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Case Notes (case + note)
Terms modified by Case Notes Selected AbstractsGiving Women Their Own Case Notes to Carry During PregnancyBIRTH, Issue 3 2004H.C. Brown No abstract is available for this article. [source] Excessive exercise in anorexia nervosa and bulimia nervosa: Relation to eating characteristics and general psychopathologyINTERNATIONAL JOURNAL OF EATING DISORDERS, Issue 4 2002Eva Peñas-Lledó Abstract Objective Excessive exercise is a well-known phenomenon in anorexia nervosa, but less is known about its role in bulimia nervosa. In addition, there is little evidence regarding the psychopathological processes that might act as predisposing, triggering, or maintaining factors for such exercise. The present study examined the presence of excessive exercise in different women with eating disorders, and its psychopathological correlates. Methods Case notes from 63 anorexia nervosa and 61 bulimia nervosa patients were examined. Two-way multivariate analyses of variance (diagnosis × use of excessive exercise) were used to determine the impact of the two factors upon eating characteristics (EAT-40 and BITE) and psychopathological symptoms (SCL-90-R). Results While high levels of depression were more likely among all patients who used excessive exercise, levels of anxiety and somatization were particularly high only among those anorexics who exercised excessively. Discussion Possible explanatory models are advanced to account for this pattern of findings, focusing on the possible use of exercise as an affect regulation strategy among anorexia nervosa patients. Further research is suggested to test and develop this model, and possible clinical implications are outlined. © 2002 by Wiley Periodicals, Inc. Int J Eat Disord 31: 370,375, 2002. [source] Rheumatological presentations of anticoagulation related hemorrhagesINTERNATIONAL JOURNAL OF RHEUMATIC DISEASES, Issue 2 2003S. R. Cox Abstract Background: Joint, back and muscle pain are common in patients referred to a rheumatology unit. Acute pain due to hemorrhage may be difficult to distinguish from more common causes of pain in these patients. This article describes a small case-series of patients who presented acutely with hemarthroses, spinal hemorrhage or muscle hematomas while receiving anticoagulant treatment. Methods: Case notes of nine patients were reviewed retrospectively. The demographic characteristics, indication for anticoagulation, international normalized ratio, and management were evaluated. Results: The majority of hemorrhages occurred when the INR was within the therapeutic range. Anticoagulation was held in all cases. Joint aspiration was performed in all cases of hemarthrosis. Surgical intervention was required in management of the spinal epidural bleed and also in one case of muscle hematoma. Conclusion: Cases described represent major hemorrhages in anticoagulated patients. There is little literature on specific treatment and prognosis, particularly with respect to hemarthrosis, and further studies are needed. [source] Explaining inequalities in access to treatment in lung cancerJOURNAL OF EVALUATION IN CLINICAL PRACTICE, Issue 5 2006Ruth H. Jack MSc Abstract Background, Geographical inequalities in lung cancer treatment and patient survival have been described. We hypothesized that lung cancer patients' access to treatment may be influenced by deprivation and the pathway to care. Methods, Case notes were reviewed for patients resident in south-east London who were registered with lung cancer at the Thames Cancer Registry in 1998. Use of surgery, chemotherapy, radiotherapy or any specific treatment and one-year survival were examined. Analyses were adjusted for age, sex, histology, stage and basis of diagnosis. Results, Data for 695 out of 958 (73%) patients were analysed. Subjects who were initially referred to a specialist in thoracic medicine, surgery or oncology were more likely to receive active treatment (71%) than subjects who were referred to other consultants (51%) or who were admitted as emergencies (42%) (P < 0.0001). Conclusion, Socio-economic deprivation was associated with lower rates of treatment and this partly explained variations in survival. Subjects who were referred to specialists were more likely to receive active treatment and treatment patterns varied between first trust attended. [source] Adverse reactions to immunization with newer vaccines in the very preterm infantJOURNAL OF PAEDIATRICS AND CHILD HEALTH, Issue 8 2005Vanessa J Ellison Objective: To study the frequency and types of adverse reactions to currently available vaccines in very preterm infants. Methods: Case notes were obtained for very preterm infants ,30 weeks' gestational age who received their first immunization at the Royal Women's Hospital, Melbourne, during 1999,2003. Data were extracted for the time periods 48 h before and 48 h after immunizations, with the data extraction blinded as to whether the period being evaluated was pre- or post-immunization. Data collected focused on the frequency and severity of apnoea, respiratory support, fever and clinical consequences of adverse reactions. Results: A total of 48 very preterm infants were immunized during the period; 37 infants had Comvax (Haemophilus influenzae type B and hepatitis B vaccine), Infanrix (diphtheria, tetanus and acellular pertussis vaccine) and inactivated poliomyelitis vaccine, and 11 infants had Comvax and Infanrix only. Their mean (SD) gestational age at birth was 26.4 (1.7) weeks with mean birthweight of 872 (235) g. The mean postnatal age at immunization was 76 (20) days. Low-grade fever (>37.5°C per axilla) occurred in 16 (33%) infants after immunization, but none before immunization (P < 0.001). There was no substantial change in recorded apnoea. No serious adverse events were noted. Four (8%) infants underwent a septic work up post-immunization. The C-reactive protein was increased in all four infants, but other tests for sepsis were negative. Conclusion: Fever remains a common adverse event following immunization of the preterm infant in spite of the development of a new generation of vaccines. [source] Role of FDG-PET in surgical management of patients with colorectal liver metastasesANZ JOURNAL OF SURGERY, Issue 8 2004Benjamin D. Teague Background: [ 18F]-fluorodeoxyglucose positron emission tomography (FDG-PET) is reported to change the management in 20,56% of patients with recurrent or metastatic colorectal cancer. It is not clear if FDG-PET has a role in all such patients or only a subgroup. The aim of the present study was to assess the influence of FDG-PET on the surgical management of patients with known or suspected colorectal liver metastases. Methods: Patients undergoing FDG-PET for investigation of known or suspected colorectal liver metastases were identified from a South Australian database. Case notes were reviewed retrospectively to determine the influence of FDG-PET findings on patient management. Findings from FDG-PET scanning were compared with findings from conventional diagnostic investigations and operative findings. Results: Overall, in four of 16 patients (25%) management was influenced by FDG-PET findings. FDG-PET altered management in four of eight (50%) patients with non-diagnostic liver lesions on computed tomography (CT) or with elevated carcinoembryonic antigen levels but no liver lesion on CT. In all eight patients with CT diagnosed resectable liver metastases, the addition of FDG-PET did not influence the management. Conclusions: The findings support the use of FDG-PET in the assessment of selected patients with suspected colorectal liver metastases and equivocal findings on conventional diagnostic investigation. [source] Long-term remission rates after pituitary surgery for Cushing's disease: the need for long-term surveillanceCLINICAL ENDOCRINOLOGY, Issue 5 2005A. Brew Atkinson Summary Objective, There have been a few reports on long-term remission rates after apparent early remission following pituitary surgery in the management of Cushing's disease. An undetectable postoperative serum cortisol has been regarded as the result most likely to predict long-term remission. Our objective was to assess the relapse rates in patients who underwent transsphenoidal surgery in order to determine whether undetectable cortisol following surgery was predictive of long-term remission and whether it was possible to have long-term remission when early morning cortisol was measurable but not grossly elevated. Endocrinological factors associated with late relapse were also studied. Patients, We reviewed the long-term outcome in 63 patients who had pituitary surgery for the treatment of Cushing's disease between 1979 and 2000. Measurements, Case notes were reviewed and the current clinical and biochemical status assessed. Our usual practice was that early after the operation, an 08:00 h serum cortisol was measured 24 h after the last dose of hydrocortisone. This was followed by a formal low-dose dexamethasone suppression test. Current clinical status and recent 24-h urinary free cortisol values were used as an index of activity of the Cushing's disease. If there was evidence suggesting relapse, a low-dose dexamethasone suppression test was performed. In many patients, sequential collections of early morning urine specimens for urinary cortisol to creatinine ratio were also performed in an attempt to diagnose cyclical and intermittent forms of recurrent hypercortisolism. We did this if there was conflicting endocrine data, or if patients were slow to lose abnormal clinical features. Results, Mean age at diagnosis was 40·3 years (range 14,70 years). Mean follow-up up time was 9·6 years (range 1,21 years). Forty-five patients (9 males/36 females) achieved apparent remission immediately after surgery and were subsequently studied long term. Of these 45 patients, four have subsequently died while in remission from hypercortisolism. Ten of the remaining 41 patients have relapsed. Of those 10, six demonstrated definite cyclical cortisol secretion. Two of the 10 had undetectable basal serum cortisol levels in the immediate postoperative period. Thirty-one patients are still alive and in remission. Fourteen (45%) of the 31 who remained in remission had detectable serum cortisol levels (> 50 nmol/l) immediately postoperatively, and remain in remission after a mean of 8·8 years. Our relapse rate was therefore 10/45 (22%), after a mean follow-up time of 9·6 years, with mean time to relapse 5·3 years. Conclusions, The overall remission rate of 56% (35/63) at 9·6 years follow-up is disappointing and merits some re-appraisal of the widely accepted principle that pituitary surgery must be the initial treatment of choice in pituitary-dependent Cushing's syndrome. Following pituitary surgery, careful ongoing expert endocrine assessment is mandatory as the incidence of relapse increases with time and also with increasing rigour of the endocrine evaluation. A significant number of our patients were shown to have relapsed with a cyclical form of hypercortisolism. [source] Treatment-emergent behavioural side effects with selective serotonin re-uptake inhibitors in adults with learning disabilitiesHUMAN PSYCHOPHARMACOLOGY: CLINICAL AND EXPERIMENTAL, Issue 2 2001A. B. Biswas Abstract Selective serotonin re-uptake inhibitors are widely used for the treatment of depression suffered by adults with learning disabilities. However, the presentation, time of onset and prevalence of treatment emergent symptoms, have not been extensively studied in adults with learning disabilities. The aim of this study was to determine these aspects of treatment. The study design involved retrospective analysis of case notes of all adults with learning disabilities treated with either fluoxetine or paroxetine for depression. During 31% of treatment episodes, patients suffered treatment emergent symptoms during treatment with either selective serotonin re-uptake inhibitor (SSRI). These symptoms subsided on discontinuation of the SSRI. The common emergent symptoms in this group were elevated mood (39%), decreased sleep (35%), hyperactivity (30%), overtalkativeness (26%), agitation (24%) and aggression (37%). In 20% symptoms developed within 1 month and in 67% within 7 months of starting treatment with a SSRI. There were no significant differences noted in the frequency and nature of treatment emergent symptoms between fluoxetine and paroxetine. Few guidelines, if any, exist for initiating and continuing antidepressant treatment for therapeutic or prophylactic use in this patient population. Close monitoring of efficacy and tolerability, including treatment emergent psychiatric symptoms is warranted. Copyright © 2001 John Wiley & Sons, Ltd. [source] The prevention of deep venous thrombosis in physically restrained patients with schizophreniaINTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 8 2010M. De Hert Summary Background:, Physical restraint and seclusion are associated with several risks. Antipsychotic drug use increases this risk. Objective:, To evaluate whether the risk of thromboembolism in physical restraint and seclusion of patients with psychosis, treated with antipsychotic medication, was considered by taking preventive measures. Method:, Anonymous data on all consecutively admitted patients with schizophrenia, treated with antipsychotic medication, between 2002 and 2009, were analysed. Diagnostic information and data about seclusion procedures and medication were collected. Preventive measures of thromboembolism in patients in physical restraint were assessed by reviewing case notes and the medication prescribed at the time of seclusion. Results:, Seclusion of patients with psychosis is common. Out of 679 identified patients, 170 had been secluded (472 events). Physical restraint use was not a rare event (N seclusions with restraint use 296, 62.7%). Pharmacological preventive measures (use of heparine dugs) were taken frequently to prevent deep vein thrombosis (DVT) by physical restraint or isolation. Sixty-five (38.2%) out of 170 secluded patients, including a majority of patients who had been under physical restraint, had been administered anticoagulants at the time of seclusion. No cases of DVT occurred. Conclusions:, Preventive measures were routinely administered in clinical practice and were effective in the prevention of DVT. For a clinical setting, it is important to establish a clear and detailed management plan on seclusion and fixation taken into account in all possible risks of physical restraint. [source] Investigating Sexual Abuse: Findings of a 15-Year Longitudinal StudyJOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES, Issue 3 2005Bob McCormack Background, There is a lack of longitudinal large-scale studies of sexual abuse in intellectual disability services. Such studies offer opportunities to examine patterns in disclosure, investigation and outcomes, and to report on incidence and trends. Methods, All allegations of sexual abuse (n = 250) involving service users as victims or perpetrators of sexual abuse over a 15-year period in a large Irish community-based service were analysed based on the data extracted from extensive contemporaneous case notes. Results, Victims or families were the most common concern raisers of abuse. Following multidisciplinary investigation, almost half (47%) of all allegations of sexual abuse were confirmed (n = 118). In confirmed episodes, more than half the perpetrators were adolescents and adults with intellectual disabilities, while almost a quarter were relatives. The most common type of abuse was sexual touch, although 31% of episodes involved penetration or attempted penetration. The most common location was the family home, followed by the day service and public places. A notable feature was the variation in the incidence of abuse over the study period, largely caused by episodes of multiple abuse. Conclusions, The incidence of confirmed episodes of sexual abuse of adults with intellectual disabilities may be higher than previously estimated. There is an urgent need for statutory guidelines, which require reporting of adult abuse, and provide protection for bona fide whistle blowers, similar to existing child protection legislation. [source] How should trainees be taught to open a clinical interview?MEDICAL EDUCATION, Issue 5 2005Alex Walter Aim, To characterise the opening of secondary care consultations. Method, We audio-taped 17 first consultations in medical clinics, transcribed them verbatim, and analysed verbal interactions from when the doctor called the patient into the consulting room to when she or he asked clarifying questions. Results, The interviews did not open with the sequence, reported by previous researchers, of ,doctor's soliciting question, patient's opening statement, interruption by the doctor'. Doctors (1) called the patient to the consultation; (2) greeted them; (3) introduced themselves; (4) made a transition to clinical talk; and (5) framed the consultation. They used a referral letter, the case notes, computer records and their prior knowledge of the patient to help frame the consultation, and did so informally and with humour. Conclusion, These 5 steps could help trainees create a context for active listening that is less prone to interruption. [source] Excessive volume expansion and neonatal death in preterm infants born at 27,28 weeks gestationPAEDIATRIC & PERINATAL EPIDEMIOLOGY, Issue 2 2003Andrew K. Ewer Summary Volume expansion is used commonly in preterm infants to treat presumed hypovolaemia. However, the amount that should be given is uncertain. We present data that were obtained from anonymised regional case notes of Project 27/28, a national case,controlled study run by the Confidential Enquiry into Stillbirths and Deaths in Infancy. Various clinical parameters were analysed, including the volume expansion administered during the first 48 h of life. All deaths in the first year of the study in the West Midlands (cases, n = 22) and matched regional controls (survivors, n = 29) were included. The primary outcome was death within 28 days. Sixteen of the 22 deaths were considered ,not inevitable' on the basis of the neonates' condition at birth. These newborns received on average more than twice the volume expansion compared with controls in the first 48 h of life (38.2 vs. 18.2 mL/kg, P = 0.007). There were no significant differences between the groups in lowest blood pressure or base deficit within the first 12 h of life. Newborns who received , 30 mL/kg volume expansion in the first 48 h of life were more likely to die than those who received < 30 mL/kg (OR 4.5 [95% CI 1.2, 17.2]). Our data suggest that administration of , 30 mL/kg volume expansion is associated with increased mortality in neonates of 27,28 weeks' gestation. Unless there is clear evidence of hypovolaemia, clinicians should exercise caution when prescribing volume expansion. [source] Medication-related problems commonly occurring in an Australian community setting,PHARMACOEPIDEMIOLOGY AND DRUG SAFETY, Issue 2 2004E. E. Roughead PhD Abstract Purpose This study characterised medication-related problems in 1000 Australian patients living in the community, and who were considered at risk of medication misadventure. Methods A review was undertaken of 1000 clinical case notes, developed during the delivery of medication management reviews. Patient demographics, medications used, medical conditions and medication-related problems were categorised according to established classification systems. Descriptive analyses were undertaken. Results Overall, 2222 problems were identified. Ninety per cent of patients had at least one medication-related problem. One in three people were found to require additional monitoring, one in four required additional medication, one in four were using the wrong or inappropriate medication and one in five were using insufficient medication. Cardiovascular, nervous system, alimentary and respiratory medicines were most commonly implicated, accounting for 69% of the medication-related problems. Conclusion This analysis reveals the need for ongoing vigilance of, and support for, people at high risk of medication misadventure. This information is also useful for informing the design of public health or health promotion strategies aiming to reduce the prevalence of these problems. Copyright © 2003 John Wiley & Sons, Ltd. [source] Risk factors for visual impairment registration due to diabetic retinopathy in Leeds, 2002,2005PRACTICAL DIABETES INTERNATIONAL (INCORPORATING CARDIABETES), Issue 3 2009Diabetes & Endocrinology, H Hayat Specialist Registrar Abstract We undertook a retrospective study of case notes of those patients registered blind or partially sighted due to diabetic retinopathy in the Leeds metropolitan area in the years 2002 and 2005. Both the incidence of visual impairment due to diabetic retinopathy and the relative contribution to total registrations are similar to those observed in other local and national studies. The main risk factors for registered visual impairment were poor glycaemic control prior to ophthalmic review, no prior retinopathy screening, late presentation with symptomatic visual loss, non-compliance with planned review and laser treatment failure. Most of these risk factors are avoidable. Nearly two-thirds of patients diagnosed with diabetes mellitus were being screened for diabetic retinopathy. These figures would suggest that the National Service Framework for Diabetes' proposed coverage of 80% by 2006 and 100% by the end of 2007 is achievable. The duration of diagnosed diabetes mellitus at the time of registration was an average of 16 years in this study. This reflects the slow development of sight-threatening retinopathy and visual loss observed previously. Conventional therapy for diabetic retinopathy with laser photocoagulation reduces the risk of visual loss more effectively than it improves visual function. Despite the increased risk of early worsening of retinopathy seen with intensive glycaemic control in the Diabetes Control and Complications Trial and the UK Prospective Diabetes Study, improved control closer to the time of diagnosis of diabetes mellitus would have helped to provide a sustained reduction in the risk of retinopathy developing or progressing. Both laser treatment failure and non-attendance may limit the benefits of improved screening coverage. Copyright © 2009 John Wiley & Sons. [source] Cyanoacrylate embolization of endoleaks after abdominal aortic aneurysm repairANZ JOURNAL OF SURGERY, Issue 11 2009Timothy Buckenham Abstract Introduction:, Type II endoleaks occur in up to a fifth of endoluminal repairs for abdominal aortic aneurysms and are commonly treated when aortic sac expansion can be demonstrated. Technical failure is common when catheter-guided particulates or coil embolic agents are used. Presented here is a feasibility study using catheter-directed N-butyl-2-cyanoacrylate (Histoacryl, Braun, Tuttlingen, Germany) embolotherapy. Method:, A retrospective review of the case notes of patients undergoing embolization procedures for type II endoleaks with expanding sacs was performed from this centre's cohort of endoluminal aortic repair patients under surveillance. Data on patients with type II endoleaks who were treated with either or both cyanoacrylate and coil embolization were extracted. The outcomes were then compared. Results:, In total, five cases were identified, and four of these cases had both coil and glue embolization. Technical success was defined as endoleak closure proven on follow-up computed tomographic imaging. Technical success was achieved in all four patients treated with intra-sac cyanoacrylate. One case treated initially with coil embolization was successful. All patients had a computed tomographic scan at 3 months. One minor complication occurred that resolved without treatment. Discussion:, Type II endoleaks after EVAR with expanding sacs require treatment. Percutaneous catheter-directed cyanoacrylate embolization offers an alternative to coil or particulate embolization and, in this series, was found to be more likely to result in endoleak closure. [source] POSSUM scoring for laparoscopic cholecystectomy in the elderlyANZ JOURNAL OF SURGERY, Issue 7 2005Andrew L. Tambyraja Background: Physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) scoring is a validated scoring system in the audit of surgical outcomes; however, evaluation of this system has mostly been applied to open surgical techniques. The present study examines the validity of POSSUM in predicting morbidity and mortality in patients undergoing laparoscopic cholecystectomy (LC) with the recognized risk factor for postoperative mortality of advanced age. Methods: All patients aged 80 years or over undergoing LC in one surgical unit between January 1993 and December 1999 were identified from the surgical operations database of the hospital. Case-note review was used to collate data in terms of clinical and operative factors as described in POSSUM. Observed/POSSUM estimated (O/E) ratio of morbidity and 30-day mortality were calculated. Results: Laparoscopic cholecystectomy was performed in 76 patients aged 80 years or over during the study period. Of these patients, case notes for 70 patients (92%) were available for review. Median (range) age was 83 years (80,93 years) and median (range) American Society of Anesthesiologists score was 2 (2,4). Twenty-six (34%) of 70 patients underwent cholecystectomy during an acute admission. The mean physiology severity score was 23 and operative severity score, 8. A significant postoperative morbidity was observed in 15 (22%) of 70 patients. There was no 30-day mortality. Using exponential analysis, POSSUM predicted morbidity in 15 patients and mortality in seven patients. Thus, O/E ratios for morbidity and mortality were 1 and 0, respectively. Conclusion: POSSUM scoring performs well in predicting morbidity, but overpredicts mortality, after LC in patients aged over 80 years. An assessment of its application to other laparoscopic procedures merits evaluation. [source] Risk axis: Implementation of structured clinical guidelines for the assessment and management of risk in psychiatryASIA-PACIFIC PSYCHIATRY, Issue 2 2009Shailesh Kumar FRANZCP MRCPsych Abstract Introduction: Mental health clinicians routinely assess risk in three domains: suicide, violence and self neglect. While the published work on the assessment of these risks has increased, concerns are often expressed that assessment alone does not lead to management of the identified risk. Not all axes of multiaxial classificatory systems are used by clinicians to the same extent, despite their proven usefulness. It is possible that a dedicated axis for risk management as a part of a multiaxial classificatory system could align risk assessment with management and increase utility of multiaxial classificatory systems. Methods: Based on our earlier work we developed a comprehensive risk management axis (RMA), which was then further refined by conducting a pilot study and then used to collect data retrospectively from the case notes of 100 patients consecutively discharged from a general psychiatric ward. Results: Common association between risk factors and three risk domains were as follows. Violence: active symptoms of major mental illness, employment problems, and major mental illness; Suicide: history of abuse, clinically significant depressive symptoms, and alcohol and drug use; Self neglect: neglect of home, personal safety, noncompliance with treatment, male gender, and low income. We also investigated whether the presence of a particular risk factor acted as a barrier or prompt for clinicians to address management factors in the RMA. Discussion: It is possible to assess risk across the three domains and to derive management plans by using the proposed RMA. Minimal clinical background is necessary for collecting data retrospectively. It should be possible to apply this axis prospectively. [source] Delayed diagnosis of Gorlin's syndrome in a renal transplant recipientAUSTRALASIAN JOURNAL OF DERMATOLOGY, Issue 2 2009Katarzyna A Mackenzie ABSTRACT A 35-year-old woman was referred to the dedicated dermatology clinic for RTR. She underwent her first renal transplant at 18 years of age due to chronic renal failure following reflux nephropathy of the single right kidney (left kidney agenesis). She has since then had two further transplants. During clinical examination she was noted to have at least 16 basal cell carcinomas (BCC) and there are records in the case notes of 10 BCC having being excised and confirmed histologically in the past. By contrast, she had only had two squamous cell carcinomas (SCC) excised. She was also noted to have distinctive facial features, a kyphoscoliosis and palmar pits, and a diagnosis of Gorlin's (naevoid BCC) syndrome (GS) was made. Although immunosuppression may have contributed to the multiplicity of her BCC, the contrasting very small number of SCC is unusual in an organ transplant recipient and this alerted the authors to the diagnosis of GS. [source] Immediate and associated complications of hysterectomy for benign diseaseAUSTRALIAN AND NEW ZEALAND JOURNAL OF OBSTETRICS AND GYNAECOLOGY, Issue 3 2002O Tamizian ABSTRACT Abdominal and vaginal hysterectomy are common operations for benign gynaecological conditions. Though safe operations, they are not without complications. Good medical practice requires that patients be fully counselled regarding risks involved in undergoing medical interventions. This can only be done by regular review of local practice and comparison with national and international standards. We have reviewed 502 case notes of patients who have undergone a hysterectomy for benign conditions over an 18-month period. [source] Increased maternal BMI is associated with an increased risk of minor complications during pregnancy with consequent cost implicationsBJOG : AN INTERNATIONAL JOURNAL OF OBSTETRICS & GYNAECOLOGY, Issue 11 2009FC Denison Objective, To investigate the effect of maternal body mass index (BMI) on minor complications, associated additional medication use during pregnancy and the consequent cost implications. Design, Retrospective analysis of case notes. Setting, Labour wards, tertiary referral hospital, Royal Infirmary Edinburgh, UK. Population, Six hundred and fifty-one women with a singleton pregnancy over four separate time periods in 2007 and 2008. Methods, Descriptive statistics, univariate and multivariate logistic regression analysis and cost analysis using standard techniques and inflation indices. Main outcome measures, Minor complications, use of medications during pregnancy and consequent incremental costs from the perspective of the National Health Service (NHS). Results, 42.4% of women were overweight or obese (BMI , 25 kg/m2). Higher BMI during the first trimester (BMI , 30 kg/m2 compared with BMI < 25 kg/m2) was associated with an increased risk of minor complications including symphysis pubis dysfunction (OR 3.97; 95% CI 2.19,7.18), heartburn (OR 2.65; 95% CI 1.42,4.94) and chest infection (OR 8.71; 95% 2.20,34.44) and with drugs used to treat these complications including Gaviscon (OR 3.52; 95% CI 1.78,6.96). The mean incremental (additional) NHS costs per woman for treating minor complications increased with maternal BMI were £15.45/woman, £17.64/woman and £48.66/woman for BMI < 25 kg/m2, BMI , 25 to <30 kg/m2 and BMI , 30 kg/m2 respectively. Conclusions, Increased maternal BMI is associated with increased risk of developing minor complications during pregnancy; use of medications associated with treating these conditions and has significant NHS costs. [source] Maternal mortality and serious maternal morbidity in Jehovah's witnesses in the NetherlandsBJOG : AN INTERNATIONAL JOURNAL OF OBSTETRICS & GYNAECOLOGY, Issue 8 2009ME Van Wolfswinkel Objective, To determine the risk of maternal mortality and serious maternal morbidity because of major obstetric haemorrhage in Jehovah's witnesses in the Netherlands. Design, A retrospective study of case notes. Setting, All tertiary care centres, general teaching hospitals and other general hospitals in the Netherlands. Sample, All cases of maternal mortality in the Netherlands between 1983 and 2006 and all cases of serious maternal morbidity in the Netherlands between 2004 and 2006. Methods, Study of case notes using two different nationwide enquiries over two different time periods. Main outcome measures, Maternal mortality ratio (MMR) and risk of serious maternal mortality. Results, The MMR for Jehovah's witnesses was 68 per 100 000 live births. We found a risk of 14 per 1000 for Jehovah's witnesses to experience serious maternal morbidity because of obstetric haemorrhage while the risk for the total pregnant population was 4.5 per 1000. Conclusions, Women who are Jehovah's witnesses are at a six times increased risk for maternal death, at a 130 times increased risk for maternal death because of major obstetric haemorrhage and at a 3.1 times increased risk for serious maternal morbidity because of obstetric haemorrhage, compared to the general Dutch population. [source] A longitudinal study over 5 to 10 years of clinical outcomes in women with idiopathic detrusor overactivityBJOG : AN INTERNATIONAL JOURNAL OF OBSTETRICS & GYNAECOLOGY, Issue 2 2008AR Morris Objective, To evaluate the long-term clinical outcome in women with idiopathic detrusor overactivity (IDO) and to identify significant prognostic factors. Design, Longitudinal study incorporating retrospective case note review and a postal questionnaire. Setting, Tertiary referral urogynaecology clinic in Australia. Population, Women with a sole urodynamic diagnosis of IDO. Methods, Audit of urodynamic records and case notes. Postal questionnaire incorporating validated disease-specific quality-of-life (QoL) instruments. Main outcome measure, Subjective assessment of overall improvement on a 4-point scale followed by scoring of short forms of the urogenital distress inventory and incontinence impact questionnaire. Results, One hundred and thirty two women were identified following examination of 1975 consecutive records with 76 (67%) returning questionnaires. Median follow up was 8 years (6,9), and the duration of symptoms was 13 years (9,18). Improvement was achieved in 25 (35%) women. Disease symptoms fluctuated in severity and QoL were worse in nonresponders to therapy (P < 0.0001). Urge incontinence at presentation was associated with treatment failure (P= 0.001) as was nocturia (P= 0.04), but urodynamic variables were not associated with outcome. Only 3 of 46 (6.5%) women not responding to therapy thought that their symptoms would improve with time. Conclusions, IDO seldom resolves and fluctuates in severity. Individual response is unpredictable, although the presence of urge incontinence is associated with a significantly worse prognosis. [source] Early-onset neonatal group B streptococcal infection in London: 1990,1999BJOG : AN INTERNATIONAL JOURNAL OF OBSTETRICS & GYNAECOLOGY, Issue 9 2004on behalf of the Health Protection Agency Group B Streptococcus Working Group Objective To identify the incidence of early-onset group B streptococcal infection and to describe the antecedent maternal risk factors, in order to provide data to inform the design of interventional strategies that could be introduced in the UK to reduce the burden of this infection. Design A retrospective study with review of case notes of mothers and babies. Setting Seven maternity units in London during 1990,1999. Population All cases of proven early-onset neonatal group B streptococcal infection. Methods Identification of presence of risk factors that could be used to select women for the offer of intrapartum antibiotic prophylaxis. Main outcome measures Incidence and case-fatality rate of invasive early-onset group B infection. Results One hundred and forty cases were identified among a birth cohort of 198,388 live births, an incidence of 0.71 per 1000 live births. Twenty-two babies died, a case-fatality rate of 15.6% or 1.1 per 100,000 live births. Women of black ethnic origin, and those who had had a previously affected infant, multiple pregnancy, preterm delivery, prolonged rupture of membranes or intrapartum fever all had a significantly increased risk of delivering an infected infant. Conclusions These data suggest that the incidence of early-onset group B streptococcal infection in these London centres is sufficiently high to warrant administration of intrapartum antibiotics to at-risk women. [source] Comparison of diagnostic accuracy for cutaneous malignant melanoma between general dermatology, plastic surgery and pigmented lesion clinicsBRITISH JOURNAL OF DERMATOLOGY, Issue 2 2003J.E. Osborne SummaryBackground Since the 1980s there have been dedicated pigmented lesion clinics (PLCs) in the U.K. Important considerations when comparing the efficacy of the PLC with other referral clinics include diagnostic accuracy. Objectives To compare the false-negative rate of clinical diagnosis (FNR) in the PLC with that in the other clinics of primary referral of malignant melanoma (MM) in the same geographical area. We have previously shown that certain clinical features are risk factors for diagnostic failure of MM. A further aim of this study was to correct for any differences in frequency of these factors in the melanoma populations between clinics and to estimate the false-positive diagnostic rate (FPR) in the PLC. Methods To compare the FNR between clinics, the case notes of all patients presenting with histologically proven cutaneous MM in Leicestershire between 1987 and 1997 were examined retrospectively. A false-negative diagnosis was defined as documentation of another diagnosis and/or evidence in the case notes that the diagnosis was not considered to be MM. The FNR was estimated as the number of false-negative clinical diagnoses/number of true-positive histological diagnoses. To estimate the diagnostic FPR, which was defined as the number of false-positive clinical diagnoses of MM/total number of positive clinical diagnoses, in the PLC, the outcome of 500 consecutive patients attending the PLC was surveyed. Results The case notes of 731 patients were available, of whom approximately two-thirds initially attended the PLC, one-fifth the General Dermatology clinics (D) and the remainder were divided approximately equally (one-twentieth each) between Plastic Surgery clinics (P), other clinics (O) and the surgery of the general practitioner (GP). The last was regarded as the primary referral clinic if the lesion were excised there prior to any referral. The FNR was lowest for the PLC, at 10%, compared with 29% (D), 19% (P), 55% (O) and 54% (GP) (P < 0·0001). Lesions with risk factors for diagnostic failure were under-represented in the PLC (P < 0·0001), the mean frequencies of the risk factors being 20% (PLC), 25% (D), 22% (P), 31% (O) and 30% (GP). Differences were not large but still could partially explain the lower FNR of the PLC. However, when the FNR was estimated for lesions exhibiting each of these risk factors, the PLC was found to have the lowest rate in every case (PLC vs. all clinics combined, P = 0·04 to P < 0·0001). The mean FNR for the risk factors combined was 18% (PLC), 45% (D), 50% (P), 68% (O) and 71% (GP). Also on logistic multivariable analysis of the PLC vs. all the other clinics on FNR and the above factors, the higher FNR of the other clinics retained significance (odds ratio 5·9, P < 0·0001). In the 500 patients surveyed separately in the PLC, the MM pick-up rate on biopsy was 32% and the diagnostic FPR was 41%. Conclusions The FNR of MM was lower in the PLC than in the other clinics, while the pick-up rate for MM on biopsy and the FPR were acceptably low. [source] Frequency and impact of extracolonic findings detected at computed tomographic colonography in a symptomatic population,,BRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 3 2007K. Y. Khan Background: Extracolonic findings are frequently recognized alongside colonic pathology at computed tomographic colonography (CTC). This study assessed the clinical impact of extracolonic findings in a symptomatic population at high risk of colorectal cancer. Methods: CTC was performed in a consecutive cohort of patients assessed in a fast-track colorectal cancer clinic as being at high risk of colorectal cancer. A review of CTC findings and case notes was undertaken. Patients with extracolonic findings were followed up for at least 12 months. Results: Thirty-one (13·8 per cent) of 225 patients investigated by CTC had colorectal cancer. Extracolonic findings were identified in 81 (53·3 per cent) of 152 patients with normal or non-neoplastic bowel findings, compared with 27 (37 per cent) of 73 patients with colorectal neoplasia (P = 0·025). Twenty-four patients (10·7 per cent) with extracolonic findings underwent further investigation or treatment. The median duration of investigation was 19·5 weeks. Seventy-five clinical events were recorded, including 14 surgical procedures. Conclusion: A prospective cost,benefit analysis of diagnostic CTC should be performed before it is established as a first-line investigation for colonic symptoms. Copyright © 2007 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [source] 3334: Corneal dystrophies: the paediatric corneal specialist viewACTA OPHTHALMOLOGICA, Issue 2010KK NISCHAL Purpose To describe the range of corneal dystrophies presenting to a tertiary refferral paediatric ophthalmology centre and the treatment approach to these various dystrophies Methods Retrospective review of case notes between Jan 1999 and March 2010 Results The range of corneal dystrophies presenting varied from Meesmans, Map-Dot , Reis-Buckler, Posterior polymorphous corneal dystrophy, congenital hereditary endothelial dystrophy, Granular and Lattice -Granular and the newly described x linked endothelial corneal dystrophy. The youngest child to present with symptoms was 14 months old. Management approach depended on the ultimate goal of allowing normal visual developemnt until the age of 8 years. Amblyopia plays a great role in the eventual visual outcome in children with corneal transplant surgery also riddled with difficulties in young children. Conclusion The classical descriptions of corneal dystrophies are not how they present in children . Certain symptoms and signs may tip the clinician off to the possibility of a corneal dystrophy. Visual rehabilitation in children is time limited and must be the priority for the treating physician. [source] Retrospective analysis of the occurrence of internal malignancy in patients treated with PUVA between 1986 and 1999 in South WarwickshireCLINICAL & EXPERIMENTAL DERMATOLOGY, Issue 2 2004J. E. Gach Summary Concerns were raised in our department when four of our patients receiving PUVA treatment developed internal malignancy. We reviewed the medical and phototherapy case notes of patients who received either systemic or bath PUVA therapy in our department between 1986 and 1999. Among the 197 patients for whom we were able to trace the hospital records we identified five patients with internal malignancies. Over the same period (1986,1999) we calculated, using the Kaplan,Meier nonparametric estimator, that 4.6 cases of internal malignancy would have been anticipated in our study population. Therefore PUVA therapy did not appear to be a risk factor for internal malignancy. [source] Use of high-dose botulinum A toxin in benign essential blepharospasm: is too high too much?CLINICAL & EXPERIMENTAL OPHTHALMOLOGY, Issue 5 2006Anna L-Y Pang MB BS (Hons) Abstract Background:, Botulinum toxin (Botox) is the mainstay treatment for benign essential blepharospasm. Current treatment practice appears restricted by several reports demonstrating adverse effects and resistance to high-frequency, higher-dose therapy. This study aimed to explore whether high-dose, high-frequency treatments could be used without developing secondary resistance and without significant side-effects in patients refractory to conventional Botox doses. Methods:, From a cohort of 120 patients being treated with Botox therapy for benign essential blepharospasm and idiopathic hemifacial spasm, case notes from six patients were retrospectively examined. In these patients, therapy had exceeded the recommended 50 units per side for a duration greater than 12 months and at less than 3 monthly intervals. Patterns in subjective severity grading and percentage of improvement as well as reported side-effects were analysed. Results:, All patients described greater than 60% improvement and 0,2 severity grading over a 3- to 15-year period with no evidence of secondary resistance. Side-effects were minor, transient and less frequently reported at higher doses. Conclusion:, In a select group of patients, Botox therapy can be used effectively at doses higher than recommended over long periods with minimal side-effects and little evidence of secondary resistance. [source] Low clinical utility of routine angiographic surveillance in the detection and management of cardiac allograft vasculopathy in transplant recipientsCLINICAL CARDIOLOGY, Issue 6 2001FRCPI, Jonathan R. Clague M.D. Abstract Background: Cardiac allograft vasculopathy (CAV), a form of accelerated atherosclerosis, is the major cause of late death in heart transplant recipients. Routine annual coronary angiography has been used as the standard surveillance technique for CAV in most transplant centers. Hypothesis: The aim of this study was to investigate the clinical utility of routine angiographic surveillance in the detection and management of CAV in transplant recipients. Methods: We reviewed the case notes and angiograms of 230 patients who underwent cardiac transplantation in our unit between January 1986 and January 1996 and survived beyond the first year post transplantation. Results: Significant complications secondary to angiography arose in 19 patients (8.2%). Cardiac allograft vasculopathy was present on none of angiograms performed 3 weeks post transplantation, but was identified in 9 patients (4%) at the first annual angiogram and an additional 25 patients by the fifth annual angiogram. A target lesion suitable for angioplasty was only identified in two patients, and only limited procedural success was achieved in both cases. Twenty-five patients (11%) died during the study period, and the most common cause of late death was graft failure which occurred in 10 patients. All patients who died from graft failure had significant CAV at autopsy, but the most recent coronary angiogram had been normal in eight of these patients. Conclusions: These data clearly illustrate the limited clinical utility of routine angiographic surveillance for CAV in heart transplant recipients and prompted us to abandon this method of surveillance in our unit. [source] Globus sensation as early presentation of hypopharyngeal cancerCLINICAL OTOLARYNGOLOGY, Issue 6 2007A. Tsikoudas Objectives:, To identify if patients with early hypopharyngeal carcinoma can present with only the single complaint of globus sensation. Design:, Retrospective case review. Setting:, Teaching Hospital in Scotland. Participants:, Cohort of 23 patients with hypopharyngeal carcinoma. Retrospective review of their case notes with regards to their hospital pathway from initial referral from the General Practitioner to diagnosis. Outcome measures:, Symptoms & signs on presentation, subsequent investigations and time interval between initial presentation and diagnosis. Results:, We identified two patients (9%) who presented early with globus or other soft symptoms as the only complaint and with normal clinical findings. There was a 78%,pick up' rate of abnormalities in the barium swallow examination. Conclusion:, We believe this can have important clinical implications in the screening & investigation of globus patients who represent a significant outpatient workload. We review the relevant literature. [source] | |||||||||||||||||||||||||||||||