Lancet
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Randomized Controlled Trial Multicenter Study Comparative Study
Intravenous remifentanil patient-controlled analgesia versus intramuscular pethidine for pain relief in labour (RESPITE): an open-label, multicentre, randomised controlled trial.
What did they do?
Wilson et al randomized 401 laboring women across multiple centers to either remifentanil PCA or pethidine/meperidine IM, then compared the progression of these women to labour epidural.
On the surface... this might appear disingenuous, as it compares remifentanil PCA to widely-shown-to-be-ineffective parenteral pethidine – rather than to the gold standard labour epidural. But it's also a study of how the technique might practically be used in the real world.
What they found
Women with remifentanil PCA progressed half as often to require epidural analgesia than those receiving pethidine (19% vs 41%).
Though it's one of the secondary findings that is most interesting: the remifentanil group were less likely to need instrumental delivery (15% vs 26%).
But don't get carried away
Despite the demonstrated superiority of remi PCA to pethidine, the technique is not without it's issues:
- Safety concerns regarding respiratory depression cannot be ignored, and because managing this relies upon staff vigilance, increased PCA use may conversely lead to a normalisation of risk and institutional complacency, rather than safety improvement.
- Analgesia is still inferior to epidural, even if maternal satisfaction is comparable.
- Technique acceptability might not be as good in communities with high pre-existing epidural use.
And finally... why are we so eager to do away with the labour epidural? Serious complications are very uncommon to rare, the technique is widely acceptable to women, and it is more effective than any other modality.
Is this change driven by the needs of pregnant women, or the health system's limited resources?
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The benefits of combination antiretroviral therapy (cART) for HIV replication and transmission control have led to its universal recommendation. Many people living with HIV are, however, still undiagnosed or diagnosed late, especially in sub-Saharan Africa, where the HIV disease burden is highest. Further expansion in HIV treatment options, incorporating women-centred approaches, is essential to make individualised care a reality. ⋯ Antiretroviral strategies are evolving towards a decrease in drug burden, and some two-drug combinations have proven efficacy for maintenance therapy. Investigational immune checkpoint inhibitors and broadly neutralising antibodies with effector functions have energised the HIV cure research field as the search for an effective vaccine continues. In this Seminar, we review advances and challenges relating to the goal of an AIDS-free world.
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Snakebite envenoming is a frequently overlooked cause of mortality and morbidity. Data for snake ecology and existing snakebite interventions are scarce, limiting accurate burden estimation initiatives. Low global awareness stunts new interventions, adequate health resources, and available health care. Therefore, we aimed to synthesise currently available data to identify the most vulnerable populations at risk of snakebite, and where additional data to manage this global problem are needed. ⋯ Bill & Melinda Gates Foundation.