Caesarean section rate and postnatal bed occupancy: a retrospective study replacing assumptions with evidence.

BACKGROUND: Obstetric units across the UK face resource pressures alongside a rising rate of Caesarean section (CS). It is assumed that this places a further burden in the form of postnatal bed demands. The number of inpatient beds has fallen nationally, and this may be used to justify attempts to restrict the CS rate. We set out to replace such assumptions with evidence. We did not find any similar contemporary analysis in a literature search. METHODS: The postnatal length of stay (LOS) of women delivering at Watford General Hospital, a large unit hosting around 5500 deliveries per annum, was stratified by mode of delivery. Differences within and across time periods were analysed. RESULTS: The CS rate rose from 14.5% in 1995 to 30.9% in 2015. The mean LOS post-CS declined from 4.2 to 2.4 days. These data were statistically significant to p < 0.001. Over this period the standardised total postnatal bed use for all delivery modes fell from 11083 days to 7894 days. A 113% rise in the CS rate was accommodated by only a 19.8% rise in postnatal bed use attributable to CS patients. CONCLUSIONS: Whatever pressures may be exacerbated by the rising CS rate, bed occupancy is not one of them. In discussion we widen our argument to suggest that resource pressures should not be used to justify limitations in the CS rate.

The impact of maternal age over forty years on the caesarean section rate: six year experience at a busy district general hospital.

A retrospective study over a 6-year period was undertaken to determine the trend in age at booking for antenatal care at West Hertfordshire Hospitals NHS Trust and to investigate the relationship between maternal age at booking for antenatal care and mode of delivery. Between 2006 and 2011, there was an 80% increase in the number of women over the age of 40 years booking for antenatal care. The overall caesarean section rate in this cohort of women increased from 34.6% in 2006 to 53.7% in 2011, comprising of an increase in both elective and emergency caesarean sections. It appears that increasing maternal age may explain a significant proportion of the rising caesarean section rate in our unit.

Determining in-patient diabetes treatment satisfaction in the UK--the DIPSat study.

AIMS: To measure in-patient diabetes treatment satisfaction and its relationship to in-patient diabetes care. METHODS: In a cross-sectional study, diabetes in-patient specialist nurses at 58 UK hospitals asked insulin-treated in-patients with diabetes to complete the recently updated Diabetes Treatment Satisfaction Questionnaire for In-patients and a general questionnaire; 1319 in-patients completed these questionnaires. RESULTS: Satisfaction with the general diabetes treatment items in the Diabetes Treatment Satisfaction Questionnaire for In-patients was high, but there were high levels of extreme dissatisfaction with meal choices, meal quality and lack of similarity of hospital meals to normal domestic choices--23% would never or rarely have made similar meal choices at home. Hyperglycaemia or hypoglycaemia was reported for much of the in-patient stay (20% and 7%, respectively) and 26% reported at least one severe hypoglycaemic episode; these groups had lower satisfaction with the timing of medication in relation to meals (P < 0.003). More frequent in-patient hyperglycaemia or hypoglycaemia were associated with significantly poorer overall satisfaction scores and negative well-being scores (both P < 0.0001). Previous experience of a multiple daily insulin injection regimen was associated with more dissatisfaction than other regimens (P < 0.01). Multiple regression models explained 36% of variability in overall treatment satisfaction, with most (22.4%) accounted for by satisfaction with time spent with a diabetes in-patient specialist nurse (P < 0.0001). Self-administration of insulin was independently associated with higher treatment satisfaction (P < 0.006) in this model. CONCLUSIONS: The DIPSat programme describes the complex relationships between diabetes in-patient treatment satisfaction and in-patient diabetes care.

Hydatoxi lualba: the worm that wasn't!

Pre-eclampsia is a disorder that occurs only during pregnancy and the postpartum period and affects both the mother and the unborn child. Affecting at least 5-8% of all pregnancies, it can be a rapidly progressive condition characterised by hypertension and proteinuria. Oedema, sudden weight gain, headaches and changes in vision are important symptoms. However, some women with rapidly advancing disease report few symptoms.

Reporting rates of ectopic pregnancy: are we any closer to achieving consensus?

Calculating rates of ectopic pregnancy in a reliable and reproducible way can be challenging. To date, there is no consensus as to which denominators to use but the authors suggest using the total number of deliveries as a benchmark. In many developing countries where ectopic pregnancy is a major cause of maternal morbidity and mortality, standardisation of epidemiological data is arguably even more important. Using the number of deliveries is probably the most pragmatic and reliable way of quoting ectopic pregnancy rates in developing countries, as structures are usually already in place to record births/deliveries. This would ensure greater consistency and allow more meaningful comparisons to be made, both within individual units over time as well as globally. Using additional denominators is more labour intensive and lends itself to inaccuracy but may nevertheless be useful depending on the issues being addressed. Ultimately, the correct denominator(s) to use should be determined by the clinical question(s) of interest. The authors acknowledge that the statistical analysis used in this paper is based on one retrospective study alone and that further work is required in this area before definitive conclusions can be made.

Ovarian ectopic pregnancy: aetiology, diagnosis, and challenges in surgical management.

Primary ovarian ectopic pregnancy (OEP) remains a rare but important type of ectopic pregnancy which is normally diagnosed at surgery. The aetiology is unknown. We have found fertility treatments (18.1%) and intrauterine contraceptive devices (19.3%) remain important associated risk factors. We undertook a world literature review of all cases since 1995. We found that 52% of cases were managed laparoscopically, which is less than the reported UK rate of all ectopics, of 85.9%. Over that time period, eight patients were treated medically with a success rate of 50%. While the original 1878 Spiegelberg's criterion still holds for the diagnosis, the addition of modern ultrasound scanning has made a radiological diagnosis possible. In a few cases, the management of OEP remains similar to that of a tubal ectopic pregnancy with the same challenges. Laparoscopy with ovarian sparing in the stable woman is today the surgical treatment of choice.

Short communication: Responses to supplemental Saccharomyces cerevisiae fermentation product and triticale grain in dairy cows grazing high-quality pasture in early lactation.

Supplementing cows grazing highly digestible pasture with a Saccharomyces cerevisiae fermentation product (SCFP) was hypothesized to increase dry matter (DM) intake and milk production. Sixty multiparous dairy cows were fed 3 kg of crushed triticale DM/cow per day for 23 ± 4.4 d before calving. Half of the cows received SCFP (60 g/d; Diamond V Original XP; Diamond V Mills, Inc., Cedar Rapids, IA). Cows in both treatment groups were randomly allocated at calving to 1 of 2 amounts (3 or 6 kg of DM/d) of triticale feeding with or without 60 g of SCFP/day (n=15/treatment) until 84 days in milk. The amount of pasture harvested (kg of DM/cow per day) and milk yield (kg/cow per day) were not affected by SCFP. Milk protein content and yield were greater in cows receiving 6 kg of crushed triticale DM/d. Plasma nonesterified fatty acids and ß-hydroxybutyrate concentrations were not affected by SCFP supplementation, but were lower in cows fed 6 kg of crushed triticale DM/d than those fed 3 kg of DM/d. Supplementation with SCFP increased milk lactose content without affecting milk production under the conditions investigated.

An updated report on the incidence and epidemiological trends of keratinocyte cancers in the United Kingdom 2013-2018.

Introduction: The most common cancers in the UK are keratinocyte cancers (KCs): the combined term for basal cell carcinomas (BCCs) and cutaneous squamous cell carcinomas (cSCCs). Registration of KC is challenging due to high numbers and multiplicity of tumours per person. Methods: We provide an updated report on the descriptive epidemiology of trends in KC incidence for the resident populations of UK countries (England, Northern Ireland, Scotland and Wales) using population-based cancer registry and pathology report data, 2013-18. Results: Substantial increases in cSCC incidence in England, Scotland and Northern Ireland can be detected for the period of 2013-18, and the incidence of cSCC also increased in Wales from 2016 to 2018. In contrast, however, the pattern of annual change in the incidence of BCC across the nations differs. In England, the incidence of BCC declined slightly from 2016 to 2018, however, the overall trend across 2013-18 is not statistically significant. In Scotland, the incidence of BCC shows some variability, declining in 2017 before increasing in 2018, and the overall trend across 2013-18 was also not statistically significant. In Northern Ireland, the incidence of BCC increased significantly over the study period, and in Wales, the incidence of BCC increased from 2016 to 2018. One in five people will develop non-melanoma skin cancers (NMSC) in their lifetime in England. This estimate is much higher than the lifetime risk of melanoma (1 in 36 males and 1 in 47 females born after 1960 in the UK), which further highlights the burden of the disease and importance of early prevention strategies. Conclusions: We highlight how common these tumours are by publishing the first ever lifetime incidence of NMSC. Additionally, the first time reporting of the age standardised incidence of KC in Wales further confirms the scale of the disease burden posed by these cancers in the UK. With approximately one in five people developing NMSC in their lifetime, optimisation of skin cancer prevention, management and research are essential.

An 'epidemic' of ectopic pregnancy in West Hertfordshire, UK?

Our clinical impression is that the incidence of ectopic pregnancy in West Hertfordshire in the UK has been steadily rising to almost 'epidemic' proportions. On the basis of our clinical suspicion, a retrospective study was performed looking at the ectopic pregnancy rates in the region from 1993 to 2007. All histologically proven ectopic pregnancies were obtained using the hospital histology database and all deliveries (live births and stillbirths) were obtained using the Ciconia Maternity information System (CMiS). The numbers of legal terminations of pregnancy (NHS and non-NHS) as well as women of reproductive age were obtained using the databases from the Office for National Statistics and Department of Health. In terms of absolute numbers of histologically proven ectopic pregnancies, there were 38 cases in 1993, rising to a peak of 68 cases in 1998 and 59 cases in 2007. This equates to 6.5/1,000 deliveries in 1993, 11/1,000 deliveries in 1998 and 10.7/1,000 deliveries in 2007. Although there have been fluctuations in ectopic pregnancy rates over 15 years, this did not reach statistical significance. Therefore, contrary to our clinical suspicion, the incidence of ectopic pregnancy in West Hertfordshire has remained stable.

Prospective randomised multi-centre trial comparing the clinical efficacy, safety and patient acceptability of circular stapled anopexy with closed diathermy haemorrhoidectomy.

OBJECTIVE: Unlike excisional haemorrhoidectomy, stapled anopexy (SA), which does not involve radical excision, has theoretical advantages, thus offering potential patient benefits. We compared the clinical efficacy, safety and patient acceptability of SA, with closed haemorrhoidectomy (CH). PATIENTS AND METHODS: 182 patients with symptomatic haemorrhoids (grades II, III, IV) were randomly assigned to receive SA or CH and were followed for up to 1 year (6, 12, 24, 48 weeks) after operation. Postoperative pain, symptom control, complications, re-treatment rates, patient satisfaction, and quality of life were compared on an intention-to-treat basis. RESULTS: Postoperative pain in the SA group (n = 91) was significantly lower (p = 0.004, Mann-Whitney U test). At 1 year there were no significant differences in the symptom load, symptom severity or the disease severity between the two groups. Overall complication rates were similar but faecal urgency was reported more frequently following SA (p = 0.093, Fisher's exact test). Despite a similar rate of residual symptoms, prolapse control was better with CH (p = 0.087, Fisher's exact test), and more patients in the SA group required re-treatment for residual prolapse at 1 year (p = 0.037, Fisher's exact test). However, more patients rated SA as an excellent operation at 6 and 12 weeks (p = 0.008 and 0.033, binary logistic regression) and were willing to undergo a repeat procedure if required (p = 0.018, Fisher's exact test). CONCLUSION: Stapled anopexy offers a significantly less painful alternative to excisional haemorrhoidectomy and achieves a higher patient acceptability. Although the overall symptom control and safety are similar in the majority of the patients, the re-treatment rate for recurrent prolapse at 1 year is higher following SA when compared to CH.

Long-term comparative outcome between laparoscopic total Nissen and Toupet fundoplication: Symptomatic relief, patient satisfaction and quality of life.

BACKGROUND: Laparoscopic antireflux surgery has become an established method of treatment of gastroesophageal reflux disease. This study compares the long-term outcome of total (Nissen) and partial (Toupet) fundoplication, performed in a single institution, by evaluating symptoms and quality of life. METHODS: 266 patients who underwent laparoscopic Nissen or Toupet fundoplication completed a preoperative reflux symptom questionnaire. Postsurgery symptom evaluation, patient satisfaction and quality of life in reflux and dyspepsia (QOLRAD) questionnaires were sent to these patients in December 2004. The two groups were compared for each item nonparametrically. RESULTS: Completed questionnaires were received from 161 patients (61%) of whom 99 had a laparoscopic Nissen fundoplication and 62 laparoscopic Toupet fundoplication. Both procedures were equivalent in improving reflux symptom scores in the long term, 79/99 (80%) and 56/62 (90%) were either symptom free or had obtained significant symptomatic relief. Both groups had equivalent QoL scores on the QOLRAD questionnaire. An equivalent number of patients (86% and 83.9% after Nissen and Toupet, respectively) were sufficiently satisfied to recommend antireflux surgery to a friend or relative complaining of reflux symptoms. CONCLUSION: In conclusion, in patients who have returned the questionnaire, long-term satisfaction, general symptom scores, and quality of life are equivalent after laparoscopic Nissen (complete) or Toupet (partial) fundoplication. There is however, a significant increased prevalence of persistent heartburn after laparoscopic Toupet fundoplication.

Ectopic pregnancy, the need for standardisation of rate.

Reported incidence of ectopic pregnancy (EP) varies widely in the literatures. Due to individual definition of the denominator used the incidence of EP, it has been expressed in various ways that are not easily comparable. Controversy has arisen over the best denominator in reporting the incidence of EP. The three commonly used denominators are the number of births, the number of pregnancies and the number of women of reproductive age (15-44 years). A reliable calculation of the incidence of EP is necessary to provide accurate information on the rate of this condition which is vital in planning health policies.

Hemodynamic instability associated with increased risk of death or brain injury in neonates with hypoxic ischemic encephalopathy.

OBJECTIVE: To determine the association between hemodynamic instability requiring inotropes and brain injury or death in neonates with hypoxic ischemic encephalopathy (HIE). METHODS: Retrospective cohort study of 221 neonates with HIE. Brain injury was defined using four HIE patterns based on MRI diffusion or T1 changes. The primary outcome was death or brain injury. Secondary outcomes were abnormal MRI, death, and abnormal EEG. Logistic regression was used to examine the risk of death or brain injury with the use of inotropes while adjusting for confounding factors. RESULTS: Brain injury or death occurred more often in neonates who received inotropes (71.1%, 69/97) compared to those who did not (44.3%, 55/124). The use of inotropes was associated with increased risk of death or brain injury (OR 3.11; 95% CI 1.39-7.004) and abnormal MRI (OR 2.78; 95% CI 1.22-6.34) after adjusting for confounding factors. Mortality was significantly higher in neonates exposed to inotropes (21.6%, 21/97) compared with those who did not receive inotropes (4%, 5/124), P < 0.001. CONCLUSION: In infants with HIE, hemodynamic instability requiring inotropes in the first 72 hours of life was associated with increased risk of death or brain injury detected by MRI.

The folding pathway of the cell-cycle regulatory protein p13suc1: clues for the mechanism of domain swapping.

BACKGROUND: The 113-residue alpha+beta protein suc1 is a member of the cyclin-dependent kinase subunit (cks) family of proteins that are involved in regulation of the eukaryotic cell cycle. In vitro, suc1 undergoes domain swapping to form a dimer by the exchange of a C-terminal beta strand. We have analysed the folding pathway of suc1 in order to determine the atomic details of how strand-exchange occurs in vitro and thereby obtain clues as to the possible mechanism and functional role of dimerisation in vivo. RESULTS: The structures of the rate-determining transition state for the folding/unfolding of suc1 and of the intermediate that is populated during refolding were probed using phi values determined for 57 mutants with substitutions at 43 sites throughout the protein. The majority of phi values are fractional in the intermediate and transition state, indicating that interactions build up in a concerted manner during folding. In the transition state, phi values of greater than 0.5 are clustered around the inner strands beta2 and beta4 of the beta sheet. This part of the structure constitutes the nucleus for folding according to a nucleation-condensation mechanism. Molecular dynamics simulations of unfolding of suc1, performed independently in a blind manner, are in excellent agreement with experiment (proceeding paper). CONCLUSIONS: Strand beta4 is the exchanging strand in the dimer and yet it forms an integral part of the folding nucleus. This suggests that association is an early event in the folding reaction of the dimer. Therefore, interchange between the monomer and dimer must occur via an unfolded state, a process that may be facilitated in vivo by accessory proteins.