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| Journal of the New Zealand Medical Association,
05-November-2010, Vol 123 No 1325
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Proceedings of the Waikato Clinical School Biannual
Research Seminar, Wednesday 13 October 2010
Trends of Chlamydia infection and related complications in New Zealand, 1998-2008J Morgan, C Colonne, A Bell. Sexual Health Service,
3 Ohaupo Road, Waikato Hospital, Private Bag 3200, Hamilton 3240.
Aim: To compare trends in Chlamydia testing
and detection with trends in hospital discharge rates of Chlamydia-related
diseases in the upper north island of New Zealand during 1998-2008.
Methods: Analysis of time trends in
regional Chlamydia testing and detection rates and regional age-specific
hospital admission rates per 100,000 females for pelvic inflammatory disease,
female infertility, ectopic pregnancy and per 100,000 males for male
epididymo-orchitis.
Results: Laboratory Chlamydia testing
volumes increased steadily, from a total of 3732 tests per 100,000 population in
1998 to 9801 tests per 100,000 population in 2008. The highest detection rates
and greatest increase over time were noted amongst women aged 15-24 years, at
773 reported cases per 100,000 in 1998, increasing to 8819 cases per 100,000 in
2008. Over the same period, for women aged 15-24 years, the rate of hospital
admissions for PID and Chlamydia-related pelvic infections declined during 1998
to 2004 but rose from 2005-2008, the rate of publicly funded infertility
admissions fell and the ectopic pregnancy rate was unchanged. The age-specific
rate for epididymo-orchitis admissions amongst 15-44 year old men remained
stable.
Conclusion: Chlamydia testing volumes from
the upper north island have trebled since 1998, as have reported rates of
Chlamydia infection, whilst disease complication rates do not appear to have
increased. Ecological data must be interpreted with caution. Nonetheless,
current high levels of chlamydia testing and detection appear consistent with
greater detection of prevalent asymptomatic infection.
Presenting tumour features of Waikato women with newly diagnosed breast cancer from 2005-2008ID Campbell, CWL Ooi, R Lawrenson, M-A Hamilton, M
Kuper, G Round, D Lamont, S Ellis, C Munt. Breast Care Centre, Waikato Hospital,
Private Bag 3200, Hamilton 3206, New Zealand.
The Waikato Breast Cancer Register (WBCR) was established in
2005 to audit all Waikato women diagnosed with breast cancer. The primary goal
is to establish the nature of breast cancer presenting in a defined regional
population to examine inequalities in presentation and outcome. The population
has the highest regional population of Maori women in New Zealand enabling
detailed comparisons and analysis.
All women residing in the Waikato region at the time of
diagnosis are eligible for WBCR after informed consent. Detailed data of mode of
presentation (screening or symptomatic), ethnicity, diagnostic and surgical
procedures undertaken, pathological findings, adjuvant treatments and follow up
are prospectively collected.
From 2005-2008, 998/1008 (95%) eligible women consented for
entry into the WBCR. The majority of patients (~80%) were of European origin
with Maori women making up approximately 15%. Of the women diagnosed with breast
cancer who were within the screening age, only 54% were screen-detected cancers.
Maori and Pacific Islanders were less likely to present with a screen-detected
cancer. Invasive cancers comprised 86% of the total. Maori and Pacific Islander
women had larger tumours and a higher proportion of node positivity. They also
had a higher proportion of Her 2 positive tumours.
Significant variation in breast cancer presentation by
ethnicity occurs in the Waikato. The extent of this variation is likely to lead
to significantly worse cancer outcomes for these ethnic groups.
8 is Great! Cognitive Outcome of Very Low Birth Weight Infants at age 8NA Keene, D Bourchier & S McGregor. Child
Development Centre, Waikato Hospital, Private Bag 3200, Hamilton,
NZ.
Infants born very early and very small are at increased risk
for development problems. Infants born weighing less than 1250g, and discharged
from Waikato Hospital New Born Unit, are routinely followed up at the Child
Development Centre, at 1 & 2 years (age corrected for prematurity) and at
age 4. The aims of this study were to: (1) assess the cognitive outcome of these
children at 8 years of age and compare to the normative data on the WISC IV, and
(2) determine the potential value of the preschool cognitive assessments in
predicting school-age outcomes.
Sixty-one infants born, weighing less than 1250g, in 1998
and 1999 were identified for the study. Of this group 4 children had been
previously identified with an Intellectual Disability (ID) so were excluded, a
further 21 were excluded for a variety of reasons. Thirty-six children were
included in the final analysis (59%). Twenty-one (58%) were male. The mean age
was 100.65 months (8yr 4mths) and the mean birth weight was 892.04gms (range
510g – 1202g). The Wechsler Intelligence Scale for children, Fourth
Edition (WISC IV) was used to assess cognitive ability. The sample was normally
distributed and individual scores were placed with in a normal distribution for
comparison (WISC IV, mean 100, SD 15).
The mean full scale cognitive score of the 36 children in
the final analysis was within the average range, but substantially lower than
the mean on the WISC IV. The mean FSIQ was 86 (SD 18) and ranged between 48 and
117. Seventeen percent of children were within the extremely low range (2 SD
below the mean and in the range consistent with Intellectual Disability), 28%
were 1 Standard Deviation below the mean and 53% were within the average range
(+/- 1SD of the mean). One child achieved an above average score. A T
test for dependent samples indicated no significant difference in cognitive
scores between 4 and 8 years.
Overall, our sample of VLBW infants achieved substantially
lower cognitive scores compared to normative data on the WISC IV. In-fact taking
into account the children that were excluded due to ID, 28% of the children in
the cohorts of 1998/1999 (N=40) had an intellectual disability. This is compared
to 2.5% expected within the normal population. Furthermore, cognitive scores at
the 4 year assessment were consistent with cognitive scores at 8 years
suggesting the 4 year assessment may be an important indicator of later
cognitive achievement and can provide information to support school entry.
Further results, limitations and clinical significance will be discussed.
Acknowledgements: This study was supported
by Summer Scholarships by Waikato Clinical School 2006-2008. We would further
like to acknowledge the families who participated in our study.
Evaluation of the CoaguChek XS system & INR online for Warfarin Management at Pharmacy 547.I McMichael and A Littlewood. Pharmacy 547, 533 Grey
Street, PO Box 7040, Hamilton, New Zealand.
Warfarin is an oral anti-coagulant used to reduce the risk
of blood clots forming in high risk patients. Warfarin dose needs to be closely
monitored by international normalised ratio (INR) blood tests. The current
system in the Waikato involves patients having a venous blood sample collected
at their local laboratory, with delayed results being sent to their general
practice. The dose is then assessed and any changes are relayed over the phone.
The CoaguChek XS is a hand held INR monitoring device which gives an instant INR
result. INRonline is an online decision support software developed to manage
warfarin dosing. A small number of general practices in New Zealand are using
the CoaguChek XS and INRonline to monitor their warfarin patients in an
anticoagulation management service (AMS).
Our aim was to demonstrate that CoaguChek XS & INRonline
could be used by community pharmacy to provide warfarin management. We also
wanted to compare the pharmacy model to the laboratory model and general
practice AMS and collect participants satisfaction responses.
A pharmacy AMS was developed and data was collected over a
six month period. The results showed that the pharmacy AMS increased time in
therapeutic range from 55% to 76%. Patients attended the pharmacy AMS on time
92% of the time. 80% of patients believed the pharmacy AMS was better than their
existing service.
This study was able to show that a pharmacy AMS could
successfully manage warfarin patients. The results gathered compared favourably
with existing systems. This study was only conducted at one pharmacy and further
studies will be needed to evaluate the system at a greater number of pharmacies.
Acknowledgements: Dr Paul Harper,
INRonline, Bronwyn Sheppard, Roche Diagnostics NZ, Prof John Shaw, University of
Auckland School of Pharmacy, Elizabeth Plant, Pharmaceutical Society of
NZ.
The Waikato Virtual Lesion Clinic: better, sooner and more convenientD Lim, A Oakley & M Rademaker. Department of
Dermatology, Waikato District Health Board, Private Bag 3200, Pembroke Street,
Hamilton 3240, New Zealand
Skin cancer is very common in New Zealand and hospital
lesion clinics struggle with the volume of referrals received. This results in
long waiting times for diagnostic assessment leading to delayed treatment.
Health Waikato is managing to reduce waiting times for skin lesion assessment
and treatment using a private teledermoscopy service.
We analysed patient flow through the new service and
compared it to traditional assessment clinics. Of the first 100 patients
referred to the service, 97% did not require a hospital appointment to establish
the diagnosis. Waiting times were reduced by two thirds. Eighteen patients with
skin cancers or suspicious lesions were placed straight onto surgical waiting
lists. Surveyed patients have been highly satisfied and confident with the
service.
Virtual lesion clinics can allow hospitals to keep up with
burgeoning referrals while providing a better, quicker and more convenient
service. The new service will potentially provide cost savings, as
teledermoscopy assessments can be cheaper than traditional assessments.
Use of device therapy in the outpatient management of congestive cardiac failureJ Mazhar, M Liang, G Devlin, & MK Stiles.
Department of Cardiology, Waikato Hospital and Waikato Clinical School, The
University of Auckland, New Zealand
Device therapy in patients with severe systolic heart
failure (HF), including cardiac resynchronization therapy (CRT) and implantable
cardioverter-defibrillators (ICD), improves survival and functional status in
selected patients1-5. This study aimed to
assess the number of patients fulfilling criteria for device prescription, as
outlined in the ACC/AHA/HRS 2008 guidelines6,
in an outpatient cardiology clinic setting.
We ascertained the following data from 321 consecutive
patients attending cardiology clinic during a one month period: Aetiology of HF,
New York Heart Association (NYHA) Class, Left Ventricular Ejection Fraction
(EF), QRS Duration and Prescription of CRT/ICD.
Fifty-seven (18%) had a diagnosis of HF documented; 22 (39%)
had an EF<35% and 4 (7%) had no EF measurement. Of those with
EF<35%, 9 (41%) patients had NYHA Class I symptoms, 6 (27%) Class II
symptoms, 3 (14%) Class III symptoms and 4 (18%) had no functional class
documented. Five (23%) patients had an ischaemic aetiology. Eleven satisfied
criteria for an ICD on primary prophylaxis basis, 9 of whom were < 75
yrs old; of these a single patient with known ventricular tachycardia had an
ICD. For those with NYHA Class 3 or more, 1 patient had a QRS duration of 178ms
with atrial fibrillation.
From our sample of HF patients, we identified a significant
number of patients who may benefit from device therapy for prophylaxis of sudden
cardiac death but had not been referred. Continuing education for physicians on
the criteria and availability of device therapy is essential.
References:
Long-term outcomes of patients with hypothyroidism: an analysis of CVD morbidity and mortality over a decade (1997-2006).Gibbons V, Conaglen JV, & Lawrenson R. Waikato
Clinical School, Waikato Hospital, Private Bag 3200, Hamilton
3240.
Some overseas observational studies have shown an increased
risk of cardiovascular morbidity and mortality in subjects with subclinical
hypothyroidism1-4. This study aimed to examine
CVD morbidity and mortality in a New Zealand population aged 20 years or older,
comparing people with normal thyroid function with people with subclinical and
overt hypothyroidism over a decade (1997-2006) by age, gender, ethnicity and
deprivation score.
We utilised laboratory data of thyroid function tests to
establish links with cardiovascular outcomes from the National Minimum Data Set
for hospital events and National Mortality Collection. Data were linked by
national health index (NHI) number. We defined subclinical hypothyroidism as
having a TSH from 5-10 mIU/L. with normal thyroxine levels.
A total of 61,935 individuals were included in the survival
analysis, of whom 56,491 were classified as normal, 3,185 as having subclinical
hypothyroidism and 2,259 as having overt hypothyroidism. 4,882 individuals had
evidence of a cardiovascular event. The estimated overall unadjusted CVD event
rate was 14.7 per 1000 person-years (95% CI = 14.3 to 15.1 per 1,000
person-years). When adjusted by age at entry in a Cox regression model, the rate
of a CVD event was 15% higher in SCH and 36% higher in OH when controlled for
gender, ethnicity and deprivation compared to normal thyroid function.
In this laboratory defined cohort, age, gender, ethnicity
and deprivation were important factors in CVD event rates for individuals with
hypothyroidism. CVD outcomes in patients within a tightly defined range of
subclinical hypothyroidism have worse outcomes than euthyroid individuals.
Whilst these differences are small they may have implications when deciding on
treatment in general practice.
References:
Use of transient elastography for non-invasive monitoring of methotrexate induced liver fibrosisR Vyas1, R
Juruwan2, M
Rademaker1, F
Weilert2, A
Yung1. Department of
1Dermatology and
2Gastroenterology, Waikato Hospital, Private
Bag 3200, Hamilton.
One of the long-term complications of methotrexate use is
liver fibrosis. Transient elastography (FibroScan®, Echosens, Paris) is a
non-invasive technique to detect liver fibrosis. Recent meta-analysis comparing
transient elastography with liver biopsy has concluded that transient
elastography (TE) has excellent diagnostic accuracy in detecting cirrhosis
(AUROC of 99% with TE score>13kPa)1.
Transient elastography can also be used to exclude liver fibrosis in patients on
methotrexate (negative predictive value 88% for TE
score<7.1kPa)2.
All patients in the dermatology department on methotrexate
were offered transient elastography. Transient elastography scores were divided
into no detectable fibrosis (0-7kPa), detectable fibrosis (7.1-13kPa) and
cirrhosis (>13kPa). Patients with transient elastography scores of more than
13kPa were to be assessed by the Gastroenterology department and considered for
liver biopsy.
132 patients underwent scanning. Of the 132 patients, 32
were unsuccessful due to obesity as accurate readings could not be obtained.
Mean age was 52 and 56% were male. Psoriasis (59%) was the most common
indication for methotrexate followed by eczema (25%). Mean methotrexate dose was
14mg per week, median cumulative dose was 510 milligrams and median duration on
methotrexate was 9 months. 85 patients (85%) had TE scores of less than 7.1kPa
(repeat scanning in 1 year). 15 patients (15%) had TE scores between 7.1-13kPa
(repeat scanning in 3-5 years). No patients had TE scores higher than 13kPa.
There was a slight correlation with TE scores and cumulative dose (Pearson
correlation 0.233, p-value 0.03).
We successfully determined minimal fibrosis in the majority
of patients obviating the need for liver biopsy. Longitudinal data are needed to
observe the reliability of this test long-term.
References:
Breast cancer treatments for Waikato women with newly diagnosed breast cancer, 2005-2008ID Campbell, CWL Ooi, R Lawrenson, M-A Hamilton, S
Ellis, C Munt, M Kuper, G Round, D Lamont. Breast Care Centre, Waikato Hospital,
Private Bag 3200, Hamilton 3240, New Zealand.
Women in New Zealand face a 20% greater chance of dying from
breast cancer compared to women in
Australia(1,2), and Maori women fare worse
still. The Waikato Breast Cancer Register (WBCR) is a comprehensive regional
population based database of breast cancer diagnosed since 2005. Using the WBCR,
this analysis seeks to examine patterns of care in Waikato women overall and by
ethnicity.
The database encompasses the breast cancer population from
both screening and symptomatic presentations. Data is also collected relating to
surgical procedures and adjuvant treatments including any chemotherapy,
radiotherapy or endocrine therapies prescribed. From 2005-2008, information on
817 women with invasive cancer and 124 women with DCIS is reported
50% of patients with invasive tumours had breast conserving
surgery (BCS) as a primary surgical procedure compared to 65% of patients with
Ductal Carcinoma Insitu. BCS rates were higher for smaller breast cancers at 64%
for T1 tumours. Maori and Pacific Islander women tend to present with more
advanced tumours leading to a higher proportion of mastectomies (>60% for
both, compared with 47% for European) and requirement for full axillary
dissection. Consequently, they were also more likely to require adjuvant
chemotherapy. 45% of Maori and 67% of Pacific Islander women required
chemotherapy compared to 36% of European women. 50% of women who had a
mastectomy received adjuvant radiotherapy compared to just over 90% of women who
had BCS. Of women with endocrine responsive invasive cancers, 90% received
endocrine therapy.
Waikato women are receiving the appropriate treatment for
their cancer stage. This also applies to Maori women who despite having worse
prognosis tumours are also receiving the appropriate treatment.
References:
Identifying Person-Specific Factors Associated With Health Change in an Intervention Programme for Chronic PainHE Jones 1, PBB
Jones 2, and K Faull
1,
1QE Health,
Rotorua, New Zealand
2Waikato Clinical
School, University of Auckland
A multi-disciplinary persistent pain programme (MDPPP,
funded by ACC compensation scheme) has been developed using a holistic
model of practice based on Health Change Process Theory. The psychometric
instrument QEHS was developed out of this theory and is used to determine
clients' health status and locus on the health change pathway. Both a total
score and a patient profile is generated. Other validated psychometric
measures used are Kessler 10 (K10, psychological distress), the Pain Self
Efficacy Questionnaire (PSEQ, a subjective measure of function) and the Return
to Activities of Daily Living Scale (RADL, assesses return to activities usual
for the client).
Aims of the Study. 1: To examine the internal
consistency, content and concurrent validity of the QEHS. 2: To identify
person-specific factors related to degree of change occurring during a chronic
pain intervention programme.
Method: Aim 1: 88 data sets prospectively gathered
from 55 participants in MDPPP between 2008-2009 were used. Internal consistency
of the QEHS was assessed using multivariate analysis (SPSS v17.0). Correlational
analysis between QEHS Total Score, the individual components of the QEHS, and
K10, PSEQ and RADL scores was used to explore concurrent and content validity.
Aim 2: Two groups were identified as having either high or low change in QEHS
Total Score between admission and discharge. Grounded theory was used to
identify factors associated with programme success or poor outcome.
The QEHS Total Score was found to have high internal
consistency with each of the subscales (p<0.01 for all); Anxiety (-0.946),
Self Worth (0.956), Motivation to Change (0.872), Awareness to Possibility of
change (0.951), Identity (0.949) and Sustainability (0.954). QEHS Anxiety score
correlated strongly with K10 score (0.477, p<0.01), and QEHS Self-Worth score
with PSEQ (0.403, p<0.01). QEHS Motivation to Change was negatively
correlated with both K10 and QEHS Anxiety scores (-0.429 and -0.887
respectively, p<0.01). Themes identified in promoting programme success were
‘Length of time off work', ‘Considering a return to work' and
‘Full engagement and participation in the programme'; low change was
associated with ‘Fixation upon a return to pre-injury functioning',
‘Aims to return to previous work/a form of work that is too strenuous' and
‘Unable to maintain new techniques learnt during the MDPPP'.
The QEHS is a valid index of health status and of change in
health. Person-specific factors are predictive of change in health status in a
multidisciplinary pain management programme.
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