Iscoe S.,Queen's University |
Beasley R.,Wellington Hospital |
Fisher J.A.,Toronto General Hospital
Critical Care | Year: 2011
Supplementary oxygen is routinely administered to patients, even those with adequate oxygen saturations, in the belief that it increases oxygen delivery. But oxygen delivery depends not just on arterial oxygen content but also on perfusion. It is not widely recognized that hyperoxia causes vasoconstriction, either directly or through hyperoxia-induced hypocapnia. If perfusion decreases more than arterial oxygen content increases during hyperoxia, then regional oxygen delivery decreases. This mechanism, and not (just) that attributed to reactive oxygen species, is likely to contribute to the worse outcomes in patients given high-concentration oxygen in the treatment of myocardial infarction, in postcardiac arrest, in stroke, in neonatal resuscitation and in the critically ill. The mechanism may also contribute to the increased risk of mortality in acute exacerbations of chronic obstructive pulmonary disease, in which worsening respiratory failure plays a predominant role. To avoid these effects, hyperoxia and hypocapnia should be avoided, with oxygen administered only to patients with evidence of hypoxemia and at a dose that relieves hypoxemia without causing hyperoxia. © 2011 BioMed Central Ltd.
Wyeth J.W.,Wellington Hospital
Journal of Gastroenterology and Hepatology (Australia) | Year: 2011
Background: Functional gastrointestinal disorders are common worldwide. Aim: To review functional gastrointestinal disorder prevalence, diagnosis and treatment in New Zealand. Methods: A Medline search was performed to identify all published studies relating to prevalence, diagnosis and treatment of functional gastrointestinal disorders in New Zealand. Results: Reflux prevalence is 30% and non-reflux dyspepsia is 34.2%. Helicobacter pylori prevalence varies considerably in NZ by geographical area and ethnicity and overall prevalence of infection is 24% in adults. 50% of patients with dyspepsia presenting for endoscopy in NZ will have no mucosal abnormality identified. National Dyspepsia Guidelines assist in management of patients. Guidelines exist for undifferentiated dyspepsia, Gastro-oesophageal Reflux Disease (GORD), H. pylori, peptic ulcer, NSAID's and gastrointestinal complications. Irritable Bowel Syndrome (IBS) is reported by 21% of adults. Symptoms were more than twice as frequent and severe in females than males. Access to colonoscopy for investigation of bowel symptoms is limited in NZ and priority is given to patients with "alarm features". Non-invasive markers of inflammation, such as faecal calprotectin, are being used to differentiate the patient with functional diarrhoea from inflammatory bowel disease. Treatment for irritable bowel symptoms is targeted to the predominant symptom. Conclusions: Functional gastrointestinal disorders are common in New Zealand. There is increasing awareness of dietary management for functional bowel symptoms. © 2011 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd.
Wong T.,Wellington Hospital
Clinical & experimental ophthalmology | Year: 2012
To evaluate the reproducibility of a new system for grading pupil ruff changes and associated findings. Observational comparative study. Forty-seven photograph sets including iris, pupil edge and ruff, and inferior anterior chamber drainage angle. A novel system for recording pupillary ruff changes was developed, along with reference iris, pupil and gonioscopy images. A prospective masked agreement study was undertaken using two observers who graded the photograph sets using this new system. Parameters included pupillary ruff absence and abnormality, pupil edge pigment, trabecular meshwork pigment, Sampaolesi line pigment, iris root pigment, and pigment 'lumps' and 'piles'. Intraobserver and interobserver agreement for the parameters of the grading system, assessed with the intraclass correlation coefficient and Bland-Altman plots. Photographs of 47 eyes of 47 glaucoma suspects and glaucoma patients were evaluated. Agreement percentages of ≥95% (average 96%) and ≥60% (average 70%) were obtained for intraobserver and interobserver agreement, respectively. The average interobserver single-measure intraclass correlation coefficient and repeat-measures intraclass correlation coefficient were 0.75 (range 0.54-0.88) and 0.85 (range 0.70-0.94), respectively. There was a non-significant trend towards interobserver systematic bias on one of the nine parameters (iris stroma pigment at the pupil edge). This grading system provides a reliable and reproducible system for encoding of clinical signs of pupil ruff atrophy for clinical research. © 2011 The Authors. Clinical and Experimental Ophthalmology © 2011 Royal Australian and New Zealand College of Ophthalmologists.
Venuraju S.M.,Wellington Hospital |
Yerramasu A.,Wellington Hospital |
Corder R.,Queen Mary, University of London |
Lahiri A.,Wellington Hospital |
And 2 more authors.
Journal of the American College of Cardiology | Year: 2010
Osteoprotegerin (OPG) is a glycoprotein that acts as a decoy receptor for receptor activator of nuclear factor κB ligand (RANKL) and tumor necrosis factor-related apoptosis-inducing ligand. The OPG/RANKL/receptor activator of nuclear factor κB axis plays an important regulatory role in the skeletal, immune, and vascular systems. The protective role of OPG, in animal models, against vascular calcification has not been replicated in human trials; moreover, increased OPG levels have been consistently associated with the incidence and prevalence of coronary artery disease. There seems to be some dichotomy in the role of OPG, RANKL, and tumor necrosis factor-related apoptosis-inducing ligand in atherosclerosis and plaque stability. In this review, we integrate the findings from some of the important studies and try to draw conclusions with a view to gaining some insight into the complex interactions of the OPG/RANKL/receptor activator of nuclear factor κB axis and tumor necrosis factor-related apoptosis-inducing ligand in the pathophysiology of atherosclerosis. © 2010 American College of Cardiology Foundation.
Thomas D.,Wellington Hospital
JAVA - Journal of the Association for Vascular Access | Year: 2015
Background Persistent left superior vena cava (PLSVC) occurs in approximately 1 in every 200 people, and with various malformations. Nurses who insert peripherally inserted central catheters (PICCs) may need to place a PICC line in this venous malformation. Aims To review the literature and assess the safety of positioning a PICC line in a PLSVC, and to also assess the ideal placement of a PICC line in a PLSVC with reference to a chest radiograph and intravenous electrocardiogram (IVECG) navigation. Methodology Literature search across 5 main databases, alongside hand-searched articles. Results No literature was found that prohibits placement of a PICC line in a PLSVC, unless the PLSVC enters the left atrium, and no literature was found that identifies an ideal position for the PICC tip in a PLSVC. Two approximate positions were highlighted: high in the PLSVC or passed through a bridging brachiocephalic vein to a right superior vena cava. Placing a PICC line in a PLSVC using IVECG navigation is shown to produce abnormal electrocardiogram readings. Conclusions A PICC line can be safely placed in a PLSVC as long as the PLSVC does not enter the left atrium, avoiding potential systemic embolization. Final positioning of the PICC tip on a chest radiograph is proposed to be in the midregion between the carina and the junction of the PLSVC/coronary sinus, with the aim of avoiding coronary sinus thrombosis and providing satisfactory dilution of infusate. If abnormal electrocardiogram readings during IVECG placement are seen, then PLSVC should be suspected. Further research and data are needed due to limited research in this area. © 2015 Association for Vascular Access.
Bomann S.,Wellington Hospital
The American journal of emergency medicine | Year: 2012
Tako-tsubo transient cardiomyopathy (TCM) is a syndrome of specific myocardial wall motion abnormalities that appear in response to extreme physiological or emotional stress. The patients have normal coronary arteries and usually present as new-onset heart failure or acute coronary syndrome. We report on a 48-year-old woman with post-community cardiac arrest presenting as an acute myocardial infarction. An emergency physician-performed echocardiogram showed significant wall motion abnormalities, suggesting myocardial infarction. Cardiac catheterization revealed patent epicoronary circulation, and ventriculography demonstrated a rare and only recently described variant of TCM:" reverse" TCM. The patient subsequently died from a subarachnoid hemorrhage.
Hamer M.,University College London |
O'Donnell K.,University College London |
Lahiri A.,Wellington Hospital |
Steptoe A.,University College London
European Heart Journal | Year: 2010
AimsPsychosocial stress is a risk factor for coronary heart disease (CHD), although the mechanisms are incompletely understood. We examined the cross-sectional association between the cortisol response to laboratory-induced mental stress and a marker of sub-clinical coronary atherosclerosis.Methods and resultsParticipants were 514 healthy men and women (mean age = 62.9 ± 5.7 years), without history or objective signs of CHD, drawn from the Whitehall II epidemiological cohort. Salivary cortisol was measured in response to mental stressors, consisting of a 5 min Stroop task and a 5 min mirror tracing task. Coronary artery calcification (CAC) was measured using electron beam computed tomography. Approximately 40 of the sample responded to the stress tasks with a notable (≥1 nmol/L) increase in cortisol. Significant CAC (Agatston score ≥ 100) was recorded in 23.9 of the sample. The cortisol response group demonstrated a higher risk of significant CAC (odds ratio = 2.20, 95 CI, 1.39-3.47) after adjustments for age, gender, baseline cortisol, employment grade, and conventional risk factors, although cortisol was unrelated to the presence of detectable CAC. Among participants with detectable CAC, the cortisol response group also demonstrated higher log Agatston scores compared with non-responders (age and sex adjusted scores; 4.51 ± 0.15 vs. 3.94 ± 0.13, P = 0.004).ConclusionIn healthy, older participants without history or objective signs of CHD, heightened cortisol reactivity is associated with a greater extent of CAC. These data support the notion that heightened hypothalamic pituitary adrenal activity is a risk factor for CHD.
Duthie J.B.,Wellington Hospital
Cochrane database of systematic reviews (Online) | Year: 2011
Overactive bladder syndrome (OAB) is a common condition with a significant negative impact on quality of life characterised by urgency with or without urge incontinence, frequency and nocturia. Intravesical botulinum toxin is being increasingly used to treat severe overactive bladder refractory to standard management. An increasing body of literature is forming that supports this technique as effective, well tolerated, and safe. This review is a substantial update of the 2007 review of the same title. The objective was to compare intravesical botulinum toxin with other treatments for neurogenic and idiopathic overactive bladder in adults. The hypothesis to be addressed were whether intravesical injection of botulinum toxin was better than placebo or no treatment; pharmacological and other non-pharmacological interventions; whether higher doses of botulinum toxin were better than lower doses; whether botulinum toxin in combination with other treatments was better than other treatments alone; whether one formulation of botulinum toxin is better than another; and whether one injection technique was better than another. We searched the Cochrane Incontinence Group Specialised Trials Register (searched 23 February 2010). The Register contains trials identified from MEDLINE, CINAHL, the Cochrane Central Register of Controlled Trials (CENTRAL), and handsearching of journals and conference proceedings. Additionally, all reference lists of selected trials and relevant review papers were searched. No limitations were placed on the searches. All randomised or quasi-randomised controlled trials of treatment for OAB in adults in which at least one management arm involved intravesical injection of botulinum toxin were included. Participants had either neurogenic OAB or idiopathic OAB with or without stress incontinence. Comparison interventions could include no intervention, placebo, lifestyle modification, bladder retraining, pharmacological treatments, surgery, bladder instillation techniques, neuromodulation, and different types, doses, and injection techniques of botulinum toxin. Binary outcomes were presented as relative risk and continuous outcomes by mean differences. Little data could be synthesised across studies due to differing study designs and outcome measures. Where applicable standard deviations were calculated from P values according to the formula described in section 184.108.40.206 of the Cochrane Handbook of Systematic Reviews of Interventions. Data were tabulated where possible with results taken from trial reports where this was not possible. Where multiple publications were found, the reports were treated as a single source of data. Nineteen studies were identified that met the inclusion criteria. Most patients in the studies had neurogenic OAB, but some included patients with idiopathic OAB. All studies demonstrated superiority of botulinum toxin to placebo. Lower doses of botulinum toxin (100 to 150 U) appeared to have beneficial effects, but larger doses (300 U) may have been more effective and longer lasting, but with more side effects. Suburothelial injection had comparable efficacy to intradetrusor injection. The effect of botulinum toxin may last for a number of months and is dependent upon dose and type of toxin used. Patients receiving repeated doses do not seem to become refractory to botulinum toxin. Botulinum toxin appeared to have beneficial effects in OAB that quantitatively exceeded the effects of intravesical resiniferatoxin. Intravesical botulinum toxin appeared to be reasonably safe; however, one study was halted due to a perceived unacceptable rate of urinary retention. Intravesical botulinum toxin appears to be an effective therapy for refractory OAB symptoms, but as yet little controlled trial data exist on benefits and safety compared with other interventions, or with placebo. Further robust data are required on long term outcomes, safety, and optimal dose of botulinum toxin for OAB.
Bajwa A.S.,Wellington Hospital |
Villar R.N.,Wellington Hospital
Journal of Bone and Joint Surgery - Series B | Year: 2011
Arthroscopy of the native hip is an established diagnostic and therapeutic procedure. Its application in the symptomatic replaced hip is still being explored. We describe the use of arthroscopy of the hip in 24 symptomatic patients following total hip replacement, resurfacing arthroplasty of the hip and partial resurfacing (study group), and compared it with arthroscopy of the native hip in 24 patients (control group). A diagnosis was made or confirmed at arthroscopy in 23 of the study group and a therapeutic arthroscopic intervention resulted in relief of symptoms in ten of these. In a further seven patients it led to revision hip replacement. In contrast, arthroscopy in the control group was diagnostic in all 24 patients and the resulting arthroscopic therapeutic intervention provided symptomatic relief in 21. The mean operative time in the study group (59.7 minutes (35 to 93)) was less than in the control group (71 minutes (40 to 100), p = 0.04) but the arthroscopic approach was more difficult in the arthroplasty group. We suggest that arthroscopy has a role in the management of patients with a symptomatic arthroplasty when other investigations have failed to provide a diagnosis. ©2011 British Editorial Society of Bone and Joint Surgery.
Tzaveas A.P.,Wellington Hospital |
Villar R.N.,Wellington Hospital
HIP International | Year: 2010
Acetabular chondral delamination is a frequent finding at hip arthroscopy. The cartilage is macroscopically normal but disrupted from the subchondral bone. Excision of chondral flaps is the usual procedure for this type of lesion. However, we report 19 consecutive patients in whom the delaminated chondral flap was re-attached to the underlying subchondral bone with fibrin adhesive. We used the modified Harris hip score for assessment of pain and function. Improvement in pain and function was found to be statistically significant six months and one year after surgery. No local or general complications were noted. Three patients underwent further surgery for unrelated reasons. In each, the area of fibrin repair appeared intact and secure. Our results suggest that fibrin is a safe agent to use for acetabular chondral delamination. © 2010 Wichtig Editore.