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Journal of the New Zealand Medical Association, 03-April-2009, Vol 122 No 1292

Proceedings of the Waikato Clinical School Research Seminar, Thursday 9 October 2008

Improving access and grading evaluations using in-depth teledermatology: image it trial

E. Tan, A. Oakley, M. Rademaker, M. Jameson and A. Yung

Department of Dermatology, Waikato Hospital, Hamilton, New Zealand

Department of Oncology, Waikato Hospital, Hamilton, New Zealand

New Zealand has one of the highest incidences of melanoma in the world. Melanoma and non-melanoma skin cancer exert a significant disease burden to society. The dermatologist plays a crucial role in diagnosis and management of skin lesions, but access to dermatology clinics is limited by an undersupply of dermatologists.

In this study, we assessed a highly structured form of teledermatology incorporating dermoscopy for its diagnostic accuracy and its role in triage for the public hospital lesion clinic. Patients attended a teledermatology consultation and face-to-face consultations with two dermatologists on the day of their clinic appointment. The teledermatology digital images were then evaluated by two experienced teledermatologists 4 weeks’ later. The diagnosis and management were then compared to those made at the face to face consultation.

Here we are reporting the results of the first 100 patients with a total of 228 lesions imaged. The mean age of participants was 60 years old. There was excellent concordance between face-to-face and teledermatology diagnosis for all lesions with only a 6-7% significant difference. This technology was 100% sensitive and >90% specific for detecting cancerous lesions. Furthermore of all lesions referred, there was potential for >80% of all lesions to be managed by the General Practitioner. The results of this study showed that teledermatology can be used as a triage tool to improve healthcare access and delivery.

Predictors of loneliness in older persons: a New Zealand study

Dr. P.S.D.V. Prasadarao@, Dr. Paul L. Merrick, Dr. Gary Cheung & Selvaraj Vasanthan

@Mental Health Services for Older people (MHSOP), Waikato Hospital, Hamilton

New Zealand’s population is ageing. As people live longer, health promotion behaviours become more important, with regard to maintaining function and independence and improving quality of life. Older persons become increasingly susceptible to experience of loneliness due to the likelihood of multiple life changes and losses. The proportion of loneliness experienced by older persons varies across cultures. Internationally, the rates of loneliness ranged from 4% to 36% among older persons. Loneliness is linked to depression, anxiety and increased vulnerability to health problems. It is also associated with changes in immune functioning. Loneliness may lead to impaired quality of life, greater need for institutional care and increased mortality. Research exploring loneliness may have important implications in developing strategies to deal with loneliness and in enhancing quality of life of older persons. There is paucity of research on loneliness in New Zealand, which prompted the present study.

The present research was a cross-sectional exploratory study utilizing convenience sample. The aims were to: 1) assess the degree of subjectively experienced loneliness; 2) find out the relationship between loneliness and subjectively rated depression; 3) find out the relationship between loneliness and subjectively rated anxiety; and 4) explore the predictors of loneliness. Individuals over 65 years of age, with adequate cognitive functioning, and independent in carrying out daily living activities were included. 176 persons consented to participate in the present study. Variables, namely, degree of perceived loneliness, subjectively rated depression and anxiety were assessed using UCLA Loneliness Scale (Russell, 1996), Geriatric Depression Scale (Sheikh & Yesavage, 1986) and Geriatric Anxiety Inventory (Pahana et al., 2007). Findings, implications and suggestions for further research were discussed.

Untreated severe aortic stenosis is associated with poor outcomes.

Suresh Perera*, Namal Wijesinghe, Elene Ly, Gerard Devlin, Sanjeevan Pasupati

Department of Cardiology, Waikato Hospital, Hamilton, New Zealand

Background Symptomatic severe aortic stenosis (AS) is a common problem in the elderly. Aortic valve replacement remains the gold standard of treatment but is often not considered due to excessive risk factors and co-morbidities. We describe the burden of untreated severe AS at Waikato Hospital.

Method All Consecutive patients who were diagnosed with severe AS (at least 1 echocardiographic parameters of valve area <1 cm2, maximum velocity > 4 m/s and mean pressure gradient > 40 mmHg) at Waikato hospital between 01.01.2005 and 30.09.2005 were studied retrospectively.

A total of 87 patients were included. The outcome was assessed by mortality and among surviving patients, number of days spent in the hospital per year and ongoing symptoms (angina > CCS class 2, dyspnoea > NYHA class 2 and syncope).

Outcome data were gathered by reviewing of medical records, telephone contacts of patients and GPs.

Results A total of 87 patients (mean age 77.3 +/- 14.1 years, 52% men) were studied. Two patients were lost to follow up. The Other 85 patients were divided into 3 groups according to their management method.(Group 1: Not referred for surgery as asymptomatic, Group 2: Declined for surgery, Group 3: Accepted for surgery) Median (Q1, Q3) follow up: Group 1: 33.3 (23.2, 35.7) months, Group 2: 24.7 (12.0, 36.0) months, Group 3: 35.4 (31.5, 36.4) months

Outcome

	Number of patients	Age (+/- SD) year	All cause mortality	Hospital days/100pts/year	Symptoms on follow up
Group1 (Asymptomatic)	20 (24%)	80.8 +/- 15.9	45%	6	00%
Group 2 (Symptomatic-No Surgery	31 (36%)	85.2 +/- 6.5	74%	16	63%
Group 3 (Surgery)	34 (40%)	66.2 +/- 11.8	21%	3	00%

Limitations Non- randomised data leading to the more sick patients being denied surgery.

Small numbers which could skew the results.
Survival is projected from median follow-up compared to Kaplan-Mier curves.

Conclusion

36% of severe AS patients (48% of symptomatic patients) have been denied aortic valve replacement. • Patients who are considered asymptomatic with severe AS and managed conservatively have poor survival and more hospital admissions compared to patients who had surgery.
For asymptomatic severe AS patients, risk factors that predict mortality and morbidity should be sought and high risk patients should follow the treatment pathway of symptomatic patients• Patients with symptomatic severe AS
1. have a major survival advantage by surgical valve replacement.
2. have more impact on the health dollar by recurrent hospital admissions.
3. have a poor quality of life with more debilitating symptoms.
For symptomatic patients who are denied surgery, alternative therapies like transcatheter aortic valve insertion should be considered

Mindfulness-based stress reduction programme for chronic pain: a pilot study

Jeannette Shennan*, Philippa Thomas**, Wendy Tuck”, Helen Conaglen^, Jill Bell^

* Pain Clinic, Waikato Hospital, ** The Psychology Centre, Hamilton, ” Health Waikato, ^ Private Practice, Hamilton

This study describes a randomised waitlist controlled trial of a mindfulness-based stress reduction (MBSR) programme for sufferers from chronic medical conditions including chronic pain.

Participants were randomised to either treatment (N=23) or waitlist (N=24) conditions; waiters were subsequently offered treatment places. Measures were administered at screening, pre- and post- treatment and at 6month follow-up. Measures included SF-36, pain NRS, Pain Catastrophising Scale (PCS), Depression Anxiety and Stress Symptom Scale (DASS) and the Kentucky Inventory of Mindfulness Scale (KIMS). Participants also kept records of daily mindfulness practice. Treatment was an 8 week group MBSR programme adapted for New Zealand conditions. Results from the whole groups were presented at the previous research seminar. Results evaluating MBSR for chronic pain are presented here.

Results from the randomised groups, excluding those with pain<3 at screening, showed significant differences between post-treatment and post-wait in the mental health and social function sub-scale of the SF-36, and with 2 additional SF-36 subscales by follow-up. Apart from one KIMS subscale, no other measure showed a significant difference.

Pooled pre- vs post-treatment measures of 36 treatment completers excluding those with pain <3 at screening were analysed, to consider the process of change over time. There was a significant difference in pain NRS at treatment end, maintained at follow-up. Differences in PCS subscales were greater during treatment for helplessness and magnification, and greater at follow-up for rumination. All DASS subscales differences were significant. There were significant differences in the Pain and 4 other of the 8 SF-36 subscales, with effect size increasing for Social Functioning and Pain subscales at follow-up. A minority of participants reported little or no benefit. Most continued with self-directed mindfulness practice to follow-up, with many individuals reporting significant achievements.

The study suggests that MBSR may be effective in reducing chronic pain and its negative consequences, with effects persisting or developing after treatment end.

Supported by a research grant from The Waikato Medical Research Foundation.

Comparison of primary melanomas excised in Waikato Hospital with the New Zealand Cancer Registry

L Chan, A Oakley

Malignant melanoma is the fourth most common cancer in New Zealand, with approximately 37.2/100 000 registered in 2004 with 244 deaths in 20011,2. Accurate and early diagnosis is critical. Melanomas are diagnosed and removed by a variety of health professionals including general practitioners (GPs), plastic surgeons, dermatologists and junior hospital doctors.

Aim To compare melanomas excised at Waikato Hospital with those recorded in the New Zealand Cancer Registry 1994-20041.

Methods: Histopathology reports and request forms were examined for all primary melanoma diagnosed at Waikato Hospital in the Dermatology and / or Plastic Surgery Departments in 2007.

Results: 105 melanomas were excised in 2007, of which 49% were invasive melanoma and the remainder melanoma in situ. Similar patterns of occurrence by body site and gender were obtained compared to the data from the New Zealand Cancer Registry and international studies1,3. All thick melanomas (Breslow depth > 3mm) occur in patients over 60 years old (8 in total) and 50% occurred in females compared to 75% and 42% respectively in the Cancer Registry.

Conclusion There was some variation in distribution of melanoma compared with the New Zealand Cancer Registry with more males overall (60% compared to 50%) and a greater proportion of thick tumours in females and those over 60 years old.

Is subclinical hypothyroidism a disease?

Veronique Gibbons, Steven Lillis, John V Conaglen, Ross Lawrenson

Introduction The prevalence of subclinical hypothyroidism (SCH) in the adult population lies between 4% and 10%, increasing with age. Treatment for subclinical hypothyroidism is contentious, with protagonists disagreeing over the rationale for medical intervention. How GPs handle patients with elevated TSH and normal FT4/FT3 results has not been investigated. The aims of this study were to examine the views of GPs about SCH.

Design A qualitative study using focus groups conducted between December 2007 and March 2008.

Participants and setting 13 GPs in 3 focus groups in Waikato, New Zealand.

Main outcome measures To understand how GPs perceive SCH and their diagnostic and management process.

Results There is wide variability in how GPs perceive SCH and their knowledge of the disease. A patient centred approach to diagnosis and management was commonly reported. Consideration of overt pathology and medico-legal issues also influenced perceptions, of SCH but lack of evidence regarding outcomes of treatment made such issues complex.

Conclusion SCH remains a complex entity because of ambiguity regarding symptoms, uncertainty regarding prognosis and variation in advice regarding treatment. This complexity is reflected in the quite disparate responses by GPs to the diagnosis and management of SCH.

What gap does this fill? GPs impressions of subclinical hypothyroidism and rationale for thyroid function testing are not well studied. This paper provides perspectives from GPs in Waikato.

This study was made possible by a grant from the Waikato Medical Research Foundation.

Prevalence of chronic kidney disease among diabetes patients in New Zealand general practice

Grace Joshy, Tesa Porter, Clem Le Lievre, Jane Lane, Mike Williams, Ross Lawrenson

Aims To estimate the prevalence of chronic kidney disease (CKD) in a population of New Zealand patients with diabetes, using estimated Glomerular Filtration Rate (eGFR); to measure the agreement between the Modification of Diet in Renal Disease (MDRD) equation and Cockcroft Gault (CG) equation in identifying CKD among Europeans and Maori.

Methods All patients diagnosed with diabetes were identified though general practice records of diagnosis codes, prescriptions and laboratory results. The MDRD equation and CG equations were used to calculate the eGFR. Agreement between the two equations was expressed using Kappa statistics and was tested using McNemar’s chi-square test.

Results

There were significant differences in agreement between the MDRD and the CG equations in identifying patients with eGFR <60 ml/min/1.73m2 for Maori females, European females and European males. While CG equation identifies more European of both genders, more Maori females were identified by MDRD.

Conclusion There are significant ethnic/gender differences in the agreement between MDRD and CG equations in identifying patients with eGFR <60 ml/min/1.73m2. MDRD equation may be overestimating CKD among Maori females or CG may not be sensitive enough for Maori females. Validation of eGFR among ethnic minorities is needed to make it a robust screening tool for CKD among diabetes patients.

Partners’ preference study: an examination of preference for tadalafil or sildenafil from the heterosexual partners’ perspective

Helen M Conaglen, University of Waikato, New Zealand

John V Conaglen, University of Auckland, New Zealand

Introduction Most research regarding oral medications for erectile dysfunction (ED) has concentrated only on the experience of the men using the drugs. This study investigated the experience of 100 heterosexual couples for whom erectile dysfunction (ED) was the presenting problem. The study hypothesis was that the female partner would reflect the previously described male preference for tadalafil over sildenafil. The specific aim of this study was to understand the extent of, and the reasons for, the women’s preference for tadalafil.

Materials and Methods This was a mixed method randomized crossover study. 100 couples (relatively naïve to ED drugs) were randomly assigned to either tadalafil or sildenafil for the first 12-week treatment period, followed by the alternative treatment for another 12 weeks. Recorded interviews with the women at baseline, crossover, and end of study allow reporting on their experience of their partner’s erectile difficulties and the couple’s experience using the medications. Both male and female participants also completed self-report sexual desire, function, relationship and general psychopathology questionnaires at each stage of the study to supplement the qualitative findings.

Results Overall 79% of the women preferred tadalafil, and 16% sildenafil, with the remainder expressing either no preference, or preferring no drug. The women’s interviews detailed reasons why they preferred one medication over the other, and the overall positive impact of the use of oral medications on their relationship. The men expressed a 76% preference for Cialis over Viagra. Questionnaire responses demonstrated that sexual function, sexual self-confidence, and general well-being were areas where most change occurred for the couples.

Conclusions Couples reported positive effects of using oral medications beyond the achievement of a useful erection; these couples reported greater intimacy, better communication and more satisfying relationships. This study demonstrates the varied clinical context in which prescribing oral medications for men with ED takes place, and argues for the inclusion of the man’s partner in the assessment and treatment process.