Journal of the New Zealand Medical Association Vol 132 | No 1499 | 26 July 2019 Older New Zealanders: addressing an emerging population of hazardous drinkers
Doctors’ rights to conscientiously object to refer patients to abortion service providers
Unplanned pregnancies of Subsequent injuries experienced What we know, and don’t women with chronic health by Māori: results from a 24-month know, about cannabis, conditions in New Zealand prospective study in New Zealand psychosis and violence Publication Information published by the New Zealand Medical Association
NZMJ Editor NZMA Chair Professor Frank Frizelle Dr Kate Baddock
NZMJ Production Editor NZMA Communications Manager Rory Stewart Diana Wolken
Other enquiries to: NZMA To contribute to the NZMJ, fi rst read: PO Box 156 www.nzma.org.nz/journal/contribute The Terrace Wellington 6140 © NZMA 2019 Phone: (04) 472 4741
To subscribe to the NZMJ, email [email protected]
Subscription to the New Zealand Medical Journal is free and automatic to NZMA members. Private subscription is available to institutions, to people who are not medical practitioners, and to medical practitioners who live outside New Zealand. Subscription rates are below. All access to the NZMJ is by login and password, but IP access is available to some subscribers. Read our Conditions of access for subscribers for further information www.nzma.org.nz/journal/subscribe/conditions-of-access If you are a member or a subscriber and have not yet received your login and password, or wish to receive email alerts, please email: [email protected] The NZMA also publishes the NZMJ Digest. This online magazine is sent out to members and subscribers 10 times a year and contains selected material from the NZMJ, along with all obituaries, summaries of all articles, and other NZMA and health sector news and information.
Subscription rates for 2019 New Zealand subscription rates Overseas subscription rates Individuals* $317 Individual $442 Institutions $549 Institutions $591 Individual article $30 Individual article $30
*NZ individual subscribers must not be doctors (access is via NZMA Membership) New Zealand rates include GST. No GST is included in international rates. Note, subscription for part of a year is available at pro rata rates. Please email [email protected] for more information. Individual articles are available for purchase by emailing [email protected]
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 2 www.nzma.org.nz/journal CONTENTS
EDITORIAL 43 8 Cost and resource implications Older New Zealanders: addressing of introducing intensive nodal an emerging population of surveillance for sentinel node hazardous drinkers positive melanoma in provincial Andy Towers, John McMenamin, New Zealand David Newcombe, Janie Sheridan, Joseph Winstanley, Emma Cervenak, Gillian White Christopher Harmston ARTICLES 49 How much rehabilitation are our 11 patients with stroke receiving? Unplanned pregnancies of women Stephanie Thompson, Annemarei Ranta, with chronic health conditions in Karen Porter, Naomi Bondi New Zealand Bryndl E Hohmann-Marriott VIEWPOINTS 18 56 Three-month use of idarucizumab Point-of-care testing governance at Christchurch Hospital through in New Zealand through the lens the emergency department and of quality: an update on a national MedChartTM regulatory framework Louisa J Sowerby, Jane Vella-Brincat Samarina MA Musaad, Geo rey CE Herd 23 64 Subsequent injuries experienced Doctors’ rights to conscientiously by Māori: results from a 24-month object to refer patients to abortion prospective study in New Zealand service providers Emma Wyeth, Michelle Lambert, Angela Ballantyne, Colin Gavaghan, Ari Samaranayaka, Helen Harcombe, Jeanne Snelling Gabrielle Davie, Sarah Derrett CLINICAL CORRESPONDENCE 36 An audit of patients with a 72 Resistant iron-induced diagnosis of idiopathic pulmonary hypophosphatemia following brosis (IPF) in Canterbury, colorectal surgery New Zealand Yu-Jen Chen, Christopher Lim, James Fulforth, Donna Thomson, Jacob McCormick Gordon Maxwell, Rachel Wiseman, Adrienne Edwards
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 3 www.nzma.org.nz/journal CONTENTS
LETTERS METHUSELAH 76 83 What we know, and don’t know, A randomised trial of prophylactic about cannabis, psychosis and antibiotics for miscarriage surgery violence Joseph M Boden, Janet K Spittlehouse 100 YEARS AGO 78 84 Sun protection policy in Myositis Ossi cans By New Zealand GORDON MACDONALD, M.D., Dunedin Ben Gray PROCEEDINGS 80 86 The thorny issue of alcohol The proceedings of the 243rd and control in Aotearoa/New Zealand: 244th meetings of the OMSRS developments in Ireland Frank Houghton
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 4 www.nzma.org.nz/journal SUMMARIES
Unplanned pregnancies of women with chronic health conditions in New Zealand Bryndl E Hohmann-Marriott Unplanned pregnancies can be a health risk for those with chronic health conditions such as diabetes, asthma and depression. In a study of about 7,000 pregnant women in New Zealand, I found that 15% had been diagnosed with a chronic health condition. Nearly half of the preg- nancies of these women with chronic health conditions were unplanned. This was higher than the number of unplanned pregnancies among women without chronic health conditions. Three-month use of idarucizumab at Christchurch Hospital through the emergency department and MedChartTM Louisa J Sowerby, Jane Vella-Brincat Idarucizumab is a high-cost medicine used to reverse the anticoagulant (anti-clotting) medicine dabigatran. We examined the use of idarucizumab from the emergency department and via the prescribing programme MedChart™. We looked at why it was being used and compared this to the national guidelines from PHARMAC and our own guidelines in Hospital HealthPathways. From 12 patients who received idarucizumab, all but one patient had idaru- cizumab prescribed for them according to both PHARMAC and local guidelines. The one exception had been a patient who had accumulated dabigatran in their body so there was high risk for the patient to have a bleed that could not be controlled. Subsequent injuries experienced by Māori: results from a 24-month prospective study in New Zealand Emma Wyeth, Michelle Lambert, Ari Samaranayaka, Helen Harcombe, Gabrielle Davie, Sarah Derrett Māori, the indigenous population of New Zealand, experience a disproportionate burden of injury compared to non-Māori. The impact of injury can be exacerbated by subsequent injuries, ie, injuries that occur after, but not necessarily because of, an earlier injury. Using interview, ACC and hospital discharge data, this study aimed to describe subsequent injuries experienced by Māori to determine: the number and timing of subsequent injury claims reported to ACC in the 24 months following an earlier injury; the proportions of Māori expe- riencing subsequent injuries; and the nature of subsequent injuries. Findings show that 62% of Māori participants who had already experienced a profound injury went on to experience a subsequent injury that reported to ACC within a 24-month period. This suggests that the subsequent injury burden for Māori is considerable, and that preventive opportunities are potentially being missed.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 5 www.nzma.org.nz/journal SUMMARIES
An audit of patients with a diagnosis of idiopathic pulmonary brosis (IPF) in Canterbury, New Zealand James Fulforth, Donna Thomson, Gordon Maxwell, Rachel Wiseman, Adrienne Edwards Idiopathic pulmonary fi brosis is a condition of unknown cause which results in progressive reduction in lung function causing breathlessness and often resulting in death. Historically, treatments have been ineffective, but newer agents have shown some promise. This paper highlights the estimated number of patients living with this condition and highlights ways in which resources could be better utilised to help them. Hopefully this may result in better overall care for patients living with this condition. Cost and resource implications of introducing intensive nodal surveillance for sentinel node positive melanoma in provincial New Zealand Joseph Winstanley, Emma Cervenak, Christopher Harmston Patients with melanoma skin cancer which has spread to their lymph glands are normally advised to have a further operation to remove these diseased glands. In the future, this will change because the second operation doesn’t make you live any longer. Instead, health boards will need to follow these patients with regular scans and clinic visits. Here we have calculated the fi nancial cost of this change. It looks to be affordable for the average provincial health board in New Zealand. How much rehabilitation are our patients with stroke receiving? Stephanie Thompson, Annemarei Ranta, Karen Porter, Naomi Bondi New Zealand community stroke rehabilitation guidelines identify how often and how soon after hospital discharge community rehabilitation should start. This service audit looked at how quickly after hospital discharge patients with stroke were seen by a Wellington-based community rehabilitation team, and how much rehabilitation they received in the fi rst four weeks and three months after discharge. We compared this to the guidelines and have made suggestions to improve the service.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 6 www.nzma.org.nz/journal SUMMARIES
Point-of-care testing governance in New Zealand through the lens of quality: an update on a national regulatory framework Samarina MA Musaad, Geo rey CE Herd Point of care testing (POCT) is testing outside of the main laboratory, like urine pregnancy testing at home and blood glucose testing at home for people with diabetes. These tests can be done by the patient or by a caregiver. The numerous POCT devices in the market means that without suitable advice and guidance, patients and healthcare workers who are not trained in laboratory medicine are at risk of purchasing devices that are not accurate or would not deliver what is medically (clinically) needed. Guidance should be provided at several levels, including: the government (Ministry of Health and Medsafe in New Zealand) through adequate regulation should provide devices that are safe and that are clinically fi t-for-purpose; funders should support government by ensuring that devices they fund are defensible and safe; healthcare providers, eg, pharmacists and doctors, should receive comprehensive training on all aspects of using the device and testing, then ensure that when they provide a device to a patient, the patient has been fully informed about all technical intricacies of testing, what a result means, possible sources of erroneous results and who to contact for help if needed; and fi nally patients should know their rights, ask questions and take responsibility for their health, devices they use and tests that they undergo. New Zealand is updating its laws that govern medical devices. The Therapeutics Products Bill 2014 was released for consultation by the Minister of Health in December 2018. It is expected that the Bill will ensure that the new laws will be aligned with International Standards but should consider the uniqueness of individual populations, the New Zealand population. The authors propose a vision that is consistent with the aims of the Bill and also supports safe and fi t-for-purpose POCT devices and tests are provided in New Zealand. Doctors’ rights to conscientiously object to refer patients to abortion service providers Angela Ballantyne, Colin Gavaghan, Jeanne Snelling Our paper critiques the current legal situation and standards of practice in New Zealand regarding doctors’ rights to refuse to refer patients for abortions and/or refuse to arrange for the patient to be seen by a colleague who will process the referral. Allowing providers to object to direct referrals, when one of their core professional obligations is to navigate patients through the health system, is one thing. But when providers object to making indirect referrals, and thereby fail to ensure the safe transfer of the patient to the care of a colleague, this amounts to abandoning the patient. We consider this ethical issue in the context of proposed abortion law reform in New Zealand.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 7 www.nzma.org.nz/journal EDITORIAL
Older New Zealanders: addressing an emerging population of hazardous drinkers Andy Towers, John McMenamin, David Newcombe, Janie Sheridan, Gillian White
recent Lancet article1 forecasts that, New Zealand has seen a year-on-year despite a reduction since the 1990s, doubling of addiction service users attending New Zealand’s per capita alcohol non-government organisations over the A 5 consumption is expected to increase over past decade. However, regional differ- the next decade. This contrasts with pre- ences in funding of addiction services mean dicted declines in Australia and the UK over that we cannot determine the degree to the same period. A critical question for New which the rise in addiction service use over Zealanders is ‘Who is driving this trend?’ this time refl ects rising use by a cohort of Both New Zealand and international data older hazardous drinkers. Our continued illustrate that those aged under 25 are not assumption that older adults are low-risk driving this trend. While those aged 25 and drinkers, our lack of understanding of their younger are still the age group with the need for addiction services, and the potential greatest proportion of hazardous drinkers, ageism in this sector underlines why the UK there have been with well-publicised reduc- Royal College of Psychiatrists identifi ed older tions over the past decade in rates of such adults as ‘our invisible addicts’.6 drinking in this cohort worldwide (including Rising alcohol use in older adults is in New Zealand), and this trend shows no concerning for a number of reasons. First, likelihood of stopping soon. Instead, New aging increases the risk of alcohol-related Zealand’s projected increase in alcohol use harms as we are less capable of processing over the coming decade is likely to be driven and diluting ethanol,7 so each drink is rela- by those aged 50 and over. tively more toxic to an older body. Second, Alcohol is still the drug of choice for research shows that—contrary to popular an ageing ‘Baby Boomer’ cohort. While belief—there are no health benefi ts of age-based alcohol legislation targeting youth moderate drinking for older adults specifi - is common (ie, purchase age restrictions; cally.8 In fact, alcohol use may best be seen zero blood alcohol limits for learner drivers), is a correlate—not a predictor—of health. few—if any—policy measures to limit alcohol Third, many older drinkers also use alco- availability for middle-aged and older adults hol-interactive medication for chronic are evident. Consequently, with the current health conditions, so almost 20% of older transition of boomers into ‘older adulthood’ adults may be at a serious risk of medica- the rate of older drinkers now consuming tion-alcohol interaction.9 In short, older alcohol at levels hazardous to their health adults are at considerably greater harm has signifi cantly increased,2 as has the rate from alcohol use than younger drinkers. of older adults with alcohol-related disorders In 2015, the New Zealand Health 3 and hospitalisations. Yet international Promotion Agency (HPA) funded a joint evidence shows that addiction services team from Massey University’s Health and (much like legislation) largely ignore older Ageing Research Team and the University 4 adults, indicating that our health systems of Auckland Centre for Addiction Research may not be prepared to cope with this demo- to explore drinking patterns, predictors graphic shift in alcohol consumption. and harms in older New Zealanders. This
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 8 www.nzma.org.nz/journal EDITORIAL
research illustrated that New Zealanders Health Board region where over half of all aged 50+ consume alcohol more frequently adults have had their alcohol use recorded and in higher quantity than their counter- in primary care in the last three years.12 10 parts worldwide. Furthermore, between New Zealand’s primary care sector thus 35–40% drink at levels hazardous to their illustrates capacity for alcohol screening, health due to the combination of drinking but the current screening approach is not patterns and comorbidities (eg, chronic sensitive to the alcohol-related risks faced health conditions and medications that may by a rising population of older drinkers. interact with alcohol) that raise the risk of A three-module HPA-funded pilot project 2 harmful outcomes. is now underway in Whanganui which is In addition to identifying key prevalence designed to assess a system that may work and risk factors for older drinkers, this within the clinical context of long-term HPA-funded research identifi ed two points conditions management. First, this project relevant for potential intervention with integrates alcohol-related risk factors from this population. First, many older drinkers a screening tool sensitive to older adults at-risk of alcohol-related harm would be within an e-screening process to auto- missed by standard screens focusing on matically identify those whose combined consumption only. Some of the most at-risk drinking, health and medication use place older drinkers in this research actually them at risk of harm. Second, this project consumed at low levels, but in combination integrates training in motivational inter- with chronic health conditions and medi- viewing based on Matua Raki’s Takitaki Mai cations that were all alcohol-interactive. guide to improve practitioner confi dence Second, regardless of whether they drank in initiating and managing alcohol-related or not, most older adults regularly saw their conversations with Māori and non-Māori GP and those at most risk of alcohol-re- populations. Third, a case study of the lated harms were actually more likely to development, initiation and outcomes of see their GP because of their comparative this pilot project will—if successful—offer a ill health. This highlights that primary blueprint for other district health boards to healthcare services are an essential point support the roll-out of this enhanced alcohol of intervention for the wider health system screening and management process for to engage with older drinkers, screen for older drinkers. potential risk and identify a pathway for The nature of alcohol use in New Zealand those in need of help. is changing. Youth, for a long time the Primary care in New Zealand has demon- focus of our attention, are reducing their strated the capacity to routinely ask about consumption. Conversely, older adults, long patient alcohol use and offer brief advice. assumed a population of low-level drinkers, A demonstration project implemented in now show a rise both in hazardous drinking general practices in the Whanganui region and alcohol-related risk. Our health system, in 2010 quickly achieved high rates of particularly primary care, needs to adapt to coverage with practices recording between this change. This requires not only asking 43% and 74% of adults’ alcohol use within older adults about alcohol but under- the fi rst 10 months of the project.11 This standing the degree to which even low-level coverage included up to 53% of Māori consumption patterns raise risk of harm for and 60% of New Zealand European/ those with comorbidities. This HPA-funded Pakeha attending practices. Subsequently, pilot is a fi rst step in the process. Changing this approach—called the Alcohol ABC our attitude towards, and understanding of, approach—has been used in a number alcohol use in later life is a culture change of New Zealand general practices, most that will take a lot longer. recently in the Counties Manukau District
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 9 www.nzma.org.nz/journal EDITORIAL
Competing interests: All authors report grants from Health Promotion Agency during the conduct of the study. Author information: Andy Towers, School of Health Sciences, Massey University, Palmerston North; John McMenamin, Health Solutions Trust, Whanganui; David Newcombe, School of Population Health, University of Auckland, Auckland; Janie Sheridan, School of Pharmacy, University of Auckland, Auckland; Gillian White, Health Solutions Trust, Whanganui. Corresponding author: Andy Towers, School of Health Sciences, Massey University, Private Bag 11222, Palmerston North. [email protected] URL: http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2019/vol-132-no-1499- 26-july-2019/7939
REFERENCES: 1. Manthey J, Shield KD, Rylett and Addiction: Service serious alcohol-medication M, Hasan OS, Probst C, Use 2015/16. Available interactions in communi- Rehm J. (2019). Global alco- online: http://www.health. ty-dwelling older adults: hol exposure between 1990 govt.nz/publication/ a prospective cohort and 2017 and forecasts mental-health-and-addic- study. European journal until 2030: a modelling tion-service-use-2015-16 of clinical pharmacology study. The Lancet. 6. Crome I, Brown A, Dar K, 2019; 75(4):569–575. 2. Towers A, Sheridan J, Harris L, Janikiewicz S, 10. Towers A, Sheridan J, Newcombe D, Szabo A. Rao T, Tarbuck A. (2011). Newcombe D. (2017). (2018). The prevalence Our invisible addicts: The drinking patterns of of hazardous drinking First report of the older older New Zealanders: in older New Zealand- persons’ substance misuse National and international ers. Wellington: Health working group of the Royal comparisons. Wellington: Promotion Agency. College of Psychiatrists. Health Promotion Agency. 3. Sacco P, Unick GJ, Kuerbis London: Royal College 11. Gifford H, Paton S, A, Koru AG, Moore AA. of Psychiatrists, 1. Cvitanovic L, McMenamin Alcohol-related diagnoses 7. Heuberger RA. Alcohol J, Newton C. Is routine in hospital admissions for and the older adult: a alcohol screening and brief all causes among middle- comprehensive review. intervention feasible in aged and older adults: Journal of Nutrition for the a New Zealand primary trends and cohort differ- Elderly 2009; 28(3):203–235. care environment? ences from 1993 to 2010. 8. Towers A, Philipp M, Dulin New Zealand Medical Journal of aging and health P, Allen J. The “health Journal 2012; 125:1254. 2015; 27(8):1358–1374. benefi ts” of moderate 12. Counties Manukau Health. 4. Wadd S, Dutton M. drinking in older adults (2018). Annual report 2018. Accessibility and suit- may be better explained Available online: http:// ability of residential by socioeconomic countiesmanukau.health. alcohol treatment for older status. The Journals of nz/assets/About-CMH/ adults: a mixed method Gerontology: Series B Reports-and-planning/ study. Substance abuse 2016; 73(4):649–654. Annual-reports-and- treatment, prevention, 9. Holton A, Boland F, plans/2017-18-CM-Health- and policy 2018; 13(1):49. Gallagher P, Fahey T, Kenny Annual-Report-Final- 5. Ministry of Health. RA, Cousins G. Longitudinal for-online-publication- (2018). Mental Health prevalence of potentially December-2018.pdf
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 10 www.nzma.org.nz/journal ARTICLE
Unplanned pregnancies of women with chronic health conditions in New Zealand Bryndl E Hohmann-Marriott
ABSTRACT AIM: Chronic health conditions can pose risks for pregnancy and childbearing which may be mitigated by preconception care and pregnancy planning. The objective of this study is to identify the proportion of pregnancies reported as unplanned among women in New Zealand with chronic health conditions and the co-occurrence of these pregnancies with socioeconomc disadvantage. METHOD: This study included 6,822 pregnant women in the Growing Up in New Zealand study. Nearly 15% identified a chronic health condition, including diabetes, heart disease, asthma, depression and anxiety. RESULTS: Pregnancies were reported as unplanned by 45% of women with chronic health conditions, as compared to 39% of women without these conditions. Among women with chronic conditions, those who identified as Māori or Pacific Islander reported two-thirds of their pregnancies as unplanned, and those who were younger, had less education, were lower-income or did not have a co-resident partner reported between 50–80% of their pregnancies as unplanned. CONCLUSION: Obstetricians and midwives in New Zealand should be prepared to provide care for women with chronic conditions who may have surprise pregnancies. Comprehensive family planning services, preconception care and systemwide reduction in health inequities are needed to help women with chronic health conditions enter pregnancy as healthy as possible.
n New Zealand, as in most low-fertility health. However, this ‘pregnancy planning countries, there has been an increase paradigm’ is problematic as it does not in the number of pregnant women with refl ect the thoughts, feelings or behaviours I 1,2 chronic health conditions. This is at least of many, perhaps most, women (Aiken et partly due to the rising age at childbear- al 2016). In New Zealand, a majority of ing.3 These conditions increase the risk of pregnancies are reported as unplanned,10 adverse events and outcomes during and suggesting that this is a normal part of life after pregnancy, including stillbirth, preterm for most women. Although planning may birth, Caesarean delivery, low birth weight not be necessary for most women, there or macrosomia, hypertensive and cardiac are some women for whom planning may complications, and postnatal depression.4–7 be benefi cial. Planning allows for precon- To address these risks, there is an increasing ception care, with unplanned pregnancies emphasis on preconception or interconcep- receiving less preconception and antenatal tion care for women with chronic health care.11 For women with chronic conditions, conditions.8,9 These forms of preconception preconception care may be able to decrease care are predicated on the pregnancy being their potential elevated risks. Therefore, planned. it will be useful to identify the extent of Planning pregnancy is often considered planning among women who may benefi t to be a necessity for increasing public from it.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 11 www.nzma.org.nz/journal ARTICLE
The extent of pregnancy planning among including diabetes, heart disease, asthma, women with a chronic health condition depression and anxiety. It leverages the in New Zealand is currently unknown. In unique capabilities of the Growing Up in Europe and the US, women with chronic New Zealand study to identify whether conditions do not appear to be planning unplanned pregnancies occur among their pregnancies any differently from women with chronic health conditions, women without chronic conditions. particularly if there is a co-occurrence of Women with diabetes, heart disease and socioeconomic disadvantage, asking: hypertension have the same number of 1. What proportion of pregnancies unintended pregnancies as women without among women with a chronic health 12 these conditions. Depression has also been condition is reported as unplanned? found to be associated with unplanned 2. For pregnant women with chronic pregnancies.13 Most young women with health conditions, which demographic diabetes are not practicing the full extent and socioeconomic characteristics of recommended pregnancy planning, co-occur with reporting their preg- including reproductive health consul- nancy as unplanned? tation and use of effective contraception if not intending pregnancy.14 Women with diabetes and hypertension may not be Method aware of the risks of pregnancy for women Data are from the antenatal wave of the with their condition, and do not consider Growing Up in New Zealand (GUiNZ) cohort preconception care a priority.15 Like other study, a nationally-representative sample women, women with chronic conditions of pregnant women due to give birth in may not have been using contraception 2008/2009.21 analysis uses the fi rst interview, because they believed that they would not conducted during the last half of pregnancy. become pregnant, did not consider using Chronic health conditions are identifi ed by contraception, or were dissatisfi ed with responses to a question asking the woman their method of contraception.16 Moreover, if she had an illness diagnosed by a doctor; their chronic condition could have made it these are coded as chronic if the respondent diffi cult to fi nd an effective contraceptive replied ‘before this pregnancy and during option.17 Because pregnancy planning is this pregnancy’. Illnesses include diabetes, complex and most studies do not consider heart disease or high blood pressure, the range of women’s experiences, there asthma, depression and anxiety or panic may be further variations among women.18 attacks. Planning is identifi ed by responses Ethnicity provides an important context to the question: “Did you plan this preg- for understanding the place of pregnancy nancy or was it a surprise?” and childbearing in family life. Planning Question 1 is answered using chi-square that focuses on behaviour and medical tests comparing the proportion of women intervention may hold a different meaning reporting planned and unplanned preg- among Pākehā (European New Zealand) nancies for the total sample, within women than among Māori and Pacifi c Island each chronic health condition, and for women.19,20 This diversity in experiences multimorbidity. of family life should be celebrated. Less Question 2 focuses on women with chronic positive, however, is that Māori and Pacifi c conditions, and uses chi-square tests to Island women face economic and health compare the proportion of women reporting disadvantages.2,10 The interdependent links planned and unplanned pregnancies between economic disadvantage, chronic by sociodemographic characteristics. health conditions and unplanned preg- Correlation analyses (not shown) confi rm nancies suggest a potential for exacerbation that all characteristics are highly correlated of health risks. with one another. The analysis of individual This is the fi rst New Zealand study to characteristics must thus be mindful that observe unplanned pregnancies among each of these characteristics is closely tied women with chronic health conditions, with all others.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 12 www.nzma.org.nz/journal ARTICLE
of unplanned pregnancies than women Results without these conditions. Women with Over 15% of the sample had at least one diabetes also had an elevated proportion chronic health condition, as shown in the with unplanned pregnancies, but due to the fi rst column of Table 1. The most frequently small number of women with this condition occurring condition was asthma, reported in the sample, the difference approached but by over 7% of the women, and the least did not reach conventional levels of signif- frequent was diabetes, reported by less than icance. When the 15% of women with any 1% of the women. Just over 2% of all women of the conditions are considered as a group, reported multimorbidity (more than one they report 44.4% of their pregnancies as condition), and of these 162 women, 81% unplanned. With this large group of women were diagnosed with depression, 64% with with a higher proportion of unplanned anxiety, 43% with asthma, 21% with heart pregnancies considered separately, women disease and 11% with diabetes. The presence without any of the conditions show a of these conditions among pregnant women smaller proportion with unplanned preg- differed by ethnicity, with signifi cant differ- nancies (38.7%). ences observed for all conditions except Characteristics associated with unplanned heart disease. For asthma, depression and pregnancies for women with chronic condi- multimorbidity, there were similar propor- tions are shown in Table 2. Unplanned tions of Māori and Pākehā women with pregnancies were reported by women across the conditions, but a lower proportion all characteristics. Even at their lowest among Pacifi c Island women and the lowest proportions, unplanned pregnancies repre- proportion for Asian women. Compared to sented one-fi fth to one-third of substantial Pākehā, all other groups showed elevated groups of women (ie, women with tertiary rates of diabetes and lower rates of diag- education, women aged 30–39). The highest nosed anxiety. proportions of unplanned pregnancies were Among all women, 39.6% reported their reported by nearly 80% of women with pregnancies as unplanned. Compared to incomes less than $30,000, three-quarters this overall proportion, a higher percentage of young women, nearly three-quarters (from 43% to nearly half) of women with of women with no coresident partner, chronic health conditions reported their two-thirds of women identifying as Māori pregnancies as unplanned (second column or Pacifi c Islander, and over half of women of Table 1). Pregnant women who had with less than a tertiary degree. Parity and been diagnosed with depression or asthma migrant status were not associated with reported a signifi cantly higher proportion unplanned pregnancy.
Table 1: Chronic health conditions and pregnancies reported as unplanned.
% Unplanned % of all women1 Women with condition Women without condition Asthma 7.3 43.6 39.2 *
Depression 2.9 49.1 39.2 ***
Anxiety 2.6 42.5 39.5
Heart disease 1.4 39.4 39.6
Diabetes 0.9 47.5 39.5 ‡
Multimorbidity 2.3 45.7 39.4
Any 15.1 44.4 38.7 ***
Note: 6,822 pregnant women in the total sample of the first wave of GUiNZ. Chi-square tests examined the di erence between planned and unplanned pregnancies for each condition. 1Women with more than one condition are included within each condition they report. ‡p<.1 *p<.05 **p<.01 ***p<.001.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 13 www.nzma.org.nz/journal ARTICLE
Table 2: Socioeconomic characteristics of women with chronic conditions and pregnancies reported as unplanned.
% of women with chronic % of pregnancies reported conditions as unplanned First pregnancy 25.5 45.2
Ethnic identification *** European 61.7 34.8
Māori 16.2 68.9
Pacific Island 12.2 62.7
Asian 6.6 38.2
Other 3.3 50.0
Immigrant 19.5 41.3
Age *** 16–24 20.1 76.3
25–29 21.4 46.8
30–34 30.4 31.3
35–39 22.9 30.9
40+ 4.5 43.5
Education *** Primary 32.8 61.5
Secondary 33.6 50.6
Tertiary 33.6 21.7
Household income *** <30,000 7.18 78.4
30–49,000 12.0 57.3
50–69,000 13.2 38.9
70–99,000 18.5 31.4
100,000+ 25.2 22.3
Missing 23.8 64.5
Relationship *** Coresident partner 79.9 36.9
No coresident partner 20.1 74.4
Note: Data are from the first wave of GUiNZ, and include 1,030 pregnant women reporting a chronic health condition (asthma, heart disease, diabetes, depression and/or anxiety). Chi-square tests examined the di erence between planned and unplanned pregnancies for each characteristic. ***p<.001.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 14 www.nzma.org.nz/journal ARTICLE
As the characteristics are interrelated, The strength of this study is its popula- these fi ndings can best be understood by tion-based sample, which allows for the viewing them as a whole and recognising comparison of pregnant women with and that unplanned pregnancies are a wide- without a range of chronic health conditions. spread experience across all characteristics, The accompanying weakness is that the but are reported most frequently by women conditions are broadly grouped, obscuring experiencing socioeconomic disadvantage. the exact diagnosis. These are self-reported diagnoses, leaving open the possibility that Discussion the analysis missed women with diagnosed conditions who did not report them, as well Unplanned pregnancies are reported as women with undiagnosed conditions. by about half of all pregnant women with The results should therefore be interpreted chronic health conditions in New Zealand. as a conservative estimate. There are also This was a higher proportion than among only a very small number of women with women without health conditions: Women diabetes in the sample. Given the suggestion with any chronic health conditions reported of disproportionate numbers of unplanned 45% of their pregnancies as unplanned, pregnancies along with the serious conse- compared to 39% of women without health quences of a lack of preconception care conditions. The proportion of unplanned for women with diabetes, further research pregnancies was particularly high among focusing on women with Type I and Type II women with diagnosed depression (49%) diabetes is warranted. and asthma (44%). Among women who identifi ed as Māori or Pacifi c Islander and An additional limitation of this study is who had a chronic health condition, about that it only includes women who are already two-thirds of pregnancies were reported pregnant. This means that it is not possible as unplanned. For women with chronic to identify the rate of pregnancy among conditions, the proportion of unplanned women with chronic conditions. That calcu- pregnancies was considerably higher among lation requires population-level data, and women whose characteristics indicate will be the target of future research. The socioeconomic disadvantage. In particular, dichotomous measure of planning used in among pregnant women with chronic health this survey does not refl ect the full range 17 conditions who were low-income, young, did of women’s experiences. A more compre- not have a coresident partner and had less hensive approach to measuring pregnancy education, from half to nearly 80% of preg- planning and perspectives is necessary, and nancies were reported as unplanned. should be considered for future surveys. Future studies could also examine the Given the prevalence of each condition prospective childbearing intentions and in the sample, the year 2008 in New contraceptive use of women with chronic Zealand would have seen an estimated health conditions, to illuminate the extent to 2,200 unplanned pregnancies of women which pregnancies are being planned and with asthma, over 1,300 of women with prevented. depression, nearly 700 of women with anxiety, nearly 500 of women with heart Both chronic illness and unplanned disease/hypertension and nearly 400 of pregnancy are more prevalent and pose women with diabetes. This is a substantial greater risks in the presence of socio- number of women with unplanned preg- economic disadvantage. Together, they nancies and chronic conditions who are at create a high-risk situation that is rarely an elevated risk of not receiving precon- considered. Current guidelines focus on ception and antenatal care, and thus a preconception care, which advises and/ higher chance of experiencing adverse or assumes planning pregnancies, as a key events in their pregnancies.9,11 This risk can part of managing pregnancy with chronic be mitigated by health practitioners, partic- conditions. Women with a chronic health ularly midwives and obstetricians who are condition are already engaged with the prepared to provide care to women with healthcare system, offering an enhanced chronic health conditions whose preg- opportunity for professionals to support nancies are a surprise. them across their reproductive lifecourse. Health professionals caring for women with
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 15 www.nzma.org.nz/journal ARTICLE
chronic conditions should ask all women stark health inequities, in particular those about their childbearing intentions and faced by Māori and Pacifi c Islanders, are provide them with a range of contraceptive addressed. The high rate of unplanned preg- options and preconception care. nancies among women with chronic health Assistance with individual planning offers conditions adds urgency to the necessity of one option, but a more effective strategy addressing the pregnancy and reproductive takes a broader approach by improving health of all women by improving access to the health of the entire population.8,22 This healthcare and by ensuring a healthy envi- will only be possible if New Zealand’s ronment for everyone.
Competing interests: Nil. Acknowledgements: The author is grateful to the Growing Up in New Zealand team for access to the data. Author information: Bryndl E Hohmann-Marriott, Sociology, Gender Studies and Criminology, School of Social Sciences, University of Otago, Dunedin. Corresponding author: Bryndl E Hohmann-Marriott, Sociology, Gender Studies and Criminology, School of Social Sciences, University of Otago, PO Box 56, Dunedin 9054. [email protected] URL: http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2019/vol-132-no-1499- 26-july-2019/7940
REFERENCES: 1. Ministry of Health. Report pregnancy in women who 9. Dunlop AL, Jack BW, on Maternity 2014. Welling- maintain or discontinue Bottalico JN, Lu MC, James ton, NZ: Ministry of Health. antidepressant treatment. A, Shellhaas CS, et al. The 2. Ministry of Health. Annual JAMA. 2006; 295(5):499–507. clinical content of precon- Update of Key Results doi:10.1001/jama.295.5.499 ception care: Women with 2015/16: New Zealand 6. Sawicki E, Stewart K, chronic medical conditions. Health Survey. Wellington, Wong S, et al. Management American Journal of NZ: Ministry of Health. of asthma by pregnant Obstetrics and Gynecology 2008; 199:S310–S327. 3. Balbo N, Billari FC, Mills women attending an M. Fertility in advanced Australian maternity 10. Hohmann-Marriott, BE. societies: a review of hospital. Aus NZ J Ob Gyn. Unplanned pregnancies in research, Euro J of Pop. 2012; 52(2):183–188. New Zealand. Aust NZ J Ob 2013; 29(1):1–38. 7. Siu SC, Sermer M, et al. Gyn. 2018; 58(2):247–250. 4. Balsells M, Garcia-Patter- Prospective multicenter 11. Mallard SR, Houghton LA. son A, Gich I, Corcoy R. study of pregnancy Socio-demographic char- Maternal and fetal outcome outcomes in women with acteristics associated with in women with type 2 heart disease. Circulation. unplanned pregnancy in versus type 1 diabetes 2001; 104:515–521. New Zealand: implications mellitus: a systematic 8. Barker M, Dombrowski for access to preconception review and meta-analysis. S U, Colburn T, et al. healthcare. Aus NZ J Ob J of Clin Endo Metabol. Intervention strategies Gyn. 2013; 53:498–501. 2009; 94:4284–4291. to improve nutrition 12. Perritt JB, Burke A, 5. Cohen LS, Altshuler LL, and health behaviours Jamshidli R, et al. Contra- Harlow BL, et al. Relapse before conception. Lancet. ception counseling, of major depression during 2018; 391:1853–64. pregnancy intention
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 16 www.nzma.org.nz/journal ARTICLE
and contraception use women with chronic medi- doctoral thesis, Victoria in women with medical cal conditions. Mat Child University of Welling- problems: an analysis of Health J. 2010; 14:713–719. ton, New Zealand. data from the Maryland 16. Mosher W, Jones J, Abma 20. Le Grice, J. Māori and Pregnancy Risk Assess- J. Nonuse of contra- reproduction, sexuality ment Monitoring System ception among women education, maternity and (PRAMS). Contraception. at risk of unintended abortion. 2014. Unpub- 2013; 88:263–268. pregnancy in the United lished doctoral thesis, 13. Wellings K, Jones KG, States. Contraception. University of Auckland, Mercer CH, et al. The 2015; 92(2):170–176. New Zealand. prevalence of unplanned 17. Bonnema RA, McNamara 21. Morton SMB, Atatoa pregnancy and associ- MC, Spencer AL. Contra- Carr PE, Bandara DK, ated factors in Britain: ception choices in women et al. Growing Up in fi ndings from the third with underlying medical New Zealand: A longi- National Survey of Sexual conditions. Am Fam tudinal study of New Attitudes and Lifestyles Phys. 2010; 82(6):621–8. Zealand children and (Natsal-3). Lancet. 18. Aiken ARA, Borrero S, their families. Report 2013; 382:1807–1816. Callegari LS, Dehlendorf 1: Before we are born. 14. Sereika SM, Becker C. Rethinking the preg- 2010. Auckland: Growing D, Schmitt P, et al. nancy planning paradigm: Up in New Zealand. Operationalizing and Unintended conceptions or 22. Chatterjee S, Kotelchuck M, examining family planning unrepresentative concepts? Sambamoorthi U. Preva- vigilance in adult women Perspect Sexual Repro lence of chronic illness in with Type 1 diabetes. Health. 2016; 48(3):147–151. pregnancy, access to care, Diabetes Care. 2016. 19. Faasalele Tanuvasa, AE. and health care costs: 15. Chang CH, Velott DL, The place of contracep- Implications for intercon- Weisman CS. Exploring tion and abortion in the ception care. Women’s knowledge and attitudes lives of Samoan women. Health Iss. 2008; 18(6) related to pregnancy and 1999. Unpublished Supplement:S107–S116. preconception health in
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 17 www.nzma.org.nz/journal ARTICLE
Three-month use of idarucizumab at Christchurch Hospital through the emergency department and MedChartTM Louisa J Sowerby, Jane Vella-Brincat
ABSTRACT AIMS: To examine idarucizumab use via the emergency department (ED), Christchurch Hospital; adherence to Hospital Medicines List (HML) criteria, licensed dosing and local coagulation monitoring guidelines. METHODS: All patients given idarucizumab were recorded over three months. Data collected included demographics, coagulation tests, dabigatran dosing and timing of idarucizumab administration. RESULTS: Twelve patients received idarucizumab. The median age (range) was 73 (56–83) years and male:female was 4:8. HML criteria were met in 11 patients. Eleven patents had idarucizumab administered within licence. Coagulation tests were taken pre-idarucizumab in all patients and post-idarucizumab in eight patients. The median thrombin clotting times pre- and post-idarucizumab were 153 and 16 seconds respectively. CONCLUSION: The indications for idarucizumab use were within HML criteria and administration was as per licensed dosing regimen in 11 of 12 patients. Appropriate monitoring of coagulation parameters was carried out in all patients as per local guidelines prior to idarucizumab administration, and thrombin clotting times pre and post were as expected for all but one patient.
darucizumab is a monoclonal antibody of dabigatran when required in situations fragment that acts as a reversal agent of life-threatening or uncontrolled bleed- Ito the direct thrombin inhibitor dabig- ing, or for emergency surgery or urgent atran. It specifi cally binds protein bound procedures. It is licensed to be given as two and unbound dabigatran and its active consecutive doses of 2.5g, the second dose metabolites to form complexes, thus stop- within 15 minutes of fi nishing the fi rst dose.2 ping dabigatran’s anticoagulant effects. It Each 5g dose of idarucizumab has a PHAR- irreversibly binds to dabigatran and has a MAC listed cost of $4,250. rapid onset and slow offset. Idarucizumab binds dabigatran with an affi nity 350 times Aims stronger than dabigatran binds thrombin. 1. To examine the use of idarucizumab While a 2g IV dose has been shown to be via the emergency department at capable of reversing dabigatran in healthy Christchurch Hospital subjects given 220mg orally twice a day of dabigatran, a 5g dose is used.1 Idarucizumab 2. To examine adherence to PHARMAC’s was fi rst registered in New Zealand in De- HML, licensed dosing regimens and cember 2015. It was included in PHARMAC’s Canterbury District Health Board Hospital Medicines List (HML) in June 2016 local guidelines (Canterbury Hospital for the reversal of the anticoagulant effects HealthPathways)
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 18 www.nzma.org.nz/journal ARTICLE
Table 1: Idarucizumab HML criteria, local guidelines and licensed dosing regimen.
PHARMAC HML criteria Canterbury Hospital HealthPathways Medsafe Datasheet – Idarucizumab For the reversal of the In addition to the HML criteria, coagulation Dose of idarucizumab anticoagulant e ects screen including INR, APTT and thrombin is 5g intravenously, of dabigatran when clotting time should be done prior to administered as two required in situations administration unless the delay would be consecutive injections of of life-threatening or significantly detrimental. The coagulation 2.5g within 15 minutes of uncontrolled bleeding, or results are used to determine if there is each other. for emergency surgery or evidence of dabigatran e ect. urgent procedures.
with a <20g/L haemoglobin decrease Methods presented with intracranial haemorrhage. All patients given idarucizumab via the Ten patients received idarucizumab as a emergency department were recorded 5g stat dose or as two 2.5g doses within 15 prospectively during September to December minutes of each other as recommended. 2017 on a data collection form situated next Two patients received two 2.5g doses with to the idarucizumab supply in the emer- an interval longer than 15 minutes. gency department. This was completed by the nurse retrieving the idarucizumab All 12 patients had coagulation tests taken and included the date and the NHI of the prior to idarucizumab administration. In patient. Further data was collected from the 11 of these the coagulation tests thrombin paper medicine chart, the electronic patient clotting time (TT) and activated partial management system Health Connect South, thromboplastin time (APTT) were consistent the electronic prescribing and adminis- with being on dabigatran. The one patient tration system MedChart™ and the electronic with normal TT and APTT who received dispensing system ePharmacy™. Data idarucizumab was to have alteplase throm- collected included demographics, idaruci- bolysis pre-clot retrieval. Eight patients had zumab dosing and timing, coagulation tests, coagulation tests done 12 hours post-idaru- dabigatran dosing and renal function. These cizumab administration and in seven were analysed using Microsoft ExcelTM. patients these were within normal limits. The median thrombin clotting times pre- and post-idarucizumab were 153 and 16 Results seconds respectively post-idarucizumab. TT Twelve patients were identifi ed as having and APTT were above normal limits at 12 received idarucizumab; nine patients had hours in one patient possibly due to rebound stock obtained from ED while three patients dabigatran effect in the setting of AKI (this had idarucizumab dispensed by the hospital patient’s coagulation tests were within pharmacy. The median age (range) was 73 normal limits immediately after idaruci- (56–83) years and the M:F ratio was 4:8. zumab administration). Idarucizumab was given to six patients Of the fi ve patients who received idaruci- for a life-threatening bleed (upper gastro- zumab prior to surgery or a procedure, two intestinal bleed, rectal bleed, intracranial patients had coagulation tests measured haemorrhage); to fi ve patients before urgent at 15 minutes post-administration, which surgery or procedure and once outside showed full dabigatran reversal. HML criteria to a patient with a high risk of The dabigatran dosing regimens for all bleeding due to poor dabigatran clearance 12 patients is shown in Table 2. The date from an acute kidney injury (AKI). and time of the last dose of dabigatran was For the six patients considered to have a available for only two patients. One had life-threatening bleed, fi ve had a haemo- their last dabigatran dose 25 hours prior to globin reduction of >20g/L. The one patient
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 19 www.nzma.org.nz/journal ARTICLE
Table 2: Dabigatran regimens.
Age Idarucizumab Dabigatran dose and Dabigatran Serum Calculated (years) indication frequency indication creatinine on creatinine admission clearance (micromol/L) (mL/min)* 73 Dabigatran 110mg every 12 hours atrial fibrillation 698 6 accumulation (acute kidney injury)
56 Thrombolysis 110mg every 12 hours atrial fibrillation 80 51 and clot retrieval
63 bleed 75mg every 24 hours atrial fibrillation 527 13
80 bleed 110mg every 12 hours atrial fibrillation 106 57**
67 bleed 110mg every 12 hours atrial fibrillation 104 64
78 bleed 110mg every 12 hours atrial fibrillation 99 54
83 bleed 110mg every 12 hours atrial fibrillation 98 31
69 bleed 150mg every 12 hours atrial fibrillation 70 52
73 surgery 110mg every 12 hours deep vein 85 55 thrombosis
83 surgery 75mg every 12 hours atrial fibrillation 94 36
70 surgery 150mg every 12 hours atrial fibrillation 77 31
74 surgery 110mg every 12 hours atrial fibrillation 132 38
*Cockcro and Gault adapted **eGFR as not all information available to calculate CrCl. idarucizumab. The other had their last dose result of an intentional overdose, although of dabigatran 8–9 days prior, however an no active bleeding was present the decision AKI prevented dabigatran clearance. was made to administer idarucizumab on Atrial fi brillation was the indication the basis of increased bleeding risk. Fifteen for dabigatran in all but one patient who hours after idarucizumab administration, was as anticoagulated to treat a deep vein TT showed a slight rebound but without 3 thrombosis. any bleeding. A review by Levy et al suggests adding Discussion “high risk of recurrent bleeding associated with high dabigatran body load from either Our fi ndings suggest idarucizumab is overdose or reduced clearance” as a further prescribed to reverse dabigatran in most indication. 4 instances for serious, life-threatening bleeds or pre urgent surgery/procedures, PHARMAC have not further defi ned the in accordance with licensed indication and meaning of urgent surgery/procedures or PHARMAC HML funding criteria. One of our life-threatening bleeds. Local guidelines patients fell outside of these indications— defi ne life-threatening bleeding as bleeding accumulation of dabigatran in a patient with a reduction in haemoglobin of 20g/L with an AKI. or more, or requiring red blood cell trans- fusion of two units or more; or involving a In a case report for a patient with high critical area or organ, eg, intracranial, intra- plasma concentrations of dabigatran as a spinal, pericardial.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 20 www.nzma.org.nz/journal ARTICLE
Thrombolysis is contraindicated by the All patients had coagulation testing prior manufacturer in patients receiving effective to idarucizumab administration as per local anticoagulation as the combination might guidelines which show whether or not an theoretically increase the risk of bleeding. anticoagulant effect from dabigatran is This has not been well studied in direct oral present, as shown particularly by raised TT anticoagulants (DOACs) and the precaution and often raised APTT. is extrapolated from warfarin and subse- The date and time of the last dabigatran 5,6 quent haemorrhage post thrombolysis. dose was not obtained in many of the It has been suggested that a dabigatran patients so an investigation would require concentration of <10 micrograms/L (or confi rmation of patient compliance. The corresponding thrombin time) would be collection of such data may not have been reasonable for thrombolysis; with further possible in situations where the patient is 6 study that threshold may increase. unable to communicate, such as aphasia in Xian et al observed no signifi cant acute ischaemic stroke, prior to idarucu- difference in bleeding outcomes between zumab administration. patients who were thrombolysed following The demographic in this audit tended to an ischaemic stroke and patients on be older adults. The reason behind this is warfarin with INR <1.7, DOACs, or no antico- likely that both older people are more likely agulants. However, compliance, coagulation to have a bleeding event and AF increases in results and time of prior DOAC adminis- prevalence with advancing age. The majority 7 tration were not recorded. of patients in this cohort were taking dabig- Evidence around administration of idaru- atran for thromboprophylaxis in AF. cizumab prior to thrombolysis is limited to In our cohort, idarucizumab use appears case-series. Outcomes from these studies to be within HML and licensed indications. have indicated dabigatran reversal prior Extension of indications into idarucizumab to thrombolysis is likely to be safe and overdose and dabigatran low clearance effective shown by patient improvement patients might be useful. Appropriate via the National Institutes of Health Stroke monitoring of coagulation parameters was Scale (NIHSS) and the modifi ed Rankin Scal carried out in all patients prior to idaruci- 8,9 (mRS). zumab administration and thrombin clotting Although 5g stat is the recommended times pre and post were as expected for all idarucizumab dose, the way it was but one patient. Dabigatran dosing at the prescribed and administered varied. The time of idarucizumab administration was licensed dosing regimen for idarucizumab variable in relation to manufacturer’s guide- is two 2.5g consecutive injections. The New lines. Further investigation may be needed Zealand Formulary prescribing guidelines to infl uence future guidance for dose-ad- have since changed to 5g stat, with separate justment to prevent serious bleeding. administration instructions.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 21 www.nzma.org.nz/journal ARTICLE
Competing interests: Nil. Acknowledgements: Dr Paul Chin, Clinical Pharmacologist, Christchurch Hospital. Author information: Louisa J Sowerby, Pharmacist, Emergency Department, Christchurch Hospital, Christchurch; Jane Vella-Brincat, Clinical Pharmacist, Pharmacy Department, Christchurch Hospital, Christchurch. Corresponding author: Louisa J Sowerby, Pharmacist, Emergency Department, Christchurch Hospital, Christchurch. [email protected] URL: http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2019/vol-132-no-1499- 26-july-2019/7941
REFERENCES: 1. Eikleboom JW, Quinlan anticoagulants: guidance Ischemic Stroke Who Take DJ, van Ryn J, Weitz from the SSC of the ISTH. Non-Vitamin K Antagonist JI. Idarucizumab: The J Thromb Haemost. 2016 Oral Anticoagulants Before Antidote for Reversal of Mar; 14(3):623–7. Stroke. Circulation. 2017 Dabigatran. Circulation. 5. Diener H, Foerch C, Riess Mar 14; 135(11):1024–1035. 2015; 132(25):2412–22. H, et al. Treatment of 8. Pikija S, Sztriha L, 2. Boehringer Ingelheim (NZ) acute ischaemic stroke Mutzenbach J, et al. Ltd. Medsafe Datasheet: with thrombolysis or Idarucizumab in Dabiga- Idarucizumab solution thrombectomy in patients tran-Treated Patients with for injection (Praxbind®) receiving anti-thrombotic Acute Ischemic Stroke updated 2017 July 17 treatment. Lancet Neurol. Receiving Alteplase: A [accessed 2018 March 26]. 2013 Jul; 12(7):677–88. Systematic Review of the Available from: http://www. 6. Kate M, Szkotak A, Witt A, Available Evidence. CNS medsafe.govt.nz/profs/data- et al. Proposed approach Drugs. 2017; 31(9):747–757. sheet/p/praxbindinj.pdf to thrombolysis in dabig- 9. Kermer P, Eschenfelder 3. Shapiro S, Bhatnagar N, atran-treated patients C, Diener H, et al. Antag- Khan A, et al. Idarucizum- presenting with ischemic onizing dabigatran by ab for dabigatran overdose stroke. Stroke Cerebrovasc idarucizumab in cases in a child. Br J Haematol. Dis. 2014 Jul; 23(6):1351–5. of ischemic stroke or 2018 Feb; 180(3):457–459. 7. Xian Y, Federspiel J, intracranial hemorrhage 4. Levy JH, Ageno W, Chan Hernandez A, et al. Use of in Germany - A national NC, et al. When and how Intravenous Recombinant case collection. Int J Stroke. to use antidotes for the Tissue Plasminogen Activa- 2017 Jun; 12(4):383–391. reversal of direct oral tor in Patients With Acute
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 22 www.nzma.org.nz/journal ARTICLE
Subsequent injuries experienced by Māori: results from a 24-month prospective study in New Zealand Emma Wyeth, Michelle Lambert, Ari Samaranayaka, Helen Harcombe, Gabrielle Davie, Sarah Derrett
ABSTRACT AIM: Māori, the indigenous population of New Zealand, experience a disproportionate burden of injury compared to non-Māori. Injury burden can be exacerbated by subsequent injuries (injuries that occur a er, but not necessarily because of, an earlier or ‘sentinel’ injury). Despite obligations under New Zealand’s Treaty of Waitangi, it appears no published studies have investigated subsequent injuries among Māori. This study aims to describe subsequent injuries experienced by Māori and reported to New Zealand’s no-fault injury Accident Compensation Corporation (ACC), and determine: the number and timing of subsequent injury (SI) claims reported to ACC in 24 months following a sentinel injury; the proportions experiencing ≥1 SI; and the nature of SIs. METHODS: The Subsequent Injury Study analysed interview, ACC and hospital discharge data. SIs were classified as injury events involving an ACC claim within 24 months of a sentinel injury. RESULTS: Of 566 participants, 349 (62%) experienced ≥1 SI in the 24 months post-sentinel injury. Those with moderate/high alcohol use, or cognitive di iculties, before the sentinel injury were more likely to experience SIs. Fewer SIs occurred between 0–3 months a er a sentinel injury compared to later periods. Spine dislocations/sprains/strains were the most common SI type. CONCLUSIONS: Despite their descriptive nature, our findings point to both the complexity of SI and the need for a greater research, ACC and health service focus on SI if the burden of injury for Māori is to be truly addressed. That 62% of Māori who had already experienced a profound sentinel injury went on to experience ≥1 SIs reported to ACC within a 24-month period suggests that the burden is considerable, and that preventive opportunities are being missed. Additional analyses are now underway to investigate factors predicting SI, while accounting for potential confounders, in order to assist in the development of SI prevention initiatives for Māori at multiple points in the complex post-injury pathway.
njury is the leading cause of disability provides a specifi c avenue for reducing the worldwide.1,2 Post-injury burden can overall injury burden. Despite this, there Ibe further exacerbated by subsequent is limited knowledge of the pathways and injuries (ie, injuries that occur after, but not predictors of subsequent injuries among necessarily because of, an earlier ‘sentinel’ general ‘all injury’ populations. An extensive injury).3–5 Subsequent injuries may also search failed to uncover specifi c literature be more detrimental, both fi nancially and relating to subsequent injuries for Māori or physically than a sentinel injury.2,5,6 There- other indigenous populations. However, one fore, investigating and developing injury US study found differences in repeat trauma prevention interventions and initiatives admissions according to ethnicity.11 aimed at preventing subsequent injuries
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 23 www.nzma.org.nz/journal ARTICLE
Recent studies have highlighted that data from the National Minimum Dataset Māori, the indigenous population of (NMDS) for those who were hospitalised. New Zealand, experience a dispropor- Participants aged between 18 and 64 years tionate burden of injury compared to were recruited following a sentinel injury non-Māori,1,3,7,8 and the health-related loss event involving an ACC entitlement claim due to injury for Māori is at least twice between 2007 and 2009. People who expe- that for non-Māori.7 Our previous research rienced injuries as a result of self-harm or has found that Māori experience poorer sexual assault were not recruited, however outcomes, at both three and 12 months SI claims of this nature were included post-injury compared with non-Māori.9,10 in our analyses. Ethical approval was Additionally, Māori who have been hospi- obtained from the New Zealand Health and talised for injury have a 70% increased Disability Multi-Region Ethics Committee risk of disability 24 months post-injury (MEC/07/07/093). 1 compared with non-Māori. The analyses presented here use data New Zealand researchers and healthcare collected from the 566 Māori POIS partici- workers have particular responsibilities and pants, 20% of the cohort.18 During the fi rst requirements to address health inequities interview, all participants were asked to for Māori.12 These are outlined in a number report their ethnicity using the New Zealand of key documents, including legislation Census question, which allows participants such as the Public Health and Disability Act to self-identify with more than one ethnic 2000.13,14 Our injury outcomes research is group.20 Those who identifi ed Māori as one underpinned by such responsibilities.12,15 of their ethnic groups were included in the The current study aims to increase our Māori cohort. understanding of subsequent injuries, Information about a variety of pre-injury, specifi cally for Māori, in order to identify injury-related and post-injury factors was key characteristics and potential for future collected during interviews held, on average, interventions to improve Māori post-injury three, 12 and 24 months post-injury.18,21–23 3 pathways. Injured Māori were recruited Age, sex and occupation were collected from following an Accident Compensation participants at the fi rst interview using Corporation (ACC; New Zealand’s no fault questions from the New Zealand Census.20 injury insurer) entitlement claim; a type of Participants were asked if they were in paid claim for injuries likely to require income employment at the time of their sentinel compensation for more than a week off injury, and if so they were asked about work or other additional rehabilitation such the nature of their main job, classifi ed as 16 as home-help. The specifi c objectives of professional, technical, trade/manual or this paper are to describe, for the fi rst time unclassifi able.24 Participants were asked for injured Māori, the: 1) proportions expe- about their adequacy of household income25 riencing at least one subsequent injury (SI) (classifi ed as ‘adequate’ if participants that involved an ACC claim, in the 12 and 24 reported having ‘enough’ or ‘more than months following their sentinel injury event, enough’ household income to meet every 2) frequency of SI claims over 12 and 24 day needs and ‘inadequate’ if they reported months, 3) number of SI per person over 24 ‘not enough’ or ‘just enough’).26 Additionally, months, 4) time periods people are at higher participants were asked whether the risk of SI, and 5) nature of SI. sentinel injury was unintentional or inten- tional (ie, assault), was work-related, and if Methods they perceived their sentinel injury to be a This paper uses data from the Subsequent threat to life or long-term disability at time 17,21,27 Injury Study (SInS),3,8,17 which combined data of injury. Information was collected from three sources: 1) Interview data from about pre-injury depressive-type episodes the Prospective Outcomes of Injury Study (using two screening questions from the (POIS),12,15,18,19 a study of 2,856 injured New Diagnostic and Statistical Manual of Mental 23,28 Zealanders (including 566 Māori), 2) admin- Disorders-III), disability (using the World istrative data from ACC for SI claims in Health Organization Disability Assessment 29 the 24 months following each participant’s Schedule II; WHODAS), health-related 29,30 sentinel injury, and 3) hospital discharge quality of life (using the EQ-5D), and
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 24 www.nzma.org.nz/journal ARTICLE
alcohol use (using the brief Alcohol Use 38.2 years (SD 12.7) for those who had at Disorders Identifi cation Test; AUDIT-C) least one SI. where participants were grouped as ‘no or Table 1 presents pre-sentinel injury socio- low’ (males AUDIT-C score 0–4; females 0–3), demographic and health characteristics of ‘moderate’ (males 5–7; females 4–6) or ‘high’ Māori participants according to whether or 21,29–31 (males 8–12; females 7–12). not they had at least one ACC SI claim in the Information about the nature, body region 24 months after their sentinel injury. In the and severity of sentinel injuries and SIs 24-month period, those with lowest propor- were derived from ACC injury diagnosis tions of SI were: females compared to males codes.21 In these analyses, 12 injury type (58% versus 63%); those in professional variables, derived from the most common occupations compared to other occupations sentinel injury nature and body region (57% versus 61–76%); and those living with groupings, have been used for both sentinel family compared to those living alone or injuries and SIs. Participants could have had with non-family (60% versus 68% and 72%). more than one injury type resulting from However, there was insuffi cient evidence to each injury event (both sentinel and subse- conclude that any of these observed differ- quent) and could also have more than one ences were statistically signifi cant. Those SI event. New Injury Severity Scores (NISS) experiencing cognitive problems prior to derived to measure the severity of an injury their sentinel injury were more likely to event were categorised as 1–3 (least severe), have a SI compared to those reporting no 4–6 and >6 (most severe).32,33 Hospitalisation cognitive problems (82% versus 60%). Those for sentinel injuries and SIs was determined reporting moderate or high alcohol use using probabilistic data linkage to the NMDS pre-sentinel injury were also more likely to of hospital discharges,34 with participants have a SI compared to those reporting no or classifi ed as being hospitalised if they had low alcohol use (69% and 62% compared to been admitted to hospital or treated at an 56%, respectively). emergency department for ≥3 hours within Those who had a sentinel injury event 21 seven days of the injury event. involving a lower extremity fracture were Sentinel injuries were all entitlement less likely to have a SI (44% versus 65%); as claims, however, SI events could be of were those who had a sentinel injury event any ACC claim type; categorised as ‘enti- involving a lower extremity open wound tlement claims’, ‘medical fees only claims’ (45% versus 63%) (Table 2). Participants (whereby participants received treatment hospitalised for their sentinel injury were from a health professional but no additional also less likely to have a SI (55% versus rehabilitation support),4 ‘other claims’ (eg, 64%). Those whose sentinel injuries were those involving additional assessments), and categorised as ‘other’ were less likely to ‘unclassifi ed’ (those claims without a spec- have a SI (49% versus 65%), however this ifi ed type, eg, where district health board category includes a mixture of different and bulk funding was associated).17,35 Statistical less common injury types. analyses are descriptive, as per the aims Of the 566 participants, 349 (62%) experi- of this paper, and were carried out using enced at least one SI in the 24-month period 36 Stata® version 14.2. after their sentinel injury; 27% (n=152) experienced one SI event, 18% (n=103) Results experienced two SI, and 8% (n=47) experi- Of the 566 Māori participants, 238 (42%) enced three or more SI. The total number had at least one SI in the 12 months after of SI events was 755 with a range of 0 to 14 their sentinel injury event, and by 24 SI events per person. Four percent of the SI months, 349 (62%) had at least one SI. The events resulted in hospitalisation. Overall, mean age of those who did not have an 12% of the SI were entitlement claims, 77% SI in the 24-month period was 40.0 years were medical fees only claims, and 11% (standard deviation (SD) 11.9) compared to were other or unclassifi ed claims.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 25 www.nzma.org.nz/journal ARTICLE
Table 1: Pre-sentinel injury sociodemographic and health characteristics of Māori participants according to ACC-reported subsequent injury (SI) status in the 24 months after sentinel injury.
Variable No SI SI P-value* (N=217) (N=349) n (%) n (%)
Sex Male 136 (37) 235 (63)
Female 81 (42) 114 (58) 0.3
Occupation Professional 55 (43) 74 (57)
Technical 43 (36) 74 (63)
Trade/manual 98 (49) 156 (61)
Unclassifiable workers 5 (24) 16 (76)
Non-workers 16 (36) 29 (64) 0.5
Household income Adequate 189 (38) 307 (62)
Not adequate 26 (39) 40 (61) 0.8
Living arrangements Alone 13 (33) 27 (68)
With non-family 13 (28) 34 (72)
With family 189 (40) 284 (60) 0.2
General health Good 201 (39) 318 (61)
Poor 14 (31) 31 (69) 0.3
EQ-5D mobility No problems 206 (39) 323 (61)
Problems 11 (30) 26 (70) 0.3
EQ-5D self-care No problems 214 (39) 340 (61)
Problems 3 (25) 9 (75) 0.3
EQ-5D usual activities No problems 205 (39) 327 (61)
Problems 12 (35) 22 (65) 0.7
EQ-5D pain/discomfort No problems 197 (39) 307 (61)
Problems 20 (33) 41 (67) 0.3
EQ-5D anxiety/depression No problems 202 (39) 321 (61)
Problems 15 (36) 27 (64) 0.7
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 26 www.nzma.org.nz/journal ARTICLE
Table 1: Pre-sentinel injury sociodemographic and health characteristics of Māori participants according to ACC-reported subsequent injury (SI) status in the 24 months after sentinel injury (continued).
EQ-5D cognition No problems 211 (40) 320 (60)
Problems 6 (18) 28 (82) 0.01
Depressive-type episodes No 157 (38) 261 (62)
Yes 56 (39) 86 (61) 0.7
Social relationships Satisfied 203 (38) 326 (62)
Not satisfied 12 (34) 23 (66) 0.6
Chronic conditions 0 110 (39) 171 (61)
1 53 (36) 96 (64)
≥2 47 (39) 75 (61) 0.8
Disability (WHODAS) 0–9 202 (39) 317 (61)
≥10 15 (34) 29 (66) 0.5
Physical activity <5 days a week 88 (38) 143 (62)
≥5 days a week 123 (38) 199 (62) 1.0
BMI <30 kg/m2 123 (39) 194 (61)
≥30 kg/m2 76 (36) 137 (64)
Undisclosed 18 (50) 18 (50) 0.3
Alcohol use No or low 85 (44) 108 (56)
Moderate 56 (31) 123 (69)
High 72 (38) 117 (62) 0.04
Smoking No 119 (38) 194 (62)
Yes 97 (38) 155 (62) 0.9
Recreational drug use No 154 (39) 246 (62)
Yes 62 (38) 103 (62) 0.8
*P-values obtained from chi-squared tests; tests exclude those with missing data. Notes: Some percentages sum to more than 100, due to rounding. Results presented are descriptive only and have therefore not been adjusted for any potential confounding factors.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 27 www.nzma.org.nz/journal ARTICLE
Table 2: Sentinel injury-related characteristics of Māori participants according to ACC-reported subsequent injury (SI) status.
Variable No SI (N=217) SI (N=349) P-value* n (%) n (%)
Type of injury**
Head/neck intracranial No 213 (39) 336 (61)
Yes 4 (24) 13 (76) 0.2
Head/neck superficial No 208 (38) 340 (62)
Yes 9 (50) 9 (50) 0.3
Spine dislocation/sprain/strain No 185 (39) 288 (61)
Yes 32 (34) 61 (66) 0.4
Upper extremity fracture No 192 (40) 294 (60)
Yes 25 (31) 55 (69) 0.2
Upper extremity dislocation/sprain/strain No 192 (39.0) 300 (61)
Yes 25 (33.8) 49 (66) 0.4
Upper extremity open wound No 208 (39) 322 (61)
Yes 9 (25) 27 (75) 0.09
Upper extremity superficial No 204 (38) 326 (62)
Yes 13 (36) 23 (64) 0.8
Lower extremity fracture No 168 (35) 310 (65)
Yes 49 (56) 39 (44) <0.01
Lower extremity dislocation/sprain/strain No 162 (38) 262 (62)
Yes 55 (39) 87 (61) 0.9
Lower extremity open wound No 199 (37.3) 334 (63)
Yes 18 (55) 15 (45) 0.05
Lower extremity superficial No 204 (38) 328 (62)
Yes 13 (38) 21 (61.8) 1.0
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 28 www.nzma.org.nz/journal ARTICLE
Table 2: Sentinel injury-related characteristics of Māori participants according to ACC-reported subsequent injury (SI) status (continued).
Other body regions/nature No 165 (35) 300 (65)
Yes 52 (51) 49 (49) <0.01
Injury severity (NISS) 1–3 (least severe) 84 (34) 164 (66)
4–6 93 (39) 143 (61)
>6 (most severe) 30 (49) 31 (51) 0.07
Hospitalised No 148 (36) 265 (64)
Yes 69 (45) 84 (55) 0.04
Injury cause Unintentional 203 (38) 328 (62)
Intentional (assault) 12 (38) 20 (63) 0.9
Self-perceived threat to life No 178 (38) 291 (62)
Yes 35 (41) 51 (59) 0.6
Self-perceived threat of long-term disability No 116 (39) 185 (61)
Yes 95 (37) 160 (63) 0.8
Work-related injury No 142 (38) 227 (62)
Yes 75 (38) 120 (62) 1.00
Access to healthcare services No trouble 195 (38) 317 (62)
Trouble/mixed 21 (40) 31 (60) 0.7
*P-values obtained from chi-squared tests; tests exclude those with missing data. **Twelve separate variables. Participants could have more than one type of injury in a given injury event. Notes: Some percentages sum to more than 100, due to rounding. Results presented are descriptive only and have therefore not been adjusted for any potential confounding factors.
The distribution of SI increased between Table 3 presents information about the each of the fi rst three three-month periods types of SI sustained by participants in the (ie, from 0–3 months to 3–6 months and from 24 months post-sentinel injury. The 755 3–6 months to 6–9 months after the sentinel SI events resulted in 962 injuries, since injury; p<0.001). After which, the frequency multiple injuries were possible from one of SI remained relatively stable, except for event. Spine dislocations/sprains/strains 12–15 months after the sentinel injury where were the most common SI type (23%), the distribution of SI was very similar to followed by lower extremity dislocations/ the 6–9-month period and for 21–24 months sprains/strains (18%). Participants could where the distribution was more similar to also have multiple SI events of the same the 3–6-month period (Figure 1). injury type during the 24-month period.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 29 www.nzma.org.nz/journal ARTICLE
Figure 1: Distribution of ACC-reported subsequent injury (SI) events over the 24-month period following the sentinel injury event for Māori participants.
Note: P-value for the increasing trend from 0–12 months is <0.001.
Table 3: Frequency of ACC-reported subsequent injury (SI) in the 24 months following the sentinel injury event by the type of injury for Māori participants.
Type of injury Number of SI Number of SI Number of Claims per of this type of events with this participants with person with injury type of injury this type of SI this type of SI† N (%) N (%) N (%) Intracranial 6 (1) 6 (1) 6 (2) 1.00
Head/neck superficial 19 (2) 18 (2) 17 (5) 1.06
Spine dislocation/sprain/strain 220 (23) 184 (22) 119 (34) 1.55
Upper extremity fracture 24 (2) 23 (3) 22 (6) 1.05
Upper extremity dislocation/sprain/strain 142 (15) 129 (16) 95 (27) 1.36
Upper extremity open wound 63 (7) 58 (7) 53 (15) 1.09
Upper extremity superficial 14 (1) 12 (1) 12 (3) 1.00
Lower extremity fracture 12 (1) 12 (1) 12 (3) 1.00
Lower extremity dislocation/sprain/strain 169 (18) 155 (18) 114 (33) 1.36
Lower extremity open wound 24 (2) 24 (3) 24 (7) 1.00
Lower extremity superficial 4 (0.4) 4 (0) 3 (1) 1.33
Other 265 (28) 217 (26) 164 (47) 1.32
Total 962* 755** 349***
*Each SI event could involve more than one type of injury. **Column total sums to 842 because each SI event could involve more than one injury diagnosis of the same injury type in a single injury event (eg, an ankle dislocation and a knee sprain would be classified as two lower extremity dislocations/sprains/strains). ***This is the total number of participants who had at least one SI. Participants could have more than one SI event and each event could involve more than one type of injury. Therefore, the total percentages exceed 100%. †Claims per person for a particular injury type is the total number of claims with that type of injury divided by the number of claimants with that type of injury.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 30 www.nzma.org.nz/journal ARTICLE
For example, 155 SI events involved lower usual activities, therefore reducing their extremity dislocations/sprains/strains, yet likelihood of SIs. these were experienced by only 114 people The timing of SI events for Māori partici- showing that some participants had multiple pants in the 24 months after a sentinel injury lower extremity dislocations/sprains/strains is similar to our observation for the entire during this period (Table 3). Spine disloca- SInS cohort17 (ie, a lower frequency of SI was tions/sprains/strains had the highest number observed in the fi rst three months after a of claims per person (1.55) during the 24 sentinel injury, this then increased for 3–6 months followed by both upper and lower months and then again for 6–9 months after extremity dislocations/sprains/strains (each a sentinel injury). These variations may be with 1.36 claims per person) (Table 3). due to a number of reasons, for example in the earlier periods after a sentinel injury, Discussion people may not be fully participating in A considerable proportion of injured their everyday activities and are therefore Māori had at least one SI event in the 12- at less risk of SI. Alternatively, people might and 24-month periods after their sentinel be more careful or aware of SI after their injury event (42% and 62%, respectively). ‘entitlement claim’ sentinel injury, which We found that those who reported moderate warranted additional rehabilitation and or high alcohol use, or who were experi- support beyond medical fees only, or may encing cognitive diffi culties prior to their have received injury prevention information sentinel injury, were more likely to have or advice at the time of their sentinel injury. 40 an SI in the 24 months following a sentinel One Canadian study investigating subse- injury. High use of alcohol is a strong risk quent injuries found that the majority of factor of injuries both worldwide37 and such injuries among a cohort of performing in New Zealand,38 so fi nding it to be asso- artists occurred between 2–12 months after ciated with SI is not unsurprising. Cognitive someone’s ‘return to full participation’ impairment or diffi culties can affect physical (measured either by a performance after performance or function. A systematic their injury or the last medical treatment for review and meta-analysis showed that their initial injury). Another study inves- those who had experienced a sports-re- tigating the timing of subsequent injuries lated concussion were at increased odds of after being hospitalised for injury found that sustaining a later musculoskeletal injury the highest rate ratio of subsequent injuries compared to those who had not sustained was 6–12 months after the sentinel injury. a concussion.39 The authors of that review However, this study only examined the fi rst pose that physical effects of concussion subsequent injury experienced by partic- are often resolved more readily than other ipants, and only injuries that resulted in 41 more persistent effects such as cognitive further hospitalisation or death. and behavioural changes, therefore those A strength of our study is that it addresses concussed require additional attention to a topic about which very little is known, reduce the risk of subsequent musculo- especially for Māori, a signifi cant popu- skeletal injuries. lation group that experiences signifi cant Those with a lower extremity fracture injury burden and injury outcome ineq- 7,8,42 or lower extremity open wound sentinel uities. Our study contributes to the injury were less likely to have an SI in the limited body of knowledge in this important following 24 months, as were those who area by describing subsequent injuries over were hospitalised for their sentinel injury. a 24-month period for a cohort of injured These fi ndings align with our previous Māori who have previously accessed ACC for non-Māori-specifi c work investigating an entitlement claim. Additional strengths self-reported subsequent injuries.4 It seems include that our study is of injured Māori plausible that those with a lower extremity who have experienced a range of different injury, or hospitalised, might be less mobile types of injuries, who were both hospi- than others after such a sentinel injury and talised and not hospitalised for injury and might be less able to participate in their both work-related and non-work-related
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 31 www.nzma.org.nz/journal ARTICLE
injuries. Limitations of our study include show that there are differences in pre-sen- the descriptive nature of the analyses tinel and sentinel injury characteristics for presented, however, this is a very complex Māori who experienced a SI. This highlights area and so a detailed understanding of the the importance of understanding SIs for proportions, frequencies, numbers, time Māori, particularly as those who do access periods and nature of SI is required before ACC present a potential point for future examining predictive factors and potential interventions. confounders, which was beyond the scope of We have described the proportions, this paper. Other limitations include that the frequencies, nature and time periods of ‘sentinel’ injury for which participants were subsequent injuries for Māori. Despite recruited is unlikely to be their ‘fi rst ever’ their descriptive nature, our fi ndings point injury. Despite this, the focus our study is to to both the complexity of SI among an ‘all examine SIs after an ACC entitlement claim injury’ Māori cohort, and to the need for a injury, not to capture participants’ fi rst ever greater research, ACC and health service ACC entitlement claim. While our cohort is focus on SI if the burden of injury for Māori relatively small, it appears to be the largest is truly to be addressed. That 62% of Māori research cohort of injured Māori who have who had already experienced a profound sustained a range of injury types, causes and sentinel injury went on to experience at severities, and importantly we have been least one SI reported to ACC within a period able to use ACC information about SI claims of only 24 months suggests both that the and not rely on participants’ self-report burden is considerable and that preventive information for these. opportunities are being missed. Additional In this study we have analysed SIs from a analyses are currently underway by our cohort of Māori who had already accessed team to investigate factors predicting SI, ACC for their sentinel injury. It is a limitation while accounting for potential confounders, that we have not been able to investigate SIs in order to assist in the development of SI for those who did not access ACC for injury. preventive initiatives at multiple points in Like other health services in New Zealand, the complex post-injury pathway specifi cally Māori experience barriers to accessing for injured Māori. ACC.43 Importantly though, our fi ndings
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 32 www.nzma.org.nz/journal ARTICLE
Competing interests: Dr Derrett, Dr Wyeth and Dr Samaranayaka report grants from Health Research Council of New Zealand during the conduct of the study. Acknowledgements: The authors are grateful to the study participants for sharing their information with us. The Subsequent injury Study was funded by the Health Research Council of New Zealand (HRC 15/091; 2015–2017). The Prospective Outcomes of Injury Study was funded by the Health Research Council of New Zealand (HRC 10/052; 2007–2013) and the Accident Compensation Corporation of New Zealand (2007–2010). The views and conclusions in the article are of the authors and may not represent those of the funders. Author information: Emma Wyeth, Senior Lecturer-Māori Health and Director, Te Roopū Rakahau Hauora Māori o Kāi Tahu (Ngāi Tahu Māori Health Research Unit), Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin; Michelle Lambert, Research Fellow-Māori Health, Te Roopū Rakahau Hauora Māori o Kāi Tahu (Ngāi Tahu Māori Health Research Unit), Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin; Ari Samaranayaka, Senior Research Fellow, Centre for Biostatistics, Division of Health Sciences, University of Otago, Dunedin; Helen Harcombe, Lecturer, Injury Prevention Research Unit, Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin; Gabrielle Davie, Senior Research Fellow, Injury Prevention Research Unit, Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin; Sarah Derrett, Professor, Injury Prevention Research Unit, Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin. Corresponding author: Dr Emma H Wyeth, Senior Lecturer-Māori Health and Director, Te Roopū Rakahau Hauora Māori o Kāi Tahu (Ngāi Tahu Māori Health Research Unit), Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin. [email protected] URL: http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2019/vol-132-no-1499- 26-july-2019/7942
REFERENCES: 1. Derrett S, Wilson S, 3. Derrett S, Harcombe H, disability. BMC Public Samaranayaka A, et al. Wyeth E, et al. Subsequent Health 2011; 11(1):492–99. Prevalence and Predictors Injury Study (SInS): 6. Lipscomb H, Cameron W, of Disability 24-Months Improving outcomes for Silverstein B. Incident and After Injury for Hospital- injured New Zealand- recurrent work injuries ised and Non-Hospitalised ers. Injury Prevention among union carpen- Groups: Results from a 2017; 23(429):429–34. ters. Occupational and Longitudinal Cohort Study 4. Harcombe H, Derrett Environmental Medicine in New Zealand. PLoS S, Samaranayaka A, et 2008; 65(12):827–34. One 2013; 8(11):e80194. al. Factors predictive 7. Ministry of Health, 2. Vos T, Flaxman AD, Naghavi of subsequent injury in Accident Compensation M, et al. Years lived with a longitudinal cohort Corporation. Injury-related disability (YLDs) for 1160 study. Injury Prevention Health Loss: A report from sequelae of 289 diseases 2014; 20(6):393–400. the New Zealand Burden and injuries 1990–2010: a 5. Ruseckaite R, Collie of Diseases, Injuries systematic analysis for the A. Repeat workers’ and Risk Factors Study Global Burden of Disease compensation claims: risk 2006–2016. Wellington: Study 2010. The Lancet factors, costs and work Ministry of Health, 2013. 2012; 380(9859):2163–96.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 33 www.nzma.org.nz/journal ARTICLE
8. Ministry of Health. Tatau 16. Accident Compen- injury. Australian and New Kahukura: Māori Health sation Corporation. Zealand Journal of Public Chart Book 2015 (3rd Investing in New Health 2017; 41(3):262–68. edition). Wellington: Zealanders - ACC Annual 24. Statistics New Zealand. Ministry of Health, 2015. Report 2017. Wellington: New Zealand Standard 9. Maclennan B, Wyeth E, Accident Compensation Classifi cation of Occupa- Hokowhitu B, et al. Injury Corporation, 2017. tions. Wellington: Statistics Severity and 3-Month 17. Harcombe H, Davie G, New Zealand, 2001. Outcomes Among Māori: Wyeth E, et al. Injury 25. Ministry of Social Develop- Results From a New upon injury: a prospective ment. Direct Measurement Zealand Prospective cohort study examining of Living Standards: The Cohort Study. N Z Med J subsequent injury claims New Zealand ELSI Scale 2013; 126(1379):39–49. in the 24 months following - Survey of Working Age 10. Maclennan B, Wyeth H a substantial injury. Injury People in 2000. Welling- E, Davie G, et al. Twelve- Prevention 2017; 24:460–67. ton: Ministry of Social month post-injury 18. Black JA, Herbison GP, Development, 2000. ouctomes for Maori and Lyons RA, et al. Recovery 26. Maclennan B, Wyeth E, non-Maori: fi ndings from after injury: an individual Davie G, et al. Twelve- a New Zealand cohort patient data meta-analysis month post-injury study. Australian and New of general health status outcomes for Māori and Zealand Journal of Public using the EQ-5D. J Trauma non-Māori: Findings from a Health 2014; 38(3):227–33. 2011; 71(4):1003–10. New Zealand cohort study. 11. Hedges BE, Dimsdale JE, 19. Derrett S, Langley J, ANZJPH 2014; 38(3):227–33. Hoyt DB, et al. Character- Hokowhitu B, et al. 27. Langley J, Davie G, Wilson istics of Repeat Trauma Prospective Outcomes S, et al. Diffi culties in Func- Patients, San Diego County. of Injury Study. Injury tioning 1 Year After Injury: American Journal of Public Prevention 2009; 15(5):e3. The Role of Preinjury Socio- Health 1995; 85(7):1008–10. 20. Statistics New Zealand. demographic and Health 12. Wyeth EH, Derrett S, New Zealand Census of Characteristics, Health Care Hokowhitu B, et al. Rangati- Population and Dwell- and Injury-Related Factors. ratanga and Ōritetanga: ings - Individual Form. Archives of physical Responses to the Treaty Wellington: Statistics medicine and rehabilita- of Waitangi in a New New Zealand, 2006. tion 2013; 94(7):1277–86. Zealand study. Ethnicity & 21. Derrett S, Samaranayaka A, 28. American Psychiatric Health 2010; 15(3):303–16. Wilson S, et al. Prevalence Association Committee 13. Health Research Council and Predictors of Sub-Acute of Nomenclature and of New Zealand. Guide- Phase Disability after Statistics. Diagnostic and lines for Researchers on Injury among Hospitalised Statistical Manual of Mental Health Research Involving and Non-Hospitalised Disorder-3rd Edition Māori. Auckland: Health Groups: A Longitudinal (DSM-3). Washington, Research Council of Cohort Study. PLoS One DC: American Psychiatric New Zealand, 2008. 2012; 7(9):e44909. Association 1980. 14. Parliamentary Counsel 22. Langley J, Derrett S, 29. Üstün T, Kostanjsek Offi ce. New Zealand Davie G, et al. A cohort N, Chatterji S, et al. Public Health and Disabil- study of short-term Measuring Health and ity Act 2000 Public Act. functional outcomes Disability: Manual for Wellington: Parliamentary following injury: the role WHO Disability Assessment Counsel Offi ce, 2000. of pre-injury socio-de- Schedule (WHODAS 2.0). 15. Wyeth E, Derrett S, Hokow- mographic and health Malta: WHO Press 2010. hitu B, et al. Indigenous characteristics, injury 30. EuroQol Group. EQ-5D A injury outcomes: life and injury-related health- standardised instrument satisfaction among injured care. Health Qual Life for use as a measure of Maori in New Zealand Outcomes 2011; 9:68–79. health outcome: http:// three months after injury. 23. Wyeth EH, Samaranayaka www.euroqol.org/; 2008 Health Qual Life Outcomes A, Davie G, et al. Prevalence [Available from: http:// 2013; 11(1):120–28. and predictors of disability www.euroqol.org/. for Māori 24 months after
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 34 www.nzma.org.nz/journal ARTICLE
31. Bradley KA, DeBenedetti 35. Accident Compensation & Science in Sports & AF, Volk RJ, et al. AUDIT-C Corporation. ACC Treat- Exercise 2018; 50:2. as a Brief Screen for ment Provider Handbook 40. Hamilton MG, Meeu- Alcohol Misuse in Primary 2017. Wellington: wisse HW, Emery AC, et Care. Alcoholism: Clinical Accident Compensation al. Subsequent Injury and Experimental Research Corporation, 2017. Defi nition, Classifi cation, 2007; 31(7):1208–17. 36. Stata Statistical Software: and Consequence. Clinical 32. Stevenson M, Segui-Go- Release 14 [program]. Journal of Sport Medicine mez M, Lescohier I, et College Station, Texas: 2011; 21(6):508–14. al. An overview of the StataCorp LP, 2015. 41. Worrell SS, Koepsell DT, injury severity score and 37. Mokdad AH, Ballestros K, Sabath RD, et al. The Risk the new injury severity Echko M, et al. The State of Reinjury in Relation to score. Injury Prevention of US Health, 1990–2016: Time Since First Injury: 2001; 7(1):10–13. Burden of Diseases, A Retrospective Popu- 33. Wilson SJ, Derrett S, Camer- Injuries, and Risk Factors lation-Based Study. The on ID, et al. Prevalence of Among US States. JAMA Journal of Trauma: Injury, poor outcomes soon after 2018; 319(14):1444–72. Infection, and Critical injury and their association 38. Connor J, Kydd R, Shield K, Care 2006; 60(2):379–84. with the severity of the et al. Alcohol-attributable 42. Statistics New Zealand. He injury. Injury Prevention burden of disease and hauā Māori Findings from 2014; 20(1):57–61. injury in New Zealand : the 2013 Disability Survey. 34. Ministry of Health. 2004 and 2007 : research Wellington: Statistics National Minimum Dataset report commissioned by New Zealand, 2015. (hospital events) 2012 the Health Promotion 43. Mauri Ora Associates. [cited 2015 10 February Agency. Wellington: Health Māori Experience of ACC: 2015]. Available from: Promotion Agency, 2013. Mauri Ora Associates Final http://www.health.govt.nz/ 39. McPherson A, Nagai T, Report for Department nz-health-statistics/nation- Webster K, et al. Risk of Labour: Department al-collections-and-surveys/ of Lower Extremity of Labour, 2010. collections/ Musculoskeletal Injury national-minimum-data- after Concussion: A set-hospital-events Meta-Analysis. Medicine accessed 10 October 2018.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 35 www.nzma.org.nz/journal ARTICLE
An audit of patients with a diagnosis of idiopathic pulmonary brosis (IPF) in Canterbury, New Zealand James Fulforth, Donna Thomson, Gordon Maxwell, Rachel Wiseman, Adrienne Edwards
ABSTRACT AIM: In light of new therapies and guidelines for the management of idiopathic pulmonary fibrosis (IPF), and in the absence of local epidemiological data, we sought to ascertain a current estimate of the prevalence of IPF in Canterbury and to audit local practices. METHODS: We performed a retrospective observational study of patients with IPF in Canterbury, New Zealand and the wider region. Patients were identified through a systematic search of hospital records and included if they were alive on 1 January 2017, had a histological or radiological diagnosis of usual interstitial pneumonia and clinical correlation consistent with a diagnosis of IPF. Clinical data was extracted from the clinical record. Follow up was complete until April 2018. RESULTS: Sixty-eight patients were included, median follow up 33 (14–49) months. Fi een (22.1%) patients died during follow up, median survival 19 (6.5–54) months. Estimated prevalence of IPF was 6.53/100,000 persons. Six (8.8%) patients were discussed at the Interstitial lung disease multi-disciplinary meeting. Resting Sp02 and end-of-life discussions were documented in 44 (64.7%) and 19 (27.9%) patients respectively, while oxygen therapy was prescribed to 15 (22.7%). 20/36 (55.5%) patients eligible for pirfenidone were treated. Those treated were more likely to have undergone a six-minute walk test (5/20 vs 3/48, p<0.05) or have been hospitalised in the last 12 months (12/20 vs 3/48, p<0.05). 7/20 patients remained on treatment at the end of follow-up (eight discontinued, five deceased). CONCLUSION: In this study the estimated prevalence of IPF in the Canterbury region is 6.53/100,000 persons. Furthermore, we have identified limitations in local practice relevant for service development.
diopathic pulmonary fi brosis (IPF) is Although there is no cure for IPF, the an incurable progressive lung disease anti-fi brotic medications pirfenidone and Icharacterised by cough and exertional nintedanib have been shown to reduce dyspnoea. Although disease course varies, the decline in forced vital capacity (FVC) the majority develop progressive respirato- in patients with IPF in phase III trials.4,5 ry failure, culminating in death within fi ve Data has since emerged about their effec- years of diagnosis unless lung transplan- tiveness in real-world IPF patients, including tation is possible.1 Worldwide prevalence from the Australian IPF registry.6 In New is estimated to be between 1.25 and 63 per Zealand, pirfenidone has been available 100,000, depending on the population stud- since January 2017 under a special authority ied and defi nition of IPF,2 while incidence scheme for patients with a diagnosis of IPF appears to be increasing globally.3 At present and FVC between 50 and 80% predicted, the epidemiology of IPF in New Zealand is while nintedanib only became funded in unknown. In Canterbury, outpatient IPF October 2018. However, at present there is diagnoses are not coded, making us reliant no IPF registry or outpatient coding allowing on inpatient coding which underestimates us to capture data on their effi cacy. the true impact of disease.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 36 www.nzma.org.nz/journal ARTICLE
In addition to anti-fi brotic therapies, providers in Canterbury were also invited to supportive and non-pharmacological care provide patients for inclusion in the study. maintains a central role in the management In order to capture all patients who of this condition. Pulmonary rehabilitation had been treated with pirfenidone, those is benefi cial in terms of six-minute walk test who were alive on 1 January 2017 then (6MWT) and health-related quality of life underwent manual review of the case notes 7 in patients with IPF. Domiciliary oxygen and were included if they had a radiological therapy benefi ts patients with IPF, and its or histological fi nding of defi nite UIP and 8 use is recommended where appropriate. documented clinical correlation consistent The role of palliative care is under-rec- with a diagnosis of IPF. Patients with a ognised but is crucial given the unremitting radiological fi nding of possible UIP were symptoms of this disease which signifi cantly included without lung biopsy, provided the 9 impacts on quality of life. treating clinician felt the clinical picture was Recently published position papers from one of IPF.11 Follow up was complete until the Thoracic Society of Australia and New April 2018 or the time of death. The prev- Zealand highlight the importance of making alent cohort included those alive in April an accurate diagnosis of IPF in the context 2018 and prevalence was estimated using of an interstitial lung disease (ILD) multi- the Ministry of Health projected populations disciplinary meeting (MDM) with the aim for the regions studied. of optimising the holistic care of patients Clinical, physiological and demographic 8,10 with IPF. In response to this, Canterbury data were collected using a pre-formatted District Health Board (DHB) instituted a spreadsheet. Physiological data collected dedicated monthly ILD MDM in 2017, with included forced vital capacity (FVC) and the ability to accept referrals both locally where available; diffusion capacity (DLCO), and from the surrounding regions. One year six-minute walk test (6MWT) and oxygen on from the institution of the MDM, and the saturation (Sp02). This included the most availability of pirfenidone in New Zealand, recent measurements and, in those treated the aims of this study were therefore; to with pirfenidone, measurements imme- establish an estimate of the prevalence of diately prior to commencing treatment. IPF in the Canterbury and neighbouring Clinical data collected included diagnostic regions; to assess current practice with investigations (radiology and histology), respect to the aforementioned position state- MDM discussion; the presence of complica- 8,10 ments; and to review the early experience tions including hospitalisation and death; with pirfenidone in our community. documentation of end-of-life discussion or advance care plans (ACP); and prescriptions Methods for pirfenidone and domiciliary oxygen We performed a retrospective obser- therapy. Palliative care, nurse specialist vational study of patients with idiopathic and pulmonary rehabilitation referrals pulmonary fi brosis managed in secondary were collected for those patients in the or tertiary care across the four Northern Canterbury DHB region only. district health boards (DHB) in New Descriptive data is presented as n (%), Zealand’s South Island: Canterbury DHB, mean (standard deviation) or median South Canterbury DHB, West Coast DHB and (interquartile range). Comparative statistics Nelson and Marlborough DHB. Patients were were performed using students t test for identifi ed through keyword searches for continuous data and Fisher’s Exact test for “usual interstitial pneumonia” (UIP), “idio- categorical data. Results were considered pathic pulmonary fi brosis” and “cryptogenic signifi cant with a p value <0.05. fi brosing alveolitis” in radiology reports As a retrospective audit, this study was and clinical communications stored in the exempted from ethical review by the electronic record, through ICD-10 coding of New Zealand Health and Disability Ethics discharge summaries over the last 10 years Committee. Approval for this study was up to April 2018 and from a database of granted by the Canterbury DHB Clinical patients discussed in the ILD MDM. Private Audit Department.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 37 www.nzma.org.nz/journal ARTICLE
Thirty-six (52.9%) patients were eligible Results for treatment with pirfenidone on the basis Three hundred and forty-nine records of their physiological parameters. The were reviewed and 68 patients who met majority of ineligible patients (22/32, 68.8%) the inclusion criteria were identifi ed. Fifty had an FVC above the treatment threshold (73.5%) were male and the median age was of 80% predicted. In total 20 (29.4%) patients 80 years (72–84). Seven (10.3%) patients were prescribed pirfenidone between 1 were of non-European descent (three (4.4%) January 2017 and the end of follow-up, 18 New Zealand Māori, four (5.9%) Asian, of whom met the special authority criteria 52 (76.5%) New Zealand European, nine and two who were treated outside of this (13.2%) other European). Median follow-up guidance with an FVC <50% predicted. was 33 months (14–49). Fifteen (22.1%) Patients prescribed pirfenidone were no patients died during follow-up, therefore 53 more likely to have been discussed in the patients made up the prevalent cohort in ILD MDM (2/20 vs 4/48, p>0.05) than those April 2018, providing an estimated preva- not prescribed pirfenidone, but were more lence of IPF of 6.53 cases/100,000 persons. likely to have undergone a 6MWT (5/20 vs All patients underwent high-resolution 3/48, p<0.05) or to have been hospitalised in computed tomogrophy as the initial inves- the last 12 months (12/20 vs 11/48, p<0.05) tigation of choice. Sixty-fi ve patients had (Table 1). radiological features consistent with UIP Seven patients were still taking (63 defi nite, two possible) and required pirfenidone at the end of follow-up. Among no further investigation. One patient those who discontinued therapy, fi ve died underwent a non-diagnostic transbron- during follow-up and eight (40%) discon- chial biopsy and proceeded to surgical lung tinued therapy due to side effects. No biopsy. Two further patients underwent patients had discontinued therapy due to surgical lung biopsy to establish the diag- progressive disease at the end of follow-up. nosis of IPF. One patient had an incidental Eighteen patients eligible for pirfenidone fi nding of UIP in a lobectomy sample were not prescribed treatment. Reasons for following surgery for non-small cell lung this were documented in the clinical record cancer. Overall, six (8.8%) patients from this in nine cases and included active decisions cohort had been discussed in the ILD MDM not to treat due to ‘stable/slowly progressive at the end of follow-up. This included three disease’ (n=4), ‘comorbidity’ (n=1), ‘patient out of 10 patients diagnosed since 1 January decision’ (n=1), and ‘treatment decision still 2017. Four out of the six patients discussed under consideration’ (n=3). were given a new diagnosis of IPF on the basis of MDM discussion; the remaining Fifteen (22.1%) patients died during two patients had an established diagnosis follow-up with a median survival of 19 supported by the MDM. months (6.5–54). These patients had signifi - cantly lower FVC (2.16L vs 2.64L, p<0.05) Eight (11.8%) patients had undergone than those who survived. They were also a 6MWT at the end of follow up. Resting more likely to have been prescribed domi- oxygen saturations were documented in ciliary oxygen therapy (6/15 vs 9/53, p<0.05), 44 (64.7%) patients. Twenty-eight (41.2%) have had end-of-life plans made (8/15 vs patients had documented resting hypoxia 11/53, p<0.05) and to have been hospitalised (Sp0 <90%), and a further six, without 2 in the last 12 months (9/6 vs 14/53, p<0.05). resting hypoxia, had evidence of exertional hypoxia. All patients with resting hypoxia Among patients in the Canterbury DHB received a discussion regarding the role region (n=53), 10 (18.9%) had been referred of oxygen therapy and domiciliary oxygen to a respiratory nurse specialist, 10 (18.9%) therapy was prescribed to 15 (22.7%) for pulmonary rehabilitation and nine patients in total. Nineteen (27.9%) patients (16.9%) to palliative care services respec- had clearly documented end-of-life discus- tively. Five patients in this region died sions or an advance care plan in place. without a referral to palliative care services.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 38 www.nzma.org.nz/journal ARTICLE
Table 1: Demographics and clinical characteristics of patients who were prescribed, and were not pre- scribed pirfenidone during the follow-up period.
Prescribed Not prescribed pirfenidone pirfenidone
N=20 N=48 Age (years) (median, IQR) 79 (69.8–80.3) 82 (73.8–85.3)
Male (n, %) 16 (80) 34 (70.8)
FVC (L) (mean, SD) 2.20 (0.44) 2.67 (0.91) *
FVC (% Predicted) (mean, SD) 65.8 (10.9) 76.7 (24.2)
FVC >50% and <80% predicted 18 (90) 18 (37.5) * (ie, eligible for treatment) (n, %)
ILD MDM discussion (n, %) 2 (10) 4 (8.3)
6MWT undertaken (n, %) 5 (25) 3 (6.3) *
Resting Sp02 documented (n, %) 11 (55) 33 (68.8)
Domiciliary 02 Discussed (n, %) 4 (20) 11 (22.9) Prescribed (n, %) 6 (30) 7 (14.6)
End-of-life discussion or ACP documented (n, %) 8 (40) 11 (22.9)
Hospital Admission in last 12 months (n, %) 12 (60) 11 (22.9) *
Died during follow up (n, %) 5 (25) 10 (20.8)
Discontinued therapy (n, %) 8 (40)
* p<0.05
an ILD MDM has only been available at Discussion Christchurch Hospital since 2017, though In this study we have estimated the prev- even among patients diagnosed since its alence of IPF in secondary and tertiary care inception, the rate is only 30%. The lack centres across Northern regions of the South of uptake likely refl ects capacity issues, Island of New Zealand to be 6.53/100,000. as the ILD MDM was only held monthly This is comparable with worldwide preva- initially and triage priority given to new or lence rates of between 1.25 and 63/100,000.2 complex ILD cases. However, four patients Our estimate is at the lower end of this were given a new diagnosis of IPF on the range, and may refl ect the fact that patients recommendation of the MDM, in keeping were only captured if they had come into with international literature whereby contact with a physician in a secondary or changes in diagnosis and management have tertiary centre, thereby underestimating the been shown to occur in >50% of ILD cases true prevalence of IPF in the community. discussed in such a forum.12 Improving the Nevertheless, the population captured is capacity and uptake of this service should likely to have included the majority of symp- therefore be considered a priority, partic- tomatic or severely affected patients and ularly as multidisciplinary discussion is a therefore this estimate remains relevant for requirement for funded pirfenidone therapy the planning of hospital-based services. in New Zealand. Guidelines recommend discussion of In this study 25% of patients prescribed all new cases of IPF in an ILD MDM to pirfenidone died during follow-up. Among confi rm the diagnosis.8 In our study only those surviving, less than half achieved 8% of patients had been discussed in such long-term adherence. The majority reported a forum. No doubt this refl ects the fact that gastrointestinal intolerance although
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 39 www.nzma.org.nz/journal ARTICLE
reasons for discontinuation were not always region. Our rate of palliative care referrals documented. This is in contrast to real world are similar to those (13.7%) identifi ed in experience of pirfenidone elsewhere in one large retrospective cohort,17 but this which discontinuation rates due to adverse would appear to be inadequate for a disease events are reported as between 16 and process with high mortality and symptom 20%.13,14 In these studies, dose adjustment burden. In fact, data from the Swedish was associated with improved adherence, Registry of Palliative Care would suggest and elsewhere dedicated close follow-up, that patients with ILD receive poorer access patient support and education has been of to end-of-life care than patients with lung benefi t.15 Currently no specifi c protocol for cancer.18 There is clearly an unmet need in treatment initiation exists in our institution, this area, and it may be the case that use of but this may be an option, incorporating the a decision support tool to prompt end-of-life above factors, that needs to be explored to discussions could improve documentation improve adherence. Alternatively, the poor of these issues and referral for appropriate tolerance may refl ect the age of our patients, supportive services where indicated.19 who had a median age of almost 10 years Limitations of this study include the retro- greater than those described elsewhere. spective nature of data collection and case The provision of supportive care and identifi cation. These may have introduced end-of-life planning are important consider- a risk of ascertainment bias, or an underes- ations in what remains a terminal condition. timate of disease prevalence respectively. Fifteen (22.7%) patients in this study were Furthermore, data on referrals to palli- prescribed either ambulatory or long-term ative care, pulmonary rehabilitation and oxygen therapy, which is comparable to specialist nursing was not available outside data from the British Thoracic Society IPF Canterbury DHB. Registry in which 26% of patients were To our knowledge this is the fi rst study 16 prescribed oxygen. However, documen- to estimate the prevalence of IPF in New tation of oxygen saturations was only Zealand and is an important step forward in complete in 64.7% of patients, and exertional planning for the future in a disease in which testing was infrequent, so it is possible that worldwide incidence is increasing, thera- patients who may benefi t from this therapy peutic options are widening and pathways are not being identifi ed in the clinic. Mean- of care are becoming increasingly complex, while, documentation of end-of-life planning yet standardised.8 Furthermore we have was complete in just 27.9% of patients. been able to identify limitations in current It is reassuring to see that patients practice locally, in terms of the uptake of who died were more likely to have been MDM discussion, physiological measure- prescribed oxygen and to have had ments and supportive care, along with high end-of-life care plans made, but the overall discontinuation rates of therapy. Improve- proportion of patients receiving these ments in these areas may be benefi cial for interventions was low, as it was for those patients but will also have impacts in terms referred to specialist nursing services and of the resources required to achieve this. palliative care in the Canterbury DHB
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 40 www.nzma.org.nz/journal ARTICLE
Competing interests: Nil. Author information: James Fulforth, Senior Registrar, Department of Respiratory Medicine, Christchurch Hospital, Christchurch; Donna Thomson, Clinical Nurse Specialist, Department of Respiratory Medicine, Christchurch Hospital, Christchurch; Gordon Maxwell, Registrar, Department of Respiratory Medicine, Christchurch Hospital, Christchurch; Rachel Wiseman, Consultant Respiratory and Palliative Care Physician, Department of Respiratory Medicine, Christchurch Hospital, Christchurch; Adrienne Edwards, Consultant Respiratory Physician, Department of Respiratory Medicine, Christchurch Hospital, Christchurch. Corresponding author: Dr Adrienne Edwards, Canterbury District Health Board, Canterbury Respiratory Service, Christchurch, Canterbury. [email protected] URL: http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2019/vol-132-no-1499- 26-july-2019/7943
REFERENCES: 1. Ley B, Collard HR, King randomised trials. Lancet. of Health Care Inequal- TE. Clinical Course 2011; 377:1760–1769. ity. Ann Am Thorac Soc. and Prediction of 6. Jo HE, Glaspole I, 2016; 13:311–316. Survival in Idiopathic Grainge C, et al. Base- 10. Prasad JD, Mahar A, Pulmonary Fibrosis. Am line characteristics of Bleasel J, et al. The J Respir Crit Care Med. idiopathic pulmonary interstitial lung disease 2011; 183:431–440. fi brosis: Analysis from multidisciplinary meeting: 2. Nalysnyk L, Cid-Ruzafa the Australian Idiopathic A position statement from J, Rotella P, Esser D. Pulmonary Fibrosis the Thoracic Society of Incidence and prevalence Registry. Eur Respir J. 2017; Australia and New Zealand of idiopathic pulmonary 49. doi:10.1183/13993 and the Lung Foundation fi brosis: review of the 003.01592-2016 Australia. Respirology. literature. Eur Respir 7. Dowman L, Hill CJ, Holland 2017; 22:1459–1472. Rev. 2012; 21:355–361. AE. Pulmonary rehabil- 11. Raghu G, Collard HR, 3. Hutchinson J, Fogarty A, itation for interstitial Egan JJ, et al. on behalf Hubbard R, McKeever lung disease. Cochrane of the ATS/ERS/JRS/ALAT T. Global incidence and Database Syst Rev. 2014, Committee on Idiopathic mortality of idiopathic Issue 10. Art No: CD006322 Pulmonary Fibrosis. An pulmonary fi brosis: A doi:10.1002/14651858. offi cial ATS/ERS/JRS/ALAT systematic review. Eur CD006322.pub3 Statement: Idiopathic Respir J. 2015; 46:795–806. 8. Jo HE, Troy LK, Keir G, et Pulmonary Fibrosis: 4. Nathan SD, Albera C, al. Treatment of idiopathic Evidence-based Guidelines Bradford WZ, et al. pulmonary fi brosis in for Diagnosis and Manage- Effect of pirfenidone on Australia and New Zealand: ment. Am J Respir Crit Care mortality: pooled analyses A position statement from Med. 2011; 183:788–824. and meta-analyses of the Thoracic Society of 12. Jo HE, Glaspole IN, Levin clinical trials in idiopathic Australia and New Zealand KC, et al. Clinical impact pulmonary fi brosis. Lancet and the Lung Foundation of the interstitial lung Respir Med. 2017; 5:33–41. Australia. Respirology. disease multidisciplinary 5. Noble PW, Albera C, 2017; 22:1436–1458. service. Respirology. Bradford WZ, et al. 9. Brown CE, Jecker NS, 2016; 21:1438–1444. Pirfenidone in patients Curtis JR. Inadequate 13. Hughes G, Toellner H, with idiopathic pulmonary Palliative Care in Chronic Morris H, et al. Real World fi brosis (CAPACITY): two Lung Disease. An Issue Experiences: Pirfenidone
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 41 www.nzma.org.nz/journal ARTICLE
and Nintedanib are Effec- pulmonary fi brosis. Respir 18. Ahmadi Z, Wysham tive and Well Tolerated Med. 2014; 108:224–226. NG, Lundstrom S, et Treatments for Idiopathic 16. The British Thoracic Society al. End-of-life care in Pulmonary Fibrosis. J Interstitial Lung Disease oxygen-dependent Clin Med. 2016; 5:E78. Registry Programme. ILD compared with 14. Cottin V, Maher T. http://www.brit-thoracic. lung cancer: a national Long-term clinical and org.uk/document-library/ population-based study. real-world experience audit-and-quality-improve- Thorax. 2016; 71:510–516. with pirfenidone in the ment/lung-disease-registry/ 19. Sharp C, Lamb H, Jordan treatment of idiopathic bts-ild-registry-annual-re- N, et al. Development of pulmonary fi brosis. Eur port-201516/17. tools to facilitate palliative Respir Rev. 2015; 24:58–64. 17. Lindell KO, Liang Z, Hoff- and supportive care 15. Chaudhuri N, Duck A, man LA, et al. Palliative referral for patients with Frank R, et al. Real world Care and Location of Death idiopathic pulmonary fi bro- experiences: pirfenidone in Decedents With Idio- sis. BMJ Support Palliat is well tolerated in pathic Pulmonary Fibrosis. Care. 2017; 8:340–346. patients with idiopathic Chest. 205; 147:423–429.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 42 www.nzma.org.nz/journal ARTICLE
Cost and resource implications of introducing intensive nodal surveillance for sentinel node positive melanoma in provincial New Zealand Joseph Winstanley, Emma Cervenak, Christopher Harmston
ABSTRACT AIMS: Two randomised trials have shown that immediate completion lymphadenectomy for sentinel node positive melanoma provides no long-term survival benefit; compared with a follow up regime of intensive nodal surveillance. The aim of this study was to assess the cost and resource implications of introducing this regime for patients with sentinel node positive melanoma in a provincial New Zealand hospital. METHODS: Patients with cutaneous melanoma presenting to Northland District Health Board between 1 January 2012 and 31 December 2014 were identified. The financial and resource burden of standard treatment was assessed, including operative, outpatient and imaging interventions. Theoretical financial and resource costs of intensive nodal observation for a theoretically equivalent cohort were calculated. RESULTS: The cost of standard treatment was $7,147 per patient and the theoretical cost of nodal observation was $5,300 per patient. Standard treatment required more operating theatre time and inpatient treatment. Nodal observation required more outpatient appointments and imaging. CONCLUSIONS: The cost of nodal observation was lower than standard treatment than in our study. There is a shi in resource requirements from operating theatre and inpatient care to outpatient appointment and imaging. The overall resource impact is low and introduction of nodal observation appears achievable.
ew Zealand has the highest age-stan- a discussion regarding the benefi ts of SLNB is dardised incidence of melanoma in recommended.5–7 Until recently, most patients the world,1 with 2,567 new cases diag- in New Zealand with a positive sentinel node N 2 nosed in 2016. The treatment of melanoma would be counselled to undergo immediate also consumes signifi cant healthcare resourc- completion lymphadenectomy. es, with the annual healthcare cost estimated Two recent randomised trials have chal- 3 to be upwards of 5.7 million dollars. lenged this traditional approach to SLNB Nodal tumour burden is an important management. The MSLT-II and De-COG SLT prognostic marker in patients with trials randomised patients with a sentinel melanoma, and can direct adjuvant node positive melanoma to immediate treatment.4 Traditionally, sentinel lymph completion lymphadenectomy; or intensive node biopsy (SLNB) is recommended for clinical follow-up and delayed dissection patients with primary cutaneous melanoma for clinically detected recurrence. Both with a Breslow thickness exceeding 1.0mm. trials showed no improvement in overall In patients with thin melanomas (less than disease-free survival in the immediate 1.0mm) with ulceration or high risk features, completion lymphadenectomy group.8,9
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 43 www.nzma.org.nz/journal ARTICLE
This has already led the Melanoma Multi- associated with the primary diagnosis of disciplinary group in New Zealand to melanoma. CostPro software was used to recommend intensive nodal observation for calculate in-house patient level costs for certain patients with a positive SLNB. In the each episode and New Zealand common nodal observation arm of the MSLT-2 study, costing standards were used throughout. patients were monitored with clinical exam- We were then able to apply these median ination and nodal ultrasound every four costs to our primary cohort and a theo- months for the fi rst two years and every six retical cohort undergoing intensive nodal months during years 3 to 5 of follow-up. observation in keeping with the regime The cost and resource implications of outlined in the MSLT-2 trial. All patients in this change in management are not well the intensive nodal observation group were understood, and there has been no study assumed to survive three-year follow up to in Australasia assessing this. It is likely that give a maximum estimated cost. intensive nodal observation will become The primary area of interest was the standard practice and it is essential that additional clinical and fi nancial resource clinicians and managers anticipate this. required to introduce intensive clinical The aim of this study is to assess the cost follow-up of the nodal basin for patients and resource implications of introducing with positive sentinel nodes in cutaneous intensive nodal observation for patients melanoma. Data was analysed in Microsoft with cutaneous melanoma and a positive Excel and presented using standard SLNB in a provincial New Zealand hospital. techniques. The study was performed as part of a Methods service review of melanoma care within Consecutive patients with a diagnosis NDHB. The study was reviewed by the of primary cutaneous melanoma and Health and Disability Ethics Committee melanoma in situ presenting to Northland who issued an ‘out of scope letter’, deeming District Health Board between 1 January formal ethical approval unnecessary. 2012 and 31 December 2014 formed the primary cohort. Patients were identifi ed Results by searching the Faster Cancer Treatment Basic demographics and clinical Registry and the NDHB databases for inpatient admissions, incoming primary outcomes Two hundred and ninety-seven new cases care referrals and incoming referrals from of primary cutaneous melanoma were other health boards were also searched for identifi ed among 294 patients, including 82 completion. Cases of ocular, intra-oral and patients with melanoma in situ. Median age anal melanoma were excluded. Cases of at diagnosis was 69.1 years (IQR 58.9–76.5). recurrent melanoma, as indicated by histo- The median length of follow-up was 1,737 pathology, were also excluded. days (IQR 1408–2024). Basic demographic Patient electronic records were accessed characteristics of our primary cohort are using the electronic record and results outlined in Table 1. All patients with a reporting system, CONCERTO. Information positive sentinel node went forward for collected included patient demographics and completion lymphadenectomy. This included tumour characteristics, operations under- three axillary, one neck and two groin dissec- taken, outpatient clinic attendances and tions. Of the six patients followed up after ultrasound attendances. immediate lymphadenectomy, four deviated In order to reduce the effect of individual from routine follow-up due to complica- costing anomalies within our small cohort, tions. These included seroma (N=3), wound we estimated the median cost for each type infection (N=1), haematoma (N=1) and of melanoma-associated intervention from damage to the spinal accessory nerve (N=1). 1,012 patient episodes. This included all Four patients died during follow-up after surgical admissions, day case procedures, immediate completion lymphadenectomy. outpatient clinic visits and outpatient ultra- There were 29 patients eligible for SLNB sound scans in Northland DHB from 1 July on the basis of Breslow thickness who 2007 until 27 September 2018 that were didn’t undertake it within Northland DHB.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 44 www.nzma.org.nz/journal ARTICLE
Table 1: Demographics, tumour characteristics and clinical outcomes within our primary cohort.
N (%) Median age (IQR) Male:female ratio Ethnicity NZ European 254 (86.7) 69.1 (58.9–76.5) 132:122
Other European 30 (9.9) 68.9 (58.7–76.1) 17:13
NZ Māori 10 (3.4) 66.4 (57.2–73.1) 5:5
Breslow thickness (mm) Melanoma in situ 82 (30.5) 70.0 (63.0–77.6) 40:42
≤ 1.0mm 99 (36.8) 64.4 (55.0–74.0) 51:48
1.01–2.0mm 42 (15.6) 69.6 (61.2–75.7) 22:20
2.01–4.0mm 28 (10.4) 71.1 (57.1–81.4) 12:16
>4.0mm 18 (6.7) 77.4 (72.0–90.6) 12:6
Clinical outcomes Wide local excision only 215 70.0 (60.6–78.0) 114:101
Wide local excision & SLNB 59 67.0 (55.6–73.2) 29:31
Positive SLNB 6 71.2 (57.0–75.8) 5:1
Nine did not proceed due to age or existing of the MSLT-2 trial. To provide context, the comorbidities, one patient suffered anaphy- overall estimated cost to Northland DHB of laxis to the blue dye, four patients were melanoma excisions (including melanoma confi rmed as having SLNB in the private in situ) and inpatient admissions for SLNB sector. Fifteen patients were lost to follow and lymphadenectomy was $513,393 over up and it is not known how many of these the study period (Appendix). went on to have private surgery elsewhere. Costs and resourcing Discussion Costs of traditional management were This study shows that in sentinel node calculated for patients (N=6) in our retro- positive melanoma, intensive observation of spective cohort with a positive sentinel node the lymph node basin is likely to be asso- biopsy (Table 2). Median length of follow-up ciated with lower costs than traditional post-lymphadenectomy was 2.60 years (IQR management. However, there is a shift in 1.32–5.21); mean 3.04 +/- 0.99 years. resource requirements with lower operative These were compared to a theoretical and inpatient costs, and higher outpatient cohort undergoing intensive nodal surveil- and imaging requirements. lance over three years as per MSLT-2 Although our population was much protocol. The overall cost of traditional smaller than the MSLT-2 study, the gender management in our retrospective cohort and tumour site distribution were compa- was $42,883 (mean cost per patient $7,147). rable. Our rate of positive SLNB was 10.2%, All six patients undergoing intensive nodal compared to 20.8% in the published liter- surveillance were assumed to survive at ature.10 Unlike MSLT-2, we also included least three years, resulting in a maximum seven patients with thin (0.75–1.0mm) estimated cost of $31,802 (mean cost per melanomas with ulceration or high mitotic patient $5,300). This includes the forty-eight rate, all of whom went on to have a negative ultrasound scans required to follow them SLNB. It is worth noting that 10 patients did up over three years. A 26.1% nodal-recur- not undergo SLNB on clinical grounds. We rence rate over three years was predicted in are unable to estimate the effect of these this cohort, in line with the observation arm patients or those lost to follow-up on our
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 45 www.nzma.org.nz/journal ARTICLE
Table 2: A cost and resource comparison of traditional management versus intensive nodal surveillance over three years.
Traditional management (N=6) Intensive nodal surveillance (N=6) Median Total Total cost Predicted Total Total cost (range) (N=6) ($) requirement (N=6) ($) per patient
Completion 1 6 $33,906 0.26 1.57 $8,858 lymphadenectomy
Outpatient 3 (2–14) 31 $8,125 8 48 $12,720 appointment
Ultrasound scan 0.5 (0–2) 4 $852 8 48 $10,224
TOTAL $42,883 $31,802 rate of SLNB positivity. However, we do not sound scans would be required on average believe that they would alter the primary per patient over a three-year period. While comparator of cost per patient in each cohort. this would require reallocation of resources The benefi ts of lymphadenectomy are within our hospital, the extra cost would be balanced against the risk of operative more than offset by the savings made from complications, which is known to be high. stopping immediate completion lymph- This is refl ected in our study where patients adenectomy. In reality, these costs are required seroma catheter insertion, anti- low when considered in the context of the biotic therapy, percutaneous drainage or overall melanoma budget. Our estimated a prolonged course of physiotherapy. A expenditure on melanoma exceeded half a drawback of our methodology is that these million dollars over three years and didn’t outpatient costs were not fully accounted take into account the countless negative for and the true fi nancial burden of excisional biopsies performed by our completion lymphadenectomy may be health board. Financial constraints should even higher than presented. It also demon- therefore pose no barrier to following new strates the importance of performing a true evidence-based guidelines in this setting. intention to treat analysis. The authors appreciate the limitations of The higher sensitivity of ultrasound over this study, in particular in trying to predict clinical palpation in the detection of nodal cost and resource requirements from recurrence is well established.11,12 However, retrospective data. It is however the fi rst sonographic criteria vary widely among study considering the resource implications published studies and no single feature of this clinical change in practice in New is suffi ciently specifi c. Ultrasound guided Zealand. Our population is small, but likely procedures are increasingly performed by to be representative of other provincial surgeons in the clinic setting. However, the DHBs across New Zealand. We also note that degree of interpretative experience required four of our completion lymphadenectomy for ultrasound surveillance can only be patients died during follow-up, highlighting expected from senior sonographers or the poor prognosis among this group. radiologists. As a result, radiology depart- In short we have demonstrated that the ments will need to anticipate the increased introduction of intensive nodal obser- demand that surveillance will have on their vation in patients with positive SLNB in staffi ng and expertise. melanoma is likely to result in decreased Our primary area of interest in this study costs, but some management or reallocation was the extra clinical and fi nancial resource of resources will be needed. As the burden required to implement this treatment of patients with a positive SLNB is low, it is paradigm. We predicted that an extra fi ve likely that the introduction of this type of outpatient appointments and eight ultra- regime would be achievable for provincial hospitals in New Zealand.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 46 www.nzma.org.nz/journal ARTICLE
Appendix
Procedure Total undertaken Estimated median cost during study per procedure
Wide local excision in minor operations clinic 140 $401 (303–521)
Wide local excision in main operating theatre 75 $1,705 (1,438–2,160)
Wide local excision and sentinel lymph node 59 $5,008 (4,223–5,933) biopsy in main operating theatre
Lymph node dissection (eg, axillary or groin) in 6 $5,651 (3,989–7,821) main operating theatre
Surgical outpatient appointment $265 (265–265)
Superficial ultrasound scan $213 (213–213)
Competing interests: Nil. Author information: Joseph Winstanley, Department of General Surgery, Whangarei Base Hospital, Whangarei; Emma Cervenak, Department of General Surgery, Whangarei Base Hospital, Whangarei; Christopher Harmston, Department of General Surgery, Whangarei Base Hospital, Whangarei. Corresponding author: Dr Joseph Winstanley, Department of General Surgery, Whangarei Base Hospital, Maunu Road, Private Bag 9742, Whangarei 0148. [email protected] URL: http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2019/vol-132-no-1499- 26-july-2019/7944
REFERENCES: 1. Jones WO, Harman CR, Zealand. [Internet]. 2009. 5. Standards of Service Provi- Ng AK, et al. Incidence of Available from: http:// sion for Melanoma Patients malignant melanoma in wellington.cancernz. in New Zealand -Provi- Auckland, New Zealand: org.nz/assets/Sunsmart/ sional [Internet]. 2013. highest rates in the world. Information-sheets/ Available from: http://www. World journal of surgery. CostsofSkinCan- health.govt.nz/our-work/ 1999 Jul 1; 23(7):732–5. cer-NZ-22October2009.pdf diseases-and-conditions/ 2. Ministry of Health, New 4. Balch CM, Soong S-J, national-cancer-programme/ Zealand. Selected Cancers Gershenwald JE, et al. cancer-initiatives/review-na- 2014, 2015, 2016 [Internet]. Prognostic Factors Anal- tional-tumour-standards 2018. Available from: ysis of 17,600 Melanoma 6. Clinical Practice Guide- http://www.health.govt.nz/ Patients: Validation of the linesfor the Management publication/selected-can- American Joint Committee of Melanoma in Australia cers-2014-2015-2016 on Cancer Melanoma and New Zealand [Inter- 3. O’Dea D. The Costs of Staging System. J Clin Oncol net]. 2008. Available from: Skin Cancer to New [Internet]. 2001 Aug 15; http://www.health.govt.nz/ Zealand. A report to The 19(16):3622–34. Available system/fi les/documents/ Cancer Society of New from: http://doi.org/10.1200/ publications/melano- JCO.2001.19.16.3622 ma-guideline-nov08-v2.pdf
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 47 www.nzma.org.nz/journal ARTICLE
7. NCCN Guidelines Version Completion Dissection examination superior to 1.2019 Cutaneous Mela- or Observation for clinical examination in noma [Internet]. 2019. Sentinel-Node Metastasis melanoma follow-up? A Available from: http://www. in Melanoma. N Engl monocentre cohort study of nccn.org/professionals/ J Med [Internet]. 2017 373 patients. Br J Dermatol. physician_gls/pdf/cuta- Jun 7;376(23):2211–22. 2005 Jan; 152(1):66–70. neous_melanoma.pdf Available from: http:// 12. Blum A, Schlagenhauff 8. Leiter U, Stadler R, Mauch doi.org/10.1056/ B, Stroebel W, et al. C, et al. Complete lymph NEJMoa1613210 Ultrasound examination node dissection versus 10. Morton DL, Thompson JF, of regional lymph nodes no dissection in patients Cochran AJ, et al. Final signifi cantly improves with sentinel lymph trial report of senti- early detection of node biopsy positive nel-node biopsy versus locoregional metastases melanoma (DeCOG-SLT): a nodal observation in during the follow-up of multicentre, randomised, melanoma. N Engl J Med. patients with cutaneous phase 3 trial. Lancet Oncol. 2014; 370(7):599–609. melanoma: results of a 2016; 17(6):757–67. 11. Machet L, Nemeth-Nor- prospective study of 1288 9. Faries MB, Thompson mand F, Giraudeau B, et al. patients. Cancer. 2000 JF, Cochran AJ, et al. Is ultrasound lymph node Jun 1; 88(11):2534–9.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 48 www.nzma.org.nz/journal ARTICLE
How much rehabilitation are our patients with stroke receiving? Stephanie Thompson, Annemarei Ranta, Karen Porter, Naomi Bondi
ABSTRACT BACKGROUND: Stroke rehabilitation o en needs to continue following discharge from hospital. The New Zealand Stroke Network recommends community team review within seven calendar days of discharge and a minimum of three hours of therapy per specialty per week. International stroke guidelines make similar recommendations. The Wellington Community Older Adults, Rehabilitation and Allied Health team aimed to determine current local community stroke rehabilitation practice and compare this to guideline recommendations. METHOD: A prospective cohort of 50 patients with a new diagnosis of stroke, referred to a community rehabilitation team in Wellington, were included in this service audit. The amount of rehabilitation patients received in the first four weeks and first three months following hospital discharge was measured, as well as time to first appointment. In addition, a service satisfaction questionnaire was sent to the patients. RESULTS: The median (interquartile range, IQR) number of days from hospital discharge until first appointment with the community team was 10 (6.3–14.8) calendar days. In the first four weeks a er hospital discharge, patients received from all health professionals an average (SD) of 1.1(0.4) rehabilitation sessions and 34.2 (43.6) minutes of rehabilitation per week. The average (SD) in the first three months or to point of discharge, whichever occurred first was 1.1 (1.1) sessions and 42.2 (49.3) minutes of rehabilitation per week. CONCLUSION: There were delays in providing an initial community rehabilitation appointment and insu icient therapy intensity when comparing audit results to New Zealand Guideline expectations. As a result of this audit, recommendations for service improvements have been made.
troke affects approximately 9,000 New At Capital and Coast District Health Zealanders annually1 and in 2016/2017 Board (CCDHB) three general community there was a prevalence of 1.5% or teams provide community stroke reha- S 2 approximately 57,000 adults. Stroke is the bilitation to patients in the area. CCDHB leading cause of long-term disability in the provides services to a population of approx- developed world3 and most people surviving imately 307,250 (2016/17 estimate).7 In the stroke will require rehabilitation.4 Wellington catchment area (population of 8 Stroke rehabilitation should begin the approximately 131,000), the Wellington day after stroke and will often need to Community Older Adults, Rehabilitation continue following discharge from hospital.5 and Allied Health (WCORA) team provides Rehabilitation in the community can lead rehabilitation to people with stroke aged to improvements in recovery in terms of 16 years and older. Approximately 25% of regaining independence and returning to stroke patients in the region are referred activities of daily living.4 While research for community rehabilitation, and these has found that rehabilitation after hospital patients make up approximately 12% of the discharge is provided in most places in team’s total workload. WCORA is an inter- New Zealand, there is great variation in disciplinary team with allied health, nursing treatment intensity and often a signifi cant and medical health professionals, however delay in the provision of these services.6 it is not a stroke-specifi c community team.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 49 www.nzma.org.nz/journal ARTICLE
The team delivers a fi ve-day-a-week service during business hours, with no treatment Aims available on weekends or public holidays, This service audit set out to determine and does not provide an early supported the current state of stroke rehabilitation discharge service. Rehabilitation is provided practice within the WCORA team and predominantly in patients’ own homes, but to compare this against best practice outpatient appointments are also available guidelines. for those able to travel. The WCORA team This audit aims to determine how quickly routinely incorporates patient ‘home work’ following hospital discharge patients with in addition to therapy sessions, in order to stroke are seen for community rehabil- increase rehabilitation intensity. However, itation, and the amount and number of this component of therapy time was not contacts of rehabilitation they receive captured in this audit. within the fi rst four weeks and three months Guidelines vary in their recommenda- of hospital discharge. In addition, patient tions for stroke rehabilitation provision satisfaction with the community stroke reha- in the community in terms of frequency, bilitation service will be assessed. intensity and how soon post-hospital discharge this should commence. The New Methods 9 Zealand National Stroke Network published Study design minimum recommended standards for Fifty consecutive patients with a new DHBs in the delivery of community reha- diagnosis of stroke referred to the WCORA bilitation for patients with stroke. These team for rehabilitation were included in recommendations included commencing this prospective audit, commencing in a rehabilitation programme within seven June 2016. Patients were identifi ed from calendar days of hospital discharge and the team’s referral register. The paper- providing three days a week of physio- based data collection tool was placed in the therapy, occupational therapy and speech front of the patient’s community medical language therapy for the fi rst four weeks, fi le. Clinicians (including physiotherapists, as clinically indicated. In 2018, the Ministry occupational therapists, speech-language of Health (MOH) introduced a community therapist, liaison nurses, social workers and rehabilitation indicator which states that rehabilitation assistants) documented where 60% of patients referred to the community treatment occurred (eg, home, workplace, rehabilitation team should have a face- outpatient setting) and the amount of time to-face contact within seven calendar days spent treating each patient for the fi rst of hospital discharge.10 Stroke rehabili- three months they were involved or until tation practice guidelines from Canada11 discharge, whichever occurred fi rst. The state that therapy for patients with stroke WCORA team is a goal-oriented service, and should be provided for at least 45 minutes patients are discharged once their therapy a day per discipline required, two to fi ve goals are met. Clinicians were asked to only days per week for at least eight weeks. The document treatment time (not assessment) Healthcare for London stroke rehabilitation during their sessions. guide12 recommends patients are contacted by the community team within twen- On completion of treatment, patients who ty-four hours of discharge from hospital, were still alive were sent a seven-question assessed within three days of discharge survey to assess their satisfaction with and that treatment is commenced within the amount of treatment received and the seven days of assessment. The guideline location in which they received it. They also recommends three sessions per week were also asked to indicate whether they of community physiotherapy, occupational would come into an outpatient clinic if therapy and speech-language therapy, as more treatment could be provided in that clinically indicated, for the fi rst four weeks setting. The survey was designed to be apha- and suggests that rehabilitation should sia-friendly so that those patients with a be provided on an ongoing basis to allow speech or language disorder could complete patients to meet their goals. the survey if they wished. As this was a
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 50 www.nzma.org.nz/journal ARTICLE
service audit project assessing the current received throughout the audit period state of practice, it was determined that (three months post-hospital discharge or formal ethics review was not required. until the patient was discharged from the Data analysis WCORA, whichever occurred fi rst). Zero hours indicates that the patient received an Simple data summaries (mean, SD, assessment, but no treatment was provided. median, IQR, minimum and maximum) were Nineteen of the 46 (41%) patients were calculated using Microsoft excel. still receiving treatment from one or more members of the WCORA team three months Results after hospital discharge. Sixteen of the 46 Fifty patients were included in the audit (35%) patients received only one or two between June 2016 and March 2017. For sessions before being discharged, based on the amount of treatment received and their clinical need. the treatment location, we had 46 sets of Forty-nine patients were still alive at the complete data at the end of the audit period. end of the follow-up period and were sent a One patient died before completing the audit survey. Of these, 18 (37%) responded. Of the period and notes for three people were not 18 patients who responded to the survey, 11 able to be located. The average (SD) number (61%) reported receiving treatment at home, of days from hospital discharge until fi rst one (5.5%) in the outpatient clinic only, fi ve appointment with the community team was (28%) both at home and in the clinic and 11.5 (7.0) days (median 10; IQR 6.3–14.8), one (5.5%) did not respond to the question. while the average (SD) number of days Eleven of the patients (61%) who responded until fi rst treatment session was 13.9 (9.1) to the survey indicated they “completely days (median 11.5; IQR 7–20). Seventeen agreed” or “mostly agreed” that their pref- of the 46 patients (37%) were seen within erence was to be seen at home. Two of the seven calendar days of hospital discharge. patients (11%) indicated that they did not Twenty-nine of 46 patients (63%) received have a strong preference on the location treatment as well as an assessment at their of their treatment. In contrast, 10 (55.5%) fi rst appointment. patients indicated that they “completely Patients received in total an average (SD) disagreed” or “mostly disagreed” with of 4.3 (3.4) visits from all required disci- the statement “I would have preferred to plines combined during the fi rst four weeks be seen as an outpatient”. Patients who after hospital discharge (median 3; range 0 responded to the survey appeared, on to 15) and a total of 11.6 (10.3) visits during the whole, satisfi ed with the amount of the fi rst three months or until discharge rehabilitation that they received from the from the community team, whichever community ORA team. Thirteen (72%) of occurred fi rst (median 7.5; range 1 to 38). the respondents completely agreed with the Table 1 presents the number of rehabili- statement “I was happy with the amount tation sessions and amount of rehabilitation of treatment I received”, two (11%) mostly received per week in the fi rst four weeks agreed, one completely disagreed (6%) and following hospital discharge and the total two (11%) did not respond to the question.
Table 1: Number of rehabilitation sessions and amount of rehabilitation received per week.
Rehab Session Total Rehab Session Total sessions per duration rehabilitation sessions duration rehabilitation week (n) (minutes) time per week per week (minutes) time per week (minutes) (n) (minutes) During initial community rehabilitation period During entire community rehabilitation period (weeks 1–4) (weeks 1–12)*
Mean (SD) 1.1 (0.4) 24.7 (17.5) 34.2 (43.6) 1.1 (1.1) 28.9 (15.3) 42.2 (49.3)
Median (IQR) 0.75 (0.5–1.4) 23.8 (13.5–35.7) 18.1 (5.3–40.3) 0.7 (0.3–1.5) 27.6 (20.4–39.4) 20 (9.1–63.5)
Range 0.3–3.3 0–62.1 0–186.3 0–4.2 0–63.9 0–212.9
*In some cases this was <12 weeks if goals were achieved sooner.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 51 www.nzma.org.nz/journal ARTICLE
Five (28%) of respondents specifi ed they It is likely that both service and patient wanted more treatment than they received, factors impacted on how quickly patients with four of the fi ve (80%) indicating that with stroke were seen in the community they would attend a group session in order for rehabilitation following hospital to receive additional treatment. discharge. Patient factors are largely outside the control of the service and are the Discussion reason why indicators are not set at 100%. Service factor delays, however, need to be This service audit set out to explore addressed. One solution could be to make current stroke rehabilitation practice available an ‘urgent’ appointment each within one community-based team in week for an allied health professional to Wellington, New Zealand. In line with see patients with stroke promptly following previous research6 the audit found that for hospital discharge. As a general community many patients with stroke there was a delay rehabilitation team providing stroke reha- following hospital discharge in receiving bilitation, care would need to be taken not to community rehabilitation. Thirty-seven disadvantage the timeliness of rehabilitation percent of patients were seen within seven to other patient groups. calendar days of hospital discharge and 6 some waited up to one month to be seen for Previous research suggests that not only their fi rst appointment. This percentage falls do patients with stroke often have to wait well short of the MOH’s indicator of 60%. for community rehabilitation to commence, but that at the fi rst appointment they may Delays in community rehabilitation only receive an assessment. In this audit, commencement can be attributed to either nearly two-thirds of patients began their service or patient factors. From a service treatment in the community during their perspective, all referrals for the WCORA fi rst contact with a WCORA health profes- team, including those for patients with sional. This is important as there needs to stroke, are screened as routine. There are be a seamless transition between inpatient no urgent appointments available with and community services, with continuation allied health professionals in the team and of intensive rehabilitation for those patients as this service is not stroke-specifi c, patients with rehabilitation needs.6,13 with stroke are not prioritised differently to other patient groups. All patients are Group therapy sessions are one method booked into the next available appointment of delivering rehabilitation post-stroke. One with the appropriate health professional. benefi t of group therapy in the community As such, the volume of referrals received is that sessions can be scheduled in the fi rst by the team will have an impact on the week after hospital discharge. This ensures length of time a patient with stroke will a smooth transition between inpatient and have to wait for community rehabilitation to community rehabilitation services and commence. In addition, in the WCORA there limits the break in rehabilitation for the 13 is no backfi ll available to cover staff leave, patient. Group therapy may be more effi - extreme weather may result in community cient and cost-effective, as there is a lower staff being taken off the road due to staff-to-patient ratio compared to individual 14 fl ooding (thus requiring appointments to therapy. English et al (2007) demonstrated be cancelled) and the Christmas period that providing inpatient physiotherapy in where, as per organisational preference, a group setting compared to individual staff are encouraged to take leave and sessions led to a signifi cant increase in only skeleton staffi ng is available. Patient therapy time with no increase in cost. factors may include other medical diagnoses However, in the community the provision of or events (eg, admission to hospital with group, clinic-based therapy may be limited another medical problem) precluding or by diffi culties with accessing the clinic due contraindicating earlier commencement of to transport requirements, or by having a rehabilitation. In addition, the patient may low referral rate of patients with stroke at a decline an earlier available appointment particular time point. in favour for a day or time that suits them This audit demonstrated that the intensity better. Neither of these issues were specifi - of rehabilitation, as well as the number of cally captured in the current audit, but any contacts patients had in the fi rst four weeks future audit should do so to help clarify after hospital discharge, fell well short of reasons for delays. recommended practice guidelines.9,11,12 The
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 52 www.nzma.org.nz/journal ARTICLE
Clinical Guidelines for Stroke Management and may not be generalisable to the other (2017)5 recommend that “rehabilitation community teams at CCDHB or in New should be structured to provide as much Zealand. Secondly, while we measured the scheduled therapy (occupational therapy amount of rehabilitation undertaken with and physiotherapy) as possible”. A study by a health professional present, we did not Ryan and colleagues15 investigated whether make provisions for patients to record the more intensive home-based rehabilitation amount of time they spent on rehabilitation resulted in improved outcomes for patients outside of therapy appointments. Any future following stroke. They found a small, but work investigating rehabilitation intensity signifi cant difference between groups in following hospital discharge should consider favour of the group that received the more applying for ethics approval to allow for intensive community rehabilitation. The the recruitment of patients to record time WCORA team could consider delegating spent undertaking rehabilitation activ- additional treatment sessions to the team’s ities independently of their therapists. rehabilitation assistants as a means of Thirdly, we had only a small sample size, increasing stroke rehabilitation intensity. therefore only a small number of patients In this audit less than 20% of patients were returned the paper-based service satis- seen by a rehabilitation assistant. Research faction survey, meaning that the results has found a number of benefi ts from having need to be interpreted with caution. The use assistants in the team, including increased of an online survey in addition to mailing intensity of clinical care.16,17 out surveys would be useful to consider for A positive fi nding from this audit is future audits. Fourthly, this audit did not that where clinically indicated, patients specifi cally ask staff to document reasons continued to receive rehabilitation beyond for delays in service provision, however three months. The WCORA team provides some staff did provide information on the a goal-focused rehabilitation service and data collection tool, and two broad cate- tailors the service provided to the individ- gories were identifi ed as potential reasons ual’s needs rather than working to a defi ned for delays. Future audits should include time-period consistent with best practice specifi c information on factors impacting guidelines.5,12 However, this prolonged input commencement of rehabilitation. Finally, may impact on the ability of the team to pick this audit did not document severity of up new patients in a timely fashion. stroke or disability, therefore it is impossible to determine whether the low number of Despite the audit showing that best contacts in the fi rst four weeks following practice guidelines for delivery of hospital discharge was clinically appropriate community stroke rehabilitation were (at least for some patients), or whether not met by the WCORA team, the service further rehabilitation was indicated but was satisfaction questionnaire demonstrated unable to be provided. generally positive feedback from patients. Care needs to be taken when interpreting the questionnaire results, however, as the Conclusion overall sample size of this project was small, This prospective service audit revealed leading to a small number of returned that the WCORA team is not currently surveys. It would be useful to administer meeting best practice recommendations for another service satisfaction questionnaire the provision of community stroke reha- to a larger sample of patients in order to bilitation. There were delays in providing confi rm the results obtained in this audit. It an initial appointment and the intensity of may also be valuable to include an option rehabilitation is lower than recommended. for completing the survey online in addition Suggestions for improving service respon- to mailing out the survey, as mixed mode siveness and intensity of rehabilitation have surveys produce a higher response rate than been made, as well as recommendations single mode surveys.18,19 for future audits. Service redesign may We identifi ed a number of limitations be needed to improve community stroke with the audit and the service satisfaction rehabilitation provision against the MOH survey. Firstly, the fi ndings are limited indicators, and further work is required at a to one community team in Wellington, team level to implement suggested changes.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 53 www.nzma.org.nz/journal ARTICLE
Competing interests: Nil. Author information: Stephanie Thompson, Study Coordinator, Clinical Trials Unit, Capital and Coast District Health Board, Wellington; Annemarei Ranta, Associate Professor and Head of Department, Department of Medicine, University of Otago, Wellington; Consultant Neurologist, Department of Neurology, Wellington Hospital, Wellington; Karen Porter, Physiotherapist, Wellington Community Team, Older Adults, Rehabilitation and Allied Health Service, Capital and Coast District Health Board, Wellington; Naomi Bondi, Speech and Language Therapist, Wellington Community Team, Older Adults, Rehabilitation and Allied Health Service, Capital and Coast District Health Board, Wellington. Corresponding author: Stephanie Thompson, Clinical Trials Unit, Capital and Coast District Health Board, Level 8 WSB, Wellington Regional Hospital, Private Bag 7902, Wellington 6242. [email protected] URL: http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2019/vol-132-no-1499- 26-july-2019/7945
REFERENCES: 1. Stroke Foundation of Organization perspective. 9. National Stroke Network New Zealand. Facts and Int J Stroke. 2013; 8:3–4. NZ Organised Stroke FAQs [Internet]. [Place 5. Stroke Foundation. The Rehabilitation Service unknown]: Stroke Founda- Clinical Guidelines for Specifi cations (in-patient tion of New Zealand; [cited Stroke Management 2017. and community) [Internet]. 2018 April 2]. Available Melbourne, Australia: [Place unknown]: National from: http://www.stroke. Stroke Foundation. 2017. Stroke Network; 2014 [cited org.nz/stroke-facts-and-faqs 2018 March 30]. Available 6. McNaugton H, McRae from: http://cdn-fl ightdec. 2. Ministry of Health. Annual A, Green G, et al. Stroke userfi rst.co.nz/uploads/ Data Explorer 2016/17: rehabilitation services in sites/strokenetwork/ New Zealand Health New Zealand: a survey fi les/pdf_word_fi les/ Survey [Internet]. [Place of service confi guration, service_defi nitions/NZ_ unknown]: Ministry of capacity and guideline Organised_Stroke_Reha- Health; 2017 [updated adherence. NZ Med J bilitation_Service_Spec- 2019; cited 2018 April 2]. 2014; 127(1402):10–19. Available from: http:// ifi cationsFINAL.pdf 7. Ministry of Health Popu- minhealthnz.shinyapps. 10. National Stroke Network lation of Capital & Coast io/nz-health-survey- Frequently asked ques- DHB [Internet]. [Place 2016-17-annual-update tions – Stroke Community unknown]: Ministry of Indicator Collection [Inter- 3. Truelsen T, Begg S, Health; 2019 [updated net]. [Place unknown]: Mathers C. The global 2019; cited 2019 May 5]. National Stroke Network; burden of cerebrovas- Available from: http://www. 2017 [cited 2018 March cular disease [Internet]. health.govt.nz/new-zea- 30]. Available from: http:// [Place unknown]: World land-health-system/my-dhb/ cdn-fl ightdec.userfi rst. Health Organisation; 2006 capital-coast-dhb/popu- co.nz/uploads/sites/stro- [cited 2018 March 30]. lation-capital-coast-dhb Available from: http:// kenetwork/fi les/Coding/ 8. Wellington City – commu- www.who.int/healthinfo/ Community_Rehabilitation/ nity profi le [Internet]. statistics/bod_cerebrovas- Frequently_asked_ques- [cited 2018 April 27]. culardiseasestroke.pdf tions_March_2018.pdf Available from: http:// 11. Herbert D, Lindsay MP, 4. Mendis S. Stroke disabil- profi le.idnz.co.nz/ McIntyre A, et al. Cana- ity and rehabilitation wellington/population of stroke: World Health dian stroke best practice
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 54 www.nzma.org.nz/journal ARTICLE
recommendations: Stroke Following Stroke. Crit and what they do: A rehabilitation practice Rev Phys Rehabil Med. systematic review of the guidelines, update 2014; 26(1–2):27–50. literature. J Multidiscip 2015. Int J Stroke. 2016; 14. English CK, Hillier SL, Healthc. 2010; 3:143–153. 11(4):459–484. Stiller KR, Warden-Flood 17. Stanmore E, Ormond S, 12. Health Care for London A. Circuit class therapy Waterman H. New roles in Stroke Rehabilitation versus individual physio- rehabilitation – the implica- Guide: supporting London therapy sessions during tions for nurses and other commissioners to commis- inpatient stroke rehabili- professionals. J Eval Clin sion quality services in tation: a controlled trial. Pract. 2006; 12(6):656–664. 2010/11 [Internet]. London: Arch Phys Med Rehabil. 18. McPeake J, Bateson Healthcare for London; 2007; 88(8):955–963. M, O’Neill A. Electron- 2009 [cited 2018 March 15. Ryan T, Enderby P, ic surveys: how to 30]. Available from: http:// Rigby AS. A random- maximise success. Nurse www.londonprogrammes. ized controlled trial to Res. 2014; 21(3):24–26. nhs.uk/wp-content/ evaluate intensity of 19. Scott A, Jeon, S-H, Joyce CM, uploads/2011/03/ community-based rehabil- et al. A randomised trial Acute-Stroke-Rehabil- itation provision following and economic evaluation itation-Guide.pdf stroke or hip fracture of the effect of response 13. McNaughton H, Thompson in old age. Clin Rehabil. mode on response rate, S, Stinear C, et al. Opti- 2006; 20(2):123–131. response bias, and item mizing the Content and 16. Lizarondo L, Kumar S, non-response in a survey Dose of Rehabilitation Hyde L, Skidmore D. of doctors. BMC Med Res in the First 12 Months Allied health assistants Methodol. 2011; 11:126.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 55 www.nzma.org.nz/journal VIEWPOINT
Point-of-care testing governance in New Zealand through the lens of quality: an update on a national regulatory framework Samarina MA Musaad, Geo rey CE Herd, on behalf of the Northern Region POCT Group
ABSTRACT Point-of-care testing (POCT) devices are in vitro diagnostic devices used in hospitals, primary care and at home to provide rapid medical test results to support decision making. Most POCT devices are not regulated in New Zealand and there is no requirement for public or private hospital providers who use POCT devices to meet minimum accreditation standards for POCT. This article describes a regulatory framework for POCT devices, which is consistent with the principles of the dra Therapeutic Products Bill 2018. The proposed framework includes thorough evaluation, laboratory validation and approval processes for devices, improved traceability, accreditation for POCT and an adverse event management system; in the interests of patient safety.
oint-of-care testing (POCT) devices Right 6 states that “every consumer has are in vitro diagnostic devices used to the right to information that a reasonable provide medical laboratory test results consumer would expect to receive”, including P 1 2 quickly and near to the patient. POCT devic- limitations and side-effects of services. In es are used in public and private hospitals, the case of POCT devices, this clause relates primary healthcare practices, pharmacies to the performance of the device, the evalu- and in patients’ homes. Traditional POCT ation process and inherent limitations. devices such as blood gas analysers, glucose meters and urine pregnancy tests have Background been in use for many years. Novel wearable POCT devices are not subject to effective devices for monitoring glycaemia are now in regulation in New Zealand.3 Urine preg- use in New Zealand. nancy test kits are the only POCT devices Patients are protected by the 10 rights that require mandatory registration in of consumers and duties of providers, as the Web Assisted Notifi cation of Devices stipulated in the New Zealand Health and Database (WAND).4 This relatively inef- Disability Code of Consumers Rights, estab- fectual system contrasts with the regulatory 2 lished in 1996. Right 4 states that consumers framework in the UK by the Medicines and are entitled to appropriate standards of Healthcare Products Regulatory Agency.5 In 2 care. Test results obtained from POCT New Zealand, POCT devices are not subject devices are used to inform clinical decision to thorough evaluation prior to distribution making, therefore consumers have the right for use in the community. This is in contrast to expect that POCT devices and tests are with the Scandinavian evaluation of labo- fi t for purpose irrespective of location and ratory equipment for point-of-care testing technology. In this context, “fi t for purpose” (SKUP) service in Scandinavia.6 implies regulation and clinical governance.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 56 www.nzma.org.nz/journal VIEWPOINT
In 2013, the authors proposed a national adverse events, reduce error and support regulatory and governance framework for documentation and longitudinal capture POCT devices, as shown in Figure 1.3 This of data in clinical registers. The draft Bill was the fi rst schematic vision of a regu- and the consultation document recognise latory framework for POCT in New Zealand. the scale and complexity associated with It was born of concern over the existence the medical devices sector and that some of signifi cant regulatory gaps with potential devices are used for in vitro diagnostic deleterious consequences. Since then medical tests in primary, secondary and Medsafe has updated its website to include home-based care. However, signifi cant a more diligent approach for the reporting gaps remain to be addressed because, of adverse events for POCT, encouraging unlike devices such joint prostheses and reporting of potential adverse incidents stents, POCT devices require validation of or near misses as opposed to only defi nite performance by accredited medical labora- events.4 The section “Information for tories before funding approval. This article Industry, Part 3: Regulatory requirements presents a revised, regulatory framework for medical devices” is currently under based on the fi rst one proposed in 2013 as construction, implying that more changes shown in Figure 1. 4 are underway. Regulation of POCT: a revised and At the time of writing, December 2018, updated framework the Minister of Health had released a draft Three pillars underpin governance and 7 of the Therapeutic Products Bill 2018 and regulation of POCT, namely: a Therapeutic Products Regulatory Scheme 1. Selection: only approved devices, consultation paper.8 The Regulatory Scheme validated by accredited laboratories covers all therapeutics products used in should be available for use by the public and private healthcare. The draft Bill healthcare sector; defi nes four types of therapeutic products: medicines, active ingredients of medicines, 2. Quality and Accreditation: only medical devices (including in vitro tests and certifi ed providers should use POCT software) and type 4 products. The draft in public and private hospitals, Bill provides for a unique device identifi er supported by quality-controlled testing to: improve identifi cation and traceability services accredited by International of medical devices, the identifi cation of Accreditation New Zealand (IANZ);
Figure 1: A national governance framework and expected outcomes.
Key: MoH: Ministry of Health; IVD: In-vitro diagnostic device manufacturers; PHARMAC: Pharmaceutical Management Agency.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 57 www.nzma.org.nz/journal VIEWPOINT
Figure 2: An updated framework for regulation and governance of point of care testing in New Zealand.
Key: ACC: Accident Compensation Corporation; WAND: web assisted notification of devices; NRA: Northern Region Alliance.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 58 www.nzma.org.nz/journal VIEWPOINT
3. Monitoring: including traceability of devices and the establishment Discussion of an accessible, adverse events Medsafe regulatory committee members management system (AEMS) designed with responsibility for POCT devices should to alert the regulatory agency, include representatives from clinical consumers and suppliers. pathology, medical laboratory scientists, healthcare practitioners, technical experts, This article proposes an updated regu- and relevant allied healthcare providers. latory framework which is more descriptive The New Zealand Best Practice Guide- than the 2013 framework and provides lines for Point-of-Care Testing should be advice on how POCT devices should be the primary source of guidance for setting approved, validated, regulated and managed quality standards.1 In the fi rst phase, a set in the interests of patient safety. This updated of predefi ned criteria should be the basis of framework is summarised in Figure 2. initial screening for acceptance or rejection In the proposed regulatory framework of POCT devices. Primary considerations industry and in vitro diagnostic (IVD) should be given to clinical safety of the test companies, providers—eg, clinicians, or device, including evidence of clinical pathologists, medical scientists and and analytical performance and history of consumers—must formally apply for intro- international recalls, local needs and cost-ef- duction of an IVD device to the New Zealand fectiveness. Reasons for a decision should be market (Step 1) through Medsafe or an clearly documented and defensible. Devices otherwise governmental regulator. (Note: that are approved at the fi rst phase would Medsafe will be considered the regulator for proceed to be evaluated in the second phase, the remainder of this article). the local environment. This requires a Medsafe would be the fi rst of two gate- national POCT laboratory service appointed keepers and will initiate Step 2. In the by the regulator to evaluate point-of-care initial phase of Step 2 an expert advisory (POC) tests and devices. committee in Medsafe would decide to Evaluation of devices must be carried support the use of a POCT device in New out locally by an accredited laboratory Zealand. Devices that have been evaluated service. It is not suffi cient to completely and scrutinised and that meet predefi ned rely on the results of overseas validation standards would then enter the second data even though such data can add to the phase of Step 2 and be subject to local New evidence-base. In New Zealand, medical Zealand evaluation by accredited labora- laboratories are accredited for medical tories. Any device that is approved for the laboratory services by International Accred- local market should be registered in the itation New Zealand (IANZ)9 against the WAND database which will act as a registry medical testing standard ISO (Interna- of all devices supported by Medsafe for tional Organisation for Standardisation) use by the consumer. Decisions regarding 15189:2012.10 funding can be made by PHARMAC or alter- Eighteen medical laboratories are native funding body (Step 3). accredited against the POCT standard ISO Regions and district health boards (DHB) 22870:2016.11 Until all laboratories that should have local clinical governance bodies offer POCT in New Zealand are required to to oversee local clinical needs; this would be accredited against ISO 22870:2016, the constitute the second gateway. For example, minimum requirement to perform eval- in the Northern Region this could be the uation of devices should be accreditation Northern Region POCT (NRPOCT) Group; against ISO 15189:2012. The criteria for these groups will undertake Step 4. scale and scope of the evaluation for each Individuals or patients who use a POCT device or test will depend on the clinical device at home should be fully trained utility and complexity of the device or test and supported with advice on the limita- and on the quality of overseas evaluations if tions of the device and how to prevent applicable. These criteria would be defi ned common problems which may occur with by the national POCT laboratory evalu- these devices. Support may come from the ation service. This approach is consistent supplier of the device, eg, pharmacist, or with section 95 of the draft Therapeutic from delegated personnel/institution.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 59 www.nzma.org.nz/journal VIEWPOINT
Products Bill 2018; which states the criteria number of consumables, or a recall notice for product approval and includes quality, and substitution options. A national adverse safety and performance.7 events monitoring system (AEMS) for POCT 12 Traditional laboratory instruments are was proposed in 2015, details of which are evaluated by experts in the medical labo- beyond the scope of this article. ratory; this is bread-and-butter of laboratory The Pharmaceutical Management Agency practice. Regulation is important for these PHARMAC decides which devices are to instruments, and because of the detailed be publicly funded to get the best possible evaluations that they are subjected to health outcomes.13 Each DHB in turn decides within the laboratory, instruments that are what devices to use in order to deliver local not fi t-for-purpose are not used. The same services; the choice would usually be from a regulatory authority does not currently national medical devices list that PHARMAC apply to POCT devices and tests, because manages. It is prudent that PHARMAC have they can be acquired by non-laboratory clear and functional timelines to prevent trained individuals, many of whom are not stalling of decision-making. This would avoid health professionals. As opposed to labora- unnecessary delays in introducing a funded tory-based instruments, POC devices need device that would benefi t the New Zealand tailor-made validation protocols that include consumer. It would also allow for timely fi eld testing to accommodate all types of responsiveness to local needs and evolving users and clinical settings. technology. It is important to have open A national evaluation laboratory service lines of communication between Medsafe, for POCT devices will prevent duplication PHARMAC and clinical governance groups, of effort and resources between labora- and to avoid a silo mentality. Appointed tories, ensure safe devices and tests are coordinators for communication would available to the New Zealand consumer, and ensure coherence of messages and a single ensure POC tests are fi t for local purpose. point of contact for responses and decisions This national evaluation laboratory service in addition to the website. Furthermore, may be a standalone laboratory or a virtual in the unlikely event that a decision made laboratory made up of experts around the by Medsafe or PHARMAC is deemed to country who are contracted by Medsafe or disadvantage patients’ clinical needs, there the Ministry of Health. This national evalu- should be an opportunity within a defi ned ation laboratory service is consistent with timeframe to appeal to the relevant body. section 207 of the draft Therapeutic Products Appointees to POCT device regulatory and Bill 2018 which states that “the Regulator governance teams need to be resourced may rely on reports, assessments or deci- appropriately with adequate time and travel sions made by, or information received sponsorship as required, to enable them from, a recognised authority”.7 to carry out evaluation, investigative and review functions effi ciently and effectively. An approved device would then be regis- tered in the WAND database. Compulsory Accreditation for POCT registration ensures traceability and The regulatory framework should also effective management of recalls or adverse include provisions so that DHB contracts events. Approved devices will be available with contracted laboratory service providers for the New Zealand consumer regardless require the provider to support and of funding status but government funding implement quality controlled, accredited supports equitable healthcare delivery. POCT services where applicable within 14 When devices are approved and made DHB hospitals. Many private hospitals use available for use, the results of the evalu- complex POCT devices, such as blood gas ation or validation need to be accessible analysers, to manage patients intra-opera- and publicly available. This aligns with tively and in critical care units. They may the consumers’ right to be informed2 and choose to maintain independent clinical provides a reference point on which to base governance but it is essential that the decisions in case an adverse event occurs. regulatory framework includes provisions Decisions could include repeat validation for mandatory POCT accreditation against testing on a suspect device, batch or lot ISO 22870:2016 for these hospitals in the interests of patient safety.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 60 www.nzma.org.nz/journal VIEWPOINT
Community settings should fall under the of end-users who are for the most part not governance structure of their local DHB or laboratory trained. This necessitates a dedi- regional POCT clinical governance groups. cated national POCT AEMS, separate from Pharmacists can be fully trained by labo- traditional laboratory incident reporting.12 ratory personnel, eg, relevant DHB staff or Such a system would consolidate evidence approved suppliers; this will ensure stan- under one umbrella, will streamline event dardised training and safe practices. An monitoring, allow timely dissemination of approved supplier is one that is deemed information among relevant parties, facil- reliable and recommended by the local itate recalls and be an effective means for POCT governance group. As is the case in monitoring of (un)safe practices or devices. accredited laboratories there should be Medsafe has made progress towards periodic recertifi cation of pharmacists who reporting of incidents albeit not specifi c to sell POCT devices. This can be done electron- POCT.4 ically after initial face-to-face training. In the event of an adverse incident Patients should be trained by the phar- involving a device, consumers and macists and should have a mechanism for providers will need to know that an inves- feedback, eg, a help-line. In the interest tigation has been completed and that if of traceability and patient-centred care, the device is withdrawn, this is the advice it may be prudent that patients or carers of the regulator, the investigators and the demonstrate their understanding of testing AEMS committee. However, if the device is technique, limitations and who to contact considered to be suitable for continued use for support. This contractual agreement then consumers and providers need to have co-signed by the trainer would facilitate a confi dence that the thorough validation balance of shared responsibility. checks have been completed and this data Commercial arrangements will again form part of the public record. Commercial arrangements with suppliers Challenges need standard provisions for surety of Fiscal resources are a common limitation supply and device performance. In addition, in all healthcare systems. Populations are these supply agreements need to be fl exible expanding and aging, and patient expec- in the event that a device is found to be tations are rising while resources are faulty and the decision is taken by the not catching up. A long-term and ethical regulator or a provider to halt or cease the perspective would be to view people as use of a device in New Zealand based on entitled to the best healthcare possible and clinical evidence and risk assessment. While to invest in long-term safety; an investment pre-evaluation (phase 2 of Step 2) will help that would secure the health of generations. avoid such a scenario, there should be safe- This far-sightedness would inevitably guar- guards for this rare, yet possible event since antee considerable fi scal returns in terms of patient safety is the primary goal. averting iatrogenic complications at an indi- Education vidual’s level and increasing productivity at a population level. It is the responsibility of the Ministry of Health, health providers and all healthcare Other challenges include political agendas, personnel to educate the public regarding ineffective communication, lack of trans- purchase of untested devices, eg, through parency, duplication of work and regulatory the internet. While such practices cannot be ‘speed bumps’. Not all of these potential stopped, our moral responsibility and duty challenges can be avoided but a focus on of care cannot be disputed. This applies to the patients’ wellbeing and providence is an patients and individuals in hospitals and in important start. the community. Attitudes can also be a challenge. Some Adverse event monitoring system leading professionals express the lack of need for local regulation of POCT devices, (AEMS) stating “We are a small country. We are POCT is ubiquitous and very large in scale happy to rely on other countries’ or juris- and scope. In its own right POCT is a stand- dictions’ regulatory systems and transfer alone virtual laboratory with a myriad of their framework to New Zealand” (personal potential risky practices due to the variety communication). The authors acknowledge
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 61 www.nzma.org.nz/journal VIEWPOINT
that re-inventing the wheel is ineffi cient POCT medical devices, approved by the but complete reliance on imported ideas appropriate regulatory and funding agencies discredits local expertise and fosters a and that approved validated devices are culture of apathy. It also defi es the norm available for home use. of differences; nations have different We have outlined a vision for an effi - cultures and population characteristics, and cient and fl exible governance framework therefore regulatory systems should accom- for POCT in New Zealand. It addresses modate these differences. regulation at a governmental level and clinical governance at a regional level. Conclusion The framework presents broad principles The authors recognise that a regu- that when embedded in the structure of latory framework for POCT devices will healthcare delivery in New Zealand enables be subject to political, economic and a robust risk-averse approach to the practice practical constraints. However, given the of POCT. It is focused on delivering high- increasing complexity and demands of quality POCT services and is aligned with the modern medical landscape, the public the New Zealand Health and Disability has genuine rights with regards to POCT Consumers Code of Rights 1996 and the in the healthcare system. These expecta- draft Therapeutic Products Bill 2018. Despite tions include but are not limited to, that potential challenges, the framework as accredited health providers use validated outlined is achievable in the interests of assuring patient safety.
Competing interests: Mr Herd reports affi liation with Radiometer Pacifi c Ltd and Roche Diagnostics NZ Ltd outside the submitted work; he is a member of the New Zealand Point of Care Testing Advisory Group and the Northern Region District Health Board Point of Care Testing Group. Acknowledgements: This article refl ects the views of the Northern Region Point-of-Care Testing Group. The authors acknowledge the support of the Northern Region Point-of-Care Testing Group and would like to thank Melanie Adriaansen and Chris Finlay for their helpful input and advice. The authors are members of this Group and the other representatives are: Waitemata DHB: Stephanie Williams, Melanie Adriaansen, Benjamin Jones, Dr Matthew Rogers; Auckland DHB: Chris Finlay, Andrew Meisner, Nadia Al-Anbuky; Counties Manukau DHB: Mark Burnett, Agnes Le, Kim Le, Dr Ross Boswell. Author information: Samarina MA Musaad, Chemical Pathologist; Labplus, Auckland District Health Board and Labtests, Healthscope Laboratories, Auckland; Geoffrey CE Herd, Point-of-Care Testing Coordinator, Whangarei Hospital, Northland District Health Board, Whangarei. Corresponding author: Dr Samarina MA Musaad, Chemical Pathologist; Labplus, Auckland District Health Board and Labtests, Healthscope Laboratories, Auckland. [email protected] URL: http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2019/vol-132-no-1499- 26-july-2019/7946
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 62 www.nzma.org.nz/journal VIEWPOINT
REFERENCES: 1. New Zealand Best Practice 6. Scandinavian evaluation 10. International Standard Guidelines for Point-of- of laboratory equipment NZS/ISO15189:2012 Care Testing 2018. New for point of care testing Medical testing – Partic- Zealand Point-of-Care (SKUP) http://www.skup. ular requirements for Testing Advisory Group. org/ accessed 7/1/2019. quality and competence. 2. Health and Disability 7. New Zealand Government. 11. International Standard Services Code of Consum- Ministry of Health 2018. NZS/ISO22870:2016 Point ers Rights 1996 http:// Minister’s press release of care testing (POCT) – www.hdc.org.nz/the-act- - http://www.beehive. Requirements for quality -code/the-code-of-rights govt.nz/release/have-your- and competence. accessed 27/9/2018. say-new-rules-medicines- 12. Musaad S, Khan S, Herd 3. Musaad S, Herd G. Point- and-medical-devices G. Point–of–care testing: of-care testing governance accessed 14/12/2018. High time for a dedicated in New Zealand: a 8. Ministry of Health. 2018 National Adverse Events national framework. Therapeutic Products Monitoring System. Clin NZMJ 2013; 126:72–79. Regulatory Scheme: Biochem Rev 2015; 36:3–6. 4. Medsafe http://www. Consultation Document. 13. Pharmaceutical Manage- medsafe.govt.nz/ Wellington: Ministry ment Agency PHARMAC Accessed 27/9/2018 of Health. http://www. http://www.pharmac.govt. health.govt.nz/publication/ 5. Medicines and Health nz/ accessed 14/12/2018. therapeutic-products-reg- Care Products Regulatory 14. Herd G, Musaad S. ulatory-scheme-con- Agency http://www. Clinical governance for sultation-document gov.uk/government/ point-of-care testing at accessed 14/12/2018. collections/regulatory-guid- provider level. NZMJ ance-for-medical-devices 9. International Accreditation 2015; 128:41–46. accessed 7/1/2019. New Zealand http://www. ianz.govt.nz/directory/ accessed 7/1/2019.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 63 www.nzma.org.nz/journal VIEWPOINT
Doctors’ rights to conscientiously object to refer patients to abortion service providers Angela Ballantyne, Colin Gavaghan, Jeanne Snelling
ABSTRACT A er five decades of restrictive laws, New Zealand is on the cusp of law reform that may result in abortion being treated as a health, rather than a criminal, matter. Given this possible liberalisation, a pressing issue is the way in which ‘conscientious objection’ (CO) will be accommodated within the new legislative landscape. In this context, CO constitutes a health provider refusing, on the grounds of personal conscience, to provide care that, although legal and potentially clinically appropriate, conflicts with their personal moral views. Currently, New Zealand law permits significant concessions for conscientious objectors. This paper argues that in the light of current reform, the justification for permitting CO should be revisited. It claims that even if it is conceded that some form of CO should be respected, a pragmatic compromise must be adopted so that both provider’s and women’s rights are su iciently protected. We argue that the current legal situation in New Zealand is unbalanced, favouring the rights of providers at the expense of women’s timely access to abortion care. At a minimum, providers with a CO should be required to ensure an indirect referral to another provider who is willing to refer the woman to abortion services.
Abortion in New Zealand legal abortion on the grounds of social and 3 Statistics indicate that around a fi fth economic circumstances. of New Zealand pregnancies are termi- The Minister’s Request for Advice nated1 and one in four women have had an on Law Reform: Law Commission abortion in their reproductive lives—more than the percentage of women who have Briefing Paper The vast majority of abortions in New ever used IUDs.2 Currently New Zealand Zealand are performed on mental health women are among the 40% of women of grounds (97.6% in 2013) and are performed childbearing age who live in countries that before the end of the 10th week of preg- the World Health Organization refers to as nancy.6 In 2017, Minister of Justice Andrew having “highly restrictive laws”.3 Northern Little requested that the New Zealand Law Ireland is the only other developed country Commission (NZLC) provide advice on with more restrictive abortion laws, while what alternative legal approaches could be the Republic of Ireland recently liberalised adopted to align abortion law with a health, its abortion law.3–5 By comparison, 61 coun- rather than criminal, model. Following a tries, home to almost 40% of the world’s public consultation, the NZLC presented a women, allow abortion upon request of the range of proposals and options for reform pregnant woman. A further approximately (see Table 1). 20% of the world’s women have access to
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 64 www.nzma.org.nz/journal VIEWPOINT
Table 1: Law Commission Alternative Approaches to Abortion Law: Ministerial Briefi ng Paper options for abortion reform.7
• Repealing the current grounds for abortion contained in the Crimes Act 1961. • Removing the requirement for abortions to be authorised by two specially appointed doctors, called ‘certifying consultants’. • Allowing women to access abortion services directly, or alternatively to be referred by any health practitioner they choose to consult (GP, nurse, midwife, counsellor), rather than having to get a referral from a doctor as required under the current law. • Removing the current restrictions governing who may perform an abortion, and where abortions must be performed. Instead, the provision of abortion services would be regulated by appropriate health bodies, just like any other healthcare procedure. • Disestablishing the Abortion Supervisory Committee. • Assigning responsibility to the Ministry of Health for collecting statistics on abortion and oversee- ing the distribution of funding and abortion services.
Signifi cantly, the NZLC posed two options women’s access to abortion services’.”7 We in regard to CO: do not engage here with the question of Either (1) maintaining the current law whether health providers should be entitled regarding conscientious objection, or to CO. In this paper we focus on the ethical question of defi ning the reasonable scope of (2) amending it so that health practitioners CO for abortion referrals. who do not wish to provide health services in relation to abortion because of a consci- The current legal position entious objection are required, as soon as regarding CO and referral reasonably practicable, to disclose the fact It is clear that a physician with a CO need of their objection and refer the woman to not perform an abortion. It is equally clear another health practitioner or abortion that they have a duty to inform: indeed the service provider able to provide the service.7 Health Practitioners Competence Assurance Health providers as ‘gatekeepers’ Act 2003 (HPCAA) states that in the context model: what obligations regarding of reproductive health services, a health practitioner who objects on the ground of referral? conscience to providing the service must “… The NZLC paper presents two possible inform the person who requests the service models: the fi rst entails clinicians acting as that he or she can obtain the service from gate keepers to the abortion process; the another health practitioner or from a family other involves women being able to self- planning clinic.”9 In addition the Code of refer to abortion service providers. Clearly Consumers Rights provides that patient have if women may self-refer for abortion, CO extensive rights, including the right to be becomes a less signifi cant issue. However, it fully informed, and providers have corre- is not yet clear which recommendations the sponding duties.10 government will adopt should law reform The most contentious question has been proceed. This paper considers how, if clini- around the issue of referral. The notion of cians retain their role as gate keepers to ‘referral’ can relate to one of two things— abortion services, the issue of CO should be referring directly to the abortion service addressed. so that the grounds for abortion can be The NZLC emphasises that these proposals considered by certifying consultants; or, would not remove all grounds for CO in if the clinician has a CO, referring to a relation to abortion. Under both options, colleague who is prepared to consider health providers would retain their right the matter and arrange a referral to the to object to perform, or participate, in the abortion service as indicated.7,11 The former 8 provision of abortion. NZLC states that sort of referral has been described as ‘direct “the Government could consider changes referral’, the latter as ‘indirect referral’.12 to ensure that CO ‘does not unduly delay
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 65 www.nzma.org.nz/journal VIEWPOINT
The High Court has made it clear that in a recent New Zealand Herald article, both direct and indirect referrals are chairwoman Kate Baddock appeared to subject to the right of CO in New Zealand.13 endorse the argument that: “For the same In 2010, the New Zealand Medical Council reason that patients have a right not to be sought to clarify that practitioners with a coerced into receiving treatment, doctors CO to providing direct referral for abortion and nurses have a right not to be coerced services must arrange for the woman’s into providing it”.16 case to be considered by another practi- This argument, which we call the tioner willing to consider and deal with “Argument from Symmetry”, is fl awed. It 14 the matter. This became the subject of fails to account for signifi cant differences a legal challenge by anti-abortion group, between the respective positions of patient New Zealand Health Professionals Alliance and provider. First, it fails to account for 13 (NZHPA). The High Court substantially the role-specifi c professional obligations of upheld NZHPA’s case, holding that, under doctors. Second, it seems to misunderstand the HPCAA, the practitioner’s statutory some of the core tenets of medical ethics and duties extend only to informing the woman professionalism, such as patient autonomy that she could be treated elsewhere, but did and non-malefi cence. As such, it cannot not extend, and importantly, could not be provide grounds for CO in general, or for the extended by the Medical Council, to referring strong version that New Zealand law pres- the woman to another practitioner who can ently protects. arrange the referral to an abortion service. Professional autonomy: the Consequently, a practitioner’s duties in New Zealand are minimal. They need only argument from symmetry To be clear, we are not disputing that inform the woman of the option of seeking there is a role for professional autonomy out another provider, but are not required for health providers. Rather, we are arguing to put her in touch with an alternative that the nature and scope of professional provider, facilitate her transfer or even autonomy cannot be derived from, nor provide contact details. The NZLC clearly seen as directly analogous to, the nature provides the option for changing the status and scope of patient autonomy. Medical quo in regards to CO and referrals, however ethics and medical law accord signifi cant the New Zealand Medical Association weight to the autonomous choices of adult (NZMA) opposes any change to the current patients. In terms of treatment refusals, scope of CO. a competent patient’s autonomy is all but Response to the NZLC absolute. They can refuse treatment even The response from the medical and allied when it is medically necessary to preserve health professions to the Law Commis- their life or health. Furthermore, at least in sion’s proposals has been mixed. The New theory, the patient is under no obligation to Zealand College of Midwives, the Australian offer any justifi cation for such a decision. It and New Zealand College of Psychiatrists does not follow that providers have an anal- and the Royal Australian and New Zealand ogous right to refuse to provide treatment College of Obstetricians and Gynaecolo- or advice without justifi cation. Rather, a gists all considered that “conscientious doctor seeking to withhold a medically objectors should either refer a woman in a indicated and requested procedure will be timely manner to another practitioner who required to justify their decision. (In much provides the services she seeks, or provide the same way, the fact that a defendant in the woman with suffi cient information a criminal trial has the right to silence does about practitioners who provide the services not mean that the judge can decline to offer to enable her to access those services”.7 reasons for his or her decision). Perhaps In contrast, the NZMA’s submission to the most obviously, a patient’s right to refuse Law Commission states that it “strongly all medical interventions could not sensibly supports the retention of the existing provi- fi nd its mirror in a physician’s right to refuse sions” of CO.14 No further justifi cation for to perform all medical procedures; such a this is offered in the submission. However, refusal, we might think, would amount to refusing to be a doctor at all.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 66 www.nzma.org.nz/journal VIEWPOINT
There are also critical differences in On Wicclair’s account, moral integrity is power, freedom and vulnerability between synonymous with one’s personal identity, the patient and the doctor that the Argument hence mere distaste or disapproval of a from Symmetry obscures. The patient is particular procedure will not provide an in need of clinical care (and may well also adequate basis for a valid CO. Wicclair be suffering morning sickness or other also claims that “an appeal to conscience pregnancy related health issues); whereas has signifi cant moral weight only if the the GP is well and working in a profes- core ethical values on which it is based sional capacity. Arguably, access to medical correspond to one or more core values in services will have signifi cantly greater medicine.”18 consequences for the patient’s life course Christopher Cowley bases his support for than providing a referral will have on the CO on a similar idea, although he prefers the doctor’s life course. The patient cannot language of “calling” over “moral integrity”; choose not to be pregnant, but we might “Once we take seriously the idea of a think that, in undertaking a professional calling, then we come closer to understanding role, the doctor has voluntarily undertaken the motivation of the conscientious objector; certain responsibilities. For these reasons, they deserve accommodation not out of the professional responsibilities of doctors respect for their integrity, but rather out of are not analogous to the moral rights of respect for their conception of medicine.”19 patients. The fact that patients cannot be coerced into accepting treatment is irrel- Like Wicclair, Cowley requires that the evant to the question of whether doctors objection be rooted in “an understanding 19 should be coerced/required to offer referrals grounded in the role of doctor as healer”. (or provide other services). If this is right, it would set an important limitation on the exercise of CO, requiring Even proponents of respecting physician the practitioner to locate his/her position autonomy stop some way short of arguing within a broader context of shared ethical for a strong autonomy right, analogous to the values. Whether opposition to abortion autonomy of an adult patient. Hence Shimon would meet this standard is, presumably, Glick and Alan Jotkowitz call for a “nuanced” arguable, but it is not a line of enquiry we and “balanced” approach, recognising pursue further here. that always giving CO priority over patient requests “would result in anarchy and in Freedom of conscience deprivation of services to many patients”.17 A second plausible basis for CO can be We argue, then, that support for CO found in the broad right to freedom of cannot plausibly be derived from a putative conscience. The New Zealand Bill of Rights equivalence between the autonomy rights Act states that “Everyone has the right to of patients and doctors, as the NZMA has freedom of thought, conscience, religion and suggested. Other grounds for recognition of belief, including the right to adopt and to 20 a right to CO have, however, been advanced. hold opinions without interference”. As the NZLC noted, these rights may, A more plausible basis of CO: moral however, be “subject to reasonable limits” integrity or vocational calling acceptable in a free and democratic society.7 One such basis for respecting CO derives The right to freedom of conscience does from the medical practitioner’s moral not automatically extend to the right to act integrity. Marc Wicclair explains moral on those beliefs (we are not, for example, integrity element in this way: permitted to refuse to pay tax because we “To claim that [the physician’s] moral object to military spending, or because we integrity is at stake implies that: (1) she has object to funding certain health services). core ethical values (eg, principles, virtues and/ Further, the broad right to conscience is not or paradigm-based maxims). (2) These core equivalent to the much more circumscribed ethical values are part of her understanding right to CO. Health providers have scope to of who she is. That is, they are integral to her act on conscience in many ways that do not self conception or identity. (3) It would be invoke CO. They choose the area in which incompatible with those core ethical values to they practice /specialise and which patient participate in [the requested treatment].”18 populations to serve; they make important
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 67 www.nzma.org.nz/journal VIEWPOINT
contributions to academic and public Even Cowley, when defending the right debates about health policy and medical to CO against critics, accepts that indirect ethics; and they participate in associations referral may be a moral duty: aimed at political reform (eg, Doctors4Ref- “Refusing to inform a patient in such a ugees, Voice for Life, Euthanasia-free New context would not only be illegal, it could Zealand). None of these expressions of also be akin to sulking and preciousness. conscience invoke the right of CO. This is one place to draw the line, and where The remainder of this article is concerned the conscientious objector has to accept the with the question of reasonable limits on the reality of a genuine moral pluralism, as well right to freedom of conscience. as her status as a minority in a reasonably 19 Reasonable limits democratic society.” Provision for CO at all has come in for Even scholars defending the right of CO, renewed criticism in recent years. For critics then, would not support the New Zealand like Julian Savulescu and Udo Schuklenk, situation, where providers can refuse to providers exempting themselves from transfer the care of the patient to another provision of healthcare is simply incom- provider who will process the referral. patible with the ethical demands of the Why we should be worried about 20 medical profession. Signifi cantly, the (unrestricted/broad) CO and delays NZLC’s proposals do not suggest dispensing with CO altogether, nor do any of the in access to abortion care We disagree with Baddock that the submissions from the medical profes- current CO provisions for referrals in New sional bodies. Moreover, recent initiatives Zealand are reasonable and working well.16 around physician aid-in-dying make specifi c Current CO provisions regarding termi- provision for CO.22 It seems unlikely, nation referral in New Zealand impose an therefore, that there is much appetite for unreasonable burden on women. It is highly removal of CO in New Zealand medicine in plausible that refusal to provide indirect the foreseeable future. referral can cause signifi cant patient harms: Thus the real debate is around the limits potential inability to fi nd another provider, of CO, and how to balance competing delay in access to care, increased fi nancial interests. For most moderate commen- cost (time off work, cost of additional consul- tators, this takes the form of a search for a tation, travel), stigma, embarrassment or 12 ‘reasonable compromise’ or ‘conventional loss of trust in the ‘non-judgmental’ role 23 compromise’ position, which typically of providers, which may have signifi cant requires a trade-off between the doctor’s implications for some patient groups that right to conscience, and other consider- already have a tenuous relationship with the ations. Advocating for the conventional health system and the medical profession. compromise, Dan Brock states: Remarkably, when a GP refuses to even “… a physician/pharmacist who has a consider referral, they remain entitled to serious moral objection to providing a claim the cost of the consultation (prenatal service/product to a patient/customer is not care is government-funded). While the required to do so only if the following three patient is left with the emotional, fi nancial conditions are satisfi ed: and time burden of fi nding another 1. The physician/pharmacist informs the provider, the doctor can be paid for refusing patient/customer about the service/ on personal grounds to perform this core product if it is medically relevant to public service. In a health system that is their medical condition; supposed to be ‘patient-centred’ the current weighting of doctor and patient interests 2. The physician/pharmacist refers the seems distorted. patient/customer to another profes- sional willing and able to provide the Refusals to refer undeniably create some service/product; delay. The length of delay will vary; but we argue that in the context of abortion 3. The referral does not impose an services in New Zealand, we should be unreasonable burden on the patient/ concerned about all delays. Compared to customer.”23 other developed countries (UK, Australia,
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 68 www.nzma.org.nz/journal VIEWPOINT
US), abortion services in New Zealand that New Zealand law currently allows for a are accessed signifi cantly later in the fi rst very wide interpretation of the scope of CO. trimester. New Zealand women wait an We should be especially concerned about the average of 25 days between the fi rst visit potential role of CO in delaying accessing to with a referring doctor and the date of their abortion referrals in New Zealand. procedure.24 Timely access to abortion services is Conclusion critical to women’s psychological and The State is responsible for ensuring the physical health, with earlier abortions provision of core health services.29 Arguably, 24, 25 safer. For example, women who intend CO provisions need to be considered at to terminate using medication (as opposed a system level—balancing the harm to to surgical abortion) need to access services potential objectors of compelling action within the fi rst 63 days of pregnancy. In contrary to their conscience, against the general, long waiting times for elective harm to patients of delaying or barring surgery increases anxiety and have a access to care. negative impact on quality of life and psycho- The NZLC’s modest proposal would social measures.26 Barriers to abortion, recognise the right to CO, and would safe- including delays, have disproportionate guard the right of objectors to be employed impact for rural women, minorities and less in roles even where they have no intention advantaged women.27 Thus the World Health of providing all the services that role would Organization recommends that “Regulatory, usually require, even where those roles are policy and programmatic barriers that in remote areas with few other doctors. hinder access to and timely provision of safe These are signifi cant concessions to those abortion care should be removed”.28 holding a minority view. Research shows that most of the existing The current legal situation in New delay in accessing abortions in New Zealand Zealand is unbalanced, favouring the rights is at the referral stage.29 Even those GPs of providers at the expense of women’s willing to refer sometimes require multiple timely access to abortion care. We endorse consultations before they refer a woman to the position of the New Zealand College an abortion provider.28 It remains unclear of Midwives, the Australian and New what is causing this delay. Specifi cally, there Zealand College of Psychiatrists, and the is no available evidence to show that the Royal Australian and New Zealand College delays in referral are the result of refusing of Obstetricians and Gynaecologists that to refer to another referrer, as opposed providers should directly refer to abortion to simply refusing to refer to the abortion services, or facilitate transfer to another provider (while facilitating referral to provider who can do the referral. Allowing another GP). This lack of specifi c data is providers to object to direct referrals, when not surprising; it is not known how many one of their core professional obligations health providers have a CO, and conducting is to navigate patients through the health research with women requesting abortion is system, is one thing. But providers objecting notoriously diffi cult given the stigma asso- to making indirect referrals, and thereby ciated with abortion. We do know that New failing to ensure the safe transfer the patient Zealand has surprising delays in the referral to the care of a colleague, amounts to aban- process relative to comparable countries and doning the patient. This takes CO too far.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 69 www.nzma.org.nz/journal VIEWPOINT
Competing interests: Nil. Acknowledgements: This paper is informed by research and arguments presented in the submission prepared by Angela Ballantyne and Liesle Theron to the New Zealand Law Commission public consultation on abortion reform. Author information: Angela Ballantyne, Associate Professor of Bioethics, University of Otago, Wellington; Colin Gavaghan, NZLF Chair in Law and Emerging Technologies, Faculty of Law, University of Otago; Jeanne Snelling, Lecturer, University of Otago, Faculty of Law, Bioethics Centre. Corresponding author: Angela Ballantyne, 23 Mein St, Newtown, Wellington 6242. [email protected] URL: http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2019/vol-132-no-1499- 26-july-2019/7947
REFERENCES: 1. Report of the Abortion 6. Report of the Abortion Care: An Ethical Analysis. Supervisory Committee Supervisory Committee Cambridge: Cambridge (2018) available at: Annual Report (Ministry University Press. http://www.justice.govt. of Health 2014) at 5. 13. Hallagan and Anor. v nz/assets/Documents/ 7. New Zealand Law Commis- Medical Council of New Publications/ASC-Annu- sion. 2018. Alternative Zealand HC WN CIV-2010- al-Report-2018.pdf at p 6. Approaches to Abortion 485-222 [2 December 2010]. 2. Chesang J, Richardson Law: Ministerial Briefi ng 14. Medical Council of New A, Potter J, Sneyd MJ, Paper (NZLC Wellington, Zealand. 2009.Beliefs and Coope P. Prevalence of October 2018) at 183. Medical Practice. Available contraceptive use in New 8. Contraception, Steril- at http://alranz.org/wp-con- Zealand women. NZMJ 28 isation, and Abortion tent/uploads/2011/11/ October 2016; 129(1444). Act 1977, s 46(1). beliefs-and-medical- 3. World Health Organization 9. Health Practitioners practice-march-2009.pdf “Safe abortion: technical Competence Assurance 15. New Zealand Medical and policy guidance for Act 2003, s 174. Association. 2018. Abortion health systems” (2nd ed, 10. Health and Disability Law Reform. Available at 2012) at 90; 15; available Commissioner (Code of http://www.nzdoctor.co.nz/ at http://www.who.int/ Health and Disability sites/default/fi les/2018-05/ reproductivehealth/ Services Consumers NZMA-Submission-on- publications/unsafe_abor- Rights) Regulations Aborton-Law-Reform.pdf tion/9789241548434/ 1996, Right 6(1). 16. Trevett C. 2018. Doctors en/ 11. Contraception, Sterilisation, to fi ght new abortion. 4. Singh S, Remez L, Sedgh and Abortion Act 1977, s The Herald 3 December G, Kwok L, Onda T. 32(1),(2) The legislation 2018. Law http://www. Abortion Worldwide 2017. refers to “the woman’s nzherald.co.nz/nz/news/ Uneven Progress and own doctor”, but the Law article.cfm?c_id=1&- Unequal Access (Gutt- Commission received objectid=12167498 macher Institute, 2018) evidence that it is quite 17. Glick SM, Jotkowitz available at http://www. common for women to A. Response to: ‘Why guttmacher.org/report/ prefer to approach some- medical professionals abortion-worldwide-2017 one other than their own have no moral claim to 5. The Health (Regulation GP when seeking abortions. conscientious objection of Termination of Preg- 12. Wicclair MR. 2011. Consci- accommodation in nancy) Act 2018 enables entious Objection in Health liberal democracies’ by abortion up to 12 weeks. Schuklenk and Smalling.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 70 www.nzma.org.nz/journal VIEWPOINT
J Med Ethics. 2017; document/BILL_74307/ van der Wal G.. Waiting 43(4):248–249. doi: 10.1136/ end-of-life-choice-bill for elective general medethics-2016-103670. 23. Brock DW. Conscientious surgery: impact on health 18. Wicclair MR. Consci- refusal by physicians related quality of life entious objection in and pharmacists: who and psychosocial conse- medicine. Bioethics. is obligated to do what, quences. BMC Public 2000; 14(3):205–27. and why? Theor Med Health. 2007; 19(7):164. 19. Cowley C. A defence of Bioeth 2008; 29:187–200. 27. O’Connor S. 2017. A conscientious objection 24. Silva M, McNeill R, Precarious Position: The in medicine: A reply to Ashton T. 2010. Ladies in State of Abortion Law Schuklenk and Savules- waiting: the timeliness in New Zealand. Salient cu. Bioethics; 2016; of fi rst trimester services (online ed, Wellington, 30:358–364, at 362. in New Zealand. Repro- 7 August 2017) at [14]. 20. New Zealand Bill of ductive Health. 7:19. 28. Johnson BR, Mishra V, Rights Act 1990, s 13. 25. Jones RK, Jerman J. Lavelanet AF, Khosla R, Ganatra B. A global 21. Savulescu J and Schuklenk 2016. Time to Appoint- database of abortion laws, U. Doctors have no right to ment and Delays in policies, health standards refuse medical assistance Accessing Care Among and guidelines. Bulletin of in dying, abortion or U.S. Abortion Patients. the World Health Organi- contraception. Bioethics, New York: Guttmacher zation. 2017; 95:542–544. 2017; 31(3):162–170. Institute. http://www. guttmacher.org/report/ doi: http://dx.doi. 22. End of Life Choice Bill delays-in-accessing-care- org/10.2471/BLT.17.197442 (David Seymour) available among-us-abortion-patients 29. New Zealand Public Health at http://www.parliament. and Disability Act 2000. nz/en/pb/bills-and-laws/ 26. Oudhoff JP, Timmermans bills-proposed-laws/ DR, Knol DL, Bijnen AB,
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 71 www.nzma.org.nz/journal CLINICAL CORRESPONDENCE
Resistant iron-induced hypophosphatemia following colorectal surgery Yu-Jen Chen, Christopher Lim, Jacob McCormick
ABSTRACT Iron-induced hypophosphatemia represents an increasingly recognised complication of iron infusion. A 34-year-old woman presented for surgical management of her colorectal cancer. Post-operative blood tests revealed severe hypophosphatemia, resistant to oral phosphate supplementation and large volumes of intravenous phosphate replacement. Further questioning and biochemical investigation led to the recognition of iron-induced hypophosphatemia as a contributory cause, secondary to iron infusion administered as part of pre-operative optimisation. Early consideration, diagnosis and management of this complication has the potential to reduce fluid burden associated with intravenous phosphate supplementation and optimise post-operative care.
ron-defi ciency anaemia is the most com- of 0.31mmol/L, decreased from a pre-op- mon form of anaemia worldwide. The erative level of 0.60mmol/L (Table 1). Iincidence is particularly high in patients Despite aggressive oral and intravenous with colorectal cancer, as unexplained iron replacement of phosphate over the following defi ciency anaemia often prompts further 72 hours, serum phosphate levels remained investigation for malignancy. Intravenous low between 0.37–0.58mmol/L (Table 2). iron supplementation is frequently used Throughout this time, the patient was for pre-operative optimisation, as it offers asymptomatic of hypophosphataemia. The superior bioavailability and convenience patient’s renal function and other electrolyte compared to oral supplementation.1 Among levels remained within normal limits. available preparations, ferric carboxymalt- On further questioning, the patient ose (FCM) is a common choice due to acces- reported recent ferric carboxymaltose sibility, a low incidence of allergic reaction, (FCM) infusion for iron-defi ciency anaemia. and fast infusion time. Hypophosphatemia Two infusions of FCM were administered is an increasingly recognised adverse effect one week apart, with the second infusion of FCM infusion, and delays in recognition, administered six days prior to her operation. diagnosis and management may lead to sub- Subsequent biochemical investigations optimal clinical outcomes. Consequently, cli- demonstrated low levels of 25-hydroxyvi- nicians must consider the adverse effects tamin D, calcitriol and a signifi cantly raised of FCM infusion when caring for patients urinary fractional excretion of phosphate undergoing colorectal surgery. of 29.8%, suggestive of renal phosphate Clinical record wasting secondary to fi broblast growth A 34-year-old woman with a new diag- factor 23 (FGF-23) excess. Differential nosis of transverse colon adenocarcinoma diagnoses included prolonged poor phos- presented for elective laparoscopic subtotal phate intake, post-operative ileus, refeeding colectomy. Although the procedure was syndrome and Fanconi syndrome. performed without intra-operative compli- The patient was commenced on addi- cation, post-operative investigations tional oral 25-hydroxyvitamin D and revealed signifi cant hypophosphataemia calcitriol replacement, with gradual
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 72 www.nzma.org.nz/journal CLINICAL CORRESPONDENCE
Table 1: Blood test results with reference ranges. The pre-operative blood tests were taken six days before the day of operation.
Blood test result (ref. range) Pre-operative Day 1 post-op Day 6 post-op Haemoglobin (115–155g/L) 96 98 109
WCC (4.0–12.0x10^9/L) 5.5 10.9 5
Platelet (150–400x10^9/L) 357 243 321
Sodium (135–145mmol/L) 142 139 138
Potassium (3.5–5.2mmol/L) 4.8 3.8 3.9
Chloride (95–110mmol/L) 108 108 112
Bicarbonate (22–32mmol/L) 26 23 20
Urea (3.0–8.0mmol/L) 2.6 2.3 0.6
Creatinine (45–90umol/L) 56 53 41
eGFR (>90) >90 >90 >90
Calcium (2.10–2.60mmol/L) 2.3 2.06 1.98
Magnesium (0.70–1.10mmol/L) 0.86 0.72 0.8
Phosphate (0.75–1.50mmol/L) 0.6 0.31 0.43
Albumin (35–50g/L) 36 31 30
CRP (<5.0mg/L) 1 72 3
25-hydroxyvitamin D (>50nmol/L) 19
1,25-dihydroxyvitamin D (1.7–10.0 pmol/L) 8.9
PTH 36
Iron studies Ferritin (20–204ug/L) 591 633
Iron (9–30umol/L) 185 10
Transferrin (2.0–3.6g/L) 2.4 1.6
Transferrin saturation (15–45%) >100 25
Random urinary sample
Creatinine (3.0–24.0mmol/L) 1.6
Albumin (<3.5mg/L) <5.0
Glucose (mmol/L) 11.3
Phosphate (mmol/L) 5
Fractional excretion of phosphate (15–20%) 29.8
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 73 www.nzma.org.nz/journal CLINICAL CORRESPONDENCE
Table 2: Trend of the patient’s phosphate level along with the total amount, in mmol, of supplemental phosphate given to the patient.
Day Serum PO4 (mmol/L) Total IV replacement (mmol) Total PO replacement (mmol) 1 0.31 40 -
2 - - -
3 0.28 70 64
4 0.54 50 64
5 0.37 60 64
6* 0.43 60 144
7 0.57 - 144
8 0.66 - 144
*25-hydroxyvitamin D and 1,25-dihydroxyvitamin D (calcitriol) supplements were started. improvement of serum phosphate levels. excess intravenous fl uid administration is Management of hypophosphataemia associated with a higher incidence of compli- prolonged her hospital stay to eight days. cations, including anastomotic leakage The patient’s phosphate levels normalised and wound dehiscence.7 Fortunately, our within one week of discharge. patient’s post-operative course remained uncomplicated due to her age and otherwise Discussion good health. The risk of complications from excessive intravenous fl uid administration Hypophosphatemia is an increasingly may be higher in an elderly population, or in recognised adverse effect of FCM infusion. those with signifi cant comorbidity. A recent randomised trial by Wolf et al reported an incidence of 50% in patients Patients undergoing colorectal surgery receiving FCM.2 This is likely mediated may develop hypophosphatemia through by an increase in FGF-23 concentration other mechanisms affecting phosphate following FCM infusion.3 As one of the uptake and regulation. These commonly main regulators of plasma phosphate include poor oral intake, post-operative concentration, FGF-23 suppresses renal ileus and refeeding syndrome. Delays tubular phosphate reabsorption, increasing in recognising the contribution of FCM urinary excretion of phosphate. FGF-23 also infusion to hypophosphatemia in this suppresses renal production of 1,25-dihy- patient were likely precipitated by its droxyvitamin D (calcitriol), which further multifactorial nature, in addition to a lack acts to reduce intestinal uptake of dietary of awareness surrounding FCM-induced phosphate.4 While FCM-induced hypophos- hypophosphatemia. phatemia is usually asymptomatic, cases This case highlights the potential impact with classical symptoms of tiredness, diffuse of delayed recognition of FCM-induced muscle pain and weakness have been hypophosphatemia in the post-operative described in the literature.5 period. These delays led to a deviation from Appropriate fl uid balance is a vital standard ERAS protocol, resulting in subop- component of post-operative management. timal fl uid management and increased ‘Enhanced Recovery After Surgery’ (ERAS) length of hospital stay. Early consideration, protocols recommend discontinuing or diagnosis and management of iron-induced restricting intravenous fl uids following hypophosphatemia may act to optimise colorectal surgery.6 In such patients, patient recovery and reduce the risk of post-operative complication.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 74 www.nzma.org.nz/journal CLINICAL CORRESPONDENCE
Competing interests: Nil. Author information: Yu-Jen Chen, Department of General Surgery, Royal Melbourne Hospital, Vic, Australia; Christopher Lim, Department of General Medicine, Royal Melbourne Hospital, Vic, Australia; Jacob McCormick, Department of General Surgery, Royal Melbourne Hospital, Vic, Australia. Corresponding author: Yu-Jen Chen, Department of General Surgery, Royal Melbourne Hospital, 300 Grattan Street, Parkville, Victoria, 3052, Australia. [email protected] URL: http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2019/vol-132-no-1499- 26-july-2019/7948
REFERENCES: 1. Munoz M, Gomez-Ramirez Proceedings of the National cal Practice Guidelines for S, Bhandari S. The safety of Academy of Sciences of the Enhanced Recovery After available treatment options United States of America. Colon and Rectal Surgery for iron-defi ciency anemia. 2011; 108(46):E1146–55. From the American Expert opinion on drug 4. Schouten BJ, Hunt PJ, Live- Society of Colon and Rectal safety. 2018; 17(2):149–59. sey JH, Frampton CM, Soule Surgeons and Society of 2. Wolf M, Chertow GM, SG. FGF23 elevation and American Gastrointestinal Macdougall IC, Kaper hypophosphatemia after and Endoscopic Surgeons. R, Krop J, Strauss W. intravenous iron polymalt- Diseases of the colon and Randomized trial of ose: a prospective study. rectum. 2017; 60(8):761–84. intravenous iron-induced The Journal of clinical 7. Brandstrup B, Tonnesen hypophosphatemia. JCI endocrinology and metab- H, Beier-Holgersen R, insight. 2018; 3(23). olism. 2009; 94(7):2332–7. Hjortso E, Ording H, 3. Farrow EG, Yu X, Summers 5. Anand G, Schmid C. Severe Lindorff-Larsen K, et al. LJ, Davis SI, Fleet JC, Allen hypophosphataemia Effects of intravenous fl uid MR, et al. Iron defi ciency after intravenous iron restriction on postoperative drives an autosomal domi- administration. BMJ case complications: comparison nant hypophosphatemic reports. 2017; 2017. of two perioperative fl uid regimens: a randomized rickets (ADHR) phenotype 6. Carmichael JC, Keller DS, assessor-blinded multi- in fi broblast growth factor- Baldini G, Bordeianou L, center trial. Annals of 23 (Fgf23) knock-in mice. Weiss E, Lee L, et al. Clini- surgery. 2003; 238(5):641–8.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 75 www.nzma.org.nz/journal LETTER
What we know, and don’t know, about cannabis, psychosis and violence Joseph M Boden, Janet K Spittlehouse
n May 2019 the advocacy group Family ‘psychosis’ is being increased as a result of First produced a press release expressing cannabis exposure. Iconcern about the upcoming cannabis The second major reason for the tenu- referendum in New Zealand in 2020. The ousness of the Family First argument is primary focus of the press release was to related to the nature of the studies linking argue for possible links between the use psychosis with violence. Most of the of cannabis and violent behaviour, appar- research linking increased risk of violence ently mediated via increases in psychotic to psychosis have examined patients with symptomatology/psychotic illness following a diagnosis of a psychotic disorder, rather cannabis use. Finally, the press release cited than those with reported symptoms.5 The a number of studies and sets of statistics as magnitude of the elevated risk among evidence for their position. In our view, the those diagnosed with a psychotic disorder attempt to link cannabis use to violence via is relatively small,5 but greater than among psychotic illness is tenuous at best, for sever- those who report symptoms but do not meet al reasons. criteria for disorder,4 and it is relatively rare The fi rst major reason is the nature of the for psychosis to precede violent behaviour.6 evidence linking cannabis use to increases in In addition, many of these studies examined psychosis. While the link has been well-es- violence among psychiatric inpatients tablished for a number of years,1 the extent who have been involuntarily committed to which cannabis leads to an increase to hospital due to risk of harm to self or in psychotic illness, rather than merely others, suggesting that sample selection increasing symptoms, is less well under- may play a strong role in the observation of stood, primarily due to heterogeneity in violent behaviour among these individuals.5 study outcomes. For example, the Dunedin Furthermore, earlier studies that have Multidisciplinary Health and Development examined the links between psychotic symp- Study reported an increase in schizophrenia tomatology and violence have found that symptoms and schizophreniform disorder there were a specifi c subset of symptoms, associated with early cannabis use (prior to related to perceived threat and internal age 15),2 while our own study (the Christ- control-override that were related to violent church Health and Development Study) behaviour, rather than psychotic symptom- reported an increase in psychotic symp- atology more generally.7 Therefore, while the tomatology as measured by the SCL-90 in risk of violence is elevated among individuals more frequent users of cannabis to age 25.3 diagnosed with psychosis, the nature of the It is important to note that psychotic symp- links between specifi c features of psychosis tomatology, while relatively uncommon, and violence is not well understood. comprises a variety of symptoms ranging A further concern with the press release from relatively mild (“believing others can by Family First is that several studies have hear your thoughts”) to severe (“believing been cited, but none of them directly link that a… force could control your movements cannabis exposure, psychosis and violence. or thoughts against your will”), with mild In addition, many of the studies have 4 symptoms being more commonly reported. been undertaken with selective samples The heterogeneity between studies makes (eg, men convicted of intimate partner it diffi cult to ascertain precisely which violence), from which conclusions about
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 76 www.nzma.org.nz/journal LETTER
these linkages in the general population We agree with Family First on one cannot be drawn. It should also be noted important point; more research is needed that some studies confl ate “substance use on the possible linkages between cannabis disorder” with alcohol use disorder, which exposure and violence. However, the use has been shown to have an unequivocal of tendentious arguments, and failing to link to increased risk of violent behaviour.8,9 properly report on the strengths and weak- Further, the press release fails to note nesses of the research literature is not the methodological weaknesses in the cited way to move forward in our discussions studies (eg, failing to control for anti-social concerning the best way to regulate the personality disorder), as well as cautious consumption of cannabis. Furthermore, interpretations made by the original such commentary serves to perpetuate authors. Finally, however, the press release the stigmatisation of persons with serious also quotes statistics from various jurisdic- mental illness.5 The New Zealand public tions in which the infl uence of cannabis is deserves a good-faith approach by all inferred by the authors of the release, but involved in the debates. clearly cannot be shown to be causal.
Competing interests: Nil. Author information: Joseph M Boden, Research Associate Professor, Christchurch Health and Development Study, Department of Psychological Medicine, University of Otago, Christchurch; Janet K Spittlehouse, Postdoctoral Research Fellow, Christchurch Health and Development Study, Department of Psychological Medicine, University of Otago, Christchurch. Corresponding author: Joseph M Boden, Research Associate Professor, Christchurch Health and Development Study, Department of Psychological Medicine, University of Otago, Christchurch. [email protected] URL: http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2019/vol-132-no-1499- 26-july-2019/7949
REFERENCES: 1. Fergusson DM, Poulton ic-like experiences in a 7. Swanson JW, Borum R, R, Smith PF, Boden JM. community sample of Swartz MS, Monahan J. Cannabis and psychosis: adolescents: implications Psychotic symptoms and A summary and synthesis for the continuum model disorders and the risk of the evidence. Br Med of psychosis and predic- of violent behaviour in J. 2006; 332:172–6. tion of schizophrenia. the community. Criminal 2. Arseneault L, Cannon M, Aust N Z J Psychiatry. Behaviour and Mental Poulton R, Murray R, Caspi 2009; 43(2):118–28. Health. 1996; 6(4):309–29. A, Moffi tt T. Cannabis use 5. Varshney M, Mahapatra 8. Boden JM, Fergusson in adolescence and risk for A, Krishnan V, Gupta R, DM, Horwood LJ. Alco- adult psychosis: Longitu- Deb KS. Violence and hol misuse and violent dinal prospective study. Br mental illness: what is behavior: Findings from a Med J. 2002; 325:1212–3. the true story? J Epide- 30-year longitudinal study. 3. Fergusson DM, Horwood miol Community Health. Drug Alcohol Depend. LJ, Ridder EM. Tests of 2016; 70(3):223–5. 2012; 122(1–2):135–41. causal linkages between 6. Skeem J, Kennealy P, 9. N utt DJ, King LA, Phillips cannabis use and psychotic Monahan J, Peterson J, LD. Drug harms in the UK: symptoms. Addiction. Appelbaum P. Psychosis a multicriteria decision 2005; 100:354–66. Uncommonly and Incon- analysis. The Lancet. 4. Yung AR, Nelson B, Baker sistently Precedes Violence 2010; 376(9752):1558–65. K, Buckby JA, Baksheev Among High-Risk Individ- G, Cosgrave EM. Psychot- uals. Clinical Psychological Science. 2016; 4(1):40–9.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 77 www.nzma.org.nz/journal LETTER
Sun protection policy in New Zealand Ben Gray
cNoe and Reeder’s paper1 on sun policies will have an unmeasured adverse protection policy in New Zealand effect by promoting vitamin D defi ciency. has an important fl aw. Although In a study at our practice (enrolled popu- M 4 data was collected on ethnicity the paper did lation around 7,000) on pregnant women, not include ethnicity in the analysis of the 87% of women were defi cient in vitamin D data. While it is accepted that New Zealand and a review of records found 10 children as a whole has a high incidence of melano- under fi ve years old having been diag- ma, this is largely within the New Zealand nosed with rickets in the previous three European population that account for 79.9% years. The practice has just 18% New of cases with low levels reported in Māori Zealand European.5 It seems counter-in- 0.7% and Pacifi c 0.2%, and probably even tuitive to walk past Newtown School to lower levels in people from Africa and the see the Somali children with sun hats on. Indian subcontinent (5.7% other and 13.5% For more detail on effects of sun exposure unknown).2 Even these statistics in New and vitamin D defi ciency, see New Zealand Zealand are diffi cult to interpret. As Callister policy statement.6 Protecting children at noted3 “In New Zealand, where there is a low risk of developing melanoma from the high rate of ethnic intermarriage and ethnic- sunlight that will increase their vitamin D ity is culturally constructed, there is likely to levels risks causing harm. The logistics and have been a weakening of the relationship costs of arranging supplementation make between ethnicity and skin colour”. It is en- it unlikely to be effectively implemented. tirely possible that the 0.7% Māori who get We could learn the lesson from the Sudden melanoma are all fair skinned. Unexpected Death in Infants (SUDI) expe- Adherence to the sun protection policy is rience. The initial public health response more important in schools with large propor- was effective in dropping the rate in the tions of New Zealand European children, New Zealand European population, but and of less importance in schools with a for 10 years Māori had a rate twice that high proportion of dark-skinned children. of the non-Māori population. A team of They did not use the ethnicity data to test researchers addressed the problem from a 7 the hypothesis that adherence to the sun Māori perspective and devised the ‘pepe protection policy was lower in schools with a pod’ that led to a dramatic reduction of SUDI 8 high proportion of children with dark skin. in Māori. An earlier appreciation that a different public health approach was needed The sun protection policies advocated in for Māori could have saved lives. this paper are essential for children with fair skin, and of diminishing benefi t as the We are an increasingly multicultural child’s skin gets darker, to the point where society. We need to be more sophisticated in for very dark-skinned children they provide our health promotion policy and take care no demonstrated benefi t. However, such not to use a one-size-fi ts-all.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 78 www.nzma.org.nz/journal LETTER
Competing interests: Nil. Author information: Ben Gray, Senior Lecturer, Department of Primary Health Care and General Practice, University Of Otago, Wellington. Corresponding author: Dr Ben Gray, Senior Lecturer, Department of Primary Health Care and General Practice, University Of Otago, Wellington. [email protected] URL: http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2019/vol-132-no-1499- 26-july-2019/7950
REFERENCES: 1. McNoe BM, Reeder AI. New Zealand? Ethnicity & ment on Vitamin D and Sun Sun protection policies Health 2011; 16:57–71. DOI: Exposure in New Zealand. and practices in New 10.1080/13557858.2010. Wellington New Zealand: Zealand primary schools. 527925. Ministry of Health, 2012. New Zealand Medical 4. Judkins A, Eagleton C. 7. Tipene-Leach D, Able S, Journal 2019; 132:46–54. Vitamin D defi ciency in Haretuku R, et al. The 2. Haynes R, Pearce J, Barnett pregnant New Zealand Maori SIDS Prevention R. Cancer survival in New women. Journal of the Programme: Challenges Zealand: Ethnic, social and New Zealand Medical and Implications of geographical inequalities. Association 2006; 119. Maori Health Service Social Science & Medicine 5. Newtown Union Health Development. Social 2008; 67:928–937. DOI: Service. Annual Report Policy Journal of New http://doi.org/10.1016/j. 2015–16, http://www. Zealand 2000: 65–77. socscimed.2008.05.005 newtownunionhealthser- 8. Mitchell EA, Cowan S, 3. Callister P, Galtry J,, Didham vice.org.nz/wp-content/ Tipene-Leach D. The R. The risks and benefi ts uploads/NUHS-Annu- recent fall in postperi- of sun exposure: should al-Report-2015-2016.pdf natal mortality in New skin colour or ethnicity (2016, accessed 17/1/17). Zealand and the Safe be the main variable for 6. Ministry of Health and Sleep programme. Acta communicating health Cancer Society of New Paediatrica 2016: n/a-n/a. promotion messages in Zealand. Consensus State- DOI: 10.1111/apa.13494.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 79 www.nzma.org.nz/journal LETTER
The thorny issue of alcohol control in Aotearoa/New Zealand: developments in Ireland Frank Houghton
ord et al recently discussed the ongo- the problem in Ireland as just over one in ing and problematic nature of alcohol fi ve (20.6%) Irish adults are, for religious Fmisuse in New Zealand.1 Like many or other reasons, teetotal. Amended per other Western countries, New Zealand capita calculations of alcohol consumption liberalised its sale and supply of liquor leg- therefore indicate that in 2015, adults that islation towards the end of the 20th Century, consumed alcohol in Ireland drank on starting with the 1989 Sale of Liquor Act.2–3 average the equivalent of 46 bottles of gin/ Over time this legislation and subsequent vodka. Heavy episodic (‘binge’) drinking is a amendments permitted a signifi cant expan- particular concern in Ireland. World Health sion in the number and types of premises Organization (WHO) research indicates that permitted to sell alcohol, a reduction in the on this measure Ireland was second only to age to legally purchase alcohol from 20 to Austria out of 194 countries and signifi cantly 18, and allowed Sunday trading in alco- ahead of the UK.21 2–3 hol. The outcome of this deregulation has Similar to New Zealand, Ireland signifi - included an increase of more than 100% in cantly deregulated its controls around the number of alcohol outlets in New Zea- alcohol in the early years of the 21st land, increasing from 6,000 to 14,000 over a Century. Despite the growing and indis- decade, and a growing state of widespread putable evidence11–16 of the negative and unease concerning the negative impact of costly impact of alcohol on Irish society, 4 alcohol on society in New Zealand. successive governments have demonstrated The adverse global impact of alcohol remarkable ambivalence towards effective is signifi cant,5 and New Zealand is no regulation of alcohol.23–24 However, the exception.4,6,7 It must be remembered that beginning of a turning point towards a more any routine assessments of the impact of responsible approach to alcohol may be alcohol on morbidity and mortality may seen with the explicit inclusion of alcohol in overlook the role of alcohol as a facilitator Ireland’s Drug strategy in 2009.25 and risk factor for both domestic violence More recently, after more than 1,000 and suicide. The inequitable negative days of debate and in the face of signif- impact of alcohol-related morbidity and icant opposition from representatives from mortality among Māori is also a particular rural constituencies, Ireland’s parliament 8-10 issue of concern. (the Dáil) has just passed a new alcohol Ireland has an equally problematic Bill which paved the way for a range of relationship with alcohol,11–17 and has more stringent control measures.26–27 These traditionally been subject to a host of include minimum unit pricing, mandatory negative stereotypes and caricatures cancer warnings and the spatial segregation internationally around this issue.17–19 Per of alcohol sales in shops.26 capita alcohol consumption in Ireland is a Given both the negative impact on 20–22 signifi cant issue of concern. However, morbidity and mortality attributable to such population-based averages lead to alcohol and the high level of public unease a gross underestimation of the extent of about this issue, it may be an opportune
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 80 www.nzma.org.nz/journal LETTER
time for New Zealand to once again seri- introduce a minimum unit price initiative.30 ously reconsider similar initiatives. New Support for such a measure may also be seen Zealand’s Sale and Supply of Alcohol Act in a recent Ministry of Justice report.31 In 2012 enacted some, but not all of the impres- relation to the segregation of alcohol sales, sively comprehensive Law Commission it should be noted that the New Zealand report Alcohol in Our Lives: Curbing the Medical Association (NZMA) has already Harm.4 Thus former opportunities for more called for a ban on the sale of alcohol from stringent protections may have been wasted, supermarkets.32 In addition, research from however now is the time for action.27 Recent New Zealand has amply demonstrated the research in New Zealand has highlighted the high level of exposure of children to alcohol failure of a voluntary code of warnings on in everyday environments that only serves alcohol.28 Additionally, despite a reluctance to normalise alcohol,33 a product that is ‘no in government circles,29 there appears to be ordinary commodity’.34 growing pressure to push for legislation to
Competing interests: Nil. Author information: Frank Houghton, HEALR Research Group, Limerick Institute of Technology, Limerick, Ireland. Corresponding author: Dr Frank Houghton, HEALR Research Group, Limerick Institute of Technology, Limerick, Ireland. [email protected] URL: http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2019/vol-132-no-1499- 26-july-2019/7951
REFERENCES: 1. Ford K, Foulds J, Coleman 4. Law Commission. Alcohol 6. Connor J, Kydd R, Shield O, Ardagh M, Pearson S, in Our lives: an issues K, Rehm J. Alcohol-at- Droste N, Newton-Howes G, paper on the reform of tributable burden of Sellman JD. Alcohol-related New Zealand’s liquor disease and injury in emergency department laws. Law Commission: New Zealand: 2004 and attendances after the Wellington, 2009. 2007. Health Promotion introduction of the Sale and 5. Lim SS, Vos T, Flaxman Agency: Wellington, 2013. Supply of Alcohol Act 2012. AD, Danaei G, Shibuya 7. Health Promotion Agency. NZMJ 2018; 131(1483). K, Adair-Rohani H, et Injuries and death from 2. Alcohol Healthwatch. al. A comparative risk traffi c crashes with alcohol Information Sheet: sale assessment of burden of as a contributing factor. and supply of liquor. disease and injury attrib- AlcoholNZ 2017; (7)1:26–29. 3. Maclennan B, Kypri K, utable to 67 risk factors 8. Ellison-Loschmann L, Connor J, Potiki T, Room and risk factor clusters in Sporle A, Corbin M, Cheng R. New Zealand’s new 21 regions, 1990–2010: a S, Harawira P, Gray M, et alcohol laws: protocol systematic analysis for the al. Risk of stomach cancer for a mixed-methods global burden of disease in Aotearoa/New Zealand: evaluation. BMC Public study 2010. Lancet 2012; A Māori population based Health 2016; 16:29. 380:2224–60. case-control study. PLoS ONE 2017; 12(7):e0181581.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 81 www.nzma.org.nz/journal LETTER
9. Connor J, Kydd R, Maclen- in Society and History with a voluntary system. nan B, Shield K, Rehm 1971; 13(4):365–375. Drug & Alcohol Rev J. Alcohol-attributable 19. Stivers R. Irish ethnic- 2018; 37(5):616–626. cancer deaths under ity and alcohol use. 29. Davison I. (2014) Govt 80 years of age in New Medical Anthropology refuses to set minimum Zealand. Drug and Alcohol 1978; 2(4):121–135. price on alcohol. New Review 2017; 36:415–423. 20. IPSOS MRBI. Healthy Zealand Herald. 24th April. 10. Herbert S, Stephens C. Ireland Survey 2017: http://www.nzherald.co.nz/ Alcohol Use and Older Summary of Findings. nz/news/article.cfm?c_ Mãori in Aotearoa. Journal Dublin: Government id=1&objectid=11243722 of Ethnicity in Substance Publications Offi ce, 2017. 30. Hapai Te Hauora. NZ urged Abuse 2015; 14(3):251–269. 21. WHO. Global status report to move on a fl oor price for 11. Lyons S, Lynn E, Walsh on alcohol and health 2014. alcohol. 16th November S, Sutton M, Long J. Geneva: World Health 2017. http://www.hapai. Alcohol-related deaths Organisation, 2014. co.nz/content/nz-urged- and deaths among people move-fl oor-price-alcohol 22. WHO. Global status report who were alcohol depen- on alcohol and health 2018. 31. Ministry of Justice (2016) dent in Ireland, 2004 Geneva: World Health Alcohol minimum pricing to 2008. Dublin: Health Organisation, 2018. policies. http://www. Research Board, 2011. justice.govt.nz/justice-sec- 23. Houghton F. A Perfect 12. Martin J, Barry J, Goggin tor-policy/key-initiatives/ Demonstration of the D, Morgan K, Ward M, sale-and-supply-of-alcohol/ Absence of Leadership: O’Suilleabhain T. Alco- alcohol-minimum-pric- Alcohol Policy in Ireland. hol-attributable mortality ing-report/ Irish J Psych Med in Ireland. Alcohol Alcohol 2012; 2993:145–146. 32. Ainge Roy E. (2017) Ban 2010; 45:379–86. alcohol from supermar- 24. Butler S. Obstacles to 13. Martin, J, Barry, J, Skally, kets, urges New Zealand the Implementation of M. Alcohol Attributable medical authority. The an Integrated National Hospitalisations and Costs Guardian, 7th August 2017. Alcohol Policy in Ireland: in Ireland, 2000-2004. Ir http://www.google.com/ Nannies, Neo-Liberals and Med J 2011; 104:140–4. amp/s/amp.theguardian. Joined-Up Government. com/world/2017/aug/07/ 14. Mongan D, Hope A, Nelson Journal of Social Policy ban-alcohol-from-super- M. Social consequences 2009; 38(2):343–359. of harmful use of alcohol markets-urges-new-zea- 25. Department of Community, in Ireland. HRB Overview land-medical-authority Rural and Gaeltacht Affairs. Series 9. Dublin: Health 33. Chambers T, Pearson AL, National Drugs Strategy Research Board, 2009. Stanley J, Smith M, Barra (interim) 2009–2017. M, Ni Mhurchu C, Signal 15. Hope A. Alcohol-related Dublin: Government L. Children’s exposure harm in Ireland. Dublin: Publications Offi ce. Health Service Executive to alcohol marketing 26. Irish Examiner. Warnings – Alcohol Implementation within supermarkets: on labels as Dáil passes Group. Dublin: Health An objective analysis alcohol bill. Thursday, Services Executive, 2008. using GPS technology and October 04, 2018. wearable cameras. Health 16. Byrne, S. Costs to society 27. Kypri K, Connor J, & Place 2017; 46:274–280. of problem alcohol use in Maclennan B, Sellman Ireland. Dublin: Health 34. Babor T, Caetano R, D. What became of New Service Executive, 2011. Casswell S, Edwards G, Zealand’s golden oppor- Geisbrecht N, Graham K, 17. Ferriter D. Drink and tunity for liquor law Grube J, Hill L, Holder H society in twentieth-cen- reform? Drug & Alcohol D, Homel R, Livingston tury Ireland. Proceedings Rev 2013; 32(6):557–60. M, Osterberg E, Rehm J, of the Royal Irish Acad- 28. Tinawi G, Gray T, Knight Room R, Rossow I. Alcohol: emy. 2015; 115C:1–21. T, Glass C, Domanski no ordinary commodity. 18. Appel JJ. From shanties N, Wilson N, Hoek J. Research and public to lace curtains: the Irish Highly defi cient alcohol policy. Oxford: Oxford image in Puck, 1876–1910. health warning labels in University Press, 2010. Comparative Studies a high-income country
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 82 www.nzma.org.nz/journal METHUSELAH
A randomised trial of prophylactic antibiotics for miscarriage surgery Surgical intervention is needed in some cases of spontaneous abortion to remove retained products of conception. Antibiotic prophylaxis may reduce the risk of pelvic infection. This trial was devised to throw some light on this issue. Three thousand four hundred and twelve patients from Malawi, Pakistan, Tanzania and Uganda were enrolled. Half of them received a single preoperative dose of 400mg of oral doxycycline and 400mg of oral metroni- dazole, and the other half received identical placebos. Pelvic infection was defi ned as two or more of four clinical features—purulent vaginal discharge, pyrexia, uterine tenderness and leucocytosis. The conclusion reached was that antibiotic prophylaxis before miscarriage surgery did not result in a signifi cantly lower risk of pelvic infection, as defi ned by pragmatic broad criteria, than placebo. N Engl J Med 2019; 380:1012–21 Management of atrial fi brillation after cardiac surgery Is atrial fi brillation (AF) that occurs after cardiac surgery best controlled by rhythm or rate control? This is questioned in this study. After reviewing more than 2,000 relevant papers the authors of this study identifi ed fi ve reports that they considered to provide the best evidence—four were reports of randomised trials and one was a retrospective cohort study. Hospital length of stay were approximately equal in the two management protocols. Freedom from AF at follow-up was found to be similar. Minimal adverse effects were seen in both groups. It appears that rate and rhythm control are equally good in the management of AF after cardiac surgery. Internal Medicine Journal 2019; 49:656–658 Use of hormone replacement therapy and risk of venous thromboembolism The aim of this nested case-control study was to assess the association between risk of venous thromboembolism and use of different types of hormone replacement therapy. 80,396 women with a diagnosis of venous thromboembolism were compared with 391,494 matched female controls. The researchers found a signifi cantly increased risk of venous thromboembolism in those taking oral contraceptives compared with the subjects with no exposure. Equine oestrogen with medroxyprogesterone had the highest risk (2.10) and estradiol with dydrogesterone had the lowest risk (1.18). Transdermal preparations were not associated with risk of venous thromboembolism. In the present study, transdermal treatment was the safest type of hormone replacement therapy when risk of venous thromboembolism was assessed. Transdermal treatment appears to be underused, with the overwhelming preference still for oral preparations. BMJ 2019; 364:k4810
URL: http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2019/vol-132-no-1499- 26-july-2019/7952
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 83 www.nzma.org.nz/journal 100 YEARS AGO
Myositis Ossi cans By GORDON MACDONALD, M.D., Dunedin
Child with a toy, in a hospital, Dannevirke. Ref: 1/2-022222-G. Alexander Turnbull Library, Wellington, New Zealand. / records/22332612
n several occasions during the past now ended fatally. ln some remarks I made few years I have sent notes to the in the original paper I have noted that Dr. ONEW ZEALAND MEDICAL JOURNAL Lendon, of Adelaide, who reported a case to regarding the progress of this disease in the fi rst Intercolonial Congress in 1887, says: a girl whose case I fi rst reported in the “In my own case, and I think, also, in that JOURNAL of 29th August, 1891. In October of William Clark, the case in the Museum of last she died suddenly from heart failure the Royal College of Surgeons, London, it is a and general weakness. No post-mortem noted fact that the disease is mainly situated examination was permitted, and thus a most in the muscles of the appendicular skeleton unusual and interesting case has passed out and has spared those of the axial skeleton.” of all further observation. As the younger Now, in my case the reverse is the fact. generation of practitioners may not have The occurrence of nodes in this case, their th access to the JOURNAL of 29 August, 1891, I appearance, disappearance, and reap- may recapitulate the principal points in the pearance, lends some colour to the theory case. The disease was fi rst observed when that it may have had its origin in some the child was two years of age. It showed syphilitic taint. Nothing, however, has been itself as a hard lump about the middle of detected in the family history to warrant the left sterno-mastoid muscle. After this any such conclusion. In a note I sent to the a series of lumps appeared, disappeared, JOURNAL in August, 1905, I stated: “The and reappeared in various positions upon internal organs are apparently healthy the head and trunk. The disease steadily and seemingly not involved in the general progressed in spite of all treatment, and has degeneration going on in the external
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 84 www.nzma.org.nz/journal 100 YEARS AGO
muscles.” In 1905 the muscles of the legs laugh, so her face always held one fi xed gaze were not very much involved, but since as if dead. She could neither feed herself, then they also became involved, so that nor dress herself, nor wash herself, nor lie the whole of the external muscular system down, nor rise up—in short, she became latterly became more or less diseased. She a helpless infant. She also suffered from was able to move about in a more or less bradycardia and slow, irregular respiration. helpless manner until some twelve months Her mental faculties were very feeble, but ago, but since then she has been entirely she developed a species of cunning which confi ned to home and to bed, her whole served her purposes to some extent. Her left frame being quite rigid. She had entirely sterno-mastoid muscle, completely ossifi ed, lost all power of expanding her chest and was removed whilst she was an inmate of movement in the muscles of the abdomen. the Dunedin Hospital in 1891. Strange, too, she could neither smile nor
URL: http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2019/vol-132-no-1499- 26-july-2019/7953
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 85 www.nzma.org.nz/journal PROCEEDINGS
The proceedings of the 243rd and 244th meetings of the OMSRS
A digital method for obtained digitally ranged from are pro-infl ammatory and M2, estimating orthodontic 19 to 35 (mean 26.8, sd 4.6) and which promote tissue repair. test-retest scores varied by a We aimed to defi ne the role of treatment need mean of only 0.1 points (sd 1.1). M1 and M2 macrophages in C Cai, S Olliver, L Mei, J Broadbent Both individual and average allograft rejection and inte- Sir John Walsh Research intra-class correlations based gration in a murine model. Institute, Faculty of Dentistry, on consistency agreement and C57BL/6 and BALB/c mice University of Otago, Dunedin. two-way mixed effects model were used as they have distinct Dental malocclusions refer to were high, at >0.95 for all immune responses. Full- the misalignment of teeth and measurements of intra- and thickness skin punch biopsies may range from trivial to debil- inter-examiner reliability. DAI were taken from a donor itating. The Dental Aesthetic scores in the Dunedin Study C57BL/6 mouse, transplanted Index (DAI) is commonly used were strongly associated into full-thickness wounds on to identify individuals with very with self-perceived dental BALB/c mice and vice versa. severe malocclusions who may appearance, reaffi rming the Three C57BL/6 and four BALB/c qualify for publicly funded care, validity of the index. mice received grafts. Mice were but estimation of DAI scores This study demonstrating euthanised and the wound may vary between referring digital measurement of DAI harvested on the day of esti- dentists. The 3Shape Trios scores allows reliable, rapid and mated 50% rejection, C57BL/6 intra-oral scanner generates accurate estimation of ortho- mice were euthanised one day accurate three-dimensional dontic treatment need outside prior to BALB/c mice. Immune digital images of the oral cavity, the clinical setting. cells within the grafts were enabling the calculation of DAI Supported by a grant from the identifi ed using fl ow cytometry digitally. However, no published Auckland Dental Association and immunofl uorescent reports have described such a Summer Scholarship. histochemistry; statistical signif- method. We aimed to determine icance was assessed with an whether a modern digital The role of unpaired t-test. imaging technique may enable macrophages in Two C57BL/6 and three more reliable estimation of allogenic skin BALB/c mice retained grafts. DAI scores and allow its use in When the graft remained, tissue the Dunedin Multidisciplinary graft rejection in showed greater viability and Health and Development Study murine models integration in wounds of BALB/c (DMHDS). mice. C57BL/6 and BALB/c T McBride,1,2 Z Lateef,1 L Wise1 World Health Organization mice had higher numbers of 1Department of Pharmacology criteria were used for esti- macrophages at the wound site, and Toxicology; 2Department of compared to controls; indicating mating clinical DAI scores and Microbiology and Immunology, were adapted to our digital School of Biomedical Sciences, an immune response. C57BL/6 method where necessary. DAI University of Otago, Dunedin. mice had higher frequencies of M1 macrophages within was measured both clinically An allograft is transplan- wounds with grafts (mean ± and digitally by two examiners tation of skin from a genetically SEM, C57BL/6 75.94±11.12%, on a sample of 16 individuals unrelated donor to a victim BALB/c 22.85±6.74%, P<0.05); presented with varying occlusal with a large area of uncovered BALB/c mice displayed higher traits: a total of four times for trauma. While an allograft can frequencies of M2 macrophages eight participants and eight restore organ function, rejection (BALB/c 10.67±1.61%, C57BL/6 times for the remaining eight is a frequent problem due to 5.35±2.24%, P<0.05). participants. After examiner the cellular destruction insti- calibration was complete, DAI gated by immune cells, such as This study implicates M1 was then collected for DMHDS macrophages. Immunosuppres- cells with a role in allograft participants. sants delay but do not prevent skin rejection and M2 cells in DAI scores obtained clin- rejection, suggesting certain skin graft integration, both are ically ranged from 19 to 37 immune cells may be critical to therefore a possible drug target. (mean 27.2, sd 5.0), but test- graft integration. Macrophages Supported by a School of retest scores varied by a mean can be categorised into two Biomedical Sciences Summer of 1.0 point (sd 1.1). DAI scores generalised subsets: M1, which Research Scholarship.
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 86 www.nzma.org.nz/journal PROCEEDINGS
Aortic size index to for age and sex. However, no for GFP expression. The small predict risk in coronary signifi cant relationship was number of cells expressing seen with ASI when history of GFP in both vector groups artery disease patients diabetes and overall CAD clas- meant results were limited to AW Blake-Barlow,1 S Co ey,1 sifi cation were included in the qualitative observations. GT Jones2 model (hazard ratio 1.21, 95% CI Like AAV9, AAV-PHP.eB 1Department of Medicine; 0.92–1.59, P=0.18). produced GFP expression 2Department of Surgical Sciences, In conclusion, ASI is in both neurons and glia. Dunedin School of Medicine, predictive of adverse events in However, GFP expression University of Otago, Dunedin. patients undergoing coronary in the brain produced by Cardiovascular disease is angiography, but does not add AAV-PHP.eB was not as high as one of the leading causes of signifi cant information over reported. Despite transduction death and disability worldwide. traditional predictors of adverse being sparse, AAV-PHP.eB was Current risk stratifi cation and outcome. more effective than AAV9 at classifi cation of coronary artery Supported by a Division of transducing cells across the disease (CAD) can be performed Health Sciences Summer Student whole brain. AAV-PHP.eB also using coronary angiography. Research Scholarship. produced much lower GFP However, signifi cant risk is expression in the liver than not accounted for with this Assessing the effi cacy AAV9, which suggests that approach. We investigated the of a novel adeno- AAV-PHP.eB has high tropism use of aortic size index (ASI, for brain cells. The low liver abdominal aortic diameter associated viral capsid transduction may mean more of divided by body surface area) in targeting the brain the vector is available to reach as a means of more accurate the brain. SN Mathiesen,1,2 SM Ohline,1 prognostication. HE Wicky,2 MYI Cheong,2 The higher effi cacy of The cohort consisted of a WC Abraham,1 SM Hughes2 AAV-PHP.eB compared to consecutive series of patients AAV9 at transducing brain 1Department of Psychology; undergoing coronary angi- 2Department of Biochemistry, cells following intravenous ography due to suspicion of School of Biomedical Sciences , delivery is encouraging when stable or unstable CAD. ASI Brain Health Research Centre, considering translation of this was calculated based on an University of Otago, Dunedin. approach to humans. After abdominal ultrasound. Standard One barrier to the treatment additional work to evaluate the demographic variables were of Alzheimer’s disease is a effectiveness of AAV-PHP.eB, obtained, and patients were lack of effective methods to it is planned to test this vector stratifi ed based on severity deliver therapeutics to the in future preclinical studies of their disease (obstructive, brain, particularly by non-in- involving animal models of non-obstructive or no luminal vasive routes. Adeno-associated Alzheimer’s disease. disease). Adverse events viral (AAV) vectors used for Supported by a Neurological were defi ned as myocardial gene therapy may provide a Foundation of New Zealand infarction, hospitalisation due solution as some serotypes can Summer Student Scholarship. to unstable angina, unplanned cross the blood brain barrier, revascularisation procedure allowing for minimally non-in- Nanosilver as an or death due to any cause. ASI vasive administration. A novel antimicrobial for was analysed as a continuous AAV capsid, AAV-PHP.eB, was grafting materials measure as a predictor of events recently reported to produce using logistic regression, and high transgene expression in and its cytotoxicity then as a categorical measure mouse brain after intravenous on human gingival (extreme ASI, referring to administration. The present fi broblasts in vitro largest and smallest ASI groups study compared the effi ciency 1 1 1 based on predefi ned cut points of two AAV vectors in targeting A Jude, C Gee, G Cotton, 2 1 2 1 (lower <0.835cm/m and upper the brain after intravenous W Duncan, S Safii, D Coates 2 >1.2cm/m ) using Cox propor- administration: AAV-PHP.eB, 1Sir John Walsh Research Institute, tional hazards regression. and a similar widely used viral Faculty of Dentistry, University of 2 Data from 867 patients vector, AAV9. Otago, Dunedin; Department of Restorative Dentistry, Faculty of were analysed (mean age 68 C75Bl/6 mice were adminis- Dentistry, University of Malaya, years, 65% male). ASI showed tered either AAV-PHP.eB (n=5) Kuala Lumpur, Malaysia. a U shape relationship with or AAV9 (n=4) carrying the Moa Bone® is a deproteinated outcomes where extremes of transgene for green fl uorescent bovine bone product which ASI had a higher risk of a subse- protein (GFP) via tail vein increases clinically important quent event. Survival analysis injection (100µL). Four weeks bone regeneration in dental revealed a 40% increase in after vector administration, procedures. However, graft event rate for those with ASI brain sections were sites are often associated with extremes (hazard ratio 1.40, immunolabelled for GFP and infections. Silver nanoparticles 95% confi dence interval 1.07– cell-type specifi c markers. Liver (AgNP) represent a promising 1.84, P=0.02), which remained sections were also examined antimicrobial, yet limited infor- signifi cant when adjusted
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 87 www.nzma.org.nz/journal PROCEEDINGS
mation is available on their Elucidating the effect of body weight, age of fi rst safety profi le. of prenatal androgen successful mating and seminal We investigated the cyto- vesicles weight. However, the excess on male normalised anogenital distance toxicity of AgNP on human reproductive function gingival fi broblasts (HGF; N=3) measurement by body weight of using both in vitro cell viability and metabolism PNAM (n=20) mice was signifi - cantly shorter (ie, female-like and caspase 3/7 apoptosis S Holland,1 M Prescott,2 E Desroziers,2 and suggestive decreased assays. Chlorhexidine (CHX), R Campbell1 silver nitrate (AgNO ) and circulating androgens) at post- 3 1Department of Physiology and silver diamine fl uoride (SDF) natal day 40 in comparison to Center for Neuroendocrinology, vehicle controls (n=15) (P<0.01). were tested as widely accepted School of Biomedical Sciences, Additionally, the normalised licensed clinical controls. Data University of Otago, Dunedin. was calculated as a mean ± SD testes to body weight ratio was Elevated maternal androgen of pairwise comparisons where signifi cantly lower in PNAM levels are associated with the controls of untreated cells were mice (Mann Whitney U test, development of polycystic ovary set to 100%. Paired t-tests were P=0.0152). syndrome (PCOS, a prevalent used for comparisons and IC50 Therefore, this study has metabolic/infertility disorder) regression analysis conducted illustrated males exposed to in females. Emerging clinical in GraphPad PRISM7. elevated prenatal androgens research has recently postu- manifest small changes in AgNP (22.5μg/mL for 4h) lated the existence of a male external genitalia and gonadal resulted in signifi cant cyto- PCOS phenotype, as it has been weight, but are still fertile toxicity to HGF with only observed that the male relatives and exhibit no overt meta- 8.42±14.58% (P=0.0083) of cells of women with PCOS manifest bolic phenotype. It remains to being viable as compared to an array of similar reproductive be determined whether men control (100%). However, no and metabolic abnormalities. exposed to elevated maternal signifi cant cytotoxic effect was Therefore, this project aimed androgens manifest any repro- seen at doses below 5μg/mL. to elucidate the reproductive ductive abnormalities. CHX is used clinically at 0.2% and metabolic phenotype of and was cytotoxic at 0.02% after prenatally androgenised mice Supported by a Division 4h (9.80±10.96%, P=0.0049). (PNAM). of Health Sciences Summer AgNO was cytotoxic at 50μg/ Research Scholarship. 3 Pregnant mouse dams were mL after 4h (0.43±0.75%, subcutaneously injected with P=0.00002). SDF is used clini- either 250µg of dihydrotes- Folia-specifi c cally at 334,000μg/mL and was tosterone (DHT) (eliciting vulnerability of the cytotoxic at 3.4μg/mL after 4h PNAM offspring) or a control cerebellar climbing (7.26±2.60%, P=0.0021). AgNP oil vehicle solution (200µL) had an IC50 of 10.2μg/mL at 4h fi bre synapse in (vehicle control offspring) on and 10.6μg/mL at 96h, indi- a mouse model of gestational days 16, 17 and 18. cating minimal cumulative Pubertal onset and fertility human spinocerebellar effect. Additionally, AgNP was analysed by determining ataxia type 1 showed a statistically signifi cant the age of the fi rst successful anti-apoptotic effect at 22.5μg/ EA Deeney, RM Empson mating (resulting in conception) mL (39.78±5.74%, P=0.0031) and Department of Physiology, and daily anogenital distance 50μg/mL (62.93±3.56%, P=0.002). School of Biomedical Sciences, (the distance between the glans University of Otago, Dunedin. The cytotoxic effect of AgNP penis and anus) measurements on HGF was similar to or less from postnatal day 35 onwards. Ataxia, or loss of movement control, is caused by disrupted than that of CHX, AgNO3 and Body weight measurements SDF and it was anti-apoptotic. were recorded every fi ve days cerebellar synaptic connections. Overall, AgNP showed a prom- throughout puberty and then The cerebellar cortex exhibits ising cytotoxicity profi le which every 10 days throughout early a foliated anatomical structure warrants its investigation as an adulthood. Testes and seminal (undergoes repeated folding) adjunct to Moa Bone®. vesicles weight was additionally that is largely conserved between mice and humans. Supported by a University of measured. All folia contain Purkinje Otago Summer Studentship from Overall, this project found neurons (PNs) that receive the Otago Medical Research no statistically signifi cant strong excitatory climbing fi bre Foundation. differences between PNAM (CF) synaptic connections that and vehicle controls in terms
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 88 www.nzma.org.nz/journal PROCEEDINGS
modulate their output, but vulnerable to loss of EAAT4 English. The contents were eval- how this CF synaptic organ- expression in SCA1 mice. Our uated using an a priori 14-item isation differs in health and fi ndings suggest the need self-management support disease remains unknown. for folia-specifi c therapeutic checklist. The 23-item Mobile PNs can be sub-grouped based targeting for early treatment of Apps Rating Scale (MARS) and on molecular markers they SCA1. HONcode certifi cation was used express, such as excitatory Supported by a Division to appraise app and website amino acid transporter, EAAT4, of Health Sciences Summer quality respectively. which varies across folia. Research Scholarship. Eighteen apps and 27 Furthermore, reduced EAAT4 websites met inclusion criteria. expression and disrupted CF Do online resources Overall, the included apps and morphology both occur in the foster self-management websites met a median of 3 early stages of spinocerebellar support in people with (range 1–8) and 5 (range 1–8) of ataxia type 1 (SCA1). Here, the 14-item self-management we test the hypothesis that CF persistent pain? checklist. For both apps and disruption in SCA1 is greatest in Devan H,1 Perry MA,1 Farmery D,2 websites, self-monitoring of cerebellar folia where EAAT4 is Cotes L,2 van Hattem A,3 Thurlow G,3 symptoms and self-tailoring normally expressed. Shepherd S,3 Muchemwa C,3 of strategies were frequently Sagittal cerebellar sections Grainger R4 featured functions, while few (30µm) were collected from online resources had features 1Centre for Health, Activity, and 15-week-old ataxic SCA1 and Rehabilitation Research (CHARR), facilitating social support and non-ataxic wild-type (WT) School of Physiotherapy, Univer- communicating with clinicians. mice for fl uorescence immu- sity of Otago, Dunedin; 2Otago None provided information nohistochemistry and confocal Medical School, University of tailored to cultural needs of microscopy. Double-labelling Otago, Dunedin; 3School of Phys- the user. The app quality mean with EAAT4 and calbindin iotherapy, University of Otago, scores using MARS ranged from 4 ensured co-localisation at PNs, Dunedin; Department of Medicine, 2.7 to 4.5 (out of 5.0). HONcode while calbindin and vesicular University of Otago, Wellington. certifi cation was present in glutamate transporter 2 were Persistent non-cancer six of the 27 websites. Only used to assess PN and CF pain affects one in fi ve New two apps and two websites morphology, respectively. Zealanders. Online resources underwent scientifi c evalu- In WT mice we observed such as smartphone applica- ation supporting their clinical higher EAAT4 expression in tions (apps) and websites are a effi cacy. posterior versus anterior cere- potential solution for fostering Although pain management bellar folia (P<0.01, one-way self-management skills such apps and websites provide ANOVA, n=4). CF morphology as self-refl ection and active information to develop self-ef- also varied across folia in WT goal setting in people with fi cacy, none provided culturally mice (anterior versus posterior, persistent pain. The aim of appropriate information. While P<0.001, two-way ANOVA, our review was to evaluate the few apps and websites were Tukey’s multiple compar- contents of online resources validated to show improved isons), but CF morphology in (apps and websites) for people health outcomes, none were SCA1 mice was only disrupted with persistent pain facilitating tested in people with persistent in posterior folia (interaction self-management support. pain. Both users and clini- P<0.001, two-way ANOVA, n=6 A systematic search was cians have to be aware of such WT, SCA1). However, SCA1 mice performed in the New Zealand limitations and make informed showed PN atrophy throughout App Store and Google Play choices in using and recom- the cerebellum, compared to Store and major search engines mending online resources as a WT mice (P<0.001, two-way Google, Bing and Yahoo. Online self-management tool. ANOVA, n=6 WT, SCA1). resources were included if they Supported by grants from Results indicate that CF were designed for people with Arthritis New Zealand and synapses located in the persistent pain, provided infor- School of Physiotherapy, posterior cerebellum are more mation on pain management University of Otago. strategies and available in
URL: http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2019/vol-132-no-1499- 26-july-2019/7954
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 89 www.nzma.org.nz/journal published by the New Zealand Medical Association
NZMJDigest http://www.nzma.org.nz/publications/nzmjdigest
The NZMA publishes the e-magazine NZMJDigest 10 times a year. It contains news and views from the profession and the NZMA, including the NZMA Chair's editorial, along with highlights from and links to the New Zealand Medical Journal. Click on the image above to view the latest issue. We welcome contributions from members and readers. To contribute to the NZMJDigest, please email [email protected]
NZMJ 26 July 2019, Vol 132 No 1499 ISSN 1175-8716 © NZMA 90 www.nzma.org.nz/journal