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Aims/hypothesisLower limb amputation is a serious complication of diabetes mellitus. Understanding how amputation risk differs by population subgroups is crucial in terms of directing preventive strategies. In this study, we describe those factors that impact amputation risk in the entire prevalent diabetic population of New Zealand.MethodsA national prevalent cohort of 217,207 individuals with diabetes in 2010 were followed up until the end of 2013 for lower limb amputations, and 2014 for mortality. Inpatient hospitalisation data were used to define lower limb amputation using ICD-10 codes. Cox proportional hazards models were used to describe relative hazard of amputation over the follow-up period.ResultsA total of 784 individuals (3.6 cases/1000 individuals) underwent a major (above-ankle) lower limb amputation during follow-up, while 1217 (5.6/1000) underwent a minor (below ankle) amputation. The risk of major and minor amputation was 39% and 77% greater for men than women, respectively (adjusted HR: major amputation 1.39, 95% CI 1.20, 1.61; minor amputation 1.77, 95% CI 1.56, 2.00). Indigenous Māori were at 65% greater risk of above-knee amputation compared with the European/Other diabetic population (HR 1.65, 95% CI 1.37, 1.97). Amputation risk increased with increasing comorbidity burden, and peripheral vascular disease conferred the greatest independent risk of all comorbid conditions. Prior minor amputation increased the risk of subsequent major amputation by tenfold (HR 10.04, 95% CI 7.83, 12.87), and increased the risk of another minor amputation by 20-fold (HR 21.39, 95% CI 17.89, 25.57). Death was common among the total cohort, but particularly among those who underwent amputation, with more than half of those who underwent a major amputation dying within 3 years of their procedure (57%).Conclusions/interpretationUsing a large, well-defined, national prevalent cohort of people with diabetes, we found that being male, indigenous Māori, living in deprivation, having a high comorbidity burden and/or having a previous amputation were strongly associated with subsequent risk of lower limb amputation. The use of this prevalent cohort strengthens the value of our estimates in terms of applicability to the general population, and highlights the subgroups at greatest risk of lower limb amputation.

ObjectivesTo identify patterns of age disparities in cancer survival, using colon and lung cancer as exemplars.DesignSystematic review of the literature.Data sourcesWe searched Embase, MEDLINE, Scopus and Web of Science through 18 December 2020.Eligibility criteriaWe retained all original articles published in English including patients with colon or lung cancer. Eligible studies were required to be population-based, report survival across several age groups (of which at least one was over the age of 65) and at least one other characteristic (eg, sex, treatment).Data extraction and synthesisTwo independent reviewers extracted data and assessed the quality of included studies against selected evaluation domains from the QUIPS tool, and items concerning statistical reporting. We evaluated age disparities using the absolute difference in survival or mortality rates between the middle-aged group and the oldest age group, or by describing survival curves.ResultsOut of 3047 references, we retained 59 studies (20 for colon, 34 for lung and 5 for both sites). Regardless of the cancer site, the included studies were highly heterogeneous and often of poor quality. The magnitude of age disparities in survival varied greatly by sex, ethnicity, socioeconomic status, stage at diagnosis, cancer site, and morphology, the number of nodes examined and treatment strategy. Although results were inconsistent for most characteristics, we consistently observed greater age disparities for women with lung cancer compared with men. Also, age disparities increased with more advanced stages for colon cancer and decreased with more advanced stages for lung cancer.ConclusionsAlthough age is one of the most important prognostic factors in cancer survival, age disparities in colon and lung cancer survival have so far been understudied in population-based research. Further studies are needed to better understand age disparities in colon and lung cancer survival.PROSPERO registration numberCRD42020151402.

ObjectivesIn this manuscript, we describe broad trends in postoperative mortality in New Zealand (a country with universal healthcare) for acute and elective/waiting list procedures conducted between 2005 and 2017.Design, participants and settingWe use high-quality national-level hospitalisation data to compare the risk of postoperative mortality between demographic subgroups after adjusting for key patient-level confounders and mediators. We also present temporal trends and consider how rates in postoperative death following acute and elective/waiting list procedures have changed over this time period.Results and conclusionA total of 1 836 683 unique patients accounted for 3 117 374 admissions in which a procedure was performed under general anaesthetic over the study period. We observed an overall 30-day mortality rate of 0.5 per 100 procedures and a 90-day mortality rate of 0.9 per 100. For acute procedures, we observed a 30-day mortality rate of 1.6 per 100, compared with 0.2 per 100 for elective/waiting list procedures. In terms of procedure specialty, respiratory and cardiovascular procedures had the highest rate of 30-day mortality (age-standardised rate, acute procedures: 3–6 per 100; elective/waiting list: 0.7-1 per 100). As in other contexts, we observed that the likelihood of postoperative death was not proportionally distributed within our population: older patients, Māori patients, those living in areas with higher deprivation and those with comorbidity were at increased risk of postoperative death, even after adjusting for all available factors that might explain differences between these groups. Increasing procedure risk (measured using the Johns Hopkins Surgical Risk Classification System) was also associated with an increased risk of postoperative death. Encouragingly, it appears that risk of postoperative mortality has declined over the past decade, possibly reflecting improvements in perioperative quality of care; however, this decline did not occur equally across procedure specialties.

Purpose: Testicular cancer (TC) remains perplexing, both in terms of what causes the disease and why certain populations are at greater risk of developing it. In New Zealand, an unusual ethnic disparity exists, whereby the indigenous Māori population suffer the highest rates of disease. In this study, we further describe the epidemiology of TC in the New Zealand context. Methods: Eligible patients diagnosed with TC between 2000 and 2011 (n = 1,800) were determined from the NZ Cancer Registry and linked to mortality data. Census data were used to estimate population incidence of TC and tumor sub-type by ethnic group. Kaplan–Meier and Cox regression analyses were used to compare survival between ethnic groups. Results: Māori males aged 15–44 were 80 % more likely to be diagnosed with TC compared to European/Other males [age-standardized relative risk (RR) 1.80, 95 % CI 1.58–2.05]. By contrast, disease burden was comparatively low among Pacific and Asian populations. Māori had a greater incidence of both seminoma (RR 1.88, 95 % CI 1.52–2.22) and non-seminoma (RR 1.67, 95 % CI 1.35–2.07) germ cell tumors than the European/Other population, reducing the likelihood that our observed disparity is driven by differential propensity to one given sub-type among Māori. Māori had poorer survival outcomes [cancer-specific adjusted hazard ratio (HR) 2.29, 95 % CI 1.14–4.59] than the European/Other population. Conclusions: Understanding the drivers of New Zealand's unusual incidence disparities—particularly between Māori and Pacific—could further our understanding of the key exposures involved in TC etiology.

Key Points Cryptorchidism (undescended testes) is one of the most common congenital abnormalities observed in boys, and is one of the few known risk factors for testicular cancer The key factors associated with the occurrence of cryptorchidism remain elusive Few factors are supported by consistent evidence of an association with cryptorchidism despite a considerable body of aetiological research For factors for which evidence seems unequivocal, the measured factor is likely to be a surrogate for the true causal factor The relative importance of each risk factor could vary considerably between mother–son pairs depending on an array of genetic, maternal, placental and fetal factors, which could vary between regions Undescended testis — known as cryptorchidism — is one of the most common congenital abnormalities observed in boys, and is one of the few known risk factors for testicular cancer. The key factors that contribute to the occurrence of cryptorchidism remain elusive and a broad range of putative risk factors have been evaluated, but their plausibility is still in question. Undescended testis — known as cryptorchidism — is one of the most common congenital abnormalities observed in boys, and is one of the few known risk factors for testicular cancer. The key factors that contribute to the occurrence of cryptorchidism remain elusive. Testicular descent is thought to occur during two hormonally-controlled phases in fetal development — between 8–15 weeks (the first phase of decent) and 25–35 weeks gestation (the second phase of descent); the failure of a testis to descend permanently is probably caused by disruptions to one or both of these phases, but the causes and mechanisms of such disruptions are still unclear. A broad range of putative risk factors have been evaluated in relation to the development of cryptorchidism but their plausibility is still in question. Consistent evidence of an association with cryptorchidism exists for only a few factors, and in those cases in which evidence seems unequivocal the factor is likely to be a surrogate for the true causal exposure. The relative importance of each risk factor could vary considerably between mother–son pairs depending on an array of genetic, maternal, placental and fetal factors — all of which could vary between regions. Thus, the role of causative factors in aetiology of cryptorchidism requires further research.

Addresses the distance that much of the New Zealand population must travel in order to access adequate acute health care, especially cancer care and radiation therapy, and especially for Māori compared to non-Māori. Sets out three recommendations for forward-movement in terms of addressing inequities in travel burden in those cases where care cannot feasibly be decentralised. Source: National Library of New Zealand Te Puna Matauranga o Aotearoa, licensed by the Department of Internal Affairs for re-use under the Creative Commons Attribution 3.0 New Zealand Licence.

Multimorbidity is common among those living with diabetes. The purpose of this manuscript was to assess the performance of the recently developed M3 multimorbidity index within a large, well-defined cohort of patients with diabetes. We compared regression model performance between three morbidity indices (M3, Charlson, and Elixhauser) for important adverse outcomes (hospitalization, amputation, and mortality) among 217,207 patients with diabetes and compared the real-world applied impact of these indices for modeling these diabetes outcomes against two key exposure variables (ethnicity and deprivation). The M3 Index outperformed both Charlson and Elixhauser indices in terms of the prediction of hospitalization events, amputation events, and death. When applied to models that were investigating the relationship between (a) ethnicity and (b) deprivation on risk of these outcomes, the M3 Index also explained more confounding due to multimorbidity than either Charlson or Elixhauser (e.g., shift in odds ratio toward the null when predicting hospitalization: M3 Index 60%, Charlson 40%, and Elixhauser 24%). These results give additional support for the utility of the M3 index in clinical populations, adding to previous observations regarding its performance in a general population setting.

Draws together cancer incidence, mortality and survival data from the 2007-2016 in order to provide clarity regarding the most important causes of cancer burden for Māori. Compares this burden to that experienced by non-Māori, and considers how this relative disparity may (or may not) have changed over time. Discusses how to reduce the occurrence and the overall cancer mortality burden for Māori, with a focus on those cancers that confer the greatest burden. Source: National Library of New Zealand Te Puna Matauranga o Aotearoa, licensed by the Department of Internal Affairs for re-use under the Creative Commons Attribution 3.0 New Zealand Licence.

Background The peripheral complications of diabetes mellitus remain a significant risk to lower-limb morbidity. In New Zealand, risk of diabetes, comorbidity and lower-limb amputation are highly-differential between demographic groups, particularly ethnicity. There is growing and convincing evidence that the use of pedobarography – or plantar pressure measurement – can usefully inform diabetic foot care, particularly with respect to the prevention of re-ulceration among high-risk patients. Methods For the current feasibility study, we embedded pedobarographic measurements into three unique diabetic foot clinic settings in the New Zealand context, and collected pedobarographic data from n  = 38 patients with diabetes using a platform-based (Novel Emed) and/or in-shoe-based system (Novel Pedar). Our aim was to assess the feasibility of incorporating pedobarographic testing into the clinical care of diabetic feet in New Zealand. Results and Conclusions We observed a high response rate and positive self-reported experience from participants. As part of our engagement with participants, we observed a high degree of lower-limb morbidity, including current ulceration and chronic foot deformities. The median time for pedobarographic testing (including study introduction and consenting) was 25 min. Despite working with a high-risk population, there were no adverse events in this study. In terms of application of pedobarography as a clinical tool in the New Zealand context, the current feasibility study leads us to believe that there are two avenues that deserve further investigation: a) the use of pedobarography to inform the design and effectiveness of offloading devices among high-risk diabetic patients; and b) the use of pedobarography as a means to increase offloading footwear and/or orthoses compliance among high-risk diabetic patients. Both of these objectives deserve further examination in New Zealand via clinical trial.

Discusses the objective set at the Cancer Care at a Crossroads conference in Wellington in early 2019 to achieve equity in cancer survival for Maori by the end of 2030. Provides a rationale for this goal, recommendations for how it might be achieved, and addresses its likely criticisms. Source: National Library of New Zealand Te Puna Matauranga o Aotearoa, licensed by the Department of Internal Affairs for re-use under the Creative Commons Attribution 3.0 New Zealand Licence.