A critique of current practice of transvaginal pudendal nerve blocks: a prospective audit of understanding and clinical practice.

Pudendal nerve blocks are a pre-requisite to forceps delivery without regional anaesthesia. Their efficacy is dependent on introducing local anaesthetic in close proximity to the pudendal nerve and allowing sufficient time for its onset of action. An audit of 57 obstetricians evaluated their clinical technique against standards using both a questionnaire and adapted model pelvis. The majority of participants were unable to describe correctly the point of infiltration and were unaware of the lag time required to effect adequate analgesia. We identify a deficiency in training and describe a method by which training can be facilitated and assessed.

Medical management of first trimester incomplete miscarriage using misoprostol.

This prospective study looked at the effectiveness of 400 microg oral misoprostol in the management of women with a first trimester incomplete miscarriage with retained products of conception measuring between 15 mm and 50 mm on transvaginal ultrasound scan. Of 164 eligible women, 131 agreed to participate. Successful treatment, defined as an empty uterus on scan after 10 days with no bleeding, was achieved in 77.7% of women. Some women with retained products opted to have further misoprostol or conservative management instead of surgical evacuation and in total 92.4% of women completed their miscarriage without requiring surgery. Most bleeding was mild (31.3%) to moderate (38.9%), lasting on average 6.4 days. Forty-five per cent of women needed no pain relief, 51% received oral analgesia and 4% intramuscular opiates. Adverse effects included nausea (10.93%), diarrhoea (2.34%), vomiting (7.8%) and hypotension (4.68%). There were no infections. We concluded that a single dose of 400 microg of oral misoprostol was an effective treatment for women presenting with an incomplete miscarriage.

Medical management of first trimester miscarriage (blighted ovum and missed abortion): is it effective?

This prospective study of 104 women investigated the dose-related efficacy of mifepristone combined with oral misoprostol in the management of first trimester miscarriage (missed abortion and blighted ovum). Forty-four women (group A) received 600 mg of oral mifepristone and 60 women (group B) received 200 mg of mifepristone, followed after 48 hours by oral misoprostol. Successful treatment was an empty uterus on scan and no bleeding after 10 days. This was achieved in 70.5% of group A and 66.7% of group B. Also studied were amount and time to cessation of bleeding, pain scores, analgesic requirements, adverse effects and infections. Of group A, 54.5% had heavy bleeding and bleeding stopped on average by 8 days. Median pain scores were 5.5 on a linear scale and 18% of women received intramuscular opiate analgesia. Adverse effects were nausea in 25% of women and diarrhoea in 16%. Of group B, 38.3% had heavy bleeding and bleeding stopped on average by 7 days. Median pain scores were 4.5 with 25% of women receiving intramuscular opiates. Nausea occurred in 7% of women and diarrhoea in 7%. We concluded that 200 mg of mifepristone and oral misoprostol is as effective and better tolerated than 600 mg mifepristone with oral misoprostol. Medical management of miscarriage is a valid option for those women seeking an alternative to traditional surgical management.

Salmonella sepsis and miscarriage.

We present a case of a miscarriage at 16 weeks of gestation due to infection and transplacental passage of Salmonella group C. This was identified as being Salmonella Virchow from genital tract swab culture, and placental Gram-staining revealed numerous colonies of Gram-negative bacilli within the fibrin between the placental villi, confirming a true villitis associated with a hematogenous infection. Based on the patient's history, it was suggested that she had contracted the salmonella infection from eating undercooked eggs. Treatment of salmonella infection in pregnancy is controversial, and antibiotic therapy should be reserved for cases of invasive disease, using amoxicillin or a cephalosporin.

Social class and semen analysis.

It has often been postulated that certain occupations may be hazardous to semen counts, but there are many conflicting views, with others finding either no differences in sperm count or only subtle differences in semen variables. We studied the effect of occupation (in relation to social class) on 207 men attending the fertility clinic of a district general hospital. In our own population azoospermic men were more likely to be of social class 3 m (3 semi-skilled manual) and below. Men who failed to provide a sample were more likely to be of social class 3 m. There was no statistical occupation difference in men whose sperm counts were normal or low. It may not be occupation alone, but also lifestyle differences between social classes which affect semen parameters.

alpha 1d Adrenoceptor signaling is required for stimulus induced locomotor activity.

alpha 1 Adrenergic receptors mediate a variety of physiological responses and have been well studied in the cardiovascular and peripheral nervous system. However, their role in the central nervous system remains ill defined because of the lack of highly specific ligands to the alpha1 receptor subtypes. Here, we have employed gene targeting to elucidate the role of alpha 1d receptors in vivo. In addition to disrupting function, the insertion of the lacZ gene into the alpha 1d receptor locus enabled the specific identification of cells expressing the alpha 1d gene. These cells are localized in the cortex, hippocampus, olfactory bulb, dorsal geniculate and ventral posterolateral nuclei of the thalamus. Behaviorally, the alpha 1d(-/-) mice show normal locomotor activity during the subjective day, or resting phase of their cycle. However, during subjective night, or active phase, wheel-running activity is significantly reduced in mutant mice. Furthermore, these mice show a reduction in exploratory rearing behavior in a novel cage environment. Lastly, alpha 1d(-/-) mice show reduced hyperlocomotion after acute amphetamine administration. Together, these data reveal the functional importance of alpha 1d adrenoceptors in mediating a variety of stimulus-induced changes in locomotor behaviors. While the sensitivity of noradrenergic neurons to environmental stimuli has been well documented, our data demonstrate that at least some of these post-synaptic responses are mediated by alpha 1d adrenergic receptors.

The value of Chlamydia trachomatis antibody testing as part of routine infertility investigations.

Laparoscopy is considered the gold standard for the evaluation of tubal disease but it is an invasive and costly procedure. Chlamydia trachomatis antibody testing is simple and inexpensive and causes minimal inconvenience to the patient. Using the micro-immunofluorescence technique we assessed the significance of positive serology. There was a marked association between the titre and the likelihood of tubal damage. In the group with low titres (1 in 32) there was only a 5% incidence of tubal damage; however, there was a progressive increase in the incidence of tubal damage in those with higher titres. Twenty out of 57 patients with titres higher than 1 in 32 had tubal damage (35%). The difference between the two groups was statistically significant (P < 0.0001, chi(2) test). By using C. trachomatis antibody testing more widely it may be possible to reduce the number of laparoscopies performed. It should therefore become an integral part of the fertility work-up.

Effect of chronic cocaine treatment on mu- and delta-opioid receptor mRNA levels in dopaminergically innervated brain regions.

The regulation of mu- (MOR) and delta-opioid receptor (DOR) after chronic cocaine administration has been studied. Male Sprague-Dawley rats were treated for 3 days with saline and cocaine (50 mg/kg/day) delivered by osmotic minipump. Expression of MOR and DOR mRNA in olfactory bulb, nucleus accumbens, and caudate-putamen (caudal and rostral parts) was estimated using quantitative competitive PCR assays after reverse transcription. No changes in the levels of mRNA for DOR were detected after exposure to cocaine in the brain regions examined. A significant increase in the level of MOR mRNA was detected in nucleus accumbens after 3 days of cocaine treatment. In caudate-putamen and olfactory bulb, no change in MOR mRNA was observed after cocaine administration. Both SCH 23390 and eticlopride, selective antagonists of D1- and D2-dopamine receptors, respectively, blocked this cocaine-induced up-regulation of MOR mRNA in nucleus accumbens. We suggest that endogenous opioid systems in nucleus accumbens, the brain region specifically associated with the reinforcing properties of addictive drugs, are regulated by dopaminergic mechanisms and influenced by cocaine treatment.

Surviving your first OSHA inspection.

With the inception of the bloodborne pathogens standard, home care agencies are more likely to undergo an inspection by the Occupational Safety and Health Administration. What should employers know, and how can they always be prepared for the startling announcement of an OSHA inspection?

Arthroscopic staple capsulorrhaphy for anterior shoulder instability.

We reviewed the results of the arthroscopic staple capsulorrhaphy on 47 patients with a followup of 4 years. Thirty-four of the 47 shoulders had a history of traumatic dislocation, while the remaining 13 had a history of subluxation. The recurrence rate was 25%, with 8 shoulders developing recurrent frank dislocation and 4 developing subluxation. Only 21 of the 47 patients were able to resume normal sporting activities after surgical repair. We had no cases of staple loosening within the joint, but we did have 3 patients whose staples were removed because of persistent pain in the shoulder.

Objective knee evaluation using the Genucom Knee Analysis System. Clinical implications.

The Genucom Knee Analysis System was used in a clinical setting to study the clinical practicality of the Genucom instrument, and the degree of correlation between Genucom and clinical knee examinations. The Genucom evaluation performed by an experienced examiner required 25 to 30 minutes for a 14 test bilateral examination. The instrument provided detailed graphical and tabular data of the test results. One hundred "normal knees" were examined in a series of seven Genucom tests. Normal "laxity bands" for both males and females were generated for a range of load applications for the seven tests. There was no significant difference observed between the male and female laxity distributions. However, a slightly lesser laxity was observed for the male population in general. A group of 38 subjects with 1 injured knee were assessed concurrently using clinical and instrument techniques. Comparisons were made for the 90 degrees anterior-posterior (AP) drawer, the 30 degrees AP drawer (Lachman), and the varus/valgus stress test. For the 90 degrees AP drawer test, 16 subjects were found clinically to have less than or equal to 5 mm of excess laxity based on comparison with the opposite normal knee. The instrumented measurement concurred in 10 cases. In the other six cases it was noted that laxity on the uninjured knee reached the maximum of the "normal" instrumented population, that is with higher than normal laxities. Fifteen subjects were clinically tested with greater than 5 mm of excess laxity. The instrumented test concurred in all but one.(ABSTRACT TRUNCATED AT 250 WORDS)

Processing of critical information by physicians and medical students.

In the study reported here, differences between physicians and medical students in their recall of information from clinical problems were investigated. The focus of the study was on the recognition and recall of critical cues within cases as a function of problem difficulty and the organization of clinical information. Two clinical cases in two structural forms (typical and random) were designed, and the participants' written recall of the cases was analyzed using the techniques of discourse analysis. The results show that the physicians recalled significantly more critical cues than the medical students. However, when the case had a temporally ordered, underlying disease process, the random structure of the text disrupted both the physicians' ability to recall critical cues and the accuracy of their diagnoses. The medical students were unaffected by problem type or structural form in the amount of information they recalled. The results show that the physicians and medical students formulate the information from clinical problems differently, and this difference is due to the fact that the physicians recognize patterns of familiar problems with respect to critical cues but the students do not.

Knee bracing and anterolateral rotatory instability.

We reviewed the efficiency of bracing in 85 patients with anterolateral rotatory instability (ALRI). We were able to compare 18 patients using an antirotational brace with 67 using the AC brace (J. E. Hanger, Montreal, Canada). We found the AC brace to offer better overall stability, 71% compared to 50%.

Pigmented villonodular synovitis of joints.

In a series of 38 young adults with intra-articular pigmented villonodular synovitis, the joint predominantly affected was the knee. For early diagnosis of intra-articular pigmented villonodular synovitis, a high level of suspicion is necessary for patients with complaints of persistent pain or swelling in the knee, or erosive osteoarthritis of the hip and shoulder of unknown etiology in young individuals. Arthrography of the knee was not found to be a very helpful test in the diagnosis of pigmented villonodular synovitis. Localized intra-articular pigmented villonodular synovitis should be treated by local excision. Diffuse intra-articular pigmented villonodular synovitis of the knee should be treated by extensive synovectomy followed by manipulation under general anesthesia two to three weeks postsurgery. Intra-articular pigmented villonodular synovitis of the shoulder and hip should be treated by extensive synovectomy or by total joint arthroplasty in cases with marked bone destruction and cyst formation.