Proceedings of the Waikato Clinical Campus Research Seminar, Wednesday, 27th September 2023
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Hypogonadism following testicular cancer
Veronica Boyle,[[1,2]] Maiea Mauriohooho,[[2]] Jade A U Tamatea,[[1,2]] Michael Jameson,[[1,3]] Alvin Tan,[[3]] Marianne S Elston[[1,2]]
1Waikato Clinical Campus, The University of Auckland, Hamilton, New Zealand; Departments of 2Endocrinology & 3Medical Oncology, Te Whatu Ora Waikato, Hamilton, New Zealand
BACKGROUND
Testicular cancer is the most common malignancy affecting young men, and Aotearoa New Zealand has one of the highest rates of testicular cancer in the world. Survival rates, even in those who present with metastatic disease, are high, with often >95% long-term survival. As such, long-term treatment complications and quality of life are particularly important. Hypogonadism has been reported to occur in 5–25% of men with a history of testicular cancer and surveillance guidelines recommend regular assessment of testosterone levels.
AIM
To determine the proportion of men who had assessment of gonadal function prior to any treatment for testicular cancer and at each of the four recommended timepoints, and the rates of hypogonadism.
METHODS
A retrospective review of patients with a new diagnosis of testicular cancer at Waikato Hospital during a 20-year period from the 1 January 2000 to 31 December 2020. Patients who had a single testis at the time of diagnosis, who had already received treatment for testicular cancer prior to 1 January 2000 or who were already receiving exogenous testosterone replacement were excluded.
RESULTS
A total of 518 cases were eligible for inclusion. Of these, 151 men (29%) had a testosterone level measured at least at one timepoint. There was no difference by age, ethnicity, BMI, tumour stage or treatment between those men who had a testosterone measured and those who did not. Of these 151 men, 69 (45%) had a testosterone level below the lower limit of the reference interval (9nmol/L). These men were more likely to have received radiotherapy (p=0.05); no other differences were identified. Of the 69 men who had at least one low testosterone level, no further action was taken in 17, seven had a repeat that was normal, nine had a repeat value consistent with hypogonadism but no further action was taken, and 37 were referred to endocrinology with 28 started on testosterone replacement. Nine did not receive treatment (repeat levels normal [n=5], waiting to be seen by endocrinology [n=3], referral declined requesting repeat morning test first [n=1]).
CONCLUSIONS
Subnormal testosterone levels are common in men who have previously received treatment for testicular cancer, but assessment of testosterone levels in this group is low. This may mean a missed opportunity to improve quality of life for these men.
Outcomes and access to angiography following non-ST segment elevation acute coronary syndromes in patients that present to rural or urban hospitals
Rory Miller,[[1]] Garry Nixon,[[2]] Tim Stokes,[[3]] Robin Turner,[[4]] Yannan Jiang,[[5]] Rawiri Keenan,[[6]] Corina Grey,[[7]] Andrew Kerr[[8]]
1Rural Doctor and Senior Lecturer, Department of General Practice and Health, University of Otago, Dunedin, New Zealand
2Rural Doctor and Professor of Rural Health, Department of General Practice and Health, University of Otago, Dunedin, New Zealand
3Professor of General Practice, Department of General Practice and Rural Health, University of Otago, Dunedin, New Zealand
4Professor of Biostatistics, Biostatistics Centre, University of Otago
5Senior Research Fellow—Statistics, Department of Statistics, The University of Auckland, Auckland, New Zealand; National Institute for Health Innovation, School of Population Health, The University of Auckland, Auckland, New Zealand
6Medical Research Centre, University of Waikato, Hamilton, New Zealand; Department of General Practice and Rural Health, University of Otago, Dunedin, New Zealand
7Public Health Physician, Department of General Practice and Primary Healthcare, The University of Auckland, New Zealand
8Cardiologist, Cardiology Department, Middlemore Hospital, Middlemore, New Zealand
AIM
In New Zealand patients with non-ST segment elevation acute coronary syndrome (NSTEACS) may present to rural hospitals, or to an urban hospital with or without routine access to percutaneous intervention (PCI). The aim of this study is to determine if there are differences in access to angiography and health outcomes for patients with NSTEACS associated with presenting to these three categories of hospital.
METHODS
First admissions for patients with NSTEACS to a New Zealand public hospital between 1 January 2014 and 31 December 2017 were included. Logistic regression was used to determine whether there was difference between the three categories of hospitals for the outcome measures: angiography performed within 1 year; 30-day, 1-year and 2-year all-cause mortality; and readmission to hospital within 1 year of presentation with either heart failure, a major adverse cardiac event or major bleeding.
RESULTS
There were 42,923 patients included in the study. The adjusted odds of a patient receiving an angiogram were reduced by 25% and 18% for urban hospitals without routine access to PCI (odds ratio [OR] 0.75: 95% confidence interval [CI] 0.71–0.79) and rural hospitals (OR 0.82: 95% CI 0.75–0.90) respectively. Patients that presented to urban hospitals without PCI had increased odds of readmission with a major adverse cardiac event (OR 1.10: 95% CI 1.03–1.16). There was a 16% increase in the odds of dying within 2 years for patients presenting to a rural hospital (OR 1.16: 95% CI 1.05–1.29).
CONCLUSION
Patients who do not present to hospitals with routine access to PCI are less likely to receive angiography. There is a small increase in 2-year mortality for patients who present to rural hospitals that may reflect poorer access to cardiac rehabilitation and secondary prevention.
Breast cancer grade—multi-institutional audit
Archana Pandita,[[1]] Reena Ramsaroop,[[2]] Gavin Harris[[3]]
1Department of Anatomic Pathology, Waikato Hospital, Hamilton, New Zealand
2Department of Anatomic Pathology, North Shore Hospital, Auckland, New Zealand
3Department of Anatomic Pathology, Canterbury Hospital, Christchurch, New Zealand
PURPOSE
Breast carcinoma is the second most common malignancy in women after colon and lung. The breast staging is based on consideration of multiple factors such as size of the tumour, number of lymph nodes involved by the metastatic carcinoma and distant metastases. Although not included in the staging of the breast carcinoma, histological grade for breast carcinoma is strongly associated with both breast cancer-specific survival and disease-free survival. Multivariate analysis have shown that histological grade is an independent predictor of both overall survival and disease-free survival in inoperable breast cancers. This can also help oncologists decide on management. Histological grading is now a part of minimum dataset for breast cancer pathology reporting included by the Royal College of Pathologists of Australasia, the United Kingdom Royal College of Pathologists, the College of American Pathologists, and is endorsed by the World Health Organization.
The national breast cancer registry shows a steady decline in the reporting of grade 3 breast cancers in the regional Waikato Hospital. Multi-institutional breast audit was undertaken to compare the grading in the three regions.
MATERIALS AND METHODS
A total of 105 de-identified slides with breast carcinoma from Waikato Hospital were sent to two different centres (centre A and centre B) for grading of the breast cancers. Pathologists (1–2) from both the centres agreed to look at these slides for grading. The slides were selected randomly from the previous year and same sets were sent to both the centres with no other information available to the grading pathologists to avoid the bias. The slides were sent in sets of three (25, 40 and 40 each) to avoid the extra workload for the pathologists, who are already busy with their routine schedule.
The clinical pathological variables were compared using contingency tables results.
RESULTS
A total of 45 cases were concordant between three institutions. There was some discordance in the grading of the remaining breast cancer slides in the three institutions. The concordant number of cases between Waikato and Centre A was 27 in total. Centre A upgraded 15 of the Waikato cases and downgraded 11 cases. There were 10 concordant cases between Waikato and Centre B. Centre B upgraded seven Waikato cases and downgraded 33 of these cases. When comparing Centres A and B, the number of concordant cases was 13. Centre A upgraded two cases of Centre B and downgraded 33 of the Centre B cases. There were 10 cases not included for the study when comparing all the centres because of the difficulty in differentiating between invasive and in situ carcinoma or cutting artefact in the tissue.
The Waikato cases were further reviewed by one pathologist after a long wash-out period, strictly using the Nottingham breast cancer scoring system. This was done randomly to avoid bias. It was noted that the discordance in grade assignment was mostly resulting from borderline morphological features. The number of cases upgraded from grade 2 to grade 3 was 12, from grade 1 to grade 3 was one and only one case was upgraded from grade 1 to grade 3; however, there were 3 cases that were downgraded to grade 2, and two cases that were downgraded to grade 1.
DISCUSSION
The breast grading is determined using the three variables including tubule formation, nuclear morphology and mitoses using a universal scoring system.
There are few factors that may affect the grade reported in different studies that can be explained by difference in the patient cohorts including age distribution, symptomatic versus chronic population, early versus advanced breast cancer or tissue fixation. There have been many studies looking at the inter-observer and intra-observer agreement of breast cancer histological grade and the value ranges from 0.43–0.83 in different studies. The range for grade 1 measures ranging between 11 and 38%, for grade 2 varies from 37 to 49% and for grade 3 ranges from 24 to 46%.
Waikato Hospital deals mostly with the breast screening cases. This is the most likely cause for lower grade 3 reporting. It was interesting to note quite a significant variation in the grading of the breast cancers across the New Zealand regions. The Waikato grading was seen to be close to Centre B grading when compared to Centre A grading.
The various measures that can be taken to get the appropriate grading is proper fixation. Spending extra time on the slide to look at the periphery or the advancing edge of the tumour may also resolve the issue where usually increased mitoses are seen. It is better to count mitoses from hot spot areas as tumour heterogeneity can be responsible for grading discordance.
CONCLUSION
Histological grade is an important, strong predictor of outcome in patients with invasive breast cancer and therefore it is important that the grading is done correctly, and that steps should be taken in the department to achieve that. Critical evaluation of these issues with recommendations from good practice guidelines with regular educational activities and associated external quality assurance can improve the discordance in the grade reporting. This will improve reproducibility and give consistent results. Work is being done in the field of artificial intelligence and digital pathology to improve the grading outcomes for breast cancers.
Quad bike is not a toy for kids
Sayanthan Balasubramaniam,[[1]] Emily Lancastle,[[2]] Mathew Crowther,[[2]] Udaya Samarakkody[[3]]
1Department of Paediatric Surgery, Te Whatu Ora Waikato, Waikato Hospital, New Zealand
2University of Edinburgh, United Kingdom
3Waikato Clinical Campus, The University of Auckland, Hamilton
BACKGROUND
Quad bikes are useful vehicles for outdoor activities and farming in New Zealand. They are lightweight and have a high centre of gravity. Their appearance and function are very attractive to children. We aim to analyse the mechanism, type of injuries and complications associated with quad bike accidents in children.
METHODS
We collected the data of children under 15 years admitted to Te Whatu Ora (TWO) Waikato – Health New Zealand who sustained quad bike injuries from January 2013 to January 2023 (10 years). The data were analysed with SPPS-22. The Clinical Audit and Safety Unit approved this project.
RESULTS
Eighty-five records were reviewed. Notably, Māori were not represented in this cohort. Sixty-two (72.9%) children were drivers, and 20 (23.5%) were passengers. Thirty-two children had accidents on a farm, 17 at home, 10 on the road, and 26 in “other” locations. Mean age was 10.2, with a range of 1–15 years (standard deviation 3.9) with 52% without helmets. The commonest injury was to limbs (n=60), followed by head injuries (n=20) and abdominal injuries (n=13). Fractures were more common in the upper limbs (n=26) than in the lower limbs (n=15). Twelve had severe concussions, and three had significant intracranial haemorrhage. Eleven children had solid abdominal organ injuries. Four had multiple injuries, including head and abdominal trauma. Thirty-four children underwent surgical interventions, four requiring ICU admission. The average hospital stay was 2.1 days. Overall, 29.4% (n=25) had minor disabilities. The majority (n=60, 58.8%) needed parental support for activities of daily living at discharge.
CONCLUSION
Quad bikes can be a dangerous recreational activity for children, causing major health hazards.
The fatigue after infusion or transfusion pilot trial and feasibility study: a three-armed randomised pilot trial of intravenous iron versus blood transfusion for the treatment of postpartum anaemia
Esther Caljé,[[1]] Joy Marriott,[[2]] Charlotte Oyston,[[2,3]] Lesley Dixon,[[4]] Frank H Bloomfield,[[1]] Katie M Groom[[1,5]]
1Liggins Institute, The University of Auckland, Auckland, New Zealand
2Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, The University of Auckland, Auckland, New Zealand
3Middlemore Hospital, Auckland, New Zealand
4New Zealand College of Midwives, Christchurch, New Zealand
5National Women’s Health, Auckland City Hospital, Auckland, New Zealand
BACKGROUND/AIM
There is a lack of high-quality evidence for the management of moderate-to-severe postpartum anaemia, with significant variation in clinical practice. A randomised trial is needed, although recruitment may be challenging. The primary objective was to determine the recruitment rate for a randomised trial of intravenous (IV) iron and/or red blood cell transfusion (RBC-T) for postpartum anaemia.
METHODS
A randomised pilot trial with surveys for women, clinicians and stakeholders. Inclusion criteria: postpartum haemoglobin 65–79g/L; haemodynamically stable. Exclusion criteria: ongoing heavy bleeding; already received or known contraindication to IV-iron/RBC-T. Intervention/control: IV-iron; RBC-T; or IV-iron and RBC-T. Primary outcome: recruitment rate (those approached, and overall). Secondary outcomes: fatigue, depression, baby-feeding and haemoglobin, at 1, 6 and 12 weeks; ferritin at 6 and 12 weeks. A health equity lens was applied to support Māori and Pacific participation.
RESULTS
Over 16 weeks from 16 October 2022 to 29 January 2023 at Auckland, Waikato and Canterbury hospitals, 26 women consented to randomisation. The proportion of those approached who were randomised was 26/34 (76%), including 8/26 (31%) Māori and one (3%) Pacific women. The proportion of all broadly eligible women was 16% (26/167). Key enablers for participation were altruism and study relevance. For clinicians and stakeholders, availability of research assistance was the key barrier/enabler. No significant differences were found for fatigue or depression amongst intervention arms. Significant differences were found between RBC-T vs (favouring) IV-iron and RBC-T for haemoglobin at 6 (p=0.0116) and 12 (p=0.0234) weeks; and for ferritin at 6 (p<0.0001) and 12 (p=0.0483) weeks. No significant differences were found between IV-iron vs IV-iron and RBC-T for haemoglobin and ferritin.
CONCLUSION
The recruitment rate indicates that a trial of IV-iron and RBC-T for postpartum anaemia is feasible. Dedicated research assistance will be critical to the success of an adequately powered trial to examine the effectiveness of postpartum anaemia interventions.
The use of kaiāwhina and technology (continuous glucose monitors) for glycaemic management in type 2 diabetes (T2D) in high-risk Māori populations
Rebekah Crosswell,[[1]] Salem Waters,[[1]] Hamish Crockett,[[1]] Donna Foxall,[[1]] Suzanne Moorhouse,[[2]] Helen Morton,[[3]] Michael Oehley,[[4]] Ryan Paul,[[4]] Lynne Chepulis[[3]]
1Waikato Medical Research Centre, University of Waikato, Hamilton
2Hauraki PHO, Hamilton
3Raukura Hauora o Tainui Māori
4Te Whatu Ora Waikato
AIMS AND OBJECTIVES
Type 2 diabetes (T2D) is a chronic, multi-systemic condition. Despite established guidelines for the management of patients with T2D, they continue to have suboptimal glycaemic control. Additionally, Māori populations are disproportionally represented in the statistics compared to non-Māori. The aim of this study is to examine whether continuous glucose monitors (CGM) use can drive behaviour change and improve diabetes management in Māori patients with high-risk diabetes (HbA1c <80mmol/L). The study has not been completed; however, progress will be reported to date at the 3-month and 6-month periods.
METHODS
Research methodology included a Te Ao Māori focus, with whakawhanaungatanga and tikanga being at the forefront. Recruitment and study design were driven by a multi-disciplinary working group, including early and mid to late career researchers and clinicians. Twenty-two participants have been recruited, all through to completion of the 3-month period. Referrals were clinician-centred from a Māori health provider. Glycated haemoglobin (HbA1c) was used as a measure of diabetes management, taken at baseline. Other data collected included lipids, eGFR and uACR. Participants wore a CGM for 4 weeks at baseline and 3-month periods. Participants were visited by Māori research kaiāwhina every few days while wearing the device, and provided with self-management education on T2D, libre use, exercise, kai and lifestyle advice.
RESULTS
Results at 3 months show an average change of 18mmol/L across all participants. For HbA1c, while some patients increased or were stable, these can be explained on a case-by-case basis with disease progression and comorbidities (e.g., kidney failure, development of metastatic cancer). To date, there is much variability in the lipid profiles.
CONCLUSIONS
Delivering care that is based on Kaupapa Māori principles, with research kaiāwhina, education and technology enables Māori patients with T2D to self-manage their condition. This is a promising model of care that leads to significant changes in glycaemic control.
Recurrence of inguinal hernia in the paediatric population
Sayanthan Balasubramaniam,[[1]] Amanpreet Singh,[[1]] Udaya Samarakkody[[1]]
1Department of Paediatric Surgery, Te Whatu Ora Waikato, Waikato Hospital, New Zealand
BACKGROUND
Inguinal hernia recurrence necessitates further surgical interventions increasing the burden on health resources. Our study aimed to assess paediatric inguinal hernia recurrence, identify risk factors, refine surgical techniques and evaluate the outcomes.
METHODS
A retrospective study was conducted on patients under the age of 15 years of age undergoing an inguinal herniotomy at Waikato Hospital between November 2012 to June 2023. Data were retrieved from the Paediatric Surgical Database and Theatre Enterprise Reporting after approval from the Clinical Audit Support Unit. The demographic information, age at time of surgery, surgical method, recurrence rate, interval from surgery to recurrence and rate of metachronous hernia were documented. Statistical analysis was performed by the SPSS software program.
RESULTS
We identified 1,093 patients, with 966 undergoing open repair; the remaining 127 patients underwent laparoscopic repair. Boys made up the majority, accounting for 85% of the cases (n=930). Additionally, Māori children constituted 40.4% of the patient population. Thirteen patients presented with inguinal hernia recurrence. Of these, 11 had primary repair by open approach (1.18%) and two by laparoscopic (1.57%) approach. Eight had comorbidities: gastroschisis, omphalocele, extreme low birth weight (ELBW<750g) and respiratory distress syndrome (RDS). Notably, Māori accounted for 46% of the recurrence cases. The earliest recurrence was repaired on day zero, while the latest was repaired on day 1,452. The metachronous contralateral inguinal hernia rate was 4.2%. Among 930 boys, 11 had recurrence and two of 163 females had recurrences with no statistical significance (p=0.962). Children under 1 year had a high recurrence rate (p=0.001).
CONCLUSION
The rate of inguinal hernia recurrence was 1.18%, with no significant difference between the open and laparoscopic group. Incidence rates of inguinal hernia and recurrence were higher in Māori. This recurrence and metachronous inguinal hernia rate are consistent with accepted international standards.
Characteristics and disease course of patients with sarcoidosis in Te Whatu Ora Waikato
Liam Petrie, Eskandarain Shafuddin
Department of Respiratory Medicine, Te Whatu Ora Waikato, Hamilton, New Zealand
BACKGROUND
Sarcoidosis is a multi-system granulomatous inflammatory disease of unknown cause with substantial racial differences in epidemiology in some countries. A study conducted in Auckland suggested that Māori patients tended to have different clinical features than NZ Europeans.
AIM
To characterise the clinical and radiological features, treatment and disease course of sarcoidosis in patients in Te Whatu Ora Waikato and to compare between Māori and NZ European patients.
METHODS
Attendees of Waikato respiratory outpatient clinics from January 2019 to December 2020 were retrospectively screened and those with a confirmed diagnosis of sarcoidosis were included in this audit. Data including extra-thoracic features, lung function, radiology findings, treatment received, hospitalisation and all-cause mortality were collected from January 2019 to November 2021. Annualised changes in lung function and changes in chest radiographs and CT were analysed. We analysed the differences in clinical and radiological features, changes in lung function and radiology, hospitalisation and mortality between Māori and NZ European patients.
RESULTS
One hundred and fifty-eight patients were included: 27 (17%) Māori and 110 (70%) NZ Europeans. Fifty-five (35%) were newly diagnosed during the study period. Sixty-two (39%) had extra-thoracic involvement, most commonly ocular and cutaneous. Most patients had radiographic stage 4 (39 [25%]) and thoracic lymphadenopathy on CT (120 [78%]). There were improvements in annualised DLCO in radiographic stage 0 and 1, but the changes were <20%. Twenty-two patients (14%) had at least one respiratory-related hospitalisation and six patients (4%) died. Thirty-three patients (14%) were started on new treatment, had no clinically significant changes in lung function, and most did not have deterioration in radiology. Of the 66 patients who were on treatment during the study period, only five (8%) stopped treatment due to intolerance and none caused hospitalisation or death. Māori patients tended to be younger, female and had more extra-thoracic sarcoidosis than Europeans (15/27 [56%] vs 38/110 [35%], p=0.045). Even though Europeans had more lung fibrosis on imaging, there were no differences in baseline lung function. There were no significant differences in the changes of lung function, imaging, respiratory-related hospitalisations and all-cause mortality.
CONCLUSION
Our cohort of sarcoidosis patients have heterogeneous staging and extra-thoracic manifestations. Systemic treatment is well tolerated but steroid-sparing agent use is sparse. Māori patients have greater extra-thoracic involvement and are less like to have lung fibrosis than Europeans.
Management of type 2 diabetes in New Zealand: a scoping review of interventions
Sara Mustafa,[[1]] Kimberley Norman,[[2]] Tim Kenealy,[[3]] Ross Lawrenson,[[1,4]] Lynne Chepulis[[1]]
1Medical Research Centre, University of Waikato, Te Huataki Waiora School of Health, Hamilton, New Zealand
2School of Primary and Allied Health Care, Monash University, Melbourne, Australia
3The University of Auckland, Auckland, New Zealand
4Te Whatu Ora – Health New Zealand, Hamilton, New Zealand
BACKGROUND
Type 2 diabetes (T2D) is an increasingly concerning public health crisis, particularly affecting Indigenous Māori and Pacific populations in New Zealand. With higher prevalence rates, financial strains on healthcare and pronounced health disparities, the urgency for effective T2D management is evident. This scoping review aims to investigate the interventions addressing T2D management in New Zealand, their impact on clinical outcomes and the factors that support and hinder the effectiveness, acceptability and feasibility of interventions.
METHODS
Three databases (PubMed, Web of Science and Scopus) were searched for articles on T2D management between January 2000 and July 2023. Articles that did not include clinical outcomes, focussed on T2D prevention or were not conducted in New Zealand were excluded. Stakeholder interviews further identified T2D interventions published in grey literature. Study characteristics, clinical outcomes and supporting and hindering factors identified by study authors were extracted.
RESULTS
A total of 11 articles were included, with most interventions focussing on education (n=10) in combination with lifestyle advice (nutrition + exercise; n=5), a dietary plan (n=3) or an exercise plan (n=1). Seven studies delivered educational sessions via healthcare professionals, of which two were delivered by a Māori or Pacific health professional. The most common supporting factors were clinical or peer support (n=8), whānau engagement (n=6), flexible interventions (n=5) and participant relationship building (n=4). Hindering factors included disliking the intervention (n=4), high costs (n=4) and being time-intensive (n=3). HbA1c, BMI and waist circumference measures improved by 6 months in most studies, but no change was found at >12 months compared to baseline. Minimal or no improvement was reported in lipid profile, renal profile and blood pressure by 24 months.
CONCLUSION
Future interventions should prioritise a holistic approach with strategies to address the barriers to improve the feasibility and acceptability of interventions, while addressing the complexity of T2D management to achieve long-term improved clinical outcomes.
Characteristics of diabetes among youth and young adults: a cross-sectional study of the Waikato/Auckland Region of Aotearoa New Zealand
Sara Mustafa,[[1]] Ryan Paul,[[1,2]] Mark Rodrigues,[[1]] Rawiri Keenan,[[1]] Lynne Chepulis[[1]]
1Medical Research Centre, Te Huataki Waiora School of Health, University of Waikato, Hamilton, New Zealand
2Te Whatu Ora – Health New Zealand, Hamilton, New Zealand
BACKGROUND
Diabetes is the one of the most common metabolic disorders in the world, with rates increasing steadily. Type 2 diabetes (T2D) is predominantly diagnosed in adults, but increasingly occurs among youth and young adults alongside type 1 diabetes (T1D) diagnoses. This study aims to investigate of the characteristics of T1D and T2D among individuals aged <25 years including clinical information and use of diabetes-related medications.
METHODS
A cross-sectional study was conducted of patient data collected via de-identified clinical records from four primary healthcare organisations in the Waikato and Auckland regions. Demographic and clinical data for individuals <25 years with diabetes were extracted for the period of February 2021 and July 2022. Dispensed medication information was obtained from the national pharmaceutical collection. Descriptive analyses were conducted, and Chi-squared tests were used to assess for associations between patient characteristics and medication dispensed.
RESULTS
A total of 1,261 youth were coded with diabetes, of which 863 (68.4%) had T1D, 335 (26.6%) had T2D, and 63 (5.0%) were unknown. Youth with T1D had a mean age of 16±5.6 years, were more likely to be European (66.4% vs 17.1% for Māori; p<0.05), and nearly half had a healthy BMI (43.6%). In contrast, the mean age of T2D was 20.4±3.4 years, and youth were more likely to be Māori (38.2%) or Pacific (31.0%) (vs 20.3% for European; p<0.05), and to have obesity (84.5%). Median HbA1c was 75.0 mmol/mol (interquartile range [IQR]: 63.0–91.5) in T1D and 62.5 mmol/mol (IQR: 48.0–88.0) in T2D patients, with variation by ethnicity. The most dispensed medication among T1D was insulin (94.7%), metformin (5.6%) and ACEi (3.4%), while metformin (68.7%), GLPR1A/SGLT2i (32.8%) and vildagliptin (29.9%) were dispensed in individuals with T2D.
CONCLUSIONS
Diabetes is a concern for New Zealand youth, with at least a quarter of patients now having T2D. Appropriate management and prevention strategies are urgently required.
Summary
Abstract
Aim
Method
Results
Conclusion
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
For the PDF of this article,
contact nzmj@nzma.org.nz
Proceedings of the Waikato Clinical Campus Research Seminar, Wednesday, 27th September 2023
View Article PDF
Hypogonadism following testicular cancer
Veronica Boyle,[[1,2]] Maiea Mauriohooho,[[2]] Jade A U Tamatea,[[1,2]] Michael Jameson,[[1,3]] Alvin Tan,[[3]] Marianne S Elston[[1,2]]
1Waikato Clinical Campus, The University of Auckland, Hamilton, New Zealand; Departments of 2Endocrinology & 3Medical Oncology, Te Whatu Ora Waikato, Hamilton, New Zealand
BACKGROUND
Testicular cancer is the most common malignancy affecting young men, and Aotearoa New Zealand has one of the highest rates of testicular cancer in the world. Survival rates, even in those who present with metastatic disease, are high, with often >95% long-term survival. As such, long-term treatment complications and quality of life are particularly important. Hypogonadism has been reported to occur in 5–25% of men with a history of testicular cancer and surveillance guidelines recommend regular assessment of testosterone levels.
AIM
To determine the proportion of men who had assessment of gonadal function prior to any treatment for testicular cancer and at each of the four recommended timepoints, and the rates of hypogonadism.
METHODS
A retrospective review of patients with a new diagnosis of testicular cancer at Waikato Hospital during a 20-year period from the 1 January 2000 to 31 December 2020. Patients who had a single testis at the time of diagnosis, who had already received treatment for testicular cancer prior to 1 January 2000 or who were already receiving exogenous testosterone replacement were excluded.
RESULTS
A total of 518 cases were eligible for inclusion. Of these, 151 men (29%) had a testosterone level measured at least at one timepoint. There was no difference by age, ethnicity, BMI, tumour stage or treatment between those men who had a testosterone measured and those who did not. Of these 151 men, 69 (45%) had a testosterone level below the lower limit of the reference interval (9nmol/L). These men were more likely to have received radiotherapy (p=0.05); no other differences were identified. Of the 69 men who had at least one low testosterone level, no further action was taken in 17, seven had a repeat that was normal, nine had a repeat value consistent with hypogonadism but no further action was taken, and 37 were referred to endocrinology with 28 started on testosterone replacement. Nine did not receive treatment (repeat levels normal [n=5], waiting to be seen by endocrinology [n=3], referral declined requesting repeat morning test first [n=1]).
CONCLUSIONS
Subnormal testosterone levels are common in men who have previously received treatment for testicular cancer, but assessment of testosterone levels in this group is low. This may mean a missed opportunity to improve quality of life for these men.
Outcomes and access to angiography following non-ST segment elevation acute coronary syndromes in patients that present to rural or urban hospitals
Rory Miller,[[1]] Garry Nixon,[[2]] Tim Stokes,[[3]] Robin Turner,[[4]] Yannan Jiang,[[5]] Rawiri Keenan,[[6]] Corina Grey,[[7]] Andrew Kerr[[8]]
1Rural Doctor and Senior Lecturer, Department of General Practice and Health, University of Otago, Dunedin, New Zealand
2Rural Doctor and Professor of Rural Health, Department of General Practice and Health, University of Otago, Dunedin, New Zealand
3Professor of General Practice, Department of General Practice and Rural Health, University of Otago, Dunedin, New Zealand
4Professor of Biostatistics, Biostatistics Centre, University of Otago
5Senior Research Fellow—Statistics, Department of Statistics, The University of Auckland, Auckland, New Zealand; National Institute for Health Innovation, School of Population Health, The University of Auckland, Auckland, New Zealand
6Medical Research Centre, University of Waikato, Hamilton, New Zealand; Department of General Practice and Rural Health, University of Otago, Dunedin, New Zealand
7Public Health Physician, Department of General Practice and Primary Healthcare, The University of Auckland, New Zealand
8Cardiologist, Cardiology Department, Middlemore Hospital, Middlemore, New Zealand
AIM
In New Zealand patients with non-ST segment elevation acute coronary syndrome (NSTEACS) may present to rural hospitals, or to an urban hospital with or without routine access to percutaneous intervention (PCI). The aim of this study is to determine if there are differences in access to angiography and health outcomes for patients with NSTEACS associated with presenting to these three categories of hospital.
METHODS
First admissions for patients with NSTEACS to a New Zealand public hospital between 1 January 2014 and 31 December 2017 were included. Logistic regression was used to determine whether there was difference between the three categories of hospitals for the outcome measures: angiography performed within 1 year; 30-day, 1-year and 2-year all-cause mortality; and readmission to hospital within 1 year of presentation with either heart failure, a major adverse cardiac event or major bleeding.
RESULTS
There were 42,923 patients included in the study. The adjusted odds of a patient receiving an angiogram were reduced by 25% and 18% for urban hospitals without routine access to PCI (odds ratio [OR] 0.75: 95% confidence interval [CI] 0.71–0.79) and rural hospitals (OR 0.82: 95% CI 0.75–0.90) respectively. Patients that presented to urban hospitals without PCI had increased odds of readmission with a major adverse cardiac event (OR 1.10: 95% CI 1.03–1.16). There was a 16% increase in the odds of dying within 2 years for patients presenting to a rural hospital (OR 1.16: 95% CI 1.05–1.29).
CONCLUSION
Patients who do not present to hospitals with routine access to PCI are less likely to receive angiography. There is a small increase in 2-year mortality for patients who present to rural hospitals that may reflect poorer access to cardiac rehabilitation and secondary prevention.
Breast cancer grade—multi-institutional audit
Archana Pandita,[[1]] Reena Ramsaroop,[[2]] Gavin Harris[[3]]
1Department of Anatomic Pathology, Waikato Hospital, Hamilton, New Zealand
2Department of Anatomic Pathology, North Shore Hospital, Auckland, New Zealand
3Department of Anatomic Pathology, Canterbury Hospital, Christchurch, New Zealand
PURPOSE
Breast carcinoma is the second most common malignancy in women after colon and lung. The breast staging is based on consideration of multiple factors such as size of the tumour, number of lymph nodes involved by the metastatic carcinoma and distant metastases. Although not included in the staging of the breast carcinoma, histological grade for breast carcinoma is strongly associated with both breast cancer-specific survival and disease-free survival. Multivariate analysis have shown that histological grade is an independent predictor of both overall survival and disease-free survival in inoperable breast cancers. This can also help oncologists decide on management. Histological grading is now a part of minimum dataset for breast cancer pathology reporting included by the Royal College of Pathologists of Australasia, the United Kingdom Royal College of Pathologists, the College of American Pathologists, and is endorsed by the World Health Organization.
The national breast cancer registry shows a steady decline in the reporting of grade 3 breast cancers in the regional Waikato Hospital. Multi-institutional breast audit was undertaken to compare the grading in the three regions.
MATERIALS AND METHODS
A total of 105 de-identified slides with breast carcinoma from Waikato Hospital were sent to two different centres (centre A and centre B) for grading of the breast cancers. Pathologists (1–2) from both the centres agreed to look at these slides for grading. The slides were selected randomly from the previous year and same sets were sent to both the centres with no other information available to the grading pathologists to avoid the bias. The slides were sent in sets of three (25, 40 and 40 each) to avoid the extra workload for the pathologists, who are already busy with their routine schedule.
The clinical pathological variables were compared using contingency tables results.
RESULTS
A total of 45 cases were concordant between three institutions. There was some discordance in the grading of the remaining breast cancer slides in the three institutions. The concordant number of cases between Waikato and Centre A was 27 in total. Centre A upgraded 15 of the Waikato cases and downgraded 11 cases. There were 10 concordant cases between Waikato and Centre B. Centre B upgraded seven Waikato cases and downgraded 33 of these cases. When comparing Centres A and B, the number of concordant cases was 13. Centre A upgraded two cases of Centre B and downgraded 33 of the Centre B cases. There were 10 cases not included for the study when comparing all the centres because of the difficulty in differentiating between invasive and in situ carcinoma or cutting artefact in the tissue.
The Waikato cases were further reviewed by one pathologist after a long wash-out period, strictly using the Nottingham breast cancer scoring system. This was done randomly to avoid bias. It was noted that the discordance in grade assignment was mostly resulting from borderline morphological features. The number of cases upgraded from grade 2 to grade 3 was 12, from grade 1 to grade 3 was one and only one case was upgraded from grade 1 to grade 3; however, there were 3 cases that were downgraded to grade 2, and two cases that were downgraded to grade 1.
DISCUSSION
The breast grading is determined using the three variables including tubule formation, nuclear morphology and mitoses using a universal scoring system.
There are few factors that may affect the grade reported in different studies that can be explained by difference in the patient cohorts including age distribution, symptomatic versus chronic population, early versus advanced breast cancer or tissue fixation. There have been many studies looking at the inter-observer and intra-observer agreement of breast cancer histological grade and the value ranges from 0.43–0.83 in different studies. The range for grade 1 measures ranging between 11 and 38%, for grade 2 varies from 37 to 49% and for grade 3 ranges from 24 to 46%.
Waikato Hospital deals mostly with the breast screening cases. This is the most likely cause for lower grade 3 reporting. It was interesting to note quite a significant variation in the grading of the breast cancers across the New Zealand regions. The Waikato grading was seen to be close to Centre B grading when compared to Centre A grading.
The various measures that can be taken to get the appropriate grading is proper fixation. Spending extra time on the slide to look at the periphery or the advancing edge of the tumour may also resolve the issue where usually increased mitoses are seen. It is better to count mitoses from hot spot areas as tumour heterogeneity can be responsible for grading discordance.
CONCLUSION
Histological grade is an important, strong predictor of outcome in patients with invasive breast cancer and therefore it is important that the grading is done correctly, and that steps should be taken in the department to achieve that. Critical evaluation of these issues with recommendations from good practice guidelines with regular educational activities and associated external quality assurance can improve the discordance in the grade reporting. This will improve reproducibility and give consistent results. Work is being done in the field of artificial intelligence and digital pathology to improve the grading outcomes for breast cancers.
Quad bike is not a toy for kids
Sayanthan Balasubramaniam,[[1]] Emily Lancastle,[[2]] Mathew Crowther,[[2]] Udaya Samarakkody[[3]]
1Department of Paediatric Surgery, Te Whatu Ora Waikato, Waikato Hospital, New Zealand
2University of Edinburgh, United Kingdom
3Waikato Clinical Campus, The University of Auckland, Hamilton
BACKGROUND
Quad bikes are useful vehicles for outdoor activities and farming in New Zealand. They are lightweight and have a high centre of gravity. Their appearance and function are very attractive to children. We aim to analyse the mechanism, type of injuries and complications associated with quad bike accidents in children.
METHODS
We collected the data of children under 15 years admitted to Te Whatu Ora (TWO) Waikato – Health New Zealand who sustained quad bike injuries from January 2013 to January 2023 (10 years). The data were analysed with SPPS-22. The Clinical Audit and Safety Unit approved this project.
RESULTS
Eighty-five records were reviewed. Notably, Māori were not represented in this cohort. Sixty-two (72.9%) children were drivers, and 20 (23.5%) were passengers. Thirty-two children had accidents on a farm, 17 at home, 10 on the road, and 26 in “other” locations. Mean age was 10.2, with a range of 1–15 years (standard deviation 3.9) with 52% without helmets. The commonest injury was to limbs (n=60), followed by head injuries (n=20) and abdominal injuries (n=13). Fractures were more common in the upper limbs (n=26) than in the lower limbs (n=15). Twelve had severe concussions, and three had significant intracranial haemorrhage. Eleven children had solid abdominal organ injuries. Four had multiple injuries, including head and abdominal trauma. Thirty-four children underwent surgical interventions, four requiring ICU admission. The average hospital stay was 2.1 days. Overall, 29.4% (n=25) had minor disabilities. The majority (n=60, 58.8%) needed parental support for activities of daily living at discharge.
CONCLUSION
Quad bikes can be a dangerous recreational activity for children, causing major health hazards.
The fatigue after infusion or transfusion pilot trial and feasibility study: a three-armed randomised pilot trial of intravenous iron versus blood transfusion for the treatment of postpartum anaemia
Esther Caljé,[[1]] Joy Marriott,[[2]] Charlotte Oyston,[[2,3]] Lesley Dixon,[[4]] Frank H Bloomfield,[[1]] Katie M Groom[[1,5]]
1Liggins Institute, The University of Auckland, Auckland, New Zealand
2Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, The University of Auckland, Auckland, New Zealand
3Middlemore Hospital, Auckland, New Zealand
4New Zealand College of Midwives, Christchurch, New Zealand
5National Women’s Health, Auckland City Hospital, Auckland, New Zealand
BACKGROUND/AIM
There is a lack of high-quality evidence for the management of moderate-to-severe postpartum anaemia, with significant variation in clinical practice. A randomised trial is needed, although recruitment may be challenging. The primary objective was to determine the recruitment rate for a randomised trial of intravenous (IV) iron and/or red blood cell transfusion (RBC-T) for postpartum anaemia.
METHODS
A randomised pilot trial with surveys for women, clinicians and stakeholders. Inclusion criteria: postpartum haemoglobin 65–79g/L; haemodynamically stable. Exclusion criteria: ongoing heavy bleeding; already received or known contraindication to IV-iron/RBC-T. Intervention/control: IV-iron; RBC-T; or IV-iron and RBC-T. Primary outcome: recruitment rate (those approached, and overall). Secondary outcomes: fatigue, depression, baby-feeding and haemoglobin, at 1, 6 and 12 weeks; ferritin at 6 and 12 weeks. A health equity lens was applied to support Māori and Pacific participation.
RESULTS
Over 16 weeks from 16 October 2022 to 29 January 2023 at Auckland, Waikato and Canterbury hospitals, 26 women consented to randomisation. The proportion of those approached who were randomised was 26/34 (76%), including 8/26 (31%) Māori and one (3%) Pacific women. The proportion of all broadly eligible women was 16% (26/167). Key enablers for participation were altruism and study relevance. For clinicians and stakeholders, availability of research assistance was the key barrier/enabler. No significant differences were found for fatigue or depression amongst intervention arms. Significant differences were found between RBC-T vs (favouring) IV-iron and RBC-T for haemoglobin at 6 (p=0.0116) and 12 (p=0.0234) weeks; and for ferritin at 6 (p<0.0001) and 12 (p=0.0483) weeks. No significant differences were found between IV-iron vs IV-iron and RBC-T for haemoglobin and ferritin.
CONCLUSION
The recruitment rate indicates that a trial of IV-iron and RBC-T for postpartum anaemia is feasible. Dedicated research assistance will be critical to the success of an adequately powered trial to examine the effectiveness of postpartum anaemia interventions.
The use of kaiāwhina and technology (continuous glucose monitors) for glycaemic management in type 2 diabetes (T2D) in high-risk Māori populations
Rebekah Crosswell,[[1]] Salem Waters,[[1]] Hamish Crockett,[[1]] Donna Foxall,[[1]] Suzanne Moorhouse,[[2]] Helen Morton,[[3]] Michael Oehley,[[4]] Ryan Paul,[[4]] Lynne Chepulis[[3]]
1Waikato Medical Research Centre, University of Waikato, Hamilton
2Hauraki PHO, Hamilton
3Raukura Hauora o Tainui Māori
4Te Whatu Ora Waikato
AIMS AND OBJECTIVES
Type 2 diabetes (T2D) is a chronic, multi-systemic condition. Despite established guidelines for the management of patients with T2D, they continue to have suboptimal glycaemic control. Additionally, Māori populations are disproportionally represented in the statistics compared to non-Māori. The aim of this study is to examine whether continuous glucose monitors (CGM) use can drive behaviour change and improve diabetes management in Māori patients with high-risk diabetes (HbA1c <80mmol/L). The study has not been completed; however, progress will be reported to date at the 3-month and 6-month periods.
METHODS
Research methodology included a Te Ao Māori focus, with whakawhanaungatanga and tikanga being at the forefront. Recruitment and study design were driven by a multi-disciplinary working group, including early and mid to late career researchers and clinicians. Twenty-two participants have been recruited, all through to completion of the 3-month period. Referrals were clinician-centred from a Māori health provider. Glycated haemoglobin (HbA1c) was used as a measure of diabetes management, taken at baseline. Other data collected included lipids, eGFR and uACR. Participants wore a CGM for 4 weeks at baseline and 3-month periods. Participants were visited by Māori research kaiāwhina every few days while wearing the device, and provided with self-management education on T2D, libre use, exercise, kai and lifestyle advice.
RESULTS
Results at 3 months show an average change of 18mmol/L across all participants. For HbA1c, while some patients increased or were stable, these can be explained on a case-by-case basis with disease progression and comorbidities (e.g., kidney failure, development of metastatic cancer). To date, there is much variability in the lipid profiles.
CONCLUSIONS
Delivering care that is based on Kaupapa Māori principles, with research kaiāwhina, education and technology enables Māori patients with T2D to self-manage their condition. This is a promising model of care that leads to significant changes in glycaemic control.
Recurrence of inguinal hernia in the paediatric population
Sayanthan Balasubramaniam,[[1]] Amanpreet Singh,[[1]] Udaya Samarakkody[[1]]
1Department of Paediatric Surgery, Te Whatu Ora Waikato, Waikato Hospital, New Zealand
BACKGROUND
Inguinal hernia recurrence necessitates further surgical interventions increasing the burden on health resources. Our study aimed to assess paediatric inguinal hernia recurrence, identify risk factors, refine surgical techniques and evaluate the outcomes.
METHODS
A retrospective study was conducted on patients under the age of 15 years of age undergoing an inguinal herniotomy at Waikato Hospital between November 2012 to June 2023. Data were retrieved from the Paediatric Surgical Database and Theatre Enterprise Reporting after approval from the Clinical Audit Support Unit. The demographic information, age at time of surgery, surgical method, recurrence rate, interval from surgery to recurrence and rate of metachronous hernia were documented. Statistical analysis was performed by the SPSS software program.
RESULTS
We identified 1,093 patients, with 966 undergoing open repair; the remaining 127 patients underwent laparoscopic repair. Boys made up the majority, accounting for 85% of the cases (n=930). Additionally, Māori children constituted 40.4% of the patient population. Thirteen patients presented with inguinal hernia recurrence. Of these, 11 had primary repair by open approach (1.18%) and two by laparoscopic (1.57%) approach. Eight had comorbidities: gastroschisis, omphalocele, extreme low birth weight (ELBW<750g) and respiratory distress syndrome (RDS). Notably, Māori accounted for 46% of the recurrence cases. The earliest recurrence was repaired on day zero, while the latest was repaired on day 1,452. The metachronous contralateral inguinal hernia rate was 4.2%. Among 930 boys, 11 had recurrence and two of 163 females had recurrences with no statistical significance (p=0.962). Children under 1 year had a high recurrence rate (p=0.001).
CONCLUSION
The rate of inguinal hernia recurrence was 1.18%, with no significant difference between the open and laparoscopic group. Incidence rates of inguinal hernia and recurrence were higher in Māori. This recurrence and metachronous inguinal hernia rate are consistent with accepted international standards.
Characteristics and disease course of patients with sarcoidosis in Te Whatu Ora Waikato
Liam Petrie, Eskandarain Shafuddin
Department of Respiratory Medicine, Te Whatu Ora Waikato, Hamilton, New Zealand
BACKGROUND
Sarcoidosis is a multi-system granulomatous inflammatory disease of unknown cause with substantial racial differences in epidemiology in some countries. A study conducted in Auckland suggested that Māori patients tended to have different clinical features than NZ Europeans.
AIM
To characterise the clinical and radiological features, treatment and disease course of sarcoidosis in patients in Te Whatu Ora Waikato and to compare between Māori and NZ European patients.
METHODS
Attendees of Waikato respiratory outpatient clinics from January 2019 to December 2020 were retrospectively screened and those with a confirmed diagnosis of sarcoidosis were included in this audit. Data including extra-thoracic features, lung function, radiology findings, treatment received, hospitalisation and all-cause mortality were collected from January 2019 to November 2021. Annualised changes in lung function and changes in chest radiographs and CT were analysed. We analysed the differences in clinical and radiological features, changes in lung function and radiology, hospitalisation and mortality between Māori and NZ European patients.
RESULTS
One hundred and fifty-eight patients were included: 27 (17%) Māori and 110 (70%) NZ Europeans. Fifty-five (35%) were newly diagnosed during the study period. Sixty-two (39%) had extra-thoracic involvement, most commonly ocular and cutaneous. Most patients had radiographic stage 4 (39 [25%]) and thoracic lymphadenopathy on CT (120 [78%]). There were improvements in annualised DLCO in radiographic stage 0 and 1, but the changes were <20%. Twenty-two patients (14%) had at least one respiratory-related hospitalisation and six patients (4%) died. Thirty-three patients (14%) were started on new treatment, had no clinically significant changes in lung function, and most did not have deterioration in radiology. Of the 66 patients who were on treatment during the study period, only five (8%) stopped treatment due to intolerance and none caused hospitalisation or death. Māori patients tended to be younger, female and had more extra-thoracic sarcoidosis than Europeans (15/27 [56%] vs 38/110 [35%], p=0.045). Even though Europeans had more lung fibrosis on imaging, there were no differences in baseline lung function. There were no significant differences in the changes of lung function, imaging, respiratory-related hospitalisations and all-cause mortality.
CONCLUSION
Our cohort of sarcoidosis patients have heterogeneous staging and extra-thoracic manifestations. Systemic treatment is well tolerated but steroid-sparing agent use is sparse. Māori patients have greater extra-thoracic involvement and are less like to have lung fibrosis than Europeans.
Management of type 2 diabetes in New Zealand: a scoping review of interventions
Sara Mustafa,[[1]] Kimberley Norman,[[2]] Tim Kenealy,[[3]] Ross Lawrenson,[[1,4]] Lynne Chepulis[[1]]
1Medical Research Centre, University of Waikato, Te Huataki Waiora School of Health, Hamilton, New Zealand
2School of Primary and Allied Health Care, Monash University, Melbourne, Australia
3The University of Auckland, Auckland, New Zealand
4Te Whatu Ora – Health New Zealand, Hamilton, New Zealand
BACKGROUND
Type 2 diabetes (T2D) is an increasingly concerning public health crisis, particularly affecting Indigenous Māori and Pacific populations in New Zealand. With higher prevalence rates, financial strains on healthcare and pronounced health disparities, the urgency for effective T2D management is evident. This scoping review aims to investigate the interventions addressing T2D management in New Zealand, their impact on clinical outcomes and the factors that support and hinder the effectiveness, acceptability and feasibility of interventions.
METHODS
Three databases (PubMed, Web of Science and Scopus) were searched for articles on T2D management between January 2000 and July 2023. Articles that did not include clinical outcomes, focussed on T2D prevention or were not conducted in New Zealand were excluded. Stakeholder interviews further identified T2D interventions published in grey literature. Study characteristics, clinical outcomes and supporting and hindering factors identified by study authors were extracted.
RESULTS
A total of 11 articles were included, with most interventions focussing on education (n=10) in combination with lifestyle advice (nutrition + exercise; n=5), a dietary plan (n=3) or an exercise plan (n=1). Seven studies delivered educational sessions via healthcare professionals, of which two were delivered by a Māori or Pacific health professional. The most common supporting factors were clinical or peer support (n=8), whānau engagement (n=6), flexible interventions (n=5) and participant relationship building (n=4). Hindering factors included disliking the intervention (n=4), high costs (n=4) and being time-intensive (n=3). HbA1c, BMI and waist circumference measures improved by 6 months in most studies, but no change was found at >12 months compared to baseline. Minimal or no improvement was reported in lipid profile, renal profile and blood pressure by 24 months.
CONCLUSION
Future interventions should prioritise a holistic approach with strategies to address the barriers to improve the feasibility and acceptability of interventions, while addressing the complexity of T2D management to achieve long-term improved clinical outcomes.
Characteristics of diabetes among youth and young adults: a cross-sectional study of the Waikato/Auckland Region of Aotearoa New Zealand
Sara Mustafa,[[1]] Ryan Paul,[[1,2]] Mark Rodrigues,[[1]] Rawiri Keenan,[[1]] Lynne Chepulis[[1]]
1Medical Research Centre, Te Huataki Waiora School of Health, University of Waikato, Hamilton, New Zealand
2Te Whatu Ora – Health New Zealand, Hamilton, New Zealand
BACKGROUND
Diabetes is the one of the most common metabolic disorders in the world, with rates increasing steadily. Type 2 diabetes (T2D) is predominantly diagnosed in adults, but increasingly occurs among youth and young adults alongside type 1 diabetes (T1D) diagnoses. This study aims to investigate of the characteristics of T1D and T2D among individuals aged <25 years including clinical information and use of diabetes-related medications.
METHODS
A cross-sectional study was conducted of patient data collected via de-identified clinical records from four primary healthcare organisations in the Waikato and Auckland regions. Demographic and clinical data for individuals <25 years with diabetes were extracted for the period of February 2021 and July 2022. Dispensed medication information was obtained from the national pharmaceutical collection. Descriptive analyses were conducted, and Chi-squared tests were used to assess for associations between patient characteristics and medication dispensed.
RESULTS
A total of 1,261 youth were coded with diabetes, of which 863 (68.4%) had T1D, 335 (26.6%) had T2D, and 63 (5.0%) were unknown. Youth with T1D had a mean age of 16±5.6 years, were more likely to be European (66.4% vs 17.1% for Māori; p<0.05), and nearly half had a healthy BMI (43.6%). In contrast, the mean age of T2D was 20.4±3.4 years, and youth were more likely to be Māori (38.2%) or Pacific (31.0%) (vs 20.3% for European; p<0.05), and to have obesity (84.5%). Median HbA1c was 75.0 mmol/mol (interquartile range [IQR]: 63.0–91.5) in T1D and 62.5 mmol/mol (IQR: 48.0–88.0) in T2D patients, with variation by ethnicity. The most dispensed medication among T1D was insulin (94.7%), metformin (5.6%) and ACEi (3.4%), while metformin (68.7%), GLPR1A/SGLT2i (32.8%) and vildagliptin (29.9%) were dispensed in individuals with T2D.
CONCLUSIONS
Diabetes is a concern for New Zealand youth, with at least a quarter of patients now having T2D. Appropriate management and prevention strategies are urgently required.
Summary
Abstract
Aim
Method
Results
Conclusion
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
For the PDF of this article,
contact nzmj@nzma.org.nz
Proceedings of the Waikato Clinical Campus Research Seminar, Wednesday, 27th September 2023
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Hypogonadism following testicular cancer
Veronica Boyle,[[1,2]] Maiea Mauriohooho,[[2]] Jade A U Tamatea,[[1,2]] Michael Jameson,[[1,3]] Alvin Tan,[[3]] Marianne S Elston[[1,2]]
1Waikato Clinical Campus, The University of Auckland, Hamilton, New Zealand; Departments of 2Endocrinology & 3Medical Oncology, Te Whatu Ora Waikato, Hamilton, New Zealand
BACKGROUND
Testicular cancer is the most common malignancy affecting young men, and Aotearoa New Zealand has one of the highest rates of testicular cancer in the world. Survival rates, even in those who present with metastatic disease, are high, with often >95% long-term survival. As such, long-term treatment complications and quality of life are particularly important. Hypogonadism has been reported to occur in 5–25% of men with a history of testicular cancer and surveillance guidelines recommend regular assessment of testosterone levels.
AIM
To determine the proportion of men who had assessment of gonadal function prior to any treatment for testicular cancer and at each of the four recommended timepoints, and the rates of hypogonadism.
METHODS
A retrospective review of patients with a new diagnosis of testicular cancer at Waikato Hospital during a 20-year period from the 1 January 2000 to 31 December 2020. Patients who had a single testis at the time of diagnosis, who had already received treatment for testicular cancer prior to 1 January 2000 or who were already receiving exogenous testosterone replacement were excluded.
RESULTS
A total of 518 cases were eligible for inclusion. Of these, 151 men (29%) had a testosterone level measured at least at one timepoint. There was no difference by age, ethnicity, BMI, tumour stage or treatment between those men who had a testosterone measured and those who did not. Of these 151 men, 69 (45%) had a testosterone level below the lower limit of the reference interval (9nmol/L). These men were more likely to have received radiotherapy (p=0.05); no other differences were identified. Of the 69 men who had at least one low testosterone level, no further action was taken in 17, seven had a repeat that was normal, nine had a repeat value consistent with hypogonadism but no further action was taken, and 37 were referred to endocrinology with 28 started on testosterone replacement. Nine did not receive treatment (repeat levels normal [n=5], waiting to be seen by endocrinology [n=3], referral declined requesting repeat morning test first [n=1]).
CONCLUSIONS
Subnormal testosterone levels are common in men who have previously received treatment for testicular cancer, but assessment of testosterone levels in this group is low. This may mean a missed opportunity to improve quality of life for these men.
Outcomes and access to angiography following non-ST segment elevation acute coronary syndromes in patients that present to rural or urban hospitals
Rory Miller,[[1]] Garry Nixon,[[2]] Tim Stokes,[[3]] Robin Turner,[[4]] Yannan Jiang,[[5]] Rawiri Keenan,[[6]] Corina Grey,[[7]] Andrew Kerr[[8]]
1Rural Doctor and Senior Lecturer, Department of General Practice and Health, University of Otago, Dunedin, New Zealand
2Rural Doctor and Professor of Rural Health, Department of General Practice and Health, University of Otago, Dunedin, New Zealand
3Professor of General Practice, Department of General Practice and Rural Health, University of Otago, Dunedin, New Zealand
4Professor of Biostatistics, Biostatistics Centre, University of Otago
5Senior Research Fellow—Statistics, Department of Statistics, The University of Auckland, Auckland, New Zealand; National Institute for Health Innovation, School of Population Health, The University of Auckland, Auckland, New Zealand
6Medical Research Centre, University of Waikato, Hamilton, New Zealand; Department of General Practice and Rural Health, University of Otago, Dunedin, New Zealand
7Public Health Physician, Department of General Practice and Primary Healthcare, The University of Auckland, New Zealand
8Cardiologist, Cardiology Department, Middlemore Hospital, Middlemore, New Zealand
AIM
In New Zealand patients with non-ST segment elevation acute coronary syndrome (NSTEACS) may present to rural hospitals, or to an urban hospital with or without routine access to percutaneous intervention (PCI). The aim of this study is to determine if there are differences in access to angiography and health outcomes for patients with NSTEACS associated with presenting to these three categories of hospital.
METHODS
First admissions for patients with NSTEACS to a New Zealand public hospital between 1 January 2014 and 31 December 2017 were included. Logistic regression was used to determine whether there was difference between the three categories of hospitals for the outcome measures: angiography performed within 1 year; 30-day, 1-year and 2-year all-cause mortality; and readmission to hospital within 1 year of presentation with either heart failure, a major adverse cardiac event or major bleeding.
RESULTS
There were 42,923 patients included in the study. The adjusted odds of a patient receiving an angiogram were reduced by 25% and 18% for urban hospitals without routine access to PCI (odds ratio [OR] 0.75: 95% confidence interval [CI] 0.71–0.79) and rural hospitals (OR 0.82: 95% CI 0.75–0.90) respectively. Patients that presented to urban hospitals without PCI had increased odds of readmission with a major adverse cardiac event (OR 1.10: 95% CI 1.03–1.16). There was a 16% increase in the odds of dying within 2 years for patients presenting to a rural hospital (OR 1.16: 95% CI 1.05–1.29).
CONCLUSION
Patients who do not present to hospitals with routine access to PCI are less likely to receive angiography. There is a small increase in 2-year mortality for patients who present to rural hospitals that may reflect poorer access to cardiac rehabilitation and secondary prevention.
Breast cancer grade—multi-institutional audit
Archana Pandita,[[1]] Reena Ramsaroop,[[2]] Gavin Harris[[3]]
1Department of Anatomic Pathology, Waikato Hospital, Hamilton, New Zealand
2Department of Anatomic Pathology, North Shore Hospital, Auckland, New Zealand
3Department of Anatomic Pathology, Canterbury Hospital, Christchurch, New Zealand
PURPOSE
Breast carcinoma is the second most common malignancy in women after colon and lung. The breast staging is based on consideration of multiple factors such as size of the tumour, number of lymph nodes involved by the metastatic carcinoma and distant metastases. Although not included in the staging of the breast carcinoma, histological grade for breast carcinoma is strongly associated with both breast cancer-specific survival and disease-free survival. Multivariate analysis have shown that histological grade is an independent predictor of both overall survival and disease-free survival in inoperable breast cancers. This can also help oncologists decide on management. Histological grading is now a part of minimum dataset for breast cancer pathology reporting included by the Royal College of Pathologists of Australasia, the United Kingdom Royal College of Pathologists, the College of American Pathologists, and is endorsed by the World Health Organization.
The national breast cancer registry shows a steady decline in the reporting of grade 3 breast cancers in the regional Waikato Hospital. Multi-institutional breast audit was undertaken to compare the grading in the three regions.
MATERIALS AND METHODS
A total of 105 de-identified slides with breast carcinoma from Waikato Hospital were sent to two different centres (centre A and centre B) for grading of the breast cancers. Pathologists (1–2) from both the centres agreed to look at these slides for grading. The slides were selected randomly from the previous year and same sets were sent to both the centres with no other information available to the grading pathologists to avoid the bias. The slides were sent in sets of three (25, 40 and 40 each) to avoid the extra workload for the pathologists, who are already busy with their routine schedule.
The clinical pathological variables were compared using contingency tables results.
RESULTS
A total of 45 cases were concordant between three institutions. There was some discordance in the grading of the remaining breast cancer slides in the three institutions. The concordant number of cases between Waikato and Centre A was 27 in total. Centre A upgraded 15 of the Waikato cases and downgraded 11 cases. There were 10 concordant cases between Waikato and Centre B. Centre B upgraded seven Waikato cases and downgraded 33 of these cases. When comparing Centres A and B, the number of concordant cases was 13. Centre A upgraded two cases of Centre B and downgraded 33 of the Centre B cases. There were 10 cases not included for the study when comparing all the centres because of the difficulty in differentiating between invasive and in situ carcinoma or cutting artefact in the tissue.
The Waikato cases were further reviewed by one pathologist after a long wash-out period, strictly using the Nottingham breast cancer scoring system. This was done randomly to avoid bias. It was noted that the discordance in grade assignment was mostly resulting from borderline morphological features. The number of cases upgraded from grade 2 to grade 3 was 12, from grade 1 to grade 3 was one and only one case was upgraded from grade 1 to grade 3; however, there were 3 cases that were downgraded to grade 2, and two cases that were downgraded to grade 1.
DISCUSSION
The breast grading is determined using the three variables including tubule formation, nuclear morphology and mitoses using a universal scoring system.
There are few factors that may affect the grade reported in different studies that can be explained by difference in the patient cohorts including age distribution, symptomatic versus chronic population, early versus advanced breast cancer or tissue fixation. There have been many studies looking at the inter-observer and intra-observer agreement of breast cancer histological grade and the value ranges from 0.43–0.83 in different studies. The range for grade 1 measures ranging between 11 and 38%, for grade 2 varies from 37 to 49% and for grade 3 ranges from 24 to 46%.
Waikato Hospital deals mostly with the breast screening cases. This is the most likely cause for lower grade 3 reporting. It was interesting to note quite a significant variation in the grading of the breast cancers across the New Zealand regions. The Waikato grading was seen to be close to Centre B grading when compared to Centre A grading.
The various measures that can be taken to get the appropriate grading is proper fixation. Spending extra time on the slide to look at the periphery or the advancing edge of the tumour may also resolve the issue where usually increased mitoses are seen. It is better to count mitoses from hot spot areas as tumour heterogeneity can be responsible for grading discordance.
CONCLUSION
Histological grade is an important, strong predictor of outcome in patients with invasive breast cancer and therefore it is important that the grading is done correctly, and that steps should be taken in the department to achieve that. Critical evaluation of these issues with recommendations from good practice guidelines with regular educational activities and associated external quality assurance can improve the discordance in the grade reporting. This will improve reproducibility and give consistent results. Work is being done in the field of artificial intelligence and digital pathology to improve the grading outcomes for breast cancers.
Quad bike is not a toy for kids
Sayanthan Balasubramaniam,[[1]] Emily Lancastle,[[2]] Mathew Crowther,[[2]] Udaya Samarakkody[[3]]
1Department of Paediatric Surgery, Te Whatu Ora Waikato, Waikato Hospital, New Zealand
2University of Edinburgh, United Kingdom
3Waikato Clinical Campus, The University of Auckland, Hamilton
BACKGROUND
Quad bikes are useful vehicles for outdoor activities and farming in New Zealand. They are lightweight and have a high centre of gravity. Their appearance and function are very attractive to children. We aim to analyse the mechanism, type of injuries and complications associated with quad bike accidents in children.
METHODS
We collected the data of children under 15 years admitted to Te Whatu Ora (TWO) Waikato – Health New Zealand who sustained quad bike injuries from January 2013 to January 2023 (10 years). The data were analysed with SPPS-22. The Clinical Audit and Safety Unit approved this project.
RESULTS
Eighty-five records were reviewed. Notably, Māori were not represented in this cohort. Sixty-two (72.9%) children were drivers, and 20 (23.5%) were passengers. Thirty-two children had accidents on a farm, 17 at home, 10 on the road, and 26 in “other” locations. Mean age was 10.2, with a range of 1–15 years (standard deviation 3.9) with 52% without helmets. The commonest injury was to limbs (n=60), followed by head injuries (n=20) and abdominal injuries (n=13). Fractures were more common in the upper limbs (n=26) than in the lower limbs (n=15). Twelve had severe concussions, and three had significant intracranial haemorrhage. Eleven children had solid abdominal organ injuries. Four had multiple injuries, including head and abdominal trauma. Thirty-four children underwent surgical interventions, four requiring ICU admission. The average hospital stay was 2.1 days. Overall, 29.4% (n=25) had minor disabilities. The majority (n=60, 58.8%) needed parental support for activities of daily living at discharge.
CONCLUSION
Quad bikes can be a dangerous recreational activity for children, causing major health hazards.
The fatigue after infusion or transfusion pilot trial and feasibility study: a three-armed randomised pilot trial of intravenous iron versus blood transfusion for the treatment of postpartum anaemia
Esther Caljé,[[1]] Joy Marriott,[[2]] Charlotte Oyston,[[2,3]] Lesley Dixon,[[4]] Frank H Bloomfield,[[1]] Katie M Groom[[1,5]]
1Liggins Institute, The University of Auckland, Auckland, New Zealand
2Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, The University of Auckland, Auckland, New Zealand
3Middlemore Hospital, Auckland, New Zealand
4New Zealand College of Midwives, Christchurch, New Zealand
5National Women’s Health, Auckland City Hospital, Auckland, New Zealand
BACKGROUND/AIM
There is a lack of high-quality evidence for the management of moderate-to-severe postpartum anaemia, with significant variation in clinical practice. A randomised trial is needed, although recruitment may be challenging. The primary objective was to determine the recruitment rate for a randomised trial of intravenous (IV) iron and/or red blood cell transfusion (RBC-T) for postpartum anaemia.
METHODS
A randomised pilot trial with surveys for women, clinicians and stakeholders. Inclusion criteria: postpartum haemoglobin 65–79g/L; haemodynamically stable. Exclusion criteria: ongoing heavy bleeding; already received or known contraindication to IV-iron/RBC-T. Intervention/control: IV-iron; RBC-T; or IV-iron and RBC-T. Primary outcome: recruitment rate (those approached, and overall). Secondary outcomes: fatigue, depression, baby-feeding and haemoglobin, at 1, 6 and 12 weeks; ferritin at 6 and 12 weeks. A health equity lens was applied to support Māori and Pacific participation.
RESULTS
Over 16 weeks from 16 October 2022 to 29 January 2023 at Auckland, Waikato and Canterbury hospitals, 26 women consented to randomisation. The proportion of those approached who were randomised was 26/34 (76%), including 8/26 (31%) Māori and one (3%) Pacific women. The proportion of all broadly eligible women was 16% (26/167). Key enablers for participation were altruism and study relevance. For clinicians and stakeholders, availability of research assistance was the key barrier/enabler. No significant differences were found for fatigue or depression amongst intervention arms. Significant differences were found between RBC-T vs (favouring) IV-iron and RBC-T for haemoglobin at 6 (p=0.0116) and 12 (p=0.0234) weeks; and for ferritin at 6 (p<0.0001) and 12 (p=0.0483) weeks. No significant differences were found between IV-iron vs IV-iron and RBC-T for haemoglobin and ferritin.
CONCLUSION
The recruitment rate indicates that a trial of IV-iron and RBC-T for postpartum anaemia is feasible. Dedicated research assistance will be critical to the success of an adequately powered trial to examine the effectiveness of postpartum anaemia interventions.
The use of kaiāwhina and technology (continuous glucose monitors) for glycaemic management in type 2 diabetes (T2D) in high-risk Māori populations
Rebekah Crosswell,[[1]] Salem Waters,[[1]] Hamish Crockett,[[1]] Donna Foxall,[[1]] Suzanne Moorhouse,[[2]] Helen Morton,[[3]] Michael Oehley,[[4]] Ryan Paul,[[4]] Lynne Chepulis[[3]]
1Waikato Medical Research Centre, University of Waikato, Hamilton
2Hauraki PHO, Hamilton
3Raukura Hauora o Tainui Māori
4Te Whatu Ora Waikato
AIMS AND OBJECTIVES
Type 2 diabetes (T2D) is a chronic, multi-systemic condition. Despite established guidelines for the management of patients with T2D, they continue to have suboptimal glycaemic control. Additionally, Māori populations are disproportionally represented in the statistics compared to non-Māori. The aim of this study is to examine whether continuous glucose monitors (CGM) use can drive behaviour change and improve diabetes management in Māori patients with high-risk diabetes (HbA1c <80mmol/L). The study has not been completed; however, progress will be reported to date at the 3-month and 6-month periods.
METHODS
Research methodology included a Te Ao Māori focus, with whakawhanaungatanga and tikanga being at the forefront. Recruitment and study design were driven by a multi-disciplinary working group, including early and mid to late career researchers and clinicians. Twenty-two participants have been recruited, all through to completion of the 3-month period. Referrals were clinician-centred from a Māori health provider. Glycated haemoglobin (HbA1c) was used as a measure of diabetes management, taken at baseline. Other data collected included lipids, eGFR and uACR. Participants wore a CGM for 4 weeks at baseline and 3-month periods. Participants were visited by Māori research kaiāwhina every few days while wearing the device, and provided with self-management education on T2D, libre use, exercise, kai and lifestyle advice.
RESULTS
Results at 3 months show an average change of 18mmol/L across all participants. For HbA1c, while some patients increased or were stable, these can be explained on a case-by-case basis with disease progression and comorbidities (e.g., kidney failure, development of metastatic cancer). To date, there is much variability in the lipid profiles.
CONCLUSIONS
Delivering care that is based on Kaupapa Māori principles, with research kaiāwhina, education and technology enables Māori patients with T2D to self-manage their condition. This is a promising model of care that leads to significant changes in glycaemic control.
Recurrence of inguinal hernia in the paediatric population
Sayanthan Balasubramaniam,[[1]] Amanpreet Singh,[[1]] Udaya Samarakkody[[1]]
1Department of Paediatric Surgery, Te Whatu Ora Waikato, Waikato Hospital, New Zealand
BACKGROUND
Inguinal hernia recurrence necessitates further surgical interventions increasing the burden on health resources. Our study aimed to assess paediatric inguinal hernia recurrence, identify risk factors, refine surgical techniques and evaluate the outcomes.
METHODS
A retrospective study was conducted on patients under the age of 15 years of age undergoing an inguinal herniotomy at Waikato Hospital between November 2012 to June 2023. Data were retrieved from the Paediatric Surgical Database and Theatre Enterprise Reporting after approval from the Clinical Audit Support Unit. The demographic information, age at time of surgery, surgical method, recurrence rate, interval from surgery to recurrence and rate of metachronous hernia were documented. Statistical analysis was performed by the SPSS software program.
RESULTS
We identified 1,093 patients, with 966 undergoing open repair; the remaining 127 patients underwent laparoscopic repair. Boys made up the majority, accounting for 85% of the cases (n=930). Additionally, Māori children constituted 40.4% of the patient population. Thirteen patients presented with inguinal hernia recurrence. Of these, 11 had primary repair by open approach (1.18%) and two by laparoscopic (1.57%) approach. Eight had comorbidities: gastroschisis, omphalocele, extreme low birth weight (ELBW<750g) and respiratory distress syndrome (RDS). Notably, Māori accounted for 46% of the recurrence cases. The earliest recurrence was repaired on day zero, while the latest was repaired on day 1,452. The metachronous contralateral inguinal hernia rate was 4.2%. Among 930 boys, 11 had recurrence and two of 163 females had recurrences with no statistical significance (p=0.962). Children under 1 year had a high recurrence rate (p=0.001).
CONCLUSION
The rate of inguinal hernia recurrence was 1.18%, with no significant difference between the open and laparoscopic group. Incidence rates of inguinal hernia and recurrence were higher in Māori. This recurrence and metachronous inguinal hernia rate are consistent with accepted international standards.
Characteristics and disease course of patients with sarcoidosis in Te Whatu Ora Waikato
Liam Petrie, Eskandarain Shafuddin
Department of Respiratory Medicine, Te Whatu Ora Waikato, Hamilton, New Zealand
BACKGROUND
Sarcoidosis is a multi-system granulomatous inflammatory disease of unknown cause with substantial racial differences in epidemiology in some countries. A study conducted in Auckland suggested that Māori patients tended to have different clinical features than NZ Europeans.
AIM
To characterise the clinical and radiological features, treatment and disease course of sarcoidosis in patients in Te Whatu Ora Waikato and to compare between Māori and NZ European patients.
METHODS
Attendees of Waikato respiratory outpatient clinics from January 2019 to December 2020 were retrospectively screened and those with a confirmed diagnosis of sarcoidosis were included in this audit. Data including extra-thoracic features, lung function, radiology findings, treatment received, hospitalisation and all-cause mortality were collected from January 2019 to November 2021. Annualised changes in lung function and changes in chest radiographs and CT were analysed. We analysed the differences in clinical and radiological features, changes in lung function and radiology, hospitalisation and mortality between Māori and NZ European patients.
RESULTS
One hundred and fifty-eight patients were included: 27 (17%) Māori and 110 (70%) NZ Europeans. Fifty-five (35%) were newly diagnosed during the study period. Sixty-two (39%) had extra-thoracic involvement, most commonly ocular and cutaneous. Most patients had radiographic stage 4 (39 [25%]) and thoracic lymphadenopathy on CT (120 [78%]). There were improvements in annualised DLCO in radiographic stage 0 and 1, but the changes were <20%. Twenty-two patients (14%) had at least one respiratory-related hospitalisation and six patients (4%) died. Thirty-three patients (14%) were started on new treatment, had no clinically significant changes in lung function, and most did not have deterioration in radiology. Of the 66 patients who were on treatment during the study period, only five (8%) stopped treatment due to intolerance and none caused hospitalisation or death. Māori patients tended to be younger, female and had more extra-thoracic sarcoidosis than Europeans (15/27 [56%] vs 38/110 [35%], p=0.045). Even though Europeans had more lung fibrosis on imaging, there were no differences in baseline lung function. There were no significant differences in the changes of lung function, imaging, respiratory-related hospitalisations and all-cause mortality.
CONCLUSION
Our cohort of sarcoidosis patients have heterogeneous staging and extra-thoracic manifestations. Systemic treatment is well tolerated but steroid-sparing agent use is sparse. Māori patients have greater extra-thoracic involvement and are less like to have lung fibrosis than Europeans.
Management of type 2 diabetes in New Zealand: a scoping review of interventions
Sara Mustafa,[[1]] Kimberley Norman,[[2]] Tim Kenealy,[[3]] Ross Lawrenson,[[1,4]] Lynne Chepulis[[1]]
1Medical Research Centre, University of Waikato, Te Huataki Waiora School of Health, Hamilton, New Zealand
2School of Primary and Allied Health Care, Monash University, Melbourne, Australia
3The University of Auckland, Auckland, New Zealand
4Te Whatu Ora – Health New Zealand, Hamilton, New Zealand
BACKGROUND
Type 2 diabetes (T2D) is an increasingly concerning public health crisis, particularly affecting Indigenous Māori and Pacific populations in New Zealand. With higher prevalence rates, financial strains on healthcare and pronounced health disparities, the urgency for effective T2D management is evident. This scoping review aims to investigate the interventions addressing T2D management in New Zealand, their impact on clinical outcomes and the factors that support and hinder the effectiveness, acceptability and feasibility of interventions.
METHODS
Three databases (PubMed, Web of Science and Scopus) were searched for articles on T2D management between January 2000 and July 2023. Articles that did not include clinical outcomes, focussed on T2D prevention or were not conducted in New Zealand were excluded. Stakeholder interviews further identified T2D interventions published in grey literature. Study characteristics, clinical outcomes and supporting and hindering factors identified by study authors were extracted.
RESULTS
A total of 11 articles were included, with most interventions focussing on education (n=10) in combination with lifestyle advice (nutrition + exercise; n=5), a dietary plan (n=3) or an exercise plan (n=1). Seven studies delivered educational sessions via healthcare professionals, of which two were delivered by a Māori or Pacific health professional. The most common supporting factors were clinical or peer support (n=8), whānau engagement (n=6), flexible interventions (n=5) and participant relationship building (n=4). Hindering factors included disliking the intervention (n=4), high costs (n=4) and being time-intensive (n=3). HbA1c, BMI and waist circumference measures improved by 6 months in most studies, but no change was found at >12 months compared to baseline. Minimal or no improvement was reported in lipid profile, renal profile and blood pressure by 24 months.
CONCLUSION
Future interventions should prioritise a holistic approach with strategies to address the barriers to improve the feasibility and acceptability of interventions, while addressing the complexity of T2D management to achieve long-term improved clinical outcomes.
Characteristics of diabetes among youth and young adults: a cross-sectional study of the Waikato/Auckland Region of Aotearoa New Zealand
Sara Mustafa,[[1]] Ryan Paul,[[1,2]] Mark Rodrigues,[[1]] Rawiri Keenan,[[1]] Lynne Chepulis[[1]]
1Medical Research Centre, Te Huataki Waiora School of Health, University of Waikato, Hamilton, New Zealand
2Te Whatu Ora – Health New Zealand, Hamilton, New Zealand
BACKGROUND
Diabetes is the one of the most common metabolic disorders in the world, with rates increasing steadily. Type 2 diabetes (T2D) is predominantly diagnosed in adults, but increasingly occurs among youth and young adults alongside type 1 diabetes (T1D) diagnoses. This study aims to investigate of the characteristics of T1D and T2D among individuals aged <25 years including clinical information and use of diabetes-related medications.
METHODS
A cross-sectional study was conducted of patient data collected via de-identified clinical records from four primary healthcare organisations in the Waikato and Auckland regions. Demographic and clinical data for individuals <25 years with diabetes were extracted for the period of February 2021 and July 2022. Dispensed medication information was obtained from the national pharmaceutical collection. Descriptive analyses were conducted, and Chi-squared tests were used to assess for associations between patient characteristics and medication dispensed.
RESULTS
A total of 1,261 youth were coded with diabetes, of which 863 (68.4%) had T1D, 335 (26.6%) had T2D, and 63 (5.0%) were unknown. Youth with T1D had a mean age of 16±5.6 years, were more likely to be European (66.4% vs 17.1% for Māori; p<0.05), and nearly half had a healthy BMI (43.6%). In contrast, the mean age of T2D was 20.4±3.4 years, and youth were more likely to be Māori (38.2%) or Pacific (31.0%) (vs 20.3% for European; p<0.05), and to have obesity (84.5%). Median HbA1c was 75.0 mmol/mol (interquartile range [IQR]: 63.0–91.5) in T1D and 62.5 mmol/mol (IQR: 48.0–88.0) in T2D patients, with variation by ethnicity. The most dispensed medication among T1D was insulin (94.7%), metformin (5.6%) and ACEi (3.4%), while metformin (68.7%), GLPR1A/SGLT2i (32.8%) and vildagliptin (29.9%) were dispensed in individuals with T2D.
CONCLUSIONS
Diabetes is a concern for New Zealand youth, with at least a quarter of patients now having T2D. Appropriate management and prevention strategies are urgently required.
Summary
Abstract
Aim
Method
Results
Conclusion
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
Contact diana@nzma.org.nz
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Proceedings of the Waikato Clinical Campus Research Seminar, Wednesday, 27th September 2023
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Hypogonadism following testicular cancer
Veronica Boyle,[[1,2]] Maiea Mauriohooho,[[2]] Jade A U Tamatea,[[1,2]] Michael Jameson,[[1,3]] Alvin Tan,[[3]] Marianne S Elston[[1,2]]
1Waikato Clinical Campus, The University of Auckland, Hamilton, New Zealand; Departments of 2Endocrinology & 3Medical Oncology, Te Whatu Ora Waikato, Hamilton, New Zealand
BACKGROUND
Testicular cancer is the most common malignancy affecting young men, and Aotearoa New Zealand has one of the highest rates of testicular cancer in the world. Survival rates, even in those who present with metastatic disease, are high, with often >95% long-term survival. As such, long-term treatment complications and quality of life are particularly important. Hypogonadism has been reported to occur in 5–25% of men with a history of testicular cancer and surveillance guidelines recommend regular assessment of testosterone levels.
AIM
To determine the proportion of men who had assessment of gonadal function prior to any treatment for testicular cancer and at each of the four recommended timepoints, and the rates of hypogonadism.
METHODS
A retrospective review of patients with a new diagnosis of testicular cancer at Waikato Hospital during a 20-year period from the 1 January 2000 to 31 December 2020. Patients who had a single testis at the time of diagnosis, who had already received treatment for testicular cancer prior to 1 January 2000 or who were already receiving exogenous testosterone replacement were excluded.
RESULTS
A total of 518 cases were eligible for inclusion. Of these, 151 men (29%) had a testosterone level measured at least at one timepoint. There was no difference by age, ethnicity, BMI, tumour stage or treatment between those men who had a testosterone measured and those who did not. Of these 151 men, 69 (45%) had a testosterone level below the lower limit of the reference interval (9nmol/L). These men were more likely to have received radiotherapy (p=0.05); no other differences were identified. Of the 69 men who had at least one low testosterone level, no further action was taken in 17, seven had a repeat that was normal, nine had a repeat value consistent with hypogonadism but no further action was taken, and 37 were referred to endocrinology with 28 started on testosterone replacement. Nine did not receive treatment (repeat levels normal [n=5], waiting to be seen by endocrinology [n=3], referral declined requesting repeat morning test first [n=1]).
CONCLUSIONS
Subnormal testosterone levels are common in men who have previously received treatment for testicular cancer, but assessment of testosterone levels in this group is low. This may mean a missed opportunity to improve quality of life for these men.
Outcomes and access to angiography following non-ST segment elevation acute coronary syndromes in patients that present to rural or urban hospitals
Rory Miller,[[1]] Garry Nixon,[[2]] Tim Stokes,[[3]] Robin Turner,[[4]] Yannan Jiang,[[5]] Rawiri Keenan,[[6]] Corina Grey,[[7]] Andrew Kerr[[8]]
1Rural Doctor and Senior Lecturer, Department of General Practice and Health, University of Otago, Dunedin, New Zealand
2Rural Doctor and Professor of Rural Health, Department of General Practice and Health, University of Otago, Dunedin, New Zealand
3Professor of General Practice, Department of General Practice and Rural Health, University of Otago, Dunedin, New Zealand
4Professor of Biostatistics, Biostatistics Centre, University of Otago
5Senior Research Fellow—Statistics, Department of Statistics, The University of Auckland, Auckland, New Zealand; National Institute for Health Innovation, School of Population Health, The University of Auckland, Auckland, New Zealand
6Medical Research Centre, University of Waikato, Hamilton, New Zealand; Department of General Practice and Rural Health, University of Otago, Dunedin, New Zealand
7Public Health Physician, Department of General Practice and Primary Healthcare, The University of Auckland, New Zealand
8Cardiologist, Cardiology Department, Middlemore Hospital, Middlemore, New Zealand
AIM
In New Zealand patients with non-ST segment elevation acute coronary syndrome (NSTEACS) may present to rural hospitals, or to an urban hospital with or without routine access to percutaneous intervention (PCI). The aim of this study is to determine if there are differences in access to angiography and health outcomes for patients with NSTEACS associated with presenting to these three categories of hospital.
METHODS
First admissions for patients with NSTEACS to a New Zealand public hospital between 1 January 2014 and 31 December 2017 were included. Logistic regression was used to determine whether there was difference between the three categories of hospitals for the outcome measures: angiography performed within 1 year; 30-day, 1-year and 2-year all-cause mortality; and readmission to hospital within 1 year of presentation with either heart failure, a major adverse cardiac event or major bleeding.
RESULTS
There were 42,923 patients included in the study. The adjusted odds of a patient receiving an angiogram were reduced by 25% and 18% for urban hospitals without routine access to PCI (odds ratio [OR] 0.75: 95% confidence interval [CI] 0.71–0.79) and rural hospitals (OR 0.82: 95% CI 0.75–0.90) respectively. Patients that presented to urban hospitals without PCI had increased odds of readmission with a major adverse cardiac event (OR 1.10: 95% CI 1.03–1.16). There was a 16% increase in the odds of dying within 2 years for patients presenting to a rural hospital (OR 1.16: 95% CI 1.05–1.29).
CONCLUSION
Patients who do not present to hospitals with routine access to PCI are less likely to receive angiography. There is a small increase in 2-year mortality for patients who present to rural hospitals that may reflect poorer access to cardiac rehabilitation and secondary prevention.
Breast cancer grade—multi-institutional audit
Archana Pandita,[[1]] Reena Ramsaroop,[[2]] Gavin Harris[[3]]
1Department of Anatomic Pathology, Waikato Hospital, Hamilton, New Zealand
2Department of Anatomic Pathology, North Shore Hospital, Auckland, New Zealand
3Department of Anatomic Pathology, Canterbury Hospital, Christchurch, New Zealand
PURPOSE
Breast carcinoma is the second most common malignancy in women after colon and lung. The breast staging is based on consideration of multiple factors such as size of the tumour, number of lymph nodes involved by the metastatic carcinoma and distant metastases. Although not included in the staging of the breast carcinoma, histological grade for breast carcinoma is strongly associated with both breast cancer-specific survival and disease-free survival. Multivariate analysis have shown that histological grade is an independent predictor of both overall survival and disease-free survival in inoperable breast cancers. This can also help oncologists decide on management. Histological grading is now a part of minimum dataset for breast cancer pathology reporting included by the Royal College of Pathologists of Australasia, the United Kingdom Royal College of Pathologists, the College of American Pathologists, and is endorsed by the World Health Organization.
The national breast cancer registry shows a steady decline in the reporting of grade 3 breast cancers in the regional Waikato Hospital. Multi-institutional breast audit was undertaken to compare the grading in the three regions.
MATERIALS AND METHODS
A total of 105 de-identified slides with breast carcinoma from Waikato Hospital were sent to two different centres (centre A and centre B) for grading of the breast cancers. Pathologists (1–2) from both the centres agreed to look at these slides for grading. The slides were selected randomly from the previous year and same sets were sent to both the centres with no other information available to the grading pathologists to avoid the bias. The slides were sent in sets of three (25, 40 and 40 each) to avoid the extra workload for the pathologists, who are already busy with their routine schedule.
The clinical pathological variables were compared using contingency tables results.
RESULTS
A total of 45 cases were concordant between three institutions. There was some discordance in the grading of the remaining breast cancer slides in the three institutions. The concordant number of cases between Waikato and Centre A was 27 in total. Centre A upgraded 15 of the Waikato cases and downgraded 11 cases. There were 10 concordant cases between Waikato and Centre B. Centre B upgraded seven Waikato cases and downgraded 33 of these cases. When comparing Centres A and B, the number of concordant cases was 13. Centre A upgraded two cases of Centre B and downgraded 33 of the Centre B cases. There were 10 cases not included for the study when comparing all the centres because of the difficulty in differentiating between invasive and in situ carcinoma or cutting artefact in the tissue.
The Waikato cases were further reviewed by one pathologist after a long wash-out period, strictly using the Nottingham breast cancer scoring system. This was done randomly to avoid bias. It was noted that the discordance in grade assignment was mostly resulting from borderline morphological features. The number of cases upgraded from grade 2 to grade 3 was 12, from grade 1 to grade 3 was one and only one case was upgraded from grade 1 to grade 3; however, there were 3 cases that were downgraded to grade 2, and two cases that were downgraded to grade 1.
DISCUSSION
The breast grading is determined using the three variables including tubule formation, nuclear morphology and mitoses using a universal scoring system.
There are few factors that may affect the grade reported in different studies that can be explained by difference in the patient cohorts including age distribution, symptomatic versus chronic population, early versus advanced breast cancer or tissue fixation. There have been many studies looking at the inter-observer and intra-observer agreement of breast cancer histological grade and the value ranges from 0.43–0.83 in different studies. The range for grade 1 measures ranging between 11 and 38%, for grade 2 varies from 37 to 49% and for grade 3 ranges from 24 to 46%.
Waikato Hospital deals mostly with the breast screening cases. This is the most likely cause for lower grade 3 reporting. It was interesting to note quite a significant variation in the grading of the breast cancers across the New Zealand regions. The Waikato grading was seen to be close to Centre B grading when compared to Centre A grading.
The various measures that can be taken to get the appropriate grading is proper fixation. Spending extra time on the slide to look at the periphery or the advancing edge of the tumour may also resolve the issue where usually increased mitoses are seen. It is better to count mitoses from hot spot areas as tumour heterogeneity can be responsible for grading discordance.
CONCLUSION
Histological grade is an important, strong predictor of outcome in patients with invasive breast cancer and therefore it is important that the grading is done correctly, and that steps should be taken in the department to achieve that. Critical evaluation of these issues with recommendations from good practice guidelines with regular educational activities and associated external quality assurance can improve the discordance in the grade reporting. This will improve reproducibility and give consistent results. Work is being done in the field of artificial intelligence and digital pathology to improve the grading outcomes for breast cancers.
Quad bike is not a toy for kids
Sayanthan Balasubramaniam,[[1]] Emily Lancastle,[[2]] Mathew Crowther,[[2]] Udaya Samarakkody[[3]]
1Department of Paediatric Surgery, Te Whatu Ora Waikato, Waikato Hospital, New Zealand
2University of Edinburgh, United Kingdom
3Waikato Clinical Campus, The University of Auckland, Hamilton
BACKGROUND
Quad bikes are useful vehicles for outdoor activities and farming in New Zealand. They are lightweight and have a high centre of gravity. Their appearance and function are very attractive to children. We aim to analyse the mechanism, type of injuries and complications associated with quad bike accidents in children.
METHODS
We collected the data of children under 15 years admitted to Te Whatu Ora (TWO) Waikato – Health New Zealand who sustained quad bike injuries from January 2013 to January 2023 (10 years). The data were analysed with SPPS-22. The Clinical Audit and Safety Unit approved this project.
RESULTS
Eighty-five records were reviewed. Notably, Māori were not represented in this cohort. Sixty-two (72.9%) children were drivers, and 20 (23.5%) were passengers. Thirty-two children had accidents on a farm, 17 at home, 10 on the road, and 26 in “other” locations. Mean age was 10.2, with a range of 1–15 years (standard deviation 3.9) with 52% without helmets. The commonest injury was to limbs (n=60), followed by head injuries (n=20) and abdominal injuries (n=13). Fractures were more common in the upper limbs (n=26) than in the lower limbs (n=15). Twelve had severe concussions, and three had significant intracranial haemorrhage. Eleven children had solid abdominal organ injuries. Four had multiple injuries, including head and abdominal trauma. Thirty-four children underwent surgical interventions, four requiring ICU admission. The average hospital stay was 2.1 days. Overall, 29.4% (n=25) had minor disabilities. The majority (n=60, 58.8%) needed parental support for activities of daily living at discharge.
CONCLUSION
Quad bikes can be a dangerous recreational activity for children, causing major health hazards.
The fatigue after infusion or transfusion pilot trial and feasibility study: a three-armed randomised pilot trial of intravenous iron versus blood transfusion for the treatment of postpartum anaemia
Esther Caljé,[[1]] Joy Marriott,[[2]] Charlotte Oyston,[[2,3]] Lesley Dixon,[[4]] Frank H Bloomfield,[[1]] Katie M Groom[[1,5]]
1Liggins Institute, The University of Auckland, Auckland, New Zealand
2Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, The University of Auckland, Auckland, New Zealand
3Middlemore Hospital, Auckland, New Zealand
4New Zealand College of Midwives, Christchurch, New Zealand
5National Women’s Health, Auckland City Hospital, Auckland, New Zealand
BACKGROUND/AIM
There is a lack of high-quality evidence for the management of moderate-to-severe postpartum anaemia, with significant variation in clinical practice. A randomised trial is needed, although recruitment may be challenging. The primary objective was to determine the recruitment rate for a randomised trial of intravenous (IV) iron and/or red blood cell transfusion (RBC-T) for postpartum anaemia.
METHODS
A randomised pilot trial with surveys for women, clinicians and stakeholders. Inclusion criteria: postpartum haemoglobin 65–79g/L; haemodynamically stable. Exclusion criteria: ongoing heavy bleeding; already received or known contraindication to IV-iron/RBC-T. Intervention/control: IV-iron; RBC-T; or IV-iron and RBC-T. Primary outcome: recruitment rate (those approached, and overall). Secondary outcomes: fatigue, depression, baby-feeding and haemoglobin, at 1, 6 and 12 weeks; ferritin at 6 and 12 weeks. A health equity lens was applied to support Māori and Pacific participation.
RESULTS
Over 16 weeks from 16 October 2022 to 29 January 2023 at Auckland, Waikato and Canterbury hospitals, 26 women consented to randomisation. The proportion of those approached who were randomised was 26/34 (76%), including 8/26 (31%) Māori and one (3%) Pacific women. The proportion of all broadly eligible women was 16% (26/167). Key enablers for participation were altruism and study relevance. For clinicians and stakeholders, availability of research assistance was the key barrier/enabler. No significant differences were found for fatigue or depression amongst intervention arms. Significant differences were found between RBC-T vs (favouring) IV-iron and RBC-T for haemoglobin at 6 (p=0.0116) and 12 (p=0.0234) weeks; and for ferritin at 6 (p<0.0001) and 12 (p=0.0483) weeks. No significant differences were found between IV-iron vs IV-iron and RBC-T for haemoglobin and ferritin.
CONCLUSION
The recruitment rate indicates that a trial of IV-iron and RBC-T for postpartum anaemia is feasible. Dedicated research assistance will be critical to the success of an adequately powered trial to examine the effectiveness of postpartum anaemia interventions.
The use of kaiāwhina and technology (continuous glucose monitors) for glycaemic management in type 2 diabetes (T2D) in high-risk Māori populations
Rebekah Crosswell,[[1]] Salem Waters,[[1]] Hamish Crockett,[[1]] Donna Foxall,[[1]] Suzanne Moorhouse,[[2]] Helen Morton,[[3]] Michael Oehley,[[4]] Ryan Paul,[[4]] Lynne Chepulis[[3]]
1Waikato Medical Research Centre, University of Waikato, Hamilton
2Hauraki PHO, Hamilton
3Raukura Hauora o Tainui Māori
4Te Whatu Ora Waikato
AIMS AND OBJECTIVES
Type 2 diabetes (T2D) is a chronic, multi-systemic condition. Despite established guidelines for the management of patients with T2D, they continue to have suboptimal glycaemic control. Additionally, Māori populations are disproportionally represented in the statistics compared to non-Māori. The aim of this study is to examine whether continuous glucose monitors (CGM) use can drive behaviour change and improve diabetes management in Māori patients with high-risk diabetes (HbA1c <80mmol/L). The study has not been completed; however, progress will be reported to date at the 3-month and 6-month periods.
METHODS
Research methodology included a Te Ao Māori focus, with whakawhanaungatanga and tikanga being at the forefront. Recruitment and study design were driven by a multi-disciplinary working group, including early and mid to late career researchers and clinicians. Twenty-two participants have been recruited, all through to completion of the 3-month period. Referrals were clinician-centred from a Māori health provider. Glycated haemoglobin (HbA1c) was used as a measure of diabetes management, taken at baseline. Other data collected included lipids, eGFR and uACR. Participants wore a CGM for 4 weeks at baseline and 3-month periods. Participants were visited by Māori research kaiāwhina every few days while wearing the device, and provided with self-management education on T2D, libre use, exercise, kai and lifestyle advice.
RESULTS
Results at 3 months show an average change of 18mmol/L across all participants. For HbA1c, while some patients increased or were stable, these can be explained on a case-by-case basis with disease progression and comorbidities (e.g., kidney failure, development of metastatic cancer). To date, there is much variability in the lipid profiles.
CONCLUSIONS
Delivering care that is based on Kaupapa Māori principles, with research kaiāwhina, education and technology enables Māori patients with T2D to self-manage their condition. This is a promising model of care that leads to significant changes in glycaemic control.
Recurrence of inguinal hernia in the paediatric population
Sayanthan Balasubramaniam,[[1]] Amanpreet Singh,[[1]] Udaya Samarakkody[[1]]
1Department of Paediatric Surgery, Te Whatu Ora Waikato, Waikato Hospital, New Zealand
BACKGROUND
Inguinal hernia recurrence necessitates further surgical interventions increasing the burden on health resources. Our study aimed to assess paediatric inguinal hernia recurrence, identify risk factors, refine surgical techniques and evaluate the outcomes.
METHODS
A retrospective study was conducted on patients under the age of 15 years of age undergoing an inguinal herniotomy at Waikato Hospital between November 2012 to June 2023. Data were retrieved from the Paediatric Surgical Database and Theatre Enterprise Reporting after approval from the Clinical Audit Support Unit. The demographic information, age at time of surgery, surgical method, recurrence rate, interval from surgery to recurrence and rate of metachronous hernia were documented. Statistical analysis was performed by the SPSS software program.
RESULTS
We identified 1,093 patients, with 966 undergoing open repair; the remaining 127 patients underwent laparoscopic repair. Boys made up the majority, accounting for 85% of the cases (n=930). Additionally, Māori children constituted 40.4% of the patient population. Thirteen patients presented with inguinal hernia recurrence. Of these, 11 had primary repair by open approach (1.18%) and two by laparoscopic (1.57%) approach. Eight had comorbidities: gastroschisis, omphalocele, extreme low birth weight (ELBW<750g) and respiratory distress syndrome (RDS). Notably, Māori accounted for 46% of the recurrence cases. The earliest recurrence was repaired on day zero, while the latest was repaired on day 1,452. The metachronous contralateral inguinal hernia rate was 4.2%. Among 930 boys, 11 had recurrence and two of 163 females had recurrences with no statistical significance (p=0.962). Children under 1 year had a high recurrence rate (p=0.001).
CONCLUSION
The rate of inguinal hernia recurrence was 1.18%, with no significant difference between the open and laparoscopic group. Incidence rates of inguinal hernia and recurrence were higher in Māori. This recurrence and metachronous inguinal hernia rate are consistent with accepted international standards.
Characteristics and disease course of patients with sarcoidosis in Te Whatu Ora Waikato
Liam Petrie, Eskandarain Shafuddin
Department of Respiratory Medicine, Te Whatu Ora Waikato, Hamilton, New Zealand
BACKGROUND
Sarcoidosis is a multi-system granulomatous inflammatory disease of unknown cause with substantial racial differences in epidemiology in some countries. A study conducted in Auckland suggested that Māori patients tended to have different clinical features than NZ Europeans.
AIM
To characterise the clinical and radiological features, treatment and disease course of sarcoidosis in patients in Te Whatu Ora Waikato and to compare between Māori and NZ European patients.
METHODS
Attendees of Waikato respiratory outpatient clinics from January 2019 to December 2020 were retrospectively screened and those with a confirmed diagnosis of sarcoidosis were included in this audit. Data including extra-thoracic features, lung function, radiology findings, treatment received, hospitalisation and all-cause mortality were collected from January 2019 to November 2021. Annualised changes in lung function and changes in chest radiographs and CT were analysed. We analysed the differences in clinical and radiological features, changes in lung function and radiology, hospitalisation and mortality between Māori and NZ European patients.
RESULTS
One hundred and fifty-eight patients were included: 27 (17%) Māori and 110 (70%) NZ Europeans. Fifty-five (35%) were newly diagnosed during the study period. Sixty-two (39%) had extra-thoracic involvement, most commonly ocular and cutaneous. Most patients had radiographic stage 4 (39 [25%]) and thoracic lymphadenopathy on CT (120 [78%]). There were improvements in annualised DLCO in radiographic stage 0 and 1, but the changes were <20%. Twenty-two patients (14%) had at least one respiratory-related hospitalisation and six patients (4%) died. Thirty-three patients (14%) were started on new treatment, had no clinically significant changes in lung function, and most did not have deterioration in radiology. Of the 66 patients who were on treatment during the study period, only five (8%) stopped treatment due to intolerance and none caused hospitalisation or death. Māori patients tended to be younger, female and had more extra-thoracic sarcoidosis than Europeans (15/27 [56%] vs 38/110 [35%], p=0.045). Even though Europeans had more lung fibrosis on imaging, there were no differences in baseline lung function. There were no significant differences in the changes of lung function, imaging, respiratory-related hospitalisations and all-cause mortality.
CONCLUSION
Our cohort of sarcoidosis patients have heterogeneous staging and extra-thoracic manifestations. Systemic treatment is well tolerated but steroid-sparing agent use is sparse. Māori patients have greater extra-thoracic involvement and are less like to have lung fibrosis than Europeans.
Management of type 2 diabetes in New Zealand: a scoping review of interventions
Sara Mustafa,[[1]] Kimberley Norman,[[2]] Tim Kenealy,[[3]] Ross Lawrenson,[[1,4]] Lynne Chepulis[[1]]
1Medical Research Centre, University of Waikato, Te Huataki Waiora School of Health, Hamilton, New Zealand
2School of Primary and Allied Health Care, Monash University, Melbourne, Australia
3The University of Auckland, Auckland, New Zealand
4Te Whatu Ora – Health New Zealand, Hamilton, New Zealand
BACKGROUND
Type 2 diabetes (T2D) is an increasingly concerning public health crisis, particularly affecting Indigenous Māori and Pacific populations in New Zealand. With higher prevalence rates, financial strains on healthcare and pronounced health disparities, the urgency for effective T2D management is evident. This scoping review aims to investigate the interventions addressing T2D management in New Zealand, their impact on clinical outcomes and the factors that support and hinder the effectiveness, acceptability and feasibility of interventions.
METHODS
Three databases (PubMed, Web of Science and Scopus) were searched for articles on T2D management between January 2000 and July 2023. Articles that did not include clinical outcomes, focussed on T2D prevention or were not conducted in New Zealand were excluded. Stakeholder interviews further identified T2D interventions published in grey literature. Study characteristics, clinical outcomes and supporting and hindering factors identified by study authors were extracted.
RESULTS
A total of 11 articles were included, with most interventions focussing on education (n=10) in combination with lifestyle advice (nutrition + exercise; n=5), a dietary plan (n=3) or an exercise plan (n=1). Seven studies delivered educational sessions via healthcare professionals, of which two were delivered by a Māori or Pacific health professional. The most common supporting factors were clinical or peer support (n=8), whānau engagement (n=6), flexible interventions (n=5) and participant relationship building (n=4). Hindering factors included disliking the intervention (n=4), high costs (n=4) and being time-intensive (n=3). HbA1c, BMI and waist circumference measures improved by 6 months in most studies, but no change was found at >12 months compared to baseline. Minimal or no improvement was reported in lipid profile, renal profile and blood pressure by 24 months.
CONCLUSION
Future interventions should prioritise a holistic approach with strategies to address the barriers to improve the feasibility and acceptability of interventions, while addressing the complexity of T2D management to achieve long-term improved clinical outcomes.
Characteristics of diabetes among youth and young adults: a cross-sectional study of the Waikato/Auckland Region of Aotearoa New Zealand
Sara Mustafa,[[1]] Ryan Paul,[[1,2]] Mark Rodrigues,[[1]] Rawiri Keenan,[[1]] Lynne Chepulis[[1]]
1Medical Research Centre, Te Huataki Waiora School of Health, University of Waikato, Hamilton, New Zealand
2Te Whatu Ora – Health New Zealand, Hamilton, New Zealand
BACKGROUND
Diabetes is the one of the most common metabolic disorders in the world, with rates increasing steadily. Type 2 diabetes (T2D) is predominantly diagnosed in adults, but increasingly occurs among youth and young adults alongside type 1 diabetes (T1D) diagnoses. This study aims to investigate of the characteristics of T1D and T2D among individuals aged <25 years including clinical information and use of diabetes-related medications.
METHODS
A cross-sectional study was conducted of patient data collected via de-identified clinical records from four primary healthcare organisations in the Waikato and Auckland regions. Demographic and clinical data for individuals <25 years with diabetes were extracted for the period of February 2021 and July 2022. Dispensed medication information was obtained from the national pharmaceutical collection. Descriptive analyses were conducted, and Chi-squared tests were used to assess for associations between patient characteristics and medication dispensed.
RESULTS
A total of 1,261 youth were coded with diabetes, of which 863 (68.4%) had T1D, 335 (26.6%) had T2D, and 63 (5.0%) were unknown. Youth with T1D had a mean age of 16±5.6 years, were more likely to be European (66.4% vs 17.1% for Māori; p<0.05), and nearly half had a healthy BMI (43.6%). In contrast, the mean age of T2D was 20.4±3.4 years, and youth were more likely to be Māori (38.2%) or Pacific (31.0%) (vs 20.3% for European; p<0.05), and to have obesity (84.5%). Median HbA1c was 75.0 mmol/mol (interquartile range [IQR]: 63.0–91.5) in T1D and 62.5 mmol/mol (IQR: 48.0–88.0) in T2D patients, with variation by ethnicity. The most dispensed medication among T1D was insulin (94.7%), metformin (5.6%) and ACEi (3.4%), while metformin (68.7%), GLPR1A/SGLT2i (32.8%) and vildagliptin (29.9%) were dispensed in individuals with T2D.
CONCLUSIONS
Diabetes is a concern for New Zealand youth, with at least a quarter of patients now having T2D. Appropriate management and prevention strategies are urgently required.
Summary
Abstract
Aim
Method
Results
Conclusion
Author Information
Acknowledgements
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Proceedings of the Waikato Clinical Campus Research Seminar, Wednesday, 27th September 2023
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