Middlemore Hospital

Auckland, New Zealand

Middlemore Hospital

Auckland, New Zealand

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Ponzoni M.,San Raffaele Scientific Institute | Issa S.,Middlemore Hospital | Batchelor T.T.,Massachusetts General Hospital | Rubenstein J.L.,University of California at San Francisco
Annals of Oncology | Year: 2014

Background: While there has been significant progress in outcomes for patients diagnosed with primary central nervous system (CNS) lymphoma (PCNSL), survival rates will likely plateau with the current armamentarium of agents used to treat these patients. Moreover, given that PCNSL increasingly impacts an older population, a significant proportion of patients are not eligible for intensive therapies such as high-dose chemotherapy or whole-brain radiation. There is a need for the development of novel agents, which target key survival pathways in order to continue to make progress in this disease. Patients and methods: We reviewed the key molecular pathways and genomic aberrations in PCNSL in order to identify candidate targets. We focused on molecules and pathways that have been identified and confirmed by more than one investigator or methodology. Results: While PCNSL tumors usually express a BCL6+, MUM1+ 'activated, germinal center' immunophenotype, they exhibit multiple shared genetic properties with ABC-type diffuse large B-cell lymphomas. Candidate targets and pathways include NFkB, the B-cell receptor, the JAK/STAT pathway, IRF4, BCL-6 as well as PIM kinases. Elements of the tumor microenvironment that may be exploited therapeutically include chemokine pathways, as well as macrophage and T-cell responses. Conclusions: There is a significant need for developing novel therapies in PCNSL, given that an increasing proportion of patients are not eligible for high-dose chemotherapy and brain radiation is associated with detrimental cognitive sideeffects. We provide an overview of potential drug targets and novel agents that may be integrated with existing strategies in order to make further progress in this disease. © The Author 2013. Published by Oxford University Press on behalf of the European Society for Medical Oncology. All rights reserved.


Biggar M.A.,Royal Infirmary | Biggar M.A.,Middlemore Hospital | Lennard T.W.J.,Royal Infirmary | Lennard T.W.J.,Northumbria University
British Journal of Surgery | Year: 2013

Background: Phaeochromocytoma in pregnancy is a rare and potentially dangerous situation for mother and fetus. This review aimed to assess current mortality rates and how medical and surgical management affect these. Methods: Articles in English published between 2000 and 2011 were obtained from a MEDLINE search. Eligible publications presented women diagnosed with phaeochromocytoma in the antenatal or immediate postnatal period, and reported management and outcomes. Results: A total of 135 reports were identified. After applying inclusion criteria, 77 pregnancies involving 78 fetuses were analysed. Fetal and maternal mortality rates were 17 per cent (13 of 78) and 8 per cent (6 of 77) respectively. Better outcomes were achieved when the diagnosis of phaeochromocytoma was made in the antenatal period than when it was made during labour or immediately postpartum (survival of both mother and fetus(es) in 48 of 56 versus 12 of 21 respectively; P = 0·012). When the diagnosis was made before 23 weeks' gestation, there was no difference in outcomes when phaeochromocytoma surgery was carried out in the second trimester, compared with when it was postponed to the third trimester or after delivery (fetal death 2 of 18 versus 2 of 8 respectively; P = 0·563). Conclusion: This review, although limited by the rarity of the condition and level of available evidence, demonstrated that survival rates are improved if the diagnosis of phaeochromocytoma can be established antenatally. With diagnosis before 23 weeks' gestation, no definite advantage of proceeding with tumour removal during the second trimester could be demonstrated. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.


News Article | February 15, 2017
Site: www.businesswire.com

NANAIMO, British Columbia--(BUSINESS WIRE)--Tilray, a global leader in medical cannabis research and production, today announced that it has received necessary approvals in Canada and New Zealand to export medical cannabis to New Zealand. “We are proud to be able to offer patients in need access to high-quality, pharmaceutical-grade medical cannabis products,” said Brendan Kennedy, Tilray President. Tilray will supply Middlemore Hospital in Auckland with precisely formulated medical cannabis oil containing tetrahydrocannabinol (THC) and cannabidiol (CBD). New Zealand law permits patients to access medical cannabis products with special authorization from the Ministry of Health. The first shipment of Tilray products is expected to arrive in Auckland by the end of February. Tilray currently supplies pharmaceutical-grade medical cannabis products – including whole flower, oils and capsules – to thousands of patients, physicians, pharmacies, hospitals, governments and researchers around the world for commercial, compassionate access and research purposes. Tilray became the first medical cannabis producer in North America to be certified in accordance with the European Medicines Agency’s (EMA) Good Manufacturing Practice (GMP) standards in December 2016. GMP certification is the most rigorous standard that manufacturers of medical products must meet in their production processes, and it provides regulators and health care providers in countries new to medical cannabis with certainty that Tilray products are the safe and smart choice. GMP certification is enabling Tilray to expand international distribution of its products for commercial, clinical research and compassionate purposes. In 2016, Tilray made history by becoming the first company to legally export medical cannabis products from North America to Australia and the European Union. In 2017, the company is focused on expanding distribution of its products to additional countries in Europe and Latin America. The company is currently partnering with hospitals and universities on three clinical trials focused on pediatric epilepsy, post-traumatic stress disorder (PTSD), and chemotherapy-induced nausea and vomiting (CINV). Tilray is a global leader in medical cannabis research and production dedicated to advancing the science, safety, and efficacy of medical cannabis. The company operates one of the largest and most sophisticated federally licensed medical cannabis cultivation facilities in the world, offering a range of products to patients, physicians, pharmacies, governments, hospitals and researchers in Australia, Canada, the European Union, New Zealand and Latin America.


Murgatroyd S.E.,Middlemore Hospital | Frampton C.M.A.,University of Otago | Wright M.S.,Auckland Hospital
Journal of Arthroplasty | Year: 2014

This study assessed the early outcomes of total hip arthroplasty compared with body mass index (BMI). 5357 hip arthroplasties were evaluated. Oxford Scores, revision for any reason and other factors including American Society of Anaesthesiology scores, length of surgery and cementation of components were analyzed. Both a high and a low BMI predicted for worse Oxford Hip Scores. Obese and morbidly obese patients had significantly lower six month Oxford Scores than healthy patients, the lowest survival, were younger than all other groups and had greater proportions with fully un-cemented prostheses. At this early stage, the results show that outcome and early revision are statistically and clinically poorer for obese patients. © 2014.


Barnard J.,Middlemore Hospital | Westenberg A.M.,Bay Urology
Neurourology and Urodynamics | Year: 2015

Introduction and Objectives A significant number of men are affected by post-prostatectomy urinary incontinence. If symptoms persist after conservative measures fail men are left with three choices: additional surgery, drainage or absorbent devices, or a penile compression device. Our center encountered a number of men for whom additional surgery was too dangerous and for whom drainage or absorbent devices were too cumbersome. Our objective was to investigate the level of symptomatic improvement and ease of utility of a penile compression device (Dribblestop™, Rennich Industries, Ltd., Calgary, Canada) in this population. Patients and Methods Patients who were prescribed the penile compression device across 10 New Zealand Centers were contacted to complete an Incontinence Impact Questionnaire (IIQ-7) regarding symptomatic improvement before and after the use of the compression device. The data were then analyzed for improvement scores pre and post intervention. Results Eighteen men were contacted across 10 New Zealand centers. There was an 89% response rate for interview. The average pre-intervention IIQ-7 score was 67.3 out of 100. The average post-intervention IIQ-7 score was 26.8 out of 100. The reduction in average symptomatic score was 40.5 (P < 0.05). The interviewees found the device easy to use, felt more confident wearing the device, and had increased levels of physical activity with device in situ. Conclusion This study demonstrates that men who used the penile compression device reduced their Incontinence Impact Questionnaire scores significantly. Further research into the side effect profile of the device is needed as its utility may be under appreciated. Neurourol. Urodynam. 34:115-116, 2015. © 2014 Wiley Periodicals, Inc. © 2014 Wiley Periodicals, Inc.


Chang W.K.,Middlemore Hospital | Srinivasa S.,University of Auckland | MacCormick A.D.,University of Auckland | Hill A.G.,University of Auckland
Annals of Surgery | Year: 2013

Objective: To determine whether gentamicin-impregnated collagen sponges (gentamicin-collagen implants) decrease the incidence of surgical site infection (SSI). Background: SSIs cause substantial morbidity and increase the costs of healthcare. Antibiotic prophylaxis is a cornerstone of SSI reduction. Prophylactic local delivery of antibiotics with novel biodegradable drug carrier systems, such as the gentamicin-collagen implant, is a potential avenue for SSI reduction. Gentamicin-collagen implants have been previously assessed in multiple randomized controlled trials (RCTs) with conflicting results. Therefore, a systematic reviewandmeta-analysis of all relevant RCTswas conducted to determine whether gentamicin-collagen implants reduce SSI. Methods: Major medical databases and trial registers were searched for published and unpublished RCTs. The endpoint of interest was the incidence of SSI. A random effects model was used and pooled estimates were reported as odds ratios (ORs), with the corresponding 95% confidence interval (CI). A subset analysis by incision type was planned a priori. Results: Fifteen RCTs encompassing a total of 6979 patients were included in the final analysis. The included studies were of moderate to high quality. Gentamicin-collagen implants significantly reduced SSI [OR =0.51;95% CI: 0.33-0.77; P = 0.001; number needed to treat (NNT) = 21; I2 = 75%]. These results were seen in subset analysis of clean (OR = 0.53;95% CI: 0.33-0.87; P = 0.01; NNT = 30) and clean-contaminated surgery (OR = 0.43;95% CI: 0.20-0.93; P = 0.03; NNT = 9) specifically. Conclusions: Gentamicin-collagen implants decrease the rate of SSI. Copyright © 2013 by Lippincott Williams and Wilkins.


Wong T.Y.,Middlemore Hospital
New Zealand Medical Journal | Year: 2011

Aim To evaluate the incidence, indications and complications associated with emergency peripartum hysterectomy (EPH) performed at Christchurch Women's Hospital, New Zealand. Methods A retrospective case series analysis of EPH from 2000-2009. Cases were identified using the hospital's computerised database. Those medical records were reviewed. EPH was defined as one performed for major postpartum haemorrhage unresponsive to other treatment within 24 hours of delivery. Results Nineteen EPH cases were identified among 47,520 deliveries, giving an incidence of 0.4 per 1000 deliveries. The indications were invasive placental adhesion-accreta, increta, percreta (63%), uterine atony (16%), placenta praevia (10.5%) and uterine tear with atony (10.5%). All cases of abnormal placentation in this study had previous caesareans or curettages. A significant association between previous uterine surgery and abnormal placentation was shown (p=0.02), especially those with previous caesarean (p=0.003). No maternal or perinatal mortality was recorded. Maternal morbidity was prevalent, including eight disseminated intravascular coagulopathies, seven intensive care, three bladder injuries, two reexplorations, one respiratory failure and one pulmonary embolism. Conclusion Invasive placental adhesion is the major indication for EPH. This study demonstrates an association between the presence of scarred uteri as a result of previous uterine surgery, and abnormal placentation. © NZMA.


Background: Symptomatic stenosis is an increasingly recognised complication following laparoscopic sleeve gastrectomy (LSG) to treat obesity with a reported prevalence between 0.1 and 3.9 %. This study aimed to determine the prevalence and management options for symptomatic stenosis (SS) after LSG.Methods: A total of 857 patients underwent LSG at Counties Health Auckland New Zealand between May 2008 and June 2013. All cases referred for management of symptomatic stenosis after LSG were recorded.Results: Symptomatic stenosis developed in 26 (3.03 %) out of 857 receiving LSG confirmed by barium swallow. Three of these 26 patients developed a fixed stenosis in the proximal stomach. These were all successfully treated by one dilatation of controlled radial expansion (CRE) balloon of <20 mm. Of the 23 patients that showed a fixed stenosis at the incisura angularis, 16 were initially treated with dilatation by a CRE balloon. Seven of these patients were successfully dilated although one needed two dilatations. Of the nine failures, six were successfully treated using a 30-mm achalasia balloon dilator and the other three required temporary placement of a self-expandable metal stent (SEMS). Based on this experience, seven other patients who presented with strictures at the incisura >3 cm long were initially treated with the achalasia balloon. Five were successfully dilated, but two required temporary placement of a SEMS. None of the 26 patients required a surgical procedure to correct their stenosis.Conclusions: The use of a 30-mm achalasia balloon and a SEMS is an effective and safe treatment for patients with SS post-LSG who do not respond to dilatation. Achalasia balloon could be the first-line treatment in selected cases. © 2014, Springer Science+Business Media New York.


Mosca V.S.,Seattle Childrens Hospital | Bevan W.P.,Middlemore Hospital
Journal of Bone and Joint Surgery - Series A | Year: 2012

Background: Surgical resection of persistently painful talocalcaneal tarsal coalitions may not reliably relieve symptoms in patients with large coalitions associated with excessive hindfoot valgus deformity and subtalar posterior facet narrowing. Since 1991, calcaneal lengthening osteotomy, with or without coalition resection, has been used at our institution to relieve symptoms and to preserve motion at the talonavicular and calcaneocuboid joints. Methods: We retrospectively reviewed the records for eight patients with thirteen painful talocalcaneal tarsal coalitions who had undergone a calcaneal lengthening osteotomy for deformity correction with or without coalition resection between 1991 and 2005. Preoperative and postoperative clinical, radiographic, and computed tomographic records were reviewed. The duration of clinical follow-up ranged from two to fifteen years. Results: Calcaneal lengthening osteotomy fully corrected the valgus deformity and provided short-to-intermediate term pain relief for the five patients (nine feet) in whom the talocalcaneal tarsal coalition was unresectable. The patient with resectable coalitions but excessive valgus deformities underwent calcaneal lengthening osteotomies along with coalition resections and had excellent deformity correction and pain relief in both feet. One of the two patients who underwent calcaneal lengthening osteotomy years after coalition resection had excellent correction and pain relief. The other patient had a coincident calcaneonavicular coalition and severe degenerative arthritis in the talonavicular joint. He underwent concurrent arthrodesis of the talonavicular joint and, although he had excellent deformity correction, had persistent pain. All feet underwent concurrent gastrocnemius or Achilles tendon lengthening. Conclusions: It is generally accepted that resection is the treatment of choice for an intractably painful small talocalcaneal tarsal coalition that is associated with a wide, healthy posterior facet and minimal valgus deformity of the hindfoot. Although triple arthrodesis has been recommended for those who do not meet all three criteria, the present study suggests that an algorithmic treatment approach is justified. Treatment of the valgus deformity appears to be as important as that of the coalition. Calcaneal lengthening osteotomy with gastrocnemius or Achilles tendon lengthening is effective for correcting deformity and relieving pain in rigid flatfeet, just as it is in flexible flatfeet. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. Copyright © 2012 by The Journal of Bone and Joint Surgery, Incorporated.


Srinivasa S.,Middlemore Hospital | Hill A.G.,Middlemore Hospital
Annals of Surgery | Year: 2012

Perioperative fluid administration is an important aspect of surgical care but is often poorly understood. Surgeons have historically made a considerable contribution to the evidence base governing current practice. This review provides an overview of the history of perioperative fluid therapy and its relevance to modern practice.Intravenous fluids (IVF) first gained therapeutic importance in the treatment of cholera in the 1830s. From the 1880s, IVF began to be administered perioperatively to compensate for the "injurious" effects of anaesthesia. Clinical improvements were consequently noted, though the adverse effects of saline were observed. The work of Ringer, Hartmann, and others emphasized the importance of the composition of IVF and laid the foundations for the balanced solutions in use today.The intravenous "drip" was introduced by Rudolph Matas in 1924. As the metabolic response to injury was increasingly investigated in the 1940s and 1950s, the cause of post-operative oliguria was debated widely with the most prominent surgeons being Moore and Shires. These differences in opinion, coupled with reports of injured soldiers from the Korean War receiving large IVF infusions and surviving, dictated the surgical practice of liberal IVF administration until very recently.Newer work in fluid therapy has explored the concept of fluid restriction. Shoemaker and colleagues also pioneered the concept of fluid administration to achieve supranormal indices of cardiorespiratory function, which has led to the advent of goal-directed fluid therapy. Alongside the development of balanced solutions, the renewed focus on perioperative fluid therapy has led to IVF administration being guided by physiological principles with a new consideration of the lessons gleaned from history. Copyright © 2012 by Lippincott Williams & Wilkins.

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