A retrospective study of colonoscopic surveillance in the elderly

BACKGROUND

Aotearoa New Zealand (AoNZ) guidelines suggest surveillance colonoscopy should be carefully considered after age 75. The authors noted a cluster of patients presenting in their 8th and 9th decade of life with a new colorectal cancer (CRC) having previously been declined surveillance colonoscopy.

METHODS

A 7-year retrospective analysis was performed of patients who underwent a colonoscopy aged between 71 and 75 years in the period between 2006 and 2012. Kaplan-Meier graphs were created with survival measured from the time of index colonoscopy. Log rank tests were used to determine any difference in survival distribution. Relative risk (RR) was calculated, and 95% confidence intervals (CI) reported.

RESULTS

A total of 623 patients met inclusion criteria; 461 (74%) had no indication for surveillance colonoscopy and 162 (26%) had an indication. Of the 162 patients with an indication, 91 (56.2%) underwent surveillance colonoscopies after the age of 75. Twenty-three (3.7%) patients were diagnosed with a new CRC. Eighteen (78.2%) patients diagnosed with a new CRC underwent surgery. The median survival overall was 12.9 years (95% CI 12.2-13.5). This did not differ between patients with (13.1, 95% CI 12.1-14.1) or without (12.6, 95% CI 11.2-14.0) an indication for surveillance.

CONCLUSION

This study found one quarter of patients who had a colonoscopy between the ages of 71-75 had an indication for surveillance colonoscopy. Most patients with a new CRC underwent surgery. This study suggests it may be appropriate to update the AoNZ guidelines and consider adopting a risk stratification tool to aid decision making.

"Failure to Rescue" following Colorectal Cancer Resection: Variation and Improvements in a National Study of Postoperative Mortality

OBJECTIVE

To examine variation in "failure to rescue" (FTR) as a driver of differences in mortality between centres and over time for patients undergoing colorectal cancer surgery.

BACKGROUND

Wide variation exists in postoperative mortality following colorectal cancer surgery. FTR has been identified as an important determinant of variation in postoperative outcomes. We hypothesized that differences in mortality both between hospitals and over time are driven by variation in FTR.

METHODS

A national population-based study of patients undergoing colorectal cancer resection from 2010 to 2019 in Aotearoa New Zealand was conducted. Rates of 90-day FTR, mortality, and complications were calculated overall, and for surgical and nonoperative complications. Twenty District Health Boards (DHBs) were ranked into quartiles using risk- and reliability-adjusted 90-day mortality rates. Variation between DHBs and trends over the 10-year period were examined.

RESULTS

Overall, 15,686 patients undergoing resection for colorectal adenocarcinoma were included. Increased postoperative mortality at high-mortality centers (OR 2.4, 95% CI 1.8-3.3) was driven by higher rates of FTR (OR 2.0, 95% CI 1.5-2.8), and postoperative complications (OR 1.4, 95% CI 1.3-1.6). These trends were consistent across operative and nonoperative complications. Over the 2010 to 2019 period, postoperative mortality halved (OR 0.5, 95% CI 0.4-0.6), associated with a greater improvement in FTR (OR 0.5, 95% CI 0.4-0.7) than complications (OR 0.8, 95% CI 0.8-0.9). Differences between centers and over time remained when only analyzing patients undergoing elective surgery.

CONCLUSION

Mortality following colorectal cancer resection has halved over the past decade, predominantly driven by improvements in "rescue" from complications. Differences in FTR also drive hospital-level variation in mortality, highlighting the central importance of "rescue" as a target for surgical quality improvement.

Management and outcomes of rib fractures in patients with isolated blunt thoracic trauma: Results of the Aotearoa New Zealand RiBZ study

AIM

Rib fractures are common and associated with significant morbidity and mortality. There is limited literature on patient care and outcomes in Aotearoa New Zealand (AoNZ). The aim of this study is to describe key clinical outcomes and management interventions for patients with rib fractures across AoNZ.

METHODS

A national prospective multicenter observational cohort study was performed. Patients admitted between 1 December 2020 and 28 February 2021 with one or more radiologically proven rib fractures and an Abbreviated Injury Score of the head or abdomen of less than 3 were included. The primary outcomes of interest were the rates of thirty-day pneumonia, re-presentation and mortality. The secondary outcomes of interest were rate of surgical stabilisation of rib fractures (SSRF) and pain management of patients with rib fractures. Binomial logistic regression was performed for the primary outcomes and funnel plots were created of the inter-hospital variation in pneumonia.

RESULTS

Fourteen AoNZ hospitals and 407 patients were included. Mean age was 57.4 (SD 18.7), 28% were female, 15% Māori and 85% non-Māori. The median number of rib fractures was 4. The rate of pneumonia, re-presentation and mortality was 11%, 8% and 2%, respectively. Logistic regression found the odds of pneumonia increased with each additional rib fracture (OR 1.15 95% CI 1.05-1.25) and the odds of re-presentation increased with age (OR 1.028 95% CI 1.005-1.051) and Māori ethnicity (OR 2.754 95% CI 1.077-7.045). The funnel plot of inter-hospital variation in pneumonia rate adjusted for clinically plausible variables found no centre lay outside the 95% confidence interval. SSRF was performed in 2% of patients. 58% of patients had a pain team review and 23% a regional block.

CONCLUSION

This study describes clinical outcomes for patients with isolated rib fractures from multiple hospitals in AoNZ. A moderate pneumonia rate of 11% was found which is likely amendable to reduction with quality improvement initiatives. Consideration should be given to further resource and improve the access to SSRF and regional analgesia given the low utilization found across AoNZ. A higher re-presentation rate in Māori and elderly patients was found which needs further investigation.

Survival of patients with small bowel neuroendocrine neoplasms in Auckland, Aotearoa New Zealand

Background

Small intestinal Neuroendocrine Neoplasms (SI‐NENs) are the most common primary malignancy of the small bowel. The aim of this study is to define the survival of patients with an SI‐NEN in Auckland, Aotearoa New Zealand (AoNZ).

Methods

A retrospective study of all patients diagnosed with a jejunal or ileal SI‐NEN in the Auckland region between 2000 and 2012 was performed. The New Zealand NETwork! Registry was searched to identify the study cohort. Retrospective data collection was performed to collect stage, survival and follow up data.

Results

One hundred and seven patients were included in the study. The mean age of patients was 62.8 years (SD 11.9). The 5 and 10‐year disease‐specific survival for all patients was 66.1% (95% CI 56.5–75.7%) and 61.8% (95% CI 51.8–71.8%), respectively. Ten‐year disease‐specific survival was 100% for stage I and II, 74% (95%CI 61.7–84.4%) for stage III and 33.9% (95%CI 16.9–35.6%) for stage IV SI‐NEN. Eleven of 40 (27.5%) patients with stage III disease had recurrence and 3 of 7 (42.8%) patients with stage IV disease had recurrence. In patients with stage IV disease, neither primary resection (HR 2.25, 95% CI 0.92–5.5) nor distant resection (HR 1.72, 95% CI 0.63–4.7) were significantly associated with a disease‐specific or overall survival benefit.

Conclusion

This study demonstrates that stage at SI‐NEN diagnosis is associated with survival, but resection of the primary or distant metastases in patients with stage IV disease is not. There was no recurrence in patients with stage I or II disease after complete resection.

Nail gun injuries: not just an occupational hazard

INTRODUCTION

Nail guns are commonly used in the construction industry. They represent an occupational hazard, and in the context of mental illness can pose a threat to life.

AIM

To determine the number of patients admitted to Auckland City Hospital (ACH) with a nail gun injury, and to review the current New Zealand legislation surrounding nail guns.

METHODS

A 25-year retrospective review of patients admitted to ACH with a nail gun injury was performed by searching the ACH Trauma Registry. New Zealand legislation was reviewed.

RESULTS

Between 1994 and 2019, 45 patients were admitted to ACH with a nail gun injury. Two subgroups were identified: 31% with an intentional injury; 69% with an unintentional injury. All patients were male. The mean age was 36.3. Patients with an intentional injury had a higher mortality rate (21.4% vs 9.5%), Injury Severity Scores (24.2 vs 3.4) and ICU admission rate (50% vs 3%) and required more intensive post-injury care when compared to unintentional injuries. There is currently no legislation in New Zealand specifically governing the use of nail guns. Only powder-actuated nail guns require certification.

CONCLUSION

The continued occurrence of unintentional nail gun injuries and the high lethality of intentional injuries represent two distinct areas of concern. The Government should publish guidance aimed at improving safety and reducing the rate of intentional injury.

Outcomes in patients with fractured ribs: middle aged at same risk of complications as the elderly

AIMS

Rib fractures occur in up to 10% of hospitalised trauma patients and are the most common type of clinically significant blunt injury to the thorax. There is strong evidence that elderly patients have worse outcomes compared with younger patients. Evolving evidence suggests adverse outcomes start at a younger age. The aim of this study was to explore the effect of age on outcomes in patients with rib fractures in Northland, New Zealand.

METHOD

A two-year retrospective study of patients admitted to any Northland District Health Board hospital with one or more radiologically proven rib fracture was performed. Patients with an abbreviated injury scale score >2 in the head or abdomen were excluded. The study population was stratified by age into three groups: >65, 45 to 65 and <45 years old.

RESULTS

170 patients met study inclusion criteria. Patients <45 had a significantly shorter length of stay (LOS) and lower rates of pneumonia compared to patients 45 and older, despite a higher Injury Severity Score and pulmonary contusion rate. There was no difference seen between groups in rates of intubation, ICU admission, mortality, empyema or acute respiratory distress syndrome.

CONCLUSION

This study found higher rates of pneumonia and an increased LOS in patients 45 and older despite their lower overall injury severity when compared to patients under 45. Patients aged 45-64 had outcomes similar to patients >65. Future clinical pathways and guidelines for patients with rib fractures should consider incorporating a younger age than 65 in risk stratification algorithms.

Antibiotic Selection for Suspected Neisseria gonorrhoeae Infection Among Penicillin-Allergic Patients in the Emergency Department

Objectives

While penicillin allergies are commonly reported, their cross-reactivity with beta-lactam antibiotics is minimal. First-line treatment of gonorrheal infections includes a cephalosporin. In emergency department (ED) environments, physicians must consider these potential allergies when selecting antibiotics for a patient with symptoms concerning for sexually transmitted infection (STI).

Methods

A retrospective chart review of adult patients with symptoms concerning for STI presenting to an urban ED from January 2014 through June 2019 was performed. Chart discovery used search terms of “STI”, “STD”, “urethritis”, “vaginitis”, and “gonorrhea”. Information abstracted included patient symptoms, type of care provider, antibiotics prescribed or administered in the ED.

Results

A total of 603 patients met inclusion criteria, of which 31 reported allergies to penicillin antibiotics, and another three reported allergies to cephalosporins. Patients reporting penicillin allergy were less likely to receive a cephalosporin antibiotic (p=0.0081). Patients reporting a non-anaphylactic allergy to penicillin received a cephalosporin at a rate of 92.3%. Patients reporting a penicillin allergy under the care of only an attending physician were less likely to receive a cephalosporin antibiotic compared with those whose care teams included either a resident physician or physician assistant (p=0.00019). Patients reporting a penicillin allergy were more likely to receive alternative antibiotics beyond cephalosporins or azithromycin (p=0.048); the most frequently given additional antibiotics were metronidazole, doxycycline, and levofloxacin.

Conclusions 

Patients with penicillin allergies represent a recurring challenge for ED physicians when faced with antibiotic selection for STI symptoms concerning for gonorrheal infection. Those with penicillin allergies are significantly less likely to receive a cephalosporin antibiotic, though these remain the only universally accepted treatment for gonorrheal infections. These findings highlight the significant need for further physician and public education on allergies and antibiotic selection.

Association between COVID-19 public health interventions and major trauma presentation in the northern region of New Zealand

Background

The New Zealand government implemented restrictive public health interventions to eradicate Covid‐19. Early reports suggest that one downstream ramification is a change in trauma presentations. The aim of this study is to evaluate the effect these public health measures had on major trauma admissions in the Northern Region, New Zealand.

Methods

A retrospective comparative cohort study was performed. Two cohorts were identified: 16 March to 8 June 2020 and the same period in 2019. Data was extracted from the New Zealand Major Trauma Registry which prospectively collects data on all major trauma in New Zealand. All patients who presented to a hospital in the Northern Region with major trauma and met the Registry inclusion criteria were included.

Results

There were 163 major trauma admissions in 2019 and 123 in 2020, a reduction of 25% (rate ratio 0.75, 95% confidence interval 0.6–0.95; P = 0.018). There was no significant difference in mechanism of injury (P = 0.442), type of injury (P = 0.062) or intent of injury (P = 0.971). There was a significant difference in place of injury (P = 0.004) with 20% of injuries happening at home in 2019 compared with 35% in 2020.

Conclusion

This study has shown that public health interventions to prevent the spread of COVID‐19 reduced major trauma admissions in the Northern Region of New Zealand. There was a variation in effect a between institutions within the region and a change in pattern of injury.

Shared electric scooter injuries admitted to Auckland City Hospital: a comparative review one year after their introduction

AIM

E-scooters were introduced to New Zealand in 2018 as a means of city transport. Since their introduction, their use has resulted in high injury rates. No studies have directly compared e-scooters to other forms of transport.

METHOD

The Auckland City Hospital trauma registry was retrospectively searched for patients admitted with an e-scooter injury. A comparison group of patients admitted with an injury secondary to cycling during the same period was collected.

RESULTS

178 patients were identified: 69 with e-scooter injuries and 109 with injuries sustained while cycling. The hospitalisation rate for e-scooter injuries was 326 hospitalisations per million hours. There was a significant difference found in blood ethanol levels (18.6 vs 6.4% positive, p-value=0.01), mechanism of injury (isolated falls: 87 vs 60.6%), time of injury (55.1 vs 40.4% between 5pm-8am) and protective gear use (worn in 10.1 vs 78.9%). No differences were found in injury severity, ICU admissions, length of stay or mortality.

CONCLUSION

This study demonstrates a concerningly high e-scooter-related hospitalisation rate and suggests e-scooters are currently not as safe as cycling. Strategies to improve e-scooter safety are needed and could include zero tolerance for alcohol, mandatory protective gear, restricted operating times and changes in road laws.

The effect of national public health interventions for COVID-19 on emergency general surgery in Northland, New Zealand

Background

The New Zealand government instituted escalating public health interventions to prevent the spread of COVID‐19. There was concern this would affect health seeking behaviour leading to delayed presentation and worse outcomes. The aim of this study was to examine the effects of these interventions on rate and severity of acute general surgical admissions in Northland, New Zealand.

Methods

A retrospective comparative cohort study was performed. Two cohorts were identified: 28 February to 8 June 2020 and same period in 2019. Data for surgical admissions and operations and emergency department (ED) presentation were obtained from the hospital data warehouse. Three index diagnoses were assessed for severity.

Results

There were 650 acute general surgical admissions in 2019 and 627 in 2020 (P 0.353). Operations were performed in 226 and 224 patients respectively (P 0.829). ED presentations decreased from 11 398 to 8743 (P < 0.001). No difference in severity of acute appendicitis (P 0.970), acute diverticulitis (P 0.333) or acute pancreatitis (P 0.803) was detected. Median length‐of‐stay, 30‐day mortality and admission diagnosis were comparable.

Conclusion

Despite a significant reduction in ED presentations, interventions for COVID‐19 did not result in a difference in the rate or severity of acute general surgical admissions.

1531. Antibiotic Selection for Neisseria gonorrhoeae among Penicillin Allergic Patients in the Emergency Department

Background

While penicillin (PCN) allergies are commonly reported, their cross-reactivity with beta-lactam antibiotics is minimal. First line treatment of gonorrheal infections includes a cephalosporin (CPH). In an emergency department (ED) environment, physicians must consider potential allergies when selecting antibiotics for a patient with symptoms concerning for sexually transmitted infection (STI).

Methods

A retrospective chart review on adult patients with symptoms concerning for STI presenting to an urban ED from January 2014 through June 2019 was performed. Chart discovery was performed using search terms of “STI”, “STD”, “urethritis”, “vaginitis”, and “gonorrhea”. Information abstracted included patient symptoms, type of care provider, and antibiotics prescribed or administered in the ED. The primary outcome was prevalence of allergy to PCN and CPH in patients evaluated for STI symptoms and secondary outcomes included prescribed antibiotic treatments. Chi-square and Fischer-exact tests were utilized to examine for statistical significance, with p values < 0.05 as statistically significant.

Results

A total of 603 patients met the inclusion criteria, of which 31 reported allergies to PCN, and another 3 reported allergies to CPH. Patients reporting PCN allergy were found to be less likely to receive a CPH antibiotic (p=0.0035). Patients reporting a non-anaphylactic allergy to PCN received a CPH at a rate of 92.3%. Attending physicians in particular were less likely to prescribe a CPH antibiotic to a patient reporting allergy compared with both resident physicians and PAs (p=0.00019). Patients reporting a PCN allergy were more likely to receive alternative antibiotics beyond CPH or azithromycin (p=0.046); the most frequently given antibiotics were metronidazole, doxycycline, and levofloxacin.

Demographic Data

Antibiotic Prescriptions by Type of Penicillin Allergy

Antibiotic Prescriptions for Penicillin Allergy vs. No Allergy

Conclusion

Patients with PCN allergies represent a recurring challenge for ED physicians when faced with antibiotic selection for STI symptoms concerning for gonorrheal infection. Those with PCN allergies are significantly less likely to receive a CPH antibiotic, though these remain the only universal treatment for gonorrheal infections. These findings highlight the significant need for further physician education on allergies and antibiotic selection.

Disclosures

All Authors: No reported disclosures

Impact of the COVID-19 national lockdown on emergency general surgery: Auckland City Hospital's experience

BACKGROUND

The New Zealand Government announced a four-level COVID-19 alert system soon after the first confirmed case in the country. New Zealand moved swiftly to the highest alert level 4, described as lockdown, as the epidemic curve quickly accelerated. Auckland City Hospital saw a temporary change in acute surgical admissions. The aim of this study is to evaluate the impact of the national lockdown on emergency general surgery.

METHODS

A retrospective analysis was performed of all patients admitted to Auckland City Hospital via the Acute Surgical Unit during lockdown from 26 March to 27 April 2020. A comparison group was collected from the 33 days prior to lockdown, 22 February to 25 March 2020.

RESULTS

The number of admissions decreased by 26% (P-value 0.000). A 56.8% decrease in patients presenting with trauma was found (P-value 0.002). After exclusion of trauma patients, no statistical difference in discharge diagnosis was found. There was a 43.6% reduction in operations performed (P-value 0.037). There was a difference found in the management of appendicitis and cholecystitis (P-value 0.003). Median length of stay was decreased from 1.8 to 1.3 days (P-value 0.031).

CONCLUSION

Auckland City Hospital had a decrease in admissions and operations during the COVID-19 lockdown. These findings suggest people with serious pathology were staying at home untreated or being treated in the community. This is a snapshot of our experience in managing emergency general surgical patients in this unusual period.

Feasibility of Health Literacy Tools for Older Patients in the Emergency Department

Introduction

This study evaluates the feasibility of using a volunteer research associate (RA) to administer two separate health literacy assessment tools in the emergency department (ED), specifically in an older population of patients. The outcomes measured were administration time and interruptions.

Methods

Using a prospective, cross-sectional study with a convenience sample, adult patients over the age of 55 presenting between June–August 2018 to one urban, academic ED were evaluated by a volunteer RA using either the Newest Vital Sign (NVS) or the Short Assessment of Health Literacy (SAHL). All patients 55 years of age or older who consented to participate were included. We excluded from this study the following: patients with dementia or other disability involving reading, speech, or cognitive function, as noted in their medical record or by their attending physician; prisoners; and those subjectively deemed in extremis or too ill to participate by their attending physician.

Results

Health literacy was assessed in 202 patients using either the NVS or SAHL. Mean time of administration was 214.0 seconds for the NVS, and 206.8 for the SAHL. The maximum time of administration for the NVS was 563 seconds, compared to 607 seconds for the SAHL. We found that 95.2% of NVS and 93.9% of SAHL tests incurred no interruptions during administration.

Conclusion

No significant difference was found between the length of time needed to administer the NVS or SAHL to older patients in the ED. Both tools averaged an administration time of around three to four minutes, and neither incurred regular interruptions to its administration by a volunteer RA. Further study is needed to assess validity of these tools in an ED setting.

A delay recruitment model of the cardiovascular control system

We develop a nonlinear delay-differential equation for the human cardiovascular control system, and use it to explore blood pressure and heart rate variability under short-term baroreflex control. The model incorporates an intrinsically stable heart rate in the absence of nervous control, and allows us to compare the baroreflex influence on heart rate and peripheral resistance. Analytical simplifications of the model allow a general investigation of the rôles played by gain and delay, and the effects of ageing.

Free trade and occupational health policy: an argument for health and safety across the North American workplace

This article considers the argument that the North American Free Trade Agreement (NAFTA) would encourage US and Canadian industry to relocate their hazardous manufacturing operations to Mexico. Proponents of this view believe that this industrial flight south would worsen working conditions in Mexico as well as lower occupational health and safety standards in the US and Canada. In evaluating this argument, the article examines working conditions in US-owned factories in the Mexican maquiladora zone, reviews the current occupational health and safety regulatory structure in Mexico, and considers those institutions established by the European Community to protect workers against the flight of hazardous industries. The article concludes that the harmonization of labor norms throughout North American and the establishment of a functional North American regulatory structure following the precedents set by the European Community are necessary steps to ensure that NAFTA does not produce the feared flight of hazardous industries to Mexico nor degrade the health of workers in Mexico, Canada, or the US.