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An Evaluation of the Effects of Simulated Visual Impairment on Driving Ability

Despite number of previous studies the relationship between visual acuity and driving errors remains uncertain. This study involved driving through an obstacle course repeatedly with different visual impairments. Five sets of pre-designed goggles were used to simulate a range of visual impairments. Results suggest even the highest levels of acutely induced visual impairment cause minor and insignificant increases in relative risk of time-weighted driving errors. Also revealed was a positive and significant correlation between the highest levels of acutely induced visual impairment and stopping distance. The greatest and most significant correlation was found between acutely induced visual impairment and the degree of driving confidence. It was clear that confidence decreases significantly with increasing visual impairment. While some uncertainties remain the importance of driver confidence and how this may impact driving ability gives rise to some interesting points. This paper concludes with discussion of results and relevant recommendations.

Authors of Report

Jannah Jaforullah, Amirala Khalessi, Rajesh Patel, Mark Smith, Po Che Yip, Kamran Zargar

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Assessment of Quality of Informed Consent in Dunedin Public Hospital

Background

The primary aim of this study was to determine both patients' and clinicians’ perceptions of the current informed consent process as practised in Dunedin Public Hospital. Research carried out to date has shown a wide range of patient perceptions regarding informed consent. Despite the fact that ideally the clinician performing the procedure should obtain consent, it has been shown that this task is often delegated to the house officer who is also the least knowledgeable.

Methods

Two types of questionnaires were used for data collection over a period of two weeks. One was mailed to fifty-one clinicians in two surgical specialities, while the other was used to conduct an interview for fifty post-operative inpatients on these wards. A reminder was mailed out to the clinicians towards the end of the two-week period to maximize clinician response. Data was analysed using SPSS 10 spreadsheet program.

Results

A total of 50 patients were interviewed. We found that nearly all patients (98%) felt that they were fully informed once given the benefit of hindsight (ie postoperatively).  Most aspects of the informed consent process were covered by hospital staff with only one major inconsistency with the ODHB policy noted – that of discussion about the disposal of body parts or fluids.  The perceived quality of information given about these aspects was excellent.  Doctors (98%) and nurses (54%) were the most common sources of information and were also perceived as the best sources with mean Likart scores of 4.7 for both.  Of a total of 51 clinician questionnaires sent out, 18 responded.  Most clinicians believed they were comprehensive in obtaining consent with regard to the policy.  It was implied that the majority of consent obtainers were in fact house officers, however most of them felt they had insufficient knowledge to fully inform patients of their surgical procedure. Only 35.3% of all clinicians stated having received formal prior training in obtaining consent. Most clinicians however, mentioned ways in which the consent process can be improved.

Interpretation

Overall both patients and clinicians were satisfied with the consent process. Despite this measures can be taken to improve the current informed consent procedure.

Authors of Report

Alveera Karim, Anselm Ong, Cherumi Silva, Dipti Lath, Hamish Mace, Nick Butterfield

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Complementary Therapies in Rheumatoid Arthritis

Background

Rheumatoid arthritis is a chronic autoimmune disease causing inflammation, pain and destruction of joints. Current therapies may relieve symptoms and slow the progress of the disease however there is no known cure.   This study assesses the use, effectiveness and costs of complementary and alternative therapy use in patients attending Rheumatology Outpatient clinics at Dunedin Public Hospital.  We assess whether patients using complementary therapies are informing their GP and rheumatologist of what they are using, and whether patients are using the internet to obtain information on their condition.

Methods

We invited 294 patients attending the Rheumatology Outpatient clinics at Dunedin Public Hospital to participate in our study.  Those that agreed were contacted and interviewed by phone or interview in their own home.  Participants were asked about their prescription medications, and their use of complementary therapies.  Complementary therapies were divided into 5 categories: complementary medications, visits to complementary health care professionals, use of complementary products, exercise and relaxation therapies and dietary modifications.  Results were then analysed.

Results

We had a 60% (178/294) response rate with  143 patients agreeing to take part in this study.  We interviewed  38% (113 / 294). 88% patients found prescriptive meds moderately or very effective. 65% of patients are currently using CT. Proportions of current CT use and their effectiveness in each categories (usage / effectiveness) are complementary Meds (29% / 62%), complementary product (19% / 46%), complementary health professionals (6% / 71%), exercise therapy (46% / 52%), and dietary changes (25% / 68%). The average total cost for CT users (CT + Prescriptive meds) is $44 /month (95% CI $30 - 57). The average total cost for non- CT users is $18 /month  (95% CI $14 - 22). There is a marginal total cost difference between current CT users and non-CT users (p = 0.0636). 28% patients found their CT burdened them financially. 54% patients found their RA condition moderately or severely affected their ability to work. 74% patients annual income <30,000.

No associations were found between CT usage and age, sex, ethnicity, income, occupation, and HAQ scores. 43% patients have access to internet. 29% patients have used internet to search for RA information in the past.15% of those who have searched online acted on the information they found. 58% of all patients think they would benefit from websites recommended by Rheumatology Department.

Conclusion

Prescriptive medications remain the most effective treatment for rheumatoid arthritis. A significant proportion of patients with rheumatoid arthritis use complementary therapies and some therapies are regarded as effective. Some patients continued to use CT despite their inability to work, low income status, and potentially high costs of CT used.

Authors of Report

Jacquie Copland, Ilaitia Delasau, Daniel Lin, Reuben Miller, Nathalie Renaud, Chris Walker, Gary Wu

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Health Impact Assessment of Changes in the Quality of Dunedin's Drink Water 1995-2003


This present study aims to assess the health impact of improvements to the Dunedin water supply of 1995-2003. Until recent times, Dunedin’s water supply has had an “Ee” grading based on the Drinking-Water Standards of New Zealand, set by the Ministry of Health (MOH). The reasons for this extremely low grading included inadequate treatment, unprotected catchment in Deep Stream, and very old distribution pipes.  Over the period 1995-2003, a number of improvements to Dunedin’s water supply were implemented.  In addition, data were collected for sporadic cases of Cryptosporidiosis and Giardiasis in the Dunedin area during this period.

The specific aims of this study were to:

  1. To review the changes in the MOH water quality grading system 1995-2003.
  2. To review the improvements to the Dunedin water supply 1995-2003.
  3. To review the current Dunedin City Council water testing programme.
  4. To carry out a descriptive epidemiological study of Giardiasis and Cryptosporidiosis in Dunedin.
  5. To make recommendations regarding the Dunedin water supply and health surveillance of waterborne diseases as appropriate.

Authors of Report

Nagham Al-Mozany, Lauren Browne, Neil Curran, Jacob Oh, Ann Sears, Angeline Teo, Daniel Then

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Hormone Replacement Therapy Use: How Have Women Responded to WHI Trial Results?

Background

The results of randomised controlled trials on Hormone Replacement Therapy have recently been published.  We carried out a descriptive study to assess the impact of the recent findings on HRT use.  We also studied where women obtained information, as well as opinions and beliefs.

Methods

500 women between the ages of 45 and 64 were randomly selected from all electoral rolls in New Zealand and sent questionnaires inviting them to participate in the study.  There was a phone follow-up for those who did not reply.  Variables were tested for associations using the chi square test and adjusted for confounding.

Results

We received 298 questionnaires back and a further 20 responses by phone (response rate 66%).  We found that 15% of women were taking HRT during June 2002 compared to 11% currently taking HRT (in December 2002).  This was a statistically significant decrease (p=0.03).  Research findings were the main reason for stopping HRT.  Women expressed an interest in more “natural” therapies over HRT.  Most women had heard information on HRT, however knowledge was lacking in some areas.

Conclusions

The recent research findings have had an impact on HRT use in New Zealand women.  Information is widely available, mainly through the media.  Accuracy of knowledge is lacking however.  Women have expressed an interest in alternative therapies – more research is required in these areas.  Methods of stopping HRT are largely unstudied also.

Authors of Report

Irma Bilgrami, Katy Blower, Jason Feng, Georgia Stefanko, Eugene Tan

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Lithium Toxicity in the Over 65 Population: Current GP Monitoring and Search for Better Methods

Background

Anecdotal evidence has shown that there were increasing numbers of patients over the age of 65 with lithium toxicity. What was especially concerning to our client was that many of these patients had serum lithium levels within the therapeutic range.

Three primary aims of this study are:

  • To investigate current GP practice in the monitoring and management of this group of patients,
  • To seek GP opinions on potential strategies which may improve their day-to-day practice to manage these patients,
  • To increase GP awareness of the possibility of lithium toxicity at serum levels generally considered to be within the therapeutic range.

Methods

Initially, we attempted an e-mail survey that was anticipated to reach GPs faster than the written version and to be a potentially more user-friendly format. We hoped this would increase our response rate. Difficulties with the distribution of the questionnaire lead to the use of a surface mailed questionnaire. Ethical approval was sought from the Otago University Ethics committee.

Result/Conclusion

  • The scope of the problem is difficult to appreciate; 10% the GPs reported having had patients with symptoms of toxicity in the last two years, our client reported having reviewed 2 or 3 patients in the last five years but we were able to identify no patients under this category from the coding at Dunedin Public Hospital.
  • We identified 136 patients over the age of 65 on lithium maintenance therapy. 48% of the GPs did not have any patients in this category.
  • Of the 16 patients with symptoms of toxicity, 5 required hospitalization (3.7% of 136 patients). This is compatible to the international data.
  • CNS symptoms of ataxia and tremor were the most frequently identified symptoms of lithium toxicity (recognized by 35 to 40% of the GPs). This was followed by constitutional symptoms, GI symptoms and renal symptoms. Only about 10% of the GPs identified possible cardiotoxicity.

Lithium Monitoring

  • 30% of the surveyed GPs were shown to follow the BPAC guidelines12 of testing serum lithium levels at 3 monthly interval.
  • 91% of the GPs check the serum lithium levels themselves. (Medicolegally it is the GP’s responsibility to review all results, abnormal or otherwise).
  • 62% of the GPs take serum lithium levels between 10-14 hours post dose.
  • It appears that awareness of toxicity is low; only 51% of GPs consider changes above the therapeutic range as significant.
  • 71% of the respondents review their patients clinically every 3 months. Several comments were made by the GPs that clinical symptoms were of greater importance than just the serum levels on their own. The literature would concur that both aspects need to be considered.
  • 2/3 of the respondents saw a role for Practice Nurses.
  • 85% of the GPs said that it was possible to test and clinically review their patients 3 monthly. The reasons against this mainly included cost and transport issues.

Other Monitoring

  • ECG: 56% of the GPs never carry out ECGs. 6% of the GPs test it yearly, which is the recommended interval according to the Canadian guidelines9 for possible arrythmias.
  • FBC: 72% of the GPs carry out FBCs 6-12 monthly (for possible leucocytosis)
  • TFT: 75% of the GPs test TFTs 6-12 monthly, which is the recommended interval according to the BNF guidelines13 for possible thyroid dysfunction.
  • Urea & Creatinine: 63% of the GPs perform urea & creatinine every 6-12 months as per BPAC recommendation12.
  • Urinalysis: 29% of the GPs never perform urinalysis and 33% perform yearly for possible proteinuria from renal dysfunction.

Possible Strategies

  • 73% of the GPs thought a lab result addendum would be useful. Similarly 62% of the GPs gave a high score for a graphical representation of sequential results. However an algorithm did not score as highly, perhaps because it might have appeared confusing.
  • 80% of the GPs thought that lithium clinics would not be useful for their patients. The reasons for this included cost and transport issues again and most GPs felt that they had skills to manage these patients themselves.
  • 87% agreed that up-to-date information would be useful, especially handouts. It was very informative that many comments focused on the need to educate the GPs themselves, as well as other staff involved in the care of these patients.

Authors of Report

Helen Bray, John Hsiang, Helen Jo, Frank Lin, Michelle MacDonald, Tracey Putt, Ann Thornton

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Otago DHB Influenza Vaccination Programme for Employees: Why Do We Have Such Low Uptake Rates?

Background

Influenza is a significant illness that causes considerable morbidity and morality.  There is an inactivated virus vaccine available whose efficacy ranges from 70 to 100% if the vaccine is well matched to the virus.  The vaccine does not cause significant side effects and has been shown to reduce patient morbidity and morality when used by health care professions.  Otago DHB has had a few vaccination program in place since 2000 but uptake of the vaccine was only 24% in 2002.

Objectives

We looked at Otago DHB staff to consider their reasons for accepting, or not accepting, the free vaccine.  The goal was to find areas that could be addressed to increase the uptake of the vaccination.

Selection Criteria

Our sample population consisted of all DHB staff.  600 were chosen at random.  The Otago Ethics committee provided ethical approval.

Data Collection

A questionnaire was developed that obtained information about employee demographcis, knowledge about the influenza vaccine, reasons for choosing to be vaccinated or not vaccinated in 2002 and ways to improve the vaccination program.  600 questionnaires were sent out via the internal mail system.  After two weeks non-responders were sent out a reminder.  366 replies were received which was 64% of our sample size.  95 respondents had been vaccinated.

Results

The medical team showed the greatest knowledge about the vaccine, with the nursing team displaying the poorest knowledge.  The medical team and the physiotherapists/occupational therapists had the highest rates of vaccination with 44.7% and 47.3% respectively; administration/management and ‘other’ had the lowest rates with 27.0% and 21.5% respectively.  Vaccination rates generally increased with age, but with a peak in the under 25s.  Vaccination rates also generally increased with knowledge about the vaccine.  The main reasons for choosing not to be vaccinated included concern about side effects (49.1%) and worry that the vaccination can cause the flu (24.1%).  Access was not a common reason for not receiving the vaccination (6.1%).  The main reasons people chose for being vaccinated included not wanting to get the flu (92.3%), the vaccine is free and convenient (76.7%) and not wanting to give patients the flu (38.8%).  38.6% of respondents were planning on getting the vaccination in 2002.

Conclusions

In order to improve the rates of those employees receiving the free vaccination, an education campaign should be undertaken that focuses on teaching staff that the vaccination is effective, the vaccination does not cause influenza or have significant side effects, and that patient morbidity and morality is decreased by staff being vaccinated.

Authors of Report

Michelle Bloor, Marilize de la Porte-Ussher, Sam Hazledine, Pamela Mooi, Nick Oscroft, Rebecca Tapp, Simon Ussher

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Primary Health Organisation: Community Awareness

Aims

To assess the current level of knowledge and understanding of Primary Health Organisations (PHOs) within the community and to investigate ways in which PHOs may be able to establish meaningful engagement with their communities.

Methods

A telephone survey was performed during a 3 week period in June 2003. Using the electoral roll 75 participants were selected from each of three regional areas, being Dunedin, West Coast, and Counties Manukau.

Results

The overall response rate was 83% and did not differ significantly between the three regional groups. Overall, 17% of respondents had some discernable knowledge regarding PHOs, and this knowledge level did not differ between the three groups. Knowledge level also did not differ by gender, age, having a regular GP, or by a respondent having visited a GP in the last year. However knowledge level was significantly higher in those reporting New Zealand European ethnicity compared to those reporting any other ethnicity (19% vs. 3.4%, p=0.023). Among those that knew about PHOs, there were low levels of awareness that community involvement is one of the aspects of a PHOs. There was moderate interest in becoming involved in PHOs amongst those that were asked.

Conclusions

PHOs by definition should be involving members of the community both in their establishment and everyday operation. This study found that not only was knowledge of PHOs poor even in areas where PHOs had been established, but also that most members of the community that had some knowledge about PHOs were not aware of the community involvement aspect of PHOs. In order to achieve success with PHOs, clear guidelines need to be disseminated on how these organisations should be established and operated, along with information on practical ways in which the community could be involved in PHOs.

Authors of Report

Joe Baker, Joy Chakraborty, Rose Duckett, Sharon Pattison, Shalvin Prasad, Bonnie Wu, Michael Yip

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