Consistency between POLARS and LARS scores regarding the incidence of low anterior resection syndrome in a Chilean population undergoing rectal surgery secondary to cancer in a high-volume hospital.

AIM: The aim of this work was to evaluate the concordance between the low anterior resection syndrome (LARS) and preoperative LARS (POLARS) scores regarding the incidence of LARS in a Chilean population undergoing rectal surgery for cancer in a high-volume hospital. METHOD: The LARS score questionnaire, following telephone requests, was used to determine the presence and severity of LARS. The POLARS score was calculated based on variables described previously. Correlations and qualitative and quantitative concordance were evaluated using Spearman's correlation coefficient, the kappa coefficient and the Bland-Altman plot with Lin's concordance correlation coefficient. RESULTS: A total of 120 patients met the inclusion criteria: 37.5% underwent neoadjuvant radiotherapy, 61% underwent total mesorectal excision (TME) and 51.6% underwent ostomy. A total of 49% of patients did not present with LARS, whereas 28% had major LARS. The correlation between scales was poor, with a fair qualitative concordance to determine the presence/absence of LARS and a slight qualitative concordance to determine the degree of the intensity. The quantitative concordance was poor. CONCLUSION: In the Chilean population, concordance between the LARS and POLARS scores was qualitatively fair to determine the presence/absence of the disease and qualitatively slight to determine the degree of intensity. We do not suggest using the POLARS score in the perioperative period in the Chilean population deliberately, as the score may help to determine the presence/absence of LARS but cannot determine its degree of intensity. Additional evaluations are required to determine the factors contributing to the degree of agreement between the scales.

Selection of Quality Indicators for the Certification of Dermato-Oncology Units: The CUDERMA Project Delphi Consensus Study. / Proyecto CUDERMA: Consenso Delphi de los indicadores de calidad para la certificación de las unidades de dermatología de atención en dermato-oncología.

Quality indicators are crucial for standardizing and guaranteeing the quality of health care practices. The Spanish Academy of Dermatology and Venereology (AEDV) launched the CUDERMA Project to define quality indicators for the certification of specialized units in dermatology; the first 2areas selected were psoriasis and dermato-oncology. The aim of this study was to achieve consensus on what should be evaluated by these indicators using a structured process comprising a literature review and selection of an initial list of indicators to be evaluated in a Delphi consensus study following review by a multidisciplinary group of experts. The selected indicators were evaluated by a panel of 28 dermatologists and classified as either «essential¼ or «of excellence¼. The panel agreed on 84 indicators, which will be standardized and used to develop the certification standard for dermato-oncology units.

Practical Update of the Guidelines Published by the Psoriasis Group of the Spanish Academy of Dermatology and Venereology (GPs) on the Treatment of Psoriasis With Biologic Agents: Part 2 - Management of Special Populations, Patients With Comorbid Conditions, and Risk. / Actualización práctica de las recomendaciones del Grupo de Psoriasis de la Academia Española de Dermatología y Venereología (GPS) para el tratamiento de la psoriasis con terapia biológica. Parte 2 «Manejo de poblaciones especiales, pacientes con comorbilidad y gestión del riesgo¼.

BACKGROUND AND OBJECTIVES: Since its inception, the Psoriasis Group (GPs) of the Spanish Academy of Dermatology and Venereology (AEDV) has worked to continuously update recommendations for the treatment of psoriasis based on the best available evidence and incorporating proposals arising from and aimed at clinical practice. An updated GPs consensus document on the treatment of moderate to severe psoriasis was needed because of changes in the treatment paradigm and the approval in recent years of a large number of new biologic agents. METHODOLOGY: The consensus document was developed using the nominal group technique complemented by a scoping review. First, a designated coordinator selected a group of GPs members for the panel based on their experience and knowledge of psoriasis. The coordinator defined the objectives and key points for the document and, with the help of a documentalist, conducted a scoping review of articles in Medline, Embase, and the Cochrane Library up to January 2021. The review included systematic reviews and meta-analyses as well as clinical trials not included in those studies and high-quality real-world studies. National and international clinical practice guidelines and consensus documents on the management of moderate to severe psoriasis were also reviewed. The coordinator then drew up a set of proposed recommendations, which were discussed and modified in a nominal group meeting. After several review processes, including external review by other GPs members, the final document was drafted. RESULTS: The present guidelines include updated recommendations on assessing the severity of psoriasis and criteria for the indication of systemic treatment. They also include general principles for the treatment of patients with moderate to severe psoriasis and define treatment goals for these patients as well as criteria for the indication and selection of initial and subsequent therapies Practical issues, such as treatment failure and maintenance of response, are also addressed.

Practical update of the Recommendations Published by the Psoriasis Group of the Spanish Academy of Dermatology and Venereology (GPS) on the Treatment of Psoriasis with Biologic Therapy. Part 1. Concepts and General Management of Psoriasis with Biologic Therapy. / Actualización práctica de las recomendaciones del Grupo de Psoriasis de la Academia Española de Dermatología y Venereología (GPS) para el tratamiento de la psoriasis con terapia biológica. Parte 1. «Conceptos y manejo general de la psoriasis con terapia biológica¼.

BACKGROUND AND OBJECTIVES: A new, updated AEDV Psoriasis Group consensus document on the treatment of moderate to severe psoriasis was needed owing to the approval, in recent years, of a large number of new drugs and changes in the treatment paradigm. METHODOLOGY: The consensus document was developed using the nominal group technique and a scoping review. First, a designated coordinator selected a group of Psoriasis Group members for the panel. The coordinator defined the objectives and key points for the document and, with the help of a documentalist, conducted a scoping review of articles in Medline, Embase, and the Cochrane Library up to January 2021. The review included systematic reviews and meta-analyses as well as clinical trials not included in those studies and high-quality real-world studies. National and international clinical practice guidelines and consensus documents on the management of moderate to severe psoriasis were also reviewed. Based on these reviews, the coordinator drew up a set of proposed recommendations, which were then discussed and modified in a nominal group meeting. After several review processes, including external review by other GPs members, the final document was drafted. RESULTS: The present guidelines include general principles for the treatment of patients with moderate to severe psoriasis and also define treatment goals and criteria for the indication of biologic therapy and the selection of initial and subsequent therapies. Practical issues, such as treatment failure and maintenance of response, are also addressed.

Lifetime psychopathology in child and adolescent offspring of parents diagnosed with schizophrenia or bipolar disorder: a 2-year follow-up study.

Having one parent diagnosed with a severe mental disorder is considered one of the main risk factors for developing that disorder in adulthood, and it also increases the risk of a wide range of mental disorders in the offspring. The aim of this study is to compare the prevalence of several psychopathological diagnoses, the presence of prodromal symptoms, and global functioning in offspring of parents with schizophrenia or bipolar disorder and in offspring of controls at baseline and 2-year follow-up. This study included 41 offspring of parents with schizophrenia, 90 offspring of parents with bipolar disorder, and 107 offspring of controls (mean age 11.7 ± 3.2 at baseline and 13.9 ± 3.2 at follow-up). The prevalence of psychopathology and comorbidity was higher in offspring of parents with schizophrenia and offspring of parents with bipolar disorder than in offspring of controls at baseline and at 2-year follow-up. Interestingly, mood disorders were more prevalent in offspring of parents with bipolar disorder and disruptive disorders were more prevalent in offspring of parents with schizophrenia. Prodromal symptoms were more frequent in offspring of parents with schizophrenia than in offspring of controls, while the offspring of parents with bipolar disorder showed an intermediate pattern. Finally, global functioning was lower in the offspring of parents with schizophrenia than the offspring of parents with bipolar disorder and the offspring of controls. Screening patients' children is clinically relevant, since, as a group, they have an elevated risk of developing a psychiatric disorder and of experiencing their first symptoms during childhood and adolescence.

Supplementation with Phaseolus vulgaris Leaves Improves Metabolic Alterations Induced by High-Fat/Fructose Diet in Rats Under Time-Restricted Feeding.

Time-restricted feeding and food enriched in polyphenols are strategies to prevent or reduce metabolic disorders. Bean leaves (Phaseolus vulgaris L.) are a recognized source of polyphenolic compounds, whose effects on metabolic pathways are not well studied. We evaluated the combined effects of dietary supplementation with Phaseolus vulgaris leaves (10% w/w) (BL) and a 7-h daytime-restricted feeding protocol (RF) under a hypercaloric diet (high fat + high fructose) (HFFD) on the metabolic parameters related to glucose and lipid handling. Adult male Wistar rats were treated for 8 weeks with standard and HFFD diets with or without BL. The results showed that RF improved metabolic alterations induced by HFFD (e.g., hepatic steatosis, increased triacylglycerols, and serum lipoproteins). Supplementation with BL significantly enhanced this effect and downregulated the mRNA expression of carbohydrate and lipid metabolism genes in the liver. These results indicate that dietary supplementation with BL enhances the benefits elicited by RF.

Multiscale design of a dairy beverage model composed of Candida utilis single cell protein supplemented with oleic acid.

One of the main challenges in the food industry is to design strategies for the successful incorporation of natural sources of bioactive compounds. Recently, yogurts and other fermented dairy beverages have been proposed as ideal carriers of such bioactive compounds such as fatty acids and antioxidants that could improve consumers' health. However, the incorporation of new ingredients causes functional and structural modifications that may affect the consumers' preferences. In this work, a dairy beverage model supplemented with oleic acid has been designed by partial substitution of milk by Candida utilis single-cell protein extract. The changes in the structural properties of this new beverage were evaluated by following the fermentation process, pH, aggregate size, microstructure, and changes in rheological properties. Furthermore, molecular dynamics simulations were carried out to analyze the interaction between its main components. Our data revealed that samples with a percentage of milk substitution of 30% showed a higher viscosity as compared with the other percentages and less viscosity than the control (no substitution). These samples were then selected for fortification by incorporating oleic acid microcapsules. A concentration of 1.5 g/100 g was shown to be the optimal quantity of microcapsules for oleic acid supplementation. Molecular dynamic simulations revealed glutathione as an important component of the micro-gel structure. The present study forms the basis for novel studies where Candida utilis single-cell protein and microencapsulated essential oils could be used to design innovative bioproducts.

Concentrations of chlorinated pollutants in adipose tissue of yellow-legged gulls (Larus michahellis) from Spain: Role of gender and age.

Concentrations of 7 different polychlorinated biphenyl (PCB) congeners, and eleven organochlorine pesticides (OCPs) and metabolites, including DDTs (dichlorodiphenyltrichloroethane), HCHs (hexachlorocyclohexane isomers), Endosulfan, Endosulfan sulfate, Endrin, Dieldrin and HCB (hexachlorobenzene), were determined in adipose tissue of 57 yellow-legged gulls collected from NW and N Spain. Furthermore, the possible differences due to two endogenous factors, age and gender, were determined. All the analyzed PCBs were detected in over 66% of the samples, with levels of 291.9 (PCB 180), 34.5 (PCB 118), 0.7 (PCB 28), 432.6 (PCB 153), 225.5 (PCB 138), 1.3 (PCB 101) and 0.4 (PCB 52) µg/kg of adipose tissue. With respect to the OCPs and metabolites, only 4,4'-DDE and HCB were detected in more than 50% of the samples, with means of 360.6 and 2.5 µg/kg of adipose tissue, respectively. From all the considered contaminants, only 4,4'-DDE levels presented significant differences depending on the gender, with females showing higher values than males (p < 0.01). Significant differences (p < 0.001) were also found related to age for the levels of PCBs 180, 138, 101, 28 and 153, as well as 4,4'-DDE, with adult levels being higher than those in young birds. The results of the present study constitute a baseline to better assess the environmental impacts of PCB and OCP contamination at other coastal sites for future biomonitoring studies, with particular emphasis on gender- and age-related differences.

Insular pathology in young people with high-functioning autism and first-episode psychosis.

BACKGROUND: Autism Spectrum Disorders (ASD) and psychosis share deficits in social cognition. The insular region has been associated with awareness of self and reality, which may be basic for proper social interactions. METHODS: Total and regional insular volume and thickness measurements were obtained from a sample of 30 children and adolescents with ASD, 29 with early onset first-episode psychosis (FEP), and 26 healthy controls (HC). Total, regional, and voxel-level volume and thickness measurements were compared between groups (with correction for multiple comparisons), and the relationship between these measurements and symptom severity was explored. RESULTS: Compared with HC, a shared volume deficit was observed for the right (but not the left) anterior insula (ASD: p = 0.007, FEP: p = 0.032), and for the bilateral posterior insula: (left, ASD: p = 0.011, FEP: p = 0.033; right, ASD: p = 0.004, FEP: p = 0.028). A voxel-based morphometry (VBM) conjunction analysis showed that ASD and FEP patients shared a gray matter volume and thickness deficit in the left posterior insula. Within patients, right anterior (r = -0.28, p = 0.041) and left posterior (r = -0.29, p = 0.030) insular volumes negatively correlated with the severity of insight deficits, and left posterior insular volume negatively correlated with the severity of 'autistic-like' symptoms (r = -0.30, p = 0.028). CONCLUSIONS: The shared reduced volume and thickness in the anterior and posterior regions of the insula in ASD and FEP provides the first tentative evidence that these conditions share structural pathology that may be linked to shared symptomatology.

Does gender influence the levels of heavy metals in liver of wild boar?

The aim of this study was to determine heavy metal reference levels for risk assessment studies. For this purpose, the levels of lead, cadmium, copper and zinc were determined in liver tissues of wild boars sampled in NW Spain. The mean values were 0.383, 0.326, 23.50 and 56.86mg/kg dried weight, respectively. In general, the levels detected were similar to or lower than the levels reported in literature. This study not only provides a useful baseline for biomonitoring the levels of the analyzed contaminants in wildlife in NW Spain, it also helps to understand the effects of gender on the levels of these elements. Similar to studies performed in other geographical regions, no significant gender-related differences could be detected. Although differences were not significant, the levels of zinc, cadmium and lead were modestly higher in males (55.78, 0.346 and 0.424mg/kg, respectively) compared to females (45.25, 0.305 and 0.341mg/kg). Our results indicate that, although gender did not significantly affect heavy metal uptake and toxicokinetics of contaminants in wild boars, these effects could vary between species, populations, organs, and elements. It is therefore essential to investigate gender-related differences for each species.

Simplified risk stratification criteria for identification of patients with MRSA bacteremia at low risk of infective endocarditis: implications for avoiding routine transesophageal echocardiography in MRSA bacteremia.

The aim of this study was to identify patients with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia with low risk of infective endocarditis (IE) who might not require routine trans-esophageal echocardiography (TEE). We retrospectively evaluated 398 patients presenting with MRSA bacteremia for the presence of the following clinical criteria: intravenous drug abuse (IVDA), long-term catheter, prolonged bacteremia, intra-cardiac device, prosthetic valve, hemodialysis dependency, vertebral/nonvertebral osteomyelitis, cardio-structural abnormality. IE was diagnosed using the modified Duke criteria. Of 398 patients with MRSA bacteremia, 26.4 % of cases were community-acquired, 56.3 % were health-care-associated, and 17.3 % were hospital-acquired. Of the group, 44 patients had definite IE, 119 had possible IE, and 235 had a rejected diagnosis. Out of 398 patients, 231 were evaluated with transthoracic echocardiography (TTE) or TEE. All 44 patients with definite IE fulfilled at least one criterion (sensitivity 100 %). Finally, a receiver operator characteristic (ROC) curve was obtained to evaluate the total risk score of our proposed criteria as a predictor of the presence of IE, and this was compared to the ROC curve of a previously proposed criteria. The area under the ROC curve for our criteria was 0.710, while the area under the ROC curve for the criteria previously proposed was 0.537 (p < 0.001). The p-value for comparing those 2 areas was less than 0.001, indicating statistical significance. Patients with MRSA bacteremia without any of our proposed clinical criteria have very low risk of developing IE and may not require routine TEE.

Concentrations of Metals, Metalloids, and Chlorinated Pollutants in Blood and Plasma of White Stork (Ciconia ciconia) Nestlings From Spain.

The aim of this study was to determine the levels of different inorganic elements (lead [Pb], mercury [Hg], and arsenic [As]) and persistent chlorinated pollutants (including polychlorinated biphenyls [PCBs] and organochlorine pesticides [OCPs]) in blood and plasma of White stork (Ciconia ciconia) nestlings from northwest (NW) Spain. The concentrations of PCBs were lower than the limit of detection in all samples. The OCPs γ-HCH, 4,4'-DDE, HCB, and endosulfan were detected most frequently in plasma from White stork nestlings. These OCPs were detected in 98, 54, 39, and 37 % of all samples, respectively. However, the concentrations of organic pollutants were lower than the risk thresholds for birds. The mean levels of the inorganic elements Pb, Hg, and As were found to be 36.92 ± 33.48, 16.48 ± 12.87, and 9.813 ± 13.84 µg/L, respectively. These levels were also lower than the risk thresholds for birds. This study not only provides a snapshot of the levels of both inorganic and organic contaminants in wild White storks in NW Spain, it also provides a useful baseline for biomonitoring levels of the measured contaminants in this area.

Detection of aromatic compounds in tequila through the use of surface plasmon resonance.

For an expert nose, the aroma of a beverage is a fingerprint that can be used to certify its authenticity, distinguish between distillation processes, or even identify the raw material used to fabricate it. In this work, we propose a simple, automatic, and repeatable optical method, which can be used as a first and quick test to authenticate tequila samples. This method is based on the measurement of beam intensity changes, using the surface plasmon resonance technique, operating at a fixed angle. We observed that each tequila, depending on the alcohol content and aging process, produces a specific change in measured intensity level.

Association of the GSTM1 null polymorphism with breast cancer in a Mexican population.

The glutathione S transferase (GST) family plays an important role in the processing of carcinogens. Data on the null GSTM1 genotype has revealed associations with cancer, and has been suggested to affect carcinogen metabolism and to contribute to tumor promotion in the mammary gland. We examined the role of the null GSTM1 genotype by comparing the genotypes of 276 healthy Mexican women with those of 558 Mexican women with breast cancer (BC). The genotype frequencies observed in the controls and patients with BC were 38 and 45% for the null GSTM1 genotype, respectively. The obtained odds ratio (OR) was 1.36, with a 95% confidence interval (95%CI) of 1.02-1.8, P = 0.04. The protective association was also evident upon analysis of the distributions of the null GSTM1 genotype in patients with positive chemotherapy response who had high plasma levels of glucose (OR 0.56, 95%CI = 0.33-0.94, P = 0.03). This study suggested that the null GSTM1 genotype is associated with BC susceptibility in the Mexican population analyzed.

Association of the C677T polymorphism in the methylenetetrahydrofolate reductase gene with breast cancer in a Mexican population.

The methylenetetrahydrofolate reductase (MTHFR) gene plays an important role in the steps involved in the processing of amino acids. The analysis of polymorphisms in the MTHFR gene has revealed associations with cancer; in particular the C677T polymorphism, which has been suggested to affect folate metabolism, DNA methylation, synthesis, and repair, and to contribute to tumor promotion in the mammary gland. We examined the role of the C677T polymorphism in the MTHFR gene by comparing the C677T genotypes of 339 healthy Mexican women with those of 497 Mexican women with breast cancer (BC). The genotype frequencies observed in the controls and patients with BC were 10 and 21% for 677TT; 41 and 36% for 677CT; and 49 and 43% for 677CC, respectively. The odds ratio (OR) for the 677TT genotype was 2.5, with a 95% confidence interval (95%CI) of 1.6-3.8; P = 0.0001. The positive association was also evident when the distributions of the 677TT genotype in control and patients affected within the following two categories were compared to alcohol consumption (OR = 0.41; 95%CI = 0.19-0.86; P = 0.018); and high level glutamate-oxaloacetate transaminase (SGOT) (OR = 0.36; 95%CI = 0.15-0.83, P = 0.017). These results suggest that the 677TT genotype of the C677T polymorphism in the MTHFR gene is associated with BC susceptibility in the Mexican population.

Brassica foods as a dietary source of vitamin C: a review.

Brassica genus includes known horticultural vegetables with major economical importance worldwide, and involves vegetables of economical importance being part of the diet and source of oils for industry in many countries. Brassicales own a broad array of health-promoting compounds, emphasized as healthy rich sources of vitamin C. The adequate management of pre- and postharvest factors including crop varieties, growth conditions, harvesting, handling, storage, and final consumer operations would lead to increase or preserve of the vitamin C content or reduced losses by interfering in the catalysis mechanisms that remains largely unknown, and should be reviewed. Likewise, the importance of the food matrix on the absorption and metabolism of vitamin C is closely related to the range of the health benefits attributed to its intake. However, less beneficial effects were derived when purified compounds were administered in comparison to the ingestion of horticultural products such as Brassicas, which entail a closely relation between this food matrix and the bioavailability of its content in vitamin C. This fact should be here also discussed. These vegetables of immature flowers or leaves are used as food stuffs all over the world and represent a considerable part of both western and non-Western diets, being inexpensive crops widely spread and reachable to all social levels, constituting an important source of dietary vitamin C, which may work synergistically with the wealth of bioactive compounds present in these foods.

School-based individualised lifestyle intervention decreases obesity and the metabolic syndrome in Mexican children.

BACKGROUND: Currently, there is limited evidence about effective strategies to manage childhood obesity and the metabolic syndrome in school settings. The present study aims to analyse changes in the prevalence of being overweight/obese and having the metabolic syndrome in relation to a 10-month lifestyle intervention based on individualised face-to-face sessions and parental education in school settings. METHODS: The study sample comprised a cross-sectional sample of 96 overweight/obese Mexican children aged 6-12 years from eight schools. Clinical, anthropometric measurements and 24-h recalls were obtained during each of 13 visits. Laboratory measurements were determined at the beginning and end. The energy-reduced diet was based on dietary recommended intakes. Individualised structured daily meals and a physical activity plan, tailored-made for each child, were provided every 3 weeks at the schools. Parental attendance was required. Student's t-test, McNemar and Shapiro-Wilk tests and simple linear regression were used for the statistical analysis. RESULTS: The prevalence of metabolic syndrome fell significantly from 44% to 16% (P < 0.01), high blood pressure fell from 19% to 0%, hypertrigliceridaemia fell from 64% to 35%, high-density lipoprotein-cholesterol ≤ 40 fell from 60% to 41%, hyperglycaemia fell from 1% to 0%, and waist circumference ≥90th percentile fell from 72% to 57%. There was a 2.84 [95% confidence interval (CI) = -4.10 to -1.58; P < 0.01] significant decrease in body mass index percentile and in body-fat percentage (95% CI = -3.31 to -1.55; P < 0.01). Of the overweight children, 32% achieved normal-weight, whereas 24% of the obese ones converted to overweight and 1% reached normal-weight. Physical activity increased 16 min/day(-1) (P = 0.02) and 2 days/week(-1) . CONCLUSIONS: A school-setting lifestyle intervention led to a decreased prevalence of being overweight/obese and to a striking reduction in the prevalence of the metabolic syndrome in a sample of Mexican children.

Non-destructive multibiomarker approach in European quail (Coturnix coturnix coturnix) exposed to the herbicide atrazine.

The effect of orally administered atrazine (25 or 100 mg/kg on days 0, 5, and 10 of the experiment) was studied in European quail (Coturnix coturnix coturnix) on four non-destructive biomarkers: fecal porphyrins, blood glutathione-S-transferase, glutathione reductase, reduced glutathione, and malondialdehyde (MDA). Uroporphyrin I (UPI) and coproporphyrins I and III (CPIII) were the main porphyrins detected in feces. The lowest dose of ATZ caused a significant (P < 0.05) increase in UPI and CPIII at day 5, and the highest dose of ATZ caused an induction of CPI and a significant (P < 0.05) decrease in MDA levels at day 30.

[Impact on the implementation of patient controlled epidural analgesia for pain management during labor. A survey in a university hospital in Chile]. / Impacto de la implantación y desarrollo de la analgesia epidural administrada por la paciente para el tratamiento del dolor del parto. Encuesta en un hospital universitario en Chile.

OBJECTIVE: Analgesia for labor is a legal obligation in Chile. In our institution we implemented patient controlled analgesia for pain relief during labor. We describe the perception of the several professionals involved in the medical care of patients in labor in terms of effectiveness, usefulness, satisfaction, and safety. MATERIAL AND METHODS: A self-reported questionnaire was given to the professionals involved, and the obstetrical and neonatal outcomes were recorded along with the workload indices. Twenty-five structured questions were presented with a Likert type score to evaluate analgesia quality, workload of professionals involved, adverse effects, patient satisfaction, and healthcare workers satisfaction. Finally, a question was asked about the overall perception. RESULTS: We found that the overall perception of the analgesic technique was (mean) 6.0 (SD) (0.88). A decrease in the anesthesiologist workload was observed, without affecting obstetric outcomes. CONCLUSION: Considering the study design limitations, absence of knowledge of economical impact, and the satisfaction level of patients under standard epidural analgesia, we recommend the patient controlled analgesia technique due to its good obstetric outcomes, general satisfaction and workload decrease.