Intrapartum epidural analgesia and breastfeeding: a prospective cohort study

BACKGROUND Anecdotal reports suggest that the addition of fentanyl (an opioid) to epidural analgesia for women during childbirth results in difficulty establishing breastfeeding. The aim of this paper is to determine any association between epidural analgesia and 1) breastfeeding in the first week postpartum and 2) breastfeeding cessation during the first 24 weeks postpartum. METHODS A prospective cohort study of 1280 women aged > or = 16 years, who gave birth to a single live infant in the Australian Capital Territory in 1997 was conducted. Women completed questionnaires at weeks 1, 8, 16 and 24 postpartum. Breastfeeding information was collected in each of the four surveys and women were categorised as either fully breastfeeding, partially breastfeeding or not breastfeeding at all. Women who had stopped breastfeeding since the previous survey were asked when they stopped. RESULTS In the first week postpartum, 93% of women were either fully or partially breastfeeding their baby and 60% were continuing to breastfeed at 24 weeks. Intrapartum analgesia and type of birth were associated with partial breastfeeding and breastfeeding difficulties in the first postpartum week (p < 0.0001). Analgesia, maternal age and education were associated with breastfeeding cessation in the first 24 weeks (p < 0.0001), with women who had epidurals being more likely to stop breastfeeding than women who used non-pharmacological methods of pain relief (adjusted hazard ratio 2.02, 95% CI 1.53, 2.67). CONCLUSION Women in this cohort who had epidurals were less likely to fully breastfeed their infant in the few days after birth and more likely to stop breastfeeding in the first 24 weeks. Although this relationship may not be causal, it is important that women at higher risk of breastfeeding cessation are provided with adequate breastfeeding assistance and support.Christine Roberts is supported by a National Health and Medical Research Council (NHMRC) of Australia Public Health Practitioner Fellowship and Siranda Torvaldsen is supported by a NHMRC Australian Research Training Fellowship. The cohort study was supported by a project grant from The Canberra Hospital Private Practice Fund. Additional funding was provided by The Canberra Hospital Auxiliary, the Nurses' Board of the Australian Capital Territory, and the Australian Capital Territory Department of Health & Community Care

SPEAR-1: An experiment to measure current collection in the ionosphere by high voltage biased conductors

An experiment is described in which a high electrical potential difference, up to 45 kV, was applied between deployed conducting spheres and a sounding rocket in the ionosphere. Measurements were made of the applied voltage and the resulting currents for each of 24 applications of different high potentials. In addition, diagnostic measurements of optical emissions in the vicinity of the spheres, energetic particle flow to the sounding rocket, dc electric field and wave data were made. The ambient plasma and neutral environments were measured by a Langmuir probe and a cold cathode neutral ionization gauge, respectively. The payload is described and examples of the measured current and voltage characteristics are presented. The characteristics of the measured currents are discussed in terms of the diagnostic measurements and the in-situ measurements of the vehicle environment. In general, it was found that the currents observed were at a level typical of magnetically limited currents from the ionospheric plasma for potentials less than 12 kV, and slightly higher for larger potentials. However, due to the failure to expose the plasma contactor, the vehicle sheath modified the sphere sheaths and made comparisons with the analytic models of Langmuir-Blodgett and Parker-Murphy less meaningful. Examples of localized enhancements of ambient gas density resulting from the operation of the attitude control system thrusters (cold nitrogen) were obtained. Current measurements and optical data indicated localized discharges due to enhanced gas density that reduced the vehicle-ionosphere impedance

An E-mail Service in a Military Adolescent Medicine Clinic: will teens use it and what for?

The goal of this study was to determine utilization patterns of an Adolescent Medicine Clinic e-mail service. An e-mail service was offered to 6134 patients presenting for care to a military Adolescent Medicine Clinic in San Antonio, Texas over a 6-month period. Families had to complete an authorization form acknowledging that the e-mail service was not encrypted and was not to be used for emergent issues prior to use. 482 families signed up for the service. A total of 42 e-mails were received from 28 of these families. 75% of all e-mails were initiated by parents. The majority of e-mails were administrative issues including: medication refills, lab follow up, and referrals requests. In conclusion, the e-mail service was a low cost method to increase communication options for our patients that was not associated with a large increase in clinic workload because of low utilization rates, especially among younger adolescents.Keywords: Adolescents; E-mail; Internet; Electronic communication; Physicianpatient communicatio

Design and performance of a multicentre, randomized controlled trial of teleconsulting.

We have designed and performed a multicentre, randomized controlled trial of teleconsulting. The trial investigated the effectiveness and cost implications in rural and inner-city settings of using videoconferencing as an alternative to general practitioner referral to a hospital specialist. The participating general practitioners referred a total of 3170 patients who satisfied the entry criteria. Of these, 1040 (33%) failed to provide consent or otherwise refused to participate in the trial. Of the patients recruited to the trial, a total of 1902 (91%) completed and returned the baseline questionnaire. Although the trial was successful in recruiting sufficient patients and in obtaining high questionnaire response rates, the findings will require careful interpretation to take account of the limits which the protocol placed on the ability of general practitioners to select patients for referral

Mapping Observations of DNC and HN^13C in Dark Cloud Cores

We present results of mapping observations of the DNC, HN^13C, and H^13CO^+ lines (J=1-0) toward 4 nearby dark cloud cores, TMC-1, L1512, L1544, and L63, along with observations of the DNC and HN^13C lines (J=2-1) toward selected positions. By use of statistical equilibrium calculations based on the LVG model, the H_2 densities are derived to be (1.4-5.5)*10^5 cm^-3, and the [DNC]/[HN^13C] ratios are derived to be 1.25-5.44 with a typical uncertainty by a factor of 2. The observed [DNC]/[HNC] ratios range from 0.02 to 0.09, assuming the [^12C]/[^13C] ratio of 60. Distributions of DNC and HN^13C are generally similar to each other, whereas the distribution of H^13CO^+ is more extended than those of DNC and HN^13C, indicating that they reside in an inner part of the cores than HCO^+. The [DNC]/[HN^13C] ratio is rather constant within each core, although a small systematic gradients are observed in TMC-1 and L63. Particularly, no such systematic gradient is found in L1512 and L1544, where a significant effect of depletion of molecules is reported toward the central part of the cores. This suggests that the [DNC]/[HNC] ratio would not be very sensitive to depletion factor, unlike the [DCO^+]/[HCO^+] ratio. On the other hand, the core to core variation of the [DNC]/[HNC] ratio, which range an order of magnitude, is more remarkable than the variation within each core. These results are interpreted qualitatively by a combination of three competing time-dependent processes; gas-phase deuterium fractionation, depletion of molecules onto grain surface, and dynamical evolution of a core.Comment: 22 pages, 8 EPS figures, aasLaTex 5.0, accepted to The Astrophysical Journa

Joint teleconsultations (virtual outreach) versus standard outpatient appointments for patients referred by their general practitioner for a specialist opinion: a randomised trial.

BACKGROUND: The current model of general practitioner referral of patients to hospital specialists in the UK is sometimes associated with unnecessary duplication of investigations and treatments. We aimed to compare joint teleconsultations between general practitioners, specialists, and patients (virtual outreach) with standard outpatient referral. METHODS: Virtual outreach services were established in London and Shrewsbury. The general practitioners referred 3170 patients, of whom 2094 consented to participate in the study and were eligible for inclusion. 1051 patients were randomly assigned virtual outreach, and 1043 standard outpatient appointments. We followed up the patients for 6 months after their index consultation. The primary outcome measure was the offer of a follow-up outpatient appointment. Analysis was by intention to treat. FINDINGS: More patients in the virtual outreach group than the standard group were offered a follow-up appointment (502 [52%] vs 400 [41%], odds ratio 1.52 [95% CI 1.27-1.82], p<0.0001). Significant differences in effects were observed between the two sites (p=0.009) and across different specialties (p<0.0001). Virtual outreach increased the offers of follow-up appointments more in Shrewsbury than in London, and more in ear, nose, and throat surgery and orthopaedics than in the other specialties. Fewer tests and investigations were ordered in the virtual outreach group by an average of 0.79 per patient (0.37-1.21, p=0.0002). Patients' satisfaction (analysed per protocol) was greater after a virtual outreach consultation than after a standard outpatient consultation (mean difference 0.33 scale points [95% CI 0.23-0.43], p<0.0001), with no heterogeneity between specialties or sites. INTERPRETATION: The trial showed that allocation of patients to virtual outreach consultations is variably associated with increased offers of follow-up appointments according to site and specialty, but leads to significant increases in patients' satisfaction and substantial reductions in tests and investigations. Efficient operation of such services will require appropriate selection of patients, significant service reorganisation, and provision of logistical support

Cosmological surveys with the Australian Square Kilometre Array Pathfinder

This is a design study into the capabilities of the Australian Square Kilometre Array Pathfinder in performing a full-sky low redshift neutral hydrogen survey, termed WALLABY, and the potential cosmological constraints one can attain from measurement of the galaxy power spectrum. We find that the full sky survey will likely attain 0.6 million redshifts which, when combined with expected Planck CMB data, will constrain the Dark Energy equation of state to 20%, representing a coming of age for radio observations in creating cosmological constraints.Comment: 10 pages, 6 figures, accepted in PASA, updated to match published versio

Women's breastfeeding experiences following a significant primary postpartum haemorrhage: A multicentre cohort study

<p>Abstract</p> <p>Background</p> <p>Postpartum haemorrhage (PPH) is a significant and increasing contributor to maternal mortality and morbidity. Following a PPH, women may have difficulties initiating and sustaining breastfeeding, although little has been published on this issue. The aim of this study was to describe breastfeeding experiences in a cohort of women following a significant PPH.</p> <p>Methods</p> <p>This is a descriptive study based on quantitative and qualitative data collected via questionnaires completed in the first week postpartum and at two and four months postpartum, by 206 women participating in a multicentre study of women's experiences of a significant primary postpartum haemorrhage (blood loss of 1500 mL or more in the 24 hours following childbirth, and/or a peripartum fall in haemoglobin (Hb) concentration to 7g/dL or less, or of ≥ 4g/dL).</p> <p>Results</p> <p>Among women with a significant PPH, 63% fully breastfed their babies from birth, whereas 85% said they had hoped to do so (p < 0.001). Only 52% of mothers who intended to either fully or partially breastfeed were able to give their baby the opportunity to suckle within an hour of the birth. Delays were longer in women with greater estimated blood loss and women with the longest delays in breastfeeding were less likely to initiate full breastfeeding. 70% of women with PPH of < 2000 mL were fully breastfeeding in the first postpartum week, whereas less than 50% of those with blood loss ≥ 3000 mL were able to do so. Overall, 58% of women with significant PPH were fully breastfeeding at two and 45% at four months postpartum.</p> <p>In qualitative data, three major themes were identified: 1) Difficulty initiating or sustaining breastfeeding, 2) Need for education and support; and 3) Emotional sequelae.</p> <p>Conclusions</p> <p>Following a significant PPH, women with greater blood loss are less likely to initiate and sustain full breastfeeding and this may be related, in part, to delays in initial contact with their baby as a consequence of the PPH. These findings have implications for postnatal care as these women may require greater support, education and assistance in initiating and sustaining breastfeeding. In particular, enabling the opportunity for the newborn to suckle as soon as is practicable should be encouraged.</p

Virtual outreach: economic evaluation of joint teleconsultations for patients referred by their general practitioner for a specialist opinion

Objectives To test the hypotheses that, compared with conventional outpatient consultations, joint teleconsultation (virtual outreach) would incur no increased costs to the NHS, reduce costs to patients, and reduce absences from work by patients and their carers.Design Cost consequences study alongside randomised controlled trial.Setting Two hospitals in London and Shrewsbury and 29 general practices in inner London and Wales.Participants 3170 patients identified; 2094 eligible for inclusion and willing to participate. 1051 randomised to virtual outreach and 1043 to standard outpatient appointments.Main outcome measures NHS costs, patient costs, health status (SF-12), time spent attending index consultation, patient satisfaction.Results Overall six month costs were greater for the virtual outreach consultations (pound724 per patient) than for conventional outpatient appointments (pound625): difference in means pound99 ($162; is not an element of138) (95% confidence interval pound10 to pound187, P=0.03). if the analysis is restricted to resource items deemed "attributable" to the index consultation, six month costs were still greater for virtual outreach: difference in means pound108 (pound73 to pound142, P < 0.0001). In both analyses the index consultation accounted for the excess cost. Savings to patients in terms of costs and time occurred in both centres: difference in mean total patient cost 8 pound (5 pound to 10 pound, P < 0.0001). Loss of productive time was less in the virtual outreach group: difference in mean cost pound11 (pound10 to pound12, P < 0.0001).Condusion The main hypothesis that virtual outreach would be cost neutral is rejected, but the hypotheses that costs to patients and losses in productivity would be lower are supported