52 results for Undergraduate, 2016

  • Vestibular Function in Vestibular Schwannoma

    Tranter-Entwistle, Isaac Brian (2016)

    Undergraduate thesis
    University of Otago

    Abstract Introduction: Traditionally vestibular function has been assessed using caloric irrigations; new methods have failed to reach the same level of accuracy. Vestibular nerve dysfunction occurs with ‘acoustic neuroma’ or ‘vestibular schwannoma. Quantitative testing of hearing by audiometry is much more widely available than quantitative vestibular testing, although consideration of vestibular dysfunction is part of clinical management. Validation of a new method of quantitative vestibular function testing could lead to more widespread integration into clinical practice and affect decision making (i.e. timing of surgery) Methods: A non-blind observational cohort study was undertaken in 31 participants. Study endpoints were either one or two separate participant measures in March/April 2013 the September/October 13. All participants underwent caloric and head impulse testing with video-oculography, while 10 underwent audiometric assessment. Repeat testing was performed for 10 subjects, including additional cognitive. The primary outcome was vestibular function test measures. Results: Video head impulse was strongly correlated with calorics (p=0.01) and showed good sensitivity (80%) and specificity (70%). Dizziness Handicap Inventory showed no correlation with other vestibular function measures. Participants showed reduced cognitive function tested using the CANTAB battery (p=0.01) Conclusion: Video head impulse testing is comparable to caloric testing to assess vestibular function. Vestibular lesions may lead to cognitive deficits. Further research is needed to better understand the role of video head impulse testing in vestibular schwannoma.

    View record details
  • What’s the harm in waiting? Patient harms in the referral waiting gap

    Patel, Vimal (2016)

    Undergraduate thesis
    University of Otago

    Background Patient safety research seeks to improve the delivery of care, and ensure that patients’ risk of injury from healthcare itself is minimised. Referral between primary healthcare, specialist diagnostic agencies (such as community medical laboratories and radiological centres), and hospital based healthcare is common and important in primary care, yet patients have highly variable waiting times before receiving their care. However, there is almost no research exploring what happens to patients while they wait. Aims This study aims to investigate patient’s waiting periods between referral from their General Practitioner (GP) and receiving specialist healthcare. Specifically, this study aims to determine if patients come to any harm in this waiting gap, and if so, which patients are harmed and what types of harm happen. Methods I reviewed 5 years (2003-2007) of healthcare records of 201 general practice patient’s notes. Each consultation record was examined to identify the types of referral that were made and to find evidence of harms while the patient was waiting for referred healthcare. A subset of 101 of these patients also had the records reviewed for investigation types and evidence of harm while waiting for investigation. A broad definition of harm was used to capture a greater number of harms. Harms were categorised as related to referral for investigation, referral to medical specialty or referral to other non-medical specialty. Harms were also graded in severity (mild, moderate and severe) and were described under the following: ‘continued symptoms’, ‘delay in subsequent management’, ‘deterioration of condition’, ‘financial cost to patient’, ‘anxiety/mental harm’ or ‘other’. Comparisons were made between patients whose referrals had evidence of harm in the waiting gap with patients who did not. Comparisons included length of waiting gap, age, gender and specialty referred to and used t-tests or non-parametric tests, as appropriate. Results 5003 Consultation records were reviewed. A referral rate of 0.21 per person per year for medical and non-medical specialties was found, and a referral rate of 1.00 per person per year for investigations was found. 45 of 183 (25.5%) of referrals to medical or non-medical specialties had evidence of harm in the waiting gap, whereas 9 of 105 (1.8%) of referrals for investigation had harm in the waiting gap. Of the 58 total harms, 43 (74.1%) of harms were minor, 12 (20.5%) were moderate and 3 (5.2%) were severe. The largest broad classification of harm was “continued symptoms” with 38 harms (65.5%), followed by “delay in subsequent management” with 14 harms (24.1%) and “deterioration in condition” with 14 harms (24.1%). There were no statistically significant relationships between the age of patient nor sex of patient nor length of waiting time and the incidence of harm in the waiting gap. Conclusion This is the first study of harm in the referral waiting gap. The findings indicate that harm does happen while patients wait for referred care, and more research is needed to explore these harms. While the relatively small number of patients in this study limits the ability to draw robust implications for changed clinical practice, it is a strong starting point for larger, future research.

    View record details
  • Characterization Of In Vitro Generated Autologous Osteoid Tissue

    Reilly, Terrence (2016)

    Undergraduate thesis
    University of Otago

    Bone disease and injury is expected to increase in the near future due to an ageing population, causing social and economic burden due to disability and lowered quality of life. Critical sized defects, the smallest bony injury that will not heal completely over the lifetime of an individual, are significant orthopedic and oral-maxillofacial issues, as they require bone grafts to facilitate repair. As the gold standard autograft is in short supply with additional disadvantages, bone tissue engineering seeks to alleviate this demand. It combines cells isolated from patients with biomaterials to produce bone tissue. This research looks into the feasibility of bone banking: the cryopreservation and storage of a patient’s cells that can be reanimated at the time of injury or disease and the engineering of a bone graft in vitro. Chitosan and nano-hydroxyapatite composite scaffolds were fabricated to produce appropriate pore diameters and porosities. A final concentration of 8% (w/v) chitosan and 5% (w/v) nano-hydroxyapatite were used in the final scaffold, where imaging studies (scanning electron microscopy, micro-computed tomography) showed pore diameters with a 106 µm average with 79% porosity. These scaffolds were subjected to testing, such as degradation, pH, sterilization, swelling studies, Fourier transform infrared spectroscopy, and energy dispersive X-ray spectroscopy in order to characterize physical and chemical properties. Using an osteogenic sarcoma cell line (SAOS-2), scaffolds were then subjected to in vitro cell studies including the LIVE/DEAD® viability assay and the MTS cell proliferation assay to characterize biocompatibility. Results indicate scaffolds are biocompatible and non-cytotoxic. Further three-dimensional in vitro testing was performed using SAOS-2 in a custom-made perfusion bioreactor for 14 days. After this period isolated cells were detected on the scaffold using histological and fluorescent microscopy techniques. Further in vitro testing was investigated using mesenchymal stem cells isolated from rats. However, these cells reached senescence rapidly, therefore, the supply of cells were limited and differentiation down the osteoblastic lineage and three-dimensional culture was unable to be accomplished. This research demonstrated the development of a biocompatible scaffold with appropriate structural parameters that promote viable cells when cultured in a bioreactor. Future study should investigate the scaffolds mechanical and structural properties to determine suitability for bearing load and the production of a homogenous scaffold matrix that results in homogenous osteoid tissue. Cell culture optimization in terms of mesenchymal stem cell proliferation and extracellular matrix production also needs to be investigated in terms of modifying tissue culture factors such as shear stress and seeding density.

    View record details
  • Comparison of Spironolactone versus Amlodipine in Hypertensive Cardiorenal Pathology

    Strickland, James Todd Langdale (2016)

    Undergraduate thesis
    University of Otago

    Hypertension is endemic worldwide, afflicting up to 40% of the global population over the age of 25. Haemodynamic stretch stress from raised blood pressure is a driver for organ damage in the heart and kidney, contributing to potentially fatal conditions. Aldosterone activated mineralocorticoid receptors have also been shown to contribute to cardiorenal damage in a hypertensive state. This study compared the effects of spironolactone, a mineralocorticoid receptor antagonist (MRA), and amlodipine, a calcium channel blocker, when administered in a chronic hypertensive Cyp1a1-Ren2 transgenic rat model. Cyp1a1-Ren2 rats characteristically develop hypertension in a dose-dependent manner in response to dietary indole-3-carbinol (I3C). Male rats (19 week old) were assigned to either standard or I3C (0.167% w/w) diet, 2 weeks prior to experimental day 0. At experimental day 40, rats in both dietary groups were assigned into three drug treatment groups (n=4/group): spironolactone (8.82 mg/kg/day), amlodipine (0.44 mg/kg/day) or vehicle control oral dosing until termination at experimental day 85. Systolic blood pressures recorded at day 0 and day 85 were significantly higher in the I3C diet group compared to standard diet. Spironolactone and amlodipine did not reduce systolic blood pressure at day 85 compared to control groups. Urine volume, proteinuria, left ventricular wall thickness, glomerulosclerosis, renal fibrosis and renal populations of both macrophages and myofibroblasts were increased in the I3C dietary group compared to standard diet; however none of these variables were significantly reduced with either spironolactone or amlodipine treatment compared to the control group in the I3C diet group. A reduction in renal fibrosis and renal cortex macrophage infiltration was observed with spironolactone treatment compared to control in the I3C diet group; however this was not statistically significant. A blood pressure independent reduction in proteinuria was seen in the spironolactone treated rats compared to control, but was also not statistically significant. The trends identified with spironolactone treatment in this study were consistent with many other published works; however these studies suggest spironolactone has been shown to have many other protective characteristics unidentified in this study. Internal validity issues arose from initial stress-related difficulties, compromising intra-group comparisons. This and the underpowered nature of this study limit the interpretation of the study’s results. Therefore this study came to no conclusion in regards to blood pressure independent benefits of addition of spironolactone to a systemic hypertensive situation

    View record details
  • Access to elective and acute orthopaedic surgery in Dunedin: an analysis of surgical delay

    Ramage, Dean James (2016)

    Undergraduate thesis
    University of Otago

    Background: Delay in surgical intervention may lead to significant personal, medical and economical consequences. For individuals undergoing treatment in the public health system, there is inevitably a delay in access to surgery. Access to elective joint replacement surgery can take anywhere from three months, to more than a year. Acute orthopaedic procedures may also be delayed due to clinical and logistical reasons. Thus the aim of this study was to compare outcomes of patients undergoing total hip and knee replacement surgery in the public and private health sectors. In addition to this, the contributing factors to acute surgical delay, and the cost of any surgical delay in Dunedin Hospital has also been investigated along with patients’ perspective of the time spent waiting for surgery. Methods: For the elective arm of the study, 232 public and 231 private patients were retrospectively recruited using New Zealand Joint Registry data. This included 253 that had total hip joint arthroplasty and 210 that had total knee joint arthroplasty. Six-month Oxford Hip and Knee Scores were the primary measure used to compare outcomes between the two groups where the 0-48 scoring system is used. NHI numbers were also used to gain access to other surgical data. For the acute arm of the study, 472 patients who underwent a total of 507 acute orthopaedic procedures were recruited retrospectively. Patients were recruited using the Dunedin Hospital surgical theatre management database and NHI numbers were used to access additional clinical information. In addition to this 47 patients were recruited prospectively to undergo a questionnaire of their perspective of waiting for surgery in Dunedin Hospital. Results: The elective arm of this study showed that private patients achieve better six month postoperative outcomes than public patients. For those undergoing THJR, private patients had a mean score of 41.74 (SD=5.7) whereas the mean for public patients was 37.94 (SD=9.1). For TKJR patients, private patients had a mean six-month postoperative score of 40.82 (SD=6.0) and public patients mean was 36.55 (SD=8.1). These differences in score persisted after adjustment for age and gender. For the acute arm of this study, 66.7% of the 507 procedures reviewed were delayed. Of the cases that were delayed, 84.3% were delayed due to a logistical reason such as unavailability of theatre time. Other factors associated with surgical delay included the priority grade, day of the week surgery was booked, and the anatomical location of the trauma. The total cost of delay was found to be approximately $145,800 for all surgeries delayed due to a logistical reason. Conclusion: The difference seen between public and private groups for hip replacement surgery supports the limited amount of prior literature. This study is the first that shows a difference in postoperative outcome for knee replacement surgery between public and private patients. In addition to this, findings show that there is a large amount of surgical delay currently present in Dunedin Hospital that comes at a high cost to the healthcare system. Prior literature suggests that a dedicated orthopaedic trauma operating theatre will reduce surgical delay. Finally, patient satisfaction with their time waited for surgery is associated with the timeliness of their surgery, and the communication they receive from medical staff.

    View record details
  • Umbilical Cord Serum Chemokines and the Development of Atopic Dermatitis

    Townsley, Hermaleigh (2016)

    Undergraduate thesis
    University of Otago

    Background: Atopic dermatitis (AD) is a chronic skin condition characterised by the development of pruritic and inflamed lesions. One key component of AD pathogenesis is a cutaneous hyper-reactivity to allergens influenced by a Th2-polarised immune response. Macrophage-derived chemokine (MDC) and Thymus and activation-regulated chemokine (TARC) are two chemokines involved in this pathological immune response. Research has shown a strong association between MDC and TARC levels in blood and AD severity. Recently, some cohort studies have suggested that levels of MDC and TARC in umbilical cord blood (UCB) may be predictive of whether infants will develop AD during childhood. This cohort study aimed to further investigate the potential predictive value of UCB MDC and TARC for AD development in childhood. Methods: This project involved a retrospective analysis of data obtained from the NZA2CS population birth cohort study. Information about AD-related outcomes was gathered using questionnaires at various time points, along with physical examination of flexural dermatitis and measurement of total and specific IgE levels at age six. UCB MDC levels were measured using enzyme-linked immunosorbent assay (ELISA) techniques for a total of 647 participants. Haemolysis of UCB samples was found to affect TARC measurement; therefore fewer (n = 270) samples were analysed for TARC. Haemolysis of UCB samples did not affect measurement of MDC concentration. Logistic regression was used to calculate odds ratios to determine the association between UCB chemokine levels and development of AD- related outcomes in childhood. Results: UCB MDC and TARC levels were not predictive of development of AD at age six. Neither were they consistently significantly associated with the development of AD-related outcomes such as an itchy rash or atopy. Some statistically significant associations were found, although their value is difficult to interpret as these were isolated findings. UCB MDC levels were significantly associated with the development of an itchy rash at four years of age (p = 0.027) and with the level of specific IgE to cat allergen at age six (p = 0.05). When the data was segregated by sex, UCB MDC levels in males were consistently significantly associated with development of an itchy rash during childhood (p < 0.05). Conclusion: UCB MDC and TARC concentrations are unlikely to be clinically useful biomarkers for the development of AD in childhood. This was the largest cohort study so far to investigate cord MDC and TARC levels as predictors of future AD onset, and the findings are concordant one other large cohort study. Therefore, these results do not warrant further research into UCB MDC and TARC as predictive biomarkers of AD development.

    View record details
  • Exploring the physiological and functional differences between stem cells isolated from the human right atrium and left ventricle

    Donnelly, Hayden (2016)

    Undergraduate thesis
    University of Otago

    Recent discovery of resident cardiac stem cells (CSCs), capable of cardiac lineage differentiation and paracrine mediated effects, suggest promise for cardiac tissue repair. The best site in the heart for obtaining CSCs remains to be determined. We therefore aim to investigate the differences between CSCs isolated from the right atrial appendage (RAA) and the left ventricle (LV) in patients undergoing on-pump cardiac surgery. Isolated CSCs were characterized using flow cytometry for the CSC specific surface markers CD90 and CD105. Hematopoietic lineage cells were identified using the CD34 surface marker. To date, approximately 80% of isolated cells (n=10) have been confirmed to be CD34 negative and CD105 positive. To exclude fibroblast contamination, immunofluorescence was performed to detect the expression of β-MHC, confirming the ability of the CSCs to differentiate into a cardiomyocyte lineage. Typically, administered CSCs undergo massive cell death in the first six weeks. Therefore, survival and paracrine factor production under conditions mimicking the microenvironment of the myocardial infarct territory were investigated. This involved measuring levels of apoptosis and production of important paracrine factors, SDF-1α and VEGF-A under conditions of hypoxia (1% O2) and serum starvation for 3 days. This was done via a luminescent caspase 3/7 assay and sandwich ELISA respectively. Results show (n = 3) lower relative caspase activity for RAA compared to LV at a ratio of 0.88 (95% CI 0.71 to 1.07, p = 0.107) and in the setting of serum starvation, hypoxia had a protective effect at a ratio of 0.79 and 0.87 for RAA and LV respectively (95% CI 0.56 to 1.11, p = 0.149 and 95% CI 0.79 to 0.95, p = 0.027). The relative expansion potential was also observed over the first 8 weeks (n=3). However, no statistically significant difference between RAA and LV expansion potential was shown. This is a preliminary study, establishing a foundation for a fair head-to-head comparison of RAA and LV. It is my hope that data collection will continue and with more statistical power, stronger statements will be made about either the equivalency, or the superiority of, one or the other cell types.¬

    View record details
  • The Use of the Ankle Brachial Pressure Index (ABPI) in General Practice: A Mixed Methods Study

    Ding, Thomas Gregory (2016)

    Undergraduate thesis
    University of Otago

    Background Peripheral Arterial Disease (PAD) is an increasingly prevalent long-term illness globally. The Ankle Brachial Pressure Index (ABPI) is a well-established, simple, relatively quick, inexpensive and non-invasive assessment useful in diagnosing and quantifying PAD with varying symptomology. Though literature has documented many theoretical benefits associated with its use, ABPIs are still underutilised in general practice. Aims The study aimed to investigate the usefulness of ABPIs in general practice. Methods This study used quantitative analysis of routine electronic practice data from Mosgiel Health Centre between 2006-2015. The study also analysed thirteen one-to-one interviews with healthcare professionals regarding views on the usefulness of the ABPI in general practice. Results The quantitative arm showed that of 379 patients having ABPI tests over ten years, half were completed to investigate venous compression therapy eligibility and half investigated arterial-related symptoms. Of all patients who had ABPIs, 26% were referred to the vascular department. ABPIs helped to prevent inappropriate referrals in over 70% of cases. Patients living in more socially deprived areas were over-represented in the ABPI group. The qualitative arm showed that GPs are aware that ABPIs are beneficial to patients: through ruling in or out PAD to aid management, to aid triage for hospital-based systems and to implement immediate therapy in the community. Practical barriers were discussed, including cost, time and low patient need. Conclusion There are marked benefits associated with ABPI use in general practice. However, practical barriers need to be overcome before ABPIs are considered as a viable investigation for some GPs.

    View record details
  • Hepatitis B in Oman, risk factors and sequelae

    AlHarthi, Rahma (2016)

    Undergraduate thesis
    University of Otago

    Background Hepatitis B is a major public health problem worldwide. The prevalence of hepatitis B is dependent on the modes in which it is transmitted. There are two common modes of hepatitis B virus (HBV) spread: vertical (mother to neonate) and the horizontal (via infected blood or body fluids). Chronic infection with HBV can progress to liver cirrhosis and liver cancer (hepatocellular carcinoma; HCC). Oman is regarded as an intermediate endemicity region and has had neonatal vaccine against HBV since 1990; however, little research has been conducted in Oman regarding risk factors for hepatitis B and its contribution to end stage liver disease and HCC. Aims  To identify the prevalence of major risk factors for acquiring hepatitis B in Omani patients currently infected with HBV (positive hepatitis B surface antigen (HBsAg)).  To estimate the contribution of hepatitis B to liver cirrhosis in Oman. Methods The prevalence of major risk factors was identified by interviewing HBsAg positive patients using a standard questionnaire. Patients were recruited from outpatient clinics at two tertiary referral hospitals in Oman’s capital city Muscat. Data on patients with liver cirrhosis admitted to two tertiary hospitals in Muscat over a period of seven years was abstracted from medical records. The diagnosis of cirrhosis was confirmed using defined criteria and the aetiology confirmed from the results of diagnostic tests including HBV serology. This data was analysed to estimate the contribution of HBV to cirrhosis in the cohort. Results For the first objective, 279 patients were interviewed. The number of male and female patients was similar, and 75.5% of the participants were aged 20 – 39 years. Antenatal screening was the most common means of detecting HBV infection in women and prior to blood donation was the most common means of identifying HBV infection in men. With respect to HBV transmission risk factors, intra-familial contact with HBV infected persons and behavioural risks such as body piercing (females) and barber shaving (males) were more common than nosocomial risk factors. Knowledge about HBV infection was scarce among our participants. For the second objective, we identified records from 419 patients with cirrhosis. The median age was 59 years and males accounted for two thirds of the total studied population. 97.1% of patients were of Omani ethnicity. There was evidence of previous or current HBV infection (positive anti-bodies to hepatitis B core antigen) in 51.3% of the cirrhotic patients. 21.5% had active HBV (positive HBsAg). Of the patients with current HBV 91.2% were infected with HBV alone while 8.8% were co-infected with hepatitis C virus (HCV). Hepatitis C was present in 30.5% of cirrhotic patients and nearly half of those patients had evidence of past exposure to HBV. When stratified by gender, HBV infection was more common among male cirrhotic patients compared to females. Conclusions This study found that risk factors for HBV infection in Omani patients include direct contact of infected individuals within a family and exposure to high-risk behaviours such as piercing and barber shaving. Reducing vertical and horizontal transmission of hepatitis B in Oman could be improved by the implementation of routine antenatal screening of pregnant women and a greater focus on contact screening respectively. Future work is required to determine whether the association with behavioural risk factors is causal, particularly piercing and shaving at barber shops. If confirmed, relatively simple and effective interventions could be developed to reduce the risk of horizontal transmission related to these activities. We found that third of the patients identified with liver cirrhosis had past exposure to HBV and 20% had evidence of chronic infection. Most patients were of older age and male sex. This group of patients may benefit from antiviral therapy to prevent decompensation and regular surveillance for early diagnosis and treatment of HCC. Further research is required to assess the role of other exposures (alcohol, co-infection with other viruses) in the prognosis of hepatitis B to cirrhosis in Oman.

    View record details
  • Mapping Perspectives on an Ethically Challenging Paediatric Case

    Reyneke, Marizanne (2016)

    Undergraduate thesis
    University of Otago

    Objectives This project aims to identify and examine in detail some of the ethically challenging aspects of the care of infants who have serious medical conditions, by looking at a multidisciplinary team (MDT) and whãnau involved in a single neonatal case. An objective is to identify what was especially important to the whãnau during the care of their baby, and examine the perspectives of various MDT members around these factors. A further objective is to identify the differing perspectives of various health professionals as well as the whãnau relating to specific themes identified, and map how these perspectives relate to one another. In order to make more sense of this data, I look at clinical and ethical frameworks that are appropriate to apply to the results of this study. An overarching objective here is to produce information that can inform health professionals, as to enhance their practise collaboratively and effectively in such testing paediatric cases during their professional careers. In particular, the case- related data may constitute a useful resource for inter-professional education sessions. Study design Seven MDT members (transport nurse, social worker, neonatologist, charge nurse, paediatrician, clinical geneticist and midwife) and the whãnau were interviewed using semi-structured qualitative interviews. Interviews were transcribed in full, and then analysed using a grounded theory-lite coding system to extract important themes. Results The analysis revealed several important themes, with each overarching theme encompassing several smaller sub-themes. The themes explored were: 1) Communication 2) Ethical issues 3) Source of perspective The family identified that effective communication from the MDT was a crucial element throughout all stages of their journey with their baby. In general, MDT members also valued communication highly, both within the team itself, and between the team and the whanau. It emerged that different MDT members have different priorities when it came to the way that they used communication. The family emphasised that it was important to them to consider the impact on the family as a whole when it came to ethical decision points. The MDT tended to focus more on the best interest of the baby as an individual. It was found that very few of the MDT members interviewed could recall any specific ethics education, and even fewer MDT members consistently used an ethical framework to assist them when considering ethically complex cases. Conclusion The single in-depth paediatric case study revealed the intricacies involved in making ethical decisions, working well within a multi-disciplinary team, and forming a relationship with the whãnau. It is clear that cases such as these are multi-faceted and that many factors contribute to either a poor or good outcome for the whãnau. Upon analysis and discussion of results and themes, I conclude that using the Family- Centered Care clinical model and Ethic of Care ethical framework in similar cases may show great benefit for both the families and MDTs. Early inter-professional education may be one way of implementing these models and ideas.

    View record details
  • Declining Intramuscular Newborn Vitamin K Prophylaxis: An Exploration of Parental Decision Making and Influencing Factors

    Miller, Hayleigh (2016)

    Undergraduate thesis
    University of Otago

    Objective Newborn infants are at risk of potentially life-threatening vitamin K deficiency bleeding. This is readily prevented with prophylactic vitamin K at birth. In New Zealand, the recommended route of prophylaxis is intramuscular (IM) but the uptake rates are lower than that of comparable countries. This study investigated the reasoning of parents who opted out of IM vitamin K prophylaxis for their newborn. Study Design Semi-structured interviews were conducted with fifteen families from the Otago/Southland region of New Zealand about their choice to opt out of IM vitamin K. Interview data was analysed using thematic analysis in order to elucidate themes capturing important aspects of parental decision making. Results Parents opt out of IM vitamin K for a variety of reasons. These were clustered into three main themes: parental beliefs and values, concerns about their child’s welfare, and external influencing factors. Parents also raised a number of concerns regarding other perinatal and childhood interventions. Conclusion This study identified factors that influence parental decision making, and lead to a decision to opt out of IM newborn vitamin K prophylaxis. These findings can contribute to the wider body of literature that informs public health initiatives focused on newborn vitamin K prophylaxis.

    View record details
  • Following the journey of seven patients with recurrent high grade glioma through hypo-fractionated salvage radiation therapy and beyond

    Knight, Jenny (2016)

    Undergraduate thesis
    University of Otago

    Primary glioblastoma multiforme is the main primary brain cancer in adults. It is a diagnosis that carries with it a devastatingly poor prognosis. Best current practice, consisting of debulking surgery, radiation therapy and Temozolomide chemotherapy, results in a mean overall survival of 15-20 months after diagnosis. There is no standard treatment for relapsed high grade glioma. The most promising chemotherapy regimens, using Temozolomide, Bevacizumab and Irinotecan, have resulted in a mean overall survival of 8.8 to 9.3 months from salvage therapy. Several clinical studies have reported a mean overall survival of 3.9 - 12.5 months after salvage hypo-fractionated radiation therapy. The aim of salvage treatment for high grade glioma patients is the palliation of symptoms and maintenance of quality of life. The research presented in this thesis follows the journey of seven patients with recurrent high-grade glioma through their salvage radiation therapy and beyond at Auckland Radiation Oncology between September 2014 and December 2015. The objectives were to 1] gain an insight into the impact of hypo-fractioned re-irradiation on Health Related Quality of Life during and after the completion of salvage treatment and to 2] determine the nature and severity of tumour associated symptoms before, during and after completion of hypo-fractioned re-irradiation. A prospective observational study design was used with a variety of methods of gathering information to document the patients’ journeys. Patients completed the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 and BN-20 quality of life questionnaires to capture self-reported severity of symptoms scores, overall health and quality of life at baseline, during and after treatment. The author attended follow-up consultations with the radiation oncologist to gain an insight into the disease and treatment-related symptoms and their effect on day-to-day life. Any notes taken during the consultations were cross referenced with notes from the treatment radiation therapists and radiation oncologist in the patient file. The author also reviewed patient notes and CT and MRI scans to understand the disease trajectory from primary diagnosis to recurrence and gain details of the radiation therapy treatment plan. The intent was to document treatment-related side effects using the Common Terminology for Adverse Events (CTCAE) adverse events criteria. CTCAE scoring was discontinued after the first patient due to the burden of an additional interview with these vulnerable patients and the similarity of the CTCAE items to those covered in the quality of life questionnaires. Side effects were also discussed during consultations with the radiation oncologist, which the author attended. The journey of each of the seven patients was very distinct. Patient expectations regarding their health and quality of life throughout salvage therapy depended on a combination of age, stage in life, time to relapse, severity of disease symptoms and the extent to which they had accepted their prognosis. All of the patients experienced some level of psychosocial distress. Six patients reported at least “a little worry or depression”; patients also reported feeling at least “a little uncertain about their future”. Salvage re-irradiation to a median dose of 35Gy in 10 fractions was found to be well tolerated although a decrease in overall health and quality of life from baseline was reported in five of the seven patients during the two weeks of treatment. Fatigue, exacerbation of tumour symptoms and disruption to daily life worsened during radiation treatment. A majority of patients responded to salvage re-irradiation with a partial response and six patients had further salvage chemotherapy. Most patients reported an increase in or reasonably stable overall health and quality of life scores after completion of radiation treatment. Limitations of the study included cohort demographics and a short and varied follow-up time. Because of the time constraints of an honours thesis project, only a small number of patients participated. Patients enrolled early in the study were followed for a much longer period of time (up to 15 months) than patients who enrolled later (minimum of five months). Even though this small cohort was very heterogeneous with respect to age, stage in life, time to relapse and salvage treatment, they all attended a private clinic and most likely belonged to a higher socioeconomic class where the pressures of having to keep working to provide for the family were not key factors. The cohort also lacked ethnic diversity as all patients identified themselves as NZ European. The patients themselves were supposed to fill in quality of life questionnaires at the start, during treatment and follow. This did not happen for all time points for all patients because in a few instances the author was not advised of a change in follow-up appointments or could not be released from clinical duties to hand out the questionnaires and in some cases patients were too sick to fill them in. Overall, the experience of this small cohort of patients suggests that hypo-fractionated radiation may be a salvage therapy option for at least some patients with relapsed high grade glioma. One of the major costs of salvage radiation therapy for patients is disruption to everyday life due to the logistics of attending daily treatment sessions. It is therefore appropriate that it is delivered over a relatively short period of two weeks. The study further identified the need for more research into the physical and psychosocial wellbeing of high grade glioma patients and the best ways to support them in coping with the challenges that living with an incurable brain tumour presents.

    View record details
  • The Overlap of Hyperventilation Syndrome with Asthma and Anxiety

    Shin, Hayden Hyunjae (2016)

    Undergraduate thesis
    University of Otago

    Hyperventilation Syndrome (HVS) is a functional breathing disorder characterised by recurrent or chronic changes in breathing pattern causing respiratory and non-respiratory complaints that cannot be attributed to any specific medical diagnosis. HVS is thought to be common yet often unrecognised or misdiagnosed as ‘difficult-to-control’ asthma. HVS can co-exist with asthma and is also a differential diagnosis of asthma. There are also similarities and overlaps between HVS and anxiety disorders. There is no gold standard for the diagnosis of HVS, but the Nijmegen Questionnaire (NQ), a 16-item symptom checklist for HVS symptoms, is most commonly used in both clinical and research settings. A high NQ indicates HVS. However, this questionnaire includes several symptoms that are also associated with asthma and anxiety disorders. This casts doubts as to whether the NQ can distinguish HVS as a distinct clinical entity. Some view HVS as undiagnosed asthma, while others consider that it is a form of panic disorder. The aim of this thesis was to explore the overlap of HVS with asthma and anxiety in a general population sample. The prevalence of HVS and its association with asthma diagnosis, symptoms, objective markers of severity, and anxiety diagnosis at age 38 years were studied in the Dunedin Multidisciplinary Health and Development Study, a longitudinal investigation of 1,037 individuals born between 1972 and 1973 in Dunedin, New Zealand. Nearly one in 10 Study members had HVS according to the NQ and it was approximately twice as common in women as men (12.1% vs. 6.5%, respectively; P = 0.003). There was a substantial overlap between HVS and asthma with up to one-third of asthmatic women (35.4%) and one-eighth of asthmatic men (13.5%) potentially affected with co-morbid HVS. A different pattern of NQ symptom scores was found in people with only HVS compared to that of people with only asthma. Additionally, the objective markers of asthma including FEV1/FVC ratio and bronchodilator response differed significantly between those with only HVS and those with only asthma, suggesting that HVS can be distinguished from asthma using the NQ and is not merely undiagnosed asthma that is falsely detected by the NQ due to overlapping symptoms. Asthmatics with high NQ scores showed higher symptom scores for all 16 NQ items, rather than scoring high only for the asthma-like symptoms suggesting that these high NQ scores represented co-morbid HVS rather than more severe asthma. Further, there were no differences observed in the objective markers of asthma between those with both asthma and HVS and those with asthma alone. A large overlap was also found between HVS and anxiety disorders, especially with panic disorder (PD). The high NQ scores found in those with both HVS and panic disorder could not solely be explained by co-morbid panic disorder diagnosis: despite a large overlap in symptoms, only approximately half of the total NQ score could be attributed to panic disorder and HVS is thus likely to be distinct from panic. This is the first descriptive study of the prevalence and the overlap of HVS with asthma and anxiety in a large population-based sample. A substantial number of young adults in the general population have HVS and it is more common in those with asthma or anxiety disorders. It is important to assess for, and recognise HVS in these contexts.

    View record details
  • The effect of polymeric formula on enterocyte differentiation

    Budd, Gabrielle (2016)

    Undergraduate thesis
    University of Otago

    Exclusive Enteral Nutrition (EEN) is commonly used in the management of Crohn's disease (CD). Polymeric formulae (PF), comprising whole proteins along with the daily requirements of vitamins and minerals, are commonly used for EEN. The mechanism by which several weeks of PF treatment induces remission is incompletely understood and appears to be a combination of modulation of the intestinal microbiota and anti-inflammatory effects on the intestinal mucosa. These include a reduction in inflammatory cytokine production and improved barrier function.The hypothesis for the current work was that PF caused an increased rate of differentiation of enterocytes at physiological concentrations. This was tested using Caco-2 cell culture and murine enteroids as in vitro models of the intestine.When Caco-2 cells were treated with PF, it caused an increase in intestinal alkaline phosphatase (IAP) expression and activity, a marker of enterocyte differentiation. This was associated with a decrease in cell proliferation and viability. Murine enteroids dissociated after several hours of exposure to PF, possibly due to interference with Wnt signalling. It was hypothesised that the observed effect of PF on Caco-2 cells might be mediated via the vitamin D receptor (VDR). However, when the activity of this receptor was reduced through use of an inhibitor, no change in PF-induced IAP activity and/or decrease in proliferation was observed. This suggests that the VDR pathway is not the primary driver of the accelerated differentiation seen in PF-treated cells.

    View record details
  • 24 – hour oxygen saturation recordings at discharge in preterm infants

    Wellington, Grace Charlotte (2016)

    Undergraduate thesis
    University of Otago

    Preterm infants have an immature respiratory system and therefore experience an increased number of respiratory pauses and oxygen desaturations. There is now advanced pulse oximetry technology that can record oxygen saturations every two seconds for extended periods of time. There has been insufficient literature that reports the incidence of intermittent hypoxia at time of discharge home from the neonatal unit in preterm infants using new generation oximeters. These respiratory events preterm infants experience have been shown to have some effect on neurodevelopment, but their effect on growth has not been investigated before. The primary aim of this study was to determine the prevalence of intermittent hypoxia in preterm infants at time of discharge home from the neonatal unit. The study also addresses the issue of artefact within oximetry recordings and compares results from automatically edited, manually edited and unedited oximetry data, as well as determining whether overnight 12-hour recordings are of equal value to full 24-hour recordings. The secondary aim of this study was to determine whether intermittent hypoxia at discharge has any effect on post discharge growth and to determine changes in amount of intermittent hypoxia from discharge oximetry to oximetry one-month post discharge. We recruited preterm infants from the Wellington neonatal intensive care unit. A 24-hour pulse oximetry recording was performed immediately prior to the infant’s discharge home. These oximetry recordings were analysed and median values for measures reported from oximetry recordings were determined. Rules to manually edit oximetry data were created and applied to oximetry recordings. These manually edited reports were then compared with automatically edited and unedited reports. Each recording was also edited to resemble a 12-hour overnight recording and this was compared to the full 24-hour recording. Infants born less than 32 weeks gestational age were further followed up with weekly growth measurements for one-month. A repeat 24-hour oximetry recording was performed at one-month post discharge for these infants and compared to their discharge recording. We report high rates of intermittent hypoxia in preterm infants at time of discharge home from the neonatal unit. For example the median 4% oxygen desaturation index (DSI 4%). was 57.9 events per hour. The incidence of these events decreased with advancing post-menstrual age. Rates of intermittent hypoxia one month post discharge were greatly decreased from discharge with improvements of 42% - 57% seen, with DSI 4% reducing to 25.5 events per hour. This study did not show a significant association between intermittent hypoxia and post-discharge growth, possibly because of the small sample size in this study subgroup. There were few clinically relevant differences on reports edited manually compared with automatically edited reports, with some difference when compared to unedited reports. We recommend automatically editing oximetry reports as this gives similar results to manual editing for the majority of measures, however the nadir of the fall in oxygen saturation is often artefact, and even after automatic editing is the one measure that may remain false. The 24-hour oximetry reports were clinically similar to 12-hour recordings and therefore we suggest 12-hour oximetry studies are sufficient.

    View record details
  • Skin cancer in IBD patients treated with immunomodulators

    Bahi, Morwan (2016)

    Undergraduate thesis
    University of Otago

    Background Both NMSC and IBD primarily manifest in the Caucasian population. Given the predominance of Caucasians in the New Zealand population, and New Zealand’s specific latitude and ozone layer depletion, it is not surprising that NZ has amongst the highest rates of both IBD and NMSC. This is a major concern as thiopurine immunosuppression in IBD patients in NZ predisposes these patients to even higher risk of NMSC, given the peak background levels of the disease. Aims The aim of this study was to investigate the rate of non-melanoma skin cancer in patients with inflammatory bowel disease treated with thiopurine immunomodulators (azathioprine and mercaptopurine) in New Zealand. Methods 180 thiopurine-immunosuppressed IBD patients from Dunedin and North Shore (Auckland) were examined to investigate the incidence of NMSC. Age- and gender-matched controls were recruited in both centres. All patients and controls completed a consent form and study questionnaire. Participants then received a full body skin examination to identify the presence of a suspicious skin lesion. Suspicious lesions were filmed and reviewed by the study dermatologist who then made recommendations as to which lesions require further following by the patient’s general practitioner. Results 359 participants were recruited (Auckland controls n=87, Auckland patients n=83, Dunedin controls n=92, Dunedin patients n=97) with a mean age of 41.4. Overall 43.2% were male. Among the 180 patients, AZA doses were available for 157 with 145 known to have used AZA for at least 6 months (median duration 42 mo, range 6 mo–300 mo). Out of the 145 patients who had received AZA, 13 cases of skin cancers were recalled, compared to 6 among the 201 who did not receive AZA. An additional 16 suspicious lesions were found among the AZA group (including 2 for patients already with a history of skin cancer) and 8 among the non-AZA group. Based on the mean 60.4 months of AZA use reported, this would give crude incidence rates for skin cancer or suspicious lesions of 37/1000 patient years for the AZA group and 14/1000 patient years for the non-exposed group. From unadjusted regression, AZA use of 6 mo or more was associated with higher risk of skin cancer or suspicious lesions (RR 2.67, 95% CI 1.40–5.10, p=0.003). This association persisted after separately adjusting for confounders (skin complexion, age, gender, tanning bed use, sunblock use and duration of sun exposure). Conclusion The results of this project support reports of increased risk of NMSC in IBD patients with use of thiopurines, as suggested by international studies. Despite peak background rates of NMSC in New Zealand, thiopurines raised NMSC risk even further. It was also evident immunosuppressed IBD patients were generally unaware of their increased NMSC risk and experience poor sun-safety. The majority of patients denied prior skin checks. As a result of our findings, it is recommended that IBD patients be advised regarding NMSC and sun safety, and also be scheduled for regular skin monitoring. These services can be provide by the IBD nurse.

    View record details
  • The Minimally Conscious State: A Snapshot : An introduction to the state, and its current management in clinical practice

    Corbett, Jared Michael (2016)

    Undergraduate thesis
    University of Otago

    The Minimally Conscious State is a relatively new state, defined in order to separate patients who show signs of conscious awareness from those who are otherwise vegetative. Extensive research in this area has allowed for production of a definition, and from that, application of diagnostic testing and management strategies, usually adapted from those previously used in vegetative patients. There has been much research around the applicability of these tests and strategies in situations of minimally conscious states, including research by Owen and Coleman, which found that bedside assessment of awareness might not be sensitive to changes in consciousness in these patients. In this thesis I argue that until we have clear and reproducible diagnostic and prognostic guidelines, situations of minimally conscious patients should be approached carefully, and with a patient-centered view of management. This is consistent with work by Honeybul et al., which describes concepts such as the Risk of Unacceptable Badness (RUB), substantial benefit and futility. A patient-centered sanctity of life clause should be applied in these situations, essentially a consideration as to what each patient would consider just and unjust procedures: procedures that would harm what they consider to be a life well lived. I also include discussion about previous legal cases of patients either in vegetative states or other similar disorders of consciousness, particularly in terms of how they were viewed in court i.e. whether there were any particular commitments to clauses such as sanctity of life. Ultimately decisions in these situations should be kept out of the courtroom; in order to do that, doctors need to be considerate of patient world-views, and aware of concepts such as sanctity of life and their applications.

    View record details
  • Geographic Description and Analysis of Factors Affecting the Demand for, and Supply of General Practice Services in New Zealand

    Poole, Ursula Bridget (2016)

    Undergraduate thesis
    University of Otago

    General Practitioner (GP) shortages are an international problem. NZ is simultaneously experiencing an increase in GP demand due to a rising chronic health burden and a decrease in GP supply due to problems with recruitment, retention and retirement. This study used a mixed methods research methodology, mixing qualitative Action Research principles with quantitative analysis. These methods were applied to data collected on the location of 1064 general practices, 186 teaching practices and 495 medical students’ origin in order to determine the feasibility of utilising GIS technology in primary care research. This geographic data was combined with demographic data from the 2013 census in a GIS database to analyse for factors related to need and supply of general practice services. The network analysis has produced the most current and up-to-date picture of general practice accessibility in New Zealand. The data resulting from these analysis comprises of general practices or ‘points of supply’, linked to thirty-minute service area polygons containing 2013 census demographic information including the NZDep Score. This method has shown that physical accessibility to general practices varies considerably throughout New Zealand but that inaccessibility in the South Island of NZ is related more to rurality than socio-economic disadvantage. Urbanisation of both population and health services is having a marked effect upon accessibility for rural regions. However the presence of clinics in rural areas is reducing the shortage of medical services and increasing the access of these populations to health professionals. The analysis of the teaching practice data showed that practices that are located within moderately to high deprivation areas were more likely to have trained students in 2014. This may have beneficial effects on GP shortages in high need areas as positive training exposure is linked to a higher likelihood of selecting General Practice as a speciality. The geographical origin of students is also associated with future career choices. This study found that the medical students were more likely to originate from the least deprived regions of NZ so exposure to high need communities is particularly important. GIS has much to offer primary care research, however its’ most effective use relies on an understanding of the software, its application to the NZ context and potential access to a specialist for assistance with data analysis.

    View record details
  • Suffering and the Dimensionality of Medical Knowledge: A Critique of Evidence Based Medicine

    McHugh, Hugh Marshall (2016)

    Undergraduate thesis
    University of Otago

    Evidence Based Medicine (EBM) is a recent philosophy that is highly influential in medicine. EBM is centred on the notion that medical practice should be supported by rigorous clinical research. This thesis explores a “dimensional” framework of knowledge and argues EBM results in the exclusion of certain non-scientific knowledge forms. Since these knowledge forms are essential to the realisation of medicine’s goals, EBM is holding medicine back. I frame the primary goal of medicine as to attend to suffering. There is a tendency to view the goal of medicine as the treatment of disease, but this fails to account for much of what occurs in practice. Suffering incorporates disease and also other humanistic aspects of medicine that may not be investigable in a scientific manner. Medical knowledge determines medical practice, so medicine must have knowledge of what suffering is to effectively attend to suffering. I propose a dimensional theory of knowledge that includes explicit, tacit, general and particular forms of knowledge. Explicated general knowledge includes the knowledge of science. Tacit knowledge is more readily enacted than articulated. Particular knowledge is knowledge that is applicable to specific circumstances and individuals. The existence of tacit and particular knowledge moderates the possibility and need for scientific justification and also means knowledge exists within the knower and not exclusively in abstracted forms. EBM’s philosophical framework excludes tacit and particular knowledge in its selective recognition of explicit-generalised “evidence”. This means that EBM’s conception of knowledge is incomplete and is philosophically inadequate. Though EBM makes useful contributions to clinical research appraisal, its normative assertions of “what counts as knowing” in medicine obscures human suffering and so might harm practice. This thesis presents the foundations for an alternative philosophy to EBM that would see “EBM” reframed as “clinical epidemiology” as a remedy for EBM’s normative restriction of medical knowledge.

    View record details
  • The transition from acute to chronic post-surgical pain – A prospective cohort study

    MacLachlan, Campbell (2016)

    Undergraduate thesis
    University of Otago

    Background: Chronic pain is pain which persists beyond the normal physiological healing timeframe. It affects up to 20% of the Australian and New Zealand populations. Chronic pain is also costly, not only in terms of healthcare costs, but also in lost work days and decreased productivity. Surgery is one of the leading causes of chronic pain, highlighting the need to understand and prevent the transition from acute to chronic post-surgical pain. This study has documented the onset and development of subacute pain and the development of chronic pain. The undertaking of this study may have added to the arsenal of tools used to predict which patients will go on to develop chronic pain. By predicting chronic pain development in advance, interventions may be developed to prevent the development of persistent post-surgical neuropathic pain. Considering the rising costs of healthcare, and the growing socioeconomic burden of chronic pain, strategies to prevent chronic post-surgical pain need to be carefully considered. Hypothesis: That one or more of the proposed factors measured perioperatively will predict continued pain at six weeks and three months after gynaecological surgery. Aims: 1) To determine the prevalence of acute persistent pain at 6 weeks following surgery 2) To determine the prevalence of chronic pain at 3 months following surgery 3) To determine the extent to which (if at all) the perioperative factors measured predict continued pain at six weeks and three months. Methods: Patients were assessed at the Christchurch Women’s Hospital Pre-Admission clinic and approached for written informed consent. Those agreeing to participate were given validated questionnaires to complete in order to document their physical, emotional and functional state pre-surgery. In addition a cold pressor test was carried out to determine pain threshold and tolerance. The cold pressor test involves placing a hand in cold water containing ice. The pain slowly builds until the participant can bear it no longer, at which point it is voluntarily removed from the stimulus. Intraoperative factors (anaesthetic techniques, surgical techniques, and analgesic use) were measured, as well as patient-controlled analgesia (PCA) use, and medications prescribed on discharge. At 6 weeks, participants were telephoned, and validated questionnaires completed. At 3 months, all participants were again telephoned, and validated questionnaires were completed. Results and conclusions: Of the 54 participants 15.7% were deemed to be experiencing significant pain at 6 weeks post-operatively; 8.2% of participants were deemed to be experiencing significant pain at 3 months postoperatively. The psychometric questionnaires used often found differences between those experiencing pain and those not experiencing pain at given observation points, but only the Brief Illness Perception Questionnaire (BIPQ) appears to be predictive of developing prolonged postoperative pain. The mean difference (7.4 on a 0-50) scale may even be enough to see it used clinically alongside other predictive measures. Many of the demographic factors correlated with the experience of pain at a given time point(s), but none were predictive of the development of prolonged pain to significant levels. The cold pressor test did not show any significant differences between those in pain at baseline, and those that are not in pain at baseline. However, pain threshold as measured by this test was shown to predict prolonged pain outcomes. Pain tolerance and pain endurance followed the same trend, but were not statistically significant. No surgical approach or group was significantly more likely to develop a prolonged pain state than the others. However, it did seem as though laparotomy may be associated with poorer pain outcomes, which is supported by the literature. Intraoperatively, those who would later develop prolonged pain states were less likely to receive opioids, but possibly likely to receive greater doses if they did. Perhaps worryingly, those who would later develop prolonged pain states were significantly more likely to receive tramadol intraoperatively. There were no statistically significant trends in postoperative inpatient or discharge prescribing, however non-significant trends were noted across both in terms of prescription of specific non-steroidal anti-inflammatory drugs (NSAIDs) and weak opioids. Introduction to this thesis: Chapters One, Two, and Four of this thesis review the relevant literature for the following: the pathophysiology and epidemiology of pain (Chapter One); the tools currently available for the management of pain (Chapter Two); the tools used in this study to measure pain; and the tools used in this study to measure pain related behaviour (Chapter Four). Chapter Three gives a brief overview of the relevant aspects of the gynaecological surgical types used in this study. Chapter Five of this thesis outlines how the protocol for this study was designed and tested, while Chapter Six outlines the hypothesis, specific aims, and methods used in data collection and analysis. Chapter Seven details the results discovered using the aforementioned methods. Chapter Eight discusses the results found in Chapter Seven, the limitations and strengths of the present study, and draws conclusions based on these. From this, Chapter Eight makes appropriate recommendations for future research and notes potential influences on clinical practice.

    View record details