Pain relief in childbirth: changing historical and feminist perspectives.

Pain during human childbirth is ubiquitous and severe. Opium and its derivatives constitute the oldest effective method of pain relief and have been used in childbirth for several thousand years, along with numerous folk medicines and remedies. Interference with childbirth pain has always been criticised by doctors and clergy. The 19th century saw the introduction of three much more effective approaches to childbirth pain; diethyl ether, chloroform and nitrous oxide. Access to pain relief was demanded by the first wave of feminist activists as a woman's right. They popularised the use of 'twilight sleep', a combination of morphine and scopolamine, which fell into disrepute as its adverse effects became known. From the 1960s, as epidural analgesia became more popular, a second wave of feminists took the opposite position, calling for a return to non-medicalised, female-controlled, 'natural' childbirth and, in some cases, valorising the importance of the pain experience as empowering for women. However, from the 1990s, a third wave of feminist thought has begun to emerge, revalidating a woman's right to choose a 'technological', pain-free birth, rather than a 'natural' one, and regarding this as a legitimate feminist position.

Therapeutic hypothermia after cardiac arrest--not so fast.

The concept of hypothermia as a protective strategy for various kinds of brain injury is far from new. Multiple mechanisms have been implicated including reduction in neuronal apoptosis, inhibition of excitatory processes caused by ischaemia and reperfusion, alterations in intracellular cation concentrations due to ion pump dysfunction, suppression of inflammatory cytokines, reduction of free radical production and reduction of cerebral oedema. Despite support from animal studies, convincing clinical evidence was lacking until recently. Two high quality clinical trials now support the use of hypothermia following cardiac arrest, but a number of issues remain. The main limitation of both trials is their highly selective entry and exclusion criteria, which limit their applicability to the majority of cardiac arrest patients. Questions about the initiation, duration, rewarming rate and the technique for producing hypothermia remain unanswered. There is also concern that side effects of hypothermia have the potential to counteract any potential benefit.

Remember the side effects of haloperidol: a case report.

An eighteen-year-old man who had a laminectomy and subtotal excision of a lipomyelomeningocele, received a single dose of haloperidol for post-operative pain and agitation. The patient suffered an acute dystonic reaction and was extensively investigated before the correct diagnosis and treatment was instituted. This case illustrates the ease with which extrapyramidal side effects following treatment with haloperidol may be overlooked in complicated medical or surgical cases.

Oral bioaccessibility of trivalent and hexavalent chromium in soil by simulated gastric fluid.

Chromium is found in soil from natural sources and anthropogenic activities. The ingestion of soil contaminated with chromium especially by children can have toxic consequences. Therefore, it is important to quantify the oral bioaccessibility of chromium in chromium in contaminated soil. In this study, chromium-51 as chromic (III) chloride and sodium chromate (VI), was mixed with an Atsion sandy soil and a Keyport clay soil and stored for 4 mo at either 21-25 degrees C or 2-4 degrees C. Utilizing simulated gastric conditions, the oral bioaccessibility of chromium in soil was determined. When the effects of soil on the bioaccessibility of chromium were compared, the data revealed the the bioaccessibility of chromium (III) from the clay soil was significantly lower than from the sandy at 21-25 degrees C. However, at 2-4 degrees C, more chromium (III) was extracted by synthetic gastric fluid from the clay soil than from the sandy soil. Temperature was also a factor as evidenced by the higher bioaccessibility of chromium (IV) in the sandy soil at 2-4 degrees C and of both chromium species in the clay soil at the same temperature. Reduction of the soluble chromium (VI) chemical to the nonsoluble chromium (III) compound in the acidic soils by naturally occurring organic matter in soil would explain the lower bioaccessibilty of chromium (VI) at 21-25 degrees C. At 2-4 degrees C, the data indicate that the rate of chromium (VI) reduction to chromium (III) was slowed. Although the results of this study are limited to one low concentration of chromium (III) and chromium (VI) and indicate that the bioaccessibility of chromium in soil can range between 18% and 72%, the data also suggest that there may be a potential health hazard from oral exposure to chromium in heavily contaminated sites. Therefore, more extensive research should be conducted to determine if thes findings can be extended to environmentally relevant concentrations.

Bed rationing and allocation in the intensive care unit.

That the resources available for intensive care cannot be infinite is self-evident. Parallel increases in medical capability, cost, and community expectations have forced intensivists to confront the reality of resource limitation. Traditional bioethical structures cope poorly with this focus beyond the traditional patient-doctor relationship. Allocation of funds for intensive care may be case-based, historically based, per diem, or capitation-based but is always heavily influenced by political and economic considerations. Attempts have been made to relate costs to severity or intervention scores, but all these techniques are limited by the high fixed costs of intensive care. Methods available to help the physician faced with patient-selection dilemmas include cost-effectiveness and cost-utility analysis. These techniques involve assessment of the quality of life with the help of several well-validated quantitative approaches. Choosing between competing patients for intensive care beds is often more a theoretical issue than a practical one, because alternative arrangements can almost always be made. Physicians have an ethical and social responsibility to further develop the tools to inform community debate on these issues.

In vitro penetration of soil-aged mercury through pig skin.

The dermal bioavailability of mercury "aged" in soil for 3 mo was compared to that of pure mercury (without soil) and to mercury in brief contact with soil (16 h). Studies were conducted in vitro with [203Hg]mercuric chloride on dermatomed male pig skin by flow-through diffusion cell methodology. Less than 0.5% of the initial mercury dose penetrated through skin into receptor fluid after each treatment. The majority of pure mercury became covalently bound to skin. However, a short contact time with either an Atsion (sandy) or Keyport (clay) soil significantly decreased the total penetration of mercury (sum of receptor fluid and skin) by 40%. After aging, a 95% reduction in total penetration was observed for the compound relative to chemical without soil. Both soils bind mercury more strongly with time, as evidenced by larger quantities of radioactivity in soil and smaller amounts in skin decontaminate after aging than in soil for 16 h. Decreased mercury bioavailability with aging indicates lower health risk and reduced need for soil cleanup.

The use of antimicrobials in ten Australian and New Zealand intensive care units. The Australian and New Zealand Intensive Care Multicentre Studies Group Investigators.

A prospective standardized collection of clinical, microbiological and pharmaceutical information on antibiotic use was conducted in Australia and New Zealand intensive care units (ICUs) involving 481 consecutive critically ill patients who were receiving antibiotics for any reason while in ICU. Patients had a mean SAPS II score of 34.1 +/- 17.8 with an expected mortality of 15.6% (actual mortality 12%). Of these, 292 (60.8%) were admitted to the ICU within 72 hours of surgery. Among such surgical patients, 233 (79.9%) received antibiotics for "surgical prophylaxis" while in ICU (48% of sample population). The second largest group of patients treated with antibiotics in ICU included those with systemic inflammatory response syndrome and clinical suspicion of infection (38%). Antibiotics were prescribed for the treatment of clinically diagnosed infection in 268 patients. Clinical response was apparent in 62.6% and in most (71%) was achieved in the first 72 hours of treatment. The incidence of antimicrobial-related side-effects was 4%, mostly in the form of diarrhoea or rash (75% of all side-effects). The most commonly prescribed antimicrobials were gentamicin (n = 146), ceftriaxone (n = 98), vancomycin (n = 94) and metronidazole (n = 111). Three times daily prescription of aminoglycosides was uncommon (< 1%). Forty-one patients had a documented infection (positive culture) with a gram-negative organism. Of these, 17 received therapy with a single antibiotic and 24 received therapy with two antibiotics. Despite similar illness severity, there were six deaths in the former group and only two in the latter.

The role of oestradiol on the dermal penetration of phenol, alone or in a mixture, in ovariectomized rats.

The human body, as well as that of animals, is almost entirely covered by skin. As a result, skin is considered the first line of defence against various types of chemicals. Many factors can affect the rate of dermal penetration of these agents either by enhancing or decreasing penetration. The aim of this study was to demonstrate the effect of oestradiol on the dermal penetration of phenol, a major chemical found in industry and hazardous waste sites. The effect of oestradiol on the dermal penetration of phenol was assessed by applying (14)C-phenol alone or in combination with trichloroethylene (TCE) to dermatomed female and male rat back skin samples in flow-through diffusion cells for 16 hours. The penetration of phenol alone was significantly lower in the ovariectomized group compared with female controls. Oestradiol restoration increased the dermal penetration of phenol alone while TCE enhanced phenol penetration in the ovariectomized group to reach control values. When the ovariectomized group receiving testosterone was treated with phenol alone or with the phenol-TCE mixture, the dermal penetration of phenol resembled the control males. These findings revealed that oestradiol plays a major role in increasing the penetration of phenol either alone or in a mixture.

Comparison between oral and dermal bioavailability of soil-adsorbed phenanthrene in female rats.

Phenathrene is a major coal tar component found in hazardous waste disposal sites. The purpose of this study was to evaluate the extent to which phenanthrene adsorption to either of 2 different soils affects the manner in which phenanthrene is subsequently handled in orally and dermally exposed adult female rats. Absorption from the gastrointestinal tract was relatively rapid for all treatments with maximum plasma concentration of radioactivity occurring within 1 h following oral administration. After dermal application, the time to reach maximum plasma concentration (12 h) was the same in all 3 phenanthrene treatment groups although sandy soil lowered the area under the plasma concentration time curve (AUC) compared to the pure and clay soil groups. Dermal exposure increased absorption half-lives 8-fold compared to oral exposure in the pure group and 15-fold in each of the soil groups. After oral or dermal treatment with phenanthrene alone or adsorbed to soil, the urine represented the primary excretion route of 14C activity. Ileum contained the highest tissue concentration of radioactivity in all oral treatment groups. However, the skin application site contained the highest concentration of radioactivity followed by ileum after dermal exposure. Phenanthrenequinone and 9,10-phenanthrene dihydrodiol were the major urinary metabolites detected in the 0-12-h urine of all treatment groups in both routes of administration. The data suggest that the oral exposure route for phenanthrene is a greater health risk than the dermal route. However, the presence of sandy or clay soil tends to delay the elimination of phenanthrene from the plasma.

Evaluation of the use of uncertainty factors in deriving RfDs for some chlorinated compounds.

Risk assessment of exposure to chemicals having a toxic endpoint routinely uses the reference dose (RfD) approach based on uncertainty factors of 10. The purpose of this investigation was to evaluate whether the magnitude of the U.S. Environmental Protection Agency (EPA) 10x uncertainty factors has scientific merit when compared with data from recent human and animal experimental studies. A compilation and comparison of ratios between LOAEL/NOAEL (lowest observed adverse effect level/no observed adverse effect level) and subchronic/chronic values was made for six chlorinated compounds, namely, carbon tetrachloride, methylene chloride, pentachlorophenol, monochlorobenzene, chlorpyrifos, and 1,1-dichloroethane. Data sets demonstrated that 91.3% of the LOAEL/NOAEL ratios were < or = 6 while 87% of the ratios for the same parameter were < or = 5. Furthermore, subchronic/chronic ratios were < or = 3.5. From our investigation we concluded that automatic safety factors of 10x are not scientifically supportable and are overly conservative for the chlorinated compounds studied here.

A comparative study of the kinetics and bioavailability of pure and soil-adsorbed naphthalene in dermally exposed male rats.

The aim of this study was to utilize pharmacokinetic techniques to assess the bioavailability of sandy or clay soil-adsorbed naphthalene vs chemical alone following dermal treatment of male rats. Animals were exposed to 43 micrograms total of 14C-naphthalene (pure or adsorbed to one of two soils) introduced into a shallow glass cap covering a 13-cm2 area on the skin of each rat. While both soils delayed the time to reach maximum plasma concentration of radioactivity and significantly increased the half-life of plasma absorption, only sandy soil significantly decreased the peak plasma concentration of radioactivity versus the pure compound. Within 12 h after dermal application, approximately 50% of the naphthalene dose was excreted in the urine of the pure and clay soil-adsorbed groups. However, when naphthalene was adsorbed to sandy soil, the percentages of the initial dose excreted in the urine collected between 0-12 h and 12-24 h were nearly equal (33-39%). Furthermore, sandy soil adsorption shifted the secondary excretion route from expired air to feces and significantly lowered the amount of radioactivity in expired air relative to naphthalene alone. In the presence of sandy soil, a significantly larger amount of radioactivity washed off of the skin application sites. In all groups the predominant urinary metabolites determined by high performance liquid chromatography were 2,7- and 1,2-dihydroxynaphthalenes.

Soil decreases the dermal penetration of phenol in male pig in vitro.

Skin is a primary route of exposure to phenol, a major chemical found in hazardous waste sites. The effect of soil adsorption on the dermal bioavailability of phenol was assessed by applying [14C]phenol alone (P) or with sandy (P-S) or clay (P-C) soil to dermatomed male pig skin samples in flow-through diffusion cells. Maximum penetration of P-S and P-C was significantly decreased by one-half and by two-thirds, respectively, compared to P. Furthermore, the penetration of phenol into receptor fluid and the amount bound to skin were significantly lower when phenol was adsorbed to either soil versus P. While less radioactivity penetrated skin with soil-adsorbed phenol treatment than P, significantly more radioactivity was loosely adsorbed to skin and could be easily washed off of the skin surface by soap and water. Only a small fraction (< 5%) of the chemical was metabolized by skin to hydroquinone and catechol in all treatment groups. The results of this study indicate that the bioavailability and thus the potential health risk from dermal exposure to phenol is reduced if the chemical is adsorbed to soil.

Prospective evaluation of residents and nurses as severity score data collectors.

OBJECTIVES: To determine the interobserver reliability of residents and nurses collecting Acute Physiology and Chronic Health Evaluation (APACHE II) data and the subsequent effect of these data collections on individual patient mortality prediction. DESIGN: In a prospective study, residents and nurses independently collected data to derive APACHE II scores. When their scores differed, a standard score was determined by one of the investigators. SETTING: A general medical and surgical ICU. PATIENTS: A total of 120 consecutive patients were included; of these patients, 79 had standard scores determined because resident and nurse scores differed. MAIN RESULTS: There was overall agreement between the residents and nurses with no significant difference between mean APACHE II scores or mean predicted mortality rates. Intraclass correlation coefficients confirmed good overall agreement between observer groups for predicted mortality rate: resident vs. nurse r2 = .94, resident vs. standard r2 = .94, and nurse vs. standard r2 = .90. However, clinically significant lack of agreement was demonstrated in 5% of the patients by the 95% confidence limits of agreement: resident vs. nurse -14 to +14%, resident vs. standard -10 to +14%, and nurse vs. standard -14 to +20%. CONCLUSIONS: While interobserver variability between resident and nurse data collection has minimal effect on derived predicted mortality rate with large patient groups, significant variability may occur in individual patients. Residents were more accurate data collectors than nurses.

Sex differences in the bioavailability of soil-adsorbed m-xylene in orally exposed rats.

The bioavailability of soil-adsorbed m-xylene was assessed in male and female rats gavaged with an aqueous suspension of 14C-m-xylene alone or adsorbed to sandy or clay soil. Sex-related differences were observed in the rate and the amount of m-xylene-derived radioactivity absorbed and excreted in the presence of the soils. A higher peak plasma concentration of radioactivity was observed in females following treatment with sandy soil-adsorbed m-xylene. Further, sandy and clay soil-adsorbed chemicals demonstrated significantly longer absorption half-lives (t1/2), while sandy soil produced a shorter elimination t1/2 vs. m-xylene alone in female rats. Increased bioavailability of sandy soil-adsorbed m-xylene in females was evidenced by a significantly increased area under the plasma concentration time curve (AUC). Neither of the soils altered the maximum plasma concentration, the rate at which xylene-derived radioactivity was absorbed or eliminated, or the AUC in male rats. Fat contained the highest tissue concentration of xylene-derived radioactivity in all treatment groups of both sexes. Further, in all male and female treatment groups m-xylene was primarily metabolized and excreted in urine with methyl hippuric acid identified as the main urinary metabolite. Sandy soil slightly delayed urinary excretion in females while both soils increased expired air excretion in males compared to m-xylene alone. Methylhippuric acid was the main urinary metabolite in all groups.

Treatment of severe cardiogenic pulmonary edema with continuous positive airway pressure delivered by face mask.

BACKGROUND: Severe cardiogenic pulmonary edema is a frequent cause of respiratory failure, and many patients with this condition require endotracheal intubation and mechanical ventilation. We investigated whether continuous positive airway pressure delivered by means of a face mask had physiologic benefit and would reduce the need for intubation and mechanical ventilation. METHODS: We randomly assigned 39 consecutive patients with respiratory failure due to severe cardiogenic pulmonary edema to receive either oxygen alone or oxygen plus continuous positive airway pressure delivered through a face mask. It was not possible to blind the investigators to the assigned treatment. Physiologic measurements were made over the subsequent 24 hours, and the patients were followed to hospital discharge. RESULTS: After 30 minutes, both respiratory rate and arterial carbon dioxide tension had decreased more in the patients who received oxygen plus continuous positive airway pressure. The mean (+/- SD) respiratory rate at 30 minutes decreased from 32 +/- 6 to 33 +/- 9 breaths per minute in the patients receiving oxygen alone and from 35 +/- 8 to 27 +/- 6 breaths per minute in those receiving oxygen plus continuous positive airway pressure (P = 0.008); the arterial carbon dioxide tension decreased from 64 +/- 17 to 62 +/- 14 mm Hg in those receiving oxygen alone and from 58 +/- 8 to 46 +/- 4 mm Hg in those receiving oxygen plus continuous positive airway pressure (P less than 0.001). The patients receiving continuous positive airway pressure also had a greater increase in the arterial pH (oxygen alone, from 7.15 +/- 0.11 to 7.18 +/- 0.18; oxygen plus continuous positive airway pressure, from 7.18 +/- 0.08 to 7.28 +/- 0.06; P less than 0.001) and in the ratio of arterial oxygen tension to the fraction of inspired oxygen (oxygen alone, from 136 +/- 44 to 126 +/- 47; oxygen plus continuous positive airway pressure, from 138 +/- 32 to 206 +/- 126; P = 0.01). After 24 hours, however, there were no significant differences between the two treatment groups in any of these respiratory indexes. Seven (35 percent) of the patients who received oxygen alone but none who received oxygen plus continuous positive airway pressure required intubation and mechanical ventilation (P = 0.005). However, no significant difference was found in in-hospital mortality (oxygen alone, 4 of 20 patients; oxygen plus continuous positive airway pressure, 2 of 19; P = 0.36) or the length of the hospital stay. CONCLUSIONS: Continuous positive airway pressure delivered by face mask in patients with severe cardiogenic pulmonary edema can result in early physiologic improvement and reduce the need for intubation and mechanical ventilation. This short-term study could not establish whether continuous positive airway pressure has any long-term benefit or whether a larger study would have shown a difference in mortality between the treatment groups.

Soil adsorption alters kinetics and bioavailability of trichloroethylene in orally exposed female rats.

Soil contamination with dangerous toxic chemicals remains one of the most difficult problems in this era. Bioavailability of a chemical absorbed through gastrointestinal tract exposure from contaminated soil may differ from that seen following exposure to the pure chemical. In this study 4.6 microCi of 14C-TCE (trichloroethylene) alone, or adsorbed to clay or sandy soil, was administered to female Sprague-Dawley rats. Maximum plasma levels of radioactivity were highest in the presence of clay soil. However, they were similar for TCE alone and sandy-soil-adsorbed chemical. The half-life (t1/2) of absorption was statistically longer and the half-life of elimination was statistically shorter in the presence of sandy soil compared with TCE alone. There were no differences in the area under the plasma concentration-time curves between groups. Liver and kidney exhibited the highest tissue concentrations of radioactivity in all groups. Urine was the primary route of excretion followed by expired air in the pure- and clay-soil-adsorbed groups. However, equal amounts of the dose were excreted in both urine and expired air of the sandy-soil-adsorbed group with a significant increase of radioactivity in expired air throughout the 72-h study period. Trichloroethanol was the major urinary metabolite of TCE.

Differences in kinetics of pure and soil-adsorbed toluene in orally exposed male rats.

Assessment of health risk following exposure to chemically contaminated soil has primarily utilized results from studies conducted with pure chemicals. However, complex interactions with soil may alter the way in which a chemical subsequently interacts with the body. This study was conducted to determine if adsorption to either of two New Jersey soils qualitatively or quantitatively altered the way in which toluene is absorbed, distributed, metabolized or excreted by the body following oral exposure. Adult, male rats were gavaged with an aqueous suspension of 14C-toluene in the presence or absence of either an Atsion (sandy soil) or a Keyport soil (clay soil). Both soils reduced the peak plasma concentration of radioactivity, while sandy soil also reduced the time to reach peak vs toluene alone. Clay soil produced a statistically significant decrease in the half-life (t1/2) of elimination of radioactivity from plasma vs toluene alone. However, neither soil altered the area under the plasma radioactivity-time curve (AUC) vs toluene alone. Three-h post administration, stomach and fat contained the highest concentrations of radioactivity. No differences were detected in the tissue concentrations of radioactivity between the treatment groups. Urine was the primary excretion route of radioactivity in all treatment groups with lesser amounts excreted in expired air and negligible amounts in feces during the 48 h following exposure. Unmetabolized toluene represented greater than 98.8% of radioactivity in expired air of all treatment groups. Clay soil produced a statistically significant decrease in the excretion of radioactivity in expired air at the 0-1, 0-12, 0-24 and 0-48 periods vs toluene alone.(ABSTRACT TRUNCATED AT 250 WORDS)