Publications by authors named "William Leung"

42 Publications

Clinical and cost-effectiveness of an online-delivered group-based pain management programme in improving pain-related disability for people with persistent pain-protocol for a non-inferiority randomised controlled trial (iSelf-help trial).

BMJ Open 2021 Feb 4;11(2):e046376. Epub 2021 Feb 4.

Centre for Health, Activity and Rehabilitation Research (CHARR), School of Physiotherapy, Wellington, New Zealand.

Introduction: Persistent non-cancer pain affects one in five adults and is more common in Māori-the Indigenous population of New Zealand (NZ), adults over 65 years, and people living in areas of high deprivation. Despite the evidence supporting multidisciplinary pain management programmes (PMPs), access to PMPs is poor due to long waiting lists. Although online-delivered PMPs enhance access, none have been codesigned with patients or compared with group-based, in-person PMPs. This non-inferiority trial aims to evaluate the clinical and cost-effectiveness of a cocreated, culturally appropriate, online-delivered PMP (iSelf-help) compared with in-person PMP in reducing pain-related disability.

Methods And Analysis: Mixed-methods, using a modified participatory action research (PAR) framework, involving three phases. Phase I involved cocreation and cultural appropriateness of iSelf-help by PAR team members. Phase II: The proposed iSelf-help trial is a pragmatic, multicentred, assessor-blinded, two-arm, parallel group, non-inferiority randomised controlled trial. Adults (n=180, age ≥18 years) with persistent non-cancer pain eligible for a PMP will be recruited and block randomised (with equal probabilities) to intervention (iSelf-help) and control groups (in-person PMP). The iSelf-help participants will participate in two 60-minute video-conferencing sessions weekly for 12 weeks with access to cocreated resources via smartphone application and a password-protected website. The control participants will receive group-based, in-person delivered PMP. Primary outcome is pain-related disability assessed via modified Roland Morris Disability Questionnaire at 6 months post intervention. Secondary outcomes include anxiety, depression, stress, pain severity, quality of life, acceptance, self-efficacy, catastrophising and fear avoidance. Data will be collected at baseline, after the 12-week intervention, and at 3 and 6 months post intervention. We will conduct economic analyses and mixed-method process evaluations (Phase IIA).

Ethics And Dissemination: The Health and Disability Ethics Committee approved the study protocol (HDEC18/CEN/162). Phase III involves dissemination of findings guided by the PAR team as outcomes become apparent.

Trial Registration Number: ACTRN 12619000771156.
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http://dx.doi.org/10.1136/bmjopen-2020-046376DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7868244PMC
February 2021

Levator palpebrae superioris myositis: An uncommon cause of ptosis.

eNeurologicalSci 2021 Mar 29;22:100295. Epub 2020 Nov 29.

Division of Neurology, Department of Medicine, Queen Mary Hospital, University of Hong Kong, PR China.

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http://dx.doi.org/10.1016/j.ensci.2020.100295DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7750547PMC
March 2021

Rising Ethnic Inequalities in Acute Rheumatic Fever and Rheumatic Heart Disease, New Zealand, 2000-2018.

Emerg Infect Dis 2021 Jan;27(1)

We describe trends in acute rheumatic fever (ARF), rheumatic heart disease (RHD), and RHD deaths among population groups in New Zealand. We analyzed initial primary ARF and RHD hospitalizations during 2000-2018 and RHD mortality rates during 2000-2016. We found elevated rates of initial ARF hospitalizations for persons of Māori (adjusted rate ratio [aRR] 11.8, 95% CI 10.0-14.0) and Pacific Islander (aRR 23.6, 95% CI 19.9-27.9) ethnicity compared with persons of European/other ethnicity. We also noted higher rates of initial RHD hospitalization for Māori (aRR 3.2, 95% CI 2.9-3.5) and Pacific Islander (aRR 4.6, 95% CI 4.2-5.1) groups and RHD deaths among these groups (Māori aRR 12.3, 95% CI 10.3-14.6, and Pacific Islanders aRR 11.2, 95% CI 9.1-13.8). Rates also were higher in socioeconomically disadvantaged neighborhoods. To curb high rates of ARF and RHD, New Zealand must address increasing social and ethnic inequalities.
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http://dx.doi.org/10.3201/eid2701.191791DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7774562PMC
January 2021

Impact of COVID-19 on seizure-related emergency attendances and hospital admissions - A territory-wide observational study.

Epilepsy Behav 2021 02 21;115:107497. Epub 2020 Sep 21.

Division of Neurology, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong Special Administrative Region. Electronic address:

This is a territory-wide study to investigate the impact of coronavirus disease 2019 (COVID-19) pandemic on Accident and Emergency Department (A&E) attendances and acute ward admissions for seizures. Adult patients who presented to the A&E with seizures from January 23, 2020 to March 24, 2020 (study period) were included and compared with parallel intervals from 2015 to 2019 (control periods). Preexisting time trend in control periods and potential changes during COVID-19 were analyzed by Poisson, negative and logistic regression models. Accident and Emergency Department attendances and ward admissions for seizures decreased significantly during the COVID-19 pandemic. A total of 319 and 230 recorded ward admissions and A&E attendances for seizures were identified during the study period in 2020, compared with 494 and 343 per annum, respectively in the control periods. The ratio of acute ward admission per A&E attendance for seizures did not change significantly. Intensive care utility and mortality rates remained stable. For some patients, delaying medical attention due to fear of nosocomial COVID-19 cross-infection may lead to severe or even life-threatening consequences. This change in medical help-seeking behavior calls for new medical care models to meet the service gap. Education to patients with epilepsy and their caregivers is of utmost importance during this pandemic.
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http://dx.doi.org/10.1016/j.yebeh.2020.107497DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7505596PMC
February 2021

Changes in pediatric seizure-related emergency department attendances during COVID-19 - A territory-wide observational study.

J Formos Med Assoc 2020 Nov 21. Epub 2020 Nov 21.

Division of Neurology, Department of Medicine, Queen Mary Hospital, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong. Electronic address:

A territory-wide retrospective observational study was conducted in Hong Kong between January 23 to April 22, 2020 to demonstrate changes in pediatric seizure-related accident and emergency department (A&E) visits during the COVID-19 pandemic. Parallel periods from 2015 to 2019 were used as control. All-cause A&E attendances in all paediatric age groups decreased significantly during the study period. Seizure-related attendances decreased across all pediatric age-groups in 2020 (RR 0.379, 95% CI 0.245-0.588), with a disproportionately large decrease in the 0-6 years age group (RR 0.303, 95% CI 0.174-0.526) compared with the 7-18 years age group (RR 0.534, 95% CI 0.393-0.719). Decrease in RTI-related A&E attendances was also more drastic in the 0-6 age group. The two time trends are congruent in the 0-6 years but not the 7-18 years age group. Such a trend is suggestive of the usefulness of infection control measures in seizure prevention, especially amongst young children.
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http://dx.doi.org/10.1016/j.jfma.2020.11.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7680012PMC
November 2020

High pathogen prevalence in an amphibian and reptile assemblage at a site with risk factors for dispersal in Galicia, Spain.

PLoS One 2020 30;15(7):e0236803. Epub 2020 Jul 30.

Institute of Zoology, Zoological Society of London, Regent's Park, London, United Kingdom.

Ranaviruses are agents of disease, mortality and population declines in ectothermic vertebrates and emergences have been repeatedly linked to human activities. Ranaviruses in the common midwife toad ranavirus lineage are emerging in Europe. They are known to be severe multi-host pathogens of amphibians and can also cause disease in reptiles. Recurrent outbreaks of ranavirus disease and mortality affecting three species have occurred at a small reservoir in north-west Spain but no data were available on occurrence of the pathogen in the other amphibian and reptile species present or at adjacent sites. We sampled nine species of amphibians and reptiles at the reservoir and nearby sites and screened for ranavirus presence using molecular methods. Our results show infection with ranavirus in all nine species, including first reports for Hyla molleri, Pelophylax perezi, Rana iberica, and Podarcis bocagei. We detected ranavirus in all four local sites and confirmed mass mortality incidents involving Lissotriton boscai and Triturus marmoratus were ongoing. The reservoir regularly hosts water sports tournaments and the risks of ranavirus dispersal through the translocation of contaminated equipment are discussed.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0236803PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7392302PMC
September 2020

Delays in Stroke Onset to Hospital Arrival Time During COVID-19.

Stroke 2020 07 20;51(7):2228-2231. Epub 2020 May 20.

Division of Neurology, Department of Medicine (K.-C.T., W.C.Y.L., Y.-K.W., R.K.C.L., A.H.Y.C., K.-K.L., M.-Y.T., R.T.F.C., K.K.L.), Queen Mary Hospital, LKS Faculty of Medicine, The University of Hong Kong.

Background And Purpose: The current coronavirus disease 2019 (COVID-19) pandemic represents a global public health crisis, disrupting emergency healthcare services. We determined whether COVID-19 has resulted in delays in stroke presentation and affected the delivery of acute stroke services in a comprehensive stroke center in Hong Kong.

Methods: We retrospectively reviewed all patients with transient ischemic attack and stroke admitted via the acute stroke pathway of Queen Mary Hospital, Hong Kong, during the first 60 days since the first diagnosed COVID-19 case in Hong Kong (COVID-19: January 23, 2020-March 24, 2020). We compared the stroke onset to hospital arrival (onset-to-door) time and timings of inpatient stroke pathways with patients admitted during the same period in 2019 (pre-COVID-19: January 23, 2019-March 24, 2019).

Results: Seventy-three patients in COVID-19 were compared with 89 patients in pre-COVID-19. There were no significant differences in age, sex, vascular risk factors, nor stroke severity between the 2 groups (>0.05). The median stroke onset-to-door time was ≈1-hour longer in COVID-19 compared with pre-COVID-19 (154 versus 95 minutes, =0.12), and the proportion of individuals with onset-to-door time within 4.5 hours was significantly lower (55% versus 72%, =0.024). Significantly fewer cases of transient ischemic attack presented to the hospital during COVID-19 (4% versus 16%, =0.016), despite no increase in referrals to the transient ischemic attack clinic. Inpatient stroke pathways and treatment time metrics nevertheless did not differ between the 2 groups (>0.05 for all comparisons).

Conclusions: During the early containment phase of COVID-19, we noted a prolongation in stroke onset to hospital arrival time and a significant reduction in individuals arriving at the hospital within 4.5 hours and presenting with transient ischemic attack. Public education about stroke should continue to be reinforced during the COVID-19 pandemic.
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http://dx.doi.org/10.1161/STROKEAHA.120.030105DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7258759PMC
July 2020

Prospective community programme versus parent-driven care to prevent respiratory morbidity in children following hospitalisation with severe bronchiolitis or pneumonia.

Thorax 2020 04 24;75(4):298-305. Epub 2020 Feb 24.

Department of Population Health, The University of Auckland, Auckland, New Zealand.

Background: Hospitalisation with severe lower respiratory tract infection (LRTI) in early childhood is associated with ongoing respiratory symptoms and possible later development of bronchiectasis. We aimed to reduce this intermediate respiratory morbidity with a community intervention programme at time of discharge.

Methods: This randomised, controlled, single-blind trial enrolled children aged <2 years hospitalised for severe LRTI to 'intervention' or 'control'. Intervention was three monthly community clinics treating wet cough with prolonged antibiotics referring non-responders. All other health issues were addressed, and health resilience behaviours were encouraged, with referrals for housing or smoking concerns. Controls followed the usual pathway of parent-initiated healthcare access. After 24 months, all children were assessed by a paediatrician blinded to randomisation for primary outcomes of wet cough, abnormal examination (crackles or clubbing) or chest X-ray Brasfield score ≤22.

Findings: 400 children (203 intervention, 197 control) were enrolled in 2011-2012; mean age 6.9 months, 230 boys, 87% Maori/Pasifika ethnicity and 83% from the most deprived quintile. Final assessment of 321/400 (80.3%) showed no differences in presence of wet cough (33.9% intervention, 36.5% controls, relative risk (RR) 0.93, 95% CI 0.69 to 1.25), abnormal examination (21.7% intervention, 23.9% controls, RR 0.92, 95% CI 0.61 to 1.38) or Brasfield score ≤22 (32.4% intervention, 37.9% control, RR 0.85, 95% CI 0.63 to 1.17). Twelve (all intervention) were diagnosed with bronchiectasis within this timeframe.

Interpretation: We have identified children at high risk of ongoing respiratory disease following hospital admission with severe LRTI in whom this intervention programme did not change outcomes over 2 years.

Trial Registration Number: ACTRN12610001095055.
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http://dx.doi.org/10.1136/thoraxjnl-2019-213142DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7231446PMC
April 2020

Diversity-Stability Dynamics of the Amphibian Skin Microbiome and Susceptibility to a Lethal Viral Pathogen.

Front Microbiol 2019 20;10:2883. Epub 2019 Dec 20.

Institute of Zoology, Zoological Society of London, London, United Kingdom.

Variation among animals in their host-associated microbial communities is increasingly recognized as a key determinant of important life history traits including growth, metabolism, and resistance to disease. Quantitative estimates of the factors shaping the stability of host microbiomes over time at the individual level in non-model organisms are scarce. Addressing this gap in our knowledge is important, as variation among individuals in microbiome stability may represent temporal gain or loss of key microbial species and functions linked to host health and/or fitness. Here we use controlled experiments to investigate how both heterogeneity in microbial species richness of the environment and exposure to the emerging pathogen influence the structure and temporal dynamics of the skin microbiome in a vertebrate host, the European common frog (). Our evidence suggests that altering the bacterial species richness of the environment drives divergent temporal microbiome dynamics of the amphibian skin. Exposure to ranavirus effects changes in skin microbiome structure irrespective of total microbial diversity, but individuals with higher pre-exposure skin microbiome diversity appeared to exhibit higher survival. Higher diversity skin microbiomes also appear less stable over time compared to lower diversity microbiomes, but stability of the 100 most abundant ("core") community members was similar irrespective of microbiome richness. Our study highlights the importance of extrinsic factors in determining the stability of host microbiomes over time, which may in turn have important consequences for the stability of host-microbe interactions and microbiome-fitness correlations.
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http://dx.doi.org/10.3389/fmicb.2019.02883DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6951417PMC
December 2019

Efficacy and tolerability of perampanel as an adjunct therapy in refractory epilepsy from real-world experience.

J Neurol Sci 2019 Oct 2;405:116416. Epub 2019 Aug 2.

Division of Neurology, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong SAR, China.

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http://dx.doi.org/10.1016/j.jns.2019.08.001DOI Listing
October 2019

Effects of historic and projected climate change on the range and impacts of an emerging wildlife disease.

Glob Chang Biol 2019 08 9;25(8):2648-2660. Epub 2019 May 9.

Queen Mary University of London, London, United Kingdom.

The global trend of increasing environmental temperatures is often predicted to result in more severe disease epidemics. However, unambiguous evidence that temperature is a driver of epidemics is largely lacking, because it is demanding to demonstrate its role among the complex interactions between hosts, pathogens, and their shared environment. Here, we apply a three-pronged approach to understand the effects of temperature on ranavirus epidemics in UK common frogs, combining in vitro, in vivo, and field studies. Each approach suggests that higher temperatures drive increasing severity of epidemics. In wild populations, ranavirosis incidents were more frequent and more severe at higher temperatures, and their frequency increased through a period of historic warming in the 1990s. Laboratory experiments using cell culture and whole animal models showed that higher temperature increased ranavirus propagation, disease incidence, and mortality rate. These results, combined with climate projections, predict severe ranavirosis outbreaks will occur over wider areas and an extended season, possibly affecting larval recruitment. Since ranaviruses affect a variety of ectothermic hosts (amphibians, reptiles, and fish), wider ecological damage could occur. Our three complementary lines of evidence present a clear case for direct environmental modulation of these epidemics and suggest management options to protect species from disease.
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http://dx.doi.org/10.1111/gcb.14651DOI Listing
August 2019

Mass media promotion of a smartphone smoking cessation app: modelled health and cost-saving impacts.

BMC Public Health 2019 Mar 8;19(1):283. Epub 2019 Mar 8.

Department of Public Health, University of Otago, Wellington, New Zealand.

Background: Smartphones are increasingly available and some high quality apps are available for smoking cessation. However, the cost-effectiveness of promoting such apps has never been studied. We therefore aimed to estimate the health gain, inequality impacts and cost-utility from a five-year promotion campaign of a smoking cessation smartphone app compared to business-as-usual (no app use for quitting).

Methods: A well-established Markov macro-simulation model utilising a multi-state life-table was adapted to the intervention (lifetime horizon, 3% discount rate). The setting was the New Zealand (NZ) population (N = 4.4 million). The intervention effect size was from a multi-country randomised trial: relative risk for quitting at 6 months = 2.23 (95%CI: 1.08 to 4.77), albeit subsequently adjusted to consider long-term relapse. Intervention costs were based on NZ mass media promotion data and the NZ cost of attracting a smoker to smoking cessation services (NZ$64 per person).

Results: The five-year intervention was estimated to generate 6760 QALYs (95%UI: 5420 to 8420) over the remaining lifetime of the population. For Māori (Indigenous population) there was 2.8 times the per capita age-standardised QALY gain relative to non-Māori. The intervention was also estimated to be cost-saving to the health system (saving NZ$115 million [m], 95%UI: 72.5m to 171m; US$81.8m). The cost-saving aspect of the intervention was maintained in scenario and sensitivity analyses where the discount rate was doubled to 6%, the effect size halved, and the intervention run for just 1 year.

Conclusions: This study provides modelling-level evidence that mass-media promotion of a smartphone app for smoking cessation could generate health gain, reduce ethnic inequalities in health and save health system costs. Nevertheless, there are other tobacco control measures which generate considerably larger health gains and cost-savings such as raising tobacco taxes.
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http://dx.doi.org/10.1186/s12889-019-6605-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6408783PMC
March 2019

Hyperphagia in Alzheimer's disease, its transient nature, and potentially reversible causes.

Psychogeriatrics 2019 Nov 27;19(6):619-621. Epub 2019 Feb 27.

Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong.

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http://dx.doi.org/10.1111/psyg.12432DOI Listing
November 2019

Sun protection and shade availability in New Zealand's outdoor recreation spaces.

N Z Med J 2018 10 26;131(1484):30-37. Epub 2018 Oct 26.

Professor, University of Otago, Wellington.

Aims: We aimed to investigate sun protection behaviours and shade availability in outdoor recreation spaces using images captured by children who, in 2014/15, wore wearable cameras for four consecutive days.

Methods: The 168 participants visited 16 outdoor recreation spaces between 10am and 4pm, capturing 378 images, on average, in each setting. People observed in the images (n=2,635) were coded for age, sex, clothing worn (38 clothing types) and shade used. Mean temperature and ultraviolet index (UVI) values were linked with the time-stamped and geo-referenced images.

Results: The UVI in most settings was high enough to warrant sun protection, but only 4.3% of people wore sun-protective hats (broad-brim, bucket and legionnaire styles) and 10.7% used shade. Areas most popular with children, including playground equipment, beach sand and pool areas, had little or no shade available.

Conclusions: Despite New Zealand having the highest incidence of melanoma skin cancer in the world, the results indicate that few New Zealanders wear hats and seek shade in outdoor recreation settings. The findings highlight the need to improve policy and environmental support for skin cancer prevention activities.
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October 2018

Economic evaluation of a multi-disciplinary community-based intervention programme for New Zealand children and adolescents with obesity.

Obes Res Clin Pract 2018 May - Jun;12(3):293-298. Epub 2018 May 17.

Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.

Objective: To determine whether Whānau Pakari, a home-based, 12-month multi-disciplinary child obesity intervention programme was cost-effective when compared with the prior conventional hospital-based model of care.

Methods: Whānau Pakari trial participants were recruited January 2012-August 2014, and randomised to either a high-intensity intervention (weekly sessions for 12 months with home-based assessments and advice, n=100) or low-intensity control (home-based assessments and advice only, n=99). Trial participants were aged 5-16 years, resided in Taranaki, Aotearoa/New Zealand (NZ), with a body mass index (BMI) ≥98th centile or BMI >91st centile with weight-related comorbidities. Conventional group participants (receiving paediatrician assessment with dietitian input and physical activity/nutrition support, n=44) were aged 4-15 years, and resided in the same or another NZ centre. The change in BMI standard deviation score (SDS) at 12 months from baseline and programme intervention costs, both at the participant level, were used for the economic evaluation. A limited health funder perspective with costs in 2016 NZ$ was taken.

Results: The per child 12-month Whānau Pakari programme costs were significantly lower than in the conventional group. In the low-intensity group, costs were NZ$939 (95% CI: 872, 1007) (US$648) lower than the conventional group. In the high-intensity intervention group, costs were NZ$155 (95% CI: 89, 219) (US$107) lower than in the conventional group. BMI SDS reductions were similar in the three groups.

Conclusions: A home-based, multi-disciplinary child obesity intervention had lower programme costs per child, greater reach, with similar BMI SDS outcomes at 12 months when compared with the previous hospital-based conventional model.
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http://dx.doi.org/10.1016/j.orcp.2018.04.001DOI Listing
April 2019

BetaMe: impact of a comprehensive digital health programme on HbA1c and weight at 12 months for people with diabetes and pre-diabetes: study protocol for a randomised controlled trial.

Trials 2018 Mar 5;19(1):161. Epub 2018 Mar 5.

Department of Medicine, University of Otago Wellington, PO Box 7343, Wellington, New Zealand.

Background: Long-term conditions (LTCs) are the biggest contributor to health loss in New Zealand. The economic cost and burden on the health system is substantial and growing. Self-management strategies offer a potential way to reduce the pressure on health services. This study evaluates a comprehensive self-management programme (the BetaMe programme) delivered by mobile and web-based technologies for people with Type 2 diabetes (T2DM) and pre-diabetes. The primary aim of this study is to evaluate the effectiveness of the BetaMe programme versus usual care among primary care populations in improving the control of T2DM and pre-diabetes, as measured by change in HbA1c and weight over 12 months.

Methods: Participants will be recruited through two primary healthcare organisations and a Māori healthcare provider in New Zealand (n = 430). Eligible participants will be 18 to 75 years old, with T2DM or pre-diabetes, with an HbA1c of 41-70 mmol/mol up to 2 years prior to study commencement. Eligible participants who consent to participate will be individually randomised to the control arm (usual care) or intervention arm (usual care and BetaMe). The programme consists of a 16-week core followed by a maintenance period of 36 weeks. It incorporates (1) individualised health coaching, (2) goal setting and tracking, (3) peer support in an online forum and (4) educational resources and behaviour-change tools. The primary outcome measures are change in HbA1c and weight at 12 months. Secondary outcomes are changes in waist circumference, blood pressure, patient activation and diabetes-specific behaviours. All outcomes will be assessed at 4 and 12 months for the total study population and for Māori and Pacific participants specifically. All primary analyses will be based on intention-to-treat. Primary analysis will use linear mixed models comparing mean outcome levels adjusted for initial baseline characteristics at 12 months.

Discussion: This is a randomised controlled trial of a comprehensive self-management intervention for people with diabetes and pre-diabetes. If effective, this programme would allow healthcare providers to deliver an intervention that is person-centred and supports the self-care of people with T2DM, pre-diabetes and potentially other LTCs.

Trial Registration: Australian New Zealand Clinical Trials Registry, ID: ACTRN12617000549325 . Registered on 19 April 2017.
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http://dx.doi.org/10.1186/s13063-018-2528-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5836439PMC
March 2018

Studying third-parties and environments: New Zealand sun-safety research.

Health Promot Int 2019 Jun;34(3):440-446

University of Otago, Wellington, New Zealand.

Wearable cameras have been used to study health behaviours, but their utility in assessing third-party behaviours and the built environment is uncertain. This paper reports on the feasibility of using wearable cameras for this purpose in a study of sun-protective behaviours and shade availability during school lunch-breaks. The Kids'Cam study provided 168 children (aged 11-13 years), recruited from 16 randomly selected schools in the Wellington region of New Zealand, with wearable cameras. The devices automatically captured images every 7 s from the child's perspective. Images captured during school lunch-breaks by a random sample of 15 children who took part during terms 4 and 1 (October 2014-April 2015) were selected and assessed for usability. The feasibility of studying third-party sun-protective behaviours and school shade availability was assessed for a subset of 320 images. Of the 3492 eligible lunch-break images, 96.4% were useable; the remainders were excluded due to obstruction, blurriness or unsuitable camera position. Overall, 1278 children and 108 shade structures were observed in the sample images. The use of shade, hats, sleeves, collars and sunglasses could be determined for 97.0%, 77.2%, 74.4%, 47.6% and 54.9% of children, respectively. All shade structures could be classified according to type, and canopy composition could be assessed for 95.4% of structures. Wearable cameras are a feasible tool for assessing sun-safety, particularly shade availability, hat wearing and shade use. This methodology could be used to objectively study other third-party health-related behaviours, and other features of the built environment.
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http://dx.doi.org/10.1093/heapro/dax094DOI Listing
June 2019

Sun Protection Among New Zealand Primary School Children.

Health Educ Behav 2018 10 3;45(5):800-807. Epub 2017 Dec 3.

1 University of Otago, Wellington, New Zealand.

Schools are an important setting for raising skin cancer prevention awareness and encouraging sun protection. We assessed the clothes worn and shade used by 1,278 children in eight schools in the Wellington region of New Zealand. These children were photographed for the Kids'Cam project between September 2014 and March 2015 during school lunch breaks. Children's mean clothing coverage (expressed as a percentage of body area covered) was calculated. Data on school sun-safety policies were obtained via telephone. Mean total body clothing coverage was 70.3% (95% confidence interval = 66.3%, 73.8%). Body regions with the lowest mean coverage were the head (15.4% coverage), neck (36.1% coverage), lower arms (46.1% coverage), hands (5.3% coverage), and calves (30.1% coverage). Children from schools with hats as part of the school uniform were significantly more likely to wear a hat (52.2%) than children from schools without a school hat (2.7%). Most children (78.4%) were not under the cover of shade. Our findings suggest that New Zealand children are not sufficiently protected from the sun at school. Schools should consider comprehensive approaches to improve sun protection, such as the provision of school hats, sun-protective uniforms, and the construction of effective shade.
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http://dx.doi.org/10.1177/1090198117741943DOI Listing
October 2018

Screening of a long-term sample set reveals two Ranavirus lineages in British herpetofauna.

PLoS One 2017 20;12(9):e0184768. Epub 2017 Sep 20.

Institute of Zoology, ZSL, Regents Park, London, United Kingdom.

Reports of severe disease outbreaks in amphibian communities in mainland Europe due to strains of the common midwife toad virus (CMTV)-like clade of Ranavirus are increasing and have created concern due to their considerable population impacts. In Great Britain, viruses in another clade of Ranavirus-frog virus 3 (FV3)-like-have caused marked declines of common frog (Rana temporaria) populations following likely recent virus introductions. The British public has been reporting mortality incidents to a citizen science project since 1992, with carcasses submitted for post-mortem examination, resulting in a long-term tissue archive spanning 25 years. We screened this archive for ranavirus (458 individuals from 228 incidents) using molecular methods and undertook preliminary genotyping of the ranaviruses detected. In total, ranavirus was detected in 90 individuals from 41 incidents focused in the north and south of England. The majority of detections involved common frogs (90%) but also another anuran, a caudate and a reptile. Most incidents were associated with FV3-like viruses but two, separated by 300 km and 16 years, involved CMTV-like viruses. These British CMTV-like viruses were more closely related to ranaviruses from mainland Europe than to each other and were estimated to have diverged at least 458 years ago. This evidence of a CMTV-like virus in Great Britain in 1995 represents the earliest confirmed case of a CMTV associated with amphibians and raises important questions about the history of ranavirus in Great Britain and the epidemiology of CMTV-like viruses. Despite biases present in the opportunistic sample used, this study also demonstrates the role of citizen science projects in generating resources for research and the value of maintaining long-term wildlife tissue archives.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0184768PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5607163PMC
October 2017

A quantitative-PCR based method to estimate ranavirus viral load following normalisation by reference to an ultraconserved vertebrate target.

J Virol Methods 2017 11 24;249:147-155. Epub 2017 Aug 24.

Institute of Zoology, Zoological Society of London, Regent's Park, London, NW1 4RY, United Kingdom; UCL Genetics Institute, Gower Street, London, WC1E 6BT, United Kingdom.

Ranaviruses are important pathogens of amphibians, reptiles and fish. To meet the need for an analytical method for generating normalised and comparable infection data for these diverse host species, two standard-curve based quantitative-PCR (qPCR) assays were developed enabling viral load estimation across these host groups. A viral qPCR targeting the major capsid protein (MCP) gene was developed which was specific to amphibian-associated ranaviruses with high analytical sensitivity (lower limit of detection: 4.23 plasmid standard copies per reaction) and high reproducibility across a wide dynamic range (coefficient of variation below 3.82% from 3 to 3×10 standard copies per reaction). The comparative sensitivity of the viral qPCR was 100% (n=78) based on agreement with an established end-point PCR. Comparative specificity with the end-point PCR was also 100% (n=94) using samples from sites with no history of ranavirus infection. To normalise viral quantities, a host qPCR was developed which targeted a single-copy, ultra-conserved non-coding element (UCNE) of vertebrates. Viral and host qPCRs were applied to track ranavirus growth in culture. The two assays offer a robust approach to viral load estimation and the host qPCR can be paired with assays targeting other pathogens to study infection burdens.
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http://dx.doi.org/10.1016/j.jviromet.2017.08.016DOI Listing
November 2017

A national quitline service and its promotion in the mass media: modelling the health gain, health equity and cost-utility.

Tob Control 2018 07 24;27(4):434-441. Epub 2017 Jul 24.

University of Otago, Wellington, New Zealand.

Background: Mass media campaigns and quitlines are both important distinct components of tobacco control programmes around the world. But when used as an integrated package, the effectiveness and cost-effectiveness are not well described. We therefore aimed to estimate the health gain, health equity impacts and cost-utility of the package of a national quitline service and its promotion in the mass media.

Methods: We adapted an established Markov and multistate life-table macro-simulation model. The population was all New Zealand adults in 2011. Effect sizes and intervention costs were based on past New Zealand quitline data. Health system costs were from a national data set linking individual health events to costs.

Results: The 1-year operation of the existing intervention package of mass media promotion and quitline service was found to be net cost saving to the health sector for all age groups, sexes and ethnic groups (saving $NZ84 million; 95%uncertainty interval 60-115 million in the base-case model). It also produced greater per capita health gains for Māori (indigenous) than non-Māori (2.2 vs 0.73 quality-adjusted life-years (QALYs) per 1000 population, respectively). The net cost saving of the intervention was maintained in all sensitivity and scenario analyses for example at a discount rate of 6% and when the intervention effect size was quartered (given the possibility of residual confounding in our estimates of smoking cessation). Running the intervention for 20 years would generate an estimated 54 000 QALYs and $NZ1.10 billion (US$0.74 billion) in cost savings.

Conclusions: The package of a quitline service and its promotion in the mass media appears to be an effective means to generate health gain, address health inequalities and save health system costs. Nevertheless, the role of this intervention needs to be compared with other tobacco control and health sector interventions, some of which may be even more cost saving.
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http://dx.doi.org/10.1136/tobaccocontrol-2017-053660DOI Listing
July 2018

Clothing Protection from Ultraviolet Radiation: A New Method for Assessment.

Photochem Photobiol 2017 11 25;93(6):1513-1518. Epub 2017 Jul 25.

University of Otago, Wellington, New Zealand.

Clothing modifies ultraviolet radiation (UVR) exposure from the sun and has an impact on skin cancer risk and the endogenous synthesis of vitamin D. There is no standardized method available for assessing body surface area (BSA) covered by clothing, which limits generalizability between study findings. We calculated the body cover provided by 38 clothing items using diagrams of BSA, adjusting the values to account for differences in BSA by age. Diagrams displaying each clothing item were developed and incorporated into a coverage assessment procedure (CAP). Five assessors used the CAP and Lund & Browder chart, an existing method for estimating BSA, to calculate the clothing coverage of an image sample of 100 schoolchildren. Values of clothing coverage, inter-rater reliability and assessment time were compared between CAP and Lund & Browder methods. Both methods had excellent inter-rater reliability (>0.90) and returned comparable results, although the CAP method was significantly faster in determining a person's clothing coverage. On balance, the CAP method appears to be a feasible method for calculating clothing coverage. Its use could improve comparability between sun-safety studies and aid in quantifying the health effects of UVR exposure.
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http://dx.doi.org/10.1111/php.12803DOI Listing
November 2017

Arsenic-Induced Neuropathy by Improper Use of Chinese Medicine: A Case Report.

Am J Ther 2018 May/Jun;25(3):e392-e393

Hong Kong Poison Information Centre, United Christian Hospital, Hong Kong SAR, China.

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http://dx.doi.org/10.1097/MJT.0000000000000576DOI Listing
February 2019

Economic evaluation of an exercise-counselling intervention to enhance smoking cessation outcomes: The Fit2Quit trial.

Tob Induc Dis 2017 29;15:21. Epub 2017 Mar 29.

University of Auckland, Private Bag 92019, Auckland, New Zealand.

Background: In the Fit2Quit randomised controlled trial, insufficiently-active adult cigarette smokers who contacted Quitline for support to quit smoking were randomised to usual Quitline support or to also receive ≤10 face-to-face and telephone exercise-support sessions delivered by trained exercise facilitators over the 24-week trial. This paper aims to determine the cost-effectiveness of an exercise-counselling intervention added to Quitline compared to Quitline alone in the Fit2Quit trial.

Methods: Within-trial and lifetime cost-effectiveness were assessed. A published Markov model was adapted, with smokers facing increased risks of lung cancer and cardiovascular disease.

Results: Over 24 weeks, the incremental programme cost per participant in the intervention was NZ$428 (US$289 or €226; purchasing power parity-adjusted [PPP]). The incremental cost-effectiveness ratio (ICER) for seven-day point prevalence measured at 24-week follow-up was NZ$31,733 (US$21,432 or €16,737 PPP-adjusted) per smoker abstaining. However, for the 52% who adhered to the intervention (≥7 contacts), the ICER for point prevalence was NZ$3,991 (US$2,695 or €2,105 PPP-adjusted). In this adherent subgroup, the Markov model estimated 0.057 and 0.068 discounted quality-adjusted life-year gains over the lifetime of 40-year-old males (ICER: NZ$4,431; US$2,993 or €2,337 PPP-adjusted) and females (ICER: NZ$2,909; US$1,965 or €1,534 PPP-adjusted).

Conclusions: The exercise-counselling intervention will only be cost-effective if adherence is a minimum of ≥7 intervention calls, which in turn leads to a sufficient number of quitters for health gains.

Trial Registration: Australasian Clinical Trials Registry Number ACTRN12609000637246.
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http://dx.doi.org/10.1186/s12971-017-0126-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5371274PMC
March 2017

Association between high cumulative dose of benzodiazepine in Chinese patients and risk of dementia: a preliminary retrospective case-control study.

Psychogeriatrics 2017 Sep 1;17(5):310-316. Epub 2017 Feb 1.

Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong.

Background: Evidence describing the association between high-dose benzodiazepine use and dementia has been conflicting. Most previous studies involved Caucasian populations, with only limited data on Chinese subjects. Possible differences exist between Chinese and Caucasian populations with regard to metabolism and prescription practice. This study aimed to assess the association between high-dose benzodiazepine use and dementia in a Chinese population.

Method: A retrospective case-control study was carried out in all public hospitals under the Hong Kong Hospital Authority Hong Kong West Cluster between 2000 and 2015. The study recruited 273 Chinese adults (91 cases, 182 controls) aged 75 and over, with at least 6 years of follow-up data. Each dementia case was matched with two controls according to sex, age group, and duration of follow-up. The number of patients with benzodiazepine ever-use and the exposure density based on the prescribed daily doses were assessed. Prescribed daily doses were categorized as either <1096 or ≥1096. Odds ratios and 95% confidence intervals were computed by multivariate analysis.

Results: The difference in exposure density between the dementia and control groups was statistically significant between prescribed daily doses <1096 and ≥1096 (P = 0.02). There were two multivariate analyses models; one factored in depression (model 1), and the other (model 2) did not. Model 2 showed a statistically significant association (odds ratio = 1.71, 95% confidence intervals = 1.02-2.89, P = 0.04) between benzodiazepine exposure density and dementia.

Conclusion: High-dose benzodiazepine use may be associated with dementia in the Chinese population. Prospective studies are required.
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http://dx.doi.org/10.1111/psyg.12239DOI Listing
September 2017

Efficacy of Clarithromycin-Naproxen-Oseltamivir Combination in the Treatment of Patients Hospitalized for Influenza A(H3N2) Infection: An Open-label Randomized, Controlled, Phase IIb/III Trial.

Chest 2017 05 22;151(5):1069-1080. Epub 2016 Nov 22.

Carol Yu Centre for Infection and Division of Infectious Diseases, State Key Laboratory of Emerging Infectious Diseases, Department of Microbiology, the University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region, China; Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Zhejiang University, Hangzhou, China. Electronic address:

Background: Influenza causes excessive hospitalizations and deaths. The study assessed the efficacy and safety of a clarithromycin-naproxen-oseltamivir combination for treatment of serious influenza.

Methods: From February to April 2015, we conducted a prospective open-label, randomized, controlled trial. Adult patients hospitalized for A(H3N2) influenza were randomly assigned to a 2-day combination of clarithromycin 500 mg, naproxen 200 mg, and oseltamivir 75 mg twice daily, followed by 3 days of oseltamivir or to oseltamivir 75 mg twice daily without placebo for 5 days as a control method (1:1). The primary end point was 30-day mortality. The secondary end points were 90-day mortality, serial nasopharyngeal aspirate (NPA) virus titer, percentage of neuraminidase-inhibitor-resistant A(H3N2) virus (NIRV) quasispecies, pneumonia severity index (PSI), and duration of hospital stay.

Results: Among the 217 patients with influenza A(H3N2) enrolled, 107 were randomly assigned to the combination treatment. The median age was 80 years, and 53.5% were men. Adverse events were uncommon. Ten patients died during the 30-day follow-up. The combination treatment was associated with lower 30-day mortality (P = .01), less frequent high dependency unit admission (P = .009), and shorter hospital stay (P < .0001). The virus titer and PSI (days 1-3; P < .01) and the NPA specimens with NIRV quasispecies ≥ 5% (days 1-2; P < .01) were significantly lower in the combination treatment group. Multivariate analysis showed that combination treatment was the only independent factor associated with lower 30-day mortality (OR, 0.06; 95% CI, 0.004-0.94; P = .04).

Conclusions: Combination treatment reduced both 30- and 90-day mortality and length of hospital stay. Further study of the antiviral and immunomodulatory effects of this combination treatment of severe influenza is warranted.

Trial Registry: BioMed Central; No.: ISRCTN11273879 DOI 10.1186/ISRCTN11273879; URL: www.isrctn.com/ISRCTN11273879.
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http://dx.doi.org/10.1016/j.chest.2016.11.012DOI Listing
May 2017

Adjuvant Trastuzumab in HER2-Positive Early Breast Cancer by Age and Hormone Receptor Status: A Cost-Utility Analysis.

PLoS Med 2016 08 9;13(8):e1002067. Epub 2016 Aug 9.

Department of Public Health, University of Otago, Wellington, New Zealand.

Background: The anti-human epidermal growth factor receptor 2 (HER2) monoclonal antibody trastuzumab improves outcomes in patients with node-positive HER2+ early breast cancer. Given trastuzumab's high cost, we aimed to estimate its cost-effectiveness by heterogeneity in age and estrogen receptor (ER) and progesterone receptor (PR) status, which has previously been unexplored, to assist prioritisation.

Methods And Findings: A cost-utility analysis was performed using a Markov macro-simulation model, with a lifetime horizon, comparing a 12-mo regimen of trastuzumab with chemotherapy alone using the latest (2014) effectiveness measures from landmark randomised trials. A New Zealand (NZ) health system perspective was adopted, employing high-quality national administrative data. Incremental quality-adjusted life-years for trastuzumab versus chemotherapy alone are two times higher (2.33 times for the age group 50-54 y; 95% CI 2.29-2.37) for the worst prognosis (ER-/PR-) subtype compared to the best prognosis (ER+/PR+) subtype, causing incremental cost-effectiveness ratios (ICERs) for the former to be less than half those of the latter for the age groups from 25-29 to 90-94 y (0.44 times for the age group 50-54 y; 95% CI 0.43-0.45). If we were to strictly apply an arbitrary cost-effectiveness threshold equal to the NZ gross domestic product per capita (2011 purchasing power parity [PPP]-adjusted: US$30,300; €23,700; £21,200), our study suggests that trastuzumab (2011 PPP-adjusted US$45,400/€35,900/£21,900 for 1 y at formulary prices) may not be cost-effective for ER+ (which are 61% of all) node-positive HER2+ early breast cancer patients but cost-effective for ER-/PR- subtypes (37% of all cases) to age 69 y. Market entry of trastuzumab biosimilars will likely reduce the ICER to below this threshold for premenopausal ER+/PR- cancer but not for ER+/PR+ cancer. Sensitivity analysis using the best-case effectiveness measure for ER+ cancer had the same result. A key limitation was a lack of treatment-effect data by hormone receptor subtype. Heterogeneity was restricted to age and hormone receptor status; tumour size/grade heterogeneity could be explored in future work.

Conclusions: This study highlights how cost-effectiveness can vary greatly by heterogeneity in age and hormone receptor subtype. Resource allocation and licensing of subsidised therapies such as trastuzumab should consider demographic and clinical heterogeneity; there is currently a profound disconnect between how funding decisions are made (largely agnostic to heterogeneity) and the principles of personalised medicine.
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http://dx.doi.org/10.1371/journal.pmed.1002067DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4978494PMC
August 2016

Decision-making in an era of cancer prevention via aspirin: New Zealand needs updated guidelines and risk calculators.

N Z Med J 2016 Mar 11;129(1431):85-92. Epub 2016 Mar 11.

Public Health, University of Otago, Wellington.

Based on new systematic reviews of the evidence, the US Preventive Services Task Force has drafted updated guidelines on the use of low-dose aspirin for the primary prevention of both cardiovascular disease (CVD) and cancer. The Task Force generally recommends consideration of aspirin in adults aged 50-69 years with 10-year CVD risk of at least 10%, in who absolute health gain (reduction of CVD and cancer) is estimated to exceed absolute health loss (increase in bleeds). With the ongoing decline in CVD, current risk calculators for New Zealand are probably outdated, so it is difficult to be precise about what proportion of the population is in this risk category (roughly equivalent to 5-year CVD risk ≥5%). Nevertheless, we suspect that most smokers aged 50-69 years, and some non-smokers, would probably meet the new threshold for taking low-dose aspirin. The country therefore needs updated guidelines and risk calculators that are ideally informed by estimates of absolute net health gain (in quality-adjusted life-years (QALYs) per person) and cost-effectiveness. Other improvements to risk calculators include: epidemiological rigour (eg, by addressing competing mortality); providing enhanced graphical display of risk to enhance risk communication; and possibly capturing the issues of medication disutility and comparison with lifestyle changes.
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March 2016

Alternatives to colonoscopy for population-wide colorectal cancer screening.

Hong Kong Med J 2016 Feb 8;22(1):70-7. Epub 2016 Jan 8.

Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong.

Colorectal cancer is one of the top three cancers in the world in terms of incidence. Colonoscopy, which many regard as the gold standard in diagnosis of colonic polyps and neoplasm, is costly, invasive and labour-intensive, and deemed an unsuitable population-wide index screening tool. Alternative modalities, including guaiac and immunohistochemical faecal occult blood tests, computed tomographic colonography, colon capsule endoscopy, flexible sigmoidoscopy, and double-contrast barium enema are available. The procedures, test characteristics, and their implications are reviewed. Immunohistochemical faecal occult blood testing appears to be the most suitable population-wide screening test for an average-risk population, with flexible sigmoidoscopy as an alternative. More evidence is needed to determine the role of computed tomographic colonography and colon capsule endoscopy in colorectal cancer screening.
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http://dx.doi.org/10.12809/hkmj154685DOI Listing
February 2016

Calcium intake and bone mineral density: systematic review and meta-analysis.

BMJ 2015 Sep 29;351:h4183. Epub 2015 Sep 29.

Department of Medicine, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand

Objective: To determine whether increasing calcium intake from dietary sources affects bone mineral density (BMD) and, if so, whether the effects are similar to those of calcium supplements.

Design: Random effects meta-analysis of randomised controlled trials.

Data Sources: Ovid Medline, Embase, Pubmed, and references from relevant systematic reviews. Initial searches were undertaken in July 2013 and updated in September 2014.

Eligibility Criteria For Selecting Studies: Randomised controlled trials of dietary sources of calcium or calcium supplements (with or without vitamin D) in participants aged over 50 with BMD at the lumbar spine, total hip, femoral neck, total body, or forearm as an outcome.

Results: We identified 59 eligible randomised controlled trials: 15 studied dietary sources of calcium (n=1533) and 51 studied calcium supplements (n=12,257). Increasing calcium intake from dietary sources increased BMD by 0.6-1.0% at the total hip and total body at one year and by 0.7-1.8% at these sites and the lumbar spine and femoral neck at two years. There was no effect on BMD in the forearm. Calcium supplements increased BMD by 0.7-1.8% at all five skeletal sites at one, two, and over two and a half years, but the size of the increase in BMD at later time points was similar to the increase at one year. Increases in BMD were similar in trials of dietary sources of calcium and calcium supplements (except at the forearm), in trials of calcium monotherapy versus co-administered calcium and vitamin D, in trials with calcium doses of ≥ 1000 versus <1000 mg/day and ≤ 500 versus >500 mg/day, and in trials where the baseline dietary calcium intake was <800 versus ≥ 800 mg/day.

Conclusions: Increasing calcium intake from dietary sources or by taking calcium supplements produces small non-progressive increases in BMD, which are unlikely to lead to a clinically significant reduction in risk of fracture.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4784773PMC
http://dx.doi.org/10.1136/bmj.h4183DOI Listing
September 2015