Flourishing and its relevance to excellence in surgical training: a scoping review

Udaya Samarakkody*, Marcus Henning[[1]], Craig Webster[[1]], Stephen Buetow[[1]]

*Waikato Hospital, Waikato Clinical Campus, Hamilton; [[1]]Faculty of Health Sciences and Medicine, University of Auckland

Eudaimonia in Aristotelian ethics indicates a good life or flourishing, which equates to realising the potential of the person to cultivate virtue or excellence. Flourishing in the context of surgical (or other medical) training is not discussed in detail in the literature. Therefore, we have produced a scoping review that locates surgical training in a strengths model of concepts, theories and determinants of flourishing. The model looks to guide a larger project on the accredited surgical trainees of the Royal Australasian College of Surgeons in New Zealand.

Methods

The scoping review follows the methods and guidelines framework by Arksey and O’Malley and the PRISMA reporting system extension. Published literature was identified by systematically searching four databases: Medline, Scopus, Philosophers index and Google scholar. The search was restricted to publications from 2000 to 2021 in the English language. Identified publications were screened for relevance. Data were extracted to identify themes that we integrated on a mind map. This model adapted the concepts of Māori model of health: Te Whare Tapa Whā to produce a unique Aotearoa New Zealand essence.

Results

Sixty-seven publications were identified. Four major themes emerged: academic prowess, trainee wellbeing, job/training satisfaction, self-actualisation with altruism leading to flourishing in surgical training.

Conclusions

The four themes listed above form the four cornerstones of flourishing in surgical training. They constitute a holistic approach to surgical training, which will inform the lead author’s doctoral study to help fill knowledge gaps.

References

Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol 2005;8:19–32.

Durie, M. (1994). Whaiora: Māori health development. Auckland: Oxford University Press.

GP and client perspectives of the barriers to obesity healthcare in New Zealand general practice: a meta-ethnography review

Kimberley Norman[[1]], Prof Lisette Burrows[[1]], Dr Lynne Chepulis[[1,2]], Prof Ross Lawrenson[[2,3]]

[[1]]Te Huataki Waiora School of Health, University of Waikato, Hamilton; [[2]]Waikato Medical Research Centre, University of Waikato, Hamilton; [[3]]Waikato District Health Board, Hamilton

Introduction

Obesity is a significant health issue which leads to further physical and psychosocial health complications, negative health outcomes and increases the strain on the national health system. There is minimal literature on the barriers to obesity healthcare in general practice from healthcare professional and client perspectives in New Zealand.

Aim

To synthesise general practitioner (GP) and client perspectives to identify barriers to obesity healthcare in New Zealand general practice.

Methods

A review and synthesis of qualitative weight management perspectives was conducted guided by meta-ethnography and grounded theory.

Results

From eight included studies, four key barriers (stigma, communication, inadequate healthcare, and sociocultural influences) that directly and indirectly impacted the efficacy of weight management in general practice. Clients reported wanting tailored, non-stigmatised, effective weight management healthcare. However, GPs reported being ill-equipped to provide this due to barriers both within and outside the limits of their practice.

Discussion

The perspective of “obesity” differed between GPs and clients. Educating both groups about the others’ perspective could assist with increasing effective communication and reclaiming the obesity discourse within the general practice context as a clinical health concern free from stigma or offense. GPs could benefit from further understanding their clients complex, socio-culturally “lived experience” of obesity, and clients could benefit from understanding their GPs clinical perspective of obesity. Further resources, effective referral options and training is needed to support GPs in their role. Further qualitative research is needed from GP, client and Māori health provider perspectives to identify barriers and sociocultural factors that impact weight management interventions in general practice.

Do we meet the Ministry of Health health target for faster lung cancer treatment? A Waikato DHB Respiratory Department experience

Emma Tan[[1]], Eskandarain Shafuddin[[1]], Janice Wong[[1]]

[[1]]Respiratory Department, Waikato Hospital, Hamilton, New Zealand

Background

The Ministry of Health (MOH) New Zealand has set targets on faster cancer treatment, including 90% of patients to be seen within two weeks of referral.[[1]] We aim to assess our performance in meeting the target, the utilisation of High Suspicion of Cancer (HSCAN) pathway, and identify any reasons for delay in the referral pathway.

Method

Data was collected for the Waikato DHB catchment area for referrals through the HSCAN pathway through the referral centre from 1 January to 31 December 2019. Breaches of target were identified.

Results

Two hundred and eighty-four HSCAN referrals were received. A further 120 referrals were accepted as HSCAN. Three hundred and thirty-three patients were reviewed by respiratory physicians, 105 (32%) being seen within 14 days of referral. One hundred and thirty-four (40%) had confirmed cancer, either primary lung or metastases; 48 (14%) had lung nodules which remained benign after two years of referral; and 151 (45%) had a final benign diagnosis. Of those with confirmed malignancy, 78 (58%) had a CT scan and 55 (41%) were reviewed within 14 days of referral.

Conclusion

Most patients were not being seen within the MOH target. Several factors identified include misclassification of referrals, delay in obtaining CT scans, and delay in getting clinic appointments within the target. There is a need to improve the referral pathway, access to CT scans and clinic availability in order to achieve the MOH target.

References

(1) 2017/18 DHB Health Targets | Nationwide Service Framework Library, 2017) Nsfl.health.govt.nz. 2017. 2017/18 DHB Health Targets | Nationwide Service Framework Library. [online] Available at: https://nsfl.health.govt.nz/accountability/performance-and-monitoring/health-targets/201718-dhb-health-targets [Accessed 24 July 2021].

(2) Williams S, Davies P, Johnson B, Iles S. A fast track clinic improves diagnosis and treatment times for those investigated for lung cancer in Northland District Health Board. The New Zealand Medical Journal. 2018 Mar 23;131(1472):29-37.

(3) Bpac.org.nz. 2014. Lung Cancer in New Zealand: overcoming barriers. [online] Available at: https://bpac.org.nz/bpj/2012/november/upfront.asp [Accessed 12 September 2021].

Severe hepatobiliary disease in congenital duodenal obstruction

Jonathan Ko[[1,3]], Tina Zhang[[13]], Askar Kukkady[[1, 2]], Stephen Adams[[2]], Udaya Samarakkody[[2,3]]

[[1]]Waikato Clinical Campus, University of Auckland, Hamilton, New Zealand; [[2]]Waikato Hospital, Hamilton, New Zealand; [[3]]University of Auckland, Auckland, New Zealand

Introduction

Duodenal atresia and stenosis are causes of intestinal obstruction in neonatal and paediatric populations. The literature regarding long-term complications in this population are limited although hepatobiliary disease is known to be a potential long-term complication. We aim to study long-term outcomes with a focus on hepatobiliary infection, which could potentially be life-threatening.

Methods

Patients were located through the Clinical Audit Support Unit (CASU) and Newborn Intensive Care Unit (NICU) database. We studied the long-term complications in patients presenting with duodenal atresia and stenosis at a tertiary hospital in New Zealand between 1987 and 2021. This included all neonatal cases of duodenal atresia in Waikato Hospital and patients presenting up to 50 years of age with a long-term complication. We reviewed the clinical notes, operative records and admission records for each patient.

Results

Due to a ransomware attack on Waikato District Health Board, patients outside the NICU database were left for a later date. Therefore, the patients located through the NICU database comprised the current study. Thirty-five patients met the inclusion criteria, in which seven (20%) presented with a long-term complication. Twenty-four (69%) had at least one documented congenital abnormality, including 12 (34%) who had Trisomy 21 and 16 (46%) born prematurely.

We identified three cases of hepatobiliary infection. Two of them had a background of trisomy 21. The first presented with severe cholecystitis and cholelithiasis. The second patient had choledocholithiasis, complex liver abscess and sepsis. Both required ventilatory support, emergency surgery and intensive care treatment. The third patient presented with weight loss due to cholangitis and was treated with IV antibiotics. The other four complications included adhesive small bowel obstruction requiring adhesiolysis.

Conclusions

Our study’s findings support the potential of severe hepatobiliary disease being a long-term complication of duodenal atresia and stenosis. The severity of these cases highlights the requirement for long-term follow-up and further reporting on long-term outcomes. An extension of this study will include the complete cohort of patients initially intended before the ransomware attack.

NZRED: early experiences of establishing a national rare endocrine disorder registry

William Park[[1]], Veronica Boyle[[2,3]], Jade Tamatea[[2,3,4]], Emily Walsh[[5]], Richard Carroll[[5,6]], Marianne Elston[[2,3]]  

[[1]]University of Otago, Wellington; [[2]]Department of Endocrinology, Waikato Hospital, Hamilton; [[3]]Waikato Clinical Campus, University of Auckland; [[4]]Te Kupenga Hauora Māori, University of Auckland; [[5]]Centre for Endocrine, Diabetes and Obesity Research, Wellington Regional Hospital, Wellington; [[6]]Department of Endocrinology, Wellington Regional Hospital, Wellington

Little is known about the epidemiology and clinical characteristics of patients with rare endocrine disorders in Aotearoa. Our aim is to establish a national registry that includes patients diagnosed with rare endocrinopathies, including acromegaly, Cushing’s disease, Addison’s disease and familial endocrine disorders. This database will provide an epidemiological description of these diseases in a local context to determine effectiveness of local diagnostic pathways, surveillance strategies and interventions, including whether these differ based on a patient’s demographics or location. Effort has been taken to ensure Te Tiriti compliance with partnership with Māori clinicians, researchers and patients in the development and ongoing oversight of the registry. This database has the potential to identify whether diagnostic and treatment outcomes in Aotearoa are comparable with international standards, and equitable across the nation.

Patients continue to be offered participation if they have or have ever been diagnosed with the conditions listed above. Demographic and diagnostic information are collected at enrolment, and information regarding disease status and treatment is gathered longitudinally as long as the patient is enrolled in the registry. All district health boards (DHBs) have approval to begin recruiting patients, with recruitment and data entry well underway in the greater Waikato and Wellington regions.

Preliminary data regarding the epidemiological characteristics of these conditions aligns with what is reported in the international literature, albeit with high variance due to a limited sample size. In our current incomplete sample, Addison’s disease prevalence appears to be lower in Māori. A preliminary analysis suggests that patients living in more socioeconomically deprived areas may have greater delays in access to care for Cushing’s disease and Addison’s disease. However, to obtain accurate, meaningful measures, especially for Māori patients, it is important that all eligible patients within Aotearoa have the opportunity to participate to increase sample size and reduce selection bias. This is indicative of the potential for this registry to monitor and inform on healthcare disparities and inequities to guide local practice and policy.

Oral health outcomes for Harti

Braedon Epps[[1]], Dr Amy Jones[[2]], Dr Nina Scott[[2]]

[[1]]Waikato Clinical Campus, University of Auckland; [[2]]Te Puna Oranga (Maori Health Unit), Waikato District Health Board, Hamilton

Oral health services are not meeting needs for Māori tamariki. In the Waikato District Health Board (DHB), only 55.4% of Māori 5-year-olds are caries-free, compared to 59.7% nationally (Ministry of Health, 2018). Oral Health Outcomes for Harti is a sub-study of Harti Hauora tamariki, a randomised controlled trial of 966 children aged 0-4 years admitted to the Waikato Hospital paediatric ward. The intervention, based on the principles of Whānau Ora, involved screening tamariki and their whānau for social and health risk factors and employed effective referral pathways, opportunistic information and resource provision to increase access to health services for whānau Māori.

The primary aim of the present study was to evaluate the experience of the oral health protocols for whānau and to determine the efficacy of the Harti oral health protocols. A secondary aim was to assess the proportion of tamariki who were up to date with oral health checks by the age of 2.5yrs in the Waikato region.

The findings indicate that the Harti tool dramatically increased access to community oral health services, particularly for tamariki Māori.

Prophylactic antibiotic use in hypospadias repair with urethral stenting (HRUS) at Waikato DHB

Aini Su[[1]], Allanah Hartley[[1]], Huiying Lin[[1]], Tim Little*,  Udaya Samarakkody[[1]]*

*Paediatric Surgery Department, Waikato Hospital, Hamilton; [[1]]Waikato Clinical Campus, Faculty of Health Sciences and Medicine, University of Auckland

Introduction

Prescribing antibiotic prophylaxis after hypospadias repair with urethral stenting (HRUS) is controversial. The risk of infection must be balanced against good antimicrobial stewardship. We wished to evaluate the practice at Waikato District Health Board (DHB). Outcomes evaluated were the rate of urinary tract infection (UTI) and surgical site infection (SSI).

Methods

Cases were identified from theatre records spanning the period January 2011 to December 2020 inclusive. Electronic clinical records were hand-searched recording demographic variables, post-discharge antibiotic prescription and post-operative presentations with UTI and SSI. Data were analysed using Microsoft Excel.

Results

There were 143 cases of HRUS over the study period. Ninety-five-point-one percent of patients were prescribed prophylactic antibiotics. The overall rate of infection in those prescribed antibiotics VS those who weren’t was 8.8% and 42.9% (P=0.026). Rate of UTI in those prescribed antibiotics VS those who weren’t was 5.1% and 14.3% respectively (P=0.338). SSI occurred in 3.7% (antibiotics) and 28.6% (no antibiotics) (P=0.039)

Conclusion

The prescription of prophylactic antibiotics was near ubiquitous for HRUS at Waikato DHB during the study period. The rates of overall infection and SSI demonstrated significant improvement with prescribing prophylaxis. No statistically significant benefit was shown for UTI with prophylaxis. These results support continuation of current practice of antibiotic prophylaxis post HRUS.

The emerging landscape of biomarket PDL1 in lung cancer

Harshitha Colonne[[1]], Dushy Samarasinghe[[2]], Michael Arendse[[2]]

[[1]]Research assistant, Department of Histopathology, Waikato Hospital, Hamilton; [[2]]Consultant, Department of Histopathology, Waikato Hospital, Hamilton

Introduction

Lung cancer is the second most common malignancy and biggest cancer-related killer in New Zealand.[[1]] Immunotherapy using anti-PDL1 (programmed death-ligand 1) therapy has shown promising results in advanced non-small cell lung cancer (NSCLC), with improved quality of life and survival in these patients.[[2]] Immunohistochemical testing for PDL1 in surgical specimens guides selection of patients for immunotherapy.[[2,3]]

Aim

To detect the emerging pattern of PDL1 in surgical specimens of NSCLC.

Methods

All NSCLC surgical specimens requested for PDL1 biomarker status by oncologists from the Histopathology Department of Waikato Hospital between 2018 to 2021 were included. Samples were stained with PDL1[SP263 clone] using Leica Bond platform.[[4]] The presence of key NSCLC driver mutations were also assessed.

Results

Seventy-nine patients, with a mean age of 68.5 years, were included, and the majority had stage IV disease (65.8%). Ninety-four percent of patients were diagnosed between 2018 and 2021, and 34% were alive at time of analysis. The mean time from diagnosis to death was 11.3 months. The predominant NCSLC subtype was adenocarcinoma (81%). Driver mutation analysis demonstrated EGFR positivity in 9.1%, BRAF positivity in 4.5%, KRAS positivity in 34.8%. No cases were positive for ALK or ROS1. There was a PDL1 score of <1 in 43%, 1–50 in 41% and ≥50 in 15%. Total PDL1 positivity was 57%. PDL1 was positive in 29% of patients with negative driver mutations, with 10% of them having a score of ≥50.

Conclusions

Fifty-seven percent of patients with advanced NSCLC were positive for PDL1. Of these, 15% had tumour PDL1 expression of ≥50%, a favourable indicator for checkpoint inhibitor therapy.[[2]] High PDL1 expression was also demonstrated in 10% of advanced NSCLC patients with no targetable driver mutation, representing a promising group for anti-PDL1 therapy. PDL1 biomarker testing may assist in directing treatment strategies in advanced NSCLC.

References

(1) Health Quality & Safety Commission New Zealand. Atlas of healthcare variation: Lung cancer. Available from: https://www.hqsc.govt.nz/ our-programmes/health-quality-evaluation/projects/atlas-of-healthcarevariation/lung-cancer/ (Accessed Jan, 2021).

(2) Reck, M, Rodríguez-Abreu D, et al. “Pembrolizumab versus chemotherapy for PD-L1—positive non—small—cell lung cancer.” New England Journal of Medicine, DOI:10;375:1823-33.

(3) Parra, Edwin, R, et al. “Variants in Epithelial-Masenchymal Transition and Immune Checkpoint Genes Are Associated with Immune Cell Profiles and Predict Survival in Non-Small cell Lung Cancer.” Archive Pathology Laboratory Medicine, vol. 144, 2020, pp. 1234 – 1244.

(4) Sholl, Lynette, M, et al. “Programmed Death Ligand-1 Immunohistochemistry-A new Challenge for Pathologists.” Archive of Pathology Laboratory Medicine, vol. 140, 2016, pp 341 – 344.

Assessment of NIS variants in patients with thyrotoxicosis receiving radioiodine therapy

Jane Wu[[1]], Marianne S Elston[[1]], Veronica Boyle[[1]], Jade AU Tamatea[[1,2]]

[[1]]Waikato Clinical Campus, University of Auckland; [[2]]Te Kupenga Hauora Māori, University of Auckland

The Sodium-Iodide Symporter (NIS) is a transmembrane protein critical for iodide transport in the thyroid gland. Dysfunction in this symporter reduces thyroid iodide transportation and, therefore, may have the potential to reduce the efficacy of radioiodine therapy (RAI). Previous work from our group has shown a significant increase in treatment failure rate amongst Māori receiving RAI for thyrotoxicosis (35.2% vs 21.5%). There are multiple possible reasons for unsuccessful RAI therapy. A possible explanation for patients who are not cured after a single dose of RAI is genetic variations within the NIS gene which could render the symporter less effective at transporting RAI.

To investigate this hypothesis, the NIS gene was sequenced from patients who underwent RAI and analysed against clinical longitudinal outcome data. Whole blood samples were collected from 96 patients and DNA-sequencing of the NIS gene was performed. Of these patients, 45 had self-reported Māori ancestry and 51 had no self-reported Māori ancestry with 16 of the 96 patients still being hyperthyroid following treatment and 26 euthyroid and 54 hypothyroid, aiming for adequate representation of Māori ancestry and treatment failure within the cohort. The data were then analysed using the integrated genome viewer. Overall, 13 single nucleotide polymorphisms and two intronic deletions were identified within the patient group. The average number of NIS variants per patient did not differ by age or sex but was lower amongst those with Māori ancestry compared to the rest of the cohort (p=<0.0001). Thyroid status after RAI did not correlate with the number of NIS variants per patient. Two new missense mutations were discovered in two patients. In one of these patients, who had persistent thyrotoxicosis after RAI, the missense mutation resulted in an amino acid change from acidic to nonpolar, which may potentially influence RAI uptake.

For the overall group, variants in the NIS did not correlate with response to RAI but further functional assessment of the novel variant identified in one patient may be warranted.

Admissions for diabetic ketoacidosis have increased five-fold in the Waikato since 2000

Valentina Papa[[1]], Joanna McClintock[[2]], Lynne Chepulis[[3]], Justina Wu[[2]], Cinthia Riguetto[[2]], Ryan Paul[[2,3]]

[[1]]Waikato Clinical Campus, University of Auckland, Hamilton; [[2]]Waikato Regional Diabetes Service, Waikato District Health Board, Hamilton; [[3]]Waikato Medical Research Centre, University of Waikato, Hamilton

Background and aims

Diabetic ketoacidosis (DKA) is a life threatening, costly and largely avoidable complication of diabetes. Admissions for DKA are increasing worldwide, but the frequency, severity and mortality of DKA admissions locally is unknown. The aim of this study was to characterise the epidemiology and severity of DKA in the Waikato region from 2000 to present.

Methods

Demographic and clinical data was obtained from a retrospective chart review of all admissions for DKA to Waikato Hospital between 1 January 2000 and 21 December 2019 (n=1,254 admissions of 594 patients). Admissions for DKA were defined as recurrent (two or more admissions with DKA within the study period), non-recurrent DKA or due to the first presentation of diabetes. Continuous data are presented as mean ± standard deviation.

Results

DKA admissions increased approximately five-fold since 2000 (n=129 admissions in 2019; P<0.001) with a seven-fold increase in recurrent DKA (n=691 admissions; 194 patients), a three-fold increase in non-recurrent DKA (n=407), and a five-fold increase in new diabetes presentations (n=156; all P<0.001). There were no temporal changes in venous pH (7.16±0.15) or bicarbonate (12±5mmol/L) levels, length of stay (4.2±3.9 days), admission to ICU (8.4%), or death during admission (0.4%) or in the following 12 months (2.4%). DKA admissions were most common in 16–30-year-olds (45%; P<0.01 versus other age groups) and recurrent DKA was more likely in females, Māori, those more socially deprived and those who did not attend specialist appointments (all P<0.05).

Conclusions

Admissions for DKA in the Waikato have increased markedly since 2000, primarily due to recurrent DKA. While the severity of presentation has not changed and mortality remains low, targeted holistic interventions are likely required to prevent DKA in those greatest at risk, particularly Māori.