Background: In 2004, we published data on the trends in New Zealand (NZ) cutaneous melanoma (CM) for the period 1995[ndash]1999. The present report documents the trends in the next period from 2000 to 2004.Method: Data were obtained from the New Zealand Cancer Registry by way of a computerized search of CM ICD-10 (172) codes from 2000 to 2004. Only one registration per person was made to avoid including patients with metastatic melanoma. The exclusion criteria were: incorrect or absent data; benign naevi; and melanoma in situ. Incidence rates were age standardised to the Segi world population.Results: The total study population was 8262 patients. There was no increase found in the overall incidence rate over the time period, but men had a statistically higher overall incidence rate (P= 0.0002) and thicker CMs (P= 0.003) compared with women. This gender difference was particularly marked in those patients aged greater than 59 years. Breslow thickness increased from 0.7 to 0.8 mm. The incidence rates varied quite significantly among District Health Boards, with Taranaki having the highest rate (70.3/100 000/year) and Southland had the lowest rate (20.1/100 000). Overall, NZ had a CM incidence rate of 41.2/100 000/year).Conclusion: The current study confirmed that NZ has the highest overall CM incidence rate in the world. Elderly men (>59 years old) have the highest risk of developing melanoma. The increase in melanoma thickness with its associated higher mortality risk is of grave concern.

Background: Ambiguity remains about the effectiveness of wearing surgical face masks. The purpose of this study was to assess the impact on surgical site infections (SSIs) when non-scrubbed operating room staff did not wear surgical face masks.Methods: Eight hundred twenty-seven participants undergoing elective or emergency obstetric, gynecological, general, orthopaedic, breast or urological surgery in an Australian tertiary hospital were enrolled. Complete follow-up data were available for 811 patients (98.1%). Operating room lists were randomly allocated to a 'Mask group' (all non-scrubbed staff wore a mask) or 'No Mask group' (none of the non-scrubbed staff wore masks). The primary end point, SSI was identified using in-patient surveillance; post discharge follow-up and chart reviews. The patient was followed for up to six weeks.Results: Overall, 83 (10.2%) surgical site infections were recorded; 46/401 (11.5%) in the Masked group and 37/410 (9.0%) in the No Mask group; odds ratio (OR) 0.77 (95% confidence interval (CI) 0.49 to 1.21), p = 0.151. Independent risk factors for surgical site infection included: any pre-operative stay (adjusted odds ratio [aOR], 0.43 (95% CI, 0.20; 0.95), high BMI aOR, 0.38 (95% CI, 0.17; 0.87), and any previous surgical site infection aOR, 0.40 (95% CI, 0.17; 0.89).Conclusion: Surgical site infection rates did not increase when non-scrubbed operating room personnel did not wear a face mask.

Background: An important determinant of long-term outcomes following total knee arthrolplasty (TKA) is post-operative alignment as measured on radiographs. Thus far, radiographs have been measured using the goniometer method (GM) and no standard protocol has been followed. The aim of this prospective study was to: (i) outline a protocol for radiographic measurement following TKA; and (ii) compare the accuracy of the traditional GM with a new trigonometric method (TM) of radiographic analysis.Methods: A protocol for the measurement of alignment on radiographs following TKA was outlined in detail with step-by-step instructions. A new TM of angle measurement was also delineated. Alignment was measured on 51 post-operative TKA radiographs. A single angle was chosen and measured by two observers using both the GM and TM.Results: The TM had a precision of 1.06° compared with 1.5° using the GM. The standard deviation of the TM was significantly smaller than the GM (P= 0.033). The intra-class correlation coefficient of the TM was 0.94 versus 0.90 for the GM.Conclusion: The study detailed a protocol for the measurement of axial alignment of the limbs and components following TKA, and provided evidence that a newer TM of angle measurement was superior in terms of precision and intra-rater reliability in comparison with the traditional method.

Background: The aim of the study was to compare the effect of laparoscopic anterior and posterior fundoplication on gastro-oesophageal reflux disease by means of a prospective randomized controlled trial.Methods: One hundred and three patients were randomised to undergo either anterior (53) or posterior (50) fundoplication. Initial enrolment and subsequent clinical appointments were undertaken 1, 3, 6 and 12 months after the procedure using a standardized questionnaire. Ambulatory pH monitoring and manometry were undertaken both preoperatively and at approximately 3 months post-procedure.Results: The mean operating time was similar in both groups (48 versus 52 min). Two operations in each group were converted to open surgery. Post-operative dysphagia in the first month was higher in the posterior fundoplication group compared with the anterior group (at 1 month, P= 0.002; and at 3 months, P= 0.014). The number of individuals suffering from post-operative heartburn was greater in the anterior fundoplication group (at 1 month, P= 0.008; at 3 months, P < 0.001; and at 6 months, P= 0.002). Eight individuals required reoperation in the anterior group and two individuals in the posterior group (P= 0.057).Conclusion: Anterior and posterior fundoplication each have their advantages and disadvantages. There is an increased risk of early post-operative dysphagia after posterior fundoplication. Anterior fundoplication carries a greater risk of persistent or recurrent reflux. Overall, a posterior fundoplication produces a better management option for controlling gastro-oesophageal reflux disease when compared with an anterior fundoplication technique which utilizes unilateral fixation of the gastric fundus.

Background: The risk of malignant conversion in oral leukoplakia is well documented. Histological findings are often unreliable and it is difficult to predict on the basis of clinical and histopathological changes which leukoplakic lesion will turn malignant.Methods: We used the technique of flow cytometry to evaluate the ploidy status, DNA index and S-phase fraction in leukoplakia, oral cancer and normal oral mucosal biopsies and compared it with histological findings. The study was carried out on 30 patients with oral cancer, 60 with leukoplakia and 30 with normal oral mucosal biopsies.Results: The aneuploidy rate in oral cancers was 64%, for leukoplakia 20%, while all normal mucosal biopsies were diploid. Aneuploid lesions also had a greater S-phase fraction (SPF). The DNA Index (DI) of aneuploid oral cancers was 1.72 and aneuploid leukoplakias was 1.24. Leukoplakia specimens which showed histological evidence of dysplasia had aneuploidy rate of 38%, DI of 1.19 and SPF of 6.2%. The corresponding values for leukoplakia specimens without dysplasia were 14%, 1.09 and 4.1%, respectively.Conclusion: The method of flow cytometry can be used to identify the subset of leukoplakia patients who are at a higher risk of malignant conversion. These patients could undergo more rigid surveillance or undergo excision biopsy of their lesions.

Introduction: There is an elevated incidence of nasopharyngeal carcinoma (NPC) in the Maori and Pacific Island (MPI) population as well as the Asian population in New Zealand; however, no studies have been conducted to evaluate how the two populations differ in their clinical presentation according to the TNM stage.Methods: A retrospective review was conducted of all patients presenting to the Auckland City Hospital ENT department with a newly diagnosed NPC between the years 1995 and 2007 inclusive. The patient's radiological and biopsy results were reviewed, and each patient was staged according to the TNM stage at presentation as per the revised 2002 American Joint Committee on Cancer staging criteria. The Fisher's exact test was used to compare the differences between ethnicities in the T and N stages of the disease at presentation; the Cochran[ndash]Armitage Trend test was used to look for statistically significant trends.Results: There was a statistically significant difference in T stage at presentation between MPIs and Asians (P < 0.0001), with a positive, statistically significant (P < 0.0001) trend indicating that MPIs present with greater T stage. A statistically significant difference in the N stage at diagnosis between MPIs and Asians, independent of the T stage, was found at stages T2 (P= 0.046) and T4 (P= 0.0083), with a statistically significant trend (T2 [ndash]P= 0.009; T4 [ndash]P= 0.026).Conclusions: These results show that MPIs have a more advanced local NPC disease than Asians at presentation, and that for specific T stages, the nodal disease is also more advanced than that found in Asians.

Purpose: We performed a prospective study of sneezes from orthopaedic registrars to assess the potential for intra-operative contamination from a masked surgeon, and to determine if head position can alter the potential for contamination.Type of Study: Prospective controlled trial.Methods: Four orthopaedic registrars from the Gold Coast Hospital each inhaled pepper to precipitate a sneeze. Cultures were taken with and without standard Smith & Nephew[trade] surgical masks, in positions directly in front and to the sides of a masked registrar. The process was repeated three times for each registrar. A control plate was left exposed to the atmosphere. A control plate and sneeze plate was cultured on blood agar. Three masks were subsequently swabbed to exclude contamination from the masks.Results: 2/24 (8.33%) of the side with mask cultures returned significant bacterial growths. Also, 1/12 (8.33%) of the front with mask cultures returned significant growths. In addition, 9/12 (75%) of the direct sneezes resulted in significant bacterial counts. The control plate failed to return any growth. Subsequent culture of the exterior of three surgical masks failed to yield significant growth. There was a statistically significant odds ratio of 0.03 comparing the front and side group with the unmasked direct group. There was no statistically significant difference comparing front and side sneeze growth.Conclusions: While the use of surgical face masks significantly reduces bacterial counts following a sneeze, it fails to eliminate the potential for surgical field contamination completely. The fact that significant bacterial counts can be returned from direct culture through a mask and to the sides of a mask suggests that head position is irrelevant and contamination is possible in any direction. It is, therefore, suggested that, if possible, a sneezing surgeon distances himself/herself as much as possible from the sterile field. We also recommend following a sneeze; surgeons should re-gown and glove, given the risk of contamination of the sterile field.Level of evidence: Level II.

Aim: To quantify delays in discharge for vascular surgical patients and identify causes of such delays.Methods: A prospective audit of delays in discharge of vascular surgical admissions over a 6-month period was performed. Expected date and time of discharge was compared with actual date and time of discharge. Day-case patients, patients who died during admission and patients not under the direct care of the vascular team were excluded.Results: There were 99 elective and 51 acute admissions accounting for 729 hospital bed days. The median (range) age was 72 years (21[ndash]92) and 94% of patients were living independently in the community. Forty-seven percent of patients were discharged on the planned day and time, 21% on the planned day but at a later-than-predicted time and 32% were delayed by more than 1 day. Delays identified in this audit accounted for 135 bed days. Fifteen percent of delays were due to causes that can be improved by internal organization (e.g. delayed paperwork). The majority of the delays (85%) were due to external factors such as lack of rehabilitation beds or lack of placement facilities in nursing homes. Elderly patients and acute admissions were more likely to have long delays in discharge.Conclusion: Delays in discharge of vascular surgical patients use a lot of acute surgical bed days. Strategies to prevent delays in discharge should include not only improving internal organization and early identification and referral of patients who require rehabilitation/placement but also increased funding for such essential non-acute services.

Background: We report results of a pilot study investigating the safety and efficacy of Botulinum A toxin on urinary incontinence and bladder function in children with neurogenic bladder.Methods: This was a prospective, non-randomized clinical trial. Seven children with median age of 16 years with spina bifida who had high storage pressures, poor bladder compliance and had failed treatment with anticholinergic medications were offered a single intra-detrusor injection of Botulinum A toxin. All subjects were on clean intermittent catheterization before and during the study. Follow-up videourodynamic studies were performed at 1 month, between 3 and 6 months, and at 9 months. Data were collected on safety and on subjective outcomes through validated questionnaires filled out by patients at each visit.Results: In majority of the patients (5/7), the injection produced an increase in bladder compliance (P < 0.05) and an improvement in incontinence (P < 0.05) at 1-month follow-up. However, in two patients whose baseline bladder capacity was markedly reduced (<200 mL), the improvement was very minimal. The beneficial effects in bladder compliance and incontinence dissipated by 9 months. The changes in subjective outcomes (incontinence and satisfaction scores) did not parallel the changes in urodynamics through the study period. No side effects of Botulinum toxin were seen.Conclusion: Botulinum A toxin injection produces beneficial urodynamics and clinical effects. These beneficial effects last for approximately 9 months. There is a poor correlation between improvement in the urodynamics and the subjective outcomes. Botulinum A toxin injection is a safe alternative treatment for patients with spina bifida and a neurogenic bladder.

Background: To determine if there is a different clinical outcome after TransFix versus endobutton femoral fixation in hamstring anterior cruciate ligament (ACL) reconstruction.Methods: Twenty-nine patients were randomized into either Endobutton (Smith & Nephew, Andover, MA, USA) (n= 13) or TransFix (Arthrex, Naples, FL, USA) (n= 16) femoral fixation in hamstring ACL reconstruction. The distal fixation was with a bioabsorbable interference screw. The evaluation methods were clinical history and examination, KT1000 arthrometry for laxity as well as the International Knee Documentation Committee (IKDC) scores over a 2-year time frame.Results: There were no significant differences between the study groups preoperatively. For the 2-year follow-up, 11 patients in the Endobutton group and 13 patients in the TransFix group were available (greater than 80%). No statistical differences between the two groups were found at the 1- or 2-year follow-up examinations. At the 2-year follow-up, 72.7% of the Endobutton and 84.6% of the TransFix group patients were in the IKDC A or B categories. Additional procedures postoperatively occurred more frequently in the TransFix group.Conclusions: There were no significant differences in the results for either technique of femoral fixation.Level of Evidence: Level I.