Claire Collins

Odds of ovarian hyperstimulation syndrome (OHSS) - time for reassessment.

Background: Ovarian hyperstimulation syndrome (OHSS) is a potentially life-threatening complication of Assisted Reproductive Technology (ART) treatment. The objective of this study was to assess the odds of OHSS hospital admission in relation to oestradiol levels on day of hCG administration and number of oocytes collected. Methods: We performed a 24 months retrospective analysis of a cohort of patients receiving ART treatment in a University teaching hospital including all patients requiring admission due to OHSS. Main outcome measures were oestradiol levels, number of oocytes collected and incidence of admission with OHSS. Results: OHSS requiring admission to hospital occurred in 1.8% of cases. While no patients with an oestradiol level at hCG ≤15,000 pmol/L developed OHSS, those with oestradiol levels ≥15,000 pmol/L had different risks of admission according to the number of oocytes collected: those with >30 oocytes were 6.7 times more likely to be admitted that those with <20 oocytes. Conclusions: This study identifies an oestradiol level (≥15,000 pmol/L) and number of oocytes (≥20) above which the odds of being admitted with OHSS increases significantly. Although OHSS cannot always be prevented, these measurable parameters should be used to allow appropriate counselling and subsequent safe management of ART patients.

The incidence and impact of increased body mass index on maternal and fetal morbidity in the low-risk primigravid population.

Objective. To determine the incidence and impact of increased body mass index (BMI) on maternal and fetal morbidity in the low-risk primigravid population. Methods. This was a prospective study with retrospective analysis of delivery outcome data. All low-risk primigravida who met the inclusion criteria during the recruitment period were approached. BMI was calculated using the formula weight/height squared. The participants were divided into five categories: ‘underweight’ (BMI <20 kg/m2), ‘normal’ (BMI 20.01–25 kg/m2), ‘overweight’ (BMI 25.01–30 kg/m2), ‘obese’ (BMI 30.01–40 kg/m2), and ‘morbidly obese’ (BMI >40 kg/m2). Maternal outcomes evaluated included gestation at delivery, onset of labor (spontaneous/induced/elective cesarean section), length of labor, use of oxytocin and epidural, mode of delivery, and estimated blood loss. Perinatal outcome measures included infant birth weight (kg) and centile, gestational age, ponderal index, Apgar score <7 at 5 minutes, cord pH <7.1, presence of meconium grade 3 at delivery, degree of resuscitation required, admission to neonatal intensive care unit (NICU), and duration of stay. Results. One thousand and eleven women participated in the study. Complete outcome data were available for 833 women (82%). A significant difference was identified in gestation at delivery between the subgroups (p < 0.004). A significant positive correlation was identified between cesarean section rates with increasing BMI, even when gestation was controlled for (p = 0.004). Similarly, women in the normal BMI group remained significantly less likely to have an infant requiring NICU admission than obese women (2.2% vs. 8.6%; p = 0.011). Conclusion. High BMI is associated with longer gestations, higher operative delivery rates, and an increased rate of neonatal intensive care admission.

Effectiveness of Motivational Interviewing in Influencing Smoking Cessation in Pregnant and Postpartum Disadvantaged Women

INTRODUCTION Systematic assessments of Motivational Interviewing (MI) in smoking behavior have been rare to date. This study aimed to determine whether an integrated approach, involving staff training in MI techniques, was sufficient to affect change in smoking status or intensity in low-income pregnant and postpartum women. METHODS Overall, 500 consecutive smokers were recruited at first prenatal visit to public antenatal clinics. Following staff training, 500 more were recruited (intervention group). Data were recorded at 28-32 weeks gestation, after birth, at 3-4 and 7-9 months postpartum. The primary outcome measure was self-reported continued abstinence from smoking verified by urinary cotinine analysis. Changes in smoking intensity were also measured. RESULTS There was no significant difference in the proportion of smokers in the intervention and control groups who reported stopping smoking at 28-32 weeks gestation (8.2% vs. 8.8%; p = .73), 1 week after birth (8.6% vs. 11.4%; p = .14), 3-4 months after birth (5.8% vs. 4.8%; p = .48), or 7-9 months after birth (5.2% vs. 4.0%; p = .36). Although more cases were nonsmoking at the second visit, 14.8% [95% CI = 11.8-18.5] vs. 13.1% controls [95% CI = 10.3-16.6], this was not statistically significant. CONCLUSIONS MI delivered at a number of time points during pregnancy and up to 9 months postpartum failed to affect quit rates. It may have had a small effect in preventing relapse among spontaneous quitters in late pregnancy though the validity of this remains uncertain.

Heartwatch: the effect of a primary care-delivered secondary prevention programme for cardiovascular disease on medication use and risk factor profiles.

Background: Heartwatch is a secondary prevention programme of coronary heart disease (CHD) in primary care in Ireland. The aim was to further examine the effect of the Heartwatch programme on cardiovascular risk factors and treatments of patients with a follow-up of 3.5 years. Design: Prospective cohort study of 12,358 patients with established CHD (myocardial infarction, percutaneous cardiac intervention, coronary artery bypass graft) recruited by participating general practitioners; patients invited to attend on a quarterly basis, with continuing care implemented according to defined clinical protocols. Methods: Changes in risk factors and treatments at 1, 2, 3 and 3.5-year follow-up from baseline were made using paired t-test for continuous and McNemars test for categorical data. Results: Important changes in systolic and diastolic blood pressure, total and low-density lipoprotein cholesterol and smoking status were observed at 1, 2, 3 and 3.5 years (P < 0.0001) with significant increase in proportions of patients within the target. However, changes in body mass index were small, with no significant improvement in waist circumference. There was a significant increase in prescription of secondary preventive medications and good patient compliance. Males were more likely to be within the target for systolic blood pressure, total cholesterol, waist circumference and exercise level at 3.5 years, but less likely for body mass index. Conclusion: Studies of cardiac rehabilitation without any follow-up programmes show that over time patients revert in part to previous lifestyle habits; this primary care-delivered programme has shown sustained improvements in major risk factors, particularly smoking, blood pressure and cholesterol, and treatments for CHD. Weight management presents a greater challenge.

Heartwatch: a secondary prevention programme in primary care in Ireland

Background Heartwatch, a secondary prevention programme in primary care was initiated in 2003, based on the second European Joint Task Force recommendations for secondary prevention of coronary heart disease (CHD). The aim was to examine the effect of the first 2 years of the Heartwatch programme on cardiovascular risk factors and treatments. Design Prospective cohort study of patients with established CHD enrolled into the Heartwatch programme. Methods Four hundred and seventy (20%) general practitioners nationwide participated in the programme, recruiting 11542 patients with established CHD (earlier myocardial infarction, coronary intervention or coronary artery bypass surgery). Clinical data were electronically transferred by each general practitioner to a central database. Comparison of changes in risk factors and treatments at 1-year and 2-year follow-up from baseline were made using paired t-test for continuous and McNemars test for categorical data. Results Statistically significant changes in systolic blood pressure, diastolic blood pressure, total and low-density lipoprotien cholesterol and smoking status at 1 and 2 years (P < 0.0001) were observed. Little or no improvements were shown for exercise, BMI or waist circumference. Increases in the prescribing of statins, angiotensin-converting enzyme inhibitors and β-blockers over the course of the study were observed. Conclusion The Heartwatch programme has demonstrated significant improvements in the main risk factors and treatments for CHD. More effective interventions are required to reduce BMI, waist circumference and physical inactivity in this population. The increases in treatment uptake are approaching the optimal levels in this population. Eur J Cardiovasc Prev Rehabil 15:651–656

Elder abuse and neglect: a survey of Irish general practitioners.

The objective of this study was to survey general practitioners (GPs) in Ireland regarding their experience with elder abuse. A random sample of 800 GPs were mailed a survey in March 2010, with a reminder in May 2010, yielding a 24% response rate. The majority, 64.5%, had encountered elder abuse, with 35.5% encountering a case in the previous year. Most were detected during a home visit. Psychological abuse and self-neglect were most common. Most GPs in Ireland have encountered cases of elder abuse, most were willing to get involved beyond medical treatment, and 76% cited a need for more education.

Epilepsy in Ireland: Towards the primary–tertiary care continuum

BACKGROUND Epilepsy is a chronic neurological disease affecting people of every age, gender, race and socio-economic background. The diagnosis and optimal management relies on contribution from a number of healthcare disciplines in a variety of healthcare settings. OBJECTIVE To explore the interface between primary care and specialist epilepsy services in Ireland. METHODS Using appreciative inquiry, focus groups were held with healthcare professionals (n=33) from both primary and tertiary epilepsy specialist services in Ireland. RESULTS There are significant challenges to delivering a consistent high standard of epilepsy care in Ireland. The barriers that were identified are: the stigma of epilepsy, unequal access to care services, insufficient human resources, unclear communication between primary-tertiary services and lack of knowledge. Improving the management of people with epilepsy requires reconfiguration of the primary-tertiary interface and establishing clearly defined roles and formalised clinical pathways. Such initiatives require resources in the form of further education and training and increased usage of information communication technology (ICT). CONCLUSION Epilepsy services across the primary-tertiary interface can be significantly enhanced through the implementation of a shared model of care underpinned by an electronic patient record (EPR) system and information communication technology (ICT). Better chronic disease management has the potential to halt the progression of epilepsy with ensuing benefits for patients and the healthcare system.

All azoospermic males should be screened for cystic fibrosis mutations before intracytoplasmic sperm injection

We assessed the frequency of CFTR mutations in groups with varying degrees of sub-fertility and compared these groups to a fertile male group with proven paternity. Screening for CFTR mutations should be routine for all azoospermic males, irrespective of obstructive or non-obstructive etiology, prior to proposing ICSI treatment. CFTR testing has no value in the investigation of non-azoospermic infertile males.

The relationship between body mass index and mid-arm circumference in a pregnant population

Our objective was to correlate body mass index (BMI) with mid-arm circumference (MAC) and also to ascertain whether maternal BMI could be calculated from MAC at booking. We approached all Caucasian women who met the inclusion criteria attending the University College Hospital, London between 1 April 1996 and 30 June 1997 and the Rotunda Hospital, Dublin, Ireland between 15 April 2003 and 19 May 2004. A total of 2,912 women agreed to participate in the research. The participants’ maternal height and weight were measured. Their BMI was calculated using the formula: BMI = weight (kg) ÷ height (m2). The MAC was measured in cm. Statistical analysis was performed using SPSS for Windows version 11 with p < 0.05 as significant. We found that BMI is directly correlated with MAC (r = 0.836) and estimates of BMI may be calculated from the simple equation BMI = MAC ± 2. Alternatively, a MAC of ≥ 27 cm allowed for a detection rate for overweight patients of 75%, with a false positive rate of 15%.

Creating a General (Family) Practice Epidemiological Database in Ireland - Data Quality Issue Management

In Ireland, while detailed information is available regarding hospital attendance, little is known regarding general (family) practice attendance. However, it is conservatively estimated that there are almost nine times as many general practice encounters than there are hospital encounters each year in Ireland. This represents a very significant gap in health information. Indeed, general practice has been shown in other countries to be an important and rich source of information about the health of the population, their behaviors and their utilization of health services. Funded by the Health Information and Quality Authority (HIQA), the Irish College of General Practitioners (ICGP) undertook a feasibility study of diagnostic coding of routinely entered patient data and the creation of a national general practice morbidity and epidemiological database (GPMED project). This article outlines the process of data quality issue management undertaken. The study’s findings suggest that the quality of data collection and reporting structures available in general practice throughout Ireland at the outset of this project were not adequate to permit the creation of a database of sufficient quality for service planning and policy or epidemiological research. Challenges include the dearth of a minimum standard of data recorded in consultations by GPs and the absence of the digital data recording and exporting infrastructure within Irish patient management software systems. In addition, there is at present a lack of recognition regarding the value of such data for patient management and service planning---including importantly, data collectors who do not fully accept the merit of maintaining data, which has a direct consequence for data quality. The work of this project has substantial implications for the data available to the health sector in Ireland and contributes to the knowledge base internationally regarding general practice morbidity data.