Proceedings of the Waikato Clinical Campus Research Seminar, Wednesday 14 October 2020

proceedings

Retrospective review of at the Neurosurgery Unit of statistical analyses and visual- meningioma treated at Waikato Hospital during the ization. Descriptive analysis of period 2007–2019. the patient cohort was carried Waikato Hospital during out using the demographic and the period 2007–2019 Aims 1. To evaluate patient tumour characteristics data. David Wang,1 Fouzia Ziad,2 characteristics in those Chi-square test for categorical Ziad Thotathil,3 Michael Jameson4,5 who had meningiomas variables (with continuity correction) and one-way test 1Dept of Pathology, University of resected at Waikato for continuous variables (with Otago, Dunedin, 2Dept of Pathology, Hospital from 2007 to Waikato Hospital, Hamilton, 3Dept 2019. equal variance assumption) of Radiation Oncology, Waikato were used to evaluate for statis- Hospital, Hamilton, 4Dept of 2. To characterise tical significance. Population Medical Oncology, Waikato Hospital, frequency of menin- data was obtained for these Hamilton, 5Waikato Clinical Campus, gioma histologic subtypes district health boards from the University of Auckland, Hamilton and grades. census for the Midland region Background between 2007 and 2019. Meningiomas are the most 3. To determine the overall Results common primary intracranial and age-standardised A total of 393 patients with and spinal tumours. Although incidence of meningioma histologically confirmed menin- 80% of meningiomas show in the Midland region giomas were identified. The benign clinical behaviour and from 2010 to 2019. incidence of meningioma in can be cured by resection alone, 4. To evaluate disparities in the Midland region has shown about 20% recur after resection incidence between Māori a rising trend over the study and need additional treatment. and other ethnicities. period. The crude incidence Histopathological assessment each year ranged from 2.69 per aims to identify patients at risk 5. To evaluate changes in 100,000 in 2008 to the highest of recurrence. There is a lack of annual age-standardised of 5.14 per 100,000 in 2018. information on the incidence of incidence of meningioma The age adjusted annualized meningiomas in New Zealand. from 2007 to 2019. incidence based on the WHO Being a benign tumour, the Methods standard population for each National Cancer Registry does A retrospective search was ethnicity group showed Māori not collect data except for the carried out with the Waikato had the highest age adjusted uncommon malignant variants. Hospital enterprise software annualised incidence at 6.90 Through this retrospective study using the keyword ‘menin- per 100,000 followed by Pacific of consecutive cases treated at gioma’ in the pathology reports Island ethnic group at 6.16 per Waikato Hospital, we hoped to during the period between 1 100,000. This rate is 2.8 times gain a better understanding of June 2007 and 1 June 2019. higher than the New Zealand the epidemiological and clinical Data on age, gender, ethnicity, European ethnicity category features that characterise number and location of lesions, and 3.75 times higher than meningiomas in New Zealand. grade of lesion (reclassified as Asian population. Female We also aimed to study ethnic per WHO grading criteria 2016), patients were the majority variations to see if there is a extent of surgery, adjuvant accounting for 73.4% of all greater incidence of menin- therapy and current status or patients. Furthermore, there gioma in Māori/Pacific Island status at last follow-up was was a statistically significant population as suggested by retrieved from the electronic difference in the proportion previous studies from Auckland. records. The R language and of females between Māori and Study design Environment for Statistical non-Māori (80.1% and 69.8% A retrospective review of Computing (release 3.5.1) was respectively, p=0.036). The mean meningioma cases operated used for data preparation, age at surgery for all patients

NZMJ 15 January 2021, Vol 134 No 1528 ISSN 1175-8716 © NZMA 118 www.nzma.org.nz/journal proceedings

was 57.9 with a standard devi- University of Auckland, Auckland, The adjusted hazard ratio of ation of 13.4. There was also a 3 Waikato District Health Board, having metastatic recurrence 4 significant difference between Hamilton, School of Medicine, The for post-menopausal women the mean ages of surgery in University of Auckland, Auckland compared to pre-menopausal Māori (54.2) vs non-Māori Aims women was 1.39 (95% CI: 1.06- (59.8). Transitional menin- This study aims to examine 1.82, p-value=0.019) for ER+ and/ giomas were the most common the association of menopausal or PR+ cases. Age did not affect subtype. Out of all the spec- status and risk of metastatic the risk of metastatic relapse for imens, 79.5% were WHO grade relapse for women diagnosed ER+ and/or PR+ cases but affect I, 19.1% were WHO grade II and with stage I–III breast cancer at the risk for ER- and PR- cases 1.4% was WHO grade III. There the age of 45–55 years in New with an adjusted hazard ratio of was a significant difference Zealand. 0.94 per year (95% CI: 0.89–1.00, between the WHO grades by Methods p-value=0.045). sex (p=0.004 for trend), 29.5% We included women diag- Conclusions of meningioma cases in males nosed with stage I–III breast Menopausal status has an were WHO grade II compared cancer at the age of 45–55 years impact on the risk of metastatic to 15.2% in females. However, with recorded menopausal recurrence for women diag- there was no significant status at time of diagnosis in nosed with ER+ and/or PR+ stage difference between WHO grades the Auckland and Waikato I–III breast cancer at the age of and overall survival with regard Breast Cancer Register. Cumu- 45–55 years, but no impact on to ethnicity. lative incidence of distant those with ER- and PR- disease. Conclusion metastatic recurrence was On the other hand, age is an The data derived from this examined with the Kaplan– important influence factor study provides an overview of Meier method by age group on risk of metastatic relapse incidence and demographics (45–49 years and 50–55 years) for women with ER- and PR- of meningioma in the Midland and by menopausal status disease, but not for ER+ and/PR+ region. It should be noted that (pre-menopausal, peri-meno- cancers. the study cohort comprised pausal and post-menopausal) of only the histologically after stratifying the data by hormone receptor status: (1) Where has all the flour confirmed meningiomas and gone? An analysis of does not include the patients estrogen receptor positive (ER+) who had imaging findings and/or progesterone receptor consumer purchasing consistent with meningioma positive (PR+) and (2) ER- and of flour products during who did not have surgery. PR-. Cox proportional hazards the COVID-19 pandemic The study shows comparable model was used to estimate 1 2 trends with data derived the adjusted hazard ratio of Leandrie Young, Judith McCool, 2 from studies from Auckland developing recurrent metastatic Alistair Woodward other parts of the world. This breast cancer by menopausal 1Medical student, University of study also confirmed a large status after adjustment for age, Auckland, Auckland, 2School of difference between the annu- ethnicity, year of diagnosis, Population Health, University alised age-adjusted incidence socioeconomic status, public/ of Auckland, Auckland between Māori and non-Māori private hospital treatment, Aim population. The obvious health mode of detection, cancer stage In December 2019, a new inequality between Māori and cancer grade. coronavirus (SARS-CoV-2) was reported in Wuhan, China. and non-Māori in this regard Results On 25 March 2020, a state of needs to be explored further We have identified 5,309 emergency was declared in to determine the likely causal women diagnosed with stage New Zealand and the country factor—whether sociocultural I–III breast cancer at the age of would be in lockdown for a and/or biological. The results 45–55 years: 2,799 pre-meno- minimum of four weeks. Media also create the foundation pausal, 929 peri-menopausal reported shelves being emptied for further studies exploring and 1,581 post-menopausal. of various products, including genetic and epigenetic charac- The Kaplan–Meier curves flour. Our aim was to study the teristics of meningioma in New showed significant difference demand in New Zealand and to Zealand. in risk of metastatic recurrence consider possible reasons for between different meno- observed changes. Association of pausal status for ER+ and/ menopausal status or PR+ cases (p-value=0.047), Method with a 10-year cumulative A comprehensive literature and risk of metastatic incidence of metastatic recur- search was undertaken as relapse of breast cancer rence of 11.2% (95% confidence a student research elective interval (CI): 9.6%–12.9%) during lockdown. Sales data Chunhuan Lao,1 Mark Elwood,2 for pre-menopausal women, were obtained from New Marion Kuper-Hommel,3 12.4% (95% CI: 9.4%–15.3%) for Zealand’s largest grocery Ian Campbell,3,4 Ross Lawrenson1,3 peri-menopausal women and distributor, Foodstuffs, 1 Medical Research Centre, The 15.6% (95% CI: 13.0%–18.1%) including flour, in store baking University of Waikato, Hamilton, for post-menopausal women. and proprietary bread sales 2 School of Population Health, The

NZMJ 15 January 2021, Vol 134 No 1528 ISSN 1175-8716 © NZMA 119 www.nzma.org.nz/journal proceedings

leading up to and during the abdomen from a bitumen truck Methods COVID-19 lockdown (and for backfire that poured bitumen Patients with a large AAA same period in 2019). over him. (5cm for females, 5.5cm for males) or those that had an Results In the absence of peanut oil, open aneurysm repair (OAR) or An increase of approximately butter was initially used but endovascular aneurysm repair 136% in sales of flour occurred application was difficult due to (EVAR) were included in the during the week preceding the solid nature of the agent, analysis. Three international lockdown. Bread sales peaked and, subsequently, when the datasets were used for external at the same time. In-store butter liquefies, the bedside and validation: New Zealand (two baking sales peaked on the patient’s clothing were covered centres: OAR, EVAR and high-risk 22 March followed by a rapid with the agent. non-operated patients), Nether- decline. An alternative, using peanut lands (one centre: EVAR patients Conclusion butter, was recommended by only) and Singapore (one Consistent with interna- our senior author, and the semi- centre: OAR and EVAR patients). tional evidence, people in New liquid nature of this agent made Discrimination using receiver Zealand engaged in a form application much easier, with operating curves (ROC) and of panic buying during the removal using a wooden spatula c-statistics>0.7 was considered lockdown pandemic. Panic simple, painless and neater sufficiently accurate. Patients buying is likely fuelled by stress than butter without peripheral survival was confirmed from and previous research suggests waste. national mortality databases and it is driven by self-preser- all patients have completed at vation. Public and social media We have received much least five years’ follow-up. function as an amplifier of this positive feedbacks from emer- Results stress and, as a result, a similar gency nurses, burn clinical There were 1,004 patients in trend in consumer purchasing nurse specialist and the patient. the New Zealand cohort, and the has occurred globally. A We would like to share this ROC for the model in predicting different degree of response positive experience for dissem- 30 days and two, four and five has been observed in different ination of a safe and effective year survival was 0.76, 0.67, supermarket chains, suggesting way to manage bitumen burn in 0.74 and 0.76, respectively. that changes in consumer the medical community. The corresponding ROC for the purchasing are greater in Singaporean database (n=301 certain populations. The data An international patients) was 0.88, 0.80, 0.80 and also indicate a global interest validation of 0.82. There were 381 patients in baking. However, whether from Netherlands, and ROC for the flour was used remains an abdominal 30 days and one, two and five unclear. aortic aneurysm years was 0.73, 0.67,0.70 and survival model 0.66, respectively. An unusual use of 1,2 3 Khashram M, Williman JA, Conclusions 4 5 6 peanut butter to treat Khashram Z, Vincent ZL, Kian CJ, The AAA DES model appears 6 7 5 bitumen burns Xuan ZTZ, Oliveira-Pinto J, Hill AA, to predict 30-day survival well Verhagen HJ7 Dr Sarah Cox,1 Mr Eric Tan2 in all datasets and accurate 1Department of Surgery, Univer- medium-term survival in the 1 Registrar, Plastics Department, 2 sity of Auckland, Department of New Zealand and Singaporean Waikato Hospital, Hamilton, 2Plastic Vascular Surgery, Waikato Hospital, cohorts. Despite differences in and Reconstructive Surgery Depart- 3 Hamilton, Biostatistics and Compu- study population, the model ment, Waikato Hospital, Hamilton tational Biology Unit, University predicted early survival well Bitumen burn is a unique of Otago, Christchurch, 4Phoenix in the Dutch population, but chemical burn, usually Creative Solutions, Inc., Toronto, 5 medium-term survival was not sustained as a result of work- Canada , Department of Vascular accurate. This might be due to place related occupational Surgery, Auckland City Hospital, Auckland, 6Department of Vascular patient selection and type of hazard. Surgery, Singapore General Hospital, AAA repair. This model requires 7 The traditional mainstay of Singapore, Department of Vascular further external validation to removal in Australasia is with Surgery, Erasmus University Medical test the broader clinical utility. Center, Rotterdam, The Netherlands peanut oil, but with heightened Background Assessing validity of questions awareness of peanut allergy in the Harti Hauora Tamariki at workplace, it is no longer Management of patients Tool, a holistic, whanau-centred available in our district health with large abdominal aortic (family-centred) health screening tool, used in the Harti-Hauora board. aneurysms can be challenging despite international guidelines randomised controlled trial We present our experience that recommend treatment at Abigail Weaver,1 Dr Amy Jones,2 of managing an acute bitumen certain diameter thresholds. Dr Nina Scott,2 Dr Polly-Atatoa Carr,2 burn in a 70-year-old man The aim of this study was to Dr Bridgette Masters-Awatere2 with short bowel syndrome externally validate a previously 1Medical student, University of who sustained this injury over validated a discrete simulation Auckland, Auckland, 2Te Puna his mouth, face, chest and AAA predictive model. Oranga (Maori Health Unit), Waikato District Health Board, Hamilton

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Aims Giant cell BCC: an or daughters and was divorced This study assessed the unusual case report from his wife two years prior. validity of questions in a He only has his more elderly screening tool called Harti highlighting the sister to check in with, but, Hauora Tamariki tool. These perils of neglecting unfortunately, she had her own questions aim to identify modi- low-risk skin cancer health issues to contend with fiable determinants of health and could not give him more Luxi Sun,1 Eric xTan1 and provide enhanced access careful attention. Remarkably, 1 to care. Plastic and Reconstructive he has a fully clinically treatable Surgery Department, Waikato cancer, for which earlier identi- Methods Hospital, Hamilton Four hundred and eighty-six fication and encouragement to Background engage with healthcare services participants were collated by Basal cell carcinomas would have significantly ethnicity (Māori and non-Māori). (BCCs) are the most common reduced his risk of morbidity. The analysis uses comparative type of non-melanomatous Although surgical planning is of population data to identify esti- skin cancers, typically with a great relief to the patient, upon mated positive predictive values slow and indolent course of follow-up, he was far more and compares these values to the progression. The incidence of grateful for his placement in a Harti data to estimate validity. BCC was estimated as 299 per rest home ultimately. As clini- Yield,which is the proportion of 100,000. Giant BCCs account for cians we are often more focused Harti participants who identified less than 1% of BCC with 50% on the medical or surgical need, was also measured. risk of regional spread and 30% process of relieving a patient distant metastasis risk when Results of their disease burden, but we they are more than 15cm. Out of the 12 questions cannot lose sight of the huge analysed, 8 were identified Our patient is a 74-year-old impact that emotional wellbeing as valid, 3 as non-valid and Caucasian gentleman who can play to a patient’s quality 1 question was classified as presented with two fungating of life. having uncertain validity. The lesions over his left back three low validity questions (15cm in diameter) and left were regarding alcohol, drug The unmet need of posterior elbow (6cm) that have use and GP enrolment. High-va- diabetic foot disease steadily grown over the last lidity and high-yield questions two years. On initial referral, in New Zealand were smoking, immunisations he also complained of getting 1,2 and oral-health categories. The Dr Odette Hart, weight loss, night sweats and 3 3 three question topics considered Ms Tass Borman, Ms Claire O’Shea, poor appetite with anaemia on 4 valid due to high yield were A/Prof Michael Jameson, investigation. He lives alone 1,2 enrolment to Well Child Mr Manar Khashram without support. A giant BCC 1 providers, participation in B4 Department of Vascular Surgery, was confirmed, and the patient School Checks and disclosure of Waikato District Health Board, underwent wide local resection 2 domestic abuse. Hamilton, Department of Surgery, of a tumour resulting in a skin University of Auckland, Auckland, Discussion deficit of almost 30cm—some- 3Department of Diabetology, Validating this tool identified thing that could have been Waikato District Health Board, 4 questions applicable across a avoided if the BCC could have Hamilton, Waikato Clinical Campus, range of settings. Importantly, been primarily excised when it University of Auckland, Hamilton this study identified a simple was much smaller in dimension. Introduction method for assessing the It is estimated that 25% of Conclusion validity of screening questions. patients with diabetes will Giant BCCs are rare subtypes This method can be included develop diabetic foot ulcers of BCC that are commonly in quality improvement and during their lifetime, with a reported with significant ensure that screening ques- high rate of recurrence (>50% local, regional and distant tions are able to identify unmet after three years). The sequel of implications. Patients and the needs, while at the same time major limb amputation due to public should be made aware avoiding asking questions that diabetic foot disease is common, that, although the majority are of little value and add time and has a major psychological, of BCCs are relatively slow to to the screening process. functional and financial impact. grow and do not metastasise, Conclusion if left untreated, these BCCs Methods The majority of questions can become giant BCCs with This prospective observa- were valid. They were effective different prognostic profiles and tional study collected patient, in identifying needs allowing treatment management. wound and outcome data from for referrals. Some questions March to September 2020 will be reconsidered and altered Upon discussion with the (excluding stage 4 COVID-19-re- for future versions of the tool. patient, he stated that the main lated lockdown) on all diabetic The two questions requiring reason he did not attend for patients reviewed at the diabetic alteration are alcohol and drug review to his GP was a lack foot ward round at Waikato concern. These questions will be of social support and embar- Hospital, New Zealand, with at altered to ask quantity of use. rassment. He does not have sons least one month follow-up. This

weekly multidisciplinary ward days, and 30% resided outside Conclusion round comprises a vascular the Waikato District Health This prospective pilot study surgeon and team, an endocri- Board region. One third of highlights the ethnic inequity nologist and team, a podiatrists patients were re-admitted with and management challenges specialised in diabetic foot an index limb issue. There were of diabetic foot disease within disease, a diabetes nurse, a 19 patients on dialysis; of those, the Waikato region. Further orthoptist and a vascular charge 18 patients identified as Māori. research is required define nurse. these issues and facilitate Twenty-one patients improvements in reducing Results underwent a major limb ampu- major limb amputation and There were 71 patients and tation, with a higher proportion mortality associated with 121 limbs treated over 104 of Māori (13/21) than non-Māori diabetic foot disease. presentations. The average age (8/21) patients. Ten (14%) was 64.5 years, 53 (75%) were patients died during the study male and 36 (51%) patients period, with 60% of deaths identified as Māori. The average occurring within 30 days of length of stay under the admission. vascular surgery team was 12.9

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