Journal of the New Zealand Medical Association, 21-May-2004, Vol 117 No 1194
Proceedings of the Waikato Clinical School Research Seminar, Thursday 25 March 2004
Is tuberculosis transmitted to staff in Waikato Hospital? S Burcher1, Noel Karalus2, S Holmes2. 1University of Auckland, Auckland; 2Waikato Hospital, Hamilton.
Aim To assess the risk of transmission of tuberculosis to staff working in Waikato Hospital, and the workload involved in monitoring this, based on the hypothesis that there is no transmission.
Methods The medical records of patients admitted to Waikato Hospital with pulmonary tuberculosis between 1998 and 2002 were reviewed. The level of staff contact tracing performed by the Public Health Unit was assessed, and the surveillance of staff working in the ‘monitored unit’ was examined.
Results Thirty-seven pulmonary tuberculosis patients were admitted to Waikato Hospital between 1998 and 2002. This lead to the investigation of 142 staff for mantoux conversion. There were 10 mantoux conversions. Two staff were prescribed chemoprophylaxis for latent infection while none was treated for active disease. Between 2002 and 2003, three staff in the monitored unit demonstrated mantoux conversions.
Conclusions The transmission of TB to staff at Waikato Hospital is not a major problem. No staff developed disease though some are infected. While the measures in place for preventing tuberculosis transmission within the hospital are adequate, a cautious approach is taken to staff contact tracing resulting in a high workload for those involved. The initial testing of all staff contacts within 21 days of exposure would provide the best chance of demonstrating a mantoux conversion. The ‘monitored unit’ model is a pragmatic approach to tuberculosis control in staff. This audit has allowed us to make recommendations regarding contact tracing of exposed staff.
Women with low sexual desire—responses to pictorial and semantic tasks and questionnaires. H M Conaglen1, J V Conaglen2, B Hedge3. 1The Psychology Centre, Hamilton; 2Waikato Hospital, Hamilton; 3Psychology Department, University of Waikato, Hamilton.
Aim This study compared persons presenting with low sexual desire problems with volunteers from a non-clinical sample with respect to responding to pictorial and semantic sexual and non-sexual cues. In addition, a comparison of questionnaire responses sought to clarify whether assumptions underpinning current therapeutic approaches are realistic.
Method In this study, participants completed mood, sexual anxiety, sexual desire and body-esteem questionnaires and carried out information processing tasks, including picture rating and recognition tasks, and timed responding to semantic stimuli; this replicates aspects of earlier work but with a group of women reporting low sexual desire.
Results The two groups of women did not differ significantly with respect to their rating of pictures, their recognition time for previously viewed pictures or for the extent of sexual content induced delay. The tasks with the semantic stimuli were completed more slowly by the low desire women, and they also rated sexual words as less familiar than the contrast women. The questionnaire responses were significantly different for sex anxiety, t(40)=4.52, p<0.0001; both sexual desire measures, t(40)=
-12.01, p<0.0001 and t(40)=-6.35, p<0.0001; and the sex attractiveness sub-scale of the body esteem scale t(40)=-2.97, p=0.005.
Discussion This study has shown that previous findings in a non-clinical sample cannot necessarily be generalised to clinical groups. The study samples were small, and a larger study may have yielded findings more in line with those found in the previous work. However the study also served to confirm the reliability of the sexual desire measures in discriminating between the two groups of women, and reinforced the understanding of the strong association between anxiety and desire problems. These findings together with the qualitative interview data further the theoretical understanding of factors that may influence some women’s problematic levels of sexual desire.
Exploring satisfaction and worries of Maori people with diabetes in the Waikato region. J Haar (Ngati Maniapoto/Ngati Mahuta), D Simmons, S Lillis, J Swan. Waikato Clinical School, University of Auckland, Hamilton.
A study of Maori people who live with diabetes in the Waikato region was conducted to explore satisfaction with care, and worries about their diabetes. From 553 responses, satisfaction was higher if blood glucose was monitored (t=2.753, p<0.01), or treatment included lipid lowering medication (t=2.640, p<0.01). Respondents with complications were less satisfied with their care (t=-4.344, p<0.001) and more worried about their diabetes (t=6.980, p<0.001). No differences were found by treatment with antihypertensive medication, oral antihyperglycaemic medication, or insulin; or by smoking or gender.
Using a Maori Tikanga (customs/beliefs) structured thematic analysis, respondent worries were categorised into four major themes. 1.Rongo (experience/information) - history of whanau (family) and friends dying “I have seen the extremes of diabetes and I don't want to die like my sister and brother did”, or having complications. Limb amputations were often mentioned. 2. Whanau (extended family) - respondents didn’t want to die and leave their whanau (e.g. children, grandchildren) “I need to take better care of myself for me and my children”, or have their whanau developing diabetes (through inherited bad habits). 3. Kai (food/eat) - kai holds a central role in Maori society. It is often the heart of family gatherings. Consequently, the ability to control type and volume of kai is a major concern “I find great difficulty always having to avoid...kai (food) which as a Maori I miss”. This leads to worries about weight. 4. Makatu (fear/afraid) - this theme was dominated by the fear of losing limbs and loss of eyesight, as well as the fear of having to inject insulin. A common response was “I worry because I may lose a limb or worse”. In conclusion, to provide the best care for Maori people who live with diabetes, it is important that consideration be given to these cultural dimensions, particularly with regard to whanau.
Child and adolescent obesity: A qualitative exploration of its assessment, management and treatment by practitioners in the Waikato region. J Howarth,
B Hedge. Psychology Department, University of Waikato, Hamilton.
Child and adolescent obesity is a rapidly rising epidemic in New Zealand. This is a matter for concern as children and adolescents who are obese are likely to continue to be so through to adulthood, and obesity can be associated with a wide range of medical, social, and psychological difficulties. This study, complimentary to a questionnaire study, aimed to explore the current strategies used, as well as the obstacles faced, by health professionals in the Waikato region in the assessment and treatment of child and adolescent obesity. General practitioners, public health nurses, paediatricians, and dieticians who practise in the Waikato were invited to participate in semi-structured interviews exploring these issues. Nine interviews were conducted, audio taped and transcribed. Thematic analysis, based on a framework model, was used to explore and interpret interview content.
Identified themes related to: 1. the presentation of child and adolescent obesity; 2. the impact of culture, ethnicity, socioeconomics and education; 3. assessment; 4. barriers to effective treatment; 5. causes; 6. elements of treatment programmes; 7. successful aspects of treatment programmes; 8. nationwide strategies to reduce child and adolescent obesity. The implications of these findings will be discussed in relation to the treatment of obese and overweight children and adolescents in the Waikato.
Does percutaneous endoscopic gastrostomy influence the course of gastroesophageal reflux? E M I Kim, U Samarakkody, R Richmond, S Brown. Department of Paediatric Surgery, Waikato Hospital, Hamilton.
Purpose Percutaneous endoscopic gastrostomy (PEG) has been widely used for children with feeding difficulties and low caloric intake. There are controversial data in the literature reporting causation and development of gastroesophageal reflux (GER), subsequent to PEG. The aim of this prospective study, commenced in the year 2001, is to analyse the influence of PEG on GER.
Methods Ambulatory 24-hour esophageal pH monitoring was performed on the patients before PEG and subsequently at the time of Mickey button placement, which was approximately 3 months after PEG. Boix-Ochoa score was used for the analysis. The medical records of all patients were reviewed to record GER related symptoms and signs before and after PEG. The site of PEG was recorded and photographed endoscopically, in order to analyse the other possible contributing factors in the development of GER after PEG.
Results The complete results of twenty patients were available. Unpredictable changes were evident in the number of acid refluxes, the number of long acid refluxes, the duration of the longest acid reflux (min), and the fraction of time pH below 4.00 (%) before and after PEG. The Boix-Ochoa scores improved in most children with few exceptions. One patient subsequently required a Nissen fundoplication.
Conclusion Our results suggest that PEG does not precipitate or exacerbate GER. Anti-reflux surgery is not necessary with PEG placement, even if there is evidence of GER. The pH monitoring prior to PEG can be used to screen the patients who may require anti-reflux surgery if they become symptomatic.
Child and adolescent obesity: assessment, management and treatment by practitioners in the Waikato region. J M McClintock, B Hedge. Psychology Department, University of Waikato, Hamilton.
The rapidly rising prevalence of obesity amongst children is of particular concern in New Zealand because children who are obese are more likely to be obese into adolescence and adulthood. This rising prevalence is likely to be associated with a corresponding increase in obesity related disorders; problems for health service practitioners to contend with in the future. Based on research conducted in the United States, the purpose of this study was to identify current assessment, management, and treatment strategies for child obesity used by health professionals in the Waikato region. 250 questionnaires were sent out to general practitioners and child health specialists in the Waikato region. 56 participants returned fully completed questionnaires.
Although the results indicate that child health practitioners are particularly concerned with childhood obesity, very few of the practitioners follow published guidelines for the medical, laboratory, and family evaluations of obesity. A greater number of participants carry out appropriate psychological and behavioural assessments. Lack of patient motivation and support services were the most heavily endorsed barriers to intervention. These findings suggest the need for increased training in the appropriate recognition, assessment and initiation of treatment for childhood obesity.
The use of ultrasound to detect position and patency of endotracheal tubes.
B Manikkam1, J Sleigh2, H Round3. 1University of Auckland; 2Anaesthetics Department, Waikato Hospital, Hamilton; 3University of Waikato, Hamilton.
Endotracheal tubes may be incorrectly placed in the oesophagus or beyond the carina, or may become kinked or blocked with mucus. This occurs particularly in the neonate and comorbidities include cerebral hypoxia and death. We attempted analysis of ultrasonic echoes, to quantify and locate blockage, and determine ETT position. The use of piezoelectric transducers was abandoned as a result of lengthy ringing and therefore poor temporal and spatial resolution. Manufacture of capacitive / electrostatic transducers was attempted to allow determination of transducer characteristics although with little success. Polaroid electrostatic transducers produced preliminary results.
After digital signal processing including filtering, we were able to quantify larger blockages to within 10% and determine its position to within 5mm of their actual values. Refinement of these methods will involve better means of directing sound from these large transducers into such small tubes. Alternately on may develop small transducers, which fit into the ETT, that are capable of delivering a single unipolar pulse. The development of a small ultrasonic device would offer a cheap, fast and reliable method of determining ETT position and patency. This could eliminate the need for, potentially hazardous, routine suctioning and facilitate prompt resolution of situations in which ETT position and patency is uncertain.
The availability and efficacy of written information addressing obesity in Hamilton. J Roach, B Hedge. Psychology Department, University of Waikato, Hamilton.
Child and adolescent obesity is reaching epidemic proportions in New Zealand. One way to affect change is by using written information. However, large discrepancies exist between the reading levels required to understand many information pamphlets and the reading levels of average people. In addition, people are only likely to attend to those health messages that are presented in attractive packages.
The aims of the study were to investigate the availability in Hamilton pamphlets targeting obesity. For those pamphlets targeting childhood obesity, their efficacy in providing good obesity related health education was assessed. Thirteen venues were investigated for the availability of pamphlets that targeted obesity.
Available pamphlets were evaluated with respect to their aims and target audience, content and general message. For those targeting childhood obesity prevention (or treatment), presentation, format, content and readability was evaluated.
Pamphlets were obtained from 13 sites. Of the eight pamphlets that targeted child and adolescent obesity, one targeted weight reduction, and seven targeted the maintenance of healthy weight. Using an 80% criterion for acceptability, only two pamphlets reached 80% for presentation, none of the pamphlets reached the 80% criterion for format, and two of the eight pamphlets were readable by 80% of the population. The best ‘all round’ pamphlet was rated 80% for presentation and was readable by 75% of the population.
High-quality written information concerning childhood and adolescent obesity is difficult to access in Hamilton. This suggests that there is an opportunity for enhancing child healthcare through the development and distribution of more effective pamphlets that target obesity.
Epidemiology of Meckel’s diverticulum in the Central North Island of New Zealand. R P Sakalkale, U Samarakkody, N Noor-Mohd, P Newman, S Brown. Waikato Hospital, Hamilton.
Purpose The epidemiology of Meckel’s diverticulum (M.D.) in children in New Zealand has not been reported in the literature. We studied the children referred to us from the Central North Island of (C.N.I.) New Zealand between 1997-2003 and who had their Meckel’s diverticulum resected.
Methodology Hospital medical records were reviewed (including pathological database) of children who had their M.D. resected. Pathology was correlated with clinical presentation. Census data for the region was used to determine the annualized incidence.
Results A total of 19 children (13 boys, 6 girls, M: F=2.1:1, 3 patients <2 years old) were identified. Their ages ranged from 4 months to 13 years (mean age: 8.2 years). The annualised incidence rate was 1.89% for the region. Seven (36.8%) presented with rectal bleeding and in these Tc99m-pertechnetate scan was positive. In the remaining 12 patients (63.2%), findings were, acute inflammation 2, volvulus alone 3, volvulus with gangrene or perforation 3, intussusception, 1 and entirely normal 3. Presentation-wise, there was no difference between the younger (<2 years) and older (>2 years) children. On histopathology, (heterotopic) epithelia were gastric 7, duodenal 1, pancreatic 3, colonic 1 and highly necrotic in 2. On a mean postoperative follow-up of 3.8 years, all have been asymptomatic.
Conclusions The Central North Island of New Zealand can be expected to have around 3 children per year with an M.D. Age at presentation is much higher than reported elsewhere. Uncommon types of epithelia are detected in many cases.
Differing perceptions of barriers to diabetes care among medical, nursing and other health staff in secondary health services in the Waikato. D Simmons, J Haar, S Lillis, J Swan. Waikato Clinical School, University of Auckland, Hamilton.
Diabetes continues to cause premature death and disability in spite of a range of effective interventions. We have undertaken a postal survey among medical, dietetic and senior nursing staff involved in the management of patients with diabetes asking perceptions of ways to improve care, issues preventing quality care and concerns about diabetes care. Initial surveys were followed up with repeated contact. Overall, 171 staff were identified, of whom 64/100 (64%) medical and 57/71 (80%) other staff responded. The number of comments (of variable length) ranged from 1-18 per respondent and 1053 comments were provided. Doctors gave 7.3 comments each and others 10.3 comments.
Comments were given one or more of 34 “barrier” codes based upon prior validated work (1) using triangulation. The major perceived barriers overall were patients knowledge of diabetes (67.8%), patient’s motivation/denial (66.1%), staffing levels/appointment systems (66.1%), unsatisfactory diabetes care/education in the past (65.3%), patients readiness to change (58.5%) and inadequate information management including professional education, coordination and audit (52.5%).
Doctors (vs others) were significantly more likely to report that obesity was an issue (21.9 vs 5.6%, p=0.012), while doctors were significantly less likely to report 10 barriers including personal finance (28.1 vs 51.9%, p=0.008), lack of community based services (26.6 vs 51.9%, p=0.005), lack of family support (4.7 vs 22.2%, p=.004) and the unsupportive macroenvironment (26.6 vs 59.3%, p<0.001). Twenty one respondents were employed by the diabetes services and were more likely to comment (vs others) on priority setting (28.6 vs 1.0%, p<0.001), time (38.1 vs 11.3%, p=0.007) and emotional responses such as fear (19.0 vs 4.1%, p=0.047) as barriers. There were no differences in perceptions of cross-cultural issues (33.1%) as barriers. Similar numbers (35.6%) indicated concern about the size of the diabetes epidemic.
We conclude that major differences in perceptions of barriers to care exist and these may influence service planning. The survey has also generated a large number of suggestions about how to improve services and these are under consideration. Surveys of patients and those in primary care are underway.
Is a routine serial ultrasound examination necessary after an initial negative complete lower limb ultrasound study to exclude DVT? R Subramaniam, K Cox, R Heath, R Allen, G Davis. Department of Radiology and Haematology, Waikato Hospital, Hamilton.
Objective To determine whether routine serial ultrasound imaging is necessary to safely exclude DVT or its complications in patients with an initial negative complete lower limb ultrasound study.
Methods 320 patients presented to the Emergency Department with suspected DVT were recruited prospectively from June 2002 to May 2003. A complete lower limb ultrasound examination was used as the gold standard to diagnose DVT. The main sonographic criterian for diagnosis of DVT was a noncompressible vein.13 variables were collected before the ultrasound examination. Simplify D dimmer and ‘D-dimer plus’ D dimer were done in all patients. All patients were followed up for 3 months for detecting any suspected evidence of recurrent DVT or Pulmonary embolism (PE).
Results A total of 68 (21.25%) patients were found to have DVT. 252 patients (78.75%) had an initial negative lower limb ultrasound study. Of those who had an initial negative study, 28 (11%) patients re-presented to Emergency Department with various presenting complaints within the 3-month follow-up period. Among these patients, 10 of them had lower limb ultrasound for the purpose of diagnosis or exclusion of DVT and one had a CTPA and Ultrasound for diagnosis or exclusion of PE / DVT. None of these 11 patients had evidence of thromboembolism. The other 252 patients with an initial negative study had no suspected episode of thromboembolism or re admission to Emergency Department. The specificity and negative predictive value of a complete lower limb ultrasound is 99.8% (95% CI 98.2%-100%) to exclude clinically significant DVT.
Conclusions A negative complete lower limb ultrasound study is a safe examination and routine serial ultrasound is unnecessary to exclude clinically significant DVT.
Screening for deep venous thrombosis using digital photoplethysmography following hip or knee arthroplasty: T Swift, P Jones. Surgical Unit, QE Health, Rotorua.
Objective Deep vein thrombosis occurs more frequently in joint arthroplasty patients than inmost other surgical groups. The purpose of this study was to evaluate the effectiveness of Digital Photoplethysmography (D-PPG) as a screening tool for DVT in this population group.
Method A prospective study of 50 patients who had undergone elective hip or knee joint replacement. Each patient was assessed by duplex ultrasound (the gold standard) and D-PPG between the 3rd and 5th postoperative day. Patients received routine DVT prophylaxis. Analysis was by 2x2 table and Chi-squared statistic for goodness of fit.
Results 6% of patients (n=3) were found to have DVT as demonstrated by duplex ultra sound. Using a refill time of 21 seconds as the optimal cut off point D-PPG achieved 100% sensitivity and negative predictive value, specificity of 32% and positive predictive value of 8.6%. Using a cutoff point of 10 seconds sensitivity and NPV remained at 100% and specificity increased to 76%, PPV 21%.
Conclusion Using published protocols for refill time cut off point D-PPG is not a useful screening tool for DVT in postoperative joint replacement patients. Varying the refill time cut off point improves the test performance but the very low rate of DVT in this patient group precludes a definite conclusion.
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