A comparison of intramuscular diamorphine and intramuscular pethidine for labour analgesia: a two-centre randomised blinded controlled trial.

OBJECTIVE: Intramuscular (i.m.) pethidine is used worldwide for labour analgesia and i.m. diamorphine usage has increased in the UK in the last 15 years. This trial aims to ascertain the relative efficacy and adverse effects of diamorphine and pethidine for labour pain. DESIGN: Prospective, parallel-arm randomised controlled trial with blinding of participants, care-givers and outcome assessors. SETTING: Maternity units in two District General Hospitals in the UK. POPULATION: After written informed consent, 484 women were randomised and recruited (244 diamorphine, 240 pethidine). Inclusion criteria included women 16 years or older, established labour, singleton pregnancy, 37-42 weeks of gestation and weight 60-120 kg. METHODS: On request of i.m. analgesia, participants received either 150 mg pethidine or 7.5 mg diamorphine based on computer-generated block randomisation. MAIN OUTCOME MEASURES: Maternal-reduction in pain intensity from baseline (10-cm visual analogue scale) at 60 minutes and over the 3-hour period after drug administration. Neonatal-requirement for resuscitation and Apgar score at 1 minute. RESULTS: Diamorphine provided modestly improved pain relief at 60 minutes, mean difference 1 cm (95% confidence interval [CI] 0.5-1.5), and over the 3 hours, mean difference 0.7 cm (95% CI 0.3-1.1). However, average length of labour in women receiving diamorphine was 82 minutes longer (95% CI 39-124) and therefore they experienced more pain overall. There were no statistically significant differences in primary neonatal outcomes. CONCLUSIONS: There is a modest difference between the analgesia provided by diamorphine or pethidine for labour analgesia but diamorphine is associated with significantly longer labours.

Prescribing intramuscular opioids for labour analgesia in consultant-led maternity units: a survey of UK practice.

BACKGROUND: Intramuscular opioids are widely used for analgesia in labour. We conducted a postal survey to establish current prescribing and monitoring guidelines for intramuscular opioids in consultant-led obstetric units in the UK. METHODS: A postal questionnaire was sent between December 2005 and January 2006 to the lead obstetric anaesthetist of all 234 consultant-led obstetric units in the UK. We enquired about dose regimens of intramuscular opioids in labour and monitoring of mother, fetus and neonate. RESULTS: The response rate was 71%; 84.4% of responding units used pethidine and 34.1% diamorphine. Meptazinol and morphine were available in 13.8% and 13.2% of units respectively. Some units used more than one opioid. The choice of opioid was dictated mainly by tradition (65.3%) and familiarity (40.7%). Prophylactic antiemetics were co-administered in 73.7% of units, the most commonly used being prochlorperazine (30.5%). Vital signs were monitored in 91.6% of units: in total 10.2% measured haemoglobin oxygen saturations and 4.8% respiratory rate. Pain scores were recorded in 13.7% of units. CONCLUSIONS: When compared with previous studies the use of intramuscular diamorphine is increasing in UK consultant-led obstetric units, although pethidine remains the widely used opioid. At present this change cannot be justified by a suitably powered, randomised study comparing intramuscular pethidine with diamorphine.

Reversible posterior leucoencephalopathy syndrome in a peripartum patient.

We present the case of a multiparous parturient who developed hypertension associated with a severe headache in the immediate post-partum period. She subsequently suffered a generalised tonic clonic seizure on the fifth post-partum day. Following recovery of consciousness, she developed a left homonymous hemianopia. Apart from hypertension, headache and convulsion, she had no symptoms and no proteinuria or other biochemical or haematological changes associated with eclampsia. The magnetic resonance imaging findings were consistent with vasogenic oedema in the right posterior parieto-occipital white matter and these in turn are consistent with reversible posterior leucoencephalopathy syndrome. The differential diagnosis of convulsions in the post-partum period is discussed and the clinical and radiological features of reversible posterior leucoencephalopathy syndrome are described.

Is antibiotic prophylaxis required for flexible cystoscopy? A truncated randomized double-blind controlled trial.

PURPOSE: To examine the incidence of urinary tract infection (UTI) after flexible cystoscopy (FC) and determine whether prophylactic norfloxacin reduces this incidence compared with placebo. PATIENTS AND METHODS: A double-blind trial was performed, randomizing 234 patients to either 400 mg of norfloxacin or placebo prior to FC. All patients provided a midstream urine specimen (MSU) before the procedure, as well as at day 3 and day 7 after FC. In addition, a telephone questionnaire was performed to correlate the nature and severity of any symptoms associated with UTI. RESULTS: Interim analysis was performed because of the low recruitment rate, and a significantly lower infection rate than expected meant that the trial was discontinued. There was one symptomatic UTI in the placebo group (0.82%) and one in the norfloxacin group (0.89%). The UTI in the placebo group was de novo, while the infection in the norfloxacin group was secondary to pre-FC bacteriuria. There was no difference in the infection rates in the two groups. The overall infection rate (de novo and secondary to existing bacteruria) after FC was 0.85%. CONCLUSION: Infection after flexible cystoscopy is rare and not associated with significant morbidity. A much larger study would be required to determine whether antibiotic prophylaxis significantly reduces the rate of postprocedure UTI.

Perioperative bradycardia and asystole: relationship to vasovagal syncope and the Bezold-Jarisch reflex.

Reflex cardiovascular depression with vasodilation and bradycardia has been variously termed vasovagal syncope, the Bezold-Jarisch reflex and neurocardiogenic syncope. The circulatory response changes from the normal maintenance of arterial pressure, to parasympathetic activation and sympathetic inhibition, causing hypotension. This change is triggered by reduced cardiac venous return as well as through affective mechanisms such as pain or fear. It is probably mediated in part via afferent nerves from the heart, but also by various non-cardiac baroreceptors which may become paradoxically active. This response may occur during regional anaesthesia, haemorrhage or supine inferior vena cava compression in pregnancy; these factors are additive when combined. In these circumstances hypotension may be more severe than that caused by bradycardia alone, because of unappreciated vasodilation. Treatment includes the restoration of venous return and correction of absolute blood volume deficits. Ephedrine is the most logical choice of single drug to correct the changes because of its combined action on the heart and peripheral blood vessels. Epinephrine must be used early in established cardiac arrest, especially after high regional anaesthesia.

Orchidectomy following failure of antiandrogen monotherapy in patients with metastatic prostate cancer.

OBJECTIVE: Patients with metastatic prostate cancer who are initially treated by oral antiandrogens and then have progressive disease may be offered surgical castration as a second-line treatment. Twenty-eight such patients were reviewed to determine the outcome in terms of secondary PSA response, symptomatic relief and disease-specific survival. MATERIALS AND METHODS: Retrospective chart-based review of patients undergoing bilateral scrotal orchidectomy after failure of antiandrogen monotherapy. RESULTS: Patients who had a >50% reduction in PSA at 12 weeks' postorchidectomy had significantly greater duration of PSA response and disease-specific survival. 64% of patients who had bone pain prior to orchidectomy had some relief of symptoms postoperatively. No prognostic indicators of improved survival were identified. CONCLUSION: Orchidectomy as a secondary hormonal treatment following relapse on antiandrogens does produce a response in terms of PSA level and symptoms in some patients.

Thoracic epidural anaesthesia and analgesia: United Kingdom practice.

BACKGROUND: Thoracic epidural analgesia has become increasingly practised in recent years. Complications are rare but potentially serious and, consequently, careful evaluation is required before undertaking this technique. The practice surrounding this procedure varies widely amongst anaesthetists. METHODS: A postal survey to examine the practice of thoracic epidural analgesia was sent to all Royal College of Anaesthetists tutors in the United Kingdom. RESULTS: Responses were received from 240 tutors, representing a return rate of 83%. When obtaining consent for thoracic epidural cannulation, 42% of respondents mentioned risk of a dural tap complication and 11% mentioned neurological damage. Fifty percent of respondents performed epidural cannulation following induction of general anaesthesia. The practice of epidural insertion in patients with abnormal coagulation varied, although over 80% of respondents did not consider concurrent treatment with either aspirin or non-steroidal anti-inflammatory drugs a contraindication. Sterile precautions for epidural insertion also varied between anaesthetists. Postoperatively, 95% of respondents used an opioid-based bupivacaine solution for epidural infusions, and these were most commonly nursed on general surgical wards (63%). Seventy-eight percent of hospitals provided an acute pain team to review epidural analgesia. CONCLUSION: In the United Kingdom, there is little consensus in the practice of thoracic epidural analgesia relating to the issues of informed consent, epidural cannulation in patients with deranged clotting and the sterile precautions taken prior to performing epidural insertion. Most respondents use an opioid-based bupivacaine solution to provide postoperative epidural analgesia. Most hospitals in the UK now provide an acute pain service for thoracic epidural follow-up.

Randomized study of intravenous fluid preload before epidural analgesia during labour.

We performed a randomized controlled trial of the effect of intravenous fluid preload on maternal hypotension and fetal heart rate (FHR) changes in labour after the first epidural injection. Group 1 (49 women) received 1 litre of crystalloid preload. Group 2 (46 women) received no preload. No statistically significant difference was shown between the two groups for either of the outcomes. Hypotension was found in three women in group 1 and five in group 2 (P = 0.4). Deterioration in FHR pattern was found in four women in group 1 and 11 in group 2 (P = 0.08). This study has not shown a significant increase in the incidence of hypotension when intravenous preload is omitted before epidural analgesia using a low concentration of bupivacaine during labour. Because of the clinical importance of the difference in the rate of FHR deterioration between the two groups, we continue to administer preload for high-risk cases.

Is there a simpler method for predicting lower pole stone clearance after shockwave lithotripsy than measuring infundibulopelvic angle?

BACKGROUND AND PURPOSE: Several anatomic factors influence the clearance of lower pole stones treated with shockwave lithotripsy (SWL). One of these is the infundibulopelvic angle, but its measurement is complex. METHODS: We proposed a more simple measure of caliceal dependence, the caliceal pelvic height (CPH), which we defined as the distance between a horizontal line from the lowermost point of the calix containing the stone to the highest point of the lower lip of the renal pelvis. RESULTS: In 62 patients who had SWL for solitary lower pole stones, a CPH < 15 mm was associated with a stone clearance rate of 92%, whereas with a CPH > or = 15 mm, the clearance rate was only 52% (p < 0.05). A majority (74%) of the patients with an infundibular width of > or = 5 mm were rendered stone free compared with 40% of those with a width of < 5 mm (p < 0.05). CONCLUSION: Measurement of the CPH, in conjunction with other anatomic factors, may more accurately predict the outcome of SWL in patients with lower pole stones.

Education and training module for a specialist registrar: a move forward in specialist registrar education.

A new post was created in Portsmouth. This produced the opportunity, for a new and innovative approach to the education and training module for the specialist registrar (SpR) training programme. The GP tutor with supervision from the university, designed, implemented and evaluated the module. It took place during the first five months of the SpR contract. The method used was a case study in which the SpR was encouraged to reflect on practice. The learning outcomes were documented initially by the GP tutor and,finally, by the SpR using a logbook based on the dental professional development log. Reflecting on practice enabled the SpR to produce the evidence of her own learning and plan her future learning needs. The project highlights the advantages and problems of reflecting on practice. These issues must be addressed if the conflict between the need to produce the competent doctor and the demands of an educationally sound programme are to be resolved, to create critical thinking and autonomous lifelong, self-directed learners.

PIP: This study concerned the efficacy of portfolio learning as a method to facilitate the Specialist Registrar (SpR) training program. A case study method, under the supervision of the university, was used for designing, implementing, and evaluating the module. The Portfolio was considered as a collection of evidence that learning had taken place. The first 5 months of the new module were demonstrated to be a positive SpR experience because self-written evidence of what had been achieved and plans for future learning were presented. However, an investment in time and resources will be needed to ensure that portfolio learning will not be relegated to another task to be "signed off." The study could be useful in future studies on how doctors in training learn and how medical teachers of the future will need to make their learning process easier.