Aromatherapy in childbirth: a pilot randomised controlled trial

OBJECTIVES

We aimed to determine the feasibility of conducting a randomised controlled trial (RCT) on the use of aromatherapy during labour as a care option that could improve maternal and neonatal outcomes.

DESIGN

RCT comparing aromatherapy with standard care during labour.

SETTING

District general maternity unit in Italy.

SAMPLE

Two hundred and fifty-one women randomised to aromatherapy and 262 controls.

METHODS

Participants randomly assigned to administration of selected essential oils during labour by midwives specifically trained in their use and modes of application.

MAIN OUTCOME MEASURES

Intrapartum outcomes were the following: operative delivery, spontaneous delivery, first- and second-stage augmentation, pharmacological pain relief, artificial rupture of membranes, vaginal examinations, episiotomy, labour length, neonatal wellbeing (Apgar scores) and transfer to neonatal intensive care unit (NICU).

RESULTS

There were no significant differences for the following outcomes: caesarean section (relative risk [RR] 0.99, 95% CI: 0.70-1.41), ventouse (RR 1.5, 95% CI: 0.31-7.62), Kristeller manoeuvre (RR 0.97, 95% CI: 0.64-1.48), spontaneous vaginal delivery (RR 0.99, 95% CI: 0.75-1.3), first-stage augmentation (RR 1.01, 95% CI: 0.83-1.4) and second-stage augmentation (RR 1.18, 95% CI: 0.82-1.7). Significantly more babies born to control participants were transferred to NICU, 0 versus 6 (2%), P = 0.017. Pain perception was reduced in aromatherapy group for nulliparae. The study, however, was underpowered.

CONCLUSION

This study demonstrated that it is possible to undertake an RCT using aromatherapy as an intervention to examine a range of intrapartum outcomes, and it provides useful information for future sample size calculations.

The outcomes of an intervention study to reduce the barriers experienced by people with intellectual disabilities accessing primary health care services

BACKGROUND

People with intellectual disabilities (IDs) experience significant health inequalities compared with the general population. The barriers people with IDs experience in accessing services contribute to these health inequalities. Professionals' significant unmet training needs are an important barrier to people with IDs accessing appropriate services to meet their health needs.

METHOD

A three group, pre- and post-intervention design was used to test the hypothesis that a training intervention for primary health care professionals would increase the knowledge and self-efficacy of participants. The intervention had two components - a written training pack and a 3-hour face-to-face training event. One group received the training pack and attended the training event, a second group received the training pack only, and a third group did not participate in the training intervention. Research measures were taken prior to the intervention and 3 months after the intervention. Statistical comparisons were made between the three groups.

RESULTS

The participants in the training intervention reported that it had a positive impact upon their knowledge, skills and clinical practice. As a result of the intervention, 35 (81.4%) respondents agreed that they were more able to meet the needs of their clients with IDs, and 33 (66.6%) reported that they had made changes to their clinical practice. The research demonstrated that the intervention produced a statistically significant increase in the knowledge of participants (F = 5.6, P = 0.005), compared with the group that did not participate in the intervention. The self-efficacy of the participants that received both components of the intervention was significantly greater than the group that did not participate in the training (t = 2.079, P = 0.04). Participation in the two components of the training intervention was associated with significantly greater change in knowledge and self-efficacy than those receiving the training pack alone.

CONCLUSION

This intervention was effective in addressing the measured training needs of primary health care professionals. Future research should directly evaluate the positive benefits of interventions on the lives of people with IDs.

Enhancing primary health care services for adults with intellectual disabilities

BACKGROUND

Primary health care teams have an important part to play in addressing the health inequalities and high levels of unmet health needs experienced by people with intellectual disabilities (ID). Practice nurses have an expanding role within primary health care teams. However, no previous studies have measured their attitudes, knowledge, training needs, and self-efficacy in their work with people with ID.

METHODS

All practice nurses working in a defined area were identified. A purpose-designed questionnaire to measure nurse attitudes, knowledge, training needs and self-efficacy was developed and piloted. All practice nurses were then invited to participate. Data from completed questionnaires were entered onto PC and analysed.

RESULTS

Of a total of 292 practice nurses 201 (69%) participated. Whilst 89% (n=179) of participants reported having infrequent contact, 25% (n=50) reported a growing workload with people with ID. Only 8% (n=16) had ever received any training in communicating with people with ID. A knowledge gap regarding the health needs of people with ID was identified. Eighty-six per cent reported having experienced specific difficulties during previous appointments, and only 23% thought they had sufficient case note information at appointments, but 68% did not modify the duration of their appointments with people with ID. Conversely, responses demonstrated that practice nurses have a high level of experience and qualification in general nursing, have positive attitudes to working with people with ID, and high self-efficacy scores were identified for work with people with ID. The practice nurses viewed ID to be a high priority area for future training.

CONCLUSIONS

Primary health care teams have a key role in tackling the unmet health needs of people with ID. Whilst this project has identified factors that may impact on the accessibility of services, it has also identified practice nurses as having positive attitudes and high self-efficacy scores in their work with people with ID. This indicates that they should be targeted for specific training in this area, which may make an important contribution in enhancing future accessibility of primary health care services for people with ID.

Spinocerebellar ataxia type 8 in Scotland: genetic and clinical features in seven unrelated cases and a review of published reports

OBJECTIVES

To establish whether the DNA expansion linked to spinocerebellar ataxia type 8 (SCA 8) is associated with ataxia in Scotland; to clarify the range of associated clinical phenotypes; and to compare the findings with previous reports.

METHODS

DNA was screened from 1190 anonymised controls, 137 subjects who had tested negative for Huntington's disease, 176 with schizophrenia, and 173 with undiagnosed ataxia. Five unrelated ataxic patients with the SCA 8 expansion and a sixth identified subsequently had clinical and psychometric assessment; the clinical features were available in a seventh. A systematic search for other reports of SCA 8 was undertaken.

RESULTS

Over 98% of SCA 8 CTA/CTG repeat lengths fell between 14 and 40. Repeat lengths over 91 were observed in three healthy controls (0.12%), two patients with suspected Huntington's disease (0.73%), and six ataxic subjects (1.74%; p<0.0005 v healthy controls). Repeat lengths over 100 occurred in five ataxic subjects but in only one control. All seven symptomatic subjects with the SCA 8 expansion had a cerebellar syndrome; four had upper motor neurone signs; and 5/6 assessed had cognitive complaints. There was personality change in two and mood disturbance in three. In published reports, SCA 8 repeat lengths over 91 occurred in approximately 0.5% of the healthy population but were over-represented among ataxic patients (3.4%; p<0.0001). The predominant clinical phenotype was cerebellar, with pyramidal signs in 50%, and neuropsychiatric features in some cases.

CONCLUSIONS

SCA 8 expansion is a risk factor for a cerebellar syndrome, often associated with upper motor neurone and neuropsychiatric features. The expansion occurs unexpectedly often in the general population.

Older people in accident and emergency departments

Older people attend accident and emergency departments more frequently than younger people. However, most assessments indicate that this higher level of use is appropriate and is the result of more serious injury and illness among this population. Older patients discharged from accident and emergency departments are frequently functionally impaired with serious impacts upon their ability to perform activities of daily living. Despite this, relatively little attention has been paid to interventions to improve older patients' ability to self-care after discharge from accident and emergency departments. One study has suggested that dependency can be reduced by health visitor intervention. Targeted bi-disciplinary interventions have been demonstrated to reduce the risk of recurrent falls in elderly patients discharged from accident and emergency departments.

Measuring clinical performance and outcomes from diabetes information systems: an observational study

AIMS/HYPOTHESIS

To examine changes in diabetes care provision after the introduction of a district diabetes information system.

METHODS

All patients with diabetes registered on the system between 1993 and 1998 (n = 6544) were included in the analysis. Drop-out cohort analysis was used to handle population changes, logistic regression models with general estimating equations were used to examine changes in clinical performance over time.

RESULTS

After the introduction of the system, care processes improved appreciably, in both primary and secondary care. The proportion of patients receiving a preventative care review within the calendar year rose from 56% in 1993 to 67% in 1998. The proportion of these in whom each process was completed improved in all categories from 1993 to 1998: blood pressure 96% to 98%; glycaemic check 67% to 93%; lipid check 31% to 68%; renal check 46% to 87%; fundoscopy 79% to 92%; foot screen 87% to 87%. Similarly there was an increase in the proportion of patients achieving intermediate outcome treatment targets (HbA1c < or = 9.0% from 29% to 43%; cholesterol < or = 5.5 mmol/1 5% to 19%; blood pressure < or = 160/90 37% to 46%).

CONCLUSION/INTERPRETATION

Our results suggest appreciable improvements in diabetes care between 1993 and 1998. These changes apply to an entire population of patients across primary and shared care. We believe that these improvements could, in part, be attributable to the way in which the district diabetes information system has facilitated the structured cascade of diabetes care.

The use of aromatherapy in intrapartum midwifery practice an observational study

The authors report the process and results of an evaluation of a midwifery aromatherapy service for mothers in labour: This study of 8058 mothers in childbirth, is the largest research initiative in the use of aromatherapy within a health-care setting. The study involved a wide range of participants, from mothers who experienced a low risk, spontaneous labour and birth, to those whose labour was induced, and those who had vaginal operative delivery and Caesarean section. The study-took place over a period of 8 years, which enabled a more challenging test of the effect of aromatherapy on intrapartum midwifery practice and outcomes. In the study a total of 10 essential oils were used, plus a carrier oil, which were administered to the participants via skin absorption and inhalation. The study found little direct evidence that the practice of aromatherapy per se reduces the need for pain relief during labour, or the incidence of operative delivery. But a key finding of this study suggests that two essential oils, clary sage and chamomile are effective in alleviating pain. The evidence from this study suggests that aromatherapy can be effective in reducing maternal anxiety, fear and/or pain during labour. The use of aromatherapy appeared to facilitate a further reduction in the use of systemic opioids in the study centre, from 6% in 1990 to 0.4% in 1997 (per woman). Aromatherapy is an inexpensive care option. In 1997 when 1592 mothers used aromatherapy, the total cost was 769.17 Pounds. The study reports a minimal incidence of associated symptoms. Out of 8058 mothers, 1% (100) recorded an associated symptom. These were mild in nature. The successful model of integrated practice that this aromatherapy study presents, offers a useful example for other units to consider.

Selective killing of cancer cells based on loss of heterozygosity and normal variation in the human genome: a new paradigm for anticancer drug therapy

Most drugs for cancer therapy are targeted to relative differences in the biological characteristics of cancer cells and normal cells. The therapeutic index of such drugs is theoretically limited by the magnitude of such differences, and most anticancer drugs have considerable toxicity to normal cells. Here we describe a new approach for developing anticancer drugs. This approach, termed variagenic targeting, exploits the absolute difference in the genotype of normal cells and cancer cells arising from normal gene sequence variation in essential genes and loss of heterozygosity (LOH) occurring during oncogenesis. The technology involves identifying genes that are: 1) essential for cell survival; 2) are expressed as multiple alleles in the normal population because of the presence of one or more nucleotide polymorphisms; and 3) are frequently subject to LOH in several common cancers. An allele-specific drug inhibiting the essential gene remaining in cancer cells would be lethal to the malignant cell and would have minimal toxicity to the normal heterozygous cell that retains the drug-insensitive allele. With antisense oligonucleotides designed to target two alternative alleles of replication protein A, 70-kDa subunit (RPA70) we demonstrate in vitro selective killing of cancer cells that contain only the sensitive allele of the target gene without killing cells expressing the alternative RPA70 allele. Additionally, we identify several other candidate genes for variagenic targeting. This technology represents a new approach for the discovery of agents with high therapeutics indices for treating cancer and other proliferative disorders.

Lack of a pharmacokinetic interaction at steady state between ropinirole and L-dopa in patients with Parkinson's disease

STUDY OBJECTIVE

To assess the interaction between therapeutic dosages of ropinirole and L-dopa plus a decarboxylase inhibitor administered at steady state in patients with Parkinson's disease. DESIGN. Open, 6-week, overlap trial with random allocation.

PATIENTS

Thirty patients with Parkinson's disease not previously treated with dopamine agonists, of whom 28 produced evaluable pharmacokinetic data for ropinirole and 23 for L-dopa.

INTERVENTION

Group A (14 patients) received L-dopa for weeks 1-5 and ropinirole in increasing increments for weeks 2-6; group B (16) received ropinirole for weeks 1-5 and L-dopa for weeks 5 and 6.

MEASUREMENTS AND MAIN RESULTS

Primary end points were AUC0-8 and Cmax for ropinirole, and AUC0-8, AUC0-infinity and Cmax for L-dopa. Secondary end points were Tmax for ropinirole, and Tmax and half-life for L-dopa. Coadministration with L-dopa at steady state did not affect rate or extent of availability of ropinirole: point estimates of the geometric mean ratio for ropinirole plus L-dopa compared with ropinirole alone for both Cmax and AUC0-8 approximated to unity. The small (16%) increase in peak concentrations of L-dopa on administration with ropinirole is unlikely to be of clinical consequence, as peak concentrations of L-dopa are typically highly variable.

CONCLUSION

There are no pharmacokinetic grounds for adjusting dosages of either ropinirole or L-dopa when given in combination.

Problem of amputations in patients with newly diagnosed diabetes mellitus

A reduction of 50% or more in diabetes-related amputations is a primary target of the St Vincent Declaration. This is thought to be achievable because both primary and secondary preventative healthcare strategies are effective in reducing the incidence of diabetic foot ulceration and progression to amputation. Unfortunately there is a group who cannot benefit from preventative health care, that is, newly diagnosed diabetic patients with already established severe complications. Using our population-based district diabetes information system we investigated, during the period 1 January 1992 to 31 December 96, the incidence and prevalence of lower extremity amputations (LEAs) and the proportion occurring in patients newly or recently diagnosed as having diabetes. Seventy-nine diabetic patients (59 male, 20 female) were recorded as having had 94 LEAs, the incidence of diabetes-related LEA being 475 per 100,000 diabetic patient-years. Of these LEAs 16 (20.2%) were performed within 1 year of diabetes being diagnosed. This study highlights an appreciable and previously unrecognized problem: patients presenting with established complications of diabetes who cannot benefit from secondary preventative healthcare. These patients pose a potential obstacle to achieving targets for reductions in diabetes-related amputations.

Randomised trial of one versus two doses of prostaglandin E2 for induction of labour: 2. Analysis of cost

OBJECTIVE

To compare the impact upon maternity unit resources and finances of two protocols for induction of labour using prostaglandins.

DESIGN

A prospective randomised trial comparing a single dose of prostaglandin E2 (2 mg) in the evening with two doses of prostaglandin E2 (2 mg), the second being given after six hours if labour had not started or the cervix was still unripe, followed if necessary by formal induction of labour by amniotomy and oxytocin infusion 14 to 20 hours after the initial prostaglandin E2 dose. Outcome for nulliparae and multiparae were analysed separately, by treatment intention.

SETTING

A maternity unit in a district general hospital delivering > 6000 women annually.

PARTICIPANTS

Nine hundred and fifty-five women with viable singleton pregnancies and cephalic presentation at term without previous history of caesarean section who were advised to have labour induced with prostaglandins.

MAIN OUTCOME MEASURES

Costs incurred in managing all aspects of labour, including time spent on the antenatal ward and, in the delivery unit; costs associated with formal induction, augmentation of labour and epidural analgesia; costs of intrapartum maternal morbidity, mode of delivery and immediate neonatal care. Costs of postpartum hospital stay were estimated from unit statistics.

RESULTS

The overall mean cost of induction of labour was Pounds 5.00 and Pounds 7.22 less per woman for nulliparae and multiparae, respectively, if the two dose regimen was used. The main reason for the differences was due to delivery suite costs from the slightly greater rate of assisted deliveries in the single treatment groups. In contrast, costs for neonatal care were marginally lower if only one prostaglandin dose was used.

CONCLUSIONS

The increased drug costs providing two prostaglandin E2 doses when required were off-set by reductions in the costs of other intrapartum interventions for both nulliparae and multiparae. The advantages of less time spent on the antenatal ward for multiparae when two prostaglandin E2 doses were used may be eliminated if amniotomy and oxytocin infusion was commenced six hours after the initial prostaglandin dose had been given if labour had not started.

Randomised trial of one versus two doses of prostaglandin E2 for induction of labour: 1. Clinical outcome

OBJECTIVE

To compare the outcome of induction of labour using a single versus two doses of prostaglandin E2 vaginal gel.

DESIGN

Prospective randomised trial comparing a single dose of prostaglandin E2 2 mg vaginal gel in the evening with two doses of prostaglandin E2 (2 mg), the second being given after six hours if labour had not started or the cervix was still unripe. Amniotomy and oxytocin titration were performed when necessary for both protocols. Nulliparae and multiparae were analysed separately by treatment intention.

SETTING

A maternity unit in a district general hospital annually delivering > 6000 women.

PARTICIPANTS

Nine-hundred and ninety-five women with viable singleton pregnancies and cephalic presentation at term without previous history of caesarean section who were advised to have labour induced with prostaglandins.

MAIN OUTCOME MEASURES

Need for formal amniotomy and oxytocin augmentation, use of epidural analgesia, rate of intrapartum interventions, mode of delivery and neonatal condition at birth.

RESULTS

For multiparae two prostaglandin doses resulted in a significant reduction in the need for formal amniotomy (15% vs 30%) and oxytocin augmentation (28% vs 38%) compared with those receiving a single dose; there was no significant difference for nulliparae. Other interventions during labour, length of labour, and mode of delivery were similar in both protocols. Failed induction occurred only in nulliparae and was similar in both protocols (1%). There was no discernible difference in fetal or neonatal outcome although passage of meconium was more common in labour if two doses had been given, as was neonatal admission to the special care baby unit.

CONCLUSIONS

There was little clinical benefit from inducing labour with two doses of prostaglandin E2 at a six-hour interval, compared with a single dose. There may be financial advantages with a two-dose regimen.

Gas chromatographic-mass spectrometric identification and quantitation of urinary phenols after derivatization with 4-carbethoxyhexafluorobutyryl chloride, a novel derivative

Urinary phenol is analyzed widely to determine benzene exposure in humans. Most methods utilize direct measurements of phenols after extraction from urine using gas chromatography or high-performance liquid chromatography. We describe a novel derivatization of urinary phenols using 4-carbethoxyhexafluorobutyryl chloride after extraction from urine and subsequent analysis by gas chromatography-mass spectrometry. The derivative elutes at significantly higher temperature than phenol and the method is free from interferences from more volatile components in urine. We also observed excellent chromatographic properties of these derivatives. In addition, we observed strong molecular ions for the 4-carbethoxyhexafluorobutyryl derivative of phenol (m/z 344), p-cresol (m/z 358) and the internal standard 3,4-dimethylphenol (m/z 372) and other characteristic ions in the electron ionization, thus aiding in unambiguous identification of these compounds. The protonated molecular ions (m/z 373 for derivatized phenol, m/z 359 for derivatized p-cresol and m/z 373 for the internal standard) were the base peaks (relative abundance 100%) in the chemical ionization, although other secondary peaks were less abundant. The assay is linear for phenol concentration of 1-100 mg/l. The within-run and between-run precisions were 4.8% (mean = 52.4, S.D. = 2.5 mg/l) and 8.1% (mean = 53.0, S.D. = 4.3 mg/l) respectively, and the detection limit was 0.5 mg/l.

Caring for older people. Community services: health

Many frail or disabled elderly people are now being maintained in the community, partially at least as a consequence of the Community Care Act 1993. This paper details the work of the major health professionals who are involved in caring for older people in the community and describes how to access nursing, palliative care, continence, mental health, Hospital at Home, physiotherapy, occupational therapy, equipment, and optical, dental, and dietetic services. In many areas, services are evolving to meet needs and some examples of innovative practice are included.

Weekly ventilator circuit changes. A strategy to reduce costs without affecting pneumonia rates

BACKGROUND

Mechanical ventilator circuits are commonly changed at 48-h intervals. This frequency may be unnecessary because ventilator-associated pneumonia often results from aspiration of pharyngeal secretions and not from the ventilator circuit. We compared the ventilator-associated pneumonia rates and costs associated with 48-h and 7-day circuit changes.

METHODS

Ventilator circuits were changed at 48-h intervals during the control period (November 1992 to April 1993) and at 7-day intervals during the study period (June 1993 to November 1993). Nosocomial pneumonias were prospectively identified using the criteria of the Centers for Disease Control and Prevention. The annual cost difference of changing circuits at 48-h and 7-day intervals was calculated using the distribution of ventilator days for the control and study periods.

RESULTS

There were 1,708 patients, 9,858 ventilator days, and a pneumonia rate of 9.64 per 1,000 ventilator days in the control group (48-h circuit changes). There were 1,715 patients, 9,160 ventilator days, and 8.62 pneumonias per 1,000 ventilator days when circuits were changed at 1-week intervals (study group). Using a logistic regression model, there were significantly greater odds of developing a ventilator-associated pneumonia in surgical patients (odds ratio 1.77, P = 0.02) and patients in critical care units (odds ratio 1.54, P = 0.05), but no significant risk of ventilator-associated pneumonia in patients in whom circuits were changed at 1-week intervals (odds ratio 0.82, P = 0.22). Changing circuits at 7-day intervals resulted in a 76.6% ($111,530) reduction in the annual cost for materials and salaries.

CONCLUSIONS

We found no difference in pneumonia rates with ventilator circuit changes at 48-h and 7-day intervals. Ventilator circuits can be safely changed at weekly intervals, resulting in large cost savings.