Dudley Gentles

Is serum urate causally associated with incident cardiovascular disease

OBJECTIVE With studies reporting both positive and negative associations, the influence of serum urate on incident cardiovascular disease (CVD) is uncertain. We sought to determine whether serum urate is causally associated with incident CVD. METHODS Participants were aged 30-80 years and were screened for CVD risk in primary care between 2006 and 2009. Participants had blood pressure, lipids, age and ethnic group recorded at assessment, with record linkage providing drug dispensing, hospital diagnoses and laboratory test results. Outcomes were derived from hospital diagnoses and mortality records until December 2009. Cox models were used to assess the influence of exposures on outcomes. RESULTS A total of 78 707 people, free of CVD, were enrolled, and 1328 CVD events occurred during follow-up. Serum urate was recorded before baseline assessment in 43% (34 008/78 707) of participants. After adjustment for confounding factors, a 2 s.d. difference in serum urate (0.45 vs 0.27 mmol/l) was associated with a hazard ratio (HR) of 1.56 (95% CI 1.32, 1.84). This was more than double that of the equivalent distributional change in high-density lipoprotein cholesterol (adjusted HR 1.22) and one-third greater than that for HbA1c (adjusted HR 1.41). CONCLUSION Serum urate is likely to be causally associated with CVD. This supports public health action to reduce urate levels in populations with significant burdens of the disease.

Markedly different clustering of CVD risk factors in New Zealand Indian and European people but similar risk scores (PREDICT‐14)

Objective: To compare the cardiovascular disease (CVD) risk profiles of Indian and European patients from routine primary care assessments in the northern region of New Zealand.

Developing and validating a cardiovascular risk score for patients in the community with prior cardiovascular disease

Objective Patients with atherosclerotic cardiovascular disease (CVD) vary significantly in their risk of future CVD events; yet few clinical scores are available to aid assessment of risk. We sought to develop a score for use in primary care that estimates short-term CVD risk in these patients. Methods Adults aged <80 years with prior CVD were identified from a New Zealand primary care cohort study (PREDICT), and linked to national mortality, hospitalisation and dispensing databases. A Cox model with an outcome of myocardial infarction, stroke or CVD death within 2 years was developed. External validation was performed in a cohort from the UK. Results 24 927 patients, 63% men, 63% European, median age 65 years (IQR 58–72 years), experienced 1480 CVD events within 2 years after a CVD risk assessment. A risk score including ethnicity, comorbidities, body mass index, creatine creatinine and treatment, in addition to established risk factors used in primary prevention, predicted a median 2-year CVD risk of 5.0% (IQR 3.5%–8.3%). A plot of actual against predicted event rates showed very good calibration throughout the risk range. The score performed well in the UK cohort but overestimated risk for those at highest risk, who were predominantly patients defined as having heart failure. Conclusions The PREDICT-CVD secondary prevention score uses routine measurements from clinical practice that enable it to be implemented in a primary care setting. The score will facilitate risk communication between primary care practitioners and patients with prior CVD, particularly as a resource to show the benefit of risk factor modification.

Taxing times? Smoker response to tax increases

Purpose – Taxing tobacco is one of the most effective means to reduce smoking but concerns about the impact on poor smokers are a barrier. New Zealand resumed increasing tobacco taxes in April 2010. The paper hypothesised smokers would attempt to stop smoking and/or adapt, changing their smoking behaviours in response to price increases. The paper aims to discuss these issues. Design/methodology/approach – The authors conducted a door knock survey of smokers and recent ex-smokers who were home when visited. Participants (n=428) were from socioeconomically deprived neighbourhoods of Auckland with large proportions of Māori and Pacific Island people. Findings – Many smokers (66 per cent) attempted to quit an average of 3 times. More than 40 per cent stopped for at least 24 hours without intending to quit altogether, monthly or more. Consumption reduced among 40 per cent of participants, by an average 7.1 cigarettes daily. More than a fifth of participants switched to cheaper brands. Switching from factory m...

Workplace injuries in Fiji: a population-based study (TRIP 7)

Background Workplace injury rates in low and middle-income countries are known to be high. Contemporary data on this topic from Pacific Island countries and territories are scant. Aims To describe the epidemiology of fatal and hospitalized workplace injuries in Fiji using a population-based trauma registry. Methods An analysis of data from a prospective population-based surveillance registry investigated the characteristics associated with workplace injuries resulting in death or hospital admission among people aged 15 years and older in Viti Levu, the largest island in the Republic of Fiji, from October 2005 to September 2006. Incidence rates were calculated using denominator data from the 2004–05 Fiji Employment Survey. Results One hundred and eighty-nine individuals met the study eligibility criteria (including nine deaths). This corresponded to annual injury-related hospitalization and death rates of 73.4 and 3.7 per 100 000 workers, respectively. Males accounted for 95% of injuries, and hospitalization rates were highest among those aged 15–29 years (33 per 100 000 workers). Fijian and Indian workers had similar rates of admission to hospital (38.3 and 31.8 per 100 000 workers, respectively). Fractures (40%) and ‘cuts/bites/open wounds’ (32%) were the commonest types of injury while ‘being hit by a person or object’ (34%), falls (27%) and ‘cutting or piercing’ injuries (27%) were the commonest mechanisms. Overall, 7% of injuries were deemed intentional. Conclusions Acknowledging the likely underestimation of the overall burden of workplace injuries, these findings support the need to identify context-specific risk factors and effective approaches to preventing workplace injuries in Fiji.

Age-specific effectiveness following each dose of acellular pertussis vaccine among infants and children in New Zealand

BACKGROUND Though it is believed the switch from whole cell to acellular pertussis vaccine has contributed to the resurgence of pertussis disease, few studies have evaluated vaccine effectiveness (VE) and duration of protection provided by an acellular vaccine schedule including three primary doses but no toddler-age dose. We assessed this schedule in New Zealand (NZ), a setting with historically high rates of pertussis disease, and low but recently improved immunisation coverage. We further evaluated protection following the preschool-age booster dose. METHODS We performed a nested case-control study using national-level healthcare data. Hospitalised and non-hospitalised pertussis was detected among children 6weeks to 7years of age between January 2006 and December 2013. The NZ National Immunisation Register provided vaccination status for cases and controls. Conditional logistic regression was used to calculate dose-specific VE with duration of immunity examined by stratifying VE into ages aligned with the immunisation schedule. RESULTS VE against pertussis hospitalisation was 93% (95% confidence interval [CI]: 87, 96) following three doses among infants aged 5-11months who received three compared to zero doses. This protection was sustained through childrens fourth birthdays (VE⩾91%). VE against non-hospitalised pertussis was also sustained after three doses, from 86% (95% CI: 80, 90) among 5-11month olds to 84% (95% CI: 80, 88) among 3-year-olds. Following the first booster dose at 4years of age, the protective VE of 93% (95% CI: 90, 95) among 4-year-olds continued through 7years of age (VE⩾91%). CONCLUSIONS We found a high level of protection with no reduction in VE following both the primary course and the first booster dose. These findings support a 3-dose primary course of acellular vaccine with no booster dose until 4years of age.