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death follows the withdrawal of ventilatory support, however, you could argue that death must be the intended result and not merely a side effect of acting in the patient's best interests. This is because paralysing drugs suppress a patient's breathing for some time after an infusion has been stopped. Because the patient completely depends on the ventilator she dies quickly when it is withdrawn. The BMA suggests that withdrawing respiratory support in these circumstances could be interpreted in law as an intended killing. 3The doctrine of double effect is difficult to apply in this case, not impossible. To avoid confusion it is necessary to deal with each decision in turn. The first decision-to use muscle relaxants-itself has dual effects, the intended one being to make ventilation possible, and the side effect being to make the patient completely dependent on it. The second decision-to withdraw ventilation-has the effect that the patient dies quickly, but this doesn't have to be the intended effect. The two decisions are morally independent, despite being chronologically and logically sequential, because the intention behind the first decision (to make ventilation possible) is not linked to the side effect of the second, the patient dies. This could be an accurate description of the doctor's intentions in the face of difficult circumstances. It could also provide a legal defence against the charge of murder, although I know of no case law testing this interpretation.The alternative would be either to continue respiratory support indefinitely or to stop the paralysing drugs first and wait for any effects to wear off completely before withdrawing ventilation. The first is arguably not in the patient's best interests. The other may prolong the patient's suffering and that of her parents because of the delay between deciding to withdraw life prolonging treatment and actually doing it. The only reason why muscle relaxants were used in the first place was to allow ventilatory support, so the intention behind withdrawing it can only be to allow the subsequent withdrawal of ventilation, thereby linking the intention of the first decision with the effect of the second. The patient may become distressed and, without the effect of the muscle relaxants, the ventilator may not work properly anyway. It is difficult to see how withdrawing muscle relaxants can be in a patient's best interests without taking him or her off the ventilator at the same time.In any case there are drugs, such as atracurium, that do not have these problematic residual effects, making this particular moral difficulty disappear.

WHAT'S KNOWN ON THIS SUBJECT: Preterm infants dependent on parenteral nutrition are vulnerable to deficits in early postnatal nutritional intake. This coincides with a period of suboptimal head growth. Observational studies indicate that poor nutritional intake is associated with suboptimal head growth and neurodevelopmental outcome. WHAT THIS STUDY ADDS:This study provides randomized controlled trial evidence that head growth failure in the first 4 weeks of life can be ameliorated with early nutritional intervention. Early macronutrient intake can be enhanced by optimizing a standardized, concentrated neonatal parenteral nutrition regimen. abstract BACKGROUND: Early postnatal head growth failure is well recognized in very preterm infants (VPIs). This coincides with the characteristic nutritional deficits that occur in these parenteral nutrition (PN) dependent infants in the first month of life. Head circumference (HC) is correlated with brain volume and later neurodevelopmental outcome. We hypothesized that a Standardized, Concentrated With Added Macronutrients Parenteral (SCAMP) nutrition regimen would improve early head growth. The aim was to compare the change in HC (DHC) and HC SD score (DSDS) achieved at day 28 in VPIs randomly assigned to receive SCAMP nutrition or a control standardized, concentrated PN regimen. METHODS:Control PN (10% glucose, 2.8 g/kg per day protein/lipid) was started within 6 hours of birth. VPIs (birth weight ,1200 g; gestation ,29 weeks) were randomly assigned to either start SCAMP (12% glucose, 3.8 g/kg per day protein/lipid) or remain on the control regimen. HC was measured weekly. Actual daily nutritional intake data were collected for days 1 to 28.RESULTS: There were no differences in demographic data between SCAMP (n = 74) and control (n = 76) groups. Comparing cumulative 28-day intakes, the SCAMP group received 11% more protein and 7% more energy. The SCAMP group had a greater DHC at 28 days (P , .001). The difference between the means (95% confidence interval) for DHC was 5 mm (2 to 8), and DSDS was 0.37 (0.17 to 0.58). HC differences are still apparent at 36 weeks' corrected gestational age. Dr Morgan developed the original concept and designed the study, ensured regulatory approvals, performed some study measurements, data collection and collation, coordinated data analysis, and drafted the initial manuscript; Mr McGowan performed most of the study measurements, data collection, and collation, contributed to data analysis and made study design modifications; Mr Herwitker was involved with study design and regulatory approval, overseeing study PN manufacture, and some data collation; Ms Hart provided the medical statistical support at the design, monitoring, and analytical stages of the study; Dr Turner was involved in study design and data analysis; and all authors approved the final manuscript as submitted. CONCLUSIONS:This trial has been registered with the ISRCTN Register (http:// isrctn.org) (identifier ISRCTN76597892 Improved survival of very preterm infants (VPIs) ha...

Objective To compare the outcomes of operative cephalic births by Kielland forceps (KF), rotational ventouse (RV), or primary emergency caesarean section (pEMCS) for malposition in the second stage of labour in modern practise.Design Retrospective observational study.Population Data were included from 1291 consecutive full-term, singleton cephalic births between 2 November 2006 and 30 November 2010 with malposition of the fetal head during the second stage of labour leading to an attempt to deliver by KF, RV or pEMCS.Methods Maternal and neonatal outcomes of all KF births were compared with other methods of operative birth for malposition in the second stage of labour (RV or pEMCS).Main outcome measures Achieving a vaginal birth was the primary outcome and fetal (admission to special care baby unit, low cord pH, low Apgar, shoulder dystocia, Erb's palsy) and maternal (massive obstetric haemorrhage-blood loss of >1500 ml, sphincter injury, length of stay in hospital) safety outcomes were also recorded.Results Women were more likely to need caesarean section if RV (22.4%) was selected to assist the birth rather than KF (3.7%; adjusted odds ratio 8.20; 95% confidence interval 4.54-14.79). Births by KF had a rate of adverse maternal and neonatal outcomes comparable to those by RV and pEMCS in the second stage for malposition.Conclusions Our results suggest that, in experienced hands, assisted vaginal birth by KF is likely to be the most effective and safe method to prevent the ever rising rate of caesarean sections when malposition complicates the second stage of labour.Keywords Emergency caesarean section, Kielland forceps, rotational vaginal birth, rotational ventouse.

While important associations were identified, much of the variance in HRQoL remains unexplained. Other clinical and psychosocial variables merit investigation. A longitudinal study is required to investigate how the disease trajectory and associated treatments affect an individual's quality of life.

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Acupuncture is increasingly used, so it is important to establish whether its benefits outweigh its risks. Numerous case reports of adverse events show that acupuncture is not free of risk, but accurate data from prospective investigations is scarce. A prospective survey was undertaken using intensive event monitoring. Forms were developed for reporting minor events each month and significant events as they occurred. The sample size was calculated to identify any adverse events that occurred more frequently than once in 10,000 consultations. Acupuncturists were recruited from two professional organisations in the UK. Seventy-eight acupuncturists, all doctors or physiotherapists, reported a total of 2178 events occurring in 31,822 consultations, an incidence of 684 per 10,000 consultations. The most common minor adverse events were bleeding, needling pain, and aggravation of symptoms; aggravation was followed by resolution of symptoms in 70% of cases. There were 43 significant minor adverse events reported, a rate of 14 per 10,000, of which 13 (30%) interfered with daily activities. One patient suffered a seizure (probably reflex anoxic) during acupuncture, but no adverse event was classified as serious. Avoidable events included forgotten patients, needles left in patients, cellulitis and moxa burns. In conclusion, the incidence of adverse events following acupuncture performed by doctors and physiotherapists can be classified as minimal; some avoidable events do occur. Acupuncture seems, in skilled hands, one of the safer forms of medical intervention.