Holistic assessment of women with hyperemesis gravidarum: A randomised controlled trial.

BACKGROUND: Hyperemesis gravidarum or severe nausea and vomiting of pregnancy affects women's physical, social and psychological wellbeing and often requires frequent hospital admissions. Current standard care may be too medically focussed to meet all of women's complex needs. AIM: The aim of this study is to test where using a validated questionnaire, the Hyperemesis Impact of Symptoms tool, delivered by a nurse to assess the overall effect of hyperemesis on an individual woman's life and to provide advice tailored to her specific needs, will help her cope better with her symptoms and reduce admissions to hospital. DESIGN: This study was a two arm randomised controlled trial in which women with hyperemesis from four hospitals were randomly allocated to one of two groups: (1) usual care and (2) usual care plus assessment with the Hyperemesis Impact of Symptoms questionnaire and a care plan tailored to their responses. PARTICIPANTS AND METHODS: Recruitment was from women who were admitted with hyperemesis gravidarum; diabetic women or those over 14 weeks gestation were excluded. Those who consented completed questionnaires to assess their quality of life and the severity of symptoms at baseline and at three time points over the following 6 weeks. RESULTS: Women's average social functioning, Hyperemesis Impact of Symptom scores and average number of admissions were not significantly different between either group. The average number of days in hospital for the questionnaire and tailored plan group was significantly lower, 4.97, compared with 6.14 in the usual care group. Using the questionnaire to plan individualised care was not associated with significant reduction in health care costs. CONCLUSION: Using the Hyperemesis Impact of Symptoms questionnaire to tailor a care plan to address women's individual needs was not associated with any significant improvements in the quality of life. The cost effectiveness analysis did not indicate that the questionnaire is cost saving. The Hyperemesis Impact of Symptoms questionnaire is a practical tool for nurses and midwives to assess the overall impact of hyperemesis gravidarum on the individual and could be useful for assessing symptoms and evaluating physical, social and psychological changes following treatment in either clinical or research settings.

Paranoia and post-traumatic stress disorder in the months after a physical assault: a longitudinal study examining shared and differential predictors.

BACKGROUND: Being physically assaulted is known to increase the risk of the occurrence of post-traumatic stress disorder (PTSD) symptoms but it may also skew judgements about the intentions of other people. The objectives of the study were to assess paranoia and PTSD after an assault and to test whether theory-derived cognitive factors predicted the persistence of these problems. METHOD: At 4 weeks after hospital attendance due to an assault, 106 people were assessed on multiple symptom measures (including virtual reality) and cognitive factors from models of paranoia and PTSD. The symptom measures were repeated 3 and 6 months later. RESULTS: Factor analysis indicated that paranoia and PTSD were distinct experiences, though positively correlated. At 4 weeks, 33% of participants met diagnostic criteria for PTSD, falling to 16% at follow-up. Of the group at the first assessment, 80% reported that since the assault they were excessively fearful of other people, which over time fell to 66%. Almost all the cognitive factors (including information-processing style during the trauma, mental defeat, qualities of unwanted memories, self-blame, negative thoughts about self, worry, safety behaviours, anomalous internal experiences and cognitive inflexibility) predicted later paranoia and PTSD, but there was little evidence of differential prediction. CONCLUSIONS: Paranoia after an assault may be common and distinguishable from PTSD but predicted by a strikingly similar range of factors.

Effect of a patient blood management programme on preoperative anaemia, transfusion rate, and outcome after primary hip or knee arthroplasty: a quality improvement cycle.

BACKGROUND: There are few data on the associations between anaemia, allogeneic blood transfusion (ABT), patient blood management, and outcome after arthroplasty in the UK. National agencies nevertheless instruct NHS Trusts to implement blood conservation measures including preoperative anaemia management. Internationally, blood management programmes show encouraging results. METHODS: We retrospectively audited 717 primary hip or knee arthroplasties in a UK general hospital and conducted regression analyses to identify outcome predictors. We used these data to modify previously published algorithms for UK practice and audited its introduction prospectively. The retrospective audit group served as a control. RESULTS: Preoperative haemoglobin (Hb) concentration predicted ABT (odds ratio 0.25 per 1 g dl(-1), P<0.001). It also predicted the length of stay (LOS, effect size -0.7 days per 1 g dl(-1), P=0.004) independently of ABT, including in non-anaemic patients. Patient blood management implementation was associated with lower ABT rates for hip (23-7%, P<0.001) and knee (7-0%, P=0.001) arthroplasty. LOS for total hip replacement and total knee replacement decreased from 6 (5-8) days to 5 (3-7) and 4 (3-6) days, respectively, after algorithm implementation (P<0.001). The all-cause re-admission rate within 90 days decreased from 13.5% (97/717) before to 8.2% (23/281) after algorithm implementation (P=0.02). CONCLUSIONS: We conclude that preoperative Hb predicts markers of arthroplasty outcome in UK practice. A systematic approach to optimize Hb mass before arthroplasty and limit Hb loss perioperatively was associated with improved outcome up to 90 days after discharge.

A comparison of patient comfort during cataract surgery with topical anesthesia versus topical anesthesia and intracameral lidocaine.

OBJECTIVE: To determine whether intraocular lidocaine increases patient comfort during cataract surgery while under topical anesthesia. DESIGN: Prospective, randomized, double-masked, placebo-controlled clinical trial. PARTICIPANTS: Both men and women between 45 and 85 years of age who were scheduled for elective cataract surgery while under topical anesthesia participated. Sixty-eight patients were randomized to each group. INTERVENTION: Patients were randomized to receive either topical anesthesia plus intracameral 1% preservative-free lidocaine or intracameral balanced salt solution. MAIN OUTCOME MEASURES: Patient assessment of pain during delivery of the anesthesia, surgery, and after surgery using a visual analog pain scale was measured. Patients also recorded the degree to which they were bothered by tissue manipulation and the microscope light. Surgeon assessments of operative conditions, patient cooperation, and intraoperative complications were recorded. The attending anesthesiologist recorded any required supplemental intravenous sedation and any increase in pulse or increase in blood pressure. RESULTS: There was no significant difference in patient-reported pain scores for delivery of anesthesia (P = 0.902), surgery (P = 0.170), or after surgery (P = 0.680). Patients in the lidocaine group reported being less bothered by tissue manipulation (P = 0.021). The surgeon assessment showed more patient cooperation in the lidocaine group (P = 0.043). CONCLUSIONS: Both topical anesthesia alone and topical anesthesia plus intracameral lidocaine provide good operative conditions for the surgeon and comfortable surgical circumstances for the patient. Injection of intraocular lidocaine increases patient cooperation and decreases the degree to which patients are bothered by tissue manipulation, two outcomes that justify its use.

Allosteric regulation of the N-methyl-D-aspartate receptor-linked ion channel complex and effects of ethanol in ethanol-withdrawal seizure-prone and -resistant mice.

The effects of ethanol, glycine, and spermidine on the specific binding of [3H]MK-801 were characterized in Triton-treated membranes prepared from the hippocampus and cortex of ethanol-withdrawal seizure-prone (WSP) and -resistant (WSR) mice. Glycine, an allosteric agonist at the NMDA receptor-linked ion channel complex, caused an increase in specific [3H]MK-801 binding to hippocampal membrane preparations. There were no significant differences in EC50 values between the selected lines for the effect of glycine (WSP, 391.7 +/- 48.4 nM; WSR, 313.4 +/- 77 nM) in the presence of 10 microM NMDA or in the maximal response to the agonist (WSP, 1.75 +/- 0.26 pmol/mg of protein; WSR, 1.67 +/- 0.22 pmol/mg of protein). The EC50 values for the spermidine-induced increase in [3H]MK-801 binding in membranes from hippocampus in the absence (WSP, 11.7 +/- 0.83 microM; WSR, 9.98 +/- 1.29 microM) or in the presence of 10 microM glycine and 10 microM NMDA (WSP, 2.1 +/- 0.35 microM; WSR, 2.37 +/- 0.42 microM) also did not differ. Similar results were obtained in cortical membranes. Saturation isotherms indicated that there was no difference in the density of [3H]MK-801 binding sites, or in their affinity for the radioligand, between the mouse lines. In addition, administration of ethanol by inhalation (24 h) to WSP and WSR mice did not cause an increase in the density of [3H]MK-801 binding sites, and there was no difference in the density or affinity of binding sites between the mouse lines.(ABSTRACT TRUNCATED AT 250 WORDS)

A salutary lesson.

When a group of nurses decided to improve facilities for patient's relatives they did not anticipate the unusual series of events described here. Fortunately the outcome was extremely satisfactory. It could, however, have been quite different, and served to heighten nurses' awareness of the potential impact that they may have on relatives.

Auditory brainstem function of the F1 offspring of the cross of CBA/CaJ and AU/SsJ inbred mice.

Inbred strains of laboratory mice have several distinct advantages as models for examining conditions that influence the human auditory system, but the CBA/J mouse which has most often been used as a normal model has recently been found to have several disadvantages. This paper is the first report of the auditory brainstem responses (ABRs) of the F1 offspring of CBA/CaJ and AU/SsJ parents. At midlife, high-frequency ABR thresholds are lower in the F1 than in either parental genotype. Tuning curves obtained by forward masking of the ABR also display heterosis, i.e. they are narrower in the F1 than in either parental strain.