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Maori HealthMaking Education Easy
Issue 2 – 2007
Tena koutou katoa
Nau mai ki te putanga tuarua o te Tirohanga Rangahau Hauora Mäori. He Tuhituhi hirahira e paa ana ki nga kaupapa rangahau me nga take o naianei, mo ia marama.
Kei te tino hari koa maatou ki nga whakautu mo te putanga tuatahi. A kei te maioha hoki ki o koutou uru pare. Te tumanako ka kitea i a koutou te pai ano o tenei putanga.
Ki a mahara, kei te hiahia maatou ki te rongo, a ki te kite i nga paanui, CVD risk and risk a tuhituhi rangahau, e painga mo taatou e mahi ana i te Hauora Mäori. management for Tonoa mai, ma maatou e whiriwhiri - mo nga putanga, kei te heke mai.
Mäori and non-Mäori Noho ora mai
Na Dr Matire Harwood (Nga Puhi)
The efficacy of bupropion in the to the second edition of Mäori Health Review,
a unique publication bringing you current and important research
Mäori population topics each month.
We have been delighted with the response to issue and appreciate
Mäori and non-Mäori your feedback, I hope that you find this issue just as stimulating. Please remember that we wish to hear about papers or research that may be of cancer statistics interest for those of us working in Mäori health. So send them through and we will consider them for future editions.
Cardiovascular Regards
Dr Matire Harwood (Nga Puhi)
rehabilitation: does Medical Research Institute of New Zealand it work for Mäori? The New Zealand Assessing differences in CVD risk and risk
Mental Health Survey management for Mäori and non-Mäori
Authors: Riddell T et al
Mäori and non-Mäori Summary: PREDICT-CVD is an opportunistic cardiovascular risk assessment
and management programme. This study compared the cardiovascular disease differences in risk factor status and risk management of Mäori with non-Mäori using data caesarean section from over 20,000 PREDICT-CVD assessments carried out between 2002 and 2006. The population assessed comprised ,450 (7%) Mäori and 9,64 non- Mäori (93%). At assessment, Mäori were an average of 3 years younger than non-Mäori. Compared to non-Mäori, Mäori patients had higher rates of cardio- vascular risk factors including smoking and diabetes. Blood pressure and TC/ Mäori experiences HDL levels were also higher in Mäori patients. Mäori with a history of CVD were of health services more likely to receive medications including anticoagulants, blood pressure- lowering and lipid-lowering drugs. However revascularisation procedures were 50% less likely to be received by Mäori compared to non-Mäori with a history of ischaemic heart disease.
Risk-taking: behind Comment: PREDICT-CVD was developed as an aid for GP's to assess and
the warrior gene story manage CVD risk. It has been shown to improve risk assessment and risk factor documentation. For primary care services utilising PREDICT-CVD in Auckland, it appears to improve the drug based management of CVD for Mäori but Mäori Warrior genes with IHD received significantly fewer revascularisation procedures than non- Mäori, a finding that is consistent with other studies. The large cohort, quality of and risk-taking information and robust analysis of data signal that we will hear more about this study in the future.
Reference: JNZMA. 2007; 120(1250)
a RESEARCH REVIEW publication
Ma¯ori Health Review
The efficacy of
Unequal impact: Mäori and non-Mäori
bupropion in the
cancer statistics
Mäori population
Authors: Robson B et al
Summary: This comprehensive report from the Ministry of Health details cancer find-
Authors: Holt S et al
ings, including disparities in incidence and outcomes between Mäori and non-Mäori for Summary: Around 50% of adult Mäori in
the period 996 to 200. Mäori ethnicity was classified using the ‘ever Mäori' approach. New Zealand are smokers, as compared to Mäori were 8% more likely to be diagnosed with cancer than non-Mäori, and were around 20% of European New Zealanders. almost twice as likely to die from their illness. Mäori were less likely to have their can- This randomised, placebo-controlled trial cer stage recorded at diagnosis, and with regard to breast, lung, colon, rectum, cervix, assessed the efficacy of bupropion as an prostate, testis, kidney, oral cancers and melanoma were more likely to be diagnosed intervention for smoking cessation in 34 at a later stage of the illness. The only cancer which was detected earlier in Mäori was Mäori smokers (> 0 cigarettes/day) aged stomach cancer. In general, Mäori have lower rates of survival for cancers. Some, but 6-70 years. Continued abstinence from not all of this disparity may be related to the later detection of the cancers. In conclusion, smoking at 3 and 2 months were the the report finds; "the existence of stark disparities in experiences and outcomes of can- primary outcome measures. At 3 months, cer between Mäori and non-Mäori" which indicates the need for "urgent and committed continued abstinence was higher with bupropion (44.3%) than placebo (7.4%), action" to address these issues.
RR 2.54 (95% CI .30-5.00). At 2 months Comment: The Cancer Chart book provides comprehensive and detailed information
abstinence rates were 2.6 and 0.9% on cancer among Mäori. The findings raise interesting questions about the quality of for the bupropion and placebo groups care along the entire cancer care pathway for Mäori: from prevention through diagnosis, respectively, RR .99 (95% CI 0.79 to staging and treatment. For example, Mäori have a lower likelihood of having their stage 5.00). In conclusion, the authors suggest of cancer at diagnosis recorded. Why? And does this impact on treatment options for that bupropion is an effective treatment for Mäori with cancer? Other issues not covered in the document but of equal importance smoking cessation in the indigenous Mäori to Mäori include participation in cancer research (often providing new treatments and population in New Zealand. technologies), whanau ora (support for whanau, financial burden of caring for someone Comment: The motivation for this study
with cancer and changing roles within the whanau) and palliative care. Disparities in came about after a conversation with experiences and outcomes of cancer between Mäori and non Mäori exist, the greatest Tariana Turia, the Assoc Minister for Health impact being on Mäori individuals and communities. Urgent and committed action is at the time. She sought evidence that necessary to address the issues raised by the researchers.
bupropion was an effective treatment for Reference: Robson B, Purdie G, Cormack D. 2006. Unequal Impact: Mäori and
smoking cessation in Mäori. What followed Non-Mäori Cancer Statistics 1996–2001. Wellington: Ministry of Health
was this study, the first RCT with Mäori only participants. Despite evidence that bupropion is effective in helping Mäori to quit smoking it is not subsidised. The Cardiovascular rehabilitation –
researchers, participants and those working in Auahi kore programmes are understand- does it work for Mäori?
ably disappointed that a significant cost Authors: Wihongi H et al
barrier to an effective treatment exists.
Summary: Mäori are less likely to use cardiovascular rehabilitation services than other
Reference: Thorax. 2005; 60(2):120-3
ethnicities, despite far greater rates of cardiovascular morbidity and mortality. The authors report on the first 6-months of a specialist mobile cardiovascular rehabilitation service provided by Te Kohao Health and based on Kirikiriroa marae. Data were collected from clinical and support assessment tools, client case notes, minutes from meetings and Disclaimer: This publication is not inten-
kanohi ki te kanohi (face to face) discussions with staff. Mäori referred to the service pre- ded as a replacement for regular medical education but to assist in the process. The sented with complex socioeconomic and socio-cultural issues. In general Mäori accessing reviews are a summarised interpretation of the the service were younger than comparable Pakeha. Retention rates were higher for this published study and reflect the opinion of the service than for other cardiovascular rehabilitation services. The authors suggest that the writer rather than those of the research group or success of this service may be as a result of providing a multi-faceted approach address- scientific journal. It is suggested readers review ing the need for cultural support combined with clinical services.
the full trial data before forming a final conclu- sion on its merits. Comment: A great study undertaken by up and coming researchers, Helen, Nina and
Te Aro describe the reality of Mäori using a mobile cardiovascular rehabilitation service. The views expressed in this Publication are Although data was from just the first 6 months since implementation of the service, the personal to the authors, and do not necessarily results are positive and provide evidence that a service tailored to Mäori does work.
represent the views or policy of the Ministry of Reference: Presented at PRIDOC, Rotorua, December 6-10 2006
Health on the issues dealt with in the publication For more information, please go to Ma¯ori Health Review
Te Rau Hinengaro: The New Zealand Mental Mäori and non-Mäori
Health Survey: The Mäori Data
differences in caesar-
Authors: Baxter J et al
ean section rates
Summary: This nationally-representative, face-to-face survey examined aspects Authors: Harris R et al
of high frequency mental disorders including mood disorders, anxiety disorders, Summary: National total, acute and elec-
and alcohol and drug abuse disorders. A version of the Composite International tive caesarean section (CS) rates (as Diagnostic Interview (CIDI 3.0), amended for use in the World Health Organisation, proportions of women giving birth in New World Mental Health Survey Initiative was used. This report presented the data Zealand hospitals during 997-200) were from over 2500 Mäori surveyed. Prevalence of mental disorders was high for Mäori used to examine relationships between (2-month prevalence 29.5%). Severity was described as moderate or severe for CS, deprivation and ethnicity. Logistic 75% of illnesses occurring in the past 2 months. High rates of co-morbid mental regression analysis was used to adjust and chronic physical disorders were also described. Rates of significant suicidal for age, deprivation, some clinical factors, thinking (3.8 %), suicidal plans (.3%) and suicide attempts (0.7%) were significant. and District Health Board. In comparison However uptake of specific health or other services was low. to Mäori, total, acute and elective rates of Comment: There is potential for epidemiological research in mental health to be CS were significantly higher in non-Mäori
undertaken in a way that further marginalises Mäori. Too often the focus or ‘gaze' women (2 vs 3%; OR .59; p < 0.000 has been on the individual and important external factors that contribute to ethnic for total CS). Increasing deprivation was differences in mental health rates and outcomes are ignored. As the authors rightly correlated with decreasing rates of CS. point out in this paper, it is vital that Mäori lead the research process (including Differences between Mäori and non-Mäori design, recruitment, analysis and dissemination of results) for studies of this kind to remained after controlling for age, dep- ensure that it is safe for Mäori. rivation and other factors. The authors concluded that although deprivation may Reference: Presented at PRIDOC, Rotorua, December 6-10 2006
contribute to the differences observed, it does not fully explain them, and suggest that further research is warranted.
Comment: A controversial topic, Harris
People like me: a survey of Mäori
and colleagues looked at rates of caesar- experiences of health services
ean sections (CS) and showed differences between Mäori and non Mäori for total, Authors: Jansen P et al
elective and acute CS. Non Mäori women Summary: This was a multi-stage study of Mäori patient experiences and percep-
were more likely to have CS than Mäori tions with regard to health, disability and ACC services. Thematic analysis of data women. Although there is support for the collected from 0 nationwide hui was used to develop a model of Mäori patient inter- delivery of baby without intervention, we actions with healthcare providers. This led to the creation of an ‘experiences of care' note that CS are necessary in certain survey tool which was used in a telephone survey of 65 Mäori. Many Mäori have circumstances to ensure the best possible concerns about interactions with health services and the cultural competence of pro- outcomes for mother and baby and can viders, although most rated their most recent experience as generally good. A cluster prevent maternal and neonatal mortality analysis found two distinct groups of respondents. Those of younger age (78%) were or morbidity. As the authors suggest, we more likely to report positive experiences with service providers, whilst the older age- need to know whether ethnic differences in CS rates are associated with ethnic group (22%) were less likely to consider returning again. The authors suggest that this differences in maternal and neonatal out- may be explained by factors such as; "poor experiences in health or other services, comes. Further research is required. expectations of lesser quality care and barriers such as a lack of cultural fit between Reference: JNZMA. 2007; 120(1250)
the patient and provider." Comment: A comprehensive study that sought the experience of Mäori using health,
disability and ACC services, Dr Jansen (Raukawa) and others at Mauri Ora describe the importance of the patient:provider interaction. One important outcome from the study was the development of a tool to measure the ‘satisfaction' of Mäori utilising Privacy Policy: Research Review will
health, disability and ACC services. Currently limited to tools that have been developed record your email details on a secure overseas or in other populations, providers may wish to consider using such a tool. It database and will not release it to anyone was developed by and for Mäori and was validated during the study.
without your prior approval. Research Review and you have the right to inspect, Reference: Presented at PRIDOC, Rotorua, December 6-10 2006
update or delete your details at any time. For more information, please go to Ma¯ori Health Review
Risk-taking: behind the
Warrior genes and risk-taking
warrior gene story
Authors: Merriman T and Cameron V
Authors: Crampton P and Parkin C
Summary: This report examines the scientific evidence behind
Summary: : In this article, the authors summarise their concerns
the recent controversial claim by Lea and colleagues (see below with regard to the veracity and ethics of the "warrior gene" line of for a link to the on-line abstract) that the low activity research. They raise concerns with regard to the informed consent monoamine oxidase-A (MAO-A) gene was strongly associated process. In line with ethical principals of research, all participants with risk-taking and aggressive behaviour in Mäori. The MAO- should have been advised that the research included the exploration A gene is believed to be important for the correct regulation of of hypotheses linking the "warrior gene" with violent and antisocial dopamine and serotonin levels, via the production of the MAO-A behaviour, and that results may be extrapolated from the research enzyme which breaks down both neurotransmitters. The high participants to the larger Mäori population despite the lack of evi- activity gene variant (found in 65% of Caucasians) has up to a 0- dence for association between the two. The authors ask questions fold greater activity than the low activity variant, and may therefore about the scientific validity of an approach which has extrapolated be more effective in removing excess dopamine and serotonin. In from a small, likely non-random sample of Mäori males to not only MAO-A deficient mice (which lack the enzyme entirely), dopamine the entire contemporary male Mäori population, but also to past and serotonin levels are increased and aggressive behaviours generations. They also point to a lack of any association between have been observed. The term "warrior gene" was first coined fol- genotype alone and anti-social behaviour from previous research lowing a small, un-replicated experiment using Rhesus macaque and the risks of making a claim of causality on the evidence of monkeys. No evidence for an association between genotype alone association alone. Finally, the authors highlight the issue of skewed and aggressive behavior was found in this study, and aggressive reporting and hype by the media, and comment that; "In such highly behaviour could be predicted by both low and high-activity gene charged social and political settings, the scientist has a particular variants under different environmental conditions. In the three responsibility for the way in which findings are disseminated and for largest population-based studies in humans (all in Caucasians) ensuring a clear public understanding of the limitations of the work the results were all similar and suggested the high-activity MAO- A variant may be protective against adult anti-social behavior for Comment: Dr Rod Lea claimed in August 2006 that there is a
children who were abused or neglected. The low-activity variant genetic explanation for negative social and health statistics for Mäori. did not predict aggressive behaviour unless these additional envi- Dubbed the warrior gene, Dr Lea stated that the low-activity MAO-A ronmental factors were also considered. The study presented by genetic variant "goes a long way to explaining some of the problems Lea et al. was conducted in a very small (n = 7) sample of Mäori Mäori have…they are going to be more aggressive and violent and males. They found the low-activity MAO-A variant present in 60% more likely to get involved in risk-taking behaviour like gambling". of subjects, and called it the "warrior allele", suggesting it was Unfortunately, information about the research came mainly via the strongly associated with risk taking and aggressive behaviour in media and the reports were sensationalised, simplified and from the Mäori males. The authors of the current report, dispute this find- perspective of Dr Lea and his team. The media were quick to point ing, citing a lack of scientific rigour and an absence of appropriate to Mäori and our genes as reasons to explain negative statistics. Not genetic epidemiological experiments testing for an association. only were the wider, external issues ignored but scientists, ethicists They also point to evidence of racial variation between genetic and Mäori were not given the opportunity to voice their concerns associations indicating that results from a Caucasian population about the study. Thankfully, we have now been provided with expert should not be extrapolated to Mäori. opinions around the science and ethics of Dr Lea's work in the latest Hall D, Green M, Chambers G, Lea R. Tracking the evolutionary NZMJ. Dr Merriman and Dr Cameron question the scientific validity history of the warrior gene in the South Pacific. th International of Lea's genetic studies and Professor Crampton and Dr Parkin raise Human Genetics Meeting, Brisbane, Australia; August 6–0; 2006. important ethical concerns. If you are considering large scale genetic Abstract at URL: research in your whanau, hapu or iwi, it would be useful to read the Comment: See comment on right.
articles in their entirety. Aroha Mead and Moana Jackson have also Reference: JNZMA. 2007; 120(1250)
critiqued genetic research undertaken by Dr Lea and others using a Kaupapa Mäori epistemology. Their presentations were recorded at HRC's Hui Whakapiripi and Pridoc in 2006. Some Iwi (Ngai Tahu for example) already have guidelines in place for DNA research and it may be useful to consider the development of guidelines or recom- mendations prior to participation in research in which DNA samples Subscribing to Mäori Health Review
To subscribe or download previous editions of Mäori Health Reference: JNZMA. 2007; 120(1250)
Review publications go to To unsubscribe reply to this email with unsubscribe in the subject line. Independent commentary by Dr Matire Harwood,
Medical Research Institute of New Zealand
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eva-schneider.at
2. Therapien 2.3. Medikamentöse Therapien Medikamente nehmen im Gesamtbehandlungsplan autistischer Störungen eine bedeutende Rolle ein, obwohl die ursächliche Behandlung von Autismus durch Medikamente nach derzeitigem Wissensstand nicht möglich ist. Daher versucht man den Einsatz von Medikamenten auf die Beeinflussung
Acute symptoms of drug hypersensitivity (urticaria, angioedema, anaphylaxis, anaphylactic shock)
MD , Pascal Demoly, MD, PhD Urticaria Angioedema Anaphylaxis Anaphylactic shock Drug hypersensitivity Drug hypersensitivity reactions (HSRs) are the adverse effects of drugs which, whentaken at doses generally tolerated by normal subjects, clinically resemble Although they occur in a small percentage of patients (about one-third of all adversedrug reactions, which affect 10% to 20% of the hospitalized patients and more than7% of the general population), these reactions are often unpredictable and can belife threatening.Only when a definite immunologic mechanism (either drug-specificantibody or T-cell) is demonstrated should these reactions be classified as drugallergy. For general communication, when a drug allergic reaction is suspected,‘‘drug HSR'' is the preferred term, because true drug allergy and nonallergic drugmay be difficult to differentiate from the clinical presentation alone, especiallyin situations of acute severe HSR, such as anaphylaxis. However, for a long-termplan of treatment and prevention, referral to an allergist-immunologist for confirmationof diagnosis is needed to offer specific preventive measurements.