Dysfunctional labor and hemoperitoneum secondary to an incidentally discovered dysgerminoma: a case report.

BACKGROUND: Ovarian dysgerminoma, a subtype of malignant germ cell tumor (GCT), is a rare ovarian neoplasm that is infrequently found in the gravid patient. When dysgerminomas do occur in pregnancy, the rapidly growing tumors can have a heterogeneous presentation and lead to peripartum complications and morbidity. Due to the rarity of this condition, diagnostic and therapeutic strategies are not well described in the literature. CASE PRESENTATION: A healthy multigravida with an uncomplicated antenatal history presented for elective induction of labor. She had a protracted labor course, persistently abnormal cervical examinations, and eventually developed a worsening Category II tracing that prompted cesarean birth. Intraoperatively, a 26 cm pelvic mass later identified as a Stage IA dysgerminoma was discovered along with a massive hemoperitoneum. The mass was successfully resected, and the patient remains without recurrence 6 months postoperatively. CONCLUSION: Although rare and generally indolent, dysgerminomas can grow rapidly and cause mechanical obstruction of labor and other complications in pregnancy. Pelvic masses, including malignant neoplasms, should be included in as part of a broad differential diagnosis when evaluating even routine intrapartum complications such as abnormal labor progression. Additionally, we demonstrate that adnexal masses can be a source of life-threatening intraabdominal hemorrhage.

Hypothesis: A wearable device may help COVID-19 patients improve lung function.

Managing respiratory status of patients with COVID-19 is a high resource, high risk healthcare challenge. Interventions that decrease need for invasive respiratory support and utilization of bedside staff would benefit patients and healthcare personnel alike. Proning has been established as optimal positioning that may reduce the need for escalation of respiratory support. We propose a new application of a wearable device to decrease supine positioning and ameliorate these risks.

A National Curriculum to Address Professional Fulfillment and Burnout in OB-GYN Residents.

BACKGROUND: Physician well-being is a priority in graduate medical education as residents suffer high rates of burnout. With complex stressors affecting the clinical environment, conflicting evidence exists as to whether a formal curriculum improves resident well-being. OBJECTIVE: We assessed the feasibility and impact of a national pilot of a yearlong wellness curriculum for obstetrics and gynecology (OB-GYN) residents. METHODS: The Council on Resident Education in Obstetrics and Gynecology Wellness Task Force developed a national multicenter pilot group of 25 OB-GYN programs to participate in a prospective cohort study. The curriculum included 6 interactive wellness workshops using uniform teaching materials delivered during didactic time. Prior to and following their participation in the curriculum, residents completed a survey containing demographic information and the Professional Fulfillment Index. RESULTS: Among 592 eligible participants, 429 (72%) responded to the pretest and 387 (65%) to the posttest. Average age of respondents was 29.1 years (range = 24-52 years) and included 350 (82%) women and 79 (18%) men. At baseline, 254 of 540 (47%) respondents met criteria for burnout, and 101 (23%) met criteria for robust professional fulfillment. Residents participated in an average of 3.9 workshops. While aggregate posttest scores did not differ from baseline, residents attending 4 to 6 workshops had improved rates of burnout (40% vs 50%, P = .017) and robust professional fulfillment (28% vs 20%, P < .001) compared with those with lower attendance. CONCLUSIONS: A wellness curriculum was a feasible addition to OB-GYN residency program curricula in programs across the country. Residents with higher attendance experienced improved professional fulfillment and less burnout.

A Review of the Pathophysiology and Management of Diabetes in Pregnancy.

Diabetes is a common metabolic complication of pregnancy and affected women fall into two subgroups: women with pre-existing diabetes and those with gestational diabetes mellitus (GDM). When pregnancy is affected by diabetes, both mother and infant are at increased risk for multiple adverse outcomes. A multidisciplinary approach to care before, during, and after pregnancy is effective in reducing these risks. The PubMed database was searched for English language studies and guidelines relating to diabetes in pregnancy. The following search terms were used alone and in combination: diabetes, pregnancy, gestational diabetes, GDM, prepregnancy, and preconception. A date restriction was not applied. Results were reviewed by the authors and selected for inclusion based on relevance to the topic. Additional articles were identified by manually searching reference lists of included articles. Using data from this search we herein summarize the evidence relating to pathophysiology and management of diabetes in pregnancy. We discuss areas of controversy including the method and timing of diagnosis of GDM, and choice of pharmacologic agents to treat hyperglycemia during pregnancy. Therefore, this review is intended to serve as a practical guide for clinicians who are caring for women with diabetes and their infants.

Effects of Overweight and Obesity in Pregnancy on Health of the Offspring.

Overweight and obesity in pregnancy confer a wide range of risks on mother, fetus, and offspring throughout their lives. In addition to compounding many common pregnancy complications, including both iatrogenic preterm delivery and cesarean delivery, obesity is associated with multiple fetal anomalies, metabolic sequelae including diabetes and obesity, allergy and asthma, attention-deficit disorder, and likely many other challenges for the offspring. As targeted interventions are being developed, encouraging solid nutrition and exercise in women of childbearing age may stave off risks and mitigate obesity in the next generation.

Resident Responses to a Wellness Survey and Significant Unreported Distress.

Resident well-being is a significant issue affecting our future physicians' abilities to fulfill their potential in training and practice. In the 2017 Council on Resident Education in Obstetrics and Gynecology National Wellness Survey, residents identified many challenges to wellness and had the opportunity to provide free-text responses about these issues. Secondary analysis of these responses revealed clusters of symptoms associated with mood disorders, including high rates of reported anxiety and depression symptoms, and even suicidality. The prevalence of these self-reported symptoms underscores the importance of targeting wellness programming efforts, improving health care work environments, advancing access to care, and destigmatizing mental health concerns for our learners.

New drug controls and reduced hospital presentations due to novel psychoactive substances in Edinburgh.

AIMS: Recreational use of novel psychoactive substance (NPS) has become increasingly common. We aimed to assess the association of national legislation and local trading standards activity with hospital presentations. METHODS: We established observational cohorts of patients with recreational drug toxicity presenting to Edinburgh Royal Infirmary and dying with detectable recreational drugs in Edinburgh. We assessed associations with two temporary class drug-orders (April 2015: methylphenidates, Nov 2015: methiopropamine), the Psychoactive Substances Act (June 2016), and trading standards forfeiture orders (October 2015). RESULTS: The methylphenidate temporary class drug-order was associated with rapid 46.7% (P = 0.002) and 21.0% (P = 0.003) reductions in presentations and admissions, respectively, for NPS drug toxicity, comparing 12 months before with 6 months after. The change was greatest for ethylphenidate toxicity (96.7% reduction in admissions, P < 0.001) that was partly offset by a tripling in synthetic cannabinoid receptor agonist cases (P < 0.001) over the next 6 months. This increase reversed following trading standards activity removing all NPS drugs from local shops in October 2015, associated with 64.3% (P < 0.001) and 83.7% (P < 0.001) reductions in presentations and admissions, respectively, for all NPS drugs over the next 12 months. The effect was sustained and associated with a reduced postmortem detection of stimulant NPS drugs. The two interventions prevented an estimated 557 (95% confidence interval 327-934) NPS admissions during 2016, saving an estimated £303 030 (£177 901-508 133) in hospital costs. CONCLUSIONS: We show here that drug legislation and trading standards activity may be associated with effective and sustained prevention. Widespread adoption of trading standards enforcement, together with focused legislation, may turn the tide against these highly-damaging drugs.

Effect of the UK's revised paracetamol poisoning management guidelines on admissions, adverse reactions and costs of treatment.

AIMS: In September 2012 the UK's Commission on Human Medicines (CHM) recommended changes in the management of paracetamol poisoning: use of a single '100 mg l(-1) ' nomogram treatment line, ceasing risk assessment, treating all staggered/uncertain ingestions and increasing the duration of the initial acetylcysteine (NAC) infusion from 15 to 60 min. We evaluated the effect of this on presentation, admission, treatment, adverse reactions and costs of paracetamol poisoning. METHODS: Data were prospectively collected from adult patients presenting to three large UK hospitals from 3 September 2011 to 3 September 2013 (year before and after change). Infusion duration effect on vomiting and anaphylactoid reactions was examined in one centre. A cost analysis from an NHS perspective was performed for 90 000 patients/annum with paracetamol overdose. RESULTS: There were increases in the numbers presenting to hospital (before 1703, after 1854; increase 8.9% [95% CI 1.9, 16.2], P = 0.011); admitted (1060/1703 [62.2%] vs. 1285/1854 [69.3%]; increase 7.1% [4.0, 10.2], P < 0.001) and proportion treated (626/1703 [36.8%] vs. 926/1854 [50.0%]; increase: 13.2% [95% CI 10.0, 16.4], P < 0.001). Increasing initial NAC infusion did not change the proportion of treated patients developing adverse reactions (15 min 87/323 [26.9%], 60 min 145/514 [28.2%]; increase: 1.3% [95% CI -4.9, 7.5], P = 0.682). Across the UK the estimated cost impact is £8.3 million (6.4 million-10.2 million) annually, with a cost-per-life saved of £17.4 million (13.4 million-21.5 million). CONCLUSIONS: The changes introduced by the CHM in September 2012 have increased the numbers of patients admitted to hospital and treated with acetylcysteine without reducing adverse reactions. A safety and cost-benefit review of the CHM guidance is warranted, including novel treatment protocols and biomarkers in the assessment of poisoning.

Assessment and management of paracetamol poisoning in adults.

Paracetamol is a low cost, effective analgesic that is widely available in the UK. Paracetamol is the drug most commonly taken in overdose and can lead to acute liver failure, which can be fatal. This article focuses on the assessment and management of paracetamol poisoning in adults. It includes current UK guidelines on paracetamol poisoning, which changed in September 2012 following a review by the Commission on Human Medicines. It also discusses strategies to reduce incidence and severity of paracetamol poisoning, and outlines the metabolism of paracetamol at therapeutic doses and in overdose.

Management of poisoning in adults.

Nurses play a key role in the care of patients presenting with poisoning. Assessment and management of such patients can be challenging, especially if they are intoxicated, have co-ingested other agents or their mental health is compromised. In addition, some nurses may be unfamiliar with current management guidelines. This article outlines a number of protocols and initiatives aimed at improving consistency in the management of patients following an overdose. The article focuses on paracetamol poisoning, the most common overdose presentation in the UK. This article was updated on May 7 2013 to include current UK guidelines for management of paracetamol overdose, which changed in September 2012 following a review by the Commission on Human Medicines. In addition, the authors published recently an article in this journal that discussed the assessment and management of patients who present to hospital following a paracetamol overdose ( Pettie and Dow 2013 ).

An integrated care pathway improves the management of paracetamol poisoning.

BACKGROUND: Paracetamol poisoning remains a major cause of morbidity and mortality. Clinical care of paracetamol poisoning depends on a range of patient variables and typically involves both medical and nursing care. An integrated care pathway (ICP) is a multidisciplinary management plan that incorporates guidelines and best practice to enhance care and documentation for a specific patient group. Paracetamol overdose is thus amenable to an ICP. AIM: To evaluate the introduction of an ICP on process of care of the paracetamol poisoned patient. METHODS: A retrospective case note review of consecutive patients admitted to the Royal Infirmary of Edinburgh following a paracetamol overdose was conducted. Data were collected for a 3-month period before and after introduction of the ICP to the emergency department and toxicology inpatient unit. RESULTS: The ICP was used in 77% of cases in the time period studied and was associated with improvements in initial documentation of patient assessment (pre-ICP vs post-ICP: 87/161 (54%) vs 101/113 (89%), p<0.0001) and appropriateness of blood sampling (146/161 (91%) vs 111/113 (98%), p=0.01), but no change in timely blood sampling (pre 124/161 (77%) vs post 93/113 (82%)). All aspects of intravenous acetylcysteine administration also significantly improved: administration of acetylcysteine if indicated (pre-ICP vs post-ICP: 57/71 (80%) vs 71/71 (100%), p<0.0001); acetylcysteine commenced in a timely fashion (33/71 (46%) vs 55/71 (77%), p=0.0002); and acetylcysteine correctly prescribed (44/58 (76%) vs 71/71 (100%), p<0.0001). CONCLUSIONS: Implementation of an ICP for paracetamol poisoning significantly improved patient management and helped to standardise inter-professional decision making in this challenging patient group. This is likely to improve patient outcome.

Third-trimester uterine rupture without previous cesarean: a case series and review of the literature.

We sought to describe a case series and literature review of uterine rupture in the absence of a previous cesarean delivery. In addition to four cases in our institution, a search of the literature from 1994 to 2008 identified cases of uterine rupture unrelated to a prior cesarean. Uterine rupture in the absence of a previous cesarean may be associated with remote unrecognized uterine perforation, myomectomy, thermal injury, and obstructed labor. Such ruptures may occur before or after labor onset, at term or preterm, and with or without nonreassuring fetal heart rate patterns. Spontaneous uterine rupture is associated with highly variable and nonspecific maternal complaints and fetal status, requiring a high index of diagnostic suspicion.

Lower incidence of anaphylactoid reactions to N-acetylcysteine in patients with high acetaminophen concentrations after overdose.

BACKGROUND: Mechanisms responsible for anaphylactoid reactions to N-acetylcysteine (NAC) are poorly understood, and acetaminophen itself may play an important role. The present study examined the relationship between serum acetaminophen concentrations and risk of anaphylactoid reactions. METHODS: Prospective study of adverse reactions to NAC administered according to standardized clinical protocols in patients who present to hospital after acute acetaminophen overdose. Subgroups were defined by serum acetaminophen concentrations 0 to 100 mg/L, 101 to 150 mg/L, 151 to 200 mg/L, 201 to 300 mg/L, and >300 mg/L. RESULTS: There were 362 patients, and anaphylactoid reactions occurred in 14.9%. Anaphylactoid reactions occurred less commonly in patients with high serum acetaminophen concentrations (p = 0.046 by Cochran-Armitage trend test) and high equivalent 4 h acetaminophen concentrations (p = 0.004). DISCUSSION: High serum acetaminophen concentrations were associated with fewer anaphylactoid reactions, suggesting that these might in some way be protective. The biological basis needs further exploration so as to allow a better understanding of the mechanisms responsible for adverse reactions to NAC treatment.