Te ara tika o te hauora hapori

Published by the Pasifika Medical Association Group Vol 136 | No 1575 | 2023 May 12

Time for New

Zealand to ban
direct-to-consumer
advertising of
prescription
medicines

Inclusive medical education for students with

disabilities: a new guidance document from
Medical Deans Australia and New Zealand

The impact of AI and ChatGPT on research

reporting

Opportunities for preventing subsequent injuries:

a qualitative study exploring perspectives of people
who have experienced injuries
 Publication information
published by the Pasifika Medical Association Group

The New Zealand Medical Journal (NZMJ) is the principal scientific journal for the
medical profession in New Zealand. The Journal has become a fundamental resource
for providing research and written pieces from the health and medical industry.
The NZMJ's first edition was published in 1887, marking the beginning of a rich
136-year history. It was a key asset of the New Zealand Medical Association (NZMA)
up until July 2022.
It is owned by the Pasifika Medical Association Group (PMAG).
The PMAG was formed in 1996 by a group of Pasifika health professionals who identified
a need for an association with the purpose of “providing opportunities to enable
Pasifika peoples to reach their aspirations”.

ISSN (digital): 1175-8716

Editorial Board

Editor in Chief

Professor Frank Frizelle: Colorectal Surgeon |University of Otago, Christchurch

Sub Editors

Assoiciate Professor David McBride: Preventative and Social Medicine | University of Otago, Dunedin
Dr Kiki Maoate: Paediatric Surgeon, Urologist | Associate Dean Pacific, University of Otago, Christchurch
Professor Roger Mulder: Psychiatrist | University of Otago, Christchurch
Professor Mark Weatherall: Geriatrician | University of Otago, Wellington
Associate Professor Cameron Lacey: Psychiatrist | Head of Department of the Māori
Indigenous Research Innovation, University of Otago, Christchurch
Professor Suzanne Pitama: Psychologist | Dean and Head of Campus, University of Otago, Christchurch
Associate Professor Janak de Zoysa: Nephrologist | Assistant Dean Faculty of Medical and Health
Sciences, Faculty of Medical and Health Sciences Administration, The University of Auckland, Auckland

NZMJ Production Editors

NZMJ Production Editor
Stephanie Batt
Brooke Soulsby
Madeline McGovern

NZMJ Production Assistant

Stephanie Batt
 Publication information
published by the Pasifika Medical Association Group

Further information Other enquiries to

ISSN (digital): 1175-8716 PMA Group

Publication frequency: bimonthy 69 The Terrace
Pubication medium: digital only Wellington 6140
New Zealand
To contribute to the NZMJ, first read:
journal.nzma.org.nz/journal/contribute
© PMA 2022

To subscribe to the NZMJ, email:

[email protected]

Subscribers to the New Zealand Medical Journal previously through the NZMA should now get
in contact to subscribe via the above email if they wish to access the Journal for 2023.
Private subscription is available to institutions, to people who are not medical practitioners,
and to medical practitioners who live outside New Zealand. Subscription rates are below.
All access to the NZMJ is by login and password, but IP access is available to some subscribers.
Read our conditions of access for subscribers for further information
journal.nzma.org.nz/legal/nzmj-conditions-of-access
If you are a member or a subscriber and have not yet received your login and
password, or wish to receive email alerts, please email: [email protected]

Subscription rates for 2022

New Zealand subscription rates Overseas subscription rates
Individuals* $360 Individual $503
Institutions $680 Institutions $700
Individual article $45 Individual article $45

*NZ individual subscribers must not be doctors (access is via NZMA Membership)
New Zealand rates include GST. No GST is included in international rates.
Individual articles are available for purchase by emailing [email protected].
 Contents
Editorial

7 Time for New Zealand to ban direct-to-consumer

advertising of prescription medicines
David B Menkes, Barbara Mintzes, Joel Lexchin

Articles

10 Opportunities for preventing subsequent injuries: a qualitative study

exploring perspectives of people who have experienced injuries
Helen Harcombe, Amy E Richardson, Emma H Wyeth, Sarah Derrett

22 Acute otolaryngological presentations in Northland, New

Zealand: analysed with respect to geography and rurality
Chelsea L Heaven, Matthew James McGuinness, Subhaschandra Shetty

33 Invasive group A streptococcal disease in Hawke’s Bay, New

Zealand: epidemiology, manifestations and impact
Johanna M Birrell, Bridget Wilson, Susan Taylor, Julie Bennett

42 Evolution of sentinel lymph node biopsy for breast cancer

patients in a rural setting: 10 years’ experience
Anthony W K Lau, Vanessa L Lau, Magdalena M Sakowska

50 Psychosocial care in DHB-based stroke services in

Aotearoa: a survey of current practice
Felicity A S Bright, John Davison, Ginny Abernethy

60 The impact of AI and ChatGPT on research reporting

Zubair M Mojadeddi, Jacob Rosenberg

Viewpoint

65 Inclusive medical education for students with disabilities: a new

guidance document from Medical Deans Australia and New Zealand
Dabrina Issakhany, Peter Crampton, members of the Medical
Deans Inherent Requirements Review Working Group

Clinical correspondence

72 Vernix caseosa peritonitis: a novel case with colonic perforation

Alexander Hart, Andrew MacLachlan, Louise Bright, Matthew James
McGuinness, Ming Yu, Lena Clinckett, Paul Manuel, Mavis Orizu

100 years ago in the NZMJ

76 Anaesthetic Mortality in New Zealand

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
 Summaries
Opportunities for preventing subsequent injuries: a qualitative study
exploring perspectives of people who have experienced injuries
Helen Harcombe, Amy E Richardson, Emma H Wyeth, Sarah Derrett

Injuries occur frequently and are costly to individuals and society. Preventing subsequent injuries from
occurring is one way of reducing the overall burden of injury. This qualitative study interviewed people
who had themselves experienced multiple injury events about potential opportunities for subsequent
injury prevention from their perspectives. Potential opportunities were wide-ranging including aspects
relating to individuals, healthcare providers and the health system as well as broader environmental
and societal aspects.

Acute otolaryngological presentations in Northland, New Zealand:

analysed with respect to geography and rurality
Chelsea L Heaven, Matthew James McGuinness, Subhaschandra Shetty

Ear, nose and throat problems are seen commonly in the emergency department by emergency doctors
and rural medicine specialists in Northland, New Zealand. Our paper reports on the numbers and types
of problems seen and treated in rural and urban patients in the region. It supports the continuing need
to target resources to centres treating rural patients with ear, nose and throat conditions.

Invasive group A streptococcal disease in Hawke’s Bay, New

Zealand: epidemiology, manifestations and impact
Johanna M Birrell, Bridget Wilson, Susan Taylor, Julie Bennett

Group A streptococcus is a bacterium that can enter the bloodstream and cause serious illness, referred
to as “invasive group A streptococcal (iGAS) disease”. This study found that, in Hawke’s Bay, iGAS disease
is more common in people of Pacific, Māori and Asian ethnicities, and those living in disadvantaged
areas. Children under 5 years, adults over 65 years, and people with diabetes and/or chronic kidney
disease are most at risk. Skin infections were the main source of iGAS disease, and further preventative
action on skin health is recommended.

Evolution of sentinel lymph node biopsy for breast cancer

patients in a rural setting: 10 years’ experience
Anthony W K Lau, Vanessa L Lau, Magdalena M Sakowska

The lymphatic track is one of the most common pathways through which breast cancer can spread.
Sentinel node biopsies are undertaken to excise the sentinel node, which indicates the first site the
cancer may have spread to if it has expanded from its primary location. Two methods for detecting
sentinel nodes were compared here, and a magnetic tracker in addition to blue dye was found to be
more effective than blue dye alone. This study shows that the magnetic tracer introduced in 2017 has
significantly enhanced early breast cancer care in a rural setting.

Psychosocial care in DHB-based stroke services in Aotearoa: a survey of current practice

Felicity A S Bright, John Davison, Ginny Abernethy

Wellbeing is often affected by stroke and should be supported by stroke services. We conducted a survey

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
 of stroke services throughout New Zealand to explore how they identified issues and how they support
people with stroke. We found that there is real inconsistency within cities and across regions in New
Zealand. There are limited supports available to people who are struggling after stroke. We are now
developing resources to help improve services for people with stroke.

The impact of AI and ChatGPT on research reporting

Zubair M Mojadeddi, Jacob Rosenberg

ChatGPT is an AI tool that can help researchers with various aspects of writing scientific articles, such as
finding relevant literature, organising ideas and even writing different sections of an article. The quality
of its output has not been formally compared to human work and it has some limitations, including
occasional incorrect answers. Though it’s not yet on par with professional medical writers, AI tools like
ChatGPT could potentially change the way research is reported in the future.

Inclusive medical education for students with disabilities: a new guidance

document from Medical Deans Australia and New Zealand
Dabrina Issakhany, Peter Crampton, members of the Medical Deans
Inherent Requirements Review Working Group

Medical Deans Australia and New Zealand (MDANZ) is the peak body representing all medical schools
in Australia and New Zealand. MDANZ reviewed its 2017 guidelines related to selecting and supporting
medical students with disabilities, and developed new recommendations. MDANZ recommends that
medical schools adopt an inclusive, strengths-based approach to recruiting and supporting medical
students with disabilities. A strengths-based and inclusive culture within medical schools is essential.
Medical schools should adopt an individualised, context-specific and inclusive approach based on early,
open dialogue with students with disabilities. As social norms and technologies evolve, regular re-
examination of guidance on how to support potential or current medical students with a disability will
be necessary.

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
editorial 7

Time for New Zealand to ban direct-to-

consumer advertising of prescription
medicines
David B Menkes, Barbara Mintzes, Joel Lexchin

T
he New Zealand government is this year DTCA; any monitoring occurs only after ads have
developing a new Therapeutic Products appeared. On the industry side, the Advertising
Bill to replace the antiquated Medicines Standards Authority (ASA), an amalgam of media
Act 1981. Among the many issues at stake is and communication agencies and advertisers, has
whether direct-to-consumer advertising (DTCA) developed the Therapeutic Products Advertising
of prescription medicines will continue to be Code, while Medicines New Zealand, a lobby for
permitted. Besides the United States (US), New research-based pharmaceutical companies, cov-
Zealand is the only other high-income country ers DTCA in its Code of Practice. The maximum
that allows unrestricted DTCA, including both penalty for Code violations is $80,000, unlikely to
the name of the drug and its indications. Most be a deterrent for multinational companies.
other countries allow unbranded “disease-
oriented” advertising, which falls outside the Claim 2: prescribing and drug
scope of pharmaceutical advertising regulations. expenditure triggered by DTCA may be
The nearly universal prohibition of DTCA is beneficial
widely regarded as a health protection measure, While stimulated prescribing may be appropri-
especially for newly marketed drugs. In a survey ate and useful in some cases, a key question is
of 300 new drugs approved in the US during 2002– the extent to which this is outweighed by the
2014, relatively small numbers of people (median unnecessary or harmful prescribing that also
1,044) were exposed to the drugs pre-market,1 too follows DTCA. The best evidence bearing on
few to discover infrequent but significant adverse this question comes from a controlled trial of
effects. More generally, drug-related harms are brand-specific requests to prescribing doctors.
a common, often preventable cause of emergency Simulated patients were randomised to present
department visits and hospitalisations,2 under- scenarios of clinical depression or “adjustment
pinning the rationale to treat prescription med- disorder”—temporary distress for which phar-
icines differently from over-the-counter and macotherapy is inappropriate. Requests from
other consumer products. patients with adjustment disorder stimulated
Despite the New Zealand Labour Party histori- prescribing to a far greater extent than requests
cally opposing DTCA, the current Labour Cabinet from patients with treatable depression.5
has proposed that DTCA should continue based on Complementary evidence showing that
four key arguments,3 summarised here in relation DTCA-stimulated prescribing can be both inap-
to the research evidence: propriate and harmful comes from a study of
patients requesting advertised COX-2 inhibi-
Claim 1: the existing combination of tors rofecoxib or celecoxib.6 Combining survey
government monitoring and industry data and health records, the authors found that
self-regulation of DTCA is adequate. patients responding to advertising were four times
This claim is manifestly false. The present as likely as others to receive an inappropriate pre-
arrangement is unable to ensure that ads contain scription. Rofecoxib (Vioxx) was heavily advertised
accurate information on either benefits or harms for 5 years prior to its worldwide withdrawal in
of medicines, or on how advertised products 2004. The VIGOR trial published in 2000 was the
compare to other available treatment options, first to establish an increased risk of myocardial
including lifestyle modification.4 Neither Med- infarction with rofecoxib;7 New Zealanders viewing
safe, the New Zealand regulatory authority, nor Vioxx advertisements in the years that followed
the Commerce Commission proactively monitor were not informed of this, with avoidable deaths

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
editorial 8

a likely consequence. in the US in 2016 found few (16%) with educational

content regarding risk factors, contrasting with
Claim 3: people with lower educational almost universal (94%) emotional appeals linking
status, poorer health or from an ethnic the advertised medicine to recreation and other
minority are more likely to seek care positive experiences.11 Only 7% discussed life-
because of DTCA style change as an adjunct to medicine use, none
While this is presented as a positive attribute, it is as an alternative. Another recent analysis of the
taken out of context from a New Zealand study that 81 most heavily advertised drugs in the US found
concludes DTCA may lead to “…the misuse or over- that only 20 (24.6%) were rated as having high
use of medications for diseases that may otherwise therapeutic value.12 Despite existing regulations,
be improved by a healthier lifestyle”,8 illustrating the content and style of televised DTCA undermine
the importance of accessible and balanced health industry claims of educational and public health
information for all sectors of the community. This value. Proponents of DTCA also tend to disregard
survey found that those tending to rely on advertis- doctors’ reports of unwelcome pressure to prescribe
ing reported less healthy lifestyle habits, suggesting advertised medicines13 and the time it takes to
that DTCA may have contributed to poorer life resist inappropriate requests.
and treatment choices. Studies in the US found
that exposure to statin DTCA was associated with Conclusion
inappropriate prescription to those at low risk
of cardiac events,9,10 suggesting DTCA can lead to In conclusion, the government’s main arguments
both over-diagnosis and over-treatment. for allowing DTCA to continue in New Zealand are
both unsustainable and bear remarkable similarity
Claim 4: a more informed society enables to those advanced by Medicines New Zealand, a
better conversations and relationships body representing the pharmaceutical indus-
between patients and prescribers try.14 This coincidence may reflect the virtually
While a well-informed public is to be encouraged, unregulated access that lobbyists have to senior
this argument is undermined by evidence of the government officials in this country.15 In any
poor quality and misleading information typical case, available evidence indicates that banning
of DTCA, irrespective of whether it comes from DTCA would help to promote population health
broadcast, print or online advertising.4 For example, by reducing over-diagnosis, over-treatment and
an analysis of 61 ads televised during prime time iatrogenic harm.

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
editorial 9

competing interests naproxen in patients with rheumatoid arthritis.

Nil. N Engl J Med. 2000;343(21):1520-8. doi: 10.1056/
NEJM200011233432103.
author information 8. Zadeh NK, Robertson K, Green JA. Lifestyle
David B Menkes: The University of Auckland, Waikato determinants of behavioural outcomes triggered
Clinical Campus, Hamilton, New Zealand. by direct-to-consumer advertising of prescription
Barbara Mintzes: The University of Sydney, Sydney, medicines: a cross-sectional study. Aust N Z
Australia. J Public Health. 2019 Apr;43(2):190-196. doi:
Joel Lexchin: York University, Toronto, Canada. 10.1111/1753-6405.12883.
9. Chang HY, Murimi I, Daubresse M, et al. Effect of
corresponding author Direct-to-Consumer Advertising on Statin Use in
David B Menkes: The University of Auckland, Waikato the United States. Med Care. 2017;55(8):759-64. doi:
Clinical Campus, Hamilton, New Zealand. 10.1097/MLR.0000000000000752.
E: [email protected] 10. Niederdeppe J, Byrne S, Avery RJ, Cantor J. Direct-
to-consumer television advertising exposure,
references diagnosis with high cholesterol, and statin use. J
1. Cherkaoui S, Pinnow E, Bulatao I, et al. The Impact Gen Intern Med. 2013;28(7):886-93. doi: 10.1007/
of Variability in Patient Exposure During Premarket s11606-013-2379-3.
Clinical Development on Postmarket Safety 11. Applequist J, Ball JG. An Updated Analysis of
Outcomes. Clin Pharmacol Ther. 2021;110(6):1512- Direct-to-Consumer Television Advertisements for
25. doi: 10.1002/cpt.2320. Prescription Drugs. Ann Fam Med. 2018;16(3):211-6.
2. Pillans PI. Clinical perspectives in drug safety and doi: 10.1370/afm.2220.
adverse drug reactions. Expert Rev Clin Pharmacol. 12. Patel NG, Hwang TJ, Woloshin S, Kesselheim
2008;1(5):695-705. doi: 10.1586/17512433.1.5.695. AS. Therapeutic Value of Drugs Frequently
3. Manatū Hauora – Ministry of Health . Therapeutic Marketed Using Direct-to-Consumer Television
products regulatory regime [Internet]. Wellington: Advertising, 2015 to 2021. JAMA Network
New Zealand Government; 2023 [cited 2023 1 Open. 2023;6(1):e2250991-e. doi: 10.1001/
May]. Available from: https://www.health.govt.nz/ jamanetworkopen.2022.50991.
our-work/regulation-health-and-disability-system/ 13. Mintzes B, Barer ML, Kravitz RL, et al. How
therapeutic-products-regulatory-regime. does direct-to-consumer advertising (DTCA)
4. Lexchin J, Menkes DB. Can direct-to-consumer affect prescribing? A survey in primary care
advertising of prescription drugs be effectively environments with and without legal DTCA. CMAJ.
regulated? N Z Med J. 2019;132(1496):59-65. 2003;169(5):405-12.
5. Kravitz RL, Epstein RM, Feldman MD, et al. Influence 14. Medicines New Zealand. Submission on the
of patients’ requests for direct-to-consumer Therapeutic Products Bill 2023 [Internet]. 2023
advertised antidepressants: a randomized [cited 2023 1 May]. Available from: https://www.
controlled trial. JAMA. 2005;293(16):1995-2002. doi: medicinesnz.co.nz/fileadmin/user_upload/
10.1001/jama.293.16.1995. Submissions/MNZTBP_Sub.pdf.
6. Spence MM, Teleki SS, Cheetham TC, Schweitzer 15. Espiner G. Lobbyists in New Zealand enjoy freedoms
SO, Millares M. Direct-to-consumer advertising unlike most other nations in the developed world
of COX-2 inhibitors: effect on appropriateness of [Internet]. Wellington: Radio New Zealand; 25 March
prescribing. Med Care Res Rev. 2005;62(5):544-59. 2023 [cited 2023 1 May]. Available from: www.
doi: 10.1177/1077558705279314. rnz.co.nz/news/lobbying/486670/lobbyists-in-
7. Bombardier C, Laine L, Reicin A, et al. Comparison new-zealand-enjoy-freedoms-unlike-most-other-
of upper gastrointestinal toxicity of rofecoxib and nations-in-the-developed-world.

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 10

Opportunities for preventing

subsequent injuries: a qualitative
study exploring perspectives of
people who have experienced injuries
Helen Harcombe, Amy E Richardson, Emma H Wyeth, Sarah Derrett

abstract
aim: This study aims to examine opportunities for subsequent injury prevention from the perspectives of people who have recently
experienced subsequent injury events.
methods: This qualitative study involved individual semi-structured interviews with people who had >2 injury events in the previous
12 months. Interviews were audio-recorded, transcribed verbatim and thematic analysis undertaken.
results: Sixteen interviews were completed with participants who had experienced a range of index and subsequent injury
types. Potential opportunities raised were wide-ranging. Some related to individuals, e.g., motivation to carry out prevention
strategies. Other opportunities were related to healthcare providers and the health system. For instance, increasing consultation
times to allow a focus on subsequent injury prevention, building rapport and tailoring their approach to the individual, proactively
referring people to a range of healthcare providers, and ensuring people are aware of resources and supports available following
injury. Broader environmental and societal opportunities were also suggested, such as ensuring adequate social support following
injury, ensuring accessibility to rehabilitation and community facilities and the modification of built environments.
conclusion: A broad range of potential opportunities to prevent subsequent injuries were raised. These opportunities are promising
and future research to trial interventions raised in this study is warranted to determine their feasibility and effectiveness.

P
eople can experience multiple injury events particular techniques or treatments may reduce
over time. Preventing subsequent injuries re-injury, e.g., neuromuscular training among
(not necessarily the same type or cause as those presenting with an ankle sprain help-
an index injury) is one way to reduce the overall ing prevent future ankle sprains.7 Previously, a
burden of injury which is considerable, comprising range of predictors of subsequent injuries (of
10% of the disability burden globally.1 The financial any type) have been reported among a general
burden is also high with injury claims costing the injury population.8,9 Factors associated with an
Accident Compensation Corporation (ACC, New increased risk of subsequent injury included the
Zealand’s universal no-fault injury insurer) $5.2 index injury being caused by assault,8 having >2
billion NZD in 2020/21.2 The incidence of subse- chronic health conditions,9 and having a prior
quent injuries is substantial, making it an important injury affecting them.9 While knowledge of these
and specific contributor to this burden. In a previ- factors may inform targeted prevention initia-
ous study, 38% of participants had >1 subsequent tives, the nature of initiatives to address such
injury claim in the 12 months following an ACC factors may warrant a wide-ranging approach.
entitlement claim (involving compensation for >1 A recent study has examined the prevention of
week off work or other rehabilitation assistance); subsequent injuries from the perspectives of
by 24 months this had risen to 58%.3 Other studies healthcare providers.10 However, it is also vitally
examining specific injury types,4 or population important to also consider the perspectives of
groups such as workers,5,6 also report a high inci- people who have experienced subsequent injuries.
dence of subsequent injury. This study aims to examine opportunities for
Importantly, when someone is injured, there subsequent injury prevention from the perspec-
may be an opportunity to intervene to prevent tives of people who have recently experienced
subsequent injuries. For specific injury types, subsequent injury events.

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 11

Methods The individual who has experienced an

injury
This qualitative descriptive study11 recruited Attention to subsequent injury prevention
participants via advertising on community notice- Some participants recognised that they them-
boards and healthcare provider clinics. Potential selves were not always focused on subsequent
participants were required to be aged >18 years injury prevention. A lack of attention occurred
and to have had >2 injury events requiring some particularly when people were busy, had other
form of treatment in the previous 12 months. priorities/competing demands or when they
Participation involved an individual face-to-face were fatigued or distracted (Quote[Q]1, Table 1).
semi-structured interview conducted by AR, Increased awareness of injury prevention and
who is experienced in conducting qualitative the consequences of actions was recommended
interviews. The interview guide included questions (Q2). However, even when people were aware
about opportunities for subsequent injury pre- of prevention strategies, these were not always
vention, as well as about actions health profes- remembered, and it was suggested it could be
sionals could take to prevent subsequent injuries beneficial to ensure that prevention advice is
for their patients. Participants received a $20 visible at times when people are undertaking
NZD voucher. activities that may cause injury (Q3).
Interviews were audio-recorded, transcribed
verbatim and then thematic analysis was under- Modification of activity
taken.12 Initially AR and HH independently The idea was raised that to prevent subsequent
developed a draft coding framework based on injuries people could sometimes better recognise
two interview transcripts. These were discussed their own limits and be willing to not undertake
with the wider research team to determine a final activities/tasks beyond their capabilities (Q4).
coding framework that was applied to four tran- Correspondingly, there could be increased accep-
scripts independently by AR and HH. Coding was tance of individual’s limitations from others (Q5).
compared and discrepancies discussed and It was also noted that sometimes people felt they
resolved. The framework was applied to the had to, or wanted to, continue with their activities,
remaining transcripts by AR. Analyses were regardless of injury risk (Q6). A balance between
carried out using NVivo 12 software.13 Ethical reducing or modifying particular activities to pre-
approval was obtained through the University of vent injury and a desire not to restrict activities
Otago Human Research Ethics Committee (Health) were also raised (Q7). A desire to know about a
(H19/034). range of options for activity was expressed (Q8).

Results Motivation
Persisting with rehabilitation to prevent
Sixteen interviews were completed, lasting subsequent injuries was recommended (Q9);
between 23–56 minutes. The majority of participants however, it was also noted that people might not
(n=12) were aged 18–30 years; 12 were female and be motivated to carry out prevention strategies
the majority (n=11) reported sole New Zealand when benefits may not be immediately obvious
European ethnicity. Participants had experienced (Q10). The nature and severity of the presenting
a range of injuries including fractures, sprains, injury and possible consequences were noted to
low back injuries and concussion. affect injury prevention motivation (Q11).
Participants held a variety of views about
subsequent injury prevention. Ideas ranged Attitudes
from asserting that individuals were primarily Overarching attitudes towards injury and
responsible for preventing their own subsequent injury prevention could also potentially influence
injuries, to healthcare providers having a key subsequent injury prevention with some feeling
role in preventing subsequent injuries. Others that injuries “could happen to anyone” (Partici-
discussed broader societal and environmental pant[P]10), while another participant raised that
aspects. Potential opportunities have therefore sometimes people would not expect that they
been categorised for discussion as: 1) the individ- would be injured (Q12). The idea was raised that
ual who has experienced an injury, 2) healthcare subsequent injury prevention may be dependent
providers, 3) healthcare systems and processes, on people’s attitudes towards the severity of their
and 4) environments and broader contexts. presenting injury, and that attitudes could vary

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 12

between people (Q13). Participants noted that aspects relating to healthcare systems and processes
negative attitudes towards preventive equipment were discussed.
could be problematic when this was an optional
requirement, or when requirements changed Time
over time (Q14, Q15). Increasing healthcare appointment length
was raised as enabling an increased focus
Healthcare providers on prevention (Q1, Table 3). Correspondingly,
Focus on subsequent injury prevention increasing the number of healthcare profession-
Having healthcare providers specifically focus als was also mentioned (Q2).
on preventing subsequent injuries, as well as
treating the presenting injury, was felt by some to Specific proactive approaches
be an important opportunity (Q1, Table 2). How- A targeted focus on those with multiple injury
ever, this did not always occur (Q2), with a lack of events was suggested (Q3). One idea was that people
time perceived as a potential contributor (Q3, Q4). experiencing multiple injury events could auto-
Participants noted they did not necessarily know, matically be connected with healthcare providers
or think about, preventing subsequent injuries to help prevent subsequent injuries (Q4). Rou-
themselves and such information from health- tinely asking people questions about whether they
care providers would be useful (Q5–7). might need to see an allied health professional
within healthcare settings, such as emergency
Relationships/rapport departments (EDs), was also suggested (Q5, Q6).
While interactions with healthcare providers Ensuring people are aware of the resources and
were noted as offering opportunities for prevent- supports they may be able to access following an
ing subsequent injuries, having a good relationship/ injury was discussed (Q7, Q8), as well as ensuring
rapport between healthcare providers and the timely access to equipment (Q9). It was suggested
person injured was felt to be critical. With good there could be a dedicated person within hospitals
rapport it was suggested those injured might be to ensure people have the required equipment
more likely to be open with their provider, enabling and other injury prevention aspects in place prior
the provider to have a better understanding of the to discharge, as a way of helping prevent subse-
underlying cause of injury. Alongside this, it was quent injuries (Q10). It was also suggested that a
felt important that providers took time to get to range of healthcare providers could provide sub-
know the person and their injury to tailor their sequent injury prevention advice (Q11).
approach to that person (Q8–10) including gaining
an understanding of their attitude towards pre- Costs
venting subsequent injuries (Q11). Good rapport One participant suggested that if people had
could also mean that people may be more inclined to pay for their treatment, if the same injury was
to listen to advice and recommendations from occurring multiple times, they might have fewer
healthcare providers (Q12). Ensuring healthcare similar injuries (Q12). However, costs of seeing
providers were not perceived as judgemental healthcare providers were also noted as barriers
was raised as important for helping people access to treatment, with people not completing their
healthcare for their injuries (Q13). rehabilitation negatively impacting on subse-
quent injury prevention (Q13).
Providing alternatives and taking a proactive
approach Resources
Rather than taking a didactic approach, pro- It was suggested that resources communicat-
viding people with alternative activities for the ing information about preventing subsequent
rehabilitation/recovery phase was felt important injuries could be provided through a range of
(Q14). Healthcare providers proactively offering approaches, including brochures, posters and
support and referring people to other appropriate websites (Q14); however, these should be engag-
healthcare providers was also raised as an oppor- ing and “fun” (P6). It was noted there could
tunity for subsequent injury prevention (Q15). potentially be an increase in programmes such
as falls prevention programmes and that preven-
Healthcare systems and processes tion programmes like these could be advertised
To facilitate healthcare provider actions focused across a range of settings e.g., “church groups… or
on preventing subsequent injuries, a range of social service agencies” (P13), as well as within

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 13

Table 1: Quotes relating to the individual who has experienced an injury theme.

“It’s always me trying to rush or run out to the car… I need to be much more aware of preventing further
Q1
injuries. I just forget, you know.” (P8)

“Everyone needs to be a little bit more aware of what they’re doing, who’s around them kind of, you know, just
Q2
spatially aware and it would make things a lot easier and safer.” (P6)

“All of this information is in front of you but at the same time, it’s easy to forget… So I guess there should be
Q3 some kind of like, you know like some kind of preventative measure, like information or notes or like
videos or something that’s on display.” (P14)

Q4 “If you can’t lift something, you can’t lift something.” (P11)

Q5 “More acceptance maybe that people can’t do everything.” (P10)

Q6 “So I couldn’t stop, like just yeah, ‘cause I have to keep training.” (P9)

“I’d still rather live a good life and risk getting injured and get injured but you know, not wanna live my life
kind of wrapped in cotton wool with injury prevention being my number one focus… I think it’s, like in some
Q7
cases, yes we definitely need to be focussing on injury prevention because where it can be prevented 100% but
I wouldn’t want people to kind of be so scared of getting injured and not do anything fun with their lives.” (P1)

Q8 “Give someone a few more options because people perhaps don’t know.” (P6)

“Don’t go oh I feel better now so I’m gonna stop everything, you know keep going with the treatment and
Q9
make lifestyle changes as well ‘cause it’s the only thing that’s gonna prevent it in the future.” (P3)

“I would probably be less likely to do the exercise and things… when you’re not gonna see… it doesn’t give
Q10
me any problem anyway so it’s like why…” (P2)

“Depends on the injury whether or not you’re motivated to follow the rules, not the rules but the
Q11 recommendations given to you… Yeah and whether or not that injury may produce future problems for you…
you’re gonna be thinking okay well I don’t want that.” (P10)

“It’s very much like ah she’ll be right, it’s not a problem and yeah I can do that, I’ll just do that, that’s not a
Q12
problem, bang off you go.” (P6)

“Some people will be like oh ok, I’m not gonna be drinking for a while, it was really silly or some people are
Q13
like meh, it’s just surgery, you know, like no big deal.” (P12)

Q14 “Like those sort of like optional stuff that I mean, we can prevent it, but a lot of people don’t like it.” (P9)

“I didn’t need [protective equipment] before then why would I need them now and that wasn’t like a
Q15
mandatory thing to wear…” (P9)

Abbreviations: Q= Quote; P= Participant.

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 14

Table 2: Quotes relating to the healthcare providers theme.

“Seeing people about your injuries and probably them telling you how you can stop getting further ones,
Q1 that’s probably the best way to sort of really tell people sort of in a one-to-one setting I guess, to stop them
getting further injuries.” (P7)

“Let’s put that on the ACC form and then move on kind of, like there was no like working on ways to prevent it
Q2
in that case.” (P1)

“You’ve got a lot who focus on just treating what’s presented to them rather than preventing but if you go to a
Q3
GP, it’s only a 15-minute consultation…” (P11)

“They do not have that much time for each patient so that’s why like they’re always in a hurry and stuff but
Q4
yeah, I can totally understand that and yeah so not quite much of a prevention I guess…” (P9)

“Trying to think about ways I could prevent them, it kind of isn’t like front of my mind… so I think if we had
Q5
that pointed out kind of from day one…” (P1)

“Just letting them know what’s going on, like even like if it’s, whether it’s just preventative… like whether you
Q6 tell them not to do something or whether you just aid them in doing the right thing, I feel like could make quite
a big difference.” (P12)

“He was the first doctor to me that actually explained what was wrong… the more information you know
Q7
about it, the more risks involved, the more likely you are to take care of it.” (P10)

“Sometimes they might use the general method, so like they probably have like guidelines where people got
Q8
their injuries… for some people, it might be too boring and it’s not interesting as well.” (P9)

“I think that little, extra couple of questions, extra little bit of research just can help that prevention in the
Q9
future.” (P8)

“So I think background and history of when falls happen needs to be forefront as well, you know, you hear of
Q10 kids all the time oh I fell off my skateboard, it’s like ok but then if they say I fell off my skateboard three times
in a week...” (P8)

“Getting to know the patient… and also their attitude towards it as well, whether or not they’re determined to
Q11
prevent it…” (P10)

“We were just engaging… straight away I was just like ok I liked him, I think naturally I was just listening to
Q12
him more.” (P10)

“Being able to support people to access health advice in a way that isn’t derogatory or judgemental. Injury
Q13
prevention is mental as much as it is physical.” (P15)

Q14 “Not just telling people not to do, but providing with the alternatives.” (P5)

“I think just offering people that extra support, you know like hey you’ve had this fall, would you like a visit
Q15 from an occupational therapist... ‘cause you don’t think about it, you don’t go to the doctor and say I’ve had a
fall, can I have a physiotherapist appointment.” (P8)

Abbreviations: Q = Quote; P = Participant.

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 15

Table 3: Quotes relating to the healthcare systems and processes theme.

“Making GP appointments longer for the same cost [to the injured person] even would be something that
Q1
would be great.” (P15)

“You know, if you’ve got one physiotherapist for 1,000 people, they’re never gonna be able to put that extra
Q2
effort into every person…” (P8)

“I think that little bit more time invested into those certain people, especially with repetitive falls and things,
Q3
there needs to be something happening, it needs to be looked at.” (P8)

“Ideally in a great world, every single person that has an injury within six months of having another injury
Q4
should have a [healthcare professional support]…” (P8)

“They have the big list when they go to ED, you know ‘Are you a drinker?’, ‘Are you a smoker?’… Even just
adding onto the bottom of someone’s form would you like to see an occupational therapist? Or would you
benefit from a physiotherapist appointment may just be the easiest thing to do and it could change that
Q5
subsequent injury, you know… it’s that little question at the end of the bottom of the thing, that’s already at
ED, it would be so easy to implement and wouldn’t really use up a lot of resources, you know, but would make
sure that people had that option if they needed it or if they wanted it, you know.” (P8)

“Just an offer of, even just hey would you like to spend half an hour with a physiotherapist talking about what
Q6 you’ve done and how we can prevent it happening again would be huge. It would, I think, would stop a lot of
injuries, a lot of subsequent injuries.” (P8)

“They’re like ok go and follow this up with physio and then it’s you know, one week or whatever, two weeks…
Q7
you don’t know that you’re entitled to things… and you go oh gosh I wish I had known about this.” (P1)

“You can go home and then that’s it, they never kind of see you again or anything like that and then you go
Q8 home and you’re like ok, well now I’m on my own, who can I call if I need anything, like who do I talk to and
then you ring ACC and then it takes ages and all of that kind of thing.” (P1)

“I think if there was something that we could do, it would be kind of getting, making sure that that kind of
Q9
equipment, that can prevent re-injury, is available from day one.” (P1)

“I know it’s like really hard but to have someone in the hospital that kind of can focus on, just making sure
that the four patients who are injured are like discharged or whatever, that they do have like the right
Q10 equipment that they need and like they’ve got someone there to support them or like if they don’t, then some
sort of support is arranged for them so that at least they go home feeling kind of, like they can manage
because I think otherwise like if you don’t know, as well, like how to prevent injuries.” (P1)

Q11 “I think the nurses probably, they can play a bigger role in educating their patients” (P13)

“If you break the same leg in the same place in the same manner three times, fourth time you’re paying for it.”
Q12
(P3)

“Because they’re so expensive, they probably don’t get people coming back so much, like just to see them for
Q13 one time and, yeah so just not enough time with the people to really tell them what would be a good thing to
do to sort of help improve things I s’pose.” (P7)

“All the pamphlets and stuff at the doctors are great. You know, those are prevention, but perhaps they don’t
Q14
need to be pamphlets. Perhaps they can be a little bit um... like a poster that has not many words on it…” (P6)

“Probably from the GP clinics, they’ve got the most power, they’re the most that these people would see of
Q15
anyway aren’t they and they could push that message better.” (P13)

Abbreviations: Q = Quote; P = Participant.

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 16
Table 4: Quotes relating to the environments and broader aspects theme.

“I think 100% having some sort of support is just so important and I know that a lot of people kind of don’t
have that because they live alone… especially if somebody’s, this is their first injury or they’re new to crutches
or new to using any of the equipment that they use and anything like that, that’s when a lot of re-injuries kind
Q1 of or different injuries even occur because they’ve fallen and things like that and then they’re by themselves
and they don’t have the support whereas if you’ve got the support, I guess either it doesn’t happen because
somebody’s doing the task for you that it’s really just too tough or they’re helping you do the task or making
sure that you don’t fall and things like that.” (P1)

“Definitely having like support people like you know, can you drive me to… yeah people supporting you so
Q2 you don’t have to push yourself too far ‘cause if you push yourself too far, you know, you can injure yourself
more, do a different injury.” (P16)

“A lot of people who don’t have support are often in poverty so like you know, rich people can afford to have,
like pay someone to come in but people like below the poverty line don’t have that luxury so even like a free
Q3 service which I know is like not extremely realistic but having like a service that, even just like funded through
ACC… workers who come in and shower her in the morning, get her lunch, so something like that but for
people who have injuries.” (P16)

“You know, if your mental health’s bad, you just don’t care, so you know I’m gonna walk across the road, I
Q4
don’t care if I get hit.” (P16)

“Making sure that the ACC and financial stuff comes in and that making sure they’re not, people aren’t
Q5
having to force themselves back into situations where they could be at risk again.” (P2)

“You’ve got a community services card, cool, that’s really good for that so I can go to the pool for $4 for that
Q6
but if… say, it’s $6 or $7 a trip and you think that’s twice…” (P6)

Q7 “I think because it’s pricey as well, the equipment, so like not a lot of people want to buy it.” (P9)

“There could be more lighting, there could be just better footpaths that are not uneven and sort of broken.”
Q8
(P15)

“Just having those same things somewhere less clinically, like somewhere less, like somewhere visited without
Q9
a purpose.” (P14)

“Like gyms and things where injuries occur and like they all have signs and warnings and you just, a lot of its
Q10
common sense I guess, but yeah, so it shouldn’t be their responsibility to like…” (P2)

Q11 “Probably targeting people who are engaging in certain types of high-risk sports.” (P9)

Q12 “Start focusing your knowledge base on your elderly people and help them out.” (P3)

“Work is a big part of everyone’s life, they’re there nine hours a day, so you’re there, that’s probably where
Q13
you’re gonna injure yourself the most…” (P11)

“I like the idea of when you’ve got an employer who goes through… like the two day inductions… and they go
Q14
through how to prevent injuries and what kinds of things…” (P11)

“Having work places have to have at least enough staff on to facilitate having good breaks and making sure
Q15
people get their breaks.” (P15)

Q16 “Making sure there’s sufficient staff… more time and more people.” (P11)

“It’s like people: enforce it, you know… Don’t turn a blind eye… No more she’ll be right ‘cause it won’t be right,
Q17
it’s the reality. Enforce what’s there and prevent what’s there.” (P3)

Abbreviations: Q=Quote, P=Participant.

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 17

healthcare settings, particularly through general Work environment

practitioner (GP) clinics (Q15). The importance of work settings was high-
lighted, with it noted that work is where many
Environments and broader aspects people spend a lot of time (Q13). The idea was raised
Social support that there seemed to be an increased awareness
Family and social supports were highlighted as and focus on health and safety compared to the
being of particular importance following injury, past. Participants appreciated employers tak-
and specifically in helping prevent subsequent ing “a proactive approach” (P11) and felt health
injury (Q1, Q2, Table 4). There could potentially and safety inductions were important (Q14). An
be an opportunity for providing funded support opportunity to prevent subsequent injury in the
if people did not have adequate social support workplace included adequate staffing levels.
(Q3). Support was noted to provide both practical This aligns with ideas raised about allowing
support such as assisting with tasks, as well as staff adequate breaks (Q15) and adequate time
emotional support. Correspondingly, the idea of the to carry out work tasks (Q16). The enforcement
importance of mental health in injury prevention of health and safety at work was also consid-
was also raised (Q4). ered important for subsequent injury prevention
(Q17).
Financial aspects
Participants noted that people’s financial situ- Discussion
ations could mean they returned to work earlier
than they should, and that providing adequate This study has explored potential opportunities
financial assistance was an opportunity for for subsequent injury prevention from the per-
subsequent injury prevention (Q5). Cost was spectives of people who have had multiple injury
noted as a barrier to some prevention activities, events. Suggestions were broad, ranging from
such as accessing community facilities like gyms those centred on individuals, those that could be
and pools (Q6) and obtaining safety equipment implemented by healthcare providers and within
(Q7). Accessibility issues were not just limited to health systems, as well as broader societal and
costs, however, with other practical issues such as environmental modifications.
transport and parking also noted. As with many preventive actions, participants
noted the benefits of such actions are, by their
Broader environments nature (i.e., preventing something from occurring),
Opportunities to prevent subsequent injuries often not immediately obvious,14 highlighting the
through modification of built environments importance of effective strategies to enhance peo-
included addressing slippery and hazardous ple’s motivation with preventive activities. Aspects
surfaces and ensuring good lighting (Q8). Oppor- relating to individuals, such as motivation, attitudes
tunities for other settings were also raised e.g., and awareness, underscore the importance of the
implementing injury prevention education in way that subsequent injury prevention strategies
schools. Gyms were noted as a setting where are communicated. Participants noted a range of
there may be opportunities to make people communication approaches could be utilised. This
aware of injury prevention e.g., by having pro- aligns with previous research advocating that the
active staff and information available. This also communication of injury prevention strategies be
aligned with a recommendation that information based on communication theory.15 Suggested guide-
(e.g., brochures) about injury prevention be lines include using a range of media and voices to
provided in non-clinical settings (Q9). However, convey prevention information to reach different
others raised the idea that although they felt groups and populations, focusing on keeping key
gyms and other facilities had a certain level of messages simple and “encouraging the confidence
responsibility for prevention, there was also a to make change” (p.262).15 Participants noted they
degree of individual responsibility required in were less cognisant of subsequent injury preven-
such spaces (Q10). The idea was raised that there tion when they were distracted or fatigued high-
could be a targeted approach focusing on high- lighting the importance of being cognisant of the
risk sports (Q11) or among particular population underlying principles of injury prevention more
groups, such as the elderly (Q12). broadly, for example the benefits of also employ-
ing passive strategies that do not require specific

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 18

actions by individuals.16 the US, with these centres also required to under-
Participants suggested many potential subse- take injury prevention activities.22 The involve-
quent injury prevention opportunities in peo- ment of a range of healthcare professionals in
ple’s interactions with healthcare providers and subsequent injury prevention in different set-
one recommendation was that healthcare pro- tings was recommended in this study. One sug-
viders explicitly include subsequent injury pre- gestion was that a question about whether the
vention as part of their practice. However, to do injured person should see an allied health pro-
this, healthcare providers need to have the time fessional could be routinely included in consul-
to be able incorporate this into their interactions tations. Specific programmes incorporating a
with patients; they need to feel that it is part of range of healthcare providers have been found
their role and they need to have the skills and to reduce subsequent injuries. For example, in
knowledge to be able to offer appropriate advice Australia, people attending a fracture preven-
and strategies to their patients. While prevention tion clinic following a minimal trauma fracture
is within the scope of practice of healthcare pro- ED presentation were found to have fewer sub-
viders who treat people following injury such as sequent fractures over the next 24 months.23 This
physiotherapists,17 emergency physicians18 and clinic was co-ordinated by a fracture prevention
GPs,19 some participants noted that subsequent nurse and involved a rheumatologist and refer-
injury prevention was not part of their interac- ral to a falls prevention clinic or other relevant
tions with their healthcare provider and noted programmes as necessary.23
that time pressures within clinical interactions While actions at the level of individuals and
may be a barrier to incorporating subsequent within the health system are important, as noted
injury prevention. As well as addressing underly- by participants, wider societal/environmental/
ing issues such as staffing shortages which could policy opportunities are also important. Ensur-
affect time pressures for healthcare providers, ing that people have adequate social support fol-
incorporating subsequent injury prevention strat- lowing an injury is something that participants
egies that are not only effective, but also time- recommended. This aligns with findings of a pre-
efficient, may facilitate their incorporation into vious study examining the perspectives of health-
consultations with healthcare providers. care providers,10 and may be something they
Thinking beyond individuals and individual could examine in their consultations with injured
healthcare providers, a range of health system people. However, there also needs to be processes
level opportunities were suggested. Having a in place for healthcare professionals to be able
process where those injured multiple times to refer people to appropriate places/services if
were given additional support/attention from this is to be accompanied by action. In addition to
healthcare providers was suggested. Correspond- social support being important for subsequent
ingly, it was noted that healthcare providers injury prevention, the reach of some inter-
should consider the injury history of the person ventions provided following injury may also
and address/examine any potential underlying extend beyond the individual who has been
causes. However, there can be barriers to people injured to those providing social support such as
obtaining treatment from healthcare providers, family, friends and colleagues. It was noted that
such as cost and accessibility issues. Addressing continued cognisance of injury prevention oppor-
these barriers are important to enable people to tunities within the built and natural environment
complete their full rehabilitation programme, for councils and town planners is also important
as raised by participants in this study, and pre- for subsequent injury prevention.
viously by healthcare providers.10 Having some- A strength of this study it that it has considered
one within healthcare settings dedicated to opportunities for subsequent injury prevention
injury prevention was recommended. Having from the perspectives of people who themselves
a dedicated injury prevention champion is have experienced multiple injury events. However,
not routine in New Zealand healthcare settings the study had a small sample, and although par-
although champions have been recommended in ticipants included a range of ages and ethnicities,
specific areas, such as wound care in aged care most were female, aged between 18–30 years,
facilities,20 and healthcare navigators have been and none were Māori. It is important that all
used in areas such as cancer care.21 Internation- these perspectives are considered in the develop-
ally, trauma prevention co-ordinators are man- ment of any future interventions. In particular,
datory in some places such as trauma centres in it is important that future research and inter-

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 19

vention development ensures the perspectives injury types, severities or mechanisms was not
of Māori are included. Māori experience greater within the scope of this study.
injury-related health loss24 and poorer outcomes A range of potential opportunities to prevent
following injury compared to non-Māori.25,26 subsequent injuries have been suggested. Impor-
Subsequent injuries occur frequently with a tantly, these are from the perspectives of those
previous study of 566 Māori who had injury who could directly benefit from such interven-
involving an ACC entitlement claim reporting tions—people who have experienced multiple
that 62% had at least one subsequent injury ACC injury events. While there would be a financial
claim in 24 months.27 In addition, this study has cost to implement some of the suggested inter-
examined subsequent injury prevention oppor- ventions, the costs (financial and otherwise) of
tunities in general rather than focusing on a spe- subsequent injuries are high, not only for individ-
cific injury type, severity or mechanism of injury. uals but also for wider society. Future research
Particular injury types or mechanisms may to trial interventions suggested in this research
have specific prevention opportunities that are is warranted to determine their feasibility and
important, however, such as examining specific effectiveness.

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 20

competing interests study of WorkSafe Victoria, Australia compensation

Nil. claims. BMJ open. 2013;3(3):e002396. doi: 10.1136/
bmjopen-2012-002396.
acknowledgements 6. Cherry NM, Sithole F, Beach JR, et al. Second WCB
The authors would like to thank all of the people who claims: who is at risk? Canadian Journal of Public
participated in this study. Health/Revue Canadienne de Sante’e Publique.
2010:S53-S7.
author information 7. Verhagen EA, Bay K. Optimising ankle sprain
Helen Harcombe: Senior Lecturer, Injury Prevention prevention: a critical review and practical appraisal
Research Unit, Department of Preventive and Social of the literature. Br J Sports Med. 2010;44(15):1082-
Medicine, Dunedin School of Medicine, University of 8. doi: 10.1136/bjsm.2010.076406.
Otago, Dunedin, New Zealand. 8. Harcombe H, Derrett S, Samaranayaka A, et
Amy E Richardson: Research Fellow: Injury Prevention al. Factors predictive of subsequent injury in a
Research Unit, Department of Preventive and Social longitudinal cohort study. Inj Prev. 2014;20(6):393-
Medicine, Dunedin School of Medicine, University of 400. doi: 10.1136/injuryprev-2014-041183.
Otago, Dunedin, New Zealand. 9. Harcombe H, Davie G, Wyeth E, et al. Predictors
Emma H Wyeth: Professor, Ngāi Tahu Māori Health of severe or multiple subsequent injuries over 24
Research Unit, Division of Health Sciences, University months among an already-injured cohort in New
of Otago, Dunedin, New Zealand. Zealand. Injury. 2020;51(3):620-7. doi: 10.1016/j.
Sarah Derrett: Professor, Ngāi Tahu Māori Health injury.2019.12.038.
Research Unit, Division of Health Sciences, University 10. Harcombe H, Richardson AE, Wyeth EH, et
of Otago, Dunedin, New Zealand. al. Preventing subsequent injury: Healthcare
providers’ perspectives on untapped potential.
corresponding author Injury. 2022;53(3):953-8. doi: 10.1016/j.
Helen Harcombe: Injury Prevention Research Unit, injury.2021.11.029.
Department of Preventive and Social Medicine, 11. Sandelowski M. Whatever happened to qualitative
Dunedin School of Medicine, University of Otago, description? Res Nurs Health. 2000;23(4):334-40.
PO Box 56, Dunedin 9054, New Zealand. 12. Braun V, Clarke V. Successful qualitative research: A
Ph: 64 3 479 9092. E: [email protected] practical guide for beginners London: Sage; 2013.
13. NVivo qualitative data analysis Software; QSR
references International Pty Ltd. Version 12. 2018.
1. Haagsma JA, Graetz N, Bolliger I, et al. The global 14. Fineberg HV. The paradox of disease prevention:
burden of injury: incidence, mortality, disability- celebrated in principle, resisted in practice. JAMA.
adjusted life years and time trends from the Global 2013;310(1):85-90. doi: 10.1001/jama.2013.7518.
Burden of Disease study 2013. Inj Prev. 2016;22(1):3- 15. Aldoory L, Bonzo S. Using communication theory
18. doi: 10.1136/injuryprev-2015-041616. in injury prevention campaigns. Injury Prevention.
2. Accident Compensation Corporation. Pūrongo- 2005;11(5):260-3. doi: 10.1136/ip.2004.007104.
a-tau Annual report [Internet}. Wellington, New 16. Haddon W, Jr. Advances in the epidemiology of
Zealand: The Accident Compensation Corporation; injuries as a basis for public policy. Public Health
2021. Available from: https://www.acc.co.nz/ Rep. 1980;95(5):411-21.
assets/Annual-report-segments/ACC8278-Annual- 17. Physiotherapy Board of New Zealand. General
Report-2021.pdf. scope of practice: physiotherapist. 2022.
3. Harcombe H, Davie G, Wyeth E, et al. Injury Available from: https://www.physioboard.org.
upon injury: a prospective cohort study nz/i-am-registered/scopes-of-practice.
examining subsequent injury claims in the 18. American College of Emergency Physicians. Role
24 months following a substantial injury. of the emergency physician in injury prevention
Inj Prev. 2018;24(6):437-44. doi: 10.1136/ and control for adult and pediatric patients. Ann
injuryprev-2017-042467. Emerg Med. 2008;52(5):594-5. doi: 10.1016/j.
4. de Visser HM, Reijman M, Heijboer MP, et al. Risk annemergmed.2008.08.017.
factors of recurrent hamstring injuries: a systematic 19. Lee R. A hazardous life - our role in injury
review. Br J Sports Med. 2012;46(2):124-30. doi: prevention. Aust Fam Physician. 2012;41(4):167.
10.1136/bjsports-2011-090317. 20. Pagan M, Trip H, Burrell B, et al. Wound
5. Ruseckaite R, Collie A. The incidence and impact of programmes in residential aged care: a systematic
recurrent workplace injury and disease: a cohort review. Wound Pract Res. 2015;23(2):52-60.

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 21

21. New Zealand Ministry of Health – Manatū Hauora. Risk Factors Study 2006-2016. Wellington:
Community Cancer Support Services Pilot Ministry of Health; 2013. Available from: https://
Project Evaluation. Wellington; 2011. Available www.moh.govt.nz/notebook/nbbooks.nsf/0/
from: https://www.health.govt.nz/publication/ C62EF09112754AFACC257BD30072F245/$file/injury-
community-cancer-support-services-pilot-project- related-health-loss-aug13.pdf.
evaluation. 25. Derrett S, Wilson S, Samaranayaka A, et al.
22. American Trauma Society. 2016-2 Trauma Prevalence and predictors of disability 24-months
centre-based injury prevention initiatives. 2022. after injury for hospitalised and non-hospitalised
Available from: https://www.amtrauma.org/page/ participants: results from a longitudinal cohort
PosState162/2016-2-Trauma-Center-Based-Injury- study in New Zealand. PLoS One. 2013;8(11):e80194.
Prevention-Initiatives.htm. doi: 10.1371/journal.pone.0080194.
23. Van der Kallen J, Giles M, Cooper K, et al. A 26. Maclennan B, Wyeth E, Davie G, et al. Twelve-
fracture prevention service reduces further month post-injury outcomes for Maori and non-
fractures two years after incident minimal trauma Maori: findings from a New Zealand cohort study.
fracture. Int J Rheum Dis. 2014;17(2):195-203. doi: Aust N Z J Public Health. 2014;38(3):227-33. doi:
10.1111/1756-185X.12101. 10.1111/1753-6405.
24. New Zealand Ministry of Health – Manatū 27. Wyeth E, Lambert M, Samaranayaka A, et al.
Hauora, Accident Compensation Corporation. Subsequent injuries experienced by Maori: results
Injury-related Health Loss: A report from the from a 24-month prospective study in New Zealand.
New Zealand Burden of Diseases, Injuries and N Z Med J. 2019 Jul 26;132(1499):23-35.

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 22

Acute otolaryngological presentations

in Northland, New Zealand: analysed
with respect to geography and rurality
Chelsea L Heaven, Matthew James McGuinness, Subhaschandra Shetty

abstract
aim: Otorhinolaryngology, head and neck surgery (ORL) diagnoses and treats disorders of the ear, nose, throat, head and neck which
can be commonly seen across a range of medical specialities. Rural patients experience a burden of ORL diseases and face greater
barriers to healthcare than their urban counterparts. We aim to provide information on the diagnoses of rural patients presenting with
ORL symptomatology to provide data that may be useful in targeting resources and training towards rural patients.
methods: A 6-year retrospective study was performed between 1 January 2015 to 31 December 2020. The Northland District Health
Board (NDHB) data warehouse was searched using ICD-10 codes relevant to ORL. The study included any patient acutely presenting
to an NDHB hospital with an ORL diagnosis. Patients with a diagnosis that was not related to ORL, a non-acute presentation, or a
diagnosis not usually managed by hospital ORL services were excluded.
results: Five thousand, five hundred and thirty-four presentations in 4,671 individual patients were included in the study. The mean
age of patients was 35.1 years (SD 26.58). Two thousand, three hundred and twenty-six (49.8%) patients were female and 2,345 (50.2%)
were male. One thousand, nine hundred and sixty-five (42.1%) were Māori and 2,699 (57.8%) were non-Māori. Median decile was
8 (4 IQR). Two thousand and seventy-seven (44.5%) patients were classified as rural and 2,594 (55.5%) as urban. The most common
presentation was epistaxis with 16.8% (n=927/5534) of total presentations. The four next most common presentations were
otological. There was a total of 224 complications including post-operative bleed, post-operative infection, and other post-operative
complications. There was a significant difference in the rate of discharge with 1,819/2,430 (74.9%) rural patients and 2,518/3,104
(81.1%) urban patients being discharged directly from the emergency department (ED) (p<0.001).
conclusion: This retrospective study provides a picture of acute ORL presentations in Northland patients, analysed with respect to
geography and rurality. It highlights the large volume of ORL patients who are seen and managed by rural and ED physicians, and the
importance of rural provision of care in Northland. These findings support the need for targeting resources and training to centres
treating rural patients for the management and treatment of ORL conditions.

O
torhinolaryngology, head and neck surgery complaints and identify differences between rural
(ORL) doctors diagnose and treat disorders and urban patients. These data may be useful in
of the ear, nose and throat, and head and targeting resources and training to centres treating
neck. ORL conditions are common, accounting for rural patients for the management and treatment of
one in eight primary care encounters, and make ORL conditions.
up a large part of the clinical workload of gen-
eral practitioners, rural physicians, emergency Methods
physicians and paediatricians.1 Rural patients
face greater barriers to healthcare compared to Design
those in urban centres.2 These include long travel A 6-year retrospective study was performed
distances, lack of access to transport, telecommuni- from 1 January 2015 to 31 December 2020. The
cation, increased costs, higher levels of deprivation, Northland District Health Board (NDHB) data
and wider socio-economic factors.2,3 As a result, warehouse was searched using the ICD-10 codes
numerous ORL presentations are managed by rural (Appendix 2) relevant to ORL. Data were retrieved
and emergency physicians in rural hospitals. To from the data warehouse including age, gen-
our knowledge, no study has looked at the type and der, ethnicity, closest hospital, domicile, decile,
volume of ORL cases of rural patients in Aotearoa, rural status, hospital of presentation, outcome
New Zealand. We aim to provide information on of encounter (admitted to hospital, discharged
the diagnoses of rural patients presenting with ORL directly from the emergency department [ED],

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 23

transfer to another hospital, general practitioner Rural and urban

[GP] follow-up, ORL outpatient clinic, did not Rural and urban status was retrieved from
wait in ED) and discharge diagnosis description. the NDHB data warehouse. This has been
Patients’ electronic clinical notes including dis- classified using the Stats NZ Urban Rural indicator,
charge summaries were reviewed to confirm based on last known patient address.9 Categories
inclusion in the study. include “Main Urban Centre”, “Secondary Urban
Centre, “Minor Urban Area”, “Rural Centre”, and
Setting “Other Rural”. This classification system does not
This study was conducted in Te Tai Tokerau, differentiate by access to rural or urban health-
Northland, which spans from Cape Reinga to Te care.9 In our study, “Rural Centres”, “Other Rural”,
Hana. The wide geographical spread of Northland and “Minor Urban Centres” were grouped as
means that patients can be more than four hours “Rural”, and “Main Urban Centres” was grouped
from specialty services in Whangārei. There is as “Urban”. Using the census indicator, areas such
a higher proportion of Māori people compared as Kaitaia and Dargaville are described as minor
to the national average.5,6 The whenua (land) of urban areas. However, these areas are serviced by
12 iwi falls either partly or wholly within Te Tai rural hospitals as seen in Figure 1. As such, minor
Tokerau, as shown in Appendix 1.7 There is an urban areas were included in the rural group as
estimated population of more than 178,000 peo- this better reflects their access to healthcare.
ple,4 and the population is older than the national
average, with age brackets of 50+ being over- Inclusion and exclusion criteria
represented.5,6 There is a very high proportion of The study included any patient acutely presenting
people living in areas of high deprivation.5,6 There to Kaitaia, Bay of Islands, Dargaville or Whangārei
are five hospitals, Whangārei Hospital being the hospitals with an ORL diagnosis. Conditions
largest and the only one providing secondary included are listed in Appendix 2. Patients with a
care services including access to 24/7 on call diagnosis that was not related to ORL, a non-acute
ORL services. Kaitaia, Bay of Islands, Dargaville presentation, or a diagnosis not usually managed
and Rawene Hospitals are rural hospitals. Rural by hospital ORL services were excluded. Patients
hospitals are staffed by trained generalists who were also excluded if their residential address
diagnose and treat a diverse range of clinical pre- was outside of Northland. Cases were excluded if
sentations.8 They provide variable levels of service they were referred directly by their GP to the ear,
to adapt to the needs of the rural communities nose and throat (ENT) service and were not seen
that they serve.8 The Royal New Zealand College of by a rural medicine or ED physician.
General Practitioners (RNZCGP) Division of Rural
Hospital Medicine identifies three levels of rural Ethics approval
hospital in the 2022 Training Handbook:8 The study was deemed out-of-scope by the
Health and Disability Ethics Commission on 5
1. A hospital with acute inpatient beds January 2022. NDHB locality approval was granted
and daily visiting medical cover. On call on 27 October 2021. The study was reviewed and
cover outside of these times is provided approved by the NDHB Māori Health Directorate
by appropriately trained nursing and/ on 27 October 2021.
or medical staff. There are no on-site
laboratory services, and limited radiology Statistical analysis
services.8 Categorical data were described with the
2. A hospital with acute inpatient beds and number and percentage. Normally distributed
medical care on-site during normal working data were described with the mean and standard
hours with on-call cover outside of these deviation (SD). Non-normally distributed data
hours. Point-of-care and off-site laboratory were described with the median and interquar-
services and on-call radiography services tile range (IQR). Dichotomous variables were
are available.8 analysed with a Chi-squared test or a Fisher’s
3. A hospital with 24-hour onsite medical exact test. A Mann–Whitney U test was used to
cover and 24-hour access to laboratory and analyse non-normally distributed data. Data were
radiology services.8 entered in IBM SPSS (Version 28.0, Armonk, NY)
for analysis.

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 24

Results Outcome of presentations

There was a significant difference in the rate of
Demographics discharge with 1,819/2,430 (74.9%) rural patients
Five thousand, five hundred and thirty-four and 2,518/3,104 (81.1%) urban patients being dis-
presentations in 4,671 individual patients were charged directly from the ED (p<0.001). Fifty-six
included in the study. The mean age of patients rural patients were transferred to another hos-
was 35.1 years (SD 26.58). Two thousand, three- pital and 21 rural patients seen in Whangārei ED
hundred and twenty-six (49.8%) patients were had been transferred from another hospital total-
female and 2,345 (50.2%) were male. One thou- ling 77 of 2,430 (3.2%). There was a significant dif-
sand, nine hundred and sixty-five (42.1%) were ference in the rate of admission to hospital with
Māori and 2,699 (57.8%) were non-Māori. Median 516 of 2,430 (21.2%) rural patients and 457 of
decile was 8 (4 IQR). Two thousand and seven- 3,104 (14.7%) urban patients requiring admission
ty-seven (44.5%) patients were classified as rural (p<0.001).
and 2,594 (55.5%) as urban. Demographic infor-
mation is shown in Table 1. Discussion
Type of presentations This retrospective review describes the num-
Rural patients were more likely to have rhi- bers and types of ORL presentations seen in the
nology or throat symptoms and less likely to emergency department acutely across Northland.
present with an otology presentation than their The most common presenting diagnosis was epi-
urban counterparts, as seen in Table 2. The most staxis while the majority of presentations as an
common presentation was epistaxis with 16.8% overall group were otological. Rural patients were
(n=927/5,534) of total presentations. Rates were more likely to present with rhinology or throat/
similar between rural (19%, n=462/2,430) and laryngology symptoms and less likely to present
urban (15%, n=465/3,104) patients. The four next with otology symptomatology compared to urban
most common presentations were otological. patients. Most rural and urban patients were
Otitis media made up 13.3% of rural, 18.1% of discharged from ED; however, rural patients
urban and 16.0% of overall presentations. Otitis were more likely to be admitted to hospital than
externa made up 8.3% of rural, 14.3% of urban urban patients. Three point two percent of rural
and 11.7% of all presentations. Otalgia made up patients were transferred to another hospital for
for 6.8% of rural, 4.9% of urban and 5.7% of over- ORL admission.
all presentations. Foreign bodies in ears were seen Our results show the significant number of
in 5.3% of rural, 5.0% of urban and 5.1% of all ORL presentations to hospital in both rural and
presentations. Following this, sinusitis was diag- urban patients. Rural ORL care is imperative
nosed in 5.1% of rural, 4.9% of urban and 5.0% of due to the geographic spread of the region and
all presentations. Nasal fractures were diagnosed the limitation of immediate specialty services
in 5.2% of rural, 4.0% of urban and 4.5% of all pre- to Whangārei Hospital. Appropriate resourcing
sentations. A full breakdown of presentations is and education opportunities need to be provided
provided in Appendix 3. to rural health practitioners to ensure they
have the knowledge and experience to manage
Complications acute ORL conditions.11 This study suggests that
There was a total of 224 complications includ- the key areas to target are the management of
ing post-operative bleed, post-operative infection, epistaxis, otitis media, otitis externa, otalgia,
and other post-operative complications shown foreign bodies in ears, nasal fractures, and post-
in Table 3. One hundred and nine complications operative bleeding. While ORL outreach services
(48.7%) were in rural patients and 115 (51.3%) are important, educational opportunities and for-
in urban patients. The most common compli- mal teaching sessions are crucial to provide high
cation in both rural and urban patients was a quality care to our rural patients.
post-operative bleed making up 71/109 (65.1%) We found that admissions to hospital were
complications in rural patients and 72/115 higher in rural patients compared to urban
(62.6%) complications in urban patients. patients. This may be due to several reasons
including greater severity of disease requiring
admission, reduced access to primary care, lack
of access to specialist review and opinion, or

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 25

Figure 1: (a) map of Northland hospitals, (b) map of travel distances in Northland. Sourced from the Northland
District Health Board Annual Report.5

Table 1: Demographic information stratified by rural or urban status.

Rural Urban Total p-value

Patients, n 2,077 2,594 4,671

Presentations, n 2,430 3,104 5,534

Age, mean (SD) 36.4 (26.9) 34.0 (26.2) 35.1 (26.6) 0.002

Gender, n (%)

Male 1,097 (52.8%) 1,248 (48.1%) 2,345 (50.2%) 0.001

Female 980 (47.2%) 1,346 (51.9%) 2,326 (49.8%)

Ethnicity, n (%)

Non-Māori 1,255 (60.4%) 1,444 (55.7%) 2,699 (57.8%) 0.001

Māori 819 (39.4%) 1,146 (44.2%) 1,965 (42.1%)

Decile, median (IQR) 7 (4) 9 (2) 8 (4) <0.001

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 26

Table 2: Presentation groups stratified by rural or urban status.

Rural Urban Total p-value

Otology, n (%) 1,038 (42.7%) 1,618 (52.1%) 2,656 (48.0%) <0.001

Rhinology, n (%) 807 (33.2%) 860 (27.7%) 1,667 (30.1%) <0.001

Throat/laryngology, n (%) 224 (9.2%) 213 (6.9%) 437 (7.9%) 0.001

Head and neck, n (%) 181 (7.5%) 232 (7.5%) 413 (7.5%) 0.971

Complications, n (%) 109 (4.5%) 115 (3.7%) 224 (4.1%) 0.137

Oral cavity, n (%) 71 (2.9%) 66 (2.1%) 137 (2.5%) 0.059

Table 3: Complications stratified by rural or urban status.

Complication Rural Urban Total

Post-operative bleed, n (%) 71 (65.1%) 72 (62.6%) 143 (63.8%)

Post-operative infection, n (%) 23 (21.1%) 25 (21.7%) 48 (21.4%)

Other post-operative complication, n (%) 15 (13.8%) 18 (15.7%) 33 (14.7%)

Total, n 109 115 224

Table 4: Outcomes for ENT presentations stratified by rural or urban status.

Patient outcome Rural patients Urban patients Total p-value

Admitted, n (%) 516 (21.2%) 457 (14.7%) 973 (17.5%) <0.001

Discharged, n (%) 1,819 (74.9%) 2,518 (81.1%) 4,337 (78.4%) <0.001

OP ENT clinic, n (%) 71 (2.9%) 104 (3.4%) 175 (3.2%) 0.366

Self-discharge, n (%) 24 (1.0%) 25 (0.8%) 49 (0.9%) 0.473

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 27

the need to address socio-economic determi- greater insight into disparities between urban
nants of health.2,3 Further research is required and rural populations.14
to accurately determine the reasons for higher Several limitations exist in this study. First
admissions in rural patients. The findings of this this is a retrospective study and is limited by
study, however, can be used to guide healthcare misclassification bias and missing information.
resources and planning. Participant identification relied on accurate
This is the first study to explore rural health diagnosis and clinical coding of patient events.
presentations in ORL in Aotearoa, New Zealand. This study did not include patients from Rawene
There is a scarcity of published literature sur- Hospital, which is run under the rural hospital
rounding rural presentations of ORL cases both medicine scope of practice by Hauora Hokianga
in Aotearoa and around the world. A prospec- as data systems are not shared with NDHB. It is
tive audit conducted in a tertiary Belgian hospital important to interpret the results of this study
found that 20.5% of patients referred to the ENT with the understanding that only patients pre-
emergency service over a 1-month period had a senting to the Hospital ED were included. Patients
nose or sinus complaint, 36.8% an otological or treated in the community, referred directly to
vestibular complaint and 42.6% with a laryngeal ORL from the community or who were seen in
or neck complaint; however, this did not focus the acute ORL clinic instead of the ED were not
on rural patients.12 A recently published scoping included.
review of 79 US based studies examining rural
disparities in ORL found that there is low-qual- Conclusion
ity evidence with large gaps in the literature in
all subspecialties.13 There is no consistent defi- This retrospective review provides a pic-
nition in the literature regarding rurality.14 In ture of acute ORL presentations in Northland,
this study rurality has been defined using the which has been analysed with respect to geog-
Stats NZ Urban Rural indicator, classified by raphy. It highlights the large volume of ORL
patient address. This is commonly used in health patients who are seen and managed by rural
research but does not consider distance from and ED physicians and the importance of rural
health services.10,14 It is for this reason that our provision of care in Northland. These find-
study grouped “Rural Centre”, “Other Rural” and ings support the need for targeting resources
“Minor Urban Areas” as rural to better reflect the and training to centres treating rural patients
distance from, and therefore access to, health ser- for the management and treatment of ORL
vices. Further study using the newly developed conditions.
Geographic Classification for Health may provide

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 28

competing Interests [cited 2022 Nov 26]. Available from: https://www.

Nil. northlanddhb.org.nz/assets/Publications/2839-
NDHB-Annual-Report-2020-WEB.PDF.
author information 6. Yong R, Browne M, Zhao J, et al. A deprivation
Chelsea L Heaven: Registrar, Department of and demographic profile of the Northland DHB.
Otolaryngology, Head and Neck Surgery, Te Whatu The University of Auckland. 2017 Oct 17. Available
Ora Te Toka Tumai, Auckland, New Zealand. from: https://www.fmhs.auckland.ac.nz/assets/
Matthew James McGuinness: Training Registrar, fmhs/soph/epi/hgd/docs/dhbprofiles/Northland.
Department of General Surgery, Te Whatu Ora pdf.
Southern, Invercargill, New Zealand. 7. Northland Regional Council. State of the
Subhaschandra Shetty: Otolaryngologist and Head and Envrionment Report – Tangata Whenua [Internet].
Neck Surgeon, Department of Otolaryngology, Head New Zealand: Northland Regional Council; 2007
and Neck Surgery, Te Whatu Ora Te Tai Tokerau, [cited 2023 Jan 1]. Available from: https://www.nrc.
Whangārei, New Zealand. govt.nz/media/jdtblsvy/18tangatawhenua.pdf.
8. The Royal New Zealand College of General
corresponding author Practitioners. Rural Hospital Medicine Training
Chelsea L Heaven: Department of Otolaryngology, Head Programme Handbook 2022 [Internet]. Wellington:
and Neck Surgery, Te Whatu Ora Te Tai Tokerau, 2021 December. Available from: https://www.
Private Bag 9742, Whangārei 0148, New Zealand. rnzcgp.org.nz/gpdocs/new-website/become_a_gp/
E: [email protected]. v6_DRHM_Handbook_2022.pdf.
9. Stats NZ. Urban accessibility – methodology and
references classification [Internet]. Wellington: New Zealand
1. Sorichetti BD, Pauwels J, Jacobs TB, et al. High Government; 2020 [cited 2022 Nov 26]. Available
frequency of otolaryngology/ENT encounters from: https://www.stats.govt.nz/assets/Uploads/
in Canadian primary care despite low medical Methods/Urban-accessibility-methodology-
undergraduate experiences. Can Med Educ J. 2022 and-classification/Download-document/Urban-
Mar 2;13(1):86-9. doi: 10.36834/cmej.72328. accessibility-methodology-and-classification.pdf.
2. World Health Organization. Delivering quality 10. Fearnley D, Lawrenson R, Nixon G. ‘Poorly defined’:
health services in rural communities. In: Delivery unknown unknowns in New Zealand Rural Health. N
quality health services: A global imperative Z Med J. 2016 Aug 5;129(1439):77.
[Internet]. OECD Publishing; 2018 Jul 5 [cited 2022 11. Curran VR, Fleet L, Kirby F. Factors influencing
Nov 26]. Available from: https://www.oecd-ilibrary. rural health care professionals’ access to
org/sites/04e76409-en/index.html?itemId=/ continuing professional education. Aust
content/component/04e76409-en. J Rural Health. 2006 Apr;14(2):51-5. doi:
3. Smith KB, Humphreys JS, Wilson MG. Addressing 10.1111/j.1440-1584.2006.00763.x.
the health disadvantage of rural populations: 12. Atta L, Delrez S, Asimakopoulos A, et al. A
how does epidemiological evidence inform prospective audit of acute ENT activity in a
rural health policies and research?. Aust university teaching hospital. B-ENT. 2019 Jan
J Rural Health. 2008 Apr;16(2):56-66. doi: 1;15(2):71-6.
10.1111/j.1440-1584.2008.00953.x. 13. Urban MJ, Shimomura A, Shah S, et al.
4. Stats NZ. Northland Region [Internet]. Wellington: Rural otolaryngology care disparities: a
New Zealand Government; 2018 [cited 2022 scoping review. Otolaryngol Head Neck
Nov 26]. Available from: https://www.stats. Surg. 2022 Jan 11:66(6):1219-1227. doi:
govt.nz/tools/2018-census-place-summaries/ 10.1177/01945998211068822.
northland-region. 14. Whitehead J, Davie G, de Graaf B, et al. Defining
5. Northland District Health Board. Northland District rural in Aotearoa New Zealand: a novel geographic
Health Board Annual Report 2020 [Internet]. classification for health purposes. N Z Med J. 2022
Northland: Northland District Health Board; 2020 Aug 5;135(1559):24-40.

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 29

Appendices
Appendix 1: Te Tai Tokerau iwi map sourced from Te Puni Kokiri and the Northland Regional Council.

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 30

Appendix 2: ICD-10 codes relevant to ORL.

Post-operative
Otitis media Rhinitis Salivary glands Laryngitis Goitre
complications

Otitis externa Sinusitis Ankyloglossia Epiglottitis Tracheostomy

Anterior neck
Ear injuries Epistaxis Glossitis Laryngomalacia
infections

Peritonsillar
Vertigo Nasal fractures Globus
abscess

Foreign body Foreign body Oral cavity

Stridor
ear nose injuries

Facial injuries Dysphagia

Laryngeal
Facial infections
spasm

Vocal cord
disorders

Oropharyngeal
burns

Foreign body
throat

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 31

Appendix 3: Breakdown of presentations.

Rural Urban Total

Ear 1,038 42.7% 1,618 52.1% 2,656 48.0%

Abscess/cellulitis/
31 1.3% 57 1.8% 88 1.6%
perichondritis outer ear

Foreign body in ear 128 5.3% 156 5.0% 284 5.1%

Hearing loss 18 0.7% 16 0.5% 34 0.6%

Impacted cerumen 41 1.7% 92 3.0% 133 2.4%

Labyrinthitis/vertigo 71 2.9% 51 1.6% 122 2.2%

Otalgia 166 6.8% 151 4.9% 317 5.7%

Otitis externa 202 8.3% 443 14.3% 645 11.7%

Otitis media 323 13.3% 561 18.1% 884 16.0%

Other 42 1.7% 59 1.9% 101 1.8%

Tympanic membrane
16 0.7% 32 1.0% 48 0.9%
perforation

Head and neck 181 7.4% 232 7.5% 413 7.5%

Bell’s palsy 85 3.5% 87 2.8% 172 3.1%

Disorder of salivary
13 0.5% 31 1.0% 44 0.8%
gland

Facial/neck swelling 46 1.9% 68 2.2% 114 2.1%

Lymphadenopathy 18 0.7% 31 1.0% 49 0.9%

Other 19 0.8% 15 0.5% 34 0.6%

Nose 807 33.2% 860 27.7% 1667 30.1%

Abscess nose 14 0.6% 26 0.8% 40 0.7%

Epistaxis 462 19.0% 465 15.0% 927 16.8%

Foreign body in nostril 59 2.4% 62 2.0% 121 2.2%

Nasal fracture 127 5.2% 124 4.0% 251 4.5%

Nasal injury 13 0.5% 17 0.5% 30 0.5%

Rhinitis 9 0.4% 13 0.4% 22 0.4%

Sinusitis 123 5.1% 153 4.9% 276 5.0%

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 32

Appendix 3 (continued): Breakdown of presentations.

Rural Urban Total

Oral cavity 71 2.9% 66 2.1% 137 2.5%

Ankyloglossia 27 1.1% 1 0.0% 28 0.5%

Cellulitis and abscess of

27 1.1% 39 1.3% 66 1.2%
mouth

Disease of lip 9 0.4% 17 0.5% 26 0.5%

Glossitis 8 0.3% 9 0.3% 17 0.3%

Post-operative 109 4.5% 115 3.7% 224 4.0%

Post-operative bleed 71 2.9% 72 2.3% 143 2.6%

Post-operative
15 0.6% 18 0.6% 33 0.6%
complication

Post-operative infection 23 0.9% 25 0.8% 48 0.9%

Throat 224 9.2% 213 6.9% 437 7.9%

Acute laryngitis 19 0.8% 34 1.1% 53 1.0%

Disorder of larynx 16 0.7% 10 0.3% 26 0.5%

Epiglottitis 9 0.4% 15 0.5% 24 0.4%

Foreign body in pharynx 58 2.4% 51 1.6% 109 2.0%

Peritonsillar abscess 88 3.6% 62 2.0% 150 2.7%

Stridor 15 0.6% 11 0.4% 26 0.5%

Other 19 0.8% 30 1.0% 49 0.9%

Total 2,430 3,104 5,534

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 33

Invasive group A streptococcal

disease in Hawke’s Bay, New Zealand:
epidemiology, manifestations and
impact
Johanna M Birrell, Bridget Wilson, Susan Taylor, Julie Bennett

abstract
aims: To describe the epidemiology, clinical features and healthcare impact of invasive group A streptococcal (iGAS) disease in Hawke’s
Bay from 2016 to 2021, to inform public health efforts.
methods: The case definition of iGAS for this study was isolation of group A streptococcus (GAS) from blood culture. “Severe iGAS”
included cases that required intensive care admission or died within 60 days. Cases were identified retrospectively from the Te Whatu
Ora Te Matau a Māui Hawke’s Bay laboratory database. Clinical data were obtained from inpatient electronic health records.
results: A total of 93 cases of iGAS were identified in Hawke’s Bay during the 6-year study period. The overall age-standardised incidence
of iGAS was 5.6 per 100,000 (95%CI 4.1–7.4). The incidence was significantly higher among people of Pacific, Māori and Asian ethnicities
than European/Other ethnicities, and higher in areas of socio-economic disadvantage. Skin infections were the most common source
(70% of cases). Thirty-seven cases (41%) were classified as severe, including 11 deaths (12% case fatality rate).
conclusions: Further action is required to address inequities in social determinants of skin health in Hawke’s Bay. Mandatory national
notification of iGAS would provide opportunity for improved surveillance of GAS-related disease, and consideration of a public health
response to iGAS disease in New Zealand.

G
roup A streptococcus (GAS) can cause a under 16 years in Kenya).2 Mean case-fatality
range of clinical syndromes, including rates from iGAS in high income countries range
superficial infections such as pharyngitis from 8% to 16%.2
and impetigo, post-streptococcal immunological In New Zealand, iGAS is not currently notifi-
complications such as acute rheumatic fever and able, despite being nationally-notifiable in a num-
glomerulonephritis, and invasive infections. The ber of other countries including Australia, the
direct costs of GAS-related disease in New Zealand United Kingdom (UK) and Canada.4–6 Recently in
have been estimated at almost 30 million NZD the UK (2022), this notification system has led to
(2015 costs) per year.1 detection of a spike in iGAS incidence and mor-
Invasive GAS (iGAS) infections occur when tality, with a nationwide public health response.7,8
GAS infects a normally sterile site, such as joints, A New Zealand study estimating the incidence of
deep tissues, pleural fluid, cerebrospinal fluid or, iGAS reported a significant upward trend from 3.9
as in this study, the bloodstream. Such infections per 100,000 in 2002 to 7.9 per 100,000 in 2012.9 Due
can be severe and sometimes life-threatening and to the lack of notification, the more recent incidence
thus require early recognition and treatment. of iGAS is uncertain. Current surveillance is
In high-income nations the incidence of iGAS primarily laboratory-based, relying on individual
typically ranges from 2 to 4 cases per 100,000.2 laboratories voluntarily sending clinically relevant
In contrast, a much higher incidence of iGAS GAS isolates to the Institute of Environmental
has been observed in some disadvantaged pop- Science and Research (ESR) for further typing.10
ulations (106 cases per 100,000 in Indigenous Therefore, this study aimed to describe the epi-
Australian people in the Northern Territory,3 46 demiology, demographics, clinical features and
cases per 100,000 in Native American people in healthcare impact of iGAS disease in Hawke’s Bay
Arizona) and lower income nations (12 cases per over six years (2016 to 2021), to inform public
100,000 in Fiji, 13 cases per 100,000 in children health efforts.

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 34

Methods Table 1 shows that the overall age-standardised

incidence of iGAS disease in Hawke’s Bay was 5.6
Definitions per 100,000 (95% confidence interval [CI] 4.1–
The case definition for iGAS disease in 7.4). People of Pacific ethnicity had the highest
this study was isolation of GAS from blood age-standardised incidence at 14.5 per 100,000,
culture. Severe iGAS disease was defined as followed by Māori and Asian peoples (see Table
cases requiring intensive care unit (ICU) admis- 1). However, case numbers were small in the
sion or with death from any cause within 60 Asian and Pacific cohorts.
days of diagnosis. Approximately half of all iGAS cases occurred
in people aged 65 years and over (n=50, 53%).
Study design and data collection Within the 65 to 79 year olds age group, there
Cases of iGAS disease were identified retro- was an incidence of 80.4 per 100,000 in Māori
spectively from the Te Whatu Ora Te Matau a (13 cases, 95% CI 42.8–137.5), compared to 10.5
Māui Hawke’s Bay microbiology laboratory blood per 100,000 in the European/Other ethnicity
culture database, including specimens collected group (13 cases, 95% CI 5.6–18.0).
from 1 January 2016 to 31 December 2021. Further In children under five years of age there was
clinical information was obtained from patients’ an incidence of 9.4 per 100,000 population (eight
electronic health records (Clinical Portal). cases, 95% CI 4.1–18.5), with Pacific, Asian and
Māori children disproportionately affected (see
Data analysis Figure 1). Cases in children under five years
Population data from the 2018 New Zealand were caused by cellulitis (six cases), pneumonia
Census (the approximate midpoint of the study (one case) or bacteraemia of unknown source
period) were used for incidence calculations.11 (one case).
Haemodialysis population data were obtained In the 15 to 34 year olds age group, there
from Australia and New Zealand Dialysis and was an incidence of 4.4 per 100,000 in females
Transplant Registry (ANZDATA) Annual Reports (five cases, 95% CI 1.4–10.3), compared to 0.8
for 2016–21, and included Hawke’s Bay Hospital, per 100,000 in males (one case, 95% CI 0.0–4.6).
satellite and home prevalent haemodialysis Cases in females in this age cohort were caused
patients.12 Age-standardisation was calculated by postpartum endometritis (two cases), lacta-
using the 2001 New Zealand Census total Māori tional mastitis and pneumonia. There was also
population data as the standard population.13 no statistically significant difference in incidence
New Zealand Index of Deprivation (NZDep) of iGAS disease between males and females in the
2018 data were used for assessment of socio- under 5 or over 64 year olds age groups.
economic deprivation.14 Residential address at No household clusters of iGAS were epidemi-
diagnosis was used to epidemiologically screen ologically identified, including in mother-baby
for household clusters of iGAS cases. Data analysis pairs. There were two possible clusters in aged
was performed using Microsoft Excel®. residential care facilities (each with two cases
diagnosed in residents from the same facil-
Ethics approval ity within 7 days). However, no molecular
Ethics approval was sought from the New typing results were accessible for laboratory
Zealand Health and Disability Ethics Commit- confirmation.
tees. The study was deemed out of scope and There was a significantly higher incidence of
not requiring ethics review. The study was iGAS in areas of greatest socio-economic depriva-
approved by the Hawke’s Bay Clinical Research tion (NZDep score 9–10; 14.9 per 100,000 population
Committee (2023/01/371). [95% CI 10.7–20.2]) than in the least deprived
areas (NZDep score 1–2; 4.0 per 100,000 [95% CI
Results 1.5–8.7]) (see Figure 2). Nine of the 11 children
under 10 year olds that developed iGAS were
A total of 93 cases of iGAS disease were iden- living in NZDep score 8–10 areas (82%).
tified in the Hawke’s Bay Region between 2016 The annualised incidence of iGAS disease
and 2021. The median age of cases was 64 ranged between 3 and 9 per 100,000 over the
years (interquartile range [IQR] 42–76 years). study period (see Figure 3).

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 35

Table 1: Age-standardised incidence of iGAS disease in Hawkes Bay, 2016–21.

Incidence per 100,000

Population Number of cases 95% CI
population

All persons 93 5.6 4.1–7.4

Sex

Female 44 6.1 3.8–8.9

Male 49 5.3 3.3–7.7

Ethnicity

Māori 40 10.5 7.2–14.6

Pacific peoples 8 14.5 6.2–28.6

Asian 6 10.5 3.4–23.7

European/Other 39 2.1 1.1–3.4

Figure 1: Crude incidence of iGAS disease by age group and ethnicity in Hawke’s Bay, 2016–21.

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 36

Figure 2: Crude incidence of iGAS disease by socio-economic decile in Hawke’s Bay, 2016–21.

Figure 3: Trend in age-standardised incidence of iGAS disease over time, 2016–21.

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 37

Table 2: Medical co-morbidities of people with iGAS disease.

Co-morbidities Number of cases % of total

Diabetes mellitus (type 1 or 2) 29 31%

Chronic kidney disease (eGFR <60) 27 29%

Diabetes mellitus AND chronic

17 18%
kidney disease

Injecting drug use 1 1%

Surgery in past 30 days 1 1%

Postpartum (within 6 weeks) 4 4%

Immunosuppressant medication 7 8%

None of the above co-morbidities

46 49%
identified

Figure 4: Number of iGAS cases by source of infection.

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 38

Clinical features, severity and Healthy Housing Program (part of the national
management Healthy Homes Initiative), which commenced in
Common pre-existing medical risk factors for Hawke’s Bay in 2015, provides an example of a
iGAS disease included diabetes mellitus (31%), successful prevention strategy addressing under-
chronic kidney disease (29%) (see Table 2). One lying social determinants of health. This program
patient (included in the chronic kidney disease has since received additional funding and been
cohort) was receiving haemodialysis. expanded nationally.19,20
Skin infections were the most common source, The Hawke’s Bay School Skin Program is an
with cellulitis diagnosed in 65 cases (70%) (see equity-driven primary prevention program that
Figure 4). Of the 93 cases, 37 (41%) met criteria for commenced in 2020 in response to the high local
severe iGAS disease. ICU admission was required rates of serious skin infections.21 Given the signifi-
for 29 patients (31%). Median length of hospital cant burden of disease attributable to skin-related
stay was 6 days (IQR 3–11) and the total combined iGAS infections in those aged under five years,
length of hospital stay for all patients was 991 days work is underway to further extend this Program
over the 6-year study period. The 60-day all-cause into the early childhood education sector, par-
mortality was 12% (11 deaths). The age range of ticularly focussing on children living in areas of
people who died following iGAS infection, was 42 socio-economic disadvantage.
to 96 years (median 75 years, IQR 67–86). Of these Known predisposing factors for iGAS
deaths, eight cases were associated with skin disease in children include varicella zoster
infections (cellulitis or necrotising fasciitis), and virus infection, influenza infection, trauma,
three with bacteraemia of unknown source. burns, surgery, immunocompromisation, malig-
nancy and age under one year.22 Scabies infection
Discussion has been shown to be a contributing factor to skin
infections among children in remote Indigenous
Invasive GAS disease is an important source Australian communities and could be further
of morbidity and mortality in Hawke’s Bay, studied in New Zealand.23 In our study, the most
particularly in children under five years of age frequent comorbidities in the older age cohort
and adults over 65 years. When compared to with iGAS disease were diabetes mellitus and
people of European or Other ethnicities, the age- chronic kidney disease.
standardised incidence of iGAS disease was 7-fold There were higher rates of severe iGAS
higher in Pacific peoples and 5-fold higher in disease (41%), requiring ICU admission or caus-
both Māori and Asian populations. As with other ing death, in this study than found in other
GAS-related disease, people residing in areas of jurisdictions that used a broader definition of
high socio-economic deprivation were significantly severe disease.3,24 Possible explanations may
over-represented.15 The annual incidence of 5.6 include a lower local case detection rate for non-
cases per 100,000 population (95% CI 4.1–7.4) severe cases, receipt of antibiotics prior to blood
described in this study is similar to rates previously cultures, or delayed diagnosis and treatment.
reported in New Zealand, but higher than findings Review and optimisation of blood culture col-
from other high income countries such as the UK lection practices is recommended. Improving
and Canada.1,9,16,17 As shown in Figure 3, the inci- access to primary care, particularly for high-risk
dence of iGAS disease was lower in 2020–21 than population groups, may help to reduce disease
in 2019. This trend may have been influenced by severity through earlier detection and treatment
the COVID-19 pandemic, with public health mea- of GAS infections.
sures to prevent COVID-19 concurrently reducing This audit will have underestimated the true
transmission of GAS. burden of iGAS disease in Hawke’s Bay, as cases
Skin infections are the most common source were only identified if GAS was isolated from
of iGAS disease in Hawke’s Bay (including in both blood culture and not from other sterile sites.
peak age groups of under five and over 65 years), Other sterile sites were not included as these data
providing further evidence for the importance of were less accessible and would require detailed
action on the social determinants of skin health review and clinical judgement against a broader
in prevention of GAS-related disease. Previous case definition. However, research from regions
studies have demonstrated an association of with active iGAS surveillance (including non-
GAS-related disease with household overcrowding blood sterile sites) have found blood cultures to
and socioeconomic disadvantage.15,18 The Child be positive in 94% of cases.3 Cases may also have

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 39

been missed if blood cultures were collected after the comparatively young age distribution of the
antibiotic exposure or less than the recommended Pacific population in Hawke’s Bay.11
volume of blood was collected. Further action is required to address the
Small case numbers in some sub-groups is an underlying social determinants of skin health and
important limitation of the incidence data. The inequities in access to primary care in Hawke’s
high incidence of iGAS in people of Asian ethnicity Bay, particularly in the highest-risk population
(10.5 per 100,000) is driven by only six cases, with groups.15,18 Mandatory national notification of
a wide 95% confidence interval (3.4–23.7). The iGAS disease would provide the opportunity for
high incidence of iGAS in people of Pacific eth- improved surveillance of GAS-related disease,
nicity was less apparent in crude (Figure 1) than and consideration of a public health response to
in age-standardised results (Table 1) because of iGAS disease in New Zealand.

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 40

competing interests the Prevention and Control of Invasive Group A

Nil. Streptococcal Disease. Canada Communicable
Disease Report. 2006 Oct;32S2:1-26. Available
acknowledgements from: https://eportal.mountsinai.ca/Microbiology/
We acknowledge all Hawke’s Bay clinical and laboratory protocols/pdf/GAS%20guidelines%202006.pdf.
staff involved in the patients’ care. We thank Neil 7. UK Health Security Agency. UKHSA update on
Campbell for his assistance with data extraction and scarlet fever and invasive Group A strep [Internet].
Susan Stewart and Linda St George for their valued 2022 Dec 2 [cited 2022 Dec 22]. Available from:
comments on this article. https://www.gov.uk/government/news/ukhsa-
update-on-scarlet-fever-and-invasive-group-a-
author information strep.
Johanna M Birrell: Public Health Registrar, National 8. Grierson J, Rawlinson K. Children at risk of strep A
Public Health Service, Te Matau a Māui Hawke’s Bay, in England could be given preventative antibiotics
New Zealand. [Internet]. The Guardian. 2022 Dec 6. Available
Bridget Wilson: Public Health Medicine Specialist/ from: https://www.theguardian.com/society/2022/
Medical Officer of Health, National Public Health dec/06/children-risk-strep-a-england-preventive-
Service, Te Matau a Māui Hawke’s Bay, New Zealand. antibiotics.
Susan Taylor: Clinical Microbiologist, Te Whatu Ora, 9. Williamson DA, Morgan J, Hope V, et al. Increasing
Te Matau a Māui Hawke’s Bay, New Zealand. incidence of invasive group A streptococcus disease
Julie Bennett: Senior Research Fellow, Public Health, in New Zealand, 2002-2012: a national population-
University of Otago Wellington, Wellington, based study. J Infect. 2015 Feb;70(2):127-34. doi:
New Zealand. 10.1016/j.jinf.2014.09.001.
10. Institute of Environmental Science and Research
corresponding author Ltd (ESR). Invasive group A streptococcal
Johanna M Birrell: Population Health, Te Matau a Māui infection in New Zealand, 2016. ESR; 2017
Hawke’s Bay, PO Box 447, Napier 4140, New Zealand. [cited 2022 Dec 28]. Available from: https://
E: [email protected] surv.esr.cri.nz/PDF_surveillance/InvasiveGAS/
InvGASinfectioninNewZealand2016.pdf.
references 11. Stats NZ – Tatauranga Aotearoa [Internet]. 2018
1. Cannon JW, Zhung J, Bennett J, et al. The economic Census Place Summaries – Hawke’s Bay Region.
and health burdens of diseases caused by group A [cited 2022 Dec 28]. Available from: https://www.
Streptococcus in New Zealand. Int J Infect Dis. 2021 stats.govt.nz/tools/2018-census-place-summaries/
Feb;103:176-81. doi: 10.1016/j.ijid.2020.11.193. hawkes-bay-region.
2. Steer AC, Lamagni T, Curtis N, Carapetis 12. Australia & New Zealand Dialysis & Transplant
JR. Invasive Group A Streptococcal Registry (ANZDATA) [Internet]. Reports [cited 2022
Disease: Epidemiology, Pathogenesis and Oct 17]. Available from: https://www.anzdata.org.
Management. Drugs. 2012;72(9):1213-27. doi: au/anzdata/publications/reports/.
10.2165/11634180-000000000-00000. 13. New Zealand Ministry of Health – Manatū Hauora.
3. Birrell JM, Boyd R, Currie BJ, et al. Invasive group A Position Paper on Māori Health Analytics – Age
streptococcal disease in the Northern Territory and standardisation [Internet]. Wellington: Ministry
the impact of melioidosis antibiotic prophylaxis. of Health; 2018 Nov. Available from: https://www.
Med J Aust. 2022 Nov 21;217(10):544-5. health.govt.nz/publication/position-paper-maori-
doi: 10.5694/mja2.51739. health-analytics-age-standardisation.
4. Communicable Diseases Network Australia. Group 14. Environmental Health Intelligence New
A streptococcal disease – invasive (iGAS). 2022 Jun Zealand (EHINZ). Socioeconomic deprivation
14 [cited 2022 Oct 17]. Available from: https://www. profile. Massey University [cited 2022 Dec
health.gov.au/diseases/group-a-streptococcal- 28]. Available from: https://ehinz.ac.nz/
disease-invasive-igas#surveillance-and-reporting. indicators/population-vulnerability/
5. GOV.UK. Notifiable diseases and causative socioeconomic-deprivation-profile/.
organisms: how to report. 2022 Sept 30 [cited 15. Baker MG, Gurney J, Moreland NJ, et al. Risk factors
2022 Oct 17]. Available from: https://www.gov. for acute rheumatic fever: A case-control study.
uk/guidance/notifiable-diseases-and-causative- Lancet Reg Health West Pac. 2022 Jul 4;26:100508.
organisms-how-to-report. doi: 10.1016/j.lanwpc.2022.100508.
6. Public Health Agency of Canada. Guidelines for 16. Health Protection Agency, Group A Streptococcus

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 41

Working Group. Interim UK guidelines for 22]. Available from: https://www.tewhatuora.

management of close community contacts of govt.nz/keeping-well/for-families-and-children/
invasive group A streptococcal disease. Commun healthy-homes-initiative/.
Dis Public Health. 2004 Dec;7(4):354-61. 21. Kane J. Rheumatic fever prevention: A review of
17. Davies HD, McGeer A, Schwartz B, et al. Invasive the evidence, and recommendations for Hawke’s
group A streptococcal infections in Ontario, Canada. Bay. Hawke’s Bay Population Health Unit [Internal
Ontario Group A Streptococcal Study Group. N Engl document]; 2021 Jan.
J Med. 1996 Aug 22;335(8):547-54. doi: 10.1056/ 22. Stevens DL, Kaplan SL. Group A streptococcal
NEJM199608223350803. (Streptococcus pyogenes) bacteraemia in children.
18. Coffey PM, Ralph AP, Krause VL. The role of UpToDate [Internet]. 2022 Nov [cited 2022 Dec
social determinants of health in the risk and 22]. Available from: https://www.uptodate.com/
prevention of group A streptococcal infection, contents/group-a-streptococcal-streptococcus-
acute rheumatic fever and rheumatic heart pyogenes-bacteremia-in-children.
disease: A systematic review. PLoS Negl Trop Dis. 23. Carapetis JR, Connors C, Yarmirr D, Krause
2018 Jun 13;12(6):e0006577. doi: 10.1371/journal. V, Currie BJ. Success of a scabies control
pntd.0006577. program in an Australian aboriginal community.
19. Pierse N, Johnson E, Riggs L, Watson N. Healthy Pediatr Infect Dis J. 1997 May;16(5):494-9. doi:
Homes Initiative: Three year outcomes evaluation 10.1097/00006454-199705000-00008.
[Internet]. Te Whatu Ora – Health New Zealand; 24. Carapetis JR, Jacoby P, Carville K, et al.
2022. Available from: https://www.tewhatuora.govt. Effectiveness of clindamycin and intravenous
nz/about-us/publications/heathy-homes-initiative- immunoglobulin, and risk of disease in contacts,
three-year-outcomes-evaluation/. in invasive group A streptococcal infections. Clin
20. Te Whatu Ora – Health New Zealand [Internet]. Infect Dis. 2014 Aug 1;59(3):358-65. doi: 10.1093/cid/
Healthy Homes Initiative; c2022 [cited 2022 Dec ciu304.

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 42

Evolution of sentinel lymph node

biopsy for breast cancer patients in a
rural setting: 10 years’ experience
Anthony W K Lau, Vanessa L Lau, Magdalena M Sakowska

abstract
Sentinel lymph node (SLN) biopsy is the standard axillary staging procedure of early breast cancer. Superparamagnetic iron oxide
(SPIO) nanoparticles have been found to be comparable to, while overcoming many of the limitations associated with, the current
standard of care for SLN biopsies (dual localisation with radioisotope and patent blue dye). Here, SPIO dual localisation (Sienna+®
and blue dye) is compared to blue dye alone for SLN biopsies in a rural centre where radioisotope techniques are not readily
available. Sienna+® dual localisation is shown to be more likely to detect nodes (detection rate of 99% compared to 90% when using
blue dye alone), and detect more nodes, than blue dye alone. The use of Magseed, a magnetic tracer, was not found to influence node
detection. The results from this work show that Sienna+® dual localisation is superior to blue dye alone for detecting SLN, suggesting
that it is an excellent alternative to dual localisation of radioisotope and blue dye for small centres lacking easy access to a nuclear
medicine department.

S
entinel lymph node (SLN) biopsy is the reports of lymph nodes found to be stained
standard axillary staging procedure for brown or black.1,4,5,7,8 When comparing SPIO to
early breast cancer and is undertaken when dual localisation of radioisotope and blue dye,
a patient is clinically and radiologically lymph the identification rate has been found to be
node negative.1–4 Dual localisation of SLN with comparable,1,4,8 suggesting that it is an excel-
both radioisotope and patent blue dye is superior lent alternative for centres not equipped to use
to single agent and has a lower false-negative radioactive isotope.
rate.2,5 Its universal uptake, however, is limited as Timaru Hospital is the only facility in New
it requires access to a nuclear medicine depart- Zealand where all practising breast surgeons
ment or a radioactive licence. Its short half-life use dual localisation of Sienna+® and blue dye
(approximately six hours for Tc 99) also reduces for sentinel lymph node biopsies. Sienna+® and
its utility for rural patients as they need to travel blue dye was first used in June 2017, with blue dye
to a large centre for its administration,6 making alone being used prior. This retrospective study
its use impractical for many rural centres within compares the use of both techniques over the last
New Zealand. ten years showing their utility in a rural setting.
Superparamagnetic iron oxide particles (SPIO)
have introduced an accurate and efficient alter- Materials and methods
native that overcomes many of the disadvantages
of the traditional dual localisation techniques for Patient population
SLN biopsy.1,3–5,7,8 Clinical use of SPIO is common Data were analysed for all patients who had
for magnetic resonance imaging intravenous clinically and radiologically node negative breast
contrast injections.4 The SPIO tracer (Sienna+®) cancer and had undergone SLN biopsy for breast
is a dextran coated nanoparticle 60 nanometres surgery (invasive carcinoma or ductal carcinoma
in diameter. Once injected subareolarly, it drains in situ [DCIS]) at Timaru Hospital, New Zealand
into the lymphatic system and accumulates in the between 1 January 2011 and 31 December 2021.
sentinel lymph nodes just like radioactive colloid Data collated from the electronic health record
and blue dye. It is detected intraoperatively using included demographics, type of surgery, tumour
a handheld magnetometer. The surgeon detects size and type, staging, lymph node status, lymph
the location by the audible pitch of the detector node detection rate and hormone receptor status.
and numerical signal range. There have also been Comparison was made between the patients who

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 43

underwent SLN biopsy using patent V blue dye patients who underwent SLN biopsy Sienna+®
localisation alone and those using dual localisation dual localisation and 96 (42.7%) using blue dye
with Sienna+® super paramagnetic iron oxide par- alone. Demographics, surgical approach and tumour
ticles and blue dye (Sienna+® dual localisation). details of the two groups are summarised in Table 1.
Sienna+® dual localisation was offered from June
Technique 2017. Blue dye alone was used up until March
Single agent blue dye localisation was carried 2020, after which time all surgeons adopted the
out with a 2ml periareolar subcutaneous injection universal dual tracer technique. The number of
of patent V blue dye administered after induction patients per technique per year is summarised in
of general anaesthesia for surgery. The injection Appendix 1.
site was massaged for two minutes. Dual localisa- SLN were successfully harvested in 99% (128/129)
tion Sienna+® dual localisation involved 2ml of of patients using Sienna+® dual localisation and
Sienna+® injected into the periareolar subcuta- 90% (86/96) of patients when using blue dye
neous tissue in clinic approximately a week prior alone (p=0.001). Three or more sentinel nodes
to each operation. Patent V blue dye was injected were detected in 34% of patients (44/129) using
at induction, as outlined above. Sienna+® dual localisation, and 13% (12/96) of
Magseed, a magnetic guide used during surgery patients when using blue dye alone (p=0.0002)
when there is no palpable mass, was used to help (see Table 2). Non-sentinel nodes were taken
locate the tumour in some wide local excision from six Sienna+ dual localisation patients, one
(WLE) procedures. After the tumour of interest of which was node positive with isolated tumour
had been excised and all metal instruments had cells. In the blue dye group, there were 11 patients
been removed from the operating field, a hand- with non-sentinel nodes harvested based on the
held magnetometer was used for localisation of the operative decision at the time. All of these nodes
sentinel lymph node. The blue node and/or “hot” were negative. The observed difference was not
(magnetic) nodes were identified and excised for significant (p=0.0739).
histological analysis. After removal of the sentinel In the Sienna+® dual localisation cohort, no
nodes, the axilla was checked with magnetometer difference was identified for the number of senti-
probe to ensure minimal residual magnetic count. nel node harvested between Magseed (n=15) and
Non-sentinel nodes may have been sampled at non-Magseed groups (n=29) (p>0.05) (Appendix
surgeon discretion. Lymph nodes were evaluated 2). No significant differences (p<0.01) were iden-
by an onsite pathologist using local protocols. tified between the two cohorts when comparing
tumour type, grade and stages, surgery type, age or
Statistics ethnicity between the treatment groups (Table 1).
Fisher Exact tests was used for demographic Sienna+® tissue staining was recorded in
comparisons between the two groups and to deter- 82% (36/44) of WLE cases, ranging from 5 to 43
mine statistical difference between the number of months follow-up.
sentinel nodes harvested between groups (Sienna+® The clinical management of DCIS has evolved
dual localisation vs blue dye alone, and Sienna+® at Timaru Hospital in line with its referring
dual localisation with and without Magseed). tertiary centres’ practice and its multidisciplinary
meeting reviews. SLN biopsies is still offered
Ethics for some high-risk patients with DCIS or those
This study was a retrospective clinical audit of undergoing mastectomy for DCIS; however, the
patient information from a single unit’s practice decline in the number of DCIS patients treated
and therefore was exempt from patient informed with sentinel node biopsies over the study period
consent. Local hospital board ethics committee does not reflect a decline in patients presenting
approval was granted. with DCIS (Appendix 1).9

Results Discussion
Between 1 January 2011 and 31 December 2021, This study shows that Sienna+® dual localisation
226 patients underwent SLN biopsy at Timaru is superior to blue dye alone for detecting sentinel
Hospital. All patients were female. One patient lymph nodes in rural women with breast cancer,
was excluded due to incomplete documentation and it is a safe alternative to use where access to
detailing their treatment, leaving 129 (57.3%) radioisotope use is limited by distance required to

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 44

Table 1: Patient and tumour characteristics of study cohort.

Sienna+® dual
Patent V blue dye
localisation P-value*
counts (percentage)
counts (percentage)

Number of patients 129 96

Age Median (range) 67 (33–90) 61 (33–87)

NZ European 107 (83%) 90 (94%) 0.015

Ethnicity Māori 15 (12%) 6 (6%)

Other 7 (5%) 0 (0%)

Mastectomy 85 (66%) 63 (66%) 1.000

Surgery type
WLE 44 (34%) 33 (34%)

G1 28 (22%) 29 (30%)

G2 61 (47%) 35 (36%) 0.1801

Grade
G3 38 (29%) 32 (33%)

Unknown 2 (2%) 0 (0%)

Tis 10 (8%) 16 (17%)

T0 4 (3%) 0 (0%) 0.0302

T1 82 (64%) 67 (70%)
Stage
T2 31 (24%) 13 (14%)

T3 1 (1%) 0 (0%)

Unknown 1 (1%) 0 (0%)

Right 71 (55%) 47 (49%) 0.42

Side
Left 58 (45%) 49 (51%)

Invasive ductal 95 (74%) 64 (67%)

Invasive lobular 10 (8%) 9 (9%)

Invasive mucinous 6 (5%) 4 (4%) 0.4889

Invasive tubular 5 (4%) 2 (2%)

Tumour type
Invasive papillary 1 (1%) 1 (1%)

Invasive
1 (1%) 0 (0%)
micropapillary

DCIS 11 (9%) 16 (17%)

Notes: * Two-sided Fisher Exact tests to calculate difference between two sentinel lymph node biopsy techniques (Sienna+® dual
localisation and blue dye alone) with at least one observation in each cell.

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 45

Table 2: Number of lymph nodes harvested using Sienna+® dual localisation or blue dye alone.

Sienna+® dual
Patent V blue dye
localisation P-value*
counts (percentage)
counts (percentage)

0 1 (1%) 10 (10%) 0.001

1 49 (38%) 50 (52%) 0.042

Nodes detected
2 35 (27%) 24 (25%) 0.761

3+ 44 (34%) 12 (13%) 0.0002

Notes: * Two-sided Fisher Exact tests to calculate the difference between two sentinel lymph node biopsy techniques (Sienna+®
dual localisation and blue dye alone).

Table 3: Initial set up cost and per patient personal and procedure cost analysis, as estimated by Sreedhar et al.
2021.

Sienna+ Radioisotope

SentiMag Gamma probe

Setup costs
$44,275 $41,400

Travel - $130
Personal costs
Hotel - $100

Magnetic tracer $557.7 -

Procedure costs Injection - $600

Radioactive colloid
injection Lymphoscintigraphy - $588

Cost per patient* $558 $1,418

Cost for 100 patients* $55,770 $141,800

Note: *excluding set up cost

travel. It also highlights that when dual tracers are ment required for the use of radioisotope. The
used, fewer women will require random axillary isotope could be administered by a licensed
sampling, as a SLN is highly likely to be found surgeon or clinical nurse specialist without
with this technique. mapping but administration around the use of
Dual localisation using radioisotope and blue radioactive materials makes its uptake prohib-
dye has been the gold standard for locating sen- itive. Additionally, due to its short half-life, sur-
tinel lymph nodes in breast cancer patients;1,4,7 gery needs to occur on the same day or as soon as
however, its utility in rural centres is limited. possible within 24 hours after injection with the
Smaller centres lack the nuclear medicine depart- radioisotope. For rural women who need to travel

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 46

to metropolitan centres with nuclear medicine makers or orthopaedic metal prostheses need to
departments this is made logistically impractical, undergo SLN detection with other non-magnetic
especially if it needs to be co-ordinated with hook- techniques. Disposable plastic retractors are
wire placement with breast conservation surgery. available; however, some products can be bulky
Timaru Hospital introduced Sienna+® dual and brittle making their design inferior to metal
localisation for SLN biopsies after SPIO was retractors for the delicate work required of them.
shown to be as effective as radioisotope and Conventional dual localisation using radioiso-
blue dye dual localisation at detecting SLN.1,4,7,8 tope detects extra-axillary sentinel nodes or high
All breast surgeons at this centre have adopted infra-clavicular nodes by lymphoscintigraphy. While
this technique and it is now the standard of care. SPIO with blue dye is a more targeted approach
Sienna+® dual localisation detected more nodes that focuses solely on detecting the axillary level
than blue dye alone. When both techniques were 2 and 3 nodes, this method is adequate as these
used, it was unlikely that no SLN would be nodes are where the most common pathway of
found. Additionally, a higher number of SLN metastases are located.8 No pre-operative map-
was found using dual technique. These findings ping is available with SPIO, and while lympho-
are consistent with previously published work scintigraphy may show extra-axillary nodes like
where Sienna+® dual localisation was found to internal mammary or supraclavicula—few centres
have a 98% detection rate, while blue dye alone would pursue these operatively due to limited
was only 86–90%.4,8,10 oncological benefit and risk of retrieval.
Sienna+® dual localisation provides a good The same SentiMag machine is also used for
alternative to radioisotope dual localisation. wide local excision technique for non-palpable
While a formal cost analysis is beyond the scope lesions as an alternative to hook-wire localisation
of this paper, Sreedhar et al. (2021) estimated with its associated timing logistics. While Sienna+®
Sienna+® to be to be the more affordable option can be used alongside Magseed localisation, it is
to administer in New Zealand, with an estimated recommended that care is taken to remove the
cost of $558 NZD per patient. Radioisotope dual tumour and the Magseed prior to undertaking
localisation costs around $1,188 for the procedure, the SLN biopsy to limit magnetic interference.
with patient travel and accommodation costs addi- Magseed was used in situ to locate the tumour
tional to this sum, indicating that Sienna+® would in 15 Sienna+® dual localisation patients. No
save approximately $86,000 per 100 patients (see significant difference was found between in the
Table 3). This suggests that the up-front costs of number of nodes detected with or without the use
the SentiMag machine ($44,275 NZD) would have of Magseed. This is consistent with similar stud-
been covered by its use for only 52 patients after ies published in New Zealand and overseas,6,11,12
implementing Sienna+® at Timaru Hospital. In suggesting that Magseed can be utilised alongside
addition to the financial benefits, Sienna+® is SPIO SLN procedures without interference. While
not a radiation-based procedure and so is not allergy when using Sienna+® is infrequent,1,4,8,13 a
restricted to access to a nuclear medicine facil- much more common side-effect is tissue staining.
ity, making it suitable for use in a rural setting.6 Light brown staining of the breast tissue was
This means patients do not need to travel out of detected in 82% (36/44) of women undergoing
town for their procedure, while staff and patients breast conservation surgery, ranging between 5 to
are not exposed to radiation. Timing of surgery is 43 months follow-up. The number of patients that
also less pressured as Sienna+® injection can be reported staining was similar to what has been
administered by a clinical nurse up to three weeks reported previously and this staining is known
prior to surgery allowing for flexibility in theatre to not be permanent.14 This light brown staining
planning especially if hook-wire placement is containing SPIO has been shown to cause void
also planned.1,7 artifacts and potentially obstruct key findings in
As a magnetic-based procedure, the main post operative MRI for up to 25 months. 15 How-
limitation of Seinna+® utilisation is the presence ever, none of the women in this study needed
of any metalware in the ipsilateral side of the MRI scanning after surgery as the threshold is
SLN biopsy.7 Metal retractors and equipment are low to obtain an MRI as part of the pre-operative
therefore not able to be used during SLN detection, workup.
while patients with metal implants such as pace-

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 47

Conclusions to dual localisation of radioisotope and blue dye

for small centres without good access to a nuclear
This is the first study to show that Sienna+® medicine department. This technique could also
dual localisation is superior to blue dye alone be offered in larger centres allowing for more
for detecting SLN and is an excellent alternative flexible operating list planning.

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 48

competing interests Breast Cancer Res Treat. 2016 Jun;157(2):281-294.

Nil. doi: 10.1007/s10549-016-3809-9.
8. Ghilli M, Carretta E, di Filippo F, Battaglia C,
author information Fustaino L, Galanou I, et al. The superparamagnetic
Anthony W K Lau: General Surgery Registrar, Department iron oxide tracer: a valid alternative in sentinel
of General Surgery, Te Whatu Ora, South Canterbury, node biopsy for breast cancer treatment. Eur J
New Zealand. Cancer Care. 2017 Jul;26(4):e12385.doi: 10.1111/
Vanessa L Lau: Research Fellow, Department of ecc.12385.
Pathology & Biomedical Science, University of Otago, 9. van Roozendaal LM, Goorts B, Klinkert M,
Christchurch, New Zealand. Keymeulen KBMI, De Vries B, Strobbe LJA, et al.
Magdalena M Sakowska: General Surgeon,Department Sentinel lymph node biopsy can be omitted in DCIS
of General Surgery, Te Whatu Ora, South Canterbury, patients treated with breast conserving therapy.
New Zealand. Breast Cancer Res Treat. 2016 Apr;156(3):517525.
doi: 10.1007/s10549-016-3783-2.
corresponding author 10. Wong A, Spillane A, Breast Surgeons of Australia
Anthony W K Lau: Timaru Hospital, Queen Street, and New Zealand Incorporated (BreastSurgANZ).
Parkside, Timaru, 7910, New Zealand. Patent Blue V dye anaphylaxis: experience
Ph: 027 242 3476. E: [email protected] of Australian and New Zealand surgeons.
ANZ J Surg. 2014 Jan-Feb;84(1-2):37-41. doi:
references 10.1111/j.1445-2197.2012.06277.x.
1. Man V, Wong TT, Co M, Suen D, Kwong A. Sentinel 11. Hersi AF, Eriksson S, Ramos J, Abdsaleh S, Wärnberg
Lymph Node Biopsy in Early Breast Cancer: F, Karakatsanis A. A combined, totally magnetic
Magnetic Tracer as the Only Localizing Agent. World technique with a magnetic marker for non-palpable
J Surg. 2019 Aug;43(8):1991-1996. doi: 10.1007/ tumour localization and superparamagnetic
s00268-019-04977-1. iron oxide nanoparticles for sentinel lymph
2. Hamdy O, Farouk O, El-Badrawy A, et al. Sentinel node detection in breast cancer surgery. Eur J
lymph node biopsy in breast cancer—an updated Surg Oncol. 2019 Apr;45(4):544-9. doi: 10.1016/j.
overview. Eur Surg. 2020 Oct 10;52(6):268-76. ejso.2018.10.064.
3. Motomura K. Sentinel node biopsy for breast 12. Pohlodek K, Sečanský P, Haluzová I, Mečiarová
cancer: past, present, and future. Breast I. Localization of impalpable breast lesions
Cancer. 2015 May;22(3):212-20. doi: 10.1007/ and detection of sentinel lymph nodes
s12282-012-0421-7. through magnetic methods. Eur J Radiol.
4. Rubio IT, Diaz-Botero S, Esgueva A, et al. The 2019 Nov;120:108699-108699. doi: 10.1016/j.
superparamagnetic iron oxide is equivalent to the ejrad.2019.108699.
Tc99 radiotracer method for identifying the sentinel 13. Ahmed M, Douek M. The role of magnetic
lymph node in breast cancer. Eur J Surg Oncol. 2014 nanoparticles in the localization and treatment of
Jan;41(1):46-51. doi: 10.1016/j.ejso.2014.11.006. breast cancer. Biomed Res Int. 2013:281230-11. doi:
5. Zada A, Peek MCL, Ahmed M, et al. Meta-analysis 10.1155/2013/281230.
of sentinel lymph node biopsy in breast cancer 14. Szynglarewicz B, Slupianek K, Szulc R, et al. Skin
using the magnetic technique. Br J Surg. 2016 staining following injection of superparamagnetic
Oct;103(11):1409-19. doi: 10.1002/bjs.10283. iron oxide (SPIO) for sentinel node biopsy in breast
6. Sreedhar S, Maloney J, Hudson S. Introducing cancer: How often, how wide, how long? Eur J Surg
SentiMag in a rural setting: a 5‐year experience. ANZ Oncol. 2019 Feb;45(2):e151-e151. doi: 10.1016/j.
J Surg. 2021 Nov;91(11):2404-2410. doi: 10.1111/ ejso.2018.10.505.
ans.17093. 15. Huizing E, Anninga B, Young P, et al. 4. Analysis
7. Karakatsanis A, Christiansen PM, Fischer L, Hedin C, of void artefacts in post-operative breast MRI
Pistioli L, Sund M, et al. The Nordic SentiMag trial: due to residual SPIO after magnetic SLNB in
a comparison of super paramagnetic iron oxide SentiMAG Trial participants. Eur J Surg Oncol. 2015
(SPIO) nanoparticles versus Tc99 and patent blue in Jun;41(6):S18-S18. doi: 10.1016/j.ejso.2015.03.005.
the detection of sentinel node (SN) in patients with
breast cancer and a meta-analysis of earlier studies.

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 49

Appendices
Appendix 1: Number of DCIS cases where SLN biopsies were performed by year within the study period.

SIENNA+® dual Blue dye

Year DCIS cases Total cases % DCIS DCIS cases Total cases % DCIS

2011 - - - 1 5 20%

2012 - - - 1 5 20%

2013 - - - 1 4 25%

2014 - - - 1 11 9%

2015 - - - 4 16 25%

2016 - - - 1 22 5%

2017 2 13 15% 6 16 38%

2018 4 16 25% 0 8 0%

2019 1 25 4% 0 8 0%

2020 2 33 6% 0 1 0%

2021 1 42 2% - - -

Appendix 2: Number of nodes harvested with and without the use of Magseed for location of impalpable tumours.

Nodes harvested WLE with Magseed WLE without Magseed *P-value

1 7 12

2 3 6
1.000
3 3 6

4+ 2 5

Note: * Two-sided Fisher exact tests to calculate the difference between WLE performed with and without Magseed.

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 50

Psychosocial care in DHB-based

stroke services in Aotearoa: a survey
of current practice
Felicity A S Bright, John Davison, Ginny Abernethy

abstract
aim: Stroke has significant psychosocial impacts which contribute to burden for the person with stroke and affect stroke outcomes.
The Psychosocial Working Group of the National Stroke Network (NSN) sought to survey current practices for assessing and supporting
psychosocial needs within district health board (DHB) based stroke services to inform national service delivery initiatives.
methods: The survey was conducted in 2021. It was distributed to senior clinicians in all DHBs via the NSN.
results: Thirty-seven responses were received from stroke services, representing 90% of DHBs. Sixty-three percent of services reported
some process for screening for psychosocial needs. Of these, only 11% used validated screens. Variability in the type of psycho-
social support was evident. Seven percent of services had routine access to psychology, while 53% could access psychology on referral.
There was limited evidence of specific screening and support processes for Māori, Pacific peoples, or those with communication impairments.
Respondents identified training and resources needs to enable better psychosocial care.
conclusion: Stroke services are not consistently meeting national guidelines which require all services have a process for screening for
psychosocial needs. This survey has informed a work programme to support psychosocial care practices in stroke services in Aotearoa
New Zealand.

S
troke is increasingly common in Aotearoa support is associated with positive outcomes.11
New Zealand. It is the third most common There are clear associations between social
cause of death and disability, with around supports, depression, and quality of life.12 Given
9,000 New Zealanders being affected by stroke that psychosocial wellbeing is a priority outcome
each year.1 Despite the incidence of strokes for people with stroke,13 that psychosocial factors
declining, as the population ages, the number of are associated with poorer rehabilitation out-
strokes is anticipated to increase, with a corre- comes9–11 and many are modifiable,14 it is important
sponding increase in the number of people living to identify impacts early and intervene in a timely
with stroke.1 Many people with stroke live with manner to facilitate recovery after stroke.
ongoing psychosocial impacts of stroke which In Aotearoa, research and policy documents have
affect their quality of life and stroke outcomes. identified that psychosocial needs should be a prior-
While the term “psychosocial” can be understood ity area for services.15,16 The National Stroke Network
in many ways, for this work, we use it to refer to (NSN) developed a stroke rehabilitation strategy in
the psychological, social and emotional impacts of 2018 to specify core standards for rehabilitation.15
stroke. Rates of psychological diagnoses are high, This requires services to “ensure that all patients
with one in three stroke survivors experiencing with suspected psychosocial needs are screened
depression,2 and with one in five experiencing and where needs are identified, are offered appro-
anxiety after stroke.3 These can develop at any priate timely interventions”.15 In 2020, Take Action
time post-stroke, with two-thirds of people with for Stroke Rehabilitation was developed to support
depression developing it at least 3 months after the enactment of the strategy,17 and details high-
stroke.4 Rates are higher in those with communi- level practice recommendations and priorities for
cation impairments.5 People experience changes action.17 With regard to psychosocial screening, it
in roles and social networks.6 Emotional impacts requires services have a documented process or
include grief, hopelessness, apathy, personality protocol to ensure that all patients are screened
changes and loss of identity.7,8 Depression, anxi- for psychosocial needs—which reflects that all
ety, and perceived social isolation are associated people with stroke are likely to have psychosocial
with poorer outcomes after stroke9–11 while social needs.18 To help services to meet the standards in

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 51

Take Action for Stroke Rehabilitation, a psycho- provided one response on behalf of all stroke
social working group was established to develop services (hyperacute, acute, inpatient and
a model of care and produce resources to support community rehabilitation) while others provided
services to meet the NSN standard. This work- responses for each service. For the purposes
ing group incorporates service providers across of analysis, if the responses only discussed the
the continuum of care and non-governmental continuum and it was not possible to identify what
organisations, people living with stroke and related to each type of service, this was classified
whānau, and academics. This paper reports as “continuum of care”. When it was possible to
the outcome of the first action of the working identify which responses related to specific ser-
group: a 2021 survey conducted to understand vices (e.g., acute or inpatient rehabilitation), then
how psychosocial care is currently provided by the data were analysed with like data. Many DHBs
stroke services in Aotearoa. operated hybrid stroke services (e.g., integrated
acute care and inpatient rehabilitation); in these
Method instances, data were analysed alongside other
acute data and inpatient rehabilitation data. Some
The purposes of the survey were to: (a) collect responses addressed some, but not all questions.
information on current psychosocial screening Data were analysed using descriptive statistics
and intervention practices, and (b) gather clinician and content analysis of qualitative responses.
and service perspectives on resources needed to
improve psychosocial care. The survey questions Results
are provided in Appendix 1. The survey was
designed by the authors before being trialled with Thirty-seven responses were received from
members of the working group; questions were stroke services within 18 of the 20 DHBs. Of the
refined after their feedback. Within the survey, responding DHBs, 14 were North Island DHBs
nine questions were asked relating to six topics: and four were South Island. They represented
DHBs in urban, regional and rural settings.
• Disciplines available The New Zealand clinical guidelines for stroke
• How psychosocial needs are identified management19 define DHBs as large, medium
• Current practices for supporting and small, based on population catchment and
psychosocial needs stroke occurrence. Responses were received
• Resources used to support wellbeing from seven out of seven large DHBs, six out of six
• Services available beyond organised stroke medium DHBs and five out of seven small DHBs.
care Of the 37 responses, 11 responses described
• Identified resource and training needs. the continuum of care within a DHB, six were
from an acute service, two from a combined
The survey was circulated to clinical leads acute/inpatient rehabilitation service, eight an
across medical, nursing and allied health inpatient rehabilitation service, two from com-
disciplines using the mailing list of the NSN in bined inpatient rehabilitation and community
July 2021. This included staff from every district services, and eight from a community service.
health board (DHB). Recipients were requested to
complete the survey (online via Survey Monkey) Psychosocial screening practices
with their teams; it was suggested that it should Respondents were asked to say how psycho-
be completed at a service level (e.g., with one social needs are identified, and if routine screen-
response from the acute stroke unit) rather than ing occurs, how this occurs, including details
by multiple individuals within the service. In the of screening approaches and/or tools used. We
instance of multiple services across one DHB, it received 35 responses to these questions, from 16
was suggested that each service should provide a DHBs, and results are summarised in Table 1.
response as staffing and care practices and pro- Forty percent of respondents (n=14) reported
cesses may differ across services or sites. there was no routine screening of psychoso-
Data management presented challenges due cial needs within their service. In services that
to variability in the responses received. This reported some approach to screening, initial
reflects the different ways stroke services are disciplinary assessments were the primary
structured across Aotearoa, and reflects how each occasion for identifying psychosocial issues.
organisation provided its responses. Some DHBs Free-text responses described this with phrases

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 52

Table 1: Current screening practices.

Screened within
Screened using
disciplinary or
Service type No routine screen validated psychosocial
transdisciplinary
screening tool
assessment

Continuum of care (n=5) 80% (4) 20% (1) -

Acute (n=10)* 27% (3) 70% (7) 10% (1)

Inpatient rehabilitation
45% (5) 45% (5) 18% (2)
(n=11)*

Community rehabilitation
22% (2) 56% (5) 33% (3)
(n=9)*

Notes: * Percentage given is greater than 100% as some services use multiple screening approaches.
Variation in screening processes was evident.

Table 2: Intervention approaches.

Examples

• Building therapeutic relationships

• Individualising rehabilitation for people’s mood, personality and fatigue
• Exploring values and priorities and incorporating into care
• Goal-setting
• Supporting social interactions on the ward (e.g., groups)
Universal care for most • Encourage active patient involvement in rehabilitation
people with stroke • Relaxation and breathing exercises
• Education (individual and group interventions, written and verbal)
• Regular discussion with the patient about wellbeing
• Whānau engagement including regular whānau hui
• Whānau room
• Monitoring mood and discussion at team meetings
• Involvement of cultural support services

• Allied health team with experience in positive psychology, Motivational

Interviewing and Cognitive Behavioural Therapy
Targeted psychosocial • Referral to social worker
supports for people • Identify individual risks and issues and develop intervention plans (e.g., sleep—
with possible or side room)
identified psychosocial • Clinical psychology advice to staff to support work with patients
needs • Support from Clinical Psychology for joint sessions
• Referral to GP for community-based patients for possible referral to health
improvement practitioners or similar located within primary care

• Psychiatry involvement in diagnosis, medical management, treatment planning,

Specialist input for liaison with mental health services
people with identified • One-on-one Clinical Psychology sessions including shared formulations,
psychological needs psychoeducation, counselling, psychological interventions, sleep or pain
management

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 53

Table 3: Disciplines in stroke services.

Acute % (n=8) Inpatient Rehabilitation % (n=13) Community rehabilitation % (n=11)

Routine Referral None Routine Referral None Routine Referral None

Social work 63% (5) 37% (3) - 92% (12) 8% (1) - 81% (9) 9% (1) -

Psychology 13% (1) 50% (4) 37% (3) 15% (2) 54% (7) 31% (4) 9% (1) 55% (6) 36% (4)

Māori cultural support 50% (4) 50% (4) - 46% (6) 46% (6) 8% (1) - 55% (6) 45% (5)

Pacific cultural support 25% (2) 63% (5) 12% (1) 15% (2) 31% (4) 54% (7) - 45% (5) 55% (6)

Asian cultural support 25% (2) 50% (4) 25% (2) 15% (2) 15% (2) 69% (9) - 27% (3) 73% (8)

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 54

such as “asked by MDT in subjective assessments” responses such as “it is not supported”, “poor”,
in acute care or “medical and nursing screen” and “not supported beyond general enquiry”.
in inpatient rehabilitation. As such, what was The second pattern (n=24 responses) pre-
screened was not clear for most services. Several dominantly described referrals to different pro-
services described comprehensive and holistic viders: psychologists or social workers within the
screening processes. One inpatient service con- team, chaplains, cultural support services, liaison
sidered multiple domains of wellbeing such as psychiatry within hospital services, or external
motivation, behaviour, sleep, whānau support supports such as general practitioners (GPs) or
and carer stress, which then were discussed and stroke-centred non-governmental organisations.
addressed within daily rapid rounds and weekly These respondents provided little detail regarding
multidisciplinary team meetings. Several com- everyday psychosocial supports provided by multi-
munity services described gathering information disciplinary members of the stroke team.
about wellbeing on the referral form, asking The third pattern (n=5 responses; three joint
specific questions relating to holistic domains of acute/inpatient services, one acute, and one
wellbeing in initial transdisciplinary assessments community rehabilitation service) reflected
(holistic assessments covering different domains multi-layered approaches to psychosocial care
relevant to stroke, completed by one team mem- provided by multidisciplinary team members
ber) such as asking about mood, social supports, within the stroke service. A variety of interven-
finances, sexuality, relationships, and in some tions were described, from universal approaches
instances, also completing validated screening. with all patients through to specialist input for
These examples reflect clear processes for review- identified psychological needs, shown in Table 2.
ing and addressing wellbeing. Five services used These respondents also described models of care
validated psychosocial screening tools. These that prioritised holistic care, which included regular
included the Patient Health Questionnaire-4 (PHQ- staff training on wellbeing, a ward environment that
4) or the Patient Health Questionnarie-9 (PHQ- supported whānau involvement, and attending
9), Generalized Anxiety Disorder Scale (GAD-7), to staff wellbeing, seeing this as a core aspect of
Depression Intensity Scale Circles (DISCs) or the them supporting patient and whānau wellbeing.
Stroke Aphasic Depression Questionnaire (SADQ) The survey prompted some services to
for those with communication impairments. Even identify how they supported the psychosocial
with specified screening policies and tools, screening needs of Māori and Pacific peoples. Responses
did not consistently occur. In the free-text box, predominantly specifed referring to cultural
one respondent identified that while they had a support services; several specified whānau
DHB-wide policy and screening process using a involvement through regular communication
validated tool, in practice “this does not always between staff and whānau, whānau rooms,
occur”. No services used culturally specific tools, and longer visiting hours as strategies in sup-
or described screening processes which reflected porting wellbeing. One non-urban commu-
Māori models of hauora. nity service described connecting with visiting
In the absence of routine screening (37% of kaumatua and supporting connection with valued
responses), respondents described psychosocial community activities.
needs being identified through staff observations While specific disciplines and services were
and conversations with patients and families. reported to be instrumental in providing psycho-
However, free text responses indicated this could social support (specifically social work, psychology,
be “ad hoc” or “hit and miss”. and cultural support services), limited availablity
was also reported. This is summarised in Table 3.
Interventions to support wellbeing Some free-text responses suggested that the actual
Three patterns of support were identified availability of these disciplines may be less than
through free-text responses to the question, “How what the numbers suggest. For instance, one DHB
is the psychosocial wellbeing of people with strokes with two acute services stated that at one hospital,
currently supported within the service?”, a question social work was available one-to-two times a week,
answered by 32 of the 37 respondents. while in the larger hospital, social work was rou-
The first pattern (n=3 responses; one each from tinely available. Another acute service indicated
acute, inpatient and community rehabilitation that the only specialist mental health support was
services) was that respondents stated psychoso- from liaison psychiatry but was difficult to access
cial wellbeing supports were limited, with as psychosocial responses were considered a normal

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 55

reaction to stroke, rather than something requir- Discussion

ing specialist input. One DHB-wide community
service highlighted geographical differences This survey sought to identify current psycho-
within the service, stating “psychology (almost social screening and intervention practices in
entirely non-existent) can only be accessed on Aotearoa New Zealand, and to resource needs to
referral” in one part of the DHB that only 10% of support service development.
patients resided within. The other 90% of stroke Clear variability in screening was evident,
patients in the DHB had no access to psychology both within DHBs and between DHBs. Current
or social work. The nature of their involvement was approaches to screening are inconsistent. Five ser-
rarely specified, for instance, whether services were
vices reported routine screening using a validated
stroke-specific or if staff were resourced and able to
screening tool and/or psychosocial assessment.
provide comprehensive psychosocial support. This is an improvement on 2014 research that
showed only 7% of services completed screening
Resource needs to improve psychosocial for >90% of patients.20 However, there is still
screening and care progress to be made. Screening processes should
Using open-ended questions, we asked be universal, attend to different domains likely to
respondents to identify training and resource be impacted by stroke, and be embedded through-
needs. Respondents sought a national approach out the continuum of care to ensure issues are
to screening that was culturally appropriate, identified in a timely manner.18,21 This includes
reflected holistic understandings of wellbeing ongoing review in primary care.
such as addressing identity, values, whānau and No services identified using culturally informed
adjustment, and incorporated Māori models of screening processes for Māori or people of other
health. Alongside this, respondents identified the cultural groups. It is imperative that screening
need for better training in understanding and processes are culturally responsive, reflect cul-
identifying psychosocial needs, and the need for tural perspectives on wellbeing, and are cultur-
care pathways so that there were clear processes ally safe.22 Additionally, all clinicians and services
and supports available and accessible if psycho- are able to be culturally safe, responsive to and
social issues were identified. To equip clinicians supporting people’s cultural needs and broader
to provide comprehensive psychosocial support, sense of oranga (wellbeing), to avoid perpetuating
a number of needs were identified: inequities in experience and outcome.23,24
1. Education addressing: When psychosocial issues are identified, timely,
evidence-based intervention is important.25 A wide
• The importance of providing psychosocial variety of approaches to supporting wellbeing were
support. Respondents suggested this education evident. Some respondents identified psychosocial
should be provided to the whole team, care was an area that was not addressed well—this
including support and ward-based staff. reflects patients’ experiences of services.26 Some
• Specific interventions such as Motivational responses focused on referrals to specialist sup-
Interviewing. port (cultural support, social work, psychology);
• Specific psychosocial issues such as risk however, there were also comprehensive examples
assessment, emotional changes, supporting of holistic psychosocial care within services. These
engagement in people who are depressed or examples reflect best practice approaches such as
anxious, managing difficult behaviour, knowing the Stepped Care Model,27 and may provide a use-
when specialist support is required. ful model for clinicians and services wishing to
enhance practice.
2. Resources for patients and family on the All staff working in stroke care, across the
different impacts of stroke. continuum of care, should be able to provide
3. Improved staffing within the team, including support for common post-stroke psychosocial
routine access to social workers and changes.27 Specialised support should be avail-
psychology, and ensuring that staff with able from appropriately trained staff, and from
specialist psychosocial skills and knowledge specialist psychologists and psychiatrists for those
have capacity to support patients, whānau and with more significant psychosocial and psychological
teams. difficulties. This is important as best-practice guide-

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 56

lines recommend talking therapies are a first line DISCs, and Behavioural Observation of Anxiety
treatment for depression; medical teams can also (BOA). It also identifies a range of strategies cli-
consider a trial of antidepressants.18 It is clear nicians can use to support wellbeing. Ongoing
from survey results, however, that access to professional development will occur through-
specialist psychological services is limited. out 2023.
This survey indicates there is a need for bet- The findings of this survey do have some limita-
ter and wider access to specialist psychological tions. There were inconsistencies in how services
support; however, it also highlights there is a responded, limiting our ability to draw conclusive
need and appetite for building the knowledge, findings from comparisons within and across ser-
skills and supports for stroke-specialist staff. vice types; this would require a different research
Building capability within the stroke team is approach. Responses to open-ended questions var-
likely to improve psychosocial care and better ied significantly in the depth provided. This does
meet the needs of patients.5,27 The creation of Te not reflect that one represents a better approach
Whatu Ora and larger localities may offer more to care than others. Instead, it reflects the nature
opportunities for providing education for multi- of the survey design and possibly respondent time.
disciplinary staff, and collaboration and connec- There is clear recognition of the need for
tion with specialist support across hospitals and improved psychosocial care for people with
services and between tertiary and primary care. stroke in Aotearoa New Zealand. The high rate of
The results of this survey have led to the devel- responses to this survey indicate a wide-spread
opment of a resource to support services to identify interest in enhancing care. This survey provides
and address psychosocial needs after stroke.28 It a valuable platform for future practice and policy
provides scripts for asking about wellbeing, and development, which should aim to better equip
recommends that specific validated screens are clinicians to support wellbeing. It is vital that
completed at transition points, or if staff have services improve psychosocial care to enable
concerns. These are PHQ-9 and GAD-7, or the better experiences and outcomes for people
HADS. If the person has communication impair- impacted by stroke.
ments, clinicians could consider the SADQ-10 or

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 57

competing interests 7. Ferro JM, Santos AC. Emotions after stroke: A

Nil. narrative update. Int J Stroke. 2020 Apr;15(3):256-
67. doi: 10.1177/1747493019879662.
acknowledgments 8. Ellis-Hill C, Horn S. Change in identity and self-
We thank the members of the Psychosocial Working concept: A new theoretical approach to recovery
Group who helped pilot and refine the survey and following a stroke. Clin Rehabil. 2000 Jun;14(3):279-
commented on the survey findings. We also thank the 87. doi: 10.1191/026921500671231410.
stroke clinicians who completed the survey. 9. Kutlubaev MA, Hackett ML. Part II: predictors of
depression after stroke and impact of depression
author information on stroke outcome: an updated systematic
Felicity Bright: Speech-language Therapist and Senior review of observational studies. Int J Stroke. 2014
Lecturer in Rehabilitation, Auckland University of Dec;9(8):1026-36. doi: 10.1111/ijs.12356.
Technology, Auckland, New Zealand. 10. de Graaf JA, Schepers VPM, Nijsse B, van Heugten
John Davison: Consultant Clinical Neuropsychologist CM, Post MWM, Visser-Meily JMA. The influence
and Service Lead, Community Rehabilitation, Whatu of psychological factors and mood on the course
Ora Te Toka Tumai Auckland, New Zealand. of participation up to four years after stroke.
Ginny Abernethy: Co-ordinator, National Stroke Disabil Rehabil. 2022 May;44(10):1855-1862. doi:
Network, New Zealand. 10.1080/09638288.2020.1808089.
11. Boden-Albala B, Litwak E, Elkind MSV, Rundek
corresponding author T, Sacco RL. Social isolation and outcomes post
Dr Felicity Bright: School of Clinical Sciences, Auckland stroke. Neurology. 2005 Jun 14;64(11):1888-92. doi:
University of Technology, Private Bag 92006, 10.1212/01.WNL.0000163510.79351.AF.
Auckland 1142, New Zealand. Ph: 09 921 9999 x7097. 12. Schindel D, Schneider A, Grittner U, Jöbges M,
E: [email protected] Schenk L. Quality of life after stroke rehabilitation
discharge: a 12-month longitudinal study.
references Disabil Rehabil. 2021 Aug;43(16):2332-2341. doi:
1. Ranta A. Projected stroke volumes to provide a 10.1080/09638288.2019.1699173.
10-year direction for New Zealand stroke services. N 13. Hill G, Regan S, Francis R, Mead G, Thomas S,
Z Med J. 2018 Jun 22;131(1477):15-28. Al-Shahi Salman R, et al. Research priorities
2. Guo J, Wang J, Sun W, Liu X. The advances of to improve stroke outcomes. Lancet Neurol.
post-stroke depression: 2021 update. J Neurol. 2022 Apr;21(4):312-313. doi: 10.1016/
2022 Mar;269(3):1236-1249. doi: 10.1007/ S1474-4422(22)00044-8.
s00415-021-10597-4. 14. Allida S, Cox KL, Hsieh CF, Lang H, House A,
3. Knapp P, Dunn-Roberts A, Sahib N, Cook L, Hackett ML. Pharmacological, psychological,
Astin F, Kontou E, et al. Frequency of anxiety and non-invasive brain stimulation interventions
after stroke: An updated systematic review and for treating depression after stroke. Cochrane
meta-analysis of observational studies. Int J Database Syst Rev. 2020 Jan 28;1(1):CD003437. doi:
Stroke. 2020;15(3):244-55. Apr;15(3):244-255. doi: 10.1002/14651858.CD003437.pub4.
10.1177/1747493019896958. Erratum in: Int J 15. Green G, Maddula M. New Zealand Stroke
Stroke. 2021 Dec;16(9):NP2. Rehabilitation: A Strategy [Internet]. Wellington,
4. Ayerbe L, Ayis S, Crichton S, Wolfe CD, Rudd AG. New Zealand: National Stroke Network; 2018
The natural history of depression up to 15 years [cited 2022 Jul 31]. Available from: https://www.
after stroke: the South London Stroke Register. strokenetwork.org.nz/resources/rehab-strategy.
Stroke. 2013 Apr;44(4):1105-10. doi: 10.1161/ 16. Theadom A, Rutherford SJ, Kent B, McPherson
STROKEAHA.111.679340. KM. The process of adjustment over time
5. Kristo I, Mowll J. Voicing the perspectives of stroke following stroke: A longitudinal qualitative study.
survivors with aphasia: A rapid evidence review of Neuropsychol Rehabil. 2019 Oct;29(9):1464-1474.
post-stroke mental health, screening practices and doi: 10.1080/09602011.2018.1440609.
lived experiences. Health Soc Care Community. 17. National Stroke Network - Rehabilitation Working
2022 Jul;30(4):e898-e908. doi: 10.1111/hsc.13694. Group. Take Action for Stroke Rehabilitation
6. Azios JH, Strong KA, Archer B, Douglas NF, [Internet]. Wellington, New Zealand: National
Simmons-Mackie N, Worrall L. Friendship matters: Stroke Network; 2020 [cited 2022 Jul 31]. Available
a research agenda for aphasia. Aphasiology. from: https://www.strokenetwork.org.nz/
2021:1-20. resources/recommendations-rehabilitation-for-

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 58

stroke-patients. on stroke care access and patient outcomes: a New

18. Lanctôt KL, Lindsay MP, Smith EE, Sahlas DJ, Zealand nationwide observational study. Lancet
Foley N, Gubitz G, et al. Canadian Stroke Best Reg HealthWest Pac. 2022 Jan 3;20:100358. doi:
Practice Recommendations: Mood, Cognition 10.1016/j.lanwpc.2021.100358.
and Fatigue following Stroke, 6th edition update 24. McLellan KM, McCann CM, Worrall L, Harwood
2019. Int J Stroke. 2020 Aug;15(6):668-88. doi: M. Māori experiences of aphasia therapy: “But
10.1177/1747493019847334. I’m from Hauiti and we’ve got shags”. Int J
19. Stroke Foundation of New Zealand. Clinical Speech Lang Pathol. 2014 Oct;16(5):5219-40. doi:
guidelines for stroke management [Internet]. 10.3109/17549507.2013.864334.
Wellington, New Zealand: Stroke Foundation of 25. Mountain A, Patrice Lindsay M, Teasell R, Salbach
New Zealand; 2010 [cited 2022 Jul 31]. Available NM, de Jong A, Foley N, et al. Canadian Stroke
from: https://www.health.govt.nz/publication/ Best Practice Recommendations: Rehabilitation,
new-zealand-clinical-guidelines-stroke- Recovery, and Community Participation following
management-2010. Stroke. Part Two: Transitions and Community
20. McNaughton H, McRae A, Green G, Abernathy G, Participation Following Stroke. Int J Stroke. 2020
Gommans J. Stroke rehabilitation services in New Oct;15(7):789-806. doi: 10.1177/1747493019897847.
Zealand: A survey of service configuration, capacity 26. Stroke Association. Feeling Overwhelmed
and guideline adherence. N Z Med J. 2014 Sep [Internet]. United Kingdom: 2015. Available from:
12;127(1402):10-9. https://www.stroke.org.uk/sites/default/files/
21. Gilham S, Clark L. Psychological care after feeling_overwhelmed_final_web_0.pdf.
stroke [Internet]. London, United Kingdom: NHS 27. Kneebone II. Stepped psychological care after
Improvement; 2011. Available from: https://www. stroke. Disabil Rehabil. 2016 Sep;38(18):1836-43.
nice.org.uk/media/default/sharedlearning/531_ doi: 10.3109/09638288.2015.1107764.
strokepsychologicalsupportfinal.pdf. 28. Bright FAS, Davison J, on behalf of the Psychosocial
22. Dudley M, Wilson D, Barker-Collo S. Cultural Working Group. Supporting psychosocial well-
invisibility: Māori people with traumatic brain being after stroke. Wellington, New Zealand:
injury and their experiences of neuropsychological National Stroke Network; 2022 [cited 2022 Nov
assessments. NZ J Psychol. 2014;43(3):14-21. 22]. Available from: https://static1.squarespace.
Available from: https://www.psychology.org.nz/ com/static/623a8069f9d2f75196b75b1b/t/6
journal-archive/Cultural-Invisibility.pdf. 37bfc412749627d280748b7/1669069947407/
23. Thompson SG, Barber PA, Gommans JH, Cadilhac NSN+Psychosocial+toolkit++Doc_FINAL.pdf.
DA, Davis A, Fink JN, et al. The impact of ethnicity

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
article 59

Appendix What needs to change?

Survey questions.
1. There are a number of groups who report
Service information limited psychosocial support from services
e.g., Māori, people with communication/
1. Please indicate in which DHB your service is cognitive impairments, residential care.
located What would help your service better support
2. Please indicate which services you work the psychosocial needs of these groups?
within (options: Hyperacute, acute, inpatient 2. What would help increase the confidence
rehab, community rehab, primary care, NGO, and competence of your team when
other) supporting people’s psychosocial needs?
3. Please indicate which disciplines/roles are 3. Do you have any other comments or
represented within your team (as routine or reflections that would be helpful for the
by referral only) (options: medical, nursing, working group who are developing a model
occupational therapy, physiotherapy, speech- of psychosocial care for stroke services?
language therapy, social work, assistant,
psychologist, community stroke advisor,
Māori cultural support, Pacific cultural
support, Asian cultural support, other)

Current service provision

1. How are psychosocial needs identified in your

service?
2. If routine screening occurs, please provide
details of this
3. How is the psychosocial well-being of people
with stroke currently supported within the
service
4. For stroke survivors
5. For family and whānau
6. For Māori and Pacific People
7. What resources do you use to support your
patients and whānau (e.g., educational material,
community support groups)?
8. What psychosocial supports are available once a
person has left the DHB stroke service?

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
review article 60

The impact of AI and ChatGPT on

research reporting
Zubair M Mojadeddi, Jacob Rosenberg

Abstract
ChatGPT and the newest GPT-4 are AI language models developed by OpenAI that have gained attention for their potential applications
in biomedical research reporting. The models can assist researchers in various stages of writing scientific articles, including literature
search, outlining, writing different sections, formatting, and translation. The use of ChatGPT or GPT-4 in research reporting has the
potential to speed up the writing process, but its limitations, such as incorrect answers and biases, should also be considered. There is
ongoing debate over the issue of AI authorship in scientific papers, with some publishers allowing it to be listed as a contributor in the
acknowledgements section, while others do not allow it to be listed as an author. The use of ChatGPT or GPT-4 in research reporting is a
recent development, and further studies and discussions are needed to determine their potential and limitations in this field.

T The capabilities of ChatGPT

he idea of artificial intelligence (AI) was first
introduced in the 1950s.1–4 A subfield of AI is
Natural Language Processing (NLP), which ChatGPT can help researchers in various
is the ability of a computer program to understand phases of writing scientific articles (Figure 1). We
the human language.1,5 However, the concept of verified the answers given by the robot in Figure
large language models (LLM) as we know them 1 and also tried other possible features in multiple
today is a type of NLP6 that is a program capable of sessions. It turned out that the robot can:
producing human language and answers based on
large data.7 In recent years, many language models • Identify relevant literature, information, and
such as Google Neural Machine Translation (GNMT)8 potential collaborators such as researchers
and the Bidirectional Encoder Representation and institutions.
from Transformers (BERT)9 have been created. In • Identify relevant topics and trends in the
2018, OpenAI launched its first model, the Gen- respected research fields.
erative Pre-trained Transformer (GPT),10 which • Organise ideas and create an outline for an
was followed by further development resulting article.
in GPT-2 and GPT-3.6,11 In November 2022, OpenAI • Conduct a literature review, such as
introduced ChatGPT, which is currently freely providing relevant articles and studies.
available online.12 The latest version, GPT-4, was • Write different sections of an article, such
made publicly available for a user fee in March as the introduction, methods, results, and
2023. GPT-4 is currently the most advanced sys- discussion.
tem available to the public, as it is based on more • Produce an abstract that fits the article.
background information, with more advanced • Help with grammar, syntax, and style.
problem solving and greater accuracy.13 • Format the manuscript according to the
Since the launch of ChatGPT, it has garnered the journal’s guidelines.
attention of many people worldwide, including • Give ideas as to how charts, graphs, and
biomedical researchers, as it appears to be able figures could be constructed if data is
to substantially assist in the reporting process of explained in text format (the answer would
biomedical research (article writing). This raises then also be in text format).
questions such as: how should AI be understood • Assist with the communication for research
in the context of research reporting? What can AI through blogs and social media by writing
help researchers with? How should the implemen- laymen’s descriptions and giving ideas as to
tation of ChatGPT be used in the world of research? what type of post could be relevant on social
Could this mean that a paradigm shift in the field of media.
research reporting is on the horizon? • Write conference abstracts.
• Translate manuscripts into other languages.

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
review article 61

• Write a covering letter. because it cannot take responsibility for the con-
• Produce title pages. tent of the scientific paper.14,17 Furthermore, the
• Format references to specific citation styles. editors of Nature17 and Science14 will not allow AI
to be listed as an author, and the publisher Tay-
These are some of the ways ChatGPT can assist lor and Francis prefers that the AI be mentioned
researchers; however, the quality of the AI output in the acknowledgements section as a contribu-
has not yet been formally tested against corre- tor.17 Due to increased use of AI, publishers will
sponding human work. Nevertheless, it is obvious need to decide on authorship issues for this new
that the robot can provide substantial help for the player in the field. Nature, along with Springer
researcher in the reporting phases of scientific work. Nature journals, have formulated two rules in
This means that a paradigm shift may be on the their author guidelines23: “Large Language Mod-
way for how research is reported in the future, els (LLMs), such as ChatGPT, do not currently sat-
potentially making it possible to produce an isfy our authorship criteria. Notably, attribution
astonishing number of scientific articles within a of authorship carries with it accountability for the
short time frame once we have learned the potential work, which cannot be effectively applied to LLMs.
of the robotic platform and how it can assist the Use of an LLM should be properly documented
researcher without compromising on quality. in the Methods section (and if a Methods section
Even though AI can help researchers in numerous is not available, in a suitable alternative part)
ways, it is not free from limitations. For example, of the manuscript.” This is fully compliant with
ChatGPT sometimes provides incorrect answers, the authorship criteria described by the Inter-
and it may reference an article that does not national Committee of Medical Journal Editors
exist.14 Furthermore, the possibility of bias in the (ICMJE)24: “1) Substantial contributions to the con-
responses is unknown as the end-user has no ception or design of the work; or the acquisition,
control of the input data sources for the robot. analysis, or interpretation of data for the work;
Thus, there is a theoretical risk that some infor- AND 2) Drafting the work or revising it critically
mation regarding a topic can be left out, which for important intellectual content; AND 3) Final
could possibly lead to misinformation being approval of the version to be published; AND 4)
spread about a topic. An example could be that Agreement to be accountable for all aspects of the
some controversial articles or data would be left work in ensuring that questions related to the accu-
out of the AI’s data. Finally, every researcher racy or integrity of any part of the work are appro-
using AI should, of course, check the output infor- priately investigated and resolved.”
mation for credibility. Thus, since the robot cannot be accountable for
There has been concern that answers by the all aspects of the work, byline authorship is not an
robot are so well-formulated and intelligent that option for an LLM such as ChatGPT. Depending on
it could be difficult to distinguish them from text the amount of contribution, it would be appropriate
produced by humans. However, new software can to mention ChatGPT in the methods section or as
now detect AI-generated text such as GPTZero15 a formal contribution in the acknowledgements
and the AI classifier,16 although they have not yet section.
been tested systematically.
Discussion
The issue of authorship
In its current version, the AI chatbot can,
When a robot assists in the writing process in principle, be seen as a medical writer. A
of a scientific paper, it is necessary to consider medical writer is a professional author with
whether the AI assistant should be accredited as a skills in language and writing,25 and they can pro-
co-author in the byline. Another possibility would be vide grant writing, laymen descriptions, scientific
to mention it in the methods section or give credit for articles, and more. 25,26 When outsourcing parts of
the contribution in the acknowledgements section. the research process is already normal, why not
Since the launch of ChatGPT, publishers have outsource part of the writing process to a medical
been trying to create authorship policies for writer or an AI robot? We already use research
the new chatbot.14,17 Currently, three articles and assistants for data collection and statisticians for
two preprints have an AI robot as a co-author.18–22 statistical analyses, so maybe it’s time to use AI
Publishers and preprint servers typically agree for various phases of manuscript production. The
that ChatGPT does not fulfill the authorship criteria cost for researchers using AI is substantially lower

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
review article 62

than paying for a medical writer, so maybe we could co-author. Depending on the contribution, the
consider the AI robot as a low-cost medical writer. AI could be thanked in the acknowledgements
An important issue, however, is the quality of section or mentioned in the methods section of
the AI output. We don’t yet know if it is as good the paper. Documenting where the AI has assisted
as a professional medical writer. With our limited will heighten the transparency and credibility
experience at present, we seriously doubt that the of the work. Furthermore, it should be noted
AI quality is good enough, but since AI has learning that ChatGPT or GPT-4 are not yet at the level of
capability and since the current versions of these a professional medical writer, and further inves-
models are still in their infancy, we don’t know tigation and research need to be conducted with
what the future will bring. AI to fully understand its capabilities. These inter-
Some researchers may be concerned that the esting new developments could mean a drastic
ease of use and low cost may trigger research paradigm shift in the field of research reporting,
misconduct with fabricated results, unintentional where various tasks may soon be taken over by
errors, or deceptive publications. However, mis- AI platforms. AI is available to every researcher,
conduct can occur with or without AI, and with whereas a medical writer is only available with
our current knowledge of these systems, we sufficient funding, so AI could potentially become
don’t believe that it would become worse or bet- more widespread than the use of a professional
ter with AI for research reporting. Rather, AI in medical writer. These AI systems are still in their
research reporting should be seen as a “low-cost infancy, and the development is exponential.
medical writer”, although we are not fully there Therefore, we are facing substantial changes in
yet regarding quality. research reporting where tasks other than article
In conclusion, AI could probably be used as writing may become the main focus for researchers
a medical writer for at least some parts of the in biomedicine in the near future.
article production phases, but in our opinion, this
does not mean that the AI should be listed as a

Figure 1: We asked the robot how it could help if we wanted to write a scientific paper. The question and answers
are shown in the figure.

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
review article 63

competing interests 7. Bengio Y, Ducharme R, Vincent P, Jauvin C. A Neural

Nil. Probabilistic Language Model. J Mach Learn Res
2003;3:1137-1155.
acknowledgements 8. Wu Y, Schuster M, Chen Z, Quoc V, Norouzi M,
The ChatGPT suggested a title and an abstract for this Macherey W et al. Google’s Neural Machine
article after giving the full text to the robot (the full text Translation System: Bridging the Gap between
was written by the authors). Human and Machine Translation. arXiv [Internet].
2016 [cited 2023 Jan 31]; 1609.08144v2. doi:
author information 10.48550/arXiv.1609.08144.
Zubair M. Mojadeddi, MS: Center for Perioperative 9. Devlin J, Chang M-W, Lee K, Toutanova K. BERT:
Optimization, Department of Surgery, Herlev and Pre-training of Deep Bidirectional Transformers
Gentofte Hospital, University of Copenhagen, for Language Understanding. arXiv [Internet]. 2019
Copenhagen, Denmark. [cited 2023 Jan 31] 1810.04805v2. doi: 10.48550/
Jacob Rosenberg, MD, DSc: Center for Perioperative arXiv.1810.04805.
Optimization, Department of Surgery, Herlev and 10. Radford A, Narasimhan K, Salimans T, Sutskever
Gentofte Hospital, University of Copenhagen, I. Improving Language Understanding by
Copenhagen, Denmark; Department of Clinical Generative Pre-Training. Semantic Scholar
Medicine, Faculty of Health and Medical Sciences, [Internet]. 2018 [cited 2023 Jan 31]. Available
University of Copenhagen, Denmark. from: https://www.semanticscholar.org/
paper/Improving-Language-Understanding-
corresponding author by-Generative-Radford-Narasimhan/
Zubair M. Mojadeddi: Center for Perioperative cd18800a0fe0b668a1cc19f2ec95b5003d0a5035.
Optimization, Department of Surgery, Herlev and 11. Brown TB, Mann B, Ryder N, Subbiah M, Kaplan
Gentofte Hospital, University of Copenhagen, J, Dhariwal P. Language Models are Few-Shot
Copenhagen, Denmark, Ph: +45 42 70 26 60, Learners. arXiv [Internet]. 2020 [cited 2023 Feb
E: [email protected] 1];14165v4. doi: 10.48550/arXiv.2005.14165.
12. Introducing ChatGPT. OpenAI [Internet]; c2015-2023
references [cited 2023 Jan 30]. Available from: https://openai.
1. Kaul V, Enslin S, Gross SA, History of artificial com/blog/chatgpt/.
intelligence in medicine. Gastrointest Endosc. 2020 13. GPT-4 is OpenAI’s most advanced system, producing
Oct;92(4): 807-812. doi: 10.1016/j.gie.2020.06.040. safer and more useful responses. OpenAI [Internet];
2. Amisha, Malik P, Pathania M, Rathaur VK. Overview c2015-2023 [cited 2023 Mar 27]. Available from:
of artificial intelligence in medicine. J Family Med https://openai.com/product/gpt-4/.
Prim Care. 2019 Jul;8(7):2328-2331. doi: 10.4103/ 14. Thorp HH. ChatGPT is fun, but not an author.
jfmpc.jfmpc_440_19. Science [Internet]. 2023 Jan [cited 2023 Feb 1];
3. Ramesh AN, Kambhampati C, Monson JR, 379(6630): 313. Available from: https://www.
Drew PJ. Artificial intelligence in medicine. Ann science.org/doi/10.1126/science.adg7879.
R Coll Surg Engl. 2004 Sep;86(5):334-8. doi: 15. Ofgang E. What is GPTZero? The ChatGPT Detection
10.1308/147870804290. Tool Explained By Its Creator. Tech & Learning
4. Holmes JH, Sacchi L, Bellazzi R, Peek N. [Internet]; 2023 Jan 27 [cited 2023 Jan 30]. Available
Artificial Intelligence in Medicine AIME 2015. from: https://www.techlearning.com/news/what-is-
Artif Intell Med. 2017 Sep;81:1-2. doi: 10.1016/j. gptzero-the-chatgpt-detection-tool-explained.
artmed.2017.06.011. 16. Kirchner JH, Ahmad L, Aaronson S, Leike J.
5. Lutkevich B, Burns E. Natural language New AI classifier for indicating AI-written text.
processing (NLP) [Internet]. TechTarget. 2023 OpenAI [Internet] 2023 Jan 31 [cited 2023 Feb
[cited 2023 Jan 31]. Available from: www. 2]. Available from: https://openai.com/blog/
techtarget.com/searchenterpriseai/definition/ new-ai-classifier-for-indicating-ai-written-text/.
natural-language-processing-NLP. 17. Stokel-Walker C. ChatGPT listed as author on
6. Radford A, Wu J, Child R, Luan D, Amodei D, research papers: many scientists disapprove.
Sutskever I. Language Models are Unsupervised Nature 2023 Jan 18 [cited 2023 Feb 2];613:620-621.
Multitask Learners. Cloudfront [Internet]. 2018 doi: 10.1038/d41586-023-00107-z.
[cited 2023 Jan 31]. Available from: https:// 18. Kung T, Cheatham M, ChatGPT, Medenilla A, Sillos
d4mucfpksywv.cloudfront.net/better-language- C, De Leon L. Performance of ChatGPT on USMLE:
models/language-models.pdf. Potential for AI-Assisted Medical Education Using

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
review article 64

Large Language Models. Preprint at medRxiv Education. Cell Mol Bioeng 2023;16:1-2. doi:
[Internet] 2022 Dec 21 [cited 2023 Feb 2]. doi:10.110 10.1007/s12195-022-00754-8.
1/2022.12.19.22283643. 23. For authors: initial submission. Nature; c2023 [cited
19. O’Connor S, ChatGPT. Open artificial intelligence 2023 Jan 31]. Available from: https://www.nature.
platforms in nursing education: Tools for com/nature/for-authors/initial-submission.
academic progress or abuse? Nurse Educ Pract 24. Defining the Role of Authors and Contributors.
2023;66:103537. doi:10.1016/j.nepr.2022.103537. International Committee of Medical Journal Editors;
20. ChatGPT Generative Pre-trained Transformer, c2023 [cited 2023 Jan 31]. Available from: https://
Zhavoronkov A. Rapamycin in the context of www.icmje.org/recommendations/browse/roles-
Pascal’s Wager: generative pre-trained transformer and-responsibilities/defining-the-role-of-authors-
perspective. Oncoscience 2022;9:82-84. doi: and-contributors.html.
10.18632/oncoscience.571. 25. Burcharth J, Pommergaard HC, Danielsen AK,
21. Gpt Generative Pretrained Transformer, Thunström Rosenberg J. Medical writers i medicinsk forskning
A, Steingrimsson S. Can GPT-3 write an academic [Medical writers in medical research]. Ugeskr Laeger
paper on itself, with minimal human input? HAL 2013 Aug 19;175(34):1867-70.
open science [Internet] 2022 [cited 2021 Feb 2]. 26. Ultimate Guide to Becoming a Medical Writer.
Available from: https://hal.science/hal-03701250/ American Medical Writers Association; c2021
document. [cited 2023 Jan 31]. Available from: https://info.
22. King M, chatGPT. A Conversation on Artificial amwa.org/ultimate-guide-to-becoming-a-medical-
Intelligence, Chatbots, and Plagiarism in Higher writer#what_is_medical_writing.

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
viewpoint 65

Inclusive medical education for

students with disabilities: a new
guidance document from Medical
Deans Australia and New Zealand
Dabrina Issakhany, Peter Crampton, members of the Medical Deans Inherent
Requirements Review Working Group

abstract
This paper outlines: 1) the work undertaken by Medical Deans Australia and New Zealand (MDANZ) to review and update its 2017
guidelines related to selecting and supporting students with disabilities, and 2) the resulting new recommendations. The review
group considered common approaches to supporting medical students with a disability through an inclusive, strengths-based lens.
The outcome was a guidance document that centres the importance of a strengths-based and inclusive culture within medical
schools, and emphasises an individualised, context-specific and inclusive approach based on early, open dialogue. Strong project
governance and broad consultation were critical to achieving this outcome. As social norms and technologies evolve, regular re
examination of guidance on how to support potential or current medical students with a disability will be necessary.

I
n both New Zealand’s medical schools, and in tation that the majority of graduates will practice
medical schools in Australia, there are ongoing as doctors. These factors, along with the regu-
efforts to increase the representativeness of latory context and the requirement for patient
medical student cohorts, with the aim of ensuring safety during medical school training, add layers
that they better reflect the different communities of complexity to medical education in relation to
they will serve, particularly in terms of ethnicity, rural how medical schools select, support and educate
background and socio-economic background.1,2,3 students.
The current health reforms in New Zealand place People with disabilities have long faced chal-
emphasis on health workforce development as a lenges in studying medicine.7 It is likely that people
means of achieving equitable health outcomes.4 with a disability have historically been under-
The focus of this article is on students with a dis- represented in the medical profession.7 Contrib-
ability, and how to increase the representativeness uting factors include the heterogenous nature of
of the medical workforce for people with a disability. disabilities, and students’ fear of disclosing their
We summarise the main recommendations of a new disability because of stigma and concern that
guidance document from Medical Deans Australia doing so might have negative consequences for
and New Zealand (MDANZ), which argues that the future training and career opportunities.7,8,9,10,11
culture of medical schools is of central importance We recognise that there are differing views
in ensuring that students with a disability are within the disability community about how people
welcomed into medical schools, feel safe and are with a disability prefer to be acknowledged. We
valued for their strengths and perspectives.5 This have chosen to refer to “students with a disability”
principle applies equally to students who acquire as this language is reflective of the “person first”
a disability while they are at medical school. approach in the United Nations Convention on
Medical schools in New Zealand and Austra- Rights of Persons with Disabilities, which both
lia have a history of educating graduates who meet Australia and New Zealand have ratified. We have
the accreditation standards of the Australian Med- consulted widely and acknowledge our use of
ical Council and are, theoretically, capable of pur- language may not be consistent with preferences
suing any branch of medicine.6 Unlike many among some disability stakeholders.
other university courses, medical education is Recently, MDANZ reviewed its 2017 guidelines
outcomes based and closely linked to the expec- Inherent requirements for studying medicine in

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
 viewpoint 66

Australia and New Zealand.12 The term “inherent and assessing the ability to demonstrate achieve-
requirement” refers to “the fundamental components ment, including reasonable adjustments, and
of a course or unit that are essential to demonstrate the statutory and regulatory landscape where
the capabilities, knowledge and skills to achieve these assessments take place. “Reasonable adjust-
the core learning outcomes of the course or unit, ments” refers to the provision of supports that are
while preserving the academic integrity of the uni- considered reasonable to enable students who
versity’s learning, assessment and accreditation have a disability to participate on the same basis
processes”.12 The 2017 guidelines were intended as students without a disability.13
to aid medical schools’ selection processes and The final guidance document was fully
enable greater access for students with a disability endorsed by MDANZ and released in 2021.
to study medicine, while maintaining safe clinical
care.12 This paper outlines the process and out- Outcome of the review
come of the review of the 2017 guidelines.
The review resulted in the new MDANZ guid-
Process of the review ance document, Inclusive Medical Education: guid-
ance for applicants and medical students with a
A working group was established by MDANZ in disability.5 It proposes a strengths-based approach
2019 to lead the review process, which is presented to supporting students with a disability to study
in Figure 1. Members included representatives medicine and identifies seven key elements for
from 13 medical schools, regulators of primary medical schools to consider in facilitating an
medical programs and medical practitioners in environment that supports potential or current
Australia and New Zealand, and representatives of students with a disability to study medicine,
student and disability peak bodies. Evidence was presented in Figure 2. This strengths-based
gathered through a literature review and two sep- approach places value on the perspectives and
arate and extensive consultation processes. The experiences that students with a disability bring to
group explored the impacts of the 2017 Inherent medical training and to the practice of medicine.
requirements document and its equivalent in other The new document presents a shift in thinking
jurisdictions, factors to consider when developing away from a medical model of disability, towards

Figure 1: Review process of the 2017 guideline statement.

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
viewpoint 67

Figure 2: Key areas to promote an inclusive culture and support students with a disability.

Source: Medical Deans Australia and New Zealand. Inclusive Medical Education – guidance on applicants and students with a
disability. Sydney, Australia; 2021.

a social model of disability, which recognises that to registration, internship or future employment.
a person’s ability to complete a task is influenced Matters of fitness to practice and competency are
by their interaction with their context (the envi- separate and may only in specific circumstances
ronmental and personal factors unique to their be related to a person’s disability. Assessing the
situation).14 capacity of a student with a disability to progress
Medical schools operate in an area of some ten- through a medical degree should not be conflated
sion. There are times when regulatory requirements, with their fitness to practice or competency, without
the law, and the expectations of students, those who first assessing whether adjustments required are
employ medical graduates or fund medical training reasonable.
may be in conflict. In addition, medical education The review also demonstrated how a narrow or
is both theory and practice based. It requires active broad interpretation of a single regulatory stan-
participation in diverse workplace environments dard can determine whether a person is eligible to
to develop the skills necessary to meet regulatory train as a doctor. For example, does “performing
standards and to become a competent doctor. CPR” require a student to physically perform the
In providing outcomes-based education and task themselves or can they direct others to do so?
involving patients in learning and assessment In this sense, regulatory standards can be seen as a
activities, medical schools sit at the intersection of powerful enabler or barrier to inclusion, depending
these factors.10,15,16 on how learning outcomes are phrased.
Given the individual nature of each person’s The working group, which included members
abilities and circumstances, a guidance docu- with a disability, disability rights advocates and
ment cannot resolve all the tensions. Rather, representatives from regulatory bodies, made
principles-based guidance was developed to the decision to steer away from providing scenar-
support decision making by medical schools and ios and examples in the guidance document. The
potential or current students with a disability. basis for this decision was that examples would
To this end, students with a disability should be necessarily need to be abbreviated and simpli-
provided with early and ongoing information fied for inclusion in the new guidance document,
about their career options, and clear expecta- running the risk of taking the emphasis off the
tions about what can and cannot be assured by need for positive cultural settings within medical
a medical school so that students can be empow- schools and the centrality of good processes (as
ered to make decisions about their own future. illustrated in Figure 2), the risk of essentialising
This process may include early consultation with different aspects of disability and the risk of not
the Medical Council of New Zealand to ensure the properly conveying the complex, interdependent
student and medical school have a shared under- variables that go into decision making. Reason-
standing of any possible limitations or challenges able adjustments are made at different points in

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
viewpoint 68

a medical degree in the context of diverse assess- active, deliberate and multifaceted approach
ments and learning and working environments across all stages of a medical program. This
where students are assessed. In addition are the approach seeks to work with students with a
highly individualised natures of individuals’ disability and empower them to feel confident
disabilities and the varied facilities available seeking adjustments where required. It also sets
at universities and health services. Instead, the out the opportunities for medical schools to be
working group recommended the formation of proactive in developing learning environments
a Special Interest Group for Australian and New that are inclusive for all students, with or with-
Zealand medical school staff to share experiences out disabilities. This includes empowering and
and learnings to better support applicants and motivating staff to actively seek opportunities
students with a disability. Establishing this net- to support and enable students with a disability
work provides an ongoing community of practice to study medicine if they desire, and to meet the
for discussion and debate acknowledging that, relevant selection criteria. In this sense the onus
because of the individualised nature of disability, on facilitating an inclusive culture and environ-
it is not possible or desirable to construct strict ment is shared between both students and the
“rules” in relation to students with a disability. medical school. The process of the review pro-
vided insights into the challenges faced by stu-
Discussion dents with a disability and medical schools in
supporting them, and the necessity of ongoing
The new guidance document was underpinned reflections on the progression of social norms in
by the following principles: the area of disability. The review also required an
examination of the assumptions, biases and pre-
• Adopt an inclusive, strengths-based conceptions of those engaged in the review pro-
approach. cess. For example, should a student with limited
• Problematise the learning environment mobility in their arms be automatically consid-
rather than the disability. ered ineligible for studying medicine if they could
• Adopt a social model for disability that not undertake a physical examination without
considers each person’s abilities on an assistance? The working group consistently chal-
individualised, context-specific basis. lenged assumptions that, by default, people with
• Encourage early and open dialogue through a disability should be excluded from medical edu-
inclusive practices and culture. cation because they cannot undertake a task in an
identical manner to a person without a disability.
The guidance acknowledges that: no two students While the guidance document acknowledges that,
are the same, even if their conditions appear even with reasonable adjustments, there may be
similar; context matters; people with less-visible cases where a student will not be able to meet the
disabilities often face different challenges com- requirements of the medical program, this should
pared to those with more visible disabilities;17 not be the default or primary assumption. Rather,
and a person’s abilities also change depending the emphasis is on early discussion between the
on their learning or working environment, or the medical school and applicant or student about
activities expected of them.17 what alternative means are available and rea-
Facilitating an inclusive culture in medical sonable to enable the student to undertake the
schools, one that values and proactively enables the programme’s components and demonstrate their
participation of diverse students, was identified as achievements in all key areas.
fundamental to implementing a strengths-based A broadly representative working group,
approach. Supporting students relies on early dis- extensive consultation and inclusion of people
closure by students with a disability. To do this, with a disability were critical to creating a new,
students need to feel confident that disclosing widely accepted document. The diverse mix in
their disability will not have an adverse effect the working group of senior leaders from medical
on their application or progression. An inclu- schools and regulatory bodies, university support
sive culture not only enables this, it also makes staff, students and people with lived experience of
students with disabilities feel seen and valued for completing medical school with a disability made
their abilities. challenges to traditional thinking more likely and
The approach set out in Figure 2 demonstrates welcome. The inclusion in the working group of
how achieving an inclusive culture requires an people with the experience of completing medical

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
viewpoint 69

school with a disability provided insights about gibility for registration as a medical practitioner
what matters to people with a disability and the after graduation—this decision is made by the
challenges they face in medical school and in Medical Council of New Zealand based on regula-
employment. Targeted and extensive consulta- tory requirements. This division of responsibility
tion provided insights from stakeholders who adds a layer of complexity when assessing the
play a role in the accreditation, design, delivery reasonableness of adjustments in both learning
and funding of medical education, as well as from and workplace environments.
those responsible for registration and employ- The COVID-19 pandemic has only exacerbated
ment. Consultation also highlighted challenges resource constraints across the university sector
that cannot be solved by guidance alone, but can and in some instances has significantly reduced
be mitigated through open dialogue between capacity in the hospital sector to support the
medical schools and applicants and students. essential education and training of medical stu-
Social norms will continue to evolve, requiring dents. These pressures add further complexity
careful and frequent re-examination of both new to ensuring the preparedness of graduates for
technologies that will enable greater participation practice, and the breadth of potential adjustments
and biases related to who can and should be required to achieve this.
our doctors. How these biases are manifested in Areas for future work could include the sharing
our policies, processes and regulatory standards of good practice examples of reasonable adjust-
related to the education and registration of future ments that enable a range of people with a disability
doctors will change over time, and constant vigi- to study medicine, and also sharing experiences of
lance will be required. the limitations of reasonable adjustments.
Navigating through the practicalities of providing
support that meets students’ environmental and Conclusion
personal needs—and the legal, regulatory and
policy framework in place—poses challenges. The review explored evolving medical, health
While centralised disability services provide and social attitudes in relation to people with
university-wide support, identifying and tailor- disabilities, resulting in a strengths-based guid-
ing adjustments that meet the specific, and often ance document that is reflective, we hope,
unique, demands of the medical programme is of our aspirations for inclusiveness. An inclu-
resource- and time-intensive for medical school sive approach to medical education is essential
staff. This process may require extensive and to achieving equitable representation of doc-
ongoing consultation with a range of stakeholders, tors with a disability in the medical workforce.
including supervisors and coordinators at different This work is never complete—as social norms
clinical placement or workplace locations, and and technologies evolve, re-examination of our
potentially engagement with regulatory bodies as expectations and approaches will continue to be
well as with the student themselves. Additionally, necessary.
medical schools do not determine a student’s eli-

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
viewpoint 70

competing interests 5. Medical Deans Australia and New Zealand

There was no external funding source for preparing this [Internet]. Inclusive Medical Education: guidance
article. The views, opinions, findings and conclusions on applicants and students with a disability.
or recommendations expressed in this paper are strictly Sydney, Australia; 2021 [cited 2021 Aug]. Available
those of the authors. They do not necessarily reflect the from: https://medicaldeans.org.au/md/2021/04/
views of the institutions where the authors currently Inclusive-Medical-Education-Guidance-on-medical-
work. program-applicants-and-students-with-a-disability-
Apr-2021-1.pdf.
acknowledgements 6. Australian Medical Council [Internet]. Standards for
We are grateful for the helpful and insightful comments Accreditation and Assessment of Primary Medical
made by the anonymous reviewers of the paper. Programs. Australian Capital Territory, Australia;
The article was developed by the authors following 2012 [cited 2021 Aug]. Available from: https://
discussions with the Inherent Requirements Review www.amc.org.au/wp-content/uploads/2019/10/
Working Group (IRRWG) of the Medical Deans Standards-for-Assessment-and-Accreditation-of-
Australia and New Zealand. The authors would like to Primary-Medical-Programs-by-the-Australian-
acknowledge the contributions to this article of the Medical-Council-2012.pdf.
IRRWG members. 7. Shrewsbury D, Mogensen L, Hu W. Problematizing
Medical Deans Australia and New Zealand would like medial students with disabilities: A critical
to acknowledge the work of the authors in reflecting policy analysis [version 1]. MedEd Publish.
in this article the process, outcomes and opportunities 2018 Feb:7(1)45-56. https://doi.org/10.15694/
created through Medical Deans’ work, and also their mep.2018.0000045.1.
contribution as IRRWG members to the development of 8. Mogensen L, Hu W. “A doctor who really knows…”:
our guidance document on Inclusive Medical Education a survey of community perspectives on medical
for students and applicants with a disability. students and practitioners with a disability.
BMC Med Educ. 2019 Jul;19(1):288. https://doi.
author information org/10.1186/s12909-019-1715-7.
Dabrina Issakhany: Independent researcher. 9. Venville A. Risky business: Mental illness,
Peter Crampton: Kōhatu, Centre for Hauora Māori, disclosure and the TAFE student. Int J Train Res.
University of Otago. 2010:8(2):128-140.
10. McNaught K. The potential impacts of ‘inherent
corresponding author requirements’ and ‘mandatory professional
Dabrina Issakhany: Independent researcher. E: dabrina. reporting’ on students, particularly those with
[email protected] mental health concerns, registering with university
disability support/equity services. Journal of
references the Australia and New Zealand Student Services
1. Reid P. Structural reform or a cultural reform? Association. 2013 Oct;42:25-30.
Moving the health and disability sector to be pro- 11. Fitzmaurice L, Donald K, de Wet C, Palipana D. Why
equity, culturally safe, Tiriti compliant and anti- we should and how we can increase medical school
racist. N Z Med J. 2021;134(1535):7-10. admissions for persons with disabilities. Med J Aust.
2. Crampton P, Weaver N, Howard A. Holding a mirror 2021;215(6):249-251.e1. doi: 10.5694/mja2.51238.
to society? Progression towards achieving better 12. Medical Deans Australia and New Zealand
sociodemographic representation among the [Internet]. Inherent requirements for studying
University of Otago’s health professional students. medicine in Australia and New Zealand. Sydney,
N Z Med J. 2018;131(1476):59-69. Australia; 2017 [cited 2021 Jul]. Available from:
3. Coyle M, Sandover S, Poobalan A, et al. https://medicaldeans.org.au/md/2020/12/Inherent-
Meritocratic and fair? The discourse of UK and Requirements-FINAL-statement_July-2017.pdf.
Australia’s widening participation policies. Med 13. Australian Government – Department of Education,
Educ. 2021;55:825-839. https://doi.org/10.1111/ Skills and Employment [Internet]. Disability
medu.14442. Standards for Education 2005. 2005 [cited 2021
4. Health and Disability System Review [Internet]. Aug]. Available from: https://www.dese.gov.au/
Health and Disability System Review - Interim disability-standards-education-2005.
Report/Hauora Manaaki ki Aotearoa Whānui – 14. World Health Organization [Internet]. International
Pūrongo mō Tēnei Wā. Wellington: Health and Classification of Functioning, Disability and Health.
Disability System Review; 2019 [cited 2022 Apr]. Geneva; 2001 [cited 2021 Aug]. Available from:

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
viewpoint 71

https://apps.who.int/iris/handle/10665/42407. placement experience of a physiotherapy student

15. Bulk LY, Easterbrook A, Roberts E, et al. ‘We with vision impairment. BMC Med Educ. 2016;74.
are not anything alike’: marginalization https://doi.org/10.1186/s12909-016-0598-0.
of health professionals with disabilities. 17. Bulk LY, Tikhonova J, Gagnon JM, et al. Disabled
Disabil Soc. 2017;32(5):615-634. DOI: healthcare professionals’ diverse, embodied, and
10.1080/09687599.2017.1308247. socially embedded experiences. Adv Health Sci
16. Johnston KN, Mackintosh S, Alcock M, Conlon-Leard Educ Theory Pract. 2020 Mar;25(1):111-129. doi:
A, Manson S. Reconsidering inherent requirements: 10.1007/s10459-019-09912-6.
a contribution to the debate form the clinical

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
clinical correspondence 72

Vernix caseosa peritonitis: a novel

case with colonic perforation
Alexander Hart, Andrew MacLachlan, Louise Bright, Matthew James McGuinness, Ming
Yu, Lena Clinckett, Paul Manuel, Mavis Orizu

V
ernix caseosa peritonitis (VCP) can occur Culture of intra-operative aspirates were negative.
following contamination of the peritoneum She discharged 16 days following surgery. Histol-
with amniotic fluid containing vernix case- ogy findings were consistent with VCP as seen in
osa, a white paste found on foetal skin. It is a Figure 3. At 6-month clinic review, she remains
rare condition with 35 cases reported since first asymptomatic and awaits ileostomy reversal.
described in 1976.1
Discussion
Case report
Most VCP cases occur after caesarean section
A 32-year-old primigravida Caucasian woman where spillage of amniotic fluid occurs routinely.
underwent a caesarean section at 41+3 weeks However, the true aetiology is not understood,
for foetal distress. Meconium-stained liquor was given that VCP develops rarely and hypersensitivity
noted. She was discharged two days later. The reactions may play a role.1 Patients commonly
pregnancy was otherwise uncomplicated, with present 3–35 days postpartum with abdominal
close monitoring required for her quiescent pain, peritonism, fever and leucocytosis.2 Investi-
ulcerative colitis controlled with infliximab. gations for an infective source are negative and
On day 5, she presented with severe abdominal imaging findings are initially normal or non-
pain, fever, and raised inflammatory markers. specific. Typically, these unexplained unwell
Antibiotics were administered for presumed patients proceed to exploratory laparotomy
endometritis without initial improvement. Ultra- where cheese-like white plaques are found
sound showed no retained products of conception. diffusely on peritoneal surfaces.2 Underlying
Computed tomography (CT) demonstrated features organ pathology is not identified. However, due
of ileus and possible peritonitis without perforation to erroneously attributing peritoneal findings to
or other clear cause. She began improving and their involvement, unnecessary appendicectomy,
was discharged 1 week later on oral antibiotics. colectomy, hysterectomy and salpingo-oophorec-
Eight days later she represented in near tomy have occurred.3,4 Biopsy later confirms VCP
identical fashion. CT now showed multiple small by identifying inflammatory infiltrates commonly
disseminated intra-abdominal abscesses and a with foreign-body giant cell reaction associated with
probable contained ascending colon perforation. anuclear squamous cells and lanugo hair shafts.5
Multiple blood cultures were negative. Despite In most respects, this case is classical of those
trialling conservative management with antibiotics described. However, this appears to be the first
for five days, she remained febrile and an interval case to report an associated colonic perfora-
CT showed no improvement (see Figure 1). Lap- tion, though the exact timing and aetiology are
aroscopy converted to midline laparotomy was unclear. In three cases who underwent segmental
performed. Findings included a large collection colectomy for suspected perforation, no perfora-
beneath the Pfannenstiel incision with adherent tion was identified.6–8 An adherent inflammatory
omentum, small bowel and sigmoid colon; mul- reaction causing focal erosion remains possible.
tiple diffuse inflammatory adhesions, multiple Iatrogenic injury is considered unlikely from the
whitish peritoneal nodules (biopsied; see Figure caesarean section or laparotomy given prior CT
2), uterine fundus defect and a pinpoint colonic findings of possible perforation. Any ulcerative
perforation near the hepatic flexure. Interventions colitis contribution is uncertain given unknown
involved suture repair of the colonic perforation, disease activity, though she remained symptom-
loop ileostomy formation, appendicectomy, uterine atically controlled.
fundus repair and extensive washout. The patient Like most cases, the underlying pathology
gradually clinically and biochemically improved. was not initially suspected by the treating teams.

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
clinical correspondence 73

This is undesirable, as early diagnostic surgical This case reinforces the need to improve
exploration and washout is the mainstay of man- awareness and early recognition of VCP to ensure
agement in the non-improving patient.1,3 This appropriate management in a timely fashion. It
can be achieved successfully laparoscopically.5 remains to be determined whether there is a true
Intra-operative recognition of VCP will prevent association between VCP and bowel perforation.
unnecessary organ resection and prolonged
antibiotics which are unlikely beneficial, unless
rare organ injury is present.

Figure 1: Axial CT slice showing numerous walled off fluid collections anterior to the uterus.

Figure 2: Laparoscopic view of creamy-white nodules (arrows) situated on the anterior abdominal wall and
associated inflammatory adhesion.

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
clinical correspondence 74

Figure 3: The sections demonstrate an admixture of inflammatory cells including multinucleated giant cells that
comprise the abscess material. Focally, there is laminated squamous debris (CK5/6 positive, calretinin negative) and
a hair fragment engulfed by a giant cell (arrow), consistent with vernix caseosa peritonitis.

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
clinical correspondence 75

competing interests references

Nil. 1. Abdullah A, Jusoh A, Samat N, Jais M.
Vernix caseosa peritonitis following vaginal
author information delivery: Cheesy peritonitis. Formos J Surg.
Alexander Hart: Registrar, General Surgery, Southland 2022;55(6):221-221.
Hospital, Southern, Te Whatu Ora, Invercargill, New 2. Wisanto E, D’Hondt M, Aerts R, et al. A cheesy
Zealand. diagnosis. Lancet. 2010;376(9740):564.
Andrew MacLachlan: House Officer, Southland Hospital, 3. Chambers AC, Patil A v, Alves R, et al. Delayed
Southern, Te Whatu Ora, Invercargill, New Zealand. presentation of vernix caseosa peritonitis. Ann R
Louise Bright: Registrar, Obstetrics and Gynaecology, Coll Surg Engl. 2012;94(8):548-51.
Southland Hospital, Southern, Te Whatu Ora, 4. Davis JR, Miller HS, Feng JD. Vernix Caseosa
Invercargill, New Zealand. Peritonitis: Report of Two Cases With Antenatal
Matthew James McGuinness: Registrar, General Surgery, Onset. Am J Clin Pathol. 1998;109(3):320-3.
Southland Hospital, Southern, Te Whatu Ora, 5. Bailey JG, Klassen D. Laparoscopic experience
Invercargill, New Zealand. with vernix caseosa peritonitis. Surg Endosc.
Ming Yu: Anatomical Pathologist, Southern Community 2012;26(11):3317-9.
Laboratories, Dunedin, New Zealand. 6. George E, Leyser S, Zimmer HL, et al. Vernix Caseosa
Lena Clinckett: Obstetrician and Gynaecologist, Peritonitis: An Infrequent Complication of Cesarean
Obstetrics and Gynaecology, Southland Hospital, Section With Distinctive Histopathologic Features.
Southern, Te Whatu Ora, Invercargill, New Zealand. Am J Clin Pathol. 1995;103(6):681-4.
Paul Manuel: General Surgeon, General Surgery, 7. Boothby R, Lammert N, Benrubi GI, Weiss B. Vernix
Southland Hospital, Southern, Te Whatu Ora, Gaseosa Granuloma: A Rare Complication of
Invercargill, New Zealand. Cesarean Section. South Med J. 1985;78(11):1395-6.
Mavis Orizu: General Surgeon, General Surgery, 8. Nuñez C. Vernix Caseosa Peritonitis. Am J Clin
Southland Hospital, Southern, Te Whatu Ora, Pathol. 1996;105:657.
Invercargill, New Zealand.

corresponding author
Mavis Orizu: General Surgeon, General Surgery,
Southland Hospital, Southern, Te Whatu Ora, 145 Kew
Road, Kew, Invercargill 9812, New Zealand.. Ph: 03 218
1949. E: [email protected]

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
100 years ago 76

Anaesthetic Mortality in New Zealand

Read at the Annual Meeting of the British Med- so far as the question of deaths from anaesthetics
ical Association at Christchurch, 1923, by D. S. was concerned, proper enquiry should precede
Wylie, C.M.G., C.B.E., F.R.C.S., (Eng.). publicity. That this intention partly failed was
not due to any action of the Health Department,

M
y reasons for bringing to your notice a but arose as the consequence of the use made of
subject which possibly some of us might certain facts and figures, which were supplied by
consider somewhat stereotyped are the the Health Department to a medical practitioner
consclusions which have been forced upon one for use in connection with a paper which he was
during the last two and a-half years as the out- reading, and details of which, I am informed,
come of having considered the details of each leaked out in an unfortunate way to the Press.
anaesthetic death during that period which ahs On considering in further detail the anaesthetic
been the subject of a coroner’s enquiry. deaths for 1920,1921 and 1922, certain facts of
In April, 1920, shortly after I undertook the interest and importance manifest themselves. In
duties of Inspect of Hospitals under the Health putting these before you I am fully aware of the
Department, I investigated the question of danger of drawing conclusions from insufficient
deaths under anaesthetics in New Zealand. data, and especially so when dealing with small
On scrutinising, however, the figures supplied numbers. So far as statistics are concerned, we
by the Registrar-General for the years 1913 to must all bear in mind the epigram of Sir Berkeley
1919, I found that in practically no case was Moynihan, when he said: “Statistics may be made
the nature of the anaesthetic administered to prove anything—even the truth”.
recorded, and, consequently, the figures for the I will now deal briefly with the various aspects
period in question were of little or no practical value. of the case which scrutiny of the 54 deaths, which
The matter was taken up with the various occurred in 1920, 1921 and 1922, compels one to
authorities concerned, and from June, 1920, consider.
until the present time, fairly full information GEOGRAPHICAL DISTRIBUTION
has been obtained concerning each death under
1. The deaths, as the attached table shows,
anaesthesia which has been the subject of a cor-
have occurred pretty evenly in the North
oner’s enquiry. The figures are interesting. From
and in the South Islands, there being for
1913 to 1919 the number of anaesthetic deaths
the period we are considering 28 deaths in
reported in New Zealand each year varied from 5
the North Island and 26 deaths in the South
(the number recorded in the years 1914 and 1918)
Island.
to 11 (the number recorded in 1919). In 1920 there
were 11 deaths; in 1921,21; in 1922, 22. That is, we Included in the number of deaths occurring
have a total of 54 deaths in three years, compared in private are four fatalities, which took place in
with 57 deaths in the preceding seven years. dental surgeries.
The sudden increase in 1921 was striking, but in Of the deaths in the North Island three occurred
considering the matter it had to be remembered that in the Public Hospital, Auckland, three occurred in
greater attention was being paid to the matter of private hospitals and one in private. The Wellington
securing accurate returns, and that for the years figures show one death in the Public Hospital and
1915 to 1919 the influence of the war upon the one death in a private hospital, making a total of
population of New Zealand, and possibly upon 2. Three deaths occurred in the Public Hospital
the amount of surgical work which was done in at Napier. 10 deaths occurred in public hospitals
the country at that time, had both to be taken elsewhere in North Island and five occurred in
into account. private, including dental surgeries, making a total
It was considered that no definite good would of sixteen anaesthetic deaths in the North Island
have resulted from taking action at the end of 1921, outside Wellington, Auckland and Napier.
having regard to the harmful effects resulting from In taking the 26 deaths, which occurred in
the publicity which was given to the question of the South Island, it is found that their incidence
maternal mortality before proper enquiries had is as follows:—5 deaths in the Public Hospital
been made into that matter. It was resolved that, at Christchurch, one in a private hospital in

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
100 years ago 77

North Island (28 deaths)

Pub Hosp. Priv. Hosp In private Total

Auckland 3 3 1 7

Wellington 1 1 0 2

Napier 3 0 0 3

Elsewhere in N.I. 10 1 5 16

17 5 6 28

South Island (26 deaths)

Pub Hosp. Priv. Hosp In private Total

Christchurch 5 1 1 7

Dunedin
6 2 0 9
(Plus Dunedin Den-
tal Sch.)
1

Timaru 2 0 0 2

Invercargill 2 0 1 3

Elsewhere in S.I. 3 2 0 5

Total 19 5 2 26

Grand Totals 36 10 8 54

Christchurch and one in private, making a total Chloroform was responsible for 8 deaths in
of 7. Seven deaths occurred in the Public Hospital 1920-21 and for 10 deaths in 1922. Chloroform
at Dunedin, including in which figure is one death and ether mixtures were responsible for 16 deaths
which took place at the Dental School. Two deaths in 1920-21 and for 10 deaths in 1922. Ether was
took place in private hospitals in Dunedin and responsible for 33 1-3 per cent. of the mortality,
none in private, making a total of 9. Two deaths chloroform and ether mixtures for slightly over
took place in thePublic Hospital in Timaru, two in 48 per cent., and ether for 18 ½ per cent.
the various private South Island hospitals other Incidentally it is interesting to note that of the
than Christchurch and Dunedin. 22 fatalities in 1922 no fewer than 12 occurred
either during the induction of the anaesthetic or
2. The next question to consider is the number just at the commencement of the operation. For
of fatalities induced by chloroform, by the sake of comparison it is of interest to con-
chloroform and ether mixtures, and by sider for a moment the figures supplied con-
ether respectively—no deaths having been cerning 700 deaths occurring during anaesthesia
recorded from the use of nitrous oxide, ethyl in England, and which are quoted in the Oxford
chloride, the use of spinal anaesthetics or of Loose-Leaf surgery. These are as follows:—Chlo-
local anaesthesia. The figures are as follows roform, 378; chloroform and ether, 100; ether, 28;
(table below):— nitrous oxide, 12; ethyl chloride, 6; spinal, 8; sco-
polamine, 2; local,6; not specified, 160. Of these

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
100 years ago 78

1920-21 1922 Total

Chloroform 8 10 18

Chloroform and ether

16 10 26
mixture

Ether 8 2 10

Total 32 22 54

233 died before the operation commenced. The would not have occurred if ether had been admin-
comments made upon these figures are as fol- istered instead of chloroform. From a purely sci-
lows:—“In analysing these figures one is at once entific point of view these statistics serve to show
impressed with the dominance of fatalities under the great need of reform in the selection and
chloroform, and it is difficult not to attribute them administration of anaesthetics.”
to the improper selection of the anaesthetic agent, I wish, however, to return to a consideration
although the inexperience of the administrators of our own figures, and desire now to direct your
may have been a contributing factor. Fleming attention to the following 15 cases which occurred
(who is responsible for the figures) is undoubtedly amongst the 18 deaths due to chloroform:—
correct in his belief that the appalling death-rate

No. Nature of operation. Age of patient.

1. Extraction of teeth Uncertain

2. ditto 4

3. ditto 15

4. ditto 38

5. Removal of tonsils 15

6. ditto and adenoids 14

7. ditto 7

8. Quinsy 27

9. Abcess of left groin 33

10. Wound of arm 30

11. Removal of septic finger nail Uncertain

12. Exophthalmic goitre 59

13. Thyroidectomy 36

14. Miscarriage 31

15. Dilation of oesophagus 44

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
100 years ago 79

Here are a series of 15 cases, the vast majority of welfare of the patients to whom the anaesthetics
which are of a comparatively minor character, in were administered.
which I am of opinion, after reading the evidence The group of fatalities occurring with the
given at the various coroners’ enquiries, that an administration of chloroform and other mixtures
appropriate, or wrongly-chosen, anaesthetic was can now be considered. These anaesthetic mix-
administered. Who can defend the administration tures have been responsible for nearly fifty per
of chloroform for teeth extraction, or for the cent. of the 54 fatalities we are now considering.
removal of tonsils and adenoids? Professor A.R. I am sorry I cannot say how many cases are due
Cushny of the University of Edinburgh, in the latest to C(1) E(1), C(1)E(2), C(2)E(3), etc., as in many
edition of his well-known book on Pharmacol- instances the exact proportions of the two drugs
ogy and Therapeutics, gives as a fair average the employed were not given in the evidence of the
occurrence of one death in each three thousand various medical men concerned. Among the 36
cases where chloroform is administered, and one deaths occurring with the use of chloroform-ether
in ten to twelve thousand cases where ether is mixtures are the following:—

No. Nature of operation Age of patient.

1 Tenotomy of Tendo Achilles 64

2 Adenoids and tonsils 13

3 ditto 6

4 Nasal obstruction and adenoids 13

5 Nasal obstruction 28

6 Extraction of teeth 23

7 Circumcision 7

8 Skin grafting 29

9 Fracture of fore-arm 38

10 Operation for fraction of femur 4

give. The Extra Pharmacopoeia gives the death- Here again, is a group of ten cases, in which
rate of chloroform as about seven times that of the use of an anaesthetic with admittedly a higher
ether, which is said to have a death-rate of one in death-rate than ether was employed, where the
thirteen thousand. use of another anaesthetic agency would have
Given two anaesthetics, one of which has a been infinitely safer. I feel sure again that in this
mortality at least three times as great as the other, group of cases insufficient care was given to the
some very specific justification for the use of the selection of the anaesthetic having due regard
more dangerous must surely be brough forward to the welfare and safety of the anaesthetist, or
and sustained before its use can be sanctioned. under his supervision. It is often used for induc-
Here in a small group of eighteen fatalities we tion purposes (admittedly the most dangerous
have chloroform given in no fewer than fif- stage of general anaesthesia), and its ease of
teen instances where the employment of other administration in comparison with he additional
anaesthetics such as nitrous oxide, nitrous oxide trouble of giving ether, together with an exaggerated
and oxygen, ether, or local anaesthetics, would idea of its safety, makes its use, I feel certain, more
have been, to say the least of it, far safer, more in frequent than should be the case.
keeping with the deliberate opinion of recognised We come now to the group of fatalities where
authorities, and more in consonance with the ether alone was employed. They total 10 and I

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
100 years ago 80

Age and sex of

No. Nature of operation
patient

21 male (at small

1 Thyroidectomy for exophthalamic goitre
pub hospital)

2 ditto ditto 20 m.

3 Abscess of lung 53 m.

4 Tracheotomy 5 m.

5 Acute Otitis Media 5 m.

6 Carcinoma of breast 37 f.

7 Epithelioma of mouth and jaw 43 m.

8 Cancer of the bowel 70 m.

9 Peritonitis 65 m.

10 Abscess of mouth (Ludwig’s angina) 56 m.

propose to give you particulars of each one. and ether supplied to its various customers
Case No, 9 occurred in the induction stage, April, 1921, to September, 1922, and from the
and Case No. 8 occurred just after the operation returns it appeared that the Wellington Hospital,
commenced. It is to be remarked, also, that four which, of all the large hospitals in New Zealand,
of the ten fatalities took place in Dunedin. It will has the lowest number of deaths, has been sup-
be noted that seven out of the ten deaths occurred plied with the largest quantity of the chloroform
in association with the performance of operative in question, namely 84lbx., and that the other
procedure of a very definitely serious character large hospitals, where the bulk of the deaths have
in contradistinction to many of the fatalities taken place, have not been supplied at all by the
which took place with the use of chloroform and Defence Department. This information should, I
of chloroform-ether mixtures in comparatively think, dispose of any misapprehension likely to
minor cases. In neither of the goitre fatalities was arise on this point.
the use of local anaesthesia in combination with Deliberate consideration of the figures which
the ether mentioned. I have adduced will show, I think, that (1) insuf-
I now come to the question of the purity or ficient care has been taken of late years in the
otherwise of the various brands of anaesthetics choice of an anaesthetic for operative purposes,
now in use in New Zealand. With reference to this (2) inadvertently, no doubt, the interests of the
the Dominion Analyst is engaged in the work of patient are not being considered enough, (3) in
their analysis at the present time, but the results many instances very faulty judgment is being
are not yet available for use. It has been stated in exercised regarding the choice and administra-
certain quarters, somewhat loosely, that the num- tion of anaesthetics. Of the 54 deaths which have
ber of anaesthetic deaths in the years 1920,1921 occurred during the period we have under review
and 1922, has some connection with an inferior I consider that between 40 and 50 per cent. might,
quality of chloroform which was supplied by the and should, have been presented by a better choice
Defence Medical Stores to various hospitals and of anaesthetic, and I am of opinion that this matter
medical men in this country. I have seen a return requires the very fullest consideration which this
prepared by the Defence Medical Stores showing meeting can give to it, and not merely that alone,
the quantities and the brands of chloroform but the taking of definite action by the meet-

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
100 years ago 81

ing to produce a happier state of affairs and one employed. This is especially noticeable at Roch-
redounding more to our credit as a profession. ester, where they have now a specially trained
I have recently returned from a visit to America medical man who does all the sacral, spinal, and
and Canada, where I visited many of the chief clin- paravertebral anaesthetic work for the various
ics and hospitals, notably those of the Mayo’s at Roch- hospitals in this town. Increasing attention
ester, Minnesota, of Dr. Crile, at Cleveland, Ohio, the is being given the question of ensuring not
Peter Bent Brigham Hospital, Boston, which is only the maximum safety for the patient, but
the hospital of the Harvard Medical School, the of administering an anaesthetic with the min-
General Hospital, Toronto, the General Hospitals imum discomfort to be endured afterwards. I
at Winnipeg, Vancouver, and many hospitals in was tremendously impressed with this point
New York. Among the many admirable things one and am sure that we can in New Zealand emu-
saw I was much impressed with the general high late to advantage in this respect our American
level of anaesthesia used in the various hospitals I colleagues. Nowhere in the States did I see chlo-
visited, with the care taken in the choice of anaes- roform used either alone or as a mixture.
thetic—especially in the class of case known as “the The question arises now as to the nature of
bad risk”—with the use made of spinal anaesthesia, the steps which can be taken to improve mat-
especially in bladder and pelvic cases, with the ters. Personally I think that the following methods
use of paravertebral anaesthesia, sacral anaes- should be adopted:
thesia and the increasing use of local anaesthesia.
Local anaesthesia is very largely used in combi- 1. KEEPING OF BETTER ANAESTHETIC
nation with nitrous oxide and oxygen analgesia, RECORDS BY HOSPITALS.—Each hospital
and very excellent results are being obtained should, I consider, keep special records
with it. I was especially impressed with the very of the administration of anaesthetics, and
high standard of anaesthetic work at the Lakeside should publish a summary annually of the
Hospital, Cleveland, where Dr. Crile does the administration of anaesthetics in their annual
majority of his operative work. At this hospital medical report, together with full details of
they have a record of 51,000 cases of nitrous oxide any fatalities which occur. Only in this way
and oxygen analgesial anaesthesia, or nitrous will statistics worth having be produced and
oxide, oxygen and ether, in combination with progress made possible.
local anaesthetics in practically all cases, with only a 2. THE APPOINTMENT BY EACH LARGE
single death. At this hospital I saw many operations HOSPITAL IN NEW ZEALAND OF EITHER
for the following conditions: Goitre, gastric ulcers, HONORARY ANAESTHETISTS, OR QF WHOLE-
duodenal ulcers, infection of biliary tract, appendi- TIME PAID ANAESTHETISTIS.—During the
citis, pelvic gynaecological cases, etc., done with last two or three years a special lecturer
nitrous oxide and oxygen analgesia and the use of and instructor in anaesthetics has been
a local anaesthetic. In some of the cases, especially appointed at the Dunedin Medical School.
in the upper abdomen, the use of ten to fifteen This was a most necessary proceeding, but
per cent. ether for perhaps 15 to 20 minutes was in itself is not enough, and I am sure that
necessary to secur adequate relaxation. I saw the the time is opportune for the appointment
patients afterwards, not only on the day of opera- of special anaesthetists to our largest public
tion, but on each subsequent day during my stay hospitals, namely Dunedin, Christchurch
in Cleveland, and was impressed not only with and Auckland. Wellington has already an
their general comfort but with the comparative honorary anaesthetist in the person of Dr.
absence of the various so-called minor unpleas- Anson, and the sooner similar appointments
antnesses which occur when ordinary inhalation are made at the other hospitals named the
anaesthesia is alone employed. The use of nitrous better for all concerned. If it is not possible
oxide and oxygen as a routine general anaesthetic to secure the services of medical men as
necessitates the employment of specially trained honorary anaesthetists who are specialising
people for the work. At Cleveland there are trained in this work outside then I consider that the
nurse anaesthetists, and very competent they are appointment of whole-time paid specialists
at their work. At certain hospitals open ether or should be undertake. Such appointments,
the nitrous oxide ether sequence is employed with the co-operation of the surgical staffs of
routinely but even in these hospitals, local, sacral, the institutions in question, should speedily
and paravertebral anaesthesia is being increasingly procure results. The administration of

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA
100 years ago 82

anaesthetics by house surgeons would to enquire into the practicability or otherwise

be properly supervised, and they would of the various suggestions which will no doubt
necessarily acquire a better knowledge be brought forward, and to communicate their
of the art of anaesthesia than they do at recommendations within all possible speed to:
present. The question of the appointment of (a) The Director-General of Health, Wellington;
special anaesthetists should be considered (b) the honorary staffs of the various public
by the honorary staffs of our large hospitals hospitals; in New Zealand; (c) the medical
at the earliest possible moment, and superintendents of all hospitals; and (d) each
recommendations made by them to their medical man practising in New Zealand,
respective Boards, who are only waiting for a whether he is a member of the British Medical
lead in this matter. Association or not.
3. The honorary medical staffs of hospitals,
and especially the surgical portions of In conclusion I wish to thank the Director-
the staff, should consider at the earliest General of health for the permission he gave me
possible moment at their monthly staff to use various departmental files for the purpose
meeting the anaesthetic problem of their of this paper, and also Mr. Clayton, the Librarian of
particular hospital, with a view to effecting the Health department, for the very careful way in
improvements where such are necessary. which he has kept and summarised the abstracts
4. The establishment by this meeting of a small which have been prepared from time to time by
committee to further consider the matter and the Health Department.

New Zealand Medical Journal 2023 May 12; 136(1575). ISSN 1175-8716
Te ara tika o te hauora hapori https://journal.nzma.org.nz/ ©PMA