Rheumatic heart disease in pregnancy: cardiac and obstetric outcomes.

BACKGROUND: Rheumatic heart disease (RHD) remains an important health issue for indigenous women of child-bearing age in northern Australia. However, the influence of RHD on maternal outcomes with current clinical practice is unclear. AIMS: To determine maternal cardiac complications and obstetric outcomes in patients with RHD. METHODS: Retrospective case note analysis of women with RHD who received obstetric care between July 1999 and May 2010 at Cairns Base Hospital in north Queensland. Outcome measures were obstetric interventions and outcomes, cardiac interventions and complications, stratified according to a cardiac risk score (CRS). RESULTS: Ninety-five confinements occurred in 54 patients, of whom 52 were Indigenous Australians. There were no maternal or neonatal deaths. With a CRS of 0, cardiac complications occurred in 0 of 70 confinements; with a CRS of 1, complications occurred in 5 of 17 confinements (29%); with a CRS of >1, complications occurred in 2 of 4 confinements (50%). Another four patients were first diagnosed with RHD after developing acute pulmonary oedema during the peripartum period. CONCLUSIONS: RHD has a major impact on maternal cardiac outcomes. However, with current management practices, maternal and fetal mortality are low, and the incidence of complications is predictable based on known risk factors.

Intravenous oxytocin bolus of 2 units is superior to 5 units during elective Caesarean section.

BACKGROUND: The optimal dose of oxytocin at Caesarean section is unclear. Oxytocin may cause adverse cardiovascular effects, including tachycardia and hypotension, whereas an inadequate dose can result in increased uterine bleeding. We compared the effects of two doses of oxytocin in a randomized double-blind trial. METHODS: Eighty patients undergoing elective Caesarean section received an i.v. bolus of either 2 or 5 units (u) of oxytocin after delivery, followed by an oxytocin infusion of 10 u h(-1). All received combined spinal-epidural anaesthesia with arterial pressure maintained by a phenylephrine infusion. We compared changes in heart rate (HR), mean arterial pressure (MAP), blood loss, uterine tone, the need for additional uterotonic drugs, and emetic symptoms. RESULTS: There was a greater increase in mean (sd) HR in patients who received 5 u of oxytocin [32 (17) beats min(-1)] than in those who received 2 u [24 (13) beats min(-1)] (P=0.015). There was a larger decrease in MAP in patients who received 5 u [13 (15) mm Hg] than in those who received 2 u [6 (10) mm Hg] (P=0.030). The frequency of nausea and antiemetic use was higher after 5 u (32.5%) than 2 u (5%) (P=0.003). There were no differences in blood loss, uterine tone, or requests for additional uterotonic drugs (17.5% in both groups). CONCLUSIONS: In elective Caesarean section, a 2 u bolus of oxytocin results in less haemodynamic change than 5 u, with less nausea and no difference in the need for additional uterotonics.

Effects of Belonolaimus longicaudatus Management and Nitrogen Fertility on Turf Quality of Golf Course Fairways.

Field experiments evaluated the effects of nematicide and fertility on performance of 'Tifway 419' bermudagrass parasitized by the sting nematode (Belonolaimus longicaudatus). Plot treatments were nontreated or nematicide (1,3-dichloropropene) treated combined with different nitrogen (N) fertilizer levels. Effects of treatments on numbers of B. longicaudatus and turf performance were compared. Nematicide consistently reduced numbers of B. longicaudatus, but fertilizer level had no effect on B. longicaudatus. Turf performance of nematicide-treated plots was improved compared with nontreated plots during both experiments. Increasing N fertilizer level improved turf performance in nematicide-treated plots in some cases, but had no effect on turf performance in nontreated plots in either experiment. Results suggest that increasing N fertilizer levels may not improve turf performance at sites infested with B. longicaudatus unless nematode management tactics are effective in reducing nematode densities.

Influence of Belonolaimus longicaudatus on Nitrate Leaching in Turf.

Experiments were conducted to quantify the effects of the sting nematode (Belonolaimus longicaudatus) on root reductions and quantity of nitrate (NO(3) (-)) leached from 'Tifdwarf' bermudagrass in lysimeters. Forty lysimeters were planted with 'Tifdwarf' bermudagrass, of which 20 were inoculated with B. longicaudatus and 20 were noninoculated. Root length was compared between treatments at six, 12, and 18 weeks after initiation of the experiments. Turf was fertilized every three weeks, and leaching events were simulated at 21 and 42-day intervals in trial one and trial two, respectively. Leachate was collected, and the quantity of NO(3) (-) leached was compared between treatments. Root reductions were observed in lysimeters inoculated with B. longicaudatus at all evaluation dates. Quantity of NO(3) (-) leached was greater in inoculated lysimeters at the 18-week evaluation during both trials. This study indicates that nematode damage to turf roots limits root vigor and N uptake, thereby increasing nitrate leaching, adding to water quality concerns.

Successful use of oral methadone after failure of intravenous morphine and ketamine.

We describe an opioid-tolerant patient with severe acute pain which was unrelieved by morphine and ketamine via intravenous patient-controlled analgesia, but almost totally relieved by methadone. In the previous 24 hours, 509 mg of intravenous morphine and 769 mg of ketamine had been used and this was replaced by 200 mg of oral methadone. This implies that the success of methadone in morphine tolerant patients chiefly involves factors other than its role as an N-methyl-D-aspartate receptor antagonist, and that methadone should be considered as a replacement for morphine when the N-methyl-D-aspartate antagonist ketamine has proved ineffective.

The impact of an acute pain service on postoperative pain management.

An audit of postoperative pain management was conducted before and after the introduction of an Acute Pain Service (APS) run entirely by medical staff. The ability of patients to complete two pain-scoring systems, a verbal rating score (VRS) and a numerical rating score (NRS, where 0 = no pain, 10 = worst pain) was compared. We surveyed 605 adults 24 hours postoperatively. For major operations, the incidence of "severe" or "unbearable" pain at rest (VRS) over the first 24 hours decreased from 18.1% before to 3.5% after the APS (P = 0.0002) and severe/unbearable pain with movement decreased from 50% to 31% (P = 0.0037). The average NRS pain scores fell from 4.65 to 3.37 at rest (P < 0.0001) and from 6.77 to 6.19 with movement (P = 0.046). The incidence of severe/unbearable pain at rest with patient-controlled analgesia (PCA) decreased from 19.7% to 3.2% after the APS (P = 0.0012) and with movement from 51.3% to 35.1% (P = 0.049). For epidural analgesia, severe/unbearable pain at rest was 18.8% prior to the APS and 4.4% after (P = 0.14), and with movement was 43.8% before and 19.1% after (P = 0.079). The NRS pain-scoring system was unsuitable for Aboriginal or Torres Strait Islander patients. Patient satisfaction was high both before and after the introduction of the APS, and was an unreliable indicator of effective pain relief. We conclude that an APS can improve postoperative pain control with PCA and epidural analgesia.