Auckland District Health Board Research Articles

Neurotrophic Keratopathy After Herpes Zoster Ophthalmicus.

The aim of this study was to describe risk factors for neurotrophic keratopathy (NK) after herpes zoster ophthalmicus (HZO). This study was a retrospective review of all patients seen at the Auckland District Health Board with HZO from 2006 through 2016. Cox proportional hazards analysis was performed to examine time to development of neurotrophic keratitis. Eight hundred sixty-nine patients were included in the study with a median follow-up of 6.3 years (5504.4 patient-years). The median age was 65.5 years (interquartile range 52.9-75.4), and 456 subjects (52.5%) were male. NK developed in 58 patients (6.7%), with the highest hazard 1 to 2 years after onset of HZO. On univariate analysis, age, White ethnicity, best-corrected visual acuity (BCVA) at presentation, intraocular pressure, corneal involvement, uveitis, and number of recurrences were associated with increased risk of NK. On multivariate analysis, the following factors were significant: age (hazard ratio [HR] = 1.03; P = 0.021), White ethnicity (HR = 3.18; P = 0.015), BCVA (HR = 1.81; P = 0.026), uveitis (HR = 3.77; P = 0.001), and recurrence (HR = 1.34; P < 0.001). Vision loss (BCVA ≤6/15) was more frequent in subjects with NK (65.5% vs. 16.3%, P < 0.001). NK is a relatively common and serious complication of HZO and occurs more frequently in older White individuals, those with poor visual acuity at presentation, and those with uveitis. Vision loss occurs in approximately two-thirds of patients.

Ethnic disparities in Phyllodes Tumour in Aotearoa New Zealand: a retrospective review.

Phyllodes tumour (PT) is a rare breast neoplasm and little is known about its epidemiological risk factors. The literature suggests a higher incidence of PT in Asian patients and other minority ethnic groups. The purpose of this study was to identify whether there was a difference in incidence, grade and age at presentation for patients with PT among minority ethnic groups when compared with European patients in Aotearoa New Zealand (AoNZ). A retrospective review was conducted across the three District Health Boards (DHBs) in Auckland, Aotearoa New Zealand (AoNZ), from 2008 to 2018 to investigate the relationship between ethnicity and clinical characteristics of PT. Demographic information and histology reports were reviewed to obtain relevant data. The primary outcome measure was ethnicity and the secondary outcome measures were age at presentation, tumour volume and grade. One hundred and fifty-nine patients were included. The total number of non-European patients were 108 (68%). Minority ethnic groups including Pasifika, Māori and MELAA were overrepresented in the patient cohort. Larger tumour volume was significantly correlated with higher tumour grade (p< 0.001). Pasifika patients presented with larger tumours (p 0.05) and at a younger age (p 0.027) when compared with European patients. This study found that patients with PT in AoNZ were significantly overrepresented in Asian, Pasifika and MELAA ethnic groups. Pasifika patients may be at an increased risk of presenting at a younger age with larger, higher grade tumours when compared with European patients. Further research is required to investigate the reasons behind these findings in minority ethnic groups.

Diagnostic performance of neuroimaging in suspected idiopathic intracranial hypertension

The diagnostic utility of neuroradiologic signs associated with idiopathic intracranial hypertension (IIH) for the evaluation of patients presenting with papilloedema remains yet to be elucidated. This multicentre retrospective cohort study assessed consecutive patients presenting with suspected papilloedema to Auckland District Health Board (NZ) and Stanford University Medical Centre (US), between 2005 and 2019, undergoing magnetic resonance imaging and venography (MRI/MRV) or computed tomography and venography (CT/CTV) prior to lumbar puncture assessment for diagnostic suspicion of IIH. Data were collected regarding demographic, clinical, radiologic, and lumbar puncture parameters, and the diagnosis of IIH was determined according to the Friedman criteria for primary pseudotumor cerebri syndrome. A total of 204 participants (174 females; mean ± SD age 29.9 ± 12.2 years) were included, and 156 (76.5%) participants fulfilled the diagnostic criteria for IIH. The presence of any IIH-associated radiologic sign on MRI/MRV demonstrated a sensitivity (95% CI) of 74.8% (65.8%–82.0%) and specificity (95% CI) of 94.7% (82.7%–98.5%), while radiologic signs on CT/CTV exhibited a sensitivity (95% CI) of 61.0% (49.9%–71.2%) and specificity (95% CI) of 100.0% (83.2%–100.0%). In summary, the modest sensitivities of radiologic signs of IIH would support the routine use of lumbar puncture assessment following neuroimaging to secure the diagnosis. However, the high specificities might lend limited support for the judicious deferment of lumbar puncture assessment among typical IIH demographic patients who consent to the inherent small risk of missed pathology, which has been proposed by some clinicians.

Rates of Herpes Simplex Virus Types 1 and 2 in Ocular and Peri-ocular Specimens

ABSTRACT Purpose To evaluate the rates of Herpes Simplex Virus types 1 (HSV-1) and 2 (HSV-2) in ocular specimens. Methods Retrospective case series of all patients with a positive laboratory evaluation for ocular HSV performed at the Auckland District Health Board, Auckland, New Zealand between 1 January 2006 and 31 December 2017 were included in the study. Results A total of 423 specimens were positive for HSV-1 (99.3%, n = 419) or HSV-2 (0.7%; n = 4). The majority of positive tests were identified through DNA amplification (n = 352; 83%) testing while the remainder were obtained by viral culture (n = 71; 17%). Ocular disease caused by HSV-2 in this study included acute retinal necrosis (n = 2), keratitis (n = 1), and blepharitis (n = 1). Conclusions HSV type 2 is a rare cause of ocular and peri-ocular infection but may cause severe, vision threatening disease.

Learning from a multidisciplinary randomized controlled intervention in retirement village residents.

Retirement villages (RVs), also known as continuing care retirement communities, are an increasingly popular housing choice for older adults. The RV population has significant health needs, possibly representing a group with needs in between community-dwelling older adults and those in long-term residential care (LTC). Our previous work shows Gerontology Nurse Specialist (GNS)-facilitated multidisciplinary team (MDT) interventions may reduce hospitalizations from LTC. This study tested whether a similar intervention reduced hospitalizations in RV residents. Open-label randomized controlled trial in which 412 older residents of 33 RVs were randomized (1:1) to an MDT intervention or usual care. RVs across two District Health Boards in Auckland, New Zealand. Residents were eligible if considered high risk of health/functional decline (triggering ≥3 interRAI Clinical Assessment Protocols or needing special consideration identified by GNS). GNS-facilitated MDT intervention, including geriatrician/nurse practitioner and clinical pharmacist, versus usual care. Primary outcome was time from randomization to first acute hospitalization. Secondary outcomes were rate of acute hospitalizations, LTC admission, and mortality. Twelve residents died before randomization; all others (n= 400: MDT intervention=199; usual care=201) were included in intention-to-treat analyses. Mean (SD) age was 82.2 (6.9) years, 302 (75.5%) were women, and 378 (94.5%) were European. Over median 1.5 years follow-up, no difference was found in hazard of acute hospitalization between the MDT intervention (51.8%) and usual care (49.3%) groups (Hazard ratio [HR]=1.01, 95% CI=0.77-1.34). No difference was found in the incidence rate of acute hospitalizations between the MDT intervention (0.69 per person-year) and usual care (0.86 per person-year) groups (incidence rate ratio=0.81, 95% CI=0.59-1.10). Similar results were seen for the proportion of residents with LTC transition (HR=1.18, 95% CI=0.65-2.11) and mortality (HR=0.70, 95% CI=0.36-1.35). Further studies are needed to assess the effects of other patient-centered interventions and outcomes with adequate primary care integration.

Factors predicting high-dose and combined antipsychotic prescribing in New Zealand: High-dose antipsychotic prescribing

ObjectiveGuidelines recommend using antipsychotic monotherapy at the lowest effective dose, however high-dose and antipsychotic polypharmacy prescribing (APP) remain commonplace. The aim of this study was to determine the prevalence and patterns of high-dose antipsychotic prescribing and APP among mental health service users in New Zealand (NZ). MethodsA retrospective audit of service users discharged from inpatient (n=657), or registered with community (n=1560), mental health services at Auckland District Health Board was undertaken. Case notes were reviewed and data on demographics, antipsychotic routes and doses were collected. Outcomes measures included: frequency of total high-dose prescribing, high-dose monotherapy, APP, high-dose APP, and factors associated with these prescribing practices. Logistic regression models were used to examine the relationships between explanatory and outcome variables. ResultsOf the service users prescribed an antipsychotic (n = 2217), 14% were prescribed a high-dose antipsychotic. The frequency of high-dose monotherapy, APP, and high-dose APP was 3%, 26% and 11%, respectively. Being male, Māori, on compulsory treatment, having a schizophrenia diagnosis, or being prescribed polypharmacy were associated with high-dose antipsychotics. Olanzapine was most frequently prescribed in both high dosing (55%) and APP (40%). ConclusionsThere is a high prevalence of high-dose prescribing and APP in this NZ setting.

Incidence and investigation of potential risk-factors for clozapine-associated myocarditis and cardiomyopathy in a New Zealand cohort

Clozapine is a uniquely effective antipsychotic indicated for treatment-resistant schizophrenia. However, its use is underutilised and often delayed for years due to potential adverse reactions including myocarditis and cardiomyopathy. The purpose of this study was to conduct a retrospective review of the clinical records of patients initiating clozapine in the Auckland District Health Board (ADHB) region to determine the incidence of clozapine-associated myocarditis and cardiomyopathy and to identify potential risk factors associated with these cardiotoxicities. The incidence of clozapine-associated myocarditis and cardiomyopathy over a two-year period in the ADHB region was 3.8% and 1.3% respectively.

Systemic Associations of Sarcoid Uveitis: Correlation With Uveitis Phenotype and Ethnicity

To examine systemic associations of sarcoid uveitis and association with uveitis clinical phenotype and ethnicity. Retrospective cross-sectional study. A total of 362 subjects with definite or presumed sarcoid uveitis from Moorfields Eye Hospital, Royal Victorian Eye and Ear, and Auckland District Health Board. Data were collected from the review of clinical notes, imaging, and investigations. Sarcoidosis was diagnosed in accordance with the International Workshop on Ocular Sarcoidosis guidelines. Diagnosis of associated systemic disease secondary to sarcoidosis. A total of 362 subjects with sarcoid uveitis were identified. Median age was 46 years, and 226 (62.4%) were female. Granulomatous anterior uveitis (47.8%), intermediate uveitis with snowballs (46.4%), and multifocal choroiditis (43.1%) were the most frequent clinical presentations, and disease was bilateral in 313 (86.5%). Periphlebitis was observed in 21.0%, and solitary optic nerve or choroidal granuloma in 11.3%. Lung parenchymal disease was diagnosed in 200 subjects (55.2%), cutaneous sarcoid in 98 (27.1%), sarcoid arthritis in 57 (15.7%), liver involvement in 21 (5.8%), neurosarcoid in 49 (13.5%), and cardiac sarcoid in 16 subjects (4.4%). Subjects with cardiac sarcoid were less likely to have granulomatous anterior uveitis (P=.017). Caucasian subjects were older at presentation (48 vs 41 years; P=.009), had less granulomatous anterior uveitis (26.4% vs 51.7%; P < .001), and were less likely to present with cutaneous involvement (23.1% vs 35.4%; P=.040). Ophthalmologists need to be aware of the systemic associations of sarcoid uveitis, in particular potentially life-threatening complications such as cardiac sarcoidosis. Differences observed in uveitis phenotype and between ethnicities require further investigation.

Better visual outcome associated with early vitrectomy in the management of endophthalmitis

AimsTo examine the role of early vitrectomy in the management of endophthalmitis from all causes.MethodsRetrospective study of 290 consecutive subjects diagnosed with endophthalmitis at Auckland District Health Board between 1...

Review of de novo uveitis in older adults presenting to a large tertiary centre

Background/aimsThe primary aim of this study was to describe the causes of de novo uveitis in individuals 60 years and older. Secondary objectives were to determine the incidence of intraocular...

Implementing the PREP2 Algorithm to Predict Upper Limb Recovery Potential After Stroke in Clinical Practice: A Qualitative Study.

Predicting motor recovery after stroke is a key factor when planning and providing rehabilitation for individual patients. The Predict REcovery Potential (PREP2) prediction tool was developed to help clinicians predict upper limb functional outcome. In parallel to further model validation, the purpose of this study was to explore how PREP2 was implemented in clinical practice within the Auckland District Health Board (ADHB) in New Zealand. In this case study design using semi-structured interviews, 19 interviews were conducted with clinicians involved in stroke care at ADHB. To explore factors influencing implementation, interview content was coded and analyzed using the consolidated framework for implementation research. Strategies identified by the Expert Recommendations for Implementing Change Project were used to describe how implementation was undertaken. Implementation of PREP2 was initiated and driven by therapists. Key factors driving implementation were as follows: the support given to staff from the implementation team; the knowledge, beliefs, and self-efficacy of staff; and the perceived benefits of having PREP2 prediction information. Twenty-six Expert Recommendations for Implementing Change strategies were identified relating to 3 areas: implementation team, clinical/academic partnerships, and training. The PREP2 prediction tool was successfully implemented in clinical practice at ADHB. Barriers and facilitators to implementation success were identified, and implementation strategies were described. Lessons learned can aid future development and implementation of prediction models in clinical practice. Translating evidence-based interventions into clinical practice can be challenging and slow; however, shortly after its local validation, PREP2 was successfully implemented into clinical practice at the same site in New Zealand. In parallel to further model validation, organizations and practices can glean useful lessons to aid future implementation.

Management of MDA-5 antibody-positive dermatomyositis with interstitial lung disease-an Auckland case series.

ObjectiveThe aim was to present our experience of managing six cases of anti-melanoma differentiation-associated gene 5 (anti-MDA-5) DM with associated interstitial lung disease (ILD), presenting between June 2017 and October 2020.MethodsThe electronic notes were reviewed for six patients being followed up by the Rheumatology service at Auckland District Health Board. Three patients were initially diagnosed and treated in neighbouring Counties Manukau District Health Board and later transferred to Auckland District Health Board. All had different initial treating clinicians at a time before any predefined treatment algorithm. Emphasis was placed on initial diagnosis and treatment, subsequent disease activity and changes in management. Local management was compared retrospectively with existing evidence relating to the treatment of anti-MDA-5 DM with ILD. Ethical approval was not obtained, according to the New Zealand Health and Disability Ethics Committee exemption for audits and related activities.ResultsSix patients with a variety of clinical presentations were identified appropriately as having anti-MDA-5 DM with ILD. They were commenced on different immunosuppressive regimens, with treatment adjusted according to response and on-going disease activity. Four have achieved clinical and biochemical remission, a fifth has improving active disease, and the sixth is in the early stages of their illness.ConclusionAnti-MDA-5 DM is commonly associated with ILD. This can be rapidly progressive, with a poor prognosis in spite of treatment, particularly among Asian patients. Disease activity can seemingly be monitored with serum ferritin. The most effective management of this condition remains poorly researched; however, increasing retrospective evidence favours early aggressive multi-agent immunosuppression and a low threshold for escalation of therapy.

Ethylenediaminetetraacetic Acid Chelation in Herpes Zoster Ophthalmicus Is Associated With a High Rate of Corneal Melt and Perforation.

To examine the rate and risk factors for band keratopathy after herpes zoster ophthalmicus (HZO) and the outcomes of ethylenediaminetetraacetic acid (EDTA) treatment. This is a retrospective review of all subjects with HZO seen at Auckland District Health Board between January 2006 and December 2016. A total of 869 subjects with HZO were included in the study. Median follow-up was 6.3 years (total 5504.4 patient-years). Band keratopathy developed in 13 subjects (1.5%). On multivariate analysis, older age at onset [hazard ratio (HR), 1.092; P = 0.034], intraocular pressure ≥30 mm Hg at presentation (HR, 5.548; P = 0.013), and number of recurrences (HR, 1.849; P < 0.001) were associated with increased risk for band keratopathy. Corneal melt occurred in 22 subjects (2.5%) during the follow-up period. On multivariate analysis, uveitis (HR, 8.618; P = 0.004) and disodium EDTA chelation (HR, 8.666; P < 0.001) were associated with increased risk for corneal melt. EDTA chelation was performed in 8 subjects. Corneal melt occurred after EDTA chelation in 4 subjects, and corneal perforation occurred in 2 subjects. One subject was eviscerated due to severe endophthalmitis after repeated corneal perforation and another required enucleation for recurrent corneal melt and microbial keratitis. Band keratopathy is an uncommon complication of HZO. Treatment with EDTA chelation might be associated with a significant risk for severe complications in these eyes and should be approached with caution.

Engaging young people in the co-design of a brand and online platform for a public health organization

This article explores how co-design was used to engage young people in the design of a new brand identity and online platform for the Auckland District Health Board’s Peer Sexuality Support Programme (PSSP). Unlike conventional branding practices that do not generally engage users as co-creators in the early discovery stages of the design process, in this research young people were brought into the design process as informants and co-designers. This drove both brand strategy and touchpoint design, positioning the brand to be better accepted by the young people involved in the programme. A series of discovery and evaluation co-design workshops, with a diverse range of PSSP youth leaders, offered game-like interactive activities and the opportunity for open discussions. Engaging young people in fun and meaningful ways helped them uncover and share insights that could only be possible by directly involving them in the design process. The outputs of this co-designed brand – FRANK – incorporated a full visual identity and a proposal for an online platform. The final brand design elicited strong positive responses from PSSP youth leaders, highlighting the importance of involving young people in the design of products and services that address issues affecting them.

Effect of tonsillectomy on antibiotic prescribing in children

IntroductionTonsillectomy is the second most common surgical procedure performed in pediatric otolaryngology. Multiple courses of antibiotics are usually prescribed prior to surgical intervention. Surgery is indicated when patients reach a certain number of infective episodes, or their obstructive symptoms warrant intervention. Little is known about the role of tonsillectomy on long term postoperative antibiotic use. Recently, our group published a retrospective case series that described the clinical characteristics and outcomes of children under the age of 16 years who underwent tonsillectomy. This study is a follow-up on this previous case series and its purpose is to determine whether tonsillectomy in this group of children led to a reduction in the number of antibiotics prescribed in the year following surgery. MethodsData were collected from the clinical records departments of two district health boards in Auckland, New Zealand. Hospital morbidity records were reviewed for all children younger than 16 years old, who underwent a tonsillectomy between December 2015 and December 2017 in the Auckland region. All antibiotics prescribed following surgery were obtained from New Zealand's national community prescribing database. ResultsA total of 1538 children underwent tonsillectomy during the study period. Following surgery, antibiotics were prescribed to 828 (54%) patients at the time of discharge, with an average of 1.2 ± 0.1 courses in the year following surgery. This was significantly reduced compared to preoperative antibiotic intake (3.4 ± 0.1 courses) in the year preceding surgery (p < 0.001). Readmission within 30 days of discharge was not associated with increased antibiotic usage postoperatively. In the two weeks following surgery, 25% of patients were prescribed a course of antibiotics for a presumed postoperative infection. ConclusionsThese findings support the benefit of tonsillectomy in reducing antibiotic consumption in the year following surgery. Furthermore, it has highlighted areas of practice, such as perioperative antibiotic prescription, which can be improved to further reduce the prescription of antibiotics for children with tonsillar hyperplasia.

Rates of spondyloarthropathies vary with age and ethnicity in HLAB27 uveitis

Background/AimsTo determine associations between HLAB27-positive uveitis, ethnicity and seronegative spondyloarthropathies (SpAs) in a New Zealand population.MethodsRetrospective observational cohort study. Medical records of all subjects with uveitis at Auckland District Health...

Using 3D-reconstruction to analyse typical growth trends of the maxillary sinus in children

ObjectivesThere remains a lack of consistent evidence surrounding the developmental anatomy of the maxillary sinus (MS), despite its clinical significance in radiological interpretation and surgical intervention. Our aim was to analyse the typical growth trends of the MS throughout development, to better understand its morphological transformation from birth until late adolescence. MethodsComputed Tomography (CT) scans of individuals aged 0–18 years within the Auckland District Health Board region in New Zealand were examined retrospectively. Sixty-five patients were selected for the study after careful review of criteria. Manual 3D-reconstruction was utilised to replicate the MS from CT images and the mean changes in size, volume and shape with increasing age were analysed. Principal component analysis (PCA) was performed to statistically calculate the mean 3D shapes of the MS in each age group and analyse the independent modes of variation evident in sinus morphology between individuals of each age category. ResultsAt 0–1 years of age, mean MS size was 1.03 × 1.82 × 1.27 cm (width, length, height) with a mean volume of 0.81 cm3. By 16–18 years, mean size increased to 3.39 × 4.30 × 4.63 cm and mean volume became 21.63 cm3. Growth increased linearly but most rapid expansion occurred in the first 4–5 years of life. No significant differences were observed between males and females or right and left sides. Sinus morphology gradually progressed throughout the course of growth from an ellipsoidal structure at its rudimentary phase to a pyramidal shape when fully matured. PCA revealed that within younger age groups significant variation was observed in MS size, while older age groups had relatively less size variation but increased variability in 3D shape. ConclusionsThe results of this study can be used as a reference for typical MS growth in healthy children and as a basis to study how disease or surgical intervention may influence sinus development in children.

Same-Day Consent for Regional Anesthesia Clinical Research Trials: It's About Time.

Same-Day Consent for Regional Anesthesia Clinical Research Trials: It's About Time.

Study protocol: older people in retirement villages. A survey and randomised trial of a multi-disciplinary invention designed to avoid adverse outcomes

BackgroundThere is increasing interest among older people in moving into retirement villages (RVs), an attractive option for those seeking a supportive community as they age, while still maintaining independence. Currently in New Zealand there is limited knowledge of the medical, service supports, social status and needs of RV residents. The objective of this study is to explore RV facilities and services, the health and functional status of RV residents, prospectively study their healthcare trajectories and to implement a multidisciplinary team intervention to potentially decrease dependency and impact healthcare utilization.MethodsAll RVs located in two large district health boards in Auckland, New Zealand were eligible to participate. This three-year project comprised three phases: The survey phase provided a description of RVs, residents’ characteristics and health and functional status. RV managers completed a survey of size, facilities and recreational and healthcare services provided in the village. Residents were surveyed to establish reasons for entry to the village and underwent a Gerontology Nurse Specialist (GNS) assessment providing details of demographics, social engagement, health and functional status. The cohort study phase examines residents’ healthcare trajectories and adverse outcomes, over three years. The final phase is a randomised controlled trial of a multidisciplinary team intervention aimed to improve health outcomes for more vulnerable residents.Residents who triggered potential unmet health needs during the assessment in the survey phase were randomised to intervention or usual care groups. Multidisciplinary team meetings included the resident and support person, a geriatrician or gerontology nurse practitioner, GNS, pharmacist and General Practitioner. The primary outcome of the randomised controlled trial will be first acute hospitalization. Secondary outcomes include all acute hospitalizations, long-term care admissions, and all-cause mortality.DiscussionThis paper describes the study protocol of this complex study. The study aims to inform policies and practices around health care services for residents in retirement villages. The results of this trial are expected early 2020 with publication subsequently.Trial registrationAustralia and New Zealand Clinical Trials Registry: ACTRN12616000685415. Registered 25.5.2016.Universal Trial Number (UTN): U111–1173-6083.

Evaluation of a Web-Based, 'Purchase Event' Intensive Monitoring Method for Pharmacovigilance of Natural Health Products: Lessons and Insights from Development Work in New Zealand.

Intensive monitoring methods are used in pharmacovigilance for prescription medicines but have not yet been implemented for natural health products (NHPs). Our objective was to assess feasibility issues with a new 'purchase event' intensive monitoring method for pharmacovigilance of NHPs, including pharmacy and NHP purchaser recruitment rates, collection of NHP purchaser key patient identifier information for data linkage and quality and completeness of data. For the Ginkgo study, 213 community pharmacies in the Auckland (Aotearoa New Zealand) District Health Board area were invited to participate. Staff in participating pharmacies (n = 3 [1.4%]) recorded ginkgo product sales and gave purchasers a study invitation card (October 2015-January 2016). Ginkgo purchaser participants were emailed links to web-based baseline and follow-up questionnaires about adverse events occurring during/after taking ginkgo. Participating pharmacists and consumers were invited to provide qualitative feedback about the study. For the NHP-Lite study, all NHPs were included for monitoring. Community pharmacies in the Green Cross Health network were invited to participate. Participating pharmacy staff gave all NHP purchasers a study invitation card over a 2-week period (May 2016). NHP purchaser participants were emailed links to web-based baseline, follow-up and feedback questionnaires. Few community pharmacists (Ginkgo study, n = 3; NHP-Lite study, n = 18) and NHP purchasers (Ginkgo study, n = 0; NHP-Lite study, n = 4) participated. Pharmacists (Ginkgo study, 3/3; NHP-Lite study, 11/18) described several reasons for participating and suggested ways to increase consumer recruitment, including simplifying study procedures. These web-based, purchase event, intensive monitoring studies, with cohorts built through NHP purchases in pharmacies, identified substantial issues with recruiting pharmacists/pharmacies and NHP purchasers that, at present, render such studies unfeasible. Future studies need to consider other methods of recruiting NHP purchasers and develop a simple method for recording NHP purchases.