Showing papers in "The New Zealand Medical Journal in 2021"

Māori and Pacific people in New Zealand have a higher risk of hospitalisation for COVID-19.

Abstract: AIMS: We aim to quantify differences in clinical outcomes from COVID-19 infection in Aotearoa New Zealand by ethnicity and with a focus on risk of hospitalisation. METHODS: We used data on age, ethnicity, deprivation index, pre-existing health conditions and clinical outcomes on 1,829 COVID-19 cases reported in New Zealand. We used a logistic regression model to calculate odds ratios for the risk of hospitalisation by ethnicity. We also considered length of hospital stay and risk of fatality. RESULTS: After controlling for age and pre-existing conditions, we found that Maori have 2.50 times greater odds of hospitalisation (95% CI 1.39-4.51) than non-Maori non-Pacific people. Pacific people have three times greater odds (95% CI 1.75-5.33). CONCLUSIONS: Structural inequities and systemic racism in the healthcare system mean that Maori and Pacific communities face a much greater health burden from COVID-19. Older people and those with pre-existing health conditions are also at greater risk. This should inform future policy decisions including prioritising groups for vaccination.

Will access to COVID-19 vaccine in Aotearoa be equitable for priority populations?

Abstract: AIM This research examines the equity implications of the geographic distribution of COVID-19 vaccine delivery locations in Aotearoa New Zealand under five potential scenarios: (1) stadium mega-clinics; (2) Community Based Assessment Centres; (3) GP clinics; (4) community pharmacies; and (5) schools. METHOD We mapped the distribution of Aotearoa New Zealand's population and the location of potential vaccine delivery facilities under each scenario. Geostatistical techniques identified population clusters for Māori, Pacific peoples and people aged 65 years and over. We calculated travel times between all potential facilities and each Statistical Area 1 in the country. Descriptive statistics indicate the size and proportion of populations that could face significant travel barriers when accessing COVID-19 vaccinations. RESULTS Several areas with significant travel times to potential vaccine delivery sites were also communities identified as having an elevated risk of COVID-19 disease and severity. All potential scenarios for vaccine delivery, with the exception of schools, resulted in travel barriers for a substantial proportion of the population. Overall, these travel time barriers disproportionately burden Māori, older communities and people living in areas of high socioeconomic deprivation. CONCLUSION The equitable delivery of COVID-19 vaccines is key to an elimination strategy. However, if current health services and facilities are used without well-designed and supported outreach services, then access to vaccination is likely to be inequitable.

What helps and hinders metformin adherence and persistence? A qualitative study exploring the views of people with type 2 diabetes.

Abstract: Aim To explore the views of people with type 2 diabetes who had initiated metformin monotherapy about what influences adherence and persistence. Methods We recruited participants through primary care, using purposive sampling, and undertook face-to-face, audio-recorded, semi-structured interviews with 10 Māori, 10 Pacific, and 10 non-Māori non-Pacific patients who had started metformin monotherapy for type 2 diabetes within the previous two years. A thematic analysis was undertaken using the Theory of Planned Behaviour as the overall theoretical framework. Results The perceived benefits of taking metformin included improving glycaemic control, preventing or slowing the progression of type 2 diabetes, and avoiding serious complications. Side effects (predominantly gastrointestinal) were the most commonly cited disadvantage. Participants employed a variety of strategies to help them take metformin regularly. Key reasons for initial sub-optimal adherence and persistence were side effects and not accepting the diagnosis of type 2 diabetes. Subsequently, omitting to take tablets was commonly unintentional (due to 'forgetfulness'). For many Pacific participants, changes in routine related to community and church events, or shift work, contributed to sub-optimal adherence. Some Māori participants would have preferred to use traditional medicines. Conclusion We identified a number of factors within the scope of healthcare services that may assist healthcare providers to focus on, and address, some of the issues that appear to be of primary importance to people when they are prescribed metformin.

Empty waiting rooms: the New Zealand general practice experience with telehealth during the COVID-19 pandemic

Abstract: Aim The primary care response to the coronavirus disease 2019 (COVID-19) pandemic in early 2020 required significant changes to the delivery of healthcare by general practices. This study explores the experiences of New Zealand general practice teams in their use of telehealth during the early stages of the COVID-19 pandemic in New Zealand. Method We qualitatively analysed a subtheme on telehealth of the General Practice Pandemic Experience New Zealand (GPPENZ) study, where general practice team members across the country were invited to participate in five surveys between 8 May 2020 to 27 August 2020. Results 164 participants enrolled in the study during survey one, with 78 (48%) completing all surveys. Five telehealth themes were identified: benefits, limitations, paying for consults, changes over time and plans for future use. Benefits included rapid triage, convenience and efficiency, and limitations included financial and technical barriers for practices and patients and concerns about clinical risk. Respondents rapidly returned to in-person consultations and wanted clarification of conditions suited to telehealth, better infrastructure and funding. Conclusion To equitably sustain telehealth use, the following are required: adequate funding, training, processes communicated to patients, improved patient access to technology and technological literacy, virtual physical examination methods and integration with existing primary health care services.

Admission to hospital for injury during COVID-19 alert level restrictions

Abstract: AIM: To assess the effects of the community lockdown phases on trauma-related admissions to Midland region hospitals over the period 15 February to 10 July 2020, and to compare volume variation with the same period in the previous three years METHODS: A retrospective, descriptive study of prospectively collected data from the Midland Trauma Registry in New Zealand RESULTS: There was a 36 7% (p< 00001) reduction in injury admissions during Alert Level 4 ('Lockdown') compared with the same period in 2017, 2018 and 2019 This was in the context of volume increases during the pre-lockdown period (17 8%, p< 00001) and a 'rebound' as restrictions eased There was an increase in injuries occurring at home (28 3%, p< 00001) and on footpaths (37 9%, p=0 00076), while there was a decline in events on roads (33 0%, p=0 017), at schools (75 0%, p< 00001) and in sports areas (79 7%, p< 00001) Falls remained the dominant mechanism of injury in 2020, contributing 39 9% of all hospitalisations CONCLUSIONS: The reduction in hospital admissions during alert levels 4 and 3 was short lived, with a rebound evident when restrictions eased Hospital resources have been strained because this rebound coincided with a planned 'catch up' on healthcare that was delayed during the higher community restriction levels Alternate abstract:The reduction in trauma hospital admissions during alert levels 4 and 3 was short lived, with a 'rebound' evident when restrictions eased across the Midland region Hospital resources have been strained as this rebound coincided with a planned 'catch up' on healthcare delayed during the higher community restriction levels

The rise of cannabis vaping: implications for survey design.

Abstract: Until about 2010, smoking of cannabis (in a joint, pipe or bong) was by far the dominant mode of use, globally and in New Zealand. Whether a survey investigated prevalence of ‘smoking’ or ‘using’ cannabis, the results would be expected to be virtually the same. That is no longer the case. Vaporisers are now available in New Zealand that allow users to vape (rather than smoke) dried cannabis leaf or buds.1,2 Additionally, in jurisdictions where cannabis has been legalised, vaping of e-liquids containing THC (the psychoactive component in cannabis) and edible cannabis products have become increasingly popular, particularly among young people.3–5 In some countries where cannabis use remains illegal, THC e-liquids and edibles are available on the black market (eg, they were widely used in Canada before legalisation of recreational cannabis in 2018).6 In New Zealand, little is known about how the evolution of cannabis products and devices has affected mode of administration at the population level.

Estimating the effect of selective border relaxation on COVID-19 in New Zealand.

Abstract: AIMS: We developed a model, updated daily, to estimate undetected COVID-19 infections exiting quarantine following selectively opening New Zealand's borders to travellers from low-risk countries. METHODS: The prevalence of infectious COVID-19 cases by country was multiplied by expected monthly passenger volumes to predict the rate of arrivals. The rate of undetected infections entering the border following screening and quarantine was estimated. Level 1, Level 2 and Level 3 countries were defined as those with an active COVID-19 prevalence of up to 1/105, 10/105 and 100/105, respectively. RESULTS: With 65,272 travellers per month, the number of undetected COVID-19 infections exiting quarantine is 1 every 45, 15 and 31 months for Level 1, Level 2 and Level 3 countries, respectively. The overall rate of undetected active COVID-19 infections exiting quarantine is expected to increase from the current 0.40 to 0.50 per month, or an increase of one extra infection every 10 months. CONCLUSIONS: Loosening border restrictions results in a small increase in the rate of undetected COVID-19 infections exiting quarantine, which increases from the current baseline by one infection every 10 months. This information may be useful in guiding decision-making on selectively opening of borders in the COVID-19 era.

The potential of school-based physical education to increase physical activity in Aotearoa New Zealand children and young people: a modelling study.

Abstract: Aims Regular physical activity (PA) is critical for children and young people's health and wellbeing. Schools are an important setting for promoting PA. This study aimed to examine prevalence of PA through physical education in New Zealand schools and the potential impact of increasing physical education on young people's PA levels. Methods We used data from the Active NZ Young People Survey of over 8,000 young people and modelled the impact of a hypothetical intervention that increased school-based physical education time to 2.5 hours (consistent with international best practice) on the distribution of PA. Results At baseline, 61.3% (95%UI 60.2-62.5) of young people were classified as being sufficiently active (7+ hours/week), 19.8% (95%UI 18.9-20.8) were moderately active, and 18.8% (95%CI 17.9-19.7) were minimally active. The intervention scenario would more than halve the prevalence of minimal activity to 8.1% (95%UI 7.5-8.8) and increase the proportion of sufficiently active young people to 68.4% (95%UI 67.3-69.5). Conclusion Increasing time being active through physical education has the potential to reduce the prevalence of minimally active young people in New Zealand. Policies to support increased physical education time, such as time-based requirements, would increase PA levels.

The Taranaki COVID-19 response from a Māori perspective: lessons for mainstream health providers in Aotearoa New Zealand.

Abstract: On 28 February 2020, the novel coronavirus SARS-CoV-2 reached New Zealand. There is an increased fear for Maori about infectious-disease pandemics such as COVID-19, based on past experiences of infectious diseases. In 1918, for example, the M ori death rate from the influenza pandemic was seven times that of non-Moori. Between March and May 2020, 16 people with COVID-19 infection were identified in Taranaki. Iwi within Taranaki and Maori health providers put actions into place to protect their people. During this first wave of infection, none of the people with the infection in Taranaki were of Moori ethnicity. The purpose of this research project was to better understand the COVID-19 response from a Taranaki-Maori perspective and how needs-based care was provided to the community.

Comparison of physical activity patterns across large, medium and small urban areas and rural settings in the Otago Region, New Zealand.

Abstract: AIM This study compared accelerometer-measured physical activity (PA) patterns in adolescents living in diverse urban and rural areas of Otago, New Zealand. METHOD Participants (n=377; age: 14.9±1.4 years; 66.8% female; 23 schools) completed an online school travel survey, anthropometry and seven-day PA accelerometer assessment. Participants resided in large (n=237), medium (n=45) and small (n=44) urban areas or rural settings (n=51). RESULTS Overall, participants participated in 54.4±21.0 minutes of moderate-to-vigorous physical activity (MVPA) daily and 35.0% met PA guidelines (school day vs weekend day: 40.8% vs 26.0%; p<0.001) with no difference across geographical settings. A greater proportion of males (43.2% vs 31.9%; p=0.016), school sport participants (70.1% vs 54.0%; p=0.005) and active-transport-to-school users (40.2% vs 26.1%) met PA guidelines compared to their counterparts. Compared to rural adolescents, those from large urban areas accumulated more MVPA during the school commute time (before school: 8.3±6.7 vs 5.3±3.8 minutes, p<0.001; after school: 10.1±6.0 vs 7.7±4.3 min, p=0.003), but overall spent more time sedentary (584.9±84.7 vs 527.8±88.2 minutes/day; p<0.001). CONCLUSION PA in Otago adolescents is low, with significant differences by gender, sport participation, mode of travel to school and geographical setting. Increased PA should be encouraged in both urban and rural adolescents.

All-of-community by all-of-government: reaching Pacific people in Aotearoa New Zealand during the COVID-19 pandemic

Abstract: A large portion of Pacific communities throughout Aotearoa New Zealand continue to face socioeconomic hardship and have ongoing health needs that are affected by social and economic influences. The impact of COVID-19 has only exacerbated these needs and will continue to have an adverse effect on the current wellbeing, future health and sustainable development of these communities-if targeted efforts are not undertaken to meet their unique needs. The collective worldview of Pacific communities is fundamental to their existence; therefore, a response needs to be within a collective community. This viewpoint looks at the worldview of Pacific communities and the impact of COVID-19 and then discusses six key priorities for working with these diverse communities. The successful management and elimination of a pandemic should be assessed by how well Pacific and other vulnerable communities survive such a crisis.

Pasifika Prediabetes Youth Empowerment Programme: learnings from a youth-led community-based intervention study.

Abstract: Aim Using a co-design approach, we describe exploratory findings of a community-based intervention to mobilise Pasifika communities into action, with the intent of reducing the risk factors of prediabetes. Method A group of 25 Pasifika youth aged 15-24 years from two distinctive Pasifika communities in New Zealand were trained to lead a small-scale, community-based intervention programme (among 29 participants) over the course of eight weeks. The intervention, which targeted adults aged 25-44 years who were overweight or obese, employed both an empowerment-based programme and a co-design approach to motivate community members to participate in a physical-activity-based intervention programme. Results Findings show significant reductions in total body weight and waist circumference, as well as improved physical activity. Conclusions The strength of this intervention was evident in the innovative approach of utilising Pasifika-youth-led and co-designed approaches to motivate communities into healthier lifestyles. The approaches used in this project could be utilised in a primary healthcare setting as a community-wide strategy to reduce diabetes risk, particularly among Pasifika peoples.

Methoxyflurane toxicity: historical determination and lessons for modern patient and occupational exposure.

Abstract: Aim Historically methoxyflurane was used for anaesthesia. Evidence of nephrotoxicity led to abandonment of this application. Subsequently, methoxyflurane, in lower doses, has re-emerged as an analgesic agent, typically used via the Penthrox inhaler in the ambulance setting. We review the literature to consider patient and occupational risks for methoxyflurane. Method Articles were located via PubMed, ScienceDirect, Google Scholar, Anesthesiology journal and the Cochrane Library. Results Early studies investigated pharmacokinetics and considered the resulting effects to pose minimal risk. Pre-clinical rodent studies utilised a species not vulnerable to the nephrotoxic fluoride metabolite of methoxyflurane, so nephrotoxicity was not identified until almost a decade after its introduction, and was initially met with scepticism. Further evidence of nephrotoxicity led to abandonment of methoxyflurane use for anaesthesia. Subsequent research suggested there are additional risks potentially relevant to recurrent patient or occupational exposure. Specifically, greater than expected fluoride production after repeated low-dose exposure, increased fluoride production due to medication-caused hepatic enzyme induction, fluoride deposition in bone potentially acting as a slow-release fluoride compartment, which suggests a risk of skeletal fluorosis, and hepatotoxicity. Gestational risk is unclear. Conclusions Methoxyflurane poses a potentially substantial health risk in high (anaesthetic) doses, and there are a number of pathways whereby repeated exposure to methoxyflurane in lower doses may pose a risk. Single analgesic doses in modern use generally appear safe for patients. However, the safety of recurrent patient or occupational healthcare-worker exposure has not been confirmed, and merits further investigation.

Deficient handwashing amenities in public toilets in the time of the COVID-19 pandemic: a multi-regional survey

Abstract: AIMS: To identify the extent of the provision of handwashing amenities in public toilets at the time of the COVID-19 pandemic, and also to make comparisons with a related pre-pandemic survey. METHODS: We collected data from 400 toilet facilities that were open to the public: all those in three contiguous city council territories (228) and a further convenience sample of 172 around other parts of New Zealand. Comparisons were made with the data on the same facilities included in a 2012/2013 survey. RESULTS: Of the toilets in this survey, 2.5% had no water for handwashing and 14.8% had no soap. There was COVID-19-related health messaging signage in 19.5% of toilets, with posters of the COVID-19 QR code used for contact tracing in 12.3%, and generic handwashing signage in 1.8%. The handwashing water had 'no-touch' activation at 28.0% of toilets, and 18.5% of toilets had no-touch bowl flushing. Toilet bowl lids were not present at 32.8%, and 2.3% of toilets had damage that would impair their functionality (eg, broken toilet seats). This new survey found significantly increased provision of soap (risk ratio = 1.47;95%CI: 1.25 to 1.72), but no increased provision of water, at the 128 sites that had also been examined in the previous survey. CONCLUSIONS: Although handwashing is probably a much less critical COVID-19 control intervention than reducing aerosol transmission, it should still be strongly supported. Yet this survey found multiple deficiencies with handwashing amenities at public toilets and only modest improvements since a previous survey.

Impact of the COVID-19 pandemic lockdown on public sector ophthalmic work by New Zealand's ophthalmologists

Abstract: AIM: In response to the COVID-19 pandemic, the New Zealand government enforced a nationwide 'alert level 4' lockdown from 26 March to 27 April 2020. We assessed the impact of this lockdown on New Zealand's public ophthalmology service. METHOD: An anonymous online survey was sent to all New Zealand-based fellows of the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) after lockdown. Respondents provided retrospective assessment of practice patterns and their personal health during the COVID-19 lockdown. This was supported by national-level administrative data, allowing survey findings to be contextualised. RESULTS: Fifty-seven respondents (response rate 49%) working in the public health system participated. A large majority of respondents reduced elective clinic and surgical volumes by at least 75% (82% and 98%, respectively). National-level information confirmed clinic reduced to 38.2% of normal and elective operating volumes to 11.5%, with virtual visits increasing 17.9-fold. Elective clinic and elective operating volumes promptly recovered to usual volumes on the second month post lockdown. Most respondents (58%) followed the RANZCO triaging guideline, and 28% triaged emergencies only. At a personal level, respondents reported a significant physical health benefit (p<0.001) associated with the lockdown experience, but no change in mental health or social wellbeing. CONCLUSIONS: Publicly employed ophthalmologists experienced dramatic reductions to elective clinic and operating volumes during the COVID-19 lockdown. The prompt recovery of service delivery volumes back to pre-lockdown levels supports the value of a COVID-19 elimination strategy in New Zealand. Virtual visits for selected patients allowed ongoing management without risking virus transmission.

Estimating the risk of outbreaks of COVID-19 associated with shore leave by merchant ship crews: simulation studies for New Zealand.

Abstract: AIM: We aimed to estimate the risk of COVID-19 outbreaks in a COVID-19-free destination country (New Zealand) associated with shore leave by merchant ship crews who were infected prior to their departure or on their ship. METHODS: We used a stochastic version of the SEIR model CovidSIM v1.1 designed specifically for COVID-19. It was populated with parameters for SARS-CoV-2 transmission, shipping characteristics and plausible control measures. RESULTS: When no control interventions were in place, we estimated that an outbreak of COVID-19 in New Zealand would occur after a median time of 23 days (assuming a global average for source country incidence of 2.66 new infections per 1,000 population per week, crews of 20 with a voyage length of 10 days and 1 day of shore leave per crew member both in New Zealand and abroad, and 108 port visits by international merchant ships per week). For this example, the uncertainty around when outbreaks occur is wide (an outbreak occurs with 95% probability between 1 and 124 days). The combination of PCR testing on arrival, self-reporting of symptoms with contact tracing and mask use during shore leave increased this median time to 1.0 year (14 days to 5.4 years, or a 49% probability within a year). Scenario analyses found that onboard infection chains could persist for well over 4 weeks, even with crews of only 5 members. CONCLUSION: This modelling work suggests that the introduction of SARS-CoV-2 through shore leave from international shipping crews is likely, even after long voyages. But the risk can be substantially mitigated by control measures such as PCR testing and mask use.

Cancellation of elective orthopaedic procedures is not a benign practice and is often preventable.

Abstract: AIM To quantify the reasons for cancelled elective orthopaedic operations, in particular hip and knee arthroplasty. Secondary aims included defining how long these patients had to wait until their operation, and investigating the impact delayed surgery has on patients in terms of re-presentation to healthcare services. METHODS We reviewed hospital records for all cancelled elective orthopaedic operations over a two-year period at a secondary hospital in New Zealand, investigated the reasons for these cancellations, wait times and comorbidities and compared total hip and knee arthroplasty to other elective orthopaedic operations. RESULTS 76 orthopaedic elective cases were cancelled. 28 (37%) were hip and knee arthroplasties. 71% of these arthroplasties were cancelled due to hospital-related factors (bed availability, operating theatre capacity). Mean wait time for an eventual operation was 56.20 days. Hip joint arthroplasties waited significantly longer (76.10 days, p=0.008). 10% of patients awaiting hip and knee arthroplasties re-presented to healthcare services before their eventual operation. CONCLUSIONS Patients are having their elective hip and knee arthroplasty operations cancelled for hospital-related reasons that could be avoidable. There are significant wait times contributing to decreased quality of life and may be contributing to avoidable re-presentation with its associated demand on healthcare services.

Teleophthalmology in the post-coronavirus era

Abstract: 173,766 New Zealanders suffer from visual impairment. The associated health-system costs are $523 million in total, or $3,008 per person. Yet eighty percent (80%) of blindness is avoidable if detected on time. Public health services have an increasing workload but are also limited by material and technical resources. Optometry practices continually increase referrals (up to 100% in one year) that cannot be solved on time, reducing the efficiency of the service. Teleophthalmology works by improving the efficiency of screening and monitoring and integrating eye healthcare and by decreasing referrals by up to 40%.

Radiological imaging of melanoma: a review to guide clinical practice in New Zealand.

Abstract: The aim of this review is to propose guidelines for initial radiological staging and the follow-up imaging regime for melanoma. This will provide consistency in the access and delivery of quality melanoma care. Radiological imaging plays an important role in assessing the extent of disease, guiding individual treatment and evaluating treatment response. However, there exists limited literature addressing the optimal radiological staging and surveillance imaging regimes for melanoma. The lack of consensus on imaging for melanoma can generate inconsistency in the standard of skin cancer care provided. This review considers the appropriate imaging techniques for both initial melanoma staging and follow-up specifically in the New Zealand clinical environment. The recommendations in this article are based on evaluation of the currently available literature and consensus of feedback from consultation with a working group of New Zealand clinicians involved in providing care to patients with melanoma. The proposed guidelines are considered the standard of care, but regional practice may differ based on access to imaging technology, cost limitations and the clinical experience of healthcare professionals.

New Zealand's vocational Rural Hospital Medicine Training Programme: the first ten years.

Abstract: Aims The Rural Hospital Medicine Training Programme (RHMTP) was established in 2008 to develop New Zealand's rural hospital medical workforce. This study evaluates the RHMTP's first 10-year outcomes. Methods A mixed-methods descriptive study. Database interrogation of: the Royal New Zealand College of General Practitioners records; University of Otago's e-Vision; the Medical Council of New Zealand's register of doctors. A survey of trainees who had graduated or withdrew from the programme. Survey questions included: current scope and place of employment; undergraduate rural experience; and trainee experiences. Results From 2009-2018, 98 doctors entered the RHMTP: 29 graduated, 20 withdrew and 49 are active registrars. Of the graduates, more than half (17/29) also completed GP training. Overall survey response rate: 80% (39/49). Graduate response rate: 97% (28/29). 92% (24/26) of currently practising graduates are working in rural New Zealand, mostly (22/24) in rural hospitals. Trainees value the RHMTP's flexibility and breadth of clinical exposure. The main challenges relate to a lack of alignment of training requirements and funding. Conclusions In its first decade, the RHMTP has been successful in generating a rural hospital workforce and the programme is steadily growing. Attention to existing barriers is needed to ensure the RHMTP can reach its potential to benefit all of New Zealand's rural communities.

Improving the prescribing practice of junior doctors through interprofessional collaboration and evidence-based education.

Abstract: The last decade (2010-2019) has seen calls to action to improve the prescribing practice of junior doctors. An in-depth investigation into the causes of prescribing errors by foundation trainees in relation to their medical education (the EQUIP study) in the UK reported a prescription error rate of 8.9% for all prescribed medicines, and although that is a UK study, there are similarities with New Zealand prevocational training programmes. The EQUIP study revealed that existing teaching strategies are not working. To believe a single intervention will prevent most prescribing errors is simplistic, and for improvement to occur, new prescribers need to learn from their mistakes. Traditionally, the education of junior doctors has focused on their competence and professional registration requirements. Working in healthcare is collective and multidisciplinary, and errors occur through human and system factors.

Use of tranexamic acid in trauma patients requiring massive transfusion protocol activation: a reassessment of prescribing behaviours in a major trauma centre in New Zealand.

Abstract: Aim To re-investigate prescribing behaviours for tranexamic acid (TXA) use in the early management of severe trauma, and to compare against the standards considered to be best practice and the same study conducted at this centre two years prior. Methods We undertook a retrospective analysis of trauma patients requiring massive transfusion protocol (MTP) activation across a 26-month period. Physical and electronic inpatient records and ambulance documentation were reviewed to determine dose and timing of TXA administration. Results During the period studied, 53 trauma patients requiring activation of the MTP were identified. Of those for whom TXA was indicated, 90.9% received at least an initial dose of TXA and 50.0% received both doses. In total, 16.7% of patients received a dose within one hour of injury, 73.8% between one and three hours and 9.52% outside three hours. Conclusions Compared with the previous study, the utilisation of TXA is now more consistent with what is considered best practice. Delayed administration beyond the three-hour therapeutic window was less than the 26.3% figure previously reported, and comparable to that of major trauma centres internationally. Persistent issues include the under-utilisation of the second dose and the potential for much earlier use, as has been achieved at centres where pre-hospital administration is the norm.

Multidisciplinary Pigmented Lesion Clinic at Auckland District Health Board: impacts on melanoma diagnosis and treatment outcomes.

Abstract: AIM To investigate the outcomes and effect of a multidisciplinary 'see and treat' pigmented lesion clinic, run jointly by dermatology and general surgery, on the diagnosis and treatment of melanoma at Auckland District Health Board (DHB). METHOD All patients attending the newly established Pigmented Lesion Clinic (PLC) between 1 March 2019 and 31 August 2019 were included in the study. They were compared against a retrospective cohort of patients seen for suspected or biopsy-proven melanomas during the same corresponding period in 2016. RESULTS 251 new patients attended the PLC, compared to 148 new patients seen at Auckland DHB in 2016. There was a significant reduction in proportion of pigmented lesions requiring biopsy (35.2% vs 64.3%, p<0.001), with a benign-to-malignant ratio of 2.4:1. Fifty-three melanomas were treated through the PLC, with a significant reduction in mean waiting time from referral to first specialist assessment (22.6 vs 35.1 days, p=0.038), and from referral to wide local excision (50.6 vs 99.1 days, p<0.001). 86.5% of patients received full skin check, from which additional skin malignancies were detected in 1-per-5.3 patients. CONCLUSION The novel PLC model has led to reduction in unnecessary excisional biopsies of benign pigmented lesions, while streamlining and improving timely access to specialist review and surgical treatment for patients with melanomas.

An evaluation of diagnostic tests in a case series of suspected leptospirosis patients seen in primary care.

Abstract: Aims This study describes 47 presentations of suspected leptospirosis in general practice in New Zealand. Our primary aim was to assess the laboratory diagnosis of leptospirosis in these patients, by comparing polymerase chain reaction (PCR) tests, microscopic agglutination test (MAT) and culture results. Methods Patients suspected of leptospirosis were recruited from general practices in the Waikato (n=17) and Wairoa (n=30) between August 2011 and June 2015. Blood and urine samples were tested for leptospirosis at two diagnostic laboratories and one research laboratory using PCR tests, MAT and culture. Results Forty-seven patients were recruited for this study: 37 during the acute phase of the illness (within 10 days of symptom onset) and 10 after the acute phase. Eleven of the acute phase patients (11/37, 30%) and two of the later phase patients (2/10, 20%) returned positive leptospirosis test results. The 11 acute phase leptospirosis positive patients had the following positive diagnostic tests: PCR and paired MAT (+/- blood culture) (n=3), PCR only (+/- blood culture) (n=4), paired MAT only (n=3) and blood culture only (n=1). Urine PCR (performed only on Wairoa patients) was the only positive test for two of these patients. Conclusion About a quarter of farm workers and meat workers presenting to general practice with flu-like symptoms will have leptospirosis, but they will not be diagnosed unless appropriately tested, and then they may only test positive for some of the tests available. To increase the likelihood of making a diagnosis, clinicians should order multiple laboratory tests, including blood and urine PCR and a paired MAT.