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.

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.

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.

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.

Impact of rurality and ethnicity on complexity of acute diverticulitis in Northland, New Zealand.

BACKGROUND: Acute diverticulitis is a common general surgical condition associated with significant costs and healthcare burden. It is unknown if rurality represents a barrier to healthcare and whether ethnic disparities exist in Northland, New Zealand. This study, therefore, aims to assess the impact of rurality and ethnicity on complexity, management, and outcomes in patients with acute diverticulitis. METHODS: A retrospective observational study of all adults aged >18 years admitted with acute diverticulitis to any Northland District Health Board hospital between 1 January 2015 and 31 December 2019 was performed. Diverticulitis complexity was assessed using the modified Hinchey classification. The primary outcome was the effect of rurality and ethnicity on complexity of diverticulitis. Multivariable logistic regression was performed. RESULTS: A total of 397 patients (mean age 60.3 years (standard deviation (SD) 13.8); 48.7% female) were included. Overall, 134 patients had complicated diverticulitis. Rurality nor distance from the hospital were not associated with complexity of diverticulitis or clinical outcomes (p > 0.05). Maori patients presented younger than non-Maori (mean 51 vs. 63 years, p < 0.001) but there was no difference in complications, management, or clinical outcomes (p > 0.05). On multivariable analysis, rurality status and Maori ethnicity were not associated with more complicated diverticulitis. CONCLUSION: This study found that rurality and ethnicity were not significant predictors of the complexity of diverticulitis.