83.3 0.0

Pre-prepared salads and sandwiches 51 35.3 64.7 92.2 7.8 11.8 88.2 0.0

Pizza 54 74.1 25.9 100.0 0.0 63.0 37.0 0.0

Ready meals 274 31.0 69.0 97.4 2.6 19.3 80.7 0.0

Soups 330 49.7 50.3 29.1 70.9 3.6 96.4 0.0

Dairy 1,743 67.4 32.6 85.9 14.1 39.3 60.7 0.0

Cheese 600 78.0 22.0 86.7 13.3 0.0 100.0 0.0

Cream 50 98.0 2.0 98.0 2.0 98.0 2.0 0.0

Desserts 172 78.5 21.5 100.0 0.0 65.1 34.9 0.0

Ice cream and edible ices 336 96.7 3.3 100.0 0.0 82.4 17.6 0.0

Milk 293 21.5 78.5 70.3 29.7 59.4 40.6 0.0

Yoghurt and yoghurt drinks 292 46.2 53.8 73.6 26.4 25.0 75.0 0.0

Edible oils and oil emulsions 303 46.9 53.1 20.1 79.9 0.0 0.0 100.0

Eggs 76 0.0 100.0 0.0 100.0 0.0 100.0 0.0

Fish and seafood products 484 18.8 81.2 10.3 89.7 12.0 88.0 0.0

Fruit, vegetables and nut products 1,539 35.7 64.3 62.8 37.2 10.1 68.5 21.4

Fresh packaged fruit and vegetables 51 0.0 100.0 0.0 100.0 0.0 100.0 0.0

Dried fruit 179 56.4 43.6 98.9 1.1 19.0 81.0 0.0

Frozen fruit 40 0.0 100.0 0.0 100.0 0.0 100.0 0.0

Fruit bars 35 42.9 57.1 100.0 0.0 100.0 0.0 0.0

Nuts and seeds 198 41.9 58.1 37.4 62.6 40.4 59.6 0.0

Jam and marmalades 151 96.0 4.0 100.0 0.0 0.0 0.0 100.0

Canned vegetables 263 23.2 76.8 44.1 55.9 0.0 100.0 0.0

Frozen vegetables 120 0.0 100.0 0.8 99.2 0.0 100.0 0.0

Frozen potato products 81 4.9 95.1 79.0 21.0 7.4 92.6 0.0

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Table 2: Classification of New Zealand packaged foods (n=13,066) by each nutrient profiling system (continued).

Meat and meat products and alternatives 1,069 69.9 30.1 40.3 59.7 69.6 30.4 0.0

Processed meat 1,005 72.5 27.5 37.9 62.1 73.9 26.1 0.0

Non-alcoholic beverages 1,116 74.6 25.4 89.1 10.9 91.1 8.9 0.0

Beverage mixes 69 100.0 0.0 100.0 0.0 100.0 0.0 0.0

Sugar-sweetened cordials 71 98.6 1.4 95.8 4.2* 100.0 0.0 0.0

Sugar-sweetened energy drinks 69 100.0 0.0 100.0 0.0 100.0 0.0 0.0

Fruit and vegetable juices 361 38.2 61.8 100.0 0.0 88.4 11.6 0.0

Sugar-sweetened soft drinks 265 100.0 0.0 98.1 1.9** 100.0 0.0 0.0

Sugar-free soft drinks 54 100.0 0.0 96.3 3.7 90.7 9.3 0.0

Waters, including flavoured 158 63.9 36.1 32.9 67.1 67.1 32.9 0.0

Sauces and spreads 1,765 90.3 9.7 90.0 10.0 0.0 0.0 100.0

Snack foods 373 89.3 10.7 98.1 1.9 97.3 2.7 0.0

Sugars, honey and related products 162 97.5 2.5 100.0 0.0 14.8 15.4 69.8

R: Restricted; NR: Not restricted O: Occasional foods; E/S: Everyday or Sometimes foods; N/A: Food groups not included in the FBCS system *3 blackcurrant fruit juice syrup products **5 carbonated juice drinks

Table 3: Classification of foods under the HSR and FBCS systems compared with WHO Model.

N % restricted (WHO) % not restricted (WHO)

HSR nutrient profiling model

Foods with HSR <3.5 stars 8,323 87.2 12.8

Foods with HSR ≥3.5 stars 4,743 42.3 57.7

MOH food and beverage classification system

Occasional foods 5,415 87.9 12.1

Everyday/sometimes foods 5,140 47.3 52.7

gories, representing 79% of all foods of 29% products; the HSR system (using a meeting the criteria for all three systems. cut point of 3.5 stars) would permit 36%; In total 32% of packaged foods did not and the FBCS system (everyday or some- meet the criteria for all three systems. times foods only) would permit 39%. Food Table 5 lists the top 10 categories, repre- category differences between three systems senting 66% of the foods that did not meet were notable however; in particular HSR the criteria for any of the three nutrient and FBCS systems would permit marketing profiling systems. of substantially more high-sugar breakfast cereals than the WHO model. HSR would also permit marketing of fruit bars and Discussion fruit juices, products largely not permitted Under the three nutrient profiling systems by the two other systems. All three systems assessed, approximately one-third (29-39%) classified a number of food categories as of New Zealand packaged foods would inappropriate for marketing to children, be permitted to be marketed to children. including biscuits, confectionery, sugar- The WHO Model would permit marketing sweetened drinks and ice cream.

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Figure 2: Types of products restricted by the WHO Model but receiving a HSR rating of >3.5 stars.

It is to be expected that the three components to promote (protein, fi bre, and nutrient profi ling systems perform differ- fruit, vegetable, nut and legume content) ently in some key food categories when and these positive constituents can offset they are underpinned by different nutri- the negative components in the total tional criteria. All three systems consider score. The major food category differences nutrients or components to limit but there observed between the systems (breakfast are differences in the number and types cereals, fruit bars, fruit/vegetable juices and considered. The WHO Model considers total dried fruit) appear to be due mainly to the fat, saturated fat, total sugars, added sugars, different weighting that each system gives non-sugar sweeteners, salt and energy; HSR to sugar with HSR in particular and FBCS considers energy, saturated fat, total sugars to a lesser extent, notably more lenient in and sodium; and FBCS considers added classifying more high sugar products as fat, added salt and added sugar. The HSR eligible/permitted. There were also some system also takes into account nutrients or notable differences in the convenience

Figure 3: Types of products restricted by the WHO Model but classifi ed as everyday or sometimes foods by the FBCS.

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Table 4: Products permitted under all three systems.

Type of food N % Plain pasta, couscous, quinoa, noodles and rice 328 14.7

Mixed grain, white, wholemeal, flat and other bread 317 14.2

Canned fish and seafood 231 10.3

Fresh packaged and frozen fruit and vegetables 210 9.4

Canned and dried vegetables 176 7.9

Frozen and chilled fish and seafood 111 5.0

Unsalted nuts 98 4.4

Dairy milk, natural and fruit-based yoghurt 91 4.1

Canned and chilled soup 86 3.9

Frozen, canned, sliced and meat 107 4.8 foods and dairy categories with FBCS in comprehensive assessment of the potential particular and HSR to a lesser extent, clas- of three nutrient profiling systems to protect sifying more products as eligible/permitted New Zealand children from exposure to compared with the WHO model. This marketing of unhealthy foods and indicates may reflect the FBCS greater emphasis on that the best system for this purpose is the core food groups than nutritional compo- comprehensive WHO Europe model. sition, and the HSR and FBS classifying Some limitations should be considered. substantially more desserts, ice creams and HSR and FBCS were not designed to limit yoghurts as eligible/permitted. marketing of unhealthy foods to children Our investigation has several strengths. It and are not ideally suited for this purpose. is the first to compare two well-known and For example, HSR is a front-of-pack accepted New Zealand nutrient profiling nutrition labelling system for packaged systems, HSR and FBCS, with an interna- foods and has no accepted threshold to tional system, the WHO Europe model dichotomize foods as healthy or unhealthy that was developed for explicit purpose although analysis suggests 3.5 stars is an of restricting marketing to children. More appropriate cut point17 and this threshold than 13,000 packaged foods available for is being used to identify healthier packaged sale in major New Zealand supermarkets in food options in the DHB National Healthy 2014 were classified using each scheme and Food and Drink Policy. FBCS includes a compared. Our study therefore provides a broader range of food categories but was

Table 5: Products not permitted under any of the three systems.

Type of food N % Sweet filled and unfilled, plain dry and savoury biscuits 586 14.1

Chocolate-based confectionery 424 10.2

Sugar-sweetened soft drinks, energy drinks and cordials 418 10.1

Ice cream and edible ices 270 6.5

Sugar-based chocolate and sweets 255 6.1

Potato crisps, pretzels, popcorn, corn chips 211 5.1

Cereal- and nut-based bars, and fruit bars 176 4.2

Cakes 146 3.5

Fruit juice 134 3.2

Pastries 131 3.2

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designed for the school setting and clas- In 2013, Rayner et al provided an sification of foods as “sometimes” foods overview of some nutrient profiling models depends on portion size in many cases and currently used or designed for regulation thus can be ambiguous.3 Nevertheless both of the advertising of foods to children.24 systems have been proposed as potential The 10 models summarised encompassed options for limiting the marketing of both industry pledges and government-led unhealthy foods to New Zealand children, in schemes, and emanated from a range of the ASA Consultation document itself and in countries including Brazil, Denmark, Korea submissions made by a number of bodies. and the US. The authors highlight that the Our analysis is therefore of direct relevance proliferation of nutrient models means that to current consideration of New Zealand there is less of a need to develop models marketing standards for children. Further, from scratch and that for the purposes of our database only included packaged foods regulating marketing of foods to children it so we were unable to compare the three may be possible to adapt a model developed nutrient profiling systems for fresh foods, for a completely different application such fast foods and mixed dishes. Finally, our as food labelling.24 analysis could not take into account the Since publication in 2015, the WHO Model frequency with which products in the Nutr- has stimulated debate and policy devel- itrack database are actually marketed to opment in a number of European countries. New Zealand children because such data In some countries exploring regulations (eg were not available, and some products new broadcast advertising restrictions), the included in the analysis might never be WHO Model has been used in national moni- marketed to children. However, previous toring exercises to compare against existing research has shown that the most common industry voluntary pledges (eg Malta). Other categories of food products promoted to countries, such as Turkey and Slovenia, have children internationally are pre-sugared incorporated the WHO Model into national breakfast cereals, soft drinks, savoury regulatory advertising codes with only 3 snacks, confectionery and fast foods. As minor adaptation. Most recently, Portugal such, implementation of any of the three in its new amendments to marketing legis- systems examined should significantly lation, made explicit reference to the WHO limit the marketing of unhealthy foods to Model nutritional criteria. New Zealand children. All three prohibit We selected the HSR and FBCS nutrient marketing of soft drinks and confectionery, profiling systems for comparison with the for example. The WHO system would also WHO Model because they are currently in impose limits on types of breakfast cereals, use in New Zealand by various sectors of savoury snacks and fast foods that could be the food industry and have been suggested marketed to children. as potentially appropriate to classify foods A limited number of other studies have as suitable/unsuitable for marketing to compared nutrient profiling systems children. However, there are other nutrient for restricting the marketing of foods profiling systems that also bear consid- and drinks to children. Brinsden and eration including the Fuelled4Life school Lobstein compared two industry-led food classification system, which is based nutrient profiling schemes with three on FBCS but has adopted additional criteria government-led schemes and found that to distinguish occasional, sometimes and government-led schemes were more everyday foods.19 A disadvantage of the restrictive than industry-led schemes, Fuelled4Life system in terms of its suitability primarily due to more stringent sugar for adaptation for marketing however is that 23 criteria. The two industry-led schemes it relies on serving size restrictions to distin- examined would permit 49% and 41% guish between occasional, everyday and of products analysed to be advertised, sometimes foods in some categories. compared with 37% under the UK Ofcom Another nutrient profiling system regulations, 14% under the US Interagency currently in use in the region that could Working Group Proposals and 7% under the be potentially adapted to limit children’s Danish Forum co-regulatory code.23 exposure to unhealthy food marketing is

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the Food Standards Australia New Zealand for marketing to children. Use of any of the Nutrient Profiling Scoring Criterion (NPSC) three systems would provide an objective, system used to determine the eligibility of evidence-based classification system to foods to carry health claims.25 The NPSC identify foods suitable for marketing to system was based on the UK Ofcom model children. Our analysis demonstrates clearly used to differentiate foods on the basis however that the WHO Model is the most of their nutritional composition in the robust system because it restricts marketing context of television advertising of foods of unhealthy foods more effectively than the to children. It also formed the basis for the other two systems evaluated. The HSR and HSR system but differs from HSR in using FBCS systems would permit marketing of a cut points to dichotomise foods as eligible number of food products of concern, partic- or not eligible to carry health claims. A ularly high-sugar breakfast cereals, fruit previous analysis of New Zealand packaged juices and ready meals. foods reported that 41% were eligible to Based on the findings of our analysis, we carry health claims based on their NPSC recommend that the WHO Regional Office 26 categorization. This suggests that the for Europe Nutrient Profiling Model be used NPSC would be even more lenient than HSR as the nutrient profiling system to underpin or FBCS and thus unlikely to be an appro- the new ASA Children’s Code for Advertising priate classification system in its current Food. Given the recognised weak nutritional form for limiting marketing of unhealthy standards employed by industry for defining foods to children. healthy foods and because many child-ori- Our findings have important implications ented food marketers do not participate in for the ASA review of its Children’s Codes self-regulation,27 the new Children’s Code for and the New Zealand Childhood Obesity Advertising Food should be subject to evalu- Plan. Existing nutrient profiling systems ation by an independent body. If the revised need to be utilised or adapted to limit New voluntary code still proves ineffective in Zealand children’s exposure to marketing reducing New Zealand children’s exposure of unhealthy foods. The three systems we to the marketing of unhealthy foods and evaluated classified just 29% to 39% of drinks, additional policy and regulatory New Zealand packaged foods as eligible actions will be necessary.

Competing interests: Cliona Ni Mhurchu is a member of the New Zealand Health Star Rating Advisory Group. The New Zealand Health Star Rating Advisory Group had no role in in study design, data collec- tion and analysis, decision to publish or preparation of the manuscript. Author information: Cliona Ni Mhurchu, Professor & Programme Leader Nutrition, National Institute for Health Innovation, University of Auckland, Auckland; Tara Mackenzie, MHSc Student, School of Population Health, University of Auckland, Auckland; Stefanie Vandevijvere, Senior Re- search Fellow, Epidemiology & Biostatistics, University of Auckland, Auckland. Corresponding author: Professor Cliona Ni Mhurchu, National Institute for Health Innovation, University of Auck- land, Private Bag 92019, Auckland Mail Centre, Auckland 1142, New Zealand. [email protected] URL: https://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2016/vol-129-no- 1441-9-september-2016/6998

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REFERENCES: 1. World Health Orga- 7. Boyland E, Harrold J, code for advertising to nization. Set of Kirkham T, Halford children and the children’s recommendations on the JCG. The extent of food code for advertising marketing of foods and advertising to children food. http://www.asa. non-alcoholic beverages. on UK television in co.nz/wp-content/ Geneva: World Health 2008. Int J Pediatr uploads/2016/03/ASA-Chil- Organization; 2010. Obes 2011;6:455–61. drens-Codes-Consulta- 2. Boyland E, Nolan S, Kelly 8. Jenkin G, Wilson N, tion-Paper-March-2016. B, et al. Advertising as Hermanson N. Identi- pdf: Advertising a cue to consume: a fying ‘unhealthy’ food Standards Authority; systematic review and advertising on television: 2016 February 2016. meta-analysis of the a case study applying 16. Food Standards Australia effects of acute exposure the UK Nutrient Profile New Zealand. Guide for to unhealthy food and model. Public Health industry to the Health nonalcoholic beverage Nutr 2009;12:614–23. Star Rating Calculator advertising on intake in 9. Galbraith-Emami S, (HSRC). Canberra: Food children and adults. Am J Lobstein T. The impact Standards Australia Clin Nutr 2016;103:519–33. of initiatives to limit the New Zealand; 2015. 3. Cairns G, Angus K, advertising of food and 17. Dunford E, Cobcroft Hastings G, Caraher M. beverage products to chil- M, Thomas M, Wu JH. Systematic review of the dren: a systematic review. Technical Report: Align- evidence on the nature, Obes Rev 2013;14:960–74. ment of NSW Healthy Food extent and effects of food 10. Australian Food and Provision Policy with the marketing to children. A Grocery Council. Health Star Rating System. retrospective summary. Responsible children’s Sydney, NSW: NSW Appetite 2013;62:209–15. marketing initiative: Ministry of Health; 2015. 4. Hastings G, McDermott 2011 compliance report. 18. Ministry of Health. Food L, Angus K, Stead M, Canberra: AFGC; 2011. and Beverage Classifica- Thompson S. The extent, 11. International Food and tion System for Years 1–13. nature and effects of food Beverage Association. Five User Guide. Wellington: promotion to children: A commitments to action: Ministry of Health; 2007. review of the evidence. 2011 progress report. 19. Heart Foundation of New Geneva: World Health Geneva: IFBA; 2012. Zealand. Food and bever- Organization; 2006. 12. Sacks G, Mialon M, age classification system 5. Vandevijvere S, Swinburn Vandevijvere S, et al. nutrient framework. B. Getting serious about Comparison of food Auckland: Heart Founda- protecting New Zealand industry policies and tion of New Zealand; 2016. children against unhealthy commitments on market- 20. ThinkTV. Advertising on food marketing. New Zeal ing to children and television: getting it right Med J 2015;128:36–40. product (re)formulation for children. http://www. 6. Federal Trade Commis- in Australia, New Zealand thinktv.co.nz/wp-content/ sion. Marketing food to and Fiji. Critical Public uploads/TTV0005_Chil- children and adolescents: Health 2015;25:299–319. drens_BookletV5-final.pdf: A review of industry 13. Lobstein T. Research TVNZ | Mediaworks; 2008. expenditure, activities and needs on food marketing 21. Dunford E, Webster J, self-regulation. https:// to children. Report of Metzler A, et al. Inter- HYPERLINK “http://www. the StanMark project. national collaborative ftc.gov/reports/market- Appetite 2013;62:185–6. project to compare and ing-food-children-ado- 14. World Health Organi- monitor the nutritional lescents-review-indus- zation. World Health composition of processed try-expenditures-activi- Organization Regional foods. Eur J Prev Cardiol ties-self-regulation:”www. Office for Europe Nutrient 2012;19:1326–32. ftc.gov/reports/market- Profiling Model. Copen- 22. Euromonitor PLC. Passport ing-food-children-ado- hagen, Denmark: World Global Market Informa- lescents-review-indus- Health Organization; 2015. tion Database. London: try-expenditures-ac- Euromonitor; 2014. tivities-self-regulation: 15. Advertising Standards Federal Trade Commission Authority. Consultation 23. Brinsden H, Lobstein T. Report to Congress; 2008. on the review of the Comparison of nutrient

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profiling schemes for 25. Food Standards Australia E, Neal B. Nutrient profile restricting the market- New Zealand. Short of 23,596 packaged ing of food and drink guide for industry to supermarket foods and to children. Pediatr the Nutrient Profiling non-alcoholic beverages Obes 2013;8:32–37. Scoring Criterion (NPSC) in Australia and New 24. Rayner M, Scarborough P, in Standard 1.2.7 - Nutri- Zealand. Public Health Kaur A. Nutrient profiling tion, health and related Nutr 2015;19:401–8. and the regulation of claims. Wellington: Food 27. Kunkel D, Castonguay J, marketing to children. Standards Australia Filer C. Evaluating Indus- Possibilities and pitfalls. New Zealand; 2013. try Self-Regulation of Food Appetite 2013;62:232–5. 26. Ni Mhurchu C, Brown R, Marketing to Children. Am Jiang Y, Eyles H, Dunford J Prev Med 2015;49:181–7.

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What’s new with the flu? Reflections regarding the management and prevention of influenza from the 2nd New Zealand Influenza Symposium, November 2015 Nadia A Charania, Osman D Mansoor, Diana Murfitt, Nikki M Turner

ABSTRACT Influenza is a common respiratory viral infection. Seasonal outbreaks of influenza cause substantial morbidity and mortality that burdens healthcare services every year. The influenza virus constantly evolves by antigenic drift and occasionally by antigenic shift, making this disease particularly challenging to manage and prevent. As influenza viruses cause seasonal outbreaks and also have the ability to cause pandemics leading to widespread social and economic losses, focused discussions on improving management and prevention efforts is warranted. The Immunisation Advisory Centre (IMAC) hosted the 2nd New Zealand Influenza Symposium (NZiS) in November 2015. International and national participants discussed current issues in influenza management and prevention. Experts in the field presented data from recent studies and discussed the ecology of influenza viruses, epidemiology of influenza, methods of prevention and minimisation, and experiences from the 2015 seasonal influenza immunisation campaign. The symposium concluded that although much progress in this field has been made, many areas for future research remain.

influenza, methods to minimise influenza Background transmission, effectiveness of influenza This paper presents a synopsis of the 2nd vaccines and experiences from the 2015 New Zealand Influenza Symposium (NZiS) seasonal influenza immunisation campaign that was hosted by the Immunisation and local healthcare service providers. Advisory Centre (IMAC) in November 2015. IMAC is a national organisation based at Ecology of influenza viruses and the School of Population Health at The the impact on humans University of Auckland. IMAC researches Influenza is a contagious respiratory aspects of vaccines and vaccine-preventable illness caused by influenza viruses, of diseases and is contracted by the Ministry of which there are three types (ie influenza A, Health to provide immunisation technical B and C) that all belong to the Orthomyxo- 2 advice and support, health professional viridae family. Influenza A viruses are training and input into policy development. comprised of eight separate strands of ribo- The 2nd NZiS brought together national and nucleic acid (RNA) that contain their genetic international experts and service providers information and high mutation rates while with the aim of improving the management replicating can lead to the creation of novel 3,4 and prevention of influenza. Building viruses. Influenza viruses constantly upon the inaugural symposium in 2014,1 evolve via antigenic drift and occasionally the topics discussed included: the ecology via antigenic shift enabling these viruses of influenza viruses, disease burden of to evade host immune memory from the

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last influenza infection by creating variants burden arises from the secondary compli- with different antigenic composition.5 These cations of infection. Influenza type A and constantly changing viruses require surveil- B viruses cause seasonal epidemics esti- lance to identify predominant circulating mated to cause 250,000 to 500,000 deaths strains and make recommendations for per year worldwide.20 While most of those annual vaccine formulation and pandemic infected will experience common signs and preparation. Many novel type A viruses symptoms (eg high fever, cough, myalgia are currently circulating with pandemic and sore throat), some may experience more potential, including highly pathogenic avian severe complications particularly young influenza (HPAI) H5N1 and H7N9 subtypes.6 children, the elderly and those with chronic 20 Wild aquatic birds are the natural hosts medical conditions. Recent literature has of all known influenza A virus subtypes noted an increased risk of influenza-asso- although influenza viruses have adapted to ciated deaths among adults with certain infect many species including humans, pigs medical conditions, such as acquired and other animals.7 Most avian influenza immunodeficiency syndrome (AIDS) and viruses (AIVs) have generally remained pulmonary tuberculosis (PTB), highlighting stable and are usually non-pathogenic to the importance of prioritizing at-risk groups 21,22 birds.8,9 Varying prevalence rates and wide for influenza vaccination. genetic diversity of influenza virus subtypes In New Zealand, seasonal influenza is have been found among animal and envi- not a notifiable condition and influenza ronmental reservoirs worldwide.10,11 Despite surveillance comprises of sentinel general the abundance and diversity of AIVs, these practice surveillance and non-sentinel viruses are generally inefficient in infecting laboratory-based surveillance. Since humans.8 Moreover, many different 2012, the sentinel influenza surveillance management interventions appear to aid network has been enhanced by the addi- in reducing the risk of zoonotic infec- tional surveillance capabilities of the tions in identified hot spots; for instance, Southern Hemisphere Influenza Vaccine implementing market rest days, banning Effectiveness Research and Surveillance overnight markets and separating species in (SHIVERS) project (2012–2016), enabling live poultry markets in Asia.12,13 the collection of robust data to better However, it is important to note that understand the national disease burden AIVs have successfully crossed the species of influenza. Data collected from the 2015 barrier to infect humans and cause disease winter season showed that influenza-like outbreaks.14,15 Most notably, hybrid viruses illness (ILI) consultation rates were within containing portions of animal viruses the normal activity range with most infec- have caused the past four influenza tions due to A(H3N2) viruses for the majority pandemics.16,17 Thus, continual and coordi- of the season until type B strains (B/Victoria nated surveillance and management efforts and B/Yamagata) predominated in the 23 are required to detect and prepare for later portion. Identified risk factors for potential pandemic threats. Evaluative tools, severe influenza included a range of host, like the influenza risk assessment tool (IRAT) socio-economic, healthcare, environmental 24 and efforts of the FLURISK Consortium play and behavioural factors. The importance important roles in helping prioritise efforts of demographic and socio-economic risk towards those influenza viruses currently factors were highlighted as the disease circulating in animals with the greatest burden is consistently highest among young potential pandemic risk.18,19 children, the elderly, those of Māori and Pacific peoples ethnicity and those living in Influenza epidemiology globally socio-economically deprived areas.23,25 In and in New Zealand addition, the higher risk of getting influenza Influenza spreads from close personal among pregnant women was noted; between contact between humans via infectious 2012 and 2014, cumulative incidence data respiratory droplets and by touching reveals that pregnant women were 4.88 infected surfaces.20 Infection with influenza times (95% confidence interval [CI] 3.14– viruses can cause asymptomatic, mild or 7.36) more likely to get influenza compared severe illness in humans and the main to non-pregnant women.23

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Prevention and minimisation of the circulating virus.38 Despite offering only influenza moderate levels of protection, vaccination still prevents influenza-related illness and Non-pharmaceutical (eg isolation, quar- complications (eg hospitalisation, death) and antine) and pharmaceutical (eg vaccine, is recommended for all of those who do not antiviral drugs) interventions can mitigate have a contraindication.39 the effects of influenza outbreaks.26 Several non-pharmaceutical interventions limit Literature has generally reported LAIVs the spread of influenza and are commonly to have similar or superior vaccine efficacy recommended. Some measures, such as and effectiveness in children compared respiratory and hand hygiene, are effective in to that of IIVs, which supports the long- reducing influenza transmission27,28 and are standing recommendation of LAIVs for viewed as acceptable, familiar and socially this age group.31,32,40 However, two recent responsible methods.29 The effectiveness studies revealed that the quadrivalent of mask wearing has been highlighted, as LAIV was not effective against the 2009 a recent study reported that surgical face- pandemic influenza A(H1N1) virus (A[H1N1] masks worn by influenza-infected patients pdm09) while the trivalent/quadrivalent resulted in an overall 3.4 fold (95% CI 1.8–6.3) IIV was effective among children aged decrease in viral aerosol shedding.30 2–17 years old during the 2013/2014 season in the US.41,42 The ineffectiveness of the The best way to prevent seasonal LAIV against the A(H1N1)pdm09 strain in influenza is annual influenza vaccination children underscores the need for constant with an inactivated influenza vaccine (IIV) monitoring to ensure the most appropriate or a live attenuated influenza vaccine type of vaccine is recommended to provide (LAIV), although it is noted that LAIVs are optimal protection.41 not yet licensed or available in New Zealand. Much research is being dedicated towards Influenza immunisation estimating vaccine effectiveness (VE) to programme and service delivery in evaluate the public health benefit of immu- New Zealand nisation campaigns and accuracy of vaccine In 2015, the Ministry of Health’s (MOH) strain selection. Recent research has indi- seasonal influenza immunisation campaign cated that the level of protection offered by achieved its target of distributing 1.2 million IIVs used in seasonal influenza vaccination doses, despite experiencing a late start to campaigns varies each year and by age the programme. Delays in vaccine avail- group, but generally offers a moderate level ability occurred as a result of adding two 31,32 of protection for most people. new strains to the vaccine.43 Particularly Starting in 2012 in New Zealand, the important was the addition of a new A(H3N2) SHIVERS project has provided robust and strain as it was noted that A(H3N2) had been timely estimations of VE of the trivalent IIV responsible for significant disease burden in and the protection offered in community the older age groups.23 Pertaining to specific and hospital settings using a test negative programme goals, provisional data on the study design.33–35 Most recently, during the funded influenza vaccines given to those 2014 influenza season, VE was 42% (95% CI aged 65 years and older indicates a steady 16%–60%) for preventing laboratory-con- increase in coverage since 2012, although firmed influenza hospitalisations and 56% room for improvement remains (Figure 1).43 (95% CI 35%–70%) against influenza cases Furthermore, progress was made in terms among general practice patients in the of improving immunisation coverage for community.35 In contrast to New Zealand healthcare workers (HCWs) (Figure 2).43 The data, studies from the northern hemisphere role of pharmacists in the seasonal influenza reported suboptimal overall VE of the immunisation campaign was also high- 2014/2015 seasonal influenza vaccine due lighted as a recent reclassification now allows to a poorly matched A(H3N2) component pharmacists to administer the non-funded of the vaccine.36,37 One study reported that influenza vaccine.44 The MOH continues to low VE levels were linked to mutations in work on enabling pharmacist vaccinators to the egg-adapted A(H3N2) vaccine strain record immunisations on the National Immu- introduced during the manufacturing nisation Register (NIR). process instead of due to antigenic drift of

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Figure 1: Immunisation benefi t claims for funded infl uenza vaccines among the elderly (65 years and older) in New Zealand, 2012–2015 (provisional data, 11 November 2015).

In 2015, a new multifaceted ‘blue dust’ During the infl uenza season, a range of promotional campaign was introduced to strategies were used to control and manage raise public awareness about infl uenza and the spread of infl uenza at the local level. the infl uenza vaccine.45 Evaluation of the To provide a service delivery perspective promotional campaign revealed that the on the infl uenza programme in 2015, campaign reached 50% of people eligible healthcare planners and providers shared for the funded vaccination, 41% of the their experiences and lessons learnt. In elderly and 80% of pregnant women.45 The addition to experiencing challenges due to most commonly reported motivators to delays in vaccine availability and extending immunise were the perceived severity and the immunisation programme dates, issues susceptibility of infl uenza, social concern related to the different types of vaccine of preventing infl uenza transmission and offered in the funded programme compared being offered the funded vaccine.45 On the with those available for private purchase other hand, commonly reported barriers were reported; in particular some people included needle phobia, concern of side were requesting the quadrivalent IIV when effects and preference of building natural only the trivalent one was available as immunity.45 Results highlighted the critical part of the funded programme.46 Methods role HCWs play in recommending infl uenza used to improve immunisation coverage vaccinations and the need for high-risk rates included offering specifi c immuni- groups in particular (eg the elderly and sation clinics, extended hours, opportunistic pregnant women) to understand the asso- vaccinations, and off-site vaccinations (eg ciated benefi ts and risks of vaccination. residential, home and workplace visits).46,47

Figure 2: Infl uenza immunisation coverage for District Health Board healthcare workers in New Zea- land, 2012–2015.

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In preparation for the 2016 influenza Conclusion and recommendations season, the need for a team-based approach for future work in planning, improved immunisation Overall, the NZiS 2015 concluded that education, better reporting and rapid point- much progress has been made regarding the of-care testing were noted.46,48 management and prevention of influenza The international debate about whether although many unanswered questions seasonal influenza vaccination should be remain. The key areas discussed and mandatory for HCWs was raised. Outbreaks recommendations for future work related of nosocomial (hospital-acquired) influenza to research, strategic planning and service can lead to severe morbidity and mortality delivery are summarised in Table 1. and HCWs are at an increased risk of As many viruses pose a potential acquiring influenza and subsequently pandemic threat, it is important that transmitting the disease to vulnerable continued effort is directed towards patients.49,50 Increased vaccination of HCWs influenza surveillance and identifying has been shown to reduce patient mortality effective management interventions to rates.51–53 All District Health Boards (DHB) reduce the incidence of zoonotic infections in New Zealand offer funded voluntary globally. In New Zealand, the SHIVERS influenza vaccination to their staff. In 2015, project has established robust surveil- Waikato District Health Board (WDHB) lance capabilities and identified groups became the first DHB in New Zealand that experience a higher disease burden. to implement a ‘Vaccinations for Health Future research should be directed towards Care Workers’ policy. The policy aimed to reducing these identified inequities based increase seasonal immunisation coverage on age, ethnicity and socio-economic rates among HCWs and reduce influenza deprivation. Moreover, research is needed transmission in healthcare settings. Similar to improve the vaccine effectiveness of to a policy introduced in British Columbia, influenza vaccinations and better under- Canada,54 it required that employed HCWs stand what type of vaccine is best suited for receive the season influenza vaccination particular age groups. To improve vacci- or don a mask while at work until the nation coverage rates, shared experiences end of the season. The CEO of the WDHB indicated that future campaigns should reported that the programme was generally consider extending the programme dates successful with 81% of HCWs receiving the and improving educational efforts. There vaccination and only 3% claiming medical also appears to be growing interest for or religious exemptions, despite some resis- strengthening policies related to influenza tance from unions and a few staff members. vaccination of HCWs.

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Table 1: Summary of key issues and suggested areas for future work identified by participants attending the 2nd New Zealand Influenza Symposium, November 2015.

Ecology of influenza • Surveillance of avian influenza viruses with pandemic potential viruses • Identification of effective management interventions to reduce influenza transmis- sion from animal sources to humans

Influenza epidemiology • Surveillance of circulating influenza viruses • Reduce inequities of influenza disease burden • Understand the extent and implications of asymptomatic influenza

Influenza vaccines • Improve vaccine effectiveness and level of protection of influenza vaccine • Improve A(H3N2) vaccine component and manufacturing process • Understand effectiveness of LAIV versus IIV in young children (in particular for pro- tection against A[H1N1]pdm09 strain) • Value of trivalent versus quadrivalent IIV • Public’s perception of trivalent versus quadrivalent IIV • Understand intra-seasonal waning immunity • Understand the impact of repeat immunisations (improves overall protection or not)

National influenza • Methods to reach people eligible for funded vaccines to improve vaccination cover- immunisation pro- age rates (focus on identified motivators and barriers to immunise) gramme • Improve vaccination rates of the elderly population and pregnant women (need to target educational efforts to understand risks and benefits) • Explore ways to better utilise pharmacist vaccinators

Healthcare service • Explore evidence to support the implementation of mandatory seasonal vaccination delivery or mask policy for HCWs • Improve influenza vaccine service delivery by allowing registered nurses to vacci- nate without a prescription or a standing order (similar to pharmacist vaccinators)

Competing interests: The Immunisation Advisory Centre and Regional Public Health are funded by the Ministry of Health to promote the delivery and uptake of influenza immunisation as part of the nation- al immunisation programme. Dr Mansoor reports my current employer, RPH is funded to promote influenza vaccine. I have undertaken work on maternal influenza immunization or WHO. Dr Turner reports other from SHIVERS study: CDC funded, outside the submitted work. Acknowledgements: The authors and the Immunisation Advisory Centre would like to thank the presenters and session chairs for their contributions: Bob Buckham (Pharmaceutical Society of New Zealand), Carolyn Clissold (Capital and Coast District Health Board), Shirley Crawshaw (Ministry of Health), Sue Huang (Institute of Environmental Science and Research), Michelle Kapinga (Na- tional Influenza Specialist Group), Heath Kelly (Australian National University, Victorian Infec- tious Diseases Reference Laboratory), Osman Mansoor (Regional Public Health), Margo Martin (Island Bay Medical Centre), Richard Medlicott (Island Bay Medical Centre), Diana Murfitt (Ministry of Health), Nigel Murray (Waikato District Health Board), Annette Nesdale (Regional Public Health), Phil Schroeder (Canterbury Primary Response Group), Nikki Turner (Immuni- sation Advisory Centre), Richard Webby (St. Jude’s Children’s Research Hospital), Marc-Alain Widdowson (Centers for Disease Control and Protection). We would also like to thank Barbara McArdle (Immunisation Advisory Centre) for organising and coordinating the symposium. Author information: Nadia A Charania, Lecturer, Department of Public Health, Auckland University of Technol- ogy, Auckland; Osman D Mansoor, Public Health Physician, Regional Public Health, Lower Hutt; Diana Murfitt, Senior Advisor - Immunisation, Service Commissioning, Ministry of Health, Wellington; Nikki M Turner, Associate Professor, Department of General Practice and Primary Health Care, University of Auckland, Auckland. Corresponding author: Dr Nadia A Charania, Department of Public Health, Auckland University of Technology, 90 Akoranga Drive, Northcote, Auckland. [email protected] URL: https://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2016/vol-129-no- 1441-9-september-2016/6999

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New Zealand. Available (2015, November). 51. Carman W, Elder A, from: http://www.immune. Presentation at the 2nd Wallace L, et al. Effects org.nz/sites/default/files/ New Zealand Influenza of influenza vaccination conferences/2015/NZiS/ Symposium, Wellington, of health-care workers BobBuckhamInfluen- New Zealand. Available on mortality of elderly zaSymposium2015.pdf from: http://www.immune. people in long-term 45. Kapinga M. Evaluation org.nz/sites/default/ care: A randomized of the 2015 national files/conferences/2015/ controlled trial. Lancet. influenza campaign. (2015, NZiS/ShroederCanter- 2000;355(9198):93–97. November). Presentation bury%20Annual%20 52. Hayward A, Harling R, at the 2nd New Zealand Flu%20Response.pdf Wetten S, et al. Effec- Influenza Symposium, 48. Medlicott R. Influenza: A tiveness of an influenza Wellington, New Zealand. general practice perspec- vaccine programmed for Available from: http:// tive. (2015, November). care home staff to www.immune.org. Presentation at the 2nd prevent death, morbid- nz/sites/default/files/ New Zealand Influenza ity, and health service conferences/2015/NZiS/ Symposium, Wellington, use among residents: KapingaEvaluation%20 New Zealand. Available A cluster randomized of%202015%20Influrn- from: http://www.immune. controlled trial. BMJ. za%20Campaign%20 org.nz/sites/default/files/ 2006;333(7581):1241–47. %28NZiS%2011%20 conferences/2015/NZiS/ 53. Lemaitre M, Meret T, Nov%2015%29.pdf MedlicottInfluenza%20 Rothan-Tondeur M, et 46. Martin M. Primary health Meeting%202015.pdf al. Effect of influenza care perspective: 2015 49. Kuster SP, Shah PS, Cole- vaccination of nursing flu season at Island Bay man BL, et al. Incidence of home staff on mortality of Medical Centre. (2015, influenza in healthy adults residents: A cluster-ran- November). Presentation and healthcare workers: domized trial. J Am Geriatr at the 2nd New Zealand A systematic review and Soc 2009;57(9):1580–86. Influenza Symposium, meta-analysis. PLoS One. 54. Ksienski DS. Mandatory Wellington, New Zealand. 2011;6(10):e26239. seasonal influenza Available from: http:// 50. Poland GA, Tosh P, vaccination or masking of www.immune.org. Jacobson RM. Requiring British Columbia health nz/sites/default/files/ influenza vaccination care workers: Year 1. conferences/2015/NZiS/ for health care work- Can J Public Health. MargoMartinfinal%20 ers: seven truths we 2014;105(4):e312–e316. Flu%20presentation.pdf must accept. Vaccine. 47. Schroeder P. 2015 primary 2005;23(17-18):2251–2255. care flu response plan.

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Improved compliance with the World Health Organization Surgical Safety Checklist is associated with reduced surgical specimen labelling errors Walston R Martis, Jacqueline A Hannam, Tracey Lee, Alan F Merry, Simon J Mitchell

ABSTRACT Aims: A new approach to administering the surgical safety checklist (SSC) at our institution using wall-mounted charts for each SSC domain coupled with migrated leadership among operating room (OR) sub-teams, led to improved compliance with the Sign Out domain. Since surgical specimens are reviewed at Sign Out, we aimed to quantify any related change in surgical specimen labelling errors. Methods: Prospectively maintained error logs for surgical specimens sent to pathology were examined for the six months before and after introduction of the new SSC administration paradigm. We recorded errors made in the labelling or completion of the specimen pot and on the specimen laboratory request form. Total error rates were calculated from the number of errors divided by total number of specimens. Rates from the two periods were compared using a chi square test. Results: There were 19 errors in 4,760 specimens (rate 3.99/1,000) and eight errors in 5,065 specimens (rate 1.58/1,000) before and after the change in SSC administration paradigm (P=0.0225). Conclusions: Improved compliance with administering the Sign Out domain of the SSC can reduce surgical specimen errors. This finding provides further evidence that OR teams should optimise compliance with the SSC.

The World Health Organization (WHO) is accumulating evidence that better introduced the Surgical Safety Checklist compliance with the administration of (SSC) with the intent of improving commu- the SSC items is associated with a greater nication and preventing errors or omissions likelihood of improved patient outcomes.3–6 in the operating room (OR).1 The SSC is With the aim of increasing compliance composed of three domains: ‘Sign In’ and engagement with the SSC in our (administered when the patient arrives in institution we eliminated the paper SSC the OR); ‘Time Out’ (administered immedi- and developed large posters (one for each ately prior to the first incision); and ‘Sign domain) to display our adapted version of Out’ (administered before the patient leaves the SSC on the OR wall. In addition, we allo- the OR). In the most common adminis- cated responsibility for leadership of each tration paradigm the SSC is initiated and domain to the OR sub-team most central to administered by the OR circulating nurse the processes occurring at the time: thus, reading from a paper copy of the checklist. the Sign In, Time Out and Sign Out domains Adoption of the SSC has been shown were led by anaesthesia, surgery and to reduce surgical complications and nursing respectively. This paradigm change mortality.2 Perhaps not surprisingly there has resulted in many significant improve-

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ments in compliance and engagement of OR Data collection sub-teams in SSC administration including In the OR, each surgical specimen is placed vastly improved compliance with adminis- in a specimen pot and labelled with patient trating the SSC Sign Out domain (from 22% identifying details and specimen details. 7 to 84% of cases). A specimen analysis request form is also One of the SSC items administered in the completed, which includes patient, specimen Sign Out domain requires a review of any and laboratory analysis details. This is surgical specimens and their labelling (the performed by one of the OR team members, words are “specimen description, quantity usually a nurse. Confirmation of completion and patient identification correct”). We and details of the specimen pot and labelling therefore hypothesised that improved is supposed to occur as part of the Sign Out compliance with the Sign Out phase of the domain, before the specimen is sent to the checklist would reduce errors in the labeling laboratory for analysis. of specimens, and undertook an evaluation We defined a specimen labelling error as of specimen labelling errors before and any error in the labelling or completion of after the roll-out of the new SSC adminis- the specimen pot or the specimen laboratory tration paradigm to investigate whether the request form identified by the laboratory improved compliance with Sign Out was after receipt of the specimen. These errors associated with error reduction. were prospectively recorded on specimen labelling error forms by laboratory staff Methods who followed up with the OR team to clarify This retrospective audit was approved by details and/or anomalies. For each suite we the Auckland District Health Board (ADHB) identified specimen labelling error forms Research office (Reference: A+ 7093). The that pre-dated and post-dated that suite’s SSC administration paradigm change was roll-out date for the new SSC administration sequentially rolled out across five OR paradigm for up to six months. suites (A-E, see Table 1) within the ADHB, This prospectively maintained file of a large tertiary health service provider for specimen labelling error forms was the source the greater Auckland region. The roll-out of all data. We included only the specimen process is described in more detail else- labelling errors occurring in the five OR suites. where.7 OR staff were not made aware of Any errors occurring in a clinic or ward envi- plans to audit specimen labelling errors ronment where the SSC was not a mandated after roll-out of the new checklist adminis- part of standard practice were excluded. In tration paradigm. Specimen labelling error addition, OR specimens that were sent to the data were collected for each OR suite over a laboratory prior to the completion of Sign Out six month period prior to, and a six month (such as frozen sections) were excluded. The period after each suite’s SSC administration total number of relevant specimens received paradigm change date (Table 1). by the laboratory from the five OR suites

Table 1: OR suites in the ADHB health service included in the current audit.

OR suite Number of ORs Surgical specialties Date of SSC paradigm change

A 13 general, orthopaedics, vascular , 24/11/2014 urology, neurosurgery

B 7 paediatric surgery 27/1/2015

C 7 cardiothoracic surgery, 9/2/2015 otorhinolaryngology

D 4 obstetrics and gynaecology 10/3/2015

E 8 Day stay unit for general surgery, 16/3/2015 oral health, otorhinolaryngology, gynaecology, urology, orthopaedics, ophthalmology

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Table 2: Rates of specimen labelling errors for all OR suites for the 12 month study period (All errors), then separated into the six month periods before (PRE) and after (POST) the SSC paradigm change. Rates are per 1,000 cases. Raw error numbers are also given in brackets.

Error type All errors PRE POST N=27 N=19 N=8

Specimen—incorrect patient identifying details 0.712 (7) 1.050 (5) 0.395 (2)

Specimen—no patient identifying details 1.120 (11) 1.682 (8) 0.592 (3)

Specimen form—no patient identifying details 0.712 (7) 0.840 (4) 0.592 (3)

Specimen form—incorrect completion 0.102 (1) 0.210 (1) 0 (0)

Specimen—empty specimen pot 0.102 (1) 0.210 (1) 0 (0) during the study period was obtained from the bution in the PRE and POST periods, are clinical records department of the laboratory. reported in Table 2. Statistical analysis The primary endpoint was a comparison Conclusions of the rate of specimen labelling errors A modified SSC administration paradigm for the periods before and after the intro- in which the checklist appears on large duction of the new SSC administration wall-mounted posters, and where lead- paradigm. Error rates were calculated as ership of each domain is allocated to a the number of specimen labelling errors different OR sub-team has been intro- divided by the total number of specimens duced to our institution. A recently received by the laboratory in each of the published study undertaken in one of the six month study periods, and were reported five OR suites (Suite A in Table 1) demon- as errors per 1,000 specimens. Rates were strated that this initiative resulted in compared using the Chi-square test, or dramatic improvements in compliance and Fisher’s exact test where rates were low. A engagement in checklist administration.7 p-value ≤0.05 was considered statistically One of the notable improvements was significant. Analyses were conducted using an increase in the frequency of admin- IBM SPSS version-22. istration of the Sign Out domain (from 22% to 84% of cases). That study did not, Results however, measure patient outcomes or other indicators of patient safety that A total of 9,825 specimens was received might be influenced by the improvement by the laboratory from the ORs in the full in SSC compliance. 12-month period: 4,760 of these were in the six-month period preceding the SSC In the present study we found that the paradigm change (PRE‑period), and 5,065 rate of surgical specimen labelling errors were in the six-month period after SSC more than halved in the six months paradigm change (POST-period). following introduction of the new SSC administration paradigm. Although we A total of 27 specimen labelling errors cannot definitively attribute this error was recorded over the 12-month period, reduction to the change in SSC paradigm, giving a total error rate of 0.275% (2.75 the related improvement in compliance errors per 1,000 specimens). There were with administration of the Sign Out domain 19 specimen labelling errors in the does provide a compelling explanation. Sign PRE-period, giving an error rate of 0.399% Out contains a checklist item which requires (3.99 errors per 1,000 specimens). There explicit review of the number, nature and were eight specimen labelling errors in labelling of specimens. The fact that this the POST-period, giving an error rate of is now administered in the vast majority 0.158% (1.58 errors per 1,000 specimens). of cases as opposed to the vast minority The difference between the error rates in likely underpins the reduction in errors, the PRE and POST-periods was statistically especially as there were no other process significant (p=0.0225). The sub-types of interventions or educational initiatives over specimen labelling errors recorded during the same period that might account for or the study period, along with error distri- have contributed to the change.

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This is an important finding for several study. We therefore cannot be certain that reasons. First, specimen labelling errors the improvement in compliance with Sign may have serious consequences in the Out was equivalent across all suites. It provision of medical and surgical care, may not have been as substantial in other having the potential to delay, impede and/ suites, but equally, it may have been even or misdirect management options.8 Mini- greater; anecdotally, Sign Out was virtually mising these errors is clearly desirable and never done in several locations before the their rate is an important quality measure paradigm change. Thus it seems very likely in patient safety.9 Complying with the Sign that there was an improvement in other Out domain of the SSC is a simple, cheap suites similar to that demonstrated in Suite intervention that, on the basis of these A (Table 1); especially given that the change findings, may have significant impact on this to SSC practice was rolled out in a stan- quality measure. Second, if we accept that dardised fashion across all suites. improved compliance with Sign Out was the Fourth, we have assumed that all explanation for the reduction in specimen specimen labelling errors are both detected errors, this study lends further weight to the and reported. This assumption may not assertion that adopting a checklist “in name” be valid, but any inaccuracy in this regard is not sufficient to reap its potential benefits. would probably be equally distributed The checklist actually has to be used; ideally across the two periods examined. with all OR staff paying full attention to the Fifth, our audit methodology was not process. This point was emphasized in a capable of capturing all errors relating to recent editorial which stated: “The obvious specimen labelling that might have been point here is that checklists do not work by affected by improved Sign Out compliance. themselves: they must be used, and used in For example, errors relating to the an engaged fashion with the mind focused description of a specimen detected at Sign on the issues at hand”.10 Out and corrected before despatch of the There are several limitations of this study specimen to the laboratory would not be that must be acknowledged. captured. It follows that the beneficial effect First, we did not conduct a parallel eval- of the SSC on this quality measure may be uation of a control hospital or group of OR greater than we have demonstrated here. suites where the checklist paradigm changes A final point which is an observation rather did not occur. This could have provided than a limitation is that we did not attempt some reassurance that the observed to subdivide the individual errors according reduction in specimen labelling errors to the risk they represented to the involved in our suites after converting to the new patients. To do so would have divided the paradigm was not due to some other unan- numerator into sizes too small to be mean- ticipated factor. Nevertheless, we believe ingful, and would have substantially missed that the association between a dramatic the point; all of these errors are indicative of improvement in compliance with sign out an imperfect process that could ultimately under the new paradigm and a concomitant result in patient harm given the right circum- reduction in specimen labelling error rates stances. Prevention of even minor errors will is plausibly explained by the prescription of almost certainly result in a milieu in which a specimen check during Sign Out. major errors are also less likely. Second, the number of specimen errors We conclude, therefore, that an was relatively small. Nevertheless, the rates improvement in compliance with the Sign are congruent with those reported from other Out domain of the WHO SSC was associated 11 institutions, and the denominator is large. with a significant reduction of specimen Third, the data demonstrating labelling errors in our hospital. These improvement in Sign Out compliance after findings lend weight to the Health Quality introduction of the new SSC administration and Safety Commission’s current advocacy paradigm published by Ong et al7 came for adoption of the SSC administration from one (albeit the largest) of the five OR paradigm described by Ong et al7 by all New suites that contributed data to the present Zealand District Health Boards.

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Competing interests: Dr Merry reports that he is Chair of Board of Health Quality and Safety Commission in New Zealand. Author information: Walston R Martis, House Officer, Auckland District Health Board, Auckland; Jacqueline A Hannam, Research Fellow, Department of Anaesthesiology, University of Auckland, Auck- land; Tracey Lee, Nurse Consultant, Auckland City Hospital, Auckland District Health Board, Auckland; Alan F Merry, Head of School, School of Medicine, University of Auckland, Consul- tant Anaesthetist, Auckland City Hospital, Auckland District Health Board, Auckland; Simon J Mitchell, Head of Department, Department of Anaesthesiology, University of Auckland, Consultant Anaesthetist, Auckland City Hospital, Auckland District Health Board, Auckland. Corresponding author: Simon J Mitchell, Head of Department, Department of Anaesthesiology, University of Auck- land, Auckland. [email protected] URL: https://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2016/vol-129-no- 1441-9-september-2016/7000

REFERENCES: 1. World Alliance for Patient National Implementation: 8. Martin H, Metcalfe S, Safety. Implementation A Longitudinal Study. Ann Whichello R. Specimen Manual for the World Surg 2016;263(1):58–63. labeling errors: A retro- Health Organization 5. van Klei WA, Hoff RG, van spective study. Online J Surgical Safety Checklist Aarnhem EE, et al. Effects Nurs Inform 2015;19(2). (First Edition). 2008. of the introduction of the 9. Makary MA, Epstein J, http://www.who.int/ WHO “Surgical Safety Pronovost PJ, et al. Surgi- patientsafety/safesurgery/ Checklist” on in-hospital cal specimen identification tools_resources/SSSL_ mortality: a cohort study. errors: a new measure of Manual_finalJun08.pdf. Ann Surg 2012;255(1):44–9. quality in surgical care. 2. Haynes AB, Weiser TG, 6. Haugen AS, Softeland Surgery 2007;141(4):450–5. Berry WR, et al. A surgical E, Almeland SK, et al. 10. Merry AF, Mitchell safety checklist to reduce Effect of the World SJ. Advancing patient morbidity and mortality in Health Organization safety through the use of a global population. N Engl checklist on patient cognitive aids. BMJ Qual J Med 2009;360(5):491–99. outcomes: a stepped Saf 2016;(Published Online 3. de Vries E, Prins H, wedge cluster randomized First: 4 January 2016). Crolla R, et al. Effect of a controlled trial. Ann 11. Francis DL, Prabhakar Comprehensive Surgical Surg 2015;261(5):821–8. S, Sanderson SO. A Safety System on Patient 7. Ong APC, Devcich DA, quality initiative to Outcomes. N Engl J Med Hannam J, et al. A decrease pathology 2010;363(20):1928–37. ‘paperless’ wall-mount- specimen-labeling errors 4. Mayer EK, Sevdalis N, Rout ed surgical safety using radiofrequency S, et al. Surgical Checklist checklist with migrated identification in a Implementation Project: leadership can improve high-volume endoscopy The Impact of Variable compliance and team center. Am J Gastroenterol WHO Checklist Compli- engagement. BMJ Qual Saf 2009;104(4):972–5. ance on Risk-adjusted 2015;(Published Online Clinical Outcomes After First: 30 December 2015).

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The uses of mental health telephone counselling services for Chinese speaking people in New Zealand: demographics, presenting problems, outcome and evaluation of the calls Christine Yang Dong

ABSTRACT Aim: This study aimed to investigate the call profiles of a Chinese-speaking mental health counselling helpline service in New Zealand (Chinese Lifeline provided by Lifeline Aotearoa) and to evaluate the calls and explore the possible factors influencing the outcome of the calls. Method: A random sample of 151 answered calls was involved. Descriptive analysis with appropriate statistical tests was used to analyse the client profile and outcome data. Results: The majority of the calls were made by female callers, aged between 21–60 both single and married. Top three presenting problems were: 1) mental health issues (82.1%); 2) family/partner relationship issues (47.0%) and 3) communication and related difficulties (45.0%). The majority of the calls (65%) ended after a clear decision in overcoming the issues made by the caller, with the help from the counsellor. Discussing mental health issues, grief and loss issues, and communication and related difficulties were shown to have influenced length of calls (p<0.05). Caller’s age, frequency of calls, discussing relationship problems with family/partner, and physical problems were shown to have influenced the helpline counsellors’ satisfaction of the helpfulness of the calls (p<0.05). Conclusion: The service receives calls from callers with a wide range of demographics and a large variety of presenting issues. This study identified several important factors which influenced counsellors’ satisfaction of the calls and the length of the calls.

In New Zealand, the Chinese population is population or the Chinese speaking popu- on a constant increase. In the recent census lation would be even larger. in 2013, it was shown that Chinese people As Ho et al2 pointed out, previous research make up 3.8% of all New Zealand resi- findings have suggested that the mental dents; the largest sub-ethnic group within health level among Asians does not differ the Asian ethnic group (‘Asian’ as defined significantly from those of the general by Statistics New Zealand in 1996.) in New population; there was also evidence of high 1 Zealand. Additionally, if we take into rates of depression among Chinese older account the Chinese people who live in New migrants. Furthermore, new or second Zealand without permanent residency (eg, generation Chinese migrants may face more international students), then the Chinese emotional stresses and issues compared

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to local people, such as issues related to All the relevant call data were then cultural differences, language and commu- entered into a standardised Excel database, nication issues, unemployment, traumatic which was set up for this study from the experiences prior to migration, migration paper files. Data was carefully cleaned and expectations not being met and regrets validated before data analysis. Data was about coming to New Zealand.2,3 then analysed using SAS 9.3. Since its establishment in 1993, Chinese Descriptive analysis was used to analyse Lifeline has provided confidential helpline the client profile and the presenting services to people who would like to problems. Chi-square tests were used talk through their issues in Mandarin or to investigate the differences in the Cantonese. The service has around 50–60 presenting problems among different Chinese volunteer helpline counsellors. demographic variables. All of the counsellors need to have a coun- For the outcome and evaluation of the selling or related qualification or studying calls, three outcome variables were used: toward a degree in this area when they length of a call (up to 30 minutes vs. longer apply for the roles. When they are accepted, than 30 minutes), immediate outcomes a six-week well-designed training program of the calls and self-rated helpline coun- would be provided by Lifeline. It has several sellors’ satisfaction on the helpfulness of a unique strengths compared to other mental call (dissatisfied vs. satisfied; ie, whether health/emotional health services such as no the counsellor thought that the telephone language barriers and no cultural differ- counselling was helpful to the caller or not). ences between the provider and the client. The length of a call provides an indication Internationally, although there are a of the efficiency of the service, while the number of research studies in the field of immediate outcomes and the counsellors’ Asian mental health issues, as Kumar et satisfaction of a call gives an indication al4 pointed out, most research focused on of the effectiveness of the service. Two the Asian ethnic group in general and did separate binary multiple logistic regres- not break it down to sub-ethnic groups (eg, sions were undertaken to investigate factors Chinese). In New Zealand, literature on associated with the length of calls being mental health issues around the Chinese longer than 30 minutes and the helpline population is even scarcer, and to the best volunteers’ satisfaction. The covariates extent of our knowledge we are not aware of were callers’ demographic variables and any existing research that studied the client the common presenting problems. Observa- profile and presenting issues of a Chinese tions with missing data were excluded from specific service in New Zealand. Thus, the the regression analyses. There were a few aim of the current study is to investigate the missing data of different variables which demographic and presenting problems of were excluded from all analysis. the callers of a Chinese speaking counselling helpline service in New Zealand (Chinese Results Lifeline). It also aims to evaluate the calls In total, there were 890 call files obtained using the length of the calls, and the counsel- from the call centre during the study lor’s satisfaction of the calls, and explore the period. Of these, 160 calls were excluded possible factors that influence these. from the study due to the exclusion criteria. In the end there were 728 eligible calls for Methods the study and the final sample size was 151 This study is a cross-sectional descriptive (ie, 20% random sample stratified by the study. All call files of Chinese Lifeline that month of the call). fell into the financial year (FY) 2013/4 (ie, 1 July 2013–30 June 2014) were obtained Callers’ demographics from Lifeline Aotearoa. There were several Table 1 presents the callers’ demo- exclusion criteria: 1) the call was a test call; graphics and the main characteristic of the 2) wrong number; 3) a hoax call. Then a 20% calls. The majority of the calls were made random sample, stratified by the month of by female callers (90.5%). More than 40% the calls, was pulled out from all the eligible of the calls were from young adults 21–30 calls in the FY 2013/4.

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years, 28% of the calls were made by callers family/partner relationship issues (47.0%; from the 31–40 years age group and 23% 95% CI [39.0%, 55.1%]); 3) communication of the calls were made by callers from the and related difficulties (45.0%; 95% CI 41–60 years age group. In addition, most [37.0%,53.1%]); 4) peers/friends/employer/ of the calls were made by either never- employee and other relationship issues married singles (41%) or married people (33.1%); and 5) work and education related (43%). Frequent callers (classified as those concerns (26.5%). With the mental health who called more than 10 times per month and family/partner relationship issues, a for at least six months) made up just over more detailed account was captured by one-third of the calls, while 27% of the calls the counsellors. Overall, the most common were from first time callers. mental health issues were “stress” (43.1%), “depression” (31.1%), “loneliness” (28.5%), Table 1: Callers’ demographics and characteristic and “anxiety” (27.2%). There was also 15.2% of the calls. (n=23) of the calls where psychiatric/mental health issues (eg, bipolar, schizophrenia) Demographic n (%) were identified. With family/partner Gender (N=147) relationship issues, the biggest group was “issues with extended family and in-laws” Male 14 (9.5) (31.1%). The risk level for most callers’ Female 133 (90.5) issues were low to moderate; however, there were occasional high risk calls (eg, Age Group (N=126) suicide-related issues). 20 or below 2 (1.6) Only 7.9% (n=12) of the calls were general enquiry calls with no presenting problems 21–30 53 (42.1) identified (ie, non-counselling calls; see 31–40 35 (27.8) Figure 1). Furthermore, of the remaining 92.1% of counselling calls, only 5.3% (n=8) 41–60 29 (23.0) were of single presenting problem calls, Over 60 7 (5.6) and 86.7% were of multiple presenting problem calls. In fact, more than half of the Marital Status (N=118) calls (54.9%) were subjected to three to four Never married 48 (40.7) presenting problems. Significant negative correlations were found between having Married 51 (43.2) family/partner relationship issues and Separated 8 (6.8) having peers/friends/employer and other relationship issues (r=-0.41, p<0.0001), and Divorced 4 (3.4) significant positive correlations were found Widow/widower 7 (5.9) between having family/partner relationship issues and having mental health issues Type of callers (N=105) (r=0.30, p=0.0002). First time callers 28 (26.7) In addition, the age groups of over 30 Several times callers 40 (38.1) years were significantly more likely to have discussed family/partner relationship issues Frequent callers 37 (35.2) (65% vs. 33%, p=0.0004) and were signifi- cantly less likely to have discussed work and education related concerns than the Presenting Problems age groups of 30 years or younger (19.7% vs. 41.8%; p=0.007). On the other hand, first Reasons for calls have been classified into time and several time callers were signifi- 13 categories as shown in Table 2. Top five cantly more likely to have discussed grief presenting problems were: 1) mental health and loss issues in the calls compared to issues (82.1%; 95% CI [75.9%, 88.3%]); 2) frequent callers (34% vs. 8%, p = 0.004).

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Table 2: Presenting problems of callers in descending order (N=151).

Presenting problem categories n (%) Mental health issues 124 (82.1)

Family/partner relationship issues 71 (47.0)

Communication and related difficulties 68 (45.0)

Peers/friends/employer and other relationship issues 50 (33.1)

Work and education related concerns 40 (26.5)

Grief and loss 34 (22.5)

Physical health concerns (eg, diabetes, obesity etc.) 29 (19.2)

General enquiries 29 (19.2)

Practical help/requests 19 (12.6)

Abuse and violence 8 (5.3)

Drug and alcohol and other addictions 3 (2.0)

Suicide related issues 2 (1.3)

Sexual health concerns 2 (1.3)

Details of Mental health issues Proportions of calls (%) Stress 43.1

Depression 31.1

Loneliness 28.5

Anxiety 27.2

Lack of confidence 22.5

Psychiatric/mental health problems 15.2

Self image 11.9

Phobia/fear 5.3

Disordered anger/violence 2.0

Details of Family/partner relationship issues Proportion of calls (%)

Family (extended and in-laws) 31.1

Relationship breaking up 12.6

Marital/de facto 9.3

Parent/child 8.6

Romantic/emotional/sexual 7.3

Divorce/separation 6.6

Boy/girlfriend 5.3

Extramarital relationship 2.7

Single parent 0.7

Blended family 0.0

Former spouse 0.0

Adopted parent/child 0.0

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Figure 1: Proportion of number of presenting problems identifi ed in a call conversation (N=151).

younger compared to if the caller was older Outcome and than 30 years (p=0.002); and if the caller evaluation of the calls was a fi rst time or several times caller, Outcome of the calls compared to if the caller was a frequent caller (p=0.02). They were less likely to be Counsellors were asked to record the satisfi ed with their part of the call if rela- immediate outcomes of the calls. Overall, the tionship problems with people other than majority of the calls (n=92, 65%) ended after family/partner were discussed during the a clear decision in overcoming the issues conversation (vs. if not) (p=0.008); and if was made by the caller, with help from the physical problems were discussed during counsellor. Out of these, only fi ve calls were the conversation (vs. if not) (p=0.004). transferred/referred to other mental health or counselling services (including the two Length of calls and factors suicide-related issues calls); whereas the associated with it rest of the callers came up with a detailed Overall, half of the calls were between self-care plan. However, the remaining 5–30 minutes (50.7%; n=73). There were 35% of calls had no clear decisions made by 11.8% (n=17) of very short calls (ie, 0–5 the end of the calls; and the reasons were minutes) and 10.4% (n=15) of very long calls either because the calls were interrupted which were over 60 minutes. by somebody else from the caller’s end and Table 4 presents the results of logistic ended unexpectedly, or the caller did not regression of factors associated with length feel like discussing the care plans at that of calls being more than 30 minutes. Length moment in time. of call was more likely to be longer than Helpline counsellors’ satisfaction 30 minutes if mental health issues were of the helpfulness of the calls and discussed during the conversation (vs. if not) associated factors (p=0.04); and if grief and loss issues were discussed (vs. if not) (p=0.01). Length of call Helpline counsellors’ satisfaction ratings was less likely to be longer than 30 minutes with the effectiveness of the calls were if communication and related diffi culties captured in 141 out of the 151 calls in the was discussed during the conversation (vs. sample. In total, they were satisfi ed with if not) (p=0.01). On the other hand, callers’ 109 (77.3%) of these calls. There were gender, age, frequency of contact and the several factors identifi ed, which infl uenced existence of any other common presenting their satisfaction (see Table 3). In particular, problems were not shown to signifi cantly the helpline counsellors were more likely to infl uence the length of a call (p>0.05 for be satisfi ed with the helpfulness of the call each of these). if the caller’s age was between 30 years or

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Table 3: Multiple logistic regression for factors associated with helpline counsellors’ satisfactions with the helpfulness of the Chinese Lifeline calls (N=80).

Factors OR (95% CI) p-value

Gender 0.27 Female Ref

Male 7.55 (0.17,334.01)

Age group 0.002 14–30 years Ref

30+ years 0.04 (0.003, 0.47)

Frequency of contact 0.02 First/several times Ref

Frequent caller 0.08 (0.009, 0.77)

Mental health issues 0.35 No Ref

Yes 0.31 (0.02, 3.97)

Family/partner relationship issues 0.45 No Ref

Yes 0.46 (0.06, 3.40)

Communication and related difficulties 0.10 No Ref

Yes 0.22 (0.03, 1.48)

Grief and loss 0.16 No Ref

Yes 0.24 (0.03, 1.76)

Physical health concerns 0.004 No Ref

Yes 0.03 (0.002, 0.46)

Practical help/requests 0.06 No Ref

Yes NA

suicide prevention helpline in UK were Discussion female. However, according to the Mental Firstly, the results indicated that Chinese Health and Addiction: Service use 2011/12 Lifeline is heavily dominated by female data,7 the overall age-standardised access clients (90%). This finding is quite similar rates to secondary mental health services to the mainstream or English speaking was actually higher in males (3851.5 per helpline services. For example, in 2008, 100,000 population) than females (3076.2 Lifeline Australia found that 76% of their per 100,000 population) in New Zealand. For callers were women,5 and Coveney et al6 the Asian population, the access rate is quite found that 78% of the callers to a national similar between females (938.5 per 100,000

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Table 4: Multiple logistic regression for factors associated with length of calls with Chinese Lifeline (N=88).

Factors OR (95% CI) p-value

Gender 0.69 Female Ref

Male 0.68 (0.11, 4.38)

Age group 0.62 14–30 years Ref

30+ years 1.45 (0.35, 6.01)

Frequency of contact 0.37 First/several times Ref

Frequent caller 0.51 (0.12, 2.25)

Mental health issues 0.02 No Ref

Yes 12.79 (1.02, 160.73)

Family/partner relationship issues 0.15 No Ref

Yes 3.21 (0.64, 16.02)

Communication and related difficulties 0.007 No Ref

Yes 0.19 (0.05, 0.70)

Grief and loss 0.007 No Ref

Yes 6.88 (1.48, 31.98)

Physical health concerns 0.20 No Ref

Yes 0.33 (0.06, 1.89)

Practical help/requests 0.40 No Ref

Yes 1.94 (0.41, 9.24) population) and males (969.0 per 100,000 receive support from mental health services. populations). Further, in the most recent However, males appear to be reluctant in Mental Health Annual report, released by approaching primary or community health the Ministry of Health in 2014,8 it highlighted services, such as counselling helplines, in that “approximately 3.3 times as many the early stages of their presenting issues. males as females died by suicide in 2011. Of As a result, these issues, if not dealt with, those service users who died by suicide in become more severe until they have to seek 2011, 24 percent were female and 76 percent help from secondary health services, or were male.”8 All of the data above suggests in some cases, results in suicide attempts. a need for males of any ethnic group to For community helpline services, such as

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Chinese Lifeline, the providers need to these cultural differences in order to provide consider how to promote the service to appropriate and responsive cultural support. males so that appropriate early interven- Next, although the study showed that the tions can be put in place, which is likely helpline counsellors were satisfied with the to reduce the need for secondary health calls most of the time, the study provides services further down the track. useful findings that are worth further inves- Secondly, our study shows that the callers tigation. The study indicated that the helpline of Chinese Lifeline often have multiple and counsellors may be less confident in dealing complex issues with their lives. Mental with callers who are over 30 years, frequent health and family relationship issues are callers or if the presenting problems were the top presenting problems and are likely related to relationship issues with people to be present at the same time. Inter- other than family/partner or physical health estingly, compared to English speaking issues. More work should be undertaken helpline services, Chinese lifeline has a in how to manage these cases more effec- much higher proportion of callers who tively. Recently, there have been quite a few are married (43.2%), while only 24% for research studies looking at regular/frequent Australia Lifeline.5 Furthermore, McNeil callers.11,12 However, most research focused found that people who are married expe- on exploring the characteristics of frequent rienced better mental health than all other callers, rather than finding a solution in marital status groups in Australia for both managing such callers more effectively. 9 men and women. However, the present Finally, the length of a call was more likely study found that the most common problem to be longer than 30 minutes if mental health with family/partner relationship issues of issues or grief and loss were discussed. At Chinese callers was, in fact, around extended Lifeline, the service sets the standard of ideal family and in-laws, and most of these callers maximum call length to 20 minutes, the red were married. This indicated that, compared flag length being 30 minutes or longer. This to Europeans, Chinese people, and perhaps is the standard brief intervention timeframe other Asian sub-ethnic groups, often face used across helplines internationally, which much more complicated family dynamics. increases efficiency and helps focus a call on Based on observations from the helpline the presenting issues. While it is important services, and due to cultural reasons, many to make sure that the counsellors are able Chinese people live with their parents and to guide the callers to focus on the present other extended family members, even after issues, it is also important to be aware that getting married. Therefore, when problems in Chinese cultures, people tend to avoid arise within the family, it is often multi-di- talking about mental health concerns. This is mensional, involving many people from because the expression of emotions and any different generations. As Chan and Parker deviation from social norms are markers of pointed out, what is very important to the incorrect social behaviour and could impact Chinese society is the collective sense of negatively on social harmony, hence stig- 10 wellbeing, rather than an individual’s. matised and shunned.10,13 This meant that Family (including extended and in-laws) Chinese callers may find it difficult to express is often considered the basic unit within a their true mental health issues in the first society. Especially given the service is for instance, but go around circles. Thus, it may those people who would like to receive be pertinent for the service to consider more tele-counselling in Chinese, it is believed that flexibility in call length given the complex the callers were more likely to be the first issues present within the Asian cultural generation of immigrants who grew up in context, especially where risk is present or China and therefore tended to have more complex mental health issues are involved. traditional beliefs and values. On the other There were a few limitations to this hand, their children might have grown up study. First, the study did not include any in New Zealand and therefore were more measurement of the effectiveness of the embedded with western culture. Thus, it service from the callers’ perspective because adds more complexity to the family issues it was not collected as part of the practice. of these Chinese families. The mental health Also, given the service is strictly anonymous, service providers need to be fully aware of it is not possible to send a survey to the

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callers either. Second, some of the calls in the service of a Chinese-specific tele-coun- sample might come from the same people, selling service in a Western country. The so there might be some clustering effects. service receives calls predominately from However, again due to the nature of the female callers (which is very common service, it is not possible to identify callers in similar helpline services), with a wide and thus interpretation of the findings should range of other demographics and with be based on calls rather than callers/indi- a large variety of presenting issues. The viduals. With appropriate ethic approvals majority of the calls ended with a definite obtained, further research could be done to decision made by the callers in solving their incorporate clients’ satisfactions or client’s problems. Additionally, the helpline coun- self-ratings of effectiveness by inviting the sellors were satisfied with the helpfulness callers to participate in a research study of the calls most of the time. There were at the end of calls and also explore better several important factors which influenced management of the regular callers. the counsellors’ satisfaction of the calls and In conclusion, this is one of the first the length of the calls. It is believed that studies in New Zealand, or perhaps inter- the implications of this study should not be nationally, to investigate the client profile, unique to Chinese Lifeline and it is gener- presenting issues and evaluating the alisable to other similar Chinese-specific helpline services.

Competing interests: Nil. Author information: Christine Yang Dong, Mental Health Research Team, Counties Manukau District Health Board, New Zealand. Corresponding author: Christine Yang Dong, Mental Health Research Team, Counties Manukau District Health Board, PO Box 74-010, Greenlane, New Zealand. [email protected] URL: https://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2016/vol-129-no- 1441-9-september-2016/7001

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REFERENCES: 1. Statistics New Zealand. Zealand. The International Australia. In: Australian 2013 Census ethnic Journal of Social Psychi- sociological association group profiles, http:// atry. 2006; 52: 408–412. conference, Newcastle, www.stats.govt.nz/ 5. Burgess N, Christensen Australia, 28 Novem- Census/2013-census/ H, Leach LS, et al. Mental ber-1 December 2011. profile-and-summary-reports/ health profile of callers 10. Chan B, Parker G. Some ethnic-profiles.aspx?re- to a telephone counsel- recommendations quest_value=24726#24726 ling service. Journal to assess depression (2013, accessed 7 of Telemedicine and in Chinese people in August 2014). Telecare. 2008; 14: 42–47. Australasia. Australian 2. Ho E, Au S, Bedford 6. Coveney CM, Pollock K, & New Zealand Journal C, Cooper, J. Mental Armstrong S, Moore J. of Psychiatry. 2004; 38: health issues for Asians Callers’ experiences of 141-147. doi:10.1111/ in New Zealand: A contacting a national j.1440-1614.2004.01321.x. literature review. suicide prevention help- 11. Spittal MJ, Fedyszyn Report for the Mental line. Crisis: The Journal I, Middleton A, et al. Health Commission, of Crisis Intervention Frequent callers to University of Waikato, and Suicide Prevention. crisis helplines: Who Hamilton, May 2003. 2012; 33: 313–324. are they and why do 3. Abbott MW, Wong S, 7. Ministry of Health. Mental they call? Australian Williams M, et al. Recent health and addiction: and New Zealand Chinese migrants’ Service use 2011/12. Journal of Psychology. health, adjustment to Wellington: Ministry 2015; 49: 54–64. life in New Zealand and of Health, 2014. 12. Leuthe J, O’Connor M. primary health care 8. Ministry of Health. Frequent callers and utilization. Journal of Office of the Director of volunteer crisis coun- Disability and Rehabili- Mental Health Annual sellors: Effective coping. tation. 2000; 22: 43–56. Report 2013. Wellington, Crisis Intervention 4. Kumar S, Tse S, Fernando Ministry of Health, 2014. 1980. 11:97–110. A, Wong S. Epidemiolog- 9. McNeil M, Baxter J, Hewitt 13. Yip KS. Chinese concepts ical studies on mental B. “In sickness and in of mental health: health needs of Asian health”: Marital status Cultural implications population in New and mental health in for social; 2005.

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Overview of the 2015 American Thyroid Association guidelines for managing thyroid nodules and differentiated thyroid cancer Bashar Matti, Ruben Cohen-Hallaleh

ABSTRACT The last few years have witnessed numerous publications addressing the management of thyroid nodules and differentiated thyroid cancers. The purpose of this review is to provide a simplified summary of the newly released guidelines by the American Thyroid Association. A systematic approach has been recommended to evaluate a thyroid nodule through clinical assessment, measurement of serum Thyroid Stimulating Hormone, neck ultrasonography and Fine Needle Aspiration where appropriate. This is followed by cytology analysis using the Bethesda scoring system to detect malignancy. Once diagnosed, thyroid cancers need to be staged and risk stratification needs to be applied to develop further treatment plans. Lastly, several recommendations have been presented to assure proper follow-up and support for thyroid cancer patients regardless of the treatment received.

Thyroid nodules are common clinical review will aim to provide an overview on presentations. The purpose of assessing and the main points of the 2015 guidelines using evaluating them is to detect the presence similar sections and recommendations or absence of malignancy, which occurs posed in the novel article. 1 in approximately 10% of all nodules. The Thyroid Nodule guidelines American Thyroid Association (ATA) has This section illustrates the steps in recently published clinical guidelines for management of thyroid nodules that the management of thyroid nodules and have been detected through palpation differentiated thyroid cancer (DTC) in or incidentally while investigating for adult patients.2 This extended document other illnesses. After careful history and consists of 101 recommendations that span clinical examination, serum Thyroid over more than 400 pages. ATA has imple- Stimulating Hormone (TSH) and ultraso- mented in these guidelines an evidence nography should be considered first when based approach in an attempt to answer the assessing a thyroid nodule.3 No role for variety of the clinically challenging ques- serum Thyroglobulin measurement and no tions related to this topic. Sixteen expert evidence to support the use of calcitonin personals were involved in interpreting serum levels at this stage.2 Nodules with and analysing the up-to-date information low TSH should proceed to have thyroid available on this subject over the course of scan (Iodine 123 or Technetium 99m). Hot two years. When compared to the previ- nodules are generally not cancerous and ously published guidelines in 2009, it need evaluation for hyperthyroidism while appears that there have been significant cold nodules have 5% chance of being changes with a number of new recommen- cancerous.3 Cold nodules and nodules dations added and others modified. This

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Table 1: ATA sonographic patterns of thyroid nodules with associated risk of malignancy and the recommendations for FNA.#

Sonographic Sonographic features Risk of malignancy Recommendation for FNA pattern High suspi- Solid hypoechoic nodule or solid hy- 70–90% FNA of nodules more than 1 cm in cion poechoic component of a partially cystic largest dimension otherwise repeat nodule with one or more of the following US in 6–12 months features: irregular margins, microcalcifi- (Strong recommendation) cations, taller than wide shape.

Intermediate Hypoechoic solid nodule without high 10–20 % FNA of nodules more than 1 cm, oth- suspicion suspicion features erwise repeat US in 12–24 months (Strong recommendation)

Low suspicion Isoechoic or hyperechoic solid nodule, or 5–10 % FNA of nodules more than 1.5 cm, partially (>50%) cystic nodule, with ec- otherwise repeat US in 12–24 months centric solid area without high suspicion (Weak recommendation) features

Very low Spongiform or partially cystic nodules <3 % • FNA or observe nodules more suspicion without high or intermediate suspicion than 2 cm in largest dimension. features • 1–2 cm nodules need repeat US in 2 years. • Less than 1 cm nodules require no intervention and no follow-up (Weak recommendation)

Benign Purely cystic nodules <1 % No FNA required but consider aspira- tion for comfort or cosmesis (Strong recommendation)

# adapted from the 2015 American Thyroid association guidelines 2

with Normal or elevated TSH results US guided, with preference to have should have a neck ultrasound (US) which on-site cytology interpretation (Strong involves thyroid and cervical lymph nodes recommendation). Repeatedly non assessment (Strong recommendation). diagnostic with high suspicion US, Fine Needle Aspiration (FNA) is the clinical risks for malignancy or procedure of choice in diagnosing thyroid growth in size of nodule requires cancer. Non-palpable, posterior thyroid surgical excision; otherwise close nodules or nodules with high cystic compo- observation can be considered (Weak nents should have FNA done under US recommendation). guidance. Table 1 illustrates the inter- 2. Benign cytology: (0–3% risk of malig- pretation of sonographic patterns, with nancy). No treatment or further estimated risk of malignancy and the recom- immediate investigations (Strong mendations for FNA associated with each.1,2,4 recommendation). Follow-up with Multi-nodular thyroid should be assessed in US and FNA in one year for high the same manner with consideration to each suspicion group, US only in 1–2 years nodule being a separate entity in the clinical for intermediate suspicion group evaluation.2,5 This is also true for assessment and US only in more than two years of thyroid nodules in pregnancy with the for low suspicion group. If repeated exception of the Iodine radionuclide scan US/FNA is benign then no further being contraindicated.2,6 follow-up will be required. Adequate Once FNA done, the results should be dietary iodine intake advised. interpreted using the Bethesda cytology 3. Atypia of Undetermined Significance reporting system. Management action post or Follicular Lesion of Undetermined cytology is listed below:2,7 Significance cytology (AUS/FLUS): 1. Non-diagnostic cytology: (1–4% (5–15% risk of malignancy). Surveil- risk of malignancy). Repeat FNA, lance, molecular testing or surgery

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can be considered on a case-by-case suspicious lymph nodes that are more than 8 basis (Strong recommendation). mm in diameter is strongly recommended.2,9 4. Follicular Neoplasm/Suspicious for Thyroglobulin (Tg) washout analysis of Follicular Neoplasm cytology (FN/ the FNA samples may provide additional SFN): (15–30% risk of malignancy). information in certain cases (inconsistent Surgery or molecular testing in sonographic and cytologic features, inade- low suspicion groups and carefully quate cytologic evaluation or cystic lymph selected low risk patients (Weak nodes) (Weak recommendation). Cross recommendation). sectional imaging (CT or MRI) with intra- venous contrast should also be considered. 5. Suspicious for Malignancy cytology However, FDG-PET and serum Tg or Tg anti- (SUSP): (60–75% risk of malignancy). bodies testing are not routinely needed prior Surgery is strongly recommended. to the surgery (Strong and weak recommen- Considering molecular testing dations respectively).2,10 Appropriate surgical only if it may change decision consent and preoperative examination and making regarding surgery (Weak assessment of voice should be performed.11 recommendation). Laryngeal exam (to detect vocal cord 6. Malignant cytology: (97– 99% risk of paralysis) should be considered when malignancy). Surgical approach is voice abnormalities noticed, thyroid cancer strongly recommended. with posterior extra thyroidal extension The introduction of molecular testing, or extensive central nodes involvement, such as BRAF mutation, in the diagnosis and or previous history of neck or upper chest prognosis of thyroid cancer is considered to surgery and where the recurrent laryngeal be a relatively new approach.8 ATA made two or vagus nerves could have been damaged strong recommendations which highlight the (Strong recommendation). importance of patient’s counselling and the When it comes to decision making consistency in laboratory techniques when regarding the surgical approach to DTC, ATA 2 molecular testing being utilised. However, makes the following recommendations:2 due to the lack of sufficient evidence and the I. Patients with cancer more than limited availability of this approach in New 4 cm in size, gross extrathyroidal Zealand and Australia, it will not be explored extension or clinical metastases any further in this article. to nodes or distant sites, should For cytologically indeterminate nodules (3, have total or near total thyroid- 4, 5 groups above), and when the decision ectomy. When the cancer is 1–4 cm has been made for surgical approach, in size, unifocal, without extrathy- 2,9 lobectomy is the surgery of choice. This roidal extension or metastasis, then is usually true unless the patient is at high lobectomy should be considered.12 risk for thyroid cancer where total thyroid- However, patients with advanced ectomy maybe preferential (large nodules age (>45), high surgical risk, previous more than 4 cm in any dimension, sono- history of head and neck radiation graphically suspicious, radiation exposure exposure or family history of thyroid history, familial thyroid cancer, positive cancer, are strongly recommended to molecular testing for cancer). It is also have total thyroidectomies. Finally, relevant here that for this group of patients, for cancerous nodules less than 1 clinical assessment is the main stem for cm, lobectomy is the recommended decision making and further investigations, approach (Strong recommendation). particularly with FDG-PET, are not rendered II. Completion thyroidectomy should be to be of benefit.10 offered for patients who underwent Initial management of lobectomy if the histopathological Differentiated Thyroid Cancer diagnosis suggests the need for it Operative intervention is the gold (Strong recommendation).13 Radio- standard for management of Differentiated active Iodine ablation cannot Thyroid Cancer (DTC).9 Multiple pre-oper- be considered as a substitute to ative measures should be considered. Neck surgery in this instance (Weak US and FNA sampling of sonographically recommendation).

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III. Therapeutic central node dissection represents a continuum, rather than a clear should be performed for all patients cut points, of disease recurrence values with central nodal involvement ranging from 1% in low risk to more than (Strong recommendation). Similar 50% in high risk individuals. Therefore, principle applies for biopsy proven individualised approach for interpreting malignant lateral lymph nodes since patient results, using the three tiers as a lateral compartment lymph node general guide, is highly recommended when dissection is needed. Prophylactic management decisions have been made. central node dissection is not routinely Also, the initial risk estimates for each recommended where no clinical patient needs continuous modification and lymph nodes involvement present. re-application throughout the follow-up However, weak evidence suggests period as new clinical materials arise. that this should be done for patients Following surgery for thyroid cancer, it is with papillary thyroid carcinoma, essential to monitor disease status. To do so, where there is lateral lymph nodes multiple investigations should be considered involvement or advanced primary such as serum thyroglobulin (Tg), neck ultra- tumour, ie clinical T3 or T4. sound and radioactive iodine (RAI) whole IV. Identification and preservation of body scan. In majority of patients, Serum Tg Recurrent Laryngeal nerve, External levels should be lowest 3–4 weeks post-opera- 2,15 branch of superior laryngeal nerve tively. In general, Serum Tg levels less than and parathyroid glands with their 1 ng/ml are associated with more favourable blood supply (Strong recommen- prognosis and further intervention may not dation).11 Nevertheless, only weak be needed. This is particularly true for Low evidence support the use of intra- and Intermediate risks groups. On the other operative neural stimulation where hand, value more than 10 ng/ml is usually feasible. associated with worse outcome and further treatment will likely be needed. RAI whole Post-operatively, staging and risk strat- body scan with or without SPEC-CT can be ification should be done in order to guide used when facing difficulties to establish the further management and predict disease extent of thyroid residual disease.16 outcome and prognosis. ATA guidelines endorse the use of the AJCC (American RAI therapy (remnant ablation or Joint Committee on Cancer) TNM staging adjuvant) and TSH suppression (using and the 2009 ATA Initial Risk Stratification thyroid hormone therapy Levothyroxine Systems.2,14 The latter provides additional L-T4), are considered the main treatment 2,14 advantage of predicting disease recurrence modalities after surgery. Despite the or persistence. In the 2015 guidelines, inconsistency of the evidence evaluated, ATA ATA suggests the addition of new prog- has made multiple recommendations about nostic variables such as mutational status the target levels for serum TSH. This has of cells when molecular testing applied, been summarised in Table 3. degree of lymph nodes invasion and RAI therapy has been the topic for many extent of vascular involvement to produce studies over the last decade.16 ATA suggests a “modified” initial stratification system that RAI therapy is not necessary for (weak recommendation with moderate level low-risk patients but strongly recommended of evidence). This information should be for high-risk group. Prior to RAI therapy accounted for in the histopathology report or scanning, thyrotropin stimulation by and according to that, ATA risk stratification levothyroxine withdrawal has been the gold system divides patient into three tiers: low, standard method as it improves the uptake intermediate and high risk. Table 2 illus- of iodine. The recommended TSH level trates the main features of each group, prior to RAI therapy is more than 30 mIU/L taking in consideration the modifications (weak recommendation due to results based introduced in the 2015 guidelines, with the on observational studies).2 Withdrawal associated risks of disease abstinence or protocols suggest stopping Levothyroxine recurrence that applies to each tier.2 When 3–4 weeks prior to RAI therapy. However, applying this risk stratification system, it if it was to be stopped for more than four is key to appreciate that these three tiers weeks, Liothyronine (L-T3) should be used

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Table 2: The 2015 ATA risk stratification system.#

ATA Risk Tier 2009 Features 2015 Modifications Risk: 1. NED$ 2. SI† LOW Papillary Thyroid Carcinoma (PTC) • For PTC, same features as 2009, AND no vas- 78–91% with complete resection, no local cular invasion AND Clinical N0 or pathologic 2–7 % invasion or distant metastasis, N1 with 5 or less lymphnodes (LN) involve- no aggressive histology AND no ments that are less than 0.2 cm in largest RAI avid metastases on the first dimension post-operative whole body RAI • Intrathyroidal, encapsulated follicular vari- scan (when performed) ant of PTC. • Intrathyroidal well differentiated Folicular Thyroid Carcinoma (FTC) with capsular inva- sion and No or minimum vascular invasion (less than 4 foci) • Unifocal or multifocal BRAF mutated intra- thyroid PTC less than 1 cm in size with No extrathyroidal involvement

INTERMEDIATE FTC or PTC with local microscopic • PTC with Clinical N1 or Pathologic N1 with 52–63 % invasion, Aggressive histology, more than 5 LN involved of less than 3 cm in 21–34 % vascular invasion AND/OR RAI avid largest dimension metastasis in the neck • BRAF mutated PTC that are 1–4 cm in size OR has extrathyroidal involvement

HIGH Gross extrathyroidal invasion • FTC with 4 or more foci of vascular invasion 14–31 % Incomplete resection • Pathologic N1 with LN size of 3 cm or more in 56–72 % Distant metastasis (clinical or largest dimension when Tg results suggestive of that)

# adapted from table 12 of the 2015 American Thyroid association guidelines 2 $ NED = No Evidence of Disease detected, † SI = Structurally Incomplete response to initial therapy

with the aim to stop the latter two weeks Thyrogen can be used in low and interme- prior to therapy (strong recommendation).17 diate risk groups with no evidence of distant Patients with any ATA risk category who metastases. However, no recommendations have significant physical or psychological were made regarding high risk group due to illness that would be exacerbated by hypo- lack of evidence.2 Patients should be advised thyroidism or could not illicit appropriate to have low iodine diet 1–2 weeks prior to endogenous thyroid stimulation response, therapy.16 The dose of RAI recommended should have recombinant human thyro- should correspond to the physiological tropin (Thyrogen or rhTSH) used as an status of patients (age, renal function, etc.) alternative to Levothyroxine withdrawal, and the extent of disease. Low risk groups in preparation for RAI therapy (strong should have doses as low as 30 mCI while recommendation).16,17 ATA also suggests that high-risk groups may dictate the use of a

Table 3: ATA recommendation of appropriate TSH suppression levels for each risk group during the initial treatment phase.#

Risk group TSH level (mIU/l) Quality of evidence High Less than 0.1 Moderate (Strong recommendation)

Intermediate 0.1–0.5 Low (Weak recommendation)

Low, post RAI ablation and serum Tg undetectable 0.5–2 Low (Weak recommendation)

Low with low level serum Tg, with or without RAI 0.1–0.5 Low (Weak recommendation) ablation

Low post lobectomy 0.5–2 Low (Weak recommendation)

# adapted from the 2015 American Thyroid association guidelines 2

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dose as high as 200 mCI.2,16,17 A post therapy b. In all the other groups (indeter- RAI scan is strongly recommended. Apart minate response, incomplete from RAI therapy and TSH suppression, response or High risk): More there is no role for other adjuvant systemic frequent neck ultrasound, serum therapy, neck radiotherapy or chemotherapy suppressed Tg, Tg antibodies and in the initial management of DTC.14 TSH testing with regular consider- Long-term cancer management ation of stimulated Tg analysis, cross sectional imaging, Whole body RAI guidelines scanning with or without SPEC-CT The aim of long term follow-up of thyroid and FDG-PET where appropriate. cancer after the initial treatment phase is to detect recurrence and monitor TSH c. When new lymph nodes detected on suppression. This is usually done by periodic ultrasound, those that are more than measurement of serum Tg, Tg Antibodies and 8 mm in size and suspicious should TSH.6,13,15 This ideally should be done using undergo FNA biopsy for cytology and the same laboratory assay technique that Tg assay (Strong recommendation). is calibrated against CRM457 standards.2,14 When positive for cancer, surgical The use of imaging modalities is governed dissection should be considered. by the clinical and biochemical findings of Non-suspicious or small nodes can each patient. The frequency of performing be monitored conservatively (Weak those tests depends on the ATA risk and the recommendation). response to treatment categories. Table 4 and d. In patients with structural or the following points illustrate the ATA recom- biochemical incomplete response, mendations in this regard.2,14 TSH levels should be kept below 0.1 a. In ATA low and intermediate risk mIU/l long term, unless significant groups who show excellent response contraindications present (Atrial to treatment: Serum Tg (stimulated fibrillation for instance). or supressed), Tg Antibodies and e. Patients with excellent or indeter- TSH testing in the first 6–12 months minate response to therapy who were then every 12–24 months thereafter in the low ATA risk group can have with no need to repeat stimulated Tg TSH levels at 0.5–2 mIU/L (strong testing. Neck ultrasound in the first recommendation). However, patients 6–12 months then every five years in the high ATA risk, then TSH level thereafter.18 should be maintained at 0.1–0.5 mIU/l (weak recommendation).

Table 4: Clinical response of differentiated thyroid cancer following initial therapy with thyroidectomy, with or with- out RAI therapy.#

Category Excellent Indeterminate Biochemical incomplete Structural incomplete Definition No evidence of Cannot confidently rule No localisable disease but Persistent or newly disease disease presence in/out suspicious biochemistry diagnosed disease

Imaging negative Non-specific/negative Negative Positive

Suppressed Tg <0.2 ng/ml <1 >1 any

Stimulated Tg <1 ng/ml <10 >10 any

Tg trend Persistently low Declining Persistent or rising any

Tg Antibodies absent Absent or declining Persistent or rising any level

Prognosis: 1–4% recurrence 15–20% recurrence 20% recurrence 11–50% death depen- Recurrence <1% death <1 % death <1% death dent on metastasis and Disease and extent of disease specific death

# adapted from table 13 in the 2015 American Thyroid association guidelines 2

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The ATA guidelines acknowledge the 5. In cases with bone metastasis, presence of different treatment options for bone-directed therapy with bisphos- recurrence and metastasis such as Radiof- phonate or Denosumab can be requency and thermal ablation, ethanol considered (Strong recommendation). injection of lymph nodes, Stereotactic radio- Outline of the differences between therapy and using lithium as an adjunct to iodine in RAI therapy.2,14 However, surgical the new (2015) and the old (2009) resection where possible and RAI therapy guidelines remain the gold standard.13,16 Patients who When looking back at the 2009 guide- undergo RAI therapy should have appropriate lines, we can see that ATA had generated 80 counselling with particular emphasis on recommendations, 103 subrecommenda- 14 potential complications, limitations and the tions and utilised 437 references. In 2015, need for ongoing treatment.18,19 Those patients 101 recommendations were published, 175 should have baseline blood count and renal subrecommendations and 1,078 references 2 function tests and pregnancy testing for were utilised. Numerous new recommen- women at child bearing age. Breastfeeding dations were associated with pre-operative women should not receive RAI and men communication and voice check, and receiving high doses should be counselled for the management of RAI refractory DTC. potential sterility. Since the risk for devel- Furthermore, new questions were answered oping secondary primary malignancy from such as the role of FDG-PET and Cross undertaking RAI therapy is small, additional sectional scanning in thyroid nodule assess- measures for secondary cancer screening is ments and the manner of histopathologic not needed apart from what is appropriate reporting of samples. A comment has also for that patient’s age. Surgical correction for been made regarding the lack of evidence problems arising from RAI therapy, such as to justify screening in people with familial nasolacrimal duct obstruction, should be follicular thyroid cancer. On the other hand, offered where appropriate.2 several parts have undergone significant changes. Reporting each section in the new RAI refractory DTC is defined as: 20 cases guidelines using the strength of recom- when the disease tissue does not accumulate mendation and the quality of associated iodine, loses the ability to accumulate evidence, where as in the 2009 version, they iodine, some parts accumulate iodine while used rating from (A) to (I). Sonographic eval- others do not, or metastasis continues to uation of nodules to the different subgroups, progress despite adequate RAI dosages. the use of FNA and the associated cytology In those instances, continuing to use RAI interpretation have been substantially therapy is strongly not recommended and changed. A more conservative approach the prognosis is considered unfavourable. has been adapted in 2015 towards smaller Treatment options include:2,20 nodules (less than 1 cm) and in surgical 1. Monitoring: mainly for cancers that approach in general (lobectomy rather than have slow progress rate, aggressive thyroidectomy for low risk cancers) when monitoring can be considered (Weak compared to 2009. The modified ATA strat- recommendation). ification system had a number of features 2. Directed therapy with surgery or introduced as previously mentioned. Target alternatives such as thermal ablation and diagnostic values for TSH and Tg assay or stereotactic radiotherapy (Weak respectively have also been revised. recommendation). 3. Referral for clinical trial, particularly Conclusion when considering using toxic agents The American thyroid association in which efficacy hasn’t been estab- has published new guidelines in the lished. (Strong recommendation). management of thyroid nodules and differ- 4. Systemic therapy such as kinase entiated thyroid cancer. These guidelines inhibitors and cytotoxic chemo- are evidence based and have been generated therapy with adequate patient after careful consideration of variety of counselling and appropriate surveil- experts’ opinions and current literature. lance for potential adverse effects. Following the discovery of a thyroid nodule,

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multiple steps should be considered to regimen. One should always keep in mind appropriately assess the nature of this that these guidelines were found to aid nodule. This should eventually lead to an the clinician in decision making, not as a appropriate management plan to be put in replacement since treatment strategies must place with realistic yet effective follow-up be tailored for each individual patient.

Competing interests: Nil. Author information: Bashar Matti, Surgical Registrar, Auckland District Health board, Auckland City Hospital, Auckland, New Zealand; Ruben Cohen-Hallaleh, Surgical Fellow, Auckland District Health Board, Auckland City Hospital, Auckland, New Zealand. Corresponding author: Bashar Matti, Surgical Registrar, Auckland District Health board, Auckland City Hospital, 2 Park Rd, Grafton, Auckland 1023, New Zealand. [email protected] URL: https://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2016/vol-129-no- 1441-9-september-2016/7002

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thyroid cancer. Thyroid. effectiveness comparisons review of the literature. 2009;19(11):1167–214. of thyroxine withdrawal, J Clin Endocrinol Metab. 15. Polachek A, Hirsch D, triiodothyronine with- 2015;100(5):1748–61. Tzvetov G, et al. Prognostic drawal, and recombinant 19. Van Nostrand D. The value of post-thyroid- thyroid-stimulating benefits and risks of ectomy thyroglobulin hormone administration I-131 therapy in patients levels in patients with for low-dose radioiodine with well-differentiated differentiated thyroid remnant ablation of thyroid cancer. Thyroid. cancer. J Endocrinol differentiated thyroid 2009;19(12):1381–91. carcinoma. Thyroid. Invest. 2011;34(11):855–60. 20. Schlumberger M, Brose M, 2010;20(2):173–9. 16. Bal CS, Padhy AK. Elisei R, et al. Definition Radioiodine Remnant 18. Lamartina L, Durante and management of Ablation: A Critical C, Filetti S, Cooper DS. radioactive iodine-re- Review. World J Nucl Low-risk differentiated fractory differentiated Med. 2015;14(3):144–55. thyroid cancer and thyroid cancer. Lancet radioiodine remnant 17. Lee J, Yun MJ, Nam KH, Diabetes Endocrinol. ablation: a systematic et al. Quality of life and 2014;2(5):356–8.

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Amniotic fluid embolism after intrauterine fetal demise Karl Kristensen, Fali Langdana, Howard Clentworth, Chu Hansby, Paul Dalley

ABSTRACT We present a case of the successful treatment of severe amniotic fluid embolism in a 41-year-old woman undergoing emergency caesarean section at 36 weeks of gestation for placental abruption and intrauterine fetal demise. The treatment included prolonged cardiopulmonary resuscitation, emergency hysterectomy, re-operation with intra-abdominal packing and intra-aortic balloon pump insertion. The patient made a remarkable recovery and to date has minimal residual morbidity. Amniotic fluid embolism syndrome (AFES) is a rare and often fatal obstetric condition that remains one of the main causes of maternal mortality in developed countries. The incidence varies from 2 to 6 per 100,000 and suggested mortality rates exceed 60%.1–2 The classic triad of sudden hypoxia, hypotension and coagulopathy with acute onset during labour or immediately after delivery forms the hallmark of the AFES diagnosis, however AFES is primarily a clinical diagnosis of exclusion. We present a case of successful maternal outcome following severe amniotic fluid embolism after placental abruption and intrauterine fetal demise.

Following closure of the uterus, the Case Report patient went into sudden cardiac arrest A 41 year-old well woman (TM), gravida with pulseless electrical activity (PEA) on 5 para 4, was admitted with a small ante- the electrocardiogram (ECG). She was intu- partum haemorrhage at 36 weeks of bated and cardiopulmonary resuscitation gestation. (CPR) commenced. She also had severe hypertension of After around 28 minutes of CPR, TM 180/110 mmHg and mild tachycardia of 100 regained circulation but the uterus beats per minute (bpm). On examination remained hypotonic despite uterotonic her uterus was tender and firm. A bedside treatment and B-Lynch sutures and it was ultrasound scan revealed intrauterine fetal decided to perform a subtotal hysterectomy. demise with an anterior placenta clear of Haemodynamic instability persisted and due the cervix and a retro-placental haematoma. to rapid availability, an intra-aortic balloon On vaginal examination the presenting part pump (IABP) was inserted by the cardiotho- was high and the cervix was posterior and racic surgeon with immediate significant closed. Initial bloods showed creatinine improvement in cardiac function. 150µmol/L (normal range 55–73µmol/L) and At around 90 minutes, TM developed subtle signs of coagulopathy with fibrinogen severe disseminated intravascular coag- 1.5g/L (normal range 3–6.9g/L). ulation (DIC) and required re-operation This diagnosis was made of a placental with pelvic-abdominal packing, Flow-Seal abruption with renal failure and coagu- administration, and aggressive treatment lopathy and warranted urgent delivery. with blood products (12 units packed red An emergency caesarean section under cells, 3 units platelets, 12 units FFP, 6 units regional anaesthesia was favoured based cryoprecipitate) including recombinant on the urgency of the situation. Intra-op- factor VIIa as per recommendation from the erative findings included a Couvelaire transfusion medicine specialist. uterus. A stillborn female infant of 2.5 kg TM was transferred to ICU with the DIC was delivered with findings of a complete resolving in the ensuing 10 hours. The placental abruption.

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intra-abdominal packs were removed on We have found one previous report of the day three and TM was extubated on day successful use of IABP for AFE although it five. In total, TM was in hospital for five is a well-known and accepted treatment for weeks with acute renal failure requiring acute cardiogenic shock.3 The use of recom- dialysis, mild residual left ventricular binant factor VIIa for management of DIC failure but no residual neurological or is controversial and recommended for AFE cognitive morbidity. when the haemorrhage cannot be stopped by massive blood product replacement.4 Discussion Intra-abdominal packing has proven safe and effective in controlling major obstetric haem- The treatment of AFES is mainly orrhage and should be considered when supportive and associated with a high there is refractory massive bleeding from mortality rate. raw surfaces or suture-lines in complicated This case demonstrates that with effective obstetric or gynaecological operations.5 CPR combined with aggressive treatment We would also like to highlight the impor- with IABP and blood products, a favourable tance of a multidisciplinary approach for outcome with minimal degree of morbidity managing complicated clinical situations is possible even in a situation with and multiple specialty involvement was key prolonged CPR and DIC. in this woman’s remarkable recovery.

Competing interests: Nil. Author information: Karl Kristensen, Obstetrics and Gynaecology Consultant, Wellington Hospital CCDHB; Fali Langdana, Obstetrics and Gynaecology Consultant, Senior Lecturer, Wellington Hospital CCDHB and Otago University; Howard Clentworth, Obstetrics and Gynaecology Consultant, Wellington Hospital CCDHB; Chu Hansby, Obstetrics and Gynaecology Registrar, Wellington Hospital CCDHB; Paul Dalley, Anaesthetics Consultant, Wellington Hospital CCDHB. Corresponding author: Fali Langdana, Obstetrics and Gynaecology Consultant, Wellington Hospital, CCDHB, Senior Lecturer, Obstetrics and Gynaecology Department, Wellington School of Medicine, Otago University. [email protected] URL: https://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2016/vol-129-no- 1441-9-september-2016/7003

REFERENCES: 1. Clark SL. Amniotic fluid 3. Gallegos R, Clarke G, 2011 Dec;115(6):1201–8. embolism. Obstet Gyne- Bashor A, Abbottsmith doi: 10.1097/ col. 2014 Feb;123(2 Pt C. Successful Use of ALN.0b013e31821bd- 1):337–48. doi: 10.1097/ Intra-Aortic Balloon cfd. Review. PubMed AOG.0000000000000107. Pump in an Amniotic PMID: 21720243. PubMed PMID: 24402585. Embolism Case. Cath 5. Ghourab S, Al-Nuaim 2. Clark SL, Hankins GD, Lab Digest. Volume L, Al-Jabari A, et al. Dudley DA, et al. Amniotic 22 - Issue 5 - May 2014. Abdomino-pelvic pack- fluid embolism: analysis 4. Leighton BL, Wall MH, ing to control severe of the national registry. Lockhart EM, et al. Use haemorrhage following Am J Obstet Gynecol. 1995 of recombinant factor caesarean hysterectomy. Apr;172(4 Pt 1):1158–67; VIIa in patients with J Obstet Gynaecol. 1999 discussion 1167–9. amniotic fluid embolism: a Mar;19(2):155–8. PubMed PubMed PMID: 7726251. systematic review of case PMID:15512258. reports. Anesthesiology.

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Stroke Family/Whānau pilot project Roslyne McKechnie, Sylvia Hach, Dianne Roy, Allanah Harrington, Victoria Andersen

We read with interest the report of an been the focus of a pilot project run in audit carried out at North Shore Hospital’s collaboration with the Waitemata District stroke services by Yeo, Zhou and Ratnasa- Health Board (DHB). The Stroke Family/ bapthy (Vol 129, No 1431, 11 March 2016), Whānau project has been ongoing since which contributes valuable data with respect 2010. Phase one (2010–2011) surveyed to acute and inpatient care. This retro- health professionals and family/whānau of spective examination of case notes from 72 stroke survivors to ascertain information patients looked at five domains of care: case- and education needs through identifying mix, processes of care in the first 72 hours, current practice and resources, the appro- discharge results, therapy intensity and post priateness, accessibility, timelines and discharge community cares. information/knowledge gaps.4 Phase two The audit highlights changes in acute (2011–2015) was a longitudinal qualitative care delivery. Despite dedicated stroke study of the experience of living as a stroke beds at North Shore Hospital increasing family/whānau and aimed to provide new by 150% since the last audit carried out in understandings of the long-term expe- 2009/10, an important deficiency in ongoing riences and needs of extended family/ 5,6 treatment and rehabilitation of stroke whānau. Preliminary findings align with survivors, particularly after discharge, was other research completed both in New identified. There were significant delays in Zealand and overseas, and data analysis is access to community rehabilitation, espe- currently being completed. cially for physiotherapy and occupational As a result of the preliminary findings therapy when compared with Australian from phases one and two, which indicated and UK post-discharge stroke services. that improving education, support and We hope to add to this emerging outcomes for family/whānau will reduce discussion by signalling some recent the burden of stroke on individuals and the work undertaken as a trial of a stroke community, Phase three (2014–2017) of the navigator service. There are two points project was initiated. The overall hypothesis to consider from the published audit. was that provision of a stroke navigator Firstly we note the lack of ethnicity data. service would improve outcomes and This represents a problem in light of New quality of life for stroke survivors and their Zealand health statistics showing that family/whānau. Phase three included the incidence rates are increasing, particu- development of the stroke navigator role larly for Māori.1,2 The inclusion of ethnicity in consultation with various stakeholders. data in audits such as this is important Following this, the stroke navigator role was in understanding service provision and trialled in a small participant sample (n=7) the design of targeted services. Secondly, who received the intervention compared qualitative data about patient experience with a comparison group (n=4) over a and satisfaction regarding communication, six-month period. Consistent with the partnership, care coordination and physical recommendations of our Māori stakeholder and emotional needs3 are required in order group, we aimed to recruit 50% Māori, and to provide a complete picture of service we used a Māori stroke navigator supported provision. The gap we may be able to fill is by the He Kamaka Waiora team who are in addressing these two points. part of the Waitemata DHB. Both ethnicity and the provision of qual- Preliminary analysis of the recently itative data about patient experience have completed pilot has shown that the stroke

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navigator intervention provided support We anticipate that ongoing research for rehabilitation and focused on indi- within the Stroke Family/Whānau project vidual family/whānau needs. During initial will supplement the data gained from the consultation, health professionals expressed Yeo et al audit. An emphasis on individual concern that the navigator role could and family needs and preferences in accor- overlap with other roles within the stroke dance with commonly agreed guidelines for team. However this was not the case; the the continuation of rehabilitative services navigator filled identified gaps in service are crucial to ensure that the stroke survivor provision for stroke families in both inpa- maintains the gains achieved through inpa- tient and community services. tient rehabilitation.

Competing interests: Nil. Author information: Roslyne C McKechnie, Clinical Researcher, Health Care Practice Pathway, Unitec Institute of Technology, Auckland; Sylvia Hach, Senior Lecturer Clinical Research, Health & Commu- nity Network, Unitec Institute of Technology, Auckland; Dianne E Roy, Associate Professor, Health Care Practice Pathway, Unitec Institute of Technology, Auckland; Allanah Harrington, MClinNeuroscience, Clinical Researcher, Health Care Practice Pathway, Unitec Institute of Technology, Auckland; Victoria Andersen, Clinical Researcher, Health Care Practice Pathway, Unitec Institute of Technology, Auckland. Corresponding author: Roslyne C McKechnie, PhD, Clinical Researcher, Health Care Practice Pathway, Unitec Insti- tute of Technology, Auckland, New Zealand. [email protected] URL: https://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2016/vol-129-no- 1441-9-september-2016/7004

REFERENCES: 1. Dyall L, Feigin V, Brown treated in February 2016. Nursing Praxis in New P, Roberts M. Stroke: a In: Commission HQaS, Zealand. 2015;31(3):7–16. picture of health dispar- editor. Wellington NZ: 6. Fischer RE, Roy DE. Differ- ities in New Zealand. Health Quality & Safety ent folks, different strokes: Social Policy Journal of Commission; 2016. becoming and being a New Zealand. 2008:178+. 4. Roy DE, Gasquoine SE, stroke family. Kai Tiaki 2. Ministry of Health. Tatau Caldwell S, Nash D. Nursing Research. 2014;5. Kahukura: Maori Health Health professional and 7. Yeo J, Zhou L, Ratnasa- Chart Book 2015. In: family perceptions of bapathy Y. Stroke care Ministry of Health, editor. post stroke information. delivery at North Shore 3rd ed. Wellington, NZ: Nursing Praxis in New Hospital, Waitemata Ministry of Health; 2015. Zealand. 2015;31(2):7–24. District Health Board 2014. 3. Health Quality and Safety 5. Duthie AJ, Roy DE, Niven New Zealand Medical Jour- Commission New Zealand. EN. Duty of care following nal. 2016;129(1431):67–79 National patient survey: stroke: Family experiences Results for patients in the first six months.

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Riding in cars with boys, and girls, while smoking...in New Zealand Frank Houghton, Bruce Duncan, Diane O'Doherty Tobacco control has clearly been iden- international praise and recognition for tified by the Governments of both New being a global leader in tobacco control,11

Zealand1 and Ireland2 as major national Ireland’s similar achievements have been priorities. Given the significant toll on both largely overlooked.12 Ireland’s entrance onto morbidity and mortality arising from ciga- the global stage of tobacco control occurred rettes,3–8 ‘the deadliest artifact in the history in 2004 when it became the first country in of human civilisation’,7 such attention is the world to implement a national workplace to be commended. Such a focus is partic- smoking ban. New Zealand followed suit ularly laudable given the often successful approximately nine months later. subversive tactics routinely employed As can be seen from the examples of by Big Tobacco to undermine tobacco tobacco control activities introduced by 9–10 control. Both countries have set broadly New Zealand and Ireland outlined in Table similar targets for becoming smoke free (ie 1, the two countries have often been rela- having a smoking rate of less than 5%) with tively matched on this issue, with New Ireland’s official target for this achievement Zealand having led the field in earlier years. being 2020,2 with New Zealand following Both Ireland14 and Aotearoa/New shortly behind with a target date of 2025.1 Zealand15 are also currently in the process There are many similarities between of introducing plain packaging for ciga- Ireland and New Zealand including popu- rettes, an issue fraught with legal challenges lation size, English as the dominant spoken from the tobacco industry. language (both countries also have other Although there are encouraging trends, official languages as well), an economic smoking remains an issue in both coun- focus on both agriculture and tourism and tries. Results from the 2014/15 New Zealand historic links with Britain as well as other Health Survey indicate a current smoking cultural similarities and sporting interests. rate in the 15 years and over total popu- It has been suggested that although lation of 16.6% (18.2% among males and New Zealand has received significant

Table 1: Sample of comparable tobacco control activities in Aotearoa/New Zealand and Ireland by year.

Aotearoa/New Zealand13 Ireland12 1963—Cigarette advertising banned on radio 1971—Tobacco Advertising banned on television and television 1978—Tobacco Advertising banned on radio

1974—Health warning introduced on cigarettes 1979—Health warnings on cigarettes introduced (3 rotating warnings)

1988—Ban on tobacco sales to anyone under 16 1988—Ban on tobacco sales to anyone under 16 years years

1997—Ban on sales of cigarettes in packs of less 1988—Ban on sales of cigarettes in packs of less than 20 than 20

1997—Ban on sales of tobacco products to any- 2002—Ban on sales of tobacco products to anyone one under 18 years under 18 years (implemented 2007)

2004—Workplace smoking ban introduced 2004—Workplace smoking ban introduced

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15% among females), with notably higher children is already illegal in Australia and rates among Maori (38.1% overall) and a number of other countries. In 2007 the Pacific (24.7%) populations, and noticeably American Academy of Pediatrics adopted lower rates in Asian groups (6.4% overall).16 a resolution calling for all State and local Ireland’s smoking rate in 2014 was 21%, bodies to “support and advocate for changes although this rate may have continued to in existing and local laws and policies that drop. Between 2012 and 2014 Ireland expe- protect children from secondhand smoke rienced the highest reduction in the smoking exposure by prohibiting smoking in any rate of any country in the European Union, vehicle while a legal minor (under 18 years of from 29% to 21%.17 age) is in the vehicle”.21 Despite manifold similarities in tobacco Interestingly, although Ireland has control between Ireland and New introduced a legal ban on smoking in Zealand one glaring difference evident cars with children, it is notable that key relates to smoking in cars with children. stakeholders explain the impact of the

Ireland introduced a law (the Protection law in non- confrontational,22 moral, of Children’s Health [Tobacco Smoke in normative23 and educational terms.24 It Mechanically Propelled Vehicles] Act) could perhaps be argued therefore that banning smoking in cars with children on New Zealand’s current educational strategy 1st January 2016,18 just three months after to combat this issue is broadly similar to England and Wales introduced such a ban. Ireland. While educational strategies are New Zealand currently has no such ban undoubtedly important, given the signif- in place and does not overtly appear to in icant volume of evidence detailing the the process of introducing such legislative adverse effects and the vulnerability of protection for children. the population involved, the addition of a This absence is glaring given that the robust and immediate legislative approach negative impact of secondhand smoke will underline societal attitudes to the is now widely accepted and the impact protection of health in our children. of smoking in cars well researched. It is It is notable that wearing front seat belts perhaps ironic that some of the research became a legal requirement in New Zealand supporting the ban on smoking in cars with in 1975. From 1979, back seat belts had to children used internationally in campaigns be fitted in cars in New Zealand, with their by groups such as Tobacco Free Kids actually use becoming mandatory a decade later in originates in New Zealand.19 There would 1989.25 Few, if any, would now question the be popular support for such legislation: 97% wisdom of such legislation. Similarly now is of respondents in the New Zealand Health the time for action on the issue of smoking and Lifestyle Survey in 2014 agreed with in cars with children in New Zealand. The the statement “smoking in cars should be moral/ethical, health and economic argu- banned where children are in them”.20 ments behind such a move are unequivocal. Looking elsewhere internationally, it is A decade from now New Zealanders will perhaps notable that smoking in cars with undoubtedly ask “Why did it take so long?”

Competing interests: Nil. Author information: Frank Houghton, Public Health & Administration, Eastern Washington University, Spokane, US; Bruce Duncan, Medical Officer of Health, Hauora Tairawhiti, New Zealand; Diane O' Doherty, Department of Social Science, University of Limerick, Ireland. Corresponding author: Frank Houghton, Public Health & Administration, Eastern Washington University, 668 N Riverpoint Blvd., Spokane, US. [email protected] URL: https://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2016/vol-129-no- 1441-9-september-2016/7005

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REFERENCES: 1. New Zealand Government. Unabashed Triumph of 19. Edwards R, Wilson Government Response to Philip Morris. New York: N, Pierse N. Highly the Report of the Maori Vintage Books; 1996. hazardous air quality Affairs Committee on its 10. Michaels D. Doubt is associated with smoking Inquiry into the tobacco Their Product: How in cars: New Zealand industry in Aotearoa Industry’s Assault on pilot study. the N Z Med J. and the consequences of Science Threatens Your 2006;119(1244): U2294. tobacco use for Maori. Health. Oxford: Oxford 20. Li J, Newcombe R, Walton Wellington: New Zealand University Press; 2008. D. Responses towards Government; 2011. 11. McCool J, Bullen C. additional tobacco 2. Department of Health. “Punching above its control measures: data Tobacco Free Ireland-Re- weight”: why New Zealand from a population-based port of the Tobacco must maintain leadership survey of New Zealand Policy Review Group. in global health. N Z Med adults. N Z Med J, Dublin: Department J. 2011;124(1345):64–8. 2016;129 (1428): 87–92. of Health; 2013. 12. Studlar DT. Punching 21. American Academy of 3. WHO. Report on the Above Their Weight Pediatrics. Resolution Global Tobacco Epidemic, Through Policy Learning: on Secondhand Smoke 2008: The MPOWER Tobacco Control Policies a exposure of Children package. Geneva: World in Ireland. Irish Political in Vehicles (Resolution Health Organization; 2008. Studies. 2015; 30(1): 41–78. #LR2, (06) - 2006/2007 Annual Leadership 4. Öberga M Woodward A, 13. The Smokefree Coalition. Forum) January 21, 2007. Jaakkolac MS, Perugad The history of tobacco A, Prüss-Ustüne A. control in New Zealand. 22. Gleeson C. Will the ban Global estimate of the Accessed on 13th July on smoking in cars with burden of disease from 2016 at: http://www.sfc. children work? The Irish second-hand smoke. org.nz/infohistory.php. Times; 19th December Geneva: WHO; 2010. 2015. Accessed on 13th 14. McDonald H. Ireland July 2016 at: http:// 5. Lim SS et al. A compar- passes plain packaging www.irishtimes.com/ ative risk assessment bill for cigarettes. The news/crime-and-law/ of burden of disease Guardian; Tuesday 3rd will-the-ban-on-smok- and injury attributable March 2015. Accessed ing-in-cars-with-chil- to 67 risk factors and on 13th July 2016 at: dren-work-1.2471685 risk factor clusters in https://www.theguard- 21 regions, 1990–2010: ian.com/world/2015/ 23. O’Regan E. James Reilly: a systematic analysis mar/03/ireland-pass- gardai won’t have to for the Global Burden es-plain-packaging-bill-cig- police smoking ban in of Disease Study 2010. arettes-smoking-tobacco cars with children. Irish Lancet. 2012; 380: 2224–60. News; 25th March 2014. 15. Plain Packs New Zealand. Accessed on 13th July 6. World Health Organiza- Accessed on 13th July 2016 at: http://www. tion. WHO Report on the 2016 at: http://www. independent.ie/irish-news/ Global Tobacco Epidemic, plainpacks.org.nz/. 2013: Enforcing bans james-reilly-gardai-wont- 16. Ministry of Health. Annual on tobacco advertising, have-to-police-smoking- Update of Key Results promotion and sponsor- ban-in-cars-with-chil- 2014/15: New Zealand ship. Luxembourg: World dren-30121427.html Health Survey. Wellington: Health Organisation; 2013. 24. McEnroe J. Ban on Ministry of Health; 2015. 7. Proctor RN. The history smoking in cars carrying 17. European Union. Attitudes of the discovery of the children. Irish Examiner; of Europeans towards cigarette-lung cancer 12th January 2013. tobacco and electronic link: evidentiary tradi- Accessed on July 13th 2016 cigarettes. Special tions, corporal denial, at: http://www.irishex- Eurobarometer. 2015; 429. global toll. Tobacco aminer.com/ireland/ Control 2012; 21:87–91. 18. Meikle J. Motorists ban-on-smoking-in-cars- alerted over upcoming carrying-children-219402. 8. Glantz SA, Slade J, Bero ban on smoking in cars html LA, Hanauer P, Barnes to prevent surge in fines. DE. The Cigarette Papers. 25. Automotive News. Seat- The Guardian; 11th Berkeley: University of belts: 50 years on in NZ August 2015. Accessed on California Press; 1996. they are still saving lives. July 13th 2016 at: https:// Accessed on 13th July 2016 9. Kluger R. Ashes To Ashes. www.theguardian.com/ at: http://www.automotive- America’s Hundred- society/2015/aug/11/motor- news.co.nz/industry-news/ Year Cigarette War, the ists-alerted-ban-smoking- seatbelts-50- years-nz- Public Health, and the cars- prevent-surge-fines saving-lives-5812

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A continuation of 10% annual tobacco tax increases until 2020: Modelling results for smoking prevalence by sex and ethnicity Frederieke Sanne van der Deen, Nick Wilson, Tony Blakely

On 26 May 2016 the New Zealand to project future smoking prevalence for Government announced it would continue a continuation of annual 10% tobacco its programme of annual 10% tobacco tax tax increases until 2020 compared to increases from 2017 to 2020 inclusive. the business-as-usual trends (albeit with Since 2010, the Government has increased the tax increases that have occurred to tobacco tax by 10% each year, albeit with a January 2016). Briefly, this model is built higher increase in 2010 (all above a routine in Microsoft Excel and includes a base and annual inflation adjustment). Tobacco tax forecasting model using demographic and is the single most effective tool used by mortality data for New Zealand. In the base governments to prevent young people from model recent annual trends in smoking taking up smoking and reducing current uptake and cessation by sex, age and smoking rates, while simultaneously bene- ethnicity were ‘solved’ by using smoking fiting population health and generating prevalence data from the 2006 and 2013 large savings on healthcare spending.1–3 censuses. To project future smoking preva- Given this background we aimed to project lence in New Zealand by sex and ethnicity future smoking prevalence for Māori and under a series of annual 10% tax increases, non-Māori men and women under the four these baseline trends in prevalence were additional years of tobacco tax compared tweaked by using age group-specific tobacco to no continuation of this programme (ie, price elasticities (ie, responsiveness to tax tax increases to January 2016 only). This increases as observed in the past). We used letter extends previous work reported in an the following age group-specific tobacco online blog, that projected smoking prev- price elasticities derived from previous alence under the scenario of tax increases BODE3 tobacco tax modelling work: -0.38 until 2020 for specific ethnic groups only.4 (15–20 years), -0.29 (21–24 year olds), -0.19 In addition, in this letter, we also aimed (25–34 years), and -0.10 (35+ years).2 The to discuss how such a programme could applied tobacco price elasticities were be enhanced by using collected tobacco scaled up by 20% for Māori as done in tax revenue to fund tobacco control activ- previous BODE3 tobacco tax modelling ities, and the need for the NZ Government work.1 There is some international evidence to explore more novel (and substantive) suggesting greater tobacco price elasticities measures to increase the chances of among low-income populations,3 and as achieving its Smokefree Nation 2025 goal. such one would expect higher price elas- ticities among Māori. While there is no Methods direct evidence of greater responsiveness to tobacco price increases among Māori, there We used a peer-reviewed dynamic is some indirect evidence from an experi- tobacco forecasting model5,6 that itself mental study,8 and some parallel evidence was initially derived from a published from a study suggesting greater sensitivity Australian model.7 This model was used to food pricing policies among Māori.9

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Figure 1: Daily adult smoking prevalence projections for Māori and non-Māori men under two tobacco taxation scenarios (annual tobacco tax increases until January 2016 only and also ending in January 2020).

produce further reductions in smoking Results rates to 17.0% and 17.6% for Māori men and Our model projects that a continuation women by 2025 and to 8.3% and 6.1% for of 10% tax increases from 2017 to 2020 non-Māori respectively. Furthermore, the inclusive will see daily adult smoking prev- additional four rounds of tax increases have alence rates reduce to 20.7% and 22.1% for the potential to reduce the absolute ethnic Māori men and women and to 10.2% and gap in smoking prevalence observed in New 7.7% for non-Māori men and women by Zealand by nearly one percentage point in 2020 (see Figures 1 and 2). These compare 2025 (eg, from 9.6% to 8.7% for men and to projected smoking rates of 22.0%, 23.5%, from 12.4% to 11.5% for women). 10.6% and 8.0% for Māori and non-Māori men and women respectively if such a Discussion programme had not continued beyond January 2016. Assuming a continuation A continuation of the programme of 10% of baseline trends in smoking uptake annual tobacco tax increases was predicted and cessation after 2020 was projected to to see tobacco smoking rates reduce further, but not sufficiently to achieve a below 5%

Figure 2: Daily adult smoking prevalence projections for Māori and non-Māori women under two tobacco taxation scenarios (annual tobacco tax increases until January 2016 only and also ending in January 2020).

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smoking prevalence for Māori or non-Māori Vietnam).10,11 Indeed, it seems unethical men and women by 2025. Yet there is for the New Zealand Government to not uncertainty around the stability of tobacco provide smokers with more motivation to prevalence elasticities into the future as they quit and more direct support to quit when it may increase with tobacco reaching higher is dealing with a highly addictive substance. prices, or increase with changes in access (The argument about smokers paying their to nicotine-containing electronic cigarettes way or not is not directly relevant when (both of which would probably favour a democratically-elected government has larger smoking reductions than we project). opted for a Smokefree Nation goal. Also There may also be various tipping points the issues are very complex and not all for higher quit rates as smoking becomes are easily quantifiable: health costs from more denormalised in New Zealand society smokers and non-smokers harmed by or psychologically significant prices are second-hand smoke (SHS), superannuation achieved (eg, the “$30” per pack threshold). costs, nuisance impacts from SHS and envi- Conversely, others have argued that the ronmental impacts such as tobacco-related effect of tobacco taxation may be under- litter and fires.) mined by a growing illicit tobacco market. Also this and past New Zealand modelling But in our past modelling we have shown work2,6,12 strongly suggest that the need for that even a substantial growth in the illicit further intensification of existing tobacco market had little impact on overall popula- control measures or completely novel 2 tion-wide prevalence of tobacco smoking. measures remains. More incremental While a continuation of the 10% annual measures such as the proposed law on plain tobacco taxation programme is a solid step packaging, expansion of smokefree areas forward towards the NZ Government’s (including a law for smokefree cars) and Smokefree 2025 goal, such a programme more mass media campaigns (especially could be enhanced by dedicating some of targeted at Māori and Pacific audience) the collected tobacco tax revenue to fund remain worthwhile. Novel measures, and tobacco control activities. This revenue potentially more substantive in terms of could particularly fund additional cessation reducing smoking, that the New Zealand support services and mass media campaigns Government could explore include the targeting low-income smokers who may be tobacco-free generation idea (thereby disproportionally affected by tax rises if essentially preventing new generations they continue to smoke. Earmarking tobacco from becoming addicted to tobacco13) or tax for tobacco control is already common a substantive reduction in the number of practice in various jurisdictions overseas tobacco retail outlets (which is currently (eg, Iceland, California, Switzerland, estimated at around 6,000 outlets12).

Competing interests: Nil. Author information: Frederieke Sanne van der Deen, Public Health, University of Otago, Wellington; Nick Wilson, Public Health, University of Otago, Wellington; Tony Blakely, Public Health, University of Otago, Wellington. Corresponding author: Frederieke Sanne van der Deen, Public Health, University of Otago, Wellington. [email protected] URL: https://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2016/vol-129-no- 1441-9-september-2016/7006

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REFERENCES: 1. Blakely T, Cobiac LJ, 5. Ikeda T, Cobiac L, Wilson 9. Ni Mhurchu C, Eyles H, Cleghorn CL, et al. Health, N, Carter K, Blakely T. Schilling C, et al. Food health inequality and What will it take to get prices and consumer cost impacts of annual to under 5% smoking demand: differences increases in tobacco tax: prevalence by 2025? across income levels and Multistate lifetable model- Modelling in a country ethnic groups. PLoS ONE ing at a country level. PLoS with a smokefree goal. Tob 2013;8(10):375934. Med 2015;12(7):e1001856. Control 2015;24:139–145. 10. Chaloupka FJ, Yurekli A, 2. Cobiac L, Ikeda T, Nghiem 6. van der Deen FS, Ikeda T, Fong GT. Tobacco taxes N, Blakely T, Wilson N. Cobiac L, Wilson N, Blake- as a tobacco control Modelling the implications ly T. Projecting future strategy. Tob Control of regular increases in smoking prevalence to 2012;21:172–180. tobacco taxation in the 2025 and beyond in New 11. World Health Organiza- tobacco endgame. Tob Zealand using smoking tion. WHO report on the Control 2015;24:154–160. prevalence data from global tobacco epidemic, 3. International Agency the 2013 census. N Z Med 2015 - raising taxes on for Research on Cancer. J 2014;127(1406):71–79. tobacco. Geneva, Swit- Effectiveness of tax and 7. Gartner CE, Barendregt zerland: World Health price policies for tobacco JJ, Hall WD. Predicting Organization; 2015. control. Lyon, France: the future prevalence 12. Pearson AL, van der Deen International Agency for of cigarette smoking in FS, Wilson N, Cobiac L, Research on Cancer; 2011. Australia: how low can Blakely T. Theoretical 4. van der Deen FS, Wilson we go and by when? Tob impacts of a range of N, Blakely T. Continuing Control 2009;18:183–189. major tobacco retail outlet annual tobacco tax 8. Grace RC, Kivell BM, reduction interventions: increases: New modelling Laugesen M. Predicting modelling results in a of the likely impact. Public decreases in smoking country with a smoke- Health Expert. https:// with a cigarette purchase free nation goal. Tob blogs.otago.ac.nz/pubheal- task: evidence from an Control 2015;24:32–38. thexpert/2016/05/28/ excise tax rise in New 13. Berrick AJ. The tobac- continuing-annual-tobac- Zealand. Tob Control co-free generation co-tax-increases-new-mod- 2015;24:582–587. proposal. Tob Control elling-of-the-likely-impact; 2013;22:i22–i26. 28 May 2016.

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Perspectives of New Zealand health professionals and smokers on e-cigarettes Trish Fraser, Nigel Chee, Murray Laugesen

Using an e-cigarette (vaping) that the smokers, Māori were the priority group contains nicotine (nicotine e-cigarettes) is because of high smoking rates.9 1 estimated to be 95% safer than smoking Table 1 shows the characteristics of 2 and can help people stop smoking. participants. However, in New Zealand the Ministry of Health does not recommend nicotine e-cig- Table 1: Characteristics of participants (N=28) arettes to quit smoking3 and e-cigarette users (vapers) can only purchase nicotine Health professionals Number for e-cigarettes online. Occupation Aukati Kai Paipa* providers 3 Vaping has grown rapidly in New General Practitioners 3 Zealand4 with most smokers trying e-ciga- rettes out of curiosity (49%) and desire to General Practice Nurses 2 quit smoking (37%).5 Low socio-economic Quitcard* Providers 2 smokers (mainly Māori and Pacific) are interested in nicotine e-cigarettes as a stop Quitline Advisers 2 smoking aid.6 Gender Female 10 Public health researchers and advocates in New Zealand and around the world are Male 2 divided in their views of the likely impact Ethnicity Māori 3 of nicotine e-cigarettes, for example, will (multiple they re-normalise smoking, be a gateway to NZ European 8 7–8 response) smoking and continue addiction? Indian 1 The rationale for combining health British 1 professionals and smokers in this study was to seek both groups’ views of nicotine e-cig- Age range 26-35 5 arettes, as health professionals have a key 36-50 3 role helping smokers stop smoking. 51-60 4

Methods Smokers This qualitative study was conducted in 2014 in Wellington, Otago and Southland. Gender Female 12 We conducted in-depth, semi-structured Male 4 interviews with 12 health professionals from Ethnicity Māori 9 a range of health professions involved in (multiple helping patients or clients stop smoking, and Pacific 2 held three focus groups with a total of ten responses) NZ European 7 smokers. Focus groups were our preferred method of interviewing but due to perceived Age range 16–35 9 difficulties recruiting health professionals to 41–55 4 these groups, we conducted interviews with them. We also had to interview six smokers 61–70 3 to reach our required number for the study. * Aukati Kai Paipa—a Māori smoking cessation programme Budgetary constraints and researchers’ past * Quitcard—prescription for subsidised nicotine experience determined sample sizes. Among replacement therapy

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Interview schedules guided interviews Most health professionals would be and focus groups beginning with the distri- hesitant to recommend nicotine e-cigarettes bution of participant information sheets, to their patients or clients as a first option to consent forms and questions seeking gender, stop smoking, however they would support age, ethnicity and knowledge of nicotine those who wished to use them. e-cigarettes. Sample e-cigarettes and bottles “I would probably inform them of of liquid (with and without nicotine) other ways of stopping smoking… start were shown to the participants. The lead with something else, then move onto researcher then demonstrated how to vape them [nicotine e-cigarettes]." Quitcard using an e-cigarette without nicotine. (prescription for subsidised nicotine Data collected were transcribed. A general replacement therapy) provider. inductive approach was utilised to analyse Most participants wanted better access to the data because it allows themes to emerge nicotine e-cigarettes albeit with a range of 10 and can produce reliable findings. Content restrictions. analysis was carried out. The Ministry of Health, Health and Discussion Disability Ethics Committee received our Concerns and contested evidence about application for ethics review but deter- nicotine e-cigarettes are reflected in this mined further consideration was not study, particularly among health profes- required for this study. sionals.7 However, there is little evidence that any of these concerns have much Results validity.1 Accurate information about Emergent themes on nicotine e-cigarettes nicotine e-cigarettes would help health were: lack of knowledge, less harmful than professionals and smokers make informed smoking, helpful for quitting, some personal decisions about their use. and population health concerns, support use Smokers wanting to try nicotine e-ciga- if smoker chose them and better access with rettes to quit smoking may not be getting some restrictions. clear advice from health professionals. Most participants (health professionals Reasons could be a combination of a and smokers) in this study self-reported not lack of knowledge about them, mixed knowing much about e-cigarettes. All, except messages in the media and medical one health professional, agreed nicotine journals, and cautionary advice from the e-cigarettes would probably be helpful as a Ministry of Health3 and the World Health quit smoking aid, and all thought they would Organisation.8 be less harmful than smoking. This was a small qualitative study and “You’ve got to add it up… I’m sure you does not purport to represent the views would be better off smoking an e-cigarette of all health professionals and smokers in [than a cigarette].” Smoker. New Zealand. A strength of the study is that Vaping with nicotine to stop smoking was it was the first time health professionals’ more acceptable to several of the health views of nicotine e-cigarettes have been professionals than as an activity to replace studied in New Zealand. smoking. Some health professionals had We recommend that the Ministry of concerns about continuing addiction to Health review personal and population nicotine and re-normalisation of smoking benefits of nicotine e-cigarettes and any due to increased vaping and the uptake of regulations that might be required if nicotine e-cigarettes by young people and nicotine for e-cigarettes were to be made non-smokers. Smokers did not generally available in New Zealand. share these concerns.

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Competing interests: Nil. Acknowledgements: We thank all the participants in this study. The study was funded by the New Zealand To- bacco Control Research Tūranga: A programme of innovative research to halve the smoking prevalence in Aotearoa/New Zealand within a decade. The Tūranga is supported through funding from the Reducing Tobacco-related Harm Research Partnership, co-funded by the Health Research Council of New Zealand and the Ministry of Health of New Zealand (HRC grant 11/818). We are grateful to Associate Professor Marewa Glover and Professor Chris Bullen for advice for the duration of the study. Author information: Trish Fraser, Director, Global Public Health, Glenorchy; Nigel Chee, Executive Chair, Inspir- ing Limited, Auckland; Murray Laugesen, Director, Health New Zealand, Christchurch. Corresponding author: Trish Fraser, Director, Global Public Health, Glenorchy. [email protected] URL: https://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2016/vol-129-no- 1441-9-september-2016/7007

REFERENCES: 1. Royal College of Physi- 4. Wilson N, Edwards R, product in general. Aust cians. Nicotine without Hoek J, Thomson G et al. N Z J Public Health. smoke: Tobacco harm Potential new regulatory 2014;38(6):524–8 doi: reduction. London: options for e-cigarettes 10.111/1753-6405.12283 RCP, 2016 https://www. in New Zealand. N Z Med 8. World Health Orga- rcplondon.ac.uk/ J. 2015;128(1425):88–96 nization. Electronic projects/outputs/ 5. Li J, Newcombe R, Walton nicotine delivery systems. nicotine-without-smoke-to- D. The prevalence, Report by WHO. 21 July bacco-harm-reduction-0 correlates and reasons 2014 http://apps.who. Accessed 28 July 2016 for using electronic int/gb/fctc/PDF/cop6/ 2. McRobbie H, Bullen cigarettes among New FCTC_COP6_10-en.pdf C, Hartmann-Boyce Zealand adults. Addict Accessed 28 July 2016 J, Hajek P. Electronic Behav. 2015;45:245–251 9. Ministry of Health. cigarettes for smoking doi: 10.1016/j. Tobacco use 2012/13: New cessation and reduction. addbeh.2015.02.006 Zealand health survey. Cochrane Database Syst 6. Glover M, Fraser T, 2014. Wellington: Ministry Rev. 2014;(12) CD010216 Nosa V. Views of low of Health http://www. doi: 101002.14651858. socio-economic smokers: health.govt.nz/publication/ CD010216.pub2 what will help them tobacco-use-2012-13-new- 3. Ministry of Health. Advice quit? Journal of Smoking zealand-health-survey on the use of e-cigarettes. Cessation. 2012;7(1):1–6 Accessed 28 July 2016 Updated 10 September 7. Li J, Newcombe R, 10. Thomas D. A general 2015. http://www.health. Walton D. The use of, inductive approach for govt.nz/our-work/ and attitudes towards, qualitative data analysis. preventative-health-well- electronic cigarettes and American Journal of Eval- ness/tobacco-control/ self-reported exposure uation. 2006;27(2):237–246 advice-use-e-cigarettes to advertising and the Accessed 28 July 2016

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Does smoking cessation prior to elective spinal surgery lead to long-term smoking abstinence Bruce Hodgson, Chris Hanrahan, Vivian Cuthbertson

Smoking is a major health hazard.1 It is While the short term benefits of smoking well known that there is a significant link cessation and surgical outcome have been between smoking and surgical complica- well documented in the literature,2,3,4,5,6,7 tions.2,3 The rate of complications are twice little is known about long-term cessation as high in patients who continue to smoke rates in patients required to stop smoking post-operatively. Of importance, those before major elective spinal surgery. patients that stop smoking before surgery It was for this reason that the current are more likely to maintain abstinence audit was carried out. The project received 2 post-operatively. full approval from the Ethics Committee, In 1996 our group noted that clinical Mercy Hospital, Dunedin. outcomes following elective spinal The senior author’s medical records surgery were inferior in those patients from 2008 to 2012 (inclusive) were used to who continued to smoke despite being identify those patients that were smoking advised not to. We therefore commenced when the decision was made to proceed an enforced smoking cessation programme with surgery. for elective spinal surgery. The Australian We decided to review patients that and New Zealand College of Anaesthetists had been discharged from follow up for recommended cessation of smoking six a minimum of 12 months in order to weeks prior to elective surgery to reduce reduce the possible impact of the surgeon’s peri-operative complications.5 We chose influence and the enforced requirement to this time interval to be consistent with stop smoking. their guidelines. An initial request to take part in the At the time of the consultation to decide audit was mailed to selected patients about surgery, patients were counselled informing them of a telephone interview about smoking and associated compli- within two weeks. cations. They were informed smoking cessation was required a minimum of In the five years outlined (2008 to 2012 six weeks prior to their surgery. Patients inclusive), 1,161 patients underwent were advised that if they were smoking elective spinal surgery of which 180 (15.5%) at the time of hospital admission, their were noted to be smokers. These patients surgery would be cancelled. Patients were sent the letter of survey request; 106 were instructed to seek help for smoking patients responded. Of those, 16 refused to cessation with their general practitioner or participate in an interview. other agency.11 The consultation to confirm 90 patients were interviewed by tele- surgery, as well as the six-week smoking phone (55 males/35 females). cessation requirement, included oral and 60 (40 males/20 females) had recom- written informed consent. Copies of these menced smoking. notes were sent to referring general prac- 30 (15 males/15 females) had remained titioners, colleagues and other agencies abstinent. where applicable.

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Thus, of the group interviewed, one to 25–30%. Of interest, in our study, only third (33%) of patients remained abstinent 52% of patients stated they sought help with following surgery (28% if those that smoking cessation. refused the interview were presumed to The MoH web site notes, on average, be smokers). We noted females rather than smokers have 14 attempts at cessation males had a greater tendency to remain before success. It is clear then that the abstinent (43% vs 27%). enforced requirement to stop smoking Long-term cessation rates referred to by before elective spinal surgery in our study the New Zealand Ministry of Health (MoH) was a powerful “one off” motivator. web site as published by the Cochrane Elective spinal surgery in New Zealand 4,10 Library extend to six months duration. is usually funded by ACC, health insurers In our study, we noted 72% of the smoking or in public hospitals by the Crown. It is group had recommenced within the first important that tax-payer funded surgery is year post-surgery. By two years 89% had carried out to avoid complications, reduce returned to their habit. costs and enable the greatest utilisation of We therefore consider six-month follow scarce public resources. It is our belief that up of smoking cessation rates to be too an enforced smoking cessation programme short and of little relevance. Long-term before elective surgery should become a follow up to confirm sustained smoking standard of care for admission to hospital. abstinence should, at the very least, be a A determined, unrelenting approach is minimum of two years. important. “If you don’t stop smoking, you Cahill et al4,10 indicates long-term cessation don’t get surgery”. is best achieved with “combined therapy”, While smoking is a person’s freedom of namely medication and supportive coun- choice, smoking cessation prior to surgery selling sessions. This approach has been is not a moral or ethical dilemma but one of shown to improve six month cessation rates patient safety.9

Competing interests: Nil. Author information: Bruce Hodgson, Marinoto Clinic, Mercy Hospital, Dunedin; Chris Hanrahan, Orthopaedic Department, Mercy Hospital, New Zealand; Vivian Cuthbertson, Orthopaedics Department, Mercy Hospital, New Zealand. Corresponding author: Bruce Hodgson, Marinoto Clinic, Mercy Hospital, 72 Newington Avenue, Dunedin, New Zea- land [email protected] URL: https://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2016/vol-129-no- 1441-9-september-2016/7011

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REFERENCES: 1. The New Zealand Cochrane Database System 8. Yoon V, Maalouf NM, Guidelines for Helping Review: May 2015. Sakhee K. The Effects People to Stop Smoking: 5. Australian and New of Smoking on Bone New Zealand Ministry Zealand College of Metabolism: Osteoporosis of Health, 6 June 2014. Anaesthetists Guidelines International; August www.health.govt.nz on Smoking as Related 2012, Volume 23, Issue 2. Glassman SD, Anagnost to the Peri Operative 8: pp2081–2092 SC, Parker A, Burke D, Period; PS 12 September 9. Canale ST, Kelly FB, Johnson JR, Dimar JR 2014. http://www.anzca. Dougherty K: Smoking (2000). The Effect of edu.au/documents/ Threatens Orthopaedic Cigarette Smoking and ps12-bp-2013-guidelines- Outcomes. AAOS Smok- Smoking Cessation on on-smoking-as-related-to-t ing Forum February 6, Spinal Fusion. Spine 6. The National Centre for 2012.www.aaos.org 25 (20):pp2608–2615 Smoking Cessation and 10. Ministry of Health (2014) 3. Lau D, Chou D, Ziewacz Training: United Kingdom: Tobacco Use 2012/13: New JE et al. The effects of 2012 www.ncsct.co.uk Zealand Health Survey, smoking on perioper- 7. Lee SM, Landry J, Wellington, New Zealand: ative outcomes and Jones PM, Buhrmanno, Ministry of Health. pseudarthrosis following Morley-Forster P. Long www.health.govt.nz anterior cervical corpec- Term Quit Rates after a 11. The Quit Group (2008). tomy. J Neurosurg Spine. Peri Operative Smoking How do Quitline Call- 2014:21(4):pp547–58 Cessation Randomised ers Compare with the 4. Cahill K, Hartmann-Boyce Controlled Trial: Annesth New Zealand Smoker J, Perera R: Can Incentives Analg 2015 March; Population? Wellington, help smokers to quit in 120 (3): pp582–7 New Zealand: The Quit the medium to long term?: Group.www.quit.org.nz

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Long-term aromatase-inhibitor therapy in breast cancer Treatment with an aromatase inhibitor for five years as up-front monotherapy or after tamoxifen therapy is the treatment of choice for hormone-receptor-positive early breast cancer in postmenopausal women. This study was designed to evaluate the benefits of extending treatment with letrozole to ten years. 1,918 women were randomised in this double-blind, placebo-controlled trial to receive 2.5 mg of letrozole or placebo for a further five years. The extension of treatment with an adjuvant aromatase inhibitor to 10 years resulted in significantly higher rates of disease-free survival and a lower incidence of contralateral breast cancer than those with placebo. Bone-related toxic effects were more frequently seen in those receiving letrozole. N Engl J Med 2016;375:209–19 Migraine and cardiovascular disease Is there an association between migraine and risk of cardiovascular disease in women? That is the question addressed in this prospective cohort study which reviews data from US Nurses Health Study. A total of 115,541 women aged 25 to 42 at baseline and free of angina and cardiovascular disease were included. The primary outcome sought was the incidence of major cardio- vascular disease. 15.2% of the women had physician-diagnosed migraine. The conclusions reached were that migraine was associated with an approximately 50% increased relative risk of major cardiovascular disease and an approximately 37% increased relative risk of cardiovascular disease mortality. An accompanying review notes the findings and speculates whether treatments decreasing the frequency and severity of the migraine would reduce the cardiovascular outcomes. The question also arises—should women with migraine be treated with statins or aspirin? BMJ 2016;353:i2610 and BMJ 2016;353:i2806 Effects of aspirin on risk and severity of early recurrent stroke after transient ischaemic attack and ischaemic stroke Aspirin is recommended for secondary prevention after transient ischaemic attack (TIA) or ischaemic stroke on the basis of trials showing a 13% reduction in long-term risk of recurrent stroke. However, several non-randomised observational studies have reported much higher reduction rates. This meta-analysis was planned to elucidate the issue. The researchers have pooled data for 15,778 participants from 12 trials of aspirin versus control in secondary prevention. They found that the risk of recurrent ischaemic stroke at six weeks was reduced by about 60%. This benefit continued up to 12 weeks but not after 12 weeks. The addition of dipyridamole to the aspirin did not improve results within 12 weeks but did reduce the risk after 12 weeks. The conclusions reached were “that medical treatment substantially reduces the risk of early recurrent stroke after TIA and minor stroke and identify aspirin as the key inter- vention. The considerable early benefit from aspirin warrants public education about self-administration after possible TIA.” Lancet 2016;388:365–75

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The therapeutics of cancer August 1916

Large rabbit being held by unidentified man. Whites Aviation Ltd :Photographs. Ref: WA-21625-G. Alexander Turnbull Library, Wellington, New Zealand. http://natlib.govt.nz/records/23209273

The “Medical Record” of April 8, 1916, discover exactly what it is that the labo- points out that the renewed interest in ratory is trying to bring about. For example, cancer which followed the discovery that while it has been discovered that mice can malignant growths can be transplanted be immunised with normal mouse tissues from one animal to another has extended against the inoculation of tumors, it has from the domain of experimental pathology been expressly stated by those best qualified to that of therapeutics, and no sooner is a to know that such treatment has no effect report issued from the laboratory than the upon transplanted tumors already estab- procedure is tried at the bedside. It is right lished. Now, as these are under relatively that this should be so, provided only inop- unfavourable conditions compared with erable cases are chosen, for in our efforts spontaneous neoplasms, being composed to control this dreadful scourge nothing of the cells of an animal other than that in which they are proliferating, while the must be left undone; the immediate and latter consists of cells of the animal itself, blind application of a method, however, is it is evident that transplantable growths not right. The attitude of the therapeutist should be much more easily cured than toward the laboratory should be as critical spontaneous; and yet even these inoculable as he can make it, in order that he may neoplasms cannot be healed at present. be in a position to select the most reliable Nevertheless, many attempts have been results for his clinical investigations; an made to cure spontaneous tumors in man, experiment, said a great investigator once, in spite of this distinction, by the injection is not necessarily scientific because it has of normal human tissues, generally in the been performed on a rabbit. form of extracts, although the laboratory has But even more important than this critical definitely explained that living and intact attitude should be one of endeavour to cells are necessary for the production of

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immunity; and not only have normal tissues cancerous organisms in the possession of been tried, but emulsions of living tumor some substance injurious to the cancer cells have been introduced, which, in several cell, or that it contains a ferment with the instances, have led to the production of new power of dissolving tumor cells. Frankel tumors at the point of inoculation. and Furer very wisely divorced themselves All this is not so much the fault of the from all theory, and set themselves the clinician, perhaps, as it is his misfortune, task of finding out simply whether foreign for he is no better able to judge between serum would or would not influence the conflicting laboratory reports than the growth of transplantable neoplasms. Mice experimental pathologist would be to bearing carcinoma or sarcoma were inoc- choose between two rival therapeutic ulated intravenously one or more times methods. On the other hand, pathologists with horse, goat, sheep, goose, rabbit, do not differ so greatly in opinion as the and guinea-pig serum, but in no case was contradictory nature of much of their the tumor definitely affected, although writing would suggest; a great deal of the amounts of from one-fortieth to one-twen- apparent disagreement is due to the fact tieth of the body weight were introduced. that it was not realised in the first few years In a few of the animals the rate of prolif- of cancer research that transplantable eration was somewhat retarded; but a tumors vary remarkably in such character- similar occurrence was noted in some of istics as type of growth, susceptibility to, the untreated controls. The experiments immunity, etc., and that in some of them have an important bearing upon the many even complete spontaneous disappearance attempts that have been made to influence is not an unusual occurrence in untreated new growths in the human subject by the animals. Frankel and Furer (“Wiener klin. injection of serum from adults or from Wochenschr.,” 1915, xxviii, 1433, and 1916, infants, the procedure being based, in the xxix, 63) have, therefore, performed a work latter instance, upon the false assumption of great value to both clinician and pathol- that because infants do not have cancer ogist in reviewing some of these earlier there must be some protective substance in conflicting findings in the light of our more their blood. recent knowledge. They have carefully In conclusion, it is necessary to point out investigated the question whether cell-free only that no authoritative cure of either juices from the tumors of rats and mice transplantable or spontaneous neoplasms have any immunising or therapeutic action in animals has yet been published, even in these animals, and have found that they the selenium cure, from which so much possess neither. was looked for in some quarters, having Their second paper is devoted to a been proved a complete failure. In man, discussion of the effect of foreign sera upon therefore, the surgeon still may, with more growing tumors, it having been assumed or less apparent justification, claim that the by various writers that the serum of a only hope of relief lies in early and complete normal individual differs from that of the surgical removal.

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Proceedings of the 233rd Otago Medical School Research Society, Summer Research studentship meeting 2016 Effect of DNA commonly influenced meth- The effects of bacterial methylation on ylation (including DNMT3A components on colonic TET1) were also investigated. expression of The expression of the selected stem cell proliferation. genes related to genes was measured using I van Hout,1 E Rodrigues,2 L Slobbe,1 PD-L1 expression quantitative real-time PCR M. Schultz,2 G Butt.1 in melanoma. and analysed using qPCR Department of Physiology, Otago data analysis software. Gene school of Medical Sciences1 J Quon, A Chatterjee, M Eccles. expression between cell-line and Department of Medicine,2 Department of Pathology, types was compared for any University of Otago, Dunedin. Dunedin School of Medicine, significant difference. It was The colon contains trillions University of Otago, Dunedin. also seen whether there was a of commensal microbes, which Melanoma, a significant relationship between the meth- are restricted to the lumen by cancer in New Zealand, ylation level and expression of the epithelial barrier. Balancing expresses the PD-L1 gene to the genes. stem cell proliferation and activate immune checkpoints Genes GATA4 (P=0.039, the apoptosis of mature cells, such as the PD-1 pathway to paired t-test), GNA14 (P=0.055), results in the turnover of the downregulate immune system TET1 (P=0.019) and DNMT3A epithelium every 3–5 days, activity. While anti PD-L1 (P=0.049) showed clear differ- which is important in barrier therapy has been promising, ences between inducible maintenance. Alterations in some patients do not respond and constitutive cell-lines. these processes can result in well to treatment. Currently, it While GATA4 and GNA14 are bacteria passing into the under- is not understood how PD-L1 genes that regulate PD-L1 lying tissue, potentially causing expression is regulated. Some expression from the gene body disease. This project aimed to melanoma cells naturally and promoter region, TET1 better understand colonic stem express PD-L1 (constitutive), and DNMT3A are genes that cell proliferation and how it is while some require a stimulus regulate DNA methylation influenced by its environment. such as interferon gamma outside of the gene. There was Human colonic organoids, (inducible). This report no significant relationship a 3D in vitro model of the examines if alteration in the between the methylation level epithelium, were used to DNA methylation of specific and relative expression of investigate proliferation via genes, which may increase GATA4 and GNA14 although 5-ethynyl-2´-deoxyuridine (EdU) or suppress the expression of this is likely due to the small incorporation into proliferating PD-L1, could explain this. If so, sample size. cells under normal conditions, such genes could be used as These results suggest the without the growth factors positive biomarkers for PD-L1 changes in DNA methylation of Wnt3A or LY2157299 and treatment. genes DNMT3A, TET1, GATA4 SB202190, with the addition Four PD-L1 inducible cell- and GNA14 may influence of the γ-secretase inhibitor lines were compared with four the expression of the PD-L1 N-[(3,5- Difluorophenyl) PD-L1 constitutive cell-lines gene and may be possible acetyl]-L-alanyl-2-phenyl] obtained from melanoma candidates for predictive glycine-1,1-dimethylethyl ester patients. A genome-scale biomarkers for PD-L1 (DAPT, 10µM) or in the presence methylation sequence was treatment response. of bacterial components used to select six genes that Supported by the Maurice and including lipopolysaccharide had significant methylation Phyllis Paykel Trust Summer (LPS), muramyl dipeptide differences between inducible Scholarship. (MDP), lipoteichoic acid (LTA) and constitutive cell-lines. and flagellin (all 20 ng ml-1). A further six genes that

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Findings showed immature resonance energy-transfer) tech- Arteriovenous (AV) fistula, spheroids consisted of 36% nology (developed by Promega formed by connecting a vein (n=21) proliferating cells, Corporation, Wisconsin, US) to an artery, allows vascular while in mature enteroids which had not previously been access for haemodialysis in only 6% were proliferating tested in one of the best-studied patients with kidney failure. (n=6, P<0.0001). Spheroids eukaryotic model organisms Vein suitability is determined were significantly affected Saccharomyces cerevisiae. by a patient’s vein diameter and by the removal of Wnt3A or The experimental approach vein’s ability to dilate, therefore LY2157299 and SB202190, was to clone plasmids in Esch- current protocol uses venous both decreasing proliferation erichia coli, and then isolate tourniquet to dilate veins prior to 8% (n=6, P<0.05) and 4% these plasmids and confirm to measurement. There is some (n=7, P<0.01), respectively. their sequence. The plasmids evidence to suggest that inter- The addition of DAPT, reduced encoded Cdr1p expression ventions other than tourniquet spheroid proliferation to 3% (n= cassettes with Cdr1p being may be more effective. This 6, P<0.001). Finally, proliferation tagged either with the novel project aimed to determine in spheroids decreased to 7% light-emitting bioluminescent whether 1) warm water bath, 2) (n=12, P<0.00001) when treated enzyme, NanoLuc luciferase, Bair Hugger (warm air through with LPS, 8% (n=8, P<0.001) with or with the acceptor fluoro- a jacket), or 3) handgrip exercise, the addition of MDP, 9% (n=13, phore, HaloTag-618. Expression was most efficient at dilating P<0.01) with the inclusion of cassettes were excised and used the cephalic vein, compared to LTA and to 6% (n=7, P<0.001) to transform S. cerevisiae. Yeast current practice in the Otago with the addition of flagellin. transformants were confirmed Vascular Lab (tourniquet). In contrast, no changes in the by DNA sequencing and Cdr1p All three interventions enteroids were seen upon dimerisation was investigated were tested on 12 participants environmental alterations. This by measuring energy transfer recruited from the dialysis unit, helps to better understand stem between NanoLuc and HaloTag, on three separate days. They cell proliferation in the human with each tag fused to a separate were compared with baseline colon, and how the epithelium Cdr1p molecule. Detection of after rest, baseline tourniquet, reacts to environmental change. energy transfer would indicate and the intervention with tour- Supported by a summer Cdr1p dimerisation, as the niquet to determine the most research scholarship from close proximity of the tags is effective mechanism. Baseline the Southern Victorian Chari- required for signal detection. The tourniquet (current protocol) table Trust and administered pump function of tagged Cdr1p and tourniquet following the by the Otago Medical Research constructs was characterised intervention was 50 mmHg for Foundation. by measuring the minimum 1 min. inhibitory concentrations of Water bath was the most Investigating Candida fluconazole required to inhibit efficient and effective method albicans Cdr1p the growth of S. cerevisiae strains. of dialing the cephalic vein, dimerisation with Functional over-expression of 16% (P<0.0001, repeated NanoBRETTM technology. the positive control construct, measures two-way ANOVA) Cdr1p tagged with a Nano- after 40 min with 1 min tour- A van Wichen, E Lamping, HJ Lee. Luc-HaloTag fusion, in S. niquet compared to current Sir John Walsh Research cerevisiae was achieved, with protocol of 1 min tourniquet. Institute, Faculty of Dentistry, strong BRET signals being Water bath also caused 50% of University of Otago, Dunedin. detected, demonstrating for participants with <3 mm with Candida albicans is a significant the first time that the novel the current protocol to reach cause of opportunistic infections NanoBRET technology can be threshold diameter after 10 min, which can become life-threat- used successfully in S. cere- and 75% after 40 min. These ening in immunocompromised visiae to study protein-protein participants would not have patients. Clinical isolates that are interactions. been put forward for AV fistula resistant to treatment with the Supported by a summer with current protocol. Hand widely-used antifungal fluco- studentship from the Southern exercise did not cause a signif- nazole often have resistance Victorian Charitable Trust, icant increase in vein diameter conferred by overexpression of administered by the Otago compared with current multidrug efflux pump Cdr1p. Medical Research Foundation. protocol, while Bair Hugger Despite the significance of Cdr1p caused 16% (P<0.0001) after 40 in the development of new anti- Water bath effectively min with tourniquet. fungal drugs and combination dilates veins to If water bath was used in therapy to combat C. albicans improve prediction clinical practice to measure vein drug resistance, little is known suitability before surgery, the about the structure and function of suitability for results suggest it would increase of this efflux pump. This study arteriovenous fistula. the number of patients put aimed to investigate potential L Smith,1 J Krysa,1 G Hill,1 K forward for AV fistula. AV fistula Cdr1p homo-dimerisation in Thomas,1 P Cessford.1 has a lower rate of complications live yeast cells, using the novel 1Department of Surgical Sciences, than other forms of haemodi- NanoBRET (bioluminescence University of Otago, Dunedin. alysis therefore the water bath

NZMJ 9 September 2016, Vol 129 No 1441 ISSN 1175-8716 © NZMA 108 www.nzma.org.nz/journal PROCEEDINGS

could improve overall outcomes each of the genes. Solubility of Zealand. A high infiltrate of T if these patients go on to form expressed protein was deter- cells within colorectal tumours successful fistulae. mined using sonication followed is associated with positive Supported by a Summer by centrifugation and sodium patient outcomes; however, the Student Scholarship from dodecyl sulfate polyacrylamide immune cell infiltrate has yet to the Otago Medical Research gel electrophoresis. Expressed be incorporated into traditional Foundation. protein was purified by staging methods of CRC, which strep-tag affinity and identified rely solely on tumour size and Expression, purification by mass spectrometry. Enzy- spread. The Immunoscore is and preliminary matic assays were completed a recently established method using a colorimetric based assay, which quantifies the infiltrate characterisation and preliminary crystallisation of T cells within the tumour and of a plant cysteine trials performed. has been proven to be a better dioxygenase. Optimal expression and predictor of patient prognosis solubility of PCO1 and PCO2 than current staging methods. BK Hayes,1 CG Davies,1,2 GNL was achieved at 18°C and 37°C, Preliminary experiments from Jameson,2 SM Wilbanks.1 respectively. Under nearly all our lab have identified that T 1 Department of Biochemistry, conditions investigated, an cells producing IL-2, a cytokine Otago School of Medical Scienc- important for T cell function, 2 expression time of six hours was es, Department of Chemistry, may have a prognostic role University of Otago, Dunedin. as effective as an expression time of 20 hours. PCO1 was in CRC. This study sought to Cysteine dioxygenase (CDO) is purified to homogeneity and this validate the predictive role of a non-heme, mononuclear-iron isoform was used for enzymatic IL-2-producing T cells in addi- enzyme responsible for the characterisation. Enzymatic tional patients with CRC. addition of molecular oxygen assays supported a K of 11±2 Immunofluorescence was to the thiol of cysteine residues. M mM for cysteine. Crystallisation used to quantify the frequency In plants this oxidation leads trials of PCO1 showed extensive and number of tumour infil- to decreased protein stability, precipitation without crystal trating IL-2-producing T cells promoting degradation of growth. Reducing protein (CD3+IL-2+) from formalin proteins that are required concentration may lead to the fixed, paraffin embedded only when the environment production of a crystal suitable tumour samples from early is depleted of dioxygen. This for x-ray diffraction. stage (II) CRC patients with facilitates both submergence-tol- recurrent (n=13) and non- erance and seed development, Overall, parameters for both recurrent disease (n=18) at the contributing to enhanced crop expression and purification invasive margin and centre of yield. In mammals CDO is were obtained and preliminary the tumour. involved in cysteine catabolism. characterisation of the enzyme Therefore, determination of its was achieved. These results give CRC patients with a high mechanistic activity may have a basis for further experimen- frequency (above median) of clinical relevance in a number tation and characterisation. IL-2-producing T cells in the of cysteine related disorders Supported by a summer invasive margin were associated including Alzheimer’s and research studentship from the with poor disease free survival Parkinson’s disease. Bioinfor- Department of Biochemistry. compared to patients with a low matic analysis shows that the frequency (below median) of active site of plant CDO differs Determining the role IL-2-producing T cells (Log rank from mammalian CDO even of tumour infiltrating test P=0.0456). However, the frequency of IL-2-producing T more so than that of bacterial IL-2 producing T CDO. Given this, plant CDO cells in the centre of the tumour offers a unique perspective on cells in patients with was not associated with disease the minimal requirements for colorectal cancer. free survival. CDO activity. This study aimed These results validated S Shen,1 ES Taylor,1 F Munro,2 JL to determine expression and previous findings from our lab McCall,2 KA Ward- Hartstonge,1 RA purification protocols to enable and indicate that the presence Kemp.1 plant CDO characterisation and of IL-2-producing T cells in the 1 comparative studies. Department of Microbiology and invasive margin of colorectal Immunology, Otago School of Medi- tumours may be predictive of Two plant CDO genes (PCO1 cal Sciences, 2Department of Surgical and PCO2) were expressed from Sciences, School of Medicine, Univer- disease relapse in patients with a pGS-21a vector in Escherichia sity of Otago, New Zealand. CRC. coli strain BL21(DE3). Optimal Colorectal cancer (CRC) Supported by an Otago temperature and expression is one of the most common Medical Research Foundation times for amount of expressed causes of cancer death in New Summer Studentship (SS). protein were established for

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NZMJ 9 September 2016, Vol 129 No 1441 ISSN 1175-8716 © NZMA 109 www.nzma.org.nz/journal