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Patients presenting for elective surgery in the Bay of Plenty area in New Zealand are increasingly elderly with significant medical comorbidities. For these patients the risk–benefit balance of undergoing surgery can be complex. We recognised the need for a robust shared decision-making pathway within our perioperative medicine service. We describe the setup of a complex decision pathway within our district health board and report on the audit data from our first 49 patients. The complex decision pathway encourages surgeons to identify high-risk patients who will benefit from shared decision-making, manages input from multiple specialists as needed with excellent communication between those specialists, and provides a patient-centred approach to decision-making using a structured communication tool.

Purpose Matrix metalloproteinase-9 (MMP-9) is a potent endopeptidase with activity against both collagens and elastin. Expression of MMP-9 is elevated in vascular disease, and in particular within aneurysm tissues. This study tested the hypothesis that the functionally more active T allele of the MMP9 C-1562T polymorphism may be overrepresented in patients with abdominal aortic aneurysm (AAA) compared with control subjects and patients with atherosclerotic peripheral vascular disease (PVD). Methods Seven hundred eighty-nine unrelated persons (AAA, n=414; control subjects, n=203; PVD, n=172) were genotyped for the common C-1562T functional promoter polymorphism of the MMP9 gene. Results Genotypes containing the T allele of this polymorphism were significantly more common in patients with AAA compared with both control subjects and patients with PVD (adjusted odds ratio, 2.41 and 2.94, respectively). The greatest shift between groups was observed in male patients, with a difference of 20.6% in CT/TT genotypes. and 12.1% in T allele frequency between patients with AAA compared with patients with PVD. Conclusions This study provides further evidence to support the role of MMP-9 in the pathogenesis of AAA, and indicates that the MMP9 C-1562T functional polymorphism may represent a genetic component contributing to susceptibility to this vascular disease.

Background Abdominal aortic aneurysm (AAA) is believed to be a rare disease in people of non-European descent. Maori, New Zealand's indigenous people, are thought to originate from South East Asia, so their incidence of AAA might also be expected to be low. The aim was to investigate the incidence and phenotypic factors associated with AAA in the New Zealand Maori population. Methods A retrospective study was performed using the audit database of the New Zealand Society of Vascular Surgeons. Age-standardized rates of admission and death were calculated for Maori and non-Maori. Results Maori comprised 3·9 per cent of the population who had an AAA repaired, similar to the percentage of the Maori population aged over 65 years. However, the death rate from AAA in Maori was 2·4 times the rate in non-Maori. Maori were younger at diagnosis than non-Maori (65·2 versus 71·8 years; P < 0·001), had more emergency procedures (46·6 versus 30·2 per cent; P = 0·018) and a significantly higher proportion of Maori admissions were for a ruptured aneurysm. Conclusion Maori had a higher mortality rate from AAA than non-Maori New Zealanders. Although admission rates between Maori and non-Maori were similar, the earlier age of onset and the increased proportion of ruptured aneurysms may indicate that the disease is more severe in Maori.

Purpose: A familial component has previously been identified in 11% to 20% of patients with abdominal aortic aneurysms (AAAs). The genetic basis of familial AAA remains elusive, however. Matrix metalloproteinases have been implicated in aneurysm development; and plasmin, a serine protease, activates metalloproteinases. Plasminogen activator inhibitor-1 (PAI-1) regulates plasmin activation through the tissue plasminogen activators. A polymorphism within the promoter area of PAI-1 has been described that modifies PAI-1 expression and consequently plasminogen activation. The 4G homozygous variant is associated with increased PAI-1 expression and consequently reduced plasmin activity and therefore may be selected against in-familial AAA. The purpose of this study was to investigate the incidence of the 4G/5G insertion/deletion polymorphism in the promoter area of the PAI-1 gene in a population with AAA. Methods: Patients seen at a tertiary referral center for repair of abdominal aortic aneurysms were recruited. DNA was extracted from blood. Primers were designed to amplify a 99 (5G)-base pair (bp) and a 98 (4G)-bp fragment bracketing the polymorphism. The 5′ primer was mutated to allow a restriction endonuclease to cleave the 5G polymorphism into a 77-bp and a 22-bp fragment. Samples were run on agarose gels and stained with ethidium bromide. Results: One hundred ninety patients with AAAs, including 39 patients with strong family histories and 163 controls were examined. The frequency of the 4G:5G alleles in the AAA population and in the control population was 0.6:0.4. However, 26% of patients with familial AAA were homozygous 5G compared with 13% of the control population. The 4G-allele frequency was 0.47 in the familial AAAs, compared with 0.62 in the nonfamilial patients ( P =.02) and 0.61 in the control population ( P =.03). Conclusion: The selection against the 4G4G genotype in the familial AAA population may indicate a role for PAI in the development of AAA in this population. (J Vasc Surg 2000;31:1026-32.)

Full disclosure of health information to patients is considered important in Western culture, but may be less appropriate for patients from other cultures, particularly when conveying news about a diagnosis with a poor prognosis. This issue is becoming important in New Zealand, given the rapidly increasing ethnic diversity of patients presenting to our hospitals. This paper explores culturally appropriate ways of breaking bad news to patients of different ethnicities in the hospital setting, with emphasis on identifying the locus of decision-making within families and decision-making about end-of-life care. Given that the most rapid population growth is presently occurring in the Asian community, attention is focussed on culturally sensitive ways of breaking bad news to Asian patients and their families.