A randomised trial of surgical, medical and expectant management of first trimester spontaneous miscarriage

Background: Medical management and expectant care have been considered possible alternatives to surgical evacuation of the uterus for first trimester spontaneous miscarriage in recent years.

Aim: To compare the effectiveness and safety of medical and expectant management with surgical management for first trimester incomplete or inevitable miscarriage.

Methods: Forty women were recruited following diagnosis of incomplete or inevitable miscarriage, and randomised to surgical, medical or expectant care via an off-site, computerised enrolment system. The primary outcome was the effectiveness of medical (vaginal misoprostol) and expectant management relative to surgical evacuation, assessed at 10–14 days and 8 weeks post-recruitment. Infection, pain, bleeding, anxiety, depression, physical and emotional recovery were assessed also. Analysis was by intention-to-treat.

Results: Effectiveness at 8 weeks was lower for medical (80.0%) and expectant (78.6%) than for surgical management (100.0%). Two women in the medical group had confirmed infections. Bleeding lasted longer in the expectant group than in the surgical group. There were no significant differences in pain, physical recovery, anxiety or depression between the groups. 54.6%, 42.9% and 57.1% of the surgical, medical and expectant groups respectively would opt for the same treatment again.

Conclusion: Expectant care appears to be sufficiently safe and effective to be offered as an option for women. Medical management might carry a higher risk of infection than surgical or expectant care.

Effect of soil texture and wheat plants on N₂O fluxes: a lysimeter study

Agricultural soils are a major source of nitrous oxide (N2O) emissions and an understanding of factors regulating such emissions across contrasting soil types is critical for improved estimation through modelling and mitigation of N2O. In this study we investigated the role of soil texture and its interaction with plants in regulating the N2O fluxes in agricultural systems. A measurement system that combined weighing lysimeters with automated chambers was used to directly compare continuously measured surface N2O fluxes, leaching losses of water and nitrogen and evapotranspiration in three contrasting soils types of the Riverine Plain, NSW, Australia. The soils comprised a deep sand, a loam and a clay loam with and without the presence of wheat plants. All soils were under the same fertilizer management and irrigation was applied according to plant water requirements. In fallow soils, texture significantly affected N2O emissions in the order clay loam > loam > sand. However, when planted, the difference in N2O emissions among the three soils types became less pronounced. Nitrous oxide emissions were 6.2 and 2.4 times higher from fallow clay loam and loam cores, respectively, compared with cores planted with wheat. This is considered to be due to plant uptake of water and nitrogen which resulted in reduced amounts of soil water and available nitrogen, and therefore less favourable soil conditions for denitrification. The effect of plants on N2O emissions was not apparent in the coarse textured sandy soil probably because of aerobic soil conditions, likely caused by low water holding capacity and rapid drainage irrespective of plant presence resulting in reduced denitrification activity. More than 90% of N2O emissions were derived from denitrification in the fine-textured clay loam-determined for a two week period using K15NO3 fertilizer. The proportion of N2O that was not derived from K15NO3 was higher in the coarse-textured sand and loam, which may have been derived from soil N through nitrification or denitrification of mineralized N. Water filled pore space was a poorer predictor of N2O emissions compared with volumetric water content because of variable bulk density among soil types. The data may better inform the calibration of greenhouse gas prediction models as soil texture is one of the primary factors that explain spatial variation in N2O emissions by regulating soil oxygen. Defining the significance of N2O emissions between planted and fallow soils may enable improved yield scaled N2O emission assessment, water and nitrogen scheduling in the pre-watering phase during early crop establishment and within rotations of irrigated arable cropping systems.

Continuity of midwifery care and gestational weight gain in obese women : a randomised controlled trial

Background: The increased prevalence of obesity in pregnant women in Australia and other developed countries is a significant public health concern. Obese women are at increased risk of serious perinatal complications and guidelines recommend weight gain restriction and additional care. There is limited evidence to support the effectiveness of dietary and physical activity lifestyle interventions in preventing adverse perinatal outcomes and new strategies need to be evaluated. The primary aim of this project is to evaluate the effect of continuity of midwifery care on restricting gestational weight gain in obese women to the recommended range. The secondary aims of the study are to assess the impact of continuity of midwifery care on: women’s experience of pregnancy care; women’s satisfaction with care and a range of psychological factors.
Methods/Design: A two arm randomised controlled trial (RCT) will be conducted with primigravid women recruited from maternity services in Victoria, Australia. Participants will be primigravid women, with a BMI≥30 who are less than 17 weeks gestation. Women allocated to the intervention arm will be cared for in a midwifery continuity of care model and receive an informational leaflet on managing weight gain in pregnancy. Women allocated to the control group will receive routine care in addition to the same informational leaflet. Weight gain during pregnancy, standards of care, medical and obstetric information will be extracted from medical records. Data collected at recruitment (self administered survey) and at 36 weeks by postal survey will include sociodemographic information and the use of validated scales to measure secondary outcomes.
Discussion: Continuity of midwifery care models are well aligned with current Victorian, Australian and many international government policies on maternity care. Increasingly, midwifery continuity models of care are being introduced in low risk maternity care, and information on their application in high risk populations is required. There is an identified need to trial alternative antenatal interventions to reduce perinatal risk factors for women who are obese and the findings from this project may have application in other maternity services. In addition this study will inform a larger trial that will focus on birth and postnatal outcomes.

Psychological and interpersonal dimensions of sexual function and dysfunction

Introduction. There are limited outcome data on the etiology and efficacy of psychological interventions for male and female sexual dysfunction as well as the role of innovative combined treatment paradigms.
Aim. This study aimed to highlight the salient psychological and interpersonal issues contributing to sexual health and dysfunction, to offer an etiological model for understanding the evolution and maintenance of sexual symptoms, and to offer recommendations for clinical management and research.
Methods. This study reviewed the current literature on the psychological and interpersonal issues contributing to male and female sexual dysfunction.
Main Outcome Measure. This study provides expert opinion based on a comprehensive review of the medical and psychological literature, widespread internal committee discussion, public presentation, and debate.
Results. Medical and psychological therapies for sexual dysfunctions should address the intricate biopsychosocial influences of the patient, the partner, and the couple. The biopsychosocial model provides an integrated paradigm for understanding and treating sexual dysfunction.
Conclusions. There is need for collaboration between healthcare practitioners from different disciplines in the evaluation, treatment, and education issues surrounding sexual dysfunction. In many cases, neither psychotherapy alone nor medical intervention alone is sufficient for the lasting resolution of sexual problems. The assessment of male, female, and couples’ sexual dysfunction should ideally include inquiry about predisposing, precipitating, maintaining, and contextual factors. Research is needed to identify efficacious combined and/or integrated treatments for sexual dysfunction.

Arsenic and heavy metal contamination of rice, pulses and vegetables grown in Samta village, Bangladesh

Arsenic contaminated water from tube wells has become the major health problem threatening millions of people in Bangladesh. However, the arsenic (As) contaminated water is not just used for drinking, it is used to irrigate crops, and to wash and prepare food. Contamination of agricultural soils by long-term irrigation with As contaminated water can lead to contamination and phyto-accumulation of the food crops with As and other toxic metals. As a consequence, dietary exposure to As and other toxic metals may contribute substantially to the adverse health effects caused by the contaminated tube wells in Bangladesh. Various vegetables, rice, pulses and the grass pea were sampled in Samta village in the Jessore district of Bangladesh and screened for As, Cd, Cu, Pb and Zn by inductively coupled plasma atomic emission spectrometry and inductively coupled plasma mass spectrometry. These local food crops provide the majority of the nutritional intake of the people in this area and are of great importance to their overall health. In general, our data show the potential for some vegetables to accumulate heavy metals with concentrations of Pb greater than Cd. The concentrations of As and Cd were higher in vegetables than in rice and pulses. The concentration of Pb was generally higher in rice than in pulses and vegetables. However, some vegetables such as bottle ground leaf, ghotkol, taro, eddoe and elephant foot had much higher concentrations of Pb. Other leafy and root vegetables contained higher concentrations oJ2n and Cu. Rice grown at Samta had increased Pb and As, but, considering an average daily intake of only 260 g rice per person per day, only the Pb is at concentrations which would be a health hazard/or human consumption.

The initiation and administration of drugs for advanced life support by critical care nurses in the absence of a medical practitioner

Current legislation does not permit the administration of first line resuscitation medications by suitably qualified Division 1 registered nurses (RNs) in the absence of a medical officer. This omission by the Drugs,  Poisons and Controlled Substances Act 1981 (Vic) and the Drugs, Poisons and The Controlled Substances Regulations 1995 (Vic) leaves many critical care nurses in a vulnerable legal position.

The primary aim of this study was to gauge the view of critical care nurses with respect to lobbying for change to the current legislation. In addition, the study aimed to explore and describe the educational preparation, practice perceptions and experiences of RNs working in critical care regarding cardiopulmonary resuscitation and the administration of first line advanced life support (ALS) medications in the absence of a medical officer. It was anticipated that data collected would demonstrate some of the dilemmas associated with the initiation and administration of ALS medications for practising critical care nurses and could be used to inform controlling bodies in order for them to gain an appreciation of the issues facing critical care nurses during resuscitation.

A mailout survey was sent to all members of the Victorian Branch of the Australian College of Critical Care Nurses (ACCCN). The results showed that the majority of nurses underwent an annual ALS assessment and had current ALS accreditation. Nurses indicated that they felt educationally prepared and were confident to manage cardiopulmonary resuscitation without a medical officer; indeed, the majority had done so. The differences in practice issues for metropolitan, regional and rural nurses were highlighted. There is therefore clear evidence to suggest that legislative amendments are appropriate and necessary, given the time critical nature of cardiopulmonary arrest. There was overwhelming support for ACCCN Vic. Ltd to lobby the Victorian government for changes to the law.

Arsenic and heavy metal contamination of vegetables grown in Samta village, Bangladesh

Drinking of arsenic (As) contaminated well water has become a serious threat to the health of many millions in Bangladesh. However, the implications of contamination of agricultural soils from long-term irrigation with As-contaminated groundwater for phyto-accumulation in food crops, and thence dietary exposure to As, and other metals, has not been assessed previously in Bangladesh. Various vegetables were sampled in Samta village in the Jessore district of Bangladesh, and screened for As, Cd, Pb, Cu and Zn by inductively coupled plasma emission spectrometry (ICP-AES) and inductively coupled plasma mass spectrometry (ICP-MS). These local food products are the basis of human nutrition in this region and of great relevance to human health. The results revealed that the individual vegetables containing the highest mean As concentrations (μg g⁻¹) are snake gourd (0.489), ghotkol (0.446), taro (0.440), green papaya (0.389), elephant foot (0.338) and Bottle ground leaf (0.306), respectively. The As concentration in fleshy vegetable material is low. In general, the data show the potential for some vegetables to accumulate heavy metals with concentrations of Pb greater than Cd. Some vegetables such as bottle ground leaf, ghotkol, taro, eddoe and elephant foot had much higher concentrations of Pb. Other leafy and root vegetables, contained higher concentrations of Zn and Cu. Bioconcentration factors (BCF) values, based on dry weight, were below 1 for all metals. In most cases, BCF values decreased with increasing metal concentrations in the soil. From the heavily As-contaminated village in Samta, BCF values for As in ladies finger, potato, ash gourd, brinjal, green papaya, ghotkol and snake gourd were 0.001, 0.006, 0.006, 0.014, 0.030, 0.034 and 0.038, respectively. Considering the average daily intake of fresh vegetables per person per day is only 130 g, all the vegetables grown at Samta had Pb concentrations that would be a health hazard for human consumption. Although the total As in the vegetables was less than the recommended maximum intake of As, it still provides a significant additional source of As in the diet.

Historical evolution and modern implications of concepts of consent to, and refusal of, medical treatment in the law of trespass

Many mischiefs arise on the change of a maxim and rule of the Common Law, which those who altered it could not see when they made the change.

Recognition by medical and nursing professionals of malnutrition and risk of malnutrition in elderly hospitalised patients

Objective: To determine the prevalence of malnutrition in a population of elderly hospitalised patients and to explore health professionals' perceptions and awareness of signs and risks of malnutrition and treatment options available.

Subjects and design: One hundred elderly patients and 57 health professionals from medical wards of a tertiary teaching hospital. Quantitative and qualitative study design using a validated malnutrition assessment tool (Mini Nutritional Assessment) and researcher-designed questionnaire to assess health professionals' knowledge of nutrition risk factors.

Main outcome measures: Mini Nutritional Assessment score, nutrition risk category and themes in health professionals' knowledge and awareness of malnutrition and its risk factors.

Results: Thirty per cent of patients were identified as malnourished while 61% were at risk of malnutrition. Documentation by health professionals of two major risk factors for malnutrition—recent loss of weight and appetite—were poor with only 19% and 53% of patients with actual loss of weight or appetite, respectively, identified by staff and only 7% and 9% of these patients, respectively, referred for dietetic assessment. While health professionals' knowledge of important medical risk factors for malnutrition was good, their knowledge of malnutrition risk factors such as recent loss of weight and loss of appetite was poor. Medical staff focused on biochemical factors when assessing nutrition status, while nursing staff focused on skin integrity and turgor.

Conclusion: Malnutrition in elderly hospitalised patients remains a significant problem with low rates of recognition and referral by medical and nursing staff. Considerable scope exists to develop training and education tools and to implement an appropriate nutrition screening policy to improve referral rates to dietitians.

Incorporation of oxygen into the succinate co-product of iron(II) and 2-oxoglutarate dependent oxygenases from bacteria, plants and humans.

The ferrous iron and 2-oxoglutarate (2OG) dependent oxygenases catalyse two electron oxidation reactions by coupling the oxidation of substrate to the oxidative decarboxylation of 2OG, giving succinate and carbon dioxide coproducts. The evidence available on the level of incorporation of one atom from dioxygen into succinate is inconclusive. Here, we demonstrate that five members of the 2OG oxygenase family, AlkB from Escherichia coli, anthocyanidin synthase and flavonol synthase from Arabidopsis thaliana, and prolyl hydroxylase domain enzyme 2 and factor inhibiting hypoxia-inducible factor-1 from Homo sapiens all incorporate a single oxygen atom, almost exclusively derived from dioxygen, into the succinate co-product.