How do hospitals help patients prepare for and participate in outpatient clinics?

BACKGROUND: Patients attending general medicine outpatient clinics (GM OPC) at hospital face multiple healthcare demands in an environment that has evolved with the clinician at its centre. The ideas, knowledge and understanding that patients bring to their clinic appointments are not well studied in the New Zealand setting. AIMS: To assess how hospitals prepare patients for their outpatient appointments and encourage people to participate actively in their own care. METHODS: A prospective survey of 50 patients attending follow-up GM OPC was performed. Participants' understanding of the purpose of their appointment and knowledge of their prescription medications was explored using a nine-item questionnaire. Patient-directed hospital communication was then analysed to assess the information supplied to patients. RESULTS: Two-thirds (66%) of participants attending follow-up GM OPC recalled being informed of an appointment at the time of leaving hospital; only half (54%) felt they had been informed of the purpose of these appointments. Patient-directed communication was not completed in half (50%) of the analysed discharge letters. One-third (36%) of participants did not have specific questions for their clinic visits. CONCLUSIONS: Limited information and support is provided to patients attending follow-up GM OPC and is not tailored to individuals' health literacy. This practice assumes patients have comparable health literacy to clinicians, which may have downstream impacts on the usefulness of the clinic experience. The information that health users bring to clinic may be improved by increasing pre-clinic user engagement and deploying patient-centred tools within the healthcare environment.

The effect of positioning on maternal anatomy and hemodynamics during late pregnancy.

INTRODUCTION: Supine positioning during late pregnancy causes dramatic compression of maternal abdominal vasculature and is a risk factor for stillbirth. The azygos vein has been shown to provide collateral circulation in this scenario. There are many well-known anatomical differences in abdominal vasculature between the left and right sides of the body. However, the effect of left and right positioning in pregnancy has not been well studied. MATERIALS AND METHODS: After obtaining ethics approval, 10 women with uncomplicated pregnancies between 34 and 38 weeks gestation underwent magnetic resonance imaging in the left and right lateral positions. Phase contrast images were evaluated to measure blood flow through the abdominal aorta, inferior vena cava, and azygos vein. RESULTS: No significant differences between left and right lateral positions were found in blood flow through the IVC at its formation (mean difference -0.15 L/min [CI -0.47, 0.18], p = .34) or through the azygos vein (mean difference 0.02 L/min [CI -0.22, 0.26], p = .87). Blood flow through the IVC just above the level of the renal veins was found to be reduced by 35% in the right lateral position when compared to the left (mean difference 1.01 L/min [CI 0.25, 1.43], p = .03). There were no significant differences in cardiac output or blood flow through the abdominal aorta. CONCLUSIONS: While it was noted that blood flow through the IVC immediately above the level of the renal veins was reduced in the right lateral position, this did not appear to impact significantly on maternal cardiac output or blood flow through the azygos vein.

Hemodynamic changes in women with symptoms of supine hypotensive syndrome.

INTRODUCTION: Supine positioning during late pregnancy causes the gravid uterus to compress the inferior vena cava, resulting in dramatic hemodynamic changes. The maintenance of placental perfusion requires maternal circulatory and autonomic adaptations. Women with supine hypotensive syndrome (defined as a drop in systolic blood pressure of anything between 15 and 30 mmHg or an increase in heart rate of 20 bpm, with or without symptoms) may have reduced ability to compensate for the effects of supine positioning. MATERIAL AND METHODS: Twelve women with uncomplicated pregnancies and no symptoms of supine hypotension (normal) and 10 women with uncomplicated pregnancies who reported symptoms of supine hypotension between 34 and 38 weeks' gestation underwent magnetic resonance imaging in the supine and left lateral positions. Phase contrast images were evaluated to measure blood flow through the aorta, inferior vena cava, superior vena cava and azygos vein. RESULTS: Women with symptoms of supine hypotension showed significant reductions in azygos venous flow rate compared with the normal group (-0.15 (-0.30 to -0.01) L/min). Those with symptoms showed no statistically significant compensatory changes in heart rate compared with the normal group (heart rate change 4.5 (-3.1 to 12.1) bpm). Hemodynamic changes in response to positioning were similar across both groups including: a reduction in inferior vena cava blood flow, reduction in cardiac output and an increase in azygos blood flow. CONCLUSIONS: Maternal hemodynamic adaptations were found to be consistent across groups irrespective of whether the women had symptoms of supine hypotension. In both groups a reduction in blood flow through the inferior vena cava occurred in the supine position with a subsequent reduction in cardiac output. Both groups showed a compensatory increase in blood flow through the azygos vein in order to partially compensate for this. Taking into account the effect of maternal position, women with symptoms were found to have reduced azygos flow compared with asymptomatic women. There was a significant increase in heart rate when the women were supine than when they were in the left lateral position.

The effect of supine positioning on maternal hemodynamics during late pregnancy.

Introduction: Recent studies have demonstrated an association between maternal supine sleep position and an increased risk of late stillbirth. During late pregnancy, the gravid uterus compresses the inferior vena cava (IVC) when a woman lies in the supine position. The azygos system of veins is the dominant pathway of collateral venous return back to the heart in the event of acute obstruction of the IVC. It is suggested that this pathway provides adequate collateral venous circulation in the event of IVC compression in the supine position during late pregnancy. Objective: Investigate the effect of supine positioning on maternal hemodynamics during late pregnancy and the role of collateral venous circulation. Methods: Ethics approval was obtained and 12 women with singleton pregnancies between 35- and 38-week gestation underwent magnetic resonance imaging in the supine and left lateral decubitus positions using a Skyra 3T system (Siemens). Phase-contrast images were evaluated to measure cardiac output, blood flow through the azygos vein, and blood flow through the abdominal aorta (AA) and IVC at two levels: at the level of aortic bifurcation and immediately above the renal veins. Results: The supine position was associated with a 16.4% reduction in cardiac output when compared to the left lateral position. In addition, blood flow through the IVC decreased at its origin by 85.3% and by 44.4% at the level of the renal veins. Blood flow through the azygos vein increased in the supine position by 220%. Blood flow through the AA at the level of the renal veins did not differ significantly; however, it is reduced by 32.3% at the level of the aortic bifurcation. Conclusions: Women in late pregnancy experience an increase in collateral venous blood flow when lying supine, likely as a response to marked compression of the IVC in this position. However, cardiac output and aortic blood flow were found to decrease while in the supine position.

The collateral venous system in late pregnancy: A systematic review of the literature.

Recent literature has reported an association between maternal supine sleep position and stillbirth during late pregnancy. In this position the gravid uterus almost completely obstructs the inferior vena cava. A small number of women experience supine hypotension, thought to be due in part to inadequate collateral venous circulation. The aim of this paper is to review the literature describing the anatomy of the collateral venous system and in particular the azygos system, the abdominal portion of which has not been well studied. A systematic review was conducted using the electronic databases: Medline, Embase, Scopus, and Google Scholar. Relevant anatomical and radiological literature concerning the azygos system in particular was reviewed. The search was limited to adult human studies only. The collateral venous system can be divided into superficial, intermediate and deep systems. The azygos system in particular provides immediate collateral venous circulation in the event of acute inferior vena caval obstruction. The abdominal portion of this pathway, including the ascending lumbar vein, has not been well studied and there are certain variations that can render it ineffective. In conclusion, the collateral venous system provides an alternative route for blood to flow back to the systemic circulation when acute occlusion of the inferior vena cava occurs in the supine position during late pregnancy. However, certain anatomical variations can render this pathway ineffective, and this could have implications for the development of supine hypotension and stillbirth in late pregnancy. Clin. Anat. 30:1087-1095, 2017. © 2017 Wiley Periodicals, Inc.