A biased coin up-and-down sequential allocation trial to determine the optimum programmed intermittent epidural bolus time interval between 5 mL boluses of bupivacaine 0.125% with fentanyl 2 µg·mL-1.

PURPOSE: The optimal epidural mixtures and settings for programmed intermittent epidural bolus (PIEB) labour analgesia have yet to be determined. A previous study by our group demonstrated that 10 mL boluses of bupivacaine 0.0625% with fentanyl 2 µg·mL-1 administered every 40 min provided effective analgesia during the first stage of labour for 90% of women, without breakthrough pain. We wanted to determine the effective PIEB time interval of 5 mL boluses of bupivacaine 0.125% with fentanyl 2 µg·mL-1 under the same study circumstances, aiming at a future comparative study. METHODS: This double-blind dose-finding study used the biased coin up-and-down sequential allocation method to determine the effective PIEB interval 90% (EI90) needed to provide effective analgesia without breakthrough pain during the first stage of labour. We used fixed 5 mL boluses of bupivacaine 0.125% with fentanyl 2 µg.mL-1 and studied time intervals of 60, 50, 40, and 30 min. The first patient was assigned an interval of 60 min and the remaining intervals were assigned as per the biased coin up-and-down method. RESULTS: The estimated EI90 was 36.5 min (95% confidence interval [CI], 34.0 to 39.0) by the truncated Dixon and Mood method and 34.2 min (95% CI, 30.8 to 41.5) by the isotonic regression method. We found that 20/40 women had an upper sensory block to ice above T6, 34/40 women had no motor block, and no woman required treatment for hypotension. CONCLUSION: The EI90 between 5 mL boluses of bupivacaine 0.125% with fentanyl 2 µg·mL-1 during the first stage of labour is approximately 35 min. TRIAL REGISTRATION: www.clinicaltrials.gov (NCT #02758405); registered 2 May, 2016.

The effect of an increased pulse width on the pattern of motor response (unilateral versus bilateral) during the Tsui test in labouring parturients: a randomized crossover trial.

BACKGROUND AND OBJECTIVES: The typical response to the Tsui test performed via an epidural catheter placed in the lumbar area is the unilateral motor response of the lower limbs. Studies show that longer pulse widths can stimulate peripheral nerves at a lower threshold current from a farther distance. Therefore, we designed a study to test the hypothesis that epidural catheter stimulation with a 1.0-msec pulse width would increase the incidence of bilateral motor response in parturients when compared with stimulation with a 0.1-msec pulse width. METHODS: Parturients requesting epidural analgesia were recruited into this randomized crossover study. The Tsui test was performed at both pulse widths before and five minutes after an epidural test dose of 2% lidocaine 3 mL. The primary outcome was the motor response pattern (either unilateral or bilateral) to the epidural catheter stimulation at baseline. RESULTS: Twenty women were recruited for the study, which was stopped early due to futility. The rates of unilateral motor response in the 0.1-msec (18/20) and the 1-msec (18/20) group were both 90% (rate difference, 0%; 95% confidence interval [CI], -0.3 to 0.3; P = 1.0). The mean (SD) current required to elicit a motor response at baseline was 4.2 (2.6) mA in the 0.1-msec group and 1.7 (1.1) mA in the 1-msec group (mean difference, 2.5; 95% CI, 1.2 to 2.3; P < 0.001). CONCLUSIONS: The motor response pattern following the stimulation of a lumbar epidural catheter with pulse widths of 0.1 msec or 1 msec is similar and typically unilateral. The threshold current is lower with the 1-msec pulse width stimulus. TRIAL REGISTRATION: www.clinicaltrials.gov, NCT02762149. Registered 2 May 2016.

A survey of mentorship among Canadian anesthesiology residents.

INTRODUCTION: Mentorship in medicine is associated with increased career satisfaction and personal development. Despite these benefits, little is known about mentorship in anesthesiology training programs. Our objectives were to determine (1) the prevalence of formal mentorship programs among anesthesiology training programs in Canada, (2) the prevalence of informal and formal mentorship among anesthesiology residents in Canada, and (3) the predictors of having an identified mentor among anesthesiology residents in Canada. METHODS: We conducted a cross-sectional web-based survey of residents and program directors from Canadian anesthesiology residency programs. Program directors were questioned about formal mentorship programs, and residents were asked to provide demographic data and information about their mentorship relationships. We analyzed the relationship between resident characteristics and mentorship. RESULTS: Our survey response rates were 76% and 39% for the Program Director Survey and the Resident Survey, respectively. Formal mentorship programs were present in 54% of residency training programs, and 94% of residents agreed that mentorship was important. Seventy-four percent of residents identified at least one mentor, although 42% of these residents did not interact regularly with their mentor. Mentors and mentees were more likely to be of the same gender. If a formal mentorship program was present, residents were more likely to identify a mentor (82 vs 17%) and interact regularly with their mentor (70 vs 46%). CONCLUSIONS: Formal mentorship programs were present in half of anesthesiology training programs. Although 74% of the residents identified a mentor, 42% did not interact regularly with their mentor. The presence of a formal mentorship program was positively associated with mentorship.

Andropause: knowledge and awareness among primary care physicians in Victoria, BC, Canada.

UNLABELLED: The causes, symptoms and treatment options for andropause have been well documented; however, not enough is known about the primary care physicians' (PCPs) knowledge in this therapeutic area. This study assesses the PCPs' awareness and knowledge of andropause in Victoria, British Columbia, Canada. METHODS: Self-administered questionnaires were developed for family physicians and general practitioners. Each questionnaire included questions in three domains: 1) General knowledge, beliefs and exposure; 2) Knowledge of diagnostic and treatment options and; 3) General demographics. RESULTS: A very high percentage of PCPs had heard of andropause (96.3%). Of the physicians who completed the survey, 92.6% agreed that men experience something similar to women's menopause when they age and 98.0% agreed that andropause is associated with an increased risk of osteoporosis. Almost all PCPs (91.5%) agreed that prostate cancer is a contraindication to treatment while around one-third (33.9%) agreed that breast cancer was a contraindication. Slightly more than half of physicians (57.4%) felt that they encountered obstacles to their investigation of andropause with the most prevalent complaint being a lack of access to education resources. There is a need for improved continuing medical education (CME) programmes in the Greater Victoria region to give PCPs the skills to diagnose and manage andropause with confidence.

Tuberculosis of the bladder without previous renal infection.

Tuberculous (TB) infections are usually limited to the pulmonary system but the hematogenous spread of TB can result in secondary infections in any part of the body. Genitourinary TB is uncommon and follows hematogenous spread from a primary pulmonary infection to the kidneys. A rare case of a TB infection of the bladder without renal involvement is described.