Protocol for a national, multicentre study of post-endoscopy colorectal and upper gastrointestinal cancers: The POET study.

AIM: The primary aim of the study is to define the post-colonoscopy colorectal cancer (PCCRC) three-year rate and the post-endoscopy upper gastrointestinal cancer (PEUGIC) three-year rate across public hospitals in Aotearoa New Zealand. METHOD: This retrospective cohort study will be conducted via the trainee-led STRATA Collaborative network. All public hospitals in Aotearoa New Zealand will be eligible to participate. Data will be collected on all adult patients who are diagnosed with colorectal adenocarcinoma within 6 to 48 months of a colonoscopy and all adult patients diagnosed with gastroesophageal cancer within 6 to 48 months of an upper gastrointestinal endoscopy. The study period will be from 2010 to 2022. The primary outcome is the PCCRC 3-year rate and the PEUGIC 3-year rate. Secondary aims are to define and characterize survival after PCCRC or PEUGIC, the cause of PCCRC as based on the World Endoscopy Organization System of Analysis definitions, trends over time, and centre level variation. CONCLUSION: This protocol describes the methodology for a nationwide retrospective cohort study on PCCRC and PEUGIC in Aotearoa New Zealand. These data will lay the foundation for future studies and quality improvement initiatives.

"Failure to Rescue" following Colorectal Cancer Resection: Variation and Improvements in a National Study of Postoperative Mortality.

OBJECTIVE: To examine variation in "failure to rescue" (FTR) as a driver of differences in mortality between centres and over time for patients undergoing colorectal cancer surgery. BACKGROUND: Wide variation exists in postoperative mortality following colorectal cancer surgery. FTR has been identified as an important determinant of variation in postoperative outcomes. We hypothesized that differences in mortality both between hospitals and over time are driven by variation in FTR. METHODS: A national population-based study of patients undergoing colorectal cancer resection from 2010 to 2019 in Aotearoa New Zealand was conducted. Rates of 90-day FTR, mortality, and complications were calculated overall, and for surgical and nonoperative complications. Twenty District Health Boards (DHBs) were ranked into quartiles using risk- and reliability-adjusted 90-day mortality rates. Variation between DHBs and trends over the 10-year period were examined. RESULTS: Overall, 15,686 patients undergoing resection for colorectal adenocarcinoma were included. Increased postoperative mortality at high-mortality centers (OR 2.4, 95% CI 1.8-3.3) was driven by higher rates of FTR (OR 2.0, 95% CI 1.5-2.8), and postoperative complications (OR 1.4, 95% CI 1.3-1.6). These trends were consistent across operative and nonoperative complications. Over the 2010 to 2019 period, postoperative mortality halved (OR 0.5, 95% CI 0.4-0.6), associated with a greater improvement in FTR (OR 0.5, 95% CI 0.4-0.7) than complications (OR 0.8, 95% CI 0.8-0.9). Differences between centers and over time remained when only analyzing patients undergoing elective surgery. CONCLUSION: Mortality following colorectal cancer resection has halved over the past decade, predominantly driven by improvements in "rescue" from complications. Differences in FTR also drive hospital-level variation in mortality, highlighting the central importance of "rescue" as a target for surgical quality improvement.

Characterising nationwide reasons for unplanned hospital readmission after colorectal cancer surgery.

BACKGROUND: Readmissions after colorectal cancer surgery are common, despite advancements in surgical care, and have a significant impact on both individual patients and overall healthcare costs. The aim of this study was to determine the 30-and 90 days readmission rate after colorectal cancer surgery, and to investigate the risk factors and clinical reasons for unplanned readmissions. METHOD: A multicenter, population-based study including all patients discharged after index colorectal cancer resection from 2010 to 2020 in Aotearoa New Zealand (AoNZ) was completed. The Ministry of Health National Minimum Dataset was used. Rates of readmission at 30 days and 90 days were calculated. Mixed-effect logistic regression models were built to investigate factors associated with unplanned readmission. Reasons for readmission were described. RESULTS: Data were obtained on 16,885 patients. Unplanned 30-day and 90-day hospital readmission rates were 15.1% and 23.7% respectively. The main readmission risk factors were comorbidities, advanced disease, and postoperative complications. Hospital level variation was not present. Despite risk adjustment, R2 value of models was low (30 days: 4.3%, 90 days: 5.2%). The most common reasons for readmission were gastrointestinal causes (32.1%) and wound complications (14.4%). Rates of readmission did not improve over the 11 years study period (p = 0.876). CONCLUSION: Readmissions following colorectal resections in AoNZ are higher than other comparable healthcare systems and rates have remained constant over time. While patient comorbidities and postoperative complications are associated with readmission, the explanatory value of these variables is poor. To reduce unplanned readmissions, efforts should be focused on prevention and early detection of post-discharge complications.

Embolic stroke and atrioesophageal fistula as complications of atrial ablation.

OBJECTIVES: Atrioesophagel fistula (AEF) is a rare, but potentially deadly complication of atrial ablation procedures. We present a case of a patient with cardioembolic cerebral infarcts and sepsis secondary to an atrioesophageal fistula, which likely developed after an atrial ablation procedure for atrial fibrillation. CASE PRESENTATION: A 66-year-old man initially presented to an emergency department with diarrhea and sepsis, but his subsequent course was complicated by development of multiple, major cerebral infarcts. Despite high suspicion of septic embolism, extensive workup was required before the diagnosis of an atrioesophageal fistula was made. CONCLUSIONS: Though rare, atrioesophageal fistula represents a high mortality complication of common atrial ablation procedures. A high index of suspicion is needed for timely diagnosis and to initiate appropriate treatment.

Management and outcomes of splenic injuries secondary to blunt trauma in patients presenting to major trauma hospitals in Aotearoa New Zealand.

BACKGROUND: Non-operative management of splenic injuries has significantly increased in the last decade with an increased emphasis on splenic preservation. This shift was assisted by increased availability of angioembolization, however, potential geographical variability in access exists in Aotearoa New Zealand (AoNZ). The aim of this study was to assess the management of splenic injury across AoNZ. METHOD: Five-year retrospective study of all patients admitted to AoNZ hospitals with blunt major trauma and a splenic injury. Patients were identified using the National Trauma Registry and cross-referenced with the National Minimum Data Set to determine their management. The primary outcome was the non-operative rate. RESULTS: Seven hundred seventy-three patients were included. Four hundred sixty-nine presented to a tertiary major trauma hospital and 304 to a secondary major trauma hospital. A difference was found in the rate of non-operative management between tertiary and secondary hospitals (P = 0.019). The rate of non-operative management was similar in mild (P = 0.814) and moderate (P = 0.825) injuries, however, significantly higher in severe injuries in tertiary hospitals (P = 0.009). No difference in mortality rate was found. CONCLUSION: This study found a difference in the management of splenic injuries between tertiary and secondary major trauma hospitals; predominantly due to a higher rate of operative management in patients with severe injuries at secondary hospitals. Despite this, no difference in mortality rate was found between tertiary and secondary hospitals.

Acute otolaryngological presentations in Northland, New Zealand: analysed with respect to geography and rurality.

AIM: Otorhinolaryngology, head and neck surgery (ORL) diagnoses and treats disorders of the ear, nose, throat, head and neck which can be commonly seen across a range of medical specialities. Rural patients experience a burden of ORL diseases and face greater barriers to healthcare than their urban counterparts. We aim to provide information on the diagnoses of rural patients presenting with ORL symptomatology to provide data that may be useful in targeting resources and training towards rural patients. METHODS: A 6-year retrospective study was performed between 1 January 2015 to 31 December 2020. The Northland District Health Board (NDHB) data warehouse was searched using ICD-10 codes relevant to ORL. The study included any patient acutely presenting to an NDHB hospital with an ORL diagnosis. Patients with a diagnosis that was not related to ORL, a non-acute presentation, or a diagnosis not usually managed by hospital ORL services were excluded. RESULTS: Five thousand, five hundred and thirty-four presentations in 4,671 individual patients were included in the study. The mean age of patients was 35.1 years (SD 26.58). Two thousand, three hundred and twenty-six (49.8%) patients were female and 2,345 (50.2%) were male. One thousand, nine hundred and sixty-five (42.1%) were Maori and 2,699 (57.8%) were non-Maori. Median decile was 8 (4 IQR). Two thousand and seventy-seven (44.5%) patients were classified as rural and 2,594 (55.5%) as urban. The most common presentation was epistaxis with 16.8% (n=927/5534) of total presentations. The four next most common presentations were otological. There was a total of 224 complications including post-operative bleed, post-operative infection, and other post-operative complications. There was a significant difference in the rate of discharge with 1,819/2,430 (74.9%) rural patients and 2,518/3,104 (81.1%) urban patients being discharged directly from the emergency department (ED) (p <0.001). CONCLUSION: This retrospective study provides a picture of acute ORL presentations in Northland patients, analysed with respect to geography and rurality. It highlights the large volume of ORL patients who are seen and managed by rural and ED physicians, and the importance of rural provision of care in Northland. These findings support the need for targeting resources and training to centres treating rural patients for the management and treatment of ORL conditions.

Colonic Investigation following acute diverticulitis in Northland, New Zealand.

AIM: Diverticulitis is common and increasing in incidence. The risk of malignancy in those with uncomplicated diverticulitis is estimated to be 0.7%, compared with 10% in complicated diverticulitis. Newer guidelines suggest colonic investigation in patients with complicated diverticulitis only. We aim to investigate which patients in Northland undergo colonic investigation following an episode of diverticulitis, define malignancy detection rate and aid in the formulation of local guidelines. METHODS: A retrospective review of adults admitted to Whangarei Hospital with diverticulitis between 2015 and 2019. Patients were classified as complicated or uncomplicated based on the Hinchey classification radiologically or intra-operatively. Patients were followed up to a minimum of 24 months. RESULTS: Three hundred and forty-nine patients were included. One hundred and eighty-two (48%) patients underwent colonic investigation following admission with diverticulitis; 50 with complicated and 132 with uncomplicated disease. The rate of colonic investigation between the groups was similar, at 53% and 47% respectively. Two patients (1.1%) were found to have a colonic malignancy, both in the uncomplicated group. The performance of a colonic investigation was not associated with complicated disease, ethnicity, gender or age on univariate or multivariate analysis. CONCLUSION: Colonic investigation following an admission for acute diverticulitis in Northland is not aligned with recently published guidelines. The rate of colonic malignancy found was low. Larger local studies are needed to guide clinicians and maximise efficiency of resource utilisation.

Incidence and outcomes of major trauma patients with thoracic injuries and rib fractures in Aotearoa New Zealand.

INTRODUCTION: Thoracic trauma represents a significant burden of disease in Aotearoa, New Zealand (AoNZ). To date, no study has examined the incidence or outcomes of patients suffering major thoracic trauma, or major trauma and rib fractures in AoNZ. METHODS: A 6 year retrospective study of all major trauma (Injury Severity Score >12) patients in AoNZ was performed. The National Trauma Registry was searched to identify patients. The National Minimum Data Set was searched for all ICD-10 codes associated with surgical stabilisation of rib fractures (SSRF). Poisson regression was used to determine the change in incidence rate over the study period adjusted for age with the logarithm of population size as the offset variable. The incidence rate ratios (IRR) with 95% confidence intervals (CI) were reported. RESULTS: 12,218 patients sustained major trauma. 7,059 (57.8%) of these patients sustained thoracic injuries. Of these patients, 5,585 (79.1%) sustained rib fractures, and 180 (3.2%) proceeded to SSRF. A flail segment was observed in 16% of patients with rib fractures. Transport was the mechanism of injury in 53% of patients. During the study the incidence (cases per 100,000 people per year) of major trauma increased from 39.5 to 49.3 (IRR 1.05, 95%CI 1.04 to 1.07, <0.001), the incidence of thoracic injuries from 21.3 to 28.7 (1.07, 95% CI 1.05 to 1.08, <0.001) and the incidence of rib fractures from 16.0 to 22.9 (1.08, 95% CI 1.06 to 1.09, <0.001). SSRF was performed in 3.2% of patients with rib fractures and increased from 0.2 to 0.8 cases per 100,000 people per year (1.27, 95% CI 1.15 to 1.41, <0.001) during the study. CONCLUSION: This study reports the incidence of major trauma patients with thoracic injury, major trauma patients with rib fractures and the incidence of SSRF in AoNZ. Transport related injuries are the predominant mechanism of injury. The incidence of SSRF was low across AoNZ. To improve the quality of care in AoNZ for major trauma patients with rib fractures, consideration should be made to create national guidelines and robust referral pathways to specialist centres that provide multidisciplinary care including performing SSRF.

A retrospective study of colonoscopic surveillance in the elderly.

BACKGROUND: Aotearoa New Zealand (AoNZ) guidelines suggest surveillance colonoscopy should be carefully considered after age 75. The authors noted a cluster of patients presenting in their 8th and 9th decade of life with a new colorectal cancer (CRC) having previously been declined surveillance colonoscopy. METHODS: A 7-year retrospective analysis was performed of patients who underwent a colonoscopy aged between 71 and 75 years in the period between 2006 and 2012. Kaplan-Meier graphs were created with survival measured from the time of index colonoscopy. Log rank tests were used to determine any difference in survival distribution. Relative risk (RR) was calculated, and 95% confidence intervals (CI) reported. RESULTS: A total of 623 patients met inclusion criteria; 461 (74%) had no indication for surveillance colonoscopy and 162 (26%) had an indication. Of the 162 patients with an indication, 91 (56.2%) underwent surveillance colonoscopies after the age of 75. Twenty-three (3.7%) patients were diagnosed with a new CRC. Eighteen (78.2%) patients diagnosed with a new CRC underwent surgery. The median survival overall was 12.9 years (95% CI 12.2-13.5). This did not differ between patients with (13.1, 95% CI 12.1-14.1) or without (12.6, 95% CI 11.2-14.0) an indication for surveillance. CONCLUSION: This study found one quarter of patients who had a colonoscopy between the ages of 71-75 had an indication for surveillance colonoscopy. Most patients with a new CRC underwent surgery. This study suggests it may be appropriate to update the AoNZ guidelines and consider adopting a risk stratification tool to aid decision making.

Management and outcomes of rib fractures in patients with isolated blunt thoracic trauma: Results of the Aotearoa New Zealand RiBZ study.

AIM: Rib fractures are common and associated with significant morbidity and mortality. There is limited literature on patient care and outcomes in Aotearoa New Zealand (AoNZ). The aim of this study is to describe key clinical outcomes and management interventions for patients with rib fractures across AoNZ. METHODS: A national prospective multicenter observational cohort study was performed. Patients admitted between 1 December 2020 and 28 February 2021 with one or more radiologically proven rib fractures and an Abbreviated Injury Score of the head or abdomen of less than 3 were included. The primary outcomes of interest were the rates of thirty-day pneumonia, re-presentation and mortality. The secondary outcomes of interest were rate of surgical stabilisation of rib fractures (SSRF) and pain management of patients with rib fractures. Binomial logistic regression was performed for the primary outcomes and funnel plots were created of the inter-hospital variation in pneumonia. RESULTS: Fourteen AoNZ hospitals and 407 patients were included. Mean age was 57.4 (SD 18.7), 28% were female, 15% Maori and 85% non-Maori. The median number of rib fractures was 4. The rate of pneumonia, re-presentation and mortality was 11%, 8% and 2%, respectively. Logistic regression found the odds of pneumonia increased with each additional rib fracture (OR 1.15 95% CI 1.05-1.25) and the odds of re-presentation increased with age (OR 1.028 95% CI 1.005-1.051) and Maori ethnicity (OR 2.754 95% CI 1.077-7.045). The funnel plot of inter-hospital variation in pneumonia rate adjusted for clinically plausible variables found no centre lay outside the 95% confidence interval. SSRF was performed in 2% of patients. 58% of patients had a pain team review and 23% a regional block. CONCLUSION: This study describes clinical outcomes for patients with isolated rib fractures from multiple hospitals in AoNZ. A moderate pneumonia rate of 11% was found which is likely amendable to reduction with quality improvement initiatives. Consideration should be given to further resource and improve the access to SSRF and regional analgesia given the low utilization found across AoNZ. A higher re-presentation rate in Maori and elderly patients was found which needs further investigation.

The effect of rurality and ethnicity in patients with acute cholecystitis in Northland, New Zealand.

AIM: Acute cholecystitis is a common reason for emergency admission. Rurality and ethnicity are associated with poorer surgical outcomes, but data in benign disease is sparse. This study aims to assess the effect of rurality and ethnicity on the severity, management, and outcomes of acute cholecystitis. METHODS: A five-year retrospective cohort study was conducted, including all adults admitted to Northland hospitals with acute cholecystitis. The primary cohort was identified using coding. Severity and outcome data was obtained. Severity was defined according to the Tokyo Guidelines 2018 (TG18). Primary outcomes of interest were the difference in severity of acute cholecystitis, and clinical management between groups. RESULTS: Three hundred and seventy-seven patients were included. There were no significant differences in the severity of acute cholecystitis, rate of acute cholecystectomy, elective cholecystectomy, or non-operative management by rurality or ethnicity. Maori patients presented at a significantly younger age and were more likely to re-present while on the waiting list for elective surgery. CONCLUSION: This study found similar clinical severity, management and outcomes comparing rural and urban patients. Maori patients presented at a significantly younger age.

Trauma Teams in Aotearoa New Zealand-a national survey.

AIMS: Improved survival of trauma patients has been shown when a multidisciplinary trauma team is available. The aim of this study is to investigate the composition of trauma teams, trauma call criteria and the role of anaesthetists in trauma care across New Zealand. METHODS: A survey was distributed using the modified Dillman's technique. Data was collected and aggregated using an online platform. The survey consisted of two streams of questions depending on trauma team availability. Trauma nurse specialists were the first contact point and if not available, direct contact with the hospital was made for completion of the survey. RESULTS: Seventy-five percent of hospitals had a trauma team and trauma call system and correlated to size of the hospital. The number of trauma team members ranged from six to 17, with a median of 10. Trauma call activation criteria encompassed physiological criteria, injury pattern and injury mechanism criteria. Physiological criterial of GCS, heart rate, blood pressure and respiratory rate were universally used. Sixty-two percent of trauma teams had involvement of anaesthetists. CONCLUSIONS: Trauma teams in New Zealand are common in regional and tertiary trauma hospitals. There is a wide variation in member numbers and criteria to trigger a trauma call. Anaesthetist involvement was in over half of trauma teams with regional variation noted. There is potential for trauma team composition and activation criteria to be standardised in New Zealand.

Cost analysis of index versus delayed cholecystectomy for acute cholecystitis in a New Zealand Provincial Centre.

BACKGROUND: Evidence suggests index cholecystectomy (IC) in patients with acute cholecystitis is safe, has decreased hospital stay and is cheaper than delayed cholecystectomy (DC). Costs of cholecystectomy have not previously been investigated in New Zealand. The aim of this study was to compare cost of IC with DC for patients with acute cholecystitis. METHODS: A retrospective analysis of adults admitted to Northland hospitals with acute cholecystitis between 1 January 2015 and 31 December 2019 who underwent subsequent cholecystectomy, was performed. Actual patient-level costs were utilized for cost comparison between IC and DC. Factors associated with increased costs were assessed using multivariate analysis. RESULTS: Two hundred and eleven patients were included in the study; 72 (34%) underwent IC and 139 (65%) DC. There was no significant difference in total cost for IC ($12 767) versus DC ($12 029) (p = 0.192); this persisted on multivariate analysis. Patients having IC had more severe cholecystitis, and 90-day representation rate following DC was 35%. Costs were increased by severity of cholecystitis, age, American Society of Anesthesiology score (ASA) and travel distance. CONCLUSION: This study showed there is no significant difference in cost between IC and DC for patients with acute cholecystitis in Northland, New Zealand. Severity, increasing age, ASA and travel distance were drivers of costs. To recognize the cost benefits of IC, it is likely that increased rates of IC are needed.

Ethnic disparities in Phyllodes Tumour in Aotearoa New Zealand: a retrospective review.

BACKGROUND: Phyllodes tumour (PT) is a rare breast neoplasm and little is known about its epidemiological risk factors. The literature suggests a higher incidence of PT in Asian patients and other minority ethnic groups. The purpose of this study was to identify whether there was a difference in incidence, grade and age at presentation for patients with PT among minority ethnic groups when compared with European patients in Aotearoa New Zealand (AoNZ). METHODS: A retrospective review was conducted across the three District Health Boards (DHBs) in Auckland, Aotearoa New Zealand (AoNZ), from 2008 to 2018 to investigate the relationship between ethnicity and clinical characteristics of PT. Demographic information and histology reports were reviewed to obtain relevant data. The primary outcome measure was ethnicity and the secondary outcome measures were age at presentation, tumour volume and grade. RESULTS: One hundred and fifty-nine patients were included. The total number of non-European patients were 108 (68%). Minority ethnic groups including Pasifika, Maori and MELAA were overrepresented in the patient cohort. Larger tumour volume was significantly correlated with higher tumour grade (p < 0.001). Pasifika patients presented with larger tumours (p 0.05) and at a younger age (p 0.027) when compared with European patients. CONCLUSION: This study found that patients with PT in AoNZ were significantly overrepresented in Asian, Pasifika and MELAA ethnic groups. Pasifika patients may be at an increased risk of presenting at a younger age with larger, higher grade tumours when compared with European patients. Further research is required to investigate the reasons behind these findings in minority ethnic groups.

Survival of patients with small bowel neuroendocrine neoplasms in Auckland, Aotearoa New Zealand.

BACKGROUND: Small intestinal Neuroendocrine Neoplasms (SI-NENs) are the most common primary malignancy of the small bowel. The aim of this study is to define the survival of patients with an SI-NEN in Auckland, Aotearoa New Zealand (AoNZ). METHODS: A retrospective study of all patients diagnosed with a jejunal or ileal SI-NEN in the Auckland region between 2000 and 2012 was performed. The New Zealand NETwork! Registry was searched to identify the study cohort. Retrospective data collection was performed to collect stage, survival and follow up data. RESULTS: One hundred and seven patients were included in the study. The mean age of patients was 62.8 years (SD 11.9). The 5 and 10-year disease-specific survival for all patients was 66.1% (95% CI 56.5-75.7%) and 61.8% (95% CI 51.8-71.8%), respectively. Ten-year disease-specific survival was 100% for stage I and II, 74% (95%CI 61.7-84.4%) for stage III and 33.9% (95%CI 16.9-35.6%) for stage IV SI-NEN. Eleven of 40 (27.5%) patients with stage III disease had recurrence and 3 of 7 (42.8%) patients with stage IV disease had recurrence. In patients with stage IV disease, neither primary resection (HR 2.25, 95% CI 0.92-5.5) nor distant resection (HR 1.72, 95% CI 0.63-4.7) were significantly associated with a disease-specific or overall survival benefit. CONCLUSION: This study demonstrates that stage at SI-NEN diagnosis is associated with survival, but resection of the primary or distant metastases in patients with stage IV disease is not. There was no recurrence in patients with stage I or II disease after complete resection.

The effect of national public health interventions for COVID-19 on emergency general surgery in Northland, New Zealand.

BACKGROUND: The New Zealand government instituted escalating public health interventions to prevent the spread of COVID-19. There was concern this would affect health seeking behaviour leading to delayed presentation and worse outcomes. The aim of this study was to examine the effects of these interventions on rate and severity of acute general surgical admissions in Northland, New Zealand. METHODS: A retrospective comparative cohort study was performed. Two cohorts were identified: 28 February to 8 June 2020 and same period in 2019. Data for surgical admissions and operations and emergency department (ED) presentation were obtained from the hospital data warehouse. Three index diagnoses were assessed for severity. RESULTS: There were 650 acute general surgical admissions in 2019 and 627 in 2020 (P 0.353). Operations were performed in 226 and 224 patients respectively (P 0.829). ED presentations decreased from 11 398 to 8743 (P < 0.001). No difference in severity of acute appendicitis (P 0.970), acute diverticulitis (P 0.333) or acute pancreatitis (P 0.803) was detected. Median length-of-stay, 30-day mortality and admission diagnosis were comparable. CONCLUSION: Despite a significant reduction in ED presentations, interventions for COVID-19 did not result in a difference in the rate or severity of acute general surgical admissions.

Association between COVID-19 public health interventions and major trauma presentation in the northern region of New Zealand.

BACKGROUND: The New Zealand government implemented restrictive public health interventions to eradicate Covid-19. Early reports suggest that one downstream ramification is a change in trauma presentations. The aim of this study is to evaluate the effect these public health measures had on major trauma admissions in the Northern Region, New Zealand. METHODS: A retrospective comparative cohort study was performed. Two cohorts were identified: 16 March to 8 June 2020 and the same period in 2019. Data was extracted from the New Zealand Major Trauma Registry which prospectively collects data on all major trauma in New Zealand. All patients who presented to a hospital in the Northern Region with major trauma and met the Registry inclusion criteria were included. RESULTS: There were 163 major trauma admissions in 2019 and 123 in 2020, a reduction of 25% (rate ratio 0.75, 95% confidence interval 0.6-0.95; P = 0.018). There was no significant difference in mechanism of injury (P = 0.442), type of injury (P = 0.062) or intent of injury (P = 0.971). There was a significant difference in place of injury (P = 0.004) with 20% of injuries happening at home in 2019 compared with 35% in 2020. CONCLUSION: This study has shown that public health interventions to prevent the spread of COVID-19 reduced major trauma admissions in the Northern Region of New Zealand. There was a variation in effect a between institutions within the region and a change in pattern of injury.

Antibiotic Selection for Suspected Neisseria gonorrhoeae Infection Among Penicillin-Allergic Patients in the Emergency Department.

Objectives While penicillin allergies are commonly reported, their cross-reactivity with beta-lactam antibiotics is minimal. First-line treatment of gonorrheal infections includes a cephalosporin. In emergency department (ED) environments, physicians must consider these potential allergies when selecting antibiotics for a patient with symptoms concerning for sexually transmitted infection (STI). Methods A retrospective chart review of adult patients with symptoms concerning for STI presenting to an urban ED from January 2014 through June 2019 was performed. Chart discovery used search terms of "STI", "STD", "urethritis", "vaginitis", and "gonorrhea". Information abstracted included patient symptoms, type of care provider, antibiotics prescribed or administered in the ED. Results A total of 603 patients met inclusion criteria, of which 31 reported allergies to penicillin antibiotics, and another three reported allergies to cephalosporins. Patients reporting penicillin allergy were less likely to receive a cephalosporin antibiotic (p=0.0081). Patients reporting a non-anaphylactic allergy to penicillin received a cephalosporin at a rate of 92.3%. Patients reporting a penicillin allergy under the care of only an attending physician were less likely to receive a cephalosporin antibiotic compared with those whose care teams included either a resident physician or physician assistant (p=0.00019). Patients reporting a penicillin allergy were more likely to receive alternative antibiotics beyond cephalosporins or azithromycin (p=0.048); the most frequently given additional antibiotics were metronidazole, doxycycline, and levofloxacin. Conclusions  Patients with penicillin allergies represent a recurring challenge for ED physicians when faced with antibiotic selection for STI symptoms concerning for gonorrheal infection. Those with penicillin allergies are significantly less likely to receive a cephalosporin antibiotic, though these remain the only universally accepted treatment for gonorrheal infections. These findings highlight the significant need for further physician and public education on allergies and antibiotic selection.

Effect of rurality and ethnicity in severity and outcomes in patients with acute pancreatitis.

BACKGROUND: Previous studies have demonstrated a high incidence of acute pancreatitis (AP) in New Zealand, with Maori having the highest reported incidence worldwide. It is possible that barriers to healthcare exist for rural and Maori patients, leading to poorer outcomes. The aim of this study is to compare differences in severity and outcomes in patients with AP with regards to rurality and ethnicity. METHODS: Multicentre retrospective study of all adults aged >16 years who were admitted to any hospital with AP in Northland between 1 January 2014 and 31 December 2018 was performed. Pancreatitis severity was classified using the Revised Atlanta classification. The primary outcome of interest was the difference in severity of pancreatitis with regards to rurality and ethnicity. Secondary outcomes of interest included clinical outcomes, aetiology of AP and re-presentation rates. RESULTS: A total of 468 patients were included. There was no difference found between rural and urban or Maori and non-Maori patients with regards to disease severity, length of stay, mortality or intensive care unit admission rate. A significant difference in aetiology was found between Maori and non-Maori patients, with a higher rate of gallstone pancreatitis in Maori. There was no difference in local complications or number of re-presentations between groups. CONCLUSION: This study showed no difference in the severity or outcomes of AP across rural and urban patients in the Northland region of New Zealand. Secondary outcomes were broadly comparable between groups, with a higher rate of gallstone pancreatitis found in Maori compared to non-Maori.

Shared electric scooter injuries admitted to Auckland City Hospital: a comparative review one year after their introduction.

AIM: E-scooters were introduced to New Zealand in 2018 as a means of city transport. Since their introduction, their use has resulted in high injury rates. No studies have directly compared e-scooters to other forms of transport. METHOD: The Auckland City Hospital trauma registry was retrospectively searched for patients admitted with an e-scooter injury. A comparison group of patients admitted with an injury secondary to cycling during the same period was collected. RESULTS: 178 patients were identified: 69 with e-scooter injuries and 109 with injuries sustained while cycling. The hospitalisation rate for e-scooter injuries was 326 hospitalisations per million hours. There was a significant difference found in blood ethanol levels (18.6 vs 6.4% positive, p-value=0.01), mechanism of injury (isolated falls: 87 vs 60.6%), time of injury (55.1 vs 40.4% between 5pm-8am) and protective gear use (worn in 10.1 vs 78.9%). No differences were found in injury severity, ICU admissions, length of stay or mortality. CONCLUSION: This study demonstrates a concerningly high e-scooter-related hospitalisation rate and suggests e-scooters are currently not as safe as cycling. Strategies to improve e-scooter safety are needed and could include zero tolerance for alcohol, mandatory protective gear, restricted operating times and changes in road laws.