Auckland District Health Board Research Articles

Inequity in timing of prenatal screening in New Zealand: Who are our most vulnerable?

In New Zealand (NZ), Maori and Pacific women are less likely to complete prenatal screening for Down syndrome and other aneuploidies than other ethnic groups. Young women <20 have low rates of completed screening compared with women >20years. Women living in deprived areas have lower completed screen rates than women living in more affluent areas. Combined first trimester screening has a superior sensitivity (85%) compared with second trimester screening (75%) for trisomy 21. The relative contribution of demographic factors to timing of screening uptake (first vs second trimester) has not previously been examined. To evaluate the association of ethnicity, deprivation, District Health Board (DHB) of domicile and maternal age with timing of prenatal screening (first vs second trimester) in pregnant women screened in NZ from 2010 to 2013. Univariate logistic regression analyses were used to explore the association between timing of completed screening and each of ethnicity, deprivation index, DHB of domicile and maternal age. Multivariate logistic regression models were developed to calculate odds ratios (OR) and 95% confidence intervals (CI). Statistical analyses were performed using SAS v9.3 RESULTS: Of completed prenatal screens, 88% were completed in the first trimester. Ethnicity, age, deprivation and DHB were all significant predictors of completed first versus second trimester screening. Maori women were almost 60% less likely (adjusted OR 0.37, CI 0.35-0.39) and Pacific women almost 80% less likely (adjusted OR 0.23, CI 0.21-0.24) than NZ European women to have completed first versus second trimester screening. Women <30years were less likely to have completed first trimester screening, as were more deprived women. Variation was also seen by DHB with women living in Whanganui DHB less likely to have completed first versus second trimester screening than women living in Auckland (adjusted OR 0.76, CI 0.71-0.81). Women living in Bay of Plenty DHB were more likely to be screened in the first versus second trimester compared with women living in Auckland (adjusted OR 1.55, CI 1.38-1.74). Within Auckland itself, women living in Counties Manukau DHB were less likely to be screened in the first versus second trimester than women living in Auckland DHB even after adjusting for ethnicity, deprivation and maternal age. Maori and Pacific women have the lowest uptake of completed first versus second trimester screening after adjusting for age, deprivation and DHB. Research is required to understand if this relates to characteristics of the carer making the offer of screening, language and/or cultural barriers to care or specific collective cultural or religious views held by women from these ethnicities. The lower completed first trimester versus second trimester prenatal screening in deprived areas, as well as variation by DHB, may relate to the availability of ultrasound and/or laboratory services in specific regions. Cost may be a contributing factor to inequity in timing of completed prenatal screening uptake, as first trimester screening incurs a part-charge to the individual, while second trimester screening is fully funded. Systemic factors within the NZ maternity model of care may also be contributory with a potential disconnect occurring for the woman between primary medical care and later registration with a Lead Maternity Carer in the first trimester.

Auckland district health board radiology service improvement: An after hours ultrasound service pilot study

AbstractIntroductionThe aim of the study was to improve acute diagnostic workflow by provision of a dedicated sonographer‐lead after hours ultrasound (US) service.MethodsData on patients referred for the four most common referrals was obtained retrospectively over a 3‐month period both prior to, and during, a 6‐month sonographer‐lead after hours US service. The primary outcome measure was mean time from referral to US exam. The secondary outcome measure was the mean number of days between US referral and discharge.ResultsThere was a statistically significant decrease in the mean referral to exam time of three of the four referral groups and a statistically significant decrease in the number of days between US referral and discharge in the post‐intervention group compared with the pre‐intervention group.DiscussionThere was a clear early indication of improvement in patient safety and ability to provide effective and efficient care. Our recommendation is to use this data to provide the basis for application for funding for a permanent sonographer‐lead after hours US service.

Interventions at Nurse Specialist Clinics for Cardiac Rehabilitation Patients at Auckland District Health Board: A 3 Month Snapshot

Aim: Early Nurse follow-up clinics 2- 3 weeks post hospital discharge have been instituted at ADHB since 2012. In the last 2 years these clinics have increased in attendance rates, patient complexity and now have medical supervision. Some patients will only have nurse follow-up post discharge. To assess rates of adherence and intervention in CR nurse clinics. Methods: The Cardiac Rehabilitation (CR) team at the Auckland District Health Board have prospectively recorded rates of adherence and interventions at Nurse Specialist clinics over a 6-month period. Results: 161 (89%) patients attended CR nurse clinics. Of these 45 (28%) patients required medication changes with 20 prescribed/up titration in ACE1/beta blocker, 2 antiplatelet agent, 11 statin and other 13 medication. A further 18 (12%) were referred for further investigation and, 15 (9%) to appropriate specialist clinics, for example diabetes/hyperventilation clinics. Conclusion: Nurse Specialist clinics with medical supervision that are scheduled early post discharge provide a safety net for patients who are discharged following short hospital stays. They also lead to increased prescription of secondary prevention medication and ensure patients have appropriate investigations and referrals

Developing Holistic Evidence Based Food Plates for Patients in Cardiac Rehabilitation at Auckland District Health Board

Developing Holistic Evidence Based Food Plates for Patients in Cardiac Rehabilitation at Auckland District Health Board

Interventions at Nurse Specialist Clinics for Cardiac Rehabilitation Patients at Auckland District Health Board: A 3-Month Snapshot

Interventions at Nurse Specialist Clinics for Cardiac Rehabilitation Patients at Auckland District Health Board: A 3-Month Snapshot

Analysis of Glaucoma Subtypes and Corresponding Demographics in a New Zealand Population

Purpose: The aim of this paper was to determine the diagnosis distribution and demographic characteristics of glaucoma in a New Zealand population. Methods: The clinical records of all patients presenting consecutively to the Auckland District Health Board Glaucoma Service over a 6-month period were reviewed. Demographic parameters including ethnicity, age at presentation, and gender were collected along with all clinical data. Results: The case records of 857 patients were reviewed. Primary open-angle glaucoma (POAG) was the most common diagnosis (39.0%, n = 235), followed by primary-angle closure (PAC) diagnoses (24.8%, n = 149). This group was formed by the combination of narrow angle 18.1% (n = 109), narrow-angle glaucoma 0.3% (n = 2), PAC 2.1% (n = 13), and PAC glaucoma 4.2% (n = 25). Normal-tension glaucoma (NTG; 17.4%, n = 105), secondary glaucoma (SG; 11.5%, n = 69), ocular hypertension (5.0%, n = 30), and mixed mechanism (2.3%, n = 14) were also found. There was a significant difference in the ethnic distribution in the study population compared to the catchment population (p < 0.001). Caucasian and Indian ethnicities were overrepresented, whereas the Pacific Island Nation ethnicity was underrepresented in all groups except SG. The Maori ethnicity was underrepresented in all groups except PAC. The underrepresentation was most prominent in POAG (only 2 patients of Pacific origin and 1 Maori patient with POAG). Significant differences were identified in gender distribution including a higher preponderance of females in NTG and PAC. Significant differences in age at presentation were also identified between different glaucoma subtypes and ethnicities. Markers of glaucoma severity did not vary with respect to demographic characteristics. Conclusion: In a tertiary glaucoma service in New Zealand, Maori, Pacific peoples, and, to a lesser extent, Asians are underrepresented, while Caucasians and Indians are overrepresented in the glaucoma population.

Identifying the barriers and enablers in the implementation of the New Zealand and Australian Antenatal Corticosteroid Clinical Practice Guidelines.

BackgroundThe ineffective implementation of evidence based practice guidelines can mean that the best health outcomes are not achieved. This study examined the barriers and enablers to the uptake and implementation of the new bi-national (Australia and New Zealand) antenatal corticosteroid clinical practice guidelines among health professionals, using the Theoretical Domains Framework.MethodsSemi-structured interviews or online questionnaires were conducted across four health professional groups and three district health boards in Auckland, New Zealand. The questions were constructed to reflect the 14 behavioural domains from the Theoretical Domains Framework. Relevant domains were identified by the presence of conflicting beliefs within a domain; the frequency of beliefs; and the likely strength of the impact of a belief on the behaviour using thematic analysis. The influence of health professional group and organisation on the different barriers and enablers identified were explored.ResultsSeventy-three health professionals completed either a semi-structured interview (n = 35) or on-line questionnaire (n = 38). Seven behavioural domains were identified as overarching enablers: belief about consequences; knowledge; social influences; environmental context and resource; belief about capabilities; social professional role and identity; and behavioural regulation. Five behavioural domains were identified as overarching barriers: environmental context and resources; knowledge; social influences; belief about consequences; and social professional role and identity. Differences in beliefs between individual health professional groups were identified within the domains: belief about consequences; social professional role and identity; and emotion. Organisational differences were identified within the domains: belief about consequences; social influences; and belief about capabilities.ConclusionThis study has identified some of the enablers and barriers to implementation of the New Zealand and Australian Antenatal Corticosteroid Clinical Practice Guidelines using the validated Theoretical Domains Framework, as perceived by health professionals. We have identified differences between individual health professional groups and organisations. The identification of these behavioural determinants can be used to enhance an implementation strategy, assist in the design of interventions to achieve improved implementation and facilitate process evaluations to understand why or how change interventions are effective.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1858-8) contains supplementary material, which is available to authorized users.

Filling gaps in notification data: a model-based approach applied to travel related campylobacteriosis cases in New Zealand.

BackgroundData containing notified cases of disease are often compromised by incomplete or partial information related to individual cases. In an effort to enhance the value of information from enteric disease notifications in New Zealand, this study explored the use of Bayesian and Multiple Imputation (MI) models to fill risk factor data gaps. As a test case, overseas travel as a risk factor for infection with campylobacteriosis has been examined.MethodsTwo methods, namely Bayesian Specification (BAS) and Multiple Imputation (MI), were compared regarding predictive performance for various levels of artificially induced missingness of overseas travel status in campylobacteriosis notification data. Predictive performance of the models was assessed through the Brier Score, the Area Under the ROC Curve and the Percent Bias of regression coefficients. Finally, the best model was selected and applied to predict missing overseas travel status of campylobacteriosis notifications.ResultsWhile no difference was observed in the predictive performance of the BAS and MI methods at a lower rate of missingness (<10 %), but the BAS approach performed better than MI at a higher rate of missingness (50 %, 65 %, 80 %). The estimated proportion (95 % Credibility Intervals) of travel related cases was greatest in highly urban District Health Boards (DHBs) in Counties Manukau, Auckland and Waitemata, at 0.37 (0.12, 0.57), 0.33 (0.13, 0.55) and 0.28 (0.10, 0.49), whereas the lowest proportion was estimated for more rural West Coast, Northland and Tairawhiti DHBs at 0.02 (0.01, 0.05), 0.03 (0.01, 0.08) and 0.04 (0.01, 0.06), respectively. The national rate of travel related campylobacteriosis cases was estimated at 0.16 (0.02, 0.48).ConclusionThe use of BAS offers a flexible approach to data augmentation particularly when the missing rate is very high and when the Missing At Random (MAR) assumption holds. High rates of travel associated cases in urban regions of New Zealand predicted by this approach are plausible given the high rate of travel in these regions, including destinations with higher risk of infection. The added advantage of using a Bayesian approach is that the model’s prediction can be improved whenever new information becomes available.Electronic supplementary materialThe online version of this article (doi:10.1186/s12879-016-1784-8) contains supplementary material, which is available to authorized users.

Natural history of corneal haze after corneal collagen crosslinking in keratoconus using Scheimpflug analysis

To analyze corneal haze after corneal collagen crosslinking (CXL) for progressive keratoconus using Scheimpflug densitometry. Auckland District Health Board, Auckland, New Zealand. Prospective randomized controlled study. Both eyes of all patients were examined preoperatively and 1, 3, 6, and 12months postoperatively. One eye of each patient was treated with corneal CXL, with the contralateral eye serving as the control. Examinations included uncorrected distance visual acuity and corrected distance visualacuity (CDVA), slitlamp biomicroscopy, and Scheimpflug tomography (Pentacam). Thirty-six eyes of 36 patients were enrolled. The mean preoperative corneal densitometry was 19.0±3.2 (SD). Postoperatively, the mean densitometry peaked at 1month, decreasing to baseline level after 6months without application of topical corticosteroids. The development of haze was significant compared with the contralateral untreated eyes (P<.01). The anterior (120μm) and inner (central 0.0 to 2.0mm) zones of the cornea had the highest densitometry after treatment. Lower preoperative central corneal thickness (CCT) was significantly correlated with higher corneal densitometry (P=.03). However, the preoperative CCT, keratometry, and astigmatism did not influence the difference in densitometry between the treated eyes and untreated eyes. There was no evidence of a relationship between densitometry and CDVA (P=.30). After corneal CXL, patients with keratoconus developed transient corneal haze in the anterior central cornea that might not require specific treatment. Thin corneas were associated with higher densitometry; thus, there might be a greater expectancy of corneal haze in patients with advanced keratoconus. None of the authors has a financial or proprietary interest in any material or method mentioned.

Raising the standard of care for oxygen delivery with nasal high flow in high-acuity areas—a controlled study

Nasal high-flow therapy and dispersion of nasal aerosols in an experimental setting Sally Roberts, N. Kabaliuk, Cjt Spence, Jane O'Donnell, Z. Zulkhairi Abidin, R. Dougherty, S. Roberts, Y. Jiang, Mc Jermy University of Canterbury, New Zealand Fisher & Paykel Healthcare, New Zealand University of KS, USA Auckland District Health Board, New Zealand University of Auckland, New Zealand Background/Purpose: Nasal high-flow (NHF) therapy delivers flows of heated and humidified gases up to 60 L/min via a nasal cannula. NHF is widely used to support patients, including those who may be infectious. It is thought that NHF gas flow velocities may increase cross-infection risk. Methods: Aerosols within the exhaled breath of healthy volunteers were imaged. Experimental breathing conditions deemed as typical patient breathing conditions were tested: at rest, with a violent exhalation (snorting), both with and without NHF, at flows of 30 and 60 L/min, and for both separate nostrils. The number, diameter, evaporation rates, and velocity of exhaled aerosols were collected. Results: The numbers of aerosols measured were greatest during a violent exhalation without NHF and reduced with NHF. The numbers of aerosols were higher at 60 than 30 L/min, suggesting that higher gas flow rates may be associated with increased aerosol production; however, the numbers were on average 43% and 56% less than without NHF, respectively. During breathing at rest, no differences were imaged between with and without NHF, except at 60 L/min where numbers of aerosols produced were equivalent to 10% of a violent exhalation. Aerosol trajectory and evaporation rates observed both with and without NHF predicted that aerosols between 25 and 250 μm may travel up to 4.4 m and remain airborne for 43 seconds. Conclusions: NHF use does not increase the risk of dispersing infectious aerosols above the risk of typical patient breathing with violent exhalation, which is the worst-case clinical scenario; therefore, standard risk control measures should apply.

Nasal high-flow therapy and dispersion of nasal aerosols in an experimental setting

Nasal high-flow therapy and dispersion of nasal aerosols in an experimental setting Sally Roberts, N. Kabaliuk, Cjt Spence, Jane O'Donnell, Z. Zulkhairi Abidin, R. Dougherty, S. Roberts, Y. Jiang, Mc Jermy University of Canterbury, New Zealand Fisher & Paykel Healthcare, New Zealand University of KS, USA Auckland District Health Board, New Zealand University of Auckland, New Zealand Background/Purpose: Nasal high-flow (NHF) therapy delivers flows of heated and humidified gases up to 60 L/min via a nasal cannula. NHF is widely used to support patients, including those who may be infectious. It is thought that NHF gas flow velocities may increase cross-infection risk. Methods: Aerosols within the exhaled breath of healthy volunteers were imaged. Experimental breathing conditions deemed as typical patient breathing conditions were tested: at rest, with a violent exhalation (snorting), both with and without NHF, at flows of 30 and 60 L/min, and for both separate nostrils. The number, diameter, evaporation rates, and velocity of exhaled aerosols were collected. Results: The numbers of aerosols measured were greatest during a violent exhalation without NHF and reduced with NHF. The numbers of aerosols were higher at 60 than 30 L/min, suggesting that higher gas flow rates may be associated with increased aerosol production; however, the numbers were on average 43% and 56% less than without NHF, respectively. During breathing at rest, no differences were imaged between with and without NHF, except at 60 L/min where numbers of aerosols produced were equivalent to 10% of a violent exhalation. Aerosol trajectory and evaporation rates observed both with and without NHF predicted that aerosols between 25 and 250 μm may travel up to 4.4 m and remain airborne for 43 seconds. Conclusions: NHF use does not increase the risk of dispersing infectious aerosols above the risk of typical patient breathing with violent exhalation, which is the worst-case clinical scenario; therefore, standard risk control measures should apply.

Development of a risk stratification system for the occurrence of prolonged postoperative ileus after colorectal surgery: A prospective risk factor analysis

Management strategies for prolonged postoperative ileus (PPOI) are principally conservative and it is therefore valuable to shift attention to prevention. This study aimed to identify prospectively the perioperative risk factors for the development of PPOI and create a tool to predict its occurrence. Patients undergoing elective colorectal surgery at Auckland District Health Board between September 2012 and June 2014 were enrolled. In total, 92 variables were investigated prospectively with uniform application of a standardized definition of PPOI. Logistic regression and area under receiver operating characteristic curves (AUC) were used to generate risk stratification models. PPOI occurred in 88 of 327 patients (26.9%). Independent predictors of PPOI were male gender (odds ratio [OR], 3.01), decreasing preoperative albumin (OR, 1.11 per g/L unit), open or converted technique (OR, 6.37 [vs laparoscopic]), increasing wound size (OR, 1.09 [per cm]), operative difficulty (OR, 1.28 [per unit on 10-point Likert scale]), operative bowel handling (OR, 1.38 [per unit on 10-point Likert scale]), red cell transfusion (OR, 1.84 [per unit]), intravenous crystalloid administration (OR, 1.55 [per liter]), and delayed first mobilization (OR, 1.39 [per day]). The I-Score assimilated preoperative and intraoperative variables to generate a score out of 6 with a 7-fold increase in risk from low-risk to high-risk strata and fair predictive capacity (AUC, 0.742; 95% CI, 0.684-0.799). Independent predictors for the development of PPOI have been identified prospectively and used to construct a novel risk stratification model.

Echocardiographic and electrocardiographic findings in patients with obesity hypoventilation syndrome.

Obesity is a risk factor for both sleep-related breathing disorders (SRBD), including obesity hypoventilation syndrome (OHS) and cardiovascular diseases (CVD). The development of CVD in patients with SRBD is usually attributed to the fact that most patients are obese in addition to conventional cardiovascular risk factors. This study aims to measure the prevalence of certain CVD in patients with OHS in the Auckland region and highlight the importance of the effects of SRBD on the heart. A dataset of all patients with a formal diagnosis of OHS that were under active follow up was compiled from Auckland District Health Board Sleep Disordered Breathing Service. Clinical notes were retrospectively reviewed for echocardiogram reports, blood pressure measurements and electrocardiograms. Forty-seven patients were included in the present study. The median age was 60 years, 24 were female (51%), 20 (42.5%) had diabetes, mean HbA1C was 53.5 mmol/mol, mean systolic blood pressure was 127 mmHg, mean body mass index was 49 kg/m(2) , mean forced expiratory volume in 1 s was 1.7 L, mean estimated glomerular filtration was 71 mL/min/1.73 m(2) and there was anti-hypertensive use in 31 (65.9%) patients. Thirty-three patients had poor quality echocardiography views (70.2%). Left ventricular systolic and diastolic function was impaired in 8 (25%) and 18 (60%) respectively. Right ventricular dysfunction and pulmonary hypertension was present in 19 (63.3%) and 13 (52%) respectively. Sixteen patients (34%) had recurrent atrial or ventricular arrhythmias. There appears to be a high prevalence of right ventricular impairment, pulmonary hypertension, left ventricle hypertrophy, diastolic dysfunction and arrhythmias in patients with OHS. These findings would appear to be higher than expected in obese patients without OHS. A larger prospective matched cohort study would be needed to confirm the clinical significance of these findings.

Prevalence of preoperative anaemia in patients having first-time cardiac surgery and its impact on clinical outcome. A retrospective observational study

The prevalence of anaemia is increasing globally. It has a close association with perioperative blood transfusion which, in turn, results in an increased risk of postoperative complications. Undesirable effects are not only limited to short-term, but also have long-term implications. Despite this, many patients undergo cardiac surgery with undiagnosed and untreated anaemia. We designed a retrospective, observational study to estimate the prevalence of anaemia in patients having cardiac surgery in Auckland District Health Board, blood transfusion rates and associated clinical outcome. Two hundred of seven hundred and twelve (28.1%) patients were anaemic. Red blood cell (RBC) transfusion rates were significantly higher in the anaemic group compared to the non-anaemic group (160 (80%) vs. 192 (38%), p-value <0.0001, RR (CI 95%) 2.133 (1.870-2.433)). Transfusion rates for fresh frozen plasma (FFP), cryoprecipitate and platelets were also higher in the anaemic group. Anaemia was significantly associated with the development of new infection (14 (7%) vs. 15 (2.9%), p-value 0.0193, RR (CI 95%) 2.389 (1.175-4.859)), prolonged ventilation time (47.01 hours vs. 23.59 hours, p-value 0.0076) and prolonged intensive care unit (ICU) stay (80.23 hours vs. 50.27, p-value 0.0011). Preoperative anaemia is highly prevalent and showed a clear link with significantly higher transfusion rates and postoperative morbidity. It is vital that a preoperative management plan for the correction of anaemia should be sought to improve patient safety and outcome.

Pregnancy loss managed by cervical dilatation and curettage increases the risk of spontaneous preterm birth

Do women with a previous miscarriage or termination of pregnancy have an increased risk of spontaneous preterm birth and is this related to previous cervical dilatation and curettage? A single previous pregnancy loss (termination or miscarriage) managed by cervical dilatation and curettage is associated with a greater risk of SpPTB. Miscarriage affects ∼20% of pregnancies and as many as a further 20% of pregnancies undergo termination. We utilized data from 5575 healthy nulliparous women with singleton pregnancies recruited to the Screening for Pregnancy Endpoints (SCOPE) study, a prospective cohort study performed between November 2004 and January 2011. The primary outcome was spontaneous preterm birth (defined as spontaneous preterm labour or preterm premature rupture of membranes (PPROM) resulting in preterm birth <37 weeks' gestation). Secondary outcomes included PPROM, small for gestational age, birthweight, pre-eclampsia and placental abruption. Women with previous pregnancy loss (miscarriage or termination) were compared with those with no previous pregnancy loss. There were 4331 (78%) women who had no previous pregnancy loss, 974 (17.5%) who had one early previous pregnancy loss, 249 (4.5%) who had two and 21 (0.5%) who had three or four losses. Women with two to four previous losses, but not those with a single loss, had an increased risk of spontaneous preterm birth (adjusted OR 2.12; 95% CI 1.55, 2.90) and/or placental abruption (adjusted OR 2.30; 95% CI 1.36, 3.89) compared with those with no previous pregnancy. A single previous miscarriage or termination of pregnancy where the management involved cervical dilatation and curettage was associated with an increased risk of spontaneous preterm birth (adjusted OR 1.64; 95% CI 1.08, 2.50; 6% absolute risk and adjusted OR 1.83; 95% CI 1.35, 2.48; 7% absolute risk, respectively) compared with those with no previous pregnancy losses. This is in contrast with women with a single previous miscarriage or termination managed non-surgically who showed no increase risk (adjusted OR 0.86; 95% CI 0.38, 1.94; 3.4% absolute risk and adjusted OR 0.87; 95% CI 0.69, 1.12; 3.8% absolute risk, respectively). Although every effort was made to record accurate previous pregnancy data, it was not feasible to confirm the history and management of previous pregnancy loss by hospital records. This may have introduced recall bias. This large prospective cohort study of healthy nulliparous women has demonstrated that women with either a previous miscarriage or termination of pregnancy were at increased risk of spontaneous preterm birth if they were managed by procedures involving cervical dilatation and curettage. However, overall, women with a single pregnancy loss did not have an increased risk of having any other of the adverse pregnancy outcomes examined. In contrast, two to four previous pregnancy losses were associated with an increased risk of having a pregnancy complicated by spontaneous preterm birth and/or placental abruption. Research is required to determine whether non-surgical management of miscarriage or termination of pregnancy should be advocated over surgical treatment. New Zealand: New Enterprise Research Fund, Foundation for Research Science and Technology; Health Research Council; Evelyn Bond Fund, Auckland District Health Board Charitable Trust. Australia: Premier's Science and Research Fund, South Australian Government. Ireland: Health Research Board. Leeds: Cerebra Charity, Carmarthen. Manchester: National Health Service NEAT Grant; Manchester Biotechnology and Biological Sciences Research Council; University of Manchester Proof of Concept Funding. King's College London: Guy's and St Thomas' Charity. King's College London and Manchester: Tommy's-The Baby Charity. N/A.

Population-based incidence and comparative demographics of community-associated and healthcare-associated Escherichia coli bloodstream infection in Auckland, New Zealand, 2005 – 2011

BackgroundEscherichia coli is a major human pathogen, both in community and healthcare settings. To date however, relatively few studies have defined the population burden of E. coli bloodstream infections. Such information is important in informing strategies around treatment and prevention of these serious infections. Against this background, we performed a retrospective, population-based observational study of all cases of E. coli bacteremia in patients presenting to our hospital between January 2005 and December 2011.MethodsAuckland District Health Board is a tertiary-level, university-affiliated institution serving a population of approximately 500,000, within a larger metropolitan population of 1.4 million. We identified all patients with an episode of bloodstream infection due to E. coli over the study period. A unique episode was defined as the first positive E. coli blood culture taken from the same patient within a thirty-day period. Standard definitions were used to classify episodes into community- or healthcare-associated E. coli bacteremia. Demographic information was obtained for all patients, including: age; gender; ethnicity; length of stay (days); requirement for intensive care admission and all-cause, in-patient mortality.ResultsA total of 1507 patients had a unique episode of E. coli bacteremia over the study period. The overall average annual incidence of E. coli bacteremia was 52 per 100,000 population, and was highest in the under one year and over 65-year age groups. When stratified by ethnicity, rates were highest in Pacific Peoples and Māori (83 and 62 per 100,000 population respectively). The incidence of community-onset E. coli bacteremia increased significantly over the study period. The overall in-hospital mortality rate was 9% (135/1507), and was significantly higher in patients who had a hospital-onset E. coli bacteremia.ConclusionsOur work provides valuable baseline data on the incidence of E. coli bacteremia in our locale. The incidence was higher that that described from other developed countries, with significant demographic variation, most notably in ethnic-specific incidence rates. Future work should assess the possible reasons for this disparity.

Increasing Incidence and Sociodemographic Variation in Community-onset Staphylococcus Aureus Skin and Soft Tissue Infections in New Zealand Children

We analyzed all cases of community-onset Staphylococcus aureus skin and soft tissue infection in children presenting to our hospital between 2007 and 2010. A total of 1860 children were included. There was significant sociodemographic disparity, with the incidence disproportionately higher in Maori and Pacific Island children residing in deprived areas.

Relationship Between Central Arterial Pressure, Exercise and Fitness Level in Stable Coronary Artery Disease

Background: An implantable cardioverter-defibrillator (ICD) is a treatment associated with significant cost and risk of morbidity. Elderly patients (arbitrarily defined as age≥ 75 years old) were under-represented in large clinical trials (e.g. MADIT-II and SCD-HeFT) which showed a mortality benefit with ICD implantation in patients with reduced left ventricular function. Thenetmortality benefit for this age group is unclear and there is no New Zealand data available. Aim: The aim of this study was to ascertain survival in elderly patients who have had ICDs implanted. The secondary objective was to document device related morbidity. Methods: This was a descriptive study with retrospective data collection on 41 patients age≥ 75 years old living in the Auckland region who received ICDs between 1st January 2000 to 31st December 2010. Demographic, clinical and survival data were collected retrospectively from Auckland District Health Board (DHB), Counties Manukau DHB, Waitamata DHB and regional ICD databases. Results: The total number of deaths was 15 (37%), eight cardiac and seven non cardiac. One and two year mortality rates were 2.4% (1/41) and 14.6% (6/41) respectively. Twenty patients (48.8%) received appropriate therapy while fivepatients (12.2%) received inappropriate therapy. Other device relatedmorbidity includes five implant complications (12.2%), five generator complications (12.2%) and one lead complication (2.4%) during follow up. Conclusions:While the total numberofpatients is small, our data support the value of ICD implantation in carefully selected elderly patients. Device related morbidity is acceptable.

Utilisation of Cardiac Resynchronisation Therapy at Auckland District Health Board

Background: Cardiac resynchronisation therapy (CRT) is an adjunctive treatment indicated for a subgroup of patients with severe left ventricular (LV) systolic dysfunction. We evaluate our CRT implant rate in patients who meet guideline indications. Methods: Retrospective review of Auckland District Health Board (ADHB) patients aged 150ms). Results: 4133 echocardiograms were data based between October 2008 and January 2013. 427 patients had an LVEF 150ms), were aged< 75 yrs, and resided within the ADHB region. Nine (23%) underwent CRT implant, while 31 (77%) did not. Of those who did not, 18 (58% of those who did not) had a clearly defined explanation, including: recovery of LV function (5, 16%), co-morbid illness expected to limit lifespan to <18mths (4, 13%), patient refusal (1, 3%), and suboptimal medical therapy (2, 6%). Four patients (13%) are actively having medical therapy titrated, 1 (3%) patient has been referred for CRT and is awaiting this, and 1 (3%) has never been reviewed by a Cardiologist. No clear reason could be identified for the remaining 13 (42%). Conclusions: In those identified as being eligible for CRT our implant rate is low.While CRTwill not be appropriate for all patients who fulfil the standard criteria for its use (based on echo, ECG, and age) our data strongly suggests this therapy is underutilised in our patients.

Risk factors for the development of prolonged post-operative ileus following elective colorectal surgery

Prolonged post-operative ileus (PPOI) increases post-operative morbidity and prolongs hospital stay. An improved understanding of the elements which contribute to the genesis of PPOI is needed in the first instance to facilitate accurate risk stratification and institute effective preventive measures. The aim of this retrospective cohort study was to therefore determine the perioperative risk factors associated with development of PPOI. All elective intra-abdominal operations undertaken by the Colorectal Unit at Auckland District Health Board from 1 January to 31 December 2011 were accessed. Data were extracted for an assortment of patient characteristics and perioperative variables. Cases were stratified by the occurrence of clinician-diagnosed PPOI. Univariate and regression analyses were performed to identify correlates and independent risk factors, respectively. Two hundred and fifty-five patients were identified of whom 50 (19.6%) developed PPOI. The median duration for PPOI was 4 days with 98% resolving spontaneously with conservative measures. Univariate analysis identified increasing age; procedure type; increasing opiate consumption; elevated preoperative creatinine; post-operative haemoglobin drop, highest white cell count and lowest sodium; and increasing complication grade as significant correlates. Logistic regression found increasing age (OR 1.032, 95% CI 1.004-1.061; p = 0.026) and increasing drop in pre- to post-operative haemoglobin (OR 1.043, 95% CI 1.002-1.085; p = 0.037) as the only independent predictors for developing PPOI. An important limitation of this study was its retrospective nature. Increasing age and increasing drop in haemoglobin are independent predictors for developing PPOI. Prospective assessment is required to facilitate more accurate risk factor analysis.