First trimester maternal blood rheology and pregnancy induced hypertension.

This study evaluates the relationship between the first trimester assessment of maternal rheology and the subsequent development of pregnancy induced hypertension. This is a prospective observational study based in the Glasgow Royal Maternity Hospital, Scotland. From an original population of 744 consecutive antenatal attendees a total of 579 women were booked at less than 14 weeks' gestation. The main study group is a further subset comprising 251 primigravid women booking with a singleton pregnancy without essential hypertension. Previously published data from a group of non-pregnant women of similar age drawn from the same local community was used for external comparison. Blood samples were collected at the booking visit, from which fibrinogen, red cell aggregation, haematocrit and plasma, whole blood, relative and corrected viscosities were recorded. Information was obtained from the case notes in retrospect starting approximately 1 year after the first patients had first been recruited into the trial. The overall outcome of the pregnancies was noted with particular reference to pregnancy induced hypertension (PIH), birth weight, antepartum haemorrhage, pre-term labour, perinatal death, condition at delivery and neonatal complication. Our results show PIH is associated with a significantly raised mean blood viscosity and fibrinogen at time of booking. All significance disappears after adjustment for smoking, diastolic blood pressure and age. Viscosity is, however, only marginally non-significant (p = 0.07). In conclusion, blood rheology, in particular blood viscosity and fibrinogen, may play a predictive role in the development of pregnancy-induced hypertension. When combined with measurement of smoking and diastolic blood pressure at booking, these measurements could be used to calculate a risk score for the development of PIH, allowing targeting of antenatal care. Further data is required.

A costed profile audit of the surgical management of female stress incontinence.

BACKGROUND AND AIMS: To conduct a profile audit of three surgical treatments for urinary stress incontinence through the application of an episode costing process. METHODS: Four stage methodology: (1) construction or a profile of care for each of the surgical approaches (setting the standard); 2) calculation of a theoretical profile cost; (3) calculation of the observed costs from real patient episodes; (4) comparison of observed costs with profile costs, (comparing present practice with established standard). RESULTS: Profiles of care were constructed and compared with 39 actual in-patient episodes. Tension free vaginal tape (TVT Gynecare) is the cheapest modality of treatment in terms of both the expected profile cost and also observed (real patient) cost. Colposuspension is the most expensive form of treatment with real costs significantly greater than the expected profile. Clinical issues such as length of stay, duration of surgery, patient selection and complication rates were revealed through the exception reporting process. Length of stay is the main determinant of overall cost. CONCLUSION: It is possible to construct a costed and auditable standard of care for a surgical procedure. This standard can be compared with real patient costs calculated using the same methodology. Exception reporting based on differences between expected and real costs can be used to facilitate the audit of clinical practice. The technique is limited, however, by the need to collect accurate and detailed activity data.

Getting a validated guideline into local practice: implementation and audit of the SIGN guideline on the prevention of deep vein thrombosis in a district general hospital.

This paper describes the implementation of a specific clinical guideline on venous thromboprophylaxis and outlines the audit design and methods used to achieve this objective. A member of the clinical staff was seconded to oversee this implementation and co-ordinate audit of current in the main clinical specialties within the trust. The Trust Clinical Audit Committee agreed to fund this low cost initiative (approximately 3,800 pounds) from clinical guideline monies. Findings from the initial audit revealed a total of 224 patients identified as 'at risk' of developing deep vein thrombosis or pulmonary embolism. Of this number 72.8%, (n = 163), were prescribed prophylaxis compared with the pre-set standard of 90.0%. Fifty four percent, (n = 122), of all identified patients were prescribed the correct prophylaxis in accordance with SIGN guideline recommendations. As a result of the initial findings local prevention protocols were developed or upgraded as required in line with the national guideline. The repeat audit findings highlighted a significant increase in the number of 'at risk' patients prescribed prophylaxis rising from 72.8% to 97.4% (P < 0.001) and similarly from 54.5% to 95.9% for those prescribed the correct prophylaxis (P < 0.001).

Case report: cerebellar hemi-hypoplasia.

Cerebellar hypoplasia is a prominent feature of fetal brain pathology. The lesion is rarely isolated or asymmetric. Various aetiological factors have been proposed. The frequency of cerebellar hypoplasia as a congenital defect in humans is unknown. A single case is described of unilateral cerebellar hypoplasia with intact vermis that was detected on prenatal ultrasound examination. Changes in the appearance of the abnormality over the course of the pregnancy raised the possibility of a disruptive vascular aetiology with destruction of normally formed structures. Prenatal ultrasound, post-delivery cranial ultrasound, and MRI images are presented to support the hypothesis.

Realising the benefits of resource management.

In 1988 Inverclyde Royal Hospital became the pilot site for the resource management initiative in Scotland. Real benefits have been achieved through the implementation of an information system which allows doctors to closely monitor every aspect of health care in the hospital, enabling them to continually reassess and evaluate their own work. The ability of doctors to use the clinical information system to fulfil operational requirements, such as the production of automated discharge summaries, whilst supporting the medical audit process through the same dataset has been a major achievement. Within the hospital the creation of an 'information flow' has been helpful to all clinical and medical records staff and at the same time has produced patient based information to support the management process. The availability of over four years of fully costed activity data is a considerable advantage for the Unit as Trust status approaches.

Magnesium metabolism in preterm infants: effects of calcium, magnesium, and phosphorus, and of postnatal and gestational age.

This study tests the hypothesis that increasing the calcium and phosphorus content of formulas for very low birth weight (VLBW) infants to the level required to decrease the incidence of rickets has a negative impact on magnesium balance. Using formulas variously supplemented with these minerals, we measured absorption and retention in two groups of preterm infants: (1) VLBW infants, less than 1500 gm and at less than 32 weeks of gestational age, with 3-day mineral balances begun at days 10, 20, 30, and 40; and (2) low birth weight infants appropriately grown and at 32 to 34 weeks of gestational age, with a single 3-day balance begun at day 10. Magnesium did not affect calcium balance in VLBW or low birth weight infants but promoted phosphorus retention in VLBW infants from day 20 onward. Absorption and retention of magnesium increased with postnatal age in VLBW infants, but this effect was obvious only when calcium or phosphorus intakes were low or when magnesium intake was high. Calcium and phosphorus supplementation further reduced magnesium absorption and retention in VLBW infants to the extent that they were in negative balance throughout the study; however, magnesium supplementation improved absorption and retention in VLBW infants. The low birth weight infants absorbed and retained more magnesium than VLBW infants at the same postnatal age whether or not magnesium was supplemented. We conclude that magnesium deficits occur at currently recommended intakes of 10 mg/kg/day for VLBW infants with calcium and phosphorus intakes that allow retentions equivalent to in utero accretions; however, with magnesium intakes approaching 20 mg/kg/day, appropriate retention can be achieved.

Changes in cardiorespiratory function during gastric lavage for drug overdose.

Cardiorespiratory function in 42 patients admitted to the Regional Poisoning Treatment Centre, Edinburgh who underwent gastric lavage for self poisoning, was studied using an electrocardiograph and an ear oximeter. Mean pulse rate rose from 92 to 121 beats per min and the mean partial pressure of oxygen fell from 95 to 80 mmHg during lavage (P less than 0.001). These changes were significantly greater in conscious than unconscious patients, in smokers than in non-smokers and most marked in male smokers aged 45 or older. No sex or age differences were noted. Electrocardiograph changes were noted in 41% of patients, including potentially serious changes in 2 patients. The indications for gastric lavage should probably be reviewed particularly in conscious older patients who smoke and due consideration given to induced emesis and ingestion of activated charcoal as alternatives.

Recovery of ingested heroin packets.

Two patients deliberately ingested single paper packages containing heroin. These were recovered intact by induction of emesis with syrup of ipecacuanha.