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A needs assessment of Otago children and adolescents with Autism Spectrum Disorder (ADS)

Autism Spectrum Disorder (ASD) is a heterogeneous group of developmental disorders with profound implications on the individual and family. The diversity of interventions available for ASD and the limited understanding in their applications have led to difficulties in standardising management for individuals with ASD. To this end, a community based needs assessment was undertaken to examine the adequacy of services for ASD here in the Otago region.

A literature review concluded that the vast number of behavioural and educational interventions for ASD as well as the difficulties in standardising research led to limitations in obtaining strong evidence for their use; this was reflected by the lack of consensus in prescribing interventions in international guidelines for ASD.

A questionnaire addressing the utilisation and perceived satisfaction with services for ASD was distributed to members (consisting largely of parents) of a local ASD support group servicing the Otago region. Of the 42 respondents from this initial survey, 16 were subsequently interviewed to further explore issues surrounding the adequacy of ASD services.

The findings identified 2 potential interventions as important: 1) Speech and Language Therapy (SLT), the highest utilised of all interventions, was valued greatly by interviewees but felt to be inadequately provided; and 2) the contentious Applied Behavioural Analysis (ABA) was rated highly by the minority who used it. Qualitative data identified a number of areas consistently raised by parents, namely the demand for provision of a ‘key worker’ and a less complicated, more comprehensive funding process.

Our findings led us to make a number of recommendations towards improving services for ASD in the Otago region, which included: prioritising funding for SLT and teacher aides and making provisions for a ‘key worker’ role for ASD. 

Authors of Report

Olivia Collyns, Thiyagaraj Krishnan, Alice Reid, Bridget Mooney, Esther Tilly, Kah Heng Lim, Priya Prasad, Luke O’Connor, Suren Subramaniam, Simon Versteeg

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Bowel Cancer Screening Preferences in Otago

Aim

To assess the preference between faecal occult blood testing (FOBT) and flexible sigmoidoscopy (FS) in the Otago population for a colorectal cancer (CRC) screening programme.

Background

Currently the New Zealand government is planning for a national CRC screening programme involving FOBT. Recent research has shown that one-off FS produces a greater reduction in the incidence of, and mortality from, bowel cancer than FOBT. The public’s preference between the two forms of tests has not yet been considered by policy makers.

Methods

497 questionnaires were sent out to randomly selected participants between ages 50 and 74 from the Otago electoral roll. Questionnaires contained information about FOBT and FS and a short survey asking about test preference and factors which may influence preferences.

Results

173 surveys were analysed. 52% preferred FS, 41% preferred FOBT, 5% preferred no test, and 2% chose both tests. Age, gender and level of education were found to influence preferences, with men, younger and better educated participants preferring FS. Known bowel cancer contacts, previous endoscopy experience, and geographical location did not significantly influence choice.

Conclusion

The Otago sample had no predominant preference for one test over the other, and this study has revealed factors which may determine uptake of a CRC screening programme.

Authors of Report

Amira Al-Bulushi, Cameron McAlister, Debbie Yeh, Lian Coppus, Arezoo Kahokehr, Michael Tatton, Nick Harrison, Dan Allan, Richard Cowley.

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Clinical Audit of Follow-up of Colorectal Cancer patients following Curative Resection

Purpose

Our aim was to determine adherence to Otago Regional guidelines on colorectal cancer (CRC) follow-up at Dunedin Hospital (DPH). Methods: Patients with stage II/III CRC, who were diagnosed between 1 January 2004, and 31 December 2007, were identified, and their electronic records were retrospectively reviewed. Follow-up modalities; including CT scanning, colonoscopy, specialist clinic appointments, and Carcinoembryonic Antigen (CEA) were recorded and compared against local guidelines.

Results

A total of 247 patients were eligible for the study at DPH. Pre-operative staging and follow-up of patients after surgery did not meet the guidelines in a significant proportion of patients. According to the guidelines, of the 134 patients with 3.5 years of follow-up, 79 (59%) of patients had the appropriate number of clinic appointments, 66 (31%) being at the appropriate times. Appropriate numbers of CT scans occurred in 45 of 152 (30%) patients at three years following surgery, with 16 (10%) receiving them at the appropriate times. CEA measurements were performed appropriately in 108 (71%), at three years following surgery, with 39 (17%) being at intervals according to guidelines.  Of the patients with 5.5 years of follow-up, 16 of 34 (47%) had a follow-up colonoscopy after surgery.

Conclusion

CRC follow-up revealed departure from Otago Regional guidelines. None of the patients were followed up in all modalities according to the guidelines. Conversely, every patient received at least one follow-up investigation, of at least one modality.  As CRC is one of the only cancers potentially curable after metastatic spread, early detection of recurrence is important.

Authors of Report

Omid Ahmadi, Mesfer Alfadhel, Hussain Allawati, Julia Christie, Bridgette Mckenzie, Sarah Missen, Argy Song, William Vaastra

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How much do the public know about adverse effects of medicines and do they act on the information?

The objectives of this project were to provide a preliminary impression of the general public’s current level of knowledge regarding medication safety, their needs and preferences in learning about medications and to find out how they respond to new information regarding the safety and risks of medications.

This was done by means of a telephone interview of a randomly selected sample (n=87) from Dunedin. The interviews were based on a standardized questionnaire developed for this purpose. There was an attempt made to over-represent Māori to ensure they were part of the sample.

The majority of the participants (n=70, 84%) who had taken medications over the preceding year felt they knew enough about their medications to take it confidently and safely while about half of them (n=47, 57%) could name at least one side-effect, warning or caution of the medication they felt they knew most about.  Various possible reasons may explain this discrepancy such as trust in doctors or not having personally experienced a side-effect, but a larger study focusing on this issue is warranted.

Information on or inside packaging, doctors and pharmacists were the top three most used and preferred sources for learning about medications. Information on or inside the packaging was the most used and the third most preferred medium overall. The internet appeared to be an under-utilized medium relative to the proportion of the population that preferred to use it. Also, the internet was relatively more popular with the younger age group (18-39years) as a preferred medium for learning about medications.

There is a need for further studies to examine the role and the quality of information on or inside the packaging available to consumers in New Zealand and also the possibility of creating an easy to access, reliable and accurate online resource for educating consumers in New Zealand about their medications.

While we could not make any useful conclusions regarding how people respond to new information about the safety and risks of medications due to the small numbers involved in this part of the study (n=20), our data suggested that the recently updated MedSafe recommendation on the use of cough and cold products in children under 6 years old had very low penetration with the general population.  Further targeted studies will be needed to explore this issue further.

To conclude, the study provides an adequate preliminary impression of the general public’s current level of knowledge regarding medication safety and their needs and preferences in learning about medications. Several interesting points for further investigation have also been raised.

Authors of Report

Anna Choi, Greg Macleod, Michael Makary, Mujeeb Taib, Ili Ruslan, Norirwanie Ismail, Rawaida Abd Latib, Shuichi Suetani, Rahul Prasad

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Inappropriate ED presentations from residential care in the Otago region – a potential problem?

This study was performed to determine the number of ED presentations between 1 July 2009 and 31 December 2009 by patients aged 65 years and over living in residential care that did not result in hospital admission and could have been assessed and treated in a residential care facility or in the community.

Hospital records of 1801 non-admission emergency department presentations between 1 July 2009 and 31 December 2009 by patients aged 65 years and over were searched and information regarding each presentation collected. From this information we first identified patients who resided in a residential care facility and then classified each of their ED presentations as either appropriate or inappropriate, according to pre-determined criteria and in consultation with our clients Dr Julie Mador and Dr Anne Worsnop. Patients who did not live in residential care were excluded from the study.

A total of 150 emergency department presentations were included in our study sample. Of these, 86 were appropriate while 64 were inappropriate. This equates to 2-3 inappropriate emergency department presentations each week.

The magnitude of inappropriate ED presentations from the study population does not necessitate the need to modify current management of acutely unwell elderly living in residential care facilities in Otago. However, adopting criteria to gauge the appropriateness of ED presentations will benefit the healthcare system overall.

Authors of Report

Mamoun Alkadhi, Mahmoud Amer, Nicholas Begg, Terry Hall, Lulu Li, Dahlia Mirdad, Natalie Reid, Jane So.

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Plumbers and Taps - Neuropsychological Effects of Solvents

Introduction

Occupational exposure to organic solvents is common in many industries. The harmful effects of solvent exposure are well recognised in some industries, with steps taken to minimise exposure through education and increased uptake of Personal Protective Equipment (PPE). Organic solvents are well absorbed through skin and inhaled in high quantities. Long-term solvent neurotoxicity includes effects on psychiatric health as well as the neurological effects of tremor, cognitive deficit, impaired colour vision and reduction in vibration sense. Short-term exposure can result in headache, nausea, reduced alertness, impaired concentration, fatigue and problems with coordination. Assessing the effect of solvents is an area that continues to be researched. The effects are often diffuse affecting the brain at the neuronal, axonal and neurotransmitter level so brain imaging, electroencephalogram (EEG) and neurological testing often reveals nothing. Therefore, neuropsychological testing forms the basis for assessment of any short- or long-term effects from solvent exposure.

The health consequences from occupational organic solvent exposure in plumbers have yet to be fully established. Since the introduction of polyvinyl chloride (PVC) piping to the plumbing industry, plumbers now use organic solvents on a regular basis often in enclosed spaces with little ventilation. Previous research has shown that PPE can decrease total body exposure to solvents by up to 60% and although overalls provide some defence, the use of solvent resistant gloves and mask are the two items of PPE likely to provide the best protection.

Methods

A solvent neurotoxicity screening questionnaire was administered to plumbers in 2009 by the Department of Labour, revealing a high prevalence of symptoms related to solvent exposure.

This study was a follow-up and aimed to assess both long-term and short-term adverse effects on neuropsychological functioning in plumbers.

Sampling

The Department of Labour provided contact details for local Dunedin plumbing companies willing to participate and they were contacted by telephone.

Data Collected

Structured questionnaires were administered in the morning and afternoon. Three neurobehavioural tests (Symbol digit modalities test, finger-tapping test and controlled oral word association test) were performed in the morning and afternoon once the questionnaires were administered.

Results

No statistically significant difference in neurobehavioural performance between the pre-work and post-work testing was demonstrated irrespective of solvent exposure. The effect of age showed those older than 45 years were approximately 10 taps slower than those younger than 45. (P<0.05). Furthermore, the older age group completed  approximately 9-13 symbols less than those aged under 45 years (P<0.05). Conversely, those over 45 years produced approximately 4 words more than those less than 30 years of age. (P<0.05). Only 39% (9/23) of participating plumbers reported using any form of PPE, with 8 of the 9 plumbers who did use PPE wearing only overalls.

Conclusions

This study demonstrates that like other trades, plumbers exhibit chronic neurotoxicity secondary to solvent use. Short-term exposure to solvents had no effect on neurobehavioural functioning. Increasing age was associated with significant change in neurobehavioural performance in either positive or negative ways depending on the test. Further study into the development of more accurate tests is warranted. Furthermore, we would recommend the administration of the Questionnaire 16 to further establish any chronic solvent induced neurotoxicity. When used, the choice of PPE provided little barrier to solvent exposure so education on the harms of solvents and correct PPE is recommended.

Authors of Report

Jia Gan, Lydia Chan, Dasun Ganhewa, Linda Yen, Anthony Harris, Queenie Son, Jessica Cheung, Alexander Lyudin, Laura Frampton.

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Scorecard on the New Zealand Health Care System

Aim

To create a scorecard which assesses the state of the New Zealand health care system, in particular the public sector.

Background

The Commonwealth Fund created a scorecard for the United States health care system in 2006 and updated it in 2008. In New Zealand, while there have been measures to assess performance of individual District Health Boards, hospitals and health providers, there have been no comprehensive measurements of the overall performance of the health care system.

Method

Based on the framework of the Commonwealth Fund scorecard, five aspects of a higher performing health care system were assessed: healthy lives, quality, access, efficiency and equity. New Zealand’s performance on 61 indicators was compared with international or national benchmarks. 

Results

New Zealand scored 71 out of a possible 100. Efficiency achieved the highest score of 81 and equity was the lowest with a score of 58.

Conclusion

The score reflects a health care system with both strengths and weaknesses and highlights areas for improvement. It is hoped that this scorecard will be repeated at regular intervals to monitor progress.

Authors of Report

Suhaila Al-wahaibi, Johanna Chisholm, Rebecca Crabbe, Boomi Kwon, Timothy Oh, Raja Palepu, Sangsu Sohn, Nic Rawcliffe.

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Use of Bivalirudin During Primary PCI For Acute STEMI

Objective

To compare clinical outcomes and direct costs of patients at Dunedin Public Hospital receiving bivalirudin to those who received the previous regimen of heparin and/or abciximab during Percutaneous Coronary Intervention (PCI) for acute ST-elevation Myocardial Infarction (STEMI).

Methods

A retrospective observational study of clinical records of patients who presented to Dunedin Public Hospital (DPH) with an acute presentation (< 12 hours) of a STEMI and received PCI at Dunedin Hospital during the period of January 2007-November 2009 was undertaken. The data collected was analysed and compared with a previous study.

Results

Our results showed that both the heparin +/- abciximab group and the bivalirudin group were comparable in terms of all the patient baseline data apart from smoking history. After adjusting for smoking history none of the clinical outcomes, including the bleeding incidence, showed statistical differences between the two groups. The direct costs calculated via RUS cost and length of stay in hospital were lower for the bivalirudin, however this was not statistically significant.

Conclusion

Despite our study not showing any statistically significant superiority in clinical outcomes or reduction in costs for bivalirudin compared to heparin and/or abciximab, it maintains that bivalirudin appears to be at least as good as the previous regime.

Authors of Report

Lora Pencheva, Adam Perley, Olivia Hill, Narae Song, Dianne Murphy, Lara Benoiton, Arshad Sheriff, Dan Allbon, Manson Ku, Vaaiga Autagavaia.

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