Impact of the COVID-19 related border restrictions on influenza and other common respiratory viral infections in New Zealand

BACKGROUND

New Zealand's (NZ) complete absence of community transmission of influenza and respiratory syncytial virus (RSV) after May 2020, likely due to COVID-19 elimination measures, provided a rare opportunity to assess the impact of border restrictions on common respiratory viral infections over the ensuing 2 years.

METHODS

We collected the data from multiple surveillance systems, including hospital-based severe acute respiratory infection surveillance, SHIVERS-II, -III and -IV community cohorts for acute respiratory infection (ARI) surveillance, HealthStat sentinel general practice (GP) based influenza-like illness surveillance and SHIVERS-V sentinel GP-based ARI surveillance, SHIVERS-V traveller ARI surveillance and laboratory-based surveillance. We described the data on influenza, RSV and other respiratory viral infections in NZ before, during and after various stages of the COVID related border restrictions.

RESULTS

We observed that border closure to most people, and mandatory government-managed isolation and quarantine on arrival for those allowed to enter, appeared to be effective in keeping influenza and RSV infections out of the NZ community. Border restrictions did not affect community transmission of other respiratory viruses such as rhinovirus and parainfluenza virus type-1. Partial border relaxations through quarantine-free travel with Australia and other countries were quickly followed by importation of RSV in 2021 and influenza in 2022.

CONCLUSION

Our findings inform future pandemic preparedness and strategies to model and manage the impact of influenza and other respiratory viral threats.

Developing a national primary care research network: a qualitative study of stakeholder views

Introduction Primary care research is critical to address Aotearoa New Zealand's (NZ) health sector challenges. These include health inequities, workforce issues and the need for evaluation of health system changes. Internationally, primary care data are routinely collected and used to understand these issues by primary care research and surveillance networks (PCRN). NZ currently has no such infrastructure. Aim To explore health sector stakeholders' views on the utility of, and critical elements needed for, a national PCRN in NZ. Methods Twenty semi-structured interviews and a focus group were conducted with key stakeholders, representing different perspectives within the health sector, including Hauora Māori providers. Data were analysed thematically. Results Six themes were identified that included both challenges within current primary care research and ideas for a future network. The themes were: disconnection between research, practice and policy; desire for better infrastructure; improving health equity for Māori and other groups who experience inequity; responding to the research needs of communities; reciprocity between research and practice; and the need for data to allow evidence-informed decision-making. Improving health equity for Māori was identified as a critical function for a national PCRN. Discussion Stakeholders identified challenges in conducting primary care research and translating research into practice and policy in NZ. Stakeholders from across the health sector supported a national PCRN and identified what its function should be and how it could operate. These views were used to develop a set of recommendations to guide the development of a national PCRN.

Structural discrimination in the COVID-19 vaccination programme for people with mental health and addiction issues: now is the time to be equally well

People with mental health and substance use issues (tāngata whai ora katoa), regardless of ethnicity, are much more likely to be hospitalised or die from COVID-19 and were identified as a priority population (Priority Group 3) in Aotearoa New Zealand's vaccination roll-out plan. Data released by the Ministry of Health show that, despite tāngata whai ora katoa being a priority group, their vaccination rates are well below those of the general population. These inequities are pronounced for Māori with mental health and addiction issues (tāngata whai ora Māori). This is not acceptable. To support tāngata whai ora physical health and wellbeing, the onus is on all of us in the health system to actively reach out, have conversations, be supportive and provide accessible vaccination for people with mental health and addiction issues. Urgent action is needed. Now is the time to ensure tāngata whai ora katoa can be equally well.

Addressing structural discrimination: prioritising people with mental health and addiction issues during the COVID-19 pandemic

Structural discrimination worsens physical health inequities and significantly reduces life expectancy for people with mental health and addiction issues. Aotearoa has recently made some notable changes in health policy by formally recognising the physical health needs of people with mental health and addiction issues. The COVID-19 vaccination sequencing framework provides an important opportunity to protect and promote the health of people with addiction and mental health issues. An expert advisory group, convened as part of the Aotearoa Equally Well collaborative, considered findings of a literature review on the vulnerability of people with mental health and addiction issues of contracting and dying from COVID-19. Evidence indicates an association between mental health and addiction issues and infection risk and worse outcomes. The group concluded mental health and addiction issues should be recognised as underlying health conditions that increase COVID-19 vulnerability, and that people with these issues should be prioritised for vaccination. For too long the health system has failed to address the life expectancy gap of people with addiction and mental health issues. Now is an opportunity to change the kōrero. People with mental health and addiction issues experience significant physical health inequities. Addressing these inequities must be integral in modern health policy-including our COVID-19 pandemic response.

Addressing structural discrimination: prioritising people with mental health and addiction issues during the COVID-19 pandemic

Structural discrimination worsens physical health inequities and significantly reduces life expectancy for people with mental health and addiction issues. Aotearoa has recently made some notable changes in health policy by formally recognising the physical health needs of people with mental health and addiction issues. The COVID-19 vaccination sequencing framework provides an important opportunity to protect and promote the health of people with addiction and mental health issues. An expert advisory group, convened as part of the Aotearoa Equally Well collaborative, considered findings of a literature review on the vulnerability of people with mental health and addiction issues of contracting and dying from COVID-19. Evidence indicates an association between mental health and addiction issues and infection risk and worse outcomes. The group concluded mental health and addiction issues should be recognised as underlying health conditions that increase COVID-19 vulnerability, and that people with these issues should be prioritised for vaccination. For too long the health system has failed to address the life expectancy gap of people with addiction and mental health issues. Now is an opportunity to change the kōrero. People with mental health and addiction issues experience significant physical health inequities. Addressing these inequities must be integral in modern health policy-including our COVID-19 pandemic response.

Impact of the COVID-19 nonpharmaceutical interventions on influenza and other respiratory viral infections in New Zealand

Stringent nonpharmaceutical interventions (NPIs) such as lockdowns and border closures are not currently recommended for pandemic influenza control. New Zealand used these NPIs to eliminate coronavirus disease 2019 during its first wave. Using multiple surveillance systems, we observed a parallel and unprecedented reduction of influenza and other respiratory viral infections in 2020. This finding supports the use of these NPIs for controlling pandemic influenza and other severe respiratory viral threats.

Why are we hiding? A qualitative exploration of New Zealand acupuncturists views on interprofessional care

BACKGROUND

In recent years more health service users are utilising complementary and alternative medicine (CAM), including acupuncture, for the management of their health. Currently general practitioners (GPs), in most cases, act as the primary provider and access point for further services and also play an important role in integrated care management. However, the interaction and collaboration between GPs and acupuncturists in relation to shared care has not been investigated. This research explored interprofessional communication between GPs and acupuncturists in New Zealand. This article reports specifically the acupuncturists' viewpoints.

METHODS

This study formed part of a larger mixed methods trial investigating barriers and facilitators to communication and collaboration between acupuncturists and general practitioners in New Zealand. Semi structured interviews of 13 purposively sampled acupuncture participants were conducted and analysed using thematic analysis.

RESULTS

The data analysis identified both facilitators and barriers to integrative care. Facilitators included a willingness to engage, and the desire to support patient choice. Barriers included the limited opportunities for sharing of information and the lack of current established pathways for communication or direct referrals. The role evidence played in integrative practice provided complex and contrasting narratives.

CONCLUSIONS

This research contributes to the body of knowledge concerning communication and collaboration between GPs and acupuncturists, and suggests that by facilitating communication and collaboration, acupuncture can provide a significant component of integrated care packages. This research provides context within a New Zealand health care setting, and also provides insight through the disaggregation of specific provider groups for analysis, rather than a grouping together of CAM as a whole.

Clinical guidelines: what happens when people have multiple conditions?

More people now live with multimorbidity than with a single long-term condition. Despite this, clinical guidelines remain focused on the management of individual conditions. When the treatment recommendations from multiple different disease-specific guidelines are combined for one individual it frequently leads to interactions between treatments, along with a high burden of treatment for patients. It is also recognised that people with multimorbidity are often excluded from the trials that generate the underlying evidence for these guidelines, and that treatment goals from guidelines often fail to align with patient goals. This viewpoint discusses the main issues with applying disease-specific guidelines to individuals with multiple long-term conditions, and presents a set of eight recommendations to improve care for people with multimorbidity in New Zealand.

A walking stick in one hand and a chainsaw in the other: patients' perspectives of living with multimorbidity

AIMS

Multimorbidity is common, yet there are major gaps in research, particularly among younger and indigenous populations. This research aimed to understand patients' perspectives of living with multimorbidity.

METHODS

A qualitative study of 61 people living with multimorbidity, 27 of whom were Māori and a third aged under 65, from urban and rural regions in New Zealand. Six focus groups and 14 interviews were conducted, recorded, transcribed and analysed.

RESULTS

For many participants, living with multimorbidity disrupted their 'normal' lives, posing challenges in everyday activities such as eating and toileting, working and managing medications. Dealing with the health system posed challenges such as accessing appointments and having enough time in consultations. Cultural competency, good communication and continuity of care from healthcare providers were all valued. Participants had many recommendations to improve management, including a professional single point of contact to coordinate all specialist care.

CONCLUSIONS

Living with multimorbidity is often challenging requiring people to manage their conditions while continuing to live their lives. This research suggests changes are needed in the health system in New Zealand and elsewhere to better manage multimorbidity thus improving patient's lives and reducing costs to the health sector and wider society.

Nurse-patient communication in primary care diabetes management: an exploratory study

BACKGROUND

Diabetes is a major health issue for individuals and for health services. There is a considerable literature on the management of diabetes and also on communication in primary care consultations. However, few studies combine these two topics and specifically in relation to nurse communication. This paper describes the nature of nurse-patient communication in diabetes management.

METHODS

Thirty-five primary health care consultations involving 18 patients and 10 nurses were video-recorded as part of a larger multi-site study tracking health care interactions between health professionals and patients who were newly diagnosed with Type 2 diabetes. Patients and nurses were interviewed separately at the end of the 6-month study period and asked to describe their experience of managing diabetes. The analysis used ethnography and interaction analysis.In addition to analysis of the recorded consultations and interviews, the number of consultations for each patient and total time spent with nurses and other health professionals were quantified and compared.

RESULTS

This study showed that initial consultations with nurses often incorporated completion of extensive checklists, physical examination, referral to other health professionals and distribution of written material, and were typically longer than consultations with other health professionals. The consultations were driven more by the nurses' clinical agenda than by what the patient already knew or wanted to know. Interactional analysis showed that protocols and checklists both help and hinder the communication process. This contradictory outcome was also evident at a health systems level: although organisational targets may have been met, the patient did not always feel that their priorities were attended to. Both nurses and patients reported a sense of being overwhelmed arising from the sheer volume of information exchanged along with a mismatch in expectations.

CONCLUSIONS

Conscientious nursing work was evident but at times misdirected in terms of optimal use of time. The misalignment of patient expectations and clinical protocols highlights a common dilemma in clinical practice and raises questions about the best ways to balance the needs of individuals with the needs of a health system. Video- recording can be a powerful tool for reflection and peer review.

PSA screening in New Zealand: total population results and general practitioners' current attitudes and practices

AIMS

Prostate cancer is the second most common cancer among men in New Zealand. Prostate-specific antigen (PSA) as a screening tool for prostate cancer remains controversial. The aim was to determine the rate of PSA screening in New Zealand and to survey general practitioners' utility of PSA and their attitudes towards PSA screening.

METHOD

A questionnaire was sent to 1000 general practitioners (GPs). In addition, a non-identifiable prospective audit of all registered New Zealand GPs' laboratory PSA tests was accessed for 2011.

RESULTS

Of the 931,923 males older than 40 years, 267,037 had a PSA test performed (28.3%). This percentage peaked in the 65-75 age group (45%). 263 GP questionnaires were completed. 79% of all GPs would initiate discussion of PSA testing. The most common method of testing was at a time of another health need or check-up.

CONCLUSION

The incidence of yearly PSA testing in the New Zealand male population over the age of 40 is 28%. GPs provide appropriate information for men to make an informed decision about PSA screening. There is an increasing population of GPs who will not initiate any discussion of PSA testing in their male patients.

Every child to thrive, belong and achieve? Time to reflect and act in New Zealand

New Zealand continues to grapple with poor and inequitable child health and wellbeing outcomes. The associated high economic costs, the long-term impact on adult health and New Zealand's international children's rights obligations provide further grounds for action. Although there have been many different reports offering solutions and some key areas of progress, gains have been limited and there has not been sufficient clarity and agreement on wider actions. The environment is complex and solutions cross agency and disciplinary boundaries. This paper reviews the current situation and proposes a set of actions to improve child health and equity. These include a group of recommendations on high-level leadership and coordination, actions to address social conditions, and a range of specific health and wellbeing actions. Progress will require the will, commitment and courage of many to acknowledge the issues and find a way forward. Preventing suffering and ensuring the wellbeing of our youngest citizens during their formative years is an ethical issue for our nation, an issue of what we value as a society, and the best investment for a highly productive, innovative and resilient nation for the future.

New Zealand general practice nurses' roles in mental health care

AIM

To examine the roles of nurses in general practice interdisciplinary teams caring for people with mild to moderate mental health conditions.

BACKGROUND

Supporting mental health and well-being is an important aspect of primary care. Until now nurses in general practice settings have had variable roles in providing mental health care. The New Zealand Primary Mental Health Initiatives are 26 government-funded, time-limited projects using different service delivery models.

METHODS

An analysis was undertaken of a qualitative data set of interviews, which included commentary about nurses mental health work collected from the different project stakeholders throughout a 29-month external evaluation.

FINDINGS

Two main groups of roles for nurses within the general practice interdisciplinary team were identified: specialist mental health nurses working in newly created roles and practice nurses working in existing roles. Barriers exist to the development of the latter roles.

CONCLUSIONS

Mental health care is a key role in general practice as this is where people frequently present. Internationally, nurses represent a large workforce with the potential to provide effective mental health care. This study found that attitudinal, structural and professional barriers are restricting New Zealand practice nurse role development in the care of those with mild to moderate mental health conditions. There is potential to develop their role within a structured pathway by workforce development and recognition of the value of interdisciplinary care. Given the shortage of mental health professionals this will be an important aspect of the improvement of primary mental health care.

Primary health care funding for children under six years of age in New Zealand: why is this so hard?

The intention of this viewpoint article is to prompt discussion and debate about primary health care funding for children under the age of six. While New Zealand offers a superb natural environment for childhood, our child health outcomes continue to be poor, ranking lowest amongst 29 countries in a recent report by the Organisation for Economic Co-operation and Development. Since 1996, various funding arrangements have been introduced with the goal of achieving free primary health care for children under six years of age and nearly 80% of practices now offer care to this group without charge. Universal no cost or very low cost access for young children, however, remains elusive, particularly for after-hours care, and this is important given that at least one in five children lives in poverty. We are under no illusions about the complexity of primary care funding mechanisms and the challenges of supporting financially-sustainable systems of after-hours care. Good health care early in life, however, is a significant factor in producing a healthier and more productive adult population and improving access to primary care lessens the impact of childhood illness. We suggest that reducing cost barriers to primary care access for young children should remain an important target, and recent examples show that further reductions in cost for primary care visits for young children, including after-hours, is possible. Further funding is needed to make this widespread, in conjunction with innovative arrangements between funding authorities, primary care providers, and emergency departments. We encourage further debate on this topic with a view to resolving the question of whether the goal of free child health care for young children in New Zealand can be realised.

Viewpoint: Primary health care funding for children under six years of age in New Zealand: why is this so hard?

The intention of this viewpoint article is to prompt discussion and debate about primary health care funding for children under the age of six. While New Zealand offers a superb natural environment for childhood, our child health outcomes continue to be poor, ranking lowest amongst 29 countries in a recent report by the Organisation for Economic Co-operation and Development. Since 1996, various funding arrangements have been introduced with the goal of achieving free primary health care for children under six years of age and nearly 80% of practices now offer care to this group without charge. Universal no cost or very low cost access for young children, however, remains elusive, particularly for after-hours care, and this is important given that at least one in five children lives in poverty. We are under no illusions about the complexity of primary care funding mechanisms and the challenges of supporting financially-sustainable systems of after-hours care. Good health care early in life, however, is a significant factor in producing a healthier and more productive adult population and improving access to primary care lessens the impact of childhood illness. We suggest that reducing cost barriers to primary care access for young children should remain an important target, and recent examples show that further reductions in cost for primary care visits for young children, including after-hours, is possible. Further funding is needed to make this widespread, in conjunction with innovative arrangements between funding authorities, primary care providers, and emergency departments. We encourage further debate on this topic with a view to resolving the question of whether the goal of free child health care for young children in New Zealand can be realised.

How could depression guidelines be made more relevant and applicable to primary care? A quantitative and qualitative review of national guidelines

BACKGROUND

Many guidelines have been developed in the area of depression but there has been no systematic assessment of their relevance to general practice.

AIM

To assess national guidelines on general practice management of depression using two complementary approaches to identify specific ways in which guidance could be made more relevant and applicable to the nature of general practice and the patients who seek help in this context.

DESIGN OF STUDY

Review of national guidelines.

SETTING

Seven English speaking countries: UK, US, Australia, New Zealand, Ireland, Canada, and Singapore.

METHOD

Seven guidelines were independently reviewed quantitatively using the Appraisal of Guidelines for Research and Evaluation (AGREE) scores and qualitatively using thematic coding.

RESULTS

The quantitative assessment highlights that most of the guidelines fail to meet the criteria on rigour of development, applicability, and editorial independence. The qualitative assessment shows that the majority of guidelines do not address associated risk factors sufficiently and the dilemma of diagnostic uncertainty flows over into management recommendations. Management strategies for depression (antidepressants and psychological strategies) are supported by all of the guidelines, with several listing drugs before psychological therapies; there is limited attention paid to the different types of psychological therapies. Moreover, the guidelines in the main fail to acknowledge individual patient circumstances, in particular the influence on response to treatment of social issues such as adverse life events or social support.

CONCLUSION

Assessments of current national guidelines on depression management in general practice suggest significant limitations in their relevance to general practice.

DeLLITE depression in late life: an intervention trial of exercise. Design and recruitment of a randomised controlled trial

Background

Physical activity shows potential in combating the poor outcomes associated with depression in older people. Meta-analyses show gaps in the research with poor trial design compromising certainty in conclusions and few programmes showing sustained effects.

Methods/design

The Depression in Late Life: an Intervention Trial of Exercise (DeLLITE) is a 12 month randomised controlled trial of a physical activity intervention to increase functional status in people aged 75 years and older with depressive symptoms. The intervention involves an individualised activity programme based on goal setting and progression of difficulty of activities delivered by a trained nurse during 8 home visits over 6 months. The control group received time matched home visits to discuss social contacts and networks. Baseline, 6 and 12 months measures were assessed in face to face visits with the primary outcome being functional status (SPPB, NEADL). Secondary outcomes include depressive symptoms (Geriatric Depression Scale), quality of life (SF-36), physical activity (AHS Physical Activity Questionnaire) and falls (self report).

Discussion

Due to report in 2008 the DeLLITE study has recruited 70% of those eligible and tests the efficacy of a home based, goal setting physical activity programme in improving function, mood and quality of life in older people with depressive symptomatology. If successful in improving function and mood this trial could prove for the first time that there are long term health benefit of physical activity, independent of social activity, in this high risk group who consume excess health related costs.

Trial registration

Australian and New Zealand Clinical Trials Register ACTRN12605000475640

Panning for gold: an evidence-based tool for assessment of performance indicators in primary health care

It is important that debate occurs between theorists, policy makers, clinicians and service end-users to develop agreement over suitable and appropriate indicators for primary health care. A formal accounting of the relative strengths and weaknesses of any proposed indicator will enable sector commentators from a variety of viewpoints to discuss the relative merits of individual indicators, to understand the political and pragmatic reasons for their inclusion in any set of indicators and to trace the likely organisational impact of any given indicator. This paper details the development of an indicator appraisal tool that combines the assessment of scientific evidence with contextual considerations from the perspective of both the policy environment and the primary health care sector. The use of the tool is discussed in the context of the proposed national implementation of a set of performance indicators in New Zealand.

Māori women and menopause

Māori are the indigenous people of New Zealand who in total make up 14.5% of the population. Although this group has a significantly lower life expectancy than non-Māori, coupled with increased rates of mortality and morbidity, very little is known about the menopausal health needs of older Māori women. As the first step in addressing the health needs of this group, older Māori women's definitions, attitudes, symptoms, expectations and health needs at menopause need to be identified and described. The study Ngā Ruahine or "Māori in Menopause" is the foundation study of the Aotearoa Women's Health Initiative (AWHI). AWHI is a women's health programme being developed by the Wellington School of Medicine, which involves a suite of studies. The objective is to describe the journey of older Māori women through menopause and beyond and to compare and contrast the experience of Māori women from both traditional and contemporary upbringings, with reference to the Pākehā (European) population. It is hoped that this work could lead to further studies such as, for example, a longitudinal observational study looking at older New Zealand women. The potential significance of this approach is discussed.

Early detection of differences in surgical outcome for cleft lip and palate

This study examined the dento-alveolar relationships of 5-year-old children born with a unilateral cleft lip and palate with primary surgical repair performed in one of two centres (Bristol or Oslo). The Bristol sample comprised 46 sets of study models and the Oslo CLP Growth Archive provided 54 cases with a very similar sex distribution. We used a recently developed 5-year-old index to measure differences in outcome between the two centres. The Oslo sample were assessed as having up to 57 per cent in the ideal groupings (1 and 2), in the Bristol group this was only 35 per cent. Bristol had up to 46 per cent of cases assessed in the worst groups (4 and 5). The comparative figure from the Oslo group was 15 per cent. These results suggest that it is possible to detect differences in surgical outcome at 5 years of age.

Satisfaction with facial appearance among subjects affected by a cleft

OBJECTIVE

This study examined the satisfaction of patients with clefting and their parents with facial appearance and how this alters with age. The relationship between satisfaction with appearance and psychosocial functioning was also examined.

DESIGN

Prospective

SETTING

Subjects were recruited for the study from nine hospital-based clinics. PARENTS, PARTICIPANTS: All subjects has some type of cleft and were 10, 15 or 20 years of age. In all, 111 subjects with clefting and 62 parents were included.

MAIN OUTCOME MEASURES

Facial appearance was rated on a subjective ordinal scale of 1 to 7; psychosocial adjustment was measured with the Childhood Experience Questionnaire.

RESULTS

Self-satisfaction with appearance among the 10- and 15-year-old subjects correlated with their psychosocial adjustment (p = .027). The 20-year-old subjects were, on average, significantly more satisfied with their appearance than the 10- and 15-year-olds (p = .009 and p = .012, respectively). However, some 20-year-old subjects remained greatly dissatisfied with aspects of their facial appearance. Subjects with visible anomalies were significantly more dissatisfied with their appearance than subjects with invisible anomalies (p = .035). The 15-year-old subjects were identified as being significantly more dissatisfied with appearance than their parents (p = .005).

CONCLUSIONS

Subjects affected by a cleft with visible impairments are more dissatisfied with their facial appearance than are subjects with invisible impairments. Satisfaction with facial appearance among 10- and 15-year-old subjects with a cleft may be associated with their self-reported levels of psychosocial functioning. Measuring self-satisfaction with appearance may help to identify subjects at risk from adjustment problems.

A new index for assessing surgical outcome in unilateral cleft lip and palate subjects aged five: reproducibility and validity

OBJECTIVE

This study assessed the reproducibility, reliability, and predictive validity of a previously developed index by the authors for assessing surgical outcome in unilateral cleft lip and palate (UCLP) children aged 5.

METHODS

Sixty randomly selected study models of 5- to 6-year-old complete UCLP subjects were obtained and the index was used to assess their surgical outcomes.

RESULTS

Assessment of these study models using the new index demonstrated excellent intra-examiner agreement. The inter-examiner agreement was shown to be good. The corresponding longitudinal models at 16 to 18 years of 54 of the initial 5- to 6-year-old sample were also acquired. These subjects had undergone orthodontic treatment but not orthognathic surgery. The need for osteotomy amongst these models was assessed. Between 13% and 18% (depending on examiner) of 5-year-olds' models were scored in the groups likely to require orthognathic surgery. In the corresponding 16- to 18-year-olds' models, 9% were assessed as likely to benefit from an osteotomy. However, on an individual basis, it was not possible to predict future growth from study models at age 5.

CONCLUSIONS

This study has provided a reliable and reproducible index for assessing the outcome of surgery in UCLP subjects earlier than indices already available. True validation of the index was not possible but it appears that it relies on face validity.

Psychological outcomes amongst cleft patients and their families

Our aims were to determine the psychological status of a sample of cleft lip and palate patients and their parents using standardised interviews and to assess subjects' satisfaction with cleft treatment. In all, 242 interviews of 112 patients and 130 parents were carried out in nine base hospitals used for cleft treatment. 73% (n = 38) of 15- and 20-year-old subjects felt their self-confidence had been very much affected as a result of their cleft. 60% of all 112 interviewed patients were teased about speech or cleft related features. A significant minority of 15-year-old subjects (23%, n = 7) felt excluded from treatment planning decisions. Despite high levels of overall satisfaction with cleft care, 60% (n = 78) of parents and 37% (n = 41) of interviewed patients made suggestions for improvements. No agreement between parent/child pairs for their satisfaction with clinical outcome of cleft related features was found using the weighted kappa statistic to determine the level of agreement. Differences between parents' and their child's satisfaction ratings for cleft related features were not statistically significant except for the ratings for 'lip' (P < 0.005) and 'teeth' (P < 0.05) for 15-year-old subjects (Wilcoxon signed rank sum test). Patients' views on planned treatment should therefore be independently sought from their parents' views, as no agreement was found within the groups for perceived satisfaction with clinical outcome. This study demonstrates the importance of identifying 'psychological outcome' as well as 'clinical outcome' in order to improve rehabilitation for cleft lip and palate patients. Seven families were referred for counselling for cleft-associated emotional problems as a result of this survey.

The use of oral dehydroepiandrosterone sulfate as an adjuvant in tetanus and influenza vaccination of the elderly

Elderly individuals often exhibit a poorer immune response and shorter duration of immunity to vaccines than younger persons. Improvement in vaccine response has been demonstrated when administering the hormone dehydroepiandrosterone sulfate (DHEAS) as an adjuvant in animal trials. Two separate, randomized double-blinded vaccine trials were therefore conducted using DHEAS as an oral adjuvant in individuals age 65 or older. Sixty-six individuals were randomized to DHEAS, 50 mg po bid for 4 days, or a placebo capsule. Tetanus vaccination was given immediately before the fifth dose. At entry the level of protective antibody was age-dependent (P = 0.009), and by 28 days post-vaccination most individuals had protective levels of antibody, with no difference noted between treatment groups. In the second study, 67 individuals received placebo capsules or DHEAS immediately before and 24 h after influenza vaccination. The number of individuals who developed protective titers (> or = 1:40) was not different in the two groups. The mean log increase in HAI response was greater in the DHEAS group to all three vaccine components, although this did not achieve significance. Minimal side-effects of DHEAS administration were noted. Given the trend toward improved response in the elderly to influenza, larger trials using DHEA as an adjuvant in vaccines that are neoantigens may be indicated.

DHEAS as an effective vaccine adjuvant in elderly humans. Proof-of-principle studies

We have demonstrated that in aged mice, the titer of serum antibody induced against tetanus toxoid correlates with resistance to local paralysis caused by injection of tetanus toxin. Only mice immunized shortly after oral dosing with DHEAS demonstrated high serum antibody titers and complete protection from paralysis. These results became the basis for initiating proof-of-principle studies in human volunteers above age 65 using a licensed influenza vaccine and tetanus toxoid in two independent studies. The use of an oral delivery form of DHEAS before influenza vaccination was associated with a demonstrable increase in the number of individuals with a fourfold increase in HAI titers following vaccination. The overall mean increase in HAI titers was highest in the DHEAS-treated group. The use of DHEAS in the immunization of elderly subjects against tetanus toxoid, while unable to enhance the responses, was not a detriment to antibody response. We conclude that further studies will justify the use of DHEAS as an adjuvant for antigens that represent primary responses in the elderly.

The effect of patient ethnicity on prescribing rates

The issuing of a prescription is central to any doctor-patient interaction. Prescribing variation exists and remains largely unexplained. There is little documented evidence of the effect of patient ethnicity on prescribing patterns. We carried out a secondary analysis of data from the General Household Surveys to examine the association between being given a prescription and patient ethnicity. After modelling, we found that Pakistanis and Indians were significantly more likely to receive a prescription from their general practitioner at a consultation compared to white and West Indian ethnic groups. In addition, consultation rate explained the different prescribing rates among women and men in the white group only. This study raises further questions of the underlying reasons causing these differences which need answering.

Platelet-derived growth factor is a potent biologic response modifier of T cells

Freshly isolated lymph node (LN) cells cultured in serum-containing medium were restricted to produce primarily interleukin 2 (IL-2) subsequent to T cell activation. Only minimal amounts of IL-4, IL-5, or interferon gamma (IFN-gamma) were produced under these conditions. Similar populations of LN cells cultured in serum-free medium were able to produce a variety of lymphokines after T cell activation, with the relative quantities of each species being dependent upon the lymphoid organ source of the lymphocytes. A similar relationship in the patterns of lymphokines produced by activated T cell hybridomas maintained under serum-free conditions was also observed, whereas activation in serum-supplemented media resulted in a predominant restriction to the secretion of IL-2. Additional studies determined that the entity in serum responsible for restricting T cell function in vitro was platelet-derived growth factor (PDGF). The PDGF-BB isoform was established to be the most active in the regulation of T cell function, enhancing IL-2 while depressing the production of IL-4, IL-5, and IFN-gamma at concentrations below 1 ng/ml. PDGF-AB was also found to be quite active, however, this isoform of PDGF was incapable of influencing IFN-gamma production at the concentrations tested. PDGF-AA was very weakly active. It therefore appears that PDGF, acting primarily through a beta receptor subunit (either alpha/beta- or beta/beta-type receptors) is able to influence profoundly the behavior of T cells, with some of its modulatory effects exhibiting isoform specificity. This is reflected by an enhancement in the production of IL-2, while simultaneously depressing the secretion of IL-4, IL-5, and IFN-gamma (PDGF-BB only) after T cell activation. Kinetic studies, where cell supernatants were analyzed both 24 and 48 h after T cell activation, suggested that "desensitization" to PDGF influences can occur naturally in vitro. Those species of lymphokines that were inhibited by PDGF over the first 24 h after activation could be produced at normal levels over the subsequent 24-h period. Finally, lymphokines maintained in the presence of PDGF-BB for greater than 24 h before their activation lost sensitivity to this growth factor. These cells regained responsiveness to PDGF after an additional incubation period in PDGF-free medium. Collectively, our data imply that the pattern of T cell lymphokines produced, plus the kinetics of their production after activation, are being controlled by the potent serum growth factor PDGF.(ABSTRACT TRUNCATED AT 400 WORDS)

Dihydrotestosterone exerts a depressive influence on the production of interleukin-4 (IL-4), IL-5, and gamma-interferon, but not IL-2 by activated murine T cells

The present study examined the effects of the androgen steroid, dihydrotestosterone (DHT), on murine T-cell production of a number of lymphokines. Direct exposure of murine T cells to DHT in vitro was found to reduce the amount of interleukin-4 (IL-4), IL-5, and gamma-interferon (gamma IFN) produced after activation with anti-CD3 without affecting the production of IL-2. Exposure of T cells to either androstenedione or testosterone (the metabolic precursors of DHT) affected no change in the biosynthesis of either of these lymphokines. We have determined that macrophages possess 5 alpha-reductase, and are thus competent to metabolize testosterone to DHT. This physicochemical information is complemented by a functional analysis of macrophage metabolism of testosterone. By incubating bone marrow macrophages with testosterone, before their use as accessory cells, the IL-4 and IL-5 producing potential of the activated T cells cocultured with them was depressed. That the observed effect was mediated by the conversion of testosterone to DHT was further corroborated by illustrating that the inhibition of IL-4 production was abrogated if 4MA, a specific 5 alpha-reductase inhibitor, was added to macrophage cultures containing testosterone. The biologic role of DHT in lymphokine and immune response regulation in vivo was addressed using several lines of investigation. First, transdermal delivery of DHT to groups of mice altered the capacity of T cells residing in the draining lymph nodes, only, to produce lymphokines. Second, treatment of either aged mice or the T cells isolated from them with a combination of dehydroepiandrosterone and DHT restored the capacity of their T cells to produce IL-2, IL-4, and gamma IFN to levels equivalent to that of younger mice. Finally, we observed a difference between males and females of a given age to produce IL-2, IL-4, and gamma IFN, with both IL-4 and gamma IFN production being elevated in females. Collectively, our findings indicate that DHT, similar to other steroid hormones, may play an important role in lymphokine regulation in vivo.

Regulation of murine lymphokine production in vivo. Ultraviolet radiation exposure depresses IL-2 and enhances IL-4 production by T cells through an IL-1-dependent mechanism

The exposure of experimental animals to the inflammatory effects of ultraviolet radiation (UVR) is known to cause depressions in their ability to initiate and effectuate various types of cellular immune responses. Contact-type and delayed-type hypersensitivity, plus the ability to generate protective forms of anti-viral and anti-tumor immunity, are all affected by the prior exposure of normal animals to the effects of this physical agent. Presently, the cellular and molecular mechanism(s) responsible for mediating the changes in immune function observed in UVR-exposed animals is not fully understood. Herein we report that one reproducible consequence of exposing normal mice to low doses of UVR is a dramatic change in the pattern of lymphokines secreted by their activated T cells. Lymphocytes isolated from UVR-exposed donors produce/secrete greatly reduced levels of the T cell lymphokines IL-2 and IFN-gamma activation in vitro with protein Ag of the polyclonal T cell stimulant anti-CD3. The secretion of IL-4 by these lymphocyte cultures, however, is consistently elevated in comparison to normal controls. Further studies determined that a similar change in lymphokine production was induced when mice were treated with either bacterial LPS or rIL-1 beta, a cytokine known to be elevated in vivo after UVR or LPS exposure. The ability of IL-1 to facilitate a change in the capacity of T lymphocytes to produce/secrete lymphokines after in vitro activation does not appear to represent a direct effect of this cytokine on lymphocyte or accessory cell targets because addition of IL-1 beta to cultures of Ag-primed lymphocytes obtained from normal donors was incapable of altering the pattern of lymphokine production. Collectively, our present results add further support to the hypothesis that UVR-induced elevations in endogenous IL-1 are, in part, responsible for the immunomodulatory effects of UVR. These findings provide compelling evidence that UVR, plus other agents capable of endogenously stimulating the production of IL-1, may function to alter the expression of different effector mechanisms in vivo. This could be facilitated through selective reductions in lymphokines produced by Th-1-type cells (IL-2 and IFN-gamma) and a simultaneous augmentation in a lymphokine produced by Th-2-type cells (IL-4).

Regulation of murine lymphokine production in vivo. Ultraviolet radiation exposure depresses IL-2 and enhances IL-4 production by T cells through an IL-1-dependent mechanism

The exposure of experimental animals to the inflammatory effects of ultraviolet radiation (UVR) is known to cause depressions in their ability to initiate and effectuate various types of cellular immune responses. Contact-type and delayed-type hypersensitivity, plus the ability to generate protective forms of anti-viral and anti-tumor immunity, are all affected by the prior exposure of normal animals to the effects of this physical agent. Presently, the cellular and molecular mechanism(s) responsible for mediating the changes in immune function observed in UVR-exposed animals is not fully understood. Herein we report that one reproducible consequence of exposing normal mice to low doses of UVR is a dramatic change in the pattern of lymphokines secreted by their activated T cells. Lymphocytes isolated from UVR-exposed donors produce/secrete greatly reduced levels of the T cell lymphokines IL-2 and IFN-gamma activation in vitro with protein Ag of the polyclonal T cell stimulant anti-CD3. The secretion of IL-4 by these lymphocyte cultures, however, is consistently elevated in comparison to normal controls. Further studies determined that a similar change in lymphokine production was induced when mice were treated with either bacterial LPS or rIL-1 beta, a cytokine known to be elevated in vivo after UVR or LPS exposure. The ability of IL-1 to facilitate a change in the capacity of T lymphocytes to produce/secrete lymphokines after in vitro activation does not appear to represent a direct effect of this cytokine on lymphocyte or accessory cell targets because addition of IL-1 beta to cultures of Ag-primed lymphocytes obtained from normal donors was incapable of altering the pattern of lymphokine production. Collectively, our present results add further support to the hypothesis that UVR-induced elevations in endogenous IL-1 are, in part, responsible for the immunomodulatory effects of UVR. These findings provide compelling evidence that UVR, plus other agents capable of endogenously stimulating the production of IL-1, may function to alter the expression of different effector mechanisms in vivo. This could be facilitated through selective reductions in lymphokines produced by Th-1-type cells (IL-2 and IFN-gamma) and a simultaneous augmentation in a lymphokine produced by Th-2-type cells (IL-4).

An adjunct trait of HEL/I-Ab-specific T helper cell is sensitivity to antigen-specific immunosuppression

The present study tests whether the specific inhibition of helper T (Th) cell (and T hybridomas) by suppressor T (Ts) cells is a phenotypic trait of Th cells correlating with their acquired specificity for antigen/major histocompatibility complex or a genotypic trait not related to selection of the T cell repertoire for antigen. To do this we took advantage of the fact that H-2d parental strains of mice commonly restrict recognition of chicken egg-white lysozyme to the L3 peptide (a.a. 105-129) and H-2b parental mice to the L2 peptide (a.a. 13-105). F1 hybrids of these strains display two subsets of lysozyme-reactive T cells, one for each parental phenotype. Using (B10 X B10.D2)F1 mice reconstituted with B10.D2 bone marrow, we were able to develop genetic H-2d T cell clones that could express an atypical specificity, that is L2/I-Ab. Clones of this type, like genetic H-2b, are also sensitive to the inhibiting effects of HEL-activated Ts cells. To overcome some of the drawbacks of using heterogeneous populations of T, B and accessory cells in our assays, we constructed T hybridomas from HEL-immune, chimeric lymph node T cell blasts which respond to a unique antigen/major histocompatibility complex with production of the lymphokine interleukin 2. Our results indicate that all HEL/I-Ab-specific T cells (helper and hybridomas) are inhibited by suppression regardless of the T cell's haplotype at the H-2 locus: H-2b (B10), H-2d (D2) or H-2b,d (BDF1). Furthermore, there is a strict correlation between the antigen and I-A specificity: I-Ab-restricted T cells recognize non-L3 determinants even though some are derived from H-2d mice.