Hamilton, New Zealand
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Harvey M.,Waikato Hospital | Cave G.,Hutt Hospital
International Journal of Emergency Medicine | Year: 2012

We report a case of profound neurologic and cardiovascular manifestations of tricyclic antidepressant intoxication following self-poisoning with multiple pharmaceuticals including amitriptyline in excess of 43 mg/kg, in a 51-yearold male. Institution of mechanical ventilation, volume expansion, systemic alkalinisation (pH 7.51), and intermittent bolus metaraminol resulted in QRS narrowing but failed to resolve the developed shock. One 100-ml bolus of 20% lipid emulsion followed by a further 400 ml over 30 min was administered with restoration of haemodynamic stability, thereby curtailing the need for ongoing vasopressor medications. Assayed blood levels were consistent with the 'lipid sink' being a major effecter in the observed improvement. © 2012 Harvey and Cave.

Rademaker M.,Waikato Hospital
Australasian Journal of Dermatology | Year: 2013

Facial involvement of atopic eczema in young children can be difficult to manage. Chronic scratching and rubbing, combined with parental reluctance to use topical corticosteroids on the face, often results in recalcitrant facial eczema. While wet wraps are a useful management option for moderate/severe atopic eczema involving the trunk and limbs they are difficult to use on the face. We describe the use of a face-mask using a widely available adhesive hydrocolloid dressing (DuoDerm extra thin) in three children with recalcitrant facial atopic eczema. Symptomatic control of itch or soreness was obtained within hours and the facial atopic eczema was markedly improved by 7 days. The face-masks were easy to apply, each lasting 1-4 days. One patient had a single adjuvant application of a potent topical corticosteroid under the hydrocolloid dressing. All three patients had long remissions (greater than 3 months) of their facial eczema, although all continued to have significant eczema involving their trunk and limbs. Face-masks made from hydrocolloid dressings, with or without topical corticosteroids, are worth considering in children with recalcitrant facial eczema. © 2012 The Australasian College of Dermatologists.

Whittaker S.J.,Waikato Hospital
The New Zealand medical journal | Year: 2013

The following case concerns a soft tissue Vibrio cholerae (V. cholerae) infection in a fisherman who cut his foot while retrieving his fishing dinghy. It is rare for V. cholerae to cause extraintestinal infection. This V. cholera was identified as a non-toxigenic organism. The patient was successfully treated with medical therapy at Waikato Hospital (Hamilton, New Zealand) and discharged home after 10 days.

Weilert F.,Waikato Hospital
Current Opinion in Gastroenterology | Year: 2016

PURPOSE OF REVIEW: Cyanoacrylate (CYA) therapy has become an important component of the therapeutic toolbox of the interventional endoscopists with direct endoscopic injection accepted as first-line therapy of gastric varices. However, its generalized use has been cautioned by its serious adverse event profile. RECENT FINDINGS: Endoscopic ultrasound guided therapy has several conceptual advantages over free-hand injection, particularly as it ensures intravascular delivery of therapy. This has allowed innovation with the use of vascular coils with or without CYA therapy, and very encouraging long-term results are now published showing reduced serious adverse events and low rebleeding rates. SUMMARY: Direct endoscopic ultrasound guided intravascular injection of CYA is gaining widespread acceptance and offers reduced complication rates and significantly lower rebleeding rates. Data are supportive of CYA use both for primary and secondary prophylaxis of gastric varices. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

This prospective observational study aimed to identify what proportion of patients presenting to Waikato Hospital with undifferentiated symptoms of an acute febrile illness (USFI) have leptospirosis or murine typhus infection, and to identify factors at presentation predictive of each infection. It also aimed to identify infecting rickettsial organism(s) causing murine typhus in the region. Between 15/10/2009-15/10/2010 all adult patients presenting with USFI of greater than and equal to 72 hours with no clear diagnosis on presentation were invited to participate in the study. A structured questionnaire and examination were administered and acute and convalescent serology was performed. For patients returning positive murine typhus serology, rickettsial PCR analysis was performed on stored acute blood samples. Fifty-seven patients were recruited. Nine were diagnosed with leptospirosis, five with murine typhus, three with Epstein-Barr virus (EBV), two with cytomegalovirus (CMV), five with bacterial sepsis and six with other diagnoses. Twenty seven had an acute febrile illness for which no diagnosis was found. A low platelet count (p<0.001) was associated with murine typhus infection, and rural occupation (p<0.001) and a low lymphocyte count (p=0.001) with leptospiral infection. There was a trend towards rural residence being associated with murine tyhpus infection (p=0.059). Two of four patients with positive murine typhus serology returned positive PCR analysis for Rickettsia typhi. A significant proportion of patients presenting to Waikato Hospital with USFI had leptospirosis or murine typhus infection. A low platelet count and rural residence were associated with murine typhus infection, and rural occupation and a low lymphocyte count with leptospiral infection. R. typhi was identified as a rickettsial organism causing rickettsial fever in the Waikato region.

Head M.,Waikato Hospital | Jameson M.B.,Waikato Hospital
Expert Opinion on Investigational Drugs | Year: 2010

Importance of the field: Targeting tumor vasculature with antiangiogenic agents improves outcomes achieved with chemotherapy in some cancers, but toxicity limits their applicability. Tumor vascular-disrupting agents (tumor-VDAs) induce an acute collapse in tumor vascular supply; ASA404 (vadimezan, 5,6-dimethylxanthenone-4-acetic acid [DMXAA]) is the tumor-VDA most advanced in clinical development. Recent randomized trials of ASA404 in combination with chemotherapy suggested a survival advantage in NSCLC comparable to that achieved with bevacizumab, but with little additional toxicity. Phase III trials in advanced NSCLC have completed accrual, and a review of this exciting agent is timely. Areas covered in this review: This review focuses on the development of ASA404 to date, its mechanisms of action, the current body of clinical research and potential avenues for therapeutic use. It includes all completed clinical trials since it entered clinical testing in 1995 through to 2009. What the reader will gain: This review will help the reader to understand why ASA404 is unique among tumor-VDAs; the clinical trial methodology required to evaluate such agents; and its remarkable potential clinical utility. Take home message: ASA404 is a tumor-VDA that offers considerable potential to improve outcomes in cancer patients in combination with existing treatments. © 2010 Informa UK Ltd.

Cave G.,Tamworth Rural Referral Hospital | Harvey M.G.,Waikato Hospital
Critical Care | Year: 2014

The use of intravenous lipid emulsions (ILEs) as antidote in local anaesthetic systemic toxicity has gained widespread support following convincing data from animal models, and successful case reports in humans. Proposed beneficial mechanisms of action for ILEs include intravascular sequestration of intoxicant and subsequent enhanced redistribution to biologically inert tissues, augmentation of fatty acid utilisation for ATP synthesis in the context of metabolic poisoning, and direct cardiotonic and ion channel effects. The evidence base for use of ILEs in acute drug intoxication is evolving. The present evidence supports use of ILEs only in local anaesthetic systemic toxicity and in lipophilic cardiotoxin intoxication when there is an immediate threat to life, and other therapies have proven ineffective. © 2014 Cave and Harvey; licensee BioMed Central Ltd.

Rademaker M.,Waikato Hospital
Australasian Journal of Dermatology | Year: 2013

With 30 years of clinical use, it is appropriate to review the use of isotretinoin. We now understand that retinoids influence cellular growth, differentiation, morphogenesis and apoptosis, inhibit tumour promotion and malignant cell growth, exert immuno-modulatory actions and alter cellular cohesiveness. This has expanded the indications of isotretinoin from just acne and rosacea to a wide range of inflammatory and malignant skin disorders. While the standard dose of 0.5 to 1 mg/kg per day for 4 months to a cumulative dose of 120-140 mg/kg per day has served us well in the management of acne vulgaris, there is emerging evidence that much lower dosages (as low as 5 mg/day) are just as effective but have significantly fewer adverse effects. Relapse of acne vulgaris continues to be a problem but we are beginning to recognise that this is related less to the cumulative dose and more to the length of sebaceous gland suppression. Other factors important for relapse include a macrocomedonal pattern of acne, smoking and age, both younger (under 14 years) and older (over 25 years). After 30 years of use, we now understand why isotretinoin is such an effective drug. Not only does it clear acne in almost all patients, long-term remission can be achieved in 70-80% of patients with a single course. Important changes in the use of isotretinoin include using a lower daily dose for a longer period of time. New indications continue to emerge, particularly as a potential treatment for both intrinsic and extrinsic (photo) aging. Teratogenicity however, remains a very significant concern. © 2012 The Australasian College of Dermatologists.

Ooi C.W.,Waikato Hospital
The New Zealand medical journal | Year: 2012

The National Breast Cancer Audit collects data on the care of early breast cancer patients in Australia and New Zealand. An overview of invasive breast cancer in New Zealand is presented with emphasis on comparing the screened population with symptomatic referrals. All New Zealand data in the National Breast Cancer Audit with a diagnosis date of 2008 have been included in the report. Data was analysed with an aim to compare the presenting features and management of screen detected invasive cancer with symptomatic referrals in New Zealand. There were 2371 cases of breast cancer, 52% of which were symptomatic referrals, 37% of which were BreastScreen Aotearoa referrals. Higher breast conservation rates were reported in the screening population. 3% of patients had involved margins after surgery. Almost two-thirds (62%) of BreastScreen patients underwent a sentinel node biopsy without further axillary surgery. 72% of screening patients and 86% of symptomatic patients who were high risk did not receive post mastectomy radiotherapy. A larger proportion of symptomatic patients received chemotherapy. Endocrine therapy was prescribed to 81% of hormone receptor positive patients. Patients with early invasive breast cancer in New Zealand were managed appropriately according to audit performance indicators and clinical guidelines. The numbers of high risk patients not receiving post mastectomy radiotherapy and the lack of endocrine treatment in some patients with hormone receptor positive tumours may warrant further investigation.

Weilert F.,Waikato Hospital
Surgical Endoscopy and Other Interventional Techniques | Year: 2014

Background: EUS-guided biliary drainage (EUS-BD) is technically challenging but alternative method of therapeutic intervention when ERCP fails.Objective: Assess the feasibility, safety and risks of EUS-BD with intra-hepatic biliary access and anterograde interventions using an algorithm to increase flexibility of interventions, limit adverse events and improve procedural time.Design: Prospective observational cohort study.Patients: 21 consecutive patients underwent EUS-BD drainage for failed ERCP.Main Outcome measures: Technical and clinical success rates with adverse event rate using simplified algorithm.Results: Patient recruitment from June 2011-October 2013; mean age of 67.4 years, predominantly male (70.5 %) with pancreatic cancer (52.4 %), cholangiocarcinoma (14.3 %), other malignant biliary obstruction (9.5 %) and benign biliary obstruction (23.8 %). Prior interventions included failed ERCP in 18/21 (85.7 %) while 3/21 (14.3 %) had primary EUS-BD. Anterograde cholangiogram was achieved in all patients. Technical success was achieved in 20/21 (95.2 %) with clinical success was achieved in 19/21 (90.4 %). Placement of access wire was across the ampulla in 10/20 (50 %) and into CBD or contra-lateral IHD in 10/20 (50 %). Tract dilatation was accomplished in 17/20 (85 %) but required completion using intra-hepatic needle knife in 3/20 (15 %). Anterograde interventions were performed in 16/20 (80 %) but crossover to rendezvous in 3/20 (15 %) or choledochoduodenostomy 1/20 (5 %). Three patients 3/21 (14.3 %) also had endoscopic duodenal SEMS placement to relieve duodenal obstruction. Two patients (9.5 %) had post-procedural bile leak and pain.Conclusion: EUS-guided anterograde biliary drainage using the intra-hepatic access route has high technical and clinical success with low adverse rate. We would promote a simplified standardized algorithm, which gives flexibility of direct anterograde interventions. © 2014, Springer Science+Business Media New York.

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