Auckland Hospital Research Articles

Forecasting severe respiratory disease hospitalizations using machine learning algorithms

BackgroundForecasting models predicting trends in hospitalization rates have the potential to inform hospital management during seasonal epidemics of respiratory diseases and the associated surges caused by acute hospital admissions. Hospital bed requirements for elective surgery could be better planned if it were possible to foresee upcoming peaks in severe respiratory illness admissions. Forecasting models can also guide the use of intervention strategies to decrease the spread of respiratory pathogens and thus prevent local health system overload. In this study, we explore the capability of forecasting models to predict the number of hospital admissions in Auckland, New Zealand, within a three-week time horizon. Furthermore, we evaluate probabilistic forecasts and the impact on model performance when integrating laboratory data describing the circulation of respiratory viruses.MethodsThe dataset used for this exploration results from active hospital surveillance, in which the World Health Organization Severe Acute Respiratory Infection (SARI) case definition was consistently used. This research nurse-led surveillance has been implemented in two public hospitals in Auckland and provides a systematic laboratory testing of SARI patients for nine respiratory viruses, including influenza, respiratory syncytial virus, and rhinovirus. The forecasting strategies used comprise automatic machine learning, one of the most recent generative pre-trained transformers, and established artificial neural network algorithms capable of univariate and multivariate forecasting.ResultsWe found that machine learning models compute more accurate forecasts in comparison to naïve seasonal models. Furthermore, we analyzed the impact of reducing the temporal resolution of forecasts, which decreased the model error of point forecasts and made probabilistic forecasting more reliable. An additional analysis that used the laboratory data revealed strong season-to-season variations in the incidence of respiratory viruses and how this correlates with total hospitalization cases. These variations could explain why it was not possible to improve forecasts by integrating this data.ConclusionsActive SARI surveillance and consistent data collection over time enable these data to be used to predict hospital bed utilization. These findings show the potential of machine learning as support for informing systems for proactive hospital management.

Intentional physical self-injury in Auckland: patterns, associations and clinical implications in a single-centre cross-sectional study

introduction: Intentional physical self-injury (IPSI) is a pressing health challenge and there is little awareness of injury patterns, management and outcomes. This study examines IPSI’s epidemiological and clinical aspects in one major Auckland hospital, highlighting demography, injury patterns and implications for clinical practice and prevention. methods: Using Auckland City Hospital Trauma Registry data, a retrospective, descriptive study was conducted covering adult patients admitted from January 2015 to December 2019. It assessed demographic characteristics, injury patterns and outcomes, using Mann–Whitney U tests, Fisher’s exact tests and Chi-squared tests. results: Among 137 IPSI admissions, 92 (67%) required surgery, and 24% experienced post-operative complications. Major trauma was identified in 39 (28.5%) admissions. Discharge destinations varied, with only 64 (47%) patients returning home unassisted. Injury severity did not significantly vary across sex, age or injury event location. Major injuries often resulted from falls (19 of 39) and minor injuries from lacerations/stabs (73 of 98). conclusions: IPSI represents a significant challenge to Auckland health services, with a notable burden of care. The study highlights the need for targeted interventions to reduce the incidence of IPSI and improve outcomes. It underscores the importance of multidisciplinary approaches to care, integrating surgical, mental health and rehabilitative services.

The spectrum of paediatric uveitis in New Zealand.

To describe the aetiology, complications, treatment and outcomes of paediatric uveitis. This was a retrospective chart review including all paediatric participants presenting with uveitis to a tertiary referral hospital in Auckland, New Zealand between January 1997 and March 2020. Two hundred and twenty-four eyes of 143 participants were included. One hundred and three (46.0%) eyes were found to have uveitis without the child reporting any symptoms. Non-infectious uveitis occurred in 97 (67.8%) participants and infectious aetiology occurred in 46 (32.2%) participants. One hundred and twenty-six (56.3%) eyes developed complications by final follow-up, including ocular hypertension (60 eyes, 26.8%), cataract (55 eyes, 24.6%) and glaucoma (21 eyes, 9.4%). Conventional disease modifying anti-rheumatic drugs (DMARDs) were required in 58 (59.8%) participants, and biologic disease modifying anti-rheumatic drugs in 31 (32.0%) participants with non-infectious uveitis. Participants who were younger at presentation were more likely to require a DMARD (OR 0.896 p=0.032). Vision loss of 6/15 or worse occurred in 38 (17.0%) eyes. Infections are an important cause of uveitis in this age group. Asymptomatic presentation and complications commonly occur. A large proportion of children with non-infectious uveitis will require steroid sparing immunosuppression.

Infants Eligible for Neonatal Hypoglycemia Screening

Neonatal hypoglycemia is common, occurring in up to 50% of infants at risk for hypoglycemia (infant of diabetic mother [IDM], small for gestational age [SGA], large for gestational age [LGA], and preterm) and is associated with long-term neurodevelopmental impairment. Guidelines recommend screening infants at risk of hypoglycemia. The proportion of infants who require screening for neonatal hypoglycemia is unknown. To determine the proportion of infants eligible for neonatal hypoglycemia screening using criteria from the highest-scoring critically appraised clinical guideline. This systematic review of the literature was conducted to identify clinical practice guidelines for neonatal hypoglycemia and took place at a tertiary maternity hospital in Auckland, New Zealand. Eligible guidelines were critically appraised using the Appraisal of Guidelines for Research and Evaluation II tool. Using screening criteria extracted from the highest-scoring guideline, the proportion of infants eligible for neonatal hypoglycemia screening was determined in a retrospective observational cohort study of infants born January 1, 2004, to December 31, 2018. Data were analyzed by logistic regression. Infant participants were included if gestational age was 35 weeks or more, birth weight was 2000 g or more, and they were not admitted to a neonatal intensive care unit less than 1 hour after birth. The data were analyzed from November 2022 through February 2023. A total of 101 372 infants met the inclusion criteria. Risk factors for neonatal hypoglycemia. Proportion of infants eligible for neonatal hypoglycemia screening. The study team screened 2366 abstracts and 18 guidelines met inclusion criteria for appraisal. There was variability in the assessed quality of guidelines and a lack of consensus between screening criteria. The highest-scoring guideline defined screening criteria as: IDM, preterm (less than 37 weeks' gestation), SGA (less than 10th percentile), birth weight of less than 2500 g or more than 4500 g, LGA (more than 90th percentile), or gestational age more than 42 weeks. A total of 101 372 infants met criteria for inclusion in the cohort study; median (IQR) gestational age was 39 (38-40) weeks and 51% were male. The overall proportion of infants eligible for screening was 26.3%. There was an increase in the proportion of eligible infants from 25.6% to 28.5% over 15 years, which was not statistically significant after adjustment for maternal age, body mass index, ethnicity, and multiple pregnancy (odds ratio, 0.99; 95% CI, 0.93-1.03; change in proportion per year). A systematic review found that practice guidelines providing recommendations for clinical care of neonatal hypoglycemia were of variable quality with is a lack of consensus regarding definitions for infants at risk for hypoglycemia. In the cohort study, one-quarter of infants were eligible for hypoglycemia screening. Further research is required to identify which infants may benefit from neonatal hypoglycemia screening.

Does cost minimization of hypofractionated radiation therapy content all health stakeholders?

Does cost minimization of hypofractionated radiation therapy content all health stakeholders?

ICD-10 codes for surveillance of non-fatal abusive head trauma in Aotearoa New Zealand: a retrospective cohort study

ObjectivesTo assess the validity of an International Classification of Diseases (ICD) code based definition of non-fatal head trauma caused by child abuse (abusive head trauma) for population surveillance in New...

Pre-school wheeze hospital presentations: A demographic profile and review of clinical management.

Pre-school wheeze is a common hospital presentation in Australasia. The aim of this study was to describe the regional hospital presentation and cost of pre-school wheeze. Audit of children diagnosed with pre-school wheeze at two hospitals in Auckland, New Zealand from October 2017 to September 2019. Guideline adherence was determined. One hundred and ninety-two children made 247 pre-school wheeze hospital presentations. Pre-school wheeze accounted for a larger proportion of acute hospital presentations for Māori versus non-Māori children (rate ratio 1.76, 95% confidence intervals 1.32-2.31). Hospital representations with pre-school wheeze occurred in 38/192 (20%) children. The proportion with a pre-school wheeze representation was larger for Māori than non-Māori (30% vs. 16%, P = 0.02). Pre-school wheeze event median length of stay increased as household deprivation increased (P = 0.01). Clinical severity of 247 pre-school wheeze episodes was mild (n = 64, 26%), moderate (n = 153, 62%) and severe (n = 30, 12%). Of 244 episodes, inhaled bronchodilators only were given for 149 (61%), oxygen for 54 (22%) and intravenous treatment for 41 (17%). Hospital guideline use was evident in 164/247 (66%) episodes. Neither clinical severity nor treatment intensity varied with child sex, age or ethnicity or household deprivation. The estimated median (interquartile range) direct medical costs of each pre-school wheeze episode were NZ$1279 (NZ$774-2158). In Auckland, pre-school wheeze accounts for a larger proportion of acute hospital presentations for Māori compared with non-Māori and Māori children have increased odds of pre-school wheeze readmissions. Length of hospital stay for pre-school wheeze episodes increased with household deprivation. In this audit pre-school wheeze guideline adherence was poor.

Resident medical officers' redeployment experiences in the Adult Emergency Department during the COVID-19 pandemic at Te Toka Tumai | Auckland Hospital.

Te Toka Tumai Auckland Hospital enacted a multi-faceted plan in response to widespread community transmission of the Omicron variant of SARS-CoV-2 in 2022.1 This included redeploying a number of resident medical officers (RMOs) from other specialties to assist emergency medicine and general medicine services within the adult emergency department (AED). The purpose of this report is to evaluate the experience of the redeployed RMOs and identify ways to improve the redeployment process in the future. An anonymous survey was sent out to the nineteen RMOs who were redeployed. Nine of 18 eligible RMOs responded (50%), with both quantitative and qualitative feedback collated. The quantitative data were descriptively compared, and a thematic analysis was performed. RMOs provided a range of responses about the redeployment experience, with 56% willing to be redeployed to the AED in a future crisis. Impact on training was the most commonly reported negative experience. Positive redeployment experiences related to feeling welcomed and appreciated, and to having the opportunity to enhance acute clinical skills. Areas for improvement included structured orientation, RMO input and consent in the redeployment planning process, and having a single point of communication between the RMOs being redeployed and the administration. The report identified areas of strength and areas for improvement in the redeployment process. Despite a small sample size, useful insights into the RMOs' experiences of being redeployed to acute medical services in the AED were gained.

Postcode osteoarthritis: geographic inequities in hip and knee arthroplasty.

It is suspected that there are differences in access to orthopaedic care within New Zealand (NZ), due to inter-hospital differences in scoring thresholds for surgical eligibility. We aimed to evaluate those patients who meet the threshold for publicly funded surgery with regard to both functional disability and severity of radiographic arthritis across three different public hospitals to assess any discrepancies. A retrospective review of prospectively collected data over a 12 month period (2018-2019) across three public hospitals (Auckland City, North Shore and Whangārei hospitals) in NZ was performed. Patients undergoing primary hip and knee arthroplasty for OA were eligible for the study. Preoperative Oxford Score and the Tonnis and Kellgren-Lawrence classification systems for hip and knees, respectively, were compared. A total of 274 scheduled total arthroplasties (161 hips and 113 knees) in 273 patients were included for analysis. The mean Preoperative Oxford scores for individuals with hip OA in Auckland, North Shore and Whangārei were 15.9 (SD 10.5), 14.5 (SD 6.9) and 11.9 (SD 5.7), respectively. The mean Preoperative Oxford scores for individuals with knee OA in Auckland, North Shore and Whangārei were 17.4 (SD 11.9), 18.2 (SD 6.2) and 12.7 (SD 6.9), respectively. Patients undergoing hip and knee joint replacement surgery in Whangārei hospital are, on average, more functionally impaired and have more severe radiographic arthritis than those having the same proposed surgery in Auckland and North Shore hospitals.

Increased workload without clinical benefit: Results following implementation of the ACR-TIRADS system for thyroid nodules.

The ACR-TIRADS system for stratifying thyroid nodule malignancy risk has been widely promoted and implemented. We audited its introduction at a large public hospital in Auckland, New Zealand. Audit of outcomes following thyroid nodule fine needle aspiration (FNA) before/after ACR-TIRADS. Individuals undergoing thyroid FNA 2017-2019. From medical records, we obtained details from the pre-FNA ultrasound (nodule size, TIRADS points/levels, radiologist recommendation for FNA), Bethesda (B) cytology classification, histology and post-FNA follow-up. Four hundred and twenty-two individuals had 564 FNAs, 163 had surgery and 54 (13%) had cancer in the primary nodule. 37/54 (69%) cancers were papillary thyroid carcinoma (median size 25 mm, 87% ≥10 mm, 61% ≥20 mm). Following ACR-TIRADS introduction, FNA recommendations increased greater than twofold, FNAs performed by 71%-83%, and the monthly rate of FNAs and operations by 60% and 40%, respectively. However, the proportion of cancers/FNA remained similar (9.9% post-TIRADS vs. 8.7% pre-TIRADS). The proportions of FNA results remained stable for B2-B4 categories, but doubled (11% vs. 5%) for B5-B6: 15 FNAs were needed to identify an additional B5/B6 lesion. TIRADS-5 nodules had a higher proportion of B5/B6 (20%) and a lower proportion of B2 (30%) than TIRADS-3 (2%, 57%, respectively) and TIRADS-4 (9%, 56%) nodules. About 5 additional cancers/year were diagnosed, but they were more often small (49% vs. 8% <2 cm, 17% vs. 0% <1 cm). ACR-TIRADS introduction increased workload (FNAs and operations), without increasing the proportion of cancers/FNA. It led to a few more cancers being diagnosed, but many were small and of uncertain clinical significance.

P769 Randomised feasibility study of preoperative medical nutrition therapy in adults undergoing surgery for Crohn’s disease

Abstract Background Preoperatively patients with Crohn’s disease are at high risk of malnutrition. Patients requiring surgery to manage stricturing disease are often advised to follow a low residue/low fibre diet to reduce risk of bowel obstruction. This diet is usually nutritionally inadequate and may negatively affect nutritional status. Research suggests that preoperative exclusive enteral nutrition (EEN) improves nutritional status, reduces intestinal inflammation and consequently improves surgical outcomes. Recently the Crohn’s disease exclusion diet has been shown to reduce intestinal inflammation in adults but its use preoperatively has not been reported. This research aimed to determine whether it is feasible to recruit and retain patients with Crohn’s disease in a single-blinded, multicentre, randomised controlled trial of three preoperative nutritional therapies. Methods Patients undergoing elective surgery to manage Crohn’s disease at three New Zealand tertiary care hospitals (Christchurch, Auckland and Waikato hospitals), aged &amp;gt;18 years old, with body mass index (BMI) &amp;gt; 18.5 kg/m2 and without recent significant weight loss were eligible to participate. Patients were randomised to six weeks of preoperative EEN, partial enteral nutrition with Phase-1 Crohn’s Disease Exclusion Diet (CDED) or standard care. Nutritional and radiological assessment at baseline and preoperatively was completed and surgical outcomes recorded. Descriptive statistical analysis was undertaken. Health and Disability Ethics Committee approval was given (20/NTB/134). Results Over 18 months (September 2020 to March 2022), 48 patients were screened and 17 were randomised. Patient characteristics were: median age 37.9 (range, 28-68) years, 9 (53%) female, 10 (59%) on biologic medication, median BMI 25.7 (range, 19.7-38.6) kg/m2 and 2 (12%) had low fat-free mass index. Medical nutrition therapy was completed by 13/17 (76%) patients (EEN n=4, CDED n=4 and standard care n=5) and four withdrew. BMI and simplified magnetic resonance index of activity (MaRIA) score changed by a median of -0.3 (range, -1.8 to 2.1) kg/m2 and 0.5 (range, -3 to 2) points respectively. At day 30, 10 patients had no surgical complications. Three patients had Clavien Dindo Grade 2 complications; one (standard care group) experienced fever treated with antibiotics, one (standard care group) had postoperative ileus requiring total parenteral nutrition and one (CDED group) required a blood transfusion postoperatively and antibiotics for a wound infection. Conclusion Patients who need elective Crohn’s disease surgery tolerate preoperative EEN or CDED. Use of preoperative nutrition therapies are feasible and the impact on surgical outcomes should be assessed in a larger study.

Diabetes knowledge and related cultural safety knowledge: What do new graduate nurses know?

In New Zealand, Type 2 diabetes mellitus (T2DM) is at epidemic proportions, with poor glycaemic control contributing to more patients with diabetes presenting to inpatient settings. These patients come from diverse cultural backgrounds, so their specific socioeconomic, psychosocial and social requirements are important to understand and address for the delivery of equitable and culturally appropriate diabetes care. Nurses have a central role in providing diabetes care, but they need sufficient diabetes knowledge and cultural safety skills to provide this care effectively. New graduate nurses are educated on the management of diabetes, however, there is no current research on how this education translates to the effective provision of appropriate care for inpatients with T2DM. The purpose of this study is twofold: to measure the diabetes management and related cultural safety knowledge of hospital-based new graduate nurses and to explore their experiences with providing diabetes care. Dewey’s pragmatic paradigm underpins this mixed methods research that will be conducted with new graduate nurses in a South Auckland Hospital. An adapted version of Daly et al.’s existing published telephone questionnaire (2019) will provide quantitative data and focus group interviews, the qualitative data. Findings will highlight nurses’ diabetes knowledge and diabetes-related cultural safety knowledge, and identify gaps that affect a nurse’s ability to tailor diabetes care to the patient’s cultural needs. Nurses who are educated and can give culturally appropriate care can help reduce the number of ethnic minorities presenting with diabetes complications improving the health users’ outcomes. The study’s findings will inform organisations about diabetes education needs and influence undergraduate and post-graduate nursing diabetes training programmes.

Developing a DBR Model for Designing Authentic Healthcare Solutions: Mobile and Wearable Technologies

&#x0D; &#x0D; &#x0D; This concise paper outlines the initial stages of a project involving a transdisciplinary team of educational researchers, practitioners, student designers, and the Auckland Hospital Design Lab in the design of innovative technology enhanced solutions to enhance patient and health care practitioner experiences. We outline the methodological design of the collaborative Design Based Research (DBR) approach. Using DBR, the project explores real world problems in health care with a team of student designers evaluating the application of mobile and wearable technologies to these problems. The goal of the project is the development of design principles for innovative learning environments that facilitate student-determined learning in real world scenarios.&#x0D; &#x0D; &#x0D;

Introduction of a Standardized Maternity Early Warning System: Indicative Data From a Before-and-After Study at a Large Pilot Site Before National Rollout in Aotearoa New Zealand

(Anaesthesia. 2021;76:1600–1606) While there are recognition and response standards in place to decrease preventable adverse outcomes for nonpregnant adult patients and there is maternity-specific observation scoring system (MEOWS) in place for obstetric patients in the United Kingdom. An in-depth multidisciplinary review of study cases in Aotearoa New Zealand showed inadequate recognition and response standards may have significantly impacted maternal morbidity. A major tertiary hospital in Auckland piloted a modified version of the Aotearoa New Zealand early warning system (NZEWS) to promote better recognition and response of deteriorating pregnant women (NZMEWS). This study aimed to determine the efficacy of NZMEWS shown in the number of code blue and code red (cardiorespiratory arrests and very unwell women need an emergency response team, respectively) comparing the occurrence of codes before and after NZMEWS implementation.

Midwives' views on the acceptability of a future trial of the Sims posture for fetal malposition in labor in the context of their knowledge and practice: A mixed-methods study.

INTRODUCTIONEvidence of safe and effective maternal interventions to improve fetal malposition in labor is inconclusive. A contemporary, randomized controlled trial of maternal posture would expand this evidence, however, collaboration with midwives will be critical. The aim of this study is to assess midwives’ views on the acceptability of a trial of the Sims posture for fetal malposition in labor and identify current midwifery knowledge and practice surrounding fetal malposition.METHODSA mixed-methods study incorporating a web-based survey and guided focus groups with midwives was conducted in New Zealand during 2020. Midwives serving Auckland Hospital and Māori and Pasifika midwives serving South Auckland (n=136) were invited to participate in the study. Data were descriptively analyzed using chi-squared and cross-tabulation. Collaboration with a trial was contextualized by thematic content from survey and focus-group data.RESULTSFifty (36%) midwives from primary and secondary/tertiary settings responded to the survey, and 19 participated in four focus groups. Most midwives thought maternal posture affects malposition, utilize changes of posture often with the peanut ball, would recommend a posture if cesareans were reduced by 20%, and would definitely or probably collaborate with a labor trial of posture. Fetal monitoring with women in the Sims posture was difficult for nearly one-fifth of midwives. Seven themes emerged regarding trial participation: trial design, relevance, practice, diagnosis, knowledge and skills, and trial compliance.CONCLUSIONSCurrent practice concerning malposition utilizes flexibility of posture. Provision of some free movement and reassurance surrounding trial equipoise may enhance trial collaboration.

'As Long as It's Used for Beneficial Things': An Investigation of non-Māori, Māori and Young People's Perceptions Regarding the Research use of the Aotearoa New Zealand Integrated Data Infrastructure (IDI).

The Aotearoa New Zealand Integrated Data Infrastructure (IDI) is a national database containing a wide range of data about people and households. There is limited information about public views regarding its use for research.A qualitative study was undertaken to examine the views of forty individuals attending a large hospital in Auckland, including those of Māori ethnicity and young people. Semi-structured interview data were analysed using Braun and Clarke's method of thematic analysis.Seven key themes emerged: 1) Limited knowledge about medical data held in national databases; 2) Conditional support for the use of the IDI, including for research; 3) Concerns regarding the misuse of IDI data; 4) The importance of privacy; 5) Different views regarding consent for use of data for research; 6) Desire for access to personal data and the results of research; and 7) Concerns regarding third party and commercial use. Young people and those of Māori ethnicity were more wary of data misuse than others.Although there is reasonable support for the secondary use of public administrative data in the IDI for research, there is more work to be done to ensure ethical and culturally appropriate use of this data via improved consent privacy management processes and researcher training.

Detection of Anastomotic Leakage Following Elective Colonic Surgery: Results of the Prospective Biomarkers and Anastomotic Leakage (BALL) Study

Anastomotic leakage (AL) is an infrequent but life-threatening surgical complication following colorectal surgery. Early diagnosis remains clinically difficult but is a necessity to reduce associated morbidity and mortality. Clinical review and radiological modalities for the diagnosis of leakage remain non-specific and often only detect AL once it is well developed. Inflammatory biomarkers however have shown promise in early pre-clinical detection of leakage following colorectal surgery. A multi-center, prospective observational study was conducted across four public hospitals in Auckland and Christchurch, New Zealand. Consecutive adults undergoing elective colectomy were initially recruited over a 3-y period. Perioperative blood samples were collected to measure interleukin (IL)-6, IL-1β, tumor necrosis factor α, IL-10, C-reactive protein (CRP), leukocyte and neutrophil counts. Statistical analysis was performed to compare patients with an uncomplicated recovery with patients with AL. Sixteen patients developed AL (5.7%), diagnosed at a median post-operative (POD) day 7. CRP and IL-6 were consistently elevated in the early post-operative period in patients with AL, and had the best diagnostic accuracy on POD 3 (area under the curve 0.70; P=0.02) and POD 1 (area under the curve 0.69; P=0.02), respectively. IL-10, once adjusted for body mass index and surgical approach, was the sole biomarker significantly elevated in patients with AL on POD4. Early post-operative elevations of CRP and IL-6 provide utility for early detection of AL after elective colectomy. Application of these inflammatory biomarkers and their combinations in daily practice warrants further investigation.

Evaluation of the inflammatory profile following uncomplicated elective colectomy.

BackgroundAttenuation of the inflammatory response in patients undergoing colectomy with modern perioperative care and laparoscopic surgery has been a focus of research in recent years. Despite reported benefits, significant heterogeneity remains with studies including patients undergoing both rectal and colon surgery and including surgery with postoperative complications. Therefore, the aim of the study was to evaluate the inflammatory response in patients undergoing elective colectomy without complications, specifically comparing open and laparoscopic approaches.MethodsA multicenter prospective study was conducted across four public hospitals in Auckland and Christchurch, New Zealand. Consecutive adults undergoing elective colectomy were included over a 3‐year period. Perioperative blood samples were collected and analysed for the following inflammatory markers: IL‐6, IL‐1β, TNFα, IL‐10, CRP, leucocyte and neutrophil count. Statistical analysis was performed using SPSS statistical software.ResultsA total of 168 colectomy patients without complications were included in the analysis. Patients that underwent laparoscopy had significantly reduced IL‐6, neutrophils and CRP on postoperative day (POD) 1 (p < 0.05) compared to an open approach. IL‐10 and TNFα were significantly reduced on POD 2 (p < 0.05) in laparoscopic patients. Patients with a Body Mass Index (BMI) greater than 30 kg/m2 had significantly higher levels of CRP regardless of operative approach. Statins altered both preoperative and postoperative inflammatory markers.ConclusionThe postoperative inflammatory response is influenced by surgical approach, perioperative medications, and patient factors. These findings have important implications in the utility of biomarkers in the diagnosis of postoperative surgical complications, in particular in the early diagnosis of anastomotic leak.

Changing the routine: a move to patient initiated follow up to improve surgical outpatient clinic

IntroductionPatient initiated follow up (PIFU) allows patients to initiate a hospital follow up appointment on an ‘as required’ basis in contrast to the traditional physician‐initiated model. We present a clinical pathway for patients referred with rectal bleeding at a large tertiary public hospital in South Auckland, New Zealand and demonstrate the utility of PIFU and its impact on reducing follow up appointments.MethodThe purpose of the pathway was to allow standardized care by the clinicians and allow for PIFU. Two separate protocols were developed ‐ ‘Painful PR bleeding’ and ‘Painless PR bleeding’. A new clinic (NC) was started following these protocols, and this was compared to historical controls (HC). The primary outcome was the rate of follow up appointments.ResultsThere were 133 patients in the NC and 135 in the HC, with significantly less follow ups in the NC (6% versus 45%, p < 0.0001). A small percentage of patients in the NC group were directly discharged (10%) whilst 70% of patients were discharged with a PIFU card. Thirty phone calls were made using PIFU, with 10 patients returning to clinic and 20 requiring advice and reassurance only. At 5 year follow up, there was a single colorectal malignancy found in both groups.ConclusionInitiating a protocol that includes patient initiated follow up vastly reduces the need for routine return to clinic for the majority of patients, without sacrificing patient care. A protocolised approach to clinic for other areas in general surgery should be considered.

Psychological well-being of women at high risk of spontaneous preterm birth cared for in a specialised preterm birth clinic: a prospective longitudinal cohort study

ObjectivesTo assess the psychological well-being of pregnant women at increased risk of spontaneous preterm birth, and the impact of care from a preterm birth clinic.DesignSingle-centre longitudinal cohort study over 1...