Does attending general practice prior to the emergency department change patient outcomes? A descriptive, observational study of one central London general practice.

BACKGROUND: The challenge of keeping Emergency Department (ED) attendances down continues and timely access to general practice (GP) is often portrayed as a potential solution. SETTING: One London general practice (registered population = 4900). QUESTION: Does seeing a GP before attending the ED affect the outcome of a patient's ED care? METHODS: Routine clinical data were extracted using SystmOne primary care computer system for all registered patients with an ED attendance between 1 October 2014 and 31 September 2015. The scanned discharge summaries from the ED and GP notes were reviewed and outcome measures extracted. RESULTS: 227 patients (121 female; 104 male) attended the ED. The most common presentation was abdominal pain (n = 11). 25% of patients had seen (n = 50), or contacted by phone (n = 6), a GP about the same presenting complaint before attending the ED. Of those, 73% (n = 41/56) were referred to the ED and 49% (n = 20/41) were admitted versus 33% (n = 60/184) who self-presented (statistically significant, p = 0.05). An additional 32% of those who saw the GP first (n = 13/41) received specialist ED treatment. DISCUSSION/CONCLUSION: Only 25% of patients see their GP prior to attending the ED. The majority of patients who were referred by their GP required admission or specialised ED treatment. It remains unclear why the majority of patients did not choose to contact their GP prior to attending the ED, despite urgent appointments being offered; research into patients' health beliefs in this group is required for greater understanding.

Outcome of pregnancies complicated by pre-gestational diabetes mellitus.

Pregestational diabetes mellitus (DM) is associated with adverse fetal and maternal outcomes. Studies suggest that optimal control of diabetes before and during pregnancy minimises these risks. There are few recent reviews of outcomes of pregnancies complicated by DM in Australia. Ninety-three pregnancies in women with DM at our hospital since 1989 were identified. We collected data for maternal age, type of diabetes, duration of therapy, complications of diabetes, maternal complications of pregnancy and fetal outcomes including malformations. The rate of pregnancy planning with optimal glycaemic control at conception was low in our population, particularly in patients with Type 1 diabetes. Women who smoked had worse glycaemic control, and a higher rate of miscarriage. There was a high rate of Caesarean section, particularly in those women with Type 1 diabetes (77.4%). The rate of Caesarean section was lower in planned pregnancies. There were no perinatal deaths. The number of neonates with major congenital anomalies was high (13%) in the Type 1 population. It is important to increase the rates of prepregnancy planning and to optimise glycaemic control before pregnancy. In many cases there has been a long interval between diagnosis and pregnancy, so all women with diabetes should receive counselling at frequent intervals about pregnancy and the importance of planning. Women who planned their pregnancies had improved outcomes, with decreased rate of Caesarean section, better glycaemic control and better neonatal Apgar scores. Women with diabetes should not smoke during pregnancy because of the increased risk of miscarriage and poorer glycaemic control.

Torsion-axial force characteristics of SR-PLLA screws.

The torsion axial-force characteristics of biodegradable screws are central to their ability to generate interfragmentary compression when used as lag screws. The purpose of this investigation was to compare the torsion-axial force characteristics of prototype self-reinforced poly-L-lactide (SR-PLLA) screws with conventional titanium screws. Axial forces developed by incremental increases in the torque applied to the individual screws were measured in a test apparatus incorporating an Instron machine. For the SR-PLLA screws, the relationship between applied torque and axial force development was non-linear with a marked relaxation throughout the test range. The axial forces reached a maximum with increasing torque, after which failure of the screws occurred. The response curve for titanium screws of the same length demonstrated a steeper slope. No failures or force relaxation were observed with the titanium screws. The results of this investigation suggest that, at this time, the use of SR-PLLA screws for lag screw fixation should be restricted to low stress bearing areas.

Pelvic actinomycosis in association with an intrauterine contraceptive device.

PIP: A case of pelvic actinomycosis, now seen as a complication of intrauterine contraceptive devices, is reported. A 32-year old nulliparous women who had developed pain and irregular bleeding over the previous month presented initially for removal of a Dalkon shield IUD. For the previous 5 years the IUD had caused no symptoms. The Dalkon shield could not be removed, and vaginal examination revealed a tender mass in the pouch of Douglas. The patient was hospitalized for a laparoscopy and removal of the IUD under general anesthesia. Laparoscopy revealed an acute pelvic inflammatory disease (PID) with pus leaking from bilteral pyosalpinges. The IUD was removed, and the patient was treated with parenterally by administered penicillin and streptomycin for 5 days. 3 weeks later the patient was readmitted, complaining of nausea, vomiting and malaise. Clinically she was febrile, with signs of an acute abdomen. On vaginal examination, a large tender mass was palpable in the pouch of Douglas, and the blood film revealed a leukocytosis. When her condition failed to improve after treatment with penicillin and streptomycin, a laparotomy was performed. Gross PID was found with a large ruptured tubo-ovarian abscess on the right side. A total abdominal hysterectomy with bilteral salpingo-oophorectomy was performed. After the removal of the infected organs, her temperature dropped and her condition improved rapidly. Pathological findings are reported.^ieng

An assessment of continuous fetal heart rate monitoring in labor. A randomized trial.

Intrapartum continuous fetal heart rate monitoring has been routinely performed at the Jessop Hospital for Women for some years. However, no controlled trials had ever been performed to show its advantages over intermittent auscultation in low-risk patients. A prospective randomized study of 504 patients compared continuous fetal heart rate monitoring with intermittent auscultation. There was no significant difference between the two groups in neonatal deaths, Apgar scores, maternal and neonatal morbidity, and cord blood gases. The cesarean section rate was significantly increased (p less than 0.05) in the monitored patients but this did not seem attributable to fetal monitoring. No beneficial or deleterious effects of continuous fetal heart rate monitoring in labor were shown.

A flexible approach for on-line computerised quantification of intra-uterine pressure data.

Utilising simple mathematical techniques of differential calculus, a computer program has been developed for real time, on-line processing of uterine contractions with a small computer. The area under the intra-uterine pressure--time curve is calculated and two distinctive values of this area are printed on-line every 512 sec. The 'active area', which is the area above the resting tone, is calculated in addition to the 'total area'--that is, the area above 0 mmHg. This allows an objective and efficient assessment of uterine activity which may be used as a basis of comparison between individual patients and groups of patients.

Changes in peripheral hormone levels after therapeutic abortion.

Plasma levels of progesterone, 17 alpha-OH progesterone, hPL and beta-subunit hCG were measured in a group of women for 24 h after therapeutic abortion. Progesterone, hCG and hPL levels fell more rapidly than 17 alpha-OH progesterone levels. This might suggest that the main site of synthesis of 17 alpha-OH progesterone is probably in the corpus luteum of pregnancy or that the prolonged half-life of hCG maintains the corpus luteum to secrete longer. Human placental lactogen fell dramatically within 4 h but the hCG level was maintained. This difference probably reflects only the differences in half-lives of these hormones.

PIP: Plasma levels of progesterone, 17 alpha hydroxyprogesterone (OHP), human placental lactogen (hPL), and beta-subunit human chorionic gonadotropin (hCG) were measured in 9 Australian and 10 Scottish therapeutic abortion patients for 24 hours after the procedure. Progesterone levels fell to 50% within 4 hours of termination and were at 15% of preabortion levels at 24 hours in the Scottish group. Among Australian subjects, the progesterone level fell to 26% of the pretermination value by 4 hours and to 6% of this after 24 hours. The mean level of 17 alpha-OHP was 83% of the pretermination value at 4 hours and 63% at 24 hours. There was no significant change in the circulating level of hCG within the 1st 4 hours; at 24 hours, the level was still 43% of the pretermination value. hPL fell drastically, to 14% of the basal level, within the 1st 4 hours and remained at this level for the next 18 hours. Changes at 24 hours were statistically significant for hPL, hCG, and progesterone. Thus, these 3 hormones can be considered reliable indices of outcome in cases of threatened abortion. The finding that 17 alpha-OHP falls more slowly than the other parameters suggests that it is primarily produced by the corpus luteum of pregnancy, or that the prolonged half-life of hCG maintains the corpus luteum to secrete longer.

Circulating levels of pregnancy-specific beta1-glycoprotein in early pregnancy.

Circulating levels of pregnancy-specific beta1-glycoprotein (SP1 or PSbetaG), luteinizing hormone (LH) and human chorionic gonadotrophin (HCG) were measured serially in 9 subjects immediately after conception. Ovulation occurred spontaneously in 3 subjects, or followed administration of clomiphene citrate (2 subjects) or bromocriptine (4 subjects). The timing of ovulation was determined by the appearance of the LH surge. Levels of HCG were detected 10 to 16 days, and SP1, 18 to 23 days after ovulation. These findings suggest that the measurement of plasma levels of SP1 may provide valuable additional biochemical evidence of pregnancy.