Which anticholinergic is best for people with overactive bladders? A network meta-analysis.

AIM: To carry out a network meta-analysis of randomised controlled trials (RCTs) of anticholinergic drug treatment for people with overactive bladders. METHODS: Comprehensive searches for relevant RCTs were carried out starting with RCTs included in previous systematic reviews with the last search in February 2017. Searches included terms for the anticholinergic drugs tolterodine, oxybutynin, trospium, propiverine, solifenacin, darifenacin, imidafenacin, and fesoterodine. Data was extracted from the systematic reviews or reports of studies for cure or improvement, voids per 24 hr, leakage episodes per 24 hr and dry mouth. Data was analysed using frequentist network meta-analysis. RESULTS: 128 studies were found. There was no clearly best treatment for cure or improvement. The differences between treatments for voids and leakages were small and unlikely to be of clinical importance. Transdermally delivered oxybutynin was clearly the best treatment for dry mouth but was still worse than placebo. CONCLUSIONS: All the anticholinergic drugs were better than placebo but apart from dry mouth were similar in effect. Transdermal oxybutynin caused less dry mouth than the other treatments, so may be worth considering as the first treatment.

Delivery mode, levator avulsion and obstetric anal sphincter injury: A cross-sectional study 20 years after childbirth.

BACKGROUND: Levator ani muscle (LAM) and anal sphincter injuries are common after vaginal birth and are associated with pelvic organ prolapse and anal incontinence. AIMS: Our objective was to investigate long-term association between delivery mode, LAM avulsion and obstetric anal sphincter injuries (OASIS) in women at least 20 years after their first birth. METHODS: All women recruited at 'index birth' of the Dunedin (New Zealand) arm of ProLong (PROlapse and incontinence LONG-term research) Study, were invited to have translabial and transperineal ultrasound assessment of LAM and anal sphincters. Post-processing analysis of imaging data was performed blinded against delivery data. Statistical analysis was performed using the χ2 test and results are expressed as odds ratios (OR). RESULTS: Of the initial 1250 participants, 196 women returned for examination. Mean age was 50.8 years with a mean body mass index of 27.6 and median parity was three. They were seen on average 23 years after their first delivery. Four data sets were unavailable and one declined ultrasound assessment, leaving 191 for analysis. LAM avulsion was diagnosed in 29 (15.2%), and 24 women (12.6%) had significant anal sphincter defect. LAM avulsion was associated with forceps delivery (OR 2.45, 95% CI 1.04-5.80, P = 0.041). Forceps conveyed a greater risk of OASIS (21%) compared to a spontaneous vaginal delivery (11%) but did not reach statistical significance. CONCLUSIONS: Forceps delivery is associated with long-term injurious effect on pelvic floor structures. Discussions of the long-term negative impact of pelvic floor structures and their functions are necessary to achieve an informed consent toward an operative vaginal delivery.

Pelvic floor muscle training for secondary prevention of pelvic organ prolapse (PREVPROL): a multicentre randomised controlled trial.

BACKGROUND: Pelvic floor muscle training can reduce prolapse severity and symptoms in women seeking treatment. We aimed to assess whether this intervention could also be effective in secondary prevention of prolapse and the need for future treatment. METHODS: We did this multicentre, parallel-group, randomised controlled trial at three centres in New Zealand and the UK. Women from a longitudinal study of pelvic floor function after childbirth were potentially eligible for inclusion. Women of any age who had stage 1-3 prolapse, but had not sought treatment, were randomly assigned (1:1), via remote computer allocation, to receive either one-to-one pelvic floor muscle training (five physiotherapy appointments over 16 weeks, and annual review) plus Pilates-based pelvic floor muscle training classes and a DVD for home use (intervention group), or a prolapse lifestyle advice leaflet (control group). Randomisation was minimised by centre, parity (three or less vs more than three deliveries), prolapse stage (above the hymen vs at or beyond the hymen), and delivery method (any vaginal vs all caesarean sections). Women and intervention physiotherapists could not be masked to group allocation, but allocation was masked from data entry researchers and from the trial statistician until after database lock. The primary outcome was self-reported prolapse symptoms (Pelvic Organ Prolapse Symptom Score [POP-SS]) at 2 years. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01171846. FINDINGS: Between Dec 21, 2008, and Feb 24, 2010, in New Zealand, and Oct 27, 2010, and Sept 5, 2011, in the UK, we randomly assigned 414 women to the intervention group (n=207) or the control group (n=207). One participant in each group was excluded after randomisation, leaving 412 women for analysis. At baseline, 399 (97%) women had prolapse above or at the level of the hymen. The mean POP-SS score at 2 years was 3·2 (SD 3·4) in the intervention group versus 4·2 (SD 4·4) in the control group (adjusted mean difference -1·01, 95% CI -1·70 to -0·33; p=0·004). The mean symptom score stayed similar across time points in the control group, but decreased in the intervention group. Three adverse events were reported, all of which were in the intervention group (one women had a fall, one woman had a pain in her tail bone, and one woman had chest pain and shortness of breath). INTERPRETATION: Our study shows that pelvic floor muscle training leads to a small, but probably important, reduction in prolapse symptoms. This finding will be important for women and caregivers considering preventive strategies. FUNDING: Wellbeing of Women charity, the New Zealand Continence Association, and the Dean's Bequest Fund of Dunedin School of Medicine.

It is the first birth that does the damage: a cross-sectional study 20 years after delivery.

INTRODUCTION AND HYPOTHESIS: Levator ani muscle (LAM) and anal sphincter tears are common after vaginal birth and are associated with female pelvic organ prolapse and anal incontinence. The impact of subsequent births on LAM and external anal sphincter (EAS) integrity is less well defined. The objective of this study was to determine the prevalence of LAM and EAS trauma in primiparous (VP1) and multiparous (VP2+) women who had delivered vaginally to assess if there were differences between the two groups. The null hypothesis was: there is no significant difference in the prevalence of LAM and EAS trauma between the two groups. METHODS: This was a cross-sectional study involving 195 women, participants of the Dunedin arm of the ProLong study (PROlapse and incontinence LONG-term research study) seen 20 years after their index birth. Assessment included a standardized questionnaire, ICS POP-Q and 4D translabial ultrasound. Post-imaging analysis of LAM and EAS integrity was undertaken blinded against other data. Statistical analysis was performed using Fisher's exact test and results were expressed as odds ratios (OR). RESULTS: LAM avulsion and EAS defects were diagnosed in 31 (16%) and 24 (12.4%) women respectively. No significant difference in the prevalence of levator avulsion and EAS defects between primiparous (VP1) and multiparous (VP2+) women who had delivered vaginally (OR 1.9, 95% CI 0.72-5.01, p = 0.26) and (OR 1.2, 95% CI 0.4-3.8, p = 0.76) respectively. CONCLUSIONS: Most LAM avulsions and EAS defects seem to be caused by the first vaginal birth. Subsequent vaginal deliveries after the first were unlikely to cause further LAM trauma.

Levator Avulsion Is Associated With Pelvic Organ Prolapse 23 Years After the First Childbirth.

OBJECTIVES: This study aimed to ascertain the association between levator avulsion and pelvic organ prolapse (POP). METHODS: This was a cross-sectional study involving 195 women enrolled in a longitudinal cohort study and seen 20 years after an index birth. All had a standardized patient-administered questionnaire, the International Continence Society Pelvic Organ Prolapse Quantification assessment and 4D translabial ultrasound. Main outcome measures were objective POP clinically and on translabial ultrasound. Postimaging assessment of levator integrity and sonographically determined pelvic organ descent was done blinded against other data. RESULTS: Of 195 women who were seen a mean of 23 (range, 19.4-46.2) years after their first birth, one declined ultrasound assessment and was excluded, leaving 194. Mean age was 50.2 (range 36.9-66.5) years with a mean body mass index (BMI) of 27.6 (range, 18.3-54.3) kg/m2 . Median parity was 3 (range 1-14). Ninety-one percent (n = 176) had delivered vaginally. Eighteen percent (n = 34) were symptomatic of prolapse. Clinically, 36% (n = 69) had significant POP. Levator avulsion was diagnosed in 16% (n = 31). Mean levator avulsion defect score was 2.2 (range, 0-12). On univariate analysis, levator avulsion and levator avulsion defect score were associated with clinically and sonographically significant POP, that is, odds ratio 2.6 (1.2-5.7), P = .01; and odds ratio 3.3 (1.4-7.7); P = .003, respectively; Ba (P < .001); bladder (P < .001); uterine (P < .001) and rectal ampulla (P = .009) descent, but not POP symptoms, C, and Bp. Multivariate analysis controlling for potential confounders confirmed our findings. CONCLUSIONS: Levator avulsion is associated with female pelvic organ prolapse, especially of the anterior and central compartments. This association may become stronger with aging.

Development of a core set of outcome measures for OAB treatment.

INTRODUCTION AND HYPOTHESIS: Standardized measures enable the comparison of outcomes across providers and treatments giving valuable information for improving care quality and efficacy. The aim of this project was to define a minimum standard set of outcome measures and case-mix factors for evaluating the care of patients with overactive bladder (OAB). METHODS: The International Consortium for Health Outcomes Measurement (ICHOM) convened an international working group (WG) of leading clinicians and patients to engage in a structured method for developing a core outcome set. Consensus was determined by a modified Delphi process, and discussions were supported by both literature review and patient input. RESULTS: The standard set measures outcomes of care for adults seeking treatment for OAB, excluding residents of long-term care facilities. The WG focused on treatment outcomes identified as most important key outcome domains to patients: symptom burden and bother, physical functioning, emotional health, impact of symptoms and treatment on quality of life, and success of treatment. Demographic information and case-mix factors that may affect these outcomes were also included. CONCLUSIONS: The standardized outcome set for evaluating clinical care is appropriate for use by all health providers caring for patients with OAB, regardless of specialty or geographic location, and provides key data for quality improvement activities and research.

Spiritual beliefs, practices, and needs at the end of life: Results from a New Zealand national hospice study.

OBJECTIVE: International studies have shown that patients want their spiritual needs attended to at the end of life. The present authors developed a project to investigate people's understanding of spirituality and spiritual care practices in New Zealand (NZ) hospices. METHOD: A mixed-methods approach included 52 semistructured interviews and a survey of 642 patients, family members, and staff from 25 (78%) of NZ's hospices. We employed a generic qualitative design and analysis to capture the experiences and understandings of participants' spirituality and spiritual care, while a cross-sectional survey yielded population level information. RESULTS: Our findings suggest that spirituality is broadly understood and considered important for all three of the populations studied. The patient and family populations had high spiritual needs that included a search for (1) meaning, (2) peace of mind, and (3) a degree of certainty in an uncertain world. The healthcare professionals in the hospices surveyed seldom explicitly met the needs of patients and families. Staff had spiritual needs, but organizational support was sometimes lacking in attending to these needs. SIGNIFICANCE OF RESULTS: As a result of our study, which was the first nationwide study in NZ to examine spirituality in hospice care, Hospice New Zealand has developed a spirituality professional development program. Given that spirituality was found to be important to the majority of our participants, it is hoped that the adoption of such an approach will impact on spiritual care for patients and families in NZ hospices.

High-Dose Monthly Maternal Cholecalciferol Supplementation during Breastfeeding Affects Maternal and Infant Vitamin D Status at 5 Months Postpartum: A Randomized Controlled Trial.

BACKGROUND: Many countries recommend daily infant vitamin D supplementation during breastfeeding, but compliance is often poor. A monthly, high-dose maternal regimen may offer an alternative strategy, but its efficacy is unknown. OBJECTIVE: The objective of the study was to determine the effect of 2 different monthly maternal doses of cholecalciferol on maternal and infant 25-hydroxyvitamin D [25(OH)D] status during the first 5 mo of breastfeeding. METHODS: With the use of a randomized, double-blind, placebo-controlled design, women who were planning to exclusively breastfeed for 6 mo (n = 90; mean age: 32.1 y; 71% exclusively breastfeeding at week 20) were randomly assigned to receive either cholecalciferol (50,000 or 100,000 IU) or a placebo monthly from week 4 to week 20 postpartum. The treatment effects relative to placebo were estimated as changes in maternal and infant serum 25(OH)D from baseline to week 20 postpartum by using a linear fixed-effects regression model. Additional secondary analyses, adjusted for potential confounders such as season of birth, vitamin D-fortified formula intake, and infant or maternal skin color, were also conducted. RESULTS: After 16 wk of supplementation, changes in maternal serum 25(OH)D were significantly higher in the 50,000-IU/mo (12.8 nmol/L; 95% CI: 0.4, 25.2 nmol/L) and 100,000-IU/mo (21.5 nmol/L; 95% CI: 9.2, 33.8 nmol/L) groups than in the placebo group (P = 0.43 and P < 0.001, respectively). For infants, the unadjusted mean changes in serum 25(OH)D were 4.5 nmol/L (95% CI: -16.2, 25.0 nmol/L) for the 50,000-IU/mo group and 15.8 nmol/L (95% CI: -4.7, 36.4 nmol/L) for the 100,000-IU/mo group, but the changes did not differ from the placebo reference group. However, after adjustment for season of birth, vitamin D-fortified formula intake, and infant skin color, the mean change effect size for the 100,000-IU/mo group was 19.1 nmol/L (95% CI: 2.5, 35.6 nmol/L; P = 0.025) higher than that in the placebo group. CONCLUSIONS: Maternal cholecalciferol supplementation at a dose of 100,000 IU/mo during the first 5 mo of breastfeeding potentially benefits infant vitamin D status. Further studies are required to determine optimum dose and dosing frequency. This trial was registered at www.anzctr.org.au as ACTRN12611000108910.

Comparative efficacy and acceptability of combined antipsychotics and mood stabilizers versus individual drug classes for acute mania: Network meta-analysis.

OBJECTIVES: Recent network meta-analyses of drug treatments for acute mania have only evaluated the efficacy and acceptability of individual drug treatments. The relative efficacy and acceptability of combined drug treatment has not been assessed. METHODS: Double-blind drug trials in acute mania were identified using a systematic search strategy. We recorded numbers of patients enrolled, endpoints for efficacy (changes in mania rating scales, numbers of responders) and acceptability (numbers of dropouts) and treatment administered (categorized as antipsychotic, mood stabilizer, combined antipsychotic/mood stabilizer or placebo). Data were analyzed using a random effects frequentist network meta-analysis. RESULTS: All three drug categories were more effective than placebo. Antipsychotics and combined antipsychotic/mood stabilizer were significantly more effective than mood stabilizers for changes in mania rating scales. Combined antipsychotic/mood stabilizer was significantly more effective than mood stabilizers and antipsychotics for responder rate. Dropout rates were significantly lower for antipsychotics compared with placebo and mood stabilizers. Combined antipsychotic/mood stabilizer had the highest probability of being the best treatment based on change in mania rating scales (96.1% for all mania scales; 85.5% for Young Mania Rating Scale), and 99.3% for being the best treatment for responders. Antipsychotics had 82.0% probability as the best treatment to minimize dropouts. CONCLUSION: Combined antipsychotic/mood stabilizer appears to have efficacy advantages over antipsychotic or mood stabilizer monotherapy in acute mania, and should be considered as first line therapy.

Evidence of secular trends in a collection of historical craniofacial growth studies.

BACKGROUND/OBJECTIVES: Although secular trends have been well documented in the craniofacial region, there is no evidence to suggest that these temporal changes exist in samples used for orthodontic research. The aim of this study is to determine the effect of secular trends on craniofacial growth in a series of longitudinal birth cohorts that are frequently used in orthodontic research. MATERIALS/METHODS: Cephalometric data from serial lateral headfilms of 138 adolescents (total of 1252 cephalograms) were collected from the Craniofacial Growth Legacy Collection, which includes nine historical growth studies that were mostly conducted throughout the past century. Mixed-effects linear models were used to test the effect of 'year of birth (yob)', 'age', and their interaction on six sagittal (SNA, SNB, ANB, S-N, Co-A, Co-Po) and two vertical (N-Me, ANS-Me) cephalometric measurements. RESULTS: Five of the eight cephalometric variables showed a significant (P ≤ 0.017) 'yob' effect, with four of these indicating an increase over time (SNA, ANB, S-N, Co-A) and one indicating a decrease (SNB). Highly significant (P < 0.001) interactions between 'age' and 'yob' were found for the measurements SNA, ANB, Co-A, and S-N. LIMITATIONS: Some of the limitations of the present study include the use of a small, non-random sample of the original large-scale growth studies. CONCLUSIONS/IMPLICATIONS: Secular trends were found in the craniofacial growth records of the 138 participants derived from the longitudinal growth studies. These secular trends are likely to have important clinical implications for the findings of controlled clinical trials in orthodontics. More research is needed to establish the presence of secular trends in other historical collections.

A nationwide nested case-control study indicates an increased risk of acute interstitial nephritis with proton pump inhibitor use.

The magnitude of the suspected increase in risk of acute interstitial nephritis among proton pump inhibitor users is uncertain. Here, we conducted a nested case-control study using routinely collected national health and drug dispensing data in New Zealand to estimate the relative and absolute risks of acute interstitial nephritis resulting in hospitalization or death in users of proton pump inhibitors. The cohort included 572,661 patients without a history of interstitial nephritis or other renal diseases who started a new episode of proton pump inhibitor use between 2005 and 2009. Cases had a first diagnosis after cohort entry of acute interstitial nephritis confirmed by hospital discharge letter or death record, and renal histology (definite, 46 patients), or discharge letter or death record only (probable, 26 patients). Ten controls, matched by birth year and sex, were randomly selected for each case. In the case-control analysis based on definite cases and their controls, the unadjusted matched odds ratio (95% confidence interval) for current versus past use of proton pump inhibitors was 5.16 (2.21-12.05). The estimate was similar when all cases (definite and probable) and their corresponding controls were analyzed, and when potential confounders were added to the models. The crude incidence rates and confidence intervals per 100,000 person-years were 11.98 (9.11-15.47) and 1.68 (0.91-2.86) for current and past use, respectively. Thus, current use of a proton pump inhibitor was associated with a significantly increased risk of acute interstitial nephritis, relative to past use.

The role of remote ischemic preconditioning in organ protection after cardiac surgery: a meta-analysis.

BACKGROUND: Remote ischemic preconditioning (RIPC) appears to protect distant organs from ischemia-reperfusion injury. We undertook meta-analysis of clinical studies to evaluate the effects of RIPC on organ protection and clinical outcomes in patients undergoing cardiac surgery. METHODS: A review of evidence for cardiac, renal, and pulmonary protection after RIPC was performed. We also did meta-regressions on RIPC variables, such as duration of ischemia, cuff pressure, and timing of application of preconditioning. Secondary outcomes included length of hospital and intensive care unit stay, duration of mechanical ventilation, and mortality at 30 days. RESULTS: Randomized control trials (n = 25) were included in the study for quantitative analysis of cardiac (n = 16), renal (n = 6), and pulmonary (n = 3) protection. RIPC provided statistically significant cardiac protection (standardized mean difference [SMD], -0.77; 95% confidence interval [CI], -1.15, -0.39; Z = 3.98; P < 0.0001) and on subgroup analysis, the protective effect remained consistent for all types of cardiac surgical procedures. However, there was no evidence of renal protection (SMD, 0.74; 95% CI, 0.53, 1.02; Z = 1.81; P = 0.07) or pulmonary protection (SMD, -0.03; 95% CI, -0.56, 0.50; Z = 0.12; P = 0.91). There was no statistical difference in the short-term clinical outcomes between the RIPC and control groups. CONCLUSIONS: RIPC provides cardiac protection, but there is no evidence of renal or pulmonary protection in patients undergoing cardiac surgery using cardiopulmonary bypass. Larger multicenter trials are required to define the role of RIPC in surgical practice.

Allopurinol use in a New Zealand population: prevalence and adherence.

Allopurinol is effective for the control of gout and its long-term complications when taken consistently. There is evidence that adherence to allopurinol therapy varies across population groups. This may exacerbate differences in the burden of gout on population groups and needs to be accurately assessed. The aim of this study was to describe the prevalence of allopurinol use in a region of New Zealand using community pharmacy dispensing data and to examine the levels of suboptimal adherence in various population groups. Data from all community pharmacy dispensing databases in a New Zealand region were collected for a year covering 2005/2006 giving a near complete picture of dispensings to area residents. Prevalence of allopurinol use in the region by age, sex, ethnicity and socioeconomic position was calculated. Adherence was assessed using the medication possession ratio (MPR), with a MPR of 0.80 indicative of suboptimal adherence. Multiple logistic regression was used to explore variations in suboptimal adherence across population groups. A total of 953 people received allopurinol in the study year (prevalence 3%). Prevalence was higher in males (6%) than in females (1%) and Maori (5%) than non-Maori (3%). The overall MPR during the study was 0.88, with 161 (22%) of patients using allopurinol having suboptimal adherence. Non-Maori were 54% less likely to have suboptimal allopurinol adherence compared to Maori (95% CI 0.30-0.72, p = 0.001). These findings are consistent with those from other studies nationally and internationally and point to the important role for health professionals in improving patient adherence to an effective gout treatment.

Hospital admissions associated with gout and their comorbidities in New Zealand and England 1999-2009.

OBJECTIVES: To describe the national demographics, comorbidities and mortality of admissions associated with gout in New Zealand (NZ) from 1999 to 2009 and compare this with English gout admission data from the same period. METHODS: The characteristics of all admissions due to or complicated by gout in NZ from 1999 to 2009 were analysed. These findings were then compared with the wider NZ population and the English National Health Service (NHS) gout admission rates from 1999 to 2009. RESULTS: There were 10 241 admissions due to gout (group A) and 34 318 admissions complicated by gout (group B) in NZ from 1999 to 2009. There were 32 741 admissions due to gout in England over the same period. Gout admissions rose at 5.5% per year in NZ and at 7.2% per year in England over the study period. NZ gout patients admitted to hospital were more likely to be Maori or a Pacific Islander and had 3-7 comorbidities. Multiple admissions were common with 1479 NZ gout patients admitted more than once. Comorbidities varied between the NZ groups A and B: hypertension (19-39%), renal disease (16-27%) and diabetes mellitus (20-27%) were common. Heart failure (27.6%) and cardiovascular disease (39.1%) were common in those who had gout complicating their hospital admission. This group also had poorer survival compared with those admitted primarily for gout. CONCLUSION: This is the first study to describe the epidemiology of admissions associated with gout across an entire country. Admissions are rising in both countries studied and those admitted in NZ have a high rate of comorbidity and re-admission.

Does a patient's physical activity predict recovery from an episode of acute low back pain? A prospective cohort study.

BACKGROUND: Advice to remain active and normalisation of activity are commonly prescribed in the management of low back pain (LBP). However, no research has assessed whether objective measurements of physical activity predict outcome and recovery in acute low back pain. METHOD: The aims of this study were to assess the predictive relationship between activity and disability at 3 months in a sub-acute LBP population. This prospective cohort study recruited 101 consenting patients with sub-acute LBP (< 6 weeks) who completed the Roland Morris Disability Questionnaire (RMDQ), the Visual Analogue Scale, and resumption of full 'normal' activity question (Y/N), at baseline and 3 months. Physical activity was measured for 7 days at both baseline and at 3 months with an RT3 accelerometer and a recall questionnaire. RESULTS: Observed and self-reported measures of physical activity at baseline and change in activity from baseline to 3 months were not independent predictors of RMDQ (p > 0.05) or RMDQ change (p > 0.05) over 3 months. A self-report of a return to full 'normal' activities was significantly associated with greater RMDQ change score at 3 months (p < 0.001). Paired t-tests found no significant change in activity levels measured with the RT3 (p = 0.57) or the recall questionnaire (p = 0.38) from baseline to 3 months. CONCLUSIONS: These results question the predictive role of physical activity in LBP recovery, and the assumption that activity levels change as LBP symptoms resolve. The importance of a patient's perception of activity limitation in recovery from acute LBP was also highlighted. TRIAL REGISTRATION: Clinical Trial Registration Number, ACTRN12609000282280.

Perspectives on psychosocial and spiritual cancer support services in New Zealand.

In New Zealand, support services have been developed in response to patient need but are variable. The benefits of psycho-social-spiritual care in reducing distress and enhancing quality of life for people with cancer and their families are well established yet unmet needs continue to feature. This project aimed to examine how health care professionals assessed for psycho-social-spiritual distress and unmet need, decisions on appropriate support, and identification of barriers in the referral process. A mixed-methods approach was used for this research. The qualitative phase entailed semistructured interviews with health care professionals working in cancer care. The quantitative phase was an online survey of oncologists and nurses. Thematic analysis was carried out by performing a side-by-side analysis of both sets of data. Nurses were most likely to assess for psycho-social-spiritual need and to refer to support services. Despite a clear mandate to provide regular psycho-social-spiritual assessment, there is no consistency of assessment and referral across New Zealand. There are clearly unmet psycho-social-spiritual needs among people affected by cancer in New Zealand, with health care professionals in this study noting structural impediments to adequate supportive care. There is a mismatch between the importance placed on such care and the capacity that is currently available. The results of this study provide evidence that can be used to argue for improvements in the infrastructure, funding allocation and policy that would allow for better psycho-social-spiritual care within the challenging context of increasing numbers of those affected by cancer.

Factors associated with hospitalization of adult psychiatric patients: cluster analysis.

OBJECTIVE: Factors associated with acute admission to inpatient psychiatric wards have been difficult to replicate, possibly reflecting methodological limitations of analyzing individual variables. The objective of this analysis was to identify factors associated with hospitalization at an inpatient psychiatric unit using cluster analytic methods. METHODS: Demographic, admission and treatment data for all admissions to a single inpatient unit in 2010 were collected retrospectively. Cluster analysis was performed using Ward's method. RESULTS: The initial clustering identified a high suicidality/crisis group, which then gave two further subclusters, an internalizing one characterized by affective symptoms and an externalizing one characterized by intoxication at admission, and a population with poor medication compliance that included most cases of psychosis. These subclusters had different clinical and demographic characteristics, different rates of hospital readmission and different durations of stay. CONCLUSIONS: Cluster analysis may be a useful exploratory technique to assist in planning and developing services for adult patients needing admission to a psychiatric hospital.

A randomized controlled trial to investigate the effects of water-based exercise to improve falls risk and physical function in older adults with lower-extremity osteoarthritis.

OBJECTIVE: To investigate the efficacy of a water-based exercise program specifically targeting balance to reduce falls risk and improve measures of balance and physical function in older adults with osteoarthritis (OA). DESIGN: Randomized controlled trial. SETTING: Community. PARTICIPANTS: Persons (N=39; mean±SD age, 74±6y; 26 women) with mild to moderate OA and at risk for falling met study criteria, were measured at baseline, and were randomly assigned to the intervention (n=23) and control groups (n=16). INTERVENTIONS: Water-based program (12wk, twice weekly; intervention group) or a time-matched computer training program (control group). MAIN OUTCOME MEASURE: The primary outcome was the short-form Physiological Profile Assessment (PPA). Secondary outcomes included the Step Test, Timed Up and Go Test, Western Ontario and McMaster Universities OA Index (Likert 3.0 version), Arthritis Impact Measurement Scales 2, and Activity-specific Balance Confidence Scale. RESULTS: No statistically significant between-group differences were found for any outcome measured (n=35; 4 lost to follow-up). Within-group analysis indicated that Step Test results improved significantly in both groups (mean change: control group, left leg, 2.07; 95% confidence interval, 3.19-.95; P=.002; intervention group, 2.14; 95% confidence interval, 3.20-1.08; P=.000). Two PPA item scores (reaction time, contrast sensitivity) improved significantly (86.83; 95% confidence interval, 9.86-163.79; P=.03; 1.43; 95% confidence interval, 2.35-.50; P=.005, respectively) in the control group, resulting in a lower falls risk score. CONCLUSIONS: Water-based exercise did not reduce falls risk in our sample compared with attending a computer skills training class. Our study is, to our knowledge, the first to compare water-based exercise in this population with a control group that attended a time-dose-equivalent seated community-based activity. Whether gaining computer skills and going out into the community twice weekly is adequate stimulus to reduce falls risk in people with OA requires further investigation.

Risk of severe postpartum hemorrhage in low-risk childbearing women in new zealand: exploring the effect of place of birth and comparing third stage management of labor.

BACKGROUND: Primary postpartum hemorrhage is a leading cause of maternal mortality and morbidity internationally. Research comparing physiological (expectant) and active management of the third stage of labor favors active management, although studies to date have focused on childbirth within hospital settings, and the skill levels of birth attendants in facilitating physiological third stage of labor have been questioned. The aim of this study was to investigate the effect of place of birth on the risk of postpartum hemorrhage and the effect of mode of management of the third stage of labor on severe postpartum hemorrhage. METHODS: Data for 16,210 low-risk women giving birth in 2006 and 2007 were extracted from the New Zealand College of Midwives research database. Modes of third stage management and volume of blood lost were compared with results adjusted for age, parity, ethnicity, smoking, length of labor, mode of birth, episiotomy, perineal trauma, and newborn birthweight greater than 4,000 g. RESULTS: In total, 1.32 percent of this low-risk cohort experienced an estimated blood loss greater than 1,000 mL. Place of birth was not found to be associated with risk of blood loss greater than 1,000 mL. More women experienced blood loss greater than 1,000 mL in the active management of labor group for all planned birth places. In this low-risk cohort, those women receiving active management of third stage of labor had a twofold risk (RR: 2.12, 95% CI: 1.39-3.22) of losing more than 1,000 mL blood compared with those expelling their placenta physiologically. CONCLUSIONS: Planned place of birth does not influence the risk of blood loss greater than 1,000 mL. In this low-risk group active management of labor was associated with a twofold increase in blood loss greater than 1,000 mL compared with physiological management. (BIRTH 39:2 June 2012).

Registrar interest in academic obstetrics and gynaecology: a cross-sectional survey.

BACKGROUND: New Zealand has an urgent need to train and retain obstetrics and gynaecology academics, and postgraduate training pathways are being considered. AIMS: To gauge registrar interest in an academic training position and an academic career; analyse the importance of various encouraging factors; and investigate how demographics, experience and encouragers may be associated with academic interest. METHODS: All obstetric and gynaecology registrars working in New Zealand were invited by their clinical directors to participate in an online survey in March-June 2011. Statistical analysis, using Fisher's Exact and chi-squared tests, was used to investigate how demographic, experience and encourager variables were associated with academic interest. RESULTS: Of the 58 participants, 46 were women, 32 were New Zealand medical graduates and 43 were on the training program. Over half (54%) indicated they would consider a 1-year rotating research/teaching position and 45% an academic career. The most important encouraging factors for academic work were interest, opportunity to balance clinical and academic roles, job flexibility (lifestyle and family) and a supportive academic environment. Women were nearly nine times more likely to consider academic training (OR 8.75, P = 0.007), and trainees were one-third as likely to consider it compared to non-trainees (OR 0.31, P = 0.073). CONCLUSIONS: New Zealand has the unique ability to approach retention and training issues in a flexible and innovative manner which utilises international links. Clinical academic training positions should be set-up with quality supervision and support similar pay scales and the opportunity for simultaneous part-time clinical practice.