Continuous epidural infusion vs programmed intermittent epidural bolus for labour analgesia: a prospective, controlled, before-and-after cohort study of labour outcomes.

BACKGROUND: Recent evidence that programmed intermittent epidural bolus (PIEB) improves maternal outcomes encouraged us to change our labour epidural analgesia protocols and investigate if we could achieve similar results in a clinical setting. METHODS: We conducted a prospective, controlled, before-and-after cohort study. Outcomes after labour analgesia delivered by continuous epidural infusion (CEI) with ropivacaine 0.2% and fentanyl 2µg ml-1 were compared with PIEB with patient controlled epidural analgesia (PIEB+PCEA) with ropivacaine 0.1% and fentanyl 2 µg ml-1. The primary outcome was lower limb motor block. Secondary outcomes were local anaesthetic and fentanyl dose, duration of the second stage of labour, mode of delivery, and maternal satisfaction. Outcomes were compared using univariate t-test, χ2 test or Fisher's exact test. Significant differences in outcomes were further evaluated by multiple regression analysis. RESULTS: A total of 397 women completed the study (CEI 188; PIEB+PCEA 209). The PIEB+PCEA group had significantly fewer patients with motor block [CEI 41/188 (21.8%) vs PCEA+PIEB 2/209 (1.0%), P<0.001], shorter second stage of labour for primiparous women [CEI 108.2 (61.2), mean (standard deviation), min vs PIEB+PCA 79.4 (55.1) min, P<0.001], and received less ropivacaine [CEI 72.5 (43.0) mg vs PIEB+PCEA 40.4 (23.8) mg, P<0.001]. There was no significant difference in mode of delivery, fentanyl dose, or maternal satisfaction. CONCLUSIONS: Benefits of PIEB+PCEA over CEI previously demonstrated in small randomised controlled trials were reproducible on a larger scale in a clinical setting.

Mild maternal stress disrupts associative learning and increases aggression in offspring.

Maternal stress has been shown to affect behaviour of offspring in a wide range of animals, but this evidence has come from studies that exposed gestating mothers to acute or severe stressors, such as restraint or exposure to synthetic stress hormones. Here we show that exposure of mothers to even a mild stressor reduces associative learning and increases aggression in offspring. Female guppies were exposed to routine husbandry procedures that produced only a minimal, non-significant, elevation of the stress hormone cortisol. In contrast to controls, offspring from mothers that experienced this mild stress failed to learn to associate a colour cue and food reward, and showed a greater amount of inter-individual variation in behaviour compared with control offspring. This mild stress also resulted in offspring that were more aggressive towards their own mirror image than controls. While it is possible that these results could represent the transmission of beneficial maternal characteristics to offspring born into unpredictable environments, the potential for mild maternal stress to affect offspring performance also has important implications for research into the trans-generational effects of stress.

Clinical parameters in male genital lichen sclerosus: a case series of 329 patients.

BACKGROUND: The dermatological aspects of male genital lichen sclerosus (MGLSc) have not received much prominence in the literature. Sexual morbidity appears under-appreciated, the role of histology is unclear, the relative places of topical medical treatment and circumcision are not established, the prognosis for sexual function, urinary function and penis cancer is uncertain and the pathogenesis has not been specifically studied although autoimmunity (as in women) and HPV infection have been mooted. OBJECTIVE: To illuminate the above by analysing the clinical parameters of a large series of patients with MGLSc. METHODS: A total of 329 patients with a clinical diagnosis of MGLSc were identified retrospectively from a dermatology-centred multidisciplinary setting. Their clinical and histopathological features and outcomes have been abstracted from the records and analysed by simple descriptive statistics. RESULTS: The collation and analysis of clinical data derived from the largest series of men with MGLSc ever studied from a dermatological perspective has been achieved. These data allow the conclusions below to be drawn. CONCLUSIONS: MGLSc is unequivocally a disease of the uncircumcised male; the adult peak is late in the fourth decade; dyspareunia is a common presenting complaint; non-specific histology requires careful interpretation; most men are either cured by topical treatment with ultrapotent steroid (50-60%) or by circumcision (>75%); effective and definitive management appears to abrogate the risk of developing penile squamous cell carcinoma; urinary contact is implicated in the pathogenesis of MGLSc; HPV infection and autoimmunity seem unimportant.

Fluoride levels in human parotid saliva following ingestion of fluoride compounds of varying solubility.

Healthy dental students received oral doses of 10.0 mg F daily in the form of compounds of widely varying solubilities. Parotid saliva F concentration and urinary F excretion were highest with NaF, Na2PO3F, and SnF2, lowest with CaF2, and intermediate with AlF3. Solubility of the ingested fluoride compound was a controlling factor in the amount of F excreted in the urine, the peak F concentration reached in parotid saliva, and the duration of a significant elevation in salivary F.

System for digital acquisition of gastrointestinal images.

Previous theoretical work and clinical experience with digital acquisition of fluoroscopic images have identified several problems which needed to be solved. These are: image resolution; blurring due to patient motion, combined with long exposure times; and excessive x-ray quantum mottle levels. We will show that application of pulsed progressive readout (PPR) methods to the TV camera solves these problems. By permitting a high-intensity x-ray pulse to be delivered, all motion is stopped and quantum mottle is reduced to acceptable levels. It will be shown that 1024 x 1024 digital matrices provide adequate resolution and 8-bit digitization is sufficient to permit the same quality as is used in conventional 100-mm photofluorography. User acceptance can be made easier by incorporation of existing photofluorographic controls (with which the radiologist is already familiar) to acquire the digital images. It is possible to interface PPR video systems using existing 100-mm exposure circuits without much modification and the resulting system can be regarded as a digital 100-mm camera.

Sexual behavior of the obese male Zucker rat.

Obese male Zucker rats displayed inadequate sexual behavior at four months placed with ovariectomized lean females pretreated with estrogen and progesterone. Only one out of seven obese males ejaculated during the test sessions. Diet-restricting the obese males at five months of age did not improve their sexual behavior when tested at six months of age. At ten months of age none of the obese males ejaculated during the test sessions. Lean littermates ejaculated during the sessions at all ages tested. Obese males which do ejaculate are capable of inducing pseudopregnancy in intact lean females. These findings suggest that inadequate sexual behavior is one factor contributing to the reduced reproductive capacity of obese male Zucker rats.

Plasma testosterone levels and sexual performance of young obese male Zucker rats.

The sexual behavior of obese male Zucker rats was studied at the age of 7, 8, 9, 10, 11, 14, and 16 weeks. Between 12-14 weeks of age, obese rats were treated with 400 micrograms testosterone propionate daily. Plasma testosterone levels were determined at the age of 10, 14, 16, and 20 weeks. Compared to lean rats, the sexual performance of the obese rats was abnormal at all ages. Plasma testosterone levels of obese rats were significantly lower at the age of 20 weeks but not at the age of 10 and 16 weeks, compared to those of their lean littermates. At the age of 14 weeks, after 2 weeks of testosterone treatment, plasma testosterone concentration rose to levels significantly higher than those of their lean littermates. However, there was no improvement in their sexual behavior following this period of hormone treatment. This study strongly suggests that obese male Zucker rats have abnormal reproductive function at all ages and that testosterone deficiency is not a primary cause of this abnormality.

Enamel solubility reduction by acidulated phosphate-fluoride (APF) treatment.

The enamel solubility reducing (ESR) potential of acidulated phosphate-fluoride (APF) solutions containing varying amounts of F was studied. Commercial APF (1.23% F, pH 3.0) reduced solubility by about 80%. Fivefold dilutions of this APF were made with either phosphoric acid or water without significant effect on ESR potential. Further dilution to 0.12% F significantly decreased effectiveness. Commercially available APF products (1.23%) can be diluted several-fold with distilled water in the dental office without significant loss of ability to reduce the solubility of enamel.

Effect of fluoride concentration on rehardening of enamel by a saliva substitute.

An evaluation was made of the effect of different concentrations of F on the ability of OraLube, a saliva substitute developed by the Veterans Administration designed for use by xerostomic patients, to reharden enamel surfaces. Test preparations contained either 0, 1.0, 2.0, 3.0, 4.0 or 5.0 ppm and groups of softened enamel surfaces were treated with these solutions for 30 minutes. Treatment with saliva substitute containing no F did not significantly alter the hardness of enamel surfaces. Including 1.0 ppm F in the formula induced a rehardening of about 5 per cent; 2.0 ppm F solution rehardened at a 12.5 per cent rate. Additional F up to 5.0 ppm did not increase rehardening significantly. The inclusion of 2.0 ppm F in OraLube assures that, in addition to its ability to relieve intraoral soft tissue problems associated with xerostomia, an optimal rehardening potential is provided.

Telephone triage: 5 years' experience.

Triaging by telephone has long been a 'bone of contention' among emergency nurses in Victoria, Australia, with some nurses adamant that telephone advice is appropriate and other nurses equally adamant that telephone advice should not be given at all. Almost unanimously agreed upon by both groups is that documentation of the call, and/or the advice given, is time consuming and may pose a legal risk to the nurse if something untoward should happen to the patient. This paper relates our experience including our policy on telephone triage with an analysis of 5 years of documented telephone calls from January 1991 to January 1996.

Managing potentially ischaemic chest pain and coronary care beds effectively.

One of the most common reasons why patients attend emergency departments in Australia is chest pain that is potentially due to coronary artery disease (myocardial infarction, unstable or stable angina pectoris). A number of models for the investigation and treatment of these patients have been employed over the last five to ten years. This paper describes the evolution of a model for managing ischaemic chest pain that aims to avoid potentially preventable deaths from undiagnosed myocardial infarction, to admit to hospital patients who could benefit from inpatient treatment, to admit to a coronary care unit patients at significant risk of complications, and to avoid inter-hospital transfer of patients. Introduction of the model has led to an increase in the appropriate hospital admission of patients with ischaemic chest pain, a marked reduction in inter-hospital transfers, and better utilisation of coronary care beds. Unmonitored, general ward management of low risk patients with clinical unstable angina has not resulted in compromised outcomes.

Effects of color and trait anxiety on state anxiety.

A 2 (trait anxiety) X 4 (color) factorial design was used to determine the effects of red, green, yellow, and blue on state anxiety as a function of high and low trait anxiety. The State-Trait Anxiety Inventory was used to assess both traint (A-Trait) and state (A-State) anxiety for the 10 students assigned to each of the eight treatment combinations. High A-Trait students were significantly more anxious while viewing blue, red, and green than were the low A-Trait students and blue produced significantly more state anxiety than did either yellow or green. These results are consitent with state-trait theory and indicate that the effects of color on state anxiety may be confounded with trait anxiety unless the levels of A-Trait are equivalent for each color condition. The role of cultural and individual differences in the relationship between color and emotion and implications for research are discussed.

Managing unstable angina and coronary care beds effectively.

This article is an evaluation of a new chest pain admission policy at Western Hospital. Our aim was to determine the clinical outcomes of patients with unstable angina treated according to this new policy. It involved attempting to identify a group at low risk of serious complications and to manage them in a general ward area without cardiac monitoring, to reduce the pressure on coronary care unit beds. We conducted a retrospective case note review and concluded that that selected patients with an admission diagnosis of unstable angina can be safely managed in unmonitored medical beds provided mechanisms are in place for their transfer to the coronary care unit if recurrent pain or a complication occurs.