Ralph Pinnock

Cost-effectiveness of palivizumab in New Zealand

Objective:  To establish the preterm infant hospitalization risks from respiratory syncytial virus (RSV) in New Zealand and the net cost per hospitalization averted by palivizumab.

Epidemiology of Munchausen syndrome by proxy in New Zealand

Objective: To determine the epidemiology of Munchausen syndrome by proxy (MSBP) in New Zealand and describe the effects of this condition on children and their paediatricians.

Variations in bronchiolitis management between five New Zealand hospitals: Can we do better?

Objectives:  To determine the current management of bronchiolitis by five major New Zealand hospitals and to identify areas for improvement.

Comparative trial of Viokase®, pancreatin and Pancrease® pancrelipase (enteric coated beads) in the treatment of malabsorption in cystic fibrosis

ABSTRACT. Pancreatic extracts, even in high doses, usually fail to completely control steatorrhoea in cystic fibrosis (CF), due to inactivation of the enzymes by acid and pepsin. Pancrease is a new formulation consisting of pH‐sensitive, enteric coated beads which protect the pancreatic enzymes from acid and pepsin denaturation. Twelve patients with CF entered an outpatient study to examine the effectiveness of this product compared with that of a conventional product (Viokase®). Two doses for each product were used during four sequential 4‐week periods. Twenty‐two capsules of Pancrease® daily was significantly better than 32 capsules of Viokase® daily (faecal fat excretion 8.7 ± 4.1 g/day, 17.3 ± 9.1 g/day, p < 0.01; coefficient of absorption 89.5 ± 4.2%, 79.3 ± 9.9%, p < 0.01; bowel actions/day 1.7 ± 0.7, 2.2 ± 0.9, p < 0.05; rank scores of stool odour and stool consistency, both p < 0.05; parents treatment preference p < 0.01). No difference was detected between Viokase® 32 capsules daily and Pancrease® 11 capsules daily, but both were significantly better than 16 capsules of Viokase® daily.

Changing the learning environment: the medical student voice.

Background:  Students’ perceptions of their learning environment influence both how they learn and the quality of their learning outcomes. The clinical component of undergraduate medical courses takes place in an environment designed for clinical service and not teaching. Tension results when these two activities compete for resources. An impending increase in medical student numbers led us to assess the learning environment with a view to planning for the future.

Trends in hospitalization and mortality from rotavirus disease in New Zealand infants.

BACKGROUND Rotavirus illness is associated with significant morbidity and mortality worldwide. We have examined trends in diarrheal disease in New Zealand children to determine the disease burden attributable to rotavirus and to estimate the proportion of hospitalizations preventable by vaccination. METHODS Hospital admissions data and laboratory records for 1994 to 1996, were obtained for children 0 to 4 years at four sites (serving -60% of the New Zealand population). Rotavirus disease burden was estimated using combined admissions and laboratory data. Severity of disease was estimated in a sample of 150 hospitalizations for rotavirus diarrhea, and the proportion of vaccine-preventable admissions was extrapolated. Mortality attributed to diarrheal causes was determined from national records for 1974 to 1993. RESULTS Between 1994 and 1996, 4436 children <5 years of age were hospitalized with diarrhea (1047/100000 children per year). Admissions associated with rotavirus were estimated at 1522 to 1535 (315 to 362/100000 annually). Infants between 6 and 17 months were most commonly affected (42% of all cases). More male children than female children were hospitalized (P < 0.001) and mean length of stay was calculated as 1.51 days (SD 2.35). Disease severity scoring revealed that 61.3 and 38.0% of admissions reviewed were severe and very severe, respectively. Deaths from diarrheal causes numbered 138 among children 0 to 4 years old for the 20-year period 1974 to 1993, with 18 deaths occurring between 1984 and 1993 (10 years). CONCLUSION Current vaccines control severe disease, suggesting that 72% of cases reviewed would be eligible for prevention. A full cost effectiveness analysis is required to demonstrate anticipated benefits of vaccination.

When parents refuse consent to treatment for children and young persons.

Abstract:  One of the most difficult ethical dilemmas in paediatric practice is parental refusal to consent to life‐saving treatment for their children. The ethical principles in such situations are complex. Although the ‘best interests’ of the child are of primary concern, these must be understood widely, as including all and not just medical interests. Though ultimately the courts must decide on a course of action where refusal is continued, we believe that in non‐emergency cases consultation with a properly constituted multidisciplinary group will be of assistance. A national group of this kind has been recommended for New Zealand. This will ensure that all aspects of the cases are considered and can lessen the sense of ‘parent versus medical profession’ opposition. If this does not lead to a resolution, the opinion of the courts may be of assistance. Following a brief discussion of important ethical considerations, this article outlines a suggested constitution for an advisory committee and a set of guidelines for clinicians faced with parental refusal of treatment for their children.

Learning clinical reasoning

Errors in clinical reasoning continue to account for significant morbidity and mortality, despite evidence‐based guidelines and improved technology. Experts in clinical reasoning often use unconscious cognitive processes that they are not aware of unless they explain how they are thinking. Understanding the intuitive and analytical thinking processes provides a guide for instruction. How knowledge is stored is critical to expertise in clinical reasoning. Curricula should be designed so that trainees store knowledge in a way that is clinically relevant. Competence in clinical reasoning is acquired by supervised practice with effective feedback. Clinicians must recognise the common errors in clinical reasoning and how to avoid them. Trainees can learn clinical reasoning effectively in everyday practice if teachers provide guidance on the cognitive processes involved in making diagnostic decisions.

Rotavirus hospitalisation in New Zealand children under 3 years of age

Objective:  To describe the epidemiology of severe rotavirus gastroenteritis and to estimate the hospitalisation rates of this illness in New Zealand children under 3 years of age.

The learning environment of paediatric trainees in New Zealand

Aims:  To assess the learning environment of New Zealand paediatric trainees, examine the factors influencing the trainees perceptions of their learning environment and to assess the suitability of using the Postgraduate Hospital Education Environment Measure (PHEEM) in New Zealand.