The 2010 Royal Australasian College of Physicians' policy statement 'Circumcision of infant males' is not evidence based.

Infant male circumcision (MC) is an important issue guided by Royal Australasian College of Physicians (RACP) policy. Here we analytically review the RACP's 2010 policy statement 'Circumcision of infant males'. Comprehensive evaluation in the context of published research was used. We find that the Statement is not a fair and balanced representation of the literature on MC. It ignores, downplays, obfuscates or misrepresents the considerable evidence attesting to the strong protection MC affords against childhood urinary tract infections, sexually transmitted infections (human immunodeficiency virus, human papilloma virus, herpes simplex virus type 2, trichomonas and genital ulcer disease), thrush, inferior penile hygiene, phimosis, balanoposthitis and penile cancer, and in women protection against human papilloma virus, herpes simplex virus type 2, bacterial vaginosis and cervical cancer. The Statement exaggerates the complication rate. Assertions that 'the foreskin has a functional role' and 'is a primary sensory part of the penis' are not supported by research, including randomised controlled trials. Instead of citing these and meta-analyses, the Statement selectively cites poor quality studies. Its claim, without support from a literature-based risk-benefit analysis, that the currently available evidence does 'not warrant routine infant circumcision in Australia and New Zealand' is misleading. The Statement fails to explain that performing MC in the neonatal period using local anaesthesia maximises benefits, safety, convenience and cost savings. Because the RACP's policy statement is not a fair and balanced representation of the current literature, it should not be used to guide policy. In the interests of public health and individual well-being, an extensive, comprehensive, balanced review of the scientific literature and a risk-benefit analysis should be conducted to formulate policy.

Clinical issues surrounding the use of terbutaline sulfate for preterm labor.

beta-mimetics have been prescribed by physicians to arrest or prevent premature labor for more than 20 years. Although not approved by the Food and Drug Administration (FDA) for tocolytic use, terbutaline sulfate has been the most widely prescribed beta-mimetic in the United States. Recently, the role of terbutaline in the treatment and prevention of preterm labor has been questioned by the FDA. Because the off-label use of drugs is a formally accepted practice in medicine when scientific studies support such use, we reviewed the currently available clinical literature on terbutaline use in various routes of delivery: intravenous, oral, and subcutaneous via infusion pump. This review describes the clinical evidence that supports the safe and effective use of terbutaline as a tocolytic agent in certain patient populations. Practicing physicians should continue to have unrestricted use of terbutaline for tocolysis as one of the few remaining therapeutic options remaining in the fight against preterm birth.

Laparoscopic ligation of the umbilical cord of an acardiac fetus.

We performed umbilical cord ligation using laparoscopic technique in twins with twin reversed arterial perfusion sequence.

Computer extraction of information on contractions and emergency conditions from the intrauterine pressure.

In this paper we describe the problems and solutions involved in getting the controlling computer in the system described in [1] to derive the necessary information about contractions and emergency conditions from the intrauterine pressure input. The required information in this case includes the detection and classification of contractions, the continuously-updated evaluation of the resting baseline tone, and the detection of emergency conditions such as excessively high intrauterine pressure, constant intrauterine pressure, the occurrence of series of contractions closely following each other whose amplitude are all exceedingly high or all exceedingly low. In extracting this information, the computer has to cope with problems of noise, both noise inherent in the monitoring system and that due to patient movement.

Induction of labor with pulsatile oxytocin by a computer-controlled pump.

OBJECTIVE: The objective was to test the safety and efficacy of a pulsatile oxytocin infusion protocol in which a computer-controlled pump adjusts the oxytocin dose rate on the basis of uterine activity. STUDY DESIGN: A total of 358 women were enrolled in, and 310 completed, a prospective, randomized clinical trial comparing three protocols for the induction of labor with oxytocin: aggressively managed continuous infusion, conservatively managed continuous infusion, and computer-controlled pulsatile infusion. Results were analyzed with Student t and chi 2 "goodness-of-fit" tests. RESULTS: Mean doses of oxytocin in the group receiving pulsed oxytocin were approximately 20% of the dose rates in the continuous infusion protocols. All protocols effectively established labor in the majority of patients, although nulliparous women with unfavorable Bishop scores were more likely to fail to establish labor within a 24-hour period when treated with the aggressive continuous protocol. There were no differences in the rates of cesarean section, hyperstimulation, blood gases, or Apgar scores among the three treatment groups. CONCLUSIONS: Oxytocin dosage was minimized by use of a computer-controlled pump. With the exception of aggressively managed nulliparous women, there were no differences in the percentages of patients with successful inductions among the three protocols. The percentage of successful inductions was lower for aggressively managed nulliparous women than for other patient and protocol groups.

Changes in fetal TCPO2 values occurring during labour in association with lumbar extradural analgesia.

Forty-six of 64 high risk labours were managed with continuous lumbar extradural analgesia. Fetal heart rate (FHR) and continuous transcutaneous PO2 (tcPO2) measurements were made in the 64 patients. Abnormal fetal heart rate patterns and low tcPO2 values associated with the onset of the extradural block were noted in 9% of these cases. A decrease in maternal arterial pressure and uterine hypertonus appeared to be responsible, singly or in combination, for the changes. These effects and the changes in FHR were not seen in the 18 mothers not receiving extradural analgesia. The supine position was associated with slightly smaller fetal tcPO2 values than the preferred lateral positions, with a significant worsening of the fetal tcPO2 values after induction of the extradural block although, overall, extradural analgesia neither improved nor impaired the fetal tcPO2.

The relationship of fetal heart rate patterns to the fetal transcutaneous PO2.

Continuous transcutaneous PO2 (tcPO2) monitoring of the human fetus was performed during 46 labors, 30 of which were complicated by abnormal fetal heart rate (FHR) patterns. FHR variability decreased with increases in the fetal tcPO2, and FHR variability increased with decreases in the fetal tcPO2. Analysis of the tcPO2 and FHR tracings provided an explanation for this apparent discrepancy. While rising fetal tcPO2 values were usually associated with decreased FHR variability, the pattern of late deceleration and decreased variability must still be considered an ominous pattern. The fetal tcPO2 declined during the deceleration and rose thereafter, with corresponding decreased FHR variability. Incomplete recovery of the fetal tcPO2 was associated with progressive acidosis. Repetitive and isolated late deceleration patterns showed markedly dissimilar fetal tcPO2 changes, suggesting different mechanisms may be involved in their production. Further studies are required before any definite conclusions can be drawn about the relationship of the FHR and the fetal tcPO2.

Fetal scalp blood sampling and transcutaneous PO2.

Continuous transcutaneous PO2 monitoring has yielded some interesting information about the relationships of fetal oxygenation and the fetal heart rate. Notwithstanding the factors that may adversely affect the results obtained by this technique, further insights regarding fetal oxygenation may be gained. Ultimately, the clinical application of this instrument in high-risk situations is possible, yielding more information about the fetus during labor. Fetal scalp blood sampling, performed meticulously, will provide accurate blood pH values and should be employed when a differentiation between fetal stress and distress must be made. Other means of obtaining information about fetal acid-base balance are being developed and may become important tools in selected instances.

Acute ischemic optic neuropathy in severe preeclampsia.

A 32-year-old woman developed bilateral blindness along with severe preeclampsia of pregnancy. Ophthalmoscopic examination disclosed chalky-white optic disks with only minimal changes in the retinal vasculature. After caesarean section, the preeclampsia improved, and complete return of visual acuity occurred during a three-day period. Blindness has rarely been reported as a complication of preeclampsia. In almost all cases it has been associated with severe compromise of the retinal vasculature. conversely, the ophthalmoscopic findings in our case strongly support acute ischemic optic neuropathy as the cause of blindness.

Lack of subhourly variations in plasma unconjugated estriol levels in pregnant diabetic patients in the third trimester.

Analysis of 94 samples of blood collected from five pregnant diabetic patients in the third trimester revealed that there were no significant variations in plasma unconjugated estriol levels. Therefore, single random samples of blood collected at the same time every day are adequate for unconjugated estriol measurements.