First report of successful isolation of a HPR0-like variant of the infectious salmon anaemia virus (ISAV) using cell culture.

ISAV is the causative agent of the infectious salmon anaemia (ISA), a disease listed by the OIE that has caused important economic losses to the Atlantic salmon (Salmo salar) industry. ISAV variants are identified as pathogenic or non-pathogenic based on the presence or absence of a deletion in the highly polymorphic region (HPR) of segment 6 (S6). HPRΔ variants (pathogenic) are the only forms of the virus known to grow in cell culture. This is the first report of a HPR0 variant isolated in cell culture. The isolate is, however, atypical as it shows a marker of virulent variants on another segment (S5), which has never been reported for any other HPR0 variants. The significance of this finding remains unclear until more in-depth work is carried out but does challenge current knowledge.

Implementing an electronic clinical handover system in a university teaching hospital.

INTRODUCTION: Clinical handover is defined as inter-clinician communication occurring at care interfaces. In this study, we analyse the clinical outcomes and physician attitudes associated with the implementation of a electronic clinical handover system in our medical department. AIM: The aim of this project was to introduce a reliable, standardised, reproducible method of communicating information regarding inpatients within our medical department. We also sought to assess the attitudes of physicians within our department to medical handover. METHODS: We designed and implemented an electronic handover template with a protocol to guide staff as to its use. Handover was audited weekly. In addition, we surveyed attitudes of doctors to handover before and after our handover pilot. RESULTS: An average of 32 patients were handed over each week. Compliance with mandatory handover of ICU/CCU patients averaged at 59%. Extrapolating our pilot results for the year would result in approximately 1655 handover events per annum in our department. One hundred percent of physicians surveyed felt that documentation of handover was beneficial, and staff satisfaction with handover improved after initiation of the pilot (81 vs 24%, p = 0.000914). While 64% of staff were concerned that typed electronic handover would increase their workload, only 6% of the post pilot survey group felt that it did increase workload significantly. CONCLUSION: Electronic clinical handover is feasible and practical within the Irish healthcare system. In addition, it was found in our study to be attractive and effective to physicians without increasing their workload.

Assessing the Appropriateness of Oral Anticoagulation for Atrial Fibrillation in Advanced Frailty: Use of Stroke and Bleeding Risk-Prediction Models.

BACKGROUND: Atrial fibrillation (AF) is common among frail older adults. Oral anticoagulation (OAC) is particularly challenging for these due to overlapping stroke and bleeding risk factor profiles. OBJECTIVE: To compare the utility of stroke and haemorrhage risk-prediction instruments in the treatment of AF among frail older adults. DESIGN: Cross-sectional study. SETTINGS AND PARTICIPANTS: Frail residents in four nursing homes with a Clinical Frailty Scale score ≥5 (median 7±0). MEASUREMENTS: The prevalence of AF was assessed by ECG and chart review. Stroke (CHADS2 and CHA2DS2-VASc) and bleeding (HASBLED and HEMORR2HAGES) risk-prediction scores were then applied. A validated, risk-based, colour-coded decision support tool, incorporating these instruments, was then used to create a risk matrix and assess the appropriateness of OAC. RESULTS: In total, 225 patients were included. The distribution of CFS scores was similar irrespective of AF status. In all, 86/225 (38%) had any history of AF. Of these, only 15/86 (17%) were prescribed OAC. All those in AF scored ≥2 on the CHA2DS2-VASc. One-third also scored high-risk of bleeding using HAS-BLED or HEMORR2HAGES. Risk-prediction scores were similar between those with 'known' (documented) and occult (only on ECG) AF. The colour-coded decision tree suggested that OAC would be recommended for the majority in AF when HAS-BLED (60/86, 70%) was used as the bleeding risk-prediction instrument. Despite this, only 12/60 (20%) were anticoagulated. When HEMORR2HAGES was incorporated instead, one patient was advised OAC, the remainder no treatment (57%) or an antiplatelet (42%). DISCUSSION: Stroke risk was high and bleeding risk levels comparatively low, suggesting that the balance of risk may favor OAC for AF in this cohort of patients with advanced frailty. Despite this and the high prevalence of AF, OAC prescription rates were low. The decision-support tool used showed mixed results, depending on the bleeding-risk score incorporated, suggesting that while useful, they should not replace clinical judgement.

Benchmarking of surgical complications in gynaecological oncology: prospective multicentre study.

OBJECTIVE: To explore the impact of risk-adjustment on surgical complication rates (CRs) for benchmarking gynaecological oncology centres. DESIGN: Prospective cohort study. SETTING: Ten UK accredited gynaecological oncology centres. POPULATION: Women undergoing major surgery on a gynaecological oncology operating list. METHODS: Patient co-morbidity, surgical procedures and intra-operative (IntraOp) complications were recorded contemporaneously by surgeons for 2948 major surgical procedures. Postoperative (PostOp) complications were collected from hospitals and patients. Risk-prediction models for IntraOp and PostOp complications were created using penalised (lasso) logistic regression using over 30 potential patient/surgical risk factors. MAIN OUTCOME MEASURES: Observed and risk-adjusted IntraOp and PostOp CRs for individual hospitals were calculated. Benchmarking using colour-coded funnel plots and observed-to-expected ratios was undertaken. RESULTS: Overall, IntraOp CR was 4.7% (95% CI 4.0-5.6) and PostOp CR was 25.7% (95% CI 23.7-28.2). The observed CRs for all hospitals were under the upper 95% control limit for both IntraOp and PostOp funnel plots. Risk-adjustment and use of observed-to-expected ratio resulted in one hospital moving to the >95-98% CI (red) band for IntraOp CRs. Use of only hospital-reported data for PostOp CRs would have resulted in one hospital being unfairly allocated to the red band. There was little concordance between IntraOp and PostOp CRs. CONCLUSION: The funnel plots and overall IntraOp (≈5%) and PostOp (≈26%) CRs could be used for benchmarking gynaecological oncology centres. Hospital benchmarking using risk-adjusted CRs allows fairer institutional comparison. IntraOp and PostOp CRs are best assessed separately. As hospital under-reporting is common for postoperative complications, use of patient-reported outcomes is important. TWEETABLE ABSTRACT: Risk-adjusted benchmarking of surgical complications for ten UK gynaecological oncology centres allows fairer comparison.

Predictors of complications in gynaecological oncological surgery: a prospective multicentre study (UKGOSOC-UK gynaecological oncology surgical outcomes and complications).

BACKGROUND: There are limited data on surgical outcomes in gynaecological oncology. We report on predictors of complications in a multicentre prospective study. METHODS: Data on surgical procedures and resulting complications were contemporaneously recorded on consented patients in 10 participating UK gynaecological cancer centres. Patients were sent follow-up letters to capture any further complications. Post-operative (Post-op) complications were graded (I-V) in increasing severity using the Clavien-Dindo system. Grade I complications were excluded from the analysis. Univariable and multivariable regression was used to identify predictors of complications using all surgery for intra-operative (Intra-op) and only those with both hospital and patient-reported data for Post-op complications. RESULTS: Prospective data were available on 2948 major operations undertaken between April 2010 and February 2012. Median age was 62 years, with 35% obese and 20.4% ASA grade ⩾3. Consultant gynaecological oncologists performed 74.3% of operations. Intra-op complications were reported in 139 of 2948 and Grade II-V Post-op complications in 379 of 1462 surgeries. The predictors of risk were different for Intra-op and Post-op complications. For Intra-op complications, previous abdominal surgery, metabolic/endocrine disorders (excluding diabetes), surgical complexity and final diagnosis were significant in univariable and multivariable regression (P<0.05), with diabetes only in multivariable regression (P=0.006). For Post-op complications, age, comorbidity status, diabetes, surgical approach, duration of surgery, and final diagnosis were significant in both univariable and multivariable regression (P<0.05). CONCLUSIONS: This multicentre prospective audit benchmarks the considerable morbidity associated with gynaecological oncology surgery. There are significant patient and surgical factors that influence this risk.

Patient-reporting improves estimates of postoperative complication rates: a prospective cohort study in gynaecological oncology.

BACKGROUND: Most studies use hospital data to calculate postoperative complication rates (PCRs). We report on improving PCR estimates through use of patient-reporting. METHODS: A prospective cohort study of major surgery performed at 10 UK gynaecological cancer centres was undertaken. Hospitals entered the data contemporaneously into an online database. Patients were sent follow-up letters to capture postoperative complications. Grade II-V (Clavien-Dindo classification) patient-reported postoperative complications were verified from hospital records. Postoperative complication rate was defined as the proportion of surgeries with a Grade II-V postoperative complication. RESULTS: Patient replies were received for 1462 (68%) of 2152 surgeries undertaken between April 2010 and February 2012. Overall, 452 Grade II-V (402 II, 50 III-V) complications were reported in 379 of the 1462 surgeries. This included 172 surgeries with 200 hospital-reported complications and 231 with 280 patient-reported complications. All (100% concordance) 36 Grade III-V and 158 of 280 (56.4% concordance) Grade II patient-reported complications were verified on hospital case-note review. The PCR using hospital-reported data was 11.8% (172 out of 1462; 95% CI 11-14), patient-reported was 15.8% (231 out of 1462; 95% CI 14-17.8), hospital and verified patient-reported was 19.4% (283 out of 1462; 95% CI 17.4-21.4) and all data were 25.9% (379 out of 1462; 95% CI 24-28). After excluding Grade II complications, the hospital and patient verified Grade III-V PCR was 3.3% (48 out of 1462; 95% CI 2.5-4.3). CONCLUSION: This is the first prospective study of postoperative complications we are aware of in gynaecological oncology to include the patient-reported data. Patient-reporting is invaluable for obtaining complete information on postoperative complications. Primary care case-note review is likely to improve verification rates of patient-reported Grade II complications.

Epidemiological investigation of a temporal increase in atonic postpartum haemorrhage: a population-based retrospective cohort study.

OBJECTIVE: Increases in atonic postpartum haemorrhage (PPH) have been reported from several countries in recent years. We attempted to determine the potential cause of the increase in atonic and severe atonic PPH. DESIGN: Population-based retrospective cohort study. SETTING: British Columbia, Canada, 2001-2009. POPULATION: All women with live births or stillbirths. METHODS: Detailed clinical information was obtained for 371 193 women from the British Columbia Perinatal Data Registry. Outcomes of interest were atonic PPH and severe atonic PPH (atonic PPH with blood transfusion ≥1 unit; atonic PPH with blood transfusion ≥3 units or procedures to control bleeding), whereas determinants studied included maternal characteristics (e.g. age, parity, and body mass index) and obstetrics practice factors (e.g. labour induction, augmentation, and caesarean delivery). Year-specific unadjusted and adjusted odds ratios for the outcomes were compared using logistic regression. MAIN OUTCOME MEASURES: Atonic PPH and severe atonic PPH. RESULTS: Atonic PPH increased from 4.8% in 2001 to 6.3% in 2009, atonic PPH with blood transfusion ≥1 unit increased from 16.6 in 2001 to 25.5 per 10 000 deliveries in 2009, and atonic PPH with blood transfusion ≥3 units or procedures to control bleeding increased from 11.9 to 17.6 per 10 000 deliveries. The crude 34% (95% CI 26-42%) increase in atonic PPH between 2001 and 2009 remained unchanged (42% increase, 95% CI 34-51%) after adjustment for determinants of PPH. Similarly, adjustment did not explain the increase in severe atonic PPH. CONCLUSIONS: Changes in maternal characteristics and obstetric practice do not explain the recent increase in atonic and severe atonic PPH.

Venous thromboembolism risk and prophylaxis in the acute hospital care setting: the Irish results of the ENDORSE study.

ENDORSE (Epidemiologic International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting), is a multinational, cross-sectional survey of venous thromboembolism (VTE) risk prevalence and effective prophylaxis in the acute hospital care setting. Three Irish hospitals enrolled in the study. The American College of Chest Physicians (ACCP) guidelines were employed to evaluate VTE risk and prophylaxis. Of 552 patients, 297 (53.8%) and 255 (46.2%) were categorised as surgical or medical, respectively, with 175 (59%) surgical and 109 (43%) medical patients deemed to be at risk for VTE. Of these, only 112 (64%) and 51 (47%) received recommended VTE prophylaxis, respectively. The results are consistent with those observed in other countries and demonstrate a high prevalence of risk for VTE and a low rate of prophylaxis use, particularly in medical patients. Awareness of VTE guidelines should be an integral component of health policy.

Identifying potentially eligible subjects for research: paper-based logs versus the hospital administrative database.

INTRODUCTION: The Canadian Perinatal Network (CPN) is a national database focused on threatened very pre-term birth. Women with one or more conditions most commonly associated with very pre-term birth are included if admitted to a participating tertiary perinatal unit at 22 weeks and 0 days to 28 weeks and 6 days. METHODS: At BC Women's Hospital and Health Centre, we compared traditional paper-based ward logs and a search of the Canadian Institute for Health Information (CIHI) electronic database of inpatient discharges to identify patients. RESULTS: The study identified 244 women potentially eligible for inclusion in the CPN admitted between April and December 2007. Of the 155 eligible women entered into the CPN database, each method identified a similar number of unique records (142 and 147) not ascertained by the other: 10 (6.4%) by CIHI search and 5 (3.2%) by ward log review. However, CIHI search achieved these results after reviewing fewer records (206 vs. 223) in less time (0.67 vs. 13.6 hours for ward logs). CONCLUSION: Either method is appropriate for identification of potential research subjects using gestational age criteria. Although electronic methods are less time-consuming, they cannot be performed until after the patient is discharged and records and charts are reviewed. Each method's advantages and disadvantages will dictate use for a specific project.

Sildenafil citrate therapy for severe early-onset intrauterine growth restriction.

Sildenafil citrate therapy for severe early-onset intrauterine growth restriction. BJOG 2011;118:624-628. Currently, there is no effective therapy for severe early-onset intrauterine growth restriction (IUGR). Sildenafil citrate vasodilates the myometrial arteries isolated from women with IUGR-complicated pregnancies. Women were offered Sildenafil (25 mg three times daily until delivery) if their pregnancy was complicated by early-onset IUGR [abdominal circumference (AC)< 5th percentile] and either the gestational age was <25(+0) weeks or an estimate of the fetal weight was <600 g (excluding known fetal anomaly/syndrome and/or planned termination). Sildenafil treatment was associated with increased fetal AC growth [odds ratio, 12.9; 95% confidence interval (CI), 1.3, 126; compared with institutional Sildenafil-naive early-onset IUGR controls]. Randomised controlled trial data are required to determine whether Sildenafil improves perinatal outcomes for early-onset IUGR-complicated pregnancies.

What is SNOMED CT and why should the ISSHP care?

SNOMED CT (Systematized NOmenclature of MEDicine Clinical Terms) is a standardized multilingual healthcare terminology. It was developed to meet the needs of our electronic world so that care can be documented and clinicians can retrieve and transmit data in electronic format. It is anticipated that SNOMED CT will provide the core general terminology for electronic health records and, as such, replace existing classification systems such as the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10). At present, there is no special interest group for the hypertensive disorders of pregnancy (HDP) within the SNOMED CT initiative. We believe that members of the ISSHP, and others interested in the HDP, should take a leadership role in this regard for a number of reasons.

Do we need community geriatrics?

Community geriatrics has evolved as a specific aspect of geriatric medicine in the UK. In Ireland there is uncertainty as to how it should be planned. This is the first national survey of consultants, specialist registrars and general practitioners to seek their opinions. Most consultants and GPs reported already having a community aspect to their current practice, e.g. nursing home visits or community hospital visits, whereas most SpRs did not. Forty three of 62 respondents (69%) agreed that there is a need for community geriatricians and that there should be integration with hospital medicine. Fifty seven of 62 respondents (92%) felt that there would be a beneficial effect on GP services, though some expressed concern about work overlap. Thirteen of the 25 SpRs (52%) in training hoped to begin practice in community geriatrics in the future.

Investigation of an increase in postpartum haemorrhage in Canada.

OBJECTIVE: To investigate the cause of a recent increase in hysterectomies for postpartum haemorrhage in Canada. DESIGN: Retrospective cohort study. SETTING: Canada between 1991 and 2004. POPULATION: All hospital deliveries in Canada as documented in the database of the Canadian Institute for Health Information (excluding incomplete data from Quebec, Manitoba and Nova Scotia). METHODS: Deliveries with postpartum haemorrhage by subtype were identified using International Classification of Diseases codes, while hysterectomies were identified using procedure codes. Changes in determinants of postpartum haemorrhage (all postpartum haemorrhage and that requiring hysterectomy) were examined, and crude and adjusted period changes were assessed using logistic models. MAIN OUTCOME MEASURES: Postpartum haemorrhage, postpartum haemorrhage with hysterectomy, postpartum haemorrhage with blood transfusion and postpartum haemorrhage by subtype. RESULTS: Rates of postpartum haemorrhage increased from 4.1% in 1991 to 5.1% in 2004 (23% increase, 95% CI 20-26%), while rates of postpartum haemorrhage with hysterectomy increased from 24.0 in 1991 to 41.7 per 100,000 deliveries in 2004 (73% increase, 95% CI 27-137%). These increases were because of an increase in atonic postpartum haemorrhage, from 29.4 per 1000 deliveries in 1991 to 39.5 per 1000 deliveries in 2004 (34% increase, 95% CI 31-38%). Adjustment for temporal changes in risk factors did not explain the increase in atonic postpartum haemorrhage but attenuated the increase in atonic postpartum haemorrhage with hysterectomy. CONCLUSIONS: There has been a recent, unexplained increase in the frequency, and possibly the severity, of atonic postpartum haemorrhage in Canada.

Risk factors for pulmonary embolism in an Irish patient cohort.

INTRODUCTION: The prevention of pulmonary embolism (PE) is an important component of medical care. AIM: To examine the risk factors for venous thromboembolism in an Irish patient cohort with acute PE, and identify cases that may have been preventable. METHODS: Retrospective review of 60 consecutive cases of computed tomography (CT)-confirmed acute PE. RESULTS: The primary thromboembolic risk factors were elective surgery (27%), medical illness (20%), primary immobility (13%) and isolated distal lower limb fracture (7%). A significant proportion (43%) had been hospitalised within the six weeks prior to PE onset. Some patients had undergone 'low risk' procedures, without prophylaxis, but had other significant thromboembolic risk factors that indicated a requirement for prophylaxis. CONCLUSIONS: Hospital- and ward-based thromboprophylaxis guidelines, based on certain categories of patient or procedure, need to be routinely supplemented by an individual risk factor assessment for each patient, to determine those at particularly high risk for venous thromboembolism.

Maternal morbidity associated with cesarean delivery without labor compared with spontaneous onset of labor at term.

OBJECTIVE: To estimate the maternal morbidity associated with cesarean deliveries performed at term without labor compared with morbidity associated with spontaneous labor. METHODS: A 14-year, population-based, cohort study (1988-2001) using the Nova Scotia Atlee Perinatal Database compared maternal outcomes in nulliparous women at term undergoing spontaneous labor for planned vaginal delivery with singleton, cephalic presentation and nulliparous women delivering by cesarean without labor. RESULTS: From a total of 18,435 pregnancies, which satisfied inclusion and exclusion criteria, 721 were cesarean deliveries without labor. There were no maternal deaths or transfers for intensive care. There was no difference in wound infection, blood transfusion, or intraoperative trauma. Women undergoing cesarean deliveries without labor were more likely to have puerperal febrile morbidity (relative risk [RR] 2.2; 95% confidence interval [CI] 1.1, 4.5; P=.03), but were less likely to have early postpartum hemorrhage (RR 0.6; 95% CI 0.4, 0.9; P=.01) compared with women entering spontaneous labor. Subgroup analyses of maternal outcomes in women delivering by spontaneous and assisted vaginal delivery and cesarean delivery in labor were also performed. The highest morbidity was found in the assisted vaginal delivery and cesarean delivery in labor groups. CONCLUSION: The increased maternal morbidity in elective cesarean delivery compared with spontaneous onset of labor is limited to puerperal febrile morbidity. Maternal morbidity is increased after assisted vaginal delivery and cesarean delivery in labor compared with cesarean delivery without labor.