Prevention of early-onset Group B Streptococcal disease - the Northern Ireland experience.

OBJECTIVES: To ascertain guideline adherence for prevention of Group B Streptococcal (GBS) neonatal infection and establish prevalence and outcomes in Northern Ireland (NI). DESIGN: Retrospective observational study. SETTING: Northern Ireland maternity units. POPULATION: Using NI Health Information Systems the following were identified: (1) a cohort of women with one or more risk factors for GBS disease in 2009-2010, (2) all culture-positive cases of GBS in babies aged 0-89 days (2008-2010), (3) stillbirths due to GBS (2009-2010). METHODS: Information was analysed for a 15% randomised sample of the available cases. Maternal and infant case notes were reviewed for confirmed cases of neonatal early onset GBS (EOGBS) during 2008-2010. MAIN OUTCOME MEASURES: Adherence to the 2003 RCOG guideline on prevention of GBS disease (2009-2010). Number of neonatal GBS infections: antenatal risk factors, management and neonatal outcomes (2008-2010). The number of stillbirths related to GBS (2009-2010). RESULTS: Five hundred and seventy-four women had one or more identifiable risk factors for GBS disease; intrapartum antibiotic prophylaxis (IAP) was administered in 42% of cases. Improved administration of IAP was noted in the presence of escalating risk factors. At best, guideline adherence was 50-70%. Forty-three neonates had proven early-onset Group B Streptococcal disease; 55.8% had maternal risk factors. Of the total identified cases, 25.5% received IAP. The total mortality rate was 11.46%. The incidence of EOGBS disease in NI was 0.57/1000 live births. CONCLUSIONS: Prevalence of EOGBS is higher in NI than the UK as a whole. Risk factors are present in 55.8% of mothers; IAP does not prevent all cases of EOGBS.

Caesarean section in the second stage of labour: a retrospective review of obstetric setting and morbidity.

Caesarean section in the second stage of labour is a difficult procedure, with little published evidence to guide practice. We investigated the background and morbidity. Case notes of all emergency caesareans at full dilatation over 1 year in two hospitals were studied for demographics, grade of attending doctor, other methods of surgical delivery and morbidity. A total of 91 (15.3%) of 595 emergency caesareans were performed at full dilatation. Instrumental delivery was attempted in 36 (40%). A consultant was present in 29 (32%). In 16 (18%), the venous pH was

Neuromuscular electrical stimulation and the treatment of lower urinary tract dysfunction in multiple sclerosis--a double blind, placebo controlled, randomised clinical trial.

AIMS: Lower urinary tract dysfunction affects up to 75% of the multiple sclerosis population. Results from our recent Pilot Study (McClurg et al., 2006) indicated that a combined programme of pelvic floor muscle training, electromyography biofeedback and neuromuscular electrical stimulation modalities may alleviate some of the distressing symptoms within this population. This clinical trial aimed to evaluate further the efficacy of these interventions and to establish the benefit of neuromuscular electrical stimulation above and beyond that of EMG biofeedback and pelvic floor muscle training. METHODS: 74 multiple sclerosis patients who presented with lower urinary tract dysfunction were randomly allocated to one of two groups - Group 1 received Pelvic Floor Muscle Training, Electromyography Biofeedback and Placebo Neuromuscular Electrical Stimulation (n=37), and Group 2 which received Pelvic Floor Muscle Training, Electromyography Biofeedback, and Active Neuromuscular Electrical Stimulation (n=37). Treatment was for nine weeks with outcome measures recorded at weeks 0, 9, 16 and 24. The Primary Outcome Measure was the number of leakage episodes. Within group analysis was by Paired Samples t-test. Group differences were analysed using Repeated Measures Analysis of Variance and Post-hoc tests were used to determine the significance of differences between Groups at each time point. RESULTS: The mean number of incontinence episodes were reduced in Group 2 by 85% (p=0.001) whereas in Group 1 a lesser reduction of 47% (p=0.001) was observed. However, there was a statistically superior benefit in Group 2 when compared to Group 1 (p=0.0028). This superior benefit was evident in all other outcome measures. CONCLUSIONS: The addition of Active Neuromuscular Electrical Stimulation to a programme of Pelvic Floor Muscle Training and Electromyography Biofeedback should be considered as a first-line option in alleviating some of the symptoms of lower urinary tract dysfunction associated with multiple sclerosis.

Comparison of pelvic floor muscle training, electromyography biofeedback, and neuromuscular electrical stimulation for bladder dysfunction in people with multiple sclerosis: a randomized pilot study.

AIM: Bladder dysfunction affects up to 90% of the multiple sclerosis (MS) population. Interventions such as Pelvic Floor Training and Advice (PFTA), Electromyography (EMG) Biofeedback, and Neuromuscular Electrical Stimulation (NMES) have received limited research attention within this population. This study aimed to determine the effectiveness of a combined programme of PFTA, EMG Biofeedback, and NMES for bladder dysfunction in MS. METHODS: Females (n = 30) who fulfilled strict inclusion/exclusion criteria were recruited. Outcome measures (weeks 0, 9, 16, and 24) included: 3-day Voiding Diary; 24 hr Pad-Test; Uroflowmetry; Pelvic Floor Muscle Assessment; Incontinence Impact Questionnaire (IIQ); Urogenital Distress Inventory (UDI); King's Health Questionnaire (KHQ), and the Multiple Sclerosis Quality of Life-54 Instrument (MSQoL-54). Following baseline (week 0) assessment, participants were randomly allocated, under double blind conditions, to one of the three groups: Group 1 (PFTA); Group 2 (PFTA and EMG Biofeedback); and Group 3 (PFTA, EMG Biofeedback, and NMES). Treatment was for 9 weeks. RESULTS: Baseline severity (measured by number of leaks and pad weight) showed some variation between groups, although not statistically significant (P > 0.05); with the caveat that this baseline imbalance makes interpretation difficult, a picture emerges that at week 9, Group 3 demonstrated superior benefit as measured by the number of leaks and pad test than Group 2, with Group 1 showing less improvement when compared to week 0; this was statistically significant between Groups 1 and 3 for number of leaks (P = 0.014) and pad tests (P = 0.001), and Groups 1 and 2 for pad tests (P = 0.001). A similar pattern was evident for all other outcome measures. CONCLUSION: Results suggest that these treatments, used in combination, may reduce urinary symptoms in MS. Further research will establish the effectiveness of these interventions.

Emergency department post-coital contraception in Northern Ireland.

BACKGROUND: The granting of a licence to Levonelle as an emergency hormonal contraceptive in the Republic of Ireland may require accident and emergency (A&E) departments to formally provide such a service. This article outlines the experiences of a Northern Ireland A&E unit. AIMS: To examine the pattern of attendance of patients requesting emergency contraception at an A&E department and to assess if adequate standards of care are achieved. METHOD: Retrospective case note review of 100 patients attending the A&E department requesting emergency contraception. RESULTS: Sixty-one per cent of requests for emergency contraception were outside normal pharmacy opening hours. Seventy-seven per cent of these patients were less than 26 years old. Most (63%) attended within 24 hours of unprotected sexual intercourse. Forty-three per cent of the patients studied had used no contraception prior to this request. Recording of menstrual details and sexual behaviour as part of the consultation was variable. CONCLUSIONS: A&E departments receive requests for emergency hormonal contraception particularly from younger women (<25 years). A&E staff must have appropriate training and support to manage these consultations effectively.

Urinary incontinence in Northern Ireland: a prevalence study.

OBJECTIVE: To determine the prevalence of urinary incontinence in a Northern Ireland community drawn from four neighbouring geographical areas and to assess factors predisposing to the development of urinary incontinence. SUBJECTS AND METHODS: A three-page self-administered postal questionnaire was sent to 1050 women (age range 35-74 years), recruited randomly from a target population of 43 829 women. The main survey was preceded by a pilot survey. Respondents and those not responding were compared. RESULTS: The overall response rate was 65.6% (689/1050); there was no significant difference between respondents and those not responding. Two-hundred and thirty-one women (33.5%) reported incontinence 'sometimes' and 161 (23.4%) 'often'. Of those who had urinary incontinence, sanitary protection was required by 21.7% (85/392). This equates to 12.3% (85) of the total study population. Age (chi2=20.34; P<0.001) and parity (Mann-Whitney U-test, P< 0.001) were associated with urinary incontinence, with a higher proportion of women aged 45-54 years having urinary incontinence. The menopause and postnatal pelvic floor exercises were not associated with urinary incontinence. Overall 19.9% (78/392) of women with urinary incontinence had consulted their general practitioner. Of those who required sanitary protection, 40% (34/85) had consulted their doctor. CONCLUSION: Urinary incontinence is common; it is sufficiently severe to require sanitary protection in 12% of women aged 35-74 years in a Northern Ireland community.

Evaluation of routine ultrasound in the prenatal diagnosis of structural anomalies of the fetus.

The objective of this study was to evaluate routine obstetric ultrasound in detecting fetal structural anomalies and the impact of changing clinical practice on success rates. A retrospective study of routine ultrasound in a population of 6,869 pregnancies was performed during 1985-86 (phase 1) to establish efficacy of ultrasound in the detection of fetal anomalies. Changes in ultrasound practice comprised timing, personnel and technique of fetal examination. After alterations in practice, a prospective study of 6,969 pregnancies during 1987-89 (phase 2) was performed. All abnormal fetuses (cases) were assessed in both studies. Random samples of normal infants (controls) were chosen from both populations to establish specificity. In 83 cases in phase 1,116 anomalies were diagnosed postnatally of which 11 were suspected by routine prenatal ultrasound at < 24 weeks (sensitivity 9%, 95% C.I. 4-15). In 72 cases in phase 2, 89 anomalies were identified postnatally of which 27 were suspected by routine prenatal ultrasound at < 24 weeks (sensitivity 30%, 95% C.I. 21-41). The change in sensitivity was statistically significant (p = 0.0003). Of the 382 control infants randomly selected in phase 1, false abnormal scans were not identified (specificity 100%, 95% C.I. 99-100). Of the 367 control infants in phase 2, 12 false abnormal scans were identified (specificity 96.7%, 95% C.I. 95-99). The decrease in specificity was statistically significant (p = 0.0013). The detection of urorenal and to a lesser degree central nervous system anomalies showed most improvement between the two phases. The alterations to routine ultrasound practice in timing, personnel and technique have significantly improved the detection of all fetal structural anomalies but at the cost of a small but significant loss of specificity.

Antenatal detection of renal abnormalities.

The aim of this retrospective study is to assess the value of routine ultrasonography in the detection of renal abnormalities. Twenty-nine pregnancies (one set of twins) with suspected renal abnormalities (i.e. renal cystic spaces, oligohydramnios or hyperechoic kidneys) were delivered over a two year period (1.8.1987-31-7-1989) in a unit where 90% of pregnancies (6,562) were scanned routinely at 18-20 weeks gestation or later, if booking for confinement was delayed. In pregnancies with suspected anomalies prenatal ultrasound was performed monthly until 28 weeks and fortnightly until delivery. Non survivors [5] had histological or postmortem examination. Liveborn infants [25] had renal ultrasonography in the neonatal period and paediatric follow-up if abnormal. Sixteen (53%) of the 30 cases (one set of twins) suspected of renal abnormalities by routine prenatal ultrasonography had renal anomalies confirmed postnatally. Five women were non survivors, all of which had associated anomalies. In the eleven survivors the diagnoses were pelvi-ureteric junction obstruction [6], renal dysplasia [2], vesicoureteric reflux [2] and suspected ureterocele [1]. Fourteen infants with pelvicalyceal dilatation had normal postnatal renal ultrasound. Although abnormal prenatal renal ultrasound is a useful indicator of postnatal disease and aids decisions on the management of pregnancy, further large collaborative studies with extended paediatric follow-up are required to assess the significance of pelvicalyceal dilatation.

Pituitary function tests in black patients with pseudocyesis.

Pituitary function was evaluated in a group of 10 patients with pseudocyesis. One patient was postmenopausal; the remainder demonstrated normal basal prolactin, luteinising hormone (LH) and follicle-stimulating hormone (FSH) levels and also normal pituitary-adrenal, pituitary-thyroid axes. Oestradiol deficiency was present in 6 patients, while 2 patients demonstrated elevated serum progesterone values, suggestive of a luteal phase. Gonadotrophin-releasing hormone administration resulted in exaggerated stimulation of LH and FSH in 4 and 2 patients, respectively. Impaired growth hormone (GH) secretion was present in 6 patients after insulin-induced hypoglycaemia and L-dopa administration. GH impairment is probably a consequence of the oestrogen deficiency that commonly occurs in this condition. It thus appears that there are aberrations in specific pituitary hormone responses after provocation in pseudocyesis.

Gynaecological day surgery at an area hospital 1983-1987.

An eight bedded self-contained day unit for minor gynaecological surgery was opened in November 1982 at Craigavon Area Hospital. In the five years from 1 January 1983 to 31 December 1987, 2091 minor procedures have been performed in the unit, or 32.85% of the total gynaecological operations. The waiting time from consultation until admission for minor surgery was reduced from 2-3 months in 1983 to 2-3 weeks in 1987 and major surgery from 5-6 months to 1-2 months. Allied to this improvement in patient service has been an increase in the in-patient major surgery operation rate, resulting in 100 extra major operations per year. Although costs of treatment in the day procedure unit were lower than the average cost for a 24 hour in-patient stay, the cost per patient is dependent upon the total patient throughput of the unit and the number of days it is used. Complication rates (ie transfer to in-patient facilities for complications of surgery or anaesthesia) are low at 1.85%.

Comparison of labetalol and dihydralazine in hypertensive emergencies of pregnancy.

Labetalol (Trandate; Allen & Hanburys), a combined alpha- and beta-adrenergic blocking agent, was compared with the more commonly used peripheral vasodilator, dihydrallazine (Nepresol; Ciba), each administered as an infusion, in the treatment of severe hypertension in 20 primigravidas at greater than or equal to 32 weeks' gestation. With the dosage regimen used in this study there was a tendency towards more effective blood pressure control with dihydrallazine. The pulse rate was unaffected by labetalol therapy and there were no harmful effects on the neonate or fetus directly attributable to either drug.

Smoking in the work place: a management perspective.

In the past, smoking in the private work place has been a matter left largely to the discretion of individual employees and employers. A recent poll of the nation's largest service and industrial companies indicates a strong employer preference for this noninterventionist approach by which employees work out smoking-related problems among themselves. Nonetheless, approximately eight states and four dozen localities have passed legislation regulating smoking in the private work place, apparently in response to the courts' reluctance to order such restrictions where the employer has undertaken reasonable efforts to accommodate smokers and nonsmokers. While these laws vary widely in their language and specifics, they may pose significant practical and compliance problems for employers. In the following article, the authors examine judicial, legislative, and employer responses to work-place smoking issues and discuss the options of private employers for coping with this problem.