RESUMEN
In total, 20 multiparous Holstein-Friesian dairy cows received one of four diets in each of four periods of 28-day duration in a Latin square design to test the hypothesis that the inclusion of lucerne in the ration of high-yielding dairy cows would improve animal performance and milk fatty acid (FA) composition. All dietary treatments contained 0.55 : 0.45 forage to concentrates (dry matter (DM) basis), and within the forage component the proportion of lucerne (Medicago sativa), grass (Lolium perenne) and maize silage (Zea mays) was varied (DM basis): control (C)=0.4 : 0.6 grass : maize silage; L20=0.2 : 0.2 : 0.6 lucerne : grass : maize silage; L40=0.4 : 0.6 lucerne : maize silage; and L60=0.6 : 0.4 lucerne : maize silage. Diets were formulated to contain a similar CP and metabolisable protein content, with the reduction of soya bean meal and feed grade urea with increasing content of lucerne. Intake averaged 24.3 kg DM/day and was lowest in cows when fed L60 (P0.05) by dietary treatment. Digestibility of DM, organic matter, CP and fibre decreased (P<0.01) with increasing content of lucerne in the diet, although fibre digestibility was similar in L40 and L60. It is concluded that first cut grass silage can be replaced with first cut lucerne silage without any detrimental effect on performance and an improvement in the milk FA profile, although intake and digestibility was lowest and plasma urea concentrations highest in cows when fed the highest level of inclusion of lucerne.
Asunto(s)
Bovinos/fisiología , Medicago sativa/metabolismo , Leche/química , Ensilaje/análisis , Animales , Dieta/veterinaria , Fibras de la Dieta/metabolismo , Ácidos Grasos/análisis , Femenino , Lactancia , Lolium/metabolismo , Poaceae/metabolismo , Glycine max/metabolismo , Urea/sangre , Zea mays/metabolismoRESUMEN
Allergic asthma is a chronic, inflammatory lung disease. Some forms of allergic asthma are characterized by T helper type 2 (Th2)-driven eosinophilia, whereas others are distinguished by Th17-driven neutrophilia. Stimulation of Toll-like receptor 4 (TLR4) on hematopoietic and airway epithelial cells (AECs) contributes to the inflammatory response to lipopolysaccharide (LPS) and allergens, but the specific contribution of TLR4 in these cell compartments to airway inflammatory responses remains poorly understood. We used novel, conditionally mutant Tlr4(fl/fl) mice to define the relative contributions of AEC and hematopoietic cell Tlr4 expression to LPS- and allergen-induced airway inflammation. We found that Tlr4 expression by hematopoietic cells is critical for neutrophilic airway inflammation following LPS exposure and for Th17-driven neutrophilic responses to the house dust mite (HDM) lysates and ovalbumin (OVA). Conversely, Tlr4 expression by AECs was found to be important for robust eosinophilic airway inflammation following sensitization and challenge with these same allergens. Thus, Tlr4 expression by hematopoietic and airway epithelial cells controls distinct arms of the immune response to inhaled allergens.
Asunto(s)
Asma/genética , Asma/inmunología , Eosinófilos/metabolismo , Expresión Génica , Neutrófilos/metabolismo , Receptor Toll-Like 4/genética , Animales , Asma/metabolismo , Asma/patología , Citocinas/metabolismo , Células Dendríticas/inmunología , Células Dendríticas/metabolismo , Modelos Animales de Enfermedad , Eosinófilos/inmunología , Eosinófilos/patología , Células Epiteliales/metabolismo , Inmunidad Innata , Lipopolisacáridos/inmunología , Pulmón/inmunología , Pulmón/metabolismo , Pulmón/patología , Ratones , Ratones Noqueados , Neutrófilos/inmunología , Neutrófilos/patología , Pyroglyphidae/inmunología , Mucosa Respiratoria/inmunología , Mucosa Respiratoria/metabolismo , Mucosa Respiratoria/patología , Receptor Toll-Like 4/metabolismoRESUMEN
Factors that influenced the choice of dose of oral transmucosal fentanyl at the time of burns dressing change were investigated in a prospective study. After Ethics committee approval, data was analysed from 29 consecutive patients who had been recruited and consented for a study of pain associated with burns dressings. Patients had completed an 11-point verbal pain intensity score (VRS) prior to and after the dressing change. Analgesic use during for this period was documented. Doses of 600 to 1200 mcg of transmucosal fentanyl (Actiq) were given based on individual assessment. The pre-dressing VRS (median [range]) in the 15 patients who received 600 mcg was 8 [3-10] and was higher than the VRS of 6 [2-9] in the 800-1200 mcg group. The time since the burn was longer in the low dose group at 7 [1-22] days compared with 5 [0-50] days in the higher dose group. In addition 73% of the low dose group was prescribed opioids regularly prior to the dressing compared with 57% of the high dose group. The choice of a lower transmucosal fentanyl dose was based on prior use of opioids and the age of the burn rather than on the patient's pain intensity.
Asunto(s)
Analgésicos Opioides/administración & dosificación , Vendajes/efectos adversos , Quemaduras/complicaciones , Fentanilo/administración & dosificación , Dolor/prevención & control , Administración Oral , Adolescente , Adulto , Anciano , Analgésicos Opioides/uso terapéutico , Conducta de Elección , Relación Dosis-Respuesta a Droga , Esquema de Medicación , Femenino , Fentanilo/uso terapéutico , Humanos , Masculino , Persona de Mediana Edad , Dolor/etiología , Dimensión del Dolor/métodos , Estudios Prospectivos , Adulto JovenRESUMEN
BACKGROUND: Women are often unprepared for emergency obstetric procedures and need to receive information about anaesthesia quickly and succinctly. In the absence of previous studies, we sought feedback from women to find out how information was given, and particular areas of concern in order to define practice and improve women's experiences. METHODS: After Ethics Committee approval this prospective structured questionnaire study was conducted in a teaching and a district general hospital. Women were recruited up to 48 h after anaesthesia. RESULTS: Of 102 women studied, 55 had no prior knowledge of obstetric anaesthetic interventions and risks until told, usually by the obstetrician (n=47), just before the procedure. The most frightening aspect was anticipating the efficacy of regional anaesthesia (n=18), but 28 women were reassured by the explanation provided by the anaesthetist. All but two women expressed satisfaction with the content of information and the described attendant risks. Nevertheless, in contrast to our observed practice, 51 (50%) would have preferred having verbal information before labour preferably from an anaesthetist or midwife. CONCLUSIONS: Most women were unprepared for emergency obstetric anaesthesia. Many received information just before the event. After delivery they expressed a clear preference for earlier information.
Asunto(s)
Anestesia Obstétrica/estadística & datos numéricos , Tratamiento de Urgencia/métodos , Encuestas de Atención de la Salud/métodos , Educación del Paciente como Asunto/normas , Satisfacción del Paciente/estadística & datos numéricos , Encuestas y Cuestionarios , Adulto , Anestesia de Conducción , Anestesia Obstétrica/efectos adversos , Estudios de Cohortes , Femenino , Conocimientos, Actitudes y Práctica en Salud , Hospitales de Distrito/normas , Hospitales de Enseñanza/normas , Humanos , Educación del Paciente como Asunto/métodos , Embarazo , Estudios ProspectivosRESUMEN
BACKGROUND: We determined the optimal inspired sevoflurane concentration for use during labour as 0.8% in our previous study. This study compared sevoflurane at a concentration of 0.8% and Entonox((R)) (nitrous oxide 50%: oxygen 50%) for analgesia during labour in 32 healthy parturients. METHODS: Each mother underwent two open-label, three-part sequences in random order, Entonox-sevoflurane-Entonox or sevoflurane-Entonox-sevoflurane. In each part the agent was self-administered during 10 contractions. A 100 mm visual analogue scores for pain relief and sedation was completed immediately after each contraction. RESULTS: Two patients withdrew during administration of sevoflurane (because of its odour) and five during Entonox (requesting epidural analgesia). Of the remaining women, data were available for analysis from 29 participants: median (IQR [range]) pain relief scores were significantly higher for sevoflurane 67 (55-74 [33-100]) mm than for Entonox 51 (40-69.5 [13-100]) mm (P<0.037). Nausea and vomiting were more common in the Entonox group [relative risk 2.7 (95% CI 1.3-5.7); P=0.004]. No other adverse effects were observed in the mothers or babies. There was significantly more sedation with sevoflurane than with Entonox {74 (66.5-81 [32.5-100]) and 51 (41-69.5 [13-100]) mm, respectively; P<0.001}. Twenty-nine patients preferred sevoflurane to Entonox and found its sedative effects helpful. CONCLUSIONS: We conclude that self-administered sevoflurane at subanaesthetic concentration (0.8%) can provide useful pain relief during the first stage of labour, and to a greater extent than Entonox. Although greater sedative effects were experienced with sevoflurane, it was preferred to Entonox.
Asunto(s)
Analgesia Obstétrica/métodos , Anestésicos por Inhalación/administración & dosificación , Éteres Metílicos/administración & dosificación , Óxido Nitroso/administración & dosificación , Oxígeno/administración & dosificación , Adulto , Analgesia Obstétrica/efectos adversos , Analgesia Controlada por el Paciente/métodos , Anestésicos por Inhalación/efectos adversos , Sedación Consciente , Estudios Cruzados , Combinación de Medicamentos , Femenino , Humanos , Éteres Metílicos/efectos adversos , Náusea/inducido químicamente , Óxido Nitroso/efectos adversos , Oxígeno/efectos adversos , Dimensión del Dolor/métodos , Satisfacción del Paciente , Embarazo , Sevoflurano , Vómitos/inducido químicamenteRESUMEN
BACKGROUND: Sevoflurane has favourable physical qualities for inhaled analgesia during labour pain. The aim of this preliminary study was to identify its optimum concentration. METHODS: In this open-labelled escalating-dose study, 22 parturients in labour self-administered sevoflurane at 10 contractions using an Oxford Miniature Vaporiser. The inspired concentration was increased by 0.2% after each contraction from 0% to 1.4% or decreased if sedation occurred. Visual analogue scores (0-100 mm) for pain intensity, pain relief, sedation, mood and coping were measured after each contraction. RESULTS: The median (IQR [range]) pain relief and sedation scores increased from 44 (43-56 [4-93]) mm and 55 (43-56 [0-98]) mm at 0.2% sevoflurane, to 74 (72-78 [50-80]) mm and 71 (71-73 [33-97]) mm at 1.2% sevoflurane, respectively. Pain relief scores did not show any significant increase above 0.8% whilst sedation continued to increase, with excessive sedation occurring at 1.2% sevoflurane. No significant changes in other scores were measured. CONCLUSIONS: We concluded that the optimal sevoflurane concentration in labour was 0.8%. This concentration allows a safety margin and balances the risk of sedation with the benefit of pain relief in labour.
Asunto(s)
Analgesia Obstétrica/métodos , Anestésicos por Inhalación/administración & dosificación , Éteres Metílicos/administración & dosificación , Adaptación Psicológica/efectos de los fármacos , Adulto , Analgesia Controlada por el Paciente/métodos , Relación Dosis-Respuesta a Droga , Esquema de Medicación , Femenino , Humanos , Dimensión del Dolor/métodos , Proyectos Piloto , Embarazo , SevofluranoRESUMEN
The handover of patient information between shifts enables continuity of care and increases patient safety. We surveyed UK practice during handovers in obstetric anaesthesia. A questionnaire was sent to 239 lead consultant obstetric anaesthetists to record routine practice in their unit and individual opinion about handover procedures. Responses were received from 168 anaesthetists, a 70% response rate. Handover policies were available in 10% of units. Most (76%) responding units had an allocated time for handover. In most units (76%), the duration of handover was reported as being < 15 min but the actual duration and depth of any discussion involved were not specified. Handovers were rarely documented in writing (7%). Consultant anaesthetists were most likely to be present at the morning handover and few handovers were multidisciplinary. Four percent of units reported critical incidents following inadequate handovers in the past 12 months. We identify features in handover procedures that could be improved.
Asunto(s)
Anestesia Obstétrica/normas , Continuidad de la Atención al Paciente/normas , Registros Médicos/normas , Actitud del Personal de Salud , Femenino , Encuestas de Atención de la Salud , Investigación sobre Servicios de Salud , Humanos , Relaciones Interprofesionales , Servicio de Ginecología y Obstetricia en Hospital/normas , Embarazo , Práctica Profesional/estadística & datos numéricos , Encuestas y Cuestionarios , Reino UnidoRESUMEN
The National Obstetric Anaesthetic Database was established in 1998 to support collection of national data on obstetric analgesia and anaesthesia. The first year's project aimed to determine the incidence, characteristics, contributing factors and management of postpartum headaches with anaesthetic interventions. A total of 65348 women were reported to have had anaesthetic interventions. There were individual records of 404 women in whom postdural puncture headache (PDPH) was diagnosed (47 mild, 134 moderate, 202 severe and 21 unspecified) and 571 in whom headache was not related to dural puncture (315 mild, 176 moderate, 44 severe and 36 unspecified). Recognised dural puncture occurred in 165 women (41%), 130 (79%) during labour. Placement of spinal catheters on dural puncture in 51 women did not influence headache severity. Abdominal compression used to test the diagnosis of PDPH was only positive in 56/186 parturients (30%). Epidural blood patch was performed in 240 women with PDPH, of whom 101 women (42%) received their first blood patch within two days of delivery. The incidence of headache ranged from 1.1% to 1.9% between all anaesthetic techniques but increased to 11% for women receiving multiple regional anaesthetics. The predominant characteristics of PDPH were limitation of daily activity (n=305, 75%), severity (moderate/severe) and a postural element (n = 325, 80%), all significantly different from headache from other causes (P = 0.001). Shoulder/neck stiffness (n=172, 43%) was the commonest symptom associated with PDPH.
RESUMEN
This study describes magnetic resonance imaging findings in women presenting with neurological complications associated with preeclampsia and eclampsia. One eclamptic and two preeclamptic women were studied after presenting with postpartum neurological events. In two women the brain increased in size on the initial follow-up images, following the same pattern seen in normal pregnancy. In the other woman, the brain was decreased in size at 13 days postpartum but increased in size at six weeks postpartum. This initial reduction in brain size may reflect the resolution of cerebral oedema resulting from underlying pathological processes.
RESUMEN
The active constituents of cannabis (predominantly cannabinoids and possibly flavonoids) are more effective than a single cannabinoid in reducing muscle spasticity in a multiple sclerosis animal model. Possible interactions include both pharmacokinetic and pharmacodynamic effects. Synthetic cannabinoids with agonist or antagonist/inverse agonist effects are available with high affinity for cannabinoids receptors. Pharmaceutical products that block their uptake and metabolism may enhance the endocannabinoid system. Government- and charity-funded clinical trials of cannabis are proceeding in pain, both acute (MRC multicenter trial) and chronic, and multiple sclerosis (MRC and Multiple Sclerosis Society multicenter trials). The design of these trials should enable evidence to be presented to regulatory bodies documenting the medicinal uses of standardized cannabis plant material.
RESUMEN
Understanding of the structure and function of the endocannabinoid system is rapidly evolving. Physiological and pharmacological manipulations based on cannabinoid receptors, ligands and endocannabinoids have explained some medicinal attributes of cannabinoids as used across the world for thousands of years. Plant-derived and synthetic cannabinoids are available for therapeutic use. Small clinical trials have demonstrated analgesic potential in acute and chronic pain. Regulatory and pharmacological limitations of these agents have hindered pain research in humans. Selective agonists, antagonists and metabolic targets to enhance endogenous cannabinoid activity are in development. Government reports in Europe and North America have encouraged research into the use of cannabinoids for pain relief and endorsed the clinical trials in acute and chronic pain. The results of large clinical trials into cannabinoid use for acute pain is expected to be the catalyst for wider studies and possible changes in legislation. Long-term effects of psychoactive cannabinoids require close monitoring and international cooperation to define their role, if any, in CNS disorders.
RESUMEN
A new classification for caesarean section was developed in a two-part study conducted at six hospitals. Initially, 90 anaesthetists and obstetricians graded ten clinical scenarios according to five different classification methods--visual analogue scale; suitable anaesthetic technique; maximum time to delivery; clinical definitions; and a 1-5 rating scale. Clinical definitions was the most consistent and useful, and this method was then applied prospectively to 407 caesarean sections at the same six hospitals. There was close agreement (86%) between anaesthetists and obstetricians for the five-point scale (weighted kappa 0.89), increasing to 90% if two categories were combined (weighted kappa 0.91). We suggest that the resultant four-grade classification system--(i) immediate threat to life of woman or fetus; (ii) maternal or fetal compromise which is not immediately life-threatening; (iii) needing early delivery but no maternal or fetal compromise; (iv) at a time to suit the patient and maternity team--should be adopted by multidisciplinary groups with an interest in maternity data collection.
Asunto(s)
Cesárea/clasificación , Complicaciones del Trabajo de Parto/clasificación , Índice de Severidad de la Enfermedad , Anestesia Obstétrica/métodos , Urgencias Médicas/clasificación , Estudios de Evaluación como Asunto , Femenino , Humanos , Embarazo , Estudios Prospectivos , TriajeRESUMEN
Closing the gaps between product design and delivery of analgesic drugs, and individual patient needs for pain relief was the focus for this meeting. The changes in theories of nociceptive activity, from a mechanistic to a biopsychosocial disorder with diverse systemic modulation, were highlighted by Mark Travers (Janssen-Cilag, Titusville, NJ, USA), including examples from clinical trials where a patient's expectations were not met and high drop-out rates occurred. The need to target drug design and delivery to defined patient groups was clearly an important issue. The potential for drug delivery systems, such as polymer matrix and transmucosal applications, was discussed. Analogs of naturally occurring compounds that interact with nociceptive systems are creating opportunities for novel antinociceptive and anti-hyperalgesic peptides. The never-ending discovery of new pain transmission and transduction mechanisms fuels the potential for synthesis of more compounds. In reality, the multifactorial nature of pain, with its large potential commercial market in hospitals and within the community, demands a similar multidimensional approach to pain therapies. Much of the emerging preclinical data suggest that interactions between the processes of nociception and the modulatory, inhibitory, immune and inflammatory systems that may generate or maintain nociceptive activity, may be important for the future development of therapeutics in pain management. Such data are being generated through studies with, for example: the tripeptides, vanilloid, galanin and neuropeptide Y receptor ligands; the pharmacological effects of sumatriptan (Glaxo Wellcome plc); and, the serotonin and norepinephrine selective antidepressant, venlafaxine (Effexor XR; Wyeth-Ayerst International Inc).