Stool testing for pulmonary TB diagnosis in adults.

BACKGROUND: Mycobacterium tuberculosis is acid-fast and able to survive in the gastrointestinal tract. Thus, bacteria can be found in stool if sputum is swallowed. In this study, the accuracy of different diagnostic stool methods (microscopy, polymerase chain reaction PCR and culture) among adults with pulmonary TB (PTB) were assessed and compared with sputum culture.METHODS: Embase and PubMed were searched to identify studies with data on stool testing among patients with clinically presumed or microbiologically verified PTB.RESULTS: Thirteen relevant studies were included. A pooled sensitivity of one or more of the three TB identifying methods was 79.1% (95% CI 61.5-92.5). The sensitivity of stool microscopy, PCR and culture was respectively 41.1% (95%CI 24.9-58.2), 89.7% (95% CI 81.4-95.9) and 38.0% (95% CI 26.2-50.6). The heterogeneity of the studies included was high.CONCLUSION: Our review findings indicate that the analysis of stool specimens as part of PTB diagnostics is useful. PCR methods were particularly helpful in detecting a substantial proportion of patients with PTB.

Effects of Adrenaline on maternal and fetal fentanyl absorption in epidural analgesia: A randomized trial.

BACKGROUND: The combination of low-dose local anesthesia and lipophilic opioids such as fentanyl is established as a standard solution for labor epidural analgesia. Fentanyl increases efficacy, but may have negative effects on the neonate in terms of reduced neonatal neurologic and adaptive capacity scores and breast feeding. We hypothesized that addition of adrenaline 2 µg/mL to a solution of bupivacaine 1 mg/mL and fentanyl 2 µg/mL would reduce the systemic uptake of fentanyl, resulting in reduced serum fentanyl in the fetus at birth. METHODS: Forty-one nulliparous women requesting epidural analgesia were randomized to epidural analgesia with or without adrenaline. Blood samples were drawn from the mother with regular intervals, and at delivery. An umbilical vein blood sample (used as a proxy for fetal exposure) was drawn after clamping. RESULTS: There were no significant differences between the groups in fentanyl concentrations in the umbilical vein and maternal serum at birth. There was a significantly lower mean area under the maternal serum-concentration curve for the first 2 hours of treatment in the adrenaline group (mean difference 0.161 nmol h/L [0.034; 0.289], P = .015), implying slower systemic uptake in the adrenaline group initially. There were no significant differences in treatment duration, motor block, Apgar scores, umbilical pH and base excess, or mode of delivery. CONCLUSIONS: The addition of adrenaline to an epidural solution containing fentanyl lowered maternal systemic serum fentanyl concentration during the first 2 hours, but did not lower serum fentanyl concentration in the umbilical vein and mother at delivery.

Searching for unknown transfusion-transmitted hepatitis viruses: a binational cohort study of 1.5 million transfused patients.

BACKGROUND: Both hepatitis B and C viruses were transmitted through blood transfusion before implementation of donor screening. The existence of additional, yet unknown transfusion transmittable agents causing liver disease could have important public health implications. METHODS: Analyses were based on the Scandinavian Donations and Transfusions (SCANDAT2) database. Cox regression models were used to estimate the hazard ratio (HR) of developing chronic liver disease in recipients of blood from donors who later developed any chronic liver disease compared to recipients who received blood transfusion from healthy donors. We also studied whether the risk of liver disease was increased in patients who received units from 'high-risk' donors, defined as donors who had a higher than expected occurrence of liver disease amongst their previous recipients. All analyses were stratified before and after 1992 to account for the effect of screening for hepatitis C virus. RESULTS: A total of 1 482 922 transfused patients were included in the analyses. Analyses showed evidence of transfusion transmission of liver diseases before, but not after the implementation of hepatitis C virus screening in 1992, with HRs for any liver disease of 1.38 [95% confidence interval (CI), 1.30-1.46] and 0.99 (95% CI, 0.91-1.07), before and after 1992, respectively. Similarly, blood components from 'high-risk' donors conferred increased risks before, but not after 1992. CONCLUSIONS: Our data provide no evidence for transfusion transmission of agents causing liver disease after the implementation of screening for hepatitis B and C, and suggest that if such transmission does occur, it is rare.

Multi-country outbreak of Salmonella enteritidis infection linked to the international ice hockey tournament.

In April 2015, Finnish public health authorities alerted European Union member states of a possible multi-country Salmonella enteritidis outbreak linked to an international youth ice-hockey tournament in Latvia. The European Centre for Disease Prevention and Control (ECDC), Finnish and Latvian authorities initiated an outbreak investigation to identify the source. The investigation included a description of the outbreak, retrospective cohort study, microbiological investigation and trace-back. We identified 154 suspected and 96 confirmed cases from seven countries. Consuming Bolognese sauce and salad at a specific event arena significantly increased the risk of illness. Isolates from Finnish, Swedish and Norwegian cases had an identical multiple-locus variable-number of tandem repeats analysis-profile (3-10-6-4-1). Breaches in hygiene and food storing practices in the specific arena's kitchen allowing for cross-contamination were identified. Riga Cup participants were recommended to follow good hand hygiene and consume only freshly cooked foods. This investigation demonstrated that the use of ECDC's Epidemic Intelligence Information System for Food- and Waterborne Diseases and Zoonoses platform was essential to progress the investigation by facilitating information exchange between countries. Cross-border data sharing to perform whole genome sequencing gave relevant information regarding the source of the outbreak.

Five-year mortality in patients treated for severe community-acquired pneumonia - a retrospective study.

BACKGROUND: The mortality rate in patients with severe community-acquired pneumonia (SCAP) is high. We investigated the 5-year mortality rate and causes of death in a patient population treated for SCAP in our intensive care unit (ICU), and compared the mortality rate in patients with or without chronic obstructive pulmonary disease (COPD) as comorbidity. METHODS: This retrospective study, which covers a period of 10 years, included patients aged > 18 years admitted to our ICU with SCAP as primary diagnosis and in need of mechanical ventilation for more than 24 h. Data were collected from the ICU internal database and the patients' medical records. The times of death were collected from the Norwegian National Registry, and the causes of death from the Norwegian Cause of Death Registry. RESULTS: Hundred and seventy three patients were included in the study. The 5-year mortality rate for the total study population was 57.2%. There were no significant differences in the mortality rate between the group with COPD and the group without COPD (61.2% vs. 54.7%, P = 0.43). There was a wide range of comorbidities. The most common were COPD, myocardial infarction and diabetes mellitus. The two main causes of death after discharge were COPD (17 deaths) and cardiovascular diseases (seven deaths). CONCLUSIONS: The 5-year mortality rate of the study population was high (57.2%). COPD did not seem to be a risk factor for mortality compared to non-COPD patients. The most common causes of death after discharge were COPD and cardiovascular diseases.

Short stay and less pain after ambulatory anterior cruciate ligament (ACL) repair: COX-2 inhibitor versus glucocorticoid versus both combined.

BACKGROUND: Many studies have demonstrated that either COX-2 antagonists or glucocorticoids are efficient analgesics after orthopaedic surgery. We wanted to evaluate if the combination of these two drugs was better than one drug alone when added to paracetamol, local anaesthesia, and cryo-cuff for outpatient anterior crucial ligament (ACL) surgery. METHODS: In a double-blind design, 89 adult patients scheduled for day-case ACL repair in general anaesthesia were randomly assigned into three groups: The COXIB group (n = 30) received either 40 mg parecoxib iv or 120 mg etoricoxib orally 1 h before surgery. The STEROID group (n = 30) received 8 mg dexamethasone iv, and the combination group (Group COMBI, n = 29) received both. RESULTS: At 24 h, Group COMBI had significantly lower visual analogue scale (0-10 cm) scores during rest (2.1 ± 1.3) (mean ± standard deviation) and movement (4.2 ± 2.5) when compared to both the COXIB group (P = 0.04) and the STEROID group (P = 0.035). The accumulated consumption of rescue opioids (5.2 ± 4,5 mg morphine) was also significantly lower at 24 h compared to the other groups (P = 0.02). Mean time to discharge from hospital was about 3 h in all groups. The pain scores in the post-anaesthetic care unit, mobilization at 24 h and 7 days, and general level of satisfaction were similar between the groups. CONCLUSION: The combination of a COX-2 inhibitor and dexamethasone results in better pain relief 24 h after surgery in patients undergoing outpatient ACL surgery, compared to COX-2 inhibitor alone or dexamethasone alone. With a dedicated multimodal pain regime, most ACL patients may be discharged within 3 h.

Effect of a single dose of pregabalin on post-operative pain and pre-operative anxiety in patients undergoing discectomy.

BACKGROUND: Pregabalin acts as a membrane stabilizer and has both analgesic and anxiolytic effects. We hypothesized that one pre-operative dose of pregabalin would reduce pre-operative anxiety and post-operative pain in patients undergoing discectomy. METHODS: We performed a randomized, placebo-controlled study of 150 mg pregabalin administered before lumbar discectomy in general anaesthesia. The primary endpoint was pain at rest [visual analogue scale (VAS)] 120 min after surgery. The secondary outcomes were morphine consumption, pre-operative anxiety (VAS) and the occurrence of side effects. RESULTS: The VAS scores for pain at rest and morphine consumption were higher in the placebo group during the 4-h stay in the post-anaesthetic care unit (PACU), but did not differ significantly 24 h after surgery. Pain scores at 7 days were similar and there was no difference in the occurrence of side effects. Pre-operative anxiety was significantly lower in the pregabalin group (2.23±1.11 vs. 4.17±2.37, 95% confidence interval: 0.82-3.05, P=0.001) and there was a significant positive correlation between the pre-operative anxiety score and post-operative pain at 120 min in the pregabalin group. CONCLUSIONS: A single dose of pregabalin (150 mg) reduced post-operative pain at rest and morphine consumption during the PACU period after lumbar discectomy. Pre-operative anxiety was lower, without increased incidence of side effects.

Management of accidental dural puncture and post-dural puncture headache after labour: a Nordic survey.

BACKGROUND: a major risk with epidural analgesia is accidental dural puncture (ADP), which may result in post-dural puncture headache (PDPH). This survey was conducted to explore the incidence of ADP, the policy for management of PDPH and the educational practices in epidural analgesia during labour in the Nordic countries. METHODS: a postal questionnaire was sent to the anaesthesiologist responsible for Obstetric anaesthesia service in all maternity units (n=153) with questions relating to the year 2008. RESULTS: the overall response rate was 93%. About 32% (22-47%) of parturients received epidural analgesia for labour. There were databases for registering obstetric epidural complications in 13% of Danish, 24% of Norwegian and Swedish, 43% of Finnish and 100% of hospitals in Iceland. The estimated incidence of ADP was 1% (n approximately 900). Epidural blood patch (EBP) was performed in 86% (n≈780) of the parturients. The most common time interval from diagnosis to performing EBP was 24-48 h. The success rate for EBP was >75% in 67% (62-79%) of hospitals. The use of diagnostic CT/MRI before the first or the second EBP was exceptional. No major complication was reported. Teaching of epidurals was commonest (86%) in the non-obstetric population and 53% hospitals desired a formal training programme in obstetric analgesia. CONCLUSION: we found the incidence of ADP to be approximately 1%. EBP was the commonest method used for its management, and the success rate was high in most hospitals. Formal training in epidural analgesia was absent in most countries and trainees first performed it in the non-obstetric population.

High-volume local infiltration analgesia combined with intravenous or local ketorolac+morphine compared with epidural analgesia after total knee arthroplasty.

BACKGROUND: Recently, high-volume local infiltration analgesia (LIA) in total knee arthroplasty (TKA) has been introduced, but dosage, timing, and effects of adjuvants are still debated. METHODS: We randomized 102 patients undergoing TKA to receive either epidural analgesia (EDA group) or LIA (ropivacaine 150 mg and epinephrine 0.5 mg) combined with ketorolac 30 mg and morphine 5 mg given either locally (LIA group) or i.v. (LIAiv group). Epidural analgesia was maintained for 48 h. Intra-articular re-injection via a catheter with ropivacaine 142.5 mg and either intra-articular or i.v. ketorolac 30 mg was given 24 h after surgery. Pain scores, morphine consumption, side-effects, and readiness for hospital discharge were studied. RESULTS: At discharge from the postoperative anaesthetic care unit, verbal pain scores were lower in the EDA group (P=0.004), but discharge was delayed [difference 101 min, 95% CI: (23, 178), P=0.007]. Group LIA reported lower pain scores at rest beyond 24 h after surgery [mean VAS (sd) at 24/48/72 h: LIA group 16/12/10 (14)/(13)/(11); LIAiv group 22/18/15 (17)/(15)/(12); EDA group 27/30/21 (21)/(29)/(19)]. Both the LIA and the LIAiv groups were mobilized faster and were earlier ready for hospital discharge [3.5 days (LIA group) vs 4 days (LIAiv group) vs 5.5 days (EDA group); P<0.001]. Cumulated morphine consumption (72 h) was lowest for the LIA group [80 vs 101 mg (EDA group) vs 118 mg (LIAiv group), P=0.007]. CONCLUSIONS: LIA with local adjuvants compared with epidural analgesia results in reduced opioid consumption, faster mobilization, and earlier readiness for hospital discharge. Ketorolac and morphine are more efficient when given locally than systemically. The study has been registered at clinicaltrials.gov (NCT00562627) before onset of participant enrolment: http://clinicaltrials.gov/ct2/show/NCT00562627?term=spreng&rank=2 (April 21, 2010).

Efficient algorithms for the discovery of DNA oligonucleotide barcodes from sequence databases.

Efficient design of barcode oligonucleotides can lead to significant cost reductions in the manufacturing of DNA arrays. Previous methods are based on either a preliminary alignment, which reduces their efficiency for intron-rich regions, or on a brute force approach, not feasible for large-scale problems or on data structures with very poor performance in the worst case. One of the algorithms we propose uses 'oligonucleotide sorting' for the discovery of oligonucleotide barcodes of given sizes, with good asymptotic performance. Specific barcode oligonucleotides with at least one base difference from other sequences in a database are found for each individual sequence. With another algorithm, specific oligonucleotides can also be found for groups or clades in the database, which have 100% homology for all oligonucleotide sequences within the group or clade while having differences with the rest of the data. By re-organizing the sequences/groups in the database, oligonucleotides for different hierarchical levels can be found. The oligonucleotides or polymorphism locations identified as species or clade specific by the new algorithm are refined and screened further for hybridization thermodynamic properties with third party software.

Acceptance of HIV testing among women attending antenatal care in south-western Uganda: risk factors and reasons for test refusal.

A problem commonly encountered in programs for prevention of mother-to-child-transmission (PMTCT) of HIV in sub-Saharan Africa is low rates of HIV test acceptance among pregnant women. In this study, we examined risk factors and reasons for HIV test refusal among 432 women attending three antenatal care clinics offering PMTCT in urban and semi-urban parts of the Mbarara district, Uganda. Structured interviews were performed following pre-test counselling. Three-hundred-eighty women were included in the study, 323 (85%) of whom accepted HIV testing. In multivariate analysis, testing site (Site A: OR = 1.0; Site B: OR = 3.08; 95%CI: 1.12-8.46; Site C: OR = 5.93; 95%CI: 2.94-11.98), age between 30 and 34 years (<20 years: OR = 1.0; 20-24 years: OR = 1.81; 95%CI: 0.58-5.67; 25-29 years: OR = 2.15; 95%CI: 0.66-6.97; 30-34 years: OR = 3.88; 95%CI: 1.21-13.41), mistrust in reliability of the HIV test (OR = 20.60; 95%CI: 3.24-131.0) and not having been tested for HIV previously (OR = 2.15; 95%CI: 1.02-4.54) were associated with test refusal. Testing sites operating for longer durations had higher rates of acceptance. The most common reasons claimed for test refusal were: lack of access to antiretroviral therapy (ART) for HIV-infected women (88%; n=57), a need to discuss with partner before decision (82%; n=57) and fear of partner's reaction (54%; n=57). Comparison with previous periods showed that the acceptance rate increased with the duration of the program. Our study identified risk factors for HIV test refusal among pregnant women in Uganda and common reasons for not accepting testing. These findings may suggest modifications and improvements in the performance of HIV testing in this and similar populations.

Does esomeprazole prevent post-operative nausea and vomiting?

BACKGROUND: Esomeprazole is a potent proton pump inhibitor (PPI), reducing acid production as well as gastric juice volume. This study evaluated the possible beneficial effect of esomeprazole on reducing post-operative nausea and vomiting (PONV). METHODS: Patients undergoing laparoscopic or open gynaecological surgery, or laparoscopic cholecystectomy were randomized to receive three peri-operative doses double blindly of either esomeprazole 40 mg or placebo, given intravenously or orally. All patients were given a standardized anaesthesia regimen including fentanyl and sevoflurane/nitrous oxide. RESULTS: The study population consisted of 284 patients. Demographic data and known PONV risk factors were similar for the two treatment groups. PONV was observed in 77% of patients on esomeprazole vs. 81% on placebo (NS) and rescue antiemetic medication was needed in 56% vs. 53%, respectively (NS). The proportion of patients that vomited during 0-24 h was lower on esomeprazole than placebo (38% vs. 49%; NS), and the mean amount of vomit was significantly lower (52 vs. 86 g; P < 0.05). The use of neostigmine, use of opioids and type of surgery were significant risk factors for PONV (P < 0.05). The 24-h incidence of PONV was 63% after laparoscopic gynaecology, 80% after laparoscopic cholecystectomy and 88% after open gynaecological laparotomy, whereas laparoscopic cholecystectomy had the lowest risk when corrected for other risk factors of PONV. CONCLUSION: Esomeprazole had no clinically relevant effect on the overall 24-h incidence of PONV. However, esomeprazole significantly reduced the total amount of vomit during 24-h post-operatively. This may be of value in patients with an increased risk of pulmonary aspiration.

[Prevalence of atopy in chronic fatigue syndrome]. / Prevalencia de atopia en el síndrome de fatiga crónica.

BACKGROUND: Several hypotheses have been postulated to explain the etiopathogenesis of chronic fatigue syndrome (CFS). Among these, immunologic dysfunction has been proposed. Up to 30 % of these patients have a history of allergic disease. The aim of this study was to investigate whether allergic sensitization is higher in patients with CFS than in the general population. METHODS: Twenty-five patients with CFS and 20 controls were evaluated. A clinical history for allergy was taken and immediate hypersensitivity tests were performed. RESULTS: Twelve patients (48 %) and eight controls (40 %) had a family history of atopy. Personal histories of atopy were as follows: rhinoconjunctivitis: 12 patients (48 %), seven controls (35 %); asthma: five patients (20 %), two controls (10 %); food allergy: three patients (12 %); atopic dermatitis: two patients; contact dermatitis: two patients. No statistically significant differences were found between the groups in any of the variables (p > 0.05). In the CSF group, 3.4 % (15/441) of the inhalant prick tests were positive, and in the control group 3.8 % (16/420) were positive. None of the tests for hypersensitivity to food or latex were positive. CONCLUSIONS: In our study atopy was not more prevalent in patients with CFS than in healthy controls, although the CSF group tended to report more respiratory symptoms and drug allergies.

Ibuprofen vs. acetaminophen vs. ibuprofen and acetaminophen after arthroscopically assisted anterior cruciate ligament reconstruction.

BACKGROUND AND OBJECTIVE: The analgesic potency of non-steroidal anti-inflammatory drugs and acetaminophen are still being debated. We have assessed the relative analgesic effect of ibuprofen, acetaminophen or the combination of both after orthopaedic surgery. METHODS: Sixty-one ASA I patients, scheduled for an elective anterior cruciate ligament reconstruction under general anaesthesia were randomized, in a double blind fashion, into one of three groups. The ibuprofen group (n = 17) received ibuprofen 800 mg orally 1 h before operation and again at 6 and 12 h after the initial dose. The acetaminophen group (n = 20) received of acetaminophen 1 g orally at the same time intervals. The combination group (n = 24) received both ibuprofen 800 mg and acetaminophen 1 g. Surgery was performed under general anaesthesia with propofol and fentanyl for induction and maintenance with propofol and nitrous oxide in oxygen. The patients were monitored for 24 h thereafter, and the following variables were assessed: pain by visual analogue and verbal scales, need for rescue intravenous opioid analgesia (i.e. ketobemidone) and adverse events. RESULTS: The ibuprofen group and the combination group experienced significantly less pain during the first 6 h after surgery than the acetaminophen group using the visual analogue and the verbal scales. The acetaminophen group also had a significantly higher average consumption of opioids during the first 6 and 24 h. There were no significant differences between the ibuprofen group and the combination group in respect of experienced pain or consumption of rescue analgesia. The incidence of side-effects, postoperative haemoglobin concentration and renal function, judged by creatinine clearance, were identical between the groups. CONCLUSION: Ibuprofen 800 mg thrice daily reduced pain to a greater degree than acetaminophen 1 g thrice daily, after anterior cruciate ligament reconstruction under general anaesthesia. The combination of acetaminophen and ibuprofen did not provide any superior analgesic effect.

[Atopic dermatitis. Allergological characteristics and association with respiratory disease]. / Dermatitis atópica: características alergológicas y asociación a patología respiratoria.

BACKGROUND: Atopic dermatitis (AD) is a chronic inflammatory skin disease that frequently precedes the development of asthma or other respiratory allergies. The aim of this study was to review allergen sensitization, type of feeding in infancy, and development of asthma or rhinitis in a group of patients with AD. METHODOLOGY: One hundred children with AD were selected. All patients underwent skin prick and patch tests to foodstuffs and inhalant allergens, total and specific IgE determination, and oral challenge tests. RESULTS: The study included 57 boys and 43 girls. The mean age at consultation was 3.77 +/- 2.81 years and mean age at onset of of AD was 1.09 +/- 1.69 years. Twenty-eight percent of the children were exclusively sensitized to food allergens, 20% to inhalant allergens and 22% to both food and inhalant allergens. Mean serum IgE levels were higher in children sensitized to Dermatophagoides pteronyssinus (DPT) (346.86 +/- 430.43 U/ml) than in non-sensitized children (78.24 +/- 132.93 U/m) (p < 0.001). Total IgE levels were also higher in patients with respiratory symptoms (283.77 +/- 336.53 U/ml) than in children without respiratory disease (124.62 +/- 285.21 U/ml) (p = 0.021). Thirty-five percent of the children developed some kind of respiratory allergic disease (asthma and/or rhinitis) in a mean interval of 2.55 years after the onset of dermatitis. Of the children sensitized to inhalant allergens (DPT), 55.26 % developed respiratory symptoms compared with 22.58 % of the non-sensitized children (p < 0.001). The odds ratio of developing respiratory allergy if the patient showed sensitization to DPT was 4.235 (95 % CI 1.768-0.147, p = 0.002). CONCLUSIONS: Children with AD that develops in the first year of life, associated with high IgE levels and early sensitization, independently of the kind of feeding, develop respiratory allergic disease more frequently than children without these factors.

High-dose diclofenac for postoperative analgesia after elective caesarean section in regional anaesthesia.

Although the use of non-steroidal anti-inflammatory drugs (NSAIDs) is well established in the postoperative setting, their use after caesarean sections is still controversial. In a randomised, double-blinded, placebo controlled study we have estimated the opioid-sparing effect of diclofenac suppositories after elective caesarean sections in spinal anaesthesia. Eighty-two women ASA class I or II scheduled for caesarean section were randomised to receive either diclofenac suppositories 100 mg or placebo every 12 h after the operation. The diclofenac group (n = 40) consumed significantly less morphine in the postoperative period (14.0 +/- 1.5 mg in 32 h) compared with the placebo group (21.5 +/- 1.6 mg in 32 h, P < 0.05). The average level of postoperative pain as estimated by a visual analogue scale (VAS) and a verbal scale tended to be lower in the diclofenac group, but this was not significant. There were no differences in demographic data, perioperative bleeding, side-effects or discharge time between the groups. Diclofenac suppositories 100 mg given twice daily after caesarean section are opioid sparing.

[Is the epidural analgesia to blame when it comes to neurological complications following labor?]. / Skyldes nevrologiske komplikasjoner etter fødselen epiduralanalgesi?

BACKGROUND: One of every four parturient in Norway receives epidural analgesia during labour. Even though epidural analgesia is considered very safe, there is a tendency to blame the epidural whenever there are neurological complications after labour. METHODS: This paper presents a case report on a woman who developed femoral mononeuropathy after labour. The various neurological complications after labour are discussed. DISCUSSION: Gynaecologists, neurologists, mid-wives and even anaesthesiologists seem unaware of the fact that the incidence of neurological complications are four to five times higher as a result of the labour per se than complications caused by the epidural. Peripheral neurological symptoms after labour occur in 1:2-3,000 labours. Postpartum drop-foot and femoral mononeuropathy are the most frequent complications. Half of all parturients will experience low back pain during pregnancy and/or labour, and one in four will complain of headache in the immediate postpartum period. Urinary bladder dysfunction after pregnancy is not uncommon, but the incidence is the same among mothers who have received epidural analgesia and those who have not. Complications after epidural analgesia, such as haematoma, abscesses and direct nerve damage are extremely rare, but need immediate treatment.

Non-opioid postoperative analgesia.

Although significant improvement has been made in the treatment of pain in the postoperative period, many patients still experience unnecessary discomfort resulting in distress, higher morbidity and prolonged stay in hospital. The standard pillar of postoperative treatment of severe pain is the use of opioids. However, adverse reactions to opioids make their use unfavourable. A better understanding of the pathophysiology of pain has helped clinicians to a more balanced approach to postoperative pain treatment. The development of the multimodal approach to postoperative analgesia, with the use of different drugs acting via different routes to give good analgesia, with minimal side-effects, represents a major development in the treatment of postoperative pain. Early, aggressive mobilisation and feeding must follow in order to restore normal conditions quickly. Alternatives to opioids should be used as extensively as possible. Local anaesthesia, used as regional blocks or as wound infiltration, is most beneficial. Paracetamol has good basic analgesic properties, and should probably be used in dosages higher than recommended today. The combination with a NSAID results in better and longer-lasting analgesia. The intravenous form propacetamol will increase the possibilities of its use. The new concept of selective COX-2 inhibiting NSAIDs will result in analgesic and anti-inflammatory drugs with fewer side-effects. The well-known inexpensive group of corticosteroids have good analgesic and anti-emetic properties, and are especially interesting to use in patients who do not tolerate NSAIDs. The alpha2-receptor agonists like clonidine, when administered epidurally or intrathecally, are useful adjuncts, but their adverse effects on sedation and hypotension limit their use. NMDA-receptor antagonists are of limited value in the postoperative period. Adenosine and neostigimine are still on a research level but may lead to new, clinically useful analgesic drugs. In the future, cannabinoids, cholecystokinin-receptor antagonists and neurokinin-1 antagonists may become important analgesic drugs.