Research ethics with real-world data (RWD) on COVID-19 infections: the unCoVer study

Issue

The aim of the Horizon 2020 unCoVer project (Unravelling Data for Rapid Evidence-Based Response to COVID-19) is to coordinate research expertise in utilising Real World Data (RWD) to investigate the underlying risk factors for COVID-19 infection and severity, the effectiveness of treatments and the impact on health systems. RWD is particularly useful in a dynamic health context as it is relevant, timely, and more ecologically valid. Pooling clinical databases and integrating epidemiological principles and powerful biostatistical tools optimises resources and fully exploits routinely-collected data.

Description of the problem

RWD sharing poses new practical and ethical challenges to research. The unCoVer network has developed a federated data platform to access diverse databases for advanced analytics. This data access process entails GDPR, and regulatory and ethical nuances. The use of large-scale data from heterogeneous sources across multiple jurisdictions for research purposes presents a complex systems challenge.

Effects & Lessons

A dedicated team of unCoVer network members is responsible for addressing these challenges. Here, we describe the ethical and regulatory aspects of RWD sources, the role of the Data Protection Authorities and the Data Protection External Authority Board (DP-EAB) of the Uncover project, and the documentation involved, including a data processing agreement and a data transfer agreement. We provide an overview of the main principles for sharing RWD whilst maintaining integrity and security and how this translates into procedures to protect the rights, security, and well-being of human research participants. This represents a practical framework for researchers.

Key messages

Covid-19 presentation among symptomatic healthcare workers in Ireland

BACKGROUND

It is recognized that healthcare workers (HCWs) are at high risk of contracting Covid-19. It is incumbent on occupational health staff to recognize potential symptoms of Covid-19 among HCWs.

AIMS

The aims of the study were to describe the presenting symptoms of HCWs who developed Covid-19 in Ireland, and to estimate the odds of specific symptoms being associated with a positive Covid-19 polymerase chain reaction (PCR) result.

METHODS

A retrospective chart review of all symptomatic HCWs who self-presented for Covid-19 testing in Cork from March to May 2020 was conducted. A sex-matched case-control study was carried out to compare presenting features among those who tested positive compared to those who tested negative. Univariate and multivariable-adjusted conditional logistic regression models were run using Stata 15.0 to identify the symptoms associated with positive Covid-19 swab results.

RESULTS

Three hundred and six HCWs were included in the study; 102 cases and 204 controls. Common presenting features among cases were fever/chills (55%), cough (44%) and headache (35%). The symptoms which were significantly associated with a positive Covid-19 swab result were loss of taste/smell (adjusted odds ratio [aOR] 12.15, 95% confidence interval [CI] 1.36-108.79), myalgia (aOR 2.36, 95% 1.27-4.38), fatigue (aOR 2.31, 95% CI 1.12-4.74), headache (aOR 2.11, 95% CI 1.19-3.74) and fever/chills (aOR 1.88, 95% CI 1.12-3.15).

CONCLUSIONS

Fever, fatigue, myalgia, loss of taste/smell and headache were associated with increased odds of a Covid-19 diagnosis among symptomatic self-referred HCWs compared with those had negative swab results. Testing criteria for HCWs should reflect the broad range of possible symptoms of Covid-19.

Have Legislative Interventions Impacted the Incidence of Needlestick Injuries?

Introduction The aim of this study was to examine the impact the EU Directive for the Prevention of Sharps injuries had on the incidence of needlestick injuries (NSI) in Ireland. Methods A five-year retrospective study prior to, and after the introduction of these regulations, was conducted. Secondary data from the Occupational Health Department's annual NSI reports were used. The population studied were healthcare workers who reported a NSI from 2013 to 2017. Results The incidence of NSI varied from 157 in 2017 to 207 in 2014. 'Miscellaneous needles' was the category which caused the most NSI (23%). 'Disposable needles with syringes' accounted for 20% of all NSI before the legislation; this figure was reduced to 12-15% after the regulations were introduced. Conclusion The EU regulations did not reduce the incidence of NSI. A lower incidence of NSI was reported from 'disposable needles with syringes' after the implementation of the regulations.

Irritant contact dermatitis in healthcare workers as a result of the COVID-19 pandemic: a cross-sectional study

COVID‐19 healthcare workers (HCWs) require frequent handwashing and use of personal protective equipment (PPE) to prevent infection. However, evidence is emerging that these practices are causing adverse effects on their skin integrity. A single‐centre, cross‐sectional study of HCWs from an Irish hospital was undertaken to evaluate the degree of COVID‐19‐related irritant contact dermatitis (ICD) between April and May 2020. Of 270 participants surveyed, 223 (82.6%) reported symptoms of ICD. The hands were the most commonly affected site (76.47%) and the most frequently reported symptom was dry skin (75.37%). Nearly all (268; 99.26%) HCWs had increased hand‐washing frequency, but 122 (45.35%) did not use emollients. In the ICD group, 24.7% cited a history of dermatitis compared with 4.3% of unaffected staff (P < 0.001). The ICD group recorded PPE usage for an average of 3.15 h compared with the non‐ICD group at 1.97 h (P = 0.21). Promoting awareness of COVID‐19‐related ICD is vital to highlight prevention and treatment for frontline staff.

Work-Related Stress Induced Takotsubo Cardiomyopathy

Aim To report a case of Takotsubo cardiomyopathy secondary to a verbal altercation in an employee who presented with chest pain. Methods The clinical history was obtained from the patient's occupational health record and correspondence from her treating cardiologist. Results The patient was diagnosed with Takotsubo cardiomyopathy following investigations for chest pain. Her echocardiogram was diagnostic. She was treated with beta blockers and advised to have complete rest; she remained out of work for six months. Conclusion There are few published cases of work related Takotsubo cardiomyopathy; it poses a challenge to physicians to be cognisant of this condition in a case of chest pain following emotional turmoil.

EUV spectral analysis of ns-laser produced bismuth plasmas at 8-17 nm

Extreme ultraviolet (EUV) spectra from laser produced bismuth plasmas were recorded in the 8-17 nm spectral region using a Nd:YAG laser with a pulse length of 8 ns operating at a range of laser power densities. Due to the broad-band emission at 8-17 nm, bismuth plasmas show promise as sources of quasicontinuous radiation in the extreme ultraviolet. When varying the incident laser power density, ionic populations of Bi ions at different power densities were estimated by the collisional-radiative (CR) model for explanation of changes in the spectral profile. Comparison of experimental spectra with atomic structure calculations using the Hartree-Fock with configuration interaction (HFCI) code of Cowan was performed in order to identify most of the features in the spectra.

Evolution analysis of EUV radiation from laser-produced tin plasmas based on a radiation hydrodynamics model

One of fundamental aims of extreme ultraviolet (EUV) lithography is to maximize brightness or conversion efficiency of laser energy to radiation at specific wavelengths from laser produced plasmas (LPPs) of specific elements for matching to available multilayer optical systems. Tin LPPs have been chosen for operation at a wavelength of 13.5 nm. For an investigation of EUV radiation of laser-produced tin plasmas, it is crucial to study the related atomic processes and their evolution so as to reliably predict the optimum plasma and experimental conditions. Here, we present a simplified radiation hydrodynamic model based on the fluid dynamic equations and the radiative transfer equation to rapidly investigate the evolution of radiation properties and dynamics in laser-produced tin plasmas. The self-absorption features of EUV spectra measured at an angle of 45° to the direction of plasma expansion have been successfully simulated and explained, and the evolution of some parameters, such as the plasma temperature, ion distribution and density, expansion size and velocity, have also been evaluated. Our results should be useful for further understanding of current research on extreme ultraviolet and soft X-ray source development for applications such as lithography, metrology and biological imaging.

Uterine artery embolization for treatment of symptomatic fibroids; a single institution experience

BACKGROUND

Uterine fibroids are the most common reproductive tract tumours in females. Uterine artery embolization (UAE) is a fertility-sparing procedure for treatment of symptomatic fibroids. We evaluated the efficacy and safety of UAE in the treatment of 118 patients with symptomatic uterine fibroids in a single Academic Centre in the West of Ireland to determine whether fibroid and uterine size affect clinical outcomes and complications.

METHODS

This was a retrospective cohort of 118 patients who underwent UAE for treatment of symptomatic fibroids between November 2006 and August 2011. Diagnosis of fibroids in symptomatic patients was established by magnetic resonance imaging (MRI) and/or transabdominal ultrasonography (US). Three different embolic agents were used. All patients had at least one follow-up using MRI, at three and/or 12 months. A non-validated questionnaire was used to report patient satisfaction with regards to symptoms improvement on a yes-or-no basis.

RESULTS

Mean fibroid volume, uterine size and dominant fibroid size were significantly reduced at three months and one year follow-up (p = 0.00) and that was tallied with symptoms improvement (p < 0.05). Overall patient satisfaction at three months was 84% falling to 75.9% by 12 months (all p < 0.05). Few complications were reported (2.5%). No significant difference was observed in safety or efficacy for different embolic agents.

CONCLUSION

The study confirms the safety and efficacy of UAE in the treatment of symptomatic fibroids. Hippokratia 2014; 18 (3): 258-261.

Care of type 2 diabetes in unresourced general practice: current practice in the Mid-West

It is estimated that 4.5% of the Irish population have type 2 diabetes. The HSE intends to move the care of uncomplicated type 2 diabetes to General Practice (GP). The study reviewed current General Practice diabetes care in the Irish Mid-West. The files of randomly selected patients from 12 GP teaching practices attached to the University of Limerick were audited. 842 patients were identified (62% male, 38% female). The mean age was 66 years. 75% were GMS patients. A practice protocol was used in 71% of patients. Average Cholesterol (4.3 mmol/l), creatinine (85.3 mmol/l), HbA1c (56.7 mmol/mol) and systolic blood pressure (SBP) (134 mmHg) measurements were well documented and controlled. However the rates of and mean intervals for foot review (60.2%), BMI measurement (52.3%), retinopathy screening (62.0%) and influenza vaccination (63.0%) were unacceptably low. Current management of type 2 diabetes in unresourced general practices is suboptimal although some biochemical parameters are well controlled.

CO2 laser pulse shortening by laser ablation of a metal target

A repeatable and flexible technique for pulse shortening of laser pulses has been applied to transversely excited atmospheric (TEA) CO(2) laser pulses. The technique involves focusing the laser output onto a highly reflective metal target so that plasma is formed, which then operates as a shutter due to strong laser absorption and scattering. Precise control of the focused laser intensity allows for timing of the shutter so that different temporal portions of the pulse can be reflected from the target surface before plasma formation occurs. This type of shutter enables one to reduce the pulse duration down to ~2 ns and to remove the low power, long duration tails that are present in TEA CO(2) pulses. The transmitted energy is reduced as the pulse duration is decreased but the reflected power is ~10 MW for all pulse durations. A simple laser heating model verifies that the pulse shortening depends directly on the plasma formation time, which in turn is dependent on the applied laser intensity. It is envisaged that this plasma shutter will be used as a tool for pulse shaping in the search for laser pulse conditions to optimize conversion efficiency from laser energy to useable extreme ultraviolet (EUV) radiation for EUV source development.

Laptops and smartphones in the operating theatre - how does our knowledge of vigilance, multi-tasking and anaesthetist performance help us in our approach to this new distraction?

There has been no research performed concerning the effects of the use of laptops and smartphones in the operating theatre on anaesthetist performance, yet these devices are now in frequent use. This article explores the implications of this phenomenon. The cognitive and environmental factors that support or detract from vigilance and multi-tasking are explored and core anaesthetic literature on the nature of anaesthetic work and operating theatre distractions is reviewed. Experienced anaesthetists are skilled at multi-tasking while maintaining situational awareness, but there are limits. Noise, interruptions and emotional arousal are detrimental to the cognitive performance of anaesthetists. While limited reading during periods of low task load may not reduce vigilance, computer use introduces text-based activities that are more interactive and potentially more distracting. All anaesthetists need to be mindful of the limits to the human attention span which requires observation and limiting distractions. Trainees have less experience and less 'attentional' safety margin, so should avoid adding additional distractions such as discretionary use of laptops or smartphones to their operating theatre work. We provide recommendations for future research on the specific advantages and disadvantages of pervasive computing in the operative theatre.

A review of the obstetric management of patients with epidermolysis bullosa

Epidermolysis bullosa (EB) is a rare inherited skin condition characterized by the development of blisters after minor mechanical friction or trauma. There are few reported pregnancies in the literature in these women. We describe a pregnancy we recently managed. The collated series of pregnancies show that there are no additional antenatal or postnatal problems and that the skin itself does not worsen during pregnancy. Vaginal delivery is most favourable, but if a caesarean section is required, regional anaesthesia should be attempted. A multidisciplinary team should be active throughout the pregnancy of these women and a well-documented labour plan should be made in advance.

Central venous catheter insertion by a clinical nurse consultant or anaesthetic medical staff: a single-centre observational study

OBJECTIVE

To compare clinical outcomes of elective central venous catheter (CVC) insertions performed by either a clinical nurse consultant (CNC) or anaesthetic medical staff (AMS).

DESIGN, SETTING AND PARTICIPANTS

Prospective audit of a convenience sample of consecutive CVC insertions between July 2005 and October 2007 at a metropolitan teaching hospital in Sydney, Australia. The sample included all outpatients and inpatients requiring a CVC for either acute or chronic conditions.

MAIN OUTCOME MEASURES

Number of CVC lines inserted; differences between outcomes in the CNC and AMS groups; complications during and after insertion.

RESULTS

Over a 28-month period, 245 CVCs were inserted by AMS and 123 by the CNC. The most common indications for CVC placement in both groups were for the treatment of oncology and autoimmune disorders (61%) and for antibiotic therapy (27%). Other indications were parenteral nutrition (2%) and other therapies (10%). There was no significant difference in complications on insertion between the CNC and AMS groups. AMS failed to obtain access in 12 attempted procedures compared with eight by the CNC. The rate of CVCs investigated for infection was twice as high in the AMS group as in the CNC group (19% v 8%). The confirmed catheter-related bloodstream infection (CRBSI) rate was 2.5/1000 catheters in the AMS group and 0.4/1000 catheters in the CNC group (P = 0.04).

CONCLUSION

Insertion outcomes were favourable in both the AMS and CNC groups. Infection outcomes differed between groups, with a higher rate of CRBSI in the AMS group.

Anaesthetic management of two different modes of delivery in patients with dystrophic epidermolysis bullosa

Dystrophic epidermolysis bullosa is an inherited severe bullous condition characterised by extreme skin fragility and blistering in response to minor trauma. We present two obstetric cases with recessive dystrophic epidermolysis bullosa, one who underwent elective caesarean section, the other who delivered vaginally. The key points in the anaesthetic management of the obstetric patient with dystrophic epidermolysis bullosa include multidisciplinary preassessment, airway management strategies and the role of regional anaesthesia.

Assisted local anaesthesia for endoscopic dacryocystorhinostomy

BACKGROUND

Endoscopic dacryocystorhinostomy is traditionally performed under general anaesthesia. However, there are reports in the literature of various local anaesthetic techniques with or without sedation for this procedure. An effective and acceptable local anaesthetic technique enables the avoidance of the risks associated with general anaesthesia, particularly for elderly patients, with the added benefit of reduced bleeding, reduced nausea and vomiting, and reduced length of hospital stay and thus health care cost savings. This study aims to evaluate the safety and patient acceptance of a minimally invasive assisted local anaesthetic technique for endoscopic dacryocystorhinostomy.

METHODS

A prospective questionnaire-based study is presented of 24 consecutive adult patients who underwent 26 endoscopic dacryocystorhinostomies in a day surgery including 22 primary and four revision procedures performed by one surgeon under local anaesthesia and sedation over a 4-month period.

RESULTS

Apart from persistent postoperative vomiting in one patient there were no anaesthetic complications. There were no instances of epistaxis. The mean pain score on a visual analogue scale of 0-10 was 1.56 and 56% reported no pain. Ninety-two per cent would recommend the procedure to others.

CONCLUSION

This assisted local anaesthetic technique for endoscopic dacryocystorhinostomy is safe and acceptable to patients.

C1-esterase inhibitor deficiency and elective caesarean section

C1-esterase inhibitor deficiency is a rare disorder of the complement system characterised by episodes of cutaneous and mucosal oedema. Life-threatening airway oedema can follow airway instrumentation or minor trauma. We describe the successful management of a 37-year-old primiparous woman with inherited C1-esterase inhibitor deficiency who was admitted at 38 weeks' gestation for elective caesarean section. Whilst undergoing general anaesthesia 18 months previously she had experienced facial and pharyngeal oedema despite prophylaxis (one unit of fresh frozen plasma). On this occasion she underwent elective caesarean section following intrathecal anaesthesia with 0.5% hyperbaric bupivacaine 2 mL and diamorphine 300 microg. Cardiovascular stability was ensured using glycopyrolate and intravenous Hartmann's solution 2 L; a live female infant was delivered successfully. There were no peri- or postoperative complications. Regional anaesthesia is the safest method for providing surgical anaesthesia in the obstetric patient. We believe elective caesarean section under regional anaesthesia should be considered if there are predicted difficulties with vaginal delivery.

Home treatment as an alternative to inpatient admission: characteristics of those treated and factors predicting hospitalization

In response to the NHS Plan, crisis and home treatment teams will be developed across the UK in order to provide intensive home treatment as an alternative to inpatient admission for individuals with severe, acute mental health problems. This study describes aspects of the work of two teams in Hertfordshire. A total of 293 individuals were taken on for intensive home treatment in a 12-month period. A range of social and demographic variables was recorded at the point of initial assessment regarding each individual, as well as two rating scales: the Brief Psychiatric Rating Scale and the Scale for Suicide Ideation. Sixty-two individuals (21.1%) required admission to hospital after a median period of home treatment of 11 days. The most frequently recorded reason for admission taking place was 'risk to self' (n = 33, 53.2%). Two variables were identified by logistic regression analysis as being predictive of an increased risk of hospitalization: high suicidal ideation at initial assessment (P < 0.01) and previous hospital admission (P < 0.01). Although statistically significant, these variables were only weakly predictive of whether admission would actually take place.

A randomised controlled trial of fluid pre-loading before low dose epidural analgesia for labour

Preloading with fluid is recommended before regional block in labour. Low dose epidurals may produce less haemodynamic disturbance than traditional stronger solutions of local anaesthetics. Our aim was to compare the incidence of hypotension in normal labouring women who received a low dose epidural (0.1% bupivacaine 15 mL with fentanyl 2 microg microg.mL(-1)) with and without an i.v. crystalloid preload. Women with normal labours were randomised to the intervention group: no i.v. crystalloid preload (n = 85) and the control group: 7 mL mL.kg(-1) i.v. crystalloid solution before epidural injection (n = 83). Mean arterial pressure was recorded every 5 min for 30 min. There was no difference between the groups in mean decrease in mean arterial pressure and similar proportions of women showed falls in mean arterial pressure of 20% or greater (13% vs. 11%, risk ratio 1.2, 95% CI 0.54 to 2.8, P = 0.6). Blinded analysis by independent obstetricians revealed no differences in the fetal heart rate abnormalities (20% vs. 15%, risk ratio 1.3, 95% CI 0.67 to 2.7). A scientifically valid conclusion whether preloading is useful cannot be drawn from this study. This study suggests that about 350 participants in each group would be necessary to exclude a type 2 error in a future study.

Assessing bupivacaine 10mg/fentanyl 20μg as an intrathecal test dose

After ethics committee approval and verbal consent, women undergoing elective caesarean section given spinal anaesthesia with hyperbaric 0.5% bupivacaine 10 mg (2 mL) plus fentanyl 20 microg (spinal group, n = 20) and women requesting epidural analgesia in labour given the same drugs and doses epidurally, either in the same concentration (epidural small volume group, n = 10) or as 10 mL of 0.1% bupivacaine plus fentanyl 20 microg (epidural large volume group, n = 12) were recruited. The temperature of the great toes, sensory block on the outer ankle (S1 dermatome), motor block at the ankle and haemodynamic changes were recorded every 2 min for 10 min. There was a significant rise in foot temperature only in the spinal group. At four minutes a combination of warm toes and motor or sensory block, usually both, were seen only in the spinal groups. Haemodynamic changes were non-specific. We conclude that bupivacaine 10 mg with fentanyl 20 microg is a reliable agent to detect intrathecal placement by 4 min by which time a combination of motor and sensory block at the ankle and toe warming should be present.

Validation of the Welch Allyn 'Vital Signs' blood pressure measurement device in pregnancy and pre-eclampsia

OBJECTIVE

To establish the accuracy the Welch Allyn 'Vital Signs' blood pressure monitor in pregnancy and pre-eclampsia according to a modified British Hypertension Society protocol.

DESIGN

Prospective observational study.

SETTING

Maternity Unit/Obstetric Ward, Guy's and St Thomas' Hospital, London, UK.

POPULATION

Forty-three pregnant women of whom 12 had pre-eclampsia.

METHODS

Nine sequential same-arm measurements were taken from each woman by two trained observers, alternating between a mercury sphygmomanometer and the device. The last seven readings were analysed according to the British Hypertension Society protocol. The accuracy of the device was determined using the grading scale indicated by the British Hypertension Society protocol (grade A/B = pass, grade C/D = fail).

MAIN OUTCOME MEASURES

Grading criteria of the British Hypertension Society Protocol.

RESULTS

The Welch Allyn 'Vital Signs' monitor achieved a grade A for both systolic and diastolic pressures in pregnant women who did not have pre-eclampsia. In those women with pre-eclampsia, it achieved a grade D and B for systolic and diastolic pressures, respectively. The mean differences between the observers and the device in women without pre-eclampsia were -2.6 (6.4) and -1.5 (7.2) mmHg for systolic and diastolic pressures [and in pre-eclamptic women -7.8 (6.3) and -5.5 (6.5)mmHg]. It therefore fulfils criteria set by the Association for the Advancement of Medical Instrumentation (mean <5 mmHg and standard deviation <8 mmHg) in pregnancy, but not in pre-eclampsia.

CONCLUSION

This is the first automated device suitable for robust clinical use that can be recommended for use in pregnancy. However, it should be borne in mind that-similar to other devices--it significantly under--recorded readings obtained in pre-eclamptic women.

Delivery of nasal drops to the middle meatus: which is the best head position?

BACKGROUND

Chronic sinusitis and intranasal polyps require long-term topical drug therapy. The issue of drug delivery to the critical area of the middle meatus is rarely addressed.

AIM

The aim of this study was to compare the delivery of drops to the middle meatus using four different head positions (Mecca, Mygind, Ragan and Head back). The study also assessed the discomfort with each position whilst administering the nasal drops.

METHODS

Nine nostrils in five healthy volunteers were studied to compare the delivery of drops to the middle meatus using the four different head positions. A neurosurgical patty was placed under direct vision in the middle meatus using a rigid nasendoscope. Six drops of dyed-saline were administered into each nostril. Upon removal, a quantitative assessment was made of the amount of dye absorbed and discomfort assessed. The direction of flow of the nasal drops in the nose was also demonstrated.

RESULTS

The 'Mygind' and 'Ragan' positions were superior to the 'Mecca' and 'Head back' positions in delivery of drops to the middle meatus. The 'Mecca' position was the most uncomfortable.

CONCLUSION

We recommend that the 'Mygind' or 'Ragan' position should be used for nasal drop administration.

Probiotic impact on microbial flora, inflammation and tumour development in IL-10 knockout mice

BACKGROUND

The enteric bacterial flora has been implicated in the pathogenesis of enterocolitis and colon cancer in C57BL/6 IL-10 knockout mice. Probiotic Lactobacilli modify the enteric flora and are thought to have a beneficial effect on enterocolitis. We conducted a controlled feeding trial in IL-10 knockout mice using the probiotic Lactobacillus salivarius ssp. salivarius UCC118.

AIM

To determine the effect of probiotic consumption on the gastrointestinal microflora, tumour development and colitis in IL-10 knockout mice.

METHODS

Twenty IL-10 knockout mice were studied (10 consumed probiotic organisms in milk and 10 consumed unmodified milk) for 16 weeks. Faecal microbial analysis was performed weekly to enumerate excretion of the probiotic UCC118, total lactobacilli, Clostridium perfringens, bacteroides, coliforms, bifidobacteria and enterococci. At sacrifice, the small and large bowel were microbiologically and histologically assessed.

RESULTS

L. salivarius UCC118 was detected in faeces from all mice in the probiotic fed group, but not the control group. Faecal coliform and enterococci levels were significantly reduced in probiotic fed animals compared to the controls (P < 0.05). At sacrifice, a significant reduction in C. perfringens numbers was observed in the test mice (P < 0.05). There were no fatalities in the test group compared to two deaths from fulminant colitis in the control group. Only one test mouse developed colonic adenocarcinoma compared to five in the control group. Test animal mucosal inflammation consistently scored lower than that of the control mice.

CONCLUSION

In this placebo controlled trial, modification of enteric flora in IL-10 knockout mice by probiotic lactobacilli was associated with reduced prevalence of colon cancer and mucosal inflammatory activity.

Effect of lateral versus supine wedged position on development of spinal blockade and hypotension

Aortocaval compression may not be completely prevented by the supine wedged or tilted positions. It is commonly believed, however, that the unmodified full lateral position after induction of spinal anaesthesia might allow excessive spread of the block. We therefore compared baseline arterial pressures in the supine wedged, sitting, tilted and full lateral positions in 40 women who were about to undergo elective caesarean section. They were then given spinal anaesthesia in the left lateral position and randomised to be turned to the right lateral or the supine wedged position, after which speed of onset and spread of blockade to cold sensation were measured every 2 min for 10 min and mean arterial pressure and ephedrine requirement were recorded every minute for 20 min. Baseline mean arterial pressure was 9 mmHg (95% CI 3 to 14) lower in the left lateral (measured in the upper arm) than in the sitting position; those in the supine wedged and tilted positions were intermediate. Following spinal anaesthesia, hypotension (defined as a reading </=80% of the baseline value in the same position) lasted 2.4 min longer (CI +0.6 to +4.1) in the supine wedged group, but there was no significant difference between the groups in maximum fall or ephedrine requirement. The upper level of block rose more rapidly in the supine wedged than in the lateral group and showed less variability. There is therefore no reason to fear the unmodified lateral group position, which may offer better protection against hypotension.

Subdural haematoma after dural puncture headache treated by epidural blood patch

Subdural haematoma is a well-documented complication of accidental dural puncture, and is thought to be preventable by prompt treatment with an epidural blood patch. An accidental dural puncture occurred in a 39-yr-old primagravida during the siting of an epidural catheter for pain relief in labour. Twenty hours after the puncture, the mother developed a typical postdural puncture headache, which increased in severity over the subsequent 24 h. An epidural blood patch was performed at 48 h, and this initially relieved the headache. After discharge from hospital, and 14 days after the dural puncture, the headache recurred, together with expressive dysphasia, poor co-ordination and sensory loss in the right arm. A magnetic resonance imaging scan demonstrated a left sided subdural haematoma, which was drained successfully with complete recovery.

True lateral dermoid cyst of the floor of the mouth

Congenital dermoid cysts of the floor of the mouth are relatively rare but when they occur, they do so inevitably in the midline. We present a case of a true lateral dermoid cyst of this region without any intra-oral extension. We discuss the anatomical and histological classification of dermoid cysts within the floor of the mouth.

Surgical management of intractable epistaxis: audit of results

We have audited our results after changing the management practice in patients with intractable epistaxis. These patients are offered trans-nasal endoscopic sphenopalatine artery diathermy with or without anterior ethmoid artery diathermy instead of conventional surgical procedures. During the first year after the change in practice, 145 patients were treated as inpatients for epistaxis. Ten patients (seven per cent) required a surgical procedure under general anaesthesia due to the recurrent nature of bleeding. All 10 patients had endoscopic sphenopalatine artery diathermy, whereas in four patients anterior ethmoid artery diathermy was also performed concurrently. The post-operative hospital stay ranged from one to three days (mean 2.1 days). The mean follow-up was 10 months. The epistaxis recurred in one patient and this was managed conservatively. There were no complications related to surgery. In the previous year, 132 patients were admitted for epistaxis and eight patients had surgical procedures, which included septoplasty, nasal packing and external carotid artery ligation. The post-operative stay ranged from three to six days (mean 3.9 days). Our audit shows that endoscopic sphenopalatine artery diathermy is a safe, successful and effective management option for patients with refractory epistaxis. The morbidity is reduced and the hospital stay is shortened. The sphenopalatine artery diathermy can be combined with anterior ethmoid surgery, when necessary.

Pars tensa retraction pockets in children: treatment by excision and ventilation tube insertion

Tympanic membrane retraction pockets involving the pars tensa are not uncommon in clinical practice. Recurrent infections, ossicular erosion and cholesteatoma are the recognized sequelae. The management options include surveillance, medical treatment and surgery. The surgical procedures range from grommet insertion to extensive tympanoplasty procedures. We report our experience with simple excision and grommet insertion, performed in 31 ears in 26 patients as day cases. The follow-up ranged from 8 to 34 months with a mean of 16 months. The procedure was successful in 23 ears (success rate of 74%). Recurrence of retraction occurred in seven ears and in one ear there was a persistent perforation. Age, previous grommet insertion and severity of retraction did not have a statistically significant influence on the final outcome. We conclude that excision and grommet insertion is a simple, safe and efficient procedure for the management of tympanic membrane retraction pockets and can be considered in preference to extensive tympanoplasty.

Paraesthesiae and nerve damage following combined spinal epidural and spinal anaesthesia: a pilot survey

Concern has been expressed that recent changes in techniques of spinal blockade may have resulted in an increase in frequency of neurological sequelae. In order to make preliminary enquiries about anaesthetists' recent experiences of neurological sequelae following spinal and combined spinal-epidural anaesthesia, a questionnaire, covering numbers of procedures, needles used and any neurological problems that had been encountered, was sent to the anaesthetist in charge of each obstetric centre on the Royal College of Obstetricians and Gynaecologists' United Kingdom list. Replies were received from 222 of the 259 units, of whom 40 reported a total of 56 cases involving prolonged neurological sequelae, of which nine were probable obstetric palsies, 18 could be attributed to the regional procedure (one instance of conus damage and the rest largely sensory disturbances) and 29 were of uncertain origin, including a second conus damage. There was no obvious difference in incidence of problems associated with combined spinal-epidural vs. the single-shot spinal technique (odds ratio 1.14, confidence interval 0.53 to 2.46), or Sprotte vs. Whitacre atraumatic needle (odds ratio 1.40, confidence interval 0.64 to 3.08). A prospective survey, or better still, randomisation would be needed to verify these findings.

Eating in labour. A randomised controlled trial assessing the risks and benefits

The aim of this study was to determine whether permitting women in labour to eat a light diet would: (i) alter their metabolic profile, (ii) influence the outcome of labour, and (iii) increase residual gastric volume and consequent risk of pulmonary aspiration. Women were randomised to receive either a light diet (eating group, n = 48) or water only (starved group, n = 46) during labour. The light diet prevented the rise in plasma beta-hydroxybutyrate (p = 2.3 x 10(-5)) and nonesterified fatty acids (p = 9.3 x 10(-7)) seen in the starved group. Plasma glucose (p = 0.003) and insulin (p = 0.017) rose in the eating group but there was no difference in plasma lactate (p = 0.167) between the groups. There were no differences between the groups with respect to duration of first or second stage of labour, oxytocin requirements, mode of delivery, Apgar scores or umbilical artery and venous blood samples. Relative gastric volumes estimated by ultrasound measurement of gastric antral cross-sectional area were larger (p = 0.001) in the eating group. This was supported by the observation that those from this group who vomited, vomited significantly larger volumes than those in the starved group (p = 0.001). We conclude that eating in labour prevents the development of ketosis but significantly increases residual gastric volume.