Kirwan Health Campus

OBJECTIVE: To determine whether digital assessment of pelvic floor contraction strength is as reliable as vaginal perineometry and to assess the practice of pelvic floor exercises by women. DESIGN: A blinded, two-assessor protocol, prospectively testing a volunteer sample of women. POPULATION: Two hundred and sixty-three women (from a total of 278), aged 16-75 years, attending a general gynaecological clinic with nonurinary symptoms. METHODS: Participants answered a questionnaire regarding urinary symptoms and practice of pelvic floor exercises. History and examination was carried out by the clinician, and pelvic floor strength scored digitally using the Oxford Scale. Pelvic floor strength was then assessed by the physiotherapist, using a PFX perineometer. The physiotherapist was blinded to the woman's history, examination findings and digital assessment score. Both the clinician and physiotherapist were blinded to the questionnaire responses. MAIN OUTCOME MEASURES: Digital pelvic floor contraction assessment, according to the Oxford Scale, was compared with perineometric assessment as the gold standard - examined against the background of the questionnaire findings. RESULTS: Of 263 patients, 53 were nulliparous (20%), and 210 parous (80%). Only 49 women carried out regular pelvic floor exercises (19%), and all were parous and admitted to troublesome urinary symptoms. Stress urinary incontinence was reported by 28% of all women (38.1% of parous women and 10.5% of nulliparous women). For both methods, there was no difference in the range of results when parity was taken into account. Concordance studies showed good agreement between digital and perineometric assessment of pelvic floor strength. The kappa value of 0.73 (95% confidence interval 0.67-0.79) indicated substantial agreement between the two methods. CONCLUSION: There is good agreement between digital assessment of pelvic floor contraction strength and vaginal perineometry. Assessment during gynaecological examination may help to identify women with fascial defects of the pelvic floor, as well as those at risk of genital prolapse or urinary symptoms.

Kepuasan kerja guru menjadi salah satu faktor yang harus diperhatikan, apabila guru merasakan kepuasan dalam dalam bekerja, maka akan tercipta semangat kerja yang tinggi sehingga tujuan sekolah dapat tercapai secara maksimal. Banyak usaha yang telah dilaksanakan untuk meningkatkan kepuasan kerja guru. Diantaranya adalah dengan memberikan kompensasi yang sesuai, melengkapi dan menyiapkan berbagai sarana dan prasarana yang diperlukan guru dalam mengajar, memberikan motivasi kepada guru dan lain sebagainya. Namun, usaha yang sudah dilaksanakan tampaknya belum memperlihatkan hasil yang memuaskan. Tujuan dari penelitian ini adalah untuk mengetahui pengaruh kompensasi, lingkungan kerja dan motivasi terhadap kepuasan kerja guru pada SMA Swasta Perkumpulan Amal Bakti 4 Sampali Medan. Penelitian ini menggunakan pendekatan asosiatif, yaitu penelitian yang dilakukan untuk mengetahui pengaruh atau hubungan antara variabel bebas dengan variabel terikat. Hasil penelitian menunjukkan bahwa secara parsial kompensasi memiliki pengaruh yang signifikan terhadap kepuasan kerja . Secara parsial lingkungan kerja memiliki pengaruh yang tidak signifikan terhadap kepuasan kerja . Secara parsial motivasi memiliki pengaruh yang signifikan terhadap kepuasan kerja. Secara simultan kompensasi, lingkungan kerja dan motivasi memiliki pengaruh yang signifikan terhadap kepuasan kerja .

PURPOSE: The tension-free vaginal tape procedure is an increasingly popular choice for treating female urinary stress incontinence. This ongoing, prospective, open label study presents the results of tension-free vaginal tape surgery at 1 year in women who have previously undergone unsuccessful stress incontinence surgery. MATERIALS AND METHODS: A total of 67 women with previous failed surgery for stress urinary incontinence underwent the tension-free vaginal tape procedure. Treatment outcome was categorized as cure, significant improvement or failure based on cystometry findings and urinary pad loss results at 3 months of followup, and on subjective questioning at 3 months and 1 year of followup. RESULTS: At 12 months 54 women (81%) were cured, 4 (6%) were significantly improved and 9 (13%) were no better. No serious morbidity was noted after the procedure. CONCLUSIONS: The tension-free vaginal tape procedure provides the prospect of a success rate similar to that of a conventional sling procedure in patients with previous failed surgery. It has a low rate of operative complications and postoperative morbidity.

Hyperekplexia (startle disease) is a rare non-epileptic disorder characterised by an exaggerated persistent startle reaction to unexpected auditory, somatosensory and visual stimuli, generalised muscular rigidity, and nocturnal myoclonus. The genetic basis is a mutation usually of the arginine residue 271 leading to neuronal hyperexcitability by impairing glycinergic inhibition. Hyperekplexia is usually familial, most often autosomal dominant with complete penetrance and variable expression. It can present in fetal life as abnormal intrauterine movements, or later at any time from the neonatal period to adulthood. Early manifestations include abnormal responses to unexpected auditory, visual, and somatosensory stimuli such as sustained tonic spasm, exaggerated startle response, and fetal posture with clenched fists and anxious stare. The tonic spasms may mimic generalised tonic seizures, leading to apnoea and death. Consistent generalised flexor spasm in response to tapping of the nasal bridge (without habituation) is the clinical hallmark of hyperekplexia. Electroencephalography may show fast spikes initially during the tonic spasms, followed by slowing of background activity with eventual flattening corresponding to the phase of apnoea bradycardia and cyanosis. Electromyography shows a characteristic almost permanent muscular activity with periods of electrical quietness. Nerve conduction velocity is normal. No specific computed tomography findings have been reported yet. Clonazepam, a gamma aminobutyric acid (GABA) receptor agonist, is the treatment of choice for hypertonia and apnoeic episodes. It, however, may not influence the degree of stiffness significantly. A simple manoeuvre like forced flexion of the head and legs towards the trunk is known to be life saving when prolonged stiffness impedes respiration.

Teratomas are formed when germ cell tumours arise from the embryonal compartment. The name is derived from the Greek word “teratos” which literally means “monster”. The ending “-oma” denotes a neoplasm.1 Sacrococcygeal teratoma is the most common congenital tumour in the neonate, reported in approximately 1/35 000 to 1/40 000 live births.2 Approximately 80% of affected infants are female—a 4:1 female to male preponderance.2 The first reported case was inscribed on a Chaldean cuneiform tablet dated approximately 2000 BC.3 In the modern era, the first large series of infants and children with sacrococcygeal teratomas was reported by Gross et al in 1951.4 Sacrococcygeal teratomas have tissues derived from ectoderm, mesoderm, and endoderm.2 Although their embryonic origin is still uncertain, they are believed to arise early in gestation (at around the late second or early third week) from the totipotential cells of Hensen's node (also called the primitive knot), a remnant of the primitive streak in the coccygeal region.5-7 The primitive streak appears as a linear thickening in the ectoderm at the caudal edge of the bilaminar embryonic disc. It usually diminishes in size, eventually disappearing after undergoing degenerative changes. As the mesoderm rapidly proliferates, the primitive streak comes to lie more and more caudally, where the remnant of Hensen's node descends to the tip or anterior surface of coccyx.5-7 Sacrococcygeal teratomas may be classified as benign (mature) and malignant or immature (composed of embryonic elements).8Mature teratomas are most common in neonates (68%) and older children (73%). Immature teratomas are cystic, whereas malignant tumours are solid. Over 50% of sacrococcygeal teratomas have calcification and ossification.8 Keslar et al reported that 69 (62%) of the 96 sacrococcygeal teratomas in their series were composed of both solid and cystic elements.8The cysts …

BACKGROUND: The estimated likelihood of lower limb amputation is 10 to 30 times higher amongst people with diabetes compared to those without diabetes. Of all non-traumatic amputations in people with diabetes, 85% are preceded by a foot ulcer. Foot ulceration associated with diabetes (diabetic foot ulcers) is caused by the interplay of several factors, most notably diabetic peripheral neuropathy (DPN), peripheral arterial disease (PAD) and changes in foot structure. These factors have been linked to chronic hyperglycaemia (high levels of glucose in the blood) and the altered metabolic state of diabetes. Control of hyperglycaemia may be important in the healing of ulcers. OBJECTIVES: To assess the effects of intensive glycaemic control compared to conventional control on the outcome of foot ulcers in people with type 1 and type 2 diabetes. SEARCH METHODS: In December 2015 we searched: The Cochrane Wounds Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; EBSCO CINAHL; Elsevier SCOPUS; ISI Web of Knowledge Web of Science; BioMed Central and LILACS. We also searched clinical trial databases, pharmaceutical trial databases and current international and national clinical guidelines on diabetes foot management for relevant published, non-published, ongoing and terminated clinical trials. There were no restrictions based on language or date of publication or study setting. SELECTION CRITERIA: Published, unpublished and ongoing randomised controlled trials (RCTs) were considered for inclusion where they investigated the effects of intensive glycaemic control on the outcome of active foot ulcers in people with diabetes. Non randomised and quasi-randomised trials were excluded. In order to be included the trial had to have: 1) attempted to maintain or control blood glucose levels and measured changes in markers of glycaemic control (HbA1c or fasting, random, mean, home capillary or urine glucose), and 2) documented the effect of these interventions on active foot ulcer outcomes. Glycaemic interventions included subcutaneous insulin administration, continuous insulin infusion, oral anti-diabetes agents, lifestyle interventions or a combination of these interventions. The definition of the interventional (intensive) group was that it should have a lower glycaemic target than the comparison (conventional) group. DATA COLLECTION AND ANALYSIS: All review authors independently evaluated the papers identified by the search strategy against the inclusion criteria. Two review authors then independently reviewed all potential full-text articles and trials registry results for inclusion. MAIN RESULTS: We only identified one trial that met the inclusion criteria but this trial did not have any results so we could not perform the planned subgroup and sensitivity analyses in the absence of data. Two ongoing trials were identified which may provide data for analyses in a later version of this review. The completion date of these trials is currently unknown. AUTHORS' CONCLUSIONS: The current review failed to find any completed randomised clinical trials with results. Therefore we are unable to conclude whether intensive glycaemic control when compared to conventional glycaemic control has a positive or detrimental effect on the treatment of foot ulcers in people with diabetes. Previous evidence has however highlighted a reduction in risk of limb amputation (from various causes) in people with type 2 diabetes with intensive glycaemic control. Whether this applies to people with foot ulcers in particular is unknown. The exact role that intensive glycaemic control has in treating foot ulcers in multidisciplinary care (alongside other interventions targeted at treating foot ulcers) requires further investigation.

Congenital fetal abnormalities are major causes of perinatal mortality and morbidity. The performance of ultrasound in the diagnosis and assessment of fetal anomalies varies enormously between tertiary referral centers and general units. Telemedicine offers a chance for tertiary realtime ultrasound consultations using standard telephone lines for remote sites. Preliminary investigations by our group have shown that real-time transmission of fetal ultrasound images over long distances via telephone (integrated systems digital network [ISDN]) lines is technically feasible. A live link of up to 2 Mb/s was established between Mater Mothers Hospital in Brisbane and Kirwan Hospital for Women in Townsville, which are 1,500 km apart. The objective of the current study was to evaluate the clinical value of a tertiary teleultrasound consultation service. Patients requiring tertiary ultrasound consultations were recruited from North Queensland. Clinicians from the referral site established an initial diagnosis and management plan. Using standard ISDN lines, the real-time ultrasound images were transmitted to the maternal fetal medicine subspecialists in Brisbane. The ultrasound examination was completed under the direction of the subspecialist. The subspecialist explained the findings to the patient at the end of the session, and discussed the diagnosis and management plans with the clinicians involved. Any diagnosis and management variations were classified into minor and major upon agreement by the two teams of clinicians involved. The clinicians and patients in Townsville rated the value of the consultation, and the subspecialists rated the confidence of their diagnoses on five-point scales. Pregnancy outcomes were obtained and the data analyzed. Over a 3-month period, 24 teleultrasound consultations were carried out. The indications for referral were: assessment of growth restriction/fetal wellbeing in the third trimester (6); detailed assessment for high-risk patients (5); evaluation of markers for anomalies (5); isolated fetal anomalies (1); and complex fetal problems such as twin/twin transfusion, multiple anomalies, etc. (7). Overall, the consultations resulted in some modifications to the clinical diagnosis in 45.8% of the cases, and modifications to the management plan in 33.3% of the cases (about half of which were minor variations). The clinicians rated the teleconsultations highly (mean rating 4.7, SD 0.44). The patients also rated the consultations highly, and were comfortable that their privacy and confidentiality were maintained during the consultation. The subspecialists were confident in making their diagnoses by telemedicine (mean score for confidence 4.2, SD 0.43). All the pregnancies have now been completed, with all antenatal diagnoses confirmed to be correct postnatally. Tertiary real-time ultrasound consultation by telemedicine is not only technically feasible, it is welcomed by the clinicians and patients involved. It also contributes to diagnostic and management differences. Larger scale clinical trials are needed to evaluate the true benefits and costs involved. The social benefits in bridging the healthcare gap between the country and the city, and in enabling patients in remote areas to stay close to their family under times of stress is well recognized by all involved.

OBJECTIVE: To study neonatal outcomes associated with gastroschisis and exomphalos in a regional neonatal unit. METHODS: A retrospective (1988-97) data analysis to study the effect of the type of defect/surgery, mode/place of delivery and associated anomalies on time to start and reach full feeds, duration of total parental nutrition (TPN) support and total hospital stay. Exact bivariate test procedures were used for data analysis. RESULTS: Twenty-one cases of gastroschisis (17 inborn) and five cases (four inborn) of exomphalos were identified. Of these, 23.8% cases of gastroschisis and 60% of cases of exomphalos had associated gut anomalies. The survival rates for gastroschisis and exomphalos were 91 and 100%, respectively. The median time to start and reach full enteral feeds in outborn neonates was longer than in inborn neonates (9 vs 25 days, respectively, P = 0.01; and 16 vs 49 days, respectively, P = 0.01), as was the duration of TPN support (14 vs 42 days, respectively; P = 0.02). Neonates with gastroschisis had significant delays in starting and reaching full feeds compared with neonates with exomphalos (median 13 vs 4.5 days, respectively, P = 0.03; and 24 vs 8, respectively, P = 0.02) and they required prolonged support with TPN (median 23 vs 6 days, respectively; P= 0.01). Antenatal detection was significantly more frequent in inborn compared with outborn neonates (100 vs 67%, respectively; P = 0.03). The severity of associated gut anomalies and the delivery to surgery interval did not differ significantly to explain the increased morbidity in outborn neonates. Outcome was not significantly different after analysis by type of surgery and mode of delivery. CONCLUSIONS: Increased morbidity in outborn neonates may be related to factors such as temperature, care, hydration status, care of the defect and vascular compromise of prolapsed gut during prolonged transportation.

We have established a realtime fetal tele-ultrasound consultation service in Queensland, which has been integrated into our routine clinical practice. The service, which uses ISDN transmission at 384 kbit/s, allows patients in Townsville to be examined by subspecialists in Brisbane, 1500 km away. For the 90 tele-ultrasound consultations performed for the first 71 patients, 90% of the babies have been delivered, and outcome data have been received on all the pregnancies. All significant anomalies and diagnoses have been confirmed. The referring clinicians would have physically referred 24 of the 71 patients to Brisbane in the absence of telemedicine. A crude cost-benefit calculation suggests that the tele-ultrasound service resulted in a net saving of A$6340, and at the same time enabled almost four times the number of consultations to be carried out.

1. Glucocorticoids are an effective treatment in the amelioration of chronic lung disease in neonates. However, systemic administration of glucocorticoids to neonates is associated with significant side-effects that preclude them as an early intervention to prevent onset of the condition. Conversely, local intratracheal administration of glucocorticoids may prevent inflammatory insult to the lungs without the development of systemic side-effects. We therefore investigated whether local intratracheal delivery of corticosteroids could be facilitated using surfactant as a vehicle. 2. Addition of dexamethasone to either diluted or commercial artificial surfactant, Survanta (Abbott Industries, Sydney, NSW, Australia), did not alter the surface properties of the surfactant. 3. After intratracheal instillation to rats, radiolabelled dexamethasone in Survanta was well distributed throughout all four lobes of the lungs. A concentration gradient of the steroid was observed between the root and the peripheral sections of all lobes. 4. Our results suggest that surfactant is an effective vehicle for intratracheal delivery of glucocorticoids. Moreover, we propose that prophylactic intratracheal administration of glucocorticoids administered shortly after birth may prevent inflammatory insult to the lungs and thereby reduce the likelihood of chronic lung disease developing.

Advances in neonatology have resulted in an increase in the absolute number of survivors with chronic lung disease (CLD), though its overall incidence has not changed. Though the single most important high-risk factor for CLD is prematurity, the focus of attention has recently changed over to minimizing the impact of other two risk factors: baro/volutrauma related to mechanical ventilation, and oxygen toxicity. Permissive hypercapnia (PHC) or controlled ventilation is a strategy that minimizes baro/volutrauma by allowing relatively high levels of arterial CO(2), provided the arterial pH does not fall below a preset minimal value. The benefits of PHC are primarily mediated by the reduction of lung stretch that occurs when tidal volumes are minimized. PHC can be a deliberate choice to restrict ventilation in order to avoid overdistention, while application of high airway pressures and large tidal volumes would permit normocapnia, or relative hypocapnia (PaCO(2), < or = 25-30 mmHg), but may result in CLD and be harmful to the developing lung. The current concept that PaCO(2) levels of 45-55 mmHg in high-risk neonates are "safe" and "well tolerated" is based on limited data. Further prospective trials are needed to study the definition, safety and efficacy of PHC in ventilated preterm and term neonates. However, designing disease/gestational-postnatal age-specific clinical trials of PHC will be difficult in neonates, given the diverse pathophysiology of their diseases and the various ventilatory modes/variables currently available. The potential benefits and adverse effects of PHC are reviewed, and its relationship to current ventilatory strategies like synchronized mechanical ventilation and high-frequency ventilation in high-risk neonates is briefly discussed.

BACKGROUND: Foot ulceration is the main precursor to lower limb amputation in patients with type 2 diabetes worldwide. Biomechanical factors have been implicated in the development of foot ulceration; however the association of these factors to ulcer healing remains less clear. It may be hypothesised that abnormalities in temporal spatial parameters (stride to stride measurements), kinematics (joint movements), kinetics (forces on the lower limb) and plantar pressures (pressure placed on the foot during walking) contribute to foot ulcer healing. The primary aim of this study is to establish the biomechanical characteristics (temporal spatial parameters, kinematics, kinetics and plantar pressures) of patients with plantar neuropathic foot ulcers compared to controls without a history of foot ulcers. The secondary aim is to assess the same biomechanical characteristics in patients with foot ulcers and controls over-time to assess whether these characteristics remain the same or change throughout ulcer healing. METHODS/DESIGN: The design is a case-control study nested in a six-month longitudinal study. Cases will be participants with active plantar neuropathic foot ulcers (DFU group). Controls will consist of patients with type 2 diabetes (DMC group) and healthy participants (HC group) with no history of foot ulceration. Standardised gait and plantar pressure protocols will be used to collect biomechanical data at baseline, three and six months. Descriptive variables and primary and secondary outcome variables will be compared between the three groups at baseline and follow-up. DISCUSSION: It is anticipated that the findings from this longitudinal study will provide important information regarding the biomechanical characteristic of type 2 diabetes patients with neuropathic foot ulcers. We hypothesise that people with foot ulcers will demonstrate a significantly compromised gait pattern (reduced temporal spatial parameters, kinematics and kinetics) at base line and then throughout the follow-up period compared to controls. The study may provide evidence for the design of gait-retraining, neuro-muscular conditioning and other approaches to off-load the limbs of those with foot ulcers in order to reduce the mechanical loading on the foot during gait and promote ulcer healing.

A number of recent epidemiological findings have implicated magnesium as being essential to fetal well-being. Few studies, however, have examined the relationship between maternal requirements for dietary magnesium and subsequent mortality and morbidity in offspring. The present study uses a rodent model of dietary-induced hypomagnesemia to investigate the effects of magnesium deficiency prior to and during gestation on neonatal morbidity and mortality. Magnesium deficiency during gestation significantly increased neonatal mortality and morbidity. Such increases were associated with a reduced free magnesium concentration in both maternal and offspring blood and an increased incidence of periventricular hemorrhage and edema in newborn pups as observed by magnetic resonance imaging and histology. Animals fed a magnesium-deficient diet before mating but given magnesium supplementation during gestation did not demonstrate a significant change in neonatal mortality and morbidity when compared to control animals. The significant improvement in fetal outcome with dietary magnesium supports the concept of magnesium supplementation during pregnancy.

Our objective was to determine obstetricians' personal choices in relation to modes of delivery and long-term outcomes. A structured confidential survey was mailed out to all Australian and New Zealand Fellows, Members, and Australian Trainees with The Australian and New Zealand Journal of Obstetrics and Gynaecology November 1999 edition. The response rate overall was 26% (478). Eleven per cent (54) chose to have an elective Caesarean section (ECS) in the absence of any clinical indication. The most common reason for this was fear of faecal and urinary incontinence (82%). Two-thirds (318) were agreeable to patients requesting an ECS in this same setting. Twenty-six per cent said they would choose ECS if the estimated fetal weight (EFW) was > 4000 g which more than doubled to 55% (261) if EFW was > 4500 g. Ventouse delivery was the most popular method of assisted rotational delivery at 45% (214) followed closely by Keilland's forceps at 40% (189). Caesarean section (CS) was chosen by only 14% (65) in this scenario. ECS was the preferred method for breech delivery at 38% (181) followed by trial of breech delivery at 23% (109). Thirty-two per cent (154) of respondents would attempt external cephalic version prior to deciding mode of delivery. Respondents felt the most important factors for postnatal incontinence included: antenatal incontinence (64%), length of second stage > one hour (50%), forceps delivery (46%), and EFW > 4000 g at term (44%).

OBJECTIVE: To study the postnatal changes in the plasma concentrations of fat soluble antioxidant vitamins and malondialdehyde (MDA) in mothers and their newborns and their relation to smoking. DESIGN: Prospective cohort study. SETTING: Tertiary perinatal centre. SUBJECTS: Eighteen non-smoking and 14 smoking mothers and 33 infants. MAIN OUTCOME MEASURES: Plasma concentrations of vitamins E, A, and beta-carotene and MDA were measured in mothers and infants at delivery and on day 4 post partum. RESULTS: Neonatal plasma levels of vitamins E, A, and beta-carotene were significantly lower than maternal levels both at delivery and on day 4 in both groups. There was a significant postnatal increase in plasma vitamin E levels in smoking mothers and neonates of both groups. A significant postnatal increase in maternal, but not neonatal, plasma vitamin A was noted in both groups. Cord plasma vitamin E levels were significantly lower in infants of smoking mothers (mean 4.7 v 6.5 micromol/l, p = 0.041). Plasma MDA was paradoxically lower in smoking mothers at delivery (3.19 v 4.01 micromol/l, p = 0.03) and on day 4 (1.37 v 3.29 micromol/l, p = 0.005) and in infants of the smoking group on day 4 (2.18 v 3.12 micromol/l, p = 0.014). Also, there was a significant postnatal fall in plasma MDA levels on day 4 in mothers and infants in the smoking group. CONCLUSIONS: The postnatal changes in plasma vitamin E were more pronounced in the smoking group. The postnatal changes in plasma vitamins A and beta-carotene were similar in both groups. The rapid decline in plasma MDA in smoking mothers and their infants suggests withdrawal of oxidative stress from smoking around delivery. This coincided with the increase in plasma vitamin E.

OBJECTIVE: High plantar pressures are implicated in the development of diabetes-related foot ulcers. Whether plantar pressures remain high in patients with chronic diabetes-related foot ulcers over time is uncertain. The primary aim of this study was to compare plantar pressures at baseline and three and six months later in participants with chronic diabetes-related foot ulcers (cases) to participants without foot ulcers (controls). METHODS: Standardised protocols were used to measure mean peak plantar pressure and pressure-time integral at 10 plantar foot sites (the hallux, toes, metatarsals 1 to 5, mid-foot, medial heel and lateral heel) during barefoot walking. Measurements were performed at three study visits: baseline, three and six months. Linear mixed effects random-intercept models were utilised to assess whether plantar pressures differed between cases and controls after adjusting for age, sex, body mass index, neuropathy status and follow-up time. Standardised mean differences (Cohen's d) were used to measure effect size. RESULTS: Twenty-one cases and 69 controls started the study and 16 cases and 63 controls completed the study. Cases had a higher mean peak plantar pressure at several foot sites including the toes (p = 0.005, Cohen's d = 0.36) and mid-foot (p = 0.01, d = 0.36) and a higher pressure-time integral at the hallux (p<0.001, d = 0.42), metatarsal 1 (p = 0.02, d = 0.33) and mid-foot (p = 0.04, d = 0.64) compared to controls throughout follow-up. A reduction in pressure-time integral at multiple plantar sites over time was detected in all participants (p<0.05, respectively). CONCLUSIONS: Plantar pressures assessed during gait are higher in diabetes patients with chronic foot ulcers than controls at several plantar sites throughout prolonged follow-up. Long term offloading is needed in diabetes patients with diabetes-related foot ulcers to facilitate ulcer healing.

Nine dogs with panniculitis due to rapidly growing mycobacteria (RGM) were examined over 17 years. Dogs were two to 15 years; five were male, four were female. All were obese or in good condition. Antecedent injury, typically a dog bite or vehicular trauma, could be identified in some patients, while one bitch had hyperadrenocorticism. Infections involved different locations, although the cervicothoracic region, dorsum or flank were most often affected. Patients were systemically well, apart from one dog with pyrexia and two with pain or lameness. Cytology demonstrated pyogranulomatous inflammation, but in only one case was it possible to see acid-fast bacilli (AFB) in smears. Histology demonstrated chronic active pyogranulomatous panniculitis and dermatitis; AFB could be detected in only four specimens. Culture of aspirates or resected tissues demonstrated RGM in all cases, comprising six Mycobacterium smegmatis group and three Mycobacterium fortuitum group isolates. Resection of infected tissues, perioperative injectable antimicrobials and long courses of oral antimicrobials chosen according to susceptibility data generally effected a cure, although some cases recurred.

Ligation of the internal iliac (hypogastric) arteries in cases of massive obstetric and gynaecological haemorrhage can be a life-saving operation, but it has never been widely practised in the British gynaecological tradition. There may be historical reasons for this. A series of 13 cases is presented from one Australian hospital over a 5-year period, and a very low rate of Caesarean hysterectomy is demonstrated. A wider knowledge of the technique is recommended. Alternative methods of management, including angiographic embolization and the use of prostaglandins are discussed.

Efficacy of oral, prophylactic erythromycin in reducing the time to establish full enteral feeds (150 ml/kg/day) was assessed in neonates < 32 weeks, ready for enteral feeds. Seventy-three consecutive neonates were randomised to receive oral erythromycin ethyl succinate (n = 36) or placebo (n = 37) in a double-blind trial until full enteral feeds or 14 days of therapy were reached. A prospectively designed feeding regimen, including plan of action for signs of feed intolerance, was common for all enrolled neonates. The median gestational age, birth weight and postnatal age at start of feeds were 29 versus 30 weeks (p = 0.40), 1232 versus 1280 g (p = 0.96) and 5 versus 5 days (p = 0.84) for erythromycin and placebo group, respectively. Time to achieve full feeds was not significantly different in the two groups. (median times: erythromycin 93.5 versus placebo 104 hours, p = 0.60). Erythromycin-related side-effects did not occur.

UNLABELLED: Addition of intravenous rifampin is reported to be useful in prompt clearance of persistent coagulase negative staphylococcal (CONS) bacteraemia in high-risk neonates. Four neonates (mean birthweight 823 g, mean gestation 25 wk) with persistent CONS bacteraemia for > 7-10 d (mean 11) were treated with i.v. rifampicin (10 mg/kg/12 h x 10 d) while continuing vancomycin (15 mg/kg/24 h). Their age at time of infection ranged from 2 to 11 d. The mean (range) vancomycin peak and trough concentrations were 29 (25-35) and 6 (4-10) microg/ml, respectively. The blood isolates were Staphylococcus epidermidis, S. hominis, and S. haemolyticus. Addition of rifampicin was associated with prompt clearance of bacteraemia within 48 h (n = 3) and 5 d (n - 1). Rifampicin-related adverse effects such as abnormal liver function tests and thrombocytopenia did not occur. CONCLUSION: Addition of i.v. rifampicin to vancomycin may optimize the outcome of persistent CONS bacteraemia and the risk of bacterial resistance related to prolonged exposure to vancomycin.