NEW ZEALAND MEDICAL JOURNAL最新文献

The concept of cultural safety, developed in the training of nurses over 30 years ago, was adopted by the Medical Council of New Zealand in 2019. We report on the journey of the Medical Council of New Zealand, Te ORA (the Māori Medical Practitioners Association) and the Council of Medical Colleges, and our increasing understanding of cultural competence and cultural safety in promoting best outcomes for Māori patients over the years. We describe in detail the key components of a cultural safety training framework as a tool for medical colleges' training of registrars and the Continuing Professional Development (CPD) of specialist medical practitioners. Finally, we discuss pathways forwards for cultural competence and cultural safety training that apply to a society with diverse cultural needs, noting that such training has been proposed as significant in shifting "difficult to change" Māori health inequities.

Aim: To provide a socio-demographic profile of Asian students enrolled in their first year of a health professional programme in polytechnics and universities in Aotearoa New Zealand and to explore differences in enrolment rates (ERs) within Asian sub-groups and by socio-economic deprivation, citizenship status, urban/rural location and gender.

Methods: Ethnic group/sub-group and socio-demographic characteristics of students enrolling within 21 health professional programmes were collected and averaged over 5 years (2016-2020). Age- and ethnicity-matched denominator data from the 2018 Census were used to calculate yearly ERs and ratios (ERR) using generalised linear modelling with the European ethnic group as the reference.

Results: The overall ER for Asian students was higher than for Europeans (ERs [95% confidence interval: 280 [269-292] per 100,000 population aged 18-29 per year vs 149 [144-154]). However, Indian, Chinese and Southeast Asian students were under-represented in occupational therapy (ERR: 0.33-0.67, p=<0.017), midwifery (ERR: 0.46-0.61, p=<0.002) and paramedicine (ERR: 0.23-0.29, p<0.001). There were proportionately fewer female Asian students compared with European students (68% vs 82%, p<0.001).

Conclusion: This novel research provides detailed information on Asian sub-group representation in health professional programmes in Aotearoa. Taken in the context of known health needs of different Asian sub-groups, these data may facilitate health workforce planning and targeted policies within health professional programmes in order to better match the health workforce to population health needs.

Aim: To develop processes for the development of decentralised clinical trial methodology for Aotearoa New Zealand, focussing on equity of access to cancer clinical trials for Māori, Pacific people, vulnerable communities and those in rural settings.

Methods: A national steering committee supported by Te Aho o Te Kahu - Cancer Control Agency was formed to: guide the adaptation and implementation of overseas decentralised clinical trial models to suit the needs of Aotearoa New Zealand with an equity focus; provide high-level oversight and expertise for direction and development of policies, procedures and infrastructure compliant with ICH GCP R2; and implement a national strategy.

Results: Twelve standard operating procedures were developed, as well as a supervision plan and a glossary. These were made freely available on the New Zealand Association of Clinical Research website.

Conclusion: Decentralised clinical trials offer a novel method of trial conduct that is patient- and whānau-centred. The model allows patients to remain in their local area with whānau and support networks, and their local treating team, increasing clinical trial accessibility and quality of care. This methodology has the potential to support improvement in research capabilities nationally and be utilised beyond oncology. It would benefit from significant investment in national clinical trial infrastructure.

Aim: This work describes the validation of an in-house extraction free real-time polymerase chain reaction (PCR) for the detection of Group A Streptococcus (GAS) in throat swabs collected in gel amies.

Method: Throat swabs received by the laboratory were prospectively tested by routine bacterial culture and an in-house PCR assay targeting the GAS SpeB gene with a multiplexed RNaseP internal control. Samples with discrepant culture/PCR results had additional testing using the commercial Xpert Group A Strep PCR assay (Cepheid). Post introduction of the in-house GAS PCR the comparative laboratory turn-around time between PCR and historic culture results was determined.

Results: Of the 1,093 throat swabs included in the final analysis, GAS was detected by culture and GAS PCR in 262 (24.0%) and 319 (29.2%) respectively. The overall, positive and negative agreement of the GAS PCR with culture was 94.2%, 98.9% and 92.8% respectively. Of the 63 discordant samples, one (33.3%) of three culture positive/in-house PCR negative samples and 56 (93.3%) of 60 culture negative/in-house PCR positive samples were GAS positive on the Xpert Group A Strep assay. Median turn-around time from laboratory receipt to result decreased from 44 to 16 hours with the introduction of the GAS PCR into routine practice. Forty-five percent of samples came from European patients and 25% from persons aged over 30 years, suggesting over-testing in persons at low risk of GAS pharyngitis complications.

Conclusion: The in-house GAS PCR provided greater and faster detection of GAS from throat swabs compared to culture. However, throat swabbing for GAS needs to be better targeted to those populations at high risk of post-GAS pharyngitis complications.

Aim: Acute myocarditis (AM) is increasingly diagnosed in the era of more sensitive imaging techniques. The natural history of AM diagnosed on cardiac magnetic resonance imaging (cMRI) may be different to historic cohorts due to the detection of milder disease. This study aims to measure the outcome of patients with AM detected by cMRI.

Methods: We retrospectively reviewed all cMRI studies performed over a 10-year period between 2012 and 2022. Patients with a diagnosis of AM based on cMRI criteria and clinical assessment were selected for inclusion.

Results: One hundred and ninety-six patients were included. The mean age was 42 years and 79% were male. Chest pain, fever or viral prodrome and dyspnoea were the most common presenting symptoms, and one patient presented with cardiac arrest. On cMRI, nine patients had left ventricular ejection fraction <40% and 174 patients had evidence of late gadolinium enhancement, most commonly affecting the basal inferolateral and inferior segments in a subepicardial and mid-wall distribution. Five patients required admission to intensive care unit (ICU). Important outcomes included the occurrence of ventricular arrhythmias in 17, recurrent or chronic myocarditis in 15 and implantable cardioverter defibrillator insertion in five patients, respectively. After a median follow-up of 4.6 years, there were no cardiac-related deaths, and three patients died from malignancy-related causes.

Conclusion: Patients with AM diagnosed by cMRI have a favourable medium-term outcome. Severe left ventricular dysfunction and ICU admission are rare. cMRI should be considered early in patients with suspected AM.

Aim: To assess the impact of physical, mental and cognitive impairments on health-related quality-of-life (QoL) of individuals who have survived sepsis after admission to an Intensive Care Unit (ICU) in New Zealand.

Methods: Survivors from a trial investigating vitamin C as an adjunctive therapy in patients with sepsis in Christchurch Hospital ICU were invited to enrol in a longitudinal QoL follow-up study. Patients were interviewed at hospital discharge, 30, 90 and 180 days, using validated physical and mental health assessment questionnaires (Short-Form-36, EuroQol-5-Dimension). Cognitive function was monitored and results compared with New Zealand population norms.

Results: Eighteen of the 26 survivors participated in the 6-month QoL follow-up. At hospital discharge, there were significant physical and mental health issues in the participants interviewed, and although a majority of the subscales improved over the 6-month follow-up, physical function, role-physical and general health were still below population norms. Following discharge, objective parameters (mobility, self-care, usual activities) normalised within 3-6 months, while subjective measures (pain/discomfort and anxiety/depression) improved earlier and were better than population norms at 3-6 months. Cognitive dysfunction persisted over the follow-up period. Short-term (4-day) vitamin C intervention in the ICU did not affect health parameters post hospital discharge.

Conclusions: Survivors of septic shock experience elevated physical, mental and cognitive issues at discharge. Most mental health issues had resolved by 6 months, but some physical and cognitive issues had not returned to population norms. Short-term vitamin C administration did not improve long-term health-related QoL; however, ongoing vitamin C supplementation may be required.

Aim: To examine the ethnic variations in trauma hospitalisations in a health region of Aotearoa New Zealand over a 10-year period.

Methods: A retrospective, observational study utilised data from the Te Manawa Taki (TMT) regional trauma registry to identify individuals of all ages and injury severities who were hospitalised due to injuries between 2013 and 2022. This investigation focusses on the epidemiology of trauma, examining factors such as ethnicity, gender, Injury Severity Score (ISS) and injury characteristics.

Results: In the TMT region, out of the 60,753 trauma patients admitted to hospitals, the distribution across ethnic groups was as follows: 39,291 (64.7%) were European and other ethnic group, 18,015 (29.7%) were Māori, 1,998 (3.3%) were Asian and 1,411 (2.3%) were Pacific peoples. Notably, there were significant differences in incidence rates among these groups, with Māori exhibiting the highest rate. Moreover, males were more predisposed to hospitalisation due to trauma compared to females. This gender discrepancy was consistent across all ethnicities. Regardless of ethnicity, falls and road traffic crashes emerged as leading causes of trauma across all severity levels. Additionally, the primary location of injury varied depending on the severity of trauma. For high-severity cases, street and highways were the predominant sites, whereas homes were more commonly associated with low-severity admissions.

Conclusions: The study examines the incidence, demographic characteristics, severity and outcomes of trauma patients across various ethnic backgrounds admitted to hospitals within the TMT region of Aotearoa New Zealand over a decade. The disparities in injury rates among different ethnic groups underscore the substantial strain on the healthcare system. Pinpointing high-risk demographics and recognising these disparities will be instrumental in devising targeted prevention measures, enhancing access to culturally sensitive trauma services and advancing health equity.

Aim: To gain insight into health practitioners' understanding of how people experience the first trimester abortion journey.

Methods: Qualitative interviews informed by phenomenology with health practitioners from a range of practice settings across Aotearoa New Zealand. Participants were recruited via a separate but related study. Inductive thematic analysis was used to develop themes.

Results: Interviews were undertaken with 18 health practitioners. Analysis revealed three main themes: 1) abortion is a stepwise process, 2) barriers to accessing abortion care, and 3) solutions to improve access to abortion care. There were a number of sub-themes.

Conclusion: While there remain multiple personal, institutional and societal barriers to abortion in Aotearoa, this study identifies potential solutions and that a desire for positive change among health practitioners exists. To achieve this, a strategy is required to ensure that the health consumer is placed at the centre of abortion services to provide accessible, equitable and culturally appropriate care. The primary care sector stands to play a significant role in future abortion provision but requires appropriate funding and support to do so.