Polypharmacy in a general surgical unit and consequences of drug withdrawal.

AIMS: To identify drug usage/withdrawal in surgical patients and the relative risk this imposes on postoperative surgical complications. METHODS: A prospective survey of patients' medicines, oral intake (food/fluids/ medicines) and postoperative complications was carried out in the General Surgical Unit, Dunedin Hospital, Dunedin, New Zealand. RESULTS: One thousand and twenty-five general surgical patients aged >/= 16 years, were entered into the study. Half of the patients were taking medicines unrelated to surgery. On average these patients received 9 different drugs (range 1-47) from a selection of 251, of which 21% were released in the last 10 years. The mean number of these drugs taken increased with age, vascular surgery and other major procedures. The majority of patients (53%) were taking drugs for cardiovascular problems. Only 8% of admissions were on the drugs more traditionally recognized to be of importance to the surgery, i.e. steroids and diabetic therapy. With respect to risk, taking a drug unrelated to surgery was associated with an increased relative risk of a postoperative complication by 2.7 (95% C.I. 1.76-4.04) compared with those who were not taking any drug. Cardiovascular drugs contributed significantly to this risk; when they were excluded from analysis, the risk dropped to 1.8 (95% C.I. 1.14-2.93). Death may be more common in those taking ACE inhibitors. Drug withdrawal and complications were analysed and as the time without medicines increased (range 1-42 days) so did the complication rate (chi2 = 14.7, DF = 2, P = 0.007). Of those patients who were taking a cardiovascular medicine and were without their normal medicines for a period of time postoperatively, 12% suffered a cardiac complication. CONCLUSIONS: Many patients admitted to a general surgical ward, are taking medicines unrelated to surgery. Drug therapy unrelated to surgery is a useful predictor for increased postoperative complications and one for which preventive action can be taken. This study provides evidence that withdrawal of regular medicines may add significant risk to the surgery and further complicate outcome. The longer patients were without their regular medicines the more nonsurgical complications they suffered. Reintroduction of patients' regular medicines early in their postoperative course may decrease morbidity and mortality in-patients.

Progestogen-only oral contraceptives and risk of breast cancer in New Zealand.

Little is known about the influence of progestogen-only oral contraceptives on a woman's risk of breast cancer. This issue was examined in a national population-based case-control study in New Zealand. A total of 891 women aged 25 to 54 years with a first diagnosis of breast cancer and 1,864 control subjects, randomly selected from the electoral rolls, were interviewed. Use of progestogen-only pills was reported by 8.7 percent of all control subjects (and by 17.3 percent of those aged 25 to 34 years). The relative risk (RR) of breast cancer in women who had ever used progestogen-only pills was estimated to be 1.1 (95 percent confidence interval [CI] = 0.73-1.5). In women aged 25 to 34 years, the RR was 2.3 (CI = 1.2-4.3). Women who had started using progestogen-only pills within the last 10 years were at increased risk of breast cancer (RR = 1.6, CI = 1.0-2.4), whereas those who had first used them earlier were at significantly reduced risk (RR = 0.44, CI = 0.22-0.90). These findings are similar to results for depot medroxyprogesterone acetate, and a possible analogy with the influence of pregnancy is also suggested.

Oral contraceptive use and risk of breast cancer in older women (New Zealand).

The effect of oral contraceptive (OC) use at older ages on the risk of breast cancer was examined in a national population-based case-control study conducted in New Zealand. A total of 891 women aged 25 to 54 years with a first diagnosis of breast cancer, and 1,864 control subjects, randomly selected from the electoral rolls, were interviewed. The relative risk (RR) of breast cancer for women aged 45 to 54 years at diagnosis who had ever used OCs was 1.0 (95 percent confidence interval [CI] = 0.77-1.3). There was no significant increase in risk of breast cancer among recent users of OCs of any age. Analyses according to age at first and last use among women aged 40 years and older at diagnosis showed no group with an elevated risk of breast cancer. Women who had used OCs for 10 years or longer after age 40 had an apparent increase in risk (RR = 2.7, CI = 0.97-7.5), but the trend in risk with duration of use was not significant. These findings suggest that OC use in older women does not affect their risk of breast cancer appreciably, but it is not possible to rule out a modest increase in risk with such use.

Premenstrual syndrome: a double-blind controlled trial of desipramine and methylscopolamine.

The aim of this study was to compare the effect of the selective noradrenergic reuptake inhibitor desipramine and methylscopolamine bromide, a parasympatholytic agent, on late luteal phase dysphoric disorder (LLPDD), or premenstrual syndrome (PMS), as defined in DSM-III-R. Fourteen patients with PMS were assessed both retrospectively and prospectively during premenstrual cycles. All met the DSM-III-R criteria for LLPDD. They received 3 months treatment each with both desipramine and methylscopolamine in random order using a double-blind cross-over design. PMS symptomatology was significantly reduced after treatment with desipramine and methylscopolamine bromide compared with baseline, but there was no significant difference between them in efficacy. There is evidence from this study that both anticholinergic and noradrenergic pathways may be involved in the genesis of PMS.

Biases in estimates from the RNZCGP computer research group.

AIM: This study aimed to determine whether conclusions drawn in studies using data from the computer research group of the Royal New Zealand College of General Practitioners (RNZCGP) could be extrapolated to other New Zealand general practices. METHOD: Retrospectively collected data on doctor, practice, and consultation variables form the study database. The control group comprised a random sample of 106 New Zealand general practitioners. The study group were 67 general practitioners participating in the RNZCGP computer research group. Comparisons between groups were based on doctor and practice variables, patient demography and morbidity, and number and type of service items observed. RESULTS: Study group doctors were more likely to have received post graduate training in general practice (p < 0.01) and saw more patients entitled to government subsidised health care (p < 0.01). The geographical distribution of the study group was skewed with more located in the south of New Zealand. Wide variability on most other study parameters was seen among doctors in both groups although overall patient morbidity was similar for both groups in the 8612 consultations analysed. Computer research group general practitioners reported lower rates of patient referral and laboratory investigations, and higher immunisation rates than the control group (p < 0.01). CONCLUSION: Although the profile of study group general practitioners was different from that of the control group, data collected by both groups provided a similar reflection of the morbidity and services of New Zealand general practice. Adjustments will be needed for extrapolating the results of research from the RNZCGP computer research group where the focus of the investigation is referrals from primary care, investigations, or immunisations.

Depot medroxyprogesterone acetate and breast cancer. A pooled analysis of the World Health Organization and New Zealand studies.

BACKGROUND: Although depot medroxyprogesterone acetate (DMPA) (Depo-Provera) has now been approved for marketing as a contraceptive in the United States, there are still unresolved issues about the relation between DMPA and risk of breast cancer. The two substantial case-control studies of this association yielded similar but inconclusive results. Because their designs were compatible, these studies were pooled to obtain more adequate data for analysis. DESIGN: Pooled results from two case-control studies. SETTING: New Zealand (entire country), Thailand (three centers), Mexico (one center), and Kenya (one center). PARTICIPANTS: A total of 1768 women with breast cancer and 13,905 controls, most of whom were younger than 55 years. MAIN OUTCOME MEASURE: Relative risk (RR) of breast cancer in women who had used DMPA. RESULTS: The RR of breast cancer for women who had ever used DMPA was 1.1 (95% confidence interval [CI], 0.97 to 1.4). There was no increase in risk with increasing duration of use of DMPA, but RR estimates were higher in certain subgroups of women. Further analyses suggested that recent (or current) use was the key factor, with women who had started using DMPA within the previous 5 years estimated to have an RR of 2.0 (95% CI, 1.5 to 2.8). CONCLUSIONS: The increased risk of breast cancer observed in recent (or current) users could be due to enhanced detection of breast tumors in women using DMPA or to acceleration of the growth of preexisting tumors. Women who had used DMPA more than 5 years previously had no increase in risk of breast cancer, regardless of their duration of use.

Diet and dental caries in preschool children.

A study was carried out in two New Zealand cities with a fluoridated water supply, to look at the dietary habits of preschool children and to investigate whether any dietary factors or other variables are associated with dental decay in the deciduous teeth of these children. From a final study of 355 (a 59% response rate), demographic data, a dental examination, a series of three 24 h recalls over a period of 1 year, and a food frequency questionnaire to cover the same 1 year interval were collected. The sample included 93 children with dental decay and 262 caries-free children, matched for age, sex and sociodemographic variables. The energy and nutrient intakes of the preschool children were sufficient to support normal growth. The main sources of dietary energy in the diets of this study group came from bakery and dairy products. Boys had slightly higher mean intakes of most nutrients than girls. No significant differences were found in the food patterns or intakes of macronutrients between the children of this study group with caries and those without. There was an inverse relationship between social background and dental health, with increasing social advantage being associated with decreasing dental health problems. Syrup medicines and, in particular, antibiotic syrups independently increased the risk that a child would have a number of carious lesions, especially if taken frequently.

Nutrient intake of Dunedin women during pregnancy.

AIM: To assess the adequacy of dietary intake of women during the three trimesters of pregnancy. METHOD: Dietary intakes of 63 primiparous and 32 multiparous healthy pregnant Dunedin women were obtained by 3 day weighed records at about 12 weeks, 24 weeks, and 36 weeks of gestation. Energy and nutrient intakes were derived using the University of Otago food composition database. RESULTS: Mean energy and nutrient intakes differed remarkably little between primiparous and multiparous women; data were combined for analysis. Energy intakes at first and second trimesters were similar to that for non pregnant women in the National Heart Foundation 1977 survey but greater than in the LINZ 1989 survey. Energy and carbohydrate intakes had increased at third trimester; across the trimesters carbohydrate accounted for 44-46% energy intake, fat for 39% and protein for 15%. Protein intakes at the 10th centile were almost the same as the recommended low risk intake of 51 g/d set by WHO/FAO: No vitamin or mineral showed a trend in intake through the trimesters. Vitamin and mineral intakes were in general greater for the pregnant women than for nonpregnant women in both 1977 and 1989 studies. By comparison with recommended intakes for NZ, Australia, USA and UK, intakes for folate, vitamin B-6, iron and possibly zinc and thiamin were potentially inadequate. Over 10% were heavy smokers and 20% were light smokers; nutrient intakes were less for the smokers than for the nonsmokers, as were birth weights; energy intakes for smokers had not increased at the third trimester. CONCLUSION: An improvement in quality of diet is needed during pregnancy and in prenatal period; smoking should continue to be strongly discouraged.

The oral health and attitudes to dental treatment of a dentate elderly population in Mosgiel, Dunedin.

As part of the Mosgiel Community Study, a longitudinal investigation of the health of the elderly, a dental survey was used to determine the oral health status and treatment needs, both objective and subjective, of a group of dentate older adults. Sixteen percent of the 817 subjects were dentate. Of these, 95 were available for the dental survey, and they were questioned and examined at their homes. The mean age was 77 years, and 55 percent of subjects were male; disproportionately more older males than females had retained some of their natural teeth. Seventy-two percent regularly sought dental treatment, and 39 percent felt they were in need of treatment. Few real barriers to treatment were identified, although a major obstacle preventing many from seeking treatment was their lack of perceived need. However, even the realisation that they required treatment was not sufficient cause for many to seek treatment. All subjects required some form of dental treatment. Eighty-five of the 95 subjects required at least one restoration, and 16 percent advanced restorative treatment. The frequencies of coronal and root surface caries were similar. Oral mucosal pathology was also common. Sixty-five percent of denture wearers required prosthetic treatment. Most subjects needed simple periodontal treatment, but 11 percent required advanced therapy. The main oral health problems of this group related to the simple management of plaque-related disease, and the wearing of dentures. However, 24 percent of people required complex restorative and periodontal treatment, or both.

A comparison of patients' perception of dental care offered by male or female dentists in New Zealand.

Recent increases in women dentists in New Zealand follow similar trends in other Western countries. The career patterns of female dentists, and male dentists' attitudes towards women dentists in New Zealand have been previously studied. The aim of this study was to compare the attitudes and preferences of patients towards dental care offered by either male or female dentists, to determine what influences these preferences, and to discover whether or not these opinions differed between regular or irregular attenders.

Treatment of postmenopausal osteoporosis with calcitriol or calcium.

BACKGROUND AND METHODS: Osteoporosis is a common problem whose management is controversial. To evaluate the efficacy and safety of calcitriol (1,25-dihydroxyvitamin D3) in the treatment of postmenopausal osteoporosis, we conducted a three-year prospective, multicenter, single-blind study in 622 women who had one or more vertebral compression fractures. The women were randomly assigned to receive treatment with calcitriol (0.25 micrograms twice a day) or supplemental calcium (1 g of elemental calcium daily) for three years. New vertebral fractures were detected by means of lateral roentgenography of the spine each year, and calcium absorption was measured in 392 of the women. RESULTS: The women who received calcitriol had a significant reduction in the rate of new vertebral fractures during the second and third years of treatment, as compared with the women who received calcium (second year, 9.3 vs. 25.0 fractures per 100 patient-years; third year, 9.9 vs. 31.5 fractures per 100 patient-years; P less than 0.001). This effect was evident only in women who had had five or fewer vertebral fractures at base line (second year, 5.2 vs. 25.3 fractures per 100 patient-years; third year, 4.2 vs. 31.0 fractures per 100 patient-years; P less than 0.0001). The groups also differed significantly in the number of peripheral fractures; 11 such fractures occurred in 11 women in the calcitriol group, whereas 24 occurred in 22 women in the calcium group (P less than 0.05). There was no significant difference between the groups in the incidence of side effects requiring withdrawal of treatment (8.6 percent in the calcitriol group vs. 6.5 percent in the calcium group). CONCLUSIONS: Continuous treatment of postmenopausal osteoporosis with calcitriol for three years is safe and significantly reduces the rate of new vertebral fractures in women with this disorder.

Long-term efficacy of single-dose mass treatment with diethylcarbamazine citrate against diurnally subperiodic Wuchereria bancrofti: eight years' experience in Samoa.

A single-dose of diethylcarbamazine citrate (DEC, 6 mg per kg body weight) was administered in three mass treatment campaigns to > 80% of the estimated total Samoan population (160,000) in 1982, 1983, and 1986. The effect of the drug was evaluated before and after each campaign by conducting four blood surveys covering 9600 to 13,700 people from 26-34 villages on each occasion. The drug reduced the prevalence of Wuchereria bancrofti microfilariae from 5.6% to 2.5% (a 55% reduction), while the transmission potential (the estimated mosquito infection rate if everyone is equally exposed to mosquito bites) dropped from 2.18 to 0.67 (a 70% reduction). The total number of microfilariae in the Samoan population is estimated to have been reduced by 80%. A spaced, single-dose treatment with DEC at a 1-2-year interval therefore seems to be an effective control measure against diurnally subperiodic W. bancrofti.

Collagen concentrations in dissected tissue compartments of rat uterus on days 6, 7 and 8 of pregnancy.

Implantation and non-implantation sites were dissected into myometrial and stromal components; a decidual/embryonic region was obtained on Days 7 and 8 of pregnancy. The concentration of collagen (as a percentage of the dry weight of tissue), measured by hydroxyproline analysis, was significantly lower in the implantation regions than in the non-implant regions in all areas studied. The concentrations in the antimesometrial myometrium and stroma of the implantation region remained the same over the days studied. In contrast, the mesometrial collagen concentration in the implantation region declined from Day 6 to Day 8 of pregnancy. Collagen concentration was low within the decidual/embryonic tissue on Days 7 and 8 of pregnancy. Remodelling of collagen within the embryonic area appears to be an important feature of the uterine response to implantation in rats.

The normal growth patterns of New Zealand preschool children.

This study was designed to update New Zealand Growth Charts for preschool children. The heights, weights and head circumferences of 12,311 children aged one month to five years were recorded. From this data growth charts were constructed. Since significant differences were found between the measurements for boys and girls, separate graphs were constructed. We strongly advise that these graphs be used by all health professionals involved with child health surveillance of the 0-5 age group.

Alcohol consumption and risk of breast cancer.

In a national case-control study, 891 New Zealand women aged 25 to 54 with newly diagnosed breast cancer were compared with 1,864 control subjects selected at random from the electoral rolls. The relative risk of breast cancer for current drinkers of alcohol, compared with women who had never drunk alcohol, was 1.0 (95% confidence interval 0.64 to 1.7). For ex-drinkers the relative risk was 1.3 (95% confidence interval 0.74 to 2.5). Women drinking up to 14 drinks per week had no increase in risk, while the relative risk in those consuming more than 14 drinks per week was 1.8 (95% confidence interval 0.87 to 3.8). There was no evidence of effect modification by age at diagnosis, menopausal status, body mass index, or any of the other variables examined. While these results provide little support for the hypothesis that moderate alcohol consumption increases the risk of breast cancer, they are not inconsistent with the weak associations that have been found in many other studies. Possible explanations for such a relationship are considered.

Psychiatric symptoms, personality and ways of coping in chronic fatigue syndrome.

This study aimed to investigate the psychological characteristics of chronic fatigue syndrome (CFS: Holmes et al. 1988). A battery of psychometric instruments comprising the General Health Questionnaire (GHQ), the Beck Depression Inventory (BDI), the Minnesota Multiphasic Personality Inventory (MMPI) and the Lazarus Ways of Coping (WoC) inventory, was administered to a sample of clinically-defined CFS sufferers (N = 58), to a comparison group of chronic pain (CP) patients (N = 81) and to a group of healthy controls matched for sex and age with the CFS sample (N = 104). Considerable overlap was found between CFS and CP patients at the level of both physical and psychological symptoms. This raises the possibility that CFS sufferers are a sub-population of CP patients. However, while there was some commonality between CFS and CP patients in terms of personality traits, particularly the MMPI 'neurotic triad' (hypochondriasis, depression and hysteria), CFS patients showed more deviant personality traits reflecting raised levels on the first MMPI factor, emotionality. Moreover, results were not consistent with the raised emotionality being a reaction to the illness, but rather were consistent with the hypothesis that emotionality is a predisposing factor for CFS. The majority of CFS patients fell within four personality types, each characterized by the two highest MMPI scale scores. One type (N = 20) reported a lack of psychological symptoms or emotional disturbance contrary to the overall trend for the CFS sample. This group conformed to the ICD-10 classification of neurasthenia.

Occurrence of AIDS in New Zealand: the first seven years. MRC AIDS Epidemiology Group.

The 179 people in New Zealand with AIDS diagnosed up to the end of 1989 and notified by 30 June 1990 are reviewed. Retrospective data collection provided the first available information on date of diagnosis, ethnic affiliation, district of usual residence, and survival. Of the 179 people with AIDS, 173 were male. AIDS occurred most commonly between the ages of 30 and 50, but there were two children under 10. The standardised cumulative incidence rates (per 100,000) in the European, Maori, and Pacific Island populations were 5.3, 4.5, and 5.5, respectively. The majority affected (154) were men who had had sexual contact with men. Three of five intravenous drug users also reported such contact. Smaller numbers were presumed to have been infected through heterosexual contact (7), treatment of haemophilia (3), blood transfusions (2), or perinatally (1). In seven cases the mode of transmission was unknown. The proportion of people who had been living overseas when first diagnosed was initially high but declined, so that 134 were known to have been diagnosed in New Zealand. Of these, 107 lived in Auckland or Wellington. Survival analysis using the Kaplan-Meier method showed that the median time from diagnosis to death was 58 weeks.