Journal of the New Zealand Medical Association, 17-December-2004, Vol 117 No 1207
Proceedings of the Waikato Clinical School Research Seminar, Thursday 16 September 2004
Effect of cool temperature dialysate on the quality and patients’ perception of haemodialysis. A Ayoub, Waikato Hospital, Hamilton.
Background: The effects of cool dialysate on the urea reduction ratio (URR) in high efficiency haemodialysis have not been completely studied. After reviewing the literature, it appeared that patients’ perceptions of cool dialysis have not been studied. Since patients’ perception have an impact on patient satisfaction, this motivated the authors to research this area of practice.
Methods: This study was designed to determine whether a high URR and haemodynamic stability could be achieved by using cool dialysate in two groups of patients. The first group of five patients were known to have hypotension episodes during dialysis, and the second group of five patients were documented as having stable blood pressure (BP) during and after dialysis, after excluding vascular access recirculation and any other problems. Each patient was dialysed for three sessions using cool dialysate (35°C) followed by another three sessions using a standard dialysate temperature (36.5°C). All other dialysis session parameters were maintained.
Results: The results show that the dialysate cooling resulted in an increased ultrafiltration in the low BP group (P=0.05). Cool dialysis had neither an adverse nor a beneficial effect on urea removal in the two groups (P=NS). The mean arterial pressure post- and intra-dialysis was significantly higher in dialysis with cool dialysate in the low BP group (P<0.01 and P<0.007, respectively). The mean arterial pressure in the stable BP group remained unchanged when cool dialysate was used (P=NS). The intra-dialytic pulse rates in the low and stable BP groups were similar. A total of seven episodes of symptomatic hypotension were observed in the low BP group, but none in the stable BP group (P<0.0001). Patients’ perceptions about cool dialysate were measured by a questionnaire which showed that 80% of them felt more energetic after dialysis and requested to be always dialysed with cool dialysate.
Conclusion: Cool dialysate improves tolerance for dialysis in hypotensive patients and helps increase ultrafiltration while maintaining haemodynamic stability during and after dialysis. Patients’ perceptions were positive, as most of the selected sample felt more energetic and generally well during and after dialysis, and this had a positive impact on their activities of daily living.
Melanoma incidence in greater Tauranga, North Island New Zealand: Preliminary findings of an epidemiologic study. W Chan, Waikato Hospital, Hamilton.
Introduction: A marked increase in the number of patients presenting with primary cutaneous melanoma to a private Dermatology practice in Tauranga, New Zealand resulted in the undertaking of this study. The primary objective was to ascertain the incidence of melanoma in this area and to compare the findings with those of other regions, both within New Zealand and other countries.
Method: Data were obtained from retrospective review of histology reports from a pathology laboratory servicing the public and private health systems in greater Tauranga (Tauranga and Western Bay of Plenty Districts). Primary cutaneous melanoma (including melanoma in situ) reported from January 1st to December 31st 2002 were included. The denominator population consisted of non Maori in this area identified from the 2001 New Zealand Census.
Results: Preliminary data show the age standardised incidence of melanoma in the greater Tauranga area was approximately 79/100 000. When in situ melanoma was included, the total incidence increased to 157/100 000.
Discussion: Tauranga, New Zealand has a high incidence of cutaneous melanoma. Clinical, demographic and histological details were also analysed in this study and will be discussed. Factors that may account for this high incidence of melanoma will also be considered.
Examining the Role of Stigma-Tolerance, Self-Concept and Pathology in Adolescent Help-Seeking and Service Utilisation. J Clarkson, J Fitzgerald, G Dolan, M Hsieh, I Evans, M Connelly. The Psychology Centre, Hamilton.
Factors that may impact on the decisions of young New Zealand people to access specialist mental health services were examined. A community sample of approximately 200 non-referred adolescents and current service users undertook semi-structured interviews and/or completed measures focusing on current psychological functioning, service utilization, attitudes and perceptions guiding decisions related to help-seeking and barriers to help-seeking. The findings from our preliminary analysis of the data are presented, along with a consideration of the implications for service planning and development.
Staff feelings and the process surrounding smokefree policy implementation in a major health organization: A descriptive qualitative study. J Lash1, K Evison2, J Henry2, L Adams2. 1AUT, Auckland; 2Waikato Hospital, Hamilton.
In 2003, the Waikato District Health Board (WDHB) launched their ‘Go Smokefree’ campaign throughout all WDHB campuses in the region. The campaign played a major part in the implementation of the smokefree policy. This led to all campuses going smokefree on January 1st, 2004.
The purpose of this study was to evaluate the feelings of staff regarding the implementation of a smokefree policy in a large organization and was part of a larger evaluation plan of the effectiveness of policy implementation. Using a combination of snowballing and purposive sampling, four focus groups were conducted to explore staff feelings. The groups consisted of Maori non-smokers (8), Maori smokers (6), non-Maori non-smokers (7) and non-Maori smokers (11). Qualitative data analysis and methodology was used, particularly content analysis to elicit common themes.
The common feelings that emerged from all of the groups were confusion surrounding the process of implementation. All groups felt disempowered although little opposition was expressed to the WDHB going smokefree. The two non-smoking groups expressed happiness at perceived improvements in health while expressing empathy for their smoking counterparts. The smoking groups however, felt targeted and isolated.
Recommendations were that in future more consultation and submissions be undertaken with a diverse group of staff to enable staff ownership in the development of policy and greater knowledge of implementation.
Implementing significant event management in general practice; potential barriers and solutions. S Lillis1, H Gaddes2. 1Waikato Clinical School, University of Auckland, Hamilton; 2Pinnacle.
Significant event management (SEM) offers general practice teams a process for reviewing significant events in a way that focuses on how and why defences against error can fail rather than the historical approach of blaming individuals for error. A series of focus groups were held with general practice teams in the Waikato with the purpose of understanding the barriers to implementing significant event reporting systems in general practice.
Factors that hinder and promote effective SEM related to the practice environment, the SEM process and external factors. Relating to the practice environment are barriers such as those created by a hierarchical structure, time constraints and financial costs. Effective leadership and a horizontal structure may assist practices to break down these barriers to promote better organisation learning and patient care through SEM.
The SEM process must be adaptable to meet the individual needs of practices. This may help avoid problems such as practitioners forgetting to follow through the process and promote confidence in the SEM process.
External barriers include fear of litigation and negative publicity as well as a perceived inability to effect change when a third party such as a hospital is involved. An umbrella organisation, such as a PHO, may be in a position to assist in the successful implementation of SEM by providing methods and motivation for practices and co-ordinate sharing of important SEM information between practices. Despite a number of barriers recognised by practices, there was strong support for the process of significant event management.
Mechano-Growth Factor (MGF), but not mature IGF-IEa, reduces the severity of myocardial infarction. C D McMahon*1, G P Devlin2, K G Matthews1, J Jensen2, S P Stuart1, P H Goldspink4, S Y Yang3, S K S Srai3, B Ramesh3, J V Conaglen2, J J Bass1 and G Goldspink3. 1AgResearch Ltd., Hamilton, NZ; 2Waikato Clinical School, University of Auckland, Hamilton, NZ; 3Royal Free and University College Medical School, London, UK; 4University of Illinois (Chicago), USA.
We sought to determine whether MGF, a splice-variant of IGF-I containing a novel E domain, could reduce the extent of ischaemic damage following myocardial infarction (MI).
MI was induced by occluding the left circumflex coronary artery of sheep. In the first experiment, ewes received one of four protein treatments (n=6 per group) delivered into the circumflex artery: vehicle (saline), 200 nM mature IGF-I, 200 nM MGF E domain, or 200 nM of full MGF (domains B, C, A and D of mature IGF-I plus the E domain of MGF). In the second experiment, 18 ewes were randomised to receive either empty vector (control), IGF-IEa, or MGF plasmid DNA into the occluded artery (n=6 per group). Left ventricular function was assessed with echocardiography before MI (baseline), and at days 1, 2 and 6 post-MI.
Cardiac ejection fraction was reduced by 40% (P<0.001) at d 1 in all sheep, but was increased by 4% at d 6 only in sheep treated with MGF peptide only (E or full peptide; at least P<0.05). Sheep were killed on d 8 and the coronary artery perfused with 0.15% Evans blue dye to distinguish the area ‘at-risk’ from the viable and necrotic areas. Hearts were sectioned transversely into 1 cm slices, digitally photographed, and the respective areas assessed. In the first experiment, only MGF (E domain and full MGF) reduced the area ‘at-risk’ (58%, P<0.01) and increased the viable area (3.2 fold, P<0.01) compared with controls. Similar changes were observed in the second experiment, but of lower magnitude suggesting that early presence of the protein is essential.
These data suggest that acute administration of protein is more effective than gene therapy at reducing the area ‘at-risk’ and furthermore that the E domain of MGF, but not mature IGF-I or the Ea domain, may prevent expansion of the infarct and remodelling of the myocardium.
Health Waikato Teledermatology Trials Phase 6. A Oakley, J Bennett, S Holmes. Waikato Hospital, Hamilton.
The incidence of melanoma and non-melanoma skin cancer in New Zealand is among the highest in the world. Patients referred to specialist dermatologists often wait months to be seen for diagnosis and management. Teledermatological triage may allow us to offer a better service. A study was designed to find out if there was any advantage to adding images of the skin lesion to the standard referral.
Referral data and images of 109 lesions from 73 unselected patients attending lesion diagnosis clinics were included in the study. Thirty-eight dermatologists (the ‘teledermatologists’) were presented with online referral text and images for 5 skin lesions, images alone for 5 lesions and text alone for 5 lesions. Diagnoses, management plans and referral priority made online using non-standardised equipment were compared with those made histologically and/or face to face by a specialist dermatologist or plastic surgeon at routine clinics.
The referring GPs made the same diagnosis as the face-to-face specialist for 31% of lesions. The teledermatologists made the same diagnosis for 56% lesions given images but only 42% with text alone, and were much less confident about the diagnosis than the face-to-face specialists, especially when provided with text alone. The concordance of diagnosis ranged from 20 to 100% of lesions and was more consistent in more experienced dermatologists using high quality computer equipment.
In conclusion, high quality images help experienced dermatologists in the triage of patients with skin lesions but face-to-face consultations may be necessary for the majority of them.
Acknowledgements: Felicity Reeves (elective medical student, Nottingham UK); Departments of Dermatology and Plastic Surgery, Health Waikato, New Zealand; Dermatological Society members; and Dermatology trainees.
Changing Pattern of Gastroschisis. S Heap, U Samarakkody, S Brown, A Kukkady. Dept of Paediatric Surgery, Waikato Hospital, Hamilton.
Introduction: There is a global increase of the incidence of gastroschisis. We have looked at the incidence of gastroschisis and other associated demographics of the patients treated in a tertiary paediatric surgical centre.
Aim: To document the recent incidence of gastroschisis in the mid north island of New Zealand and compare it with the national figures.
Method: All patients born with Gastroschisis treated in the unit during a period of seven years are analysed. The case notes of patients at Waikato hospital and referring hospitals are reviewed. The incidence, ethnicity, maternal age, associated abnormalities and the method of delivery are analysed. The indications for Caesarean section and the effect it has on the outcome are critically reviewed. The surgical procedure and postoperative complications are reported. The results are compared with the national statistics obtained through Statistics New Zealand.
Results: There is a gradual increase in the incidence of gastroschisis. The Maori ethnicity is disproportionately represented. The maternal age is lower than the national average. The gestational age and birth weight are lower than average. Indications for Caesarean section seem to be not objective.
Conclusion: The incidence of Gastroschisis is increasing in the Mid north island of New Zealand.
Complicated intestinal atresias need individualised approach. R Sakalkale, U Samarakkody, S Brown, A Kukkady. Dept of Paediatric Surgery, Waikato Hospital, Hamilton.
Aims: Retrospective study of complicated intestinal atresias.
Methods: We studied retrospectively, two groups of complicated and uncomplicated jejuno-ileal intestinal atresias respectively, presenting to us in the last five years. The study parameters were birth weight, gestational age, maternal age, antenatal factors, chromosomal and associated systemic abnormalities, surgical diagnosis and management.
Results: A total of 13 neonates presented to us with jejuno-ileal atresias in the last five years. Nine were males and four females. Six patients (5 male, 1 female) had complicated intestinal atresias associated with antenatal perforation (2), gastroschisis (1^ + 1*), patent vitello-intestinal duct* (1), posterior urethral valves (1), congenital short bowel^ and meconium ileus/CF (1). There was no difference in these two groups regarding birth weight, maternal age and antenatal factors. In the complicated atresia group all except one, who had a definitive anastamosis, had stomas fashioned initially followed by definitive closure several weeks later. There was one death in this group, namely the child with short bowel syndrome, at 9 months of age due to combined liver and bowel failure.
1. Current embryological concepts fall short of explaining some of these complicated atresia associations
2. Almost all patients in the complicated atresia group had more morbidity, prolonged hospital stay and multiple procedures.
Learning Outcomes for Medical Student Radiology Teaching. R M Subramaniam12 , J Sherriff1 , K Holmes1 , M C Chan1. 1 Department of Radiology, Waikato Hospital, Hamilton; 2Department of Radiology, Waikato Clinical School, University of Auckland, Hamilton.
Objectives: To establish a set of learning outcomes for medical student radiology teaching from non-radiology clinicians perspective.
Methods: A single tertiary centre study was conducted and a questionnaire was sent to consultant clinicians in all specialties, except radiology. Each learning outcome was graded on a scale of 1 (very strongly disagree) to 6 (very strongly agree). Participants also graded a list of 14 common radiological investigations in terms of the importance for students to observe during their training. Opportunity was given for clinicians to put forward any suggestions other than those presented on the questionnaire and grade them.
Results: 45 out of 90 questionnaires were returned. All educational learning outcomes scored above an average of 4 (agree). The five highest ranking learning outcomes in order of importance were: viewing chest films, viewing abdominal films, viewing bone and joint films, distinguishing normal structures from abnormal and identifying gross bone or joint abnormalities. Clinicians agreed for observing computed tomography (CT) and possibly for Magnetic Resonance Imaging (MRI), abdominal ultrasound (US) and chest films during medical student radiology training.
Conclusion: A set of learning outcomes for medical student radiology teaching was established from a clinicians’ perspective.
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