Counties Manukau District Health Board Research Articles

Prevalence of Micronutrient Deficiencies in Preoperative Bariatric Patients in a New Zealand Tertiary Centre.

A potential complication of bariatric surgery is development of nutritional deficiencies. Study aims were to assess prevalence of micronutrient deficiencies in preoperative bariatric patients and to examine for ethnic differences. Retrospective analysis of 573 patients that underwent bariatric surgery at Counties Manukau District Health Board was carried out. Mean preoperative levels of albumin, calcium, phosphate, folate, vitamin B12, vitamin D, magnesium, haemoglobin, haematocrit, mean cell volume, mean cell haemoglobin, ferritin, iron, and transferrin were calculated. Chi square, fisher exact test, and multiple logistic regression was used to assess for differences in prevalence of micronutrient deficiencies across ethnicities. The most common micronutrient deficiency was vitamin D (30.85%). There were statistically significant differences invitamin D deficiency across ethnicities(p < 0.0001). Asians hadthe highest prevalence of vitamin D deficiency (60%), followed by Pacifica (44.57%), and Māori (31.68%). Asians were more likely to have vitamin D deficiency compared to NZ/Other Europeans (OR = 14.93, p < 0.001). Vitamin D deficiency was associated with higher BMI (OR = 1.05, p = 0.008). The second most common deficiency was iron (21.1%). Asians had the highest prevalence of iron deficiency (44%), followed by Māori (27.95%), and Pacifica (19.57%) (p = 0.0064). Compared to NZ/Other Europeans, Asians (OR = 4.26) and Māori (OR = 1.78) were more likely to be iron deficient (p = 0.004). Female gender was associated with iron deficiency(OR = 2.12, p = 0.007). Vitamin D and iron are the most common micronutrient deficiencies among preoperative bariatric patients in this cohort and ethnic differences were seen. There may be a role for preoperative supplementation in these at-risk ethnic groups.

Orbital Fractures Treated in Auckland From 2016 to 2020: Review of Patient Outcomes

Orbital reconstruction is a complex procedure demanding accurate placement of implants to restore volume and anatomic shape to the orbits. Intra-operative computed-tomography (CT) and rapid-prototype (RP) biomodels have been recently introduced as surgical aids to improve outcomes. Investigation is required to determine if there is a reduction in post-operative ophthalmic complications. Study Design Retrospective cohort study. Objective To evaluate the impact of intra-operative CT and RP biomodels on the incidence of post-operative diplopia, paraesthesia, cosmetic issues and ability to return to work following orbital reconstruction surgery. Methods Adult (&gt;18 years) patients treated at Counties Manukau District Health Board, Auckland, by the Department of Oral and Maxillofacial Surgery for isolated orbital fractures were retrospectively enrolled into this study. An audit of clinical records was undertaken to determine incidences of diplopia, altered sensation, cosmetic concerns and ability to return to work. These findings were compared against our previous audit which documented these findings in patients treated between 2010 and 2015, prior to the introduction of intra-operative CT and RP biomodels. Results Routine use of intra-operative CT and RP biomodels was associated with a reduced incidence of post-operative diplopia. No significant difference was observed with regards to paraesthesia and cosmetic deficits. Conclusions The relatively low radiation exposure and cost associated with intra-operative CT and RP biomodels is justified with improved outcomes in subjective diplopia. Titanium as a material for orbital reconstruction was confirmed to be associated with low complication rates.

Investigating the distribution of primary and secondary care referrals for public-funded bariatric surgery at Counties Manukau Health (CMH).

This study investigated variations in referral rates for bariatric surgery from primary and secondary care providers across the Counties Manukau district health board (CMDHB), with the aim of identifying "hot spots" for referrals so that intervention to help achieve equitable access to bariatric surgery can be implemented. Referral data was gathered from hospital referral records from January 2017 to January 2019 (n=1,440). Referral rate per geographical location within the CMDHB catchment was calculated using 2018 census figures. Of the 1,195 referrals included, 1040 (87%) referrals were from primary care. The referrals came from 328 general practitioners (GPs) across 158 practices. There was considerable regional variation in referral rates per 1000 people, from a peak of 71.5/1000 to a low of 0.2/1000. Eighty-six percent of secondary care referrals were received from the public system and the remainder from private practice. The most common referral specialty was diabetes, followed by general surgery and orthopaedics. Out of these referrals, 434 (36%) proceeded to bariatric surgery. Pākehā (50%) were more likely to proceed to surgery than Māori (31%) and Pasifika (22%), despite similar referral numbers. There is significant variation in referrals for bariatric surgery across CMDHB. Systematic discussion of bariatric surgery with every patient who is likely to benefit is not occurring, given relatively low referral volumes.

Do Māori and Pacific Peoples Living with Dementia in New Zealand Receive Equitable Long-Term Care Compared with New Zealand Europeans?

<strong>Context:</strong> Compared to Europeans, Māori and Pacific peoples living with dementia in the Counties Manukau District Health Board region are three times less likely to use Aged Residential Care (ARC). <strong>Objectives: </strong>The aim of this study was to investigate whether reduced ARC utilisation by Māori and Pacific peoples living with dementia is equitably compensated by an increase in Home Based Support Service (HBSS). <strong>Methods:</strong> Routinely collected sociodemographic and clinical data for people diagnosed with dementia at an NZ memory service (2013–2019) were linked with administrative ARC and HBSS invoicing data. Two-part models were used to estimate adjusted costs of HBSS utilisation or ARC placement. <strong>Findings: </strong>six hundred fifty-seven people of European, Māori and Pacific ethnicity were included in the analysis. Compared to Europeans, both unadjusted and adjusted ARC costs per person-year were significantly lower for both Māori (–NZD$3580, 95%CI: –$6890, –$140) and Pacific peoples (–NZD$3110, 95%CI: –$5590, –$540) but HBSS cost per person-year was only higher for Pacific peoples (+NZD$640, 95%CI: $100, $1180) and not Māori (+NZD$180, 95%CI: –$470, $840). There was no significant difference in the combined HBSS and ARC cost per person-year for Māori (–NZD3460, 95%CI –7200, 280) or Pacific peoples (–NZD2490 95%CI –5090, 110). <strong>Conclusions:</strong> Lower ARC utilisation amongst Māori and Pacific peoples living with dementia does not translate to an equitable increase in HBSS spend. The difference is likely to be compensated by care provided by unpaid family carers. Addressing the wider determinants of long-term care use in these populations and providing alternative culturally appropriate services must be prioritised to address this inequity in allocation of public sector resources.

Tube thoracostomy for trauma at Counties Manukau District Health Board, Aotearoa New Zealand.

Tube thoracostomy (TT) in trauma is lifesaving. A previous audit at Counties Manukau District Health Board (CMDHB), New Zealand, showed a 22% complication rate for trauma TT. Subsequently CMDHB introduced a procedural guideline to reduce complications. The Health and Disability Commission published a report concerning oversights in TT removal. This led us to evaluate complications, documentation and procedural monitoring to identify ways to improve patient safety. A 30-month retrospective audit of patients presenting to CMDHB, with injuries which may require TT. Those who had a TT in situ, did not require a TT or whose presentation was not secondary to trauma were excluded. One hundred and forty-three TTs were performed in one hundred and fifteen patients. About 87% had injuries secondary to blunt mechanism. Penetrating injuries were more likely to require TT (P= 0.015). Non-accidental injuries were more likely to need TT (P= 0.025). The complication rate was 25.2%. TT prior to imaging had a 31% complication rate (P< 0.03). About 23% had no TT insertion note. 40% had no TT removal note. About 9% TT insertions had no tertiary information to identify the proceduralist and a complication rate of 46%. About 22% of insertions and 4% of removals documented consent. About 2% of insertions documented anticoagulation status. Interventional radiology had the best documentation of data points assessed (P< 0.0001). Post-procedural monitoring recommendations were documented in 1% insertions and 11% removals. The complication rate has not reduced despite introduction of a guideline. Procedural documentation and monitoring were inadequate, potentially impacting patient safety.

Audit of cervical excision depth of large loop excision of the transformation zone procedures at Counties Manukau District Health Board.

Cervical cancer is the fourth most common malignancy in females worldwide. Large loop excision of the transformation zone (LLETZ) procedures remain the preferred surgical technique to remove squamous cervical intraepithelial neoplasia (CIN) lesions globally. This study aimed to assess whether the depth of LLETZ procedures at Counties Manukau District Health Board (CMDHB) met established standards of care. Hospital records were reviewed for all LLETZ procedures performed at CMDHB between 1 June 2020 to 3 May 2021, and these were compared to Public Health England's (PHE) 2020 Colposcopy Guidelines. One hundred and eighty-four cases were identified. Forty-eight percent of all LLETZ procedures were the correct excision depth relative to PHE's ≥95% threshold, primarily due to excisions being too shallow, particularly in patients with type 2 and 3 transformation zones (TZ), 48% and 86%, respectively. Māori and Pasifika patients represented only 16% and 13% of all LLETZ procedures in this study, respectively. This study identified significant oversampling of LLETZ excisions in patients with type 1 TZs, and significant under-sampling in patients with types 2 and 3 TZs. Ultimately, these findings highlight the need for additional quality improvement processes and emphasise the importance of auditing LLETZ procedures nationwide.

Are patients receiving recommended bone protection therapy after a non-hip fracture? A retrospective study of the Fracture Liaison Service at Counties Manukau District Health Board.

To review the Fracture Liaison Service (FLS) recommendations for bone protection therapy and assess treatment implementation in the community. All patients screened from 1 January to 31 March 2019 at Counties Manukau District Health Board were evaluated. Exclusion criteria included death within six months following sentinel fracture, and hip fractures, which are studied elsewhere. Patient risk factors assessed included age, gender, type of fracture, history of previous fracture, and dual X-ray absorptiometry scan results if performed. If bone protection therapy was recommended, electronic dispensing records were utilised as a proxy for treatment initiation. One hundred and sixty-nine of the 238 patients referred were included. Thirty-seven patients had evidence of a previous fragility fracture, with thirteen patients not on bone protection treatment following their prior fracture. Of the 99 patients in the study recommended bone protection therapy, 31.3% (n=31) did not have this dispensed at six months following written FLS assessment. Three of thirteen patients with a previous fragility fracture and not on bone protection treatment, still did not have this dispensed at 6 months. A high proportion of patients recommended bone protection therapy did not receive this in a timely manner, including patients with a history of repeated fracture.

Diagnostic use of ultrasound in giant cell arteritis in Counties Manukau District Health Board, New Zealand.

ObjectivesA retrospective observational study was undertaken to assess the diagnostic performance (sensitivity and specificity) of colour duplex ultrasound (CDUS) compared with temporal artery biopsy (TAB) for the diagnosis of GCA in the Counties Manukau District Health Board (CMDHB), New Zealand using clinical diagnosis as the reference standard.MethodsThe study population included patients with clinically suspected GCA who were referred to Middlemore Hospital and underwent CDUS, TAB or both between January 2019 and December 2020.ResultsSixty-nine patients were included in the study. Sixty-one percent were >75 years of age, with no cases <50 years of age and a female predominance of 71%. The sensitivity of CDUS was 26% (95% CI 10, 48) and specificity was 97% (95% CI 84, 100). The sensitivity of TAB was 57% (95% CI 34, 77) and specificity was 100%. CDUS had a positive predictive value of 86% (95% CI 42, 99) and a negative predictive value of 65% (95% CI 49, 78).ConclusionA positive CDUS in patients with a high risk for GCA may preclude the need for TAB due to the high specificity of CDUS in GCA. In contrast, patients with a high risk for GCA with a negative CDUS may still need TAB to confirm or exclude GCA. The duration from commencement of steroids to the time of CDUS is crucial in confirming GCA and, for this, shortening the waiting time in the CMDHB would be necessary to ensure adequate test performance in practice.

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

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

The selective use of preoperative MRI in the staging of breast cancer: a single-institution experience.

Routine use of preoperative breast magnetic resonance imaging (MRI) for loco-regional staging of breast cancer remains controversial. At Counties Manukau District Health Board (CMDHB), preoperative breast MRI is used selectively within a multidisciplinary setting. The purpose of this study is to determine the accuracy of selective use of preoperative MRI in staging loco-regional disease and how it has impacted our clinical practice. Patients who received preoperative MRI at CMDHB between October 2015 and October 2018 were identified on a prospective database. The decision to offer MRI was made by multidisciplinary consensus. Patient data were collected retrospectively from clinical, imaging and histology records. The accuracy of MRI was determined by comparing it against histology as gold standard, and its potential contribution to treatment decisions and treatment delay was determined by clinical record review. Ninety-two patients received preoperative MRI. Additional foci of cancer were identified in ten patients (11%). Sixteen patients (17%) required additional biopsies. In fourteen patients (15%), MRI identified more extensive disease than conventional imaging prompting a change of surgical management. This 'upstaging' was confirmed histologically in twelve (13%). In one (1%) patient, MRI incorrectly 'downstaged' disease, but it did not alter the management. No patients experienced a delay in treatment due to MRI. A selective, considered use of preoperative MRI within a multidisciplinary setting at our local institution results in more biopsies but with an acceptable risk-benefit ratio. It provides accurate staging to aid treatment decisions without resulting in a delay in treatment.

Management of MDA-5 antibody-positive dermatomyositis with interstitial lung disease-an Auckland case series.

ObjectiveThe aim was to present our experience of managing six cases of anti-melanoma differentiation-associated gene 5 (anti-MDA-5) DM with associated interstitial lung disease (ILD), presenting between June 2017 and October 2020.MethodsThe electronic notes were reviewed for six patients being followed up by the Rheumatology service at Auckland District Health Board. Three patients were initially diagnosed and treated in neighbouring Counties Manukau District Health Board and later transferred to Auckland District Health Board. All had different initial treating clinicians at a time before any predefined treatment algorithm. Emphasis was placed on initial diagnosis and treatment, subsequent disease activity and changes in management. Local management was compared retrospectively with existing evidence relating to the treatment of anti-MDA-5 DM with ILD. Ethical approval was not obtained, according to the New Zealand Health and Disability Ethics Committee exemption for audits and related activities.ResultsSix patients with a variety of clinical presentations were identified appropriately as having anti-MDA-5 DM with ILD. They were commenced on different immunosuppressive regimens, with treatment adjusted according to response and on-going disease activity. Four have achieved clinical and biochemical remission, a fifth has improving active disease, and the sixth is in the early stages of their illness.ConclusionAnti-MDA-5 DM is commonly associated with ILD. This can be rapidly progressive, with a poor prognosis in spite of treatment, particularly among Asian patients. Disease activity can seemingly be monitored with serum ferritin. The most effective management of this condition remains poorly researched; however, increasing retrospective evidence favours early aggressive multi-agent immunosuppression and a low threshold for escalation of therapy.

Pilonidal sinus: is histological examination necessary?

Pilonidal sinus is a common pathology occurring in a number of sites including the gluteal cleft between the buttocks. Surgery is the principal mode of treatment with a variety of techniques proposed to cure the disease and prevent recurrence. The rate of malignant degeneration is estimated at 0.1% in patients with chronic pilonidal disease. A case series study of pilonidal sinus found that most patients with malignancy were over the age of 50 years and had had chronic pilonidal disease for several years. This study aimed to review the value of histological analysis of pilonidal sinus specimens. A retrospective observational study was conducted of all patients who have undergone pilonidal sinus excision by the Department of General Surgery at Counties Manukau District Health Board in the past 10 years. This study reviewed 1324 admissions with a pilonidal disease requiring surgical management. There were 325 pilonidal resections with 320 histological specimens analysed. Pilonidal sinus was detected in 312 specimens, eight others were benign and there were no specimens with malignancy. No cases of malignancy were found in all pilonidal specimens that were sent for histological review. Routine histological examination of pilonidal sinus specimens appears to be unnecessary; however, it should be considered in patients over the age of 50 years.

Feasibility of a hearing screening programme using DPOAEs in 3-year-old children in South Auckland

ObjectivesIn New Zealand (NZ), permanent hearing loss is associated with higher levels of socioeconomic deprivation, and is more prevalent amongst Māori and Pacific than NZ European children. Many of these hearing losses are detected through newborn hearing screening, however there is a need to screen children again later, to look for childhood hearing losses that are either late-onset, progressive, or acquired. This study evaluated the feasibility of implementing an objective screening protocol that includes otoscopy, distortion product otoacoustic emission screening (DPOAEs), and tympanometry. It also evaluated the feasibility of using Early Learning Centres (ELCs) to contact families, recruit, and test 3-year-old children from an area of high socioeconomic deprivation in Auckland, New Zealand. MethodsSixty-one 3-year-old children were recruited from ELCs within the Counties Manukau District Health Board (CMDHB) region which services the geographical area of South Auckland. The first part of the screening protocol consisted of otoscopy, DPOAEs, and tympanometry. Children identified with hearing loss and/or middle ear problems were either referred directly to Otolaryngology/Audiology at the local hospital or invited back for a re-screen 4–8 weeks later. Children who were referred from the screening were followed up to track and document their subsequent clinical pathway through the public health system. ResultsMean overall time for the screening protocol was 4.1 minutes. The combination of otoscopy, DPOAEs, and tympanometry was well accepted by the 3-year-old children. DPOAE amplitude and signal-to-noise ratio results significantly differentiated between different tympanometry results, providing support for this combination of measures to accurately screen for hearing loss and/or middle ear disease. Thirty-eight of the 61 children (62%) passed the screening protocol. Of the remaining 23 children, five were referred to the hospital after not passing the screening, but following more in-depth audiological testing, were discharged with normal hearing. Six children referred to the hospital were diagnosed with varying degrees of conductive hearing loss, and two of the six received grommet insertion surgery. The remaining 12 children who were referred to the hospital were lost to follow-up, highlighting challenges for the families to successfully navigate the current public health system. ConclusionThis study demonstrates that identifying hearing loss and ear disease in 3-year-old children in the pre-school setting is feasible. A number of barriers were identified in the current health system that contribute to a large proportion of children referred with suspected hearing loss and ear disease being unsuccessful in accessing Otolaryngology/Audiology clinical care through the local hospital.

Bortezomib Induction and Consolidation in Patients with Multiple Myeloma Who Received Frontline Autologous Stem Cell Transplant

Introduction For multiple myeloma patients who are eligible for transplant determined by age and physiological reserve, autologous stem cell transplant (ASCT) following induction chemotherapy is considered as frontline treatment due to the better depth of response, progression-free (PFS) and overall survival (OS). Bortezomib is effective as part of a multi-agent induction regimen prior to ASCT as supported by long-term analysis with survival benefit. However, the role of Bortezomib and Thalidomide consolidation remains controversial. In New Zealand, Bortezomib was funded for up to nine cycles in front line setting. To maximise Bortezomib exposure, patients were typically given four to five cycles of Cyclophosphamide-Bortezomib-Dexamethasone (CyBorD) induction and later received the remaining number of cycles as consolidation after ASCT. Here we present our real-world data on patients who had CyBorD induction followed by ASCT and VTD consolidation. Method Data from 3 centres across New Zealand (Waitemata District Health Board, Counties Manukau District Health Board and Northland District Health Board) were extracted from the patient electronic database. All patients with multiple myeloma under the age of 70 who received CyBorD induction and ASCT as frontline treatment between 1 January 2013 and 31 December 2019 were included. Treatment response was determined as per the International Myeloma Working Group criteria and survival time was determined from the time of commencement of CyBorD. All statistical analyses were performed using IBM SPSS version 20.The data cut-off date is 10th October 2019. Result A total of 263 patients were identified from the 3 centres who were aged &amp;lt;70 and received frontline CyBorD. 125 patients did not proceed with frontline ASCT due to comorbidities, patients' choice, or progressive disease. In total, 138 patients received ASCT following CyBorD induction from the 3 centres. The median age was 60.8 (range: 34.2 - 69.8) and 86 (62.3%) were male. 69.6% of the patients were European, 9.4% were New Zealand Maori, 10.9% were Pacific Islanders, and 5.8% were Asians. The international staging system (ISS) was able to be determined in 89.1% of the patients, and 48.0% and 21.1% of them were ISS II and III, respectively. FISH cytogenetic results were available in 91.3% of the cases, and 13.5% of these patients were deemed to have high-risk disease (del(17p) 7.9%, t(4;14) 3.2%, t(14;16) 1.6%, and concurrent del(17p) and t(4;14) 0.8%). The median number of cycles given in induction was 5 (range: 4 - 9). 60.1% of the patients achieved at least a very good partial response after induction, and this was increased to 84.1% after ASCT and 87.7% after consolidation. Complete response was increased from 22.5% after induction to 30.4% after ASCT and 40.6% after consolidation. After a median follow-up of 54.5 months (range: 1.8 - 96.9 months), the median progression-free survival was 47.8 months and the median overall survival was not reached (Figure1). The estimated 2 and 5-year survival were 93% and 84%, respectively. Thalidomide was added to the induction regimen in 19 patients and this was commonly done due to the presence of high risk clinical features or suboptimal clinical response as determined by the treating clinicians. These patients did not appear to have an inferior treatment outcome with a comparable median PFS (median 42.2 vs 49.5 months, p = 0.291). Conclusion Our real-world data shows that Bortezomib-based consolidation following ASCT improves depth of response and results in favourable long-term outcomes. Patients who required the addition of Thalidomide during induction due to suboptimal response do not appear to have an inferior long-term outcome. Figure Disclosures Jackson: Abbvie: Honoraria. Chan:AbbVie: Membership on an entity's Board of Directors or advisory committees; Roche: Other: TRAVEL, ACCOMODATIONS, EXPENSES (paid by any for-profit health care company); Amgen: Other: TRAVEL, ACCOMODATIONS, EXPENSES (paid by any for-profit health care company); Celgene: Other: TRAVEL, ACCOMODATIONS, EXPENSES (paid by any for-profit health care company); Janssen: Membership on an entity's Board of Directors or advisory committees, Other: TRAVEL, ACCOMODATIONS, EXPENSES (paid by any for-profit health care company), Research Funding, Speakers Bureau.

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

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

P9 Ethnic variability in Post-Mastectomy Breast Reconstruction (PMBR)

Background Current evidence for best practice indicates breast reconstruction post-mastectomy is associated with greater quality of life and psychological well-being.1 However, rates of reconstruction many not be equivalent across all ethnicities, which contributes to disparities in health outcomes.2 Methods A retrospective review of patients diagnosed with breast cancer between January 1st and December 31st, 2017 at Counties Manukau District Health Board (CMDHB) was performed. Patient demographics, eventual breast cancer treatment, and evidence of whether a reconstruction discussion took place were collected. This data was analysed to assess rates of reconstruction by ethnic group. Results 386 patients were diagnosed with cancer in CMDHB Breast cancer clinic in 2017. Of these women, 190 underwent mastectomy as primary treatment with 30 of these women also receiving reconstruction (either immediate or delayed) giving a reconstruction rate of 15.8%. Indigenous Maori women represented only 10% of the total immediate and delayed reconstructions in CMDHB in 2017. European women comprised 70% of total reconstructions but only represented 50% of all mastectomies. 34.7% of patients receiving mastectomy in 2017 were of Maori or Pasifika ethnicity. Of these patients, only 31.8% of women met eligibility criteria for immediate breast reconstruction at CMDHB (Body Mass Index (BMI) < 35 and non-smoker). There was a statistically significant difference between eligibility in Maori, Pasifika, European and Asian ethnicity groups for post-mastectomy reconstruction at BMI values below 35 (p < 0.05). Conclusion Eligibility rates for post-mastectomy reconstruction are significantly lower (p < 0.05) in Maori and Pasifika women when compared with European and Asian populations. This difference reflects higher smoking rates and higher BMI values in Maori and Pasifika women. Changing eligibility criteria such as having a higher BMI threshold for Maori and Pasifika women may improve access to breast reconstruction in these populations. 1. Cagli B, Cogliandro A, Barone M, Persichetti P. Quality-of-life outcomes between mastectomy alone and breast reconstruction: comparison of patient-reported BREAST-Q and other health-related quality-of-life measures. Plast Reconstr Surg. 2014 Apr;133(4):594e–5e2. Schumacher JR, Taylor LJ, Tucholka JL, Poore S, Eggen A, Steiman J, et al. Socioeconomic Factors Associated with Post-Mastectomy Immediate Reconstruction in a Contemporary Cohort of Breast Cancer Survivors. Ann Surg Oncol. Springer International Publishing; 2017 Aug 1;24(10):3017–23.

Bilateral Plunging Ranulas in South Auckland: Evidence for a Genetic Basis.

We present a series of bilateral plunging ranula patients to examine the etiology, diagnosis, treatment, and prognosis of this condition. A retrospective chart review was performed on all cases of plunging ranula treated at the Department of Otolaryngology-Head and Neck Surgery, Counties Manukau District Health Board, New Zealand, between 2001 and 2019. There were 17 patients with bilateral plunging ranulas from a total of 187 plunging ranula patients. Eight patients were of Pacific Island descent; six were Maori; and three were Asian. There were no European patients with bilateral plunging ranulas. There were three types of bilateral plunging ranula patients: 1) Metachronous plunging ranulas-Five patients presented with a unilateral plunging ranula with no evidence of a contralateral plunging ranula on initial imaging. Despite negative contralateral imaging findings, these patients developed a clinically evident contralateral plunging ranula 21 to 61 months later. 2) Synchronous plunging ranulas detected on imaging-Eight patients presented with a clinically evident unilateral plunging ranula but also had a contralateral plunging ranula detected on imaging. 3) Clinically evident synchronous plunging ranulas-Four patients presented with bilateral clinically evident plunging ranulas, which were also evident on imaging. Twelve patients underwent bilateral transoral sublingual gland excision and plunging ranula evacuation. All patients with a unilateral plunging ranula should be advised of the potential for developing contralateral disease, and this should be emphasized in patients of Pacific Island, Maori, and Asian descent. 4 Laryngoscope, 131:73-77, 2021.

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

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

A060 Māori and Pacific Patients With Non-Ischaemic Cardiomyopathy, Undergoing Cardiac Magnetic Resonance Imaging Have Worse Clinical Outcomes than European Patients

Cardiac Magnetic Resonance (CMR) imaging is increasingly utilised to assess the aetiology and severity of cardiomyopathies. Non-ischaemic cardiomyopathy (NICM) is a heterogeneous condition, with varying clinical and demographic factors influencing outcome. This study assesses differences in clinical outcomes in European compared with Māori and Pacific NICM patients undergoing CMR in South Auckland. CMR reports from Counties Manukau District Health Board region (2005 – 2019) were analysed from an ANZACS-QI linked CMR database. 536 patients with a diagnosis of NICM were identified and linked ethnicity data recorded. 498 patients were grouped according to European (n = 231) vs Māori and Pacific ethnicity (n = 267). Clinical, biochemical, imaging and demographic data was collected from electronic medical records. The primary end point was combined all cause mortality and readmission rate for decompensated heart failure. Māori and Pacific patients were younger (52.3 +/-11.6 vs 57.2 +/- 14.6 years, p<0.001), had higher Body Mass Index (36.7 kg/m2 vs 29.5 kg/m2 , p<0.001), and weight (105.3kg vs 87.4kg, p<0.001). CMR markers of left ventricular (LV) volumes (p=0.95), LV ejection fraction (p=0.14), and presence of myocardial fibrosis (p=0.13) were similar between the two groups. Implantable Cardiac Defibrillator, and Cardiac Resynchronisation Therapy implantation rates were similar (p=0.58). The primary combined outcome of readmission for decompensated heart failure and all cause mortality was significantly higher in Māori and Pacific patients (96 vs 48, p<0.001). Māori and Pacific patients with NICM have worse clinical outcomes than European patients, despite similar disease severity on CMR.

A065 Demographic, Investigation, Management and Outcome in Patients Presenting with Acute Myocarditis. A 10-Year Audit

To review demographics, investigations, follow up and outcomes (measured by mortality and left ventricular [LV] impairment) of patients with confirmed and suspected acute myocarditis in the New Zealand population. A retrospective review of clinical records in patients >15 years of age with confirmed or suspected acute myocarditis admitted to Coronary Care Unit (CCU) and Step-Down Unit (SDU) at Counties Manukau District Health Board from 1/1/2010 to 1/1/2020. Over 10 years 57 patients presented with acute myocarditis and required admission to CCU or SDU. 70% were male, median age was 39. Māori (21%) were over-represented. Troponin assay was performed in all patients. One patient did not have cardiac imaging due to death. 3 patients had an endomyocardial biopsy. LV impairment was present in 28% of patients. Patients presenting with LV impairment is likely to have higher Troponin I (17,976ng/L vs 6277 ng/l) than those without LV impairment. 61% of patients (n=35) were successfully followed up. 35% of patients (n=20) completed outpatient echocardiogram, 25% (n=14) completed outpatient cardiac magnetic resonance imaging. Among these patients, all had normal or low-normal LV functions. There were 3 deaths attributable to myocarditis. Male over-representation in myocarditis is surprising but has been reported in a previous New Zealand study. All patients had Troponin assay performed, almost all patients had cardiac imaging. Patients that were followed up all had normal or near-normal LV function. There were 3 deaths.