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The use, safety and effectiveness of topical and systemic tranexamic acid in endoscopic sinus surgery

Agrani Ratnayake Kumar,1, 2 Dr Andrew James Wood,1–3

1Department of Surgery, Waikato Clinical Campus, The University of Auckland, Auckland, New Zealand; 2Waikato Institute of Surgical Education and Research, Hamilton, New Zealand; 3Department of Otolaryngology-Head and Neck Surgery, Waikato Hospital, Hamilton, New Zealand.

Aims

Bleeding after endoscopic sinus surgery (ESS) is unpleasant for patients and generates significant healthcare costs. The aim of this retrospective study is to evaluate the combined use of topical and IV TXA in practice with regards to safety and efficacy.

Methods

We performed a retrospective single-surgeon study of all comprehensive ESS cases from January 2017–December 2019. There were no exclusion criteria. Descriptive statistics were used to report the rates of re-presentation and thromboembolic complications in the 28 days after surgery. The rate of revision surgery was used as a proxy measure of post-operative healing and scar formation.

Results

One hundred and seventy-seven patients underwent comprehensive ESS within the study period, of which, 13 (7.3%) re-presented to hospital acutely following surgery. Five (2.8%) of these cases were due to post-operative bleeding. The only thromboembolic complication was a transient ischemic attack unrelated to TXA use. Over the study period five (2.8%) patients underwent revision surgery.

Conclusion

Although liable to type 2 error, results suggest the combined use of topical and intravenous TXA is safe as well as effective at minimising post-operative bleeding and scar formation. This study highlights the need for prospective trials assessing the use of topical TXA in ESS.

Comparative analysis of lumbar spine vertebral morphology between Māori and European: a computed tomography study

William H Cook,1 Joseph F Baker1,2

1Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand; 2Department of Orthopaedic Surgery, Waikato District Health Board, Hamilton, New Zealand.

Aims

Many existing studies of lumbar anatomy do not consider ethnic influence and recruit white participants. Recent studies have considered other populations; however, none have assessed Māori, the indigenous population of New Zealand. A computed tomography study of vertebral body and canal dimensions was performed for lumbar vertebrae of Māori and European patients to evaluate for significant ethnic variation.

Methods

Lumbar vertebrae from 196 patients were measured using CT. A single trained examiner measured vertebral body (VB) anterior and posterior height, VB superior, inferior and pediculolaminar length, segmental angle, left and right pedicle height and width, and vertebral canal length and width for each level. Canal:body ratio was calculated from these measurements. Demographic data recorded included age, sex and ethnicity.

Results

Vertebral canal length remained relatively constant down the lumbar spine while canal width increased to a maximum of 28.2mm at L5. Canal:body ratios and pedicle height decreased while pedicle width increased to a maximum of 16.1mm at L5. There were few differences between Māori and Europeans except at the L5 level, where vertebral canal length and canal:body ratio were larger in Europeans and pedicle height, width and VB pediculolaminar length were larger in Māori. Females had generally smaller measurements and age was largely a positive predictor of measured values.

Conclusions

The present study is the first to characterise the lumbar anatomy of a Māori population. Adequately powered results demonstrated few differences between Māori and Europeans. Isolated differences observed at L5 may be due to sacropelvic anatomical differences, which represents an area for further investigation.

The role of suction rectal biopsy and open rectal biopsy in the diagnosis of Hirschsprung’s disease

Stacey Caldwell,1 Udaya Samarakkody2

1Faculty Medicine and Health Sciences, University of Auckland, Auckland, New Zealand; 2Department of Paediatric Surgery, Waikato Hospital, Hamilton, New Zealand

Aims

To determine the role of suction rectal biopsy (SRB) and open rectal biopsy (ORB) in the diagnosis of Hirschsprung’s disease (HD), to determine how to correctly select patients for ORB, reducing demand on hospital services.

Method

Retrospective review of all patients who had SRB or ORB performed at Waikato Hospital between Jan 2018–May 2020. Primary outcome measured was patient’s diagnosed with HD based on indications for biopsy (low, medium, high suspicion). Secondary outcomes included histopathology results.

Results

Data from 55 patients undergoing biopsy at WDHB was analysed. Two patients had both biopsies completed. 51.7% of patients were low or moderate suspicion. 48.3% of patients were high suspicion. Overall in the past 2.5 years 16.4% of patients have been diagnosed with HD. 100% of these patients were high suspicion.

Table 1: Hirschsprung diagnosis based on level of suspicion/indication for biopsy.

Conclusion

This review supports the need for further investigation of alternative first-line investigations in children considered to be low or moderate suspicion of HD as the yield rate is low. This could include; anorectal manometry, consideration of SRB in children under three years or a more selective approach to offering ORB.

Review of Akoranga Te Reo Māori teaching in the Paediatric Department at Waikato Hospital

Jessica Chanwai,1 Abigail Weaver,1 Dr Alex Wallace,2 Dr Te Aro Moxon,3 Dr Penny Brandt2

1Faculty Medicine and Health Sciences, University of Auckland; Auckland, New Zealand; 2Department of Paediatrics, Waikato Hospital, Department of Paediatrics: Child and Youth Health, University of Auckland; Auckland, New Zealand; 3Department of Paediatrics, Waikato Hospital, Hamilton, New Zealand.

Aims

To review perceptions of the Akoranga Reo Māori teaching for the Waikato Paediatric medical staff and explore opportunities for improvement.

Methods

An anonymous online survey was emailed to 61 paediatric staff, with a two-week timeframe for responses. Paper copies of the survey were provided as an alternative. A follow-up email was distributed a week prior to survey closure.

Results

40/61 (66%) staff responded. 38/40 (95%) respondents reported they “agreed” or “strongly agreed” that using Te Reo in clinical practice was important. 37/40 (93%) respondents reported improved confidence in pronouncing words and phrases in Māori after attending teaching, with 29/40 (73%) reporting they feel comfortable pronouncing Māori names in front of whānau. 35/40 (88%) reported Te Reo pronunciation was the most helpful contributor to communicating with whānau. Those surveyed favoured a structured curriculum that repeats itself on a regular basis and 38/40 (95%) were happy to continue with the general emphasis on pronunciation and medically relevant vocabulary.

Conclusion

The WDHB paediatric department perceived Akoranga Reo Māori an important tool for improving outcomes for Māori patients. The vast majority identified the best format conducive for learning was a regular, repetitive structure with emphasis on pronunciation, short sentences and medically relevant terminology.

Staged contoured marginal excision—a Waikato experience

Fangbo Lin,1 Eric Tan2

1Waikato Hospital, Waikato District Health Board, Hamilton, New Zealand; 2Waikato Hospital, Waikato District Health Board, Hamilton, New Zealand.

Achieving clear surgical margins in excision of melanoma in situ (MIS) is challenging. The concurrent Australasian Guidelines on melanoma recommended an excision margin of 5–10mm. This case describes our experience of using staged contoured marginal excision (CME) as an alternative technique to achieve clearance of a persistent residual MIS after multiple failed wide local excisions (WLE).

Case description

A 77-year-old woman was diagnosed with a left arm pT3a malignant melanoma by excision biopsy. Three subsequent WLEs with adequate clinical margins all showed histology that was clear of invasive melanoma but MIS persistently present peripherally. A CME technique was used to achieve histological clearance. Two 5mm wide strips of skin were excised 5mm beyond the macroscopic extent of the pigmented lesion. Paraffin embedded radially sliced sections from the excision was evaluated for residual disease. The positive 12 o’clock margin subsequently excised with another 5mm rim of tissue which was extended into two triangular skin flaps proximally and distally to allow the wound closure in an ellipse. 10mm margins clearance was achieved with direct closure of the wound within a single 24-hour period.

Discussion

This is the first case we are aware of using CME for MIS in Australasia. Benefits include achieving clearance of a difficult to manage MIS within a 24-hour period without undue risk of disfigurement or a prolonged period of open wound pending histological analysis. CME requires close support from histopathology and we have been advised that it was superior to slow Mohs or Mohs surgery.

Conclusion

Staged CME is a well described technique in overseas and we have had a positive experience utilising CME in our centre. In the future this will be a value addition to our armamentarium in managing challenging MIS in anatomically sensitive areas.

Clinical utility of cardiac magnetic resonance imaging to assess the left atrium before catheter ablation for atrial fibrillation—a systematic review and meta-analysis

Khashayar Ghafouri,1 Kyle Franke,2 Fang Shawn Foo,3 Martin K Stiles1,3

1Faculty of Medicine and Health Sciences, The University of Auckland, Hamilton, New Zealand; 2The University of Adelaide, South Australia, Australia; 3Department of Cardiology, Waikato Hospital, Hamilton, New Zealand.

Aims

This systematic review and meta-analysis aims to clarify the role of cardiac magnetic resonance imaging (CMRI) in identifying the association between left atrial (LA) characteristics and atrial fibrillation (AF) recurrence after ablation. These characteristics include LA fibrosis, passive emptying function, sphericity and post contrast T1 relaxation time.

Methods

PubMed, EMBASE and Cochrane were searched up to the July 2020 for English language articles reporting the use of MRI in catheter ablation for AF. Studies reporting relevant prognostic information of CMRI in AF ablation were included in the analysis. All references and forward citations were filtered for relevant manuscripts.

Results

Twenty-four publications reporting the prognostic value of pre-ablation MRI were identified. In the nine studies on LA fibrosis quantification included in the meta-analysis, every 10% increase in LA fibrosis was associated with a 1.54-fold increase in post ablation AF recurrence (95% CI: 1.39–1.70, I2=50.1%, P<0.042). In the three studies on LA sphericity included in the meta-analysis, there was no significant association with post-ablation AF recurrence (HR: 1.032 [95% CI: 0.962–1.103 I2=49.6%, P=0.137]). Egger’s test was non-significant for publication bias. LA passive emptying function and post-contrast LA T1 relaxation time had insufficient publications to conduct a meta-analysis.

Conclusion

LA fibrosis quantified by CMRI is clearly associated with risk of AF recurrence after AF ablation. There remains insufficient evidence to support the routine measurement of LA sphericity, LA passive emptying function and LA T1 relaxation time to predict AF recurrence after AF ablation.

Type A and B aortic dissections in the Midlands DHB: an analysis of all-cause and aortic mortality by ethnicity

William Xu,1 Manar Khashram1,2

1Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; 2Vascular Surgery Department, Waikato Hospital, Hamilton, New Zealand.

Aims

To analyse long-term survival following all types of aortic dissection based on ethnicity in New Zealand.

Methods

Consecutive patients diagnosed with Type A or B dissection at Waikato Hospital from January 2010–June 2020 were included. Demographic data including ethnicity and mortality data, were collected from clinical records. Aortic-related mortality was obtained from the national mortality collection. Kaplan-Meir survival analysis was performed.

Results

A total of 289 patients presented with aortic dissection to Waikato hospital over a 10-year period. Ninety-eight (33.9%) were Māori. Other ethnicities were as follows: European (n=172, 59.5%), Pasifika (n=13, 4.5%), Asian (n=3, 1.0%), unspecified (n=3, 1.0%). Māori patients were younger at index presentation (56.7±11.6 years vs 67.7±13.5, p<0.001). There was a higher unadjusted incidence of dissection among Māori compared to non-Māori (3.96 per 10,000 vs 2.79 per 10,000, p<0.001). There was no difference in survival after aortic dissection from all-cause mortality (p=0.48) or aortic-related mortality (p=0.69) between Māori and non-Māori.

Conclusions

Māori patients present at a younger age with aortic dissection with no difference in long-term survival. Aortic dissection is a high mortality disease requiring prompt diagnosis, treatment and surveillance.

Cinemeducation for trainee interns in psychiatry: what to use? how to deliver it? does it work?

Dr David Brunskill1,2

1Consultant Forensic Psychiatrist, PUAWAI, Waikato DHB, Hamilton, New Zealand; 2Honorary Senior Lecturer, Dept. of Psychological Medicine, University of Auckland, Auckland, New Zealand.

Aims and objectives

To explore whether ‘cinemeducation’ can be a useful educational tool for trainee interns in psychiatry (final year medical students, University of Auckland).

Methods

Suitable prior material (curated) was identified, with a documentary being preferred to a film/movie: “The Snowman”, Directed by Juliet Lamont, 2008.

As part of their orientation, the TI cohort were given a DVD to watch. A questionnaire was also emailed to each student, designed to elicit their personal reflections, after they had seen it. Once received, they were acknowledged by the tutor, along with further educational comments based upon their reflection and learnings. A final discussion occurred at the end of the attachment, as part of a de-brief group tutorial.

Results and conclusions

Thirty-nine Trainee Interns in Psychiatry were placed at the Waikato Clinical Campus in the 2020 academic year (January–October). The response rate ran at approximately 70%. In general terms, feedback was positive, with many students reporting that emailing a personal response to a tutor allowed for a deeper reflection to occur, and without peer judgement. For many students, traditional group discussion also remained valuable, eg, to see what others think.

Almost all students identified that watching and reflecting upon the documentary, had added something significant and meaningful to their psychiatry attachment. This included areas where exposure and experience (learnings) can be hard to consistently come by on a four-week attachment (eg, the longer-term effects of mental illness on the individual, and their whanau).

Cinemeducation has clear benefits in psychiatric medical education, particularly when curated and paired with facilitated reflection. Greater depth occurs via correspondence—as per verbatim:

“A good use of my learning time. I found value in having learning points portrayed through film, rather than through textbooks (visual learner). Emotional aspects of mental health were portrayed extremely well through this documentary—something I would not have received through reading textbooks, or during brief patient interactions. This experience also came at a good time. As my medical training progresses, it is important to always consider the ‘human’ side of medicine and not lose track of why I wanted to become a doctor in the first place.”

The effect of remifentanil PCA vs epidural in labour—maternal and neonatal outcomes

Jignal Bhagvandas,1 Richard Foon,2 Kevin Fong,3 Arun Nair,3 Caroline Ariaens4

1Department of General Medicine, Northland DHB, Whangarei, New Zealand; 2Department of Obstetrics and Gynaecology, Waikato DHB, Hamilton, New Zealand; 3Department of Paediatrics, Waikato DHB, Hamilton, New Zealand; 4Department of Anaesthetics, Waikato DHB, Hamilton, New Zealand.

Objective

Remifentanil is commonly used in obstetrics due to its fast metabolism time. Its effect on the neonate is unclear and studies are currently unable to correlate a negative effect of remifentanil on the newborn.

Method

Using a retrospective approach, we identified a total of 285 patients requiring remifentanil PCA presenting to Waikato delivery suite between the years 2017 to 2019. The primary outcome measured was an assessment of patients requiring further epidural analgesia post-remifentanil PCA. Secondary outcomes included number requiring caesarean section, instrumental use, number with a PPH or tear, apgars of neonates delivered, requirement for respiratory support after delivery, admission to the NICU, blood gas results of neonates and breastfeeding. This was compared to 285 patients requiring epidural analgesia.

Results

We found 24% (68 of 285) of remifentanil patients required an epidural post PCA for further pain relief. Of the epidural patients, 1.75% (5 of 285) required a second epidural after failing their first (RR 13.6, 95% CI 5.57–33.22, P=0.0001, P<0.05). Nineteen percent (53 of 285) of remifentanil patients required caesarean section delivery compared to 31% (89 of 285) of epidural patients (RR 0.595, 95% CI 0.442–0.802, P=0.0006, P<0.05). Four percent (12 of 285) of remifentanil patients required instrument use compared to 11.2% (32 of 285) of epidural patients (RR 0.375, 95% CI 0.197–0.713, P=0.0028, P<0.05). 2.8% (8 of 285) of remifentanil patients had a large PPH or tear compared to 3.5% (10 of 285) of epidural patients (RR 0.800, 95% CI 0.320–1.998, P=0632, P>0.05). NICU admission were less in the remifentanil PCA group (48 neonates [17%] vs 22 neonates [11%], p = 0.04), but when corrected for premature gestational age (a confounder for admission into NICU) this observation remains statistically significant (p=0.04). Proportionately more babies were documented as requiring assistance breast feeding in the epidural group (103 women [37%] 29 women) [17%], p=0.02). Cord gases showed no statistical significance in acid base status.

Conclusion

This data demonstrates advantages for both maternal and neonatal outcomes with remifentanil IV PCA but that a significant number of women will go on to require epidural analgesia after receiving remifentanil. More research is required before a causal relationship can be identified.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Acknowledgements

Correspondence

Correspondence Email

Competing Interests

Contact diana@nzma.org.nz
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The use, safety and effectiveness of topical and systemic tranexamic acid in endoscopic sinus surgery

Agrani Ratnayake Kumar,1, 2 Dr Andrew James Wood,1–3

1Department of Surgery, Waikato Clinical Campus, The University of Auckland, Auckland, New Zealand; 2Waikato Institute of Surgical Education and Research, Hamilton, New Zealand; 3Department of Otolaryngology-Head and Neck Surgery, Waikato Hospital, Hamilton, New Zealand.

Aims

Bleeding after endoscopic sinus surgery (ESS) is unpleasant for patients and generates significant healthcare costs. The aim of this retrospective study is to evaluate the combined use of topical and IV TXA in practice with regards to safety and efficacy.

Methods

We performed a retrospective single-surgeon study of all comprehensive ESS cases from January 2017–December 2019. There were no exclusion criteria. Descriptive statistics were used to report the rates of re-presentation and thromboembolic complications in the 28 days after surgery. The rate of revision surgery was used as a proxy measure of post-operative healing and scar formation.

Results

One hundred and seventy-seven patients underwent comprehensive ESS within the study period, of which, 13 (7.3%) re-presented to hospital acutely following surgery. Five (2.8%) of these cases were due to post-operative bleeding. The only thromboembolic complication was a transient ischemic attack unrelated to TXA use. Over the study period five (2.8%) patients underwent revision surgery.

Conclusion

Although liable to type 2 error, results suggest the combined use of topical and intravenous TXA is safe as well as effective at minimising post-operative bleeding and scar formation. This study highlights the need for prospective trials assessing the use of topical TXA in ESS.

Comparative analysis of lumbar spine vertebral morphology between Māori and European: a computed tomography study

William H Cook,1 Joseph F Baker1,2

1Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand; 2Department of Orthopaedic Surgery, Waikato District Health Board, Hamilton, New Zealand.

Aims

Many existing studies of lumbar anatomy do not consider ethnic influence and recruit white participants. Recent studies have considered other populations; however, none have assessed Māori, the indigenous population of New Zealand. A computed tomography study of vertebral body and canal dimensions was performed for lumbar vertebrae of Māori and European patients to evaluate for significant ethnic variation.

Methods

Lumbar vertebrae from 196 patients were measured using CT. A single trained examiner measured vertebral body (VB) anterior and posterior height, VB superior, inferior and pediculolaminar length, segmental angle, left and right pedicle height and width, and vertebral canal length and width for each level. Canal:body ratio was calculated from these measurements. Demographic data recorded included age, sex and ethnicity.

Results

Vertebral canal length remained relatively constant down the lumbar spine while canal width increased to a maximum of 28.2mm at L5. Canal:body ratios and pedicle height decreased while pedicle width increased to a maximum of 16.1mm at L5. There were few differences between Māori and Europeans except at the L5 level, where vertebral canal length and canal:body ratio were larger in Europeans and pedicle height, width and VB pediculolaminar length were larger in Māori. Females had generally smaller measurements and age was largely a positive predictor of measured values.

Conclusions

The present study is the first to characterise the lumbar anatomy of a Māori population. Adequately powered results demonstrated few differences between Māori and Europeans. Isolated differences observed at L5 may be due to sacropelvic anatomical differences, which represents an area for further investigation.

The role of suction rectal biopsy and open rectal biopsy in the diagnosis of Hirschsprung’s disease

Stacey Caldwell,1 Udaya Samarakkody2

1Faculty Medicine and Health Sciences, University of Auckland, Auckland, New Zealand; 2Department of Paediatric Surgery, Waikato Hospital, Hamilton, New Zealand

Aims

To determine the role of suction rectal biopsy (SRB) and open rectal biopsy (ORB) in the diagnosis of Hirschsprung’s disease (HD), to determine how to correctly select patients for ORB, reducing demand on hospital services.

Method

Retrospective review of all patients who had SRB or ORB performed at Waikato Hospital between Jan 2018–May 2020. Primary outcome measured was patient’s diagnosed with HD based on indications for biopsy (low, medium, high suspicion). Secondary outcomes included histopathology results.

Results

Data from 55 patients undergoing biopsy at WDHB was analysed. Two patients had both biopsies completed. 51.7% of patients were low or moderate suspicion. 48.3% of patients were high suspicion. Overall in the past 2.5 years 16.4% of patients have been diagnosed with HD. 100% of these patients were high suspicion.

Table 1: Hirschsprung diagnosis based on level of suspicion/indication for biopsy.

Conclusion

This review supports the need for further investigation of alternative first-line investigations in children considered to be low or moderate suspicion of HD as the yield rate is low. This could include; anorectal manometry, consideration of SRB in children under three years or a more selective approach to offering ORB.

Review of Akoranga Te Reo Māori teaching in the Paediatric Department at Waikato Hospital

Jessica Chanwai,1 Abigail Weaver,1 Dr Alex Wallace,2 Dr Te Aro Moxon,3 Dr Penny Brandt2

1Faculty Medicine and Health Sciences, University of Auckland; Auckland, New Zealand; 2Department of Paediatrics, Waikato Hospital, Department of Paediatrics: Child and Youth Health, University of Auckland; Auckland, New Zealand; 3Department of Paediatrics, Waikato Hospital, Hamilton, New Zealand.

Aims

To review perceptions of the Akoranga Reo Māori teaching for the Waikato Paediatric medical staff and explore opportunities for improvement.

Methods

An anonymous online survey was emailed to 61 paediatric staff, with a two-week timeframe for responses. Paper copies of the survey were provided as an alternative. A follow-up email was distributed a week prior to survey closure.

Results

40/61 (66%) staff responded. 38/40 (95%) respondents reported they “agreed” or “strongly agreed” that using Te Reo in clinical practice was important. 37/40 (93%) respondents reported improved confidence in pronouncing words and phrases in Māori after attending teaching, with 29/40 (73%) reporting they feel comfortable pronouncing Māori names in front of whānau. 35/40 (88%) reported Te Reo pronunciation was the most helpful contributor to communicating with whānau. Those surveyed favoured a structured curriculum that repeats itself on a regular basis and 38/40 (95%) were happy to continue with the general emphasis on pronunciation and medically relevant vocabulary.

Conclusion

The WDHB paediatric department perceived Akoranga Reo Māori an important tool for improving outcomes for Māori patients. The vast majority identified the best format conducive for learning was a regular, repetitive structure with emphasis on pronunciation, short sentences and medically relevant terminology.

Staged contoured marginal excision—a Waikato experience

Fangbo Lin,1 Eric Tan2

1Waikato Hospital, Waikato District Health Board, Hamilton, New Zealand; 2Waikato Hospital, Waikato District Health Board, Hamilton, New Zealand.

Achieving clear surgical margins in excision of melanoma in situ (MIS) is challenging. The concurrent Australasian Guidelines on melanoma recommended an excision margin of 5–10mm. This case describes our experience of using staged contoured marginal excision (CME) as an alternative technique to achieve clearance of a persistent residual MIS after multiple failed wide local excisions (WLE).

Case description

A 77-year-old woman was diagnosed with a left arm pT3a malignant melanoma by excision biopsy. Three subsequent WLEs with adequate clinical margins all showed histology that was clear of invasive melanoma but MIS persistently present peripherally. A CME technique was used to achieve histological clearance. Two 5mm wide strips of skin were excised 5mm beyond the macroscopic extent of the pigmented lesion. Paraffin embedded radially sliced sections from the excision was evaluated for residual disease. The positive 12 o’clock margin subsequently excised with another 5mm rim of tissue which was extended into two triangular skin flaps proximally and distally to allow the wound closure in an ellipse. 10mm margins clearance was achieved with direct closure of the wound within a single 24-hour period.

Discussion

This is the first case we are aware of using CME for MIS in Australasia. Benefits include achieving clearance of a difficult to manage MIS within a 24-hour period without undue risk of disfigurement or a prolonged period of open wound pending histological analysis. CME requires close support from histopathology and we have been advised that it was superior to slow Mohs or Mohs surgery.

Conclusion

Staged CME is a well described technique in overseas and we have had a positive experience utilising CME in our centre. In the future this will be a value addition to our armamentarium in managing challenging MIS in anatomically sensitive areas.

Clinical utility of cardiac magnetic resonance imaging to assess the left atrium before catheter ablation for atrial fibrillation—a systematic review and meta-analysis

Khashayar Ghafouri,1 Kyle Franke,2 Fang Shawn Foo,3 Martin K Stiles1,3

1Faculty of Medicine and Health Sciences, The University of Auckland, Hamilton, New Zealand; 2The University of Adelaide, South Australia, Australia; 3Department of Cardiology, Waikato Hospital, Hamilton, New Zealand.

Aims

This systematic review and meta-analysis aims to clarify the role of cardiac magnetic resonance imaging (CMRI) in identifying the association between left atrial (LA) characteristics and atrial fibrillation (AF) recurrence after ablation. These characteristics include LA fibrosis, passive emptying function, sphericity and post contrast T1 relaxation time.

Methods

PubMed, EMBASE and Cochrane were searched up to the July 2020 for English language articles reporting the use of MRI in catheter ablation for AF. Studies reporting relevant prognostic information of CMRI in AF ablation were included in the analysis. All references and forward citations were filtered for relevant manuscripts.

Results

Twenty-four publications reporting the prognostic value of pre-ablation MRI were identified. In the nine studies on LA fibrosis quantification included in the meta-analysis, every 10% increase in LA fibrosis was associated with a 1.54-fold increase in post ablation AF recurrence (95% CI: 1.39–1.70, I2=50.1%, P<0.042). In the three studies on LA sphericity included in the meta-analysis, there was no significant association with post-ablation AF recurrence (HR: 1.032 [95% CI: 0.962–1.103 I2=49.6%, P=0.137]). Egger’s test was non-significant for publication bias. LA passive emptying function and post-contrast LA T1 relaxation time had insufficient publications to conduct a meta-analysis.

Conclusion

LA fibrosis quantified by CMRI is clearly associated with risk of AF recurrence after AF ablation. There remains insufficient evidence to support the routine measurement of LA sphericity, LA passive emptying function and LA T1 relaxation time to predict AF recurrence after AF ablation.

Type A and B aortic dissections in the Midlands DHB: an analysis of all-cause and aortic mortality by ethnicity

William Xu,1 Manar Khashram1,2

1Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; 2Vascular Surgery Department, Waikato Hospital, Hamilton, New Zealand.

Aims

To analyse long-term survival following all types of aortic dissection based on ethnicity in New Zealand.

Methods

Consecutive patients diagnosed with Type A or B dissection at Waikato Hospital from January 2010–June 2020 were included. Demographic data including ethnicity and mortality data, were collected from clinical records. Aortic-related mortality was obtained from the national mortality collection. Kaplan-Meir survival analysis was performed.

Results

A total of 289 patients presented with aortic dissection to Waikato hospital over a 10-year period. Ninety-eight (33.9%) were Māori. Other ethnicities were as follows: European (n=172, 59.5%), Pasifika (n=13, 4.5%), Asian (n=3, 1.0%), unspecified (n=3, 1.0%). Māori patients were younger at index presentation (56.7±11.6 years vs 67.7±13.5, p<0.001). There was a higher unadjusted incidence of dissection among Māori compared to non-Māori (3.96 per 10,000 vs 2.79 per 10,000, p<0.001). There was no difference in survival after aortic dissection from all-cause mortality (p=0.48) or aortic-related mortality (p=0.69) between Māori and non-Māori.

Conclusions

Māori patients present at a younger age with aortic dissection with no difference in long-term survival. Aortic dissection is a high mortality disease requiring prompt diagnosis, treatment and surveillance.

Cinemeducation for trainee interns in psychiatry: what to use? how to deliver it? does it work?

Dr David Brunskill1,2

1Consultant Forensic Psychiatrist, PUAWAI, Waikato DHB, Hamilton, New Zealand; 2Honorary Senior Lecturer, Dept. of Psychological Medicine, University of Auckland, Auckland, New Zealand.

Aims and objectives

To explore whether ‘cinemeducation’ can be a useful educational tool for trainee interns in psychiatry (final year medical students, University of Auckland).

Methods

Suitable prior material (curated) was identified, with a documentary being preferred to a film/movie: “The Snowman”, Directed by Juliet Lamont, 2008.

As part of their orientation, the TI cohort were given a DVD to watch. A questionnaire was also emailed to each student, designed to elicit their personal reflections, after they had seen it. Once received, they were acknowledged by the tutor, along with further educational comments based upon their reflection and learnings. A final discussion occurred at the end of the attachment, as part of a de-brief group tutorial.

Results and conclusions

Thirty-nine Trainee Interns in Psychiatry were placed at the Waikato Clinical Campus in the 2020 academic year (January–October). The response rate ran at approximately 70%. In general terms, feedback was positive, with many students reporting that emailing a personal response to a tutor allowed for a deeper reflection to occur, and without peer judgement. For many students, traditional group discussion also remained valuable, eg, to see what others think.

Almost all students identified that watching and reflecting upon the documentary, had added something significant and meaningful to their psychiatry attachment. This included areas where exposure and experience (learnings) can be hard to consistently come by on a four-week attachment (eg, the longer-term effects of mental illness on the individual, and their whanau).

Cinemeducation has clear benefits in psychiatric medical education, particularly when curated and paired with facilitated reflection. Greater depth occurs via correspondence—as per verbatim:

“A good use of my learning time. I found value in having learning points portrayed through film, rather than through textbooks (visual learner). Emotional aspects of mental health were portrayed extremely well through this documentary—something I would not have received through reading textbooks, or during brief patient interactions. This experience also came at a good time. As my medical training progresses, it is important to always consider the ‘human’ side of medicine and not lose track of why I wanted to become a doctor in the first place.”

The effect of remifentanil PCA vs epidural in labour—maternal and neonatal outcomes

Jignal Bhagvandas,1 Richard Foon,2 Kevin Fong,3 Arun Nair,3 Caroline Ariaens4

1Department of General Medicine, Northland DHB, Whangarei, New Zealand; 2Department of Obstetrics and Gynaecology, Waikato DHB, Hamilton, New Zealand; 3Department of Paediatrics, Waikato DHB, Hamilton, New Zealand; 4Department of Anaesthetics, Waikato DHB, Hamilton, New Zealand.

Objective

Remifentanil is commonly used in obstetrics due to its fast metabolism time. Its effect on the neonate is unclear and studies are currently unable to correlate a negative effect of remifentanil on the newborn.

Method

Using a retrospective approach, we identified a total of 285 patients requiring remifentanil PCA presenting to Waikato delivery suite between the years 2017 to 2019. The primary outcome measured was an assessment of patients requiring further epidural analgesia post-remifentanil PCA. Secondary outcomes included number requiring caesarean section, instrumental use, number with a PPH or tear, apgars of neonates delivered, requirement for respiratory support after delivery, admission to the NICU, blood gas results of neonates and breastfeeding. This was compared to 285 patients requiring epidural analgesia.

Results

We found 24% (68 of 285) of remifentanil patients required an epidural post PCA for further pain relief. Of the epidural patients, 1.75% (5 of 285) required a second epidural after failing their first (RR 13.6, 95% CI 5.57–33.22, P=0.0001, P<0.05). Nineteen percent (53 of 285) of remifentanil patients required caesarean section delivery compared to 31% (89 of 285) of epidural patients (RR 0.595, 95% CI 0.442–0.802, P=0.0006, P<0.05). Four percent (12 of 285) of remifentanil patients required instrument use compared to 11.2% (32 of 285) of epidural patients (RR 0.375, 95% CI 0.197–0.713, P=0.0028, P<0.05). 2.8% (8 of 285) of remifentanil patients had a large PPH or tear compared to 3.5% (10 of 285) of epidural patients (RR 0.800, 95% CI 0.320–1.998, P=0632, P>0.05). NICU admission were less in the remifentanil PCA group (48 neonates [17%] vs 22 neonates [11%], p = 0.04), but when corrected for premature gestational age (a confounder for admission into NICU) this observation remains statistically significant (p=0.04). Proportionately more babies were documented as requiring assistance breast feeding in the epidural group (103 women [37%] 29 women) [17%], p=0.02). Cord gases showed no statistical significance in acid base status.

Conclusion

This data demonstrates advantages for both maternal and neonatal outcomes with remifentanil IV PCA but that a significant number of women will go on to require epidural analgesia after receiving remifentanil. More research is required before a causal relationship can be identified.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Acknowledgements

Correspondence

Correspondence Email

Competing Interests

Contact diana@nzma.org.nz
for the PDF of this article

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The use, safety and effectiveness of topical and systemic tranexamic acid in endoscopic sinus surgery

Agrani Ratnayake Kumar,1, 2 Dr Andrew James Wood,1–3

1Department of Surgery, Waikato Clinical Campus, The University of Auckland, Auckland, New Zealand; 2Waikato Institute of Surgical Education and Research, Hamilton, New Zealand; 3Department of Otolaryngology-Head and Neck Surgery, Waikato Hospital, Hamilton, New Zealand.

Aims

Bleeding after endoscopic sinus surgery (ESS) is unpleasant for patients and generates significant healthcare costs. The aim of this retrospective study is to evaluate the combined use of topical and IV TXA in practice with regards to safety and efficacy.

Methods

We performed a retrospective single-surgeon study of all comprehensive ESS cases from January 2017–December 2019. There were no exclusion criteria. Descriptive statistics were used to report the rates of re-presentation and thromboembolic complications in the 28 days after surgery. The rate of revision surgery was used as a proxy measure of post-operative healing and scar formation.

Results

One hundred and seventy-seven patients underwent comprehensive ESS within the study period, of which, 13 (7.3%) re-presented to hospital acutely following surgery. Five (2.8%) of these cases were due to post-operative bleeding. The only thromboembolic complication was a transient ischemic attack unrelated to TXA use. Over the study period five (2.8%) patients underwent revision surgery.

Conclusion

Although liable to type 2 error, results suggest the combined use of topical and intravenous TXA is safe as well as effective at minimising post-operative bleeding and scar formation. This study highlights the need for prospective trials assessing the use of topical TXA in ESS.

Comparative analysis of lumbar spine vertebral morphology between Māori and European: a computed tomography study

William H Cook,1 Joseph F Baker1,2

1Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand; 2Department of Orthopaedic Surgery, Waikato District Health Board, Hamilton, New Zealand.

Aims

Many existing studies of lumbar anatomy do not consider ethnic influence and recruit white participants. Recent studies have considered other populations; however, none have assessed Māori, the indigenous population of New Zealand. A computed tomography study of vertebral body and canal dimensions was performed for lumbar vertebrae of Māori and European patients to evaluate for significant ethnic variation.

Methods

Lumbar vertebrae from 196 patients were measured using CT. A single trained examiner measured vertebral body (VB) anterior and posterior height, VB superior, inferior and pediculolaminar length, segmental angle, left and right pedicle height and width, and vertebral canal length and width for each level. Canal:body ratio was calculated from these measurements. Demographic data recorded included age, sex and ethnicity.

Results

Vertebral canal length remained relatively constant down the lumbar spine while canal width increased to a maximum of 28.2mm at L5. Canal:body ratios and pedicle height decreased while pedicle width increased to a maximum of 16.1mm at L5. There were few differences between Māori and Europeans except at the L5 level, where vertebral canal length and canal:body ratio were larger in Europeans and pedicle height, width and VB pediculolaminar length were larger in Māori. Females had generally smaller measurements and age was largely a positive predictor of measured values.

Conclusions

The present study is the first to characterise the lumbar anatomy of a Māori population. Adequately powered results demonstrated few differences between Māori and Europeans. Isolated differences observed at L5 may be due to sacropelvic anatomical differences, which represents an area for further investigation.

The role of suction rectal biopsy and open rectal biopsy in the diagnosis of Hirschsprung’s disease

Stacey Caldwell,1 Udaya Samarakkody2

1Faculty Medicine and Health Sciences, University of Auckland, Auckland, New Zealand; 2Department of Paediatric Surgery, Waikato Hospital, Hamilton, New Zealand

Aims

To determine the role of suction rectal biopsy (SRB) and open rectal biopsy (ORB) in the diagnosis of Hirschsprung’s disease (HD), to determine how to correctly select patients for ORB, reducing demand on hospital services.

Method

Retrospective review of all patients who had SRB or ORB performed at Waikato Hospital between Jan 2018–May 2020. Primary outcome measured was patient’s diagnosed with HD based on indications for biopsy (low, medium, high suspicion). Secondary outcomes included histopathology results.

Results

Data from 55 patients undergoing biopsy at WDHB was analysed. Two patients had both biopsies completed. 51.7% of patients were low or moderate suspicion. 48.3% of patients were high suspicion. Overall in the past 2.5 years 16.4% of patients have been diagnosed with HD. 100% of these patients were high suspicion.

Table 1: Hirschsprung diagnosis based on level of suspicion/indication for biopsy.

Conclusion

This review supports the need for further investigation of alternative first-line investigations in children considered to be low or moderate suspicion of HD as the yield rate is low. This could include; anorectal manometry, consideration of SRB in children under three years or a more selective approach to offering ORB.

Review of Akoranga Te Reo Māori teaching in the Paediatric Department at Waikato Hospital

Jessica Chanwai,1 Abigail Weaver,1 Dr Alex Wallace,2 Dr Te Aro Moxon,3 Dr Penny Brandt2

1Faculty Medicine and Health Sciences, University of Auckland; Auckland, New Zealand; 2Department of Paediatrics, Waikato Hospital, Department of Paediatrics: Child and Youth Health, University of Auckland; Auckland, New Zealand; 3Department of Paediatrics, Waikato Hospital, Hamilton, New Zealand.

Aims

To review perceptions of the Akoranga Reo Māori teaching for the Waikato Paediatric medical staff and explore opportunities for improvement.

Methods

An anonymous online survey was emailed to 61 paediatric staff, with a two-week timeframe for responses. Paper copies of the survey were provided as an alternative. A follow-up email was distributed a week prior to survey closure.

Results

40/61 (66%) staff responded. 38/40 (95%) respondents reported they “agreed” or “strongly agreed” that using Te Reo in clinical practice was important. 37/40 (93%) respondents reported improved confidence in pronouncing words and phrases in Māori after attending teaching, with 29/40 (73%) reporting they feel comfortable pronouncing Māori names in front of whānau. 35/40 (88%) reported Te Reo pronunciation was the most helpful contributor to communicating with whānau. Those surveyed favoured a structured curriculum that repeats itself on a regular basis and 38/40 (95%) were happy to continue with the general emphasis on pronunciation and medically relevant vocabulary.

Conclusion

The WDHB paediatric department perceived Akoranga Reo Māori an important tool for improving outcomes for Māori patients. The vast majority identified the best format conducive for learning was a regular, repetitive structure with emphasis on pronunciation, short sentences and medically relevant terminology.

Staged contoured marginal excision—a Waikato experience

Fangbo Lin,1 Eric Tan2

1Waikato Hospital, Waikato District Health Board, Hamilton, New Zealand; 2Waikato Hospital, Waikato District Health Board, Hamilton, New Zealand.

Achieving clear surgical margins in excision of melanoma in situ (MIS) is challenging. The concurrent Australasian Guidelines on melanoma recommended an excision margin of 5–10mm. This case describes our experience of using staged contoured marginal excision (CME) as an alternative technique to achieve clearance of a persistent residual MIS after multiple failed wide local excisions (WLE).

Case description

A 77-year-old woman was diagnosed with a left arm pT3a malignant melanoma by excision biopsy. Three subsequent WLEs with adequate clinical margins all showed histology that was clear of invasive melanoma but MIS persistently present peripherally. A CME technique was used to achieve histological clearance. Two 5mm wide strips of skin were excised 5mm beyond the macroscopic extent of the pigmented lesion. Paraffin embedded radially sliced sections from the excision was evaluated for residual disease. The positive 12 o’clock margin subsequently excised with another 5mm rim of tissue which was extended into two triangular skin flaps proximally and distally to allow the wound closure in an ellipse. 10mm margins clearance was achieved with direct closure of the wound within a single 24-hour period.

Discussion

This is the first case we are aware of using CME for MIS in Australasia. Benefits include achieving clearance of a difficult to manage MIS within a 24-hour period without undue risk of disfigurement or a prolonged period of open wound pending histological analysis. CME requires close support from histopathology and we have been advised that it was superior to slow Mohs or Mohs surgery.

Conclusion

Staged CME is a well described technique in overseas and we have had a positive experience utilising CME in our centre. In the future this will be a value addition to our armamentarium in managing challenging MIS in anatomically sensitive areas.

Clinical utility of cardiac magnetic resonance imaging to assess the left atrium before catheter ablation for atrial fibrillation—a systematic review and meta-analysis

Khashayar Ghafouri,1 Kyle Franke,2 Fang Shawn Foo,3 Martin K Stiles1,3

1Faculty of Medicine and Health Sciences, The University of Auckland, Hamilton, New Zealand; 2The University of Adelaide, South Australia, Australia; 3Department of Cardiology, Waikato Hospital, Hamilton, New Zealand.

Aims

This systematic review and meta-analysis aims to clarify the role of cardiac magnetic resonance imaging (CMRI) in identifying the association between left atrial (LA) characteristics and atrial fibrillation (AF) recurrence after ablation. These characteristics include LA fibrosis, passive emptying function, sphericity and post contrast T1 relaxation time.

Methods

PubMed, EMBASE and Cochrane were searched up to the July 2020 for English language articles reporting the use of MRI in catheter ablation for AF. Studies reporting relevant prognostic information of CMRI in AF ablation were included in the analysis. All references and forward citations were filtered for relevant manuscripts.

Results

Twenty-four publications reporting the prognostic value of pre-ablation MRI were identified. In the nine studies on LA fibrosis quantification included in the meta-analysis, every 10% increase in LA fibrosis was associated with a 1.54-fold increase in post ablation AF recurrence (95% CI: 1.39–1.70, I2=50.1%, P<0.042). In the three studies on LA sphericity included in the meta-analysis, there was no significant association with post-ablation AF recurrence (HR: 1.032 [95% CI: 0.962–1.103 I2=49.6%, P=0.137]). Egger’s test was non-significant for publication bias. LA passive emptying function and post-contrast LA T1 relaxation time had insufficient publications to conduct a meta-analysis.

Conclusion

LA fibrosis quantified by CMRI is clearly associated with risk of AF recurrence after AF ablation. There remains insufficient evidence to support the routine measurement of LA sphericity, LA passive emptying function and LA T1 relaxation time to predict AF recurrence after AF ablation.

Type A and B aortic dissections in the Midlands DHB: an analysis of all-cause and aortic mortality by ethnicity

William Xu,1 Manar Khashram1,2

1Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; 2Vascular Surgery Department, Waikato Hospital, Hamilton, New Zealand.

Aims

To analyse long-term survival following all types of aortic dissection based on ethnicity in New Zealand.

Methods

Consecutive patients diagnosed with Type A or B dissection at Waikato Hospital from January 2010–June 2020 were included. Demographic data including ethnicity and mortality data, were collected from clinical records. Aortic-related mortality was obtained from the national mortality collection. Kaplan-Meir survival analysis was performed.

Results

A total of 289 patients presented with aortic dissection to Waikato hospital over a 10-year period. Ninety-eight (33.9%) were Māori. Other ethnicities were as follows: European (n=172, 59.5%), Pasifika (n=13, 4.5%), Asian (n=3, 1.0%), unspecified (n=3, 1.0%). Māori patients were younger at index presentation (56.7±11.6 years vs 67.7±13.5, p<0.001). There was a higher unadjusted incidence of dissection among Māori compared to non-Māori (3.96 per 10,000 vs 2.79 per 10,000, p<0.001). There was no difference in survival after aortic dissection from all-cause mortality (p=0.48) or aortic-related mortality (p=0.69) between Māori and non-Māori.

Conclusions

Māori patients present at a younger age with aortic dissection with no difference in long-term survival. Aortic dissection is a high mortality disease requiring prompt diagnosis, treatment and surveillance.

Cinemeducation for trainee interns in psychiatry: what to use? how to deliver it? does it work?

Dr David Brunskill1,2

1Consultant Forensic Psychiatrist, PUAWAI, Waikato DHB, Hamilton, New Zealand; 2Honorary Senior Lecturer, Dept. of Psychological Medicine, University of Auckland, Auckland, New Zealand.

Aims and objectives

To explore whether ‘cinemeducation’ can be a useful educational tool for trainee interns in psychiatry (final year medical students, University of Auckland).

Methods

Suitable prior material (curated) was identified, with a documentary being preferred to a film/movie: “The Snowman”, Directed by Juliet Lamont, 2008.

As part of their orientation, the TI cohort were given a DVD to watch. A questionnaire was also emailed to each student, designed to elicit their personal reflections, after they had seen it. Once received, they were acknowledged by the tutor, along with further educational comments based upon their reflection and learnings. A final discussion occurred at the end of the attachment, as part of a de-brief group tutorial.

Results and conclusions

Thirty-nine Trainee Interns in Psychiatry were placed at the Waikato Clinical Campus in the 2020 academic year (January–October). The response rate ran at approximately 70%. In general terms, feedback was positive, with many students reporting that emailing a personal response to a tutor allowed for a deeper reflection to occur, and without peer judgement. For many students, traditional group discussion also remained valuable, eg, to see what others think.

Almost all students identified that watching and reflecting upon the documentary, had added something significant and meaningful to their psychiatry attachment. This included areas where exposure and experience (learnings) can be hard to consistently come by on a four-week attachment (eg, the longer-term effects of mental illness on the individual, and their whanau).

Cinemeducation has clear benefits in psychiatric medical education, particularly when curated and paired with facilitated reflection. Greater depth occurs via correspondence—as per verbatim:

“A good use of my learning time. I found value in having learning points portrayed through film, rather than through textbooks (visual learner). Emotional aspects of mental health were portrayed extremely well through this documentary—something I would not have received through reading textbooks, or during brief patient interactions. This experience also came at a good time. As my medical training progresses, it is important to always consider the ‘human’ side of medicine and not lose track of why I wanted to become a doctor in the first place.”

The effect of remifentanil PCA vs epidural in labour—maternal and neonatal outcomes

Jignal Bhagvandas,1 Richard Foon,2 Kevin Fong,3 Arun Nair,3 Caroline Ariaens4

1Department of General Medicine, Northland DHB, Whangarei, New Zealand; 2Department of Obstetrics and Gynaecology, Waikato DHB, Hamilton, New Zealand; 3Department of Paediatrics, Waikato DHB, Hamilton, New Zealand; 4Department of Anaesthetics, Waikato DHB, Hamilton, New Zealand.

Objective

Remifentanil is commonly used in obstetrics due to its fast metabolism time. Its effect on the neonate is unclear and studies are currently unable to correlate a negative effect of remifentanil on the newborn.

Method

Using a retrospective approach, we identified a total of 285 patients requiring remifentanil PCA presenting to Waikato delivery suite between the years 2017 to 2019. The primary outcome measured was an assessment of patients requiring further epidural analgesia post-remifentanil PCA. Secondary outcomes included number requiring caesarean section, instrumental use, number with a PPH or tear, apgars of neonates delivered, requirement for respiratory support after delivery, admission to the NICU, blood gas results of neonates and breastfeeding. This was compared to 285 patients requiring epidural analgesia.

Results

We found 24% (68 of 285) of remifentanil patients required an epidural post PCA for further pain relief. Of the epidural patients, 1.75% (5 of 285) required a second epidural after failing their first (RR 13.6, 95% CI 5.57–33.22, P=0.0001, P<0.05). Nineteen percent (53 of 285) of remifentanil patients required caesarean section delivery compared to 31% (89 of 285) of epidural patients (RR 0.595, 95% CI 0.442–0.802, P=0.0006, P<0.05). Four percent (12 of 285) of remifentanil patients required instrument use compared to 11.2% (32 of 285) of epidural patients (RR 0.375, 95% CI 0.197–0.713, P=0.0028, P<0.05). 2.8% (8 of 285) of remifentanil patients had a large PPH or tear compared to 3.5% (10 of 285) of epidural patients (RR 0.800, 95% CI 0.320–1.998, P=0632, P>0.05). NICU admission were less in the remifentanil PCA group (48 neonates [17%] vs 22 neonates [11%], p = 0.04), but when corrected for premature gestational age (a confounder for admission into NICU) this observation remains statistically significant (p=0.04). Proportionately more babies were documented as requiring assistance breast feeding in the epidural group (103 women [37%] 29 women) [17%], p=0.02). Cord gases showed no statistical significance in acid base status.

Conclusion

This data demonstrates advantages for both maternal and neonatal outcomes with remifentanil IV PCA but that a significant number of women will go on to require epidural analgesia after receiving remifentanil. More research is required before a causal relationship can be identified.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Acknowledgements

Correspondence

Correspondence Email

Competing Interests

Contact diana@nzma.org.nz
for the PDF of this article

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