To compare three low-lactose milk formulas differing in osmolality and degree of protein hydrolysis in the treatment of diarrhoea and malnutrition in subjects with high rates of lactose intolerance, osmotic diarrhoea and a tropical/environmental enteropathy. A randomized double-blind trial of 180 Aboriginal children under 3 years of age admitted with acute diarrhoea and/or malnutrition was carried out. The intervention milk formulas were: (i) De-Lact, a low-osmolality lactose-free formula; (ii) O-Lac, a lactose-free formula; and (iii) Alfaré, a partially hydrolysed formula. Outcome measures were diarrhoeal severity, weight gain, formula palatability and changes in intestinal permeability (L/R ratios). The duration of diarrhoea in days (mean; 95% confidence interval) was significantly longer on Alfaré (8.5; 7.0-10.0) compared to De-Lact (6.1; 5.0-7.2) and O-Lac (6.9; 5.6-8.1; P = 0.04). There were no differences in mean intake between formulas, but palatability of Alfaré was significantly worse (P < 0.01) than the other formulas. Over the trial 5 days, improvement in L/R ratios was significantly greater (P = 0.05) for De-Lact (18.6; 10.6-26.6) than for Alfaré (8.5; 2.1-14.9). Weight gain was not significantly different between the three formulas, except in a malnourished subgroup who had better weight gain on De-Lact (P = 0.05). In these Aboriginal children with diarrhoea and growth failure, a low osmolality milk was associated with better outcomes and a partially hydrolysed formula with less improvement in mucosal recovery, suggesting that cow's milk protein intolerance is not contributing to greater diarrhoeal severity or enteropathy in Aboriginal children.

The aim of this study was to examine the effectiveness of ropivacaine administered by a simple intraperitoneal technique in relieving pain following laparoscopic application of Filshie clips. Nineteen patients were randomised to receive either ropivacaine (200 mg) or normal saline through the umbilical port following clip application. Using a visual analogue scale women receiving ropivacaine had significantly lower pain scores 2 hours post operatively (0.97 vs 2.03 p < 0.05). The mean total postoperative fentanyl use was also significantly lower on the ropivacaine group (40 microg vs 104 microg p < 0.02). Only 10% (1/10) of the women in the ropivacaine group complained of nausea compared with 44% (4/9) in the control group. Furthermore, 80% (8/10) of women in the ropivacaine group were either very or totally satisfied with their pain relief. Only 56% (5/9) of the women in the control group were very or totally satisfied with their pain relief. Ropivacaine administered by a simple intraperitoneal technique following laparoscopic sterilisation significantly reduces postoperative pain and parenteral analgesic requirements. It would be reasonable to consider this method as standard practice following laparoscopic tubal ligation.

To evaluate the role of levosimendan in improving cardiac performance and the success rate of weaning from mechanical ventilation in ventilatordependent, difficult-to-wean patients with impaired cardiac function in the intensive care unit. Prospective, observational study in the ICU of Westmead Hospital, a university-affiliated tertiary referral hospital in Sydney, NSW, between January 2003 and October 2004. 47 ICU patients who were ventilator-dependent for > or =10 days and had failed a weaning or extubation attempt due to respiratory insufficiency were identified as difficult to wean from mechanical ventilation. All were assessed by transthoracic or transoesophageal echocardiography. Twelve who had impaired left ventricular performance (demonstrated by left ventricular ejection fraction [LVEF] <40%) and were already established on diuretic and vasodilator treatment were given a 24-hour infusion of levosimendan. LVEF was measured again within 24 hours after infusion, and weaning from mechanical ventilation and extubation were re-attempted, when clinically deemed feasible. Levosimendan administration was associated with significantly improved LVEF (28.3% before v 34.6% after, P=0.04) and PaO2/FIO2 ratio (179mmHg v 197mmHg, P=0.002) and reduced FIO2 (0.45 v 0.39, P=0.01). These changes were associated with significant improvement in the success rate in weaning from mechanical ventilation (P=0.02), with seven of the 12 patients successfully weaned after levosimendan therapy, and six surviving to hospital discharge. There was no significant difference in any other important parameter between pre- and post-levosimendan weaning attempts. Levosimendan may provide significant benefit to ventilator-dependent patients with impaired left ventricular function. Randomised controlled trials appear justified.