UK Medical Cannabis Registry: Assessment of clinical outcomes in patients with insomnia.

INTRODUCTION: The primary aim of this study was to assess changes in sleep-specific health-related quality of life (HRQoL) for those prescribed cannabis-based medicinal products (CBMPs) for insomnia. METHODS: A case series of UK patients with insomnia was analyzed. Primary outcomes were changes in the Single-Item Sleep-Quality Scale (SQS), Generalized Anxiety Disorder-7 (GAD-7), and EQ-5D-5L at up to 6 months from baseline. Statistical significance was identified as a p value < .050. RESULTS: 61 patients were included in the analysis. There was an improvement in the SQS from baseline at 1, 3, and 6 months (p < .001). There were also improvements in the EQ-5D-5L Index value and GAD-7 at 1, 3, and 6 months (p < .050). There were 28 (45.9%) adverse events recorded by 8 patients (13.1%). There were no life-threatening/disabling adverse events. CONCLUSION: Patients with insomnia experienced an improvement in sleep quality following the initiation of CBMPs in this medium-term analysis. Fewer than 15% of participants reported one or more adverse events. However, due to the limitations of the study design, further investigation is required before definitive conclusions can be drawn on the efficacy of CBMPs in treating insomnia.

UK medical cannabis registry: assessment of clinical outcomes in patients with headache disorders.

OBJECTIVES: Headache disorders are a common cause of disability and reduced health-related quality of life globally. Growing evidence supports the use of cannabis-based medicinal products (CBMPs) for chronic pain; however, a paucity of research specifically focuses on CBMPs' efficacy and safety in headache disorders. This study aims to assess changes in validated patient-reported outcome measures (PROMs) in patients with headaches prescribed CBMPs and investigate the clinical safety in this population. METHODS: A case series of the UK Medical Cannabis Registry was conducted. Primary outcomes were changes from baseline in PROMs (Headache Impact Test-6 (HIT-6), Migraine Disability Assessment (MIDAS), EQ-5D-5L, Generalized Anxiety Disorder-7 (GAD-7) questionnaire and Single-Item Sleep Quality Scale (SQS)) at 1-, 3-, and 6-months follow-up. P-values <0.050 were deemed statistically significant. RESULTS: Ninety-seven patients were identified for inclusion. Improvements in HIT-6, MIDAS, EQ-5D-5L and SQS were observed at 1-, 3-, and 6-months (p < 0.005) follow-up. GAD-7 improved at 1- and 3-months (p < 0.050). Seventeen (17.5%) patients experienced a total of 113 (116.5%) adverse events. CONCLUSION: Improvements in headache/migraine-specific PROMs and general health-related quality of life were associated with the initiation of CBMPs in patients with headache disorders. Cautious interpretation of results is necessary, and randomized control trials are required to ascertain causality.

Economic analysis of the 'Take Charge' intervention for people following stroke: Results from a randomised trial.

OBJECTIVE: To undertake an economic analysis of the Take Charge intervention as part of the Taking Charge after Stroke (TaCAS) study. DESIGN: An open, parallel-group, randomised trial comparing active and control interventions with blinded outcome assessment. SETTING: Community. PARTICIPANTS: Adults (n = 400) discharged to community, non-institutional living following acute stroke. INTERVENTIONS: The Take Charge intervention, a strengths based, self-directed rehabilitation intervention, in two doses (one or two sessions), and a control intervention (no Take Charge sessions). MEASURES: The cost per quality-adjusted life year (QALY) saved for the period between randomisation (always post hospital discharge) and 12 months following acute stroke. QALYs were calculated from the EuroQol-5D-5L. Costs of stroke-related and non-health care were obtained by questionnaire, hospital records and the New Zealand Ministry of Health. RESULTS: One-year post hospital discharge cost of care was mean (95% CI) $US4706 (3758-6014) for the Take Charge intervention group and $6118 (4350-8005) for control, mean (95% CI) difference $ -1412 (-3553 to +729). Health utility scores were mean (95% CI) 0.75 (0.73-0.77) for Take Charge and 0.71 (0.67-0.75) for control, mean (95% CI) difference 0.04 (0.0-0.08). Cost per QALY gained for the Take Charge intervention was $US -35,296 (=£ -25,524, € -30,019). Sensitivity analyses confirm Take Charge is cost-effective, even at a very low willingness-to-pay threshold. With a threshold of $US5000 per QALY, the probability that Take Charge is cost-effective is 99%. CONCLUSION: Take Charge is cost-effective and probably cost saving.

Food 4 Health - He Oranga Kai: Assessing the efficacy, acceptability and economic implications of Lactobacillus rhamnosus HN001 and ß-glucan to improve glycated haemoglobin, metabolic health, and general well-being in adults with pre-diabetes: study protocol for a 2 × 2 factorial design, parallel group, placebo-controlled randomized controlled trial, with embedded qualitative study and economic analysis.

BACKGROUND: The rates of pre-diabetes and type 2 diabetes mellitus are increasing worldwide, producing significant burdens for individuals, families, and healthcare systems. In New Zealand, type 2 diabetes mellitus and pre-diabetes disproportionally affect Maori, Pacific, and South Asian peoples. This research evaluates the efficacy, acceptability, and economic impact of a probiotic capsule and a prebiotic cereal intervention in adults with pre-diabetes on metabolic and mental health and well-being outcomes. METHODS: Eligible adults (n = 152) aged 18-80 years with pre-diabetes (glycated haemoglobin 41-49 mmol/mol) will be enrolled in a 2 × 2 factorial design, randomised, parallel-group, placebo-controlled trial. Computer-generated block randomization will be performed independently. Interventions are capsulated Lactobacillus rhamnosus HN001 (6 × 109 colony-forming units/day) (A) and cereal containing 4 g ß-glucan (B), placebo capsules (O1), and calorie-matched control cereal (O2). Eligible participants will receive 6 months intervention in the following groups: AB, AO1, BO2, and O1O2. The primary outcome is glycated haemoglobin after 6 months. Follow-up at 9 months will assess the durability of response. Secondary outcomes are glycated haemoglobin after 3 and 9 months, fasting glucose, insulin resistance, blood pressure, body weight, body mass index, and blood lipid levels. General well-being and quality of life will be measured by the Short-Form Health Survey 36 and Depression Anxiety Stress Scale 21 at 6 and 9 months. Outcome assessors will be blind to capsule allocation. An accompanying qualitative study will include 24 face-to-face semistructured interviews with an ethnically balanced sample from the ß-glucan arms at 2 months, participant focus groups at 6 months, and three health professional focus groups. These will explore how interventions are adopted, their acceptability, and elicit factors that may support the uptake of interventions. A simulation model of the pre-diabetic New Zealand population will be used to estimate the likely impact in quality-adjusted life years and health system costs of the interventions if rolled out in New Zealand. DISCUSSION: This study will examine the efficacy of interventions in a population with pre-diabetes. Qualitative components provide rich description of views on the interventions. When combined with the economic analysis, the study will provide insights into how to translate the interventions into practice. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12617000990325. Prospectively registered on 10 July 2017.

Prescribing by nurse practitioners: Insights from a New Zealand study.

BACKGROUND AND PURPOSE: Nurse practitioners (NPs) in New Zealand have been able to prescribe medicines since 2001; however, little is known about their prescribing practice. This study describes the NPs who prescribe community-dispensed medicines, the patients, and identifies the most frequently prescribed medications. METHODS: A retrospective search of the Ministry of Health pharmaceutical collection was completed from 2013 to 2015. NP registration number, patient age, gender, deprivation index, and the name and date of dispensed medication, including the New Zealand pharmaceutical schedule therapeutic group, were identified. CONCLUSIONS: NPs prescribe a broad range of medications across all therapeutic groups with antibacterial and analgesics being the most commonly prescribed medicines. This is comparable to all prescribers in New Zealand and NPs in Australia. The majority of patients lived in the more deprived areas of New Zealand indicating that NPs are working in areas of greater health need. IMPLICATIONS FOR PRACTICE: The majority of NPs registered in New Zealand prescribe medicines. Those in primary care prescribe the most medications. NPs prescribe a broad range of medicines across all drug therapeutic groups. The patients seen by NPs often live in the most deprived areas of New Zealand. Understanding prescribing patterns will help to inform curricular development and continuing education programs for NPs.

Validation of a classification system for causes of death in critical care: an assessment of inter-rater reliability.

OBJECTIVE: Trials in critical care have previously used unvalidated systems to classify cause of death. We aimed to provide initial validation of a method to classify cause of death in intensive care unit patients. DESIGN, SETTING AND PARTICIPANTS: One hundred case scenarios of patients who died in an ICU were presented online to raters, who were asked to select a proximate and an underlying cause of death for each, using the ICU Deaths Classification and Reason (ICU-DECLARE) system. We evaluated two methods of categorising proximate cause of death (designated Lists A and B) and one method of categorising underlying cause of death. Raters were ICU specialists and research coordinators from Australia, New Zealand and the United Kingdom. MAIN OUTCOME MEASURES: Inter-rater reliability, as measured by the Fleiss multirater kappa, and the median proportion of raters choosing the most likely diagnosis (defined as the most popular classification choice in each case). RESULTS: Across all raters and cases, for proximate cause of death List A, kappa was 0.54 (95% CI, 0.49-0.60), and for proximate cause of death List B, kappa was 0.58 (95% CI, 0.53-0.63). For the underlying cause of death, kappa was 0.48 (95% CI, 0.44-0.53). The median proportion of raters choosing the most likely diagnosis for proximate cause of death, List A, was 77.5% (interquartile range [IQR], 60.0%-93.8%), and the median proportion choosing the most likely diagnosis for proximate cause of death, List B, was 82.5% (IQR, 60.0%-92.5%). The median proportion choosing the most likely diagnosis for underlying cause was 65.0% (IQR, 50.0%-81.3%). Kappa and median agreement were similar between countries. ICU specialists showed higher kappa and median agreement than research coordinators. CONCLUSIONS: The ICU-DECLARE system allowed ICU doctors to classify the proximate cause of death of patients who died in the ICU with substantial reliability.

Cluster randomized controlled trial of TIA electronic decision support in primary care.

OBJECTIVE: To test if TIA/stroke electronic decision support in primary care improves management. METHODS: Multicenter, single-blind, parallel-group, cluster randomized, controlled trial comparing TIA/stroke electronic decision support guided management with usual care. Main outcomes were guideline adherence and 90-day stroke risk. Secondary outcomes were cerebrovascular/vascular/death/adverse events, cost, and user feedback. Main analysis was logistic regression with a normal random effect for clusters using a generalized linear mixed model. RESULTS: Twenty-nine clinics were randomized to intervention, 27 to control, recruiting 172 and 119 eligible patients. More intervention patients received guideline-adherent care (131/172; 76.2%) than control patients (49/119; 41.2%) (adjusted odds ratio [OR] 4.57; 95% confidence interval [CI] 2.39-8.71; p < 0.001). Ninety-day stroke occurred in 2/172 (1.2%) intervention and 5/119 (4.2%) control patients (OR 0.27; 95% CI 0.05-1.41; p = 0.098). Ninety-day TIA or stroke occurrence was lower in the intervention group, 4/172 (2.3%) compared to 10/119 (8.5%) control (adjusted OR 0.26; 95% CI 0.70-0.97; p = 0.045). Fewer vascular events/deaths occurred in intervention, 6/172 (3.5%), than in control patients, 14/119 (11.9%) (adjusted OR 0.27; 95% CI 0.09-0.78; p = 0.016). Treatment cost ratio of 0.65 (95% CI 0.47-0.91; p = 0.013) favored the intervention without increased adverse events. Clinician feedback was positive. CONCLUSION: Primary care use of the TIA/stroke electronic decision support tool improves guideline adherence, safely reduces treatment cost, achieves positive user feedback, and may reduce cerebrovascular and vascular event risk following TIA/stroke. CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that a primary care electronic decision support tool improves guideline adherence and might reduce 90-day stroke risk.

An assessment of the Hua Oranga outcome instrument and comparison to other outcome measures in an intervention study with Maori and Pacific people following stroke.

AIM: 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. METHODS: 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. RESULTS: 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'. CONCLUSION: 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.

Efficacy and safety of a TIA/stroke electronic support tool (FASTEST) trial: study protocol.

BACKGROUND: Strokes are a common cause of adult disability and mortality worldwide. Transient ischaemic attacks (TIA) are associated with a high risk of subsequent stroke, and rapid intervention has the potential to reduce stroke burden. This study will assess a novel electronic decision support (EDS) tool to allow general practitioners (GPs) to implement evidence-based care rapidly without full reliance on specialists. METHODS/DESIGN: This is a cluster randomized controlled trial comparing TIA/stroke management of GPs with access to the EDS tool versus usual care. The intervention period is 12 months with a 3-month follow-up period for individual patients. Primary outcomes consist of stroke within 90 days of presenting event and adherence to the New Zealand national TIA guideline. DISCUSSION: A positive study will provide strong evidence for widespread implementation of this tool in practice and has the potential to improve key outcomes for patients and reduce the burden of stroke. TRIAL REGISTRATION: Australia New Zealand Clinical Trials Registry ACTRN12611000792921.

Design, objectives, execution and reporting of published open-label extension studies.

RATIONALE, AIMS AND OBJECTIVES: Open-label extension (OLE) studies following blinded randomized controlled trials (RCTs) of pharmaceuticals are increasingly being carried out but do not conform to regulatory standards and questions surround the validity of their evidence. OLE studies are usually discussed as a homogenous group, yet substantial differences in study design still meet the definition of an OLE. We describe published papers reporting OLE studies focussing on stated objectives, design, conduct and reporting. METHOD: A search of Embase and Medline databases for 1996 to July 2008 revealed 268 papers reporting OLE studies that met our eligibility criteria. A random sample of 50 was selected for detailed review. RESULTS: Over 80% of the studies had efficacy stated as an objective. The most common methods of allocation at the start of the OLE were for all RCT participants to switch to one active treatment or for only participants on the new drug to continue, but in three studies all participants were re-randomized at the start of the OLE. Eligibility criteria and other selection factors resulted in on average of 74% of participants in the preceding RCT(s) enrolling in the OLE and only 57% completed it. CONCLUSIONS: Published OLE studies do not form a homogenous group with respect to design or retention of participants, and thus the validity of evidence from an OLE should be judged on an individual basis. The term 'open label' suggests bias through lack of blinding, but slippage in relation to the sample randomized in the preceding RCT may be the more important threat to validity.

Taking charge after stroke: promoting self-directed rehabilitation to improve quality of life--a randomized controlled trial.

OBJECTIVE: Few community interventions following stroke enhance activity, participation or quality of life. We tested two novel community interventions designed to promote self-directed rehabilitation following stroke. DESIGN: This was a randomized, controlled parallel group 2×2 trial. SETTING: Community. PARTICIPANTS: Maori and Pacific New Zealanders, >15 years old, randomized within three months of a new stroke. INTERVENTIONS: A DVD of four inspirational stories by Maori and Pacific people with stroke and a 'Take Charge Session'--a single structured risk factor and activities of daily living assessment, designed to facilitate self-directed rehabilitation. MAIN MEASURES: Primary outcomes were Health-related Quality of Life (Physical Component Summary (PCS) and Mental Component Summary (MCS) scores of the Short Form 36 (SF-36)) 12 months from randomization. Secondary outcomes were Barthel Index, Frenchay Activities Index, Carer Strain Index and modified Rankin score. RESULTS: One hundred and seventy-two people were randomized with 139 (80.8%) followed up at 12 months post randomization. The effect of the Take Charge Session on SF-36 PCS at 12 months was 6.0 (95% confidence interval (CI) 2.0 to 10.0) and of the DVD was 0.9 (95% CI -3.1 to 4.9). Participants allocated to the Take Charge Session were less likely to have a modified Rankin score of >2 (odds ratio (OR) 0.42, 95% CI 0.2 to 0.89) and their carers had lower (better) Carer Strain Index scores (-1.5, 95% CI -2.8 to -0.1). CONCLUSION: A simple, low-cost intervention in the community phase of stroke recovery aiming to promote self-directed rehabilitation improved outcomes.

International medical graduates' training needs: perceptions of New Zealand hospital staff.

OBJECTIVE: To determine the opinion of New Zealand doctors and nurses on the possible training needs of international medical graduates (IMGS) in New Zealand hospitals. DESIGN: A postal questionnaire sent to hospital doctors and nurses. METHODS: All doctors working at Wellington, Kenepuru, and Hutt Hospitals in the greater Wellington region, and nurses working in acute medical wards at the same hospitals, were asked to complete a questionnaire based on the Northern Clinical Training Network and Capital Coast District Health Board resident medical officer assessment forms regarding an overseas-trained doctor they had worked with in the last year. RESULTS: The response rate for the doctor's questionnaires was 68/174 (39.1%), with 51 of these from New Zealand doctors rating an international medical graduate. The response rate for the nurses was 58/60 (96.7%). Areas where the median score of the questionnaire was unsatisfactory (less than three out of five on an ordinal scale rating performance) were clinical documentation; communication with patients, families, and other health professionals; knowledge of hospital policies and procedures, and medicolegal matters; and some aspects of patient management. There was no difference in median ratings between doctors and nurses. CONCLUSIONS: More specific training may improve the performance of overseas-trained doctors in the New Zealand health system. A further study of the perceived needs of the overseas-trained doctors themselves may be useful.

Nocturia in adults: draft New Zealand guidelines for its assessment and management in primary care.

Nocturia is a common bothersome condition. An ad hoc group of interested clinicians from a variety of backgrounds has developed draft guidelines for the assessment and management of this condition in primary care in New Zealand. The guidelines propose four steps in the assessment and management: clinical evaluation; simple investigations; assignment of a provisional diagnosis; and management based on the provisional diagnosis. For nocturnal polyuria-associated nocturia, the draft guidelines recommend that: lifestyle measures should be used as part of the management; if a patient complaining of nocturia has other features of overactive bladder, then bladder retraining and/or anticholinergics can be used; hypnosedatives should not be used to treat nocturia in older adults because of the increased risk of falls; loop diuretics given in the afternoon should be considered for the treatment; and desmopressin can be considered in the management of nocturnal polyuria associated nocturia but that it should be used cautiously in people aged over 65 because of the risk of hyponatraemia. A draft algorithm based on international guidelines is presented.

Risk factors for entry into residential care after a support-needs assessment.

AIMS: To establish the influence of risk factors derived from the national 'Support Needs Assessment Form' for entry into residential care in New Zealand. METHODS: Using a retrospective cohort design, data was obtained for assessments of people aged over 65 years over a 12-month interval (August 2001 to August 2002) from an administrative database developed by the Needs Assessment and Service Co-ordination Service for Wellington, New Zealand. The risk factors for entry into residential care were examined by logistic regression. RESULTS: 2060 assessments were carried out over this period for people were aged over 65 years; 67.9% were female. The median age was 83 years, inter-quartile range 78 to 88 years. For 33.4% of people, residential care was recommended. For those aged 80 years or older, the relative risk of residential care was 2.95 (95% CI: 2.27 to 3.82) if continence problems were present, and 3.75 (95% CI: 2.99 to 4.73) for those aged 80 years or younger if continence problems were present. For those with mobility problems who had cognitive impairment the relative risk of residential care was 2.95 (95% CI: 2.25 to 3.87), and 1.77 (95% CI: 1.35 to 2.33) if there were no mobility problems. CONCLUSIONS: All of older age, continence problems, mobility problems and dementia predicted residential care after assessment. The effect of continence was more prominent for those aged under 80 years of age. The effect of dementia was more prominent for those with mobility problems. Intervention for continence problems and mobility problems has the potential to reduce the use of residential care.

Avoiding pitfalls of correlation coefficients in the assessment of measurement instruments in rehabilitation research.

OBJECTIVE: To provide a practical guide on how to avoid the pitfalls of correlated correlation coefficients when comparing multiple instruments in rehabilitation research. DESIGN: An observational study comparing a number of instruments measuring quality of life (QoL) compared with an external criterion. SUBJECTS: Sixty-eight patients admitted to a rheumatology ward for intensive treatment of rheumatoid arthritis. METHODS: Patients completed three new (QoL) instruments and an established instrument before and after intensive treatment for rheumatoid arthritis. MAIN OUTCOME MEASURES: Correlation coefficients together with their confidence intervals and a test for the difference between a set of correlated correlation coefficients for the change in the EuroQoL Quality of Life scale (EuroQoL), the World Health Organization Quality Of Life-Abbreviated version (WHOQoL-BREF) and the Quality of Life Profile (QLP) against the Stanford Health Assessment Questionnaire (HAQ). RESULTS: Although the range of correlation between the new instruments and the external criterion was between -0.37 and -0.59 and suggested that one new instrument was far more responsive than the others,; an omnibus test for an overall difference could find no difference in responsiveness. CONCLUSIONS: It is conceptually simple to use correlation coefficients to assess the properties of multiple instruments measured on the same subjects to find a 'best' instrument. However, proper interpretation of results when correlated correlation coefficients are calculated is complex. We recommend analysis includes: (a) that simple plots of the pairs of analysed variables are shown, (b) that simple linear model-fitting statistics, e.g., the R-squared statistic, accompany the plots, (c) that confidence intervals are presented for correlation coefficients, (d) that an omnibus statistical test for the difference between correlated correlation coefficients is presented, and (e) that normal model assumptions are tested.

Duration of condition is unrelated to health-state valuation on the EuroQoL.

OBJECTIVE: To determine whether health valuations, such as those used in economic evaluation, are affected by duration of a health condition. People with disabling health conditions tend to value health more highly than members of the general population, and one explanation for this is that over time their experience of living with a disabling illness changes the way in which they value health. If this is so, a relationship between the duration of an individual's disabling health condition and the valuation they assign to their health-state might reasonably be expected. DESIGN: A postal survey using the EuroQoL (EQ-5D) instrument to collect descriptions and valuations for health from people who reported a diagnosis of either stroke or multiple sclerosis. Contact with participants was made through national support organizations and questionnaires were returned by mail. RESULTS: Eight hundred and ninety-four people completed the survey. One hundred (11 %) had one health-state indicating moderate problems in all five dimensions of the EQ-5D descriptive profile. For people with this health-state, analysis of covariance showed no relationship between valuation of health-state and time from onset of illness (F = 0.38, p = 0.54). This finding applied irrespective of the diagnosis, and for some other less frequently reported health-states. CONCLUSION: Clinical experience suggests that over time people adapt to long-term disability. However we found no evidence to support the proposition that higher health-state valuations by people with disabling conditions are explained by the actual duration of their condition.

The relationship between FEV1 and PEF in the assessment of the severity of airways obstruction.

OBJECTIVE: International consensus guidelines suggest that in asthma and chronic obstructive pulmonary disease (COPD), measurements of FEV1 and PEF are equivalent in the assessment of the degree of airflow obstruction when expressed as the per cent of predicted values. METHODOLOGY: In this retrospective study, 2,587 paired measurements of PEF and FEV1 performed by 101 adult patients with asthma (n = 56) and COPD (n = 45) attending an outpatient chest clinic were obtained. The mean differences between FEV1 and PEF measurements when expressed as the percentage of predicted values was determined. The level of agreement between the two measurements in the classification of asthma severity (life-threatening, severe, moderate and mild asthma determined by PEF or FEV1 measurements of <30%, 30-60%, 60-80%, and >80% of the predicted values, respectively) was determined. RESULTS: There was considerable variability between measurements of FEV1 and PEF when expressed as % predicted values. In both asthma and COPD, the FEV1% predicted was smaller than the PEF % predicted, with the mean difference being -10.9% (95% CI, -12.8% to -8.9%) with limits of agreement of -35.4% to +13.6%. The weighted Kappa statistic for agreement was 0.59 (95% CI, 48-70%) in the classification of the severity of airflow obstruction. CONCLUSION: When expressed as percentage of predicted values, PEF and FEV1 values are not equivalent. We recommend that guidelines be modified to state that across the spectrum of the severity of airflow obstruction there is considerable variability between measurements of FEV1 and PEF when expressed as % predicted such that the FEV1 may be as much as 35% lower or up to 15% higher than the PEF for patients with obstructive lung diseases.

The accuracy of clinical assessment of bladder volume.

OBJECTIVE: To determine the usefulness of physical examination in detecting elevated bladder volume. DESIGN: A blinded study of clinical examination by physicians to detect elevated bladder volumes compared with a criterion standard (ultrasonic bladder volume measurement). SETTING: Outpatient department of a general hospital in New Zealand. PARTICIPANTS: Sixteen healthy adult volunteers (age range, 21-37 y; body mass index range, 22.9-37.2 kg/m(2)) and 8 qualified resident physicians with 2 to 6 years of clinical experience. INTERVENTION: Elevated bladder volumes were achieved by randomly allocating the volunteers to void or not to void before the clinical examination. MAIN OUTCOME MEASURE: Clinical examination of the abdomen by abdominal palpation and suprapubic percussion, compared with portable ultrasound findings, to determine whether a healthy adult has a full bladder. RESULTS: For bladder volumes of 400 to 600 mL, physical examination to detect a full bladder was 81% sensitive (95% confidence interval [CI], 54-96), 50% specific (95% CI, 39-68), and 55% accurate (95% CI, 45-65). The likelihood ratio for a positive finding on physical examination was 1.62 (95% CI, 1.17-2.24). CONCLUSION: Physical examination of the abdomen by relatively junior physicians is unreliable in detecting bladder volumes between 400 and 600 mL in healthy volunteers.

The comparability of resource utilisation for Europeans and non-Europeans following stroke in New Zealand.

AIMS: We sought to explore resource use both in hospital and the community twelve months after hospital discharge for patients of different ethnicity admitted to hospital with acute stroke. METHODS: Resource utilisation data were collected for consecutive patients admitted to each of three general hospitals in the Wellington region over a nine month period. Patients were interviewed, where possible, at three, six and twelve months after hospital discharge. Ethnicity was determined by self report. RESULTS: Non-Europeans had longer hospital stays than Europeans (median 36 days vs 18 days, p = 0.01). Contact with rehabilitation professionals in the community was low for all groups with no significant differences between Europeans and non-Europeans. For the entire cohort, spending on institutional care was around ten times higher than spending on community rehabilitation in the first twelve months following stroke. CONCLUSIONS: Differences in hospital stay after stroke may reflect problems of access to inpatient rehabilitation services for younger people and not relate directly to the ethnicity of the patient. With the projected increasing proportion of Maori and Pacific people in the population, combined with the aging of that population, health policy-makers need to consider the implications of differences in resource utilisation for different ethnic groups in New Zealand. How to manage all the available resources for people with stroke to maximise outcome remains an important issue for health funders.