Engaging women in decision making about their heart health: A literature review with patients' perspective.

Cardiovascular disease (CVD) remains the leading cause of death globally. Although the burden of CVD risk factors tends to be lower in women, they remain at higher risk of developing complications when affected by these risk factors. There is still a lack of awareness surrounding CVD in women, both from a patient's and a clinician's perspective, especially among visible minorities. However, women who are informed about their heart health and who engage in decision-making with their healthcare providers are more likely to modify their lifestyle, and improve their CVD risk. A patient-centered care approach benefits patients' physical and mental health, and is now considered gold-standard for efficient patient care. Engaging women in their heart health will contribute in closing the gap of healthcare disparities between men and women, arising from sociocultural, socioeconomic and political factors. This comprehensive review of the literature discusses the importance of engaging women in decision-making surrounding their heart health and offers tools for an effective and culturally sensitive patient-provider relationship.

Blowing the whistle on mixed gender hospital rooms in Australia and New Zealand: a human rights issue.

The practice of placing men and women in the same hospital room (mixed gender rooms) has been prohibited in the UK National Health Service for over a decade. However, recent research demonstrates that the practice is common and increasing in a major New Zealand public hospital. Reports and complaints show that the practice also occurs in Australia. We argue that mixed gender rooms violate the fundamental human rights of personal security and dignity. The high rates of cognitive impairment, sensory impairment and frailty in hospital wards exacerbates the risk for these violations and subsequent harm. We argue for the adoption of specific national policies prohibiting mixed gender rooms and public reporting of breaches. Importantly, these guidelines can be adopted without compromising the rights of gender minorities. In the long term, hospitals should be built with single occupancy rooms.

Neurotuberculosis with paradoxical reaction treated with infliximab: case report and literature review.

Paradoxical reactions are immune-mediated disease exacerbations that can occur in Mycobacterium tuberculosis (TB) following initiation of treatment. They are rare, challenging to manage and often fatal. We present a case of neurotuberculosis in a young woman, complicated by a paradoxical reaction in which infliximab was trialled without success. This case demonstrates the severity of presentation that can occur in neurotuberculosis, and the complications that paradoxical reactions can present. It also highlights the difficulty of delivering palliative care within the context of communicable disease with challenges posed by both TB and the COVID-19 pandemic.

High penetrance, recurrent attacks and thrombus formation in a family with hereditary coproporphyria.

Hereditary coproporphyria (HCP) is the rarest of the autosomal dominant acute porphyrias with an estimated incidence of 0.02 per 10 million per year. HCP has been considered to be mild in presentation compared with the more common acute intermittent porphyria although there is limited information comparing the subtypes. Penetrance in the acute porphyrias is low with 90% of patients with a mutation never exhibiting symptoms. We present seven members from a family with HCP with a novel mutation in whom penetrance and severity are high. In addition, they appear to have a high rate of veno-thromboembolism. Penetrance is confirmed at 57% but is suspected to be 71%. The first patient experienced life-threatening complications, four of the seven have had recurrent attacks and the development of opioid dependence has complicated management. The case series documents the impact of a new mRNA interference molecule givosiran as well as a plan for embryo selection which is not commonly used in porphyria. The use of ketamine for the treatment of acute attacks is also documented for the first time in the porphyria literature. The use of international registries would aid the characterisation and management of this very rare disease.

Mixed gender accommodation: prevalence, trend over time and vulnerability of older adults.

Admitting male and female patients to the same room compromises the safety of female patients and violates the rights of all patients. We demonstrate that mixed bedding is common (47.22% of admissions), increasing and disproportionately affects vulnerable older patients in a large New Zealand hospital from 2011 to 2019 (n = 160 048). Eliminating mixed bedding should be a priority for our hospital system.

Revisiting the equity debate in COVID-19: ICU is no panacea.

Throughout March and April 2020, debate raged about how best to allocate limited intensive care unit (ICU) resources in the face of a growing COVID-19 pandemic. The debate was dominated by utility-based arguments for saving the most lives or life-years. These arguments were tempered by equity-based concerns that triage based solely on prognosis would exacerbate existing health inequities, leaving disadvantaged patients worse off. Central to this debate was the assumption that ICU admission is a valuable but scarce resource in the pandemic context.In this paper, we argue that the concern about achieving equity in ICU triage is problematic for two reasons. First, ICU can be futile and prolong or exacerbate suffering rather than ameliorate it. This may be especially true in patients with COVID-19 with emerging data showing that most who receive access to a ventilator will still die. There is no value in admitting patients with poor prognostic indicators to ICU to meet an equity target when intensive critical care is contrary to their best interests. Second, the focus on ICU admission shifts focus away from important aspects of COVID-19 care where there is greater opportunity for mitigating suffering and enhancing equitable care.We propose that the focus on equity concerns during the pandemic should broaden to include providing all people who need it with access to the highest possible standard of end-of-life care. This requires attention to culturally safe care in the following interlinked areas: palliative care, communication and decision support and advanced care planning.

Opioid Utilization and Perception of Pain Control in Hospitalized Patients: A Cross-Sectional Study of 11 Sites in 8 Countries.

BACKGROUND: Hospitalized patients are frequently treated with opioids for pain control, and receipt of opioids at hospital discharge may increase the risk of future chronic opioid use. OBJECTIVE: To compare inpatient analgesic prescribing patterns and patients' perception of pain control in the United States and non-US hospitals. DESIGN: Cross-sectional observational study. SETTING: Four hospitals in the US and seven in seven other countries. PARTICIPANTS: Medical inpatients reporting pain. MEASUREMENTS: Opioid analgesics dispensed during the first 24-36 hours of hospitalization and at discharge; assessments and beliefs about pain. RESULTS: We acquired completed surveys for 981 patients, 503 of 719 patients in the US and 478 of 590 patients in other countries. After adjusting for confounding factors, we found that more US patients were given opioids during their hospitalization compared with patients in other countries, regardless of whether they did or did not report taking opioids prior to admission (92% vs 70% and 71% vs 41%, respectively; P < .05), and similar trends were seen for opioids prescribed at discharge. Patient satisfaction, beliefs, and expectations about pain control differed between patients in the US and other sites. LIMITATIONS: Limited number of sites and patients/country. CONCLUSIONS: In the hospitals we sampled, our data suggest that physicians in the US may prescribe opioids more frequently during patients' hospitalizations and at discharge than their colleagues in other countries, and patients have different beliefs and expectations about pain control. Efforts to curb the opioid epidemic likely need to include addressing inpatient analgesic prescribing practices and patients' expectations regarding pain control.

A case of hereditary coproporphyria with posterior reversible encephalopathy and novel coproporphyrinogen oxidase gene mutation c.863T>G (p.Leu288Trp).

A 21-year-old female had recurrent presentations to the emergency department with myalgia, vomiting, abdominal pain and subsequently developed generalized seizures. She was volume depleted with a plasma sodium of 125 mmol/L (reference interval: 135-145) and she had fluctuating hypertension. Acute porphyria was suspected and confirmed with raised urine porphobilinogen/creatinine ratio of 12:4 µmol/mmoL (reference interval < 1:5) and she was treated with intravenous haem arginate. Urinary porphyrin/creatinine ratio was 673 nmol/mmoL (reference interval <35) and faecal porphyrins 2430 µmol/kg dry weight (reference interval: <200) were markedly elevated, with raised faecal CIII:CI ratio, consistent with acute coproporphyria. Diagnosis was confirmed by the demonstration of a novel missense variant in the coproporphyrinogen oxidase gene c.863T > G (p.Leu288Trp) predicted to be deleterious and which segregated with three other affected family members. Although CT head was normal, magnetic resonance imaging scan revealed symmetrical signal abnormalities and swelling in the parietal and occipital lobes consistent with posterior reversible encephalopathy. Over several days, her seizures ceased and sodium and blood pressure normalized. The aetiology of the acute porphyric attack was likely multifactorial with contributions from a recent viral illness and caloric deprivation. No drug precipitant was identified. We postulate that untreated hypertension played a key role in the development of posterior reversible encephalopathy. Early clinical suspicion and urine porphobilinogen testing are the key components in preventing morbidity and mortality in acute porphyrias.

Primary endometrial uterine Burkitt lymphoma in a 65-year-old woman.

•Primary Burkitt lymphoma of the uterus is a rare disease.•Differential of postmenopausal bleeding and night sweats should include lymphoma.•Outpatient endometrial sampling expedites diagnosis of endometrial malignancy.

Extensively drug-resistant tuberculosis: New Zealand's first case and the challenges of management in a low-prevalence country.

In 2010, an immigrant from Burma was the first person to be diagnosed in New Zealand with extensively drug-resistant tuberculosis (XDR-TB). The strain of Mycobacterium tuberculosis is the most resistant reported to date in Australasia. Key difficulties of managing this disease in a low-prevalence country were delays from drug-susceptibility testing and in acquiring appropriate medicines, and a lack of evidence-based guidelines. Solutions are needed for New Zealand and the wider region as more cases of XDR-TB are likely to be encountered in the future.

Walking to school: frequency and predictors among primary school children in Dunedin, New Zealand.

AIM: To estimate the frequency of walking to school among primary school children and examine associated factors. METHOD: In-class survey of Years 1-6 children attending Dunedin primary schools, November 2004, and a take home, written questionnaire for parents and caregivers. RESULTS: On study day, 34.5% of children walked to school and 36.8% intended to walk home. Overall, 1157 completed caregiver questionnaires were returned (68%) indicating that 47.5% of children walked to or from school less than three times per week. The strongest predictor of walking was proximity to school (<1 km OR 29.3, 1-2 km OR 7.7, 2-3 km OR 3.0, >3 km OR 1.00). Other predictors were not having a car in the household (OR 10.9), attending a (low socioeconomic) decile 2 to 4 school (2.35), having three or more adults in the household (1.85), being in a higher school year (1.72), having non-New Zealand European ethnicity (>1.41), having a parent who had walked to school (1.35), and being male (1.33). CONCLUSIONS: This study established a baseline for the percentage of Dunedin primary school children walking to school. Key potentially modifiable predictors of walking were proximity to school and not having a car in the household. These findings have implications for health, transport and educational policies.

Stem cells: public policy and ethics.

Debate on the regulation of human stem cells needs to bring together scientific, ethical and policy considerations if it is to be adequately informed. Scientific issues of importance include the relevance of the environment in appreciating the extent of stem cell plasticity, and the relative potential of embryonic and adult stem cells to produce other cell types. An awareness that blastocysts (early embryos) and stem cells in the laboratory are pluripotential and not totipotential has implications for ethical and policy debate. The regulations on stem cell research are reviewed, showing that four positions have emerged. Position A corresponds to the prohibition of all embryo research, position B confines the use of embryonic stem cells to those currently in existence and therefore extracted prior to some specified date, position C allows for the use and ongoing isolation of embryonic stem cells from surplus in vitro fertilization embryos, and position D approves of the creation of human embryos specifically for research. Position B which has been adopted by the United States, Germany, and Australia (with subtle differences between them) and which is regarded as a compromise position, is critiqued. This is principally on the basis that, in spite of claims made about it, the ongoing destruction of human embryos will continue. This is because these countries allow in vitro fertilization programs, inherent within which is embryo destruction. It is argued that position C would be a more consistent ethical position for these countries. The possibility of moving to position D is also raised.

The Orewa Speech: another threat to Maori health?

In early 2004, Dr Don Brash, leader of the National Party (New Zealand's opposition political party), gave a speech to a community group regarding what he perceived to be the preferential treatment of Maori in health and education policies. This viewpoint article is written by a group of concerned medical students at Otago University. It argues that epidemiological data provide strong support for specifically addressing Maori health need, whilst the Treaty of Waitangi represents a contractual obligation on behalf of the New Zealand Government to ensure equity of outcome for Maori. Underpinning both the epidemiological and legal arguments, are ethical principles. The central tenets of medicine (ie, to reduce suffering, and to improve and prolong the quality and length of life) should provide a strong driving force to address these inequalities.