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Background: Diabetes mellitus (DM) triples a person's risk of active tuberculosis (TB) and is associated with increased mortality. It is unclear whether diabetes status and/or the associated renal dysfunction is associated with poor TB outcomes in New Zealand, which has high diabetes screening. Aim: To characterise the population of TB‐DM and TB‐alone to assess the effect of diabetes status and renal function on hospitalisation and mortality. Methods: Clinical records from all adult patients diagnosed with TB in Auckland over a 6‐year period (2010–2015) were reviewed. Baseline demographics, clinical presentation and microbiological data were assessed to compare the rates of hospitalisation and mortality between those with TB‐DM and TB‐alone. Statistical significance was defined as P < 0.05. Results: A total of 701 patients was identified with TB; 120 (17%) had an unknown diabetes status and were excluded, and 135 had co‐existing diabetes. The TB‐DM and TB‐alone groups had similar distribution of TB site and proportions of Mycobacterium tuberculosis culture positivity. Univariate analysis showed TB‐DM patients had statistically significantly higher proportions of acute hospitalisation and mortality. Multivariate logistic regression showed only a reduced estimated glomerular filtration rate (eGFR) accounted for the higher rates of hospitalisation, with the odds of hospitalisation increasing by 2% for every unit decrease in eGFR. The odds of mortality increased by 6% for every year increase in age, and the odds of mortality increased by 3% for every unit reduction in eGFR. Conclusions: Diabetes is associated with higher TB hospitalisation and mortality; however, this is likely mediated by increased age and chronic kidney disease. [ABSTRACT FROM AUTHOR]

Background: Central venous access device (CVAD) is a common procedure in ICU which, although generally safe, can lead to acute and delayed complications. Training and accreditation process for its insertion vary worldwide. Aims: The objective of this study was to explore variability in existing training and accreditation processes for central venous access device (CVAD) insertion among different intensive care units (ICU), current practices of CVAD insertion among fellows of the College of Intensive Care Medicine (CICM) working in Australia and New Zealand (ANZ) and their recommendations for improvement. Methods: A prospective cross‐sectional web‐based survey was sent through email and CICM e‐newsletter to intensivists and directors of ICU across ANZ. All responses were tabulated, post‐hoc exploratory analysis using multivariable ordinal logistic regression was used and free texts were analysed thematically and summarised. Results: A total of 115 responses was received from various public and private ICU from all states of ANZ; 32% of the participants did not have any accreditation process for CVAD insertion skill in their ICU, whereas 91% of respondents revealed there were no processes to assess deskilling. Most intensivists recommended supervision, simulation, various education tools and ultrasound training to improve training and assessment. Thirty‐five percent of the participants inserted 0–5 CVAD and more than half of the intensivists had inserted <10 CVAD in a 1‐year period. Two‐thirds of the respondents recommended inserting between 6 and 20 CVAD each year to maintain competence. Conclusion: The study identified wide variability in current practice, training methods and accreditation process for CVAD insertion among intensivists and ICU trainees in ANZ. Policy makers should consider revising the current clinical practice and training policies to new policies for accreditation and ongoing assessment for CVAD insertions across ANZ ICU. [ABSTRACT FROM AUTHOR]

Background/Aims We aimed to assess differences in patient management, and outcomes, of Australian and New Zealand patients admitted with a suspected or confirmed acute coronary syndrome ( ACS). Methods We used comprehensive data from the binational Australia and New Zealand ACS ' SNAPSHOT' audit, acquired on individual patients admitted between 00.00 h on 14 May 2012 to 24.00 h on 27 May 2012. Results There were 4387 patient admissions, 3381 (77%) in Australia and 1006 (23%) in New Zealand; Australian patients were slightly younger (67 vs 69 years, P = 0.0044). Of the 2356 patients with confirmed ACS, Australian patients were at a lower cardiovascular risk with a lower median Global Registry Acute Coronary Events score (147 vs 154 P = 0.0008), but as likely to receive an invasive coronary angiogram (58% vs 54%, P = 0.082), or revascularisation with percutaneous coronary intervention (32% vs 31%, P = 0.92) or coronary artery bypass graft surgery (7.0% vs 5.6%, P = 0.32). Of the 1937 non-segment elevation myocardial infarction/unstable angina pectoris ( NSTEMI/ UAP) patients, Australian patients had a shorter time to angiography (46 h vs 67 h, P < 0.0001). However, at discharge, Australian NSTEMI/ UAP survivors were less likely to receive aspirin (84% vs 89%, P = 0.0079, a second anti-platelet agent (57% vs 63%, P = 0.050) or a beta blocker (67% vs 77%, P = 0.0002). In-hospital death rates were not different (2.7% vs 3.2%, P = 0.55) between Australia and New Zealand. Conclusions Overall more similarities were seen, than differences, in the management of suspected or confirmed ACS patients between Australia and New Zealand. However, in several management areas, both countries could improve the service delivery to this high-risk patient group. [ABSTRACT FROM AUTHOR]

Background High on-treatment platelet reactivity has been associated with poor outcomes following acute coronary syndromes ( ACS). Both the loss of function CYP 2 C 19*2 allele and the gain of function CYP 2 C 19*17 allele along with a range of clinical characteristics have been associated with variation in the response to clopidogrel. Aim The study aims to examine the frequency of CYP2 C19 variants and understand the factors associated with on-treatment platelet reactivity in a New Zealand ACS population. Methods We prospectively enrolled 312 ACS patients. We collected clinical characteristics and measured on-treatment platelet reactivity using two validated point-of-care assays, VerifyNow and Multiplate. DNA was extracted and CYP 2 C 19*2 and *17 alleles were identified using real-time polymerase chain reaction. Results CYP 2 C 19*2 or CYP 2 C 19*17 alleles were observed in 101 (32%) and 106 (34%) of patients, respectively, with significant differences in distribution by ethnicity. In Maori and Pacific Island patients, 47% (confidence interval ( CI) 31-63%) had CYP 2 C 19*2 and 11% ( CI 4-19%) CYP 2 C 19*17 compared with 26% ( CI 19-32%) and 41% ( CI 32-49%) in white people. Carriage of CYP 2 C 19*2 alleles was associated with higher levels of platelet reactivity measured by either assay, but we observed no relationship between platelet reactivity and CYP 2 C 19*17. In multivariate analysis diabetes, clopidogrel dose and CYP 2 C 19*2 status were all significant independent predictors of platelet reactivity. Conclusions Both CYP 2 C 19*2 and *17 were common in a New Zealand ACS population, with CYP 2 C 19*2 observed in almost half the Maori and Pacific Island patients. CYP 2 C 19*2, diabetes and clopidogrel dose were independent contributors to on-treatment platelet reactivity. [ABSTRACT FROM AUTHOR]

Background/Aims To determine the effect of introducing a decision rule on the duration of continuous cardiac monitoring ( CCM) for patients with suspected acute coronary syndrome in an adult emergency department ( ED). Methods This was a retrospective observational study of 220 patients with suspected acute coronary syndrome made up of two consecutive cohorts collected before and after introduction in July 2010 of a decision rule that made use of a new high-sensitivity troponin T assay. The primary outcome was median CCM duration in the ED ( CCMED). Secondary outcomes were median duration of CCM in the first 24 h, rate of adverse events, proportion of patients after the intervention who had the rule adhered to, and estimated median CCMED had the decision rule been adhered to by all patients. Results The decision rule was adhered to in 59.3% (95% confidence interval 49.8-68.1) of patients post-intervention. There was no statistically or clinically significant difference in median CCMED before (240 min, interquartile range 156-313) and after (230 min interquartile range 145-353) introduction of the decision rule ( P = 0.74) nor in CCM in the first 24 h (908 min vs 929 min). Seven (3.2%, 95% confidence interval 1.4-6.6) adverse events occurred overall. All three patients with adverse events after the intervention were monitored in ED according to the decision rule. Conclusion Introduction of this decision rule did not decrease the median CCMED. All adverse events after the intervention occurred in appropriately monitored patients, including patients with initially negative high-sensitivity troponin T, suggesting that the decision rule would not compromise patient safety. [ABSTRACT FROM AUTHOR]

Background and Aims Pulmonary arterial hypertension ( PAH) is associated with significant morbidity and mortality. In New Zealand, access to PAH-specific pharmacotherapy has been restricted for economic reasons. Since 2009, access to medication has been provided by a Special Authority scheme that ensures equity of access for all patients. Management of patients with PAH in this environment poses unique challenges. This study describes outcomes of patients managed in the Auckland PAH clinic over a 12-year period. Methods The clinic database was interrogated. Patients were eligible for this study if they had PAH ( World Health Organization ( WHO) Class 1, 1′ and 4) and had been managed in the clinic from the year 2000. Results One hundred and twenty-six patients (75% female, mean age at diagnosis 50) were included. Most had idiopathic PAH (37%) or PAH because of connective tissue disease (29%). At diagnosis, patients had advanced disease (median WHO Class III, 6-min walk distance 367 m and pulmonary vascular resistance of 10.6 Wood Units). Initial therapy was sildenafil in most cases. PAH-specific therapy was associated with improved WHO class and longer 6-min walk distance ( P < 0.01 for both). Thirty per cent of patients were escalated to combination therapy. Survival was 91% at 1 year and 67% at 5 years. Conclusions Despite historic difficulties with access to PAH-specific therapy, these data confirm benefits of therapy (primarily sildenafil as first-line treatment) for patients with PAH managed within the Auckland PAH clinic. Survival data are comparable with other reported cohorts. [ABSTRACT FROM AUTHOR]

Background: In 2010, Waitemata District Health Board piloted a new model of care for total hip and knee arthroplasties. The pilot was incentive based and clinically led. The participating surgeons and anaesthetists were responsible for increasing surgical throughput. The pilot aimed to increase productivity, reduce cost and increase quality for patients. Aim: To compare costs and outcomes for elective hip and knee arthroplasties carried out at the pilot site (Waitakere Hospital) compared with the main District Health Board hospital site (North Shore Hospital (NSH)). Methods: A retrospective matched cohort study of hip and knee replacements discharged between 1 July 2010 and 31 March 2011, comparing costs and outcomes at the pilot site compared with the NSH site. Only non-complex procedures were included, and routinely collected data were used. Results: One hundred and seventy-seven hip replacements (77 NSH, 100 pilot) and 158 knee replacements (88 NSH, 70 pilot) were analysed. Total inpatient event costs were 12% and 17% lower for hip and knee replacements, respectively, at the pilot site compared with NSH. Significant reduction in operation length (39% hip, 36% knee) and length of stay (38% hip, 39% knee) were found in the pilot groups compared with NSH. Conclusion: Implementation of an innovative new model in a public hospital setting has produced significant increases in productivity and reduced overall costs. This model could potentially be used in other public healthcare settings for non-complex elective surgery. [ABSTRACT FROM AUTHOR]

Background: Understanding factors that contribute to low continuous positive airway pressure (CPAP) compliance will lead to improvements in the long-term outcome of patients with obstructive sleep apnoea (OSA) syndrome. Both cultural and socioeconomic factors are likely to be important but have not been systematically studied. Aim: To examine the effect of ethnicity and socioeconomic status on initial CPAP usage for people with OSA in New Zealand. Methods: We retrospectively collected demographic, clinical and CPAP treatment-related data on patients undergoing a 1-month CPAP trial for a 10-month period. We compared objectively measured CPAP usage (by anova) with self-identified ethnicity; levels of socioeconomic deprivation (NZDep06 index), Epworth Sleepiness Scale (ESS) and Apnoea-Hypopnoea Index (AHI). Results: A total of 214 patients with a mean age of 52.7 (±11.8) years, mean AHI 57.3 (±35.8) events per hour and mean ESS 13 (±5.58)/24 made up the cohort. CPAP usage which averaged 5.13 ± 2.34 h per night was significantly lower in patients of non-European ethnicity ( P = 0.019 univariate) and remained significant after socioeconomic status was added to the model ( P = 0.048). Patients living in the most socioeconomically deprived areas showed significantly lower compliance with CPAP on univariate analysis ( P = 0.024, NZDep06 scores 1&2, average 5.3 per night compared to score NZDep06 scores 9&10, average 4.3 h per night), but this effect was no longer significant once ethnicity was added to the model ( P = 0.28). Conclusion: CPAP usage in New Zealand is affected by both ethnicity and level of socioeconomic deprivation. We recommend further research to unravel specific cultural and socioeconomic reasons for the variance reported. [ABSTRACT FROM AUTHOR]

Background: High concentration oxygen is commonly administered during acute exacerbations of chronic obstructive pulmonary disease (AECOPD). The aim of this study was to determine the association between oxygen, severity markers and poor outcomes in AECOPD. Methods: In an audit of patients with AECOPD arriving by ambulance to the Emergency Department of Wellington Hospital, details of oxygen administration, clinical outcomes and severity markers were documented. The main outcome measure was a composite of death, assisted ventilation, or respiratory failure. Associations between oxygen therapy, severity markers and poor clinical outcomes were assessed by logistic regression. Results: Of 250 patients 77 (31%) died, required assisted ventilation or were in respiratory failure. Increased oxygen flow was associated with increasing risk of death, assisted ventilation or respiratory failure with an odds ratio (OR) of 1.2 (95% CI 1.0-1.4) per 1 L/min oxygen flow. Increasing PaO2 was associated with a greater risk of a poor outcome with an OR of 1.1 (95% CI 1.0-1.3) per 10 mmHg higher PaO2. Home oxygen (OR 2.8, 95% CI 1.5-5.1), previous respiratory failure (OR 2.6, 95% CI 1.5-4.6), previous ventilation (OR 3.2, 95% CI 1.7-5.9) and home nebulizer use (OR 2.4, 95% CI 1.4-4.3) were associated with an increased risk of a poor outcome. Conclusion: In AECOPD high flow oxygen in the ambulance is associated with poor clinical outcomes. A number of easily identified markers of chronic disease severity indicate an increased risk of a poor clinical outcome. [ABSTRACT FROM AUTHOR]

The aim of this study is to determine whether the analysis of CD38 expression by chronic lymphocytic leukaemia (CLL) cells provides useful additional prognostic information. Clinical, laboratory, overall survival (OS) and treatment-free survival (TFS) data were collected on 130 CLL patients who had CD38 expression analysed at Canterbury Health Laboratories, New Zealand (NZ) during 1998-2008. The detection of any level of CD38 expression by CLL cells was associated with a significantly shorter OS and TFS. When analysis was restricted to Binet stage A patients, CD38 expression identified a subset of patients (21%) who, in common with Binet stage B/C patients, had a significantly shorter OS and TFS ( P < 0.0015), and a TFS at 4 years of <10%. In contrast, CD38-negative Binet stage A patients had an OS that was not significantly different from that of an age/sex-matched NZ population and a 5-year TFS of 77%. This study indicates that, when combined with clinical staging, the presence of any detectable CD38 expression can be used to further improve the identification of CLL patients with more aggressive disease (i.e. Binet stage B/C or Binet stage A and CD38 positive). This will allow better identification of those patients requiring more intensive monitoring and also allow improved patient counselling regarding prognosis. [ABSTRACT FROM AUTHOR]

Background In Australia, correspondence is routinely sent to general practitioners following a specialist consultation. Written communication is an important way to enhance patient experiences and understanding, yet most patients do not receive copies of their medical correspondence. Aims To determine whether providing clinic correspondence and endoscopy reports to patients leads to improved understanding, satisfaction or anxiety. Methods This is a prospective, randomised controlled study conducted at an Australian tertiary hospital from October 2013 to February 2015. New adult referrals to the general gastroenterology clinic requiring an urgent endoscopic procedure were eligible for the study. The intervention group received a copy of their clinic correspondence and endoscopy report, while the control group received neither. Participants completed questionnaires, including visual analogue scales and the Hospital Anxiety and Depression Scale, at three time points. Primary outcomes were patient understanding, anxiety and satisfaction. Results A total of 70 participants was included in the study. There was no reduction in anxiety levels ( P = 0.52), no increase in understanding ( P = 0.73) or any increase in satisfaction ( P = 0.33) in participants receiving correspondence. However, 97% of participants indicated that they wished to receive correspondence in the future, and 94% of participants in the correspondence group reported that receiving correspondence had helped them to understand their medical condition. Conclusion Patients wish to receive copies of their correspondence and feel it improves their understanding of their medical condition. Although we were unable to demonstrate a measurable reduction in anxiety, increase in understanding or satisfaction, we recommend that patients be offered the choice of receiving copies of their clinic correspondence and endoscopy reports. [ABSTRACT FROM AUTHOR]

Background Neoadjuvant systemic therapy ( NAST) has become an established treatment option for women with operable breast cancer. Aim We aimed to better understand NAST treatment patterns, barriers and facilitators in Australia and New Zealand. Methods We undertook a cross-sectional survey of the current clinical practice of Australian and New Zealand breast cancer specialists. Questions included referral patterns for NAST, patient selection, logistics, decision making and barriers. Results Of 207 respondents, 162 (78%) reported routinely offering NAST to selected patients with operable breast cancer (median 9% of patients offered NAST). Specialty, location, practice type, gender or years of experience did not predict for offering NAST. In all, 45 and 58% wanted to increase the number of patients who receive NAST in routine care and in clinical trials respectively. Facilitators included the multidisciplinary team meeting and access to NAST clinical trials. Specialist-reported patient barriers included: patient desire for immediate surgery (63% rated as important/very important); lack of awareness of NAST (50%); concern about progression (43%) and disinterest in downstaging (32%). Forty-three per cent of participants experienced system-related barriers to the use of NAST, including other clinicians' lack of interest (27%); lack of clinical trials (24%) and unacceptable wait for a medical oncology appointment (37%). Conclusion This group of Australian and New Zealand clinicians are interested in NAST for operable breast cancer in routine care and clinical trials. Patient- and system-related barriers that prevent the optimal uptake of this treatment approach will need to be systematically addressed if NAST is to become a more common approach. [ABSTRACT FROM AUTHOR]

To compare anticoagulant control using self-testing and decision support provided via the internet with standard laboratory testing. A prospective comparative study of 41 patients on long-term warfarin. All patients were monitored using a laboratory-based service for at least 12 months prior to changing to self-testing using a portable testing device and online decision support. The level of anticoagulant control was assessed using the time the international normalized ratio (INR) was within the therapeutic range (TTR), the proportion of INR results in range and the interval between tests. This was a non-inferiority study. There was no statistically significant difference between the two methods of anticoagulant control with a trend in favour of self-testing; the mean TTR was 72% vs 81%. However, a small cohort of patients with poor control (TTR 38%) during laboratory testing achieved a significant improvement (TTR 71%) using self-testing. The INR was above the therapeutic range for a similar time in both groups but below the range for a significantly shorter period during self-testing suggesting a lower risk of complication in this group. Self-testing with online computer decision support achieved anticoagulant control at least as good as laboratory management. Additional benefits of a home-based service make this an attractive option for selected patients. [ABSTRACT FROM AUTHOR]