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Health outcomes research for Maori has been hampered by the lack of adequately validated instruments that directly address outcomes of importance to Maori, framed by a Maori perspective of health. Hua Oranga is an outcome instrument developed for Maori with mental illness that uses a holistic view of Maori health to determine improvements in physical, mental, spiritual and family domains of health. Basic psychometric work for Hua Oranga is lacking. We sought to explore the psychometric properties of the instrument and compare its responsiveness alongside other, more established tools in an intervention study involving Maori and Pacific people following acute stroke. Randomised 2x2 controlled trial of Maori and Pacific people following acute stroke with two interventions aimed at facilitating self-directed rehabilitation, and with follow-up at 12 months after randomisation. Primary outcome measures were the Physical Component Summary (PCS) and Mental Component Summary (MCS) of the Short Form 36 (SF36) at 12 months. Hua Oranga was used as a secondary outcome measure for participants at 12 months and for carers and whanau (extended family). Psychometric properties of Hua Oranga were explored using plots and correlation coefficients, principal factors analysis and scree plots. 172 participants were randomised, of whom 139 (80.8%) completed follow-up. Of these, 135 (97%) completed the Hua Oranga and 117 (84.2%) completed the PCS and MCS of the SF36. Eighty-nine carers completed the Hua Oranga. Total Hua Oranga scores and PCS improved significantly for one intervention group but not the other. Total Hua Oranga scores for carers improved significantly for both interventions. Total Hua Oranga score correlated moderately with the PCS (correlation coefficient 0.55, p<0.001). Factor analysis suggested that Hua Oranga measures two and not four factors; one 'physical-mental' and one 'spiritual-family'. The Hua Oranga instrument, developed for Maori people with mental illness, showed good responsiveness and adequate psychometric properties in Maori and Pacific people after stroke. Its simplicity, relative brevity, minimal cost and adequate psychometric properties should favour its use in future studies with both Maori and Pacific people. Suggestions are made for refinements to the measure. These should be tested in a new population before Hua Oranga is recommended for general use in a clinical setting. Source

Milne R.J.,University of Auckland | Beasley R.,Medical Research Institute of New Zealand
New Zealand Medical Journal

Aim To determine the number, distribution and cost of hospital admissions for chronic obstructive pulmonary disease (COPD) in New Zealand. Methods National patient-level routine data on admissions with a principal diagnosis of COPD (mostly ICD-10-AN J440 & J441) were obtained for the period July 1st 2008 to June 30th 2013. Admissions with length of stay (LOS) ≥ 90 days were excluded. Results There were 61,516 admissions in 5 years. Admission rates and budget impact (in 2012/13 dollar values) were stable but the average length of stay (ALOS) declined from 5.09 to 4.37 days. In FY2012/13 the admission rate was 2.82 per 1000 population, with age standardised rate (ASR) 4.4- and 3.6-fold higher for Māori and Pacific peoples respectively than for European/others. For age ≥ 15 years the ASR was 2.55 per 1000. Admission rates were higher for men than women and increased steeply with age and socioeconomic deprivation (NZDep06). The mean age at discharge was lower for Māori and Pacific peoples than for European/Others (63.4, 67.1 and 72.3 years). The mean 30-day readmission rate was 6.7%. The average LOS increased with age and was shorter for Māori (3.6 days) and Pacific peoples (3.5 days) than for European/Others (4.7 days). Admission rates varied widely across District Health Boards, and were higher in rural than urban regions. The estimated cost of admissions in FY2012/13 was $NZ59.6m. Conclusions Hospital admissions for COPD are costly and are over-represented in high risk groups including rural, elderly, socioeconomically deprived and Māori and Pacific peoples. Effective interventions that are targeted to high risk groups are required to improve equity and reduce the burden of COPD. © NZMA. Source

Mitchell E.A.,University of Auckland | Beasley R.,Medical Research Institute of New Zealand | Keil U.,University of Munster | Montefort S.,University of Malta | Odhiambo J.,Kenya Medical Research Institute

Background: Exposure to parental smoking is associated with wheeze in early childhood, but in 2006 the US Surgeon General stated that the evidence is insufficient to infer a causal relationship between exposure and asthma in childhood and adolescents. Aims To examine the association between maternal and paternal smoking and symptoms of asthma, eczema and rhinoconjunctivitis. Methods: Parents or guardians of children aged 6-7 years completed written questionnaires about symptoms of asthma, rhinoconjunctivitis and eczema, and several risk factors, including maternal smoking in the child's first year of life, current maternal smoking (and amount) and paternal smoking. Adolescents aged 13-14 years self completed the questionnaires on these symptoms and whether their parents currently smoked. Results: In the 6-7-year age group there were 220 407 children from 75 centres in 32 countries. In the 13-14-year age group there were 350 654 adolescents from 118 centres in 53 countries. Maternal and paternal smoking was associated with an increased risk of symptoms of asthma, eczema and rhinoconjunctivitis in both age groups, although the magnitude of the OR is higher for symptoms of asthma than the other outcomes. Maternal smoking is associated with higher ORs than paternal smoking. For asthma symptoms there is a clear dose relationship (1-9 cigarettes/day, OR 1.27; 10-19 cigarettes/day, OR 1.35; and 20+ cigarettes/day, OR 1.56). When maternal smoking in the child's first year of life and current maternal smoking are considered, the main effect is due to maternal smoking in the child's first year of life. There was no interaction between maternal and paternal smoking. Conclusions: This study has confirmed the importance of maternal smoking, and the separate and additional effect of paternal smoking. The presence of a doseeresponse effect relationship with asthma symptoms suggests that the relationship is causal, however for eczema and rhinoconjunctivitis causality is less certain. Source

Cameron L.,Medical Research Institute of New Zealand
Postgraduate medical journal

Prehospital high concentration oxygen therapy leads to worse clinical outcomes in patients presenting with acute exacerbations of chronic obstructive pulmonary disease (AECOPD). Less is known about the risks of hypoxaemia despite oxygen treatment. Current respiratory and ambulance guidelines recommend titration of supplemental oxygen to a target oxygen saturation range of 88%-92%. To explore the association between PaO(2) and risk of serious adverse clinical outcomes in AECOPD. A retrospective review of consecutive patients presenting via ambulance to the Wellington Regional Hospital Emergency Department with AECOPD between June 2005 and January 2008. Patients with an arterial blood gas taken within 4 h of triage were included in the study and were categorised as hypoxaemic (PaO(2)<60 mm Hg), normoxaemic (PaO(2) 60-100 mm Hg) or hyperoxaemic (PaO(2)>100 mm Hg). Serious adverse outcome was defined as a composite of hypercapnic respiratory failure, assisted ventilation or inpatient death. Multivariate logistic regression analysis examined the association between PaO(2) category and the composite outcome. Of the 680 patients presenting with AECOPD in the review period, 254 presentations in 180 patients had data suitable for analysis. Hyperoxaemia occurred in 61/254 (24%) presentations and was strongly associated with serious adverse outcome compared with normoxaemia (OR 9.17, 95% CI 4.08 to 20.6). Hypoxaemia was also associated with an increased risk of serious adverse outcome compared with normoxaemia (OR 2.16, 95% CI 1.11 to 4.20). Compared with the recommended target oxygen saturation range of 88%-92%, the risk of a serious adverse outcome was increased in both the <88% group (OR 2.0, 95% CI 1.03 to 3.80) and the >96% group (OR 2.37, 95% CI 1.34 to 4.20). In patients presenting via ambulance to the Emergency Department with AECOPD, serious adverse clinical outcomes are associated with both hypoxaemia and hyperoxaemia. These data provide further support for the principle of titrating supplemental oxygen therapy to target oxygen saturations. Source

Jefferies S.,Medical Research Institute of New Zealand | Saxena M.,St George Hospital | Young P.,Medical Research Institute of New Zealand
Critical Care and Resuscitation

Background: Paracetamol is one of the commonest medications used worldwide. This review was conceived as a consequence of evaluating the literature in the protocol development of two randomised, controlled clinical trials investigating the safety and efficacy of paracetamol in ICU patients (the HEAT [Permissive HyperthErmiA Through Avoidance of Paracetamol in Known or Suspected Infection in the Intensive Care Unit] study; the Paracetamol After traumatic Brain Injury [PARITY] Study). Objective: To provide a historical perspective on the introduction of paracetamol into clinical practice, to present the pharmacology of paracetamol in critical illness, and evaluate the current evidence for its use as an antipyretic and analgesic in intensive care. Design: Literature searches were performed using keywords: 'paracetamol', 'acetaminophen', 'critical illness', 'intensive care', 'history', 'pharmacology', 'antipyre*', 'analgesi*', 'adverse effect*', 'administration and dosage', 'toxicity', 'animals' and 'humans'. Data sources: Embase, MEDLINE, PubMed (1947/1950 to July 2011). Review methods: The authors examined each article's title and abstract, fully reviewing relevant articles, with searching of reference lists and additional hand-searching. The most recent and highest quality available evidence was included. Results: Limited data are available on the pharmacology of paracetamol in the critically ill. Among patients with sepsis, paracetamol may inhibit the immunological response. Among patients with neurological injury paracetamol can reduce temperature but appears not to improve outcome. When administered with opioids after major surgery, paracetamol does not reduce the incidence of pain or opioidrelated side-effects. Conclusion: Despite the widespread use of paracetamol in critical illness, there is a paucity of data supporting its utility in this setting. Further research is required to determine how paracetamol should be used in the critically ilnot reduce the incidence of pain or opioidrelated side-effects. Conclusion: Despite the widespread use of paracetamol in critical illness, there is a paucity of data supporting its utility in this setting. Further research is required to determine how paracetamol should be used in the critically ill. Source

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