NEW ZEALAND MEDICAL JOURNAL最新文献

Background: Computed tomography colonography (CTC) is an alternative to colonoscopy for the detection of polyps and colorectal cancer (CRC). One-third of CRCs arise via the sessile serrated pathway. Evidence supports using CTC to detect adenomas and CRC; however, its accuracy for sessile serrated lesions (SSLs) remains uncertain. This study aimed to determine the accuracy of CTC in detecting SSLs compared with colonoscopy.

Method: Electronic records identified all colonoscopy procedures where a histologically validated SSL was excised over a 11-month period. In those patients who had a CTC within 1 year prior to colonoscopy, the presence, size and location of SSLs were compared to determine the accuracy of CTC in SSL identification.

Results: A total of 4,346 procedures were performed (2,548 people, 2,082 [47.9%] male, mean age 59.6). A total of 2,204 SSLs were removed, representing 24% of all polypectomies. SSLs were predominantly located in the right colon (65.1%) and were typically (85%) <10mm in size. A total of 110 SSLs were obtained from 39 procedures with a prior CTC. Of these procedures, 12 (30.8%) had lesions identified on CTC; however, CTC only accurately identified 14.5% of the total SSLs. Five of 16 (32%) SSLs ≥10mm were correctly identified compared with 11 of 94 (11%) SSLs 1-9mm, (odds ratio 3.42, p=0.0495).

Conclusion: This study demonstrated that CTC has poor efficacy in detecting SSLs, irrespective of polyp size and location. Based on these findings, CTC as a substitute for colonoscopy is not advisable in patients at risk of SSLs.

Outpatient referrals for hospital specialist assessment are an increasing workload that carry significant risk if not attended to in a timely manner. This viewpoint discusses how decision support (including artificial intelligence and machine learning) may address this problem. Of the many possible approaches, we choose a combination of two that illustrate the breadth of available tools and how they combine to complement each other. To understand the issues and inform this discussion, a survey of general practitioners' views was conducted (Appendix 2), an audit of declined referrals was undertaken (Appendix 3) and draft decision trees were constructed (Appendix 4). To have data suitable for automated decision support, the current referral needs to change from free text to a structured format that ensures every patient has a complete minimum dataset. Regarding triaging decisions, at present there is human variability, but the decision support tools will need to be trained on a set of referrals that have an agreed gold-standard decision. In order to maintain patient safety throughout, the process needs to be incremental. We suggest that one way to assure patient safety is to combine simple decision trees with sophisticated contemporary machine learning.

Aotearoa New Zealand has one of the highest bowel cancer rates in the world. Bowel cancer incidence is increasing for Māori (the Indigenous people of Aotearoa), while trending downwards for non-Māori. Over half of Māori who get bowel cancer are diagnosed before the age of 60 years and are more likely than non-Māori to die within 2 years. Pacific people also experience bowel cancer inequities. In 2016, a national bowel screening programme for Aotearoa was announced, with an age range of 60-74 years. However, equity modelling showed that the proposed programme would disproportionately benefit non-Māori and that lowering the screening age for Māori and Pacific peoples to 50 years could achieve equal health gains. Over subsequent years, Māori cancer leaders advocated for policy change to lower the bowel screening age by 10 years for Māori. They used academic publications, presentations, letters, position statements, media stories and meetings with government leaders. Despite this advocacy, in 2020, the Government announced it was not going to lower the bowel screening age for Māori and Pacific peoples. The advocates persevered. They were supported in their efforts by new data that further confirmed the increasing bowel cancer incidence for Māori. In 2022, the Government committed to lowering the bowel cancer screening age to 50 for Māori and Pacific peoples. However, what followed was a tardy, phased rollout in only three regions. A year on, a new government embarked on a politically motivated agenda to reject ethnically targeted policies, with further significant equity changes to the programme announced. This paper summarises the lobbying efforts of cancer leaders and the government response, revealing structural and institutional racism, represented by inaction and active rejection of evidence-based advice. We describe the perseverance required to advocate for equity in the face of structural racism and the cost to Māori lives while inaction and racism persist.

Aim: This study aims to investigate the perceptions of Māori, Pacific, and non-Māori/Pacific breast cancer patients' treatment experience in Wellington, Aotearoa New Zealand. It will also explore the support they received throughout their treatment journey and the information provided to them over the course of their care.

Method: Qualitative semi-structured focus groups were carried out including breast cancer patients who had completed treatment within the past 2 years. Participants were recruited through breast cancer clinics. Data were analysed using reflexive thematic analysis.

Results: Participants reported a need for more tailored information from health professionals. Many participants reported barriers accessing services and follow-up appointments. Additionally, many participants, especially Māori and Pacific participants, emphasised the importance of ongoing support from healthcare professionals and their personal networks.

Conclusion: The findings highlight the need for improving patient-centred communication, recognising the important role of patient support systems and providing more tailored information and resources throughout breast cancer treatment. Addressing these factors could improve different patient groups' experiences and outcomes by fostering a more informed and supported treatment journey.

Aim: Cardiovascular disease (CVD) inequities in Aotearoa New Zealand disproportionately affect Māori and Pacific peoples, who experience higher risk factors, hospitalisations and mortality than NZ Europeans. These disparities stem from the historical and contemporary effects of colonisation, including institutional racism, impacting access to healthcare and socio-economic resources. Despite guidelines for earlier CVD risk assessments (CVDRA), gaps in identification and management persist.

Method: The Manawataki Fatu Fatu (MFF) for Māori and Pacific Hearts in Unison for Achieving Cardiovascular Care in Equity Studies (ACCESS) is a Māori and Pacific-led research programme examining CVD inequities in Aotearoa New Zealand. This study presents phase three, focussing on qualitative co-design hui (meetings) across Aotearoa New Zealand to gather insights from Māori and Pacific patients, whānau (family/supports) and kaimahi (healthcare workers) engaged with CVD services spanning primary to secondary care.

Results: A total of 105 participants attended four regional hui focussed on the heart healthcare experiences of Māori and Pacific peoples in Aotearoa New Zealand. Template analysis revealed four key themes for achieving equitable healthcare: the importance of the whānau/community, the need for providers to engage with patients at their level, the persistent barriers faced and a strong commitment to protecting Māori and Pacific communities and kaimahi.

Conclusion: This study is a comprehensive qualitative investigation into heart healthcare for Māori and Pacific peoples in Aotearoa New Zealand. The findings reiterate that care must align with the realities of Māori and Pacific peoples and that interventions must address long-standing systemic barriers to care.

Aim: We aimed to examine barriers and enablers to mental health support for transgender and gender-diverse individuals in rural Aotearoa New Zealand, drawing on research conducted in the Whanganui Region.

Method: Findings were drawn from a qualitative study involving interviews with transgender and gender-diverse participants in Whanganui, where mental health concerns consistently arose despite not being the study's primary focus.

Results: Participants reported high levels of psychological distress, shaped by intersecting factors such as gender dysphoria, neurodivergence, financial hardship and social isolation. Major barriers to accessing support included a lack of affirming and knowledgeable mental health providers, limited service availability and experiences of discrimination-both systemic and interpersonal. Some participants described additional difficulty related to provider biases or the ineligibility of publicly funded therapy for gender-related issues. At the same time, protective factors included access to gender-affirming care, culturally safe counselling and peer or community-based support. For neurodivergent participants, inflexible service design and diagnostic barriers further impacted mental health access.

Conclusion: Strengthening culturally safe, affirming and accessible mental health services is essential for improving outcomes for transgender and gender-diverse communities in rural Aotearoa. Strategies such as increasing provider training, supporting community-led initiatives, expanding telehealth and creating clearer care pathways may help address persistent inequities.