Covering ENT out of hours: how confident are senior house officers?

Background: The implementation of the European working time directive has led to an increase in cross-speciality out-of-hours cover. This survey illustrates ENT out-of-hours cover arrangements and assesses the implications for senior house officers (SHOs) responsible for managing emergencies.

Methods: A telephone survey of 100 ENT departments was conducted, asking the on-call SHO about departmental structure, on-call rota design, their previous ENT experience, access to SHO training and their confidence in managing emergencies.

Results: 44 per cent of departments used only ENT SHOs on the on-call rota. 73 per cent always had an ENT middle grade on call. In 60 per cent of hospitals, the ENT consultant was sometimes on call with only a non-ENT SHO. At the time of the study, 5 per cent of SHOs had no ENT experience, no access to training, were not confident in managing simple emergencies and were on-call without middle-grade cover.

Conclusion: The current junior on-call structure for ENT has implications for patient management.

Capturing postoperative pain responses in critically ill infants aged 0 to 9 months

OBJECTIVES

The purpose of this study was to describe physiologic and behavioral pain behaviors in postoperative critically ill infants. A secondary aim was to identify how these pain responses vary over time.

DESIGN

This observational study was conducted in the pediatric intensive care unit at two tertiary referral hospitals. Using ethological methods of observation, video recordings of postoperative infants were viewed to depict different situations of pain and no pain and were then coded using a reliable checklist.

PATIENTS

A total of 803 recorded segments were generated from recordings of five critically ill infants aged between 0 and 9 months who had undergone major surgery.

MEASUREMENTS AND MAIN RESULTS

There was an 82% agreement between the two coders. Multivariate analyses showed that physiologic responses differed only when adjusted for time. Significant decreases in systolic and diastolic arterial pressure (p < .001 and p = .036, respectively) were associated with postoperative pain exacerbated by painful procedures on day 2. On day 3, however, heart rate, arterial pressure (systolic, diastolic, and mean), and central venous pressure significantly increased (p < .05) in response to postoperative pain. Indicators included vertical stretch of the mouth, hand twitching, and jerky leg movements for postoperative pain and increase in respiratory distress, frown, eyes tightly closed, angular stretch of the mouth, silent or weak cry, jerky head movements, fist, pulling knees up, and spreading feet for postoperative pain exacerbated by painful stimuli.

CONCLUSIONS

Findings support the ability to capture different intensities of postoperative pain in critically ill infants beyond neonatal age. These pain indicators can be used for the development of a pain assessment tool for this group of infants.

Homocysteine, renal disease and cardiovascular disease in a remote Australian Aboriginal community

BACKGROUND

Rates of renal and cardiovascular disease are high among Aboriginal Australians living in remote communities. Nutritional problems, in particular low folate levels, are also common. This suggests that increased homocysteine concentrations might be widespread, and a possible contributor to the high rates of cardiovascular disease.

AIMS

To examine homocysteine concentrations, and their relationships to folate levels, and to markers of renal disease and cardiovascular disease in a remote Aboriginal Australian community

METHODS

As part of a cross-sectional survey among adults in one community, homocysteine concentrations, concentrations of the crucial determinants (red blood cell (RBC) folate, vitamin B(12) and the C677T methylene tetrahydrofolate reductase polymorphism) and cardiovascular risk factors were examined.

RESULTS

Among 221 people, geometric mean homocysteine concentration was 11.8 micromol/L (range: 11.1-12.5 micromol/L), with 57/221 (26%) values > or =15.0 micromol/L. Higher concentrations were associated with older age, male gender, lower RBC folate and lower vitamin B(12) concentrations and homozygosity for C677T. Homocysteine concentrations were not related to the presence of albuminuria, other than over the overt albuminuria range. Homocysteine concentrations were inversely correlated with calculated glomerular filtration rate (GFR). Carotid intima-media thickness, however, was not related to homocysteine concentration. In multivariate analyses, age, male gender, lower RBC folate concentrations, lower vitamin B(12) concentrations, lower calculated GFR and the C677T polymorphism were all associated with homocysteine concentrations.

CONCLUSIONS

Homocysteine concentrations were consistent with previous limited reports in Aboriginal communities. Although superficially they are similar to reports from non-Aboriginal settings, the younger age of this cohort and the association of homocysteine concentrations with age suggest that age-specific concentrations are higher among Aboriginal Australians. In addition to dietary determinants, the high prevalence of apparently reduced renal function renal disease appears to be an important determinant of homocysteine concentrations in remote Aboriginal communities. The role of homocysteine concentrations as a potential mediator of the high rates of cardiovascular disease remains to be determined.

Test of charge conjugation invariance

We report on the first determination of upper limits on the branching ratio (BR) of eta decay to pi0pi0gamma and to pi0pi0pi0gamma. Both decay modes are strictly forbidden by charge conjugation (C) invariance. Using the Crystal Ball multiphoton detector, we obtained BR(eta-->pi0pi0gamma)<5 x 10(-4) at the 90% confidence level, in support of C invariance of isoscalar electromagnetic interactions of the light quarks. We have also measured BR(eta-->pi0pi0pi0gamma)<6 x 10(-5) at the 90% confidence level, in support of C invariance of isovector electromagnetic interactions.

Efficacy and acceptability of a new topical skin lotion of sodium cromoglicate (Altoderm) in atopic dermatitis in children aged 2-12 years: a double-blind, randomized, placebo-controlled trial

BACKGROUND

Atopic dermatitis (AD) is a common inflammatory allergic disease of children. The primary anti-inflammatory therapy is topical steroids. An effective treatment without the topical and systemic adverse effects of corticosteroids would be useful. Topical formulations of sodium cromoglicate have been researched in the past, but without consistent results. We report a trial of a new aqueous skin lotion of sodium cromoglicate (Altoderm) in children with AD.

OBJECTIVES

To compare the efficacy, safety and acceptability of Altoderm lotion with a placebo control in the treatment of AD in children.

METHODS

A double-blind, controlled study in which children aged 2-12 years with AD were randomized to 12 weeks of treatment with a lotion containing 4% sodium cromoglicate (Altoderm) or the lotion base. To be included subjects had to have a SCORAD score of > or = 25 and < or = 60 at both of two clinic visits 14 days apart. Subjects continued using existing treatment which included emollients and topical steroids. The primary outcome was the change in the SCORAD score. The two groups were compared for the change in the SCORAD score from the second baseline visit to the visit after 12 weeks of treatment using an analysis of variance. Secondary outcome measures included parents' assessment of symptoms, usage of topical steroids recorded on daily diary cards, and final opinions of treatment by parent and clinician. Parents were asked about adverse effects at each clinic visit and the responses recorded.

RESULTS

Fifty-eight children were randomized to Altoderm and 56 to placebo and all were included in the intention-to-treat analysis. The mean +/- SD SCORAD scores at baseline were 41.0 +/- 9.0 (Altoderm) and 40.4 +/- 8.73 (placebo). These scores were reduced after 12 weeks by 13.2 (36%) with Altoderm and by 7.6 (20%) with placebo. The difference of 5.6 (95% confidence interval 1.0-10.3) is statistically significant (P = 0.018). Diary card symptoms improved with both treatments but the improvement was greater in the Altoderm-treated patients. Topical steroid usage was reduced in both groups and was larger in the Altoderm-treated patients. The differences were statistically significant for the mean of all symptoms, the overall skin condition and use of topical steroids. Those for itching and sleep loss were not. Treatment-related adverse events were reported in 11 subjects (Altoderm seven, placebo four). Most of these referred to irritation, redness and burning at the site of application. There were four reports of erythema and pruritus (Altoderm three, placebo one), and three reports of application site burning (Altoderm two, placebo one). None was reported as severe or very severe.

CONCLUSIONS

These results show a clinically useful benefit of this sodium cromoglicate lotion in children with moderately severe AD.

The stipulations of one institutional review board: a five year review

OBJECTIVES

This study was designed to explore the prevalence and types of stipulations (such as clarifications or changes) required of investigators by the institutional review board (IRB) of one institution over a five year period.

DESIGN

Stipulations to research proposals (n = 124) were documented from the minutes of the IRB meetings.

SETTING

Community hospital.

PARTICIPANTS

IRB submissions.

MAIN MEASUREMENTS

Number and type of IRB stipulations.

RESULTS

Nineteen research submissions (15.3%) were approved without any stipulations. For the remainder, the majority of stipulations related to consent forms (74.2%).

CONCLUSIONS

Consent forms appear to be at highest risk for IRB stipulations. Being aware of high risk areas before submission of research proposals may reduce the frequency of stipulations required of investigators.

Pre-operative education for hip or knee replacement

BACKGROUND

Hip or knee replacement is a major surgical procedure which can be physically and psychologically stressful for patients. It is hypothesised that education before surgery reduces anxiety and enhances postoperative outcomes.

OBJECTIVES

To determine whether preoperative education improves postoperative outcomes (anxiety, pain, mobility, length of stay and the incidence of deep vein thrombosis) in patients undergoing hip or knee replacement surgery.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library issue 2, 2003), MEDLINE (1966 to April 2003), EMBASE (1980 to June 2002), CINAHL, PsycINFO and PEDro until May 2003. We handsearched the Australian Journal of Physiotherapy (1954 to 2001) and reviewed the reference lists.

SELECTION CRITERIA

Randomised trials of preoperative education (verbal, written or audiovisual) delivered by a health professional within six weeks of surgery to patients undergoing hip or knee replacement.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed study quality and extracted data. Continuous outcomes were combined using weighted mean difference (WMD) and 95% confidence intervals (CI).

MAIN RESULTS

Nine studies involving 782 participants met the inclusion criteria. Four studies involving 365 participants assessed length of hospital stay (days) but detected no significant difference between preoperative education and usual care (WMD -0.97; 95% CI -2.67 to 0.73). However, one study of 133 participants with more complex needs, indicated that individually tailored programmes of education and support were beneficial in reducing length of stay. The four studies reporting length of stay did not find any significant effect of preoperative education on days to standing and days to climb stairs. Three trials found preoperative education was beneficial in reducing preoperative anxiety (WMD -5.64; -7.45 to -3.82) on a scale of 0 to 100. No significant effect on postoperative anxiety was detected either on the day following surgery, or at discharge. None of the five studies reporting postoperative pain detected any difference between the groups.

REVIEWER'S CONCLUSIONS

There is little evidence to support the use of pre-operative education over and above standard care to improve postoperative outcomes in patients undergoing hip or knee replacement surgery, especially with respect to pain, functioning and length of hospital stay. There is evidence that preoperative education has a modest beneficial effect on preoperative anxiety. There may also be beneficial effects when preoperative education is tailored according to anxiety, or targeted at those most in need of support (e.g. those who are particularly disabled, or have limited social support structures).

Prophylactic ergometrine-oxytocin versus oxytocin for the third stage of labour

BACKGROUND

The routine prophylactic administration of an uterotonic agent is an integral part of active management of the third stage of labour, helping to prevent postpartum haemorrhage (PPH). The two most widely used uterotonic agents are: ergometrine-oxytocin (Syntometrine) (a combination of oxytocin 5 international units (iu) and ergometrine 0.5 mg) and oxytocin (Syntocinon).

OBJECTIVES

To compare the effects of ergometrine-oxytocin with oxytocin in reducing the risk of PPH (blood loss of at least 500 ml) and other maternal and neonatal outcomes.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register (May 2003).

SELECTION CRITERIA

Randomised trials comparing ergometrine-oxytocin use with oxytocin use in women having the third stage of labour managed actively.

DATA COLLECTION AND ANALYSIS

We independently assessed trial eligibility and quality and extracted data. We contacted study authors for additional information.

MAIN RESULTS

Six trials were included (9332 women). Compared with oxytocin, ergometrine-oxytocin was associated with a small reduction in the risk of PPH using the definition of PPH of blood loss of at least 500 ml (odds ratio 0.82, 95% confidence interval 0.71 to 0.95). This advantage was found for both a dose of 5 iu oxytocin and a dose of 10 iu oxytocin, but was greater for the lower dose. There was no difference detected between the groups using either 5 or 10 iu for the stricter definition of PPH of blood loss at least 1000 ml. Adverse effects of vomiting, nausea and hypertension were more likely to be associated with the use of ergometrine-oxytocin. When heterogeneity between trials was taken into account there were no statistically significant differences found for the other maternal or neonatal outcomes.

REVIEWER'S CONCLUSIONS

The use of ergometrine-oxytocin as part of the routine active management of the third stage of labour appears to be associated with a small but statistically significant reduction in the risk of PPH when compared to oxytocin for blood loss of 500 ml or more. No statistically significant difference was observed between the groups for blood loss of 1000 ml or more. A statistically significant difference was observed in the presence of maternal side-effects, including elevation of diastolic blood pressure, vomiting and nausea, associated with ergometrine-oxytocin use compared to oxytocin use. Thus, the advantage of a reduction in the risk of PPH, between 500 and 1000 ml blood loss, needs to be weighed against the adverse side-effects associated with the use of ergometrine-oxytocin.

Dynamics of the pi(-)p-->pi(0)pi(0)n reaction for p(pi(-))<750 MeV/c

Data are presented for the reaction pi(-)p-->pi(0)pi(0)n in the range from threshold to p(pi(-))=750 MeV/c. The systematics of the data and multipole analyses are examined for sensitivity to a f(0)(600) ("sigma") meson. A one-pion-exchange mechanism is found to be very weak, or absent. The reaction appears to become dominated by sequential pi(0) decays through the Delta(1232) resonance as the beam momentum increases, along with substantial interference effects from several competing mechanisms.

Full publication of trials initially reported as abstracts in the Australian and New Zealand Journal of Medicine 1980-2000

Abstract Failure to identify all relevant reports of controlled trials is a potential source of bias in systematic reviews of health-care interventions. The present study aims to identify how many reports of trials -initially published as conference abstracts in the Australian and New Zealand Journal of Medicine were subsequently published in full. We identified trial reports by handsearching conference abstracts published in the Journal from 1980 to 2000. We then searched the Cochrane Controlled Trials Register and PubMed to determine how many of these had been subsequently published in full. A total of 962 reports of controlled trials was identified from the conference proceedings of 17 medical societies. Of these, 589 (61%) reports of trials were subsequently published in full, and on average within 1-2 years. Handsearching conference abstracts identified a large number of reports of controlled trials, over one-third of which were unpublished and therefore not easily accessible.

Brain activity during simulated deception: an event-related functional magnetic resonance study

TheGuilty Knowledge Test (GKT) has been used extensively to model deception. An association between the brain evoked response potentials and lying on the GKT suggests that deception may be associated with changes in other measures of brain activity such as regional blood flow that could be anatomically localized with event-related functional magnetic resonance imaging (fMRI). Blood oxygenation level-dependent fMRI contrasts between deceptive and truthful responses were measured with a 4 Tesla scanner in 18 participants performing the GKT and analyzed using statistical parametric mapping. Increased activity in the anterior cingulate cortex (ACC), the superior frontal gyrus (SFG), and the left premotor, motor, and anterior parietal cortex was specifically associated with deceptive responses. The results indicate that: (a) cognitive differences between deception and truth have neural correlates detectable by fMRI, (b) inhibition of the truthful response may be a basic component of intentional deception, and (c) ACC and SFG are components of the basic neural circuitry for deception.

The genome sequence of Schizosaccharomyces pombe

We have sequenced and annotated the genome of fission yeast (Schizosaccharomyces pombe), which contains the smallest number of protein-coding genes yet recorded for a eukaryote: 4,824. The centromeres are between 35 and 110 kilobases (kb) and contain related repeats including a highly conserved 1.8-kb element. Regions upstream of genes are longer than in budding yeast (Saccharomyces cerevisiae), possibly reflecting more-extended control regions. Some 43% of the genes contain introns, of which there are 4,730. Fifty genes have significant similarity with human disease genes; half of these are cancer related. We identify highly conserved genes important for eukaryotic cell organization including those required for the cytoskeleton, compartmentation, cell-cycle control, proteolysis, protein phosphorylation and RNA splicing. These genes may have originated with the appearance of eukaryotic life. Few similarly conserved genes that are important for multicellular organization were identified, suggesting that the transition from prokaryotes to eukaryotes required more new genes than did the transition from unicellular to multicellular organization.

Properties of the Lambda(1670)(1-)/2 resonance

Recently the Crystal Ball Collaboration measured precise new data for the near-threshold reaction K(-)p-->etaLambda, which is dominated by formation of the Lambda(1670)1 / 2(-). In this Letter, we present results of a unitary, multichannel analysis that incorporates the new Crystal Ball data. For our preferred fit, we obtain mass M = 1673+/-2 MeV, width Gamma = 23+/-6 MeV, and elasticity x = 0.37+/-0.07. This elasticity is significantly larger than previously recognized. Resonance parameters of our preferred fit are in striking agreement with the quark-model predictions of Koniuk and Isgur.

Determination of the quadratic slope parameter in eta-->3pi(0) decay

We have determined the quadratic slope parameter alpha for eta-->3pi(0) to be alpha = -0.031(4) from a 99% pure sample of 10(6)eta-->3pi(0) decays produced in the reaction pi(-)p-->n(eta) close to the eta threshold using the Crystal Ball detector at the AGS. The result is four times more precise than the present world data and disagrees with current chiral perturbation theory calculations by about four standard deviations.

Why barium enemas fail to identify colorectal cancers

BACKGROUND

The aim of the present study was to determine the cause and clinicopathological factors associated with the failure of barium enemas to detect colorectal cancers.

METHODS

A histopathological database was used to identify all patients with a diagnosis of colorectal cancer between 1991 and 1995. These records were matched with the records from patients who underwent barium enema examinations between 1990 and 1995. Those patients who had a colorectal cancer histologically diagnosed within 24 months of a barium enema in which no carcinoma was seen, were identified. Where possible the radiology was reviewed. Failure to identify a carcinoma was then attributed to either simple failure, technical, interpretive or perceptive difficulties.

RESULTS

There were 967 patients with colorectal cancers treated in Christchurch Hospital during the study period 1991-1995. Matching of these patient details with all barium enema records revealed 313 patients who had barium enemas and histologically proven colorectal cancer. There were 21 (6.7%) patients in whom a carcinoma was missed. Of these, 18 had a barium enema within 8 months of surgery, and three were performed outside this timespan (15, 18 and 28 months, respectively). On review, 11 carcinomas could not be identified (nine due to technical error: poor coating (n = 1), overlapping loops (n = 3), single-contrast enema (n = 4), faecal residue (n = 1)); and seven could be seen on review of the films (two interpretation errors, one technical and perceptive error, and four perceptive errors). In three cases films could not be found for review. In 16 of the 21 missed lesions the patient had a double-contrast barium enema (DCBE) while five patients had single-contrast barium enema (SCBE). The site and stage of missed tumours is presented.

CONCLUSIONS

The most common reason for missed tumours was technical. The percentage of missed tumours in each region of the bowel correlates with the known incidence of tumours in each region and with a normal Dukes stage distribution, except in the caecum where the number of missed lesions was higher than expected.

Social information processing in adolescents: data from normally developing adolescents and preliminary data from their peers with traumatic brain injury

OBJECTIVE

To assess aspects of social information processing in naturalistic conversations, using online videotape tasks.

DESIGN AND PARTICIPANTS

The tasks were administered to 60 normally developing (ND) subjects ages 13 to 21, and 10 adolescents with traumatic brain injury (TBI).

SETTING

University.

MAIN OUTCOME MEASURE

Task accuracy scores and measures of reliability and validity.

RESULTS AND CONCLUSIONS

ND group scores were generally high, without significant differences by race, sex or age. TBI group scores were significantly lower than ND group scores for both emotion recognition and detection of conversation skills. The results are discussed in light of the evaluation of pragmatic competence in adolescents with TBI.

Where to put a practice: factors to consider

The temple of the Oracle at Delphi has "Know Thyself" engraved above it. Using modern demographic and psychographic research, it is both possible and practical to "know thy practice site" so that this important and risk-filled decision can be made rationally.

catena-Poly[dibromozinc(II)-mu-ethylenediamine-N:N']: resolution of structural anomalies resulting from the interpretation of vibrational spectra

The title structure, [ZnBr2(C2H8N2)], is made up of infinite -ZnBr2-(en)-ZnBr2-(en)- zigzag chains. Each repeat unit contains a trans ethylenediamine ligand [N-C-C-N -179 (1) degrees ], which bridges two approximately tetrahedral but crystallographically distinct Zn atoms. One Zn atom is bisected by a crystallographic twofold axis, whereas the other has mirror symmetry. Even though the crystal packing does not allow significant interaction between Zn and N atoms on adjacent chains, it does facilitate extensive intermolecular N-H...Br hydrogen bonding (N...H 2.69-2.96 A).

Frequency and prevention of symptomless deep-vein thrombosis in long-haul flights: a randomised trial

BACKGROUND

The true frequency of deep-vein thrombosis (DVT) during long-haul air travel is unknown. We sought to determine the frequency of DVT in the lower limb during long-haul economy-class air travel and the efficacy of graduated elastic compression stockings in its prevention.

METHODS

We recruited 89 male and 142 female passengers over 50 years of age with no history of thromboembolic problems. Passengers were randomly allocated to one of two groups: one group wore class-I below-knee graduated elastic compression stockings, the other group did not. All the passengers made journeys lasting more than 8 h per flight (median total duration 24 h), returning to the UK within 6 weeks. Duplex ultrasonography was used to assess the deep veins before and after travel. Blood samples were analysed for two specific common gene mutations, factor V Leiden (FVL) and prothrombin G20210A (PGM), which predispose to venous thromboembolism. Asensitive D-dimer assay was used to screen for the development of recent thrombosis.

FINDINGS

12/116 passengers (10%; 95% CI 4.8-16.0%) developed symptomless DVT in the calf (five men, seven women). None of these passengers wore elastic compression stockings, and two were heterozygous for FVL. Four further patients who wore elastic compression stockings, had varicose veins and developed superficial thrombophlebitis. One of these passengers was heterozygous for both FVL and PGM. None of the passengers who wore class-I compression stockings developed DVT (95% CI 0-3.2%).

INTERPRETATION

We conclude that symptomless DVT might occur in up to 10% of long-haul airline travellers. Wearing of elastic compression stockings during long-haul air travel is associated with a reduction in symptomless DVT.

Key factors in determining a dental practice site

There is no single "right" place to place a dental practice. Personal preferences, family, friends, church, and recreation all have a hand in determining a dentist's likelihood of happiness with a particular location. Still, the science of demographics and psychographics (who people are and what they do) can provide a dentist with necessary insights into knowing the potential of a location. This article discusses important demographic and psychographic information that should be considered when determining a dental practice site.

Prophylactic use of oxytocin in the third stage of labour

BACKGROUND

Many maternal deaths across the world result from complications of the third stage of labour (when the placenta is delivered).

OBJECTIVES

To examine the effect of oxytocin given prophylactically in the third stage of labour on maternal and neonatal outcomes.

SEARCH STRATEGY

Relevant trials were identified in the Cochrane Collaboration Controlled Trials Register and the Pregnancy and Childbirth Review Group's Specialised Register of Controlled Trials. Date of last search: May 2001.

SELECTION CRITERIA

All acceptably randomised or quasi-randomised controlled trials including pregnant women anticipating a vaginal delivery where oxytocin was given prophylactically for the third stage of labour.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed studies for relevance and methodological quality, and extracted data. Analysis was by intention to treat. Subgroup analyses were based on extent of selection bias, oxytocin in the context of active or expectant management of the third stage, and timing of administration. Results are presented as relative risks, and weighted mean difference, both with 95% confidence intervals using a fixed effects model.

MAIN RESULTS

In seven trials involving over 3000 women in hospital and/or developed country settings, prophylactic oxytocin showed benefits (reduced blood loss (relative risk (RR) for blood loss > 500 ml 0.50; 95% confidence interval (CI) 0.43, 0.59) and need for therapeutic oxytocics (RR 0.50; 95% CI 0.39, 0.64).) compared to no uterotonics, although there was a non-significant trend towards more manual removal of the placenta (RR 1.17; 95% CI 0.79, 1.73) which was most marked in the expectant management subgroup, and blood transfusions (RR 1.30; 95% CI 0.50, 3.39) in the trials with more manual removals of the placenta). In six trials involving over 2800 women, there was little evidence of differential effects for oxytocin versus ergot alkaloids, except ergot alkaloids are associated with more manual removals of the placenta (RR 0.57; 95% CI 0.41, 0.79), and with the suggestion of more raised blood pressure (RR 0.53; 95% CI 0.19, 1.58) than with oxytocin. In five trials involving over 2800 women, there was little evidence of a synergistic effects of adding oxytocin to ergometrine versus ergometrine alone. For all other outcomes in the comparisons either there are no data or the number of adverse events is very small, and so definite conclusions cannot be drawn.

REVIEWER'S CONCLUSIONS

There are strong suggestions of benefit for oxytocin in terms of postpartum haemorrhage, and the need for therapeutic oxytocics, but without sufficient information about other outcomes and side-effects it is difficult to be confident about the trade-offs for these benefits, especially if the risk of manual removal of the placenta may be increased. There seems little evidence in favour of ergot alkaloids alone compared to either oxytocin alone, or to Syntometrine, but the data are sparse. More trials are needed in domiciliary deliveries in developing countries, which shoulder most of the burden of third stage complications.

Measurement of pi(0)pi(0) production in the nuclear medium by pi(-) interactions at 0.408 GeV/c

We report on an investigation of the (pi(-),pi(0)pi(0)) reaction by means of measurements of the pi(0)pi(0) invariant mass distributions from pi(-) interactions on H, D, C, Al, and Cu targets at p(pi(-)) = 0.408 GeV/c. The sharp, strong peak in the pi(+)pi(-) invariant mass near 2m(pi) reported by the CHAOS Collaboration is not seen in our pi(0)pi(0) data. However, we do observe a change in the shape of the pi(0)pi(0) invariant mass spectrum for the different targets, indicating that the pi(0)pi(0) interaction diminishes in the nuclear medium as represented by nuclei D, C, Al, and Cu, compared to hydrogen.

Body mass index in aboriginal Australians in remote communities

OBJECTIVES

To describe the distribution of body mass index (BMI) and estimate the prevalence of potential chronic energy deficiency (CED) and obesity in Aborigines in remote communities (ARC) in the Top End of the Northern Territory, Australia.

METHODS

Centile charts were constructed for BMI from 1,631 sets of measurements from 1,138 Aborigines, aged five to 77 years, in three remote communities on the Tiwi Islands, using Cole's LMS method. These were compared with European, American white and American black reference charts. The prevalences of CED and obesity were also compared to the corresponding values from a national Indigenous sample.

RESULTS

The BMI centiles change with age. Compared with reference populations, BMIs are lower in ARC children and adult males. Young adult females have similar BMIs to American black and higher BMIs than American white and French counterparts up to 45 years. Aborigines older than 50 years are 'thinner'. Compared with a national sample of Indigenous Australians, our sample has a higher prevalence of CED and a lower prevalence of obesity.

CONCLUSIONS

The BMI centile curves describe the contemporary nutritional status in the remote communities. Nutritional status measured by BMI is different in ARC than in other populations.

IMPLICATIONS

The difference in nutritional status between ARC and other populations should be considered when planning nutritional intervention strategies. The centile charts will allow health workers to determine the relative ranking of BMI for individual Aborigines in the remote communities.

The professional consequences of whistleblowing by nurses

When nurses encounter misconduct in the workplace, their ethical codes of conduct bind them to the role of patient advocacy and compel them to safeguard the patient from harm. However, reporting misconduct can be personally and professionally risky. The aim of the research was to examine the professional consequences of whistleblowing and nonwhistleblowing in nursing. A descriptive survey design was used to examine the professional effect of reporting misconduct (whistleblowing) and not reporting misconduct (nonwhistleblowing). Ninety-five respondents were included in the study; 70 were self-identified as whistleblowers and 25 were self-identified as nonwhistleblowers. Results indicated that there were severe professional reprisals if the nurse reported misconduct, but there were few professional consequences if the nurse remained silent. Official reprisals included demotion (4%), reprimand (11%), and referral to a psychiatrist (9%). Whistleblowers also reported that they received professional reprisals in the form of threats (16%), rejection by peers (14%), pressure to resign (7%), and being treated as a traitor (14%). Ten per cent reported that they felt their career had been halted. These findings suggest that when nurses identify and report misconduct in the workplace, they may experience serious professional consequences.

Exploring the cognitive basis of right-hemisphere pragmatic language disorders

Despite considerable interest in the linguistic dimensions of right-hemisphere (RH) pragmatic language disorders, the cognitive bases for these are rarely examined. This study investigated two alternative explanations. First, RH pragmatic language disorders may reflect failure of the RH to synthesise incoming and preexisting information, verbal and visuospatial. In this case language and visuospatial performance should covary. Alternatively such disorders may reflect damage to executive control of all cognitive processing secondary to frontal system failure. In this case language and executive function would be associated. Further, in the former case, subjects should be insensitive to the plausibility of information, whereas in the latter they would be fixated by the literal meaning of information and therefore highly sensitive to plausibility. Eighteen patients with RH damage were compared to 20 matched controls on a range of language and neuropsychological tasks. Pragmatic performance was generally correlated to RH (visuospatial) function, not to executive function. Nonetheless RH patients were found to have problems ignoring plausibility. Thus the specific RH hypothesis described needs to be reconsidered.

Search for the CP forbidden decay eta-->4pi(0)

We report the first determination of the upper limit for the branching ratio of the CP forbidden decay eta-->4pi(0). No events were observed in a sample of 3.0x10(7) eta decays. The experiment was performed with the Crystal Ball multiphoton spectrometer installed in a separated pi(-) beam at the AGS (Alternating Gradient Synchrotron). At the 90% confidence limit, B(eta-->4pi(0))</=6. 9x10(-7).

Cognitive impairment among methadone maintenance patients

AIMS

To compare the cognitive performance of methadone maintenance patients (MMPs) and a matched sample of non-heroin-using control subjects, and to ascertain risk factors for poorer cognitive performance.

DESIGN

Matched control study.

SETTING

Sydney, Australia.

PARTICIPANTS

Thirty MMPs and 30 non-heroin using controls, matched for age, gender and education.

FINDINGS

The MMP group had significantly higher rates than controls of alcohol dependence, heroin overdose and head injury. There was no difference between the groups on pre-morbid functioning. The MMP group performed significantly poorer than controls on all of the neuropsychological domains measured: information processing, attention, short-term visual memory, delayed visual memory, short-term verbal memory, long-term verbal memory and problem solving. A life-time diagnosis of alcohol dependence and the number of non-fatal heroin overdoses were independent significant predictors of poorer cognitive performance.

CONCLUSIONS

In addition to high rates of psychiatric morbidity, MMPs also show cognitive deficits compared to matched controls. A history of alcohol dependence and repeated exposure to overdose increase the likelihood of cognitive impairment. The current study does not rule out the possibility of other factors, that were not measured, that may contribute to cognitive impairment among this MMPs.

Ligand responsiveness in human prostate cancer: structural analysis of mutant androgen receptors from LNCaP and CWR22 tumors

Androgen receptors (ARs) belong to the family of hormone receptors that are ligand-dependent transcription factors. Endocrine therapy provides effective treatment for prostate cancer until mutations arise that alter the ligand responsiveness of AR. In this study, structural models were developed for the functional domains of human AR by homology modeling from crystal structures of closely related nuclear receptors. These models were used to locate the sites of two frequently occurring mutations in prostate cancer. The substitutions that develop in LNCaP (threonine-->alanine at residue 877) and CWR22 (histidine-->tyrosine at residue 874) tumor cell lines are both located on helix 11 that forms part of the ligand-binding pocket. However, the results suggest that these mutations influence ligand responsiveness by completely different mechanisms. Residue 877 contacts the ligand directly, and substitution at this site alters the stereochemistry of the binding pocket. Thus, the LNCaP mutation apparently broadens the specificity of ligand recognition. In contrast, residue 874 is located down the helical axis, projects away from the ligand pocket, and does not contact ligand. The side chain of residue 874 lies in a cavity between helices 11 and 12. Substitution of tyrosine for histidine 874 in CWR22 tumors may affect a conformational change of helix 12 and, thus, influence binding of coactivator proteins and their regulatory effect on transcriptional activation.

Prophylactic syntometrine versus oxytocin for delivery of the placenta

BACKGROUND

The routine prophylactic administration of an oxytocic agent is an integral part of active management of the third stage of labour. These agents help prevent postpartum haemorrhage.

OBJECTIVES

The objective of this review was to assess the effects of ergometrine-oxytocin (syntometrine) with oxytocin alone in reducing the risk of postpartum haemorrhage (blood loss of equal to or greater than 500 millilitres) and other maternal and neonatal outcomes.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register.

SELECTION CRITERIA

Trials of oxytocic drugs (syntometrine or oxytocin) in women having the third stage of labour managed actively.

DATA COLLECTION AND ANALYSIS

Eligibility, trial quality assessment and data extraction were done independently by three reviewers. Study authors were contacted for additional information.

MAIN RESULTS

Six trials were included. Compared with oxytocin, ergometrine-oxytocin (syntometrine) was associated with a small reduction in the risk of postpartum haemorrhage (odds ratio 0.74, 95% confidence interval 0.65 to 0.85). This advantage was smaller but still significant when 10 international units of oxytocin was used. There was no difference seen between the groups using either five or 10 international units for blood loss equal to or greater than 1000 millilitres. Adverse effects of vomiting and hypertension were associated with the use of ergometrine-oxytocin. No significant differences were found in other maternal or neonatal outcomes.

REVIEWER'S CONCLUSIONS

The use of the combination preparation syntometrine (oxytocin and ergometrine) as part of the routine active management of the third stage of labour appears to be associated with a statistically significant reduction in the risk of postpartum haemorrhage when compared to oxytocin where blood loss is less than 1000ml. No difference was seen between the groups using either five or 10 international units for blood loss equal to or greater than 1000 millilitres. This needs to be weighed against the more common adverse effects associated with the use of syntometrine.

Active versus expectant management in the third stage of labour

BACKGROUND

Expectant management of the third stage of labour involves allowing the placenta to deliver spontaneously or aiding by gravity or nipple stimulation. Active management involves administration of a prophylactic oxytocic after delivery, early cord clamping and cutting, and controlled cord traction of the umbilical cord.

OBJECTIVES

The objective of this review was to assess the effects of active versus expectant management on blood loss, post partum haemorrhage and other maternal and perinatal complications of the third stage of labour.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register.

SELECTION CRITERIA

Randomised trials comparing active and expectant management of the third stage of labour in women with singleton pregnancies whose babies were presenting head first and who were expecting a vaginal delivery.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed and data were extracted independently by the reviewers.

MAIN RESULTS

Four studies were included. Three of the trials were of good quality. Compared to expectant management, active management (in the setting of a maternity hospital) was associated with the following reduced risks: maternal blood loss (weighted mean difference -79.33 millilitres, 95% confidence interval -94.29 to -64. 37); post partum haemorrhage of more than 500 millilitres (odds ratio 0.34, 95% confidence interval 0.28 to 0.41); prolonged third stage of labour (weighted mean difference -3.40 minutes, 95% confidence interval -4.66 to -2.13). Active management was associated with an increased risk of maternal nausea (odds ratio 1. 95, 95% confidence interval 1.58 to 2.42), vomiting and raised blood pressure (probably due to the use of ergometrine). No advantages or disadvantages were apparent for the baby.

REVIEWER'S CONCLUSIONS

Routine 'active management' is superior to 'expectant management' in terms of blood loss, post partum haemorrhage and other serious complications of the third stage of labour. Active managment is, however, associated with an increased risk of unpleasant side effects (eg nausea and vomiting), and hypertension, where ergometrine is used. Active management should be the routine management of choice for women expecting a single baby by vaginal delivery in a maternity hospital. The implications are less clear for other settings including domiciliary practice (in developing and industrialised countries).

Detection of Francisella tularensis in biological specimens using a capture enzyme-linked immunosorbent assay, an immunochromatographic handheld assay, and a PCR

The early detection of Francisella tularensis, the causative agent of tularemia, is important for adequate treatment by antibiotics and the outcome of the disease. Here we describe a new capture enzyme-linked immunosorbent assay (cELISA) based on monoclonal antibodies specific for lipopolysaccharide (LPS) of Francisella tularensis subsp. holarctica and Francisella tularensis subsp. tularensis. No cross-reactivity with Francisella tularensis subsp. novicida, Francisella philomiragia, and a panel of other possibly related bacteria, including Brucella spp., Yersinia spp., Escherichia coli, and Burkholderia spp., was observed. The detection limit of the assay was 10(3) to 10(4) bacteria/ml. This sensitivity was achieved by solubilization of the LPS prior to the cELISA. In addition, a novel immunochromatographic membrane-based handheld assay (HHA) and a PCR, targeting sequences of the 17-kDa protein (TUL4) gene of F. tularensis, were used in this study. Compared to the cELISA, the sensitivity of the HHA was about 100 times lower and that of the PCR was about 10 times higher. All three techniques were successfully applied to detect F. tularensis in tissue samples of European brown hares (Lepus europaeus). Whereas all infected samples were recognized by the cELISA, those with relatively low bacterial load were partially or not detected by PCR and HHA, probably due to inhibitors or lack of sensitivity. In conclusion, the HHA can be used as a very fast and simple approach to perform field diagnosis to obtain a first hint of an infection with F. tularensis, especially in emergent situations. In any suspect case, the diagnosis should be confirmed by more sensitive techniques, such as the cELISA and PCR.

Subcellular localisation of NS3 in HCV-infected hepatocytes

Hepatitis C virus (HCV) NS3 is a multifunctional protein with both protease and helicase activities and has been shown to interact with host cell proteins. It is shown that NS3 is present in the hepatocytes from patients with chronic HCV infection by using anti-NS3 antisera. NS3 is detectable in approximately 4% of the hepatocytes from these patients. In most infected cells, NS3 is present in the cytoplasm; however, in a minority of HCV-infected cells, both the cytoplasm and the nucleus or the nucleus on its own are positive for NS3. The presence of NS3 in the nuclei of hepatocytes in chronically infected patients indicates that the protein may play a role other than in virus replication, such as in persistence of HCV infection.