Anaphylaxis is a potentially fatal hypersensitivity reaction, characterised by rapid onset of life-threatening respiratory and cardiovascular symptoms. Adrenaline is the core treatment for acute reaction. Long term management of anaphylaxis includes education about avoiding triggers and risk reduction.

There are several different opioid options that can be considered at step two of the WHO analgesic ladder for chronic pain. Choice of drug, after contraindicated drugs are excluded, comes down to a balance between possible adverse effects and the desired analgesic effect.

Methadone is a strong opioid that may be suitable for people whose pain is uncontrolled with, or who are unable to tolerate, morphine. Methadone is a complex drug that requires careful dosing and monitoring.

When advice is provided to patients about reducing cardiovascular risk, lifestyle advice is usually discussed first. The mechanisms by which lifestyle factors contribute to increased risk are not fully understood. Research is continuing into how smoking, increased weight, exercise and diet affect cardiovascular risk. This article provides background information into what is currently known about these modifiable cardiovascular risk factors.

Vegetarian diets are becoming increasingly popular, but is this type of diet healthy for a child? The answer is that a well-planned and balanced vegetarian diet which includes adequate amounts of important nutrients can be healthy and nutritious, without any detrimental effect. However vegan diets which exclude dairy products and eggs are more complicated to manage.

Pregnancy outcomes can be improved by following important nutritional guidelines; achieve a healthy body weight prior to conception and maintain appropriate weight gain during pregnancy, take a folic acid supplement and consider a low dose iron supplement, use iodised salt and if taking a multivitamin supplement, ensure that excess vitamin A is not consumed.

The management of two conditions that commonly, but unnecessarily, lead to discontinuation of breastfeeding are outlined.

Gardasil vaccine has now been added to the National Immunisation Schedule. In this article we outline the eligibility criteria for the vaccine and discuss potential issues that patients may raise.

Two recent studies have raised concern that the use of ipratropium and tiotropium for COPD is associated with an increased risk of cardiovascular events. However a large four-year study did not detect any increase in risk. Tiotropium remains a safe and effective treatment for most patients with COPD.

Debate about the clinical usefulness of a diagnosis of metabolic syndrome has been ongoing since it was first described. It is suggested that the only value of the syndrome may be that it is useful simply as a basis for guiding risk assessment and promoting lifestyle interventions.

• Upfront: The unequal impact of cancer. Cancer has a significant and disproportionate impact on Māori, with significant disparities in experiences, quality of health care and resulting outcomes. This suggests that focused interventions for Māori are needed.
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• Correspondence: Dose titration in neuropathic pain