Continuous extradural infusion of lignocaine 0.75% vs bupivacaine 0.125% in primiparae: quality of analgesia and influence on labour

We studied 86 primiparous women with uncomplicated pregnancy and labour requesting extradural analgesia in labour. All the women were over 36 weeks of gestation with a cephalic-presenting singleton fetus. The women were allocated randomly to two groups: group A, who received an extradural infusion of lignocaine 0.75%, after an initial dose of 10 ml of lignocaine 1.5%, and group B, who received an infusion of bupivacaine 0.125% after an initial dose of 10 ml of bupivacaine 0.25%. All the women had their labour actively managed. Assessment of analgesia during labour and delivery, and the requirements for additional top-ups were noted, as were mode of delivery, requirement for oxytocic augmentation and incidence of fetal distress. Maternal and umbilical cord plasma concentrations of lignocaine were measured at delivery in 12 women receiving extradural lignocaine. There were no statistically significant differences between the two groups in terms of the mode of delivery, incidence of fetal distress, fetal heart rate abnormalities, or Apgar scores of the babies. Women in the bupivacaine group had a significantly better quality of analgesia during both the first and second stages of labour (p = 0.0005) and required fewer top-ups than those in the lignocaine group. However, the requirement for oxytocin augmentation during the first and second stages of labour was significantly less in the lignocaine group (p = 0.004). Similarly, the duration of the second stage was shorter compared with the bupivacaine group. In spite of high plasma concentrations of lignocaine, no side effects were noted in either mothers or babies.     

ANTAGONISM OF ATRACURIUM-INDUCED NEUROMUSCULAR BLOCKADE BY NEOSTIGMINE OR EDROPHONIUM

Antagonism of atracurium-induced neuromuscular blockade by neostigmineor edrophonium has been studied using the tetanic (50 Hz) andtrain-of-four (2 Hz) or single twitch responses of the adductorpollicis muscle in 22 anaesthetized patients. A further ninepatients not given an anticholinesterase acted as a controlgroup. In two groups (six patients for each anticholinesterase)in whom antagonism was attempted at 95–98% blockade ofthe tetanic response, recovery of the tetanic response aftertwo or three doses of edrophonium 0.75 mg kg^–1 i.v. wasnot statistically different from that in the control group;recovery after two doses of neostigmine 2.5 mg i.v. was significantlyfaster (P < 0.001). Recovery of the single twitch responseafter antagonism with edrophonium, although longer than thatwith neostigmine (P < 0.01), was significantly shorter thanin the control group (P < 0.05). When edrophonium is givenat the commencement of recovery, the initial rapid antagonismof tetanic block is not sustained, whereas antagonism by neostigmineis more persistent and the recovery phase is significantly shortened.In a further two groups of patients (n = 5) given atracurium0.3 mg kg^–1 i.v. antagonism was not attempted until thepeak height of the tetanic contraction had reached approximately50% of the control value. It was found that recovery of thetetanic and train-of-four responses was significantly faster(P < 0.05–0.001) after antagonism with edrophonium0.75 mg kg^–1 i.v. than with neostigmine 2.5mg i.v. (approx.0.04 mg kg^–1). The train-of-four response recovered moreslowly than did the tetanic response after both agents (P <0.05–0.01). Department of Anaesthetics, University College Hospital, LondonWC1. ^*Clinical Investigation Department, Clinical and Applied researchDivision, The Wellcome Research Laboratories, Beckenham, Kent.     

EVALUATION OF ATRACURIUM IN ANAESTHETIZED MAN

Atracurium is a potent competitive neuromuscular blocking agentin anaesthetized man with no cardiovascular effects at dosesrequired for paralysis. Endotracheal intubation can be accomplishedafter i.v. doses of 0.6 and 0.3 mg kg^–1, within 1 and2 min respectively. Paralysis is readily antagonized by neostigmineand is enhanced by halothane. The consistent response in termsof block and recovery which emerged when the drug was givenas increments of 0.05 or 0.1 mg kg^–1 indicates the absenceof cumulative effects. The course of action of atracurium wasappreciably shorter than that of other recognized competitiveblocking agents. Doses of 0.3–0.6 mg kg^–1 i.v. providedadequate relaxation during surgical intervention for 15–45min; spontaneous recovery without the use of neostigmine wasobserved in some patients. In addition to the non-enzymic decompositionby "Hofmann Elimination", atracurium may also undergo an enzymicester hydrolysis but, unlike suxamethonium, it may not be destroyedby pseudocholinesterase.     

ATP1A3 mutations in infants: a new rapid‐onset dystonia–Parkinsonism phenotype characterized by motor delay and ataxia

We report new clinical features of delayed motor development, hypotonia, and ataxia in two young children with mutations (R756H and D923N) in the ATP1A3 gene. In adults, mutations in ATP1A3 cause rapid‐onset dystonia–Parkinsonism (RDP, DYT12) with abrupt onset of fixed dystonia. The parents and children were examined and videotaped, and samples were collected for mutation analysis. Case 1 presented with fluctuating spells of hypotonia, dysphagia, mutism, dystonia, and ataxia at 9 months. After three episodes of hypotonia, she developed ataxia, inability to speak or swallow, and eventual seizures. Case 2 presented with hypotonia at 14 months and pre‐existing motor delay. At age 4 years, he had episodic slurred speech, followed by ataxia, drooling, and dysarthria. He remains mute. Both children had ATP1A3 gene mutations. To our knowledge, these are the earliest presentations of RDP, both with fluctuating features. Both children were initially misdiagnosed. RDP should be considered in children with discoordinated gait, and speech and swallowing difficulties.     

Hearts and Minds Project: A breastfeeding curriculum intervention to improve the education outcomes for nutrition and dietetics graduates

Aim: Dietitian nutritionists play an important role in supporting and promoting breastfeeding. Improving undergraduate training to create a competent and motivated workforce to deliver these outcomes has been recommended. This study evaluated a breastfeeding curriculum intervention designed to improve knowledge, attitudes and beliefs, and increase graduates' motivation to support breastfeeding into the future. Methods: Final‐year students studying nutrition and dietetics were surveyed at baseline in 2005 and post‐intervention in 2010. Questions related to student profile, breastfeeding knowledge, attitudes and beliefs, perceived professional role in breastfeeding support, intentions to support breastfeeding in the future and perceptions of the breastfeeding curriculum. Curriculum interventions were based on relevant evidence including recommendations from the baseline survey report, a gap analysis of existing curriculum, previous literature identifying key barriers to the support of breastfeeding by health professionals and learning and behaviour change theories and approaches. Results: General improvements in knowledge and attitudes and beliefs were found over the intervention period, although knowledge gaps remained on the risks associated with not breastfeeding for mothers and infants and when to recommend the cessation of breastfeeding. A significant increase was found in the percentage of respondents agreeing that their studies had engendered a strong interest in work involving breastfeeding. Significant improvements were also seen in student perceptions of the degree to which breastfeeding was addressed in the dietetic course. Conclusion: Curriculum interventions can effectively influence new graduates' future intention to support and promote breastfeeding if they address knowledge gaps, attitudes, beliefs and perceived social concerns about breastfeeding promotion.