Auckland District Health Board Research Articles

Clozapine metabolism and cardiotoxicity: A prospective longitudinal study

BackgroundClozapine-induced myocarditis and cardiomyopathy are difficult to detect clinically and may be fatal if not detected early. The current/routine biomarkers for clozapine-induced myocarditis are non-specific indicators of inflammation (C-reactive protein) or cardiomyocyte damage (troponins I and T) that lack sensitivity, and for which changes often arise too late to be clinically useful. MethodsThe Clozapine Safety Study was a prospective, longitudinal, observational study to determine what, if any, the plasma concentrations of clozapine, N-desmethylclozapine, and clozapine-N-oxide in patients contribute to cardiotoxicity. Samples were collected and analysed using liquid chromatography mass spectrometry over a 41-month period from patients in the Auckland District Health Board. ResultsSixty-seven patients were included. Six patients were diagnosed with myocarditis; none were diagnosed with cardiomyopathy in the study period. In patients not undergoing dose titration, clozapine biotransformation may shift to the N-oxide pathway rather than the N-desmethyl pathway with increasing dose. During dose titration, the timeframe in which myocarditis occurs, the rate of increase in the plasma concentration of clozapine-N-oxide, as well as the ratio of N-oxidation relative to N-desmethylation, were significantly higher in patients diagnosed with myocarditis. ConclusionsThe assessment of clozapine-N-oxide formation, and N-oxidation relative to N-desmethylation ratios during treatment, may help identify a biomarker to aid the early detection of patients at risk of developing clozapine-induced cardiotoxicity.

Quality outcomes for end-of-life care among people with haematological malignancies at a New Zealand cancer centre.

Little is known about the end-of-life (EOL) experience and specialist palliative care use patterns of patients with haematological malignancies (HMs) in New Zealand. This retrospective analysis sought to examine the quality of EOL care received by people with HMs under the care of Auckland District Health Board Cancer Centre's haematology service and compare it to international data where available. One hundred consecutive adult patients with HMs who died on or before 31 December 2019 were identified. We collected information on EOL care quality indicators, including anticancer treatment use and acute healthcare utilisation in the last 30 days of life, place of death and rate and timing of specialist palliative care input. During the final 14 and 30 days of life, 15% and 27% of the patients received anticancer therapy respectively. Within 30 days of death, 22% had multiple hospitalisations and 25% had an intensive care unit admission. Death occurred in an acute setting for 42% of the patients. Prior contact with hospital and/or community (hospice) specialist palliative care service was noted in 80% of the patients, and 67% had a history of hospice enrolment. Among them, 15% and 28% started their enrolment in their last 3 and 7 days of life respectively. The findings highlight the intensity of acute healthcare utilisation at the EOL and high rates of death in the acute setting in this population. The rate of specialist palliative care access was relatively high when compared with international experiences, with relatively fewer late referrals.

Potentially inappropriate medications and potential prescribing omissions in hospitalised older adults in New Zealand: A retrospective study.

Medication errors can have detrimental effects on patient outcomes, yet there are limited data on the prevalence of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) among older adult inpatients in New Zealand (NZ). This study investigated exposure to PIMs and PPOs in older adults in a New Zealand hospital. Electronic medical records of 846 older adults (≥ 65 years) discharged from the Auckland District Health Board between June 2020 and May 2021 were retrospectively reviewed to extract data on sociodemographic, medication and diagnostic information. STOPP/START version 2 was used to evaluate PIMs and PPOs on admission and discharge. The mean age was 77.47 ± 8.12 years, and 51% were female. On admission, 48% had ≥1 PIMs and 40% had ≥1 PPOs. On discharge, 45% had ≥1 PIMs and 40% had ≥1 PPOs. Increasing age (adjusted odds ratio [AOR] = 1.02, 95% CI [confidence interval] 1.01, 1.04), number of medicines (AOR = 1.23, CI 1.17, 1.29) and 28-day admission history (AOR = 1.58, CI 1.15, 2.18) were associated with higher odds of PIMs use on admission. At discharge, the number of medicines (AOR = 1.19, CI 1.13, 1.25) and history of readmission (AOR = 1.47, CI 1.08, 2.02) were associated with higher odds of PIMs. Female patients had higher odds of PPOs both on admission (AOR = 1.35, CI 1.02, 1.78) and discharge (AOR = 1.34, CI 1.01, 1.78). Māori, Asian and Pacific patients were more likely to have prescribing omissions compared to NZ Europeans. Prescribing omissions and inappropriate medications were common in older inpatients. There were differences observed between different ethnic groups, with NZ Europeans having fewer omissions than other ethnic groups. These findings highlight key opportunities for health-care providers to improve medication use in older adults in NZ.

Diabetes Mellitus Related Anterior Uveitis – An Overlooked Clinical Entity

ABSTRACT Background This study aimed to evaluate the characteristics of anterior uveitis in patients presenting with poorly controlled diabetes mellitus and with no other identifiable cause for their uveitis. Methods A retrospective study of 121 eyes in 89 patients who presented at Auckland District Health Board with idiopathic acute anterior uveitis and uncontrolled diabetes between September 2009 and January 2022. Results The diagnosis of diabetes mellitus was known prior to presentation in 80 subjects (89.9%) and was discovered as a result of screening tests in the remainder. Mean HbA1c at presentation was 117.3 mmol/mol. Most uveitis was severe with 3+ (30 eyes, 25.4%) or 4+ cells (30 eyes, 25.4%) in the anterior chamber. Recurrence occurred in 22 eyes (18.2%) and was associated with elevated HbA1c. The visual prognosis was good with median visual acuity at 12 months of 6/7.5. Conclusion Poorly controlled diabetes can be associated with acute anterior uveitis.

Assessment of Health Disparities and Barriers to Accessing Keratoconus and Crosslinking at a Tertiary Referral Center.

The aim of this study was to determine the barriers to accessing the crosslinking service in Auckland, New Zealand. This was a prospective 1-year study of patients at Auckland District Health Board. Studied parameters included age, sex, body mass index, ethnicity, New Zealand Deprivation (NZDep; an area-based measure of socioeconomic status, 1 = low deprivation-10 = high deprivation) score of residence, disease severity (maximum keratometry and thinnest corneal thickness), attendance, distance travelled, car ownership, employment status, and visual outcomes. Statistical analysis was performed using independent t tests, Pearson correlation, independent samples ANOVA, MANCOVA, and binomial logistic regression. Four hundred fifty-four patients with keratoconus were analyzed and had a mean age of 24.1 ± 0.8 years, mean body mass index of 33.0 ± 9.7 kg/m 2 , and 43% were female. Pacific Peoples consisted 40.2% of the population; Māori 27.2%; Europeans 21.2%; Asian 9.9%; and Middle Eastern, Latin American, and African (MELAA) 1.3%. The mean distance travelled was 12.5 ± 9.5 km, NZDep score was 6.8 ± 2.6, and attendance was 69.0 ± 42.5%. The lowest attendance was observed in Pacific Peoples (58.9%) and the highest was in Asians (90%) ( P = 0.019). The mean worst-eye visual acuity at attendance was 0.75 ± 0.47 logMAR (6/35). Unemployment was associated with worse best-eye visual acuity at FSA ( P = 0.01) and follow-up ( P < 0.05). Māori and Pacific Peoples had the highest NZDep ( P < 0.001), were younger at presentation ( P = 0.019), had higher disease severity ( P < 0.001), and worse visual acuity ( P < 0.001). Poor attendance was seen in this cohort. Pacific Peoples and Māori presented younger with worse disease severity and visual acuity but also had the highest nonattendance. These results suggest that deprivation, factors associated with ethnicity, and unemployment are potential barriers to attendance.

O.17.1Communication Aids for the Clinical Child Protection Setting and Sexual Assault Examination: Presenter(s): Meera Raithatha, Auckland District Health Board, New Zealand

O.17.1Communication Aids for the Clinical Child Protection Setting and Sexual Assault Examination: Presenter(s): Meera Raithatha, Auckland District Health Board, New Zealand

MOBILE DATA SECURITY: INSTANT MESSAGING IN ORTHOPAEDICS

Instant messaging via WhatsApp is used within hospital teams. Group messaging can lead to efficient and non-hierarchical communication. Despite being end-to-end encrypted, WhatsApp is owned by Facebook, raising concerns regarding data security. The aims of this study were: 1) to record the prevalence of WhatsApp group instant messaging amongst clinical teams; 2) to ascertain clinician attitudes towards use of instant messaging, 3) to gauge clinicians’ awareness of best practice regarding mobile data protection and 4) to create a practical guideline based off available literature that can be used to by clinicians to improve data security practice.Over a two-week period, clinical nurse specialists in the Auckland District Health Board Department of Orthopaedics retrospectively completed a blind audit of all messaging activity across the five teams WhatsApp group message threads, recording quantity of messages sent and the nature of the messages. Concurrently individuals in these WhatsApp groups completed an anonymous survey of their use of WhatsApp and their awareness of local data security policies and practice. A guideline adapted from available literature was created to compare current practice to recommended standards and subsequently adopted into local policy.1360 messages were sent via WhatsApp in a two-week period. 384 (28%) of the messages contained patient identifiable data. Thirty-six photos were shared. Participants rated use of WhatsApp at 9.1/10 – extremely beneficial. Sixty-five per cent of clinicians reported they had not read or were unaware of the ADHB policies regarding mobile devices and information privacy and security.WhatsApp use is widespread within the Orthopaedic department and is the preferred platform of communication with many perceived benefits. Data security is a risk and implementation of an appropriate guideline to assist clinicians in achieving best practice is crucial to ensure patient data remains protected.

Navigating Coronavirus Disease 2019 Vaccination and Uveitis: Identifying the Rates and Risk of Recurrent Uveitis after Coronavirus Disease Vaccination

To identify rates of uveitis reactivation both prior and following the COVID-19 vaccine in subjects with a previous diagnosis of uveitis. Retrospective study. Subjects were identified from the Inflammatory Eye Disease Registry at Auckland District Health Board diagnosed with uveitis between 1st January 2010 and 31st December 2020. Date of COVID vaccination was determined from the patient clinical record. Rate of flare was calculated for three months prior to vaccination and for three months after each vaccination. Uveitis flare was defined as the presence of new uveitis activity or increased activity that required a change in uveitis treatment. 4,184 eyes of 3,008 patients were included in the study with a total of 8,474 vaccinations given during the study period. Median age was 54.8 years and 1,474 (49.0%) were female. Non-infectious etiology was most common, occurring in 2,296 patients (76.3%) and infectious etiology in 712 (23.7%). Rate of uveitis flare was 12.3 per 1,000 patient months at baseline, 20.7 after first dose, 15.0 after second dose, 12.8 after third dose and 23.9 after fourth dose. Median period of quiescence prior to flare was 3.9 years.An increase in uveitis flare was seen both in infectious uveitis (baseline 13.1 compared to 20.2 after first dose, 154% increase) and for non-infectious uveitis (baseline 12.4 compared to 20.9 after first dose, 169% increase). Risk factors for uveitis flare were identified to be recurrent uveitis, chronic uveitis, shorter period of quiescence and first dose of vaccine. Median time to uveitis flare was 0.53 months following the first vaccination, 1.74 months following second vaccination, and 1.35 months following the third vaccination. The current study demonstrates an increased risk of uveitis flare following first dose of COVID vaccination. This risk was highest in those with previous recurrences, chronic uveitis, and shorter period of quiescence.

Telephone follow-up one day post-cataract surgery

ABSTRACT Clinical relevance With the increasing use of technology and an emerging need for virtual clinical reviews, particularly following the recent pandemic, it is essential to evaluate the safety of these clinical tools. Background This retrospective study aims to determine the safety of virtual follow-up day one after cataract surgery. Methods All patients who underwent cataract surgery at Auckland District Health Board, New Zealand (Aotearoa), and were triaged for telephone review the day after surgery, from 5th November 2018 to 31st January 2020, were eligible. Outcomes measured: presentations to the acute eye clinic prior to the post-operative visit (number and reasons) and complications at the one-month follow-up (persistent inflammation, cystoid macular oedema, raised intra-ocular pressure). Results Nine hundred and eighty-seven cataract surgeries were triaged for virtual follow-up over the retrospective study period. Nine hundred and eighty-five cases in 928 patients met the inclusion criteria. The median duration of phone calls was 5 minutes (range 2–30). Prior to the one-month post-operative visit, there were 66 presentations to the acute eye clinic, most commonly due to ocular surface irritation (33.3%) and persisting inflammation (25.8%). At the one-month post-operative review, 110 cases (11.2%) had complications; 62 (6.3%) had persisting inflammation, 46 (4.7%) had cystoid macular oedema, and two (0.2%) had raised intraocular pressure. Conclusions This is the largest study of a virtual day one post-operative follow-up following cataract surgery, and demonstrates that, in carefully selected subjects, virtual follow-up is a safe alternative to a clinic review. This method could significantly reduce healthcare costs and serve to be more efficient and favourable for patients and clinicians.

Venetoclax combined with low dose cytarabine compared to standard of care intensive chemotherapy for the treatment of favourable risk adult acute myeloid leukaemia (VICTOR): Study protocol for an international, open-label, multicentre, molecularly-guided randomised, phase II trial

BackgroundFor patients with acute myeloid leukaemia (AML), the only potentially curative treatment is intensive chemotherapy (IC). This is highly toxic, particularly for patients > 60 years, potentially leading to prolonged hospitalisations requiring intensive supportive care, and sometimes treatment-related death. This also results in extensive healthcare costs and negatively impacts quality of life (QoL). Venetoclax with low-dose cytarabine (VEN + LDAC) is a novel, low-intensity treatment for AML patients who cannot receive IC. VEN + LDAC is given as an outpatient and toxicity appears significantly lower than with IC. Analysis of clinical trials performed to date are promising for patients with the genotype NPM1mutFLT3 ITDneg, where remission and survival rates appear comparable to those achieved with IC.MethodsVICTOR is an international, two-arm, open-label, multi-centre, non-inferiority, randomised-controlled phase II trial to assess VEN + LDAC compared to standard of care (IC) as first-line treatment in older patients (initially aged ≥ 60 years) with newly diagnosed AML. The trial will recruit patients with a NPM1mutFLT3 ITDneg genotype; those with a favourable risk in relation to the experimental treatment. University of Birmingham is the UK co-ordinating centre, with national hubs in Aarhus University Hospital, Denmark, and Auckland District Health Board, New Zealand. The primary outcome is molecular event-free survival time where an event is defined as failure to achieve morphological complete response (CR) or CR with incomplete blood count recovery after two cycles of therapy; molecular persistence, progression or relapse requiring treatment change; morphological relapse, or; death. Secondary outcomes include cumulative resource use at 12- and 24-months, and QoL as assessed by EORTCQLQ-C30 and EQ-5D-3L at 3-, 6-, 12-, 18- and 24-months. The trial employs an innovative Bayesian design with target sample size of 156 patients aged > 60 years.DiscussionThe principle underpinning the VICTOR trial is that the chance of cure for patients in the experimental arm should not be compromised, therefore, an adaptive design with regular checks on accumulating data has been employed, which will allow for a staged expansion of the trial population to include younger patients if, and when, there is sufficient evidence of non-inferiority in older patients.Trial registrationEudraCT: 2020–000,273-24; 21-Aug-2020.ISRCTN: 15,567,173; 08-Dec-2020.

Rapid treatment of endophthalmitis with intravitreal antibiotics is associated with better vision outcomes.

To discover whether the timing of intravitreal antibiotics, from the time of presentation to injection, affects the visual outcomes of patients with endophthalmitis from all causes. A retrospective study of consecutive patients managed at Auckland District Health Board between 1 January 2004 and 1 July 2021. The main outcome measure was final visual acuity at follow-up and the proportion of subjects with severe vision loss (≤6/60). Three hundred and seventy-four eyes were included in the study, with a median age of 69.7 years at presentation; 192 subjects (51.6%) were female. The median presenting visual acuity was hand movements and hypopyon was present in 194 subjects (51.9%). Cataract surgery was the most frequent aetiology in 115 subjects (30.7%), followed by intravitreal anti-vascular endothelial growth factor injections in 89 subjects (23.8%) and endogenous endophthalmitis in 54 subjects (14.4%). Median time to injection of intravitreal antibiotics was 3.5h (Interquartile range 2-6). On multivariate analysis, early treatment with intravitreal antibiotics was associated with better visual outcome, particularly for those treated within 2 h, while poor presenting visual acuity and culture-positive endophthalmitis were associated with worse outcomes. Rapid intravitreal antibiotic administration is associated with better final visual acuity outcomes, particularly for those receiving treatment within 2 h of presentation. Patients with severe vision loss on presentation, benefit the most with improved final visual acuity following expedited treatment.

A task service and a talking service: A qualitative exploration of bereaved family perceptions of community nursing care at the end of life

Background: Greater emphasis on community-based care at the end of life is supported by the premise that most people want to be cared for and die at home. As such, it is important to understand the current state of palliative care nursing within an integrated generalist-specialist model of care in the community. Aim: To explore bereaved family perceptions and experiences of community nursing at the end of life, with a particular focus on service integration. Design: A qualitative study design using semi-structured telephone interviews with bereaved family. A critical realist framework was used to inform the analysis of interview data and thematic analysis of data was used to identify key themes. Setting/participants: Participants were the family carers of patients who had died within the catchment area of two large District Health Boards in Auckland, New Zealand. Results: Twenty-three participants were interviewed. Participants described their experiences of community nursing in terms of the service they provided. Hospice nursing roles were described in terms of a “talking service” and District Nursing as a “task service.” There was minimal expectation of the general practice nurse in terms of palliative care support and little evidence of service integration. Conclusion: Findings from this study support the need for a new integrated model of palliative care nursing which utilizes the unique skill set of nurses working across all community care settings including general practice, hospice and district nursing services. Accommodating different models of nursing care which can be responsive to patient need rather than limited to a defined service delivery model.

Prompt Antiviral Therapy Is Associated With Lower Risk of Cerebrovascular Accident Following Herpes Zoster Ophthalmicus

To examine risk factors associated with cerebrovascular accident (CVA) following herpes zoster ophthalmicus (HZO). Retrospective cohort study. Review of medical records of all patients with HZO seen at the department of Ophthalmology, Auckland District Health Board, New Zealand, between January 1, 2006, and December 31, 2016. The main outcome measure was cerebrovascular accident within 12 months of diagnosis. A total of 869 patients diagnosed with HZO were included in the study. The median age at onset of HZO was 65.5 years (interquartile range [IQR] 52.9-75.4), and 52.5% (n=456) were male. Antiviral therapy was started in 765 participants (88.0%), not used in 95 (10.9%), and not documented in 9 participants (1.0%). Four hundred sixty-eight participants (54.9%) received prompt oral antiviral therapy (≤72 hours of rash onset). A CVA occurred in the 12 months following HZO in 14 patients (1.6%) and was most common in older patients, occurring in 2.5% aged ≥65 years, 0.7% aged 40-65 years, and 0.9% aged <40 years. Hazard of CVA was highest immediately following HZO, with median time to CVA of 2.3 months (IQR 0.8-5.9 months). Patients who received prompt acyclovir had a 76.2% lower hazard of CVA (0.9% vs 2.6%, P=.022) on multivariate analysis. Cerebrovascular accident occurs in a low proportion of individuals within 1 year following HZO. Antiviral treatment for HZO may reduce the risk of subsequent CVA when given within 72 hours of rash onset.

Treatment and outcomes of multidrug-resistant tuberculosis in Auckland, 1995-2018.

New Zealand has a low burden of tuberculosis; however, multidrug-resistant tuberculosis (MDR-TB) still represents a challenge for clinicians. This is the first description of clinical aspects of MDR-TB in New Zealand. To evaluate the treatment and outcomes of patients with MDR-TB disease in Auckland. Secondary aims were to review the incidence and clinical characteristics of MDR-TB disease. Clinical data were obtained for patients treated for MDR-TB at Auckland District Health Board (ADHB). There were 60 patients nationally with MDR-TB between 1989 and 2018; 41 (69%) of 60 patients received care at ADHB. Pulmonary infection was present in 36 (88%) of 41 patients, with 19 (46%) of 41 patients with smear-positive sputum (smear 1-2+ in 6/41, 15%; smear 3-4+ in 13/41, 32%). The median duration of treatment was 22 months (range 7.5-26) for 18 (44%) of 41 patients who completed MDR-TB treatment by August 2018. The median duration of amikacin treatment was 6 months (range 2-12) for the 23 (61%) of 38 patients in whom these data were available. All 38 patients who received treatment for MDR-TB experienced adverse effects, most commonly gastrointestinal (66%), neurological (50%), ototoxicity (47%) and psychiatric (37%). Complications of intravenous access were experienced by 10 (27%) of 37 patients. Of the 19 (46%) of 41 patients who completed treatment, 18 (95%) achieved cure. There was one case who had recurrence because of inadequate treatment, and one case who had spontaneous resolution without treatment. Seventeen (41%) patients left Auckland prior to completion of treatment, mostly to return to their country of origin (15/17, 88%). MDR-TB is uncommon in New Zealand. Treatment is frequently associated with adverse events; however, rates of cure for people completing treatment in New Zealand are high.

Predictors of glaucoma in patients with uveitis and scleritis.

To examine risk factors for development of glaucoma in a large cohort of subjects with uveitis and scleritis. Retrospective review of subjects diagnosed with uveitis or scleritis between 2006 and 2019 at Auckland District Health Board. Subjects were excluded if they had glaucoma due to another cause. Main outcome measure was development of glaucoma. Data for local steroid use was not available. 3462 eyes of 2414 subjects were included in the study. Mean follow-up was 5.7 years (total follow-up time 19,897 eye years). Median age was 44.3 years and 1189 (49.3%) were female. Glaucoma developed in 222 eyes (6.3%) during the follow-up. Five-year cumulative risk of glaucoma was 6.2% (CI 5.0-7.5%) for anterior uveitis, 5.4% (CI 3.2-9.0%) for intermediate uveitis, 1.6% (CI 0.4-6.7%) for posterior uveitis, 8.7% (CI 6.5-11.7%) for panuveitis, and 3.2% (CI 1.0-9.5%) for scleritis. Five-year cumulative risk of glaucoma was lowest in HLA-B27 uveitis at 0.9% (CI 0.4-2.1%) and highest in viral uveitis 15.1% (CI 10.1-22.3%), sarcoidosis 9.9% (CI 6.1-15.9%) and tuberculosis 9.7% (CI 5.4-17.0%). On multivariate analysis, risk factors for development of glaucoma were older age at presentation, higher presenting intraocular pressure, chronic inflammation, and cystoid macular oedema. Glaucoma is a common complication of uveitis and scleritis and was more frequent in older subjects, high presenting IOP, chronic inflammation and those with cystoid macular oedema. Local steroid therapy contributes to this, but is not quantifiable in this study. Targeted screening is required to avoid irreversible progression of glaucomatous optic neuropathy.

Postdischarge opioid use and persistent use after general surgery: A retrospective study

BackgroundOpioid overprescribing after surgery is a significant public health issue in most developed countries, including New Zealand. However, there is a lack of literature on the patterns and risk factors for postoperative opioid use among general surgical patients in New Zealand. This study aimed to examine opioid use in patients undergoing general surgery at Auckland District Health Board between January and December 2019 and to identify factors associated with opioid use after surgery and persistent opioid use (defined as having filled ≥1 opioid prescription in the 91 to 180 days after surgery). Methods and MaterialsThis is a retrospective cohort study. Data from patients’ electronic clinical records and community pharmacy dispensing records were extracted to obtain data on sociodemographics, surgical characteristics, comorbidities, co-prescribed medications, and opioid use. ResultsA total of 1,110 patients were included in the study, with 42.4% dispensed an opioid following discharge after surgery. Of opioid-naïve patients who filled opioids after surgery (n = 401), 9.5% became persistent opioid users. Preoperative use of nonopioid analgesics, longer hospital stays, higher operation severity, procedure type, and higher pain scores were positively associated with opioid use, whereas older age was a negative predictor. Longer hospital stays, an initial discharge prescription with high opioid load, and female sex increased the risk of persistent opioid use. Conversely, a higher severity of surgery was associated with lower risk of persistent opioid use. ConclusionThe findings suggest that a considerable proportion of patients become persistent opioid users after surgery. The risk factors identified can guide clinicians to prescribe in a manner that reduces opioid-related adverse outcomes and help guide future interventions.

An interRAI derived frailty index predicts acute hospitalizations in older adults residing in retirement villages: A prospective cohort study.

ObjectivesThe development of frailty tools from electronically recorded healthcare data allows frailty assessments to be routinely generated, potentially beneficial for individuals and healthcare providers. We wished to assess the predictive validity of a frailty index (FI) derived from interRAI Community Health Assessment (CHA) for outcomes in older adults residing in retirement villages (RVs), elsewhere called continuing care retirement communities.DesignProspective cohort study.Setting and participants34 RVs across two district health boards in Auckland, Aotearoa New Zealand (NZ). 577 participants, mean age 81 years; 419 (73%) female; 410 (71%) NZ European, 147 (25%) other European, 8 Asian (1%), 7 Māori (1%), 1 Pasifika (<1%), 4 other (<1%).MethodsinterRAI-CHA FI tool was used to stratify participants into fit (0–0.12), mild (>0.12–0.24), moderate (>0.24–0.36) and severe (>0.36) frail groups at baseline (the latter two grouped due to low numbers of severely frail). Primary outcome was acute hospitalization; secondary outcomes included long-term care (LTC) entry and mortality. The relationship between frailty and outcomes were explored with multivariable Cox regression, estimating hazard ratios (HRs) and 95% confidence intervals (95%CIs).ResultsOver mean follow-up of 2.5 years, 33% (69/209) of fit, 58% (152/260) mildly frail and 79% (85/108) moderate-severely frail participants at baseline had at least one acute hospitalization. Compared to the fit group, significantly increased risk of acute hospitalization were identified in mildly frail (adjusted HR = 1.88, 95%CI = 1.41–2.51, p<0.001) and moderate-severely frail (adjusted HR = 3.52, 95%CI = 2.53–4.90, p<0.001) groups. Similar increased risk in moderate-severely frail participants was seen in LTC entry (adjusted HR = 5.60 95%CI = 2.47–12.72, p<0.001) and mortality (adjusted HR = 5.06, 95%CI = 1.71–15.02, p = 0.003).Conclusions and implicationsThe FI derived from interRAI-CHA has robust predictive validity for acute hospitalization, LTC entry and mortality. This adds to the growing literature of use of interRAI tools in this way and may assist healthcare providers with rapid identification of frailty.

Mobile data security: instant messaging in orthopaedics.

Instant messaging via WhatsApp is used within hospital teams. Group messaging can lead to efficient and non-hierarchical communication. Despite being end-to-end encrypted, WhatsApp is owned by Facebook, raising concerns regarding data security. The aims of this study were: (1) to record the prevalence of WhatsApp group instant messaging amongst clinical teams; (2) to ascertain clinician attitudes towards use of instant messaging and (3) to gauge clinicians' awareness of best practice regarding mobile data protection. Over a two-week period in May 2018, clinical nurse specialists in the Auckland District Health Board Orthopaedic department retrospectively collected data from all five team WhatsApp group message threads recording quantity of messages sent and the nature of the messages. Concurrently individuals in these WhatsApp groups completed an anonymous survey of their use of WhatsApp and their awareness of local data security policies and practice. One thousand three hundred and sixty messages were sent via WhatsApp in a two-week period. 384 (28%) of the messages contained patient identifiable data. Thirty-six photos were shared. Participants rated use of WhatsApp at 9.1/10 - extremely beneficial. Sixty-five percent of clinicians reported they had not read or were unaware of the ADHB policies regarding mobile devices and information privacy and security. WhatsApp use is widespread within the Orthopaedic department and is the preferred platform of communication with many perceived benefits. Data security is a risk and implementation of appropriate guidelines to assist clinicians in achieving best practice is crucial to ensure patient data remains protected.

Neurotrophic Keratopathy After Herpes Zoster Ophthalmicus.

The aim of this study was to describe risk factors for neurotrophic keratopathy (NK) after herpes zoster ophthalmicus (HZO). This study was a retrospective review of all patients seen at the Auckland District Health Board with HZO from 2006 through 2016. Cox proportional hazards analysis was performed to examine time to development of neurotrophic keratitis. Eight hundred sixty-nine patients were included in the study with a median follow-up of 6.3 years (5504.4 patient-years). The median age was 65.5 years (interquartile range 52.9-75.4), and 456 subjects (52.5%) were male. NK developed in 58 patients (6.7%), with the highest hazard 1 to 2 years after onset of HZO. On univariate analysis, age, White ethnicity, best-corrected visual acuity (BCVA) at presentation, intraocular pressure, corneal involvement, uveitis, and number of recurrences were associated with increased risk of NK. On multivariate analysis, the following factors were significant: age (hazard ratio [HR] = 1.03; P = 0.021), White ethnicity (HR = 3.18; P = 0.015), BCVA (HR = 1.81; P = 0.026), uveitis (HR = 3.77; P = 0.001), and recurrence (HR = 1.34; P < 0.001). Vision loss (BCVA ≤6/15) was more frequent in subjects with NK (65.5% vs. 16.3%, P < 0.001). NK is a relatively common and serious complication of HZO and occurs more frequently in older White individuals, those with poor visual acuity at presentation, and those with uveitis. Vision loss occurs in approximately two-thirds of patients.

Ethnic disparities in Phyllodes Tumour in Aotearoa New Zealand: a retrospective review.

Phyllodes tumour (PT) is a rare breast neoplasm and little is known about its epidemiological risk factors. The literature suggests a higher incidence of PT in Asian patients and other minority ethnic groups. The purpose of this study was to identify whether there was a difference in incidence, grade and age at presentation for patients with PT among minority ethnic groups when compared with European patients in Aotearoa New Zealand (AoNZ). A retrospective review was conducted across the three District Health Boards (DHBs) in Auckland, Aotearoa New Zealand (AoNZ), from 2008 to 2018 to investigate the relationship between ethnicity and clinical characteristics of PT. Demographic information and histology reports were reviewed to obtain relevant data. The primary outcome measure was ethnicity and the secondary outcome measures were age at presentation, tumour volume and grade. One hundred and fifty-nine patients were included. The total number of non-European patients were 108 (68%). Minority ethnic groups including Pasifika, Māori and MELAA were overrepresented in the patient cohort. Larger tumour volume was significantly correlated with higher tumour grade (p< 0.001). Pasifika patients presented with larger tumours (p 0.05) and at a younger age (p 0.027) when compared with European patients. This study found that patients with PT in AoNZ were significantly overrepresented in Asian, Pasifika and MELAA ethnic groups. Pasifika patients may be at an increased risk of presenting at a younger age with larger, higher grade tumours when compared with European patients. Further research is required to investigate the reasons behind these findings in minority ethnic groups.