Auckland Hospital Research Articles

Book Review: In the Beginning: A history of the Medical Unit at Auckland Hospital and the formative years of the Department of Medicine, by David Richmond, Thomas Miller and Judy Murphy

Book Review: In the Beginning: A history of the Medical Unit at Auckland Hospital and the formative years of the Department of Medicine, by David Richmond, Thomas Miller and Judy Murphy

Surgeon-scientist Downunder

IN THE FALL OF 1968, FRANCIS D. MOORE was a visiting Professor of Surgery to the University of Otago in New Zealand. He gave many lectures and presided over several presentations. One of these presentations was given by a surgical trainee who described the successful nutritional treatment of a pediatric patient with a chylothorax resulting from complications of thoracic surgery. That trainee was Graham L. Hill and the encounter with the ‘‘great bridge-tender from Boston’’ unimaginably influenced his life to the benefit of countless patients and surgical science. Although Boston is now only 2 flights from New Zealand, in the 1960s it seemed much farther away. Thus, the ‘‘heroes’’ of surgery were as far away as the moon to New Zealand surgeons. A visit by a doyen of surgery such as Dr Moore was therefore a huge moment to the surgeons of the country and an awe inspiring experience for the surgery residents of the day (including Dr Murray Brennan, who went to work with Moore after this visit). A similar visit by Franklin Martin and Will Mayo in 1924 had lead to the founding of the Royal Australasian College of Surgeons. The paper presented to Dr Moore was Graham Hill’s first research project and was published in The Lancet. He began his academic career while working as a missionary in rural Indonesia and he went on to work alongside luminaries such as Stanley Dudrick in Houston and John C. Goligher in Leeds before returning to New Zealand as the Professor and Head of Surgery at Auckland Hospital and the University of Auckland. His stated

Neurological manifestations of phaeochromocytomas and secretory paragangliomas: a reappraisal

ObjectiveTo determine the frequency and range of neurological manifestations of phaeochromocytomas and secretory paragangliomas.MethodsA retrospective review of case notes of patients admitted to Auckland Hospital from 1985 to 2011 with...

Primary prevention of pediatric abusive head trauma: A cost audit and cost-utility analysis

ObjectivesTo obtain comprehensive, reliable data on the direct cost of pediatric abusive head trauma in New Zealand, and to use this data to evaluate the possible cost–benefit of a national primary prevention program. MethodsA 5 year cohort of infants with abusive head trauma admitted to hospital in Auckland, New Zealand was reviewed. We determined the direct costs of hospital care (from hospital and Ministry of Health financial records), community rehabilitation (from the Accident Compensation Corporation), special education (from the Ministry of Education), investigation and child protection (from the Police and Child Protective Services), criminal trials (from the Police, prosecution and defence), punishment of offenders (from the Department of Corrections) and life-time care for moderate or severe disability (from the Accident Compensation Corporation). Analysis of the possible cost-utility of a national primary prevention program was undertaken, using the costs established in our cohort, recent New Zealand national data on the incidence of pediatric abusive head trauma, international data on quality of life after head trauma, and published international literature on prevention programs. ResultsThere were 52 cases of abusive head trauma in the sample. Hospital costs totaled $NZ2,433,340, child protection $NZ1,560,123, police investigation $NZ1,842,237, criminal trials $NZ3,214,020, punishment of offenders $NZ4,411,852 and community rehabilitation $NZ2,895,848. Projected education costs for disabled survivors were $NZ2,452,148, and the cost of projected lifetime care was $NZ33,624,297. Total costs were $NZ52,433,864, averaging $NZ1,008,344 per child. Cost-utility analysis resulted in a strongly positive economic argument for primary prevention, with expected case scenarios showing lowered net costs with improved health outcomes. ConclusionsPediatric abusive head trauma is very expensive, and on a conservative estimate the costs of acute hospitalization represent no more than 4% of lifetime direct costs. If shaken baby prevention programs are effective, there is likely to be a strong economic argument for their implementation. This study also provides robust data for future cost–benefit analysis in the field of abusive head trauma prevention.

Sir Brian Gerald Barratt-Boyes—Pioneer Cardiac Surgeon

N t h F t Dana-Farber Cancer Institute, Boston, MA (D.P.S.). B orn on January 13, 1924, in Wellington, New Zealand, Brian Barratt-Boyes attended Wellington College and then Victoria University, both in Wellington. He graduated in medicine from Otago Medical School (Dunedin, New Zealand) in 1946. He received initial surgical training in New Zealand and then trained with pioneering cardiac surgeon John Kirklin at Mayo Clinic in Rochester, Minnesota, from 1953 to 1955. Following a 1-year Nuffield Fellowship in England—a program endowed in 1940 by Viscount Nuffield of Oxford (William Morris, founder of Morris Motors) to support research in health care policy—BarrattBoyes was recruited by Sir Douglas Robb, New Zealand’s pioneer of heart surgery, to Green Lane Hospital in Auckland, New Zealand. At Green Lane, Barratt-Boyes pioneered the development of cardiopulmonary bypass surgery, using this technique for the first time on a patient in New Zealand in 1958. He was also one of the first surgeons to implant a pacemaker (a prototype built in a university laboratory) in the human heart before these devices became commercially available in 1961. He credited these early successes in part to the remoteness of New Zealand with its accompanying freedom from the distractions of large urban centers, and he compared this to the single-minded devotion that the small city of Rochester had allowed Kirklin. In 1962, independently and almost simultaneously with Donald Ross of London, Barratt-Boyes introduced human cadaveric aortic homografts for aortic valve replacement. He championed the physiologic advantages of such grafts and simplified their surgical implantation technique. He also introduced the use of hypothermia and cardiac arrest for major surgery in neonates and infants. He was coauthor t

Safety of Conscious Sedation for Cardiology Procedures at Auckland Hospital

Safety of Conscious Sedation for Cardiology Procedures at Auckland Hospital

Socioeconomic deprivation, readmissions, mortality and acute exacerbations of bronchiectasis

Bronchiectasis is known to cause significant morbidity in children in New Zealand. Little is known of the disease in adults. Our objective was to characterise a cohort of adults who presented to hospital with acute exacerbations of the disease. We retrospectively collected information on all exacerbations treated as inpatients from a single hospital in South Auckland, New Zealand during 2002. We collected information on 307 exacerbations in 152 patients. Twenty-seven per cent were of Maaori ethnic origin, and 44% Pacific. Seventy per cent lived in areas categorised as the 20% most deprived in New Zealand. Comorbid conditions were present in 80% of patients - most commonly chronic obstructive pulmonary disease, asthma, diabetes and cardiac disease. Seventy (46%) patients had at least one readmission and 32 patients (21%) died within 12 months of admission to hospital. Greater deprivation was associated with increased mortality at 12 months after admission after adjusting for other factors (OR 11, 95% CI 2.0-61, P= 0.006). In the subgroup who underwent high-resolution computed tomographic scanning (93), increasing severity of bronchiectasis (modified Bhalla score) was associated with readmission within 12 months (P= 0.004), but not mortality (P= 0.419). We have shown that exacerbations of bronchiectasis in South Auckland are more common in patients who are predominantly of Maaori or Pacific descent and are socioeconomically deprived. Admission to hospital for an exacerbation is associated with high readmission and mortality rates.

Comparative epidemiology of CTX-M-14 and CTX-M-15 producing Escherichia coli: Association with distinct demographic groups in the community in New Zealand

Extended spectrum beta-lactamase producing E. coli (ESBL-EC) are an emerging public health issue. In New Zealand (NZ), bla (CTX-M-14) and bla (CTX-M-15) are the most common ESBL genes. Although many studies describe risk factors for ESBL-EC, few describe risk factors for specific ESBL genes. Between January 2006 and December 2007, we characterized 108 consecutive, non-duplicate isolates of ESBL-EC at the Auckland Hospital laboratory. Demographic and clinical data were recorded. Of the 108, 54.6% (59) were CTX-M-15-EC, 26.9% (29) were CTX-M-14-EC and 12.09% were CTX-M-9 (13). The remaining seven isolates carried CTX-M-3 (3; 2.7%), CTX-M-65 (2; 1.8%), CTX-M-27 (1; 0.9%) and CTX-M-57 (1; 0.9%). CTX-M-15-EC were more likely than CTX-M-14-EC to be fluoroquinolone-resistant (86.4% versus 32.4%; p=0.006) and to be non-susceptible to amoxicillin-clavulanate (84.7% versus 41.4%; p=0.0001). Patients with CTX-M-15-EC were more likely to be of Indian ethnicity (34.5% versus 0%; p=0.0012) and to have travelled recently (31.6% versus 4%; p=0.0088). Patients with CTX-M-14-EC were more likely to have Chinese or South-East Asian ethnicity (48.1% versus 5.2%; p<0.0001) and to have no history of either travel or prior hospital admission (44% versus 8.9%; p=0.0006). These data imply that CTX-M-15 and CTX-M-14 producing E. coli are associated with distinct demographic subgroups in NZ.

Impact of Coeliac Disease on the Partner’s diet- No Altruism

Background: Coeliac disease is an autoimmune disorder characterised by intolerance to gluten in genetically susceptible individuals. Withdrawal of dietary gluten remains the only effective treatment at present. Aim: To investigate whether partners of patients with coeliac disease adopt a gluten-free diet to support the patients and to assess the impact of gender on dietary concordance. Methods: A pilot case-control study was carried out at university teaching hospitals in Auckland, New Zealand and Cardiff, United Kingdom. 38-item dietary questionnaires were completed by patients, controls and their partners. The discordance between the diet of patients or controls and their partners was compared and Student’s t -test applied to the results. Results: The discordance scores were significantly greater in case couples than in control couples. (16.6-female patient couples, 15.1-male patient couples versus 6.2-control couples; p<0.00003). Amongst case couples, the discordance scores were similar irrespective of the gender of the patient. Couples in New Zealand and Wales behaved in a similar manner. Conclusion: There is no evidence that partners of patients with coeliac disease adopt the gluten free diet of the patient in order to support them with their diet.

The Appointment of a Huntington's Disease Nurse Specialist has Reduced Admission Rate and Improved Admission Quality.

We aimed to determine if the appointment of a Huntington's disease (HD) nurse specialist has influenced inpatient admission rates and admission quality at Auckland Hospital. We collated HD inpatient admission data for the 32 months before and after her appointment and compared the quality of cognition, mood, speech/swallowing and safety assessments between admissions where the nurse was and was not involved. After the appointment of the HD nurse there was a 51% reduction in average monthly HD admission rates (p = 0.0009). HD admissions specifically related to HD decreased by 54% (p = 0.005). There was also an improvement in the quality of admissions.

How experience shapes the brain

Simon Rowley, paediatrician at Auckland Hospital and Brainwave Trustee, wrote this informative article for the July 2009 Chronicle.

PROTHROMBINEX ®-VF (PTX-VF) usage for reversal of coagulopathy: Prospective evaluation of thrombogenic risk

Introduction Prothrombin complex concentrates (PCCs) are used for the urgent reversal of oral vitamin K antagonists in patients with life-threatening bleeding or prior to urgent procedures/surgery. PCCs offer rapid and complete reversal without the disadvantages of volume overload and adverse reactions seen with fresh frozen plasma (FFP). There is concern about the risk of thrombosis associated with the use PCCs; data on this is limited at present. Objectives To determine the incidence of objectively confirmed arterial or venous thromboembolism within 30 days following the administration of PROTHROMBINEX®-VF (PTX-VF) to acutely reverse a prolonged INR. Materials/Methods A prospective observational study was conducted at two teaching hospitals in Auckland, NZ. All patients who received PTX-VF for the acute reversal of prolonged INR were eligible. Baseline patient demographics and reasons for PTX-VF administration were recorded. Patients were reviewed at days 7 and 30, to confirm/exclude thromboembolism or adverse events. Results 173 patients were enrolled from August 2008 to March 2009. The most frequent indication for reversal was acute bleeding. At 30 days 4.6% (8/173) patients had a definite/probable thrombotic event, and 16.7% had died either due to the presenting bleed (intracranial haemorrhage) or a complication of their presenting complaint (e.g. sepsis, renal failure). Conclusions Acute reversal of anticoagulant therapy with PTX-VF is associated with a significant rate of thromboembolism (4.6%) within 30 days. These events can be explained by ongoing cessation of anticoagulant therapy in patients with ongoing risk factors for arterial or venous thrombosis, rather than directly attributable to PTX-VF therapy.

Acculturation of Pacific mothers in New Zealand over time: findings from the Pacific Islands Families study.

BackgroundThe epidemiological investigation of acculturation has often been hampered by inconsistent definitions and measurement, and methodological short-comings. Adopting a bi-directional model, with good theoretical and psychometric properties, this study aimed to describe the temporal, ethnic and socio-demographic influences of acculturation for a group of Pacific mothers residing in New Zealand.MethodsPacific mothers of a cohort of Pacific infants born at a large tertiary hospital in South Auckland in 2000 were interviewed at 6-weeks, 4-years and 6-years postpartum. At each measurement wave a home interview lasting approximately 90 minutes was conducted with each mother. Adapting the General Ethnicity Questionnaire, two scales of acculturation were elicited: one measuring New Zealand cultural orientation (NZAccult) and one measuring Pacific Islands cultural orientation (PIAccult). Acculturation scores were standardised and analysed using random intercept polynomial and piecewise mixed-effects regression models, accounting for the longitudinal nature of the repeated measured data. Mothers who immigrated to New Zealand and those who lived their lives in New Zealand were investigated separately.ResultsOverall, 1276 Pacific mothers provided 3104 NZAccult and 3107 PIAccult responses over the three measurement waves. Important and significant differences were observed in both bi-directional acculturation measures between the two maternal groups studied. New Zealand cultural orientation increased, on average, linearly with years lived in New Zealand both for immigrant mothers (0.013 per year, 95% CI: 0.012, 0.014), after adjusting for maternal age, and for mothers who lived their lives in New Zealand (0.008 per year, 95% CI: 0.06, 0.010). Immigrant mothers maintained their Pacific cultural orientation for, on average, 12 years before it began to linearly decrease with each year lived in New Zealand thereafter (-0.009 per year, 95% CI: -0.010, -0.008), after adjusting for maternal age. Mothers who lived their lives in New Zealand had a Pacific orientation that was, on average, unchanged regardless of the number of years lived in New Zealand. Significant ethnic and socio-demographic variations were noted.ConclusionsUnderstanding the patterns and trajectories of acculturation over time, and its key determinants, is necessary for the development of appropriate targeted health policy and care in typically vulnerable and marginalised immigrant populations.

Do Maori and Pacific Islander men present with more advanced prostate cancer than European New Zealand men? An analysis of 486 men undergoing biopsy in Auckland

• To address the question of whether Maori and Pacific Islander men in Auckland present with more advanced prostate cancer at diagnosis than New Zealand European or European men. • A retrospective database audit was undertaken of all men presenting for a first prostate biopsy under the Auckland Hospital Urology Service in 2005 and 2006. • Ethnicity was coded from self-identification codes on hospital databases. • Population numbers were obtained from the 2006 Census figures from Statistics New Zealand. • Primary outcome measures used as surrogates for advanced disease were PSA level at biopsy, Gleason Score and palpable abnormality on digital rectal examination and rates of metastatic disease as determined by nuclear medicine bone scan. • There was no appreciable difference when Maori and Pacific Islander men were compared with European men for median PSA level (13.30 vs 12.55 ng/mL, P = 0.264); median Gleason score (7 and 7), mean Gleason score (7.0 vs 6.9, P = 0.196) or the proportion of Gleason Score 7 or 8-10 (P = 0.431) • There was no difference between the rates of metastatic disease at presentation (11.5% vs 7.8%, P = 0.376). • There appeared to be a significant difference in the proportion of Maori and Pacific Islanders presenting with palpable disease (67.2%) compared with European men (53.3%, P = 0.042). • The crude population biopsy rate per 100,000 was similar for Maori and Pacific Islander and European men (560 vs 547). • Maori and Pacific Islander men present with similar prostate cancer characteristics to European men at diagnosis but there appears to be a real discrepancy in the rates of palpable disease.

Sudden unexpected infant death in Auckland: a retrospective case review

To review autopsy reports of all SUDI deaths in the Auckland region, New Zealand, from October 2000 to December 2009. Information on all SUDI cases from 2000 to 2009 was extracted from autopsy and police reports from the National Forensic Pathology Service at Auckland Hospital. Of the 332 post-mortems in this period, 221 were classified as SUDI. Of these, 83% were Māori or Pacific infants. The median age at death was 11 weeks and 11% occurred in 7- to 28-day-olds. At the time of death, 64% overall were bedsharing; this was more common in 7-28 day olds (92%). Bedsharing infants were significantly younger at death than non-bedsharing infants (p=0.008). Where sleep position was known, 57% were placed in non-supine at the last sleep. There was no evidence of diagnostic shift and the prevalence of bedsharing did not change over the decade. Bedsharing was associated with a high proportion of SUDI cases, especially in the youngest infants, and non-supine sleep positions were common. There is a need to enhance SUDI prevention messages and consider innovative ways of promoting safe sleeping environment and supine sleep position in Māori and Pacific communities.

Pregnancy and neonatal outcomes following hyperemesis gravidarum.

Undernutrition during pregnancy is associated with detrimental pregnancy and neonatal outcomes, which can have long-term implications for the infant. Hyperemesis gravidarum may severely limit nutritional intake. The aim of this study was to investigate the effect of hyperemesis on pregnancy and neonatal outcome, particularly gestation length and infant size at birth. Seventy-five prospectively recruited women admitted to a tertiary level hospital in Auckland, with hyperemesis gravidarum between March 2003 and October 2005, were compared to 142 controls matched for age, parity, ethnicity and expected date of delivery. Data were obtained from electronic records and analysed by Student's t-test, χ2, Wilcoxon, Fisher's exact tests and linear regression. Length of gestation, birth weight and crown-heel length were not different between participants and controls. Infants born to women with hyperemesis gravidarum had smaller head circumferences (Z-score mean (s.d.) 0.02 (0.16) v. 0.43 (0.11), P = 0.04 in all infants and -0.02 (1.24) v. 0.48 (1.29), P = 0.01 in-term infants). This study found hyperemesis gravidarum to be associated with smaller head circumferences in offspring. Given the reported associations between smaller head circumference at birth and lower cognitive ability and higher risk of cardiovascular disease in later life, further study is necessary to confirm these results and to determine whether there are any long-term implications for the offspring.

Multimodal Rehabilitation in the Laparoscopic Era: Still Worth it?

Auckland, New Zealand Correspondence: Mattias Soop, M.D., Ph.D., Department of Surgery, University of Auckland and North Shore Hospital, Private Bag 92 019, Auckland 1142, New Zealand. E-mail: [email protected]

FAM13A locus in COPD is independently associated with lung cancer &amp;ndash; evidence of a molecular genetic link between COPD and lung cancer

Recent genome-wide association studies have reported a FAM13A variant on chromosome 4q22.1 is associated with lung function and COPD. We examined this variant in a case-control study of current or former smokers with chronic obstructive pulmonary disease (COPD, n = 458), lung cancer (n = 454), or normal lung function (n = 488). Sex, age, and smoking history were comparable between groups. We confirmed the FAM13A variant (rs7671167) confers a protective effect on smoking-related COPD alone (C allele odds ratio [OR] = 0.79, P = 0.013, and CC genotype OR = 0.71, P = 0.024) and those with COPD, both with and without lung cancer (C allele OR = 0.80, P = 0.008, and CC genotype OR = 0.70, P = 0.007). The FAM13A variant also confers a protective effect on lung cancer overall (C allele OR = 0.75, P = 0.002, and CC genotype OR = 0.64, P = 0.003) even after excluding those with co-existing COPD (C allele OR = 0.67, P = 0.0007, and CC genotype OR = 0.58, P = 0.006). This was independent of age, sex, height, lung function, and smoking history. This protective effect was confined to those with nonsmall cell lung cancer (C allele OR = 0.72, P = 0.0009, and CC genotype OR = 0.61, P = 0.003). This study suggests that genetic predisposition to COPD is shared with lung cancer through shared pathogenetic factors such as the 4q22.1 locus implicating the Rho-kinase pathway.

10. The origin of the neurology department at Auckland hospital

10. The origin of the neurology department at Auckland hospital

A multi-faceted approach to the physiologically unstable patient

Patients on general hospital wards who deteriorate clinically are often not recognised as needing an escalation in care, and effective interventions are delayed. This study reviews a multifaceted approach to the identification and management of these patients in a large metropolitan hospital in Auckland, New Zealand. Four interventions were combined into the Physiologically Unstable Patient (PUP) programme. These were: (1) redesign of the vital sign observation chart; (2) introduction of an early warning scoring system; (3) deployment of a nurse-led rapid response team; and (4) a comprehensive ward-based education programme. Completeness and accuracy of routine observations; actions taken in accordance with the algorithm; impact on medical emergency team callouts, cardiac arrest calls and unplanned intensive care unit admissions. The PUP programme was implemented in 16 wards over 15 months. Vital sign recording improved, and the PUP score became a recognised metric for prioritising patients for review. Consistent with others' experience, there was a reluctance to call for help. Raised PUP scores prompted action around 30% of the time on average. Medical emergency team calls increased significantly from a median of 27.5 calls per month to 70.5. There was no significant change in unplanned transfers to intensive care unit or in cardiac arrest calls. A multifaceted programme to identify physiologically unstable patients on general wards can be introduced and can improve the recognition of such patients, but there are still barriers to ensuring that these patients receive the extra care that they require. These systemic failings need to be investigated and addressed for real change to occur.