Placental transfer of bupivacaine, pethidine and lignocaine in the rabbit. Effect of umbilical flow rate and protein content

Summary. The factors determining the placental transfer of drugs used in labour were studied in the rabbit placenta perfused in situ with Krebs bicarbonate buffer. During concurrent maternal intravenous infusion of bupivacaine, lignocaine, pethidine and antipyrine, drug concentrations were measured in maternal arterial plasma and placental effluent perfusate, the flow rate and protein content of which were varied. Protein binding and content were also measured. Placental clearance of antipyrine, which is unbound, was unaltered by perfusate protein content, and increased with umbilical perfusate flow up to 2 ml/min. Clearance of lignocaine and pethidine, which were 20–30% protein bound, increased to a small extent with perfusate protein, and were flow-dependent up to the maximum perfusate flow of 4 ml/min. Clearances of bupivacaine, which was > 80% bound, increased markedly with perfusate protein but, though flow-dependent, was one-tenth to one-fifth that of the other drugs. Fetal binding and glycoprotein content were less than maternal, hence the equilibrium fetal: maternal ratio is predictably lower for the highly bound bupivacaine than for lignocaine or pethidine. Measured fetal: maternal ratios of bupivacaine were, however, only one-half to one-third of the predicted equilibrium values, suggesting that bupivacaine does not unbind readily in a single transit through the rabbit placenta. Thus, though bupivacaine crosses the placenta more slowly than thc other drugs, the fetal dose of all these drugs will be greatest in healthy babies with good placental blood flows and high plasma proteins.     

Employment Rehabilitation Needs of Hospital In patients

A survey of men inpatients at an acute teaching hospital wasundertaken to estimate the prevalence of problems related toreturn to work, and to ascertain whether advice on return towork was needed at the inpatient stage. Only 11 men (5 per cent of the whole sample and 11 per centof the 101 men of working age) needed immediate independentreplacement advice and, as 10 of these 11 men had been off workfor a mean/median time of two years before this hospital admission,it was concluded that they would have benefited more from employmentadvice during this prolonged period off work, rather than duringtheir hospital admission. Dr F. C. Edwards, Senior Employment Medical Adviser (Rehabilitation), Health & Safety Executive, McLaren Building, 2 Masshouse Circus, Queensway, Birmingham B4 7NP.     

Species specific grass pollen sensitivity: diagnosis and treatment with single grass species Allpyral vaccines

Skin test titrations and nasal provocation tests in sixty patients with hay fever showed specific reactions to extracts of individual grass species. There was, however, no correlation between skin and nasal sensitivity. Repeat testing after treatment with Allpyral vaccines consisting of only the grass species to which the nasal reaction was most severe, or only one of several pollens to which reactions were equally severe, showed marked diminution of skin and nasal sensitivity not only to the single pollen used for immuno-therapy but to all five common pollens used in the Allpyral grass mix. Clinical results seemed much improved as compared with results in the same year for Allpyral five grass mix vaccines, especially in the case of patients treated with Timothy, rye, or cocksfoot. It was concluded that these three grasses were to be preferred for treatment in England, and that these grasses contain common allergens.     

PLASMA CONCENTRATIONS OF BUPIVACAINE DURING CONTINUOUS EPIDURAL ANALGESIA IN LABOUR: THE EFFECT OF ADRENALINE

Continuous epidural analgesia has been provided for eighteenpatients during the first and second stages of labour. Ninepatients received bupivacaine 0.5 per cent with adrenaline 5µg/ml, and nine bupivacaine alone, using a double-blindtechnique. The initial dose of bupivacaine was 30 mg, repeatedand increased as necessary. A total of fifty-nine doses wasgiven. Plasma concentrations of bupivacaine were measured inthe mother throughout the blockade, and in the baby at delivery.The duration of action of bupivacaine was not significantlyprolonged by adrenaline, though plasma concentrations were significantlyreduced 20 minutes after the first dose and 40 minutes afterthe second. In neither treatment group did bupivacaine accumulatemarkedly in maternal plasma unless the second stage necessitatedincreased doses. Neonatal bupivacaine concentrations were alwayslow and neonatal: maternal ratios increased by the use of adrenaline.It is thus uncertain whether adrenaline offered a significantadvantage except with large doses of bupivacaine, when it reducedthe likelihood of maternal intoxication.     

Health care managers' perspectives on new nursing and midwifery roles: perceived impact on patient care and cost effectiveness

Aims  The aim of this study was to explore new nursing and midwifery roles and associated levels of practice from the health care providers' perspective. This paper will present findings relating to the perceived cost effectiveness of these roles and their impact on patient care.
Background  Profound changes in the way the health care systems are organized, managed and financed have resulted in the proliferation of new nursing and midwifery roles. However, the evidence base for these workforce developments is limited, especially with regard to health care providers' perspectives on cost effectiveness and patient outcomes.
Method  Qualitative interviews were carried out with all Directors of Nursing in the 18 Health and Social Services (HSS) Trusts and the Chief Nurses and Directors of Primary Care in the four HSS Boards in Northern Ireland.
Results  Key findings were as follows: there was widespread support for the development of these roles, they are perceived to have a positive impact on patient care; however, the need for support was recognized to ensure the continuation of such roles. Securing funding was problematic and this was influential on the kind of new roles that were developed.
Implications for Nursing Management  Issues relating to effective implementation and the need for further research into the efficacy and effectives of such initiatives is required.     

HEALTH SERVICES RESEARCH METHODS IN PHARMACY: Evaluation of pharmaceutical services: (2) Methods and measures

Numerous studies have been undertaken to evaluate pharmaceutical services. These include both the evaluation of existing practice and assessments of innovative services in both hospital and community settings. Evaluation requires employment of methods and measures to ensure that relevant data on the effects of a programme are obtained. To evaluate a service from different perspectives (eg, acceptability to health professionals or patients, uptake, clinical outcomes or resource implications), a number of methods may be required. The outcomes may also be wide‐ranging. Measures must be selected which provide a true reflection of the extent to which these outcomes are, or are not, achieved. Designs and frameworks used in the evaluation of pharmacy services have been discussed previously,¹ this paper reviews the methods and measures that have been employed.     

Problem Drinkers in Medical Wards: consumption patterns and disabilities in newly identified male cases

One hundred and sixty-one male medical inpatients were identified as problem drinkers according to criteria previously defined. This paper describes the pattern of their drinking and the associated medical and psychosocial problems. Over half had been admitted with an illness not typically related to alcohol and a similar proportion reported levels of consumption which have previously been considered safe. Classical symptoms of dependence were uncommon but specific enquiry revealed a broad range of social problems related to alcohol. Recognition of this profile is necessary if problem drinkers are to be identified at an early stage and to benefit from counselling.