A New Zealand based cohort study of anaesthetic trainees' career outcomes compared with previously expressed intentions

Predicting workforce requirements is a difficult but necessary part of health resource planning. A 'snapshot' workforce survey undertaken in 2002 examined issues that New Zealand anaesthesia trainees expected would influence their choice of future workplace. We have restudied the same cohort to see if that workforce survey was a good predictor of outcome. Seventy (51%) of 138 surveys were completed in 2009 compared with 100 (80%) of 138 in the 2002 survey. Eighty percent of the 2002 respondents planned consultant positions in New Zealand. We found 64% of respondents were working in New Zealand (P < 0.01). We found that family ties were an important influence on the choice of country of residence for 80% of New Zealand based respondents but only 40% of those living outside New Zealand agreed or strongly agreed with this statement (P < 0.01). Remuneration influenced country of residence for 76% of those living outside New Zealand but was important for only 2% of those resident in New Zealand (P < 0.01). Salaries in New Zealand were predominantly between NZ$150,000 and $200,000 while those overseas received between NZ$300,000 and $400,000. Of those that are resident in New Zealand, 84% had studied in a New Zealand medical school compared with 52% of those currently working overseas (P < 0.01). Our study shows that stated career intentions in a group do not predict the actual group outcomes. We suggest that 'snapshot' studies examining workforce intentions are of little value for workforce planning. However we believe an ongoing program matching career aspirations against career outcomes would be a useful tool in workforce planning.     

家兔肝纤维化肝癌模型的研究

目的建立新西兰白兔的肝纤维化合并肝癌模型。方法32只新西兰白兔随机分为2组,每组16只。模型组给予CCl_4油溶液灌胃,每周2次,共8周,第6周末肝脏接种VX-2肿瘤;对照组陪同饲养。观察实验兔的一般情况、体重变化、肝功能变化情况,并行CT及B超影像学检查和病理学检查。结果模型组共存活11只。与对照组比较,模型组体重下降,血清丙氨酸氨基转移酶(alanine aminotransferase,ALT)、天门冬氨酸氨基转移酶(aspartate aminotransferase,AST)、γ-谷氨酰转肽酶(γ-Glutamyl Transpeptidase,GGT)、总胆红素(Total Bilimbin,TBil)升高,血清白蛋白(albumin,ALB)和白球比(A/G)下降,CT和B超发现肝脏占位,病理检查证实模型组新西兰白兔出现肝纤维化肝癌。结论使用CCl_4灌胃法诱发新西兰白兔肝纤维化,并种植肝脏VX-2肿瘤,可以建立肝纤维化肝癌的模型。     

PS15PAEDIATRIC GUN SHOT INJURIES IN NEW ZEALAND: A DEMOGRAPHIC ANALYSIS OF AN AVOIDABLE CAUSE OF SIGNIFICANT CHILDHOOD MORBIDITY

Purpose New Zealand has a reputation for an outdoors lifestyle that includes hunting and tramping. New Zealanders own over a million guns and these are widely distributed throughout the rural and urban communities. Although its gun laws are not liberal, children still suffer gun shot injuries. The aim of this study was to examine the injuries children receive from firearms in New Zealand, their circumstances and long term morbidity. Methodology A retrospective review of all children admitted to the four New Zealand paediatric surgical hospitals (at Auckland, Hamilton, Wellington and Christchurch) with gun shot injuries over 10 yr period 1996–2005 was undertaken. Data were compared with published literature from elsewhere. Results Overall, the incidence of gunshot injuries in New Zealand is low compared with many other developed countries. The majority are caused by air rifles. Most are superficial but some may lead to long term morbidity. Conclusions Although New Zealand gun laws require air rifle owners to be over 18 yrs of age, children often are victims of air rifle misuse, particularly in urban areas. Mortality is rare, but some children suffer long term morbidity. Our data may enable preventative measures to be better focused.     

Prevalence of asthma among 12 year old children in New Zealand and South Wales: a comparative survey.

A survey of 12 year old schoolchildren was carried out in New Zealand and South Wales, the same questionnaire and exercise provocation test being used. The prevalence of a history of asthma at any time was higher in New Zealand (147/873, 17%) than in South Wales (116/965, 12%). The New Zealand children were also more likely than the Welsh children to have a history of "wheeze ever" (27% versus 22%), and wheeze brought on by running (15% versus 10.5%). The sex ratio of asthmatic and wheezy children was very similar in the two countries. A history of hospital admission for chest trouble was twice as common in New Zealand as in South Wales. An exercise test produced a fall in peak expiratory flow rate of 15% or more in more New Zealand children (12.2%) than Welsh children (7.7%). These results suggest that the prevalence of childhood asthma is higher in New Zealand than in South Wales.     

ROBOTIC TECHNOLOGY IN SURGERY: CURRENT STATUS IN 2008

There is increasing patient and surgeon interest in robotic‐assisted surgery, particularly with the proliferation of da Vinci surgical systems (Intuitive Surgical, Sunnyvale, CA, USA) throughout the world. There is much debate over the usefulness and cost‐effectiveness of these systems. The currently available robotic surgical technology is described. Published data relating to the da Vinci system are reviewed and the current status of surgical robotics within Australia and New Zealand is assessed. The first da Vinci system in Australia and New Zealand was installed in 2003. Four systems had been installed by 2006 and seven systems are currently in use. Most of these are based in private hospitals. Technical advantages of this system include 3‐D vision, enhanced dexterity and improved ergonomics when compared with standard laparoscopic surgery. Most procedures currently carried out are urological, with cardiac, gynaecological and general surgeons also using this system. The number of patients undergoing robotic‐assisted surgery in Australia and New Zealand has increased fivefold in the past 4 years. The most common procedure carried out is robotic‐assisted laparoscopic radical prostatectomy. Published data suggest that robotic‐assisted surgery is feasible and safe although the installation and recurring costs remain high. There is increasing acceptance of robotic‐assisted surgery, especially for urological procedures. The da Vinci surgical system is becoming more widely available in Australia and New Zealand. Other surgical specialties will probably use this technology. Significant costs are associated with robotic technology and it is not yet widely available to public patients.     

Changing incidence of non-melanoma skin cancer in New Zealand

Background: Basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) are the commonest types of non‐melanoma skin cancer (NMSC). The incidence of NMSC has been increasing globally with Australia recording a 1.5‐fold increase over the last 17 years. The incidence of NMSC in New Zealand is currently unknown. Given that Australia and New Zealand share similar latitude, sun exposure levels, and other risk factors, it is conceivable this increase has also occurred in New Zealand. This study aimed to provide an analysis of the incidence of NMSC within the Central Region of New Zealand based on longitudinal data derived from pathology reports. Methods: This retrospective study examined the pathology records of 26 411 patients who underwent surgical excision for 54 004 NMSC lesions which were histologically confirmed, over a 10‐year period from 1 January, 1997 to 1 January, 2007, within the Central Region of New Zealand. Results: Over the study period, 50 411 primary NMSC lesions were excised. The age‐standardized incidence for NMSC, BCC and SCC was 406, 299 and 118 per 100 000, respectively. Since 1999, the annual incidence of BCC and SCC has increased by 4.0% and 1.1%, respectively, with the greatest increases seen in the population over the age of 50 years. Conclusion: New Zealand has one of the highest incidence of NMSC in the world. The high and increasing incidence of NMSC underscores the importance for the development and implementation of a national health‐care delivery model, and a commitment to continued monitoring of the NMSC problem.     

Report of renal failure treatment in Australia and New Zealand from the dialysis and transplant registry (ANZDATA)

Summary: The Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) has recorded 15675 patients resident in Australia and 2909 patients in New Zealand who have been treated by dialysis and transplantation for end-stage renal failure. the majority of patients have a functioning transplant (51% Australia, 50% New Zealand). Cadaveric organs have been the mainstay of the transplant programme from 1963 to 1993 (91% Australia, 87% New Zealand). In recent years the early graft survival has dramatically improved; the 12 month graft survivals were 74 and 87% in Australia, and 68 and 78% in New Zealand in 1983 and 1992, respectively. A large majority of patients have dialysed at home (49% Australia, 84% New Zealand) or with low level assistance in facilities remote from tertiary level hospital renal units (21% Australia). While most patients use haemodialysis (64% Australia, 41% New Zealand), continuous ambulatory peritoneal dialysis is the predominant form of dialysis in the home (63% Australia, 70% New Zealand). the demographic analysis displays a slight predominance of males (55.5% Australia, 50.4% New Zealand), and a steadily increasing number of patients over 65 years old (31% Australia, 15% New Zealand), and of diabetics (16% Australia, 31% New Zealand). Aborigines, Maoris and Pacific Islanders have a strikingly higher rate of renal failure per million population than the Caucasoid/Europid population. Certain causes of renal failure such as excess analgesic ingestion and malignant hypertension have declined. Glomerulonephritis has been the most common cause of renal failure in Australia (33%), diabetic nephropathy the most common in New Zealand (31%).     

Anaesthesia medical workforce in New Zealand

This survey was conducted in all 28 New Zealand District Health Boards with a response rate of 100%. The Clinical Directors of Departments of Anaesthesia were asked to quantify their current anaesthesia service delivery and to assess their workforce level. Over half of the District Health Boards reported understaffing, fifty percent occurring in hospitals of provincial cities or towns with an inability to attract specialist anaesthesia staff. Financial constraint was the other main reason for understaffing. With the information from the survey, an attempt was made to predict future New Zealand anaesthesia workforce requirements. A model for Australasia established by Baker in 1997 was used. In comparing this survey to previous studies, there is evidence that the nature and expectations of the anaesthesia workforce are changing as well as the work environment. Currently, there is no indication that anaesthesia specialist training numbers should be reduced. Close, ongoing monitoring and planning are essential to ensure future demands for anaesthesia services can be met.     

Pancreatic cancer: management and survival

AIM: To review the management and survival from all pancreatic cancer over a 5-year period at a tertiary referral hospital in New Zealand and to examine similar outcome data from the national cancer registry. METHODS: A retrospective audit was conducted for the 5-year period 1994-99 of patients discharged from Christchurch Hospital (Christchurch, New Zealand) and all patients in the New Zealand Cancer Registry with a diagnosis of pancreatic cancer. Kaplan- Meier survival curves were used for analysis. RESULTS: From Christchurch Hospital a total of 230 patients were identified with a discharge diagnosis of pancreatic cancer. Medium survival for all groups was 3.9 months. There was a median survival of 1.6 months for the non-interventional group, 3.1 months for the stent group, 6.2 months for the bypass group and 12.6 months for the pancreatico-duodenectomy group. These data are very similar to the New Zealand National Cancer Registry data, where the overall median survival was 3.1 months and median survival for a pancreatico-duodenectomy was 13.9 months. CONCLUSION: A pancreatico-duodenectomy is usually a palliative surgical technique and not a curative procedure. Those selected for resection have been shown to have an advantage over operative bypass in terms of length of survival, however, this most likely reflects selection bias.     

The population prevalence of undetected abdominal aortic aneurysm in New Zealand Māori

BackgroundThe prevalence of abdominal aortic aneurysm (AAA) in Polynesian populations such as the New Zealand Māori has not been characterized. We measured this in a large population-based sample.MethodsA cross-sectional population-based prevalence study was conducted as part of an AAA screening pilot; 2467 Māori men aged 54 to 74 years and 1526 women aged 65 to 74 years registered with a primary care practice in Auckland (New Zealand) were invited to be screened by abdominal ultrasound between June 2016 and March 2018. Patients with pre-existing AAA disease and those with terminal conditions or circumstances that would make them unlikely to benefit from screening were excluded. The prevalence rate of AAA in Māori women was calculated with a cutoff definition of 27 mm as well as with the normal 30-mm definition (used in men). A log-binomial regression model estimated the prevalence rate at exactly 65 years for the purpose of comparison with screened populations in the United Kingdom.ResultsThe crude prevalence rate of undiagnosed AAA in Māori men aged 60 to 74 years was 3.6%. In women, it was 1.7% at the 30-mm threshold and 2.3% at 27 mm. The prevalence rate at exactly 65 years of age was calculated from the log-binomial regression model to be 2.7% (confidence interval [CI], 2.0%-3.8%) in men, 0.9% (CI, 0.4%-2.2%) in women at the 30-mm threshold, and 1.5% (CI, 0.7%-3.0%) in women at the 27-mm threshold. Among smokers, the crude prevalence rates were 7.5% (CI, 4.9%-11.5%) in men and 6.9% (CI, 4.1%-11.5%) in women (30 mm+).ConclusionsThe prevalence of undiagnosed AAA in New Zealand Māori men is considerably higher than in screened populations of equivalent age in the United Kingdom and Sweden. Prevalence rates in New Zealand Māori women are close to those of screened British men. New Zealand should consider implementing a population-based screening program for Māori men and conduct further research into the health impact of screening Māori women.     

Comparison of the Aotearoa New Zealand Early Warning Score and National Early Warning Score to predict adverse inpatient events in a vital sign dataset

Aotearoa New Zealand uses a single early warning score (EWS) across all public and private hospitals to detect adult inpatient physiological deterioration. This combines the aggregate weighted scoring of the UK National Early Warning Score with single parameter activation from Australian medical emergency team systems. We conducted a retrospective analysis of a large vital sign dataset to validate the predictive performance of the New Zealand EWS in discriminating between patients at risk of serious adverse events and compared this with the UK EWS. We also compared predictive performance for patients admitted under medical vs. surgical specialties. A total of 1,738,787 aggregate scores (13,910,296 individual vital signs) were obtained from 102,394 hospital admissions to six hospitals within the Canterbury District Health Board of New Zealand's South Island. Predictive performance of each scoring system was determined using area under the receiver operating characteristic curve. Analysis showed that the New Zealand EWS is equivalent to the UK EWS in predicting patients at risk of serious adverse events (cardiac arrest, death and/or unanticipated ICU admission). Area under the receiver operating characteristic curve for both EWSs for any adverse outcome was 0.874 (95%CI 0.871–0.878) and 0.874 (95%CI 0.870–0.877), respectively. Both EWSs showed superior predictive value for cardiac arrest and/or death in patients admitted under surgical rather than medical specialties. Our study is the first validation of the New Zealand EWS in predicting serious adverse events in a broad dataset and supports previous work showing the UK EWS has superior predictive performance in surgical rather than medical patients.     

Trauma care systems in New Zealand

Trauma in New Zealand is modest in extent in relation to many other areas of the world. Trauma care is delivered in the context of an ad hoc trauma system which nevertheless seems to function reasonably well. Current funding strictures in the short term seem likely to prevent formal adoption of a trauma system which would have the prospect of providing information determining the real quality of trauma care in New Zealand.     

Identification of pig circovirus type 2 in New Zealand pigs

Interest in porcine circovirus has been stimulated by the recent emergence of postweaning multisystemic wasting syndrome (PMWS) in pigs and the potential use of pig organs for xenotransplantation in humans. Porcine circovirus type 1 (PCV1) is considered to be widespread in pigs but nonpathogenic. Circovirus type 2 (PCV2) is a similar virus but has been differentiated only recently as a separate type. High tissue concentrations of PCV2 are associated with lesions in PMWS cases, but the etiological role of this agent in the disease remains unclear. The presence of PCV1 in New Zealand pigs has been previously reported based on serological data. PMWS has been recently recorded in New Zealand pigs. The epidemiology of PCV2 in New Zealand pigs has not been examined. The purpose of the study was to look for evidence of circoviruses in New Zealand pig herds. Pig circovirus DNA was sought in various tissues using the polymerase chain reaction. Circovirus type 2 was found in New Zealand pig herds, without any evidence that PMWS has ever occurred in these herds. Newborn piglets were shown to have infection, suggesting vertical transmission of the virus.     

PR35THE INCIDENCE OF NON‐MELANOMA SKIN CANCER IN NEW ZEALAND

Background It is estimated that skin cancers cost $33 million per annum to the New Zealand healthcare system. Basal cell carcinoma and squamous cell carcinoma are the commonest types of non melanoma skin cancers (NMSCs). Anecdotal evidence indicates that there has been a doubling in the incidence of NMSCs in New Zealand over the last decade. Because of the high incidence mandatory reporting of NMSCs to the National Cancer Registry is not required. This lack of accurate data has led to poor health care policies and strategies including funding and workforce planning. Aims The aims of this study are to (1) present the latest statistics on NMSCs in New Zealand, including the incidence across different regions over the last decade, patient demographics, anatomic distribution of NMSCs, incidence and sites of metastasis, and disease‐specific survival; to (2) the histopathology of NMSCs, including surgical margins, histologic grade, and perineural, lymphatic, and vascular invasion; and (3) the relative role of different faculties treating NMSCs. Method This project has been approved by the multi‐centre ethics committee. A retrospective review was conducted from patients’ histology records from public and private pathology laboratories within defined catchment areas. Criterion for analysis is a confirmed diagnosis of NMSC treated surgically. A Microsoft Access database is created that will facilitate subsequent data retrieval and analysis. Results and Conclusion It is hoped that this up‐to‐date data will form the framework for the development of sound and sustainable healthcare policies of management of NMSCs including management strategies and workforce planning, and research direction on this common disease.     

Cutaneous melanoma in Caucasian New Zealanders: 1995-1999

Background: The aim of the present study was to evaluate the spectrum of cutaneous melanoma in Caucasian New Zealanders. Method: Data were obtained from the New Zealand Cancer Registry by way of a computerized search of the melanoma ICD‐9 codes from 1995 to 1999. The final database used is for people identifying themselves as European. The denominator population were people stating their ethnicity as European in the 1996 New Zealand Census; all others were excluded. The Cancer Registry Act 1993 made reporting of cancer mandatory. Cancer data before July 1994 are of dubious accuracy. Results: There were 4966 cases of cutaneous melanoma reported in New Zealand between 1995 and 1999 by people identifying themselves as European. The trends and statistically relevant findings will be discussed. Conclusion: New Zealand continues to have one of the highest rates of melanoma in the world, with an increasing Breslow thickness of melanoma (P < 0.001) over the 5‐year period. Men have a higher rate and deeper melanomas than women (P < 0.001). The incidence of melanoma appears to have reached a plateau over the review period. The far north of New Zealand (Whangarei and further north) had the highest rate of melanoma in New Zealand (59.1/100 000, age standardized) and the lowest rate is in Southland (23.5/100 000).     

Models of acute care for injured older patients—Australia and New Zealand practice

IntroductionThe epidemiology of injured patients has changed, with an increasing predominance of severe injury and deaths in older (65 years and above) patients after low falls. There is little evidence of the models of care that optimise outcomes for injured older patients. This study aims to describe clinician perspectives of existing models of acute care for injured older patients in Australia and New Zealand.MethodsThis cross-sectional online survey of healthcare professionals (HCP) managing injured older patients in Australia or New Zealand hospitals was conducted between November 2nd and December 12th, 2020. Recruitment was via survey link and snowball sampling to professional organisations and special interest groups via email and social media. HCP were asked, using a Likert scale, how likely four typical case vignettes were to be admitted to one of twelve options for ongoing care. Additional questions explored usual care components.ResultsParticipants (n=157) were predominantly Australian medical professionals in a major trauma service (MTS) or metropolitan hospital. The most common age defining “geriatric” was aged 65 years and older (43%). HCP described variability in the models and components of acute care for older injured patients in Australia and New Zealand. As a component of care, cognitive, delirium and frailty screening are occurring (60%, 61%, 46%) with HCP from non-major trauma services (non-MTS) reporting frailty and cognitive impairment screening more likely to occur in the emergency department (ED). Access to an acute pain service was more likely in a MTS. Participants described poor likelihood of a geriatrician (highest 16%) or physician (highest 12%) review in EDConclusionDespite a low response rate, HCP in Australia and New Zealand describe variability in acute care pathways for injured older patients. Given the change in epidemiology of injury towards older patients with low force mechanisms, models of acute injury care should be evaluated to define a cost-effective model and components of care that optimise patient-centred outcomes relevant to injured older patients. HCP described some factors they perceive to determine care, and outcomes of variability, offering guidance for future research and resource allocation in the Australia and New Zealand trauma system.     

Predictive performance of Acute Physiological and Chronic Health Evaluation releases II to IV: a single New Zealand centre experience

There is debate in Australia and New Zealand around the appropriate use of illness severity scoring systems in Australasian intensive care units. The international benchmark is the Acute Physiological and Chronic Health Evaluation (APACHE) system. In order to compare the performance of recent APACHE releases, we audited 2080 sequential patients admitted between 1 January 2006 and 31 March 2008 to the Middlemore Hospital intensive care unit, Auckland, New Zealand. We compared the predictive performance of the proprietary APACHE II, IIIh, IIIj and IV releases, and the performance of a 'localised' version of APACHE II containing re-estimated coefficients derived from a legacy dataset (7703 sequential patients admitted between 1 January 1997 and 31 December 2005). Discrimination assessed by receiver operating characteristic curves was highest with the APACHE III and IV releases, and significantly better than the APACHE II releases. Calibration assessed by the Hosmer-Lemeshow statistic was poor with all releases, although it was best with APACHE IV and 'localised' version of the APACHE II release. Overall accuracy assessed by the Brier Mean Probability score and Shapiro's R statistic was best with APACHE IV. Our study suggests the possibility of improved prediction in moving to APACHE IV from older releases, although broader multicentre study within the Australian and New Zealand critical care community is warranted. Our study also suggests localisation of the APACHE system offers further opportunity to improve prediction, although these improvements may not be major without ground-up development of a new risk prediction model within our local critical care setting.     

Objectives for undergraduate education in resuscitation and anaesthesia for children.

A statement of objectives for teaching undergraduates in the fields of resuscitation and anaesthesia for children is presented. The value of such objectives and the requirements for undergraduate teaching by anaesthetists in Australia and New Zealand are briefly discussed.     

Efficacy of bupropion in the indigenous Maori population in New Zealand

BACKGROUND: Smoking rates are high in indigenous populations and contribute to their poor health. In New Zealand the indigenous Maori population has a high rate of smoking, with around 50% of adults being smokers compared with 20% of the adult European population. A study was undertaken to determine whether bupropion is effective in the treatment of smoking cessation in the indigenous Maori population in New Zealand. METHODS: A randomised, placebo controlled, double blind, parallel group study was performed in 134 Maori smokers aged 16-70 years who smoked more than 10 cigarettes per day. The main outcome measures were continued abstinence from smoking at 3 and 12 months. RESULTS: At each time point continued abstinence was better for the subjects allocated to bupropion, with a risk ratio for abstinence over all time points of 2.44 (95% CI 1.22 to 4.88). The rates of continued abstinence in the bupropion and placebo groups at 3 months were 44.3% and 17.4%, respectively, with a risk ratio of 2.54 (95% CI 1.30 to 5.00). The corresponding figures at 12 months were 21.6% and 10.9%, respectively, with a risk ratio of 1.99 (95% CI 0.79 to 5.00). CONCLUSION: Bupropion is an effective treatment for smoking cessation in the indigenous Maori population in New Zealand.