Portable System for In-Clinic Differentiation of Skin Cancers from Benign Skin Lesions and Inflammatory Dermatoses.

The exquisite sensitivity of Raman spectroscopy for detecting biomolecular changes in skin cancer has previously been explored; however, this mostly required analysis of excised tissue samples using bulky, immobile laboratory instrumentation. In this study, the technique was translated for clinical use with a portable Raman system and customized fiber optic probe and applied to differentiation of skin cancers from benign lesions and inflammatory dermatoses. The aim was to provide an easy-to-use, easy-to-manage assessment tool for clinicians to use in their daily patient examination routine to perform rapid Raman measurements of skin lesions in vivo. Using this system, >867 spectra were measured in vivo from 330 patients with a wide variety of different benign skin lesions (n = 603), inflammatory dermatoses (n = 140), and skin cancers (n = 124). Ethnicities represented were 70% European; 16% Asian; 6% Maori; 5% Pacific people; and 4% Middle East, Latin American, and African. Accurate differentiation of skin cancers from benign lesions and inflammatory dermatoses was achieved using partial least squares discriminant analysis, with area under curve for the receiver operator curves for external validation sets ranging from 0.916 to 0.958. This study shows evidence for robust clinical translation of Raman spectroscopy for rapid, accurate diagnosis of skin cancer.

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.

Rapid culture of human keratinocytes in an autologous, feeder-free system with a novel growth medium.

BACKGROUND AIMS: The ability to culture human keratinocytes is beneficial in the treatment of skin injury and disease, as well as for testing chemicals in vitro as a substitute for animal testing. RESULTS: We have identified a novel culture medium for the rapid growth of keratinocytes from human skin. "Kelch's medium" supports keratinocyte growth that is as rapid as in the classical Rheinwald and Green method, but without the need for cholera toxin or xenogeneic feeder cells. It enables keratinocytes to out-compete co-cultured autologous fibroblasts so that separation of the epidermis from the dermis is no longer required before keratinocyte culture. Enzymatic digests of whole human skin can therefore be used to generate parallel cultures of autologous keratinocytes, fibroblasts and melanocytes simply by using different cell culture media. CONCLUSIONS: This new keratinocyte medium and the simplified manufacturing procedures it enables are likely to be beneficial in skin engineering, especially for clinical applications.

Indigenous early career researchers: creating pearls in the academy.

This paper provides a snapshot of Indigenous Early Career Researchers in Australia derived from demographic information collected in the first stage of the 'Developing Indigenous Early Career Researchers' project. Analysis of the data to date has evidenced much diversity across this cohort. However, one commonality across all Indigenous Early Career Researchers was a commitment to the value and validity of Indigenous Ways of Knowing in the higher education sector. With the use of Tribal Critical Race Theory this paper explores the ways in which Indigenous Early Career Researchers disrupt Western-based academies and schools of thought and proposes that Indigenous Early Carer Researchers grow 'pearls' of experience and knowledge within the higher education sector that are essential to the development of a richer academy and stronger Indigenous communities.

Impact of local anesthesia block on pain medication use and length of hospital stay in elderly indigenous patients in Alaska hospitalized for fragility fracture.

Introduction: Fragility fractures (low-energy, minimal-trauma fractures) are common in the aging population and can lead to decreased function, increased mortality, and long-lasting pain. Although opioids are helpful in reducing acute postoperative pain, they present risks that may lead to increased morbidity and mortality. Materials and Methods: This was a retrospective review of medical records of all Alaska Native and American Indian people older than 50 years, who received surgery for hip fracture repair between January 2018 and June 2019 (n = 128). Results: We found that receipt of a peripheral nerve block (PNB) is a predictor for decreased length of hospital stay. However, receipt of PNB did not predict a reduction in postoperative morphine milligram equivalents opioid doses. Discussion: Further study is required to determine whether one PNB method is superior to others based on individual-level characteristics.

Raising an Indigenous academic community: a strength-based approach to Indigenous early career mentoring in higher education.

This paper reports on Indigenous early career researchers' experiences of mentoring in Australian higher education, with data drawn from a longitudinal qualitative study. Interviews were conducted with 30 Indigenous participants. A consistent theme in the findings and contemporary critical literature has been a reaction against institutionalised and hierarchical cloning and investment models of mentoring that reinforce the accumulation of White cultural capital, in favour of strength-based relational models tailored to build Indigenous cultural wealth in parallel with career development. We write from an equity-based standpoint addressing mentoring as a complex and raced space where individual Indigenous ECRs articulate a desire and will to develop a successful and meaningful career, rich in cultural wealth and with their identity intact. It is our intent that these findings will also have global significance and support the more sustainable and ethical career development of First Nation early career academics in relationally like colonised contexts.

Have Factors Influencing Female Medical Students' Intention to Pursue a Career in Surgery Changed over the Last 10 Years? A Systematic Review.

In 2012, a systematic review reported on factors influencing female medical students, career intentions for surgery. This current review is a direct follow-up of that article with the aim of assessing whether factors affecting female medical student career choices have changed over the last decade. This review has identified access to research opportunities as a new factor that can be used to promote female medical student and trainee interest in surgery. Other factors have largely remained unchanged over the last 10 years, such as lack of access to leave, part-time work, and same-gender role models.

Niosomal Nanocarriers for Enhanced Dermal Delivery of Epigallocatechin Gallate for Protection against Oxidative Stress of the Skin.

Among green tea catechins, epigallocatechin gallate (EGCG) is the most abundant and has the highest biological activities. This study aims to develop and statistically optimise an EGCG-loaded niosomal system to overcome the cutaneous barriers and provide an antioxidant effect. EGCG-niosomes were prepared by thin film hydration method and statistically optimised. The niosomes were characterised for size, zeta potential, morphology and entrapment efficiency. Ex vivo permeation and deposition studies were conducted using full-thickness human skin. Cell viability, lipid peroxidation, antioxidant enzyme activities after UVA-irradiation and cellular uptake were determined. The optimised niosomes were spherical and had a relatively uniform size of 235.4 ± 15.64 nm, with a zeta potential of -45.2 ± 0.03 mV and an EE of 53.05 ± 4.46%. The niosomes effectively prolonged drug release and demonstrated much greater skin penetration and deposition than free EGCG. They also increased cell survival after UVA-irradiation, reduced lipid peroxidation, and increased the antioxidant enzymes' activities in human dermal fibroblasts (Fbs) compared to free EGCG. Finally, the uptake of niosomes was via energy-dependent endocytosis. The optimised niosomes have the potential to be used as a dermal carrier for antioxidants and other therapeutic compounds in the pharmaceutical and cosmetic industries.

Volcanic disruption: the impact of Whakaari White Island on the provision of elective surgical care in Counties Manukau.

INTRODUCTION: On 9 December 2019, Whakaari White Island erupted while 47 people were on the island. Thirty-one people were subsequently hospitalized. Fourteen volcanic burn victims were managed at the National Burns Centre at Middlemore Hospital. Between December 2019 and March 2020 these patients required 124 procedures in theatre, using 23 709 operative minutes. Elective surgical lists were cancelled to fulfil this demand for acute operating theatre time and theatre staff. OBJECTIVES: To quantify the elective surgical resource lost in the aftermath of the Whakaari White Island eruption by surgical specialty. METHODS: A data set listing all surgical procedures undertaken within Counties Manukau District Health Board during the period 1 December 2019-1 March 2020 and the corresponding months from the preceding 3 years was analysed. Sum operating time and procedures post-Whakaari were compared with the average of the prior 3 years to quantify loss in resource. RESULTS: In the 3 months post-Whakaari, 698 fewer elective operations were completed across all surgical specialties than the average of the previous 3 years, a decrease of 26.3%. All major surgical specialties except urology showed an absolute decrease in elective procedures completed. The most significant decrease was the 59.1% (533 procedures) loss in plastic surgery elective procedures, with no sign of recovery by March 2021. CONCLUSIONS: The plastic surgery department was the worst affected by the Whakaari disaster. Overall elective surgical delivery within Counties Manukau was substantially impacted, and would not yet recover by the time of the national COVID-19 lockdown in March 2020.

Burn Lessons Learned From the Whakaari White Island Volcanic Eruption.

New Zealand's most active volcano, Whakaari White Island was a common tourist attraction prior to its eruption on December 9, 2019. At the time of the eruption, there were 47 people on the island from 3 tour groups. Thirty-nine people survived the initial eruption and were extracted. Thirty-one entered into the New Zealand National Burn Service across four hospitals. The median age of the patients treated at the National Burn Centre was 45.5 years (range: 14-67 years) and median TBSA burn was 49.5% (range: 9%-90%). The 3-month survival of this eruptive event was 55%, which subsequently fell to an overall rate of 53% following one late death of an early survivor after repatriation home. Of the patients who survived the initial eruption for long enough to be admitted to the National Burn Service, the overall survival rate was 71% at 3 months. We describe 12 lessons we have learnt from our management of the survivors. The key surgical lessons among these are: 1) The injuring mechanism combined ballistic trauma, thermal and acidic burn components, with the acid component being the most problematic and urgent for management; 2) Volcanic ash burns result in ongoing burn depth progression, deep underlying tissue damage and significant metabolic instability; 3) Early skin grafting was not successful in many cases; 4) Reconstructive strategy needed adjusting to cope with the high operative demand and limited donor sites in all patients; 5) Protect yourself from potential dangers with additional personal protective equipment in an unfamiliar setting.

Thoracic manifestations of inhalational injury caused by the Whakaari/White Island eruption.

INTRODUCTION: Thoracic imaging of people who have survived exposure to a volcanic pyroclastic flow has not been described. In December 2019, an active volcano in New Zealand erupted with loss of life and severe burns to groups of people who were within one kilometre of a new fissure. Our aim was to describe the range of pulmonary abnormality in patients admitted to the Burns unit at Middlemore Hospital. METHODS: We describe the initial radiographic and computed tomography (CT) appearance of lung injuries in 14 people close to this fissure who were transported to our national burns centre in Middlemore hospital. We compared these appearances with bronchoscopy findings and A-a gradients as a measure of oxygen utilisation. RESULTS: All patients had chest radiographs and eight had CT scans within two days after admission. Nine had bronchoscopies within the first week. Two were repatriated to Australia, one of whom did not survive. Two died within 3 days after admission, and the remaining ten patients survived the first week. Eight patients required ongoing ventilation, seven of whom had abnormal CXRs or CT scans on admission. Two of these patients developed an ARDS pattern of oedema reflecting lung injury from the toxic surge but they recovered. In the five patients who survived the first week with relatively minor evidence of lung injury, bibasal atelectasis was the most common finding. CONCLUSION: Pyroclastic flow effect caused a variety of lung abnormalities most likely due to toxic gas emissions. Upper airway burns were seen at bronchoscopy in only 5 patients. An ARDS response in the lungs of two patients improved within three months.

Comparison of Predictive Model of Care Requirements for Burn Patients With Operative Requirements Following Volcanic Burns.

On December 9, 2019, Whakaari/White Island volcano in New Zealand erupted with 47 people on the island. Thirty-one people survived long enough to enter the New Zealand National Burn network-13 were repatriated to Australia within 72 hours and 14 of the remaining 18 were treated at the National Burn Center at Middlemore Hospital in Auckland. Our department has previously published a model to calculate the total operative requirements for any given burn surface area for the first 4 weeks of burn treatment. From this model, we calculated the predicted surgical time and operative visit requirements for each patient and compared this to their actual requirements. Actual requirements were also recorded beyond 4 weeks until discharge. Results show that the average variance for operative minutes was significantly above predicted with both the full-thickness burn model (average variance 3.24) and the electrical burn model (average variance 2.65). There was a wide range in both cases (0.54-6.17 and 0.44-5.06, respectively). There was less variance from predicted values of operative visits required than operative minutes (mean: 1.58; range 0.9-3.02). Overall, the values for patients with smaller burns showed the greatest variability from predictions with regard to the total number of operative visits during the first 4 weeks of care. Additionally, patients with burn size greater than 50% TBSA required significant theater access beyond 4 weeks. Analysis of these findings will assist with future planning in both disaster and non-disaster settings in the provision of burn care.

Non-ionic surfactant vesicles as a carrier system for dermal delivery of (+)-Catechin and their antioxidant effects.

Numerous skin disorders and diseases are related to oxidative stress. The application of an antioxidant, serving as a strong defense agent against oxidation, is of great interest in dermatology yet remains challenging for delivery. This paper aimed to develop a niosome carrier system to deliver the antioxidant (+) Catechin into the skin. (+) Catechin-loaded niosomes were prepared using film hydration technique and the physicochemical properties of drug-loaded niosomes were characterised and investigated by a series of in vitro and ex vivo studies. The optimised formulation displayed an acceptable size in nanoscale (204 nm), high drug entrapment efficiency (49%) and amorphous state of drug in niosomes. It was found that (+) Catechin-loaded niosomes could effectively prolong the drug release. Drug deposition in the viable layers of human skin was significantly enhanced when niosomal carriers were applied (p < 0.05). Compared to the pure drug, the niosomal formulation had a greater protective effect on the human skin fibroblasts (Fbs). This is consistent with the observation of internalisation of niosomes by Fbs which was concentration-, time- and temperature-dependent, via an energy-dependent process of endocytosis. The research highlighted that niosomes are potential topical carriers for dermal delivery of antioxidants in skin-care and pharmaceutical products.

Is Surgical Site Infection (SSI) after skin surgery affected by home municipal versus non-municipal water supply?

PURPOSE: SSI represent one of the most common sources of morbidity and escalated healthcare costs in skin cancer management. It has been shown that exposing wounds to treated water does not increase SSIs, however a large proportion of Australasian patients reside in rural areas dependant on roof or bore collected water for their primary water supply, and no data exist regarding the association between tank water supply and SSI following skin surgery. METHODOLOGY: A nine-month retrospective analysis of patients undergoing skin cancer surgery at the Auckland Regional Plastic Surgery Unit was performed. Wounds assessed using a validated wound infection scoring system. Rates of SSI analysed against various clinical factors (water supply, smoking status, immunocompromise, glucose intolerance) and surgical factors (type of reconstruction, ulceration, lesion site, surface area of lesion). RESULTS: 857 lesions were excised from 357 patients over the period studied. 718 lesions (83.7%) had municipal and 139 lesions (16.3%) had non-municipal water as their primary supply. Overall rate of clinically significant SSI was 15.6%, with no difference between municipal and non-municipal water groups (15.6% vs. 15.8% P = 0.946). Further subgroup analysis did not reveal any difference in rate of SSI based on type of surgical closure (direct closure, skin graft vs. flap). CONCLUSION: Non-municipal water supply was not associated with change in SSI relative to home municipal water supply in patients receiving skin cancer surgery. Our data supplements existing literature that water exposure does not influence SSI following skin surgery irrespective of primary home water supply.

Ethnic variability in post-mastectomy breast reconstruction in Counties Manukau District Health Board in 2017: a retrospective review.

BACKGROUND: Post-mastectomy breast reconstruction (PMBR) is associated with greater quality of life and psychological well-being. However, rates of PMBR may not be equivalent across all ethnicities which contributes to disparities in health outcomes. METHODS: A retrospective review of patients diagnosed with breast cancer between 1 January and 31 December 2017 at Counties Manukau District Health Board (CMDHB) was performed. Data regarding patient demographics, cancer stage, breast cancer treatment and whether reconstruction took place were collected. These data were analysed to assess the rates of reconstruction by ethnic group. RESULTS: A total of 365 patients were diagnosed with cancer in CMDHB breast cancer clinic in 2017. Of these, 177 were treated with mastectomy and 26 (15%) of these patients received PMBR. Thirty-four percent of patients receiving mastectomy were of Maori or Pasifika ethnicity. Of these patients, one-third met the eligibility criteria for PMBR at CMDHB, having body mass index <35 and being non-smokers. Maori women represented only 4% of the PMBR performed at CMDHB in 2017. European women comprised 50% of all mastectomies but received 77% of all PMBR. There was a significant difference in eligibility between the different ethnic groups for PMBR, due to higher body mass index and higher rates of smoking in Maori and Pasifika patients. CONCLUSION: Eligibility rates for post-mastectomy reconstruction are significantly lower (P < 0.05) in Maori and Pasifika women when compared with European and Asian populations. Strategies to address smoking and obesity may help increase rates of PMBR in Maori and Pasifika women.

Equity of access to post-mastectomy breast reconstruction at a regional plastic surgery centre.

BACKGROUND: The Plastic and Reconstructive Surgery Department at the Counties Manukau District Health Board provides tertiary-level access to post-mastectomy breast reconstruction for all women in the northern region of New Zealand. Access to breast reconstruction is not always equitable. We aim to assess equity of access to breast reconstruction in this department. METHODS: A retrospective review of all women referred to this service for immediate and delayed post-mastectomy breast reconstruction between January 2013 and June 2018 was performed. Demographic information and progression to reconstruction were assessed in comparison to expected population figures available from health statistics. RESULTS: A total of 882 women were referred for breast reconstruction during this period. Significant discrepancies in ethnicity and geographical location were found between expected population proportions and the women referred for reconstruction. European women were more likely to be referred for, and receive, reconstruction. Maori women were proportionally represented in the cohort, whereas Asian and Pacific women were under-represented (P = 0.0016). Within the referral cohort, Maori and Asian women were less likely to proceed to reconstruction following first specialist assessment than European women (P = 0.0015 and 0.0193, respectively). Proportionally fewer referrals for reconstruction were received from health services further away from the treatment centre than were received from closer health services. CONCLUSION: There is inequity in the rates of tertiary referral for breast reconstruction across ethnicities and geographical location in the northern region of New Zealand. Strategies to identify potential barriers such as access to transport may improve equity of access to breast reconstruction.

New Syrphidae (Diptera) of North-eastern North America.

BACKGROUND: This paper describes 11 of 18 new species recognised in the recent book, "Field Guide to the Flower Flies of Northeastern North America". Four species are omitted as they need to be described in the context of a revision (three Cheilosia and a Palpada species) and three other species (one Neoascia and two Xylota) will be described by F. Christian Thompson in a planned publication. Six of the new species have been recognised for decades and were treated by J. Richard Vockeroth in unpublished notes or by Thompson in his unpublished but widely distributed "A conspectus of the flower flies (Diptera: Syrphidae) of the Nearctic Region". Five of the 11 species were discovered during the preparation of the Field Guide. Eight of the 11 have DNA barcodes available that support the morphology. NEW INFORMATION: New species treated in this paper include: Anasimyia diffusa Locke, Skevington and Vockeroth (Smooth-legged Swamp Fly), Anasimyia matutina Locke, Skevington and Vockeroth (Small-spotted Swamp Fly), Brachyopa caesariata Moran and Skevington (Plain-winged Sapeater), Brachyopa cummingi Moran and Skevington (Somber Sapeater), Hammerschmidtia sedmani Vockeroth, Moran and Skevington (Pale-bristled Logsitter), Microdon (Microdon) scauros Skevington and Locke (Big-footed Ant Fly), Mixogaster fattigi Locke, Skevington and Greene (Fattig's Ant Fly), Neoascia guttata Skevington and Moran (Spotted Fen Fly), Orthonevra feei Moran and Skevington (Fee's Mucksucker), Psilota klymkoi Locke, Young and Skevington (Black Haireye) and Trichopsomyia litoralis Vockeroth and Young (Coastal Psyllid-killer). Common names follow the "Field Guide to the Flower Flies of Northeastern North America" (Skevington et al. 2019).

Recent advances in non-ionic surfactant vesicles (niosomes): Fabrication, characterization, pharmaceutical and cosmetic applications.

Development of nanocarriers for drug delivery has received considerable attention due to their potential in achieving targeted delivery to the diseased site while sparing the surrounding healthy tissue. Safe and efficient drug delivery has always been a challenge in medicine. During the last decade, a large amount of interest has been drawn on the fabrication of surfactant-based vesicles to improve drug delivery. Niosomes are self-assembled vesicular nano-carriers formed by hydration of non-ionic surfactant, cholesterol or other amphiphilic molecules that serve as a versatile drug delivery system with a variety of applications ranging from dermal delivery to brain-targeted delivery. A large number of research articles have been published reporting their fabrication methods and applications in pharmaceutical and cosmetic fields. Niosomes have the same advantages as liposomes, such as the ability to incorporate both hydrophilic and lipophilic compounds. Besides, niosomes can be fabricated with simple methods, require less production cost and are stable over an extended period, thus overcoming the major drawbacks of liposomes. This review provides a comprehensive summary of niosomal research to date, it provides a detailed overview of the formulation components, types of niosomes, effects of components on the formation of niosomes, fabrication and purification methods, physical characterization techniques of niosomes, recent applications in pharmaceutical field such as in oral, ocular, topical, pulmonary, parental and transmucosal drug delivery, and cosmetic applications. Finally, limitations and the future outlook for this delivery system have also been discussed.

The Epidemiology of Breast Implant-Associated Anaplastic Large Cell Lymphoma in Australia and New Zealand Confirms the Highest Risk for Grade 4 Surface Breast Implants.

BACKGROUND: The epidemiology and implant-specific risk for breast implant-associated (BIA) anaplastic large cell lymphoma (ALCL) has been previously reported for Australia and New Zealand. The authors now present updated data and risk assessment since their last report. METHODS: New cases in Australia and New Zealand were identified and analyzed. Updated sales data from three leading breast implant manufacturers (i.e., Mentor, Allergan, and Silimed) were secured to estimate implant-specific risk. RESULTS: A total of 26 new cases of BIA-ALCL were diagnosed between January of 2017 and April of 2018, increasing the total number of confirmed cases in Australia and New Zealand to 81. This represents a 47 percent increase in the number of reported cases over this period. The mean age and time to development remain unchanged. The implant-specific risk has increased for Silimed polyurethane (23.4 times higher) compared with Biocell, which has remained relatively static (16.5 times higher) compared with Siltex implants. CONCLUSIONS: The number of confirmed cases of BIA-ALCL in Australia and New Zealand continues to rise. The implant-specific risk has now changed to reflect a strong link to implant surface area/roughness as a major association with this cancer.