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Author Archives: Rory

Delay to surgery: #NOF

Monday, October 5th, 2020 | Rory | No Comments

Hansen, S, Liu, S, D’Souza, R, Miller, R. Time to surgery for fractured neck of femur in the Waikato District Health Board: Comparison between rural and metropolitan hospitals between 2017 and 2019. Aust. J. Rural Health. 2020; 00: 1– 3. https://doi.org/10.1111/ajr.12664

A pre-publication open-access version can be found by clicking here.

This is a short report by a couple of fifth year medical students and a rural hospital medicine registrar who were on attachment at Thames Hospital. They found that there is an average of a 29 hour delay to surgery for those that presented to a rural hospital compared to patient’s that presented to Waikato Hospital, with 13% fewer patients receiving surgery within the Aus/NZ guideline of 48 hours. There was a trend towards higher mortality at 40 and 120 days for those that presented to rural hospitals.

Further work is required exploring the reasons for this delay (the transfer took on 7 hours on average – so 22 hours to make up somewhere), which would be ideal for a research elective for a Trainee Intern. Would also be interesting to see what is happening in other regions around the country.

Awesome to see this report published, with a lot of the mahi done during Level 4 lockdown!

 

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Webinar – Heart Failure

Friday, October 2nd, 2020 | Rory | No Comments

Welcome to the next Rural Doctor CME webinar – an update on Heart Failure with Associate Professor Garry Nixon and Dr Rory Miller.  Our webinars are brought to you by the University of Otago Rural Postgraduate Programme and the Division of Rural Hospital Medicine.

Previous webinars and podcasts can be found at the Leaning on Fenceposts blog.

To register for this webinar click here.

 

Thursday, October 1st, 2020 | Rory | No Comments

Elliott, B.M., Witcomb Cahill, H. and Harmston, C. (2019), Paediatric appendicitis: increased disease severity and complication rates in rural children. ANZ Journal of Surgery, 89: 1126-1132. doi:10.1111/ans.15328

This Northland based study shows that children with appendicitis who lived in rural areas (see below) had increased odds (over double) more severe disease, more complications and more unexpected readmissions. Māori patients had a higher perforation rate.

The authors used the StatsNZ definition and we may see different results once an appropriate classification system is sorted. But thy including driving time in their model, which was significant so suspect the results will hold.

I understand there are more general surgical based metro-rural comparisons planned by this group of registrars. Great stuff.

Abstract

Background

Appendicitis is the most common surgical emergency affecting children. Rurality has been shown to be a predictor of worse surgical outcomes in patients with acute appendicitis compared to urban residents. There are no previously published studies investigating this in Australasia.

Methods

A 10‐year retrospective study of all patients aged ≤16 years who underwent an acute appendicectomy in Northland, New Zealand, was conducted. The cohort was identified by searching the hospital database for theatre events and admission diagnoses coded as appendicitis. Primary outcome of interest was the difference in the American Association for the Surgery of Trauma (AAST) anatomical severity grading of appendicitis and the Clavien–Dindo complication rate. The role of ethnicity was also examined.

Results

A total of 470 children underwent appendicectomy during this period. On multivariate analysis, increased AAST grade was twice as likely in rural patients (odds ratio 2.04). Post‐operatively, rural patients had higher Clavien–Dindo complication grade (P = 0.001), longer median length of stay and increased rates of intra‐abdominal collection (19% versus 4%; P = 0.018), 30‐day readmission (19% versus 4%; P = 0.020) and perforation (27% versus 19%; P = 0.031). Māori children had increased perforation rates (28.9% versus 19.0%; P = 0.014) but ethnicity was not found to be independently associated with increasing AAST grade.

Conclusion

Accounting for ethnicity, socio‐economic deprivation and age, we implicate rural patient status as being associated with increasing severity and complicated paediatric appendicitis. This work adds to the evolving description of inequities in rural health outcomes. Further prospective studies are needed to confirm these findings at a national level.

Geographical Narcissism

Wednesday, September 9th, 2020 | Rory | No Comments

Fors, M. (2018, May 28). Geographical Narcissism in Psychotherapy: Countermapping Urban Assumptions About Power, Space, and Time. Psychoanalytic Psychology. Advance online publication. http://dx.doi.org/10.1037/pap0000179

Open access

From time to time, I circulate articles to a wide network of individuals around the world who are involved or have an interest in rural health and rural practice. This article is the one that triggered the most responses with comments that it resonates with their own rural experience. The author, Malin Fors, a psychotherapist in Hammerfest, a small community in the far north of Norway is involved in teaching University of Tromso medical and nursing students based in Finnmark county. In the article, she relates her own experience to the rural geography and psychology literature, as well as psychoanalysis. Essentially, the message is that the cities see their rural communities as existing for the aggrandisement of the cities. This is geographical narcissism.

Comment from Professor Roger Strasser – Professor of rural health at the University of Waikato

Saul Steinberg’s March 29, 1976 “View of the World from Ninth Avenue” cover of The New Yorker – image credit: https://en.wikipedia.org/wiki/View_of_the_World_from_9th_Avenue

Abstract:

In the field of psychotherapy there is a subtle, often unconscious, devaluation of rural knowledge, conventions, and subjectivity, and a belief that urban reality is definitive. Through metaphors from geography and cartography and via psychoanalytic theory on privilege, I formulate urbanity as a seldom-addressed privilege and consider implications of the misrepresentation or absence of the rural world on the “map” of psychotherapy. I countermap urban biases on power, space, and time and explore consequences of frame, self-disclosure, ethics, and interpretations as I investigate urban valuing of specialized expertise over wisdom, urban disconnection from weather and distance, urban colonizing behavior, the dumping of incompetent professionals into rural areas, and the urban sense of entitlement to anonymity.

Rural post-graduate society:

We are still seeking feedback on developing a voluntary post-graduate rural society that will help fund exisiting CME activities that are free to access and allow development of future activities.

Please click here to let us know what you think!

Exploration of rural physician’s lived experience

Friday, September 4th, 2020 | Rory | 1 Comment

Konkin J, Grave L, Cockburn E, et al. Exploration of rural physicians’ lived experience of practising outside their usual scope of practice to provide access to essential medical care (clinical courage): an international phenomenological study. BMJ Open2020;10:e037705. doi:10.1136/bmjopen-2020-037705

Open access

A hermeneutic phenomenological study (look it up or read the methods) undertaken by a group of prominent rural health leaders, most of them well known to a us in Aotearoa. This qualitative study uses interviews with rural doctors to explore a fundamental part of rural medicine, practicing outside your comfort zone aka ‘clinical courage’. The investigators identified a number of features of clinical courage:

the commitment to deliver the care your community needs;

accepting uncertainty;

understanding and making the most of the resources at hand (limited as they are);

consciously testing and understanding your limits;

once you have decided that ‘its needs done’ and ‘you are the best person available to do it’, having the confidence to get on and act;

the importance of supportive rural colleagues in maintaining clinical courage.

The themes will resonate strongly with those working rurally and form a useful insight for those involved in educating the rural workforce.

Comment kindly from Associate Professor Garry Nixon

ABSTRACT

Objectives: Rural doctors describe consistent pressure to provide extended care beyond the limits of their formal training in order to meet the needs of the patients and communities they serve. This study explored the lived experience of rural doctors when they practise outside their usual scope of practice to provide medical care for people who would otherwise not have access to essential clinical services.

Design: A hermeneutic phenomenological study.

Setting: An international rural medicine conference.

Participants: All doctors attending the conference who practised medicine in rural/remote areas in a predominantly English-speaking community were eligible to participate; 27 doctors were recruited.

Interventions: Semi-structured interviews were conducted. The transcripts were initially read and analysed by individual researchers before they were read aloud to the group to explore meanings more fully. Two researchers then reviewed the transcripts to develop the results section which was then rechecked by the broader group.

Primary outcome measure: An understanding of the lived experiences of clinical courage.

Results: Participants provided in-depth descriptions of experiences we have termed clinical courage. This phenomenon included the following features: Standing up to serve anybody and everybody in the community; Accepting uncertainty and persistently seeking to prepare; Deliberately understanding and marshalling resources in the context; Humbly seeking to know one’s own limits; Clearing the cognitive hurdle when something needs to be done for your patient; Collegial support to stand up again.

Conclusion: This study elucidated six features of the phenomenon of clinical courage through the narratives of the lived experience of rural generalist doctors.

Rural post-graduate society:

We are still seeking feedback on developing a voluntary post-graduate rural society that will help fund exisiting CME activities that are free to access and allow development of future activities.

Please click here to let us know what you think!

Rural Postgraduate Society: an idea

Tuesday, September 1st, 2020 | Rory | 1 Comment

The Division of Rural Hospital Medicine and Uni. Otago are considering setting up a postgraduate society and we are keen to get feedback on the idea.

Why do we need a rural postgraduate society?

The Division and the University have been running CME targeted at the educational needs of rural clinicians (and delivered by rural clinicians who understand those needs).  Some of these, such as the RiSC courses and the annual CME workshop, have a fee associated with them, but as many as possible are free and open to everyone. This includes the articles on Leaning on Fence Posts, the webinars and the podcasts. These have proven very popular. Leaning on Fence Posts get up to 100 visits per week and average webinar attendance is around 60 people. We need to find other ways of resourcing these activities if we and to ensure sustainability and see them grow.

Some of us have good access to CME funds but there is big variation in our ability to pay for CME. A postgraduate society could be a way of those with CME allowances (who maybe are having second thoughts about European cardiology conferences) to use some of it to support home grown open access  CME for ourselves and the whole rural health professionals community.

How would a rural postgraduate society work?

Membership would be entirely voluntary. It would be a non profit making society governed by its members and would support the current CME activities and grow new ones. Members would likely be offered a discount course fees but the majority of the funds would be used for open access CME.

Please click here to let us know what you think!

Recruiting and retaining

Thursday, August 27th, 2020 | Rory | No Comments

Recruiting and retaining general practitioners in rural practice: systematic review and meta-analysis of rural pipeline effects                                                                     

Ogden J, Preston S, Partanen RL, Ostini R, Coxeter P. Recruiting and retaining general practitioners in rural practice: systematic review and meta-analysis of rural pipeline effects. Med J Aust. 2020;1–9.

Why is this paper important? 

It brings together the evidence in a formal systematic review and meta-analysis. It only includes papers that look at place of work after completion of postgraduate training. It does not include softer outcomes like intention to practice rurally, undertaking an intern or early PGY/registrar job in a rural area. 

Does is provide any new information? 

Not really. It just reinforces what we know about the 3 proven strategies.

That is:

1) taking students from a rural background,

2) prolonged (and ideally repeated) undergraduate attachments in rural areas and

3) targeted postgraduate training in rural communities.

All these increase the uptake of rural careers – and combining the strategies works even better.

Are there any surprises? 

Not really. There were not a lot of eligible studies, and none from NZ (someone needs to do one).

Many thanks to Associate Professor Garry Nixon and Katelyn Costello for their comments.

Abstract

Objective: To synthesise quantitative data on the effects of rural background and experience in rural areas during medical training on the likelihood of general practitioners practising and remaining in rural areas.

Study design: Systematic review and meta-analysis of the effects of rural pipeline factors (rural background; rural clinical and education experience during undergraduate and postgraduate/vocational training) on likelihood of later general practice in rural areas.

Data sources: MEDLINE (Ovid), EMBASE, Informit Health Collection, and ERIC electronic database records published to September 2018; bibliographies of retrieved articles; grey literature.

Data synthesis: Of 6709 publications identified by our search, 27 observational studies were eligible for inclusion in our systematic review; when appropriate, data were pooled in random effects models for meta-analysis. Study quality, assessed with the Newcastle–Ottawa scale, was very good or good for 24 studies, satisfactory for two, and unsatisfactory for one. Meta-analysis indicated that GPs practising in rural communities was significantly associated with having a rural background (odds ratio [OR], 2.71; 95% CI, 2.12–3.46; ten studies) and with rural clinical experience during undergraduate (OR, 1.75; 95% CI, 1.48–2.08; five studies) and postgraduate training (OR, 4.57; 95% CI, 2.80–7.46; eight studies).

Conclusion: GPs with rural backgrounds or rural experience during undergraduate or postgraduate medical training are more likely to practise in rural areas. The effects of multiple rural pipeline factors may be cumulative, and the duration of an experience influences the likelihood of a GP commencing and remaining in rural general practice. These findings could inform government-led initiatives to support an adequate rural GP workforce.
Protocol registration: PROSPERO, CRD42017074943 (updated 1 February 2018).

COVID in rural US

Saturday, August 22nd, 2020 | Rory | No Comments

Pro G, Hubach R, Wheeler D, Camplain R, Haberstroh S, Giano Z, Camplain C, Baldwin JA.  Differences in US COVID-19 case rates and case fatality rates across the urban–rural continuum. Rural and Remote Health 2020; 20: 6074. https://doi.org/10.22605/RRH6074

This short letter published in Rural and Remote Health (Open access) shows that using a ranking score in the US up to April 2020; while there were fewer cases, the mortality was increased compared to metropolitan areas of the US.

The authors acknowledge issues with testing capabilities skewing the data, and we can only assume that things are getting worse given the US’ COVID trajectory.

Fortunately in NZ we don’t have nearly enough data to draw any conclusions (even if we could) but the important message from the paper is equally valid in a NZ context:

“The US and international responses to the COVID-19 pandemic must include plans for strengthening rural health systems, most notably in the form of improving access to treatment for severe cases.”

 

Worth noting that Doctors Without Borders was deployed in the US to help in rural areas with high proportion of indigenous peoples – the first time the aid organisation has had to be deployed. Gives some further perspective, if any more was needed, on the state of healthcare in the states.

 

 

Webinar # 4: Diabetes management

Thursday, August 20th, 2020 | Rory | No Comments

Diabetes management with Dr. Alex McCleod and Sharon Sandilansd, hosted by Dr. Matilda Hamilton. The link is below and is available on YouTube. The audio is also available via podcast on the Leaning on Fenceposts podcast via iTunes or wherever you listen to your podcasts (may take a few hours to become available).

Show notes:

Type I Diabetes & HHS

  • Type I diabetes
    • More common onset in the young
    • However, can occur any stage in life & second peak later in life
    • Will often present with higher sugars than a Type II diabetic
    • High glucose directly toxic to pancreas
      • Explains ‘honey-moon’ phase when Type I treatment starts, pancreatic function temporarily improves
    • Glucose spikes around meals, as opposed to Type II with higher basal BSL (although can develop post-prandial highs too)
  • HHS = Hyperglycaemic Hyperosmolar State (previously called HONK)
    • Profound metabolic derangement
    • Profound dehydration
    • Require large volumes & treatment underlying illness
    • Higher glucose levels than DKA/not acidotic/not ketosis
  • Continuous glucose monitoring
    • Available in NZ, not funded

Insulin in acute illness

  • Use novorapid for correction (NOT actrapid, it is actSLOW and lasts around 8 hours)
  • Novorapid – quick acting, 3 hours action
  • No insulin is as good as our native insulin – rapid onset/offset
  • Consider stopping metformin during acute illness and starting insulin
  • Don’t forget to restart metformin before discharge!
  • BSL monitoring during admission: pre-meal, pre-bed, 0200 (monitor for hypos) +/- post-meal (?post-prandial highs)
  • Suggested regime for basal/bolus regime during admission
    • Australian Subcutaneous Insulin Chart
    • Total daily insulin requirement = 0.5 units/kg
      • Split this 50:50 basal & bolus
    • Basal Wt(kg/4) = basal insulin requirement
    • Pre-meal blous = remaining daily insulin requirement/3
    • Example: 100kg woman
      • Estimated total daily dose = 0.5*100 = 50 units
      • Basal requirement = 100/4 = 25 units (note this is half daily dose)
      • Bolus doses = 25/3 = 8 units (8 units pre meal)
      • 25 units (basal) + 8 units + 8 units + 8 units = 50 units (daily dose)
    • Correction factors
      • These are doses of insulin given pre-meal (based on the BSL) that are added onto the usual pre-prandial (bolus) dose
      • Correction factor calculated 100/total daily dose (eg. Case above 100/50 = 2). The correction factor is the expected reduction in BSL for every unit of inulin. (For cases expect BSL to drop by 2 for every unit of insulin).
      • For example this patient may have BSL target of ~ 10.Pre meal BSL 20.  Want to drop BSL by 10, therefore add correction factor of 5 units onto usual pre-meal insulin.
    • Reviewing insulin dosing during acute admission
      • Add up previous 24 hours insulin requirement, then split this 50:50, adjusting the basal and bolus doses accordingly.

Insulin for long-term treatment:

  • When to start?
    • Not reaching target HbA1c despite ma oral therapy
    • Targets
      • Younger patients HbA1c ~50
      • Slightly older ~ 64
      • Elderly more lenient – must avoid hypos!
    • Continue metformin once on insulin
      • Improves insulin sensitivity
    • Options: long-acting vs mixed vs basal bolus
      • Need BSL profile to guide prescribing eg. Post-prandial highs may be indication for mixed insulin
      • Patient factors – eg. May opt for most simple option = safest
    • Mixed insulin – a note
      • Mixture or short-acting & intermediate acting
      • Last ~ 8 hours, therefore often BD dosing

Diabetic Medications – the old & the new

  • Metformin
    • Reduce oral absorption of glucose
    • Increase glucose uptake by cells, by increasing insulin sensitivity
    • Reduce liver production of glucose
    • Main side effect – GI upset
  • Sulfonylureas
    • Being phased out
    • Augment insulin secretion
    • Risk hypoglycaemia
  • GLP-1 receptor agonists (glucagon-like- peptide)/incretin mimetics
    • Increase insulin production when BSL elevated
    • Slow gastric emptying (can cause nausea)
    • Increase weight loss
    • Injection only
    • Not really available in Aotearoa
  • DPP – 4i, enzyme blocker
    • Reduce glucagon & increase insulin
    • Reduce weight
    • Vildaglitpin = Galvus (available in NZ)
    • Galvumet = vildagliptin + metformin
  • SGLT2 – inhibitors (Flozins)
    • NZ dapagliflozin (Forxiga) (not funded)
    • CKD/CVD benefits
    • Probably add on therapy for heart failure
    • Enhances renal excretion of glucose
    • Increase risk of UTIs and thrush
    • Risk DKA with relatively normal BSL

Non-pharmaceutical management = the important stuff

  • Remember the importance of advice around:
    • Diet to reduce glucose intake
    • Exercise to improve insulin sensitivity
  • Engage patients with appropriate services (eg. Free annual diabetic review, Kaupapa Māori services)
  • Walk beside your patients and be gentle on them – diabetes is a long, hard road.

Podcast:

Available on iTunes or any other podcast apps