Assessment of the clinical effectiveness of pulmonary artery catheters in management of patients in intensive care (PAC-Man): a randomised controlled trial

BACKGROUND

Over the past 30 years the pulmonary artery catheter (PAC) has become a widely used haemodynamic monitoring device in the management of critically ill patients, though doubts exist about its safety. Our aim was, therefore, to ascertain whether hospital mortality is reduced in critically ill patients when they are managed with a PAC.

METHODS

We did a randomised controlled trial to which we enrolled 1041 patients from 65 UK intensive care units. We assigned individuals to management with (n=519) or without (n=522) a PAC. The timing of insertion and subsequent clinical management were at the discretion of the treating clinician. Intensive care units decided a priori to have the option of using an alternative cardiac output-monitoring device in control patients.

FINDINGS

1014 patients were eligible for analysis. We noted no difference in hospital mortality between patients managed with or without a PAC (68% [346 of 506] vs 66% [333 of 507], p=0.39; adjusted hazard ratio 1.09, 95% CI 0.94-1.27). We noted complications associated with insertion of a PAC in 46 of 486 individuals in whom the device was placed, none of which was fatal.

INTERPRETATION

Our findings indicate no clear evidence of benefit or harm by managing critically ill patients with a PAC. Efficacy studies are needed to ascertain whether management protocols involving PAC use can result in improved outcomes in specific groups if these devices are not to become a redundant technology.

Systematic review and evaluation of physiological track and trigger warning systems for identifying at-risk patients on the ward

OBJECTIVE

Physiological track and trigger warning systems (TTs) are used to identify patients outside critical care areas at risk of deterioration and to alert a senior clinician, Critical Care Outreach Service, or equivalent. The aims of this work were: to describe published TTs and the extent to which each has been developed according to established procedures; to review the published evidence and available data on the reliability, validity and utility of existing systems; and to identify the best TT for timely recognition of critically ill patients.

DESIGN AND SETTING

Systematic review of studies identified from electronic, citation and hand searching, and expert informants. Cohort study of data from 31 acute hospitals in England and Wales.

MEASUREMENTS AND RESULTS

Thirty-six papers were identified describing 25 distinct TTs. Thirty-one papers described the use of a TT, and five were studies examining the development or testing of TTs. None of the studies met all methodological quality standards. For the cohort study, outcome was measured by a composite of death, admission to critical care, 'do not attempt resuscitation' or cardiopulmonary resuscitation. Fifteen datasets met pre-defined quality criteria. Sensitivities and positive predictive values were low, with median (quartiles) of 43.3 (25.4-69.2) and 36.7 (29.3-43.8), respectively.

CONCLUSION

A wide variety of TTs were in use, with little evidence of reliability, validity and utility. Sensitivity was poor, which might be due in part to the nature of the physiology monitored or to the choice of trigger threshold. Available data were insufficient to identify the best TT.

Stress and adrenal function

The natural environment is composed of various potentially hostile stressors. It is a basic requirement of life that the cells of an organism must be maintained within closely defined physiological limits. The maintenance of a constant interior mileu results from physiological and behavioural homeostatic adaptations. The physiological regulation of homeostatis is achieved by complex endocrine interactions, principally by the hormones secreted from the adrenal glands. In this brief review the responses of the avian adrenal glands to stressful stimuli, the mechanism of adrenal activation, and the function of the adrenal responses will be considered.

Synthetic pheromones that promote inter-male aggression in mice

Two volatile constituents of male mouse urine, dehydro-exo-brevicomin and 2-(sec-butyl)-dihydrothiazole, have been found active in bioassays of inter-male aggressive behavior. The two synthetic compounds act synergistically when added to castrated male urine but not when added to water, and they provoke fighting that is quantitatively and qualitatively comparable to that elicited by intact male urine.

The clinical pathology of Crimean-Congo hemorrhagic fever

Observations were made of 15 fatal and 35 nonfatal Crimean-Congo hemorrhagic fever (CCHF) infections diagnosed from February 1981 to March 1987 in Kimberly and Sandringham, Republic of South Africa. Following an incubation period of 2-9 days after exposure to infection, patients had a sudden onset of disease with fever, nausea, severe headache, and myalgia. Petechial rash and hemorrhagic signs such as epistaxis, hematemesis, and melena supervened on days 3-6 of illness. Deaths occurred on days 5-14 of illness. Patients with fatal infections had thrombocytopenia and markedly elevated levels of serum aspartate and alanine aminotransaminases, gamma-glutamyltransferase, lactic dehydrogenase, creatine kinase, bilirubin, creatinine, and urea. Total protein, albumin, fibrinogen, and hemoglobin levels were depressed. Values for prothrombin ratio, activated partial thromboplastin time, thrombin time, and fibrin degradation products were grossly elevated, findings that indicate the occurrence of disseminated intravascular coagulopathy. Many of the clinical pathologic changes were evident at an early stage of the disease and had a highly predictive value for fatal outcome of infection. Changes were present but less marked in nonfatal infections.

Promotion of the Whitten effect in female mice by synthetic analogs of male urinary constituents

Two volatile constituents of male mouse urine, 2-(sec-butyl)-4,5-dihydrothiazole and dehydro-exo-brevicomin, were synthesized and tested for their ability to induce estrous cycle in female mice (the Whitten effect). The suppression of ovarian cycling activity that resulted from grouping the females was abolished by exposure to normal male urine. The synthetic compounds, when added together in appropriate concentrations to the (previously inactive) urine of castrated males, or even to water, were found to be as effective as normal male urine. The action of the synthetic compounds appears attenuated for singly caged females.

Identification and characterization of a potent, selective, and orally active antagonist of the CC chemokine receptor-1

The CC chemokine receptor-1 (CCR1) is a prime therapeutic target for treating autoimmune diseases. Through high capacity screening followed by chemical optimization, we identified a novel non-peptide CCR1 antagonist, R-N-[5-chloro-2-[2-[4-[(4-fluorophenyl)methyl]-2-methyl-1-piperazinyl ]-2-oxoethoxy]phenyl]urea hydrochloric acid salt (BX 471). Competition binding studies revealed that BX 471 was able to displace the CCR1 ligands macrophage inflammatory protein-1alpha (MIP-1alpha), RANTES, and monocyte chemotactic protein-3 (MCP-3) with high affinity (K(i) ranged from 1 nm to 5.5 nm). BX 471 was a potent functional antagonist based on its ability to inhibit a number of CCR1-mediated effects including Ca(2+) mobilization, increase in extracellular acidification rate, CD11b expression, and leukocyte migration. BX 471 demonstrated a greater than 10,000-fold selectivity for CCR1 compared with 28 G-protein-coupled receptors. Pharmacokinetic studies demonstrated that BX 471 was orally active with a bioavailability of 60% in dogs. Furthermore, BX 471 effectively reduces disease in a rat experimental allergic encephalomyelitis model of multiple sclerosis. This study is the first to demonstrate that a non-peptide chemokine receptor antagonist is efficacious in an animal model of an autoimmune disease. In summary, we have identified a potent, selective, and orally available CCR1 antagonist that may be useful in the treatment of chronic inflammatory diseases.

Purification and radioimmunoassay of chicken growth hormone

Chicken growth hormone has been isolated from adenohypophysial tissue from which the glycoprotein hormones had been removed. The procedure entailed alkali extraction, ammonium sulphate precipitation and ion-exchange chromatography on DEAE-cellulose. The resulting fraction was homogeneous, active in the rat tibia bioassay and had a similar isoelectric point, molecular weight and amino acid composition to mammalian growth hormone. A specific homologous radioimmunoassay has been developed using the avian growth hormone.

Chemistry of male dominance in the house mouse, Mus domesticus

Two terpenic constituents, E,E,-alpha-farnesene and E-beta-farnesene, were found to be elevated in dominant male urine when compared to subordinate or control males. These two urinary compounds were absent in the bladder urine of males; however, they were the most prominent constituents of the perputial gland's aliquots. The results of a two-choice preference test, conducted on ICR/Alb subordinate males, gave a strong indication that these two terpenic constituents introduced into the previously attractive stimulus significantly discouraged prolonged investigations by male mice. The compounds, whether present in the urine matrix or water, rendered the stimulus with a quality behaviorally similar to the urine of dominant males. It appears that they may be synonymous with the previously described aversion signal produced by dominant males. We suggest that these compounds may play a wide-ranging role in the territorial marking behavior of male mice.

Growth hormone: roles in female reproduction

GH, as its name suggests, is obligatory for growth and development. It is, however, also involved in the processes of sexual differentiation and pubertal maturation and it participates in gonadal steroidogenesis, gametogenesis and ovulation. It also has additional roles in pregnancy and lactation. These actions may reflect direct endocrine actions of pituitary GH or be mediated by its induction of hepatic or local IGF-I production. However, as GH is also produced in gonadal, placental and mammary tissues, it may act in paracrine or autocrine ways to regulate local processes that are strategically regulated by pituitary GH. The concept that GH is an important modulator of female reproduction is the focus of this review.

End-of-life decisions: a cohort study of the withdrawal of all active treatment in intensive care units in the United Kingdom

OBJECTIVE

To describe the epidemiology of active treatment withdrawal in a nationally representative cohort of intensive care units (ICUs) focusing on between-unit differences.

DESIGN AND SETTING

Cohort study in 127 adult general ICUs in England, Wales and Northern Ireland, 1995 to 2001.

PATIENTS

118,199 adult admissions to ICUs.

MEASUREMENTS AND RESULTS

The decision to withdraw all active treatment was made for 11,694 of 118,199 patients (9.9%). There were a total of 36,397 deaths (30.8%) before discharge from hospital, and 11,586 (31.8%) of these occurred after the decision to withdraw active treatment, with no change over time (p=0.54). Considerable variation existed between units regarding the percentage of ICU deaths that occurred after the decision to withdraw active treatment (1.7-96.1%). Median time to death after the decision to withdraw active treatment was 2.4 h; 8% survived more than 24 h. After multilevel modelling, the factors independently associated with the decision to withdraw active treatment were: older age, pre-existing severe medical conditions, emergency surgery or medical admission, cardiopulmonary resuscitation in the 24 h prior to admission, and ventilation or sedation/paralysis in the first 24 h after admission. Substantial between unit variability remained after accounting for case-mix differences in admissions.

CONCLUSIONS

Although we were unable to examine partial withdrawal or withholding of care in this study, we found that the withdrawal of all active treatment is widespread in ICUs in the United Kingdom. There was little change in this practice over the period examined. However, there was considerable variation by unit, even after accounting for patient factors and differences in size and type of ICU, suggesting improved guidelines may be useful to facilitate uniform decision making.

The CC chemokine I-309 inhibits CCR8-dependent infection by diverse HIV-1 strains

Using a chemokine receptor model based on known receptor sequences, we identified several members of the seven transmembrane domain G-protein superfamily as potential chemokine receptors. The orphan receptor ChemR1, which has recently been shown to be a receptor for the CC chemokine I-309, scored very high in our model. We have confirmed that I-309, but not a number of other chemokines, can induce a transient Ca2+ flux in cells expressing CCR8. In addition, the human erythroleukemic cell line K562 responded chemotactically in a dose-responsive manner to this chemokine. Since several chemokine receptors have been shown to be required as coreceptors for HIV-1 infection, we asked whether human immunodeficiency virus type 1 (HIV-1) could efficiently utilize CCR8. Here we show that the CCR8 receptor can serve as a coreceptor for diverse T-cell tropic, dual-tropic, and macrophage-tropic HIV-1 strains and that I-309 was a potent inhibitor of HIV-1 envelope-mediated cell-cell fusion and virus infection. Furthermore, we show by flow cytometry and immunohistochemistry that antibodies generated against the CCR8 receptor amino-terminal peptide cross-reacted with U-87 MG cells stably expressing CCR8, THP-1 cells, HL-60 cells, and human monocytes, a target cell for HIV-1 infectivity in vivo.

Pulmonary artery catheters for adult patients in intensive care

BACKGROUND

Since pulmonary artery balloon flotation catheterization was first introduced in 1970, by HJ Swan and W Ganz, it has been widely disseminated as a diagnostic tool without rigorous evaluation of its clinical utility and effectiveness in critically ill patients. A pulmonary artery catheter (PAC) is inserted through a central venous access into the right side of the heart and floated into the pulmonary artery. PAC is used to measure stroke volume, cardiac output, mixed venous oxygen saturation and intracardiac pressures with a variety of additional calculated variables to guide diagnosis and treatment. Complications of the procedure are mainly related to line insertion. Relatively uncommon complications include cardiac arrhythmias, pulmonary haemorrhage and infarct, and associated mortality from balloon tip rupture.

OBJECTIVES

To provide an up-to-date assessment of the effectiveness of a PAC on mortality, length of stay (LOS) in intensive care unit (ICU) and hospital and cost of care in adult intensive care patients.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 12); MEDLINE (1954 to January 2012); EMBASE (1980 to January 2012); CINAHL (1982 to January 2012), and reference lists of articles. We contacted researchers in the field. We did a grey literature search for articles published until January 2012.

SELECTION CRITERIA

We included all randomized controlled trials conducted in adults ICUs, comparing management with and without a PAC.

DATA COLLECTION AND ANALYSIS

We screened the titles and abstracts and then the full text reports identified from our electronic search. Two authors (SR and MG) independently reviewed the titles, abstracts and then the full text reports for inclusion. We determined the final list of included studies by discussion among the group members (SR, ND, MG, AK and SC) with consensus agreement. We included all the studies that were in the original review. We assessed seven domains of potential risk of bias for the included studies. We examined the clinical, methodological and statistical heterogeneity and used random-effects model for meta-analysis. We calculated risk ratio for mortality across studies and mean days for LOS.

MAIN RESULTS

We included 13 studies (5686 patients). We judged blinding of participants and personnel and blinding of outcome assessment to be at high risk in about 50% of the included studies and at low risk in 25% to 30% of the studies. Regardless of the high risk of performance bias these studies were included based on the low weight the studies had in the meta-analysis. We rated 75% of the studies as low risk for selection, attrition and reporting bias. All 13 studies reported some type of hospital mortality (28-day, 30-day, 60-day or ICU mortality). We considered studies of high-risk surgery patients (eight studies) and general intensive care patients (five studies) separately as subgroups for meta-analysis. The pooled risk ratio (RR) for mortality for the studies of general intensive care patients was 1.02 (95% confidence interval (CI) 0.96 to 1.09) and for the studies of high-risk surgery patients the RR was 0.98 (95% CI 0.74 to 1.29). Of the eight studies of high-risk surgery patients, five evaluated the effectiveness of pre-operative optimization but there was no difference in mortality when these studies were examined separately. PAC did not affect general ICU LOS (reported by four studies) or hospital LOS (reported by nine studies). Four studies, conducted in the United States (US), reported costs based on hospital charges billed, which on average were higher in the PAC groups. Two of these studies qualified for analysis and did not show a statistically significant hospital cost difference (mean difference USD 900, 95% CI -2620 to 4420, P = 0.62).

AUTHORS' CONCLUSIONS

PAC is a diagnostic and haemodynamic monitoring tool but not a therapeutic intervention. Our review concluded that use of a PAC did not alter the mortality, general ICU or hospital LOS, or cost for adult patients in intensive care. The quality of evidence was high for mortality and LOS but low for cost analysis. Efficacy studies are needed to determine if there are optimal PAC-guided management protocols, which when applied to specific patient groups in ICUs could result in benefits such as shock reversal, improved organ function and less vasopressor use. Newer, less-invasive haemodynamic monitoring tools need to be validated against PAC prior to clinical use in critically ill patients.

Adrenal-mediated endogenous metabolites inhibit puberty in female mice

While assessing a potential role of adrenal glands in the production of the hitherto unidentified puberty-delaying pheromone of female mice, the urinary volatile profiles of normal and adrenalectomized animals were quantitatively compared. Six components, whose concentrations were depressed after adrenalectomy, were identified: 2-heptanone, trans-5-hepten-2-one, trans-4-hepten-2-one, n-pentyl acetate, cis-2-penten-1-yl acetate, and 2,5-dimethylpyrazine. When these laboratory-synthesized chemicals were added (in their natural concentrations) to either previously inactive urine from adrenalectomized females or plain water, the biological activity was fully restored.

The effect of thyrotropin-releasing hormone (TRH) and somatostatin (GHRIH) on growth hormone and prolactin secretion in vitro and in vivo in the domestic fowl (Gallus domesticus)

The effects of thyrotropin-releasing hormone (TRH) on growth hormone (GH) and prolactin (Prl) secretion have been investigated in vitro and in vivo in domestic fowl. In both conscious and anaesthetized immature chickens the administration (i.v.) of TRH (2.5 and 25 microgram/kg) significantly increased the concentration of plasma GH. The simultaneous administration of somatostatin (GHRIH), 2.5 microgram/kg, to conscious birds significantly reduced the magnitude of the GH response to TRH treatment, but had no effect on the basal levels of plasma GH. The repeated injection of TRH (10 microgram/kg) every 20 min over a 100-min period failed to maintain the concentration of plasma GH at a high level. Prl secretion was not stimulated in any of these experiments, and in anaesthetized birds TRH (2.5 and 25 microgram/kg) treatment was followed by a depression in the level of plasma Prl. The effects of TRH and GHRIH on GH secretion by an in vitro dispersed pituitary cell suspension system were very similar to the in vivo studies. TRH stimulated Prl release in vitro, in contrast to the in vivo studies, and the response was dose related. GHRIH had no effect on the basal release of Prl in vitro but significantly inhibited the response to TRH treatment.

Influence of stress on the secretion of corticosterone in the duck (Anas platyrhynchos)

The influence of stress on the secretion of corticosterone has been investigated by radioimmunoassay in domestic ducks (Anas platyrhynchos) of 6-8 weeks of age. Intravenous and i.m. injections of synthetic ACTH (Synacthen, 25 i.u./bird and Synacthen Depot, 100 i.u./bird respectively) markedly increased (2.7- to 10-fold) basal concentrations of corticosterone in plasma (3-6 ng/ml) in comparison with those in birds injected with 0.9% saline (1 ml/bird). Maximum levels of 30-40 ng/ml plasma were reached after 30 min and 5 h respectivley. Increased levels of corticosterone in plasma were also seen within 5 min of i.v. administration of saline and remained as high as those in birds treated with Synacthen for at least 20 min after injection. Blood sampling (from the brachial vein) was, by itself, sufficient to increase levels of corticosterone in plasma; a large (twofold) rise being observed as soon as 1 min after initial handling and bleeding, with concentrations of 30-40 ng/ml being found in birds bled 15 times during a period of 14 min. However, in a flock of birds, the alarm created in unhandled birds while others were being bled had no effect on concentrations of corticosterone in plasma. Deprivation of food or water for 24 h also enhanced levels of corticosterone in plasma, as did 24 h of adaptation to 0.2 M-NaCl drinking water. These results have demonstrated the lability of the secretion of corticosterone in response to stress and demonstrated its usefulness as a physiological indicator of stress in ducks.

A unique urinary constituent, 6-hydroxy-6-methyl-3-heptanone, is a pheromone that accelerates puberty in female mice

BACKGROUND

Olfactorily mediated puberty acceleration in female mice (measured by an increase in uterine weight) has been observed since the 1960s without the active chemosignal being structurally identified. There are many controversies in the literature as to whether this male-originated pheromone is a volatile substance. We investigated the chemical nature of the urinary fractions that are responsible for the characteristic uterine weight increases.

RESULTS

The active pheromone was identified as 5,5-dimethyl-2-ethyltetrahydrofuran-2-ol and/or its open-chain tautomer (6-hydroxy-6-methyl-3-heptanone). A series of cyclic vinyl ethers were isolated from chromatographically active fractions of the urine. Because these compounds did not accelerate puberty, we postulated that these ethers were degradation products of a lactol (5,5-dimethyl-2-ethyltetrahydrofuran-2-ol). The lactol was then detected directly in the mouse urine extract using a silylation agent. Synthetic 6-hydroxy-6-methyl-3-heptanone had strong biological activity, whereas its close structural analogs did not.

CONCLUSIONS

The male house mouse excretes into its urine a large quantity of a volatile substance that has a unique lactol/hydroxyketone structure. This substance is capable of binding to the less volatile urinary constituents, such as proteins or peptides, and is active in puberty-acceleration bioassays. The controversies regarding the volatility of the puberty-accelerating pheromones can now be explained by considering a complex of volatile lactol/hydroxyketone and urinary proteins.

Risk factors for invasive fungal disease in critically ill adult patients: a systematic review

Introduction

Over 5,000 cases of invasive Candida species infections occur in the United Kingdom each year, and around 40% of these cases occur in critical care units. Invasive fungal disease (IFD) in critically ill patients is associated with increased morbidity and mortality at a cost to both the individual and the National Health Service. In this paper, we report the results of a systematic review performed to identify and summarise the important risk factors derived from published multivariable analyses, risk prediction models and clinical decision rules for IFD in critically ill adult patients to inform the primary data collection for the Fungal Infection Risk Evaluation Study.

Methods

An internet search was performed to identify articles which investigated risk factors, risk prediction models or clinical decisions rules for IFD in critically ill adult patients. Eligible articles were identified in a staged process and were assessed by two investigators independently. The methodological quality of the reporting of the eligible articles was assessed using a set of questions addressing both general and statistical methodologies.

Results

Thirteen articles met the inclusion criteria, of which eight articles examined risk factors, four developed a risk prediction model or clinical decision rule and one evaluated a clinical decision rule. Studies varied in terms of objectives, risk factors, definitions and outcomes. The following risk factors were found in multiple studies to be significantly associated with IFD: surgery, total parenteral nutrition, fungal colonisation, renal replacement therapy, infection and/or sepsis, mechanical ventilation, diabetes, and Acute Physiology and Chronic Health Evaluation II (APACHE II) or APACHE III score. Several other risk factors were also found to be statistically significant in single studies only. Risk factor selection process and modelling strategy also varied across studies, and sample sizes were inadequate for obtaining reliable estimates.

Conclusions

This review shows a number of risk factors to be significantly associated with the development of IFD in critically ill adults. Methodological limitations were identified in the design and conduct of studies in this area, and caution should be used in their interpretation.

Variations in concentrations of prolactin, luteinizing hormone, growth hormone and progesterone in the plasma of broody bantams (Gallus domesticus)

The concentrations of prolactin, LH, progesterone and GH were measured in the blood of broody bantam hens. The concentration of prolactin was at its highest when the birds began to incubate their eggs and in six out of nine hens it tended to remain raised until the eggs hatched. The increase in the concentration of prolactin was small: in incubating hens it was only 23% higher than in hens caring for their young and 14% higher than in laying hens (P less than 0.05 for both comparisons). The concentration of GH tended to be depressed in hens caring for young but otherwise was not related to reproductive activity. The concentrations of LH and progesterone decreased at the onset of incubation and remained depressed while the hens sat on their eggs (P less than 0.001) for both comparisons). After the chicks hatched, the level of LH began to increase slowly whereas the level of progesterone remained low. The hens stopped showing broody behaviour between 4 and 10 weeks after the chicks had hatched; this corresponded to the time when the concentration of LH had increased to values found in laying hens. These observations provide some evidence that prolactin secretion increases at the onset of incubation and support the view that the hormone is not secreted at an increased rate while hens are caring for their young.

Life-threatening focal status epilepticus due to occult cortical dysplasia

OBJECTIVE

Neuronal migration disorders are usually, but not necessarily, demonstrated by magnetic resonance imaging. Preoperative suspicion of these anomalies in the presence of normal magnetic resonance studies has important practical implications. This study delineates some clinical features that permit early suspicion of focal cortical dysplasia localized in the central and precentral regions.

DESIGN

In a retrospective case series, we studied the clinical presentation of four consecutive patients with normal preoperative magnetic resonance images in whom focal cortical dysplasia was found in the surgical specimen.

SETTING

Patients were seen in three referral centers specializing in epilepsy surgery.

PATIENTS

Four patients (three female), between the ages of 4 and 21 years, had intractable partial seizures leading to resective brain surgery.

INTERVENTION

Three patients had corticectomies in the central (two patients) or frontal (one patient) regions. One underwent an en bloc resection of the central area after two unsuccessful corticectomies and cortical transection.

RESULTS

Three patients presented with life-threatening focal motor status epilepticus necessitating intubation, and one had epilepsia partialis continua. All had had seizures previously, and the attacks progressed to intractability after 1 1/2 to 3 years. Surgery led to control of the seizures, but only two patients became seizure free (mean follow-up, 15.7 months). All but one developed a postoperative deficit, which eventually improved.

CONCLUSIONS

Focal cortical dysplasia should be suspected when life-threatening focal motor status epilepticus or epilepsia partialis continua occur in children or young persons without another obvious cause. Normal magnetic resonance studies do not exclude neuronal migration disorders.

Evaluation of satisfaction with midwifery care

OBJECTIVE

to determine if there were differences in women's satisfaction with maternity care given by doctors and midwives. In addition a simple, six-question, satisfaction questionnaire was to be tested.

DESIGN

a randomised controlled trial comparing two models of maternity care.

SETTING

a tertiary referral centre in Alberta, Canada.

PARTICIPANTS

one hundred and ninety four women with a low-risk pregnancy were randomly assigned to either the midwife care, experimental group (n = 101), or the doctor care, control group (n = 93).

INTERVENTIONS

a pilot midwifery programme was introduced into a maternity services delivery system that did not have established midwifery.

MEASUREMENTS

women's satisfaction was measured, at two weeks postpartum, with the Labour and Delivery Satisfaction Index (LADSI), general attitudes toward the birth experience, also at two weeks postpartum; with the Attitudes about Labour and Delivery Experience (ADLE) questionnaire. Fluctuations in satisfaction were measured with a Six Simple Questions (SSQ) questionnaire at 36 weeks gestation and 48 hours, two and six weeks postpartum.

FINDINGS

women in the midwife group reported significantly greater satisfaction and a more positive attitude toward their childbirth experience than women in the doctor group (p < 0.001). The SSQ demonstrated scores similar to the LADSI. Satisfaction in both groups was lowest at 36 weeks gestation and highest immediately postpartum.

KEY CONCLUSIONS

women experiencing low-risk pregnancies were more satisfied with care by midwives than with care provided by doctors. Satisfaction scores were high for both groups and may have been lower for women in the doctor group as a result of disappointment with caregiver assignment as all women had sought midwifery care. The SSQ measures similar dimensions to the LADSI but the agreement is not strong enough to recommend its use as a substitute at this time.

IMPLICATIONS FOR PRACTICE

the significantly higher satisfaction of the women with the care provided by the midwives together with better clinical outcomes reported elsewhere suggest that the option of midwifery care should be accessible as an option for all women in Canada. Further research is suggested to determine the usefulness of the SSQ.

Evidence that vasoactive intestinal polypeptide is a physiological prolactin-releasing factor in the bantam hen

Vasoactive intestinal polypeptide (VIP)-like material was localised immunohistochemically in the hypothalamus of the bantam hen. Abundant immunoreactive VIP terminals were seen in the external layer of the median eminence and most immunoreactive VIP cell bodies were located in the basal hypothalamus. A few immunoreactive VIP cell bodies and many fibres were found in the preoptic hypothalamus. Intravenous injections of synthetic porcine VIP over a dose range of 12.5 to 100 micrograms kg-1 body wt resulted in dose-related increase in concentration of plasma prolactin in incubating bantams deprived of their nests for 24 hr. These doses of VIP did not stimulate the release of growth hormone. Studies in vitro showed that synthetic VIP directly stimulated prolactin release from the anterior pituitary gland. The glands from incubating bantams were more responsive to the prolactin-releasing effects of VIP than were the glands from laying birds. Studies in vitro showed that the amount of prolactin released in response to an iv injection of 50 micrograms kg-1 VIP was greater in incubating birds deprived of their nests for 24 hr than in laying hens. Prolactin release was not stimulated in ovariectomized hens after an injection of 50 micrograms kg-1 VIP unless the birds were first treated with oestrogen or oestrogen and progesterone. It was concluded that a VIP-like material in the bantam hypothalamus may be a physiological prolactin-releasing factor acting at least in part at the level of the anterior pituitary gland.(ABSTRACT TRUNCATED AT 250 WORDS)