North Shore Hospital is a large public hospital in Takapuna, New Zealand, serving the northern part of Auckland. Located on Shakespeare Road near Lake Pupuke, it is administered by the Waitemata District Health Board, which provides health services to approximately 600,000 residents of the North Shore, Waitakere and Rodney districts of Auckland. Emergency Department staff at North Shore see more than 46,000 cases each year.
To compare perioperative, oncological, and survival outcomes of total gastrectomy (TG) versus subtotal gastrectomy (SG) in patients with locally advanced distal diffuse gastric adenocarcinoma treated with perioperative 5-fluorouracil, leucovorin, oxaliplatin and docetaxel (FLOT) chemotherapy. Diffuse distal gastric cancer is characterized by infiltrative growth patterns and early nodal metastasis. Whilst radical resection remains the cornerstone of curative treatment, the optimal extent of surgery with TG or SG, remains debated. This international multicenter cohort study analyzed data from patients with histologically confirmed diffuse gastric adenocarcinoma, located > 5 cm from the gastroesophageal junction. Endpoints included surgical margin status, nodal yield, perioperative morbidity, recurrence patterns, time-to-recurrence (TTR), and overall survival (OS). Outcomes were compared using multivariate analyses. In total, 188 (39.0
Noise (synonyms: variability, imprecision) in clinical data is underappreciated. All measurements are affected by noise and bias. Research studies enrol many patients to average out noise and use randomisation and double-blinding to counter bias. These mitigation techniques are often not available in clinical medicine, where individual patients typically have a variable measured only once. The example of echocardiographic assessment of aortic stenosis severity illustrates how the conventional presentation of data as point estimates masks wide variability in noise between variables, which affects utility. Adding aortic valve area to the quantification of aortic stenosis may result in poorer (noisier) estimates. Every clinical variable reported as a point estimate comes with an invisible cloud of uncertainty (noise) of varying size across variables. Being mindful of how this noise varies across variables should facilitate optimal clinical decisions.
BACKGROUND AND AIMS:Lipoprotein(a) [Lp(a)] is a causal contributor to atherosclerotic cardiovascular disease (ASCVD). While no therapies are currently approved solely for lowering Lp(a), subgroup analyses suggest that individuals with elevated Lp(a) may gain added benefit from intensive lipid-lowering strategies. No prior meta-analysis has compared evolocumab, alirocumab, inclisiran, lerodalcibep, and enlicitide in their Lp(a)-lowering efficacy. We aimed to determine whether proprotein convertase subtilisin/kexin type 9 (PCSK9) targeted therapies differ significantly in Lp(a) reduction, or whether agent selection can be guided primarily by other factors such as dosing frequency, cost, and patient preference. SOURCES OF MATERIAL:We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) reporting percent change in Lp(a) following treatment with the 5 PCSK9-targeted agents. A random-effects model calculated pooled estimates of percentage Lp(a) change, and mixed-effects meta-regression assessed differences between agents. ABSTRACT OF FINDINGS:Thirty-one RCTs were included. PCSK9 inhibitors and inclisiran reduced Lp(a) by a pooled mean of -25.76% vs control (95% CI -29.54 to -21.99; P < .0001). Meta-regression revealed no significant differences between agents (alirocumab vs evolocumab: +3.3%, 95% CI -1.40 to 8.07, P = .16; inclisiran vs evolocumab: +4.9%, 95% CI -2.31 to 12.16, P = .18; inclisiran vs alirocumab: +1.6%, 95% CI -5.38 to 8.55, P = .65). Lerodalcibep and enlicitide demonstrated similar approximate 25% reductions; however, insufficient trial numbers precluded a powered head-to-head comparison. CONCLUSIONS:No statistically significant differences in Lp(a) reduction were observed between currently available PCSK9-targeting medications. Agent selection may reasonably be based on non-efficacy factors, including administration frequency, cost, and patient preference.
BACKGROUND:Patient complaints provide a complementary lens on surgical safety, yet prior analyses have been small and specialty specific. We aimed to characterise themes, perioperative processes, system factors and outcomes in surgical complaints using a scalable, large language model (LLM)-assisted approach. METHODS:We performed a national, retrospective, cross-sectional, sequential methods study of publicly available investigation reports from the Aotearoa New Zealand Health and Disability Commissioner. All reports published since 1998 were retrieved and screened for relevance across all surgical specialties. A fixed-parameter LLM workflow extracted demographics, clinical context, complications, breached patient rights, system factors and outcomes. An inductive LLM-supported thematic synthesis generated complaint themes, followed by rescoring of theme relevance across reports. Human validation supported the LLM-assisted process (Cohen's κ >0.85). RESULTS:Of 1827 reports screened, 650 involved surgical care. Postoperative complications were frequent (84.2%), commonly accompanied by permanent disability (33.2%) or death (24.2%). Delays in recognition of deterioration (76.1%), escalation (58.3%) and definitive management (49.5%) of complications were common and associated with higher mortality. Prominent themes concerned postoperative clinical management/monitoring, communication/informed consent and professional conduct/competence. Technical/procedural errors and medication errors were comparatively less common. Breaches are most often related to reasonable care and skill, and to informed consent, with marked variation across specialties. CONCLUSIONS:Complaints about surgical care predominantly reflect postoperative monitoring, escalation and communication rather than intraoperative technical errors. System priorities should include robust deterioration recognition and response, reliable handover and escalation pathways, and strengthened consent and communication processes. An LLM-assisted pipeline can scale complaint analysis to support organisational learning and quality improvement.
Patients with chronic kidney disease (CKD) develop anaemia in the setting of abnormal iron metabolism and reduced endogenous erythropoietin. Pure red cell aplasia (PRCA) is a condition that, in rare cases, has been associated with erythropoietin products, commonly prescribed in patients with CKD-related anaemia. We describe 14 cases of Epoetin-alfa associated PRCA which have resulted in significant morbidity. Our cases were predominantly male (71%) with a median age of onset 68 years old. Each presented with profound anaemia 4-48 months (median 9.5 months) after commencing subcutaneous Epoetin. Heterogeneous immunosuppression regimens were used, predominantly with either monotherapy prednisone or ciclosporin. Two patients did not receive immunosuppression. Of our 14 cases, eight have since been commenced and maintained on Roxadustat with six of these subsequently reaching target haemoglobin. Of the six not commenced on Roxadustat, only one has reached target haemoglobin. This is the first multi-patient report of Roxadustat in patients with ESA-PRCA. Our cluster of cases highlights the need for strong suspicion of acquired PRCA in patients treated with erythropoietin products who present with refractory anaemia. HIF stabilisers such as Roxadustat, which have otherwise not been licensed in New Zealand, seem to be beneficial in these cases, possibly minimising the need for heavy immunosuppression.
