Exploring melanoma shifts: a two-decade analysis in New Zealand.

AIMS: New Zealand melanoma incidence rates are amongst the highest in the world. The study aims to provide information on the incidence of cutaneous melanoma in New Zealand from 2000 to 2022. METHODS: De-identified data were extracted from the New Zealand Cancer Registry using the ICD-10 code for malignant melanoma (C34) and melanoma in situ (MIS) (D03) from 2000 to 2022. Statistical analysis was performed to calculate melanoma incidence rates. RESULTS: Invasive melanoma (IM) incidence rates demonstrated an increasing trend from 2000 to 2008 (+1.10 per 100,000 person-years per year), followed by an inflection point at 2008 and then a decreasing trend from 2008 to 2022 (-0.28 per 100,000 person-years per year), which was not statistically different from zero/no change. MIS incidence increased from 30.3 to 72.1 per 100,000 person-years between 2000 and 2022. CONCLUSIONS: The incidence of IM in New Zealand has plateaued in the last decade and was associated with an increase in MIS incidence over the same period. While this trend is encouraging, further research is required to investigate whether there is an actual decline in IM incidence.

Effect of Microdoses of Incisional Antibiotics on the Rate of Surgical Site Infections in Skin Cancer Surgery: A Randomized Clinical Trial.

Importance: Surgical site infections (SSIs) represent a costly and preventable complication of cutaneous surgery. However, there is a paucity of randomized clinical trials investigating antibiotic prophylaxis for reducing SSIs in skin cancer surgery, and evidence-based guidelines are lacking. Incisional antibiotics have been shown to reduce the rate of SSIs before Mohs micrographic surgery, but this represents a small subset of skin cancer surgery. Objective: To determine whether microdosed incisional antibiotics reduce the rate of SSIs before skin cancer surgery. Design, Setting, and Participants: In this double-blind, controlled, parallel-design randomized clinical trial, adult patients presenting to a high-volume skin cancer treatment center in Auckland, New Zealand, for any form of skin cancer surgery over 6 months from February to July 2019 were included. Patient presentations were randomized to one of 3 treatment arms. Data were analyzed from October 2021 to February 2022. Interventions: Patients received an incision site injection of buffered local anesthetic alone (control), buffered local anesthetic with microdosed flucloxacillin (500 µg/mL), or buffered local anesthetic with microdosed clindamycin (500 µg/mL). Main Outcomes and Measures: The primary end point was the rate of postoperative SSI (calculated as number of lesions with SSI per total number of lesions in the group), defined as a standardized postoperative wound infection score of 5 or more. Results: A total of 681 patients (721 total presentations; 1133 total lesions) returned for postoperative assessments and were analyzed. Of these, 413 (60.6%) were male, and the mean (SD) age was 70.4 (14.8) years. Based on treatment received, the proportion of lesions exhibiting a postoperative wound infection score of 5 or greater was 5.7% (22 of 388) in the control arm, 5.3% (17 of 323) in the flucloxacillin arm, and 2.1% (9 of 422) in the clindamycin arm (P = .01 for clindamycin vs control). Findings were similar after adjusting for baseline differences among arms. Compared with lesions in the control arm (31 of 388 [8.0%]), significantly fewer lesions in the clindamycin arm (9 of 422 [2.1%]; P < .001) and flucloxacillin (13 of 323 [4.0%]; P = .03) arms required postoperative systemic antibiotics. Conclusions and Relevance: This study evaluated the use of incisional antibiotics for SSI prophylaxis in general skin cancer surgery and compared the efficacy of flucloxacillin vs clindamycin relative to control in cutaneous surgery. The significant reduction in SSI with locally applied microdosed incisional clindamycin provides robust evidence to inform treatment guidelines in this area, which are currently lacking. Trial Registration: anzctr.org.au Identifier: ACTRN12616000364471.

Operative Autonomy in a Gender-Balanced Cohort of Surgical Trainees.

BACKGROUND: Gender inequity continues to be a major focus of improvements within surgical education. Female trainees are fewer and experience reduced quality of surgical training. Prior studies have demonstrated that surgical autonomy for female trainees in a range of surgical disciplines is less than that of male trainees. As a unique example among Australasian specialty training boards, the New Zealand Board of Plastic and Reconstructive Surgery has boasted a gender-balanced cohort of surgical trainees since 2013. The authors sought to examine the effect of gender on surgical autonomy in a cohort of trainees where gender balance has been achieved. METHODS: A retrospective cohort study was undertaken. Anonymized logbook data for New Zealand plastic surgery trainees were analyzed, for the study period, consisting of rotations from December of 2013 to June of 2020. Self-reported levels of trainee supervision were compared against gender. Outcomes were tested using multivariate analysis. RESULTS: Thirty-eight trainees were included in the study (58% female), with a total of 81,178 cases recorded over the 6.5-year study period. No overall statistically significant difference in surgical autonomy was identified when analyzed by gender. Male and female trainees showed similar trends of increasing surgical autonomy throughout the course of surgical training. CONCLUSIONS: In a cohort of surgical trainees that has reached gender balance, the negative impact of gender on surgical autonomy was not identified. These findings suggest that where women make up an equal proportion of trainees, the implicit gender bias within surgical training may be ameliorated.

The Impact of a Pharmacist-Led Intravenous to Oral Switch of Metronidazole: A Before-and-After Study.

(1) Background. Intravenous (IV) to oral switch (IVOS) of antibiotics can reduce the length of hospitalisation, risk of IV catheter complications, and hospital costs. Pharmacists can play an instrumental role in implementing an IVOS initiative. The aim of this study is to evaluate the impact of pharmacist-led IVOS of metronidazole. (2) Method. This was an observational study conducted in a New Zealand hospital. During a 3-month intervention period, pharmacists identified patients receiving IV metronidazole; then initiated an IVOS for patients who met the criteria. The comparator groups were patients who were not switched by pharmacists in the post-intervention (post-IVOS) group, or patients treated with either IV or oral metronidazole prior to the intervention (pre-IVOS). Primary outcome measures were switch rate and duration of IV metronidazole treatment. Secondary outcome measures were readmission and/or repeat surgery within 90 days of discharge and the length of hospital stay. (3) Results. In total, 203 patients were included: 100 in the pre-IVOS and 103 in the post-IVOS groups. Pharmacists switched 63/93 (67.7%) of eligible patients to oral metronidazole in the post-IVOS period. Only 9/89 (10.1%) of IVOS eligible patients were switched in the pre-IVOS group. In the post-IVOS group, the mean duration of IV metronidazole treatment in patients switched by pharmacists was shorter than in those who were not switched by pharmacists (2.5 ± 2.8 days vs. 4.8 ± 5.9 days, p = 0.012). No significant difference was found in readmission or repeat surgery within 90 days of discharge for patients switched by pharmacists versus patients who were not switched by pharmacists. (4) Conclusion. Our data have demonstrated successful implementation of the hospital-approved pharmacist-led IVOS service.

The utility of hyperspectral imaging in patients with chronic venous disorders.

OBJECTIVE: The underlying pathophysiology of lower limb changes in chronic venous disorders (CVD) may involve alteration in microcirculation and tissue oxygenation. Hyperspectral imaging (HSI) is a noninvasive tool that is used clinically to measure transcutaneous oxygenation in peripheral artery disease and diabetic foot disease. However, there has been little application in venous disease. The aim of this study was to determine if transcutaneous oxygenation in the lower limb, as measured by HSI, changes depending on the clinical component of the Clinical-Etiological-Anatomical-Pathophysiological (CEAP) classification in CVD. METHODS: This was an observational study of patients with CVD recruited from a vascular specialist clinic at a tertiary hospital from January 2020 to January 2021. Participants were allocated to eight groups according to the clinical component of CEAP classification of CVD. Baseline demographic and risk factor information were collected. Transcutaneous oxygenation was measured using HSI at seven sites around the foot and gaiter area in the supine and standing position. Participants rested supine for 15 minutes before the supine measurements and then stood for 15 minutes before the standing measurements. Tissue oxygenation was analyzed over a fixed circular surface area of 79 mm2 at the target location. Calculations of oxyhemoglobin level (artificial unit [AU]), deoxyhemoglobin level (AU), oxygen saturation (%), and temperature (°C) were obtained. The Northern Ethics Committee (18/NTA/78) approved this conduct of the study and participants signed written consent forms. RESULTS: There were 94 participants (164 lower limbs) included in the study. The median age was 59 years and 59 participants (63%) were women. At all sites except the heel, deoxyhemoglobin measurements increased in the standing position compared with the supine position (P < .001). In the gaiter region, there was nearly a doubling in deoxyhemoglobin level at 5 cm above the medial malleolus (supine 43.88 AU vs standing 80.46 AU; P < .001) and 5 cm above the lateral malleolus (supine 46.33 AU vs standing 87.72 AU; P < .001). When measurements were stratified by clinical class of the CEAP classification, there was a greater increase in deoxyhemoglobin levels with increasing clinical class in the standing position (P < .001). This finding was not observed in the supine measurements. CONCLUSIONS: In CVD, HSI shows an increase in deoxyhemoglobin in the standing compared with supine position, particularly in the gaiter region. Furthermore, standing deoxyhemoglobin increases as the CEAP clinical class increases. Thus, this noninvasive tool may respond to venous physiology and may supplement the clinical class of the CEAP classification system.

Age-Adjusted Reference Values for Prostate Specific Antigen - A Systematic Review and Meta-Analysis.

OBJECTIVES: To systematically evaluates the evidence on ethnic differences in age-adjusted reference values of PSA. MATERIALS AND METHODS: In concordance with the Preferred Reporting Items for Systematic Review and Meta-analysis statement, a review of English articles using Medline, Embase and Cochrane databases, from inception to December 2019 was conducted. Studies that reported the PSA upper reference value as 95th percentile of the cohort distribution, in healthy men aged 40 to 79, were included. Methodological quality was assessed with a modified version of the Agency for Healthcare Research and Quality checklist for cross-sectional studies. RESULTS: Forty-three studies examining 325,514 participants were included in the analysis. These were published between 1993 and 2018. Majority were prospective observational studies and reported the reference values in ten-year age intervals. Only five reports directly compared ethnic differences in PSA values. Due to missing data, six studies were not considered in the quantitative synthesis. For the remainder (37/43), heterogeneity in PSA reference values was considerable (Higgin's index = 99.2%), with age and ethnicity being the sole identified significant contributors. Accordingly, the pooled upper limits for PSA reference values were 2.1, 3.2, 4.9 and 6.5 ng/ml for men in their 40 s, 50 s, 60 s, and 70 s, respectively. CONCLUSION: Moderate quality evidence suggest that upper PSA reference limits increased with age and significant ethnic differences were present.

Morbidity following thyroid and parathyroid surgery: Results from key performance indicator assessment at a high-volume centre in New Zealand.

BACKGROUND: Complications following thyroid/parathyroid surgery include recurrent laryngeal nerve (RLN) injury, hypocalcaemia and return to theatre for haematoma evacuation. Rates of these form the basis of key performance indicators (KPI). An endocrine database, containing results from 1997, was established at the North Shore Hospital in Auckland, New Zealand. We aimed to measure complication rates by procedure (thyroid and parathyroid), explore a temporal change in our unit and compare our results against international literature. METHODS: A retrospective review of the database between July 1997 and February 2020 was performed. The results for each KPI were analysed in total and over consecutive time periods. A review of the literature was carried out to find international complication rates for comparison. A cumulative sum (CUSUM) analysis was performed to give visual feedback on performance. RESULTS: There were 1062 thyroidectomies and 336 parathyroidectomies from July 1997 to February 2020. Thyroid surgery results found rates of temporary/permanent RLN injury of 1.9%/0.3%, temporary/permanent hypocalcaemia of 22.3/2.5%, and return to theatre for haematoma evacuation of 1.1%. Parathyroid surgery results were, temporary RLN injury of 0.8% (no permanent injury), temporary/permanent hypocalcaemia of 1.7%/0.4%, and return to theatre for haematoma evacuation of 0.3%. CUSUM analysis found KPI results to be comparable with international literature. CONCLUSION: Our unit's KPI results are comparable to published results in the literature. The use of this clinical database will help in future monitoring of performance and help drive improvement in the service. Embedding prospective data collection as routine practice allows for continuous improvement for the unit.

Primary medication non-adherence to analgesics and antibiotics at Counties Manukau Health Emergency Department.

AIM: To measure primary medication non-adherence to antibiotics, paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) in patients discharged from Counties Manukau Health Emergency Department (CMH-ED). METHOD: A retrospective observational study based on 1,600 discharged patients' data collected between 28 April-6 May and 28 July-9 August 2014. Data were included for patients who were residents within the Auckland Regional Public Health Service boundaries, presented to CMH-ED and were discharged with a prescription. RESULTS: Of 992 patients, 48.5% did not have at least one medication on their discharge prescription filled. Patients were mostly born in New Zealand (66.5%), of Pacific Island descent (42.8%), living in the most socioeconomically deprived areas (78.1%) and under 10 years of age (32.6%). Filling rates significantly increased with >1 prescribed item (p≤0.01). NSAIDs were significantly more likely to be filled compared with paracetamol (59.9% vs 51.3%, p=0.034); antibiotics were significantly more likely to be filled than all other medicines (80.4%, p<0.001). The most significant predictors for non-adherence when accounting for number and types of medications were patients 10-44 years (p<0.05) and smokers (p<0.01). CONCLUSIONS: Age, smoking and number of prescribed medications were predictors of non-adherence to medication type. Further research is warranted to assess whether changes to prescription co-payments affect the rate of nonadherence.

Clinical factors associated with successful embolization of lower gastrointestinal bleeding.

AIM: To develop a model of clinical factors that may predict: (1) technically and clinically successful embolization of a bleeding vessel at digital subtraction angiography (DSA) for lower gastrointestinal bleed (LGIB); (2) a negative DSA in the presence of positive CT-mesenteric angiography (CTMA) for LGIB. METHODS: A retrospective cohort study of all DSAs conducted with intent for embolization for acute LGIB over a 10-year period was undertaken. Pre-procedural and intra-procedural clinical variables were evaluated using uni- and multi-variate analysis. RESULTS: One hundred and twenty-three DSAs were evaluated. Technical success was 81% and clinical success 78% where DSA was positive. Technical success was associated with super-selective approach, contrast extravasation on CT, haemoglobin drop, anatomical source and time from CT to DSA on univariate analysis. On multivariate analysis, time from CT to DSA was significant with a higher success probability within 120 min with different factors being salient depending on degree of delay. Clinical success was only associated with activated partial thromboplastin time (<27.5 s). A negative DSA was associated with anatomical source, haemodynamic stability, platelet count and time from CT to DSA on univariate analysis. The latter three remained so on multivariate analysis. CONCLUSION: A triaging approach to utilizing emergency DSA may be helpful. If prolonged delay between CT and DSA is anticipated, with haemodynamic stability and a near-normal platelet count, the DSA may not be fruitful. Technical success may be more likely if DSA occurs within 120 min. Clinical success may be more likely if activated partial thromboplastin time is within normal range.

Differences in sphere-forming cells from keratoconic and normal corneal tissue: Implications for keratoconus pathogenesis.

Keratoconus is primarily an anterior corneal disorder of unclear aetiology. Stem cells may play a role in the perpetuation of keratoconus, although this has yet to be definitively established. Sphere-forming cells from normal human donor corneas have previously been shown to be a heterogenous mix of epithelial, stromal, stem and progenitor cell components which have potential for treatment of corneal dystrophies. Our work set out to isolate and characterise sphere-forming cells from human keratoconic tissue. Keratoconic donor corneas were successfully used to culture sphere-forming cells in vitro. Time lapse imaging of these spheres on a collagen surface over 8 days revealed keratoconic spheres lack the ability to maintain a central core and have diminished ability to repopulate the surface. Immunocytochemistry showed positive labelling for the stem cell marker 'Adenosine triphosphate-binding cassette sub-family B member 5 (ABCB5)' indicating stem cell retention and the myofibroblast marker alpha smooth muscle actin indicating wound repair while droplet digital Polymerase Chain Reaction confirmed an increase in expression of stem and stromal cell markers in keratoconic spheres compared to spheres cultured from normal donors at day 7 post-placement. Keratoconic sphere-forming cells showed a diminished repopulation ability, a faster wound healing response and lack of central core retention. These results suggest stem cells in keratoconus may be in an elevated state of wound repair and unable to respond appropriately to further injury in corneal maintenance. Sphere forming cell populations in keratoconus appear to be different to those isolated from normal corneas and this may be an important consideration in unearthing keratoconus aetiology.

Assessment of Autonomy in Operative Procedures Among Female and Male New Zealand General Surgery Trainees.

Importance: The need for trainee sex equality within surgical training has resulted in an appraisal of the training experience in the New Zealand general surgery training program. Objective: To investigate the association between trainee sex and surgical autonomy in the operating room in the New Zealand general surgery training program. Design, Setting, and Participants: Retrospective cohort study conducted from December 10, 2012, to December 10, 2017, examining all endoscopic, major, and minor procedures performed by all New Zealand general surgery trainees in every training hospital in New Zealand. Main Outcomes and Measures: The primary outcome was the level of meaningful autonomy by each New Zealand general surgery trainee (ie, trainee as primary operator without the surgeon mentor scrubbed for the case). Outcomes were compared using multivariable analysis. Results: This study included 120 New Zealand general surgery trainees (42 women [35%] and 78 men [65%]) who were analyzed over 279.5 trainee-years (88.5 trainee-years for women and 191.0 trainee-years for men). Included were 119 380 general surgery procedures (17 465 endoscopic, 56 964 major, and 44 951 minor) in 18 hospitals. By the end of the 5-year training program, female trainees had a lower cumulative mean autonomous caseload than male trainees for endoscopic (284.0 [95% CI, 207.0-361.0] vs 352.2 [95% CI, 282.9-421.6], P = .03), major (139.9 [95% CI, 76.7-203.2] vs 198.1 [95% CI, 142.3-254.0], P = .02), and minor (456.3 [95% CI, 394.8-517.9] vs 519.9 [95% CI, 465.6-574.2], P = .007) procedures. Conclusions and Relevance: After accounting for differences among trainees, hospital type, number of female and male surgeon mentors at each hospital, and trainee seniority, female trainees performed fewer cases with meaningful autonomy compared with male trainees. These findings support the need for pragmatic solutions to address this bias and further investigations on mechanisms contributing to discrepancies.

Primary medication non-adherence at Counties Manukau Health Emergency Department (CMH-ED), New Zealand: an observational study.

OBJECTIVES: To measure primary medication non-adherence (failure to fill prescription medicines) in patients discharged from the emergency department (ED), and to determine whether sociodemographic factors, smoking status and access to a general practitioner affect prescription filling. Little is known about primary medication non-adherence in EDs, and less so in New Zealand (NZ). Identifying reasons for non-adherence will enable development of strategies to improve adherence and reduce morbimortality. DESIGN AND SETTING: An observational study based on patient data from the ED of a large public hospital in South Auckland, NZ. PARTICIPANTS: Data were collected from 1600 patients discharged between 28 April-6 May and 28 July-9 August 2014. Data were included if patients were residents within the Auckland Regional Public Health Service boundaries, admitted to ED and discharged with a prescription. Data were excluded if patients were admitted to another ward, transferred to another hospital or left the ED without seeing a doctor. RESULTS: 992 patients were included in the study, the majority were under 10 years (32.6%), of Pacific Island descent (42.8%), NZ-born (67.7%) and living in the most socioeconomically deprived areas (78.1%). Almost 50% of patients failed to fill all prescription medications. Simple linear regression analysis indicated that non-adherence was significant for those 10-24 years (n=236; adherence=47.2%; p<0.05), of NZ Maori ethnicity (n=175; 51.3%; p=0.01), unemployed (n=77; 46.8%; p<0.01), homemakers (n=66; 45.7%; p<0.01), students (n=228; 55.6%; p<0.05) and cigarette smokers (n=139; 50.3%; p<0.01). Following multivariable analysis, the strongest predictors for non-adherence were those aged between 10 and 17 years (n=116; p<0.01), the unemployed (n=77; p=0.01) and homemakers (n=66; p=0.01). CONCLUSIONS: Age and occupation were the greater predictors of non-adherence; however, no other significant differences were found. Since this study, changes to prescription co-payments have been made. Further research is warranted to assess whether this change has more recently affected the rates of non-adherence.

The epidemiology of patients undergoing meningioma resection in Auckland, New Zealand, 2002 to 2011.

The incidence of meningioma is known to vary by gender and ethnicity. This study aimed to describe the epidemiological characteristics of a 10-year cohort of patients undergoing meningioma resection at Auckland City Hospital, Auckland, New Zealand. Of particular interest was whether there was any difference in meningioma incidence and recurrence rates between New Zealand Maori and Pacific Island patients compared with other ethnic groups. The study was a retrospective analysis of 493 patients with pathologically confirmed meningioma over the period 1 January 2002 to 31 December 2011. Based on this neurosurgical cohort, the minimum incidence of meningioma in the Auckland region was 3.39 per 100,000 population per year (95% C.I. 3.02-3.80) for the study period. Meningioma was significantly more common in women than men by a ratio of 4.2:1. New Zealand Maori and Pacific Island patients had a significantly higher incidence of meningioma than other ethnic groups. New Zealand Maori had a meningioma incidence 2.74 times that of Europeans (95% C.I. 2.01-3.73, p < 0.001). Pacific Island patients had 2.03 times higher incidence of meningioma than Europeans (95% C.I. 1.42 - 2.89, p < 0.001). The overall meningioma recurrence rate was 21.6% with a mean follow-up of 77 months. Recurrence rates for meningioma among Pacific Island patients were significantly higher than for other ethnic groups (hazard ratio 1.73, p = 0.008). Multivariate analysis of clinical variables confirmed the significance of traditional prognostic factors such as WHO tumour grade and Simpson grade of surgical excision in predicting meningioma recurrence.

Multidisciplinary clinics reduce treatment costs and improve patient outcomes in diabetic foot disease.

OBJECTIVE: Diabetic foot disease poses a significant and rising financial burden on health care systems worldwide. This study investigated the effect of a new multidisciplinary diabetic foot clinic (MDDFC) in a large tertiary hospital on patient outcomes and treatment cost. METHODS: Patients' records were retrospectively reviewed to identify all patients who had been managed in a new MDDFC between July 2014 and July 2017. The wound episode-the period from initial presentation to the achievement of a final wound outcome-was identified, and all relevant inpatient and outpatient costs were extracted using a fully absorbed activity-based costing methodology. Risk factor, treatment, outcome, and costing data for this cohort were compared with a group of patients with diabetic foot wounds who had been managed in the same hospital before the advent of the MDDFC using a generalized linear mixed model. RESULTS: The MDDFC and pre-MDDFC cohorts included 73 patients with 80 wound episodes and 225 patients with 265 wound episodes, respectively. Compared with the pre-MDDFC cohort, the MDDFC group had fewer inpatient admissions (1.56 vs 2.64; P ≤ .001). MDDFC patients had a lower major amputation rate (3.8% vs 27.5%; P ≤ .001), a lower mortality rate (7.5% vs 19.2%; P ≤ .05), and a higher rate of minor amputation (53.8% vs 31.7%; P ≤ .01). No statistically significant difference was noted in the rate of excisional débridement, skin graft, and open or endovascular revascularization. In the MDDFC cohort, the median total cost, inpatient cost, and outpatient cost per wound episode was New Zealand dollars (NZD) 22,407.465 (U.S. dollars [USD] 17,253.74), NZD 21,638.93 (USD 16,661.97), and NZD 691.915 (USD 532.77), respectively. The MDDFC to pre-MDDFC wound episode total cost ratio was 0.7586 (P < .001). CONCLUSIONS: This study is the first to compare the cost and treatment outcomes of diabetic foot patients treated in a large tertiary hospital before and after the introduction of an MDDFC. The results show that an MDDFC improves patient outcomes and reduces the cost of treatment. MDDFCs should be adopted as the standard of care for diabetic foot patients.