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1.  How common are symptoms? Evidence from a New Zealand national telephone survey 
BMJ Open  2014;4(6):e005374.
To assess the frequency of symptoms in a general population sample over the previous week and the associations between symptom reporting and demographic factors, medical visits and medication use.
A representative general population sample (n=1000) was recruited using random digit dialling. Participants were asked whether they had experienced any of a list of 46 symptoms in the previous 7 days and if so, whether the symptom was mild, moderate or severe. Demographic data and information on medical visits and medication use were also collected.
Symptom reporting was very common. The median number of symptoms reported by participants in the previous week was 5 with only 10.6% of participants reporting no symptoms. The five most common symptoms in the previous 7 days were: back pain (38%), fatigue (36%), headache (35%), runny or stuffy nose (34%) and joint pain (34%). The five symptoms rated highest in terms of severity were sexual difficulties, vomiting, tremor, suicidal thoughts and sleep problems. Symptom reporting was significantly positively associated with medical visits in the previous year and current medication taking. Women reported a significantly greater number of symptoms. We found no significant association between age or household size and symptom reporting.
This population-based study found that symptoms are more commonly experienced in the general population than previously estimated and are strongly associated with healthcare visits. Appreciation of the high prevalence of symptoms may help normalise the experience of symptom reports among the general population.
PMCID: PMC4067867  PMID: 24928596
Public Health; General Medicine (see Internal Medicine); Epidemiology
2.  The Link between Health Complaints and Wind Turbines: Support for the Nocebo Expectations Hypothesis 
The worldwide expansion of wind energy has met with opposition based on concerns that the infrasound generated by wind turbines causes health problems in nearby residents. In this paper, we argue that health complaints are more likely to be explained by the nocebo response, whereby adverse effects are generated by negative expectations. When individuals expect a feature of their environment or medical treatment to produce illness or symptoms, then this may start a process where the individual looks for symptoms or signs of illness to confirm these negative expectations. As physical symptoms are common in healthy people, there is considerable scope for people to match symptoms with their negative expectations. To support this hypothesis, we draw an evidence from experimental studies that show that, during exposure to wind farm sound, expectations about infrasound can influence symptoms and mood in both positive and negative directions, depending on how expectations are framed. We also consider epidemiological work showing that health complaints have primarily been located in areas that have received the most negative publicity about the harmful effects of turbines. The social aspect of symptom complaints in a community is also discussed as an important process in increasing symptom reports. Media stories, publicity, or social discourse about the reported health effects of wind turbines are likely to trigger reports of similar symptoms, regardless of exposure. Finally, we present evidence to show that the same pattern of health complaints following negative information about wind turbines has also been found in other types of environmental concerns and scares.
PMCID: PMC4227478  PMID: 25426482
wind farms; infrasound; nocebo effect; psychological expectations; health scares; symptom reporting; environmental risks; media warnings
3.  Mental health in adolescents with Type 1 diabetes: results from a large population-based study 
BMC Endocrine Disorders  2014;14(1):83.
Diabetes has previously been linked to mental health problems in adolescents, but more recent studies have yielded mixed findings. The aim of the current study was to compare symptoms of mental health problems, sleep and eating disturbances in adolescents with and without Type 1 diabetes in a population based sample.
Data were taken from the youth@hordaland study, a large population based study in Hordaland County in Norway conducted in 2012. In all, 9883 adolescents aged 16–19 years (53% girls) provided self-reported data on both diabetes and a range of instruments assessing mental health symptoms, including depression, anxiety, obsessive-compulsive behaviours, hyperactivity, impulsivity, inattention, perfectionism, resilience, sleep problems and eating behaviour.
40 adolescents were classified as having Type 1 diabetes (prevalence 0.4%). We found that adolescents with Type 1 diabetes did not differ from their peers on any of the mental health measures.
This is one of the first population-based studies to examine mental health of adolescents with Type 1 diabetes. There was no evidence of increased psychopathology across a wide range of mental health measures. These findings contradict previous studies, and suggest that Type 1 diabetes is not associated with an increased risk of psychosocial problems.
PMCID: PMC4197324  PMID: 25303963
Type 1 diabetes; Mental health; Eating disturbances; Sleep; Correlates; Epidemiology
4.  How distressing is it to participate in medical research? A calibration study using an everyday events questionnaire 
JRSM Short Reports  2013;4(10):2042533313493271.
To investigate how distressing participating in medical research is perceived to be, compared to everyday events.
Anonymous questionnaire.
Scotland and New Zealand.
One hundred members of the Scottish general public, 94 University of Auckland students, 22 New Zealand Ministry of Health ethics committee members.
Main outcome measures
Distress ratings made on a 0–10 scale for everyday events and common medical research procedures.
Both general population and student samples generally rated the distress caused by participating in various medical research procedures as low or very low. Most research procedures were rated less than the distress caused by not being able to find a car park at a supermarket. In contrast, the ethics committee members rated the distress caused by most of the medical research procedures at a significantly higher level than the ratings of the student and general population samples. Ethics committee members overestimated the distress caused by interview or questionnaire assessments (M = 203.31%, SE = 11.42, 95% CI [179.79, 226.83]) more than medical testing for research (M = 158.06%, SE = 12.33, 95% CI [132.66, 183.46], p = 0.04) and everyday events (M = 133.10%, SE = 7.80, 95% CI [117.03, 149.16], p < 0.001).
Common medical research procedures are not rated as particularly distressing by the general public, and ethics committees may be adopting an over-protective role when evaluating research applications that involve the use of questionnaire or survey methodology.
PMCID: PMC3831865  PMID: 24319581
5.  Prescription and dosing of urate-lowering therapy, rather than patient behaviours, are the key modifiable factors associated with targeting serum urate in gout 
Long term serum urate (SU) lowering to a target of <0.36 mmol/l (6 mg/dl) is recommended for effective gout management. However, many studies have reported low achievement of SU targets. The aim of this cross-sectional study was to examine the clinical and psychological factors associated with SU targets in patients with gout.
Patients with gout for <10 years were recruited from primary and secondary care settings. SU target was defined as SU concentration <0.36 mmol/L at the time of the study visit. Both clinical and psychological factors associated with SU target were analysed. The relationship between SU target and measures of gout activity such as flare frequency, tophi, work absences, and Health Assessment Questionnaire-II was also analysed.
Of the 273 patients enrolled into the study, 89 (32.6%) had SU concentration <0.36 mmol/L. Urate-lowering therapy (ULT) use was strongly associated with SU target (p < 0.001). In those patients prescribed ULT (n = 181), allopurinol dose, patient confidence to keep SU under control, female sex, and ethnicity were independently associated with SU target. Other patient psychological measures and health-related behaviours, including adherence scores, were not independently associated with SU target in those taking ULT. Creatinine clearance, diuretic use, age, and body mass index were not associated with SU target. Patients at SU target reported lower gout flare frequency, compared with those not at target (p = 0.03).
ULT prescription and dosing are key modifiable factors associated with achieving SU target. These data support interventions focusing on improved use of ULT to optimise outcomes in patients with gout.
PMCID: PMC3493372  PMID: 22978848
Gout; Urate; Target; Allopurinol
6.  Impact of television coverage on the number and type of symptoms reported during a health scare: a retrospective pre–post observational study 
BMJ Open  2012;2(4):e001607.
This study investigated the impact of television news coverage on total adverse event reporting rates 1 month before and after the bulletins during a medication health scare. We further investigated whether individual side effects mentioned in each bulletin were reflected in the adverse event reports following the coverage.
A retrospective pre–post observational study.
New Zealand Centre for Adverse Reactions Monitoring.
Adverse events reported from May to December 2008 relating to Eltroxin formulation change.
Primary and secondary outcome measures
Primary outcome measure was the total rate of adverse event reporting per day. Secondary outcome measure was the rate of reporting of seven individual symptoms mentioned in the television coverage.
After story 1, a significant increase in total reporting rates was evident (MdnPre=0, MdnPost=13.5, U=2, p<0.001, r=−0.86) with larger effect sizes for increases in television-mentioned symptoms. Story 2 also showed a significant increase in total adverse event reporting (MdnPre=6, MdnPost=18.5, U=86.5, p=0.002, r=−0.49) driven by significant increases only in television-reported symptoms. Story 3 did not result in a significant increase in total reporting (MdnPre=12; MdnPost=15.5, U=171, p=0.432, r=−0.12), and showed a significant increase in reporting rates for only one of the two television-reported symptoms.
The findings suggest that television news coverage can impact on the overall rate of adverse event reporting during a health scare, in part via increased reporting of media-mentioned side effects. The effects of television media coverage on adverse event reporting appear strongest for earlier reports.
PMCID: PMC3425900  PMID: 22904334
Mass media; Television; nocebo; symptoms
7.  A text message programme designed to modify patients’ illness and treatment beliefs improves self-reported adherence to asthma preventer 
Asthma is a common medical condition caused by chronic inflammation of the airways. Characteristic symptoms of the illness include attacks of shortness of breath, wheezing, tightness in the chest, and cough. Asthma is commonly treated by inhaled corticosteroids, which help to suppress inflammation of the airways and reduce the frequency of severe symptoms and attacks. This medication in the form of inhalers is known as preventer or controller medication and many patients also take short-acting bronchodilators to control acute symptoms (reliever medication). In order to provide therapeutic benefit, preventer medication needs to be taken regularly on a daily basis. However, non-adherence to preventer medication is a common problem in patients diagnosed with asthma and these results in the overuse of reliever medication, increased asthma symptoms, more frequent asthma attacks, and hospital admissions (Stern et al., 2006). Optimal adherence to inhaled corticosteroids requires patients to take their preventer medication on 80% or more occasions, as this is associated with greatest asthma control (Lasmar et al., 2009).
While effective preventative medication is readily available for asthma, adherence is a major problem due to patients’ beliefs about their illness and medication. We investigated whether a text message programme targeted at changing patients’ illness and medication beliefs would improve adherence in young adult asthma patients.
Two hundred and sixteen patients aged between 16 and 45 on asthma preventer medication were recruited from pamphlets dispensed with medication and e-mails sent to members of a targeted marketing website. Participants were randomized to receive individually tailored text messages based on their illness and medication beliefs over 18 weeks or no text messages. Illness and medication beliefs were assessed at baseline and at 18 weeks. Adherence rates were assessed by phone calls to participants at 6, 12, and 18 weeks and at 6 and 9 months.
At 18 weeks, the intervention group had increased their perceived necessity of preventer medication, increased their belief in the long-term nature of their asthma, and their perceived control over their asthma relative to control group (all p<0.05). The intervention group also significantly improved adherence over the follow-up period compared to the control group with a relative average increase in adherence over the follow-up period of 10% (p<0.001). The percentage taking over 80% of prescribed inhaler doses was 23.9% in the control group compared to 37.7% in the intervention group (p<0.05).
A targeted text message programme increases adherence to asthma preventer inhaler and may be useful for other illnesses where adherence is a major issue.
PMCID: PMC3571184
medicines; adherence; text message; asthma
8.  How accurate is patients' anatomical knowledge: a cross-sectional, questionnaire study of six patient groups and a general public sample 
BMC Family Practice  2009;10:43.
Older studies have shown that patients often do not understand the terms used by doctors and many do not even have a rudimentary understanding of anatomy. The present study was designed to investigate the levels of anatomical knowledge of different patient groups and the general public in order to see whether this has improved over time and whether patients with a specific organ pathology (e.g. liver disease) have a relatively better understanding of the location of that organ.
Level of anatomical knowledge was assessed on a multiple-choice questionnaire, in a sample of 722 participants, comprising approximately 100 patients in each of 6 different diagnostic groups and 133 in the general population, using a between-groups, cross-sectional design. Comparisons of relative accuracy of anatomical knowledge between the present and earlier results, and across the clinical and general public groups were evaluated using Chi square tests. Associations with age and education were assessed with the Pearson correlation test and one-way analysis of variance, respectively.
Across groups knowledge of the location of body organs was poor and has not significantly improved since an earlier equivalent study over 30 years ago (χ2 = 0.04, df = 1, ns). Diagnostic groups did not differ in their overall scores but those with liver disease and diabetes were more accurate regarding the location of their respective affected organs (χ2 = 18.10, p < 0.001, df = 1; χ2 = 10.75, p < 0.01, df = 1). Age was significantly negatively correlated (r = -0.084, p = 0.025) and education was positively correlated with anatomical knowledge (F = 12.94, p = 0.000). Although there was no overall gender difference, women were significantly better at identifying organs on female body outlines.
Many patients and general public do not know the location of key body organs, even those in which their medical problem is located, which could have important consequences for doctor-patient communication. These results indicate that healthcare professionals still need to take care in providing organ specific information to patients and should not assume that patients have this information, even for those organs in which their medical problem is located.
PMCID: PMC2700077  PMID: 19523189
9.  Effect of providing information about normal test results on patients' reassurance: randomised controlled trial 
BMJ : British Medical Journal  2007;334(7589):352.
Objective To investigate whether providing information about normal findings before a diagnostic test improves patients' reassurance and reduces anxiety about symptoms.
Design Randomised controlled trial.
Setting Outpatient cardiology clinic.
Participants 92 patients with chest pain referred for a diagnostic exercise stress test.
Intervention Before undergoing testing patients were randomised to receive standard information (n=28; control group), a pamphlet explaining the function of the test and the meaning of normal test results (n=30; pamphlet group), or the pamphlet and a brief discussion about the meaning of normal test results (n=34; discussion group).
Main outcome measures The primary outcome was patients' reported reassurance on a 5 item scale immediately after the test and at one month. Secondary outcomes were the proportion of patients still with chest pain and still taking cardiac drugs at one month.
Results The mean levels of reassurance after testing and feedback from the doctor were significantly higher in the discussion group (42.0, 95% confidence interval 39.7 to 44.2) than in the pamphlet (39.2, 36.1 to 42.3) and control groups (35.8, 31.6 to 39.9). This difference was maintained at one month. The proportion of patients still reporting chest pain at one month decreased significantly in the discussion group (to 17%) and pamphlet group (to 28%) but not in the control group (to 36%). A trend was for fewer patients in the discussion group to be taking cardiac drugs at one month.
Conclusion Providing patients with information about normal test results before testing can improve rates of reassurance and reduce the likelihood of future reports of chest pain.
Trial registration Current Controlled Trials ISRCTN87589121.
PMCID: PMC1800996  PMID: 17259186
10.  Patients and Computers as Reminders to Screen for Diabetes in Family Practice 
In New Zealand, more than 5% of people aged 50 years and older have undiagnosed diabetes; most of them attend family practitioners (FPs) at least once a year.
To test the effectiveness of patients or computers as reminders to screen for diabetes in patients attending FPs.
A randomized-controlled trial compared screening rates in 4 intervention arms: patient reminders, computer reminders, both reminders, and usual care. The trial lasted 2 months. The patient reminder was a diabetes risk self-assessment sheet filled in by patients and given to the FP during the consultation. The computer reminder was an icon that flashed only for patients considered eligible for screening.
One hundred and seven FPs.
The primary outcome was whether each eligible patient, who attended during the trial, was or was not tested for blood glucose. Analysis was by intention to treat and allowed for clustering by FP.
Patient reminders (odds ratio [OR] 1.72, 95% confidence interval [CI] 1.21, 2.43), computer reminders (OR 2.55, 1.68, 3.88), and both reminders (OR 1.69, 1.11, 2.59) were all effective compared with usual care. Computer reminders were more effective than patient reminders (OR 1.49, 1.07, 2.07). Patients were more likely to be screened if they visited the FP repeatedly, if patients were non-European, if they were “regular” patients of the practice, and if their FP had a higher screening rate prior to the study.
Patient and computer reminders were effective methods to increase screening for diabetes. However, the effects were not additive.
PMCID: PMC1490216  PMID: 16191138
diabetes; screening; family practice; computer reminder; patient intervention
11.  Getting well from water 
BMJ : British Medical Journal  2004;329(7480):1417-1418.
PMCID: PMC535954  PMID: 15604162
12.  Modern worries, new technology, and medicine  
BMJ : British Medical Journal  2002;324(7339):690-691.
PMCID: PMC1122629  PMID: 11909772
13.  Photographic memory, money, and liposuction: survey of medical students' wish lists 
BMJ : British Medical Journal  1999;319(7225):1593-1595.
To examine whether medical students made fewer altruistic wishes and more money oriented wishes in later years of the medical course than students in earlier years.
Anonymous questionnaire survey.
Auckland University School of Medicine.
520 medical students from 6 years of the course responded to the questionnaire item “If you had three wishes what would you wish for?”
Main outcome measures
Proportion of wishes in various categories.
The three most popular categories of wishes were happiness (34% of students), money (32%), and altruistic wishes (31%). Rates of altruistic wishes (odds ratio=1.05, 95% confidence interval 0.94 to 1.18; P=0.36) and wishes for money (odds ratio=0.96, 0.86 to 1.08; P=0.52) did not vary over the years of the course. Female medical students were more likely than males to make altruistic wishes (36% v 26%; χ2=5.68, P=0.02), intimacy wishes (25% v 18%; χ2=3.74, P=0.05), and happiness wishes (42% v 26%; χ2=18.82, P=0.0001). Men were more likely than women to make sexual wishes (5% v 0.8%; χ2=7.34, P=0.01).
We found no evidence that students were less altruistic and more money oriented in the later years of the medical course.
PMCID: PMC28301  PMID: 10600951

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