Sue Ross

First year medical student stress and coping in a problem-based learning medical curriculum

Objective  To examine the prevalence of psychological morbidity, sources of stress and coping mechanisms in first year students in a problem‐based learning undergraduate medical curriculum.

Reducing hospital admission through computer supported education for asthma patients. Grampian Asthma Study of Integrated Care (GRASSIC).

Abstract Objective : To evaluate a personalised computer supported education programme for asthma patients. Design : Pragmatic randomised trial comparing outcomes over 12 months between patients taking part in an enhanced education programme (four personalised booklets, sent by post) and patients receiving conventional oral education at outpatient or surgery visits. Setting : Hospital outpatient clinics and general practices in north east Scotland. Subjects : 801 adults attending hospital outpatient clinics, with a diagnosis of asthma confirmed by a chest physician and pulmonary function reversibility of at least 20%. Main outcome measures : Numbers of hospital admissions, consultations with general practioner for asthma, steroid courses used, bronchodilators and inhaled steroids prescribed, days of restricted activity, and disturbed nights. Results : Patients with asthma judged too severe for randomisation between clinic care and integrated care and thuse retained in clinic care had 54% fewer hospital admissions after receiving enhanced education than did the control group (95% confidence interval 30% to 97%; P<0.05) over the study year. Patients had not all spent a full year as “educated” patients within the study year: when “educated days” were controlled for, annual admission rates for the entire enhanced education group were 49% (31% to 78%) of those in the control group. Among patients with sleep variation, sleep disturbance in the education group in the week before a regular review was 80% (65% to 97%) of that in the control group. There was no significant difference in days of restricted activity, prescription of bronchodilators or inhaled steroids, use of oral steroids, or number of general practioner consultations for asthma, and no significant interaction between ownership of a peak flow meter and education. Conclusions : An asthma education programme based on computerised booklets can reduce hospital admissions and improve morbidity among hospital outpatients.

Implementation of the Canadian C-Spine Rule: prospective 12 centre cluster randomised trial

Objective To evaluate the effectiveness of an active strategy to implement the validated Canadian C-Spine Rule into multiple emergency departments. Design Matched pair cluster randomised trial. Setting University and community emergency departments in Canada. Participants 11 824 alert and stable adults presenting with blunt trauma to the head or neck at one of 12 hospitals. Interventions Six hospitals were randomly allocated to the intervention and six to the control. At the intervention sites, active strategies were used to implement the Canadian C-Spine Rule, including education, policy, and real time reminders on radiology requisitions. No specific intervention was introduced to alter the behaviour of doctors requesting cervical spine imaging at the control sites. Main outcome measure Diagnostic imaging rate of the cervical spine during two 12 month before and after periods. Results Patients were balanced between control and intervention sites. From the before to the after periods, the intervention group showed a relative reduction in cervical spine imaging of 12.8% (95% confidence interval 9% to 16%; 61.7% v 53.3%; P=0.01) and the control group a relative increase of 12.5% (7% to 18%; 52.8% v 58.9%; P=0.03). These changes were significant when both groups were compared (P<0.001). No fractures were missed and no adverse outcomes occurred. Conclusions Implementation of the Canadian C-Spine Rule led to a significant decrease in imaging without injuries being missed or patient morbidity. Final imaging rates were much lower at intervention sites than at most US hospitals. Widespread implementation of this rule could lead to reduced healthcare costs and more efficient patient flow in busy emergency departments worldwide. Trial registration Clinical trials NCT00290875.

Peripartum hysterectomy: 1999 to 2006.

OBJECTIVE: To estimate the rate of peripartum hysterectomy over the last 8 years in Calgary, the primary indication for peripartum hysterectomy (defined as any hysterectomy performed within 24 hours of a delivery), and whether there was an increase in the rate of peripartum hysterectomy during that time. METHOD: Detailed chart review of all cases of peripartum hysterectomy, 1999–2006, including previous obstetric history, details of the index pregnancy, indications for peripartum hysterectomy, outcome of the hysterectomy, and infant morbidity. RESULTS: The overall rate of peripartum hysterectomy was 87 of 108,154 or 0.8 per 1,000 deliveries. The primary indications for hysterectomy were uterine atony (32 of 87, 37%) and suspected placenta accreta (29 of 87, 33%). After hysterectomy, 46 (53%) women were admitted to the intensive care unit. Women were discharged home after a mean 6-day length of stay. The rate of peripartum hysterectomy did not appear to increase over time. CONCLUSION: Our population-based study found that abnormal placentation is the main indication for peripartum hysterectomy. The most important step in prevention of major postpartum hemorrhage is recognizing and assessing women’s risk, although even perfect management of hemorrhage cannot always prevent surgery. LEVEL OF EVIDENCE: III

Does induction of labour increase the risk of caesarean section? A systematic review and meta‐analysis of trials in women with intact membranes

Recent literature on the effect of induction of labour (compared with expectant management) has provided conflicting results. Reviews of observational studies generally report an increase in the rate of caesarean section, whereas reviews of post‐dates and term prelabour rupture of membrane (PROM trials suggest either no difference or a reduction in risk.

Effectiveness of progestogens to improve perinatal outcome in twin pregnancies: an individual participant data meta-analysis

In twin pregnancies, the rates of adverse perinatal outcome and subsequent long‐term morbidity are substantial, and mainly result from preterm birth (PTB).

Transobturator tape compared with tension-free vaginal tape for stress incontinence: a randomized controlled trial.

OBJECTIVE: To compare the effectiveness of transobturator tape with tension-free vaginal tape (TVT) in terms of objective cure of stress urinary incontinence (SUI) at 12 months postoperatively. METHOD: Women with SUI were randomly allocated to either transobturator tape or TVT procedures and reviewed at 12 months after surgery. The primary outcome was objective evidence of “cure,” evaluated by standardized pad test (cure defined as less than 1 g urine leaked). Other outcomes included complications, subjective cure, incontinence-related quality of life, return to usual sexual activity, and satisfaction with surgery. Primary analysis compared the proportion of patients in each group who were cured at 12-month follow-up. RESULTS: A total of 199 women participated (94 in the transobturator tape group, 105 in the TVT group). Sixty-eight women (81%) in the transobturator tape group were cured, compared with 67 (77%) in the TVT group (relative risk 1.05, 95% confidence interval 0.90–1.23, P=.577). On vaginal examination, the tape was palpable for 68 women (80%) in the transobturator tape group and for 24 (27%) in the TVT group (relative risk 0.22, 95% confidence interval 0.13–0.37, P<.001). More women in the transobturator tape group experienced groin pain during vaginal palpation (13 [15%] in the transobturator tape group and five [6%] in the TVT group, P=.044). Quality of life improved significantly from baseline in both groups (30-point improvement in IIQ-7 score for both groups). CONCLUSION: At 12 months, the majority of women had minimal leakage and their quality of life had improved significantly, but differences were not observed between groups. The presence of palpable tape, particularly among the transobturator tape group, is concerning; longer follow-up is needed to determine whether this outcome leads to extrusion or resolves over time. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00234754. LEVEL OF EVIDENCE: I

Recurrent Urinary Tract Infection

OBJECTIVE to provide an update of the definition, epidemiology, clinical presentation, investigation, treatment, and prevention of recurrent urinary tract infections in women. OPTIONS continuous antibiotic prophylaxis, post-coital antibiotic prophylaxis, and acute self-treatment are all efficient alternatives to prevent recurrent urinary tract infection. Vaginal estrogen and cranberry juice can also be effective prophylaxis alternatives. EVIDENCE a search of PubMed and The Cochrane Library for articles published in English identified the most relevant literature. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date restrictions. VALUES this update is the consensus of the Sub-Committee on Urogynaecology of the Society of Obstetricians and Gynaecologists of Canada. Recommendations were made according to the guidelines developed by the Canadian Task Force on Preventive Health Care (Table 1). OPTIONS recurrent urinary tract infections need careful investigation and can be efficiently treated and prevented. Different prophylaxis options can be selected according to each patients characteristics.

Primary and secondary care management of women with early breast cancer from affluent and deprived areas: retrospective review of hospital and general practice records

Abstract Objectives: To investigate whether poorer survival of breast cancer among deprived women compared with affluent women is related to their NHS care. Design: Retrospective review of hospital and general practice case records. Setting: Greater Glasgow Health Board area. Subjects: Women diagnosed with breast cancer in 1992-3 who lived in the most affluent (deprivation categories 1 and 2) and the most deprived areas (deprivation categories 6 and 7) of Glasgow (Carstairs and Morris deprivation index). Main outcome measures: Breast cancer treatment, time from general practice consultation to clinic visit and surgery, and details of hospital admissions and follow up in primary and secondary care. Results: The access to care and surgical and oncological treatment of women from affluent and deprived areas were similar. Admissions to hospital for problems not related to breast cancer were more common in those living in deprived areas (number admitted once or more: 51 (24%) v13 (10%), P=0.001). Consultation patterns in general practice by the second year after diagnosis showed women in deprived areas consulting more frequently than women in affluent areas (median (interquartile range) number of consultations (5 (2-10) v 7 (4-13), P=0.01). Conclusion: Women living in affluent areas did not receive better NHS care for breast cancer than women in deprived areas. However, women from deprived areas seem to have greater comorbidity, and poorer outcomes from breast cancer among these women is probably due to factors which result in deprived communities having poorer health outcomes rather than to management of their breast cancer.

The Control of Hypertension In Pregnancy Study pilot trial

Objective  To determine whether ‘less tight’ (versus ‘tight’) control of nonsevere hypertension results in a difference in diastolic blood pressure (dBP) between groups.