Comparison of Hard and Soft Cervical Collars for the Management of Odontoid Peg Fractures in the Elderly.

Introduction: Odontoid peg fractures (OF) are the most common cervical spine fracture in the elderly. This retrospective analysis aimed to compare the outcomes of older patients with OF who had been managed non-operatively with either a hard or soft cervical collar. Materials and Methods: We analysed the retrospective data of the clinical and radiographic records of patients 60 years or older who presented over a 10-year period with OF and were treated non-operatively with a cervical collar. Mortality was the primary outcome measure with mechanism of injury, complications, and fracture healing secondary measures. Results: 45 patients (hard collar n = 22; soft collar n = 23) were included with comparable demographics for frailty and co-morbidities in each group; age was significantly higher in the soft collar group (80.6 vs 86.4 years; P = .0065). Associated injuries and complications were not significantly different overall, or when Type II fractures were separately analysed (P = .435 associated injuries, P = .121 complications). All-cause mortality was greater in the soft collar group (30-day mortality hard: 0%, soft: 9%; 1-year mortality hard: 18%, soft: 48% P = .035). However, once corrected for age, this proved not to reach significance (P = .333) in any fracture type. Non-union was common (77%) but was not significantly different (hard = 70%; soft = 87%; P = .419). Discussion: Consistent with other reports, non-union rates remained substantial regardless of which collar was used. After controlling for age, there was no difference in all-cause mortality between elderly patients treated with a hard or soft cervical collar for odontoid peg fractures. Conclusions: Soft collars appear suitable for the treatment of odontoid peg fractures in the elderly without compromising outcome. Larger cohort analyses will help confirm this finding.

Counting the cost of major infection and sepsis in New Zealand: an exploratory study using the National Minimum Data Set.

AIM: To explore the population-at-risk and potential cost of a sepsis episode in New Zealand. METHOD: Retrospective analysis of the National Minimum Data Set using two code-based algorithms selecting (i) an inclusive cohort of hospitalised patients diagnosed with a 'major infection' with the potential to cause sepsis and (ii) a restricted subset of these patients with a high likelihood of clinical sepsis based on the presence of both a primary admission diagnosis of infection and at least one sepsis-associated organ failure. RESULTS: In 2016, 24% of all inpatient episodes were associated with diagnosis of a major infection. The sepsis coding algorithm identified a subset of 1,868 discharges. The median (IQR) reimbursement associated with these episodes was $10,381 ($6,093-$10,964). In both groups, 30-day readmission was common (26.7% and 11% respectively). CONCLUSIONS: Infectious diseases with the potential to cause sepsis are common among hospital inpatients. Direct treatment costs are high for those who present with or progress to sepsis due to these infections.

The experience of final year medical students undertaking a general practice run with a distance education component.

In recognition of the difficulties posed for New Zealand medical students by travel during rural general practice attachments, a system of distance teaching was devised for final year medical students at the Waikato Clinical School. In place of weekly small group teaching using reflection on practice at the central campus led by a tutor, students participated in reflective learning via an electronic web based message board and once weekly brief individual discussion with a tutor. Moodle and Skype, both freeware applications, were used as the methods of facilitating asynchronous and synchronous learning environments. Students experienced significantly less travel time as a result of the innovation. They also reported enthusiasm for the modes of teaching and the technology. A small increase in tutor time commitment was necessary. Distance education initiatives can be undertaken with minimal expense in the general practice setting. The educational opportunities it offers can be similar to, but not identical to small group teaching.

Epidemiology of thyroid disease in Hamilton (New Zealand) general practice.

OBJECTIVE: To retrospectively review health records in two general practices in Hamilton, New Zealand (NZ) linking three data sources to estimate the prevalence of diagnosed thyroid dysfunction (TD). METHODS: A record-linkage study using computerised searches to find cases of diagnosed TD by diagnostic codes, prescribing data, and laboratory data. Data was verified against computerised and written records. RESULTS: The prevalence of diagnosed TD was 3.1%. Overt hypothyroidism was diagnosed in 2.5%, overt hyperthyroidism in 0.2% and 'other' conditions such as goitres, nodules and thyroiditis in 0.4% of the study population. CONCLUSIONS: This study provides a representation of TD in the community prior to mandatory iodine fortification. Our prevalence data is similar to national and international literature with the burden of TD being greater in women and in the older population. IMPLICATIONS: A national study with a sufficient sample of Maori and Pacific patients is needed before supplementation with iodine is introduced.

An audit of risk assessments for suicide and attempted suicide in ED: a retrospective review of quality.

AIM: The primary aim of this audit was to determine the quality of psychiatric risk assessments conducted by Mental Health & Addiction Services clinicians for patients presenting to the emergency department, Waikato Hospital, Hamilton, New Zealand following an attempted suicide. METHOD: A retrospective, randomised audit of 376 files of patients who had presented to the ED over a 12-month period from 1 July 2015 to 30 June 2016 was conducted, following the standards outlined in the present New Zealand Ministry of Health Clinical Practice Guideline for Deliberate Self Harm (DSH). RESULTS: It was found that clinicians routinely focused on the historical features of the suicide attempt presentation while failing to record judgements about future suicidal behaviours. Interactions with family members were recorded in less than half of the cases. The guideline most poorly adhered to was checking whether Maori patients wanted culturally appropriate services during the assessment and treatment planning, with this recorded in less than 10% of the clinical records. CONCLUSIONS: To improve the quality of the suicide risk assessments, and to better align with Clinical Practice Guidelines, the authors propose redevelopment of clinician training, including focus on cultural competence, and training in confidentiality and privacy relating to an attempted suicide episode.

Advanced Choice Employment (ACE) factors influencing PGY-1 workplace selection and future career intentions of a cohort of doctors in Waikato.

AIM: To assess whether or not a sample of PGY-1 doctors in the Waikato region remained satisfied with the ACE system for employment 12 years after its inception. METHOD: An anonymous paper-based survey was completed by a cohort (n=60) of 2015 and 2016 PGY-1 doctors based at the Waikato DHB. Questions were based around reasons for selecting the DHB, satisfaction with the ACE process and future career intentions. RESULTS: Overall satisfaction with the ACE selection process was reasonable (63%). Over 60% of the 2015 and 2016 cohorts chose Waikato as their first choice DHB, and of those, over 90% intended to carry on through to at least PGY2 level at the DHB. An overwhelming majority (93-96%) intended to continue practicing in New Zealand. CONCLUSIONS: Consistent trends were observed across the two cohorts in regards to their reasons for selecting the DHB, satisfaction with ACE and future intentions, with some differences observed with familial background and interest in pursuing hospital-based specialties. Our findings suggest that ACE remains a satisfactory recruiting system for postgraduate junior doctors, however, motives around initial DHB selection and future vocational intentions remain unclear and warrant further investigation.

Rural women's perspectives of maternity services in the Midland Region of New Zealand.

INTRODUCTION Rural women face many challenges with regards to maternity services. Many rural primary birthing facilities in New Zealand have closed. The Lead Maternity Carer (LMC) model of maternity care, introduced in 1990, has moved provision of rural maternity care from doctors to independent midwifery services. Shortages of rural midwives in the Midland region led to rural maternity care being seen as a vulnerable service. AIM To understand the views and experiences of rural women concerning maternity care, to inform the future design and provision of rural maternity services. METHODS Participants were drawn from areas purposively selected to represent the five District Health Boards comprising the Midland health region. A demographic questionnaire, focus groups and individual interviews explored rural women's perspectives of antenatal care provision. These were analysed thematically. RESULTS Sixty-two women were recruited. Key themes emerging from focus groups and interviews included: access to services, the importance of safety and quality of care, the need for appropriate information at different stages, and the role of partners, family and friends in the birthing journey. While most women were happy with access to services, quality of care, provision of information, and the role of family in their care, for some women, this experience could be enhanced. CONCLUSION Midwives are the frontline service for women seeking antenatal services. Support for rural midwives and for local birthing units is needed to ensure rural women receive services equal to that of their urban counterparts.

12 h shifts and rates of error among nurses: A systematic review.

OBJECTIVE: To determine the effect of working 12 h or more on a single shift in an acute care hospital setting compared with working less than 12 h on rates of error among nurses. DESIGN: Systematic review. METHOD: A three-step search strategy was utilised. An initial search of Cochrane, the Joanna Briggs Institute (JBI), MEDLINE and CINAHL was undertaken. A second search using all identified keywords and index terms was then undertaken across all included databases (Embase, Current contents, Proquest Nursing and Allied Health Source, Proquest Theses and Dissertations, Dissertation Abstracts International). Thirdly, reference lists of identified reports and articles were searched for additional studies. Studies published in English before August 2014 were included. FINDINGS: Following review of title and abstract of 5429 publications, 26 studies were identified as meeting the inclusion criteria and selected for full retrieval and assessment for methodological quality. Of these, 13 were of sufficient quality to be included for review. Six studies reported higher rates of error for nurses working greater than 12 h on a single shift, four reported higher rates of error on shifts of up to 8 h, and three reported no difference. The six studies reporting significant rises in error rates among nurses working 12 h or more on a single shift comprised 89% of the total sample size (N=60,780 with the total sample size N=67,967). CONCLUSION: The risk of making an error appears higher among nurses working 12 h or longer on a single shift in acute care hospitals. Hospitals and units currently operating 12 h shift systems should review this scheduling practice due to the potential negative impact on patient outcomes. Further research is required to consider factors that may mitigate the risk of error where 12 h shifts are scheduled and this cannot be changed.

Polycystic ovary syndrome: a review of cases from general practice.

This paper reports a review of 55 cases of polycystic ovary syndrome by general practice registrars in the Waikato region of New Zealand. In addition to demographic data, presenting symptoms, diagnostic tests, associated conditions and treatment post-diagnosis are discussed. The majority of cases (76%) were first diagnosed by the general practitioner. The review suggests there may be a need for better recording of key diagnostic criteria and that ultrasound is being widely used as a diagnostic test despite local guidelines discouraging its use if other appropriate diagnostic criteria are met.

Palliative care patients' use of emergency departments.

AIM: To compare attendances of Maori with non-Maori palliative care patients at Emergency Departments (ED) and the outcome of their visits. METHOD: This was an observational study using record linkage. The study population was Waikato palliative care patients registered in a 12-month period, aged over 20 years. For each patient we recorded from the hospital records their age, gender, ethnicity, domicile (Hamilton or other), hospital visited and number of visits to the emergency department in the study period. We compared likelihood of attendance at ED and also looked at reasons for the visits and the outcome--including admit to hospital or place of discharge RESULTS: 1185 palliative care patients were identified from the palliative care register. There were 645 men (54.4%), 197 Maori (16.6%) and 18 Pacific (1.5%). The mean age overall was 70.8 years and mean length of time on the register during the year of interest was 120.7 (median 66) days. 449 (37.9%) of the study population visited ED at least once. A multivariate analysis revealed that men visited ED more than women (Odds Ratios [OR] 1.6, p=0.001) and women with a gynaecological cancer visited ED more often than other palliative care conditions (OR 3.3, p<0.001). No other factor including ethnicity was associated with the risk of visiting ED. CONCLUSION: This study has helped quantify the characteristics of palliative care patients utilising ED in a relatively rural population with a high proportion of Maori. It has shown that a significant proportion of palliative care patients will attend ED, that men with palliative care needs are more likely to attend ED but Maori are not more likely to utilise the services. We believe that New Zealand hospitals should consider the role of their ED in the management of palliative care patients.

Investigating the pathways in primary practice leading to the diagnosis of central hypothyroidism.

AIM: Clinical diagnosis of central hypothyroidism is not always obvious: patients may live for years with symptoms. Endocrinologists and biochemists have suggested that a first-line TSH strategy will lead to avoidable delays in diagnosis and treatment of patients with central hypothyroidism. In order to improve timely diagnosis, and thus decrease morbidity from a treatable disease, this study aimed to investigate the diagnostic journey of patients with central hypothyroidism in the Waikato region of New Zealand. METHOD: A retrospective convenience sample seeking note review and semi-structured interviews were carried out with 16 patients who had a diagnosis of central hypothyroidism that was not caused by pituitary surgery or radiotherapy to the pituitary or hypothalamus. RESULTS: Seventy-five percent of participants had tests performed in general practice with results suggesting either pituitary disease or that further investigation would be required. In 38% (6/16) of participants diagnosis was made by the general practitioner. Time to diagnosis ranged from 3 months to more than 12 months. Seven participants identified having 3-6 visits to their general practitioner and five participants made 6 to 12 visits to their general practitioner prior to diagnosis. Lethargy was the most common symptom in 94% of participants. This was followed by changes in skin texture and body hair distribution and texture in 75% of participants and headaches in 63% of participants. CONCLUSION: Due to the era during which these patients were diagnosed, we did not find that a delay in diagnosis was due to an absence of FT4 requests; which a first-line TSH strategy would imply. It is important to recognise that a normal TSH does not exclude central hypothyroidism. By raising awareness with general practitioners of pituitary disease, with potential for deficiency of other anterior pituitary hormones, would focus more specific questioning on related symptoms.

Needlestick injuries in a healthcare setting in New Zealand.

AIM: The aim of this study was to quantify the extent of needlestick underreporting, to examine factors which may contribute to underreporting, and to optimise the relevant risk management strategy. METHOD: An 11-item structured postal questionnaire was adapted from an existing CDC design. RESULTS: The survey results showed that 9% of respondents had experienced at least one needlestick injury in the past year, and three practitioners had five or more injuries in the same period. The overall underreporting rate for needlestick injuries was 33%, which is consistent with internationally-reported figures. More than one in six respondent doctors (17.8%) had sustained one or more needlestick injuries in the past year, compared with nurses (7.6%) or midwives (6.7%). CONCLUSION: The survey identified the level of underreporting and the factors that influence needlestick reporting. This has resulted in a series of recommendations that will help our DHB to formulate an appropriate strategy to manage needlestick incidence and impact.

Cultural issues in research, a reflection.

In New Zealand, Maori have been the subject of research where the objectives, methodology and outcomes have failed to address many issues for Maori including power, equity, and the validity of alternative understandings of health and knowledge. A community-based diabetes intervention in the Waikato was designed as a partnership between Maori, health workers and researchers to demonstrate a significant reduction in diabetes incidence in Maori over 3 years. The priorities and challenges which face Maori and community-based researchers are explored in this paper particularly with reference to being both providers of and participants in research.

A raised thyroid stimulating hormone result--a 12-month follow-up study in general practice.

INTRODUCTION: Subclinical hypothyroidism (SCH) is common in older patients. AIM: To review the management of patients identified with a raised thyroid stimulating hormone (TSH) result in a 12-month period and compare this to current guidelines from the New Zealand Best Practice Advocacy Centre (BPAC). METHODS: We collected laboratory data on thyroid function tests (TFTs) that were reported between December 2005 and November 2006 from two general practices with an adult population of approximately 21 000. Data were collected on symptoms, investigations, thyroid medication, family history and comorbidities. We used chi-squared tests to compare findings by age, gender and ethnicity. RESULTS: Older women of European descent were more likely to be to have initial results suggesting SCH. The number of follow-up tests ranged from 0 to 5 tests in a 12-month period. Forty-eight percent of individuals did not have any follow-up investigations. Seventy-three percent of FT4 tests taken are requested concurrently with TSH. Of those who had a repeat TSH test, just over 40% had a result within the reference interval. Twenty-eight percent had two TSH results consistent with SCH. Thirty-five percent of patients with antibody results were positive. The most commonly-recorded symptoms were tiredness and weight gain. DISCUSSION: We found inconsistencies in the management of SCH which were not related to patient characteristics such as age, gender or ethnicity. Further research is needed to determine if SCH is associated with increased morbidity and to provide a clear rationale for management of patients with SCH.

Are there disparities in care in people with diabetes? A review of care provided in general practice.

AIM: To estimate the prevalence of diabetes by age, gender and ethnicity; to look at quality of care and to investigate disparities in care. METHOD: A cross-sectional study in three practices in Hamilton. A comprehensive register was generated by identifying patients with diabetes through queries on the practices' computer system looking for diagnosis codes for diabetes, prescription of hypoglycaemic agents, participation in the 'Get Checked' programme or laboratory test for HbA1c. We then compared the glycaemic control and uptake of retinal screening in adult patients with Type 2 diabetes. RESULTS: The overall prevalence of diabetes in patients aged 20 years or older was 1221/26 096 (4.7%). Eighty percent had attended for a 'Get Checked' annual review in the last 12 months. After adjusting for age, we found that Maori, males and those diagnosed more than five years ago were at increased risk of having unsatisfactory glycaemic control. Maori or Asian patients and women appeared less likely to have accessed retinal screening in the last two years. DISCUSSION: Computerised records including diagnostic codes and prescriptions in general practices can be used to develop comprehensive diabetes registers. Whilst this study shows that high levels of annual review can be achieved in patients with diabetes, the next challenge is to tackle the disparities in uptake of services such as retinal screening or the achievement of intermediate outcomes such as good glycaemic control.

The reality of subclinical hypothyroidism in general practice.

INTRODUCTION: Subclinical hypothyroidism (SCH) is common, reported to affect 4-10% of the adult population. Recommendations for treatment of SCH are contentious, with protagonists even disagreeing over the rationale for medical intervention. How general practitioners (GPs) manage patients with elevated thyroid stimulating hormone (TSH) and normal thyroid hormone results are unknown. This study aimed to explore how GPs think about diagnosing and managing SCH. METHODS: A qualitative study using focus groups conducted between December 2007 and March 2008 to understand how GPs perceive SCH and their diagnostic and management process. FINDINGS: Thirteen GPs in three focus groups in Waikato, New Zealand participated. 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 medicolegal 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 disparate responses by GPs to the diagnosis and management of SCH.

Do general practitioners use thyroid stimulating hormone assay for opportunistic screening?

AIM: The presenting features of early thyroid disease can be subtle and non-specific; consequently, general practitioners (GPs) have a low threshold for ordering thyroid function tests (TFTs). This study examined the use and results of TFTs by GPs in a 1-year period in a population-based sample of adults without known thyroid disease enrolled in general practice. METHOD: This record linkage study analysed the use of TFTs over a 12-month period from laboratory data, which were linked to patient's GP records from two large urban New Zealand general practices with a total registered population of 21,290 patients. Outcomes were analysed by age and gender. RESULTS: One in six adult patients visiting their GP in a 12-month period had a thyroid stimulating hormone (TSH) test, whilst only 1 in 20 had a free thyroxine (FT4) test. 7.0% had an elevated TSH concentration and 1.0% had a low TSH concentration, most with subclinical disease. Rate of testing was higher in females compared with males. CONCLUSION: This study suggests that general practitioners are opportunistically screening with TSH alone to find new cases of thyroid disease.

The use of amino-terminal fraction brain natriuretic peptide (NT-proBNP) assays in general practices in Waikato, New Zealand.

AIMS: To assess the use of the amino-terminal fraction brain natriuretic peptide (NT-proBNP) assay in the management of patients with suspected heart failure in general practice in Waikato District Health Board (DHB). METHODS: We undertook an audit of all BNP requests to Waikato Health Laboratory from 1 March 2005 to 28 February 2006 inclusive. Data were analysed for age, gender, test result, and requesting general practitioner (GP). Crude incidence rate of BNP test by age group, sex, and by district was obtained. Second tests were analysed to ascertain numbers of patients re-tested in primary care. RESULTS: 1553 tests were ordered on 1327 patients; 1182 (89%) of patients had only one test in primary care; 680 (51.2%) of first tests were <40 pmol/L, 409 (30.8%) were between 40-220 pmol/L; and 238 (17.9%) were >220 pmol/L. Of the estimated 250 GPs in Waikato DHB, 75% (189) of GPs had requested one or more BNP tests. 27% (51/189) of GPs requested a repeat test on one or more patient. 27% of patients with result >220 pmol/L had a further BNP test in general practice. CONCLUSIONS: The majority of Waikato GPs have experience with BNP testing in primary care. It appears to be used appropriately as a tool to rule out the diagnosis of heart failure by most GPs. A small number of doctors appear to use BNP more frequently, possibly to monitor treatment or change in condition (an indication for which it is not currently recommended). The use of BNP varies by district.