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THE NEW ZEALAND MEDICAL JOURNAL
Journal of the New Zealand Medical Association
CONTENTS
This Issue in the Journal
4 A summary of the original articles featured in this issue
Editorial
6 Why teach human anatomy at Otago School of Medical Sciences? Robin Fraser
Original Articles
9 The profile of body donors at the Otago School of Medical Sciences has it changed? Kathryn McClea, Mark D Stringer Immune thrombocytopaenia in adults: a single-centre retrospective review of patients presenting over 7 years Emma Jane McDonald, Andrew Butler Health service use amongst users of complementary and alternative medicine Megan J Pledger, Jacqueline Cumming, Mili Burnette Chiropractic claims in the English-speaking world Edzard Ernst, Andrew Gilbey
18
26
36
Viewpoints
45 Clinical and epidemiological characteristics of the hospitalised patients due to pandemic H1N1 2009 viral infection: experience at Hutt Hospital, New Zealand Stephen Dee, Sisira Jayathissa Physiology of the placebo effect, and the evidence for changes in brain metabolism Martin Wallace
54
Clinical Correspondence
61 A case of misdiagnosed squamous cell carcinoma due to alternative medical misadventuretime for tightening regulation? Raakhi Mistry, Brecon Wademan, Gary Avery, Swee T Tan Purple urine bag syndrome in a patient with a nephrostomy tube Mohammad I Hirzallah, Donna L DSouza
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NZMJ 9 April 2010, Vol 123 No 1312; ISSN 1175 8716 URL: http://www.nzma.org.nz/journal/123-1312/4068/
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71
A case of green urine due to a traditional Chinese medicine containing methylene blue Choong-Weng Lam, Sau Y J Wong Non-classic congenital adrenal hyperplasia due to 21-hydoxylase deficiency as a cause of infertility and miscarriages Henrik Falhammar Medical image. Punched-out lesions in skull Vishal Sharma, Alka Sharma
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81
Special Series
83 Setting up new learning environments in regional and rural areas Warwick Bagg, Anna J Dare, Barbara J OConnor, Phillippa Poole, James J Reid, Joy Rudland, Mike J Tweed, Tim J Wilkinson
100 Years Ago in the NZMJ

91 Correspondence: Colonial Reception Committee and fund for Dr Macintire
Proceedings
92 101 103 Proceedings of the Waikato Clinical School Research Seminar, Thursday 18 March 2010 Proceedings of the 201st Scientific Meeting of the Otago Medical School Research Society, Thursday 25 March 2010 Proceedings of the Health Research Society of Canterbury Seminar Series, Friday 26 March 2010
Methuselah
107 Selected excerpts from Methuselah
Letters
109 Asthma Control Test scores obtained from an Asthma NZ educational activity Shaun Holt Spontaneous central nervous system bleeding in a child with cyanotic congenital heart disease Syed Ahmed Zaki, Vishal Chavan, Preeti Shanbag Application of mobile phones in improving healthcare delivery Raktim Kumar Ghosh, Ratul K Ghosh, Raktim Kumar Ghosh BMI cut-off point Viroj Wiwanitkit
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115 117
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Medicolegal
118 Health Practitioners Disciplinary Tribunal Professional Misconduct (Med08/87P)
Erratum
121 Capillary glucose meter accuracy and sources of error in the ambulatory setting (Lunt H, Florkowski C, Bignall M, Budgen C) NZMJ
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This Issue in the Journal

The profile of body donors at the Otago School of Medical Scienceshas it changed? Kathryn McClea, Mark D Stringer The Otago School of Medical Sciences continues to depend on altruistic whole body donation for anatomical teaching and research. An anonymous questionnaire was sent to 200 randomly selected donors who registered their bequest to donate their body to the Otago School of Medical Sciences between 2000 and 2009. From 140 replies, it was evident that most people made their bequest after the age of 50 years. Almost all respondents understood that their body would be used for teaching and research. Word of mouth and literature continue to be the dominant methods of learning about body donation. Nearly 40% of bequestees come from families where other members have donated their bodies.
Immune thrombocytopaenia in adults: a single-centre retrospective review of patients presenting over 7 years Emma Jane McDonald, Andrew Butler Immune thrombocytopenia is a common cause of low platelets in the blood (platelets are involved in blood clotting). International guidelines have been published with recommendations for investigation and treatment of patients. These guidelines were generally closely adhered to in Christchurch . We wish to increase awareness both of the need to test for HIV infection in patients presenting with low platelets and not to undertake invasive tests looking for a cause in young patients with isolated low platelet counts.
Health service use amongst users of complementary and alternative medicine Megan J Pledger, Jacqueline Cumming, Mili Burnette We studied data comes from the New Zealand Health Survey 2002/2003 which sampled 12,529 people, aged 1565 years. We compared users and non-users of complementary and alternative medicine (CAM). CAM users are more likely to be middle-aged, rich, well-educated, of European descent, and female. They are more likely to have hard-to-treat conditions and to be less well but actively try to maintain their health. They utilise more health services and are more likely to seek information about their health and medicines.
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Chiropractic claims in the English speaking world Edzard Ernst, Andrew Gilbey A survey of the websites of English-speaking chiropractors (200) and their associations (9) found widespread evidence of direct or indirect claims regarding the chiropractic treatment of asthma, headache/migraine, infant colic, colic, ear infection/earache/otitis media, neck pain, and whiplash. We are not aware of any good quality scientific evidence that chiropractic treatment is effective for any of these conditions. Chiropractic often claims to be scientific and based upon evidence, we therefore urge the chiropractic community to address this situation adequately and urgently by ensuring that claims are only made for the conditions for which there is sound evidence of effectiveness. Currently, we believe such evidence is limited to spinal manipulation for lower back pain.
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Why teach human anatomy at Otago School of Medical Sciences?

Robin Fraser Thorough teaching of human anatomy is the core undergraduate business of the University of Otagos Department of Anatomy and Structural Biology in Dunedin. This may seem a routine and, in this modern era, an unexciting exercise; however, (as reported in this Journal issue) the Departments careful enquiries into the profile of body donors, reasons for donating, and changes in motivation over many years, indicates their contemporary commitment to this essential training of our undergraduate students in normal structure.1 Otago, by an accident in history, has an archive of valuable and historic anatomy and other medical books and manuscripts in its Medical Library, most of which originally belonged to one or other of three men; father, son, and grandson, each called Alexander Monro.2 These men in succession, over a period of 126 years from 1720 to 1846, held the Chair of Anatomy at Edinburgh University. They were also responsible for the teaching of surgery. Thus the importance of structure, function, and healing go back over the centuries, from Edinburgh (in the north) to Dunedin (the Edinburgh of the south). This legacy came to our Medical School via the great grandson, David Monro, a doctor-turned-immigrant farmer and politician in Nelson, New Zealand, who had inherited the collection and donated it to his friend and son-in-law, the Edinburghtrained explorer, naturalist and surgeon Sir James Hector, Founding President of the New Zealand Institute (later the Royal Society of New Zealand) and Chancellor of the University of New Zealand.3 Hector, who first was employed in New Zealand in Otago as a geologist, passed this treasure to our Dunedin Medical School. Emeritus Professor Douglass W Taylor, (a physiologist, so representing function) is the current guardian of this priceless collection, which has surely influenced our current mors of our Universitys teaching and research. I am biased towards structural anatomy, being both an experimental and anatomical pathologist by profession. I tell our students that they must know the normal to explain the abnormal anatomy and physiology in the understanding of the pathogenesis or step-by-step changes leading to disease from abnormal structure and function. These include the smallest of structural changes, such as an individual amino acid, so changing the shape of a vital protein such as alpha-1-antitrypsin leading to emphysema and cirrhosis.4 It is now known that similar conformational changes in proteins lead to other genetic diseases, such as some dementias.5 On the larger scale, changes to the suns structure and function, such as a decrease in sun spots, led to the little Ice Age of 1645 to 1715 and probably the increase in scurvy in Europe from the death of citrus trees.6
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University teaching by statute is research-based, as well as being a vocational apprenticeship in our Faculty.7 The Dunedin anatomists must believe also in thisas evidenced in their well-known diverse research on anatomical ultrastructure, molecular biology, effect of hormones on structure, function and behaviour, as well as the gross dissection of human corpses.1,8 The recent documentary Donated to Science produced in the Dunedin Department and recently shown on TV3, depicted the altruistic behaviour of the donors as well as our students mature and compassionate learning, which augers well for the nations future medical care.9 I noted in the documentary an important aspect was the Otago Universitys regional thanks to the relatives of those who had donated, yet in their current paper some donors are reported that they did not wish a fuss over their own death.1 This documentary may solve both family and donors wishes? In summary, the Human Anatomy course in Dunedin in my opinion is superb and will equip our students to be knowledgeable about structure as well as function and to be thoughtful doctors, surgeons, and medical scientists. In our own field of research in Christchurch, structure and function are supreme. The ultrastructural filter of the liver fenestrated sinusoids (liver sieve) has been shown to control hepatic metabolism of cholesterol and triglycerides in lipoproteins so affecting diseases as diverse as atherosclerosis, and cirrhosis.10 In the United States recent experiments on the filtration of adenovirus vectors (carrying factor IX genes to hepatocytes to cure haemophilia),11 and lipoid nanoparticle vectors (transporting siRNA to inhibit the formation of mutated or foreign proteins in hepatocytes to suppress genetic diseases such as amyloidosis, some cancers and of hepatitis C) have been shown to be dependent on the relative diameter of the vector to that of the fenestrae in the liver sinusoid.12 Decreased fenestral diameter may also decrease immune tolerance to hepatocyte derived proteins. These are examples from our personal medical research interests stressing the importance of structure and function in the treatment and understanding of the pathogenesis of disease. Long live the teaching, understanding, and research into the relationship of structure and function. We give thanks for our early instruction made possible by our beneficent body donors.
Competing interests: None known.
Author information: Robin Fraser, Emeritus Professor Pathology, University of Otago, Christchurch Correspondence: Robin Fraser, Emeritus Professor Pathology, University of Otago, PO Box 4345, Christchurch, New Zealand. Email: robin.fraser@otago.ac.nz References:
1. McClea K, Stringer MD. The profile of body donors at the Otago School of Medical Scienceshas it changed? N Z Med J. 2010;123(1211). http://www.nzma.org.nz/journal/1231312/4050 Taylor DW. The Monro Collection in the Medical Library of the University of Otago. Dunedin: University of Otago Press; 1979. Nathan S, Varnham M, eds. The Amazing World of James Hector. Awa Press, Wellington; 2008.
2. 3.
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Carrell RW, Jeppsson J-O, Laurell C-B, et al. Structure and variation of human 1antitrypsin.. Nature. 1982;298:5872;329-334. 5. Davis RL, Shrimpton AE, Carrell RW, et al. Association between conformational mutations in neuroserpin and onset and severity of dementia. Lancet. 2002;359:2242-47. 6. Eddy JA. The case of the missing sunspots. Scientific American. 1977;236(5):80-88. 7. Fraser R. Undergraduate medical education. N Z Med J. 2001;114:554-5. 8. Jones DG, Fennell S. Bequests, cadavers and dissections: sketches from New Zealand history. N Z Med J. 1991;104:210-212. 9. Donated to Science. Humanity is more than skin deep. PRN Films,(2009) 27 Currie St, Port Chalmers, paul@prnfilms.co.nz 10. Fraser R, Dobbs BR, Rogers GWT. Special Article. Lipoproteins and the liver sieve: the role of the fenestrated sinusoidal endothelium in lipoprotein metabolism, atherosclerosis and cirrhosis. Hepatology. 1995;21(3):863-874. 11. Fraser R, Le Couteur DG, Warren A, et al. The liver sieve and gene therapy [Letter to Editor and Response]. Blood 2003;101:3338-9. 12. Love KT, Mahon KP, Levins CG, et al. Lipid-like materials for low-dose, in vivo gene silencing. Proceedings of the National Academy of Sciences 2010;107(5):1864-1869. 4.
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The profile of body donors at the Otago School of Medical Scienceshas it changed?
Kathryn McClea, Mark D Stringer Abstract Aims In 1992 the characteristics of individuals who bequeathed their bodies to Otago Medical School were reported. The aim of our study was to determine if the profile of bequestees has changed. Methods An anonymous questionnaire was sent to 200 randomly selected donors who registered their bequest between 2000 and 2009. Questions focused on age, gender, marital status, occupation, reason for making the bequest, sources of information, the decision to choose whole body donation, and research. Results There were 140 replies (response rate 70%). As in the previous study, most people bequeathed after the age of 50 years. Few respondents were in healthcare jobs and none was a medical doctor. Reasons for donation have changed slightly; the proportion bequeathing their body primarily to aid medical science and teaching has increased to 90%. Almost all respondents believe their body would be used for teaching and research. Word of mouth and literature continue to be the dominant methods of learning about body donation. Nearly 40% of bequestees come from families where other members have donated their bodies. Conclusions The Otago School of Medical Sciences continues to depend on altruistic whole-body donation for anatomical teaching and research. The profile of our bequestees has changed slightly during the past 20 years. Although there has been no fundamental shift in donor attributes, bequestees appear to be better informed about how their body will be used. The first official bequest to the Otago Medical School was recorded in 1943. Before then, the school was reliant on a supply of unclaimed bodies from psychiatric hospitals and The Benevolent Institution (poor house).1 A survey published by Fennell and Jones in 1992 outlined for the first time the types of people who bequeathed their bodies to the School, and their reasons for doing so.2 Their study sample consisted of individuals who had bequeathed their bodies during the 1960s, 1970s, and 1980s. They found that it was mainly people in their 50s, 60s, and 70s who donated their bodies, with the dominant reason being to aid medical science and teaching. Most had not considered organ donation, or felt that they were too old or ill for their organs to be of any value. At the time of the 1992 survey, cadavers were used wholly for teaching purposes yet 84% of respondents considered that their body would be used for medical research. Today, our Department receives more than 100 registrations each year, and more than 40 bodies (cadavers). Bequests are accepted from Dunedin, Christchurch, and Nelson, and surrounding areas. A number of restrictions are applied to the acceptance of a
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body at the time of death, including body weight, and cause of death. For example, the Department will not accept the body of a person who has displayed rapid onset of dementia, undergone recent complex surgery, or contracted an untreated contagious disease. A person who has lived in the United Kingdom, France or the Republic of Ireland between 1980 and 1996 for a cumulative period of 6 months or more is not able to become a body donor because of the remote possibility of transmitting variant Creutzfeldt-Jakob disease. The aim of the current survey was to determine whether the profile of individuals bequeathing their body to the Otago School of Medical Sciences has changed since the survey published by Fennell and Jones in 1992.2
Methods
The body bequest processTo understand the results of this survey it is important to understand how the bequest programme works. This has recently been described by McClea (2008)3 and only a brief summary of the process follows. When a person first contacts the Department, they are sent information outlining the process of making a bequest, how cadavers are used in the Department, restrictions on acceptance at the time of death, and disposal following anatomical study. Potential donors are informed that the chief value of bequests continues to be for the teaching of anatomy to medical, dental, physiotherapy, physical education and science students and that human material is also used for research. The bequest programme is governed by the New Zealand Human Tissue Act 2008 and the Department is answerable to an Inspector of Anatomy. Donors and a next-of-kin are required to complete a registration form accepting the terms of the bequest. Donors are urged to talk openly with their family regarding their wish as, under current legislation, the Department is not able to accept a persons body if any near relative objects to the bequest after death, even if the donor has previously registered with the Department. The anatomical study of a cadaver extends throughout a teaching year and sometimes beyond. In some cases, human material is retained in the Department for an indefinite period of time. Following the completion of study, the remains are cremated and the ashes scattered. When requested, the Department will arrange to return the ashes of the donor to the relatives but this limits our ability to retain material for long-term study. At the beginning of each teaching year, a whakawatea, or clearing of the way ceremony is held in the Dissecting Room to acknowledge the significance of the cadaver in our society. The Department also holds an annual Thanksgiving Service to which family and friends of donors are invited. The surveyDonors were invited to participate in this survey using a similar selection process to the previous survey,2 namely by selecting those with a Christian name beginning with the letter J who had registered their bequest between January 2000 and June 2009. This sample of 200 bequestees represents 24% of all individuals who completed the bequest registration process during this period (n=843) and 13% of all donors currently registered with the Department (n=1514). Each questionnaire was anonymous and consisted of nine questions, eight of which were the same as in the previous survey (age; gender; marital status; occupation at the time of making the bequest; the main reason for making the bequest; the source of bequest information; the decision to choose whole body donation over organ donation; and whether they believed their body would be used in research). An additional question enquiring about other family members who had donated their body was included. The study received institutional ethical approval from the University of Otago.
Results
From a total of 200 invited participants (94 [47%] female), 140 replies were received giving a response rate of 70% (68 [49%] females). Another 11 questionnaires were returned because the donor had changed their address and in 2 cases the donor had died without fulfilling their bequest. Thus, the true response rate was 75%. Many
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respondents underlined their strong continuing desire to donate their body to the Department. Age and marital status at time of making bequestThe ages of men and women at the time of making their bequest were remarkably similar (Figure 1); the majority of individuals were in their 60s (32% females; 35% males) and 70s (29% females; 26% males). The youngest bequest recorded in this survey was a male in his 20s and the oldest a female in her 90s. Figure 1. Age at time of making bequest
The majority of donors (53% females; 69% males) were married or in a long-term relationship when they decided to donate their body. A smaller proportion were widowed (26% females; 13% males), divorced/separated (13% both sexes), or single (7% female; 6% male). OccupationOccupations of donors at the time of making their bequest varied widely. Of the women, nine had retired, seven did not state an occupation and nine described themselves as housewives. Forty-three female respondents were in paid employment at the time of making their bequest: office/clerical work (12); healthcarerelated jobs such as nursing, pharmacy assistant, and community carer (6); teaching (6); factory work (5); retail work (3); laboratory technician (2); and catering or hairdressing (6). Three women were managers. Of the males, five had retired (two ex-military), two did not state an employment and one was unemployed at the time of making the bequest. Of the remaining 64, 28 (39%) were in manual jobs such as gardening, building, carpentry, electrical engineering and farming and three were in health care related jobs: a psychiatric nurse, first-aid tutor, and an Officer in the Royal New Zealand Army Medical Corps.
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Other occupations included engineering and surveying (3), teaching (4), driver/retail worker (8), and hospitality industry worker (3). There were seven managers and one of each of the following: overseas missionary, ships captain, solicitor, and accountant. Two men were members of the New Zealand armed services at the time of making their bequest. Prime reason for making bequestRespondents cited 209 main reasons for bequeathing their body, some individuals offering more than one reason (Figure 2). 126 (90%) respondents considered that aiding medical science and teaching was the main reason for bequeathing their body. Next in frequency (22% of respondents) was gratitude to the medical profession for treatment received by the respondent, or by relatives and friends. As in the previous survey, many respondents commented that their medical conditions might be of interest to students; these included joint replacements, arterial bypass operations, cancer, multiple sclerosis, and emphysema. All the comments in this section reflected a sincere appreciation for medical treatment received and an unselfish desire to give something back to the medical profession. Four female respondents considered that their experience as a health professional was a major factor in their decision. Figure 2. Prime reason for bequeathing
Twenty-five (18%) respondents referred to a dislike of funerals as a prime reason for bequeathing but only 9 (6%) considered the cost of a funeral as a main factor. One donor indicated that her prime reason for bequeathing her body was the death of her
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daughter from cancer in her 40s and another commented that donation was a cleaner and more useful conclusion than burial. Overall, there were no significant differences in responses between men and women. Sources of informationSeventeen respondents became aware of the bequest programme through more than one source, resulting in 160 sources among 140 respondents (Figure 3). Fifty-two respondents (37%) first became aware of the opportunity to bequeath their body through family or friends. Thirteen percent cited their family doctor as their prime source of information. Many others learnt of the bequest programme through literature (e.g. bequest pamphlets in doctors surgeries, funeral homes, and hospitals) including newspapers (articles and death notices), or television. The other category included 14 donors who could not remember where they had first heard about body donation but had been aware of it for many years; six attributed this knowledge to working in hospitals and others had learned about bequeathing from the Kidney Foundation, from a parent who was a surgeon, and after studying anatomy as a physical education student. Only one respondent had mainly become aware of body donation through an application for a drivers licence among other sources. Figure 3. Main source of bequest information
Fifty-four respondents (39%) were aware of other family members who had donated their bodies, mainly to institutions in New Zealand and Australia but in three cases to medical schools in the UK and India. The relationship to these family members varied from next-of-kin (mother, father, partner, sibling), to in-laws, aunts, uncles and cousins.
Organ donationBequestees were asked why they had chosen whole body donation rather than organ donation. Responses fell into four main categories: To benefit medical research (53 respondents [33 male]). To assist training medical students to become doctors (44 respondents [24 male]). A belief that their organs would be unsuitable for donation (mostly because of old age but in some cases diabetes was specifically mentioned) (29 respondents [9 male]). And a belief that their medical condition(s) would be of particular interest (injuries, diseases and/or surgical procedures) (20 respondents [10 male]).
Thirty-one respondents explicitly stated that whole body donation maximised the opportunities for both teaching and research, whereas organ donation had more limited applications. Eleven respondents commented that they were previously or concurrently registered as organ donors. The rationale for not donating organs because of old age was summed up wonderfully by one donor who wrote You wouldnt like to have model T Ford parts put into a Ford Falcon would you! Use of bodies for research and teachingInformation given to donors at the time of registration explains that bodies are used for research as well as teaching, and an overwhelming 96% of respondents thought their body would be used in this way. Three respondents chose not to answer this question, two considered that their bodies would be used for research only, and one for teaching only.
Discussion
The 1992 survey by Fennell and Jones2 was the first to examine the characteristics of individuals who bequeathed their bodies to science. Only two similar studies have since been published: the first surveyed individuals expressing an interest in whole body donation in the UK4 and the second retrospectively reviewed actual body donors in the USA.5 No previous study has investigated changes in the profile of bequestees over time. The previous Otago survey related to individuals who had bequeathed their bodies during the 1960s, 70s and 80s, whereas the current survey relates to bequestees who had registered since January 2000. We had a gratifying response rate of 70% (compared to 38% in 1992). Numerous similarities and differences between the two surveys are apparent. As in the previous study, most people decided to bequeath after the age of 50 years and a greater proportion of women than men were single at the time of making their bequest. Relatively few respondents were in health care jobs and none was a medical doctor. The broad range of occupations spans the whole spectrum of society and socioeconomic strata. Reasons for donation have changed slightly. In the 1992 report, two-thirds of respondents bequeathed their body primarily to aid medical science and teaching. Recently, this figure has increased to 90%. Encouragingly, from the aspect of informed consent, almost all respondents now acknowledge that their bodies will be used for teaching and research, although the type of research, which tends to focus
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more on structure and function rather than specific diseases, may not be fully appreciated. About one-fifth of respondents, a similar proportion to the previous study, cited gratitude to the medical profession as a main reason for bequeathing. Nearly one in five respondents cited dislike of the ritual of a funeral as a main reason for bequeathing their body. Reassuringly, only 6% of individuals considered that funeral expenses were a factor, compared with 10% in 1992. The average cost of a funeral in New Zealand is currently around $8,500 (personal communication, The Funeral Directors Association of New Zealand). There is no doubt that altruism is the dominant motivation behind most bequests. The willingness to bequeath ones body to medical science varies between societies and may be influenced by ethnicity, religion, and education among other factors. In a random telephone survey of 385 households in Maryland, USA conducted in 2000 half of all individuals reported they would consider whole body donation, although willingness to consider this was more likely among Caucasian individuals and in those with a more advanced level of educational achievement.6 In contrast, from a random sample of 1,950 adults in Sweden in 1990 only 15% were receptive to whole body donation for dissection.7 We are very fortunate in having such an altruistic community of donors prepared to gift their bodies. In this context, it is interesting to note that New Zealand also has an unusually high rate of non-directed (neither genetically or emotionally related) living kidney donation.8 In 2008, figures for non-directed living donor kidney transplants were 8 of 69 (12%) nationally and 4 of 28 (14%) in Christchurch. This compares with Australia where only 0.6% of such transplants have been non-directed.8 Not surprisingly, the sources of information about the bequest programme have changed a little since the previous survey. Word of mouth and printed literature continue to be the most common methods of learning about body donation but, in contrast to the 1992 report, television is now a significant factor and solicitors are no longer a prominent source. Only one respondent became aware of the bequest facility through the internet, perhaps reflecting the computer usage of our study sample. As in 1992, a higher proportion of men than women relied on printed matter for information but the greater reliance by women on family and friends for information was no longer apparent. It was interesting to discover that almost 40% of our bequestees had other family members who had donated, suggesting that this form of altruistic behaviour is not only a feature of individuals but, in some cases, families. Many respondents regard bequeathing their body as being more useful than organ donation although this is confounded by the perception that organs from elderly donors are not likely to be so useful. Unlike the previous survey, no respondents made negative comments about organ transplantation or brain death, probably reflecting how much transplantation has advanced in the last 20 years and how it has become accepted by the public as part of routine medical practice. We did not explore the reasons for whole body donation rather than organ donation but it is possible that some bequestees believe that whole body donation is more compatible with keeping body parts together; this is certainly a major reason why
some family members object to organ donation from a deceased relative, even if that relative expressed the desire to be an organ donor when they were alive.9 Our survey has several limitations. Because we were interested in how things have changed, our questionnaire remained very similar to that used in the 1992 survey. Neither survey collected data on religious affiliation or ethnicity. Whilst we have had donors from Mori and other ethnic groups, it is our impression that the vast majority of bequestees are of New Zealand European descent. The Otago School of Medical Sciences continues to depend on and benefit from a robust body bequest programme. Body donations have enabled us to develop a wide range of training courses for both undergraduate and postgraduate health professionals.10 Several universities in the United States temporarily withdrew their undergraduate dissection programmes, only to reinstate them when they found that the standard of anatomical knowledge in their students was adversely affected.11 Moreover, it is well known that the experience gained from cadaver dissection encompasses much more than learning anatomy.1113 Body donation also greatly facilitates research in clinical anatomy. Like Jones et al (2002),14 we continue to believe that a research ethos is important since it encourages a more critical evidence-based approach to teaching and counteracts the diminishing status of anatomy as a research-led discipline.15 To ensure this research ethos is not only maintained, but developed, a body bequest programme is vital. However, the maintenance of high ethical standards is essential, particularly in view of notable high-profile scandals surrounding the misuse of body parts.16
Author information: Kathryn McClea, Bequest Administrator; Mark D Stringer, Professor; Department of Anatomy and Structural Biology, Otago School of Medical Sciences, University of Otago, Dunedin Acknowledgements: We thank all those who kindly contributed to this survey and make the body bequest programme possible. We are also grateful to Professor Gareth Jones for his helpful comments on the manuscript. Correspondence: Kathryn McClea, Bequest Administrator, Department of Anatomy and Structural Biology, Otago School of Medical Sciences, PO Box 913, University of Otago, Dunedin, New Zealand. Fax: +64 (0)3 4797254; email: kathryn.mcclea@stonebow.otago.ac.nz References:
1. 2. 3. Jones DG, Fennell S. Bequests, cadavers and dissections: sketches from New Zealand history. N Z Med J. 1991;104:210-212. Fennell S, Jones DG. The bequest of human bodies for dissection: a case study in the Otago Medical School. N Z Med J. 1992;105:472-474. McClea K. The Bequest Programme at the University of Otago: cadavers donated for clinical anatomy teaching N Z Med J. 2008;121(1274). http://www.nzma.org.nz/journal/1211274/3076/content.pdf Richardson R, Hurwitz B. Donors' attitudes towards body donation for dissection. Lancet. 1995;346:277-9. Dluzen DE, Brammer CM, Bernard JC, Keyser ML. Survey of cadaveric donors to a body donation program: 19781993. Clin Anat. 1996;9:183192.
4. 5.
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6. 7. 8.
9. 10. 11. 12. 13. 14. 15. 16.
Boulware LE, Ratner LE, Cooper LA, et al. Whole body donation for medical science: a population-based study. Clin Anat. 2004;17(7):570-7. Sanner M. A comparison of public attitudes toward autopsy, organ donation, and anatomic dissection. A Swedish survey. JAMA. 1994;271(4):284-8. Armstrong S, Endre Z, Lynn K, et al. Eleven year experience of non-directed living renal donation in Christchurch, New Zealand (abstract). Presented at 14th European Society for Organ Transplantation Congress, Paris 2009. Sque M, Long T, Payne S, Allardyce D. Why relatives do not donate organs for transplants: 'sacrifice' or 'gift of life'? J Adv Nurs. 2008;61(2):134-44. Cornwall J, Stringer MD. The wider importance of cadavers: educational and research diversity from a body bequest program. Anat Sci Educ. 2009;2:234237. Rizzolo L, Stewart WB. Should we continue teaching anatomy by dissection when ? Anat Rec. 2006;289B:215218. Aziz MA, McKenzie JC, Wilson JS, et al. The human cadaver in the age of biomedical informatics. Anat Rec. 2002;269B:2032. Parker LM. Anatomical dissection: Why are we cutting it out? Dissection in undergraduate teaching. ANZ J Surg. 2002;72:910912. Jones DG, Dias GJ, Mercer S, et al. Clinical anatomy research in a research-driven anatomy department. Clin Anat. 2002;15:228232. Dyer GS, Thorndike ME. Quidne mortui vivos docent? The evolving purpose of human dissection in medical education. Acad Med. 2000;75:969979. Jones DG, Whitaker MI. Speaking for the Dead. Ashgate Publishing Ltd., Farnham, England 2009.
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Immune thrombocytopaenia in adults: a single-centre retrospective review of patients presenting over 7 years
Emma Jane McDonald, Andrew Butler Abstract Aim To compare the investigation and management of adult immune thrombocytopaenia in our institution with international guidelines. Method Adults presenting with immune thrombocytopaenia over a 7-year period were identified from a database. Written and electronic case records were reviewed. Patient demographics, results of investigations and management were recorded and compared with international guidelines. Results ITP was mild or asymptomatic in 57 of 67 patients (85%). Bone marrow aspiration was performed in 45 patients including 23 of 45 patients under 60 yrs. 15 patients (22%) were tested for HIV at presentation. 28 patients (42%) were inpatients including 18 patients who were asymptomatic or mildly symptomatic. 53 patients (79%) received first-line treatment with oral prednisone including 6 who were asymptomatic with platelets >30109/L. Splenectomy was performed in 17 patients at a median 7 months after diagnosis. Conclusion Guidelines were followed in most cases although bone marrow aspirates were often performed unnecessarily in young patients. HIV testing was infrequently requested and should be considered in all new patients presenting with ITP. Asymptomatic patients have a low risk of serious or life-threatening bleeding and do not require admission to hospital. Most patients will eventually achieve a platelet count >30109/L off treatment. Immune thrombocytopaenic purpura (ITP) is an autoimmune condition in which reduced production and increased peripheral destruction of platelets occurs. The incidence is between 1 per 1000 to 1 per 10,000 people and increases with increasing age.1,2 Approximately 30% of patients will have chronic thrombocytopaenia which is refractory to first and second-line treatments.3 Spontaneous remission in adult patients is less common than in children. The bleeding risk remains low even with a platelet count less than 30109/L. The fatal bleeding rate is 0.020.04 cases per patient year in those with a platelet count persistently less than 30109/L.4 There have been few randomised controlled trials to guide investigation and management. A review of UK practice in paediatric patients was published in 1997.5 Guidelines based on expert opinion have been published by the American Society of Haematology6 and the British Committee for Standards in Haematology7 with the aim of standardising investigation and treatment of this condition. We retrospectively reviewed a cohort of patients with ITP treated at our institution to compare local practice with these guidelines.
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Methods
The institution database was searched for patients diagnosed with ITP between 2000 and 2007. We selected patients with idiopathic immune thrombocytopaenia for whom no underlying or associated disease was found. A retrospective case record analysis was performed to record patient age, date of presentation, symptoms at presentation (categorised by type and severity of symptoms) and initial investigations. An investigation was considered as not performed if we were unable to find a result in either the clinical or electronic records. The reason for performing a bone marrow was recorded if stated in the written clinical record. The numbers of inpatient days and platelet transfusions were recorded. Treatments were recorded as were the response, time to response and any treatment specific side-effects. We recorded the number of patients who continue to be followed-up and the most recent platelet count available. Symptoms were graded as previously described in a paediatric population asymptomatic, mild (bruising, petechiae, occasional minor epistaxis, very little or no interference with daily living), moderate (more severe skin manifestations with some mucosal lesions, and more troublesome epistaxis and menorrhagia) and severe (bleeding episodes requiring hospital admission and/or blood transfusion, symptoms interfering with quality of life).5 Hospital admission alone without significant symptoms was not considered as severe. The response to treatment was graded as no response (NR); partial response (PR), platelet count rising to >50 or >100 but <150 in those patients whose platelet count was >50 at diagnosis; complete response (CR), platelet count > 150; or progressive disease. Time to response was taken as the number of days between the start of treatment and reaching a platelet count >30. The data was analysed using Microsoft Office Excel 2003. The standards that we compared our practice to are taken from the British Committee for Standards in Haematology Guidelines on the investigation and management of ITP.7 We looked at the following recommendations: All adult patients with suspected ITP should have a full blood count and blood film to confirm the presence of thrombocytopaenia and an autoimmune profile. No other routine blood investigations are recommended if the history is typical of ITP; platelet antibody testing is not advised. A bone marrow examination is not routinely required unless there are atypical features in the history or examination; the patient is over 60 years old; the patient is due to undergo a splenectomy; those who relapse, on or off treatment, after a complete remission. It is suggested that patients with a platelet count over 30 do not need treatment unless they have symptoms or signs. The first-line treatments are steroids and IVIG, with IVIG recommended if more urgent treatment is required.
Results
A total of 123 patients records were reviewed. Six patients were excluded from the analysis as records were incomplete or the initial diagnostic work-up had been completed at another centre. Sixty two patients were seen in the haematology outpatient clinic. Fifty five patients with suspected mild ITP were initially managed with written advice to the referring practitioner. Additional advice was requested for 15 of these 55 patients. Eight of the 15 patients were subsequently seen by a haematologist and 5 patients who were followed in the haematology clinic were included in the subsequent analysis. Data regarding the remaining 50 patients who were managed with written advice have been previously published.8 The remaining 67 patients were the subject of this report. Figure 1 shows the frequency with which investigations were performed.
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Figure 1. Initial investigations
100 90 80 70 60 50 40 30 20 10 0
Patients tested (%)
74 65 65 62 52 43 23 22
16
12
12
All patients had a full blood count (FBC). The most frequently requested investigations were anti-nuclear antibodies (74%), lupus anticoagulant (65%) and a coagulation screen (62%). All 15 patients (22%) who were tested for HIV at presentation were sero-negative. Of 51 patients not tested at diagnosis one was later found to be HIV positive (data not available for 1 patient). Eight of 35 patients who received second-line treatment were tested for Helicobacter pylori and none were positive. Bone marrow aspiration was performed at presentation in 45 patients (67%); 23 of 45 patients were younger than 60 years; 18/23 had asymptomatic or mild disease at presentation. Three of 25 patients aged 60 years and over did not have bone marrow aspiration at presentation. One of the three patients had a bone marrow aspirate after presentation and before proceeding to splenectomy. ITP was mild or asymptomatic in 57 of 67 patients (85%) including 22 patients with platelets <10109/L. 7/67 patients had moderate symptoms; 2/67 patients presented with severe symptoms (1 patient with menorrhagia presented with a haemoglobin of 45 g/L; 1 patient had severe epistaxis); data was not available for 1 patient. There were no deaths attributable to thrombocytopaenia and no cases of intracranial haemorrhage. Symptoms were more common when the platelet count was less than 10109/L (Figure 2). One patient with severe symptoms and a platelet count between 50-99109/L had significant underlying gynaecological pathology which contributed to the bleeding
An
Bo
uc le ar ne an m tib ar o r Lu ow die pu as s s pi an tic rate oa gu Bo C la ne oa gu nt m ar la ro tio w n Im tre m u n phi ne og lo bu B1 lin s 2 H IV / fola an te tib od C oo ie Pl m s at b el 's et an test tib od H ie el s ic ob ac te r
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tin
Figure 2. Severity of symptoms according to platelet count
30 25 No. of patients 20 15 10 5 0
<1 0 -2 9 -4 9 -9 9 9 30 20 50 >1 0 -1 0
Severe Mod Mild Asymptomatic
10
Platelet count x 10 /l
Twenty-eight patients (42%) were admitted to hospital including 18 patients who were asymptomatic or mildly symptomatic. Twenty-one of 29 patients (72%) with platelets <10109/L were admitted, 8/29 (28%) were not. The proportion of patients admitted fell as the platelet count increased (Figure 3). The median length of stay was 3.5 days with a range of 1-13 days. One patient admitted for 13 days had non-medical problems preventing discharge. 1/67 patients received a platelet transfusion on a single occasion when the platelet count was 8109/L prior to cardioversion for supraventricular tachycardia. Twelve of 67 patients did not receive immediate treatment. Fifty-five of 67 patients (82%) received first-line treatment with either oral prednisone (n=53) or IVIG (n=2). Six of 55 patients who received treatment were asymptomatic with platelets >30. Forty-three of 53 patients receiving prednisone achieved a response (CR 18; PR 25; NR 9; PD 1) which occurred after a median 6 days. Both patients who received first-line treatment with IVIG had a complete response after one and two days. Patients requiring subsequent lines of treatment are summarised in Figure 4.
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Figure 3. Inpatients according to platelet count
35 30 No. of patients 25 20 15 10 5 0
<1 0 -1 -2 9 -4 9 20 30 50 -9 9 9
OP IP
10
Platelet count x 10 /l
Figure 4. Summary of treatment
60 50 40 30 20 10 0 1st 2nd 3rd 4th 5th Line of treatment Vincristine Azathiaprine Splenectomy IVIG Prednisone
No. patients
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Splenectomy was performed in 17 patients (9 female, 8 male) and data was available for 14/17 patients. The median age at the time of splenectomy was 48 years (range 1676). The operation was performed at median 7 months after diagnosis (range 236months). The numbers of patients receiving first-, second-, and third-line treatment prior to surgery were 8, 6 and 1 respectively. These treatments included prednisone alone or prednisone and IVIG; the third-line treatment used was azathioprine. Eight operations were performed prior to 2002 and 7 between 2003 and 2005. Eleven patients had a bone marrow examination at diagnosis; 2 patients did not have one at diagnosis but did so prior to splenectomy; 2 did not have a bone marrow examination at any stage. 12 patients achieved a CR; 3 patients received further treatment, of whom one did not achieve any response and has since been entered into the RAISE trial studying the effect of Eltrombopag. Twenty one of 67 patients (31%) were followed-up in the haematology clinic for a median 21 months. 46 patients were followed up by their general practitioner. Figure 5 shows the platelet count for these patients at last follow-up. Six of 67 patients (9%) have a platelet count persistently <30109/L. The number of patients with platelet counts 30-49109/L, 50-99109/L and >100109/L were 4, 11 and 46 respectively. Figure 5. Platelet count at follow up (median 21 months)
50 45 40 No. of patients 35 30 25 20 15 10 5 0 <10 10-29 30-49 Platelet count x10 /l

9
50-99
>100
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Discussion
The investigation of patients presenting with thrombocytopaenia is directed towards excluding causes other than ITP. Bone marrow examination is recommended for selected patients: age over 60 years; before splenectomy; following relapse; and those with atypical features.7 In our institution bone marrow aspirates were performed without explanation in some younger patients for whom the likelihood of an alternative diagnosis was low. It is possible in these cases that the clinician felt the presentation was atypical for ITP although such no reason was recorded in the clinical notes and none was apparent on review of the data. HIV antibody screening was infrequently requested and should be considered in all new patients presenting with thrombocytopaenia. Asymptomatic patients have a low risk of serious or life-threatening bleeding and do not always require admission to hospital. No randomised trials have been performed to determine the clinical outcomes of treatment of adult ITP and published guidelines therefore reflect a wide variety opinion. In adult patients active treatment is rarely required if the platelet count is more than 30109/L and there is no bleeding. In line with current recommendations prednisone was used as first-line treatment with IVIG used in patients with significant bleeding where a more rapid response to treatment was required. In our patients the response to prednisone was seen after a median of 6 days (range 2 to 16 days). Second-line treatments do not need to be considered before this time unless the patient has bleeding complications. Six patients have platelet counts persistently <30109/L consistent with published data showing that around 10% patients develop chronic, refractory ITP.9 Splenectomy is the only treatment for adult ITP that is considered potentially curative but more than a third of patients will relapse and there is a risk of both immediate and long-term morbidity and mortality.10 The role of splenectomy in the management of ITP has been questioned with the emergence of new treatments and studies supporting the avoidance of aggressive strategies in patients with mild to moderate disease. It is unnecessary for a patient presenting with uncomplicated ITP to require a splenectomy as their second and probably even third-line of treatment in the absence of severe or life-threatening bleeding. New agents e.g. anti-D immunoglobulin, anti-CD20 monoclonal antibody (Rituximab) and thrombopoetin receptor agonists (Eltrombopag) may eventually replace splenectomy although these agents need further evaluation in clinical trials and are not widely available in New Zealand. The low uptake of splenectomy-sparing strategies in our cohort of patients most likely reflects the high cost, lack of availability of these treatments in New Zealand during the study period and lack of randomised trials comparing these with traditional treatment options.
Conclusion
This audit found disparity between our practice and current recommendations for the investigation of ITP. It highlights that younger patients with typical features of ITP do not routinely require bone marrow biopsy at presentation but all patients should be tested for exposure to HIV. Most patients treated at our institution responded to first-
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line therapy with oral corticosteroids but a minority developed chronic, refractory thrombocytopaenia consistent with previously published series.
Author information: Emma Jane McDonald, Specialist Registrar in Haematology, Christchurch Hospital, Christchurch; Andrew Butler, Consultant Haematologist, Christchurch Hospital, Christchurch Acknowledgements: We thank Norma Gilmartin as well as Drs Fernyhough, Ganly, Gibbons, Smith, and Spearing for access to patient records. Correspondence: Dr Andrew Butler, Canterbury Health Laboratories, PO Box 151, Christchurch, New Zealand. Fax: +64 (0)3 3641067. andrew.butler@cdhb.govt.nz References:
Cines DB, Blanchette VS. Immune Thrombocytopenic Purpura. New England Journal of Medicine 2002;346(13):995-1008. 2. Frederiksen H, Schmidt K. The incidence of idiopathic thrombocytopenic purpura in adults increases with age. Blood 1999;94(3):909-13. 3. McMillan R, Durette C. Long-term outcomes in adults with chronic ITP after splenectomy failure. In: Blood; 2004:956-60. 4. Cohen YC, Djulbegovic B, Shamai-Lubovitz O, Mozes B. The bleeding risk and natural history of idiopathic thrombocytopenic purpura in patients with persistent low platelet counts. Arch Intern Med 2000;160(11):1630-8. 5. Bolton-Maggs PHB, Moon I. Assessment of UK practice for management of acute childhood idiopathic thrombocytopenic purpura against published guidelines. Lancet 1997;350:620-3. 6. George JN, Woolf SH, Raskob GE, et al. Idiopathic thrombocytopenic purpura: a practice guideline developed by explicit methods for the American Society of Hematology [see comments]. Blood 1996;88(1):3-40. 7. Provan D, Norfolk D, Bolton-Maggs P, et al. Guidelines for the investigation and management of idiopathic thrombocytopenic purpura in adults, children and in pregnancy. Br J Haematol 2003;120(4):574-96. 8. Ganly PS, Keeman H, Spearing RL, et al. Written advice can provide a safe and acceptable alternative to new patient assessment for selected referrals to haematologists. Medical Journal of Australasia 2008;188:9-12. 9. Portielje JE, Westendorp RG, Kluin-Nelemans HC, Brand A. Morbidity and mortality in adults with idiopathic thrombocytopenic purpura. Blood 2001;97(9):2549-54. 10. Kojouri K, Vesely SK, Terrell DR, George JN. Splenectomy for adult patients with idiopathic thrombocytopenic purpura: a systematic review to assess long-term platelet count responses, prediction of response, and surgical complications. Blood 2004;104(9):2623-34. 1.
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Health service use amongst users of complementary and alternative medicine

Megan J Pledger, Jacqueline Cumming, Mili Burnette Abstract Aim To describe people using complementary and alternative medicines (CAM) and to compare their utilisation of health services with non-CAM users. Methods The data comes from the New Zealand Health Survey 2002/2003 which sampled 12,529 people, aged 1565 years, living in private dwellings in New Zealand. Participants self-reported socio-demographic details, health status, and health service use. Proportions (and 95% confidence intervals) of people using each CAM service are presented. CAM and non-CAM users are compared across a range of factors using regression, logistic regression or multinomial regression so that the different age and sex structure in the two groups can be accounted for. Results CAM users are more likely to be middle-aged, rich, well-educated, of European descent and female. They are more likely to have hard to treat conditions and to be less well but actively try to maintain their health. They utilise more health services and are more likely to seek information about their health and medicines. Complementary and alternative medicines (CAM) are a loosely defined group of medical practices that typically lie outside of mainstream medical practice. Efforts to quantify their use in the population depends on what practices are included in the definition and this makes comparisons across studies problematic. Surveys reporting on the use of CAM across population groups include one by Eisenberg1 which found a 1-year prevalence rate of 34% for CAM use in the United States and an average of 19 visits a year to CAM providers. Middle-aged, female, educated whites were the most frequent users. From this study, there were more visits to CAM providers than to primary care physicians. A second United States study found 42% of those aged 18 years and over had used some type of alternative care in the past year, with the most common therapies being herbal therapy (17%), chiropractic (16%), massage therapy (14%), and vitamin therapy (13%). 2 A third study found a similar prevalence rate (40%) with popular therapies including chiropractic (15.7%), lifestyle diet (8%), exercise (7.2%), and relaxation (6.9%). The three most powerful predictors were high educational level, poor health status and a holistic approach to health. 3 A further United States study asked about use of chiropractic, massage, relaxation or acupuncture, with prevalence rates of 6.8%, 3.1%, 1.3%, and 0.4% respectively. 4 A United Kingdom study found a prevalence rate of 8.5% for all forms of CAM use. This figure is lower than the prevalence rate found elsewhere, possibly explained by
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the private funding of CAM in the United Kingdom and the timing of the survey, which was undertaken during a difficult economic period. 5 Studies by MacLennan and colleagues6 in South Australia show a much higher rate of CAM use. However, in his review Ernst found the survey was confusing, as it included items not usually counted as CAM, such as vitamins, and used overlapping categories7; the study also included over-the-counter medicines. 6 In Germany, a study found a 65% prevalence rate in 1996, but it was not clear if this was a lifetime or 1-year rate. Women used CAM more frequently than men. 8 In Canada, 15% of the population reported seeing a CAM provider in 1994/95 (the study included only CAM provided by practitioners, not self-prescribed use). Those disproportionately likely to use CAM were women, people who had received higher education and people aged 25-64 years. 9 In Ernsts review, only one reliable longitudinal study is reported. Over the period of that study, CAM use increased from 33.8% in 1990 to 42.1% in 1997 in the United States. Use of medical herbalism showed the biggest increase over time. 10 Later studies support the findings from the above longitudinal study. A Canadian study found the prevalence of use of CAM in 1998/99 (19%) had increased from 1994/95 (15%). This study also found that women were more likely to use CAM, when other factors were taken into account, although the percentage of men and women using chiropractic services was the same. A greater proportion of those aged 2544 years used CAM in the Canadian studies and a lower proportion of those aged 1824 and 65 years and older. Those with at least some post-secondary education and those in higher household income groups were more likely to consult an alternative practitioner. Those with chronic illnesses were also more likely to consult alternative practitioners, even after other factors were taken into account. Those using alternative practitioners were more likely to also have seen a specialist in the past year, to have had 10 or more physician visits in that time, and to have had their blood pressure checked; these trends remained even when controlling for chronic conditions. 11 Similarly a South Australian study undertaken in 1993, 2000 and 2004 showed a significant increase in use of CAM from 11.1% to 16.6% to 24.9% (p<0.05) respectively, with women in particular increasing their use of herbal medicines over this time. However, expenditure on CAM fell in South Australia between 2000 and 2004, suggesting that CAM users were using fewer CAMs per person. 12 CAM use was greatest in women, and in individuals with post-secondary school education, aged 2544 and with household incomes over $30,000, living in metropolitan areas and born in Australia. CAM use was less likely among those aged 65 years and over, separated or divorced, with no post-secondary school education and living in households with incomes of less than $30,000 in total. The National Center for Complementary and Alternative Medicine analysed data from a 2004 National Health Interview Survey in the United States. It found that 36% of adults were using some form of CAM, although the prevalence rate rose to 62% when including prayer specifically for health reasons and megavitamin therapy. The survey found that women were more likely than men to use CAM, as were people from
higher educational backgrounds, those who had been hospitalised in the past year, and former smokers compared with current smokers and those who had never smoked. 13 There is limited research in New Zealand on CAM. The Ministerial Advisory Committee on Complementary and Alternative Health reports on a 1997 New Zealand Consumers Institute survey which was conducted with their members and which found that just over 50% of respondents had tried a non-conventional therapy. In another 1997 survey reported by the advisory committee, the New Zealand Charter of Health Practitioners found 74% of New Zealand households using vitamins, minerals, amino acids, herbal remedies, or other CAM products. 14 Researchers in New Zealand have focused in particular on alternative therapy use in cancer patients. One study found high levels of uncertainty over the effectiveness of such therapies for cancer treatment, suggesting the need for further education. 15 In addition, it appears CAM use (including vitamins, spiritual, and diets) may be common among New Zealand cancer patients and often followed without consultation with the oncologist. 16 A study of 26-year-olds found one in ten used an unconventional practitioner. These users were characterised by relative affluence, frequent medical service use, poorer perceived health and greater likelihood of reporting a back, neck or shoulder problem. Women were more likely to use unconventional practitioners than men. 17 In one survey of people who presented themselves to a Hamilton hospital for various reasons, a third of those surveyed indicating they used alternative therapies. Common therapies used by patients include Arnica, Rescue Remedy and St Johns Wort. The study author notes two particular issues arising from the research: first, over 60% of the users did not realise that alternative medicines may react with medication; and second, over half did not report to their doctors that they were using the remedies. The author suggests that users of alternative medicines are unaware of the potential risks, and notes the lack of education of both doctors and patients on the use of alternative medicines. 18 A nationwide study that updated information on general practitioners views and use of CAM clearly shows the different viewpoints of general practitioners (GPs) as to whether therapies are conventional or CAM. Specifically, around 20% of GPs practised one or more CAM therapies, in particular acupuncture (10%) and herbal medicine (5%), and 32% had formal training in one or more CAM therapies. Almost 95% of GPs referred patients to one or more CAM therapies. The authors suggest that while there was a decrease in the number of GPs who had practised CAM therapy between 1990 and 2005, the number of patient referrals to CAM practitioners had increased. GPs also felt more education on CAM should be included as part of their medical education. 19
Methods
Confidentialised, unit record data from the 2002/2003 National Health Survey were supplied by the Ministry of Health.20 This data set contains 12,529 respondents, aged 1565 years old, who were living in a private dwelling in New Zealand. The survey over-sampled Maori, Pacific and Asian Peoples and used a complex method of sampling, however the survey has been weighted to produce a representative sample. Estimates produced by these weights form unbiased estimates of population values.
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The data set also includes a set of 100 replicate weights which were created using the delete-group method.20 Each of these weights creates an estimate. The variance of these 100 estimates around the unbiased estimate gives the sampling variance of the unbiased estimate. For the purpose of this paper, Sudaan21 was used to do these calculations. Respondents were asked a range of questions about their health, including the SF36 questionnaire health service use, risk factors, including the AUDIT questionnaire on alcohol use, and sociodemographic factors. They were also asked about their use of a range of complementary or alternative health services and were then asked to nominate any that hadnt been covered. Except for height and weight which were measured, the responses given were self-report. Respondents could answer the question with dont know or not respond. If the number in both categories was less than 1% then they were excluded from the analysis. If the number was more than 1% then they were assigned a category of their own. There were generally few people answering in either category. Proportions are used to describe what CAM services people use and means are used to describe how often they are used. CAM and non-CAM users are compared across a range of factors. The comparisons were tested using regression techniques depending on the question type and the comparisons were adjusted for age and sex. For questions in the survey where respondents could choose only one of two possible answers, logistic regression was used. For questions where respondents could choose only once answer from a range of answers, multinomial logistic regression was used. For questions where respondents could select any number of answers from a range of answers, logistic regression was used on each answer from that range. If the question was numeric than regression was used. There is said to be a difference between the two groups if the difference is significant at the 5% level. All reported differences can be assumed to be significant unless a p-value is given indicating otherwise. The relative sampling error (RSE) is calculated for each estimate and is annotated in the tables. If the RSE is between 30% and 50% then the data should be used with caution. If it is over 50% the data is generally considered too unreliable for most practical purposes.
Results
The proportion of people using a CAM service over a twelve month period was 23.4% (95% CI 22.424.5). The different CAM types appear in Table 1 and show that people were most likely to visit a massage therapist and chiropractor. The people who visited a CAM service were asked why they used the service. The most popular reasons were 1) that they had a condition that other health providers couldnt treat (53%, 95% CI 50.556.1), 2) they were referred by friends and family (29.2%, 95% CI 26.731.8) or 3) they required specialist services (12.5%, 95% CI 10.814.5). For 12.0% (95% CI 10.413.8) of people, a GP referred them. Respondents who used CAM services were asked if they had seen a GP about the same condition and 33.4% (95% CI 30.736.2) said they had. People who use CAM were more likely to be middle-aged, female and be of European descent. They were likely to be richer, to be more highly educated and to be an Administrator/Manager if they were employed (see Table 2). CAM users were less likely to have heart disease than non-CAM users. They were more likely to have hard-to-treat conditions e.g. spinal disorders, arthritis, migraines, irritable bowel and other bowel problems, and depression (see Table 3). All eight SF36 scales show that CAM users have significantly lower average health status (data not presented).
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Table 1. Utilisation of different CAM services

All 95% Confidence Interval
Estimate
Number of People1 (n) 12527 CAM Service use in the last year Massage Therapist Yes (%) 9.1 (8.3, 9.9) Number of consults per year for those who visit (n) 5.9 (5.2, 6.7) Acupuncturist Yes (%) 2.6 (2.3, 3.0) Number of consults per year for those who visit (n) 6.1 (4.8, 7.3) Homeopath or naturopath Yes (%) 4.5 (3.9, 5.1) Number of consults per year for those who visit (n) 3.9* (2.6, 5.3) Feldenkrais or Alexander teacher Yes (%) 0.2** (0.1, 0.4) Number of consults per year for those who visit (n) 7.2** (2.5, 11.9) Herbalist Yes (%) 1.8 (1.5, 2.2) Number of consults per year for those who visit (n) 3.7 (2.9, 4.5) Osteopath Yes (%) 4.9 (4.4, 5.5) Number of consults per year for those who visit (n) 5.1 (4.3, 5.9) Aromatherapist Yes (%) 0.7* (0.5, 1.0) Number of consults per year for those who visit (n) 6.2* (3.7, 8.7) Chiropractor Yes (%) 6.1 (5.6, 6.7) Number of consults per year for those who visit (n) 8.3 (7.0, 9.6) Traditional Chinese medicine practioner Yes (%) 1.4 (1.1, 1.7) Number of consults per year for those who visit (n) 4.5* (2.9, 6.1) Spiritual healer Yes (%) 1.9 (1.6, 2.3) Number of consults per year for those who visit (n) 6.5 (4.7, 8.3) Maori traditional healer Yes (%) 0.9 (0.7, 1.1) Number of consults per year for those who visit (n) 6.5* (4.3, 8.7) Pactific Traditional Healer Yes (%) 0.2* (0.2, 0.4) Number of consults per year for those who visit (n) 6.8** (3.3, 10.4) Other Yes (%) 1.3 (1.0, 1.6) Number of consults per year for those who visit (n) 5.9* (4.0, 7.9) Notes 1: The sample contains 12529 participants of whom 2 have missing responses to the CAM question. 2: A * indicates that the relative sampling error is between 0.30 and 0.5 3: A ** indicates the relative sampling error is over 0.5 4: A - indicates that there are less than 10 participants giving information for that cell
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Table 2. Demographics of CAM and non-CAM users

CAM Users Estimate 95% CI Non-CAM Users Estimate 9753 18.1 18.0 19.5 16.0 12.0 8.6 7.8 51.2 48.8 81.0 11.0 5.7 6.9 16.9 19.5 20.0 22.3 21.4 23.8 29.3 27.1 19.7 12.3 17.2 6.6 7.7 17.9 9.4 12.8 6.3 9.8 0.7* 3.8 15.9 15.9 12.4 10.6 15.7 25.0 36.3 62.2 1.5 (17.4, (17.4, (18.9, (15.5, (11.5, (8.3, (7.6, 18.7) 18.6) 20.0) 16.6) 12.4) 8.9) 8.1) 0.0313 0.2892 0.0002 0.0000 0.3531 0.0000 0.0000 0.0000 0.0000 0.0000 0.2906 0.0000 0.0000 0.0000 0.9849 0.0360 0.0304 0.0000 0.0000 0.6511 0.1437 0.0006 0.0000 0.8586 0.5479 0.7350 0.6071 0.9745 0.0996 0.0430 0.0001 0.0910 0.9661 0.0000 0.0173 0.1393 0.0410 0.3809 0.0000 0.0000 0.0000 0.7513 95% CI p-value for difference between groups 6
2274 Number of People1 (n) Age Group7 (col % of each CAM group) 15-24 14.9 (12.8, 17.2) 25-34 19.4 (17.5, 21.5) 35-44 24.0 (22.3, 25.9) 45-54 21.3 (19.6, 23.1) 55-64 11.1 (9.8, 12.6) 65-74 6.0 (5.1, 7.0) 75+ 3.2 (2.6, 4.0) Sex 8 (col % of each CAM group) Men 37.7 (35.2, 40.3) Women 62.3 (59.7, 64.8) Ethnicity 9 (% of each CAM group) NZ European/ Other 89.0 (87.7, 90.2) Maori 10.5 (9.5, 11.7) Pacific People 2.2 (1.7, 2.9) Asian 3.0 (2.4, 3.7) NZ Deprivation Index 2001 (col % of each CAM group) Quintile 1 23.9 (22.1, 25.8) Quintile 2 19.4 (17.7, 21.3) Quintile 3 22.3 (20.5, 24.1) Quintile 4 19.4 (17.7, 21.3) Quintile 5 15.0 (13.3, 17.0) Highest Educational Qualifications (col % of each CAM group) None 16.7 (14.8, 18.8) School 29.2 (26.8, 31.7) Trade or Professional 28.2 (25.8, 30.7) University 25.9 (23.7, 28.3) Current Employment (col % of each CAM group) Administrator/Manager 19.2 (17.0, 21.7) Professionals 18.6 (16.1, 21.4) Technicians & Associated 7.1 (5.8, 8.6) Clerks 10.1 (8.5, 12.0) Service & Sales Workers 18.5 (16.1, 21.1) Agriculture & Fishery 8.6 (6.8, 10.8) Trade Workers 8.1 (6.4, 10.3) Plant & Machinery Operators 3.8* (2.8, 5.2) Labourers/Unskilled Work 6.0 (4.5, 7.8) Total Income5 (col % of each CAM group) Zero or loss $1 - $10,000 3.7* (2.4, 5.5) $10,001 - $20,000 10.7 (9.1, 12.5) $20,001 - $30,000 12.8 (11.1, 14.9) $30,001 - $40,000 10.7 (9.3, 12.3) $40,001 - $50,000 8.9 (7.5, 10.6) $50,001 - $70,000 17.5 (15.7, 19.5) $70,000+ 35.4 (32.6, 38.3) Medical Insurance (col % of each CAM group) Yes 46.7 (44.1, 49.3) No 52.1 (49.5, 54.7) Don't Know 1.2** (0.6, 2.2)
(50.5, 52.0) (48.0, 49.5) (80.4, (10.6, (5.3, (6.7, (16.3, (18.9, (19.4, (21.8, (20.8, (22.5, (28.1, (25.5, (18.5, 81.6) 11.3) 6.0) 7.1) 17.5) 20.0) 20.5) 22.9) 22.0) 25.2) 30.7) 28.7) 21.1)
(11.1, 13.6) (15.7, 18.8) (5.7, 7.6) (6.7, 8.7) (16.4, 19.5) (7.7, 11.5) (11.5, 14.3) (5.4, 7.4) (8.7, 11.1) (0.4, 1.0) (3.3, 4.5) (15.0, 16.8) (14.8, 17.0) (11.6, 13.4) (9.8, 11.6) (14.6, 16.8) (23.7, 26.2) (34.8, 37.7) (60.7, 63.6) (1.2, 2.0)
Notes: 1: The sample contains 12529 participants of whom 2 have missing responses to the CAM question. 2: A * indicates that the relative sampling error is between 0.30 and 0.5. 3: A ** indicates the relative sampling error is over 0.5. 4: A - indicates that there are less than 10 participants giving information for that cell. 5: Total household income was imputed for 24% of the participants. 6: The test used adjusts for age and sex. 7: No adjustment for sex. 8: No adjustment for age. 9: People are included in each ethnic group that they identify with. 10: The "other" ethnicity is included with NZ European and Other European as it had too few respondents to stand alone.
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Table 3. The medical conditions of CAM and non-CAM users

Cam Users Estimate Number of People (n) Cronic Diseases (% of each CAM Spinal Disorders Asthma (age < 45) COPD (age>45) Arthritis Migraine Heart Disease Cancer Irritable bowel, other bowel Diabetes Depression Osteoporosis 5 Women's health conditions 6 Stomach ulcers Stroke5 Eczema/psoriasis Hiatus hernia/reflux 5 Epilepsy Thyroid condition5 Other
1
Non-Cam Users Estimate 9753 95% CI
95% CI
p-value for difference between groups 7
2274 group) 40.7 25.9 5.5 17.3 8.7 8.4 6.6 4.3 3.2 3.0 2.7 2.4* 1.8* 1.7* 1.3* 1.3** 1.0* 0.9** 13.3
(38.0, 43.5) (22.8, 29.2) (4.0, 7.4) (15.6, 19.1) (7.4, 10.3) (7.1, 10.0) (5.6, 7.8) (3.4, 5.5) (2.5, 4.1) (2.2, 4.0) (2.0, 3.6) (1.6, 3.5) (1.3, 2.6) (1.2, 2.5) (0.8, 2.1) (0.8, 2.3) (0.6, 1.7) (0.5, 1.5) (11.6, 15.2)
20.1 17.8 5.5 15.2 5.0 9.3 7.0 2.5 4.6 1.6 2.3 1.1* 1.6 2.2 1.0 0.8 1.0 0.8* 10.2
(18.9, 21.4) (16.1, 19.6) (4.6, 6.6) (14.3, 16.1) (4.3, 5.7) (8.5, 10.0) (6.4, 7.8) (2.1, 2.9) (4.0, 5.2) (1.2, 2.0) (2.0, 2.7) (0.8, 1.6) (1.3, 2.1) (1.9, 2.7) (0.7, 1.3) (0.6, 1.1) (0.8, 1.4) (0.6, 1.0) (9.3, 11.2)
0.0000 0.0000 0.7886 0.0003 0.0003 0.0313 0.6462 0.0029 0.1086 0.0234 0.3329 0.0373 0.3282 0.5362 0.3368 0.1757 0.8785 0.9115 0.0005
Notes 1: The sample contains 12529 participants of whom 2 have missing responses to the CAM question. 2: A * indicates that the relative sampling error is between 0.30 and 0.5 3: A ** indicates the relative sampling error is over 0.5 4: A - indicates that there are less than 10 participants giving information for that cell 5: Age groups 1 and 2 were combined to give sufficient numbers for analysis 6: Out of females only 7: The test used adjusts for age and sex
CAM users make greater utilisation of a range of health services (see Table 4). The most striking difference is in pharmacy use. CAM users are more likely to go to a pharmacist for a second opinion (8.9% vs 4.9%), to get advice about potential medicines (32.3% vs 19.3%) and prescribed medicines (9.8% vs 5.4%). They purchase more medication (81.5% vs 75.3%) and more vitamins and herbal medicines (33.3% vs 15.4%). However, they are also more likely to report not utilising health services when they are needed. The proportion of CAM users who report they needed to see a GP but didnt go was 15.7% compared to 10.8% for non-CAM users. The proportion of CAM users who didnt pick up a prescription was 23.3% compared to 15.1% for non-CAM users.
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Table 4. Health Service utilisation of CAM and non-CAM users

Cam Users Estimate 2274 Number of People (n) Health Service Utilisation in the last 12 months GP Consultation (%) 85.6 No of consultations (n) 4.5 Consultation with a Practise Nurse that was not part of a GP consultation (%) No of consultations (n) Medical Specialist Consultation (%) No of consultations (n) Visit Pharmacist for health related information or products (%) No of consultations (n) Physiotherapist (%) No of consultations (n) Dietician (%) No of consultations (n) Dentist or dental therapist (%) No of consultations (n) Optician or optometrist (%) No of consultations (n) Social worker,psychologist or councellor (%) No of consultations (n) Occupational therapist (%) No of consultations (n) Midwife5 (%) No of consultations (n) Helpline use in last year (%) 20.1 2.7 37.9 3.3 92.0 8.0 20.1 9.3 3.7* 2.9* 49.6 2.1 24.8 1.6 8.5 9.9 2.1* 5.7** 4.9 10.0 22.9
1
Non-Cam Users Estimate 9753 95% CI
95% CI
p-value for difference between groups 6
(83.7, 87.4) (4.2, 4.8) (18.0, (2.3, (35.7, (2.9, 22.4) 3.1) 40.2) 3.6)
79.4 3.8 15.2 2.9 29.6 2.8 84.0 6.3 13.1 7.5 2.4 2.6 37.6 2.0 16.4 1.4 3.8 7.8 0.9 5.2** 3.6 8.9 13.3
(78.1, 80.6) (3.7, 4.0) (14.1, (2.6, (28.4, (2.6, (83.0, (6.1, (12.2, (6.8, (2.0, (1.9, (36.1, (1.9, (15.4, (1.3, 16.4) 3.2) 30.8) 3.1) 85.0) 6.5) 14.1) 8.1) 2.9) 3.4) 39.1) 2.1) 17.5) 1.4)
0.0000 0.0000 0.0002 0.6859 0.0321 0.0934 0.0000 0.0000 0.0000 0.0122 0.0790 0.8157 0.0000 0.3268 0.0000 0.0173 0.0000 0.2175 0.0055 0.8396 0.6974 0.2385 0.0000
(91.0, 94.0) (7.5, 8.4) (18.2, 22.2) (8.1, 10.6) (2.7, 4.9) (2.0, 3.8) (46.8, 52.5) (1.9, 2.2) (22.5, 27.2) (1.4, 1.7) (7.1, 10.3) (7.6, 12.2) (1.4, 3.1) (2.5, 9.0) (3.8, 6.3) (8.6, 11.4) (20.5, 25.4)
(3.2, 4.4) (5.5, 10.0) (0.7, 1.2) (2.4, 7.9) (3.1, 4.1) (8.0, 9.9) (12.2, 14.4)
Notes 1: The sample contains 12529 participants of whom 2 have missing responses to the CAM question. 2: A * indicates that the relative sampling error is between 0.30 and 0.5 3: A ** indicates the relative sampling error is over 0.5 4: A - indicates that there are less than 10 participants giving information for that cell 5: Out of females only 6: The test used adjusts for age and sex
CAM users are more likely to get the recommended daily intake of vegetables (75.1% vs 66.5%) and fruit (61.0% vs 52.6%). CAM users are less likely to do no exercise (12.1% vs 18.0%) and to exercise on more days per week i.e. 56.0% of CAM users exercise 5, 6 or 7 days a week compared to 52.8% of non-CAM users. They are less likely to abstain from alcohol (11.5% vs 18.0%) but are more likely to drink nonhazardously (71.3% vs 64.8%) where hazardous drinking is defined by AUDIT score. They are more likely to have consumed marijuana in the last year (16.4% vs 13.5%) and less likely to be current regular smokers (21.0% vs 23.5%) or to be passive smoking (22.3% vs 25.4%).
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Discussion
CAM users have lower health status, as given by their SF36 scores and have greater chance of having some chronic health conditions. Their conditions tend to be hard to treat and their use of CAM services may indicate that mainstream medical treatments have not improved their health. However, they have a higher utilisation of many mainstream health services than non-CAM users. CAM users tend to be highly educated and appear interested in understanding their medical conditions and possible treatments as seen by their use of pharmacists and healthlines as sources of information. They also tend to be richer than non-CAM users so have the financial capacity to explore non-standard medical treatments. CAM users appear to be actively trying to maintain their health by being more likely to eat the recommended daily intake of fruit and vegetables and more likely to exercise and exercise more often. They are less likely to abstain from alcohol and more likely to drink non-hazardous levels of alcohol. Given that CAM users tend to be middle-aged drinking moderate quantities of alcohol could be seen as a healthy choice to reduce the risk of heart disease. Last-year marijuana use is higher in CAM users and this is surprising in a group that tends to be rich, European New Zealanders/Other, female and middle-aged, a group not typically associated with marijuana use. However, cannabis has a long history as a herbal medicine and it is possible that CAM users are exploring marijuana use as an alternative medicine in its own right.
Conclusion
CAM users in New Zealand are more likely to be middle-aged, rich, well-educated, of European descent, and female. They are more likely to have hard-to-treat conditions and to be less well but actively try to maintain their health. They utilise more health services and are more likely to seek information about their health and medicines.
Author information: Megan Pledger, Senior Research Fellow; Jacqueline Cumming, Director; Mili Burnette, Research Assistant; Health Services Research Centre, School of Government, Victoria University of Wellington, Wellington Acknowledgements: We thank the respondents of the New Zealand Health Survey, 2002/03 for their participation in the survey. Correspondence: Megan Pledger, Health Services Research Centre, School of Government, Victoria University of Wellington, PO Box 600, Wellington 6140, New Zealand. Fax: +64 (0)4 4636568, email: Megan.Pledger@vuw.ac.nz References:
1. 2. 3. Eisenberg D. Trends in alternative medicine use in the United States, 1990-1997. Journal of American Medical Association 1998;280:1569-75. Landmark. The Landmark Report on Public Perceptions of Alternative Care1998. Astin JA. Why patients use alternative medicine. Results of a national study. Journal of the American Medical Association 1998;279:1548-53.
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4.
5. 6. 7. 8. 9. 10. 11. 12.
13.
14. 15.
16.
17. 18.
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20. 21.
Paramore LC. Use of alternative therapies: estimates from the 1994 Robert Wood Johnson Foundation National Access to Care Survey. Journal of Pain and Symptom Management 1997;13 83-9. Vickers A. Use of complementary therapies. British Medical Journal 1994;309:1161. MacLennan AH, Wilson DH, Taylor AW. Prevalence and cost of alternative medicine in Australia. Lancet 1996;347:569-73. Ernst E. Prevalence of use of complementary/alternative medicine: A systematic review. Bulletin of the World Health Organization 2000;78(2):252-7. Haussermann D. [Increased confidence in natural therapies]. Deutshes Arzteblatt 1997;94:1857-8. Millar W J. Use of alternative health care practitioners by Canadians. Canadian Journal of Public Health 1997;88:1550-8. Eisenberg D. Trends in alternative medicine use in the United States, 1990-1997. Journal of the American Medical Association 1998;280:1569-75. Millar WJ. Patterns of use - Alternative health care practitioners. Health Reports2001;13(921). MacLennan AH, Myers SP, Taylor AW. The continuing use of complementary and alternative medicine in South Australia: costs and beliefs in 2004. The Medical Journal of Australia2006 2 January 2006;184(1):27-31. National Centre for Complementary and Alternative Medicine. The Use of Complementary and Alternative Medicine in the United States: National Centre for Complementary and Alternative Medicine; 2004. Ministerial Advisory Committee of Complementary and Alternative Health. CAM Consumers 2007. Trevana J, Reeder A. Perceptions of New Zealand adults about complementary and alternative therapies for cancer treatment. The New Zealand Medical Journal 2005;118(1227). http://www.nzmj.com/journal/118-1227/1787/content.pdf Chrystal K, Allan S, Forgeson G, Issacs R. The use of complementary/alternative medicine by cancer patients in a New Zealand regional cancer treatment centre. The New Zealand Medical Journal 2003;116(1168). http://www.nzmj.com/journal/116-1168/296/content.pdf Milne BJ, Waldie KE, Poulton R. Users of unconventional practitioners: a profile of 26 year old New Zealanders. The New Zealand Medical Journal 2000;113:396-9. Nicholson T. Complementary and alternative medicines (including traditional Maori treatments) used by presenters to an emergency department in New Zealand: a survey of prevalence and toxicity. The New Zealand Medical Journal 2006;119(1233). http://www.nzmj.com/journal/119-1233/1954/content.pdf Poynton L, Dowell A, Dew K, Egan T. General practitioners' attitudes towards (and use of) complementary and alternative medicine: a New Zealand nationwide survey. New Zealand Medical Journal 2006;119(1247). http://www.nzmj.com/journal/119-1247/2361/content.pdf Ministry of Health. A Portrait of Health: Key Results from the 2002/03 New Zealand Health Survey. Wellington: Ministry of Health; 2004. Research Triangle Institute. SUDAAN Language Manual, Release 9.0. Research Triangle Park, NC: Research Triangle Institute; 2004.
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Chiropractic claims in the English-speaking world

Edzard Ernst, Andrew Gilbey Abstract Background Some chiropractors and their associations claim that chiropractic is effective for conditions that lack sound supporting evidence or scientific rationale. This study therefore sought to determine the frequency of World Wide Web claims of chiropractors and their associations to treat, asthma, headache/migraine, infant colic, colic, ear infection/earache/otitis media, neck pain, whiplash (not supported by sound evidence), and lower back pain (supported by some evidence). Methods A review of 200 chiropractor websites and 9 chiropractic associations World Wide Web claims in Australia, Canada, New Zealand, the United Kingdom, and the United States was conducted between 1 October 2008 and 26 November 2008. The outcome measure was claims (either direct or indirect) regarding the eight reviewed conditions, made in the context of chiropractic treatment. Results We found evidence that 190 (95%) chiropractor websites made unsubstantiated claims regarding at least one of the conditions. When colic and infant colic data were collapsed into one heading, there was evidence that 76 (38%) chiropractor websites made unsubstantiated claims about all the conditions not supported by sound evidence. Fifty-six (28%) websites and 4 of the 9 (44%) associations made claims about lower back pain, whereas 179 (90%) websites and all 9 associations made unsubstantiated claims about headache/migraine. Unsubstantiated claims were made about asthma, ear infection/earache/otitis media, neck pain, whiplash in at least half of all chiropractor websites. Conclusions The majority of chiropractors and their associations in the Englishspeaking world seem to make therapeutic claims that are not supported by sound evidence, whilst only 28% of chiropractor websites promote lower back pain, which is supported by some evidence. We suggest the ubiquity of the unsubstantiated claims constitutes an ethical and public health issue. The raison d'tre of chiropractic is to enhance the natural healing abilities of the body by correcting a malfunction of the spine called a vertebral subluxation through adjustment.1 Chiropractic is advocated as being much more than a way of seeking relief from back pain,1 the third largest healthcare profession in the world,2 and entering the healthcare mainstream.3 The relationship between chiropractic and mainstream medicine has, at times, been somewhat uneasy. For example, Chiropractics founder, DD Palmer, was once imprisoned for practising medicine without a licence in America4and, in New Zealand in the 1970s, the medical profession argued that chiropractic is an unproven treatment directed at an unlimited range of disorders.5 More recently, in a survey of chiropractic brochures provided by 9 national organisations in the United States and
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Canada, all were found to have made claims for chiropractic services that have not been scientifically validated.6 Similarly, a survey of World Wide Web claims of chiropractic colleges in the United States and Canada found that 8 out of 16 made unsubstantiated claims for the value of chiropractic clinical care.7 In response to a fictitious email enquiry sent to 13 New Zealand chiropractors, purportedly from a concerned parent about their childs asthma and recurrent ear infection (conditions for which there is no sound evidence to support chiropractic interventions), 12 encouraged a consultation, 9 suggested that they could treat asthma, and 8 that they could treat ear infection.8 In a small pilot study of chiropractors claims in their World Wide Web websites, 9 of 10 United Kingdom clinics were found to have made unsubstantiated claims about the effectiveness of chiropractic.9 Criticisms regarding unsubstantiated claims have been raised even by Doctors of Chiropractic, two of whom suggested that those outside the chiropractic profession may interpret widespread unsubstantiated claims of effectiveness as evidence of a lack of professionalism and of quackery that have evolved within a tradition of dogma, fallacious reasoning, and unconventional attitudes about research and science.6 Contrarily, many chiropractic associations and practitioners believe chiropractic is essentially based in scientific principles and supported by research, the same as is orthodox medicine.10,11 This debate may be of esoteric interest only, as chiropractic is clearly thriving irrespective of criticism.3,12 Although there is evidence that some chiropractic brochures, colleges, and phone advice make claims not supported by evidence,6,7,8 apart from a small pilot-study of 10 UK chiropractors,9 no studies have so far tested claims made or implied on chiropractors Websites, from which potential first-time users of chiropractic may seek information. The purpose of the current study was therefore to investigate the websites of chiropractic associations and practitioners, in Australia, Canada, New Zealand, the United Kingdom, and the United States, regarding direct or indirect claims to treat seven conditions that are not supported by sound evidence from well-designed controlled trials: asthma, headache/migraine, infant colic, colic, ear infection/ache/otitis media, neck pain, and whiplash (Table 1). These conditions were chosen for investigation as from experience we were aware that they frequently appear in chiropractic literature, despite a lack of sound supporting evidence. We accept that some studies purportedly demonstrate the effectiveness of chiropractic. However, when case studies, non-controlled, non-randomised, or nonpeer reviewed studies were excluded, as they do not constitute quality evidence in any hierarchy of which we are aware, and systematic reviews or randomised control trials (if systematic reviews were not available) were consulted instead, we could find no evidence of chiropractic effectiveness for the seven conditions. Claims regarding lower back pain were also reviewed as evidence suggests it may respond to chiropractic spinal manipulations13 and thus might reasonably be expected to be robustly promoted in chiropractors websites.
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Table 1. The best current evidence for conditions commonly referred to by chiropractors
Condition Asthma Back pain (lower) Type of evidence (ref) Cochrane review 14 Cochrane review13 Conclusions There is insufficient evidence to support the use of manual therapies for patients with asthma* No evidence that spinal manipulation is superior to other standard treatments for acute or chronic low back pain* No evidence No convincing evidence* No sound evidence no rigorous evidence* evidence did not favour spinal manipulation/mobilisation done alone* No controlled clinical trials*
Colic Infant Colic Ear infection/ache/otitis media Headache/migraine Neck pain Whiplash
*Verbatim.
None found Health Technology Report 15 Only a feasibility study is available16 Systematic review 17 Cochrane review 18 Systematic review19
Method
A search for chiropractors websites and chiropractic associations on the World Wide Web was carried out between 1 October 2008 and 26 November 2008, using the internet search engine Google, with the appropriate domain extension for Australia, Canada, New Zealand, the United Kingdom, and the United States. The keywords, were chiropract*AND association, chiropract*AND organisation, chiropract*AND society, and chiropractor. All international and national associations and the first 40 chiropractors websites returned for each country would form the sample for review. Sponsored links were not included, as these may be high profile practices with little in common with the average practice. Our convenience sample was limited to 40 websites for each country as most chiropractors were clearly using one of two common templates for their websites and further data collection would therefore contribute little. We believe that a convenience sample is the best strategy for the current study as it would replicate the results of a World Wide Web based search by a member of the public seeking information about chiropractic; had we randomly sampled from a register of practitioners in each country, then we may have found websites not readily returned on a member of the publics search of the World Wide Web. In the first 300 New Zealand search results, using the keyword chiropractor, 32 chiropractor websites were returned. To increase the New Zealand sample size, a second search using the keyword chiropractic was conducted; as a result, 8 further chiropractor websites were returned. All reviewed materials were saved in both electronic and hard copy. The material thus located was systematically checked by one author (AG) for evidence of claims regarding any of the above-named conditions. The criterion deemed sufficient to conclude evidence of a claim was that the condition would be mentioned by name on the website. Evidence would thus include direct claims (e.g. chiropractic may help with headaches) or indirect claims (e.g. conditions for which people consult chiropractors include headache). If an association or advertisement mentioned a condition of interest as not suitable for chiropractic treatment (e.g. a person suspecting they had condition X should consult their general medical practitioner), then it would not be interpreted as an unsubstantiated claim. Whenever the phraseology used in the reviewed materials was ambiguous about a particular condition, we (EE & AG) classified the website or association as not making an unsubstantiated claim. Evidence of claims for other conditions was also noted in a non-systematic fashion if they seemed sufficiently extraordinary to be noted.
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Results
Two international and 7 national chiropractic associations were identified (see note 1 to Table 2 for names/countries of the associations). Chiropractic associations and chiropractors claims (direct or indirect) about the 8 conditions are shown in Table 2. Table 2. Chiropractic association and chiropractor website claims regarding the eight conditions
There was evidence that 190 (95%) chiropractor websites make unsubstantiated claims regarding at least one of the conditions. Only 56 (28%) chiropractor websites and 4 of the 9 (44%) associations appeared to explicitly mention lower back pain, although tentative evidence suggests it may respond to chiropractic manipulation,13 whilst 179 (90%) websites and all 9 associations mentioned headache/migraine, which is not supported by sound evidence. When claims for colic and infant colic were collapsed into a single heading, 76 (38%) of chiropractor websites were found to make unsubstantiated claims about all the conditions for which there is a lack of sound supporting evidence.
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There was evidence that some chiropractic associations make unsubstantiated claims about conditions outside the scope of this survey; for example, allergies, arthritis, immune system, longevity, osteoarthritis. There was also evidence that some chiropractor websites make unsubstantiated claims regarding conditions outside the scope of this survey; for example, attention deficit hyperactivity disorder, cancer, epilepsy, immune function, infertility. In the case of infertility, one chiropractors website printed what we believe is the extraordinary claim of research showing that 14 of 15 women unable to conceive, some for up to 10 years, had given birth after beginning regular chiropractic care.
Discussion
Our results provide evidence that the professional chiropractic organisations of Australia, Canada, New Zealand, the United Kingdom, and the United States make or imply therapeutic claims that are not backed up by sound scientific evidence. Perhaps as a consequence, many chiropractor websites of these countries follow suit. Most healthcare professionals associate chiropractic with musculoskeletal problems. Yet, several of the conditions claimed to respond to treatment are clearly not musculoskeletal by nature (e.g., asthma, otitis, colic). One way to understand this finding is to consider it within the wider context of chiropractic history. The birthday of chiropractic is said to be September 18, 1895. On this day, D. D. Palmer manipulated the spine of a deaf janitor allegedly curing him of his deafness.20 Palmers second patient, a man suffering from heart disease, was also claimed to be cured.21 Following these early successes, Palmer articulated his theory of chiropractic, coining the term innate intelligence (or innate) for the energy or vital force he believed to be the essence of life. The innate is said to regulate all body functions. The presence of a vertebral subluxation inhibits, according to Palmer, its flow. Chiropractic is a system of healing based on the premise that the body requires unobstructed flow through the nervous system ofinnate intelligence.22 Based upon this notion, chiropractors use spinal manipulations to correct subluxations to treat a very broad range of conditions: 95% of all diseases are caused by displaced vertebrae, the remainder by luxations of other joints.23 Broadly similar to our findings, early chiropractic pamphlets hardly mention back pain or neck pain, but assert that, chiropractic could address ailments such as insanity, sexual dysfunction, measles and influenza.24 More recently the chiropractic profession split into those aligned to Palmers original teachings (the straights) and those who also used treatments other than spinal manipulation and focussed on musculoskeletal problems (the mixers). For many years it seemed that the mixers dominated and chiropractors tended to fashion themselves as back pain specialists using many forms of non-pharmacological treatments. Now there is evidence that this process might be reversing. In 1991, hardly any UK chiropractors admitted treating conditions other than spinal problems.25 In 2003, 69% of all UK chiropractors felt confident to treat visceral/organic conditions,26 currently this figure stands at 74%.27 In the US, nearly 80% of chiropractors teach a relationship between subluxation and internal health,28 88% of US chiropractors believe that subluxation contributes to
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over 60 % of all visceral ailments and 90% feel that chiropractic treatments should not be limited to musculoskeletal conditions.29 The American Chiropractic Association stresses that chiropractic care is not limited to back pain, neck pain or other musculoskeletal disorders,30 and most chiropractic texts discuss spinal manipulation as a treatment for visceral disorderse.g.31,32,33,34 Based on the data presented here, the situation seems to be similar in the other English-speaking countries. Unsubstantiated claims of the nature described above may put patients at risk and are simply at odds with the notion that chiropractic is in any way scientific. As evidence of these claims is so widespread, we suggest this amounts to a public health issue. If, for instance, a child suffering from severe asthma is treated with ineffective spinal manipulation instead of effective drug therapy, there is an increased chance that this patients life might be lost. In this context, one must, of course, also consider the direct risks of spinal manipulation, which evidence suggests may be considerable35,36,37 (although it is noted that orthodox medicine is by no means free of risk38). A survey of UK chiropractors shows that 90% of them believe they support evidencebased practice principles,39 and their code of ethics states that chiropractors provisions of care must be evidence-based....40 The data summarized above suggest that chiropractors fail to abide by their own rules, although we suspect this is not intentionally but due to the paucity of science in their curriculum. The same code of ethics also regulates chiropractors advertising and provides that the information used must be factual and verifiable. The information must not be misleading or inaccurate in any way.40 The ethical guidelines in Canada, New Zealand, and the United States are similar, but the Chiropractors Association of Australia does not appear to prescribe guidelines for advertisements. Claims such as those disclosed here in chiropractors websites, in our view, violate the most fundamental rules of medical ethics: beneficence, non-maleficence and autonomy.41 This has further important practical implications; for instance, informed consent is not a realistic possibility if it is given based on misleading information.42 Our analyses have some important limitations. Web-based information can only generate an indirect picture of what might happen in actual clinical practice, even although it may be the first place that potential patients may use. However, more direct ways to ascertain such information seem to confirm the bleak impression gained by our surveys: direct questioning of chiropractors, for instance, revealed that the advice issued by them is frequently not responsible. New Zealand and UK chiropractors have been shown to recommend chiropractic for childhood asthma,8,43 Canadian chiropractors have recommended treatment for an 11 year old female assessed as healthy by an experienced paediatric orthopaedic surgeon,37 and many UK chiropractors advise parents against immunisation of their children.43 Future research in this area should seek to explore differences in the degree to which the practices of mixers and straights are successful; that is, does claiming to treat conditions that are clearly not of musculoskeletal origin lead to a more successful practice; for example, in number of consultations and financial remuneration. The extent to which chiropractor websites make unsubstantiated claims could also be explored in relation to length of time since graduating in chiropractic, as new
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graduates are more likely to believe their scope of practice extends beyond the treatment of back, head, and neck pain.37 Finally, the healthcare community at large might investigate ways of minimizing the risk to patients caused by unsubstantiated claims, particularly insofar as patients may delay or fail to seek out orthodox care. In conclusion, we have presented evidence that many of the direct or indirect claims made by chiropractors and their organisations around the world are not supported by current sound evidence. This, we feel, raises important issues and may even put lives at risk. We therefore urge the chiropractic community to address this situation adequately and urgently.
Author information: Edzard Ernst, Director, Complementary Medicine, Peninsula Medical School, University of Exeter, Exeter, England; Andrew Gilbey, Lecturer, College of Business, Massey University (Turitea Campus), Palmerston North, New Zealand Correspondence: Andrew Gilbey, College of Business, Massey University, Private Bag 11 222, Palmerston North, New Zealand. Email: a.p.gilbey@massey.ac.nz References:
New Zealand Chiropractors Association. Frequently asked questions: Do I still need to see a chiropractor if there is no pain? http://www.chiropractic.org.nz/frequently-asked-questions Accessed 1 December 2008. 2. Roughan S. Setting the record straight: New Zealand Chiropractors' Association response. N Z Med J. 2008;121(1280):7273. http://www.nzma.org.nz/journal/121-1280/3222/content.pdf 3. Meeker WC, Haldeman S. Chiropractic: A profession at the crossroads of mainstream and alternative medicine. Ann Intern Med; 2002;(136):21627. 4. Kremer R. Strength in diversity: Professional and legislative opportunities in primary care by the recognition, defining and promotion of the licensure of chiropractic medical education, competencies and skills. J Chiropr Med. 2002;1(4):139148. 5. Dew, K. Apostasy to orthodoxy: debates before a commission of inquiry into chiropractic. Sociol Health Illn. 2002;22(3):13101330. 6. Grod JP, Sikorski D, Keating JC. Unsubstantiated claims in patient brochures from the largest state, provincial and national chiropractic associations and research agencies. J Manipulative Physiol Ther. 2001;24:5149. 7. Sikorski D, Grod JP. (2003). The Unsubstantiated Web Site Claims of Chiropractic Colleges in Canada and the United States. J Chiropr Educ. 2003;17(2):113119. 8. Holt S. The responses of alternative practitioners when approached about common childhood illnesses. N Z Med J. 2008;121(1283):114116. 9. Ernst E. The ethics of chiropractic. N Z Med J. 2008;(121)1281:96. 10. Roughan S. Colquhoun's opinion versus sciencea response from the New Zealand Chiropractors' Association. N Z Med J. 2008;121(1281):99101. 11. The Canadian Chiropractic Association. Chiropractic Health Care Commission Manitoba. http://www.ccachiro.org/client/cca/cca.nsf/web/A667B070372C0BCA85256D3600559607?O penDocument Accessed 21 January 2009. 12. Cooper RA, Laud P, Craig L, Dietrich CL. Current and Projected Workforce of Nonphysician Clinicians JAMA. 1998;280:788794. 1.
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13. Assendelft WJJ, Morton SC, Yu EI, et al. Spinal manipulative therapy for low-back pain. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD000447. DOI: 10.1002/14651858.CD000447.pub2. 14. Hondras MA, Linde K, Jones AP. Manual therapy for asthma. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD001002. DOI: 10.1002/14651858.CD001002.pub2. 15. Husereau D, Clifford T, Aker P, et al. Spinal manipulation for infantile colic. Canadian Coordinating Office for Health Technology Assessment 2003; (Technology report no 42). 16. Sawyer CE, Evans RL, Boline PD, et al. A feasibility study of chiropractic spinal manipulation versus sham spinal manipulation for chronic otitis media with effusion in children. J Manip Phsiol Ther 1999;22(5):292267. 17. Fernandez-de-Las-Penas C, Alonso-Blanco C, Cuadroado ML. Are manual therapies effective in reducing pain from tension-type headache?: A systematic review. Clin J Pain. 2006;22(3):278285. 18. Gross A, Hoving JL, Haines T, et al. Manipulation and mobilisation for mechanical neck disorders. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD004249. DOI: 10.1002/14651858.CD004249.pub2. 19. Ernst E. Chiropractic spinal manipulation for whiplash injury? A systematic review of controlled clinical trials. FACT. 2009;2:8586. 20. Wardwell W. History and evolution of a new profession. St. Louis, MO. Mosby-Yearbook; 1992. 21. DeVocht JW. History and overview of theories and methods of chiropractic: a counterpoint. Clin Orthop Relat Res. 2006;444:243249. 22. Martin SC. The only truly scientific method of healing. Chiropractic and American Science 1895-1990.1994;85:207227. 23. Homola S. Bonesetting, chiropractic and cultism. Panama City, FL: Critique Books; 1963. 24. Palmer BJ. Chiropractic proofs. Davenport, Iowa; 1903. 25. Pedersen P. A survey of chiropractic practice in Europe. Europ J Chiropractic. 1994;42:328. 26. Wilson FJH. A survey of chiropractors in the United Kingdom. Eur J Chiropract. 2003;50:185198. 27. Pollentier A, Langworthy JM. The scope of chiropractic practice: a survey of chiropractors in the UK. Clin Chiropractic. 2007;10:147155. 28. Chiropractic News Digest 2003, June 11, http://www.chirobase.org/18CND/03/03-02.html Accessed 3 December 2008. 29. McDonald W, Durkin K, Iseman S, et al. How Chiropractors Think and Practice. Ada, OH; Institute for Social; Research, Ohio University; 2003. 30. American Chiropractic Association. About chiropractic. http://www.amerchiro.org/level2_css.cfm?t1id=13&t2id=61 Accessed 3 December 2008. 31. Redwood D. Chiropractic. In Micozzi MS, ed. Fundamentals of complementary and integrative medicine. (3rd Edition). St Louis: Elsevier; 2006. 32. Gay RE. Chiropractic. In Yuan CS, Bibber EJ, Brent AB. eds. Textbook of complementary and alternative medicine. 2nd ed. Abingdon: Informa Healthcare; 2006. 33. Wiles MR. Visceral disorders related to the spine. In: Gatterman MI, ed. Chiropractic management of spine-related disorders. Baltimore: Williams & Wilkins; 1990;37996. 34. Swenson RS. Clinical investigation of reflex function. In: Haldeman S. ed. The modern developments in the principles and practice of chiropractic. 2nd ed. rev. Norwalk, CT: Appleton Century Crofts. 1992;10514. 35. Ernst E. Adverse effects of spinal manipulation: a systematic review. J R Soc Med. 2007;100:3308. 36. Rubinstein SM, Leboeff-Yde C, Knol DL, et al. Predictors of adverse events following chiropractic care for patients with neck pain. J Manip Phys Ther. 2008;31:94103.
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37. Benedetti P, MacPhail W. Spin doctors: The chiropractic industry under examination. Toronto, Ontario: Dundurn Press; 2002. 38. Helmreich RL (2000). On error management: lessons from aviation. BMJ 2000;320: 781785. 39. General Chiropractic Council. Consulting the profession: A survey of UK chiropractors. http://www.gcc-uk.org/files/link_file/ConsultTheProfession.pdf Accessed 1 December 2008. 40. General Chiropractic Council. Code of Practice and Standard of Proficiency. http://www.gccuk.org/files/link_file/COPSOP_8Dec05.pdf Accessed 1 December 2008. 41. Fisher F. Medical ethics today: its practice and philosophy. London, England: British Medical Association; 1993. 42. Ernst E, Cohen M. Informed consent in complementary and alternative medicine. Arch Intern Med. 2001;161:228892. 43. Schmidt K, Ernst E. Letter to the Editor: Are asthma sufferers at risk when consulting chiropractors over the Internet? Respiratory Med. 2003;97:1045. 44. Schmidt K, Ernst E. MMR vaccination advice over the Internet. Vaccine. 2003;21:10447.
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Clinical and epidemiological characteristics of the hospitalised patients due to pandemic H1N1 2009 viral infection: experience at Hutt Hospital, New Zealand
Stephen Dee, Sisira Jayathissa Abstract Aim Pandemic H1N1 2009 virus (H1N1 2009) community transmission was first noted in New Zealand in the Wellington region. There is limited information of clinical and epidemiological characteristics of H1N1 2009 patients from USA and Mexico but no published reports available in New Zealand. We studied clinical and epidemiological features of patients with H1N1 2009 infection admitted to Hutt Valley Hospital. Methods We collected and analysed clinical and epidemiological information of all adult inpatient admitted to Hutt Hospital with confirmed H1N1 2009 infection over 5week period from 17 June 2009 to 22 July 2009. Results There were 54 adult inpatient admissions with confirmed H1N1 2009 infection during the study period. Epidemic curve suggest rapid increase in number of cases during first 2 weeks with abrupt cessation of new cases by mid-July. The majority of the patients were female (74%) and belonged to Mori (38%) and Pacific (25%) races. Most of the patients were below 50 years of age (76%) but mean age of the cases increased weekly with progression of outbreak. The majority had comorbidities (78%) including asthma, obesity, and diabetes. 38% were smokers. 20% had diarrhoea and vomiting. 48% of the patient had multi-lobar infiltrates on chest X-ray. Nine patients received ICU/HDU (intensive care unit/high dependency unit) care and all of these patients had significant comorbidities. There were no deaths during this period. Conclusions H1N1 2009 infection predominantly affected young Mori and Pacific women with relative sparing of the elderly. Patient who received ICU/HDU care had significant comorbidities. This study provides a reliable account of clinical and epidemiological features of H1N1 2009 infection in a medium-size hospital in New Zealand. Flu pandemic due to H1N1 2009 infection is spreading rapidly throughout the world. As of the 5 August 2009, 2872 confirmed cases of H1N1 2009 in New Zealand and 14 deaths16 with testing only now being performed on patients with severe illness. Recent experience in Wellington region suggest high rate of transmission of virus1 with significant morbidity compared to seasonal winter flu. High rates of sickness associated with H1N1 2009 and hospitalisation with serious respiratory problems has lead to significant added pressure into already overstretched public hospitals. Community transmission of H1N1 2009 was first reported on 13 June 2009, with all previous confirmed cases being international travellers.2 The Wellington region, of which, the Hutt Valley is a part, was the first area in New Zealand to report
community spread of H1N1 2009.2 Hospital admissions at Hutt Valley District Health Board due to H1N1 2009 were recognised from 17 June 2009. During the first week of the outbreak the staff noticed unique clinical and demographic characteristics of the patients presenting to the hospital. Miller13 and others emphasised the relative sparing of elderly in 20th Century influenza pandemics. Several hypotheses have been postulated including previous exposure. A recent case series from California and Mexico11,12 indicate that H1N1 2009 predominantly a disease of younger people with very low rate of infection among adults over 50 years. There are regular media reports15 and updates from ministry of health and public health services about H1N1 2009 infection.16 However, there is no published literature on epidemiological and clinical characteristics of hospitalised patients with this illness in New Zealand. Therefore we analysed epidemiological and clinical characteristics of all confirmed cases of swine flu admitted to adult medical service. Paediatric patients who were discharged from the hospital will be reported in a separate analysis
Methods
General medical service is one of the biggest services in Hutt Hospital providing acute medical assessment in ED and an inpatient services for all adult acute medical admissions except cardiac patients. The study was carried out over a 5 week period starting from 17 June to 20 July 2009 among hospitalised patients.
As a part of planning for the outbreak a clinical protocol was developed in conjunction with regional infectious disease service and public health. According to this protocol all patients with an influenza-like illness requiring admission had a nasopharyngeal swab for influenza viruses. Swabs were transported to Capital and Coast DHB laboratory for confirmatory tests. RT-PCR testing was done in accordance with published guidelines from the US Center for Disease Control and Prevention17.
All inpatients admitted with flu-like illness were isolated initially in single rooms but as the epidemic progressed suspected patients were isolated in four bedded cubicles. Visiting was restricted and visitors were provided with appropriate barrier protection. All patients were treated with 5-day course of oseltamivir phosphate 75 mg bid and antibiotics. H1N1 2009 PCR results from testing laboratory were notified to a single physician for ease of administration. These results were recorded in a Microsoft Excel spreadsheet. For the purpose of this study all discharge summaries and notes of the patients were reviewed to obtain demographic and clinical information. Descriptive statistics and graphs were drawn with Microsoft Excel. Wellington regional ethics committee determined that the study fell under the category of observational research and audit conducted by employees for the purpose of outcome assessment and did not require ethical approval.
Results
Hutt Hospital is a secondary care hospital serving a population of 140,000. The ethnicity mix of the community is NZ European 67%, Mori 16%, Samoan 4.2%.3
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There were 54 confirmed cases of H1N1 2009 admitted under Adult Medicine Service at Hutt Valley Hospital during the first 5 weeks of the outbreak. There was rapid increase in the cases from the 17 June with an abrupt decrease around the third week of July (see Figure 1). Figure 1. Epidemic curve for admission with H1N1
Majority of the patients were female (74%), under 50 years old (76%) (see the age breakdown in Figure 2). The mean age of the patients admitted during each week progressively increased with time. The respective mean ages of patients from week 1 to week 5 were 28.1, 30.5, 40.8, 55.1, and 54 years. There were high proportions of Mori (38%) and Pacific patients (25%) compared to our catchments population (see Figure 3). The presenting symptoms of these patients are described in Figure 4, with respiratory symptoms predominating but 20% of patients had diarrhoea or vomiting. The commonest reason for admission has been pneumonia (48%) half of these had multilobar infiltrates. The next most common presentation is exacerbation of asthma (19%).
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Figure 2. Ages of H1N1 adult inpatients
Figure 3. Ethnicity of H1N1 inpatients
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Figure 4. Presenting symptoms H1N1
The common comorbidities have been asthma, obesity, diabetes and other respiratory diseases (see Figure 5). Smoking was also common in our population group with 37% of patients admitted being current smokers. Figure 5. Comorbidities of H1N1 admissions
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Pregnancy and the post-partum patients seem to be a special at risk group. Two patients who were pregnant (3.7%) and four who were post-partum (7.4%)were admitted to hospital and one of these patients required HDU management. The inpatient adult group included nine patients treated in HDU/ICU. All of these patients had significant comorbidities with asthma (56%), diabetes (33%) and obesity (33%) being the commonest. Two patients were ventilated and both had obesity and diabetes as comorbidities. There were no deaths reported during this period.
Discussion
Early experience during current outbreak suggests severe illness in younger patients compared to elderly. The median age of adults admitted to hospital was 31 years with three-quarters of the patients being aged less than 50 years. This is similar to the experience in California and Mexico and pattern described in other influenza pandemics where young population was predominantly affected with sparing of the elderly.4 Pacific patients had six times and Mori patients had two and half times the expected admission rate based on their population size. The reasons for these populations being particularly affected is uncertain but may include social and environmental factors such as the number of people in households, the greater proportion of young people and children in these ethnic groups, increased social contact (50% of the population under 25 years of age),3 possibly lower immunisation rates or a greater susceptibility to this strain of influenza. In the 1918 pandemic the death rate from Influenza was seven fold that in Mori compared to the European population in NZ.5 In Samoa in 1918 the incidence of cases of influenza was 80% of the population and the number of deaths was 7264 out of a total population of 36,405.6 This was higher than seen in most countries during that pandemic. The reason for the high incidence and mortality from influenza in Samoa (Western) is unknown though it included lack of medical assistance, food shortages and lack of an effective maritime quarantine.18 An earlier date of arrival of the 191819 pandemic influenza virus in South Pacific nations was associated with higher mortality compared with those islands affected later in 1919 or 19201 including American Samoa.18 This may be related to change in virulence of organism or other unknown factors . Disparity in vaccination rates may account for some difference in ethnic groups but the free Influenza vaccine in New Zealand has only been taken up in 26% of those eligible under 65 years with chronic conditions.7 A case control study from Mexico City shows partial protection of those immunised with the current trivalent inactivated influenza vaccine which has the same components as that administered in New Zealand this season.19 In Australia, the Aboriginal population and Torres Strait Islanders are also deemed as high-risk population groups.9 Comorbidities have played an important role in those with serious disease requiring admission and especially in those with very severe illness. Morbid obesity has been associated with severe illness requiring ventilation.10 In this case series, 9 out of 10 patients admitted to an ICU for ventilation had morbid obesity. Asthma and diabetes
were also common in those with illness requiring hospitalisation. Only 22% of the inpatients though had no significant comorbidities. According to media reports in New Zealand most of the deaths were also associated with significant comorbidities but a few deaths were reported in healthy young people. It is interesting to note that 20% had gastrointestinal symptoms. This is similar to cases described in USA10 and could lead to second mode of transmission apart from droplet infection. Jamieson and others14 recently reported increased rate of admission among pregnant women compared to rest of the population. In our case series there were two pregnant and four post partum women were admitted with H1N1 infection. We havent calculated the specific admission or attack rates but we agree with others that the H1N1 may be over represented in pregnant and post partum women. Smoking predisposes to respiratory illness. However it has not been described during this epidemic as an important risk factor but was prevalent in our group (37%). In a previous outbreak of H1N1 influenza in a group of Israeli soldiers smoking was more prevalent among those who developed disease and those with complications.8 There is no plausible explanation for abrupt cessation of cases in mid July and this may represent end of the first wave of epidemic. It was anticipated that number of cases would increase from mid July when the schools recommence but in our experience this didnt happen. This study has several limitations. It only describes early part of this outbreak and may not provide useful information to its evolution and its effect on older people and other high-risk groups. We have no recorded clinical information on seasonal influenza and therefore not able to compare with the clinical and epidemiological characteristics of seasonal illness with the current outbreak. However, senior physicians at this hospital have never seen such an outbreak with so many inpatients admitted with influenza type illness. H1N1 2009 has been shown in New Zealand to have higher reproduction number than that of season influenza (that is the average number of secondary cases generated by a single primary case).1 We are not aware of clinical and epidemiological characteristics of patients presenting to other DHB areas and this result may not be generalisable. Case series are always considered as least robust study due to various biases. Nevertheless this information may guide other clinicians and epidemiologists in understanding features of the H1N1 2009 infection in their area and to identify highrisk populations.
Conclusions
Our experience suggest increased severity of illness due to H1N1 infection among young Mori and Pacific women aged under 50 years old and those with a background of history of asthma, obesity or diabetes. High dependency and intensive care use were usually associated with comorbidities asthma, morbid obesity, and diabetes.
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The elderly appear to be spared from serious illness at the onset of epidemic. Young Samoan and Mori women represent a specific high-risk population at this early stage of the novel H1N1 epidemic.
Author information: Stephen Dee, Sisira Jayathissa, Consultant Physicians, Department of General Medicine, Hutt Valley Hospital, High Street, Lower Hutt, New Zealand. Acknowledgments: We acknowledge Regional Public Health, Regional Infectious Disease Team, and staff of Molecular Genetics Laboratory at Capital Coast District Health Board. Correspondence: Dr Stephen Dee, Hutt Valley DHB, High St Private Bag 31-907, Lower Hutt, New Zealand. Fax: +64 (0)4 5709001; email: stephen.dee@huttvalleydhb.org.nz References:
1. Nishiura H, Wilson N, Baker M. Estimatins the reproduction number of the novel influenza A virus (H1N1) in a Southern Hemisphere setting: preliminary estimate in New Zealand. N Z Med J. 2009;122:1299;73-77. Ministry of Health, Influenza A (H1N1) Swine Flu - Update Seventy-Two. Wellington: Ministry of Health, 2009. http://www.moh.govt.nz/moh.nsf/indexmh/influenza-a-h1n1update-seventytwo-130609 Statistics New Zealand, New Zealand Census Data 2001. Centre for Disease Control, Hospitalized Patients with Novel Influenza A (H1N1) Virus Infection--California, April--May, 2009. May 18, 2009 / 58(Early Release);1-5. Atlanta, GA: , 2009. http://www.cdc.gov/mmwr/PDF/wk/mm5819.pdf Rice G, Bryder L. Black November: The 1918 influenza pandemic in New Zealand, 2nd Ed. Christchurch: Canterbury University Press, 2005. Influenza in Samoa. Br Med J. 1919; 2(3068): 499500. Baker S. An Evaluation of the Free Influenza Immunisation Programme. Auckland: Ministry of Health 2001. http://www.moh.govt.nz/moh.nsf/0/.../InfluenzaVaccinationProgramme.pdf Kark J, Lebiush M, Rannon, L. Cigarette smoking as a risk factor for epidemic influenza in young men. N Eng J Med. 1982; 307:1042-1046. Cheng A, Dwyer D, Kotsimbos A. et al. ASID/TSANZ guidelines: treatment and prevention of H1N1 influenza 09 (human swine influenza) with antiviral agents. Med J Aust. 2009;191:18. Intensive care patients with severe novel influenza virus infection, Michigan: June 2009, MMWR. July 10, 2009 / 58(Dispatch); 1-4, 2009 Chowell G, Bertozzi S, Colchero A, et al. Severe Respiratory Disease Concurrent with the Circulation of H1N1 Influenza. N Eng J Med. 2009;361 (Epub ahead of print) PMID: 19564633. Novel Swine-Origin Influenza A (H1N1) Virus Investigation Team. Emergence of a Novel Swine-Origin Influenza A (H1N1) Virus in Humans. N Eng J Med. 2009;360:2605-2615. Miller M, Viboud C, Balinska M, et al. The Signature Features of Influenza Pandemics implications for Policy. N Eng J Med. 2009;360:2595-2598. Jamieson D, Honein M, Rasmussen S, et al. H1N1 2009 influenza virus infection during pregnancy in the USA. Lancet. 2009;374:451-458. Health Ministry cautious over flu results. NZ Herald; 5 August 2009. Ministry of Health: Swine flu update, Wellington: Ministry of Health, 2009. http://www.moh.govt.nz/moh.nsf/indexmh/influenza-a-h1n1-update-124-040809
2.
3. 4.
5. 6. 7. 8. 9.
10. 11.
12. 13. 14. 15. 16.
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17. CDC protocol of realtime RTPCR for influenza A (H1N1). Geneva: World Health Organization, April 2009. http://www.who.int/csr/resources/publications/swineflu/CDCRealtimeRTPCR_SwineH1Assa y-2009_20090430.pdf 18. McLeod M, Baker M, Wilson N. et al. Protective effect of maritime quarantine in South Pacific juristictions, 1918-19 Influenza Pandemic. Emerg. Infect. Dis. 2008;14,3:468-470. 19. Garcia-Garcia L, Valsespino-Gomez J, Lazcano-Ponce E, et al. Partial protection of seasonal trivalent inactivated vaccine against novel pandemic influenza A/H1N1 2009: case-control study in Mexico City. BMJ 2009; 339:b3928 doi:10.1136/bmj.b3928.
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Physiology of the placebo effect, and the evidence for changes in brain metabolism
Martin Wallace
(This paper is based on a presentation to the NZ Skeptics Conference, 2008)
Abstract Placebo effects are accompanied by localised changes in brain physiology. Variation between individuals in the extent of a placebo effect is due to genetic variation in brain enzyme activity. Some of the effect of any active drug is a placebo effect, and this should be considered in the evaluation of overall action. Early in 2008, Dr Tipu Aamir of the Auckland Pain Management Service drew my attention to the following. In a double-blind, randomised, placebo-controlled trial of morphine after a standard knee operation, 30% of those receiving a placebo get pain relief. When those people are given a specific morphine antagonist (antidote), their pain comes back! My excited reaction had all the hallmarks of an epiphany. I needed to know more. After all, how could something that was all in the mind be changed predictably by a substance with a known pharmacological action? Any study of homeopathy raises the issue of the placebo effect. As a result of a metaanalysis of a number of studies comparing homeopathic remedies with orthodox treatment, it was concluded that the effect of homeopathic remedies was no greater than that of a placebo.1 Not that they had no effect, but that it was no greater than that of a placebo. Sceptical thinkers are often happy to accept the explanation that if a response to some arcane practice is a placebo response, then that settles the issue. Over the last 30 years there has been a large amount of research into the (undoubted) effects of placebos. I was unaware of the results of this activity and the light they shed on our nature. I thought it might be of interest to review this work, and our frequent use of placebo effect to explain the unscientific. Placebo is a Latin word for I shall be pleasing, or acceptable. It is the first word of the first antiphon of the Roman Rite of the Vespers for the Dead, Placebo Domino. (Dating from the 7/9th Centuries of the current era). Chaucer called one of his characters Placebo in the Merchants Tale, because by the 14th Century, it had come to mean a flatterer, a sycophant, or a parasite.2
Placebo seyde: Ful little need had ye, my lord so deare, Council to ask, of any that are here But that ye be so ful of sapience.
He also used it in the Parsons tale: Flatterers be the Devils chaplains, which sing ever Placebo
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In the 1811 edition of Hoopers Medical Dictionary, placebo was defined as an epithet for any medicine adopted more to please than benefit the patient. In a recent edition of Collins Concise Dictionary of the English Language it is defined as an inactive substance administered to a patient to compare its effects with those of a real drug, but sometimes for the psychological benefit of the patient through his believing he is receiving treatment. However, placebos do benefit patients, and they are certainly not inactive in the context in which they are given. The most dramatic example of this that I saw in clinical practice involved a young man on artificial kidney treatment. When erythropoietin became available for the treatment of the severe anaemia seen so often in this situation, he was the first patient in our unit to receive it.(Erythropoietin is a hormone made in the healthy kidney, which increases the number of red cells in the blood and the amount of the oxygen carrying haemoglobin. The synthetic version has achieved notoriety as a performance enhancer in sport; for example in the Tour de France.) We were all very enthusiastic about this improvement in management for our patient, and he was given his first dose with much interest from all of us. That night he went home, recovered his bicycle from the shed where it had been undisturbed for many months, and rode all around his town with great energy and pleasure. He hadnt heard the information that the drug took 3 weeks to act on the anaemia. We are left with some questions. What was the physiology of his sudden ability to exercise at a normal rate, long before there was any change in his blood count? What does its all in the mind mean? Was he somehow at fault, or was it me and the staff who were lacking in understanding? I would like to consider: The psychological processes involved in the placebo effect. The physiological mechanisms in the brain. The site of this activity in the brain. Why there is variation in the placebo effect from individual to individual. What are the implications for the classical drug trial format?
Psychological mechanisms
Those who study the psychological processes of the placebo effect, cite two major mechanisms. ConditioningPavlov (18491936) showed that dogs given meals as a bell rang would subsequently salivate when the bell rang despite not being given food. This process has been explored in humans, who will experience pain relief when a placebo is substituted for a pain reliever when a sequence of active analgesia has been associated with an environmental cue. It is an unconscious process. At the nerve cell level, conditioning leads to a stronger and more sustained response. 3 ExpectancyThis effect is seen when the patient has great expectations of the substance being given. These are raised by the conscious or unconscious attitude of the therapist. It is a conscious process on the part of the patient.
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It is currently suggested that both conditioning and expectancy are active in the placebo effect, and that in fact, as an inert placebo can have no effect per se; what we see is the effect of the context in which the treatment is given.
Neurophysiology of placebo pain relief

Over the last 30 years, there has been much interest in the neuro-physiological mechanisms of the placebo response. In 1975, two related pentapeptides (a chain of five amino acids linked together) with potent opium-like action were identified in the brain. 4 Many more have been identified since. These compounds act on specific receptors on the membranes of neurones, and via intracellular metabolic changes increase synaptic transmission. They are made in the pituitary and hypothalamus, and are called endorphins. A digression In pharmacology the term agonist denotes a drug with an effect, and antagonist, a drug which specifically blocks the effect of the first substance. When I spent a year in the pharmacology lab in Dunedin (1959) it was becoming recognised that drugs exerted their effects by way of a specific receptor molecule at the cell surface. The actions of adrenaline, for example, were explained by the presence of two different molecules to which it could attach, which mediated different effects. Noradrenaline would latch on to only one, explaining its more limited range of action. With their usual desire for learned coherency, pharmacologists called them alpha and beta receptors. Antagonist molecules attach to the receptor molecule and block access by the agonist. Hence the term beta-blockers. These are substances which block the action of adrenaline on its beta receptor. They are widely known for their action in the control of blood pressure, and recently for their unwanted effects when given to protect patients at risk of heart trouble when undergoing operations. Agonists and antagonists are related by similarities in molecular size, shape, and charge. Morphine antagonists have been available for some time. In 1961 as a housesurgeon in casualty, I was asked to manage an opium addict, brought in because he was deeply unconscious, and breathing perhaps once a minute. (He had been without drug for some weeks, due to market fluctuations. When access was resumed, he used a dose which was the same as his habituated dose. This was much more than he could now tolerate.) I had access to nalorphine, a specific morphine antagonist, and 30 seconds after an IV injection, the patient took several deep breaths, sat up, expressed considerable surprise at his surroundings, and then lapsed back into his former state. I was able to repeat this dramatic procedure several times until he recovered! In 1978 a group of dental surgeons working in California carried out the following experiment.5 Patients who had had an impacted wisdom tooth extracted were treated routinely with nitrous oxide, diazepam and a local anaesthetic. At 3 hours after the procedure they were given either a placebo or naloxone (a specific morphine antagonist). At 4 hours they were given a placebo or naloxone. Those who had initial
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pain relief with the first dose of placebo (39%), when given naloxone had an increase in pain. The authors concluded that this was consistent with the hypothesis that endorphin release mediates placebo analgesia in dental postoperative pain. The elegance of this study lies in the unequivocal evidence that a supposedly psychological state (placebo analgesia) was reversed by a specific opioid antagonist. Note that none of the patients was given morphine. There must be a physiological cause for placebo analgesia. This sort of study has been repeated many times, and always naloxone reverses placebo analgesia.
The site of action of opioids in the brain

The site of this process has been determined. The sites for opioid receptors in the brain can be found by specific cell staining methods and histology on brain tissue. But more exact, real-time evidence comes from PET scans. Another digression Positron emission tomography utilises short half-life radioactive elements which undergo spontaneous beta decay. In the process, they emit a positron, which collides with an adjacent electron resulting in mutual annihilation, and the generation of two high-energy photons at a nearly 180 degree angle. These can be detected, and with many, many such events, used to build up a tomographic picture of the source in relation to surrounding tissue. In the studies of the brain, radioactively-labelled glucose is injected, and congregates where activity (utilisation) is greatest. PET scans are used to monitor metabolic activity in specific organs. For example, the extent of heart muscle damage after a heart attack. In 2002, it was shown that both opioid and placebo analgesia are associated with increased brain activity in specific regions: the anterior cingulate cortex (ACC) and the brain stem. 6 There was no increase of activity in these regions with pain only. Similar localised brain activity has been shown in placebo responses in Parkinsonism (dopamine) and some depressive states (serotonin). I find these studies exciting and provocative.
Genetic predilection
A further question can be asked in the light of the evidence for a physiological mechanism for the placebo effect. Why does it occur in only3040% of us for a given situation? It may occur in a greater proportion of a population sample if the context is made more convincing. But why dont we all have the benefits? Variation in a physiological function begs the question of a genetic predilection. Individual differences in suggestibility contribute significantly to the magnitude of placebo analgesia. 7 The higher the suggestibility score (there are several tests available) the greater the placebo analgesic effect.
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As early as 1970, it was shown that there was a correlation of suggestibility between monozygotic twins but not dizygotic (fraternal) twins.8 (Monozygotic twins are the result of the fertilisation of one ovum by one sperm. The resulting zygote splits into two cells which each develop into an individual. These individuals have exactly the same genes of course.) There is a relationship between hypnotic susceptibility and familial handedness. 9 Subjects with left handed (sinistral) close relatives scored lower in a test for hypnotic susceptibility. A number of studies have been carried out on twins who for a variety of reasons, were reared apart. 10 Correlations between identical twins (monozygotic) and between fraternal twins (dizygotic) have been done and compared. The studies from this group (in Minnesota) have shown a large group of correlations in identical twins reared apart, which do not occur in fraternal twins reared apart. The correlations differ very significantly. Here are some examples in twins reared apart:
Religious fundamentalism Broad religiosity Right wing attitudes 62% in identical twins 58% 69% 2% in fraternal twins 27% 0%
Similar studies have given similar results in Australia and Western Europe. Because the nurture of these twins is different, and identical twins have identical genes, the similarities must be genetic. This approach to behaviour has lead to the science of behaviour genetics. (Physical attributes are of course also correlated more between identical twins reared apart, than fraternal twins reared apart.) A group in New York State have shown that a genetic polymorphism (more than one version of a specific gene) exists for a gene on chromosome 22, which codes for an enzyme active in the breakdown of dopamine, a neurotransmitter.11 One amino acid substitution (valine for methionine) in the gene alters the enzyme activity by a factor of four times. Since we have a copy of this gene from each parent, we may have val/val, or val/meth, or meth/meth genotypes: Val/meth heterozygote confers the greater suggestibility. The enzyme is called COMT or catechol-o-methyl transferase.
Brain pathways in which opioid receptors are active are linked to those in which dopamine is the transmitter (nerve to nerve). If there is genetically conferred variation in dopamine activity it is likely that this will influence the result of changes in activity in the opioid pathways. (We must remember that we are talking of a genetic predisposition to be suggestible, and not a gene for suggestibility. It is not that 69% of identical twins vote Republican, but that if one does there is a 69% probability that the other one does too.)
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The implications for drug trials

The open / hidden model for drug trials: A group in Turin have examined pain relief in patients after thoracotomy.12 Patients were allocated to either open infusions of morphine, with information about the efficacy of the drug, or to receive hidden doses of morphine by infusion without any information and without any doctor or nurse present. With the same dose, same infusion rate, same timing and same drug, pain relief was less in the hidden group. In the open group, the meaning-induced expectations had enhanced the drug effect. This group and others have gone on to postulate that in all drug treatment the effect is the sum of actual physiological effect plus the effect of expectations.13 This means that the placebo effect will always cause part of the usual physiological response to active drugs. They say that the classical double blind randomized placebo controlled trial does not allow for expectation effects, and may suggest that a drug has a specific effect greater than it actually has. They suggest an open/hidden paradigm will give more meaningful results.
Conclusions
The analgesic placebo effect is accompanied by a distinct, observable, and locatable physiological event in the brain. Susceptibility to the placebo effect varies in the population at large. This susceptibility is at least in part genetically determined. It may be possible to harness this facet of human behaviour for the benefit of individuals, and to prevent its on-going exploitation by charlatans. Although placebos are inert and cannot have any effect on the healing processes, the context in which they are given can. All drug effects include some placebo effect, except when the drug is given surreptitiously. This should alter the classic clinical trial structure.
We have come a long way from the Vespers for the Dead! Placebos are inert substances but the context in which they are given can alter neurophysiology in such a way as to cause subjective and objective effects. This is not due to the molecular memory of water, nor to strange force- fields as yet unknown to physicists. It is due to our human nature, how we react to our environment, and the relationship, between our minds and our bodies.
Author information: Martin Wallace, Retired Renal Physician, Hamilton Correspondence: Martin Wallace, 24 Stonebridge Estate, Wallace Road, R D 9, Hamilton 3289, New Zealand. Email: mart-jan@xtra.co.nz
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References:
1. Shang A, Huwiler-Muntener K, Nartey L, et al. Are the clinical effects of homoeopathy placebo effects? Comparative study of placebo-controlled trials of homoeopathy and allopathy. Lancet. 2005;366(9487):726-32. Chaucer G. The Merchants Tale. In: Fisher, JH, editor. The Complete Poetry and Prose of Geoffrey Chaucer. New York: Holt, Rinehard and Winston; 1977. Squire LR, Kandel ER. Memory, From Mind to Molecules. Scientific American Library; 1999. Hughes J, Smith TW, Kosterlitz HW, et al. Identification of two related pentapeptides from the brain with potent opiate agonist activity. Nature. 1975; 258(5536):577-80. Levine JD, Gordon NC, Fields HL. The mechanism of placebo analgesia. Lancet. 1978;2(8091):654-7. Petrovic P, Kalso E, Petersson KM, Ingvar M. Placebo and opioid analgesia imaging a shared neuronal network. Science. 2002;295(5560):1737-40. De Pascalis V, Chiaradia C, Carotenuto E. The contribution of suggestibility and expectation to placebo analgesia phenomenon in an experimental setting. Pain. 2002;96(3):393-402. Morgan AH, Hilgard ER, Davert EC. The heritability of hypnotic susceptibility of twins: a preliminary report. Behav Genet. 1970;1(3):213-24. Wallace B, Persanyi MW. Hypnotic susceptibility and familial handedness. J Gen Psychol. 1989;116(4):345-50. Bouchard TJ Jr, Lykken DT, McGue M, et al. Sources of human psychological differences: the Minnesota Study of Twins Reared Apart. Science. 1990;250(4978):223-8. Raz A. Attention and hypnosis: neural substrates and genetic associations of two converging processes. Int J Clin Exp Hypn. 2005;53(3):237-58. Finniss DG, Benedetti F. Mechanisms of the placebo response and their impact on clinical trials and clinical practice. Pain. 2005;114(1-2):3-6. Koshi EB, Short CA. Placebo theory and its implications for research and clinical practice: a review of the recent literature. Pain Pract. 2007;7(1):4-20.
2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.
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A case of misdiagnosed squamous cell carcinoma due to alternative medical misadventuretime for tightening regulation?
Raakhi Mistry, Brecon Wademan, Gary Avery, Swee T Tan Abstract We present a patient with locally advanced squamous cell carcinoma that had grown significantly during 16 months of intensive alternative therapy. The alternative medicine practitioner allegedly repeatedly reassured the patient that her condition was benign and advised against seeking conventional medical treatment. Due to the delayed presentation, the patient required extensive surgery and postoperative adjuvant radiotherapy. This case highlights the risks of alternative therapy in the place of proven conventional medical treatment and emphasises the limitations of current regulation of complementary and alternative medicine in New Zealand.
Case report
A 65-year-old woman sought advice from an alternative medicine practitioner regarding a 3 cm ulcerated lesion on her scalp. The alternative medicine practitioner allegedly diagnosed the lesion as an infected sebaceous cyst and reassured the patient that it was benign. The patient was commenced on a skin treatment regimen involving daily application of herbal poultice and dressing changes. After 6 months of treatment, the lesion had grown to 8 cm and developed a purulent discharge. When the patients family became concerned that the treatment was ineffective, the alternative medicine practitioner allegedly dismissed these concerns and reiterated that the lesion was benign and advised against seeking conventional medical advice. After 16 months of treatment the lesion had grown to 20 cm and eroded through the calvarium to involve the dura. The pulsation of the exposed dura was noted by the family and mentioned to the alternative medicine practitioner who again allegedly dismissed and attributed to the bones of the skull were flexible like the fontanelles of a newborn. The patients pain was now severely debilitating leaving her housebound. Desperately concerned, her family took a photograph of the lesion and showed it to their family doctor who immediately referred the patient to the hospital. On admission, there was a 20 cm ulcerated fungating lesion over the left frontotemporo-parietal scalp (Figure 1). Culture of the purulent discharge grew Staphylococcus aureus and Pseudomonas aeruginosa. There was microcytic anaemia with a haemoglobin of 77 g/L and white cell count of 15.7109/L. CT and MRI scans confirmed widespread bony destruction of the underlying fronto-temporo-parietal skull with extension to the greater wing of the sphenoid and involvement of the dura including the area over the sagittal sinus (Figure 2 and 3). Biopsies of the lesion demonstrated poorly differentiated squamous cell carcinoma. It was felt that a combined treatment with radical surgery and postoperative adjuvant
radiotherapy would improve her quality of life with a small chance of cure. Surgery involved wide local excision of the tumour including the underlying skull, the greater wing of sphenoid, dura and part of the temporalis muscle. Reconstruction included dural repair with a dura substitute, split rib grafts to span the bony defect and an overlying free latismuss dorsi muscle flap covered with a split thickness skin graft. Eight months following surgery and radiotherapy, the patient experienced greatly improved quality of life but had developed parasthesia within the left trigeminal nerve distribution (Figure 4) although a repeat MRI scan failed to demonstrate a skull base lesion. Figure 1. Photograph showing a 20 cm ulcerated fungating lesion on admission
Figure 2. A MRI scan showing extensive bony destruction and dural involvement
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Figure 3. A CT scan showing extensive bony destruction
Figure 4. Photograph following surgery and radiotherapy
In this case, the perseverance with alternative medicine led to a delay of appropriate medical intervention with a resultant locally advanced disease. If the original lesion was managed timely and appropriately, treatment would have been simpler with a high likelihood of a cure. Instead, the patient required radical surgery and radiation therapy, with a remote chance of cure. In addition, the delay put the patient at significant risk of life-threatening complications such as meningeal infection and profuse haemorrhage.
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Discussion
This case highlights the risks of delayed medical treatment and the limitations of current regulation of complementary and alternative medicine (CAM) in New Zealand. CAM is an umbrella term used to describe a range of health practices, modalities and therapies that exist outside of mainstream medicine. The National Centre for Complementary and Alternative Medicine (NCCAM) categorises CAM into five categories: alternative medical systems; mind-body interventions; biologically based therapies; manipulative and body based methods; and energy therapies. Treatment can be further categorised as being complementary or alternative.1 Complementary medicine is that which is used alongside mainstream medicine, whereas alternative medicine is used in the place of mainstream medicine. In recent years, the popularity of CAM amongst the general population has increased significantly.24 Despite its widespread use, CAM practitioners are not subject to the same level of regulation as mainstream health practitioners. In New Zealand, mainstream health practitioners are regulated by the Health Practitioners Competence Assurance Act (HPCAA).5 The HPCAA was enacted in 2003 and brings together all mainstream health practitioners under one piece of legislation. The purpose of the Act is to protect the health and safety of members of the public by providing mechanisms to ensure that health practitioners are competent and fit to practice their professions. Under the Act, practitioners must be overseen by a registration body (e.g. the New Zealand Medical Council). Each registration body is responsible for defining their scope of practice and standards of competence. Practitioners are then required to undertake continuing professional development and quality assurance activities to maintain their annual registration. Failure to meet the required standards can result in loss of registration to practice. The HPCAA provides a system that ensures mainstream practitioners are competent and fit to practice. This system does not exist for CAM practitioners. At present, the majority of CAM practitioners in New Zealand lie outside the HPCAA or a similar legislative framework that regulates their practice. Exceptions to this rule are chiropractors and osteopaths who are now regulated under the HPCAA. The remaining CAM practitioners are either under voluntary regulation or self regulation. In other words, individual competency and fitness to practice is not regulated by statute. At present, there is no system to ensure that these CAM practitioners are competent and fit to practice. Another important regulatory framework governing health care practitioners in New Zealand is the Health and Disability Commissioner Act (HDCA).6 The HDCA was enacted in 1994 following the Cartwright Inquiry and applies to all health and disability care providers in New Zealand, both mainstream and CAM practitioners. The HDCA makes provision for the Code of Rights, which represents the accepted standard of care within New Zealand. The purpose of the Act is to promote and protect the rights of health and disability service consumers, and, to that end, to facilitate the fair, simple, speedy, and efficient resolution of complaints related to infringements of those rights.6 In the event of a breach, a formal investigation is undertaken by the Health and Disability
Commissioner. Options upon finding a breach include making recommendations to the provider, appropriate authorities (e.g. the registration body or professional college), the Minister of Health, the Director-General of Health, District Health Boards, Accident Compensation Corporation, and consumer and provider groups. These recommendations range from a written apology, undertaking specific training, and implementing and reviewing systems to prevent further breaches. If there are concerns about the competency of a registered health practitioner, the Commissioner may recommend review by their registration body (e.g. the New Zealand Medical Council). If disciplinary and/or other proceedings are deemed necessary, the Commissioner may refer the case to the Human Rights Review Tribunal (HRRT). The HRRT has a range of actions that it can take including awarding compensatory and punitive damages, and ordering health care providers to undergo remedial training.6 While the HDCA and the HPCAA are both enacted to protect health and safety of the public, there are fundamental differences between these two Acts. The HDCA is based on the Code of Rights and is geared towards complaints resolution. In contrast, the HPCAA is focused on ensuring that health practitioners are competent and fit to practice and therefore preventing adverse events from occurring. At present, mainstream health practitioners in New Zealand are subject to both statutes. Thus they provide the confidence that they are both competent and fit to practice and the assurance of a formal complaints resolution process should a negative outcome occur. This is not the case for CAM practitioners in New Zealand. With the exception of chiropracters and osteopaths, the remaining CAM practitioners are subject only to the HDCA. While the HDCA is an important pathway to resolve complaints, it is limited in its ability to prevent cases such as one presented in this report from occurring. There is no HPCAA-equivalent statute regulating CAM practitioners competency and fitness to practice. In this case, the alternative medicine practitioner appears to have breached the HDCA Code of Rights. Namely, the right to services of an appropriate standard and the right to be fully informed6 and working beyond the scope of practice. While it may have been reasonable for an alternative medicine practitioner to manage the lesion initially, when it was noted the lesion was not responding to therapy but rather progressing, appropriate referral should have been sought. Also, from the time of the initial consultation and throughout the duration of alternative therapy the patient was allegedly repeatedly reassured that the lesion was not cancer and advised against seeking a second opinion. This advice was allegedly given despite the patient and her familys repeated enquiries in the face of continued clinical deterioration. To determine if a practitioner has breached the Code of Rights, the individual must be measured against the practice of a reasonably careful practitioner within his/her relevant profession. As such, the care provided by this alternative medicine practitioner must be compared with that of a reasonably careful alternative medicine practitioner.7 It is doubtful that a reasonable alternative medicine practitioner would have undertaken the same practice when faced with the same deteriorating clinical scenario.
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The issue of regulating CAM practitioners has been widely debated in the literature.7 11 Arguments in favour of regulating CAM practitioners centre around the need to ensure public health and safety. The cost of unsafe health care (both personal and economic) to the individuals, families, communities, and the country is huge. As illustrated in this case, the practice of CAM is not without risk. General risks include making misleading claims, lack of appropriate referral resulting in delays in treatment, and lack of first aid knowledge. More specific risks associated with particular CAM therapies can include tissue, nerve or organ damage, infection, poisoning, allergic reaction or interaction with other treatments.12 Regulation has the potential to contain these risks by defining the scope of practice and the standard of competence. Throughout the health care sector there is increasing pressure to ensure that treatments are evidence-based. To date, research into the safety and efficacy of CAM is still rudimentary compared with mainstream medicine. As such, there is little high quality evidence for many CAM treatments. Critics of CAM argue that this is a true reflection of the lack of validity of CAM. Proponents of CAM argue that it is difficult to apply standard research methods to CAM. It is argued that methodologies such as randomised-controlled trials have too much emphasis on quantifiable outcomes.8 There are also a number of arguments opposing regulation of CAM. One such argument is that regulation would restrict access to CAM practitioners, through its effect on compliance costs and on the number of practitioners. Another concern is that statutory regulation may appear to give CAM official endorsement for treatments that, so far, are not evidence based. This unwarranted status may run counter to achieving consumer and public safety.8,12 In 2001, the Ministerial Advisory Committee on Complementary and Alternative Health (MACCAH) was established.12,13 The goal of the Committee was to review the issues surrounding CAM regulation in New Zealand and provide advice to the Minister of Health. In 2004, the MACCAH published their recommendations.13 The Committee recommended that CAM practitioners should be regulated according to the level of inherent risk involved in the modalities they practice. They recommended high-risk CAM modalities should be regulated under the HPCAA. To date, the only CAM practitioners to be identified as high-risk in New Zealand are osteopaths and chiropractors. It was felt that the remaining CAM practitioners were of low-risk and could continue to self-regulate.13 We argue that self-regulation of these so-called low-risk CAM practitioners is inadequate. We have presented a case which demonstrates the need for closer scrutiny of all CAM practitioners. One avenue for achieving this is statutory regulation. We recommend review of current regulations to prevent further similar cases from occurring.
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Author information: Raakhi Mistry, Formerly House Surgeon, Wellington Regional Plastic, Maxillofacial & Burns Unit, Hutt Hospital, Wellington; Brecon Wademan, Formerly House Surgeon, Wellington Regional Plastic, Maxillofacial & Burns Unit; Hutt Hospital, Wellington; Gary Avery, Plastic Surgery Registrar, Wellington Regional Plastic, Maxillofacial & Burns Unit, Hutt Hospital, Wellington; Swee T Tan, Consultant Plastic & Cranio-Maxillofacial Surgeon and Director of Surgery, Hutt Hospitaland Professor in Plastic Surgery, University of Otago, Wellington Acknowledgements: We are grateful to Mr Agadha Wickremesekera (Neurosurgeon at Wellington Hospital) and Dr Claire Hardie (Radiation Oncologist at Palmerston North Hospital) for their input in to this patients care as well as Professor Peter Skegg, Professor of Law, University of Otago, for his comments on this manuscript. This paper was presented, in part, at the New Zealand Association of Plastic Surgeons Annual Scientific Meeting, Auckland, New Zealand, on 21 November 2009. Correspondence: Professor Swee T Tan, Wellington Regional Plastic, Maxillofacial & Burns Unit, Hutt Hospital, Private Bag 31-907, High St, Lower Hutt, New Zealand. Fax +64 (0)4 5872510; email swee.tan@huttvalleydhb.org.nz References:
1. National Centre for Complementary and Alternative Medicine. National Centre for Complementary and Alternative Medicine. http://nccam.nih.gov/health/whatiscam/overview.htm Eisenburn D, Davis R, Ettner S, et al. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA. 1998;280:1569-75. MacLennan A, Wilson D, Taylor A. Prevalence and cost of alternative medicine in Australia. Lancet. 1996;347:569-73. Ernst E. Prevalence of use of complimentary / alternative medicine: a systematic review. Bulletin of the World Health Organization. 2000;78:252-7. Health Practitioners Competence Assurance Act. New Zealand 2003. Health and Disability Commissioner Act. New Zealand 1994. Skegg PDG, Paterson R, Manning J, Brookbanks W. Medical law in New Zealand Wellington: Thomson Brookers 2006. Colquhoun D. Secret remedies: 100 years on. BMJ. 2009;339:b5432. Colquhoun D. Should NICE evaluate complementary and alternative medicines? BMJ. 2007 Mar 10 Mar 10;334(7592):507. Ineson S. International Best Practice in Health Workforce Regulation: Sue Ineson Consultant; 2008. Colquhoun D. What to do about CAM? BMJ. 2007 Oct 13;335(7623):736. Ministerial Advisory Committee on Complimentary and Alternative Health. Complementary and Alternative Medicine Current Policies and Policy Issues in New Zealand and Selected Countries: A Discussion Document. Wellington; 2003. Ministerial Advisory Committee on Complimentary and Alternative Health on Complementary and Alternative Health. Complementary and Alternative Health Care in New Zealand: Advice to the Minister of Health. Wellington; 2004.
2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
13.
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Purple urine bag syndrome in a patient with a nephrostomy tube

Mohammad I Hirzallah, Donna L DSouza Abstract Purple urine bag syndrome is an uncommon condition characterised by purple colouring of the urine in a chronically catheterised patient. Typically seen in patients with a Foley catheter in the bladder, we report an uncommon case of purple urine bag syndrome in a patient with a long-term nephrostomy tube and discuss the pathophysiology of this condition.
Case report
A 78-year-old female patient with a history of leukaemia and obstructive uropathy requiring a nephrostomy tube presented to our interventional radiology department for routine change of her nephrostomy tube. We were struck by the appearance of her urine bag and tubing, both of which were vivid purple in colour (Figure 1). The patient was asymptomatic, afebrile, and had normal vital signs. Figure 1. First panel shows marked purple colourisation of the urine bag and the tubing extending from the nephrostomy. The second panel is a close-up on the urine bag further demonstrating its purple colour
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Discussion
First described in 1978,1 purple urine bag syndrome (PUBS) is an uncommon condition. It is typically seen in patients with chronic bladder catheterisation and accompanying colonisation by bacteria possessing certain enzymes.24 Purple urine bag syndrome in the setting of a nephrostomy tube appears to be very uncommon; to our knowledge only one other case has been reported in the literature.5 Other associated risk factors include bedridden status, constipation, female gender, alkaline urine, and receiving a diet high in tryptophan. The exact biochemical cause of PUBS is unknown; however, most authors believe it is a mixture of indigo (blue) and indirubin (red) that becomes purple in colour. The pathway begins when tryptophan is metabolised by the normal gut flora to indole. Indole is absorbed by the portal circulation and converted in the liver to indoxyl sulphate. Indoxyl sulphate is excreted in the urine and, in the presence of an alkaline environment and bacterial enzymes (indoxyl sulphatase and indoxyl phosphatase), indoxyl sulphate is metabolised into indigo (blue) and indirubin (red) which gives urine a purple colour (Figure 2).3,4 Figure 2. Metabolic pathway of purple urine bag syndrome
Bacterial species that can produce indoxyl sulphatase and indoxyl phosphatase include (but are not limited to) Providencia stuartii, Providencia rettgeri, Klebsiella pneumoniae, Proteus mirabilis, Escherichia coli, Morganella morganii, and Pseudomonas aeruginosa.2,3
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PUBS is generally a benign condition that reflects bacterial colonisation of a chronically catheterised urinary tract. It resolves after managing the associated urinary tract infection and/or removal of the catheter.2,3 Author information: Mohammad I Hirzallah, Medical Student, Faculty of Medicine, University of Jordan, Amman, Jordan; Donna Louise DSouza, MD, Department of Radiology, University of Minnesota, Minneapolis, MN, USA Correspondence: Mohammad I Hirzallah, Faculty of Medicine, University of Jordan, PO Box 13651, Amman 11942, Jordan. Email: mihh1986@yahoo.com References:
1. 2. 3. 4. Barlow GB, Dickson JAS. Purple urine bags. Lancet 1978; 28:2201. Vallejo-Manzur F, Mireles-Cabodevila E, Varon J. Purple urine bag syndrome. Am J Emerg Med 2005; 23(4):5214. Lin CH, Huang HT, Chien CC, et al. Purple urine bag syndrome in nursing homes: ten elderly case reports and a literature review. Clin Interv Aging 2008; 3(4):72934. Dealler SF, Hawkey PM, Millar MR. Enzymatic degradation of urinary indoxyl sulfate by Providencia stuartii and Klebsiella pneumoniae causes the purple urine bag syndrome. J Clin Microbiol 1988; 26:21526. Lazimy Y, Delotte J, Machiavello JC, et al. Purple urine bag syndrome: a case report. Prog Urol. 2007; 17(4):8645.
5.
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A case of green urine due to a traditional Chinese medicine containing methylene blue
Choong-Weng Lam, Sau Y J Wong Abstract Abnormal discolouration of the urine is always alarming to the patient and intriguing to physicians. Green colouration in urine can be of endogenous or exogenous aetiology. We present a case of green urine caused by a side effect of a traditional Chinese medicine (TCM) containing methylene blue, an uncommon occurrence. This case also highlights the importance of thorough history taking from the patient, especially diet and medications. Simple analysis in the clinical biochemistry laboratory can play a role in avoiding other expensive and unnecessary investigations.
Case report
An 86-year-old female presented to the Accident & Emergency Department with a 2day history of inability to pass urine, dysuria, suprapubic pain, and constipation. Her past medical history included diabetes mellitus, ischaemic heart disease, hypertension, hyperlipidaemia, chronic renal failure, and congestive cardiac failure. Physical examination was remarkable of an elderly lady in mild dehydration, afebrile, stable blood pressure of 110/70 mmHg and a palpable bladder. The patient was on the following medication: tolbutaminde, isosorbide dinitrate, carvedilol, omeprazole, aspirin, ezetimibe, simvastatin, frusemide, and potassium chloride. On further questioning, the patients daughter revealed the patient had been taking a traditional Chinese medicine (TCM) known as Wilisan pills for the past 2 months prior to admission. The content of a Wilisan pill was identified as follows: extract buchu 15 mg, extract uva ursi 15 mg, and methylene blue 15 mg. The following urine sample was received in the clinical biochemistry laboratory (Figure 1). Figure 1. Green urine sample
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Discussion
Normal freshly voided urine appears amber-yellow, is sterile and clear, and has an average slightly acidic pH of 6.0 and a characteristic odour. Abnormal discolouration of urine can indicate an underlying pathogenic or benign condition. Most frequently, the abnormal discolouration of urine is caused by gross haematuria, where a pink to red-brown urine is encountered. Green urine encountered in our case is an uncommon occurrence. Green colouration in urine can be of endogenous or exogenous aetiology. It must be noted that blue compounds may appear green or blue-green in the urine, due to presence of urochrome which is a major yellow pigment in the urine. Endogenous causes include pathological conditions such as chronic obstructive jaundice where presence of biliverdin (oxidation product of bilirubin) in urine can give a green hue. Urinary tract infection caused by Pseudomonas can turn urine green due to pyocyanin and pyoverdin pigments produced by the bacterium.8 A rare inherited metabolic disorder known as the Blue Diaper Syndrome in which there is tryptophan malabsorption, can also give rise to blue-green urine. In this metabolic disorder, excessive production of indoles from bacterial metabolism of unabsorbed tryptophan leads to indicanuria where tryptophan indole metabolites cause a blue-green colouration in urine. Exogenous causes of green urine are more likely causes and are mostly due to oral or intravenous administration of certain compounds. Some medications can give rise to green urine. Certain phenol-containing drugs have the disposition to cause green urine due to phenol metabolites excreted in urine. Propofol, a commonly used phenol-containing intravenous anaesthesia drug has been reported to give green colouration in urine.5,7 Other phenol-containing drugs of the same green urine effect are cimetidine and promethazine.1,4 In addition, a number of other medications such as triamterene, indomethacin, methocarbamol, magnesium salicylate and the antibiotic rinsapin can produce green to blue-green urine as possible side-effects.2-6,8 Water-soluble artificial dyes can cause green urine. Food dye FD&C blue no. 1 has been reported to give green urine when it was added to enteral feed during tube feeding.2 Other benign artificial dyes such as indigo carmine, methylene blue (methylthioninium chloride) and indigo blue can be filtered in the urine causing a green colouration. Of these, methylene blue is a well-known culprit of causing green or blue-green urine. In medicine, methylene blue is used as a contrast dye and also for treating conditions such as cyanide poisoning and methaemoglobinaemia. Multi-ingredient medications containing methylene blue either as pigment or treatment purposes can potentially colour urine green. Methylene blue excretion in the urine is slow; with bulk of the dye is excreted as a stabilized form leucomethylene blue and the remainder as unchanged methylene blue.
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In our case, methylene blue was found to be a component of a traditional Chinese medicine (TCM) pill which the patient was consuming. Samples of the patients green urine and a few Wilisan (TCM) pills were sent to the clinical biochemistry laboratory for investigation. A spectrophotometric scan was performed on the patients green urine sample (Figure 2). An absorbance maximum at around = 660 nm was found. Spectrophotometric scans were also performed on a normal control urine sample (Figure 3), and on a normal control urine sample spiked with dissolved Wilisan pill in water (Figure 4). The absorbance peak of 660 nm was absent in the normal urine sample but present in the other two spectra. Absorbance spectrum of the green urine resembled closely to that of the dissolved pill, strongly suggesting the presence of the contents of the pill in the urine. Methylene blue absorbs light at a wavelength of 550700 nm, with a preferential maximum absorbance at 660 nm and 609 nm (shoulder peak). Presence of these two peaks in the green urine sample and Wilisan pills confirm the presence of methylene blue in both. Figure 2. Absorbance spectrum of green urine sample
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Figure 3. Absorbance spectrum of a normal urine sample
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Figure 4. Absorbance spectrum of urine spiked with Wilisan
Other significant investigation findings include a urine culture positive for E. coli. pH of urine measured was 7.8 at time of collection. Urine bilirubin was negative. Lessons learnt from this case include excluding the endogenous and exogenous causes of green urine through a careful examination of the patients clinical history, diet and medications. The patient was managed by discontinuing the offending drug, in this case the TCM and treating the urinary tract infection with appropriate antibiotics. On review at the outpatient clinic 2 months later, the green urine had cleared. Abnormal discolouration of the urine is always alarming to the patient and intriguing to physicians. In this case, green urine was caused by a side effect of a TCM drug containing methylene blue. In patients suffering from chronic renal failure as in our case, excretion of methylene blue in urine could be compromised. Although methylene blue is a harmless dye, it is not known if chronic accumulation of the dye would be benign or potentially toxic in patients with compromised renal function.
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This case brings to our awareness that not all abnormal discolourations in urine are pathologic. Moreover, careful history-taking and the physicians awareness of potential side effects of medications as well as a quick, simple analysis in the clinical biochemistry laboratory had merit in avoiding unnecessary and expensive investigations. Author information: Choong-Weng Lam, Chemical Pathologist; Sau Y J Wong, Scientific Officer; Department of Pathology, Singapore General Hospital, Singapore (At the time of publication, Dr Lam is the Acting Head, Laboratory Medicine of Jurong General Hospital.) Correspondence: Dr Choong-Weng Lam, Department of Laboratory Medicine, Jurong General Hospital, 378 Alexandra Road, Singapore 159964. Email: leslie_lam@jgh.com.sg References:
1. 2. 3. 4. 5. 6. 7. 8. Bowling P, Belliveau RR, Butler TJ. Intravenous Medications and Green Urine. JAMA 1981;246:216 Carpenito G, Kurtz I. Green Urine in a critically ill patient. Am J Kidney Dis 2002;39:E20 Ehrig F, Waller S, Misra M, et al. A case of green urine. Nephrol Dial Transplant 1999; 14: 190-192. Fisher JA. Why was the urine green? Can J Anaesth 1995;42:87-89 Leclercq P, Loly C, Delanaye P, et al. Green Urine. The Lancet 2009;373:1462. Raymond JR, Yarger WE. Abnormal urine color: differential diagnosis. South Med J 1988;81:837-841. Tan CK, Lai CC, Cheng KC. Propofol-related green urine. Kidney Int 2008;74:978. Yip TPS, Lui SL, Lo WK. Green Urine. Hong Kong J Nephrol 2002;4:114.
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Non-classic congenital adrenal hyperplasia due to 21-hydoxylase deficiency as a cause of infertility and miscarriages
Henrik Falhammar Abstract Miscarriages and infertility can be presenting symptoms of non-classic congenital adrenal hyperplasia (NCAH). Two sisters are described with fertility issues and multiple miscarriages occurring up to 20 weeks of pregnancy. After diagnosing NCAH due to 21-hydroxylase deficiency and initiating glucocorticoid treatment, conception occurred within 3 months and uneventful pregnancies and deliveries ensued. Classic congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency is a disease affecting the synthesis of cortisol, and often aldosterone as well, with an increased production of steroid precursors and androgens.1 As a result of the elevated androgens, females are virilised at birth. In contrast, non-classic CAH (NCAH) only demonstrates a slight increase of steroid precursors and androgens with mild symptoms of androgen excess such as oligomenorrhoea, hirsutism, acne and infertility.1 NCAH can easily be misdiagnosed as polycystic ovary syndrome.2 Sometimes NCAH is asymptomatic and may be found serendipitously.3 NCAH is the most frequent autosomal recessive disorder affecting 0.11% of the general population, however only a minority of cases is diagnosed.1 Two sisters with spontaneous abortions and fertility issues subsequently diagnosed with NCAH and excellent response to glucocorticoid therapy are presented.
Case 1
A 35-year-old married woman of Middle East origin presented with miscarriages and difficulties in conceiving. Menarche was experienced at 14 years-of-age and the menstrual cycle had always been regular. She had for the last 15 years tried to become pregnant and 10 years previously she managed to conceive but had a miscarriage at 20 weeks. However, a few months later, she conceived once more and a healthy boy was delivered at term. Some years later, she once more experienced a late miscarriage, this time at 15 weeks. She was subsequently investigated at an infertility clinic where ovaries and uterus seemed to be normal on a vaginal ultrasound, and hysterosalpingography demonstrated normal tubes and uterus. Sperm analysis on her husband was normal. Serum testosterone was markedly elevated (6.8 nmol/L; normal 0.33.0), serum sexual hormone binding globulin (SHBG) was normal (40nmol/L; normal 2995), testosterone/SHBG ratio was markedly increased (0.17; normal <0.05), serum
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androstenedione was elevated (22.1 nmol/L; normal 3.29.6) and serum dehydroepiandrostendione sulphate was normal (4.8micromol/L; normal 1.659.15). She was then referred for endocrine evaluation. At this evaluation, mild hirsutism was noted, blood pressure was 110/70 mmHg supine and 105/65 mmHg standing, height was 165 cm and weight 52 kg. Repeated bloods now showed a normal testosterone level (2.5 nmol/L), normal SHBG (46 nmol/L) and a borderline testosterone/SHBG ratio (0.051). However, elevated level was found for serum 17-hydroxyprogesterone (48nmol/L; normal <6 in follicular phase) indicating NCAH due to 21-hydroxylase deficiency. Analysis of the CYP21A2-gene revealed the mutations V281L/Q318X confirming the diagnosis of NCAH. Prednisolone 2.5 mg twice daily was initiated. On a subsequent review four months later she was pregnant of 67 weeks gestation. Prednisolone was increased to 3.75 mg twice daily. The pregnancy was otherwise normal and a healthy boy was delivered vaginally at week 39. The prednisolone dose was decreased to 2.5 mg daily after delivery. She noted that her hirsutism had improved since the initiation of prednisolone.
Case 2
A sister to Case 1, who still lived in the Middle East, had the same problem with multiple miscarriages and infertility. She was initiated on glucocorticoid therapy on the suspicion of also having NCAH. Within 3 months she conceived without any problems and delivered a healthy child. She soon conceived once more on glucocorticoid treatment and a second healthy child was delivered. Both pregnancies were reported to be normal.
Discussion
Second trimester pregnancy loss is rare and NCAH is usually not even listed as a cause in first trimester.4 Moran et al reported a miscarriage frequency in undiagnosed NCAH to be 25.4%, however, after the women had been diagnosed with NCAH the frequency decreased to only 6.2%.5 This is in accordance with a previous study reporting a miscarriage frequency of 33.3% before the diagnosis of NCAH and 0% after the diagnosis and initiation of hydrocortisone.6 A recent study has described a similar miscarriage rate (7.4%) in mixed group of classic and non-classic CAH, all treated with glucocorticoids, which did not differ from an age-matched control group (6.8%, p=NS).7 However, no case of second trimester miscarriage has previously been reported in CAH. Infertility is common in NCAH with a frequency of about 50%, but almost all women with CAH wishing to conceive can do so with a glucocorticoid, sometimes in combination with a mineralocorticoid and/or adding clomiphene, metformin, gonadotropins and in vitro fertilisation.1,2,57 The two cases presented here responded very well on glucocorticoids with conception occurring within 3 months and no complications during pregnancy and delivery. It is controversial if all NCAH should be treated with glucocorticoids due to the increased risk of metabolic complications, osteoporosis and fractures, however, treatment should probably be initiated in all symptomatic patients, especially if desiring pregnancy.13,6,8,9
Diagnosing NCAH is usually done by measuring early morning serum 17hydroxyprogesterone in the follicular phase. A value of 17-hydorxyprogesterone <6.0 nmol/L will normally exclude the disorder while a value >45 nmol/L confirms it.1 An ACTH stimulation test with 17-hydroxyprogesterone >45 nmol/L 60 min after the injection is considered diagnostic of NCAH.1 Analysis of the CYP21A2-gene can be used for further classification and confirmation. In the first case, the serum testosterone levels differed considerably without clear cause. However, two different pathology services had been used with presumably different assays. It has been suggested to exclude CAH only if testosterone >5 nmol/L,10 but this would have prevented Case 1 being correctly diagnosed if only the second testosterone value had been considered. Serum testosterone is largely bound to SHBG and Case 1 also demonstrates the value of calculating free testosterone, especially in the normal to mildly elevated range of testosterone, as otherwise a pathological increase of free testosterone could be overlooked. In conclusion, the two presented sisters highlight the importance of recognising NCAH, especially in young females with infertility and/or miscarriage issues even in the second trimester. Failing to diagnose NCAH can have tragic consequences but success can be immediate if diagnosis is made and proper treatment is initiated. Author information: Henrik Falhammar, Consultant Endocrinologist and Physician, Departments of Endocrinology and Medicine, Cairns Base Hospital, Cairns, AustraliaDepartment of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Swedenand Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden Correspondence: Dr Henrik Falhammar, Department of Endocrinology, Cairns Base Hospital, PO Box 902, Cairns, QLD 4870, Australia. Fax: +61 (0)7 40506817. Email: henrik.falhammar@ki.se References:
1. 2. Merke DP, Bornstein SR. Congenital adrenal hyperplasia. Lancet. 2005;365:2125-36. Falhammar H, Thorn M, Hagenfeldt K. A 31-year-old woman with infertility and polycystic ovaries diagnosed with non-classic congenital adrenal hyperplasia due to a novel CYP21 mutation. J Endocrinol Invest. 2008;31:176-80. Falhammar H, Thorn M. An 88-year-old woman diagnosed with adrenal tumor and congenital adrenal hyperplasia: connection or coincidence? J Endocrinol Invest. 2005;28:449453. Brown S. Miscarriage and its associations. Semin Reprod Med. 2008;26:391-400. Moran C, Azziz R, Weintrob N, et al. Reproductive outcome of women with 21-hydroxylasedeficient nonclassic adrenal hyperplasia. J Clin Endocrinol Metab. 2006;91:3451-6. Feldman S, Billaud L, Thalabard JC, et al. Fertility in women with late-onset adrenal hyperplasia due to 21-hydroxylase deficiency. J Clin Endocrinol Metab. 1992;74:635-9. Hagenfeldt K, Janson PO, Holmdahl G, et al. Fertility and pregnancy outcome in women with congenital adrenal hyperplasia due to 21-hydroxylase deficiency. Hum Reprod. 2008;23:160713. Falhammar H, Filipsson H, Holmdahl G, et al. Metabolic profile and body composition in adult women with congenital adrenal hyperplasia due to 21-hydroxylase deficiency. J Clin Endocrinol Metab. 2007;92:110-6. Falhammar H, Filipsson H, Holmdahl G, et al. Fractures and bone mineral density in adult women with 21-hydroxylase deficiency. J Clin Endocrinol Metab. 2007;92:4643-9.
3.
4. 5. 6. 7.
8.
9.
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10. Taylor A. ABC of subfertility. Making a diagnosis. BMJ. 2003;327:494-7.
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Punched-out lesions in skull

Vishal Sharma, Alka Sharma Clinical A 74-year-old male presented with history of low backache and fatigue for 6 months. His haemoglobin was 6.2 gm/dL, blood urea 132 mg/dL, serum creatinine 8 mg/dL, serum calcium 10.8 mg/dL, and alkaline phoshatase 242 IU/L. A lateral skull radiograph was performed (Figure 1). Figure 1. Punched-out lesions in skull
What is the most likely diagnosis?
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Answer Multiple myeloma. This condition is characterised by activation of osteoclasts and depressed osteoblastic response which results in generalised osteopenia. At later stages, numerous lytic lesions can be seen giving appearance of punched-out holes, as seen in the skull radiograph (Figure 1). Although these are classically described in multiple myeloma, it can also result from osteolytic metastasis from other malignancies.1 Author information: Vishal Sharma, Senior Resident; Alka Sharma, Postgraduate Student; Department of Medicine, University College of Medical Sciences, Delhi, India Correspondence: Vishal Sharma 308, SRD Hostel, University College of Medical Sciences, PO Box -110095, Delhi, India. Email: docvishalsharma@gmail.com Reference:
1. Yalin O, Yildirim T, Kizilkili O, et al. CT and MRI findings in calvarial non-infectious lesions. Diagn Interv Radiol 2007;13:68-74.
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Setting up new learning environments in regional and rural areas

Warwick Bagg, Anna J Dare, Barbara J OConnor, Phillippa Poole, James J Reid, Joy Rudland, Mike J Tweed, Tim J Wilkinson Abstract The shortage of doctors in New Zealand, especially in regional and rural areas, together with the recognition that medical students need to learn in a variety of contexts has led to new learning environments being developed. This paper describes some of the key factors that have led to the successful implementation of year-long regional and rural clinical placements for medical students in New Zealand. New Zealand (NZ), like many other countries, faces a shortage of doctors in rural and regional areas that is reaching crisis level.1 In addition, medical students need to learn in a variety of contexts, seeing a wide range of patient presentations. Clinical attachments in most medical schools aim to provide such a varietyusing tertiary hospitals, secondary hospitals and primary health services including rural and urban general practices. Increasingly tertiary hospitals do not provide the varied diet our students need; shorter length of patients stay reduces time for meaningful contact, and more focus on rare or serious ends of the illness spectrum, rather than on chronic disease. These factors have driven medical schools to explore better learning opportunities more aligned with current health needs of NZ. A recent analysis showed that a significant proportion of rural general practitioners had doctor to patient ratios over 1:20002, well above the alert level of 1:1200 set out in the Implementation of the Primary Healthcare Strategy in Rural New Zealand.3 Regional hospitals are also currently struggling to fill vacancies and attract new graduates.3 Exposure to rural medicine for significant periods during undergraduate training is a positive predictor of future rural practice.4-6 A rural curriculum in undergraduate medical training can produce attitudinal changes in students irrespective of whether the students come from a rural background or not.6 However, a rural background is estimated to have three times the effect of curricula.1, 5 This evidence was a driver to increase the places available to students from rural backgrounds in both NZ medical schools from 2004 onwards. In 2007 the Workforce Taskforce recommended that all medical practitioners acquire a broad general foundation, which includes community and regional hospital experience, before entering vocational training and that universities be invited to bring forward proposals for a primary care based undergraduate programme which is targeted to areas of need such as rural, Mori and high deprivation populations.7 Consequently, designing medical programmes that encourage recruitment of new
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medical graduates into regional and rural practice has become a priority area in medical education. This paper describes factors to consider when implementing regional and rural medical programmes (where students are immersed for at least a year while meeting equivalent learning outcomes to the students based in the standard programme). We use illustrations from the experiences of the Universities of Auckland and Otago in implementing regional and rural programmes.
Regional and rural programmes

Rural community-based programmes are sound alternatives to traditional urban-based medical courses with students performing well academically and reporting positive experiences.8-11 In NZ different approaches have been adopted by the two Universities as described below. In 2007 the University of Otago piloted a Rural Medical Immersion Programme (RMIP), developed by Dunedin School of Medicines Te Waipounamu Rural Health Unit. For the first time in NZ, six medical students spent the entire fifth year of their undergraduate clinical training based in rural communities; in 2008 this was increased to 12 students and since 2009, 20 students per year complete the RMIP. The RMIP is based on comparable outcomes to the students on the standard programme but these outcomes are met in the rural setting. The learning occurs in context, and specific objectives are achieved over the whole year, rather than in discipline attachments. The locations used for RMIP are: Greymouth, Dannevirke, Masterton, Blenheim, Balclutha and Queenstown. The students are supported by IT and other learning resources from the clinical schools. The programme is generalist in nature and includes primary and secondary care. Pkawakawa, the University of Auckland regional-rural medical programme, was designed in 2007 and the first cohort of 20 Year 5 students commenced the programme in 2008. The programme is based on a hub and spoke model located in Northland, an area of 150,000 people with a high proportion of Mori and relative social deprivation. This 27 week parallel experience incorporates three longer attachments compared with the standard programme: Integrated Care and General Practice (7 weeks) based at Rawene, Kaitaia or Dargaville; Women and Childrens Health (8 weeks), and Secondary Care (10 weeks) based at Whangarei Hospital. While these were designed to be equivalent to the standard programme in terms of the meeting of core learning outcomes, the longer attachments are aimed to allow more continuity with patients and supervisors and a greater likelihood of a rural career. A more detailed description of the programme has been published.12 In 2009, the University of Otago Wellington introduced a regional immersion programme at Palmerston North, for seven students for the whole of their Trainee Intern (TI) year (Year 6). In 2010 this number has been increased to 11 students. In previous years students rotated to Palmerston North from University of Otago Wellington for discipline attachments and this also continues to complement those students spending the complete year in Palmerston North.
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Since the early 1990s University of Auckland TIs have had year-long attachments outside of Auckland. 24 TIs complete the year in Hamilton, while 12 TIs complete the TI year in Rotorua. The attachments mirror those of the standard programme and assessments are identical. For Auckland students learning at rural teaching sites, we have found that they experience greater continuity of patient care and are more involved in therapeutic decision making. They also feel part of the team, get to do more procedures, are more involved in acute and emergency management and have more longitudinal encounters with patients with chronic illnesses (unpublished internal evaluation). While this paper concentrates on these new initiatives we acknowledge the other experiences already being delivered in rural and regional centres in NZ by both medical schools.
Partnership the key to successful implementation of regional-rural programmes in New Zealand

The successful implementation of parallel pathways requires partnerships with key stakeholders. In particular corporate buy in from management of local District Health Boards (DHBs), Primary Health Organisations and iwi (indigenous) providers to provide the high level support required to implement the necessary support structures and mandate for clinicians to engage with Universities. In addition, lead clinicians actively partner with University departments for the delivery of suitable learning environments, teaching and assessment The communities in which students are based have embraced the presence of students. Examples of this engagement include: Pwhiri, refurbished accommodation, medical students participation in local sports teams and tournaments, and visits to local schools where they encourage students to consider professional careers. Local media have written articles affirming the students positive engagement with, and impact on, the community. Partnerships may be useful catalysts to solve some local organisational shortcomings and Universities can become advocates for rural health. One of the tangible outcomes of the partnership is that many of the TIs who have completed the year in Rotorua, Hamilton or Palmerston North have stayed on as junior doctors.
Be innovative
The implementation of new programmes provides the opportunity to pilot innovations and new pathways. Because each context offers unique opportunities and constraints, but the curricula need to be equivalent, the situation is ripe for innovation. This means that finding a new way to deliver part of the curriculum might not only work well in the new programme but may give ideas on different ways to deliver the curriculum in the traditional programme. For example, the RMIP has been able to draw on the particular strengths of each of Otagos three main campuses. Although the Otago course has been keen to promote greater sharing of resources among the campuses anyway, the RMIP may well have catalysed such synergies.
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Students have the opportunity to travel with rural patients to the closest main hospital to appreciate the continuity of care provided. Often this requires ambulance, or on a few occasions, helicopter travel. This clearly demonstrates the link between primary and secondary care, transfer of responsibility, and team work. Opportunities also exist for re-engineering of the traditional curriculum according to good evidence based practice (e.g. long attachments with the same supervisors)13 which is difficult to achieve in historically dictated and constrained traditional curricula. Continuity- of curriculum, of patient contact, and of supervision- is increasingly seen as a holy grail in medical education13, regardless of delivery site.
Enabling teachers
The clinical staff requires adequate support from educators and development in order to know how and what to teach. In our experience local clinicians and management often enthusiastically support the introduction of regional and rural medical programmes. University staff provided induction training at each teaching site prior to the arrival of students. In addition, practically-based Teach the Teachers programmes have been offered. In general, clinicians want to learn but finding time to attend teaching sessions may be a challenge given the significant service loads and for GPs, the direct impact on income. One of the realities of delivering the programmes in regional and rural areas may be the reliance on a small number of key people. Thus the programme may be vulnerable when key clinicians are unavailable. To mitigate this factor arrangements have been agreed with clinical services to deliver the teaching rather than individual clinicians. Videoconferencing is invaluable for meetings between local clinicians and university staff, as well as for teaching. Getting acceptance from academic staff located in the main medical school sites that students can learn specialty content from generalists can be a challenge. To this end, both universities emphasise the importance of learning from being involved in care of more undifferentiated patients and apprentice-style learning in such settings, not just formal tutorials or lectures.
Equivalence in learning and assessment

Although attachments and the context of learning are different to the standard programme, learning outcomes and assessment are equivalent. Staff and students require assuredness of equivalence, with students often looking over their shoulders at students based at larger urban medical school sites. These fears may be mitigated by common formal teaching programmes, similar assessments and university support at the local sites. Different approaches have been used to ensure common assessment. For University of Auckland students end of year written assessments and medicine and surgical short cases are undertaken back in Auckland. In contrast, the O & G OSCE and paediatric Mini-CEX are completed in Northland. This has required university staff to coach local clinicians, who act as examiners. Additionally, university staff have examined alongside Northland clinicians to aid benchmarking.
Similarly, at the University of Otago the common end of Year 5 examination ensures equivalence and a clear method for determining comparability of learning in different environments. Common paper assignments are cross marked by experienced assessors. Assessments of observed consultations can be assured for quality and fairness either by travelling examiners and travelling students. Staff training and discussion maintains quality and fairness for supervisor reports. Reassuringly, and in line with overseas evidence14-16, academic performance has proved at least as good on the immersion programmes as on the standard programmes.17
Consider a selection strategy

Ensure that a selection strategy maximises the likelihood of students returning to rural areas as practitioners. There are varied reasons why students choose to study in regional and rural environments. The most important factor cited by students is lifestyle considerations i.e. more relaxed, recreational activities, and experiencing country life. This is followed by learning more about rural community health, and community identity. Better learning opportunities also feature as a priority including: more opportunities and variety to improve clinical skills; smaller students to clinician ratio; greater clinical autonomy, and active participation in patient care. Students from rural backgrounds are more likely to apply for the Pkawakawa programme even though they are not obligated to do so.12
Practical support for students in the regional rural environments

Accommodation needs to be provided for students on site. This allows small groups of students, who may not know each other well, to live and work together. While the peer support can be valuable, on occasion tensions between students can arise. Where students are unable to resolve these issues they preferred not to involve academic staff, perceiving a conflict of interest. As such an independent counsellor has been made available for students to access. Access to an independent personal GP for students can be problematic if they are attached to the only GP in the district. Careful and specific arrangements need to be put in place so that the one GP is not acting as teacher/assessor alongside counsellor/doctor. Students highly value good IT access. To this end dedicated IT facilities have been provided at the Whangarei Hospital site which are linked to the university intranet and therefore have direct access to the library and other university electronic resources. In addition IT access is provided in the residence. All Otago RMIP students are provided with a laptop computer, on loan, with broadband wireless internet access.
Governance
Governance is required to ensure the smooth progress of innovative new programmes. Failure to attend to this issue can cause unnecessary tensions. Governance of any programme has several dimensions: There are the managerial aspects of budgets, human relations, the curriculum aspects of planning and
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administering the learning programme, and the monitoring of student progress. For a large programme, these functions are undertaken by separate groups. For a small programme, it is always important to have fewer committees than students. Of necessity therefore, many of the functions must be undertaken by the same group of people. The inevitable conflicts of interest that can arise from this are not insurmountable but need to be acknowledged. While it is important to have good governance of the new programme, it is also critical that this governance is not isolated from the governance of the main programme. For the RMIP, there is cross-representation on the various committees so that RMIP is represented on the main programme discussions and vice versa. However, this arrangement can make it very easy for RMIP teachers to be expected to spend all their time on committees clearly an undesirable outcome. Achieving the right balance of representation, constructive input and ownership is likely to be a negotiated process that constantly evolves. The approach at the University of Auckland has been to have a Joint Relations Executive between the University and the DHB as well as other key stake holders. This body deals with the high level issues requiring input from the CEO and Dean. Academic governance resides with the Board of Studies (Medical Programme). A subcommittee of the BOS, The Regional Rural Curriculum Committee, has representation from the Medical Programme Directorate, university departments, local clinicians, rural sites and students. This committee provides a forum for planning of the curriculum and resolution of concerns raised by staff and students. In Northland an academic coordinator, together with a clinical case coordinator and an administration manager provide onsite support for the students and assist with the day-to-day running of the campus. There is an Associate Dean (Palmerston North) who sits on the University of Otago Wellington curriculum committee and student progress committee. They have local oversight for delivery of the core outcomes for student learning and support role for students. Adequate administrative support is essential for the successful functioning of the local programme. Evaluation and monitoring of the immersion programmes are important to ensure that outcomes are indeed equivalent and that students concerns can be addressed in a timely manner. Feedback from evaluation and monitoring to appropriate members of the governance team is essential to help shape and enhance the curriculum. It is however tempting to over-evaluate a new initiative and this can lead to both staff and student evaluation fatigue.
Financial considerations
Regional and rural immersion programmes are not cheap and have to be appropriately costed and funded. Both programmes were initiated with additional funding. Without such funding neither programme would be viable or sustainable. It costs approximately double to train immersion students compared to those on the standard programme. If further expansion of these immersion programmes is to be achieved then additional sources
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of revenue will be required, such as the dedicated federal funding for rural clinical schools in Australia. Hopefully, these costs will be offset in the long term by students who have participated in the programmes returning to work as doctors in regional and rural areas. These data are being gathered prospectively but will take some years to demonstrate the effectiveness, or otherwise, of these programmes.
Measures of success
The success of immersion programmes needs to be evaluated. Evaluation focus will be determined by the specific emphasis of the programmes, some of which have already been mentioned in this paper. These include: Student academic performance that is at least as good as students studying on the standard programme; Sustainability from a staffing and financial point of view; Ultimately, that a significant proportion of students who participate in these immersion programmes choose to work in a rural or regional area; and Improved capacity of the local health system and community to meet health needs.
Conclusion
The innovative regional and rural programmes described have broken the mould of usual medical teaching programmes in NZ and challenge traditional medical education thinking. Students and teachers are enthusiastic and actively participate in improving the learning in new settings and novel ways. Already there is anecdotal evidence that these programmes are of benefit to the community and hopefully will ultimately be good for the country. For the future it is essential that research and evaluation is undertaken to determine whether the planned goals are actually being realised.
Author information: Warwick Bagg, Associate Dean (Medical Programme), Director Medical Programme Directorate, , University of Auckland, Auckland; Anna J Dare, Junior Doctor, Department of Surgery, Auckland District Health Board, Auckland; Barbara J OConnor, Educational Project Manager, Faculty of Medical and Health Sciences, The University of Auckland, Auckland; Phillippa Poole, Head, Medical Education Division, School of Medicine, University of Auckland, Auckland; James J Reid, Head of General Practice and Rural Health, Deputy Dean, Dunedin School of Medicine, University of Otago, Dunedin; Joy Rudland, Director Faculty Education Unit, University of Otago, Dunedin; Mike J Tweed, Associate Dean (Medical Education), Medical Education Unit, University of Otago, Wellington; Tim J Wilkinson, Associate Dean (Medical Education), University of Otago, Christchurch Acknowledgements: We acknowledge the many stakeholders and students who have participated in implementing these new programmes.
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Correspondence: Assoc Prof Warwick Bagg, Associate Dean (Medical Programme), Medical Programme Directorate, The University of Auckland, Private Bag 92019, Auckland Mail Centre, Auckland 1142, New Zealand. Fax: +64 (0)9 3677146; email w.bagg@auckland.ac.nz References:
1. 2. 3. 4. Hsueh W, Wilkinson T, Bills J. What evidence-based undergraduate interventions promote rural health? NZ Med J 2004;117:U1117. Analysis of the New Zealand General Practitioner Workforce. Wellington: New Zealand Medical Association; 2004. Implementing the Primary Health Care Strategy in Rural New Zealand, in a report from the Rural Expert Advisory Group. Wellington: Ministry of Health; 2002. Brooks R, Walsh M, Mardon R. The roles of nature and nurture in the recruitment and retention of primary care physicians in rural areas: a review of the literature. Acad Med 2002;77:790-8. Rabinowitz H. A program to increase the number of family physicians in rural and underserved areas: impact after 22 years. JAMA 1999;281:255-60. Williamson M, Gormley A, Farry P. The new rural health curriculum at Dunedin School of Medicine: how has it influenced the attitude of medical students to a career in rural general practice? NZ Med J 2002;116:537-47. Workforce Taskforce. Reshaping medical education and training to meet the challenges of the 21st century: a report to the Ministers of Health and for Tertiary Education from the Workforce Taskforce. Wellington: Ministry of Health; 2007. Denz-Penhey H, Murdoch JC, Lockyer-Stevens VJ. What makes it really good, makes it really bad.' An exploration of early student experience in the first cohort of the Rural Clinical School in the University of Western Australia. Rural Remote Health. 2004;4:300. Farry P, Williamson M. Aligning medical education with the healthcare needs of the Population. NZ Med J 2004;117:U1114. Hunsaker ML, Glasser ML, Neilsen KM, et al. Medical students' assessments of skill development in rural primary care clinics. Rural Remote Health 2006;6:616. Worley P, Strasser R, Prideaux D. Can medical students learn specialist disciplines based in rural practice: lessons from students self reported experience and competence. Rural Remote Health 2004;4:338. Poole P, Bagg W, O'Connor BJ, et al. The Northland Regional-Rural program (Pkawakawa): broadening medical undergraduate learning in New Zealand. Rural Remote Health 10 (online) 2010: 1254. http://www.rrh.org.au Hirsh D, Ogur B, Thibault G, et al. "Continuity" as an organizing principle for clinical education reform. N Engl J Med 2007;356:858-66. Schauer RW, Schieve D. Performance of medical students in a nontraditional rural clinical program 199899 through 200304. Acad Med 2006;81:603-7. Waters B, Hughes J, Forbes K, et al. Comparative academic performance of medical students in rural and urban clinical settings. Med Educ 2006;40:117-20. Worley P, Esterman A, Prideaux D. Cohort study of examination performance of undergraduate medical students learning in community settings. BMJ 2004;328:207-9. Poole P, O'Connor BJ, Bagg W, editors. Pkawakawa - innovative but academically equivalent. Association for the Study of Medical Education Annual Scientific Meeting 2009 15-17 July; Edinburgh. http://www.asme.org.uk/images/ABSTRACTS_09.pdf
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Correspondence: Colonial Reception Committee and fund for Dr Macintire

Published in NZMJ 1910 February;8(33):48.
GREATER BRITAIN AND THE ANNUAL MEETING Colonial Reception Committee Sir.The Colonial Reception Committee is particularly desirous of bringing the Annual Meeting, to be held in London in July next, to the notice of all medical practitioners residing in the dominions beyond the seas, as affording them an unusual opportunity of visiting London, both for the scientific purposes of the meeting and also for social intercourse with their fellow-practitioners throughout the Empire. The Colonial Reception Committee, in conjunction with the Colonial Committee of the Central Council, desires, through the medium of the JOURNAL, to extend a very cordial invitation personally to all medical practitioners in the colonies, and assures them of a hearty welcome to the Annual Meeting and to the capital of the Empire. Great efforts are being made by these two committees to arrange such entertainments as it is hoped will meet with the approval of their colonial brethren and so add to the success of the meeting of 1910. We are, etc., EDMUND OWEN, Chairman. DONALD ARMOUR, Hon Secretary. of the Colonial Reception Committee 429, Strand, W.C. January 3rd., 1910.
Dr. George Wilson of Palmerston North, writes to the Editor asking friends of Dr. Macintire to contribute to a fund being raised to provide for his needs during his illness. All who knew Dr. Macintire in his earlier days respected and loved him, and will be glad of this opportunity of assisting him now. Dr. Macintire is suffering from inoperable sarcoma, and his need for help and sympathy is great. Subscriptions will be received by Drs. R. S. Abraham, G. Wilson, or J.M. Johnston, the latter being the Hon. Secretary and Treasurer of the fund.
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Proceedings of the Waikato Clinical School Research Seminar, Thursday 18 March 2010
PERCUTANEOUS CORONARY INTERVENTION IN OCTOGENERIAN POPULATION: WAIKATO EXPERIENCE Michael Liang, Aniket Puri, James Liang, Sarah Pilkington, Sanjeevan Pasupati, Gerard Devlin Department of Cardiology, Waikato Hospital, Hamilton, New Zealand Abstract Background: As population ages and life-expectancy increases there is increasing demand for percutaneous coronary intervention (PCI) in patients >80 years-old. Outcomes in these patients, peri-procedural and longer term, are less predictable than in younger patients. Percutaneous coronary interventions (PCI) have become quite common in this set of patients we report our experience with consecutive interventions in patients > 80 years old and provide survival and major adverse cardiac and cerebrovascular events (MACCE) free outcome data. Methods: 105 consecutive PCI in 95 patients were performed from May 2006 to Aug 2009 in patients >80 years. All patients who had successful or unsuccessful procedure were included in the retrospective analysis. Results: Mean age is 83 + 3 yrs, range 80-93 yrs, 58% were male. All patients accepted for PCI had reasonable survival of > 6months with expected favourable procedural outcome. The mean follow-up was 14 + 11 months (maximum follow-up was 3 years). The indications for PCI were unstable angina 29%, NSTEMI 43%, STEMI 18% and stable angina 10%. PCI was unsuccessful in 3%. Bare-metal stents were used in 58% of cases, drug-eluting stents in 30% and combination of stents in 6%, balloon only in 3%. The MACCE rate during follow up period was 29%: including 6% MI, 9% repeated revascularization, 5% CVA, 15% Death. The KaplanMeier 2 year survival and MACE-free survival for all octogenarian interventions is 84% and 68% respectively.
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Conclusion: In the octogenarian population, PCI can be performed with a high expectation of procedural success and a favourable 2-year survival. However, 1 in 3 expected an adverse cardiovascular event in 2-years time. PHOTOTHERAPY IN CHILDREN A NEW ZEALAND EXPERIENCE Eugene Tan, David Lim* and Marius Rademaker Department of Dermatology, Waikato Hospital, Hamilton, New Zealand
*
Department of Medicine, Waikato Hospital, Hamilton, New Zealand
Abstract Aim: Phototherapy is an effective treatment for many dermatoses in adults, but there is a paucity of data in children. A retrospective analysis was undertaken of children (<16 years old) who had undergone phototherapy over a 15-year period between January 1993 and December 2008. Method: 132 children received phototherapy with a total of 171 phototherapy courses. Their mean age was 11.2 years (range, 2.6 15.9 years) with majority being of European origin (89 children or 67%) and having Fitzpatrick skin phototype II (65 children or 49 %). Atopic dermatitis was the most common indication for treatment (62 children or 47%) followed by psoriasis (50 children or 38%), pityriasis lichenoides (5 children or 4%), nodular prurigo (3 children or 2%) and morphea (3 children or 2%). Narrowband ultraviolet B (nbUVB) was the preferred modality and was used to treat 93% (123 children). The rest (9 children or 7%) received broadband ultraviolet B (bbUVB). Results: Treatment was effective in the majority of children with 75% (99 children) being clear or showing marked improvement. Most children received only 1 course of phototherapy (112 children or 80%). For responders, the mean number of treatments in each course was 27.8 (range, 5-87). The mean dose per treatment (cumulative dose/number of treatment) to achieve clearance was 644.1 mJ/cm2 (range, 5.1 4,040.9) and the mean maximum treatment dose per treatment was 1,143.9 mJ/cm2 (range, 8 - 3996). All children tolerated treatment well with only 32% (42 children) developing brief, minimally symptomatic, erythema. Only 3 children experienced exacerbations of their underlying dermatoses. Conclusion: This study shows that phototherapy is an effective and well-tolerated treatment modality in children. CAN A GENETIC TEST PREDICT PERIOPERATIVE OPIOID REQUIREMENTS? Gregory Jacobson1, Harriet Francis1, Jono MacColl1, Jamie Sleigh2, Corinne Law2 1. Molecular genetics laboratory, University of Waikato 2. Waikato Clinical School, Auckland University
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Abstract Aim: The ability to adjust opioid dose perioperatively according to a patients predicted requirements for pain relief would help to minimize postoperative pain and reduce recovery times. As part of a larger study which is examining EEG as a tool to predict opioid requirements, we are studying the utility of patterns of genetic variations called single nucleotide polymorphisms (SNPs) in anticipating levels of pain. Method: We genotyped 40 patients for a total of five SNPs in the Mu opioid receptor 1 gene (OPRM1), an inwardly rectifying potassium channel gene (KCNJ6) and a drug transporter gene (ABCB1) using RFLP-PCR. Results: Patterns of SNP variation were compared against self-reported pain levels, which divided the patients into the groups strong responders, responders and non-responders, and morphine usage in the post anaesthetic care unit (PACU), to conclude whether these SNPs can predict requirements for opioid drugs. Conclusion: In this pilot study data, we found an association between SNPs in KCNJ6 (rs2075572) and ABCB1 (rs1045642) - G and C alleles respectively - higher VAS scores and higher morphine consumption in PACU. IDENTIFICATION OF WIF1 AS A POSSIBLE PITUITARY TUMOUR SUPPRESSOR GENE USING GENE EXPRESSION PROFILING Marianne S. Elston1 , John V. Conaglen1 , Anthony J. Gill 2 , Janet Shaw3, Andrew JJ Law4, Roderick J. Clifton-Bligh3, Bruce G. Robinson3,5, Kerrie L. McDonald3 Department of Endocrinology, Waikato Hospital, Hamilton; 2Department of Anatomical Pathology, Royal North Shore Hospital, St Leonards, NSW, Australia; 3 Cancer Genetics Unit, Kolling Institute of Medical Research, St Leonards, NSW;4Department of Neurosurgery, Auckland City Hospital, 5University of Sydney, Sydney Abstract Aim: The aetiology of sporadic pituitary tumours is currently unknown. Wnt pathways have been implicated in the pathogenesis of a variety of human tumours but the role of these pathways in pituitary tumours needs elucidating. Method: The objective of the study was to identify genes involved in pituitary tumorigenesis. Human pituitary tumours were collected at the time of surgery, snap-frozen and stored at -80C. Microarray analysis using Affymetrix HG U133 plus 2.0 GeneChips identified down-regulation of several Wnt pathway inhibitors in pituitary tumours (n=20) versus normal pituitary controls (n=3). In particular, Wnt inhibitory factor 1 (WIF1) was down-regulated 91-fold. Validation using quantitative PCR confirmed reduced WIF1 mRNA expression in tumours (n=42) compared with normal pituitary (n=5) (p <0.001). Results: Assessment of WIF1 protein status was performed using immunohistochemistry with 76% of pituitary tumours (n=41) demonstrating absent or
1
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weak cytoplasmic WIF1 staining compared with strong staining in 92% of normal pituitary controls (n=13) (p<0.001). To ascertain why WIF1 expression was reduced in pituitary tumours methylation status of the WIF1 promoter was assessed. Hypermethylation of tumours was demonstrated compared with normal pituitary controls (p=0.001). Additionally a subset of tumours (n=12) were assessed for the presence of somatic mutations in WIF1. No mutations were identified. Transfection of the rat pituitary GH3 cell line with cloned human WIF1 decreased cell proliferation and colony formation compared with empty vector controls. Conclusion: In conclusion, this data supports loss of WIF1 mRNA in pituitary tumours occurring as an early event, since it is common to all subtypes examined, suggesting that the Wnt pathways are important in pituitary tumorigenesis. Restoration of WIF1 expression in the GH3 cell line reduced cell growth suggesting that WIF1 may be acting as a tumour suppressor in the pituitary. COT-SIDE EEG MONITORING IS NOT CLINICALLY USEFUL IN THE MANAGEMENT OF NEONATAL HYPOGLYCAEMIA Deborah L Harris 1, 2, Claire V Spooner 3, Malcolm R Battin 2, 4, Chris E Williams 2, Phil J Weston 1, Jane E Harding 2 1. Newborn Intensive Care Unit, Waikato District Health Board, Hamilton, New Zealand 2. Liggins Institute, University of Auckland, Auckland, New Zealand 3. Department of Neurology, Starship Childrens Hospital, Auckland, New Zealand 4. Newborn Services, Auckland City Hospital, Auckland, New Zealand Abstract Background: Neonatal hypoglycaemia is common and the best approach to diagnosis and treatment remains unclear. Aim: We sought to determine whether reversible electroencephalography (EEG) changes related to neonatal hypoglycaemia could be detected on a cotside amplitude integrated EEG monitor (aEEG) in at risk newborn babies. Method: Eligible babies were 32 weeks gestation, identified as being at risk of neonatal hypoglycaemia, and admitted to the Newborn Intensive Care Unit. They received routine clinical care and remained in the study until hypoglycaemia was considered no longer a risk, or up to seven days. EEG electrodes were placed in the P3-P4, O1-O2 montages, and a sensor was placed subcutaneously for continuous interstitial glucose monitoring. Blood glucose levels were measured using the glucose oxidase method. Low glucose concentration was defined as a blood or interstitial glucose concentration < 2.6mM. EEG parameters analysed included aEEG, intensity, continuity and spectral edge frequency. The raw EEG files were also reviewed by a paediatric neurologist. Results: One-hundred and two babies were enrolled, with median weight 2179 g and gestation 35 weeks. Seventy babies were hypoglycaemic before EEG monitoring
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commenced, and 24 had EEG recordings while glucose concentrations were low (mean 2.3 mM, range 1.7 to 2.5 mM). There were 103 episodes of low glucose concentrations (median duration 20 min, range 5 to 475 min). All hypoglycaemia was asymptomatic. There were no detectable changes in any of the examined aEEG parameters related to low glucose concentrations. Review of the raw EEG revealed one baby who experienced an electrical seizure during an episode of hypoglycaemia. Conclusion: The amplitude integrated EEG does not appear to be a useful clinical tool in the detection of early neurological changes related to mild hypoglycaemia in at risk babies in neonatal intensive care. WOUND INFILTRATION STUDY: LOCAL ANAESTHETIC IN BREAST SURGERY Emily Kerr, Ian Campbell, Shelley Cavanagh, Jane Creighton, Rowan French, Marcus Ehrstrom, John Moodie and Shramana Banerjee. Abstract Aim: Wound infiltration is commonly used as standard practice during surgical procedures; however there is limited evidence to support its use in breast surgery. The study objective is to determine evidence for wound infiltration of local anaesthetic Marcaine (0. 25%) in breast surgery. The study hypothesis is wound infiltration of local anaesthetic decreases postoperative pain and analgesic use, without increasing postoperative complications. Method: A prospective randomized, single blind study was undertaken of 90 patients undergoing breast lump excision, wide local excision and mastectomy with or without axillary surgery, at Waikato Hospital. Patients were randomized into two groups. Group LA received local 20mls Marcaine (0. 25%) into the surgical wound at the end of surgery. Group No LA served as a control receiving no infiltration. Pain scores were taken postoperatively at 1 hour, 24, and 48 hours and any complications associated with wound healing were documented at the one week postoperative visit. Mann-Whitney, Chi square and Students t-test were used to analyse the data using SPSS (version 15.0) software. Results: 40 patients received local anaesthetic infiltration and 34 patients received no infiltration. There were no significant differences between patient groups or surgical details. Analgesic analysis revealed Group LA used significantly less Morphine (1.37 0.49 mg vs. 2.54 2.36 mg; p=0.008) and significantly less Oxynorm (8.46 2.35 mg vs. 10.0 4.01 mg; p=0.038) postoperatively. There were no significant differences in postoperative pain scores or complications associated with wound healing between the two groups. Conclusion: Group No LA (the control) consumed a much higher level of opioid analgesics, showing infiltration of local anaesthetic Marcaine (0.2 5%) during breast surgery has a sparing effect on opioid use.
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CORRELATION OF THE ABCD2 SCORE WITH THE DEGREE OF ICA STENOSIS Manar Khashram, Thodur M Vasudevan. Department of Vascular Surgery, Waikato Hospital Abstract Background: ABCD2 is a validated scoring system that predicts the risk of stroke following a transient ischaemic attack (TIA). Guidelines have suggested that patients who have a low score can be investigated as an outpatient. However, the ABCD2 score does not identify which patients have internal carotid artery (ICA) disease and hence could benefit from urgent carotid endarterectomy (CEA). Studies showed that patients with carotid artery disease have a higher risk of stroke recurrence. To date there have been no studies correlating ICA stenosis with the ABCD2 scores. Aims: To document the prevalence of ABCD2 scores in carotid artery related TIA, and identify a correlation between the ABCD2 scores ICA stenosis. Methods: Subjects undergoing carotid duplex ultrasound scan for TIA from January 2009 to February 2010 were identified from the vascular database retrospectively. Clinical notes were reviewed and outcomes measures were recorded: number of scans for TIA and ABCD2 scores (age, blood pressure, clinical features, diabetes and duration). Results: 40 patients with a mean (range) age of 74 years (56-90) had ICA stenosis of 50- 100%. Four patients (10%) were low risk, 15 patients (38%) were moderate risk and 21 patients (52%) were high risk. There was no significant correlation between ABCD2 scores and degree of ICA stenosis. Conclusion: Most patients with >50% stenosis of the ICA had ABCD2 scores of 4 & 5. There was no correlation between ABCD2 scores and the degree of ICA stenosis. Hence all suitable patients for surgery, with carotid related TIA should be investigated rapidly as some could benefit from urgent CEA. THE IMPACT OF MALE DEPRESSION AND ANTI-DEPRESSANT USE ON A COUPLES SEXUAL DESIRE, FUNCTIONING AND RELATIONSHIP L McKay-Brown, C Kirby, L Piterman, HM Conaglen, JV Conaglen Abstract Aim: Depression is a highly prevalent and often debilitating condition that can have a strong personal impact on mens emotional and physical well-being. Among the many impacts, research has identified a clear and bi-directional link between depression and male sexual dysfunction. Method: This project investigated the impact of mens depression and anti-depressant use on their own and their partners sexual desire, functioning and relationship using questionnaires and interviews. Results: The key findings indicated that both depression and anti-depressant medication appear to impact on mens sexual desire. Anti-depressant medication had
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an impact on mens sexual functioning, with the majority of the men in this study experiencing medication induced anorgasmia or erectile dysfunction. Women retrospectively reported decreased sexual desire when their partner was suffering from depression prior to treatment. While their sexual desire increased after their partner commenced anti-depressant use, other issues such as rebuilding the relationship and moving from a care-giver role to a sexual partner had a greater impact on their sexual relationship than did level of sexual desire or functioning. However, couples experience of mens anti-depressant use was generally positive, with both men and women noticing positive changes in the males level of depression and behaviour. For most couples, the use of anti-depressants enhanced their emotional well-being, intimacy and sexual relationship together. Conclusion: The findings from this research have clear implications for health professionals working in primary health care, psychology, and health education. Consumer-based education should address not only the potential benefits of antidepressant therapy, but the potential side-effects and impacts on the couples relationship, sexual intimacy and sexual functioning, and promote couples shared decision making and communication about a mans anti-depressant use before commencement, and during use. Professional education strategies should encourage health care providers who prescribe anti-depressants to discuss the possible positive outcomes and side-effects with men, and where possible their partner, prior to treatment. Follow-up appointments are also essential, to enable health care providers to assess the effectiveness of the treatment, and address any difficulties encountered by the couple. MICRORNA EXPRESSION IN PHAEOCHROMOCYTOMA AS A POTENTIAL DIAGNOSTIC MARKER FOR MALIGNANT DISEASE Goswin Y Meyer-Rochow1,2, Diana E Benn1, John V Conaglen2, Denis E Whittle2, Bruce G Robinson1, Stanley B Sidhu1 Cancer Genetics, Hormones and Cancer Group, Kolling Institute of Medical Research, Royal North Shore Hospital and University of Sydney, Sydney, Australia Department of Endocrinology / Surgery, Waikato Clinical School, Hamilton, New Zealand Abstract Aim: Phaeochromocytomas are neuroendocrine tumours of chromaffin cell origin, arising from the adrenal medulla and less commonly from extra-adrenal sympathetic paraganglia. Approximately 70% of phaeochromocytomas are sporadic and 10% will be malignant. The genetic events resulting in sporadic tumorigenesis and in malignancy remain unclear. MicroRNAs are small endogenous noncoding RNAs involved in the posttranscriptional regulation of gene expression. These molecules are therefore implicated in tumorigenesis and are potential molecular targets for cancer diagnosis and therapy. Method: Total RNA extracted from 5 normal adrenal medulla, 5 SDHB mutation postitive, 12 sporadic benign and 12 malignant pheochromocytoma human tissue samples were included for a two-colour chip microRNA profiling analysis. Validation
2 1
of microRNA expression was performed with real-time quantitative reverse transcription PCR (RT-qPCR) including a further cohort of tissue samples. Results: Unsupervised cluster analysis demonstrated differentiation between the normal adrenal medulla, benign and malignant samples but not the SDHB mutation positive pheochromocytoma tissue samples. When compared to normal adrenal medulla there were 11, 29 and 45 microRNAs differentially expressed in SDHB positive, benign, and malignant pheochromocytoma tissue samples respectively. The genomic location of underexpressed microRNAs tended to cluster but at a number of different chromosomal regions. Seventeen microRNAs were differentially expressed between benign and malignant pheochromocytoma tissue samples. Conclusions: The results of this study suggest that microRNAs are involved in the tumorigenesis of pheochromocytomas. The differential expression of microRNAs between benign and malignant pheochromocytomas may allow for the early diagnosis of malignant disease and may lead to the future development of novel therapies for the treatment of patients with malignant pheochromocytoma. ACCESS TO RENAL SERVICES IN THE WAIKATO: UPTAKE OF DIALYSIS TREATMENT Grace Joshya, Hanin Kananb, Margaret Fisherc, Peter Dunnd, Ross Lawrensona a b c d Waikato Clinical School, University of Auckland, Hamilton, New Zealand Student, University of Auckland, New Zealand. Renal Unit, Waikato Hospital, Hamilton, New Zealand Waikato Regional Diabetes Service, Waikato Hospital, Hamilton, New Zealand.
Abstract Aim: End Stage Renal Disease (ESRD) is a major complication among diabetes patients in New Zealand, especially among Maori. Incidence of ESRD is usually estimated using new patients entering the Australia and New Zealand Dialysis and Transplant (ANZDATA) registry database. There are concerns that among some patients with ESRD (e.g. Maori and rural patients) may be less likely to access dialysis treatment. The aim of this study is to review the uptake of dialysis among ESRD patients in the Waikato. Methods: This is a retrospective review of all renal disease patients in the Waikato, who developed ESRD during 2003-2008. The list of new patients ANZDATA registry and electronic patient records indicating offer of dialysis treatment following specialist renal assessment at the Waikato Renal Unit (WRU) were used to identify ESRD and dialysis treatment uptake. Results: Of the 1765 patients seen at the WRU, 655 were offered dialysis treatment. 486 new patients from WRU entered the ANZDATA registry during the study period (2003-2008). A further 169 patients, without prior history of dialysis/transplantation, who attended their first renal assessment at Waikato Renal Unit during the study
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period, were offered dialysis treatment. 91 of them subsequently started dialysis treatment.
Entered ANZDATA during 2003-2008 486 74%
Offered dialysis during 2003-2008 Started dialysis since 2008 Still Undecided Rejected offer Deceased Total
169 91 33 24 21 655 14% 5% 4% 3%
Dialysis Accepted: 577 (88%)
No Dialysis Uptake: 78 (12%)
78 patients did not commence dialysis treatment until end of 2009. Among them 30(38%) had diabetes co-morbidity, 35(45%) were Maori and 49(63%) were domiciled outside of Hamilton. The profile of patients without dialysis uptake has been compared with those who commenced treatment. Conclusion: Current results show that rates based on acceptance of dialysis/transplant alone may be an underestimate. Uptake of dialysis continues to be an issue in the Waikato, especially among Maori. Uptake in the Midlands region is being studied.
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Proceedings of the 201st Scientific Meeting of the Otago Medical School Research Society, Thursday 25 March 2010
Nike says Just Do It but what does your brain say? K Hillman, D Bilkey. Department of Psychology, Division of Sciences, University of Otago, Dunedin Optimal decision-making requires careful assessment of the costs and benefits associated with each available option. While costs may involve investing money or time, perhaps no decision cost is as biologically and socially universal as investing effort. Nikes mantra of Just Do It suggests we should always expend effort to reach loftier goals, but does your brain always encode and implement such a strategy? Here we present electrophysiological evidence that neurons in a specific region of the brain, the anterior cingulate cortex (ACC), encode a cost-benefit representation of choice options biased towards the better choice in terms of effort-outcome ratio. We recorded from ACC neurons in rats (n = 10) as they performed a spatial decisionmaking task. In the baseline configuration 2:6B rats could pursue 2 or 6 food pellets, the latter obtained by climbing a barrier (high-cost, high-reward (HCHR)). A substantial portion of ACC neurons (63%) exhibited significantly higher firing for one goal trajectory versus the other (P < 0.05, t-test); for 94% of these cells higher firing was associated with the HCHR option. This HCHR-bias was not attributable to the larger reward or barrier. In inter- and intra-session manipulations (2:6B, 2B:6B, 2:2B), ACC activity rapidly adapted to each configuration and firing rates were consistently higher for the economically advantageous option. Interestingly, when only a difference in reward magnitude was presented (2:6, no barrier), ACC activity was minimal and non-biased. Our data suggest that the ACC encodes an integrated cost-benefit representation of choice options that is specifically recruited when an assessment of reward and effort is required for optimal decision-making. These findings elucidate one neural mechanism underlying motivated choice behaviour, and may further our understanding of clinical conditions where goalrelated effort expenditure is impaired. Targeted manipulation of ACC activity may prove an intriguing therapeutic approach to modulate that Just Do It feeling. Nerve root sedimentation sign - evaluation of a new radiological sign in lumbar spinal stenosis. M Melloh1, T Barz2, L Staub3, S Lord3,4, J Theis1. 1Department of Orthopaedic Surgery, Dunedin School of Medicine, University of Otago, Dunedin. 2Department of Orthopaedic Surgery, Asklepios Klinikum Uckermark, Schwedt/Oder, Germany. 3NHMRC Clinical Trials Centre, University of Sydney, New South Wales, Australia. 4The Screening and Test Evaluation Program, University of Sydney, New South Wales, Australia In the diagnosis of lumbar spinal stenosis (LSS), radiological findings do not always correlate with clinical symptoms; additional diagnostic signs are needed. In patients without LSS, we observe the sedimentation of lumbar nerve roots to the dorsal part of the dural sac on supine Magnetic Resonance Imaging (MRI) scans. In patients with
LSS, this sedimentation is rarely seen. We named this phenomenon sedimentation sign defining the absence of sedimenting nerve roots as a positive sedimentation sign for the diagnosis of LSS. The purpose of our study was to assess whether the new sedimentation sign discriminates between non-specific lower back pain (LBP) and LSS. This prospective case-control study included 200 patients in an orthopaedic in- and outpatient clinic. Patients in the LBP group (n = 100) had lower back pain, a cross sectional area (CSA) of the dural sac of >120 mm2, and a walking distance >1000 m; patients in the LSS group (n = 100) showed claudication (limping), a CSA of <80 mm2, and a walking distance <200 m. The frequency of a positive sedimentation sign was compared between the two groups, and intra-observer and inter-observer reliability were assessed in a random subsample (n = 40). A positive sedimentation sign was identified in 94 patients in the LSS group but in no patients in the LBP group. Reliability showed a Kappa coefficient of = 1.0 (intraobserver) and = 0.93 (inter-observer). Our findings show that a positive sedimentation sign exclusively and reliably occurs in patients with LSS, suggesting its usefulness in clinical practice. If future accuracy studies confirm the signs high specificity, a positive sedimentation sign can indicate LSS, and with a high sensitivity, a negative sedimentation sign can rule out LSS. The sedimentation sign is potentially a valuable tool to identify patients who will benefit from spinal surgery.

Proceedings of the Health Research Society of Canterbury Seminar Series, Friday 26 March 2010
Screening for Diabetic Retinopathy Using Computer Vision and Physiological Markers CE Hann1, J Revie1, D Hewett1, JG Chase1 and GM Shaw2 1Bioengineering Centre, Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand, 2Department of Intensive Care Medicine, Christchurch Hospital, Christchurch, New Zealand Hyperglycemia and diabetes result in vascular complications, most notably diabetic retinopathy (DR). The prevalence of DR is growing and it is a leading cause of blindness and/or visual impairment in developed countries.1 Current methods of detecting, screening and monitoring DR are based on subjective human evaluation, which is also slow and time consuming.2 As a result, the initiation and progress monitoring of DR is clinically hard. Computer vision methods were developed to isolate and detect two of the most common DR dysfunctions, dot hemorrhages (DH) and exudates. The algorithms use specific colour channels and segmentation methods to separate these DR manifestations from physiological features in digital fundus images. The algorithms are tested on the first 100 images from a published database. Diagnostic outcome and the resulting positive and negative prediction values (PPV and NPV) are reported. The first 50 images are marked with specialist determined ground truth for each individual exudate and/or DH, which are also compared to algorithm identification.. Exudate identification had 96.7% sensitivity and 94.9% specificity for diagnosis (PPV = 97%, NPV = 95%). DH identification had 98.7% sensitivity and 100% specificity (PPV = 100%, NPV = 96%). Greater than 95% of ground truth identified exudates and DHs were found by the algorithm in the marked first 50 images, with less than 0.5% false positives. A direct computer vision approach enabled high quality identification of exudates and DHs in an independent dataset of fundus images. The methods are readily generalisable to other clinical manifestations of DR. The results justify a blinded clinical trial of the system to prove its capability to detect, diagnose and, over the long term, monitor the state of DR in diabetic individuals.
1. 2. Fong D, Aiello L, Gardner T, King G, Blankenship G, Cavallerano J, Ferris F 3rd, Klein R (2004). Retinopathy in diabetes. Diabetes Care, 27 Suppl 1:584-7. Kinyoun JL, Martin DC, Fujimoto WY, Leonetti DL (1992). Ophthalmoscopy versus fundus photographs for detecting and grading diabetic retinopathy. Invest Ophtalmol Vis Sci. 33(6):1888-93.
Changes in BOLD activity during behavioural microsleeps GR Poudel 1, 2, 3, RD Jones 1, 2, 3, 4, CR Innes1, 3, PJ Bones1, 4, R Watts1, 5. 1Van der Veer Institute for Parkinson's and Brain Research, Christchurch, 2Medicine, University of Otago, Christchurch, 3Medical Physics and Bioengineering, Christchurch Hospital, Christchurch, 4Electrical and Computer Engineering, University of Canterbury, Christchurch, 5Physics and Astronomy, University of Canterbury, Christchurch Behavioural microsleeps are transient failures (< 15 s) to respond accompanied by behavioural signs of sleep. They are of considerable concern in occupations in which public safety depends on extended unimpaired performance. We investigated neuronal changes in the brain during behavioural microsleeps by recording blood-oxygenationlevel-dependent (BOLD) functional magnetic resonance imaging (fMRI) signal. Twenty healthy non-sleep-deprived volunteers (10 males and 10 females) participated in an experiment requiring continuous tracking for 50 min inside an MRI scanner. Eye video, VEOG, EEG, and tracking response were recorded simultaneously with wholebrain BOLD fMRI data. Behavioural data were visually rated by two raters to identify behavioural microsleeps. fMRI data were analysed using a mixed-effects model to identify brain regions with increased and decreased BOLD activity during behavioural microsleeps. The BOLD signal was extracted from the thalamus and the average BOLD percent signal changes during behavioural microsleeps of three durations (0.5 5 s, 5 10 s, and 10 15 s) were estimated for each subject. A one-way ANOVA was used to test for differences in the peak amplitude of the average BOLD response across behavioural microsleeps in the three duration bins. The BOLD signal was observed to increase in several cortical brain regions including, inferior frontal cortex, posterior parietal cortex, and occipital cortex, during behavioural microsleeps. Conversely, the BOLD signal was seen to decrease bilaterally in the thalamus, posterior cingulate cortex, and striate cortex during behavioural microsleeps. There was a difference in peak-amplitude in the right and left thalamus across the three durations (p < 0.05). This is the first study to investigate BOLD activity during behavioural microsleeps. It has shown that BOLD activity is dependent on the duration of the behavioural microsleeps. Knowledge gained from this research will, ultimately, help develop interventions/devices which can warn users of an actual or imminent behavioural microsleep. An hourly and accurate model-based insulin sensitivity clinical biomarker for sepsis in critical care patients JD Parente1, D Lee2, J Lin3, JG Chase1, GM Shaw4. 1Centre for Bioengineering, Department of Mechanical Engineering, University of Canterbury, Christchurch, 2 Department of Mathematics and Statistics, University of Canterbury, Christchurch, 3 Department of Medicine, University of Otago Christchurch, Christchurch, 4 Department of Intensive Care Medicine, Christchurch Hospital, Christchurch.
Sepsis is a serious medical condition characterized by systemic inflammatory response syndrome (SIRS) due to infection, and is a leading cause of ICU admission, death, and cost. Current guidelines recommend early intervention of confirmed infections within 6h. However, blood culture confirmation takes 24-48h, by which time the disease may be advanced. Hence, there is significant need for timely, accurate, and non-invasive sepsis biomarkers. Insulin sensitivity (SI) decreases with worsening patient condition. A validated modelbased glycemic control protocol estimates SI hourly in clinical real time. The primary research goal is to develop an hourly clinical biomarker to support treatment decisions for severe sepsis in the ICU using this SI value and clinical data available at the bedside. Retrospective clinical data is used from 36 adult patients with sepsis in the Christchurch Hospital ICU, and includes: temperature, heart rate, respiratory rate, blood pressure, and SIRS score. Kernel density estimates were used for development of joint probability density profiles for sepsis and non-sepsis data hours (213 and 5858 respectively of 6071 total hours) and for classification. The clinical biomarker identifies the majority of sepsis and non-sepsis hours. The clinical biomarker performs with 69.5-94.4% sensitivity, 74.6-94.4% specificity, 9.137.8% positive predictive value, 98.5-99.8% negative predictive value, and 0.78-0.99 area under the ROC curve. The overall result lies between these maximum estimate bounds. The clinical biomarker provides effective real-time negative predictive diagnostics for sepsis with high accuracy. The high ratio of non-sepsis to sepsis hours is clinically realistic, but provides too limited data for high positive predictive performance. Comparatively, diagnostic performance of the clinical biomarker equals or exceeds the performance of blood culture, which is only typically measured daily. The hourly diagnostic presented is unique and provides real-time early detection of sepsis. A prospective validation trial is ongoing at Christchurch Hospital. Toxicity of oxidised cholesterol as a mechanism of cardiovascular disease L.D. Rutherford and S.P. Gieseg. Free Radical Biochemistry Laboratory, School of Biological Sciences, University of Canterbury, Christchurch, New Zealand. Atherosclerosis is a complex inflammatory disease involving the deposition of cholesterol-loaded macrophages within the artery wall. Progression of the initial fatty streak to an advanced atherosclerotic plaque is characterised by the development of a necrotic core region containing free cholesterol and dead cells. The formation of oxidised low-density lipoprotein (oxLDL) and the resulting cytotoxicity to macrophage cells is a key driver in the development of the necrotic core [1]. OxLDL contains the oxysterol, 7-ketocholesterol (7KC), which is found in significant quantities within atherosclerotic plaques. 7-Ketocholesterol is known to be highly cytotoxic, but the route of 7-ketocholesterol delivery may be important to its toxicity to macrophage cells. This work compares the toxicity of 7-ketocholesterol given directly to cells, as is done traditionally, to the toxicity when 7-ketocholesterol is incorporated into unoxidised LDL.
Human monocyte-like U937 cells at 5 x 105 cells/ml were cultured in RPMI-1640 supplemented with 5% heat-inactivated fetal bovine serum and 10,000 units/ml penicillin G and 10,000 g/ml streptomycin. 7-Ketocholesterol was loaded into LDL by incubation in human plasma before LDL isolation. LDL was isolated by density gradient ultracentrifugation and acetylated by treatment with acetic anhydride to convert it to a high uptake form, which is readily absorbed by cells. Concentrations of free and esterfied 7-ketocholesterol were measured by HPLC analysis. 7-Ketocholesterol added directly to U937 cells was found to be highly toxic, confirming previous observations. Despite being readily taken up by U937 cells, 7KC-loaded acetylated LDL did not cause a decrease in U937 cell viability at the same 7-ketocholesterol uptake that was earlier confirmed to be highly toxic. This shows that 7-ketocholesterol is not significantly cytotoxic when entering the cell within a lipoprotein. These results suggest that 7-ketocholesterol, and possibly oxysterols in general, are not the cytotoxic component of oxLDL.
1. Gieseg, S.P., et al., Macrophage antioxidant protection within atherosclerotic plaques. Frontiers in Bioscience, 2009. 14: p. 1230-1246.

Difficult-to-treat head liceany new treatments?

The authors of this study kick off by noting that head lice are universal human parasites, affecting over 100 million people worldwide each year. In the developed world, children 311 years of age are most likely to be affected. Topical permethrin or malathion are usually effective if used appropriatelyi.e. good coverage and a second treatment 710 days later. However, parasitic resistance is known to occur and may be increasing. This study addresses this problem in a randomised trial comparing treatment of head lice subjects with malathion lotion or oral ivermectin. 812 patients were randomised to oral ivermectin 400 micrograms and dummy lotion on days 1 and 8 or 0.5% malathion and dummy tablets on days 1 and 8. All 812 had been identified as having head lice resistant to topical insecticide. Ivermectin was found to be significantly better suggesting that it is a useful alternative treatment.
N Engl J Med 2010;362:896905.
How useful are urinary antigen tests for Streptococcus pneumoniae and Legionella pneumophila in the management of community acquired pneumonia (CAP)?
Clinical examination, chest X-rays, sputum and blood cultures are known to be unreliable in identifying the pathogen causing CAP. Are the urinary antigen tests helpful? This was tested in this Spanish study. Their hospitalised CAP patients were randomly assigned to receive either empirical treatment, according to international guidelines, or targeted treatment, on the basis of the results from antigen tests. Overall they found no benefit for the targeted treatment group. Indeed the relapse rate in the targeted cohort (12%) was significantly worse than the relapse rate (3%) in the empirical cohort (p = 0.04). They speculate that this may be due to more than one pathogen. A reviewer is skeptical pointing out that only 25 of 177 patients were targeted (ie study numbers too small). Furthermore targeted treatments commenced at 2-6 days after admission in the study. As urinary antigen results are usually available within a few hours the reviewer wonders why target treatments were not instituted earlier.
Thorax 2010;65:101-6 & 93-4..
Gastric banding surgery vs supervised lifestyle intervention for severely obese adolescents
This paper from Melbourne points out that severely obese adolescents are at risk of type 2 diabetes and the metabolic syndrome with all of its consequences including premature death.
They report on a prospective, randomised controlled trial of 50 adolescents between 14 and 18 years with a body mass index (BMI) higher than 35. They were assigned either to a supervised lifestyle intervention or to undergo gastric banding, and followed up for 2 years. Twenty-one (84%) in the gastric banding and 3 (12%) in the lifestyle groups lost more than 50% of excess weight, corrected for age. Nine of the banded group had the metabolic syndrome before surgery but were normal at 2 years. Four of 10 with the metabolic syndrome before the lifestyle modification had persistence of the syndrome at 2 years. Clearly banding produced better results but lifestyle intervention was useful in some. The researchers point out that unlike other procedures banding is easily reversed. We note that one-third of the banded subjects needed operative revision procedures.
JAMA 2010;303(6):519-26.
Does tonsillectomy reduce the risk of recurrent pharyngitis?

A frequently asked question about a frequently performed operation. This literature review started off with 7765 papers with the keyword TONSILLECTOMY in their title. However, only 4 randomised trials with recorded pre and post operative pharyngitis rates were discovered in their search. Three of these concerned children and the other involved subjects older than 14 years. In all there were 789 patients and all four trials showed that surgery was significantly better than medical therapy in reducing pharyngitis. The reduction rate was 43% which the authors considered to be modest. The number needed to treat with tonsillectomy to prevent one sore throat per month for the first year after surgery was 11.
Otolaryngology-Head and Neck Surgery 2009;140:291-7.
Use and abuse of faecal occult blood tests in an acute hospital inpatient setting?
The authors of this provocatively titled paper point out that the faecal occult blood test (FOBT) can be done by a guaiac (chemical) test that detects the pseudoperoxidase activity of haemoglobin and an immunological test using antibodies against human haemoglobin. For accuracy the guaiac test requires 72 hours abstention from red meat, melons, raw turnips, radishes, broccoli and cauliflower to prevent false positive results and avoidance of vitamin C tablets (false negative). Both tests require abstention from medications that increase gut bleedingaspirin, other antiplatelet medications, anticoagulants and selective serotonin reuptake inhibitors. The point of the paper is that when they reviewed 461 FOBT in 330 patients they found that only 2% had appropriate dietary restriction and 66% took one or more of the relevant medications. In these circumstances they felt their own hospital group should cease using these tests.
Internal Medicine Journal 2010;40:10711.

Asthma Control Test scores obtained from an Asthma NZ educational activity

Asthma is a common and chronic disease, affecting around 1 in 6 New Zealanders and causing the third largest number of years lost to disability.1 Unlike many other chronic diseases such as high blood pressure or raised cholesterol, there is no simple test or score by which asthma control can be assessed and monitored. Instead, a combination of different questions and assessments, such as peak flow readings and questions about reliever use, are used by health professionals. The Asthma Control Test (ACT) and Childhood Asthma Control Test are recently validated questionnaires that are completed by the patient and parents/caregivers.24 They consist of 5 simple questions, resulting in a score between 5 and 25, and the questions can be completed in less than a minute. A score of 20 or above indicates well or completely controlled asthma, 15-19 indicates somewhat controlled asthma and a score of 14 or less identifies patients with poorly or uncontrolled asthma. These questionnaires have been clinically validated by specialist assessment and spirometry and are recognized by the National Institutes of Health. Around 80% of patients with asthma in New Zealand have uncontrolled asthma, yet most of these patients think that their asthma is well controlled.5,6 By having a single score that the health professional and patient can monitor, it is hoped that it will be easier to identify patients with suboptiomal asthma control and outcomes will improve. As part of a recent fund-raising activity, Asthma NZ held mobile asthma clinics for free asthma education for 4 hours each day in 9 New Zealand cities from Christchurch to Auckland on consecutive days in March 2010. Anyone with asthma could attend the clinic and the Asthma Control Test and Childhood Asthma Control Test were completed as part of the educational activities. Although this was not a controlled study the data collected provides an interesting snapshot of asthma symptoms in patients with asthma who attended the sessions and illustrates the usefulness of the Asthma Control Tests in quickly identifying patients whose asthma could be better controlled. 125 adults and parents/caregivers completed the ACT questionnaires. There were 70 males and 55 females, with a mean age of 38 (range 2-86). 88 participants selfidentified as European, 27 as Maori, 3 as Asian and 3 as Pacific Islander. The mean ACT score was 17.7 (range 6-25), with a distribution of:
ACT score <15 15-19 >19 Level of control poorly or uncontrolled asthma somewhat controlled asthma well or completely controlled asthma N (%) 36 (28.8%) 35 (28%) 54 (43.2%)
Therefore this uncontrolled survey using a validated questionnaire found that around 57% of self-selected patients with asthma had asthma that was not well or completely controlled. The Asthma Control Test is simple and quick to complete and may become a standard part of asthma management. Shaun Holt
Clinicanz, Tauranga
References:
1. 2. Holt S, Beasley R. The burden of asthma in New Zealand. Published by Asthma and Respiratory Foundation of New Zealand, 2002. ISBN 086471095X US Department of Health and Human Services, National Institutes of Health, National Heart, Lung and Blood Institute. Expert Panel Report Guidelines for the Diagnosis and Management of Asthma (EPR-3 2007). NIH Item No. 08-4051. http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm Nathan RA et al. Development of the asthma control test: A survey for assessing asthma control. J Allergy Clin Immunol. 2004;113:59-65. Liu A et al. Development and cross-sectional validation of the Childhood Asthma Control Test. J Allergy Clin Immunol. 2007;119:817-825. POMS Steering Committee. Asthma morbidity, control and treatment in New Zealand: results of the Patient Outcomes Management Survey (POMS), 2001. New Zealand Medical Journal 16 May 2003; 116. Holt S. NZ INSPIRE study. Research Review, 2007. http://www.researchreview.co.nz/NZ%20Inspire%20Report.pdf
3. 4. 5.
6.

Spontaneous central nervous system bleeding in a child with cyanotic congenital heart disease
A 9-year-old Indian boy was admitted with complaints of bifrontal headache since 2 days and one episode of left-sided tonic-clonic convulsion lasting for 10 minutes followed by weakness of left upper and lower limb. There was no history of fever, drug intake, unconsciousness, trauma or bleeding manifestations. Patient was a known case of cyanotic congenital heart disease (CCHD) diagnosed at the age of 3 years. Echocardiography showed double outlet right ventricle with ventricular septal defect (5 mm) and pulmonary stenosis. In view of cyanotic spells, he was started on propranolol. On admission, child was afebrile with a heart rate 104/min, respiratory rate 24/min and blood pressure 96/60 mmHg. Central cyanosis and grade 3 clubbing was present. There were no petechiae or purpura. An ejection systolic murmur of grade 3/6 was audible in the pulmonary area. The child was conscious with normal cranial nerve and sensory system examination. Power was normal in the right upper and lower limb. It was grade 3/5 in the left upper limb and grade 2/5 in the left lower limb. Bilateral plantar reflexes were extensor with well-sustained ankle clonus. There were no meningeal or cerebellar signs. Other systemic examination was normal. Investigations done on the day of admission are shown in Table 1. Table 1. Summary of haematologic and biochemical investigations
Variables Haemoglobin (gm/dl) Haematocrit Platelet count(per cumm) Prothrombin time Partial thromboplastin Bleeding time (N: 16 min) Serum bilirubin (mg/dl) Serum aspartate aminotransferase (IU/L) Serum alanine aminotransferase (IU/L) 1st day of admission 24.1 75 53,000 42 sec/12 sec 56 sec/32 sec 8 min 2.7 112 120 8th day of admission 19.6 59 95,000 20sec/12 sec 38 sec/32 sec 4 min 1.6 67 78 Discharge 18.1 54 70,000 22 sec/12 sec 42 sec/32 sec 4 min 1.1 54 57
The fibrinogen levels, D-dimer level, factor VII, factor VIII, and antithrombin III were normal. Renal function tests, blood sugar and serum electrolytes were normal. Arterial blood gas analysis revealed hypoxemia and saturation of 65%. Computed tomography (CT) scan of brain showed an isodense lesion (Hounsfield unit 45) of 3.72.54.8 cm-sized peripherally-enhancing lesion in the right centrum semiovale reaching up to the right high parietal region with tiny adjacent satellite lesion with surrounding perilesional oedema suggestive of resolving hematoma with superadded infection. The lesion was without enhancing wall or definite borders, usually seen with abscess (Figure 1).
Figure 1. Computed tomography scan showing a 3.72.54.8 cm-sized peripherally-enhancing lesion (Hounsfield unit 45) in the right high parietal region with surrounding perilesional oedema suggestive of a haematoma with superadded infection
Echocardiography confirmed earlier findings. The child was started on intravenous vancomycin and metronidazole. In view of high haematocrit and the child being posted for surgery, phlebotomy was done five times over a period of 7 days. Fresh frozen plasma and platelet transfusion were given preoperatively. The child was taken for surgery on the eight admission day. A right parietal burr hole was done and 30 ml of blood admixed with pus was drained. Blood culture sent on the day of admission was negative. Postoperatively he was started on physiotherapy and a repeat CT scan was done after 1 month which showed decrease in the size of the hematoma. He was discharged after 6 weeks of intravenous antibiotics. He was well on follow-up at 2 months and is currently awaiting corrective cardiac surgery. Thromboembolism is generally considered as a cause when a patient of CCHD presents with a focal neurological deficit. Our case highlights the haemorrhagic tendencies associated with CCHD and the importance of considering them in the
differential diagnosis. Abnormal haemostasis was the cause of spontaneous CNS bleed in our patient. Polycythemia due to chronic hypoxia is mainly responsible for these abnormalities which include thrombocytopenia, decreased production of coagulation factors and accelerated fibrinolysis.1 Both qualitative and quantitative defects in platelets occur in CCHD. Qualitative defects include abnormal aggregation of platelets in response to adenosine diphosphates, epinephrine and collagen, which is directly related to the degree of polycythemia.1 Quantitative defects appear when the haematocrit is more than 65% leading to the margination of platelets.2 High shear stress caused by hyperviscosity leads to formation of markedly smaller platelet aggregrates. Chronic hypoxia shortens platelet survival, affects megakaryocyte differentiation, maturation, and apoptosis via oxygen tension and alteration of the physiological regulator (thrombopoietin).2 Hypoxic damage to the liver and sluggishness of microcirculation caused by hyperviscosity causes deficient synthesis of the coagulation factorsi.e. II, V, VII, IX and X.3 Abnormal haemostasis resulting from a state of consumptive coagulopathy or disseminated intravascular coagulation has also been observed in some patients with elevated D-dimer levels.3 Bleeding tendency is usually mild to moderate and is characterized by easy bruising, petechial haemorrhage, gingival bleeding, epistaxis and haemoptysis.4 However, serious and sometimes fatal bleeding can occur during haemostatic stress following trauma or surgery. In the usual clinical setting, phlebotomy is recommended only in patients with symptomatic hyperviscosity when haematocrit levels exceed 65%. Symptoms related to hyperviscosity include headache, fatigue, faintness, dizziness, visual disturbance, paresthesia, irritability, myalgia, reduced mentation, and anorexia.4 Also, preoperatively, phlebotomy is recommended to reduce the haematocrit below 65%, which improves haemostasis and decreases the risk of postsurgical haemorrhage.5 Volume replacement with an equal volume of 0.9% saline or colloid should be done whenever venesection is performed for preventing the acute fall in systemic blood flow, oxygen delivery, and cerebral perfusion.6 Platelet and fresh frozen plasma transfusion should be given if thrombocytopenia and coagulation abnormalities are present. Syed Ahmed Zaki
Assistant Professor, Department of Paediatrics Lokmanya Tilak Municipal General Hospital and Medical College Mumbai, India drzakisyed@gmail.com
Vishal Chavan
Registrar, Department of Paediatrics Lokmanya Tilak Municipal General Hospital Mumbai, India
Preeti Shanbag
Professor, Department of Paediatrics Lokmanya Tilak Municipal General Hospital Mumbai, India
Acknowledgements: We thank Dr Sandhya Kamath (Dean of our institution) for permitting us to publish this manuscript and Dr Mamta Manglani, Head of Department of Paediatrics for her guidance in the management of the case.
References:
1. 2. 3. 4. 5. Perloff JK. Noncardiac surgery in adults with congenital heart disease. In: Perloff JK, Child JS, editors. Congenital heart disease in adults. Philadelphia: WB Saunders; 1991, p239. Olgar S, Ertugrul T, Nisli K, et al. Shunt operations improved thrombocytopenia in a patient with congenital cyanotic heart disease.Ann Thorac Cardiovasc Surg. 2008;14:32932. Goel M, Shome DK, Singh ZN, et al. Haemostatic changes in children with cyanotic and acyanotic congenital heart disease. Indian Heart J. 2000;52:55963. Territo MC, Rosove MH. Cyanotic congenital heart disease: hematologic management. J Am Coll Cardiol. 1991;18:320322 Milam JD, Austin SF, Nihill MR, et al. Use of sufficient hemodilution to prevent coagulopathies following surgical correction of cyanotic heart disease. J Thorac Cardiovasc Surg. 1985;89:6239. Thorne SA. Management of polycythemia in adults with cyanotic congenital heart disease. Heart. 1998;79:3156.
6.

Application of mobile phone in improving healthcare delivery

India has more than 500 million mobile phone subscribers. Today the mobile phone is undoubtedly the most commonly used gadget by Indians. The usage of mobile phone has moved beyond its fundamental role of communications and started offering valueadded services (VAS) like booking railway and air tickets, reading newspapers, etc. Surprisingly, the healthcare sector in our country has not experienced much benefit from this mobile revolution. The authors discuss some of the ways of implementing mobile phone services to improve quality and reach of healthcare delivery. Substantial numbers of patients visiting Indian hospitals are not so educated to follow the instructions written in the prescriptions. There is no active supervision whether they are actually following the advices given by the physicians in terms of regular medicinal intake, medicine uptake before or after food, stoppage of medicine on date, healthy diet and periodic laboratory investigations. They can be regularly reminded and updated about their medical treatment through SMS services in regional languagee.g. Stop antibiotics today and continue the rest for next 5 days, Lipid profile test tomorrow; overnight fasting from tonight etc. In a previous study, 91% respondents benefitted from the instructions given by the caregivers over phone from time to time.1 The follow-up attendance rates in hospital OPDs are quite low since many patients do not remember the exact dates or any change in OPD schedules. This could be improved by sending regular SMS reminder before the actual date of OPD visit. A previous study on hypertensive patients reported that those who received SMS reminder for regular OPD visits had improved blood pressure, body weight, waist circumference, and HDL-C control.2 Telemedicine services could be taken at the doorstep of the patients with the introduction of 3G mobile services and facilities of video calling from mobile phone. Mobile phone based telemedicine overcomes the shortcomings of computer based telemedicine like requirement computer literacy, computer operator, broadband wire service, and uninterrupted electricity. In a study reported from Spain, patients used to send images of post surgical wound healing to their physicians from their mobile phones. The outcome of the study was significant improvement in patient satisfaction, avoidance of unnecessary hospital visits and increase efficiency of home follow up.3 Mobile phone could be used to monitor medical conditions like diabetes and send immediate reports to consultant doctor. In a study reported from England, patients were trained to measure their blood glucose with a sensor which transmitted the readings to a mobile phone via a Bluetooth wireless link.
Clinicians were then able to examine and respond instantly through web-based communication. The telemonitoring group (7.76%) had a significantly lower HbA1C than those in the control group (8.4%).4 Many times, particularly during medical emergency, a patient is brought to the hospital only to be refused due to non availability of beds. If an updated database of bed availability in a hospital is accessible through SMS service then patient can actually be taken to the hospital where vacancies are available. It would save valuable time and lives in an emergency. Mobile phone can play important role in spreading healthcare messages like dos and donts to prevent spreading of infectious diseases like malaria, dengue, swine flu, HIV and tuberculosis in community. The healthcare access in India could be substantially improved if telecom, information technology and healthcare are successfully integrated. The reduction in cost of mobile phone usage, improved computer and internet services in hospital and preference of regional languages would certainly help in materialising these ideas.
Raktim Kumar Ghosh

Postgraduate Student, Maulana Azad Medical College New Delhi, India dr.raktimghosh@yahoo.co.in
Ratul K Ghosh
Software Consultant, PricewaterHouse Coopers Kolkata, India
References:
1. 2. Bali S, Singh AJ. Mobile phone consultation for community health care in rural north India. J Telemed Telecare. 2007; 13:421-4. Park MJ, Kim HS, Kim KS. Cellular phone and Internet-based individual intervention on blood pressure and obesity in obese patients with hypertension. Int J Med Inform. 2009; 78:704-10. Martnez-Ramos C, Cerdn MT, Lpez RS. Mobile phone-based telemedicine system for the home follow-up of patients undergoing ambulatory surgery. Telemed J E Health. 2009; 15:531-7. Istepanian RS, Zitouni K, Harry D, et al. Evaluation of a mobile phone telemonitoring system for glycaemic control in patients with diabetes. J Telemed Telecare. 2009; 15:125-8.
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4.

BMI cut-off point

I read the recent NZMJ article by Duncan et al with great interest. Duncan et al concluded that the ethnic-specific BMI cut-off points developed in this study are more appropriate than universal definitions of overweight and obesity for predicting excess adiposity in New Zealand girls.1 I agree with Duncan et al that the adjustment of BMI might be valuable in more accurate classification. Indeed, Rush et al had advocated for the requirement of new adjusted BMI for specific minorities.2 However, there are some issues to be addressed. It is questionable whether the new adjusted BMI cut-off is user friendly. Is it more difficult to add a step to clarify the ethnical origin of every subject. Nevertheless, a previous cross publication by Duncan et al in Asia Pac J Clin Nutr also mentioned that BMI can be an acceptable proxy measure of excess fatness in girls from diverse ethnicities.3 The universal BMI might still be acceptable if it used as a screening tool. Additional determination of % body fat, which is a more reliable parameter without interference from ethnical background,4 might be used in cases that further definitive diagnosis and management of overweight problem are required. Professor Viroj Wiwanitkit
Bangkok, Thailand wviroj@yahoo.com
References:
1. Duncan JS, Duncan EK, Schofield G. Ethnic-specific body mass index cut-off points for overweight and obesity in girls. N Z Med J. 2010 Mar 19;123(1311):22-9. http://www.nzma.org.nz/journal/123-1311/4031/content.pdf Rush E, Plank L, Chandu V, et al. Body size, body composition, and fat distribution: a comparison of young New Zealand men of European, Pacific Island, and Asian Indian ethnicities. N Z Med J. 2004 Dec 17;117(1207):U1203. http://www.nzma.org.nz/journal/1171207/1203/content.pdf Duncan JS, Duncan EK, Schofield G. Accuracy of body mass index (BMI) thresholds for predicting excess body fat in girls from five ethnicities. Asia Pac J Clin Nutr. 2009;18(3):40411. Rush EC, Freitas I, Plank LD. Body size, body composition and fat distribution: comparative analysis of European, Maori, Pacific Island and Asian Indian adults. Br J Nutr. 2009 Aug;102(4):632-41. Epub 2009 Feb 10.
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Health Practitioners Disciplinary Tribunal Professional Misconduct (Med08/87P)

Charge Dr Brent William James Anderson, Medical Practitioner of Taranaki (the Doctor), was charged with professional misconduct by a Professional Conduct Committee (PCC). The particulars of the charge were that the doctor: 1. Requested the XX Medical Centre staff to fax to him a prescription completed and signed by Dr X (a member of the Doctors practise), thereby involving those staff. 2. Attempted to contact Dr X to request her to represent to the Land Transport Safety Authority that she had medically examined the Doctor for the purpose of obtaining a heavy truck licence, when in fact she had not. 3. Entered Dr Xs name on a Land Transport Safety Authority medical examination form, thereby representing that Dr X had conducted a medical examination and found the Doctor medically fit to hold a heavy truck licence. 4. Submitted the signed Land Transport Safety Authority medical examination form to the Land Transport Safety Authority in order to obtain a heavy truck licence. Finding The hearing proceeded on the basis of an agreed summary of facts and the Doctor acknowledged that he was guilty of professional misconduct. The Tribunal found that the conduct amounted to professional misconduct. Background The Doctor applied with the Land Transport Safety Authority (LTSA) to obtain a Class 2 heavy vehicle drivers licence (HT licence) for the purposes of driving a horse truck. The Doctor was scheduled to sit the theoretical component of the HT licence on the afternoon of Thursday, 30 August 2007 at the AA centre. He was scheduled to sit the practical component of the HT licence on Saturday, 1 September 2007. It is not possible to sit the practical component without first sitting and passing the theoretical component. The Doctor was required to submit (as part of the theoretical component of the HT licence) the original of a standard LTSA medical form certifying that he is safe to drive (or setting out the conditions under which he can drive) and signed by a New
Zealand registered medical practitioner (Medical Form). The Doctor did not obtain a Medical Form prior to 30 August 2007. The Doctor rang his surgery and asked to speak to Dr X as he wanted to ask her if he could use her name on the Medical Form. Dr X was not available at that time and so the Doctor did not speak to her. At some stage on the morning of 30 August following the Doctors request, the receptionist faxed a prescription signed by Dr X to the Doctor. The Doctor, without Dr Xs consent or knowledge, wrote Dr Xs name on the Medical Form but he told the Tribunal that he signed the form with his own signature. The Doctor submitted that Medical Form for the purposes of obtaining an HT licence. Around lunch time, the receptionist rang Dr X to inform her that she had received a telephone call from the Doctor requesting her to fax through a prescription signed by Dr X so that the Doctor could use this on a Medical Form because he did not have time to complete a medical examination before his HT licence test. The receptionist advised Dr X that she had faxed through a prescription to the Doctor. Dr X telephoned the AA Centre. She spoke with Ms W (customer services consultant) and advised her that she had not medically examined the Doctor and had not signed any Medical Form certifying that she had medically examined the Doctor. Dr X then rung another doctor and informed him of what had happened and requested him to pass the information onto the Medical Council. Following her conversation with Dr X, Ms W approached the Doctor (who was at the AA Centre for the purposes of sitting his theoretical test). The Doctor admitted that he had submitted the Medical Form without Dr Xs consent. The submitted Medical Form was returned to the Doctor and then destroyed. He was asked to undertake a medical examination with his doctor and to submit another Medical Form. The Doctor went to the practice of his General Practitioner and obtained a signed Medical Form which was submitted to the AA Centre. On 31 August 2007, the Doctor wrote a handwritten note to Dr X again apologising for his conduct. Later that day the Doctor spoke to Dr X and again apologised. The Doctor sat the practical examination of the HT licence on Saturday, 1 September 2007, and passed. Reasons for Finding The Tribunal considered that the completion of medical certificates by general practitioners is an important part of their role and the correct completion is relied upon by employers, Transport Authority, ACC and numerous other government bodies as truth of the certificate. In putting Dr Xs name on the medical certificate completed by and for himself, the Doctor was clearly acting in a way that most of his peers would believe was inappropriate. The Tribunal also considered that the Doctor lacked insight into one of the reasons why completing his own medical certificate was inappropriate. Notwithstanding the fact that all of the medical evidence in the certificate was factual, nonetheless another
doctor may have considered that there were matters about the Doctors health that ought to have been noted on the medical certificate or would have taken into account other matters that the Doctor himself might not have recognised as being important. The Tribunal considered that self completion of a certificate is capable of abuse either deliberately or accidentally. The Tribunal concluded that the Doctors conduct amounted to professional misconduct being malpractice and conduct that is likely to bring discredit to the profession. Penalty The Tribunal considered while this case did involve dishonesty, the dishonesty was discovered before it could lead to the issue of the licence, and a new medical certificate was obtained almost immediately. The act was an act of stupidity as much as an act of dishonesty. Nonetheless, it was a serious matter but the Tribunal did not think that cancellation or suspension was called for. The Tribunal ordered that the Doctor be censured, pay a fine of $5,000 and pay costs of 25%. The costs were reduced to reflect a discount for the Doctors guilty plea. Appeal The Doctor appealed the Tribunals decision to decline permanent name suppression to the High Court. The High Court upheld the Tribunal decision not to grant the practitioner permanent name suppression (Dr Anderson v Professional Conduct Committee (High Court, Wellington CIV 2008-485-1646, 14 November 2008, Gendall J).
The full decisions relating to the case can be found on the Tribunal web site at www.hpdt.org.nz Reference No: Med08/87P.

Erratum
Lunt H, Florkowski C, Bignall M, Budgen C. Capillary glucose meter accuracy and sources of error in the ambulatory setting. N Z Med J. 123(1310):7485. http://www.nzma.org.nz/journal/123-1310/4018 and http://www.nzma.org.nz/journal/123-1310/4018/content.pdf The authors apologise for an error in the section Case 4 Interfering substances, which relates to glucose monitoring in peritoneal dialysis patients using icodextrin. Glucose meter and strip systems that use glucose dehydrogenase coupled with pyrroloquinolinequinone (GDH-PQQ) are susceptible to interference from icodextrin metabolites. Those meters that use glucose dehydrogenase coupled with nicotinamide adenine dinucleotide (GDH- NAD) are not susceptible to such interference. The Optium Xceed is a GDH-NAD-based system, thus the Optium Xceed meter and strip system can be used safely in patients undergoing peritoneal dialysis. Please see the links above for the corrected article.

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THE NEW ZEALAND MEDICAL JOURNAL

Journal of the New Zealand Medical Association

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100 Years Ago in the NZMJ

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THE NEW ZEALAND MEDICAL JOURNAL

This Issue in the Journal

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THE NEW ZEALAND MEDICAL JOURNAL

Why teach human anatomy at Otago School of Medical Sciences?

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THE NEW ZEALAND MEDICAL JOURNAL

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9. 10. 11. 12. 13. 14. 15. 16.

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THE NEW ZEALAND MEDICAL JOURNAL

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Figure 1. Initial investigations

Patients tested (%)

Figure 2. Severity of symptoms according to platelet count

Severe Mod Mild Asymptomatic

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Figure 3. Inpatients according to platelet count

Figure 4. Summary of treatment

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50 45 40 No. of patients 35 30 25 20 15 10 5 0 <10 10-29 30-49 Platelet count x10 /l

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THE NEW ZEALAND MEDICAL JOURNAL

Health service use amongst users of complementary and alternative medicine

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Table 1. Utilisation of different CAM services

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Table 2. Demographics of CAM and non-CAM users

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Table 3. The medical conditions of CAM and non-CAM users

Non-Cam Users Estimate 9753 95% CI

p-value for difference between groups 7

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Table 4. Health Service utilisation of CAM and non-CAM users

Non-Cam Users Estimate 9753 95% CI

p-value for difference between groups 6

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5. 6. 7. 8. 9. 10. 11. 12.

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THE NEW ZEALAND MEDICAL JOURNAL

Chiropractic claims in the English-speaking world

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