The impact of the Covid-19 pandemic on care of women with ectopic pregnancy in a tertiary London hospital.

BACKGROUND: In response to the COVID-19 pandemic, a central London tertiary referral hospital's nurse-led Early Pregnancy & Acute Gynaecology Unit (EPAGU) suspended its walk-in service in favour of a telephone triage system with scheduled appointments. OBJECTIVE: To assess if the pandemic and this adaptation to clinical services had an impact on the presentation, management and complication rate of ectopic pregnancies. MATERIALS AND METHODS: A retrospective review was performed of ectopic pregnancies diagnosed in the EPAGU between 5th of March 2020 - 15th of July 2020 (pandemic) and 5th of March 2019 - 15th of July 2019 (pre-pandemic). MAIN OUTCOME MEASURES: Ultrasound findings, patient demographics, serum hCG concentrations, operative findings and complications. RESULTS: There was a 36% reduction in attendances to the unit during the pandemic. Allowing for this, there was no significant difference in the diagnosis rate between the two periods. There was no significant difference in the gestation at diagnosis, serum hCG concentration or volume of mass at presentation. There was also no significant difference in rate of surgical intervention or complications including rupture of fallopian tube, haemoperitoneum or need for blood transfusion. CONCLUSION: This study suggests this is a safe means of caring for women with ectopic pregnancies which does not limit management options nor lead to higher complication rates. WHAT IS NEW: Other EPAGUs may choose to adopt a telephone triage system with reassurance of its safety.

Field parasitism of nontarget weevil species (Coleoptera: Curculionidae) by the introduced biological control agent Microctonus aethiopoides Loan (Hymenoptera: Braconidae) over an altitude gradient.

The parasitoid, Microctonus aethiopoides Loan (Hymenoptera: Braconidae) was introduced into New Zealand in 1982 to control the alfalfa pest, Sitona discoideus Gyllenhal (Coleoptera: Curculionidae). Studies have shown that a number of nontarget weevil species are attacked in the field by this parasitoid. A field study was carried out to investigate nontarget parasitism by M. aethiopoides over an altitudinal sequence from the target host habitat (alfalfa) into native grassland. Three locations were selected for the study, and at each, the alfalfa growing in the valley floor was sampled annually for parasitism of the target pest that ranged between 17 and 78%. At progressively higher altitudes, three further grassland sites at each location were sampled monthly during spring to autumn for up to 6 yr. Weevil densities were estimated, species identified, and dissections carried out to determine reproductive status and parasitism. Almost 12,000 weevils were collected during the study, which were identified as 36 species in total from the three locations. Eight weevil species were found to be parasitized, including S. discoideus, the target host that was found at all sites. Parasitism of nontarget species was approximately 2% overall but varied with location, site, and season. Substantial nontarget parasitism was found at only one of the locations, with up to 24% parasitism of a native weevil, Nicaeana fraudator Broun (Coleoptera: Curculionidae), recorded. Another species, Irenimus egens (Broun) (Coleoptera: Curculionidae), was also found at this location at similar population densities but was attacked far less by M. aethiopoides. Results are discussed in relation to weevil phenology.

Preconception care of women attending adult general diabetes clinics--are we doing enough?

BACKGROUND: The presence of diabetes in pregnancy can result in substantial morbidity to both mother and baby if management is sub-optimal. AIMS: To assess the process of standards of preconception care (against the National Service Framework standards) of women attending the adult general diabetes clinics in a district general hospital. METHODS: Retrospective review of case notes of women aged 18-40 years attending the general diabetes clinics for annual review, over a period of 6 months. RESULTS: Seventy sets of notes were reviewed. The mean age of the patients was 32 years. Fifty-six patients had type-1 diabetes and 14 patients had type-2 diabetes. Mean duration of diabetes was 13 years. Eighty-six percent of the patients had blood pressure recordings documented. Mean blood pressure was 124/74 mmHg. Mean HbA1c was 9.1%. Documented evidence of home blood glucose monitoring was seen in 66% of the patients. Preconception counselling/contraception were discussed in 17 patients (25%). Twenty-nine patients (41%) were on potentially teratogenic medications. Alcohol and smoking history was not documented in 91% and 61% of the patients, respectively. CONCLUSIONS: This retrospective assessment highlights that reproductive issues in an at risk population of women with diabetes are not included in routine management of diabetes care in outpatient clinics.

An assessment of the coverage of a district-wide diabetic retinopathy screening service.

AIMS: To assess the coverage of the diabetes retinopathy screening service (DRSS) in North Staffordshire, to identify patient characteristies associated with non-attendance and to assess the proportion of patients with diabetic retinopathy who achieved glycaemic and blood pressure (BP) control targets. METHODS: Data for all patients who underwent annual retinal screening between 1 May 2000 and 30 April 2001 were obtained from the North Staffordshire Diabetes Register. Age, gender, ethnicity, socio-economic status, type and duration of diabetes were compared between patients who underwent eye screening and those who did not. Frequencies of patients who achieved glycaemic and BP targets in these groups of patients were compared to the remaining patients. RESULTS: 5646 of the 11682 (48%) patients on the diabetes register underwent retinal screening during the year. Patients with Type 2 diabetes, older patients, patients belonging to ethnic minorities and those wholly managed in primary care were less likely to attend for eye screening (P < 0.05 for all groups) with ethnic minority or primary care management demonstrating independent influence (P < 0.001). The percentage of patients with retinopathy achieving HbA1c and systolic BP targets was significantly lower than in their unaffected counterparts (chi2 = 63, P < 0.001 and chi2 = 71, P < 0.001 respectively). CONCLUSIONS: The efficacy of the DRSS in North Staffordshire is low and might be improved by targeting specific patient groups. Glycaemic control and systolic BP control needs to be improved in patients with diabetic retinopathy.

Diabetic ketoacidosis in pregnancy.

The occurrence of diabetic ketoacidosis in pregnancy compromises both the fetus and the mother. It usually occurs in the later stages of pregnancy and is also seen in newly presenting type 1 diabetes patients. Despite improvement in its incidence rates and outcomes over the years, it still remains a major clinical problem since it tends to occur at lower blood glucose levels and more rapidly than in non-pregnant patients often causing delay in the diagnosis. This article illustrates a typical case of diabetic ketoacidosis in pregnancy and reviews the literature to provide an insight into its pathophysiology and management.

An assessment of care of paediatric and adolescent patients with diabetes in a large district general hospital.

AIMS: To assess the process of clinical care and outcomes of young patients with diabetes attending clinics at a large district general hospital. METHODS: Retrospective analysis of data obtained from 106 case notes of patients aged 12-22 years attending the paediatric, combined adolescent or adult diabetes clinics between 1998 and 2000. The frequency of follow-up, rate of admission, glycaemic control, systolic blood pressure, weight change and screening for complications were assessed. RESULTS: The mean attendance rate was 78%. The admission rate was 91 admissions per 1000 patient years. Overall, the mean HbA1c was 9.1% with only 15% of paediatric and adolescent patients having mean HbA1c

Combination of insulin and thiazolidinedione therapy in massively obese patients with Type 2 diabetes.

AIMS: To evaluate the influence of addition of rosiglitazone to insulin therapy over a 24-week period in massively obese patients with poorly controlled Type 2 diabetes taking large doses of insulin. METHODS: Eight massively obese patients (median body mass index (BMI) 42 kg/m2) with Type 2 diabetes who were on large doses of insulin (median daily dose of 204 U) and/or had poor glycaemic control (median HbA1c of 8.1% (upper limit for normal 5.5%)) were treated over a 24-week period with the combination of insulin and maximum doses of rosiglitazone. Outcomes monitored were changes in weight, BMI, HbA1c, dose of insulin and development of side-effects. RESULTS: At the end of 24 weeks there was a median weight gain of 3 kg (P < 0.01), a fall in median HbA1c from 8.1% to 6.7% (16% reduction from baseline) (P < 0.01) and a reduction in median insulin dose from 204 U/day to 159 U/day (P < 0.01) (23% reduction from baseline). Peripheral oedema was the only significant side-effect and was seen in five patients. CONCLUSIONS: Combination of insulin and rosiglitazone is effective in massively obese patients with Type 2 diabetes, though there is a high incidence of peripheral oedema.

Influence of congenital heart disease on mortality after noncardiac surgery in hospitalized children.

OBJECTIVE: To evaluate the incremental risk of congenital heart disease on mortality after noncardiac surgery in children. DESIGN: We reviewed the clinical information network database of the University Hospital Consortium for the period January 1, 1993, through December 31, 1996, and identified 191 261 patients <18 years old having 1 or more noncardiovascular surgical procedures. Of these patients, 6.5% had a diagnosis of congenital heart disease. Patients having ambulatory surgery are excluded from this database. Short-term (1-, 2-, and 3-day) and 30-day mortality were compared, as well as mortality for neonates, infants (31 days to 1 year), and older children (1-17 years); mortality for the 100 most common surgical procedures, mortality for 10 relatively minor surgical procedures, and mortality in subgroups of patients with minor versus severe cardiac diagnoses. RESULTS: Short-term and 30-day mortality was increased in the patients with congenital heart disease patients (30-day mortality odds ratio 3.5; 95% confidence limit, 3.2-3.9). Mortality was also increased in patients with congenital heart disease in the 2 youngest age groups, for the 100 most common operations, and for 10 relatively minor operations. Children with more severe heart disease diagnoses had higher mortality than did children carrying less serious cardiac diagnoses. CONCLUSION: A diagnosis of congenital heart disease adds significant incremental risk of mortality in children requiring inpatient noncardiovascular surgery. This outcome difference is present for both minor and major surgical procedures, and regardless of whether mortality is measured at 1, 3, or 30 days. The incremental risk is greatest in neonates and infants where the presence of congenital heart disease is associated with a 2-fold increase in mortality from noncardiac surgery.

Managing pain during mediastinal chest tube removal.

OBJECTIVE: To compare four analgesic regimens used in preparing patients for chest tube removal. DESIGN: Prospective, randomized, controlled multiple-group comparison. SETTING: Mid-atlantic university affiliated tertiary medical center. PATIENTS: 80 adult patients who underwent heart surgery and who had two mediastinal chest tubes. OUTCOME MEASURES: Subject's pain intensity rating on a 0 to 100 mm visual analog scale and subject's description of sensations blindly rated by six nurses. INTERVENTION: Before chest tube removal, subjects were medicated with either: (1) intravenous morphine sulfate (morphine), (2) intravenous morphine and subfascial angiocatheter lidocaine hydrochloride (lidocaine), (3) intravenous morphine and subfascial angiocatheter normal saline solution, or (4) subfascial angiocatheter lidocaine. RESULTS: Mean pain rating scores for groups 1, 2, 3, and 4 were 43.7 40.9, 36.4, and 38.1, respectively. Analysis of variance showed no significant difference between scores (p = 0.8948). The percentage of comments rated as "not bad at all" or "not bad" for groups 1, 2, 3, and 4 were 56%, 83%, 47% and 75%, respectively. Chi-square analysis showed a significant difference between ratings (p < 0.01). CONCLUSIONS: Blind ratings of subjects' descriptions of sensations suggest subfascial lidocaine may be useful in reducing discomfort during chest tube removal.

A microcomputer application for managing information used when weaning patients from mechanical ventilation.

This article describes a microcomputer application designed to manage data collected from patients assessed for weaning from mechanical ventilation. The application has menu options for obtaining individual summaries of serial weaning assessments. These summaries provide an overview of patients' progress during the weaning process. Users also have the option of obtaining information about procedures and problems often encountered during weaning. In addition, weaning summary data are easily transferred to mainframe computers for statistical analyses. The application is an efficient data manager and provides information that can be used during the patient care decision process, for staff and student instruction, and for research purposes.

Weaning from mechanical ventilation: a method for assessment and planning.

Weaning patients from mechanical ventilator assistance is difficult and often requires the input of experts. Though researchers have identified numerous factors that impede weaning and continue to develop criteria to determine ability to wean, no single factor or set of criteria have yet emerged to guide clinicians. In an effort to design a tool that assists critical care nurses in forwarding the wean process, the authors developed a comprehensive, integrated, computerized ventilator weaning program that stimulates the thinking and care planning strategies of experts. The Burns Wean Assessment Program also teaches complex concepts and tracks the progress of the weaning patient.

Social problems of women patients in a private obstetrics and gynecology clinic.

Patients present or exhibit problems other than physical ones to their physicians and need access to some type of assistance for them. Over a 1 year period, women patients were referred to and seen by the medical social worker employed by a private obstetrics and gynecology clinic. Their social problems were studied by content analysis of patients' records, patients' social services cards, and monthly social services summaries. Results showed that 163 women exhibited 288 social problems consisting of three major types, financial, marital, and emotional. Various relationships were shown between the type of social problem and the primary reason the patient visited the clinic. It was also shown that if a patient has a financial problem, she is more likely to have a greater number of social problems than are other patients.