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INTRODUCTION: Obesity is disproportionately prevalent among Pacific population groups in New Zealand. Lifestyle behaviours of excessive consumption of high energy, unhealthy foods and inadequate physical activity are risk factors for obesity that can be modified. AIM: To identify and describe the risk factors for and protective factors against obesity among Pacific Island (PI) adolescents who attend church and compare them with PI adolescents who do not attend church. METHODS: We investigated the lifestyle behaviours of 2495 PI adolescents at six secondary schools in Auckland, New Zealand (NZ), 77% of whom attend a church or other place of worship. The cross-sectional survey was undertaken in 2005. Structured individual interviews and anthropometric measurements were undertaken. RESULTS: Church attendees had a higher mean body mass index (BMI) compared with non-attendees (BMI 27.4 vs BMI 26.6), adjusted for age, gender and PI ethnicity (p=0.01). The weight status of attendees was associated with less healthy breakfast and lunch sources, lower levels of physical activity, and limited knowledge of the risk factors for obesity (p

INTRODUCTION: The prevalence of gout among Maori is one of the highest in the world. This study explores the perceptions, understanding and treatment of gout among Maori. METHODS: A qualitative general inductive approach was used, guided by kaupapa Maori principles. Participants included 12 Maori aged 48-79 years with gout. Semi-structured interviews were undertaken, taped and transcribed. Themes were identified from transcripts. FINDINGS: Participants described overwhelming sufferance due to gout, which was sometimes considered inevitable. All participants believed or had been informed that gout is caused by food and/or drink. This led to feelings of self-blame and blame from partners and employers. Whanau (family) were a resource for information and a support when independence was limited. Rongoa (traditional medicine) played a role in the lives of rural but not urban participants. Many reported stoicism, putting up with pain and putting others before themselves, as the 'Maori way'. Medicines used for gout management were predominantly non-steroidal anti-inflammatory drugs, colchicine and prednisone, with allopurinol only playing a role late in the disease. Medications were often poorly understood and consequently improperly used. Relationships with health professionals were important, but cultural, financial and time barriers impaired access and understanding. Gout had a huge, negative impact on the lives of participants. CONCLUSION: The quality of lives of many people with gout could be improved by better understanding through educational campaigns for health professionals and the community. Culturally sensitive health care systems and a paradigm shift in gout management and early preventive treatment are needed.

Aim To assess the cost-effectiveness of exercise on prescription with ongoing support in general practice. Methods Prospective cost-effectiveness study undertaken as part of the 2-year Women's lifestyle study randomised controlled trial involving 1089 'less-active' women aged 40-74. The 'enhanced Green Prescription' intervention included written exercise prescription and brief advice from a primary care nurse, face-to-face follow-up at 6 months, and 9 months of telephone support. The primary outcome was incremental cost of moving one 'less-active' person into the 'active' category over 24 months. Direct costs of programme delivery were recorded. Other (indirect) costs covered in the analyses included participant costs of exercise, costs of primary and secondary healthcare utilisation, allied health therapies and time off work (lost productivity). Cost-effectiveness ratios were calculated with and without including indirect costs. Results Follow-up rates were 93% at 12 months and 89% at 24 months. Significant improvements in physical activity were found at 12 and 24 months (p<0.01). The exercise programme cost was New Zealand dollars (NZ$) 93.68 (45.90) per participant. There was no significant difference in indirect costs over the course of the trial between the two groups (rate ratios: 0.99 (95% CI 0.81 to 1.2) at 12 months and 1.01 (95% CI 0.83 to 1.23) at 24 months, p=0.9). Cost-effectiveness ratios using programme costs were NZ$687 (331) per person made 'active' and sustained at 12 months and NZ$1407 (678) per person made 'active' and sustained at 24 months. Conclusions This nurse-delivered programme with ongoing support is very cost-effective and compares favourably with other primary care and community-based physical activity interventions internationally. [ABSTRACT FROM AUTHOR]

Background: The health and economic burden of physical inactivity is well documented. A wide range of primary care and community-based interventions are available to increase physical activity. It is important to identify which components of these interventions provide the best value for money.Aim: To assess the cost-effectiveness of physical activity interventions in primary care and the community.Design Of Study: Systematic review of cost-effectiveness studies based on randomised controlled trials of interventions to increase adult physical activity that were based in primary health care or the community, completed between 2002 and 2009.Method: Electronic databases were searched to identify relevant literature. Results and study quality were assessed by two researchers, using Drummond's checklist for economic evaluations. Cost-effectiveness ratios for moving one person from inactive to active, and cost-utility ratios (cost per quality-adjusted life-year [QALY]) were compared between interventions.Results: Thirteen studies fulfilled the inclusion criteria. Eight studies were of good or excellent quality. Interventions, study populations, and study designs were heterogeneous, making comparisons difficult. The cost to move one person to the 'active' category at 12 months was estimated for four interventions ranging from €331 to €3673. The cost-utility was estimated in nine studies, and varied from €348 to €86,877 per QALY.Conclusion: Most interventions to increase physical activity were cost-effective, especially where direct supervision or instruction was not required. Walking, exercise groups, or brief exercise advice on prescription delivered in person, or by phone or mail appeared to be more cost-effective than supervised gym-based exercise classes or instructor-led walking programmes. Many physical activity interventions had similar cost-utility estimates to funded pharmaceutical interventions and should be considered for funding at a similar level. [ABSTRACT FROM AUTHOR]

Objective: To derive a 5-year cardiovascular disease (CVD) risk equation from usual-care data that is appropriate for people with type 2 diabetes from a wide range of ethnic groups, variable glycemic control, and high rates of albuminuria in New Zealand.Research Design and Methods: This prospective open-cohort study used primary-care data from 36,127 people with type 2 diabetes without previous CVD to derive a CVD equation using Cox proportional hazards regression models. Data from 12,626 people from a geographically different area were used for validation. Outcome measure was time to first fatal or nonfatal cardiovascular event, derived from national hospitalization and mortality records. Risk factors were age at diagnosis, diabetes duration, sex, systolic blood pressure, smoking status, total cholesterol-to-HDL ratio, ethnicity, glycated hemoglobin (A1C), and urine albumin-to-creatinine ratio.Results: Baseline median age was 59 years, 51% were women, 55% were of non-European ethnicity, and 33% had micro- or macroalbuminuria. Median follow-up was 3.9 years (141,169 person-years), including 10,030 individuals followed for at least 5 years. At total of 6,479 first cardiovascular events occurred during follow-up. The 5-year observed risk was 20.8% (95% CI 20.3-21.3). Risk increased with each 1% A1C (adjusted hazard ratio 1.06 [95% CI 1.05-1.08]), when macroalbuminuria was present (2.04 [1.89-2.21]), and in Indo-Asians (1.29 [1.14-1.46]) and Maori (1.23 [1.14-1.32]) compared with Europeans. The derived risk equations performed well on the validation cohort compared with other risk equations.Conclusions: Renal function, ethnicity, and glycemic control contribute significantly to cardiovascular risk prediction. Population-appropriate risk equations can be derived from routinely collected data. [ABSTRACT FROM AUTHOR]

Purpose: We wanted to assess the effectiveness of a home-based physical activity program, the Depression in Late Life Intervention Trial of Exercise (DeLLITE), in improving function, quality of life, and mood in older people with depressive symptoms.Methods: We undertook a randomized controlled trial involving 193 people aged 75 years and older with depressive symptoms at enrollment who were recruited from primary health care practices in Auckland, New Zealand. Participants received either an individualized physical activity program or social visits to control for the contact time of the activity intervention delivered over 6 months. Primary outcome measures were function, a short physical performance battery comprising balance and mobility, and the Nottingham Extended Activities of Daily Living scale. Secondary outcome measures were quality of life, the Medical Outcomes Study 36-item short form, mood, Geriatric Depression Scale (GDS-15), physical activity, Auckland Heart Study Physical Activity Questionnaire, and self-report of falls. Repeated measures analyses tested the differential impact on outcomes over 12 months' follow-up.Results: The mean age of the participants was 81 years, and 59% were women. All participants scored in the at-risk category on the depression screen, 53% had a Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases, Tenth Revision diagnosis of major depression or scored more than 4 on the GDS-15 at baseline, indicating moderate or severe depression. Almost all participants, 187 (97%), completed the trial. Overall there were no differences in the impact of the 2 interventions on outcomes. Mood and mental health related quality of life improved for both groups.Conclusion: The DeLLITE activity program improved mood and quality of life for older people with depressive symptoms as much as the effect of social visits. Future social and activity interventions should be tested against a true usual care control. [ABSTRACT FROM AUTHOR]

BACKGROUND: Primary care is accessible and ideally placed for case finding of patients with lifestyle and mental health risk factors and subsequent intervention. The short self-administered Case-finding and Help Assessment Tool (CHAT) was developed for lifestyle and mental health assessment of adult patients in primary health care. This tool checks for tobacco use, alcohol and other drug misuse, problem gambling, depression, anxiety and stress, abuse, anger problems, inactivity, and eating disorders. It is well accepted by patients, GPs and nurses. AIM: To assess criterion-based validity of CHAT against a composite gold standard. DESIGN OF STUDY: Conducted according to the Standards for Reporting of Diagnostic Accuracy statement for diagnostic tests. SETTING: Primary care practices in Auckland, New Zealand. METHOD: One thousand consecutive adult patients completed CHAT and a composite gold standard. Sensitivities, specificities, positive and negative predictive values, and likelihood ratios were calculated. RESULTS: Response rates for each item ranged from 79.6 to 99.8%. CHAT was sensitive and specific for almost all issues screened, except exercise and eating disorders. Sensitivity ranged from 96% (95% confidence interval [CI] = 87 to 99%) for major depression to 26% (95% CI = 22 to 30%) for exercise. Specificity ranged from 97% (95% CI = 96 to 98%) for problem gambling and problem drug use to 40% (95% CI = 36 to 45%) for exercise. All had high likelihood ratios (3-30), except exercise and eating disorders. CONCLUSION: CHAT is a valid and acceptable case-finding tool for most common lifestyle and mental health conditions. [ABSTRACT FROM AUTHOR]

Objective: To assess whether pedometers and text messaging increase physical activity in adolescents with type 1 diabetes.Research Design and Methods: A 12-week randomized controlled trial was conducted. A total of 78 subjects participated in the trial (mean +/- SD age 14.4 +/- 2.37 years, 36 [47%] male). Intervention participants wore an open pedometer and received regular motivational text messages. Control participants received usual care. Primary outcomes were daily step count (4-day closed pedometer) and physical activity questionnaire.Results: Baseline median step count was 11,063 steps/day (range 1,541-20,158). At 12 weeks, mean daily step count reduced by 840 (95% CI -1,947 to 266) in the control group and by 22 (-1,407 to 1,364) in the intervention group (P = 0.4). Mean self-reported moderate or vigorous physical activity increased by 38.5 min/week in the control group and by 48.4 in the intervention group (P = 0.9).Conclusions: A 12-week intervention using pedometers and text messaging as motivational tools in adolescents with type 1 diabetes did not increase physical activity. [ABSTRACT FROM AUTHOR]

Introduction The Safer Prescribing and Care for the Elderly (SPACE) cluster randomised controlled trial in 39 general practices found that a search of the practice database to identify and generate for each general practitioner (GP) a list of patients with high-risk prescribing, pharmacist-delivered one-on-one feedback to GPs, and electronic tick-box for GPs to select action for each patient (Patient letter; No letter but possible medication review when patient next in; No action), prompted safer prescribing at 6 months but not at 1 year. Aim This process evaluation explores research participation, intervention uptake and effect on GPs. Methods Mixed methods were used including quantitative data (log of practice recruitment, demographic data, intervention delivery and GP responses including tick-box selections) and qualitative data (trial pharmacist reflective journal). Data were analysed using descriptive statistics and general inductive analysis, respectively. Results Recruitment of general practices was challenging, with only 39% of eligible practices agreeing to participate. Those who declined were often 'too busy'. Engagement was also challenging, especially in larger practices, with the trial pharmacist managing to meet with only 64% of GPs in the intervention group. The GPs who did engage were positive about the intervention, but elected to send letters to only 23% of patients with high-risk prescribing, either because the high-risk prescribing had already stopped, the GP did not agree the prescribing was 'high-risk' or the GP was concerned a letter would upset the patient. Conclusions Effectiveness of the SPACE cluster randomised controlled trial could be improved by changes including ensuring searches are current and relevant, repeating cycles of search and feedback, and integrating pharmacists into general practices.

Background: Safer prescribing in general practice may help to decrease preventable adverse drug events (ADE) and related hospitalisations., Aim: To test the effect of the Safer Prescribing and Care for the Elderly (SPACE) intervention on high-risk prescribing of non-steroidal anti-inflammatory drugs (NSAIDs) and/or antiplatelet medicines and related hospitalisations., Design & Setting: A pragmatic cluster randomised controlled trial in general practice. Participants were patients at increased risk of ADEs from NSAIDs and/or antiplatelet medicines at baseline. SPACE comprises automated search to generate for each GP a list of patients with high-risk prescribing; pharmacist outreach to provide education and one-on-one review of list with GP; and automated letter inviting patients to seek medication review with their GP., Method: The primary outcome was the difference in high-risk prescribing of NSAIDs and/or antiplatelet medicines at 6 months. Secondary outcomes were high-risk prescribing for gastrointestinal, renal, or cardiac ADEs separately, 12-month outcomes, and related ADE hospitalisations., Results: Thirty-nine practices were recruited with 205 GPs and 191 593 patients, of which 21 877 (11.4%) were participants. Of the participants, 1479 (6.8%) had high-risk prescribing. High-risk prescribing improved in both groups at 6 and 12 months compared with baseline. At 6 months, there was no significant difference between groups (odds ratio [OR] 0.99; 95% confidence intervals [CI] = 0.87 to 1.13) although SPACE improved more for gastrointestinal ADEs (OR 0.81; 95% CI = 0.68 to 0.96). At 12 months, the control group improved more (OR 1.29; 95% CI = 1.11 to 1.49). There was no significant difference for related hospitalisations., Conclusion: Further work is needed to identify scalable interventions that support safer prescribing in general practice. The use of automated search and feedback plus letter to patient warrants further exploration., (Copyright © 2021, The Authors.)

Objective: The aim of this study was to determine the effect of polypill-based care on the achievement of 2016 European Society of Cardiology (ESC) guideline targets for blood pressure (BP), low-density lipoprotein (LDL) cholesterol and antiplatelet therapy., Methods: We conducted an individual participant data meta-analysis of three randomised clinical trials that compared a strategy using a polypill containing aspirin, statin and antihypertensive therapy with usual care in patients with a prior cardiovascular disease (CVD) event or who were at high risk of their first event. Overall, the trials included 3140 patients from Australia, England, India, Ireland, the Netherlands and New Zealand (75% male, mean age 62 years and 76% with a prior CVD event). The primary outcome for this study was the proportion of people achieving ESC guideline targets for BP, LDL and antiplatelet therapy., Results: Those randomised to polypill-based care were more likely than those receiving usual care to achieve recommended targets for BP (62% vs 58%, risk ratio (RR) 1.08, 95% CI 1.02 to 1.15), LDL (39% vs 34%, RR 1.13, 95% CI 1.02 to 1.25) and all three targets for BP, LDL and adherence to antiplatelet therapy (the latter only applicable to those with a prior CVD event) simultaneously (24% vs 19%, RR 1.27, 95% CI 1.10 to 1.47) at 12 months. There was no difference between groups in antiplatelet adherence (96% vs 96%, RR 1.00, 95% CI 0.98 to 1.01). There was heterogeneity by baseline treatment intensity such that treatment effects increased with the fewer the number of treatments being taken at baseline: for patients taking 3, 2 and 0-1 treatment modalities the RRs for reaching all three guideline goals simultaneously were 1.10 (95% CI 0.94 to 1.30, 22% vs 20%), 1.62 (95% CI 1.09 to 2.42, 27% vs 17%) and 3.07 (95% CI 1.77 to 5.33, 35% vs 11%), respectively., Conclusions: Polypill-based therapy significantly improved the achievement of all three ESC targets for BP, LDL and antiplatelet therapy compared with usual care, particularly among those undertreated at baseline., Competing Interests: Competing interests: Support for the submitted work: RW is funded by an NHMRC early career fellowship. The authors have received grants from several research charities and national funding agencies for research on cardiovascular polypills, and from Dr Reddy’s Laboratories for coordination of the SPACE programme (www.spacecollaboration.org). The polypills used in the SPACE trials were manufactured and supplied by Dr Reddy’s Laboratories free of charge. Some authors received funding from Dr Reddy’s Laboratories to attend investigator meetings related to the polypill (VS, RW, AP, ST, NR, AW and AR). George Health Enterprises, the social enterprise arm of The George Institute for Global Health (employer of some coauthors) has received investment for the development of fixed dose combination therapy containing statin, aspirin and blood pressure lowering medications., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2019. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: High-risk prescribing places patients at increased risk of adverse drug events (ADEs). High-risk prescribing and ADE hospitalisations are increasingly common as people are living longer and taking more medicines for multiple chronic conditions. The Safer Prescribing and Care for the Elderly (SPACE) intervention is designed to foster patient engagement in medicines management and prompt medicines review., Aim: To pilot the SPACE intervention in preparation for a larger cluster randomised controlled trial (RCT)., Design & Setting: A pilot study in two general practices. Study participants were all patients at increased risk of an adverse drug reaction (ADE) from non-steroidal anti-inflammatory drugs (NSAIDs) and/or antiplatelet medicines. The primary outcome was the proportion of participants receiving high-risk prescribing at 6 months and 12 months compared with baseline., Method: The SPACE intervention comprised automated practice audit to identify and generate for each GP a list of patients with high-risk prescribing for these medicines; an outreach visit by clinical advisory pharmacist to deliver education and to go through with each GP their list of at-risk patients and indicate in a tick-box the intended action for each patient; and a mail-out from GPs to selected patients containing a medicines information brochure and a letter encouraging patients to discuss their medicines when they next see their GP., Results: SPACE can be delivered within existing primary care infrastructure. The rate of high-risk prescribing was reduced at 6 months following the delivery of the intervention, but these improvements were not evident at 12 months., Conclusion: SPACE prompts medicines review and shows promising signs of supporting safer prescribing in general practice in the short term. A randomised trial of SPACE started in 2018.

Background: The Thrombolysis in Myocardial Infarction (TIMI) Risk Score for Secondary Prevention (TRS2°P), a 0-to-9-point system based on the presence/absence of 9 clinical factors, was developed to classify the risk of major adverse cardiovascular events (MACE) (a composite of cardiovascular death, recurrent myocardial infarction, or ischemic stroke) among patients with a recent myocardial infarction. Its performance has not been examined internationally outside of a clinical trial setting., Methods and Results: We evaluated the performance of TRS2°P for predicting MACE in 53 599 patients with recent myocardial infarction in 5 international cohorts from New Zealand, South Korea, Sweden, and the United States participating in the Chronic Kidney Disease Prognosis Consortium. Overall, there were 19 444 cases of MACE across 5 cohorts over a mean follow-up of 5 years, and the overall MACE rate ranged from 5.0 to 18.4 (per 100 person-years). The TRS2°P showed modest calibration (Brier score ranged from 0.144 to 0.173) and discrimination (C-statistics >0.61 in all studies except 1 from Korea with 0.55) across cohorts relative to its original Brier score of 0.098 and C-statistic of 0.67 in the derived data set. Although there was some heterogeneity across cohorts, the 9 predictors in the TRS2°P were generally associated with higher MACE risk, with strongest associations observed (meta-analyzed adjusted hazard ratio 1.6-1.7) for history of heart failure, age ≥75 years, and prior stroke, followed by peripheral artery disease, kidney dysfunction, diabetes mellitus, and hypertension (hazard ratio 1.3-1.4). Prior coronary bypass graft surgery and smoking did not reach statistical significance (hazard ratio ≈1.1)., Conclusions: TRS2°P, a simple scoring system with 9 routine clinical factors, was modestly predictive of secondary events when applied in patients with recent myocardial infarction from diverse clinical and geographic settings., (© 2018 The Authors and Merck Sharpe & Dohme Corp. Published on behalf of the American Heart Association, Inc., by Wiley.)

Background: High-risk prescribing, adverse drug events, and avoidable adverse drug event hospitalizations are common. The single greatest risk factor for high-risk prescribing and adverse drug events is the number of medications a person is taking. More people are living longer and taking more medications for multiple long-term conditions. Most on-going prescribing occurs in primary care. The most effective, cost-effective, and practical approach to safer prescribing in primary care is not yet known., Objective: To test the effect of the Safer Prescribing And Care for the Elderly (SPACE) intervention on high-risk prescribing of nonsteroidal anti-inflammatory and antiplatelet medicines, and related adverse drug event hospitalizations., Methods: This is a protocol of a cluster randomized controlled trial. The clusters will be primary care practices. Data collection and analysis will be at the level of patient., Results: Recruitment started in 2018. Six-month data collection will be in 2018., Conclusions: This study addresses an important translational gap, testing an intervention designed to prompt medicines review and support safer prescribing in routine primary care practice., Trial Registrationgeneral Practice: Australian New Zealand Clinical Trials Registry: ACTRN12618000034235 http://www.ANZCTR.org.au/ACTRN12618000034235.aspx (Archived with Webcite at http://www.webcitation.org/6yj9RImDf), Competing Interests: None declared., (©Katharine Ann Wallis, Carolyn Raina Elley, Arier Lee, Simon Moyes, Ngaire Kerse. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 26.04.2018.)

Objective: To investigate maternal and birth-related risk factors associated with infant respiratory hospitalisations in New Zealand., Methods: A Kaupapa Māori-framed retrospective cohort analysis of public hospital maternal data linked to infant data (54,980 births 1995-2009). Primary outcome was rate of hospitalisation for respiratory disease in the first year of life. Risk variables examined included socioeconomic status (SES), age, smoking, parity, gestation, time to hospital discharge, breastfeeding and maternal ethnicity as a potential marker of differential exposure to risk factors., Results: Independent risk factors for hospitalisation included low maternal SES (rate ratio: 1.33 [95% CI 1.19-1.49]); smoking (1.3 [1.19-1.41]); parity (2.77 [2.37-3.24]); preterm birth (3.14 [2.58-3.83]; 30 compared with 40 weeks); but not breastfeeding (0.99 [0.87-1.11]). After adjustment for risk factors, respiratory hospitalisations remained highest among infants of young Māori women (rate ratio 1.93 [1.46-2.55] at age 22.5 years) and Pacific women across all maternal age groups (rate ratios 2.43 to 2.55), compared with infants of European women., Conclusions: Maternal and birth factors are strongly associated with ethnic disparities in infant hospital admissions for respiratory disease., Implications: Interventions that begin in pregnancy and address risk factors and social determinants of health are needed to address these disparities., (© 2016 Public Health Association of Australia.)

Problem: There is evidence that peer-support programs can improve mental health indices and help-seeking behavior among students in some secondary school and university settings and that mindfulness can improve mental health in medical students. Peer-led programs have not been formally assessed in a medical student population, where psychological issues exist and where it has been shown that students approach peers for help in preference to staff members or professional services., Intervention: Medical students elected peer leaders who underwent training and then provided the intervention. The peer leaders provided support to students in the intervention group, as well as offering teaching in mindfulness meditation., Context: An exploratory study was conducted with 2nd- and 3rd-year medical students at 1 medical school in New Zealand randomized into 2 groups. In addition to existing mental health resources, intervention participants received a program including peer support and peer-taught mindfulness practice. Study participants not offered the intervention participants could use existing mental health resources. Primary measures included depression (PHQ-9) and anxiety (GAD-7) scores. Secondary measures were quality of life, resilience (15-item resilience scale), academic self-concept, and motivation to learn, assessed at baseline and 6 months., Outcome: Of the 402 students eligible, 275 (68%) participated and 232 (58%) completed the study. At baseline, 53% were female and mean age was 21 years (SD = 3)-PHQ-9 score (M = 5.2, SD = 3.7) and GAD-7 score (M = 4.5, SD = 3.4). Twelve peer leaders were elected. There was good participation in the intervention. One fourth of intervention students used the face-to-face peer support and more than 50% attended a peer social event and/or participated in the mindfulness program. Although improvements in mental health were seen in the intervention group, the difference between the intervention and nonintervention groups did not reach statistical significance., Lessons Learned: Although evidence exists for effectiveness of peer support and mindfulness in other contexts, this exploratory study was not able to show a statistically significant effect. Future studies could consider using a longer training period for the peer leaders, as well as targeting the study population to those most likely to benefit such as those with poorer mental health, or using a more intensive intervention or larger sample size. A cluster randomized study design would also reduce the risk of contamination.

Objective: This study assessed whether 12 weeks of chiropractic care was effective in improving sensorimotor function associated with fall risk, compared with no intervention, in community-dwelling older adults living in Auckland, New Zealand., Methods: Sixty community-dwelling adults older than 65 years were enrolled in the study. Outcome measures were assessed at baseline, 4 weeks, and 12 weeks and included proprioception (ankle joint position sense), postural stability (static posturography), sensorimotor function (choice stepping reaction time), multisensory integration (sound-induced flash illusion), and health-related quality of life (SF-36)., Results: Over 12 weeks, the chiropractic group improved compared with the control group in choice stepping reaction time (119 milliseconds; 95% confidence interval [CI], 26-212 milliseconds; P = .01) and sound-induced flash illusion (13.5%; 95% CI, 2.9%-24.0%; P = .01). Ankle joint position sense improved across the 4- and 12-week assessments (0.20°; 95% CI, 0.01°-0.39°; P = .049). Improvements were also seen between weeks 4 and 12 in the SF-36 physical component of quality of life (2.4; 95% CI, 0.04-4.8; P = .04) compared with control., Conclusion: Sensorimotor function and multisensory integration associated with fall risk and the physical component of quality of life improved in older adults receiving chiropractic care compared with control. Future research is needed to investigate the mechanisms of action that contributed to the observed changes in this study and whether chiropractic care has an impact on actual falls risk in older adults., (Copyright © 2016 National University of Health Sciences. Published by Elsevier Inc. All rights reserved.)

Importance: Identifying patients at risk of chronic kidney disease (CKD) progression may facilitate more optimal nephrology care. Kidney failure risk equations, including such factors as age, sex, estimated glomerular filtration rate, and calcium and phosphate concentrations, were previously developed and validated in 2 Canadian cohorts. Validation in other regions and in CKD populations not under the care of a nephrologist is needed., Objective: To evaluate the accuracy of the risk equations across different geographic regions and patient populations through individual participant data meta-analysis., Data Sources: Thirty-one cohorts, including 721,357 participants with CKD stages 3 to 5 in more than 30 countries spanning 4 continents, were studied. These cohorts collected data from 1982 through 2014., Study Selection: Cohorts participating in the CKD Prognosis Consortium with data on end-stage renal disease., Data Extraction and Synthesis: Data were obtained and statistical analyses were performed between July 2012 and June 2015. Using the risk factors from the original risk equations, cohort-specific hazard ratios were estimated and combined using random-effects meta-analysis to form new pooled kidney failure risk equations. Original and pooled kidney failure risk equation performance was compared, and the need for regional calibration factors was assessed., Main Outcomes and Measures: Kidney failure (treatment by dialysis or kidney transplant)., Results: During a median follow-up of 4 years of 721,357 participants with CKD, 23,829 cases kidney failure were observed. The original risk equations achieved excellent discrimination (ability to differentiate those who developed kidney failure from those who did not) across all cohorts (overall C statistic, 0.90; 95% CI, 0.89-0.92 at 2 years; C statistic at 5 years, 0.88; 95% CI, 0.86-0.90); discrimination in subgroups by age, race, and diabetes status was similar. There was no improvement with the pooled equations. Calibration (the difference between observed and predicted risk) was adequate in North American cohorts, but the original risk equations overestimated risk in some non-North American cohorts. Addition of a calibration factor that lowered the baseline risk by 32.9% at 2 years and 16.5% at 5 years improved the calibration in 12 of 15 and 10 of 13 non-North American cohorts at 2 and 5 years, respectively (P = .04 and P = .02)., Conclusions and Relevance: Kidney failure risk equations developed in a Canadian population showed high discrimination and adequate calibration when validated in 31 multinational cohorts. However, in some regions the addition of a calibration factor may be necessary.

Aim: Lower limb amputation is a serious complication of diabetic foot disease and there are unexplained ethnic variations in incidence. This study investigates the risk of amputation among different ethnic groups after adjusting for demographic, socio-economic status and clinical variables., Methods: We used primary care data from a large national multi-ethnic cohort of patients with Type 2 diabetes in New Zealand and linked hospital records. The primary outcome was time from initial data collection to first lower limb amputation. Demographic variables included age of onset and duration since diabetes diagnosis, gender, ethnicity and socio-economic status. Clinical variables included smoking status, height and weight, blood pressure, HbA1c , total cholesterol/HDL ratio and albuminuria. Cox proportional hazards models were used., Results: There were 892 lower limb amputations recorded among 62 002 patients (2.11 amputations per 1000 person-years), followed for a median of 7.14 years (422 357 person-years). After adjusting for demographic and socio-economic variables and compared with Europeans, Māori had the highest risk [hazard ratio (HR) 1.84 (95%CI:1.54-2.19)], whereas East Asians [HR 0.18, (0.08-0.44)] and South Asians [HR 0.39 (0.22-0.67)] had the lowest risk. Adjusting for available clinical variables reduced the differences but they remained substantial [HR 1.61 (1.35-1.93), 0.23 (0.10-0.56) and 0.48 (0.27-0.83), respectively]., Conclusions: Ethnic groups had significantly different risk of lower limb amputation, even after adjusting for demographic and some major clinical risk factors. Barriers to care should be addressed and intensive prevention strategies known to reduce the incidence of lower limb amputations could be prioritized to those at greatest risk., (© 2015 The Authors. Diabetic Medicine © 2015 Diabetes UK.)

Background: Diabetes mellitus and hypertension are risk factors for acute kidney injury (AKI). Whether estimated glomerular filtration rate (eGFR) and urine albumin-creatinine ratio (ACR) remain risk factors for AKI in the presence and absence of these conditions is uncertain., Study Design: Meta-analysis of cohort studies., Setting & Population: 8 general-population (1,285,045 participants) and 5 chronic kidney disease (CKD; 79,519 participants) cohorts., Selection Criteria for Studies: Cohorts participating in the CKD Prognosis Consortium., Predictors: Diabetes and hypertension status, eGFR by the 2009 CKD Epidemiology Collaboration creatinine equation, urine ACR, and interactions., Outcome: Hospitalization with AKI, using Cox proportional hazards models to estimate HRs of AKI and random-effects meta-analysis to pool results., Results: During a mean follow-up of 4 years, there were 16,480 episodes of AKI in the general-population and 2,087 episodes in the CKD cohorts. Low eGFRs and high ACRs were associated with higher risks of AKI in individuals with or without diabetes and with or without hypertension. When compared to a common reference of eGFR of 80mL/min/1.73m(2) in nondiabetic patients, HRs for AKI were generally higher in diabetic patients at any level of eGFR. The same was true for diabetic patients at all levels of ACR compared with nondiabetic patients. The risk gradient for AKI with lower eGFRs was greater in those without diabetes than with diabetes, but similar with higher ACRs in those without versus with diabetes. Those with hypertension had a higher risk of AKI at eGFRs>60mL/min/1.73m(2) than those without hypertension. However, risk gradients for AKI with both lower eGFRs and higher ACRs were greater for those without than with hypertension., Limitations: AKI identified by diagnostic code., Conclusions: Lower eGFRs and higher ACRs are associated with higher risks of AKI among individuals with or without either diabetes or hypertension., (Copyright © 2015 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Insomnia is common in primary care. Cognitive behavioural therapy for insomnia (CBT-I) is effective but requires more time than is available in the general practice consultation. Sleep restriction is one behavioural component of CBT-I., Aim: To assess whether simplified sleep restriction (SSR) can be effective in improving sleep in primary insomnia., Design and Setting: Randomised controlled trial of patients in urban general practice settings in Auckland, New Zealand., Method: Adults with persistent primary insomnia and no mental health or significant comorbidity were eligible. Intervention patients received SSR instructions and sleep hygiene advice. Control patients received sleep hygiene advice alone. Primary outcomes included change in sleep quality at 6 months measured by the Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), and sleep efficiency (SE%). The proportion of participants reaching a predefined 'insomnia remission' treatment response was calculated., Results: Ninety-seven patients were randomised and 94 (97%) completed the study. At 6-month follow-up, SSR participants had improved PSQI scores (6.2 versus 8.4, P<0.001), ISI scores (8.6 versus 11.1, P = 0.001), actigraphy-assessed SE% (difference 2.2%, P = 0.006), and reduced fatigue (difference -2.3 units, P = 0.04), compared with controls. SSR produced higher rates of treatment response (67% [28 out of 42] versus 41% [20 out of 49]); number needed to treat = 4 (95% CI = 2.0 to 19.0). Controlling for age, sex, and severity of insomnia, the adjusted odds ratio for insomnia remission was 2.7 (95% CI = 1.1 to 6.5). There were no significant differences in other outcomes or adverse effects., Conclusion: SSR is an effective brief intervention in adults with primary insomnia and no comorbidities, suitable for use in general practice., (© British Journal of General Practice 2015.)

Aims: Type 2 diabetes is common and is associated with an approximate 80% increase in the rate of mortality. Management decisions may be assisted by an estimate of the patient's absolute risk of adverse outcomes, including death. This study aimed to derive a predictive risk model for all-cause mortality in type 2 diabetes., Methods: We used primary care data from a large national multi-ethnic cohort of patients with type 2 diabetes in New Zealand and linked mortality records to develop a predictive risk model for 5-year risk of mortality. We then validated this model using information from a separate cohort of patients with type 2 diabetes., Results: 26,864 people were included in the development cohort with a median follow up time of 9.1 years. We developed three models initially using demographic information and then progressively more clinical detail. The final model, which also included markers of renal disease, proved to give best prediction of all-cause mortality with a C-statistic of 0.80 in the development cohort and 0.79 in the validation cohort (7610 people) and was well calibrated. Ethnicity was a major factor with hazard ratios of 1.37 for indigenous Maori, 0.41 for East Asian and 0.55 for Indo Asian compared with European (P<0.001)., Conclusions: We have developed a model using information usually available in primary care that provides good assessment of patient's risk of death. Results are similar to models previously published from smaller cohorts in other countries and apply to a wider range of patient ethnic groups., (Copyright © 2015. Published by Elsevier Ireland Ltd.)

Objective: To determine the feasibility of implementing a large-scale primary care-based diabetes prevention trial., Methods: A feasibility cluster randomized controlled trial was conducted in British Columbia, Canada, amongst adults with prediabetes using the Facilitated Lifestyle Intervention Prescription (FLIP) vs. usual care. FLIP included lifestyle advice, a pedometer, and telephone support from a lifestyle facilitator for 6 months. Indicators of feasibility included recruitment rates of family practices, participants and facilitators, as well as feasibility and retention rates in the FLIP program and study protocols., Results: Six family practices participated; 59 patients were enrolled between October 2012 and March 2013. The trial protocol was acceptable to practices and participants and had a 95% participant retention rate over the 6 months (56/59). Adherence to the intervention was high (97%), with 34 of 35 patients continuing to receive telephone calls from the facilitator for 6 months. The mean cost of the intervention was C$144 per person. Compared with control, intervention participants significantly reduced weight by 3.2 kg (95% CI, 1.7 to 4.6); body mass index by 1.2 (95% CI, 0.7 to 1.7) and waist circumference by 3 cm (95% CI, 0.3 to 5.7)., Conclusions: It is feasible to implement FLIP and to conduct a trial to assess effectiveness. A larger trial with longer follow up to assess progression to diabetes is warranted., (Copyright © 2015 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.)

Aims: The aim of this study was to develop an evidence-based self-help website, Computer Assisted Learning for the Mind (CALM) designed to improve mental health amongst medical students; and to assess the proportion, demographics and mental health of students who chose to use the site., Methods: All 2nd and 3rd year medical students from one New Zealand university were invited to participate. Demographics and mental health scores of those accessing CALM were compared with those not accessing it. Outcome measures included depression (PHQ-9) and anxiety (GADS-7) scores recorded at baseline. Anonymous identifiers were used to track website use., Results: Baseline questionnaires were completed by 279/321 (87%) of eligible students. CALM was accessed by 80/321 (25%) of the students over a 5 week period. Those who accessed CALM and could be linked by unique identifier (n=49) had significantly higher anxiety scores (p=0.01) but not higher depression scores (p=0.067) at baseline, than those who did not access CALM (n=230). Of those students with both PHQ-9 scores and GAD-7 scores =10 (at risk of significant depression and anxiety) at baseline, 41% went on to access CALM., Conclusions: The CALM website was used by 25% of medical students, particularly those with poorer anxiety scores. Self-selection to a web-based resource may provide assistance to those most in need, but further research would be needed to assess effectiveness.

Introduction: Obesity and low levels of physical activity are increasing among Pacific and Maori adolescents in New Zealand., Aim: To assess the feasibility of an after-school exercise and lifestyle programme to improve cardiorespiratory fitness, health and usual activity in less-active Pacific and Maori adolescents over six weeks., Methods: Eighteen less-active secondary school students participated. The six-week programme included 3 x 1.5 hour exercise and healthy lifestyle sessions per week. Outcomes included estimated cardiorespiratory fitness (VO2max), insulin resistance (Homeostasis Model Assessment), physical activity, glycated haemoglobin (HbA1c), fasting plasma glucose, blood pressure, waist circumference and fasting lipids, measured at baseline and six weeks. Programme attendance and qualitative comments were also recorded. Student's t-tests were used., Results: Of the 18 students enrolled, 16 (89%) completed six-week follow-up, 14 (78%) were female, 13 (72%) were Pacific ethnicity and 5 (28%) were Maori . At baseline, mean age was 16.3 (standard deviation [SD] 1.0) years, body mass index (BMI) 35.2 (SD 6.7) kg/m2, VO2max 31.5 (SD 4.3) mL/kg/min, systolic blood pressure 125.0 (SD 12.9) mm Hg, HbA1c 39.9 (SD 3.8) mmol/mol, fasting serum insulin 28.3 (SD 27.8) μU/mL. At follow-up, improvements had occurred in VO2max (3.2 mL/kg/min; p=0.02), systolic blood pressure (-10.6 mm Hg; p=0.003), HbA1c (-1.1 mmol/mol; p=0.03) and weekly vigorous (4 hours, p=0.002) and moderate (2 hours, p=0.006) physical activity, although waist circumference increased (p=0.005). Programme attendance was over 50%. Comments were mostly positive., Discussion: The after-school exercise and lifestyle programme and study methods were feasible. Such programmes have the potential to improve health outcomes for Pacific and Maori adolescents.