Publications by authors named "Jonathan Williman"

49 Publications

Learning Challenges of Health Care Professionals Supporting Open-Source Automated Insulin Delivery.

Diabet Med 2021 Nov 26:e14750. Epub 2021 Nov 26.

Department of Paediatrics, University of Otago, Christchurch, New Zealand.

Background: Open-source automated insulin delivery (AID) is a user-driven treatment modality used by thousands globally. Health care professionals' (HCPs) ability to support users of this technology is limited by a lack of knowledge of these systems.

Aims: To describe the challenges experienced by HCPs supporting participants' use of open-source automated insulin delivery in the Community deRivEd AuTomatEd insulin delivery (CREATE) study.

Methods: Data were collected prospectively from the study team's fortnightly meetings and Slack Workspace (Slack Technologies, Ltd. 2018) during the first four months of the trial. Key topics were identified from minutes of meetings. Slack conversations were categorised by topic, with the number of posts per conversation, number of sites per conversation and involvement of experts in open-source AID being recorded.

Results: In the first four months of the trial, there were 254 conversations in Slack with a mean of 5.2 (+/- 4.25) posts per conversation. The most frequent learning challenge was insulin pump and cannula problems relating to the DANA-i insulin pump, which totalled 24.0% of all conversations. Experts on open-source AID use were involved in 83.3% of conversations.

Conclusions: A significant proportion of challenges related to specific devices, rather than AID. Challenges relating to the functioning of open-source AID were more likely to involve input from experts in open-source AID. This is the first report of challenges experienced by a multi-disciplinary team in a supported open-source environment that may inform expectations in routine clinical care.
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http://dx.doi.org/10.1111/dme.14750DOI Listing
November 2021

Circulating protein carbonyls are specifically elevated in critically ill patients with pneumonia relative to other sources of sepsis.

Free Radic Biol Med 2021 Nov 21. Epub 2021 Nov 21.

Department of Pathology and Biomedical Science, University of Otago, Christchurch, PO Box 4345, Christchurch, 8140, New Zealand. Electronic address:

Background: Septic shock is a life-threatening dysregulated response to severe infection and is associated with elevated oxidative stress. We aimed to assess protein carbonyls in critically ill patients with different sources of sepsis and determine the effect of vitamin C intervention on protein carbonyl concentrations.

Methods: Critically ill patients with septic shock (n = 40) were recruited, and sources of sepsis and ICU severity scores were recorded. The patients were randomised to receive either intravenous vitamin C (100 mg/kg body weight/day) or placebo infusions. Blood samples were collected at baseline and daily for up to three days for measurement of cell counts, vitamin C concentrations, protein carbonyls, C-reactive protein, and myeloperoxidase concentrations.

Results: Protein carbonyl concentrations increased 2.2-fold in the cohort over the duration of the study (from 169 to 369 pmol/mg protein; p = 0.03). There were significant correlations between protein carbonyl concentrations and ICU severity scores (APACHE III r = 0.47 and SOFA r = 0.37; p < 0.05) at baseline. At study admission, the patients with pneumonia had nearly 3-fold higher protein carbonyl concentrations relative to the patients with other sources of sepsis (435 vs 157 pmol/mg protein, p < 0.0001). The septic patients had deficient vitamin C status at baseline (9.8 ± 1.4 μmol/L). This increased to 456 ± 90 μmol/L following three days of intravenous vitamin C intervention. Vitamin C intervention did not attenuate the increase in protein carbonyl concentrations.

Conclusions: Circulating protein carbonyls are specifically elevated in critically ill patients with pneumonia relative to other sources of sepsis. The reasons for this are currently unclear and may indicate a mechanism unique to pulmonary sources of sepsis. Intravenous vitamin C administration did not attenuate the increase in protein carbonyls over time.
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http://dx.doi.org/10.1016/j.freeradbiomed.2021.11.029DOI Listing
November 2021

Predicting regression of cervical intraepithelial neoplasia grade 2 in women under 25 years.

Am J Obstet Gynecol 2021 Sep 14. Epub 2021 Sep 14.

National Women's Health, Auckland District Health Board, Auckland, New Zealand; Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand.

Background: A number of retrospective and prospective studies have documented substantial rates of regression in cervical intraepithelial neoplasia grade 2 lesions in young women. Initial observational management of cervical intraepithelial neoplasia grade 2 is increasingly accepted as appropriate for women under 25 years of age with screen-detected abnormalities and is included in a number of clinical guidelines. However, there has been a paucity of large prospective studies on observational management with strict inclusion criteria. A number of important questions remain, specifically regarding the clinical variables that are associated with the risk of progression or persistence of disease. To investigate these factors and to ensure that young women with cervical intraepithelial neoplasia grade 2 undergoing observational management were being managed in a well-monitored and an appropriately informed fashion, we conducted a large, multicenter prospective study on observational management of cervical intraepithelial neoplasia grade 2 in women under 25 years.

Objective: This study aimed to determine the regression rates and clinical, cytologic, and pathologic predictors of regression of cervical intraepithelial neoplasia grade 2 in women under 25 years undergoing observational management over 24 months.

Study Design: This study was a multicenter prospective study on observational management of cervical intraepithelial neoplasia grade 2 (ie, repeat colposcopy, cytology, and cervical biopsy every 6 months) for up to 24 months. A total of 615 consenting women under 25 years with newly-diagnosed, biopsy-proven cervical intraepithelial neoplasia grade 2 were recruited (from 2010 to 2016) through 16 hospital-based colposcopy units in New Zealand and Australia.

Results: At completion, 326 women had confirmed regression, 156 had persistent high-grade cervical intraepithelial neoplasia grade 2 or 3 or adenocarcinoma in situ, and 24 had unconfirmed regression (ie, first regression at the 24-month follow-up). A total of 109 women did not complete the protocol (41 because of delayed follow-up, 41 lost to follow-up, 22 elected treatment, 4 refused a biopsy, and 1 died of an unrelated cause). Confirmed regression was observed in 53% (326 of 615) of all women enrolled in the study and, when missing data were imputed, it was estimated that 64% of women (95% confidence interval, 60%-68%) would have experienced regression. Similarly, lesions regressed in 64% (326 of 506) of women who completed the observational protocol. Based on a multivariable analysis, detection of human papillomavirus 16 in a liquid-based cytology sample at the time of initial colposcopy decreased the chance of regression by 31% (risk ratio, 0.69; 95% confidence interval, 0.56-0.86; P<.001). In addition, at initial colposcopy, low-grade or normal colposcopic impression, later year of diagnosis, low-grade or normal cytology, and being a nonsmoker were all independently associated with an increased chance of regression.

Conclusion: More than half of women under 25 years with cervical intraepithelial neoplasia grade 2 will regress to cervical intraepithelial neoplasia grade 1 or normal within 24 months without destructive treatment. The absence of human papillomavirus 16 is the most important predictor of regression.
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http://dx.doi.org/10.1016/j.ajog.2021.09.009DOI Listing
September 2021

Protocol for a mixed-method cohort study investigating the prevalence and impact of obsessive-compulsive disorder (OCD) in chronic pain rehabilitation.

BMJ Open 2021 08 13;11(8):e052288. Epub 2021 Aug 13.

Department of Population Health, University of Otago, Christchurch, New Zealand.

Introduction: While there is considerable and growing research in the individual fields of obsessive-compulsive disorder (OCD) and chronic pain, focused research into their potential association remains limited. By exploring this potential association, better theoretical understanding of and better therapeutic approaches to chronic pain management could be developed. The study's aim is to explore the prevalence and impact of obsessions-compulsions on the experience and rehabilitation of chronic pain among individuals attending different branches of a New Zealand pain service.

Methods And Analysis: This is a cohort study using well-validated questionnaires and semistructured interviews. Participants will be recruited through community pain services from a private rehabilitation-focused company with branches across New Zealand. Participants will complete an OCD screening measure (Obsessive-Compulsive Inventory-Revised (OCI-R)). These results will be used to compare results from the specialist pain services benchmarking electronic Persistent Pain Outcomes Collaboration measure sets, at both participant intake and completion of each Pain Service Programme. Prevalence rates of OCD caseness from the OCI-R will be estimated with 95% CI. Generalised linear regression models will be used to explore differences in pain baseline and outcome factors between those with high and low obsessive-compulsive symptoms. Semistructured interviews, assessed through interpretative phenomenological analysis (IPA), will be used to provide information on lived experiences of individuals with comorbid chronic pain and OCD. This will be supported through the administration of an Obsessive Beliefs Questionnaire 44.

Ethics And Dissemination: Ethical approval has been obtained from the Health and Disability Ethics Committee (HDEC20/CEN/82). Study results will be disseminated at professional conferences and in peer-reviewed journals. A lay summary of findings will be provided to requesting participants or through attendance at a local hui (gathering).

Trial Registration Number: Australian New Zealand Clinical Trials Registry (ACTRN12621000758808).
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http://dx.doi.org/10.1136/bmjopen-2021-052288DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8365798PMC
August 2021

Protocol for a mixed-method cohort study investigating the prevalence and impact of obsessive-compulsive disorder (OCD) in chronic pain rehabilitation.

BMJ Open 2021 08 13;11(8):e052288. Epub 2021 Aug 13.

Department of Population Health, University of Otago, Christchurch, New Zealand.

Introduction: While there is considerable and growing research in the individual fields of obsessive-compulsive disorder (OCD) and chronic pain, focused research into their potential association remains limited. By exploring this potential association, better theoretical understanding of and better therapeutic approaches to chronic pain management could be developed. The study's aim is to explore the prevalence and impact of obsessions-compulsions on the experience and rehabilitation of chronic pain among individuals attending different branches of a New Zealand pain service.

Methods And Analysis: This is a cohort study using well-validated questionnaires and semistructured interviews. Participants will be recruited through community pain services from a private rehabilitation-focused company with branches across New Zealand. Participants will complete an OCD screening measure (Obsessive-Compulsive Inventory-Revised (OCI-R)). These results will be used to compare results from the specialist pain services benchmarking electronic Persistent Pain Outcomes Collaboration measure sets, at both participant intake and completion of each Pain Service Programme. Prevalence rates of OCD caseness from the OCI-R will be estimated with 95% CI. Generalised linear regression models will be used to explore differences in pain baseline and outcome factors between those with high and low obsessive-compulsive symptoms. Semistructured interviews, assessed through interpretative phenomenological analysis (IPA), will be used to provide information on lived experiences of individuals with comorbid chronic pain and OCD. This will be supported through the administration of an Obsessive Beliefs Questionnaire 44.

Ethics And Dissemination: Ethical approval has been obtained from the Health and Disability Ethics Committee (HDEC20/CEN/82). Study results will be disseminated at professional conferences and in peer-reviewed journals. A lay summary of findings will be provided to requesting participants or through attendance at a local hui (gathering).

Trial Registration Number: Australian New Zealand Clinical Trials Registry (ACTRN12621000758808).
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http://dx.doi.org/10.1136/bmjopen-2021-052288DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8365798PMC
August 2021

Challenges facing essential workers: a cross-sectional survey of the subjective mental health and well-being of New Zealand healthcare and 'other' essential workers during the COVID-19 lockdown.

BMJ Open 2021 07 19;11(7):e048107. Epub 2021 Jul 19.

Department of Psychological Medicine, University of Otago, Wellington, New Zealand.

Objectives: To compare psychological outcomes, experiences and sources of stress over the COVID-19 lockdown in New Zealand in essential workers (healthcare and 'other' essential workers) with that of workers in nonessential work roles.

Design: Online cross-sectional survey.

Setting: Conducted in New Zealand over level 4 lockdown in April/May 2020.

Participants: Findings from employed participants (2495) are included in this report; 381 healthcare workers, 649 'other' essential workers and 1465 nonessential workers.

Primary And Secondary Outcome Measures: Measures included psychological distress (Kessler Psychological Distress Scale (K10)), anxiety (Generalised Anxiety Disorder (GAD-7)), well-being (WHO-5), alcohol use, subjective experiences and sources of stress. Differences between work categories were quantified as risk ratios or χ tests.

Results: After controlling for confounders that differed between groups of essential and nonessential workers, those in healthcare and those in 'other' essential work were at 71% (95% CI 1.29 to 2.27) and 59% (95% CI 1.25 to 2.02) greater risk respectively, of moderate levels of anxiety (GAD-7 ≥10), than those in nonessential work. Those in healthcare were at 19% (95% CI 1.02 to 1.39) greater risk of poor well-being (WHO-5 <13). There was no evidence of differences across work roles in risk for psychological distress (K10 ≥12) or increased alcohol use. Healthcare and 'other' essential workers reported increased workload (p<0.001) and less uncertainty about finances and employment than those in nonessential work (p<0.001). Healthcare and nonessential workers reported decreased social contact. No difference by work category in health concerns was reported; 15% had concerns about participants' own health and 33% about other people's health.

Conclusions: During the pandemic lockdown, essential workers (those in healthcare and those providing 'other' essential work) were at increased risk of anxiety compared with those in nonessential work, with those in healthcare also being at increased risk of poor well-being. This highlights the need to recognise the challenges this vital workforce face in pandemics.
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http://dx.doi.org/10.1136/bmjopen-2020-048107DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8290948PMC
July 2021

The role of Kingella kingae in pre-school aged children with bone and joint infections.

J Infect 2021 09 12;83(3):321-331. Epub 2021 Jul 12.

Department of Paediatrics, University of Otago, Christchurch School of Medicine, New Zealand. Electronic address:

Objectives: The Pre-school Osteoarticular Infection (POI) study aimed to describe the burden of disease, epidemiology, microbiology and treatment of acute osteoarticular infections (OAI) and the role of Kingella kingae in these infections.

Methods: Information about children 3-60 months of age who were hospitalized with an OAI to 11 different hospitals across Australia and New Zealand between January 2012 and December 2016 was collected retrospectively.

Results: A total of 907 cases (73%) were included. Blood cultures grew a likely pathogen in only 18% (140/781). The peak age of presentation was 12 to 24 months (466/907, 51%) and Kingella kingae was the most frequently detected microorganism in this age group (60/466, 13%). In the majority of cases, no microorganism was detected (517/907, 57%). Addition of PCR to culture increased detection rates of K. kingae. However, PCR was performed infrequently (63/907, 7%).

Conclusions: This large multi-national study highlights the need for more widespread use of molecular diagnostic techniques for accurate microbiological diagnosis of OAI in pre-school aged children. The data from this study supports the hypothesis that a substantial proportion of pre-school aged children with OAI and no organism identified may in fact have undiagnosed K. kingae infection. Improved detection of Kingella cases is likely to reduce the average length of antimicrobial treatment.
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http://dx.doi.org/10.1016/j.jinf.2021.06.028DOI Listing
September 2021

Nortriptyline for pain in knee osteoarthritis: a double-blind randomised controlled trial in New Zealand general practice.

Br J Gen Pract 2021 07 24;71(708):e538-e546. Epub 2021 Jun 24.

Department of General Practice, University of Otago, Christchurch.

Background: Osteoarthritis (OA) of the knee is a common cause of chronic pain. Analgesics that are currently available have limited efficacy and may be poorly tolerated. Tricyclic antidepressants are used as analgesics for other chronic conditions, but they have not been evaluated as analgesics in OA.

Aim: To investigate the analgesic efficacy of nortriptyline in people with knee OA.

Design And Setting: A two-arm, parallel-group, 1:1, double-blind, randomised, placebo-controlled trial in Christchurch, New Zealand.

Method: Participants were recruited from orthopaedic outpatient clinics, primary care, and through public advertising. Adults with knee OA and a pain score of ≥20 points on the 50-point Western Ontario and McMaster University Osteoarthritis Index (WOMAC) pain subscale were randomised to receive either nortriptyline or identical placebo for 14 weeks. The primary outcome was knee pain at 14 weeks measured using the WOMAC pain subscale. Secondary outcomes included: function; stiffness; non-steroidal anti-inflammatory drug, opioid, and/or paracetamol use; each participant's global assessment; and adverse effects at 14 weeks.

Results: Of the 205 randomised participants, 201 (98.0%) completed follow-up at 14 weeks. The baseline-adjusted mean WOMAC pain subscale score at week 14 was 6.2 points lower (95% confidence interval = -0.26 to 12.6, = 0.06) in the nortriptyline arm versus the placebo arm. Differences in secondary outcomes generally favoured the nortriptyline arm, but were small and unlikely to be clinically relevant. However, the following were all more commonly reported by participants taking nortriptyline than those taking a placebo: dry mouth (86.9% versus 51.0%, respectively, <0.001), constipation (58.6% versus 30.4%, respectively, <0.001), and sweating (31.3% versus 20.6%, respectively, = 0.033).

Conclusion: This study suggests nortriptyline does not significantly reduce pain in people with knee OA. The adverse effect profile was as expected.
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http://dx.doi.org/10.3399/BJGP.2020.0797DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8177953PMC
July 2021

Pregnant women's knowledge of, and adherence to, New Zealand Food Safety in Pregnancy guidelines.

N Z Med J 2020 11 20;133(1525):41-52. Epub 2020 Nov 20.

Infectious Diseases Specialist and Consultant Paediatrician, University of Otago, Christchurch.

Aim: Pregnant women are at increased risk for contracting foodborne illness. Simple food safety precautions can prevent illness. The aim of this study was to examine pregnant women's knowledge of, and adherence to, the New Zealand Food Safety in Pregnancy guidelines.

Method: Participants were recruited when attending antenatal clinics, and via online pregnancy support groups. Knowledge and behaviours were assessed by way of a self-administered questionnaire.

Results: In total, 205 women participated in this study; 100 from antenatal clinics, 105 via Facebook. The median knowledge score was 95% (interquartile range (IQR) 83-100%, minimum = 17.4%). Only 25% of participants answered all questions correctly. The median adherence score was 77% (IQR = 62-92%, minimum = 8%); 13% of participants reported complete adherence to the food safety guidelines. Mean knowledge scores in participants of Māori ethnicity (76.6%) were lower than in participants of European/other ethnicity (91.7%, p=0.004). Māori participants had the lowest mean adherence scores (63.2%) and this requires further investigation.

Conclusions: The majority of participants reported continuing to consume foods considered unsafe in pregnancy. This study highlights the need for improved food safety education during pregnancy. The results also suggest a need for food safety guidance to be made more accessible and relevant to the needs of Māori women.
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November 2020

Pregnant women's knowledge of, and adherence to, New Zealand Food Safety in Pregnancy guidelines.

N Z Med J 2020 11 20;133(1525):41-52. Epub 2020 Nov 20.

Infectious Diseases Specialist and Consultant Paediatrician, University of Otago, Christchurch.

Aim: Pregnant women are at increased risk for contracting foodborne illness. Simple food safety precautions can prevent illness. The aim of this study was to examine pregnant women's knowledge of, and adherence to, the New Zealand Food Safety in Pregnancy guidelines.

Method: Participants were recruited when attending antenatal clinics, and via online pregnancy support groups. Knowledge and behaviours were assessed by way of a self-administered questionnaire.

Results: In total, 205 women participated in this study; 100 from antenatal clinics, 105 via Facebook. The median knowledge score was 95% (interquartile range (IQR) 83-100%, minimum = 17.4%). Only 25% of participants answered all questions correctly. The median adherence score was 77% (IQR = 62-92%, minimum = 8%); 13% of participants reported complete adherence to the food safety guidelines. Mean knowledge scores in participants of Māori ethnicity (76.6%) were lower than in participants of European/other ethnicity (91.7%, p=0.004). Māori participants had the lowest mean adherence scores (63.2%) and this requires further investigation.

Conclusions: The majority of participants reported continuing to consume foods considered unsafe in pregnancy. This study highlights the need for improved food safety education during pregnancy. The results also suggest a need for food safety guidance to be made more accessible and relevant to the needs of Māori women.
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November 2020

Enhancement of Culture of Legionella longbeachae from Respiratory Samples by Use of Immunomagnetic Separation and Antimicrobial Decontamination.

J Clin Microbiol 2020 10 21;58(11). Epub 2020 Oct 21.

Department of Pathology and Biomedical Science, University of Otago, Christchurch, New Zealand.

is the commonest species identified in patients with community-acquired pneumonia in New Zealand. Isolation of the organism on culture is the gold standard for the diagnosis of Legionnaires disease, but it has poor sensitivity (40%) compared with quantitative PCR (qPCR). We have developed a selective decontamination process using glycine, vancomycin, polymyxin, and cycloheximide (GVPC) with immunomagnetic separation (IMS) for culturing A polyclonal antibody specific for was produced from New Zealand White rabbits and coupled to tosyl-activated magnetic beads. Stored qPCR-positive respiratory samples were retrieved from -80°C storage for testing. One portion of test samples was mixed with GVPC and the antibody bead complex, separated, washed, and cultured on modified Wadowsky and Yee agar (MWY) agar. Another portion was exposed to HCl-KCl acidic buffer (pH 2.2) before incubation on MWY agar. qPCR used probes specific for the ITS (internal transcribed spacer) region of the genome. Cultures were positive in 10/53 (19%) samples after acid wash and 26/53 (49%) after GVPC-IMS ( = 0.001). Growth of contaminants was rare. The mean qPCR threshold cycle values were lower in culture-positive samples after acid wash than in the culture-negative samples (mean, 29.9 versus 34.8; difference, 4.9; 95% confidence interval [CI], ±2.9; = 0.001) but not after GVPC-IMS (mean, 33.0 versus 34.7; difference, 1.7; 95% CI, ±2.48;  = 0.16). The sensitivity of culture for in respiratory specimens may be improved by using GVPC-IMS rather than acid wash for decontamination, but this should be confirmed in a prospective study of fresh specimens.
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http://dx.doi.org/10.1128/JCM.01218-20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7587110PMC
October 2020

Kids in a Candy Store: An Objective Analysis of Children's Interactions with Food in Convenience Stores.

Nutrients 2020 Jul 18;12(7). Epub 2020 Jul 18.

Health Promotion and Policy Research Unit, Department of Public Health, University of Otago, Wellington 6242, New Zealand.

Increasing rates of childhood obesity worldwide has focused attention on the obesogenic food environment. This paper reports an analysis of children's interactions with food in convenience stores. Kids'Cam was a cross-sectional study conducted from July 2014 to June 2015 in New Zealand in which 168 randomly selected children aged 11-14 years old wore a wearable camera for a 4-day period. In this ancillary study, images from children who visited a convenience store were manually coded for food and drink availability. Twenty-two percent of children ( = 37) visited convenience stores on 62 occasions during the 4-day data collection period. Noncore items dominated the food and drinks available to children at a rate of 8.3 to 1 (means were 300 noncore and 36 core, respectively). The food and drinks marketed in-store were overwhelmingly noncore and promoted using accessible placement, price offers, product packaging, and signage. Most of the 70 items purchased by children were noncore foods or drinks (94.6%), and all of the purchased food or drink subsequently consumed was noncore. This research highlights convenience stores as a key source of unhealthy food and drink for children, and policies are needed to reduce the role of convenience stores in the obesogenic food environment.
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http://dx.doi.org/10.3390/nu12072143DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7400802PMC
July 2020

Participation-focused practices in paediatric rehabilitation for children with neurodisability in New Zealand: An observational study using MAPi audit tool.

Child Care Health Dev 2020 09 23;46(5):552-562. Epub 2020 Jun 23.

University of Otago, Wellington, New Zealand.

Background: Participation outcomes and family-centred services are now widely agreed standards of care in paediatric rehabilitation. Evidence suggests that adoption of these practices into usual care has been slow internationally, and no studies of participation-focused or family-centred practices in New Zealand have been undertaken to date. The aims of this study were to identify the extent that goal setting in paediatric rehabilitation services is participation focused and family centred and to profile clinicians' beliefs about these foci.

Methods: Observational study including a retrospective case note audit and questionnaire. Case notes ('charts') were audited for participation-focused goal-related practice. Subgroup analysis of audit data by service, profession and child ethnicity were completed using weighted mean differences. Clinicians whose case notes were audited completed a 42-item questionnaire on factors related to practice behaviour including text responses with each item. Numerical and text data were analysed descriptively.

Results: Five services were recruited (N = 46 clinicians) with case notes for 220 children audited. Auditors extracted 368 potentially participation-related goals (Mdn = 2 goals per child) with no goals extracted for 43 (20%) of case notes. Subsequent coding of extracted goals identified 61% reflected participation (225/368). Subgroup analysis revealed significant differences between services (p = 0.006) and professions (p < 0.001). Clinicians' reported valuing participation outcomes and family involvement and largely felt they did target participation. Skill gaps, absence of self-monitoring strategies and unsupportive professional and work cultures were cited as key challenges.

Conclusions: Although valued by clinicians, participation-focused practice is unusual care in paediatric rehabilitation in New Zealand. Substantial gains in the quality of care for children with disabilities could be afforded through training in collaborative goal setting to target participation outcomes.
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http://dx.doi.org/10.1111/cch.12789DOI Listing
September 2020

Surveillance of Leprosy in Kiribati, 1935-2017.

Emerg Infect Dis 2020 05;26(5):833-840

In Kiribati, unlike most countries, high and increasing numbers of cases of leprosy have been reported despite the availability of multidrug therapy and efforts to improve case finding and management. Historic records show that 28 cases had been identified by 1925. A systematic population survey in 1997 identified 135 new cases; the mean incidence rate for 1993-1997 was 7.4/10,000 population. After administering mass chemoprophylaxis, the country reached the elimination threshold (prevalence <1/10,000), but case numbers have rebounded. The mean annualized rate of new cases in 2013-2017 was 15/10,000 population, with the highest new case rates (>20/10,000 population) in the main population centers of South Tarawa and Betio. Spread is expected to continue in areas where crowding and poor socioeconomic conditions persist and may accelerate as sea levels rise from climate change. New initiatives to improve social conditions are needed, and efforts such as postexposure chemoprophylaxis should be implemented to prevent spread.
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http://dx.doi.org/10.3201/eid2605.181746DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7181941PMC
May 2020

Evaluation of guidelines for observational management of cervical intraepithelial neoplasia 2 in young women.

Am J Obstet Gynecol 2020 09 25;223(3):408.e1-408.e11. Epub 2020 Feb 25.

Department of Obstetrics and Gynaecology, University of Otago, Christchurch, New Zealand; Christchurch Women's Hospital, Christchurch, New Zealand. Electronic address:

Background: A high rate of regression in young women with cervical intraepithelial neoplasia grade 2 has been recorded. However, there are few prospective data by which to evaluate management guidelines.

Objective: This study evaluates the American Society for Colposcopy and Cervical Pathology recommendations for follow-up of young women with cervical intraepithelial neoplasia 2 using data created by a large prospective multicenter study of observational management.

Materials And Methods: Participants were 616 women under 25 years with biopsy-diagnosed cervical intraepithelial neoplasia 2 following a referral to colposcopy for an abnormal smear with no previous high-grade abnormality. The protocol included colposcopy, cytology, and colposcopically directed biopsy at the initial visit and at 6- and 12-month follow-ups visits, and these data were analyzed. Histology from the corresponding cervical biopsy was treated as the reference diagnostic test. For young women with cervical intraepithelial neoplasia 2, we aimed to determine the following: (1) the ability of colposcopy to identify women with cervical intraepithelial neoplasia 3 or worse at 6 months; and (2) the ability of colposcopy, cytology, and a combination of cytology and colposcopy to identify residual high-grade abnormalities at 12 months. In addition, although not specified in the guidelines, we investigated the ability of high-risk human papillomavirus positivity alone or with cytology as a co-test to identify residual high-grade abnormalities at 12 months.

Results: At 6 months, cervical intraepithelial neoplasia 3+ colposcopic appearance identified only 28% (95% confidence interval, 18-40%) of women diagnosed with cervical intraepithelial neoplasia 3. At 12 months, a high-grade colposcopic appearance identified only 58% (95% confidence interval, 48-68%) of women with residual histological cervical intraepithelial neoplasia 2 or 3. At 12 months, high-grade cytology identified only 58% (95% confidence interval, 48-68%) of women with cervical intraepithelial neoplasia 2 or 3. However, the combination of either high-grade cytology or colposcopic appearance proved substantially more sensitive (81%; 95% confidence interval, 72-88%). High-risk human papillomavirus positivity at 12 months was a sensitive (96%; 95% confidence interval, 89-99%) indicator of persisting high-grade histology. However, this sensitivity came at the expense of specificity (52%; 95% confidence interval, 45-58%). A co-test of high-risk human papillomavirus positivity or high-grade cytology at 12 months provided a high sensitivity (97%; 95% confidence interval, 90-99%) but low specificity (51%; 95% confidence interval, 45%-58%).

Conclusion: Colposcopy and cytology are limited in their ability to exclude persistent high-grade abnormality for young women undergoing observational management for cervical intraepithelial neoplasia 2. We recommend biopsy for all women at 12 months. High-risk human papillomavirus positivity is a sensitive indicator of persistent abnormality and should be considered in those not having a biopsy.
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http://dx.doi.org/10.1016/j.ajog.2020.02.029DOI Listing
September 2020

The epidemiology of listeriosis in pregnant women and children in New Zealand from 1997 to 2016: an observational study.

BMC Public Health 2020 Jan 28;20(1):116. Epub 2020 Jan 28.

Department of Paediatrics, University of Otago, PO Box 4345, Christchurch Mail Centre, Christchurch, 8140, New Zealand.

Background: Listeria monocytogenes causes the foodborne infection listeriosis. Pregnant women, infants and immunocompromised children are at increased risk for infection. The aim of this study was to describe the trends in the epidemiology of disease notifications and hospital admissions due to listeriosis in pregnant women aged 15 to 45 years and children aged less than 15 years in New Zealand (NZ) from 1997 to 2016.

Methods: In this population-based descriptive study, listeriosis notification and hospitalization rates from 1997 to 2016 were analyzed. Notification data were extracted from the Institute of Environmental Science and Research (ESR) Notifiable Diseases Database (EpiSurv) and hospitalization data were extracted from the National Minimum Dataset (NMDS). Pregnant women aged 15 to 45 years and children less than 15 years of age were included. Subgroup analysis was conducted for age and ethnicity. Outcomes of infection were described.

Results: In the 20-year period considered, there were 147 pregnancy-associated cases of listeriosis either notified to ESR (n = 106) and/or coded in the NMDS (n = 99), giving a crude incidence rate of 12.3 (95% CI 10.4, 14.4) per 100,000 births. In addition, there were 22 cases in children aged 28 days to < 15 years (incidence =0.12, 95% CI 0.08 to 0.19 per 100,000). There were no trends observed over time in the incidence of pregnancy-associated listeriosis. Incidence rates of pregnancy-associated and childhood listeriosis were highest in people of Pacific and Asian ethnicity.

Conclusions: NZ has a low incidence of listeriosis in pregnant women and children, however, the consequences of infection are frequently severe. Those of Pacific and Asian ethnicity have the highest rates of disease and future messaging around food safety should target these groups. This study provides important insights into the epidemiology of listeriosis in pregnant women and children in NZ.
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http://dx.doi.org/10.1186/s12889-020-8221-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6988350PMC
January 2020

Impact of human papillomavirus vaccination on rates of abnormal cervical cytology and histology in young New Zealand women.

N Z Med J 2020 01 17;133(1508):72-84. Epub 2020 Jan 17.

Department of Obstetrics and Gynaecology, University of Otago, Christchurch; Christchurch Women's Hospital, Christchurch.

Aim: Determine the impact of quadrivalent human papillomavirus (HPV) vaccination on abnormal cervical cytology and histology rates in young New Zealand women.

Methods: Retrospective population-based cohort study of women born 1990-1994, with a cervical cytology or histology recorded when aged 20-24 between 1 January 2010 and 31 December 2015. Data was obtained through linking the National Immunisation Register and National Cervical Screening Programme Register.

Results: N=104,313 women (376,402 person years of follow up) were included. The incidence of high-grade cytology was lower in vaccinated women (at least one dose prior to 18 years) than in unvaccinated women (8.5 vs 11.3 per 1,000 person years [p1000py], incidence rate ratio [IRR 0.75], 95% CI 0.70, 0.80, p<.001). The incidence of high-grade histology was lower in vaccinated women than in unvaccinated women (6.0 vs 8.7 p1000py, IRR 0.69, 95% CI 0.64, 0.75, p<.001). There was no evidence of a difference in the incidence of high-grade histology between European and Māori women overall or after taking vaccination status into account.

Conclusions: Receiving at least one dose of quadrivalent HPV vaccine prior to 18 years was associated with a 25% lower incidence of high-grade cytology and 31% lower incidence of high-grade histology in women aged 20-24 years.
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January 2020

Why Women Might Choose a Career in Pediatric Surgery and Ensuring There Are No Impediments to Selecting the Best.

Eur J Pediatr Surg 2021 Apr 1;31(2):135-139. Epub 2020 Jan 1.

Department of Population Health, University of Otago, Christchurch, New Zealand.

Introduction:  Although pediatric surgery in Australasia has a higher proportion of women than any other surgical specialty, women remain underrepresented. There is concern that residual impediments may still deter women from choosing this specialty as a career option.

Materials And Methods:  A survey of years 2 to 6 medical students, with focused analysis on those who selected pediatric surgery as their most (or least) attractive surgical specialty and the characteristics they deemed important when considering a surgical career.

Results:  The survey was completed by 357 students of whom 50 selected pediatric surgery as their most attractive surgical specialty and 12 as their least attractive surgical specialty, at equal gender rates. The specialty was not perceived as being prestigious, well paid, or one that emphasized technical skill but was perceived as having good work-life balance, when compared with the other surgical specialties. Those who selected pediatric surgery as their most attractive specialty were otherwise less likely to choose a career in surgery.

Conclusion:  Pediatric surgery is perceived as being less aligned to characteristics stereotypically associated with males and more with those characteristics associated with females. Overall, it seems to be more female friendly than other surgical specialties. It would behove the pediatric surgical community to better understand how it is perceived, so that perceptions can be aligned to reality and gender diversity can be increased.
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http://dx.doi.org/10.1055/s-0039-3402711DOI Listing
April 2021

'E' therapy in the community: Examination of the uptake and effectiveness of BRAVE (a self-help computer programme for anxiety in children and adolescents) in primary care.

Internet Interv 2019 Dec 3;18:100249. Epub 2019 May 3.

Department of Psychological Medicine, University of Auckland, New Zealand.

Objective: Recognizing and treating anxiety early is an important public mental health objective. There is clinical trial evidence that 'e' therapies are appealing, engaging and effective and have the potential to improve access to treatment. However, their implementation and effectiveness in real world settings is still emerging. Following a major natural disaster in NZ, an online therapist assisted CBT programme for children with anxiety, (BRAVE_TA) was made available in primary care.

Methods: Uptake and feasibility of BRAVE_TA delivery was assessed by examining referral patterns, non-engagement rates and programme progression within a geographic region of NZ (Canterbury population of around 500,000). Effectiveness of BRAVE_TA was measured by the extent of change in the primary outcome measure of anxiety, the CAS8, between baseline and last completed session.

Results: There were 1361 referrals to BRAVE_TA over 2014-2018, mostly from primary care doctors and nurses in primary schools. After attrition due to triage and family withdrawal, 75% (N = 1026) were enrolled. Around half of children/adolescents completed 4 sessions with moderate effect sizes achieved Children/adolescents who completed more sessions, had lower anxiety after their last session, with most of the improvement occurring within the first three to four sessions.

Conclusion: BRAVE_TA has shown to be an acceptable and effective 'e' therapy tool in a 'real world' primary care setting for children/adolescents with anxiety. This study supports the role of 'e' therapy as part of a stepped-care model within primary care in improving access to treatment and thus improving public mental health in children.: ACTRN12612000063819.
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http://dx.doi.org/10.1016/j.invent.2019.100249DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6926167PMC
December 2019

Epidemiology of Campylobacter Gastroenteritis in New Zealand Children and the Effect of The Campylobacter Strategy: A 20-year Observational Study.

Pediatr Infect Dis J 2019 06;38(6):569-576

From the Department of Pediatrics.

Background: Campylobacter species are a common cause of gastroenteritis in New Zealand (NZ) as well as worldwide. This study aimed to describe epidemiologic trends in disease notifications and hospital admissions because of Campylobacter gastroenteritis in NZ children from 1997 to 2016.

Methods: In this population-based descriptive study, age-specific and age-standardized notification and hospitalization rates were analyzed for Campylobacter infections in children <15 years of age. Variations in disease by time, sex, age, ethnicity and geography were described.

Results: During the 20-year period considered, there were 39,970 notifications (59.1% male) and 1458 hospitalizations (61.8% male) because of Campylobacter gastroenteritis in NZ children. Before 2006, notification rates increased by 3.4% annually [95% confidence interval (CI): 0.7%-6.2%], with a peak of 340 notifications per 100,000 children in 2003. The average percentage change (APC) in hospitalizations was 7.4% (95% CI: 4.0%-10.9%) in the same period. From 2006 to 2008, notification and hospitalization rates fell by 25% and 30%, respectively. Since 2008, age-standardized incidence rates have been stable at 161 notifications (APC: -3.1; 95% CI: 0.82 to -6.9) and 6.73 hospitalizations (APC: 2.2; 95% CI: -2.0 to 6.5) per 100,000 children per year. Notification rates were highest in children 1-4 years of age. Hospitalizations rates were highest in children <1 year of age.

Conclusions: NZ has previously had high rates of Campylobacter gastroenteritis in children. Implementation of a national strategy to reduce foodborne Campylobacter infection appears to have contributed to an observed reduction in rates between 2006 and 2008. The burden of Campylobacter disease is highest in the community health setting, with only a small proportion of cases needing hospitalization.
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http://dx.doi.org/10.1097/INF.0000000000002228DOI Listing
June 2019

Comparative risk of new-onset diabetes following commencement of antipsychotics in New Zealand: a population-based clustered multiple baseline time series design.

BMJ Open 2019 02 21;9(2):e022984. Epub 2019 Feb 21.

Pegasus Health (Charitable), Christchurch, New Zealand.

Objective: Newer antipsychotics are increasingly prescribed off-label for non-psychotic ailments both in primary and secondary care settings, despite the purported risk of weight gain and development of type 2 diabetes mellitus. This study aims to determine any relationship between the development of clinically significant new-onset type 2 diabetes mellitus and novel antipsychotic use in New Zealand using hypnotic drugs as control.

Design: A population-based clustered multiple baseline time series design.

Setting: Routinely collected data from a complete national pharmaceutical database in New Zealand between 2005 and 2011.

Participants: Patients aged 40-60 years in the year 2006 who were ever dispensed antipsychotics (exposure groups-first-generation antipsychotics, second-generation antipsychotics and antipsychotics with low, medium and high risk for weight gain) or hypnotics (control group) between 2006 and 2011.

Main Outcome Measure: First ever metformin dispensed to patients in each study group between 2006 and 2011 as proxy for development of clinically significant type 2 diabetes mellitus, no longer amendable by lifestyle modifications.

Results: Patients dispensed a second-generation antipsychotic had 1.49 times increased risk (95% CI 1.10 to 2.03, p=0.011) of subsequently commencing metformin. Patients dispensed an antipsychotic with high risk of weight gain also had a 2.41 times increased risk of commencing on metformin (95% CI 1.42 to 4.09, p=0.001).

Conclusions: Patients dispensed a second-generation antipsychotic and antipsychotics with high risk of weight gain appear to be at increased risk of being secondarily dispensed metformin. Caution should be taken with novel antipsychotic use for patients with increased baseline risk of type 2 diabetes mellitus.
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http://dx.doi.org/10.1136/bmjopen-2018-022984DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6398760PMC
February 2019

The epidemiology of non-viral gastroenteritis in New Zealand children from 1997 to 2015: an observational study.

BMC Public Health 2019 Jan 5;19(1):18. Epub 2019 Jan 5.

Department of Paediatrics, University of Otago, PO Box 4345, Christchurch Mail Centre, Christchurch, 8140, New Zealand.

Background: Acute gastroenteritis is a substantial cause of hospitalization in children. Shigella, Salmonella, Campylobacter, Yersinia, enterotoxigenic Escherichia coli (ETEC), Giardia and Cryptosporidium are gastrointestinal pathogens that are notifiable in New Zealand (NZ). The impact of these infections in the pediatric population has not yet been analyzed. The aim of this study was to describe the epidemiological trends in disease notifications and hospital admissions due to non-viral gastroenteritis in NZ children.

Methods: In this population-based descriptive study, age-specific and age-standardized notification and hospital admission rates were analyzed from 1997-to-2015 for Shigella, Salmonella, Campylobacter, Yersinia, ETEC, Giardia and Cryptosporidium infections in children < 15 years of age. Variations in disease by gender, age, ethnicity and geography were described.

Results: From 1997-to-2015 there were 74,454 notifications (57.6% male) and 3192 hospitalizations (56.4% male) due to non-viral gastroenteritis in NZ children aged < 15 years. There was an overall trend towards a reduction in disease notifications and hospitalizations, however each disease showed a unique pattern of change over time. Campylobacter was the pathogen most frequently notified, accounting for 51.7% of notifications and 43.4% of hospitalizations. The hospitalization-to-notification ratios were, from highest to lowest, Salmonella typhi (1:1.09), Shigella (1:4.0), ETEC (1:7.81), nontyphoidal Salmonella (1:13.1), Campylobacter (1:27.8), Yersinia (1:29.2), Cryptosporidium (1,33.4), and Giardia (1,72.5). Compared to females, male notification rates were approximately 40% higher for Campylobacter, 25% higher for Giardia and Yersinia, and 15% higher for Cryptosporidium and nontyphoidal Salmonella (p < 0.001). Notification rates were highest in children 1-4 years, with the exceptions of nontyphoidal Salmonella, Salmonella typhi and Yersinia. Notification rates for nontyphoidal Salmonella and Yersinia were highest in children < 1 year, and for Salmonella typhi those aged 5-9 years. Children < 1 year were most likely to be hospitalized.

Conclusions: The incidence of non-viral gastroenteritis in NZ children reduced during the 19-year period considered. The burden of disease was highest in the community, with only a small percentage of cases requiring hospitalization. This study provides important insight into the non-viral causes of gastroenteritis in NZ children and how environmental influences and changes in food safety practices may have helped to reduce the burden of these diseases in children.
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http://dx.doi.org/10.1186/s12889-018-6229-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6321731PMC
January 2019

Changes in human papillomavirus genotypes associated with cervical intraepithelial neoplasia grade 2 lesions in a cohort of young women (2013-2016).

Papillomavirus Res 2018 12 1;6:77-82. Epub 2018 Nov 1.

Department of Obstetrics and Gynaecology, University of Otago, Christchurch, New Zealand; Christchurch Women's Hospital, Christchurch, New Zealand.

In 2008, a quadrivalent human papillomavirus (HPV) vaccine (genotypes 6, 11, 16, 18) became available in New Zealand. This study investigated whether the proportion of cervical intraepithelial neoplasia grade 2 (CIN2) lesions associated with HPV genotypes 16 and 18 changed over time in young women recruited to a prospective CIN2 observational management trial (PRINCess) between 2013 and 2016. Partial HPV genotyping (16, 18, or other high risk HPV) was undertaken on n = 392 women under 25 years (mean age 21.8, range 17-24) with biopsy-diagnosed CIN2. High risk HPV genotypes were detected in 96% of women with CIN2 lesions. Between 2013 and 2016, the proportion of women whose liquid-based cytology samples were HPV 16 or 18 positive decreased from 43% to 13%. HPV vaccination status was known for 78% of women. Between 2013 and 2016, the proportion of HPV 16/18 positivity did not significantly change in HPV-vaccinated women, but decreased from 66% to 17% in unvaccinated women. The reducing proportion of HPV 16/18-related CIN2 in our cohort of young New Zealand women may be attributable to the introduction of a national HPV vaccination program. The substantial decrease in HPV 16/18 positivity observed in unvaccinated women is likely to be due to a herd effect.
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http://dx.doi.org/10.1016/j.pvr.2018.10.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6260284PMC
December 2018

Vaccine Impact on Long-term Trends in Invasive Bacterial Disease in New Zealand Children.

Pediatr Infect Dis J 2018 10;37(10):1041-1047

Department of Population Health, University of Otago, Christchurch, New Zealand.

Background: Vaccines against Haemophilus influenzae type B (Hib), Neisseria meningitidis and Streptococcus pneumoniae have been serially introduced into the New Zealand national immunization schedule since the 1990s. This study aimed to describe long-term trends in the rates of these invasive bacterial infections in children from New Zealand and compare these to recent UK data.

Methods: This population-based observational study used 2 national datasets that collect data about hospital discharges (National Minimum Dataset) and notifiable diseases (Epurv). Annual age-specific and age-standardized hospital admission rates and notification rates were analyzed for all children <15 years of age.

Results: Hospital admissions for Hib reduced by 79% during the 2 years after the introduction of the Hib vaccine (5.94-1.24/100,000). Meningococcal disease notifications fell by 75% over 8 years after the introduction of MeNZB vaccine (26.15-2.48/100,000) and have continued to decline. Meningococcal disease rates were lower than in the United Kingdom despite the absence of an ongoing meningococcal vaccination program in New Zealand (8.16 compared with 10.37/100,000 for 2007-2011). There rates of notifications and hospital admissions for pneumococcal disease were discordant, but both reduced substantially after the introduction of pneumococcal conjugate vaccines. Maori children had the highest rates of disease and the greatest reduction in rates after the introduction of both meningococcal and pneumococcal vaccines.

Conclusions: Vaccines have had a substantial impact on the rates of invasive bacterial disease in children from New Zealand because of Hib, pneumococcus and meningococcus. Reductions in rates of disease have been greatest in Maori children, improving longstanding disparities in disease burden.
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http://dx.doi.org/10.1097/INF.0000000000002071DOI Listing
October 2018

A proposed clinical conceptual model for the physiotherapy management of Complex Regional Pain Syndrome (CRPS).

Musculoskelet Sci Pract 2018 12 5;38:15-22. Epub 2018 Sep 5.

Department of Psychological Medicine, University of Otago, Christchurch, Corner of Riccarton and Hagley Avenues, Christchurch 8042, New Zealand. Electronic address:

There are no validated clinical models to show a reliable pathway of guaranteeing an effective recovery for Complex Regional Pain Syndrome (CRPS) with physiotherapy management. An array of medical, psychological and physiotherapy intervention methods show weak benefit. Spearman correlations, with significance p < 0.05, from an observational, prospective, longitudinal, multi-centre study of regional standard physiotherapy CRPS management showed complete recovery to be potentially associated with baseline factors of: better mental health; better functional ability and quality of life; higher scores of extraversion personality trait; lower scores of intraversion personality trait; and interventions such as concurrent prescription of the anticonvulsant secondary analgesia group and a higher intensity of physiotherapy education intervention. These correlations were integrated with the literature evidence and the crux of previously suggested models to conceptualise a clinical model that can contribute to the broader knowledge of physiotherapy management in CRPS that should be tested with future research.
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http://dx.doi.org/10.1016/j.msksp.2018.08.001DOI Listing
December 2018

Development and Validation of a Predictive Model to Aid in the Management of Intact Abdominal Aortic Aneurysms.

Eur J Vasc Endovasc Surg 2018 07 9;56(1):48-56. Epub 2018 Apr 9.

Department of Surgery, University of Otago, Christchurch, New Zealand.

Objective/background: Predicting outcomes prior to elective abdominal aortic aneurysm repair (AAA) requires critical decision making, as the treatment offered is a prophylactic procedure to prevent death from a ruptured AAA. The aim of this work was to develop and validate a model that may predict outcomes for patients with an AAA and hence aid in clinical decision making.

Methods: A discrete event simulation model was built to simulate the natural history of a patient with an AAA and to predict the 30 day and 2-5 year survival of patients undergoing treatment and surveillance. The input parameters of AAA behavior and impact of comorbidities on survival were derived from the published literature and the New Zealand national life tables. The model was externally validated using a cohort of patients that underwent AAA repair (n = 320) and a cohort of patients undergoing small AAA surveillance (n = 376). All patients had completed at least 5 years of follow up.

Results: The model was run three times for each data set to test. This produced a SD < 1%, indicating excellent reproducibility. The observed 30 day mortality for the patients undergoing AAA repair was 9/320 (2.8%) and the expected (model predicted) mortality was 3.8% (c-statistic 0.87 [95 confidence interval 0.75-1.0]). The c-statistic for the predicted 2-5 year survival ranged from 0.68 to 0.71 for the repaired AAA cohort and 0.69 to 0.73 for patients with a small AAA on surveillance.

Conclusion: The AAA clinical decision tool has the ability to accurately predict the 5 year survival of patients with an AAA. This tool can be used during clinical decision making to better inform clinicians and patients of long-term outcomes. Further validation studies in a wider AAA population are required to test the broader clinical utility of this AAA clinical decision tool.
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http://dx.doi.org/10.1016/j.ejvs.2018.03.013DOI Listing
July 2018

The prevalence of comorbid alcohol use disorder in the presence of personality disorder: Systematic review and explanatory modelling.

Personal Ment Health 2018 08 2;12(3):216-228. Epub 2018 Apr 2.

Department of Psychological Medicine, University of Otago, Wellington, New Zealand.

Comorbid personality disorder (PD) worsens outcome in mental state disorders; however, the proportion of people with PD who have an alcohol use disorder (AUD) is poorly described. A systematic review of the literature for studies reporting on AUD in those with PD was completed. Lifetime prevalence figures were meta-analysed using multilevel models, accounting for type of PD and population examined. Sixteen unique studies contributed data to the analysis. PD type accounted for most of the heterogeneity in lifetime AUD prevalence. People with antisocial PD had the highest lifetime AUD prevalence, at 76.7%, followed by those with borderline PD at 52.2%, while those with other forms of PD, or undifferentiated PD, had a prevalence of 38.9%. Lifetime AUD prevalence was not significantly higher in clinical compared with population samples. The majority of people with PD experience an AUD at some time in the life course. This has clinical screening and management implications. Copyright © 2018 John Wiley & Sons, Ltd.
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http://dx.doi.org/10.1002/pmh.1415DOI Listing
August 2018

A review of cervical cancer occurrences in New Zealand 2008-2012.

N Z Med J 2018 03 23;131(1472):53-63. Epub 2018 Mar 23.

University of Otago, Christchurch; Canterbury District Health Board, Christchurch.

Background: A review of the screening histories of women/wahine diagnosed with cervical cancer was undertaken to assess where the screening pathway can be improved.

Methods: Women diagnosed with confirmed or possible cervical cancer during 1 January 2008-31 December 2012 were identified from the National Cancer Registry (NCR) records. Screening histories for these women were obtained from the National Cervical Screening Programme (NCSP) Register along with pathology and cytology reports and staging information. Women aged 25-69 years with confirmed cervical cancer underwent a review of their screening history. Cervical cancer incidence rates were calculated using Statistics New Zealand mid-year population estimates.

Results: Seven hundred and seventy-two confirmed diagnoses of cervical cancer were made during 2008-2012 for an incidence rate of 6.9 per 100,000 women per year. Only 13% of 644 women aged 25-69 years had regular cervical cancer screening according to New Zealand guidelines and this proportion was lower among Māori and Pacific people and those living in deprived areas. However, 37% of women had had a screen in the preceding three-year screening interval, excluding screens undertaken within six months of histological diagnosis. In addition, a significant number developed cancer following an abnormal screen.

Conclusion: Ongoing efforts are required to improve uptake of regular cervical screening particularly for Māori and socio-economically disadvantaged women/wahine. Further investigation of incident cervical cancers using population-linked data, slide reviews of screens reported as negative and more clinical information is needed to facilitate clinical pathway review to determine the contributing factors that lead to the development of cervical cancer following normal and abnormal screening tests.
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March 2018

Prediabetes in pregnancy, can early intervention improve outcomes? A feasibility study for a parallel randomised clinical trial.

BMJ Open 2018 03 3;8(3):e018493. Epub 2018 Mar 3.

Biostatistics and Computational Biology Unit, University of Otago, Christchurch, New Zealand.

Objective: Measurement of glycated haemoglobin (HbA1c) in early pregnancy is routine in New Zealand to identify women with diabetes and prediabetes. However, the benefit of early intervention in women with prediabetes is inconclusive. Our aim was to test the feasibility of a two-arm parallel randomised controlled trial of standard care versus early intervention in pregnancies complicated by prediabetes.

Setting: Two tertiary referral centres in New Zealand.

Participants: Women <14 weeks' gestation and HbA1c ≥5.9%-6.4% (41-46 mmol/mol) measured at booking, without pre-existing diabetes.

Interventions: Randomisation was done by remote web-based allocation into one of two groups. Women in the early intervention group attended an antenatal diabetes clinic, commenced daily home blood glucose monitoring, and medication was prescribed if lifestyle measures failed to maintain target blood glucose levels. Controls received lifestyle education, continued standard care with their midwife and/or obstetrician, and were asked to perform a 75 g oral glucose tolerance test at 24 weeks' gestation with a referral to clinic if this test was positive. Both groups received lifestyle questionnaires at recruitment and in late pregnancy.

Outcome Measures: Recruitment rate, adherence to protocol and validation of potential primary outcomes.

Results: Recruitment rates were lower than expected, especially in Māori and Pacific women. Non-adherence to allocated treatment protocol was significant, 42% (95% CI 24% to 61%) in the early intervention group and 30% (95% CI 16% to 51%) in controls. Caesarean section and pre-eclampsia were signalled as potential primary outcomes, due to both the high observed incidence in the control group and ease of measurement.

Conclusions: For a future definitive trial, extending the gestation of eligibility and stepped-wedge cluster randomisation may overcome the identified feasibility issues. Consistent with published observational data, pre-eclampsia and emergency caesarean section could be included as primary outcome measures, both of which have a significant impact on maternal and neonatal morbidity and healthcare costs.

Trial Registration Number: ACTRN12615000904572; Pre-results.
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http://dx.doi.org/10.1136/bmjopen-2017-018493DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5855392PMC
March 2018

Inequity in dialysis related practices and outcomes in Aotearoa/New Zealand: a Kaupapa Māori analysis.

Int J Equity Health 2018 02 20;17(1):27. Epub 2018 Feb 20.

Māori and Indigenous Health Institute, University of Otago Christchurch, 2 Riccarton Ave, Christchurch, 8140, New Zealand.

Background: In Aotearoa/New Zealand, Māori, as the indigenous people, experience chronic kidney disease at three times the rate of non-Māori, non-Pacific New Zealanders. Māori commence dialysis treatment for end-stage kidney disease at three times the rate of New Zealand European adults. To examine for evidence of inequity in dialysis-related incidence, treatment practices, and survival according to indigeneity in Aotearoa/New Zealand, utilising a Kaupapa Māori approach.

Methods: We conducted a retrospective cohort study involving adults who commenced treatment for end-stage kidney disease in Aotearoa/New Zealand between 2002 and 2011. We extracted data from the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA) linked to the New Zealand National Health Index (NHI). Propensity score methods were used to assemble a cohort of 1039 Māori patients matched 1:1 on clinical and socio-demographic characteristics with a cohort of 1026 non-Māori patients. We compared incidence of end-stage kidney disease and treatment practices. Differences in the risks of all-cause mortality during treatment between propensity-matched cohorts were estimated using Cox proportional hazards and generalised linear models.

Results: Non-Māori patients were older, more frequently lived in urban areas (83% versus 67% [standardised difference 0.38]) and bore less socioeconomic deprivation (36% living in highest decile areas versus 14% [0.53]). Fewer non-Māori patients had diabetes (35% versus 69%, [- 0.72]) as a cause of kidney failure. Non-Māori patients were more frequently treated with peritoneal dialysis (34% versus 29% [0.11]), received a pre-emptive kidney transplant (4% vs 1% [0.19]), and were referred to specialist care < 3 months before treatment (25% vs 19% [0.15]) than Māori patients. Fewer non-Māori started dialysis with a non-tunnelled dialysis vascular catheter (43% versus 47% [- 0.08]). The indigenous-age standardised incidence rate ratio for non-Māori commencing renal replacement therapy in 2011 was 0.50 (95% CI, 0.40-0.61) compared with Māori. Propensity score matching generated cohorts with similar characteristics, although non-Māori less frequently started dialysis with a non-tunnelled venous catheter (30% versus 47% [- 0.35]) or lived remotely (3% versus 14% [- 0.50]). In matched cohorts, non-Māori experienced lower all-cause mortality at 5 yr. after commencement of treatment (risk ratio 0.78, 95% CI 0.72-0.84). New Zealand European patients experienced lower mortality than Māori patients in indigenous age-standardised analyses (age-standardised mortality rate ratio 0.58, 95% CI 0.51-0.67).

Conclusions: Non-Māori patients are treated with temporary dialysis vascular access less often than Māori, and experience longer life expectancy with dialysis, even when socioeconomic, demographic, and geographical factors are equivalent. Based on these disparities, health services should monitor and address inequitable treatment practices and outcomes in end-stage kidney disease care.
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http://dx.doi.org/10.1186/s12939-018-0737-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5819180PMC
February 2018
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