Oral oxycodone offers equivalent analgesia to intravenous patient-controlled analgesia after total hip replacement: a randomized, single-centre, non-blinded, non-inferiority study.

BACKGROUND: To determine if oral oxycodone (OOXY) could provide equivalent postoperative analgesia and a similar side-effect profile to i.v. patient-controlled morphine in patients undergoing elective primary total hip replacement (THR) under spinal anaesthesia. METHODS: We studied 110 consecutive patients aged 60-85 yr. After operation, patients were randomly allocated to receive either oral controlled- and immediate-release OOXY or i.v. patient-controlled analgesia (IVPCA) with morphine. Both groups received regular co-analgesia and antiemetics. The primary outcome measures were: (i) postoperative pain at rest and movement and (ii) nausea score recorded 12 hourly. The secondary outcome measures were: (i) time to first mobilization, (ii) total amount of opioid consumed, (iii) number of additional antiemetic doses, and (iv) time to analgesic discontinuation. RESULTS: There were no statistically significant differences in the primary outcome measures of pain at rest and movement (P>0.05, 95% confidence intervals -0.41, +0.96) or nausea score (P>0.5). The secondary outcome measures showed no significant difference in the total amount of opioid consumed (102 vs 63 mg; P>0.05) or time to mobilization (24.45 vs 26.6 h, P=0.2). The number of antiemetic doses required in the first 24 h was significantly lower in the OOXY group (1.1 vs 1.4, P<0.05). The time to analgesic discontinuation was significantly shorter in the OOXY group (50.5 vs 56.6 h, P<0.05). Oral analgesia with OOXY was approximately GBP 10 less expensive per patient than IVPCA. CONCLUSIONS: Oral analgesia with OOXY after THR offers non-inferior analgesia to IVPCA and may offer some logistical and cost advantages.

A survey of intensive care unit visiting policies in the United Kingdom.

Admission to an intensive care unit is a highly stressful event for both patients and their relatives. Feelings of anxiety, pain, fear and a sense of isolation are often reported by survivors of a critical illness, whilst the majority of relatives report symptoms of anxiety or depression while their relative was in the intensive care unit. Traditionally, infection control concerns and a belief that liberal visiting by patients' relatives interferes with the provision of patient care have led many units to impose restricted visiting policies. However, recent studies suggest that an open visiting policy with unrestricted visiting hours improve visitors' satisfaction and reduces anxiety. In order to determine current visiting practice and provision for relatives within intensive care units, a questionnaire was sent to the principal nurse in all units within the United Kingdom. A total of 206 hospitals out of 271 completed the survey (76%). We found that 165 (80.1%) of responding units still impose restricted visiting policies, with wide variations in the facilities available to patients' relatives.

Social norms, social networks, and HIV risk behavior among injection drug users.

Social network structure and norms are linked to HIV risk behavior. However little is known about the gradient of norm of HIV risk that exists among social networks. We examined the association between injection risk network structure and HIV risk norms among 818 injection drug users (IDUs). IDUs were categorized into four distinct groups based on their risk behaviors with their drug networks: no network members with whom they shared cookers or needles, only cooker-sharing member, one needle-sharing member, and multiple needle-sharing members. The riskiest group, networks of multiple needle sharers, was more likely to endorse both risky needle-sharing and sex norms. Networks of only cooker sharers were less likely to endorse high-risk norms, as compared to the networks with no sharing. There were also differences based on gender. Future HIV prevention interventions for IDUs should target both injection and sex risk norms, particularly among IDUs in the multiple needle-sharing networks.

Bacterial contamination of PCA and epidural infusion devices.

We prospectively audited the bacterial contamination of re-usable analgesia infusion pumps. In a one-month period, 112 samples from the handset and keypads of our analgesia infusion pumps were cultured for bacterial contamination. Forty-five percent of handset swabs and 46% of keypad swabs grew bacteria; the commonest organism being coagulase-negative staphylococcus. An additional cleaning step using 70% isopropyl alcohol wipes was introduced and the contamination rate was re-audited in 100 samples. The contamination rate was reduced to 6% of handset swabs and 4% of keypad swabs. A high initial rate of bacterial contamination of re-usable analgesia infusion pumps was significantly reduced by the implementation of a simple, additional cleaning procedure.

Postoperative muscle weakness in a patient recently treated with infliximab.

We present a case of profound postoperative muscle weakness in a patient who had been treated with infliximab, and whose weakness had not manifested pre-operatively. We believe this to be the first case report of infliximab-related muscle weakness manifesting immediately after anaesthesia.

An examination of perceived norms and exchanging sex for money or drugs among women injectors in Baltimore, MD, USA.

Injection drug users who exchange sex for money or drugs may serve as a bridge group for transmitting HIV between injectors and non-injectors. While many individual characteristics have been linked to exchanging sex, little attention has been given to the influence of social network members. The present study assessed the relationship between exchanging sex and perceptions of peers' sex exchange behaviour and attitude toward sex exchange. The sample was composed of 267 women heroin and cocaine injectors in Baltimore, MD, USA. The results indicate that women who believed that their friends exchanged sex were more twice as likely to exchange sex in the past 90 days (95% CI: 1.49-2.70). Also, participants who thought their peers disapproved of sex exchange were 20% less likely to exchange sex (95% CI: 0.67-0.95). These findings suggest the need for peer education interventions that promote norms about safer behaviours.

Diagnosis, management and prevention of ventilator-associated pneumonia in the UK.

BACKGROUND AND OBJECTIVE: Ventilator-associated pneumonia is a nosocomial infection that occurs in patients receiving mechanical ventilation for >48 h. Many aspects of its diagnosis, treatment and management are controversial. We used a postal questionnaire to survey current practice within the UK. METHODS: Questionnaire study of 207 general intensive care units in the UK. RESULTS: The response rate was 77.3%. Regarding diagnosis, 30% of units obtained specimens from the lungs invasively, while the remainder relied on tracheal aspirates. In only 28.2% of units using tracheal aspirates were results reported in a quantitative manner. A clinical suspicion of ventilator-associated pneumonia would lead to the administration of empirical antibiotic therapy in the majority of units (77.2%), opinion being almost equally divided on whether this should be mono (49.1%) or combination therapy (50.9%). Although most units received regular microbiology feedback (90.5%), the involvement of a microbiologist in the antibiotic decision-making process was variable. Antibiotics were continued for a median of 7 days (inter-quartile range 5-8.5, range 2-14 days). Compliance with the principal methods of ventilator-associated pneumonia prevention was good. CONCLUSION: There is widespread variation in the methods used for the diagnosis of ventilator-associated pneumonia within the UK. The majority of units rely on non-quantitative analysis of tracheal aspirates. This technique has a high percentage of false-positives, and suggests widespread over utilization of antibiotics. However, most agree that antibiotics should be given empirically when there is a clinical suspicion of ventilator-associated pneumonia. The widespread introduction of 'ventilator bundles' appears to have ensured that most units actively take measures to prevent ventilator-associated pneumonia.

Lack of effect of supplementation with essential fatty acids on bone mineral density in healthy pre- and postmenopausal women: two randomized controlled trials of Efacal v. calcium alone.

Randomized controlled trials of the effects of the dietary supplement Efacal (Scotia Pharmaceuticals Plc, Guildford, Surrey, UK) v. Ca only on total body bone mineral density (BMD) and markers of bone turnover were conducted in healthy pre- and postmenopausal women separately. Total daily dose for 12 months for the Efacal groups was: Ca 1.0 g, evening primrose oil 4.0 g and marine fish oil 440 mg; and for the control groups was: Ca 1.0 g. Reported compliance was better than 90% in both age groups. For the forty-three premenopausal women (age range 25-40 years), initial mean total body BMD values were similar for Efacal and control groups and both groups showed highly significant mean increases of about 1%; however, there were no significant between-group differences for the changes in BMD or markers of bone turnover. For the forty-two postmenopausal women (age range 50-65 years), initial mean total body BMD values were again well-matched across treatment groups. Both Efacal and control groups showed highly significant decreases in total body BMD of about 1%, but again there were no significant between-group differences in total body BMD or markers of bone turnover. Possible confounding variables such as initial total body BMD were explored but had no effect on the outcome in either age group. Nail quality improved in both age groups and in both Efacal and control groups. Again, there was no significant difference between treatment groups. No evidence was found to support a beneficial effect of Efacal on BMD in these women.

Frequency and allelic association of common variants in the lipoprotein lipase gene in different ethnic groups: the Wandsworth Heart and Stroke Study.

The lower serum triglyceride (Tg), higher high density cholesterol (HDL-C) levels and low coronary heart disease (CHD) mortality in black populations, contrast with that in whites. By comparison, South Asian populations display a higher mortality from CHD associated with increased Tg and low HDL-C levels. Lipoprotein lipase (LPL) plays a major role in Tg metabolism. To determine if variation in the LPL gene contributes to the differences in lipid levels, we studied the frequencies and allelic associations of five common variants in the lipoprotein lipase (LPL) gene (-93T/G, D9N, N291S, S447X, and the HinddIII RFLP in intron 8) with serum Tg and HDL-cholesterol concentrations in population samples of middle-aged men and women of whites, South Asians, and blacks of African origin co-resident in South London. Significantly higher frequencies of the H(-) (P < 0.00001), N9 (P < 0.001), and -93G (P < 10(-10)) alleles were seen in blacks compared to the other two groups. Allelic association between -93G and N9, and H(+) and X447 was strong in all three groups. However, no association was observed between serum Tg and HDL-cholesterol concentrations and these variants in the three ethnic groups. A single common polymorphism in the LPL gene is unlikely to account for the differences in fasting serum Tg in populations of different ethnic background. The importance of the differences in frequencies and the mechanism(s) whereby these may contribute towards a beneficial LPL genotype in black populations remain to be determined.

A population study of ethnic variations in the angiotensin-converting enzyme I/D polymorphism: relationships with gender, hypertension and impaired glucose metabolism.

BACKGROUND: The presence of the deletion allele of the angiotensin-converting enzyme (ACE) I/D polymorphism is associated with an excess risk of vascular disease and diabetic nephropathy. OBJECTIVE: To examine the importance of this polymorphism as a determinant of hypertension and impaired glucose metabolism in a population-based study of three ethnic groups and assess the potential modifying effect of gender. DESIGN: Population-based cross-sectional study in South London. The population-based sample of 1577 men and women, age 40-59 years, was obtained from stratified random sampling of general practice lists where 25% of the residents were born outside the UK. The ACE I/D polymorphism was determined for 1366 individuals (86.6%): 462 whites, 462 of African descent and 442 of South Asian origin. RESULTS: The genotype frequency within each ethnic group was in Hardy-Weinberg equilibrium. The frequencies were similar in whites and those of African descent (II, ID, DD: 18.4%, 49.6%, 32.0% for whites and 18.4%, 50.5%, 30.9% for those of African descent), but there was a much higher frequency of the II genotype in those of South Asian origin (39.8%, 41.8%, 18.3%; chi2 = 77.6; P < 0.0001). There was no association between the I/D polymorphism and impaired glucose metabolism in any ethnic group. There were also no significant associations between the I/D polymorphism and hypertension in whites and in those of South Asian origin. This contrasts with a highly significant association between the D allele and hypertension in women of African descent (OR = 2.54; 95% CI 1.38-4.65; P = 0.003) but not in men of African descent (0.79; 0.36-1.72) (test for differences between sexes P = 0.023). CONCLUSIONS: These observations provide estimates of the frequency distribution of the ACE I/D polymorphism in whites, in people of African descent and in people of South Asian origin. Moreover, these results highlight the potential importance of gender-dependent interactions between genetic background and expression of hypertensive phenotype.

Pre- and postmenopausal women have different bone mineral density responses to the same high-impact exercise.

The effects of a vertical jumping exercise regime on bone mineral density (BMD) have been assessed using randomized controlled trials in both pre- and postmenopausal women, the latter stratified for hormone replacement therapy (HRT). Women were screened for contraindications or medication likely to influence bone. The premenopausal women were at least 12 months postpartum and not lactating; the postmenopausal women had been stable on, or off, HRT for the previous 12 months and throughout the study. BMD was measured blind using dual-energy X-ray absorptiometry at the spine (L2-L4) and the proximal femur. The exercise consisted of 50 vertical jumps on 6 days/week of mean height 8.5 cm, which produced mean ground reactions of 3.0 times body weight in the young women and 4.0 times in the older women. In the premenopausal women, the exercise resulted in a significant increase of 2.8% in femoral BMD after 5 months (p < 0.001, n = 31). This change was significantly greater (p < 0.05) than that found in the control group (n = 26). In the postmenopausal women, there was no significant difference between the exercise and control groups after 12 months (total n = 123) nor after 18 months (total n = 38). HRT status did not affect this outcome, at least up to 12 months. It appears that premenopausal women respond positively to this brief high-impact exercise but postmenopausal women do not.

The uptake and release of fluoride by ion-leaching cements after exposure to toothpaste.

OBJECTIVES: The cariostatic action associated with the glass-ionomer cement (GIC) is usually attributed to its sustained release of fluoride. However the ability of the GIC to act as a fluoride reservoir, taking it up from an external source (e.g. toothpaste, mouthwash) and subsequently releasing it over time, may also be a contributory factor. This study investigated the reservoir effect of various recently introduced ion-releasing cements: two resin-modified glass-ionomer cements (Fuji II LC, Vitremer), a compomer (acid-modified composite resin) (Dyract), and a recently introduced conventional glass-ionomer (Fuji IX). METHODS: Specimens were exposed to a fluoridated toothpaste after 28 and/or 58 days. The release of fluoride into the storage water, both before and after exposure, was monitored using a differential electrode cell. RESULTS: There was no significant difference in the fluoride releases from Vitremer and Fuji II LC. These materials released significantly more fluoride than Fuji IX and Dyract. All the materials released more fluoride on the day after exposure to an external fluoride source compared with the day before exposure. Release rates returned to baseline within 3 days. Within the time periods of the study, only the uptake/re-release of Fuji IX was adversely affected by late exposure. All the materials showed an enhanced uptake and release on repeated exposure to the external fluoride source. CONCLUSIONS: All the materials under test (Dyract, Fuji II LC, Vitremer and Fuji IX) released significant amounts of fluoride and reacted positively to exposure to an external fluoride source.

Association of hypertension with T594M mutation in beta subunit of epithelial sodium channels in black people resident in London.

BACKGROUND: Liddle's syndrome is a rare inherited form of hypertension in which mutations of the epithelial sodium channel result in increased renal sodium reabsorption. Essential hypertension in black patients also shows clinical features of sodium retention so we screened black people for the T594M mutation, the most commonly identified sodium-channel mutation. METHODS: In a case-control study, 206 hypertensive (mean age 48.0 [SD 11.8] years, men:women 80:126) and 142 normotensive (48.7 [7.4] years; 61:81) black people who lived in London, UK, were screened for T594M. Part of the last exon of the epithelial sodium-channel beta subunit from genomic DNA was amplified by PCR. The T594M variant was detected by single-strand conformational polymorphism analysis of PCR products and confirmed by DNA sequencing. FINDINGS: 17 (8.3%) of 206 hypertensive participants compared with three (2.1%) of 142 normotensive participants possessed the T594M variant (odds ratio [OR]=4.17 [95% CI 1.12-18.25], p=0.029). A high proportion of participants with the T594M variant were women (15 of 17 hypertensive participants and all three normotensive participants), whereas women comprised a lower proportion of the individuals screened (61.2% hypertensive, 57.7% normotensive). However, the association between the T594M variant and hypertension persisted after adjustment for sex and body-mass index (Mantel-Haenszel OR=5.52 [1.40-30.61], p=0.012). Plasma renin activity was significantly lower in 13 hypertensive participants with the T594M variant (median=0.19 ng mL(-1) h(-1)) than in 39 untreated hypertensive individuals without the variant (median=0.45 ng mL(-1) h(-1), p=0.009). INTERPRETATION: Among black London people the T594M sodium-channel beta subunit mutation occurs more frequently in people with hypertension than those without. The T594M variant may increase sodium-channel activity and could raise blood pressure in affected people by increasing renal tubular sodium reabsorption. These findings suggest that the T594M mutation could be the most common secondary cause of essential hypertension in black people identified to date.

Epidural complications and a case of malignant meningitis.

We report a case in which the signs of a malignant meningitis could have been confused with complications of an in-dwelling epidural catheter which was being used for analgesia. This confusion could have had disastrous implications for the patient's pain relief. We also discuss some of the issues and problems surrounding the use of in-dwelling epidurals in terminal care patients.

Conn's syndrome can cause malignant hypertension.

We present a case in which a patient, having already sustained an episode of malignant hypertension, was subsequently found to have an underlying Conn's adenoma. Ablation of the adenoma improved control of her hypertension. When a second adenoma developed in her remaining adrenal gland, control of her hypertension deteriorated.

Acute changes in haematological parameters on cessation of smoking.

Cigarette smoking is known to affect many haematological parameters but little is known of their rate of return to normal on withdrawal of cigarettes. Two groups of chronic smokers were studied whilst smoking and in the 2 weeks after cessation. A rapid return towards normal was found in the elevated haemoglobin concentration, packed cell volume, red cell count, white cell count, neutrophil count, lymphocyte count and platelet count, indicating that at least some of the abnormalities in these parameters are an acute, reversible effect of cigarette smoking rather than being a response to tissue damage.

Haemorheological changes in the very short term after abstention from tobacco by cigarette smokers.

A study was made of the haemorheological changes that took place in the days immediately following tobacco withdrawal from cigarette smokers. In both males and females substantial and persistent reductions in blood viscosity occurred within 2 d, the fall at high shear rate corresponding to about 8% while at low shear rate it was approximately twice as much. These changes were due partly to a fall in packed cell volume (PCV), but also to reductions in total plasma protein and fibrinogen concentrations which led to reductions in plasma viscosity and rouleaux formation. These plasma protein-related changes were less pronounced in the female group. The results indicate that, even in the very short-term, abstention from cigarettes leads to substantial improvements in the haemorheological profile of heavy smokers.