Comparison of a single vs. a four intradermal sterile water injection for relief of lower back pain for women in labour: A randomised controlled trial

Objectivesterile water injections are a simple, safe, effective, non-pharmacological technique for relieving back pain in labour, however the number of injections required to achieve optimal analgesia is unknown. The objective of this trial was to evaluate the degree and duration of analgesia provided by a single injection of sterile water, compared to four injections.Designrandomised controlled non-inferiority trial.Participants and settingthree hundred and five women in labour at term, requesting analgesia for back pain were recruited from two metropolitan hospitals in Brisbane, Australia.Interventionparticipants were randomly assigned to receive either one (n=147) or four (n=158) sterile water injections.Outcome measuresdifference in self-reported pain measured using a visual analogue scale (VAS) between baseline and 30 mins post-intervention. The clinically acceptable margin of difference was defined as ≤1 cm on the VAS between the single injection compared to four injection technique. Secondary outcomes include VAS score on injection and 10, 60, 90 and 120 mins post-intervention, analgesia use, mode of birth and maternal satisfaction.Findingsthe mean difference in the pre and post (30 mins) injection scores between two groups was ?1.48 cm (95% CI ?2.10, ?0.86) in favour of the FI technique, however the injection pain associated with the FI was significantly greater than that of the SI technique (p<0.001). There were no significant differences between the two groups in terms of other analgesic use, mode of birth or maternal satisfaction.Conclusionthe four injection technique was associated with increased level of analgesia at 30 mins post-intervention compared to the single injection, but also a greater degree of injection pain.     

Homosexuals' attitudes to male homosexuality— survey

A questionnaire looking at attitudes towards male homosexuality was circulated to 94 members of the Gay Medical Association (GMA) and 510 members of various homophile organisations. The response rates were 56% and 34.7% respectively. Some clear differences emerged between the two groups in looking at stereotypes of male homosexuals. Nearly hlf the respondents in both the groups agreed that male homosexuals in general are promiscuous. The differences are discussed and suggestions made for further research.     

Impact of severe tricuspid regurgitation on accuracy of systolic pulmonary arterial pressure measured by Doppler echocardiography: Analysis in an unselected patient population

Pulmonary arterial pressure is an important index in cardiovascular disorders, especially for pulmonary hypertension (PH). Doppler echocardiography (DE) is widely used as a noninvasive method to assess pulmonary arterial pressure. However, recent studies have found several hemodynamic factors that affect its accuracy in estimating systolic pulmonary arterial pressure (sPAP). But the effect of tricuspid regurgitation (TR) has not been investigated. Therefore, our study is aimed to determine whether the severity of TR will affect the accuracy of sPAP measured by DE in an unselected patient population. We retrospectively studied 177 patients who underwent DE and right heart catheterization (RHC) examinations. Patients were categorized into 3 groups according to the severity of TR (mild, moderate, and severe). The discrepancy in sPAP measured by DE and RHC was calculated and compared in each group. Determinants of discordant results between two methods were also evaluated. Age, gender, interval between DE and RHC, sequence of DE and RHC were similar among groups (all P>.05). Differences in sPAP, RAP, and tricuspid regurgitation pressure gradient (TR‐PG) were similar in group 1 and 2 (all P>.05), while all significantly higher in group 3 (all P<.05). The difference in sPAP between DE and RHC was affected independently by severe TR and severe PH (both P<.05). Severe TR and severe PH affect the accuracy of sPAP measured by DE. Modification of echocardiographic sPAP measurements by taking into consideration of these factors may lead to reduced systemic errors.     

Retrograde access via the popliteal artery to facilitate the re‐entry technique for recalcitrant superficial femoral artery Chronic total occlusions

Subintimal recanalization is beneficial in selected patients with peripheral chronic total occlusions (CTO). However, in complex cases, re‐entry into the true arterial lumen may prove to be unsuccessful with a conventional guidewire or a re‐entry catheter when using standard femoral artery access. Our case series describes these technical dilemmas along with strategies that can be utilized to overcome these challenges. © 2011 Wiley‐Liss, Inc.     

The gut mucosal immune system in the neonatal period

Invasive sepsis in the newborn period is a major cause of childhood morbidity and mortality worldwide. The infant immune system undoubtedly differs intrinsically from the mature adult immune system. Current understanding is that the newborn infant immune system displays a range of competencies and is developing rather than deficient. The infant gut mucosal immune system is complex and displays a plethora of phenotypic and functional irregularities that may be clinically important. Various factors affect and modulate the infant gut mucosal immune system: components of the intestinal barrier, the infant gut microbiome, nutrition and the maternal–infant hybrid immune system. Elucidation of the phenotypic distribution of immune cells, their functional significance and the mucosa‐specific pathways used by these cells is essential to the future of research in the field of infant immunology.     

A dilemma for doctors

Community physicians have recently, albeit often reluctantly, been involved in preparations for nuclear war. This paper suggests an alternative: that they should use their skills in epidemiology and in preventive and social medicine in the prevention of nuclear war.     

Clinical outcomes after upgrading from pacemakers to cardiac resynchronization therapy

1 Background and aims

Right ventricular pacing may lead to heart failure (HF). Upgrades from pacemakers to cardiac resynchronization therapy (CRT) were excluded from most randomized, controlled trials. We sought to determine the long‐term outcomes of upgrading from pacemakers to CRT with (CRT‐D) or without (CRT‐P) defibrillation in patients with no history of sustained ventricular arrhythmias.

2 Methods and results

In this observational study, clinical events were quantified in relation to the type of implant (de novo or upgrade) and device type at upgrade (CRT‐P or CRT‐D). Patients underwent CRT implantation (n = 1,545; 1,314 [85%] de novo implants and 231 [15%] upgrades) over a median of 4.6 years [interquartile range: 2.4–7.0]. In analyses of crude event rates, upgrades had a higher total mortality (adjusted hazard ratio [aHR]: 1.33; 95% confidence interval [CI] 0.10–1.61), a higher total mortality or HF hospitalization (aHR: 1.26; 95% CI 1.05–1.51), but similar mortality or hospitalization for major adverse cardiac events (MACEs, aHR: 1.15; 95% CI 0.96–1.38). No group differences emerged in any of these endpoints after propensity score matching. After inverse probability weighting in upgrades, total mortality (HR: 0.55; 95% CI 0.36–0.73), total mortality or HF hospitalization (HR: 0.56; 95% CI 0.34–0.79), and total mortality or hospitalization for MACEs (HR: 0.61; 95% CI 0.40–0.82) were lower after CRT‐D than after CRT‐P.

3 Conclusion

Upgrading from pacemakers to CRT was associated with a similar long‐term risk of mortality and morbidity to de novo CRT. After upgrade, CRT‐D was associated with a lower mortality than CRT‐P.