The role of depression in the association between mobilisation timing and live discharge after hip fracture surgery: Secondary analysis of the UK National Hip Fracture Database.

PURPOSE: The aim was to compare the probability of discharge after hip fracture surgery conditional on being alive and in hospital between patients mobilised within and beyond 36-hours of surgery across groups defined by depression. METHODS: Data were taken from the National Hip Fracture Database and included patients 60 years of age or older who underwent hip fracture surgery in England and Wales between 2014 and 2016. The conditional probability of postsurgical live discharge was estimated for patients mobilised early and for patients mobilised late across groups with and without depression. The association between mobilisation timing and the conditional probability of live discharge were also estimated separately through adjusted generalized linear models. RESULTS: Data were analysed for 116,274 patients. A diagnosis of depression was present in 8.31% patients. In those with depression, 7,412 (76.7%) patients mobilised early. In those without depression, 84,085 (78.9%) patients mobilised early. By day 30 after surgery, the adjusted odds ratio of discharge among those who mobilised early compared to late was 1.79 (95% CI: 1.56-2.05, p<0.001) and 1.92 (95% CI: 1.84-2.00, p<0.001) for those with and without depression, respectively. CONCLUSION: A similar proportion of patients with depression mobilised early after hip fracture surgery when compared to those without a diagnosis of depression. The association between mobilisation timing and time to live discharge was observed for patients with and without depression.

Homelessness in pregnancy.

OBJECTIVES: To evaluate the association, if any, of homelessness or refuge accommodation on delivery and short term perinatal outcomes in an Irish tertiary maternity hospital. METHODS: A retrospective cohort study of 133 singleton pregnancies in women reporting to be homeless or living in refuge at their booking antenatal appointment between 2013 and 2022. Analysis compared sociodemographic characteristics and perinatal outcomes in this cohort to a reference population of 76,858 women with stable living arrangements. RESULTS: Women in the homeless/refuge population were statistically more likely to be single (75.2 % vs 39.5 %, p < 0.001), have an unplanned pregnancy (73.7 % vs 27.2 %, p < 0.001), report a history of psychiatric illness (42.9 % vs 22.4 %, p < 0.001), domestic violence (18.8 % vs 0.9 %, p < 0.001) alcohol consumption in pregnancy (3.0 % vs 0.8 %, p < 0.001) or smoking in pregnancy (41.3 % vs 9.7 %, p < 0.001). They were significantly more likely to have a preterm birth (adjusted OR 1.71 (1.01-2.87) p = 0.04). They also had a significantly lower median birth weight compared to the reference population (birthweight 3270 g vs 3420 g, p < 0.001). CONCLUSION: Women in the homeless and refuge population are more likely to experience poorer perinatal outcomes compared to women with stable living arrangements.

A retrospective observational study of labour ward work Intensity: The challenge of maternity staffing.

BACKGROUND: The UK and Ireland are facing significant challenges in the recruitment and retention of midwifery staff. Deficiencies in staffing, training and leadership have been cited as contributory factors to substandard care in both regional and global independent maternity safety reports. Locally, workforce planning is critical to maintaining 'one to one' care for all women in labor and to meet the peaks of daily birthing suite activity. OBJECTIVES: Analyze the variation in work intensity, defined by the mean number and range of births per midwifery working hours. METHODS: Retrospective observational study of birthing suite activity between 2017 and 2020. 30,550 singleton births were reported during the study period; however, 6529 elective Cesarean sections were excluded as these were performed during normal working hours by a separate operating theatre team. The times of 24,021 singleton births were organized into five proposed midwifery working rosters lasting eight or 12 h; A (00.00-07.59), B (08.00-15.59), C (16.00-23.59), D (20.00-0.759) and E (0.800-19.59). RESULTS: The number of births was comparable between the eight-hour and 12-hour work periods with a mean of five to six babies born per roster (range zero to 15). Work periods D and E lasting 12-hours both recorded a mean of eight births (range zero to 18). Hourly births ranged from a minimum of zero to a maximum of five births per hour (greater than seven times the mean), a number that was achieved 14 times during the study period. CONCLUSIONS: The mean number of births is consistent between normal working hours and unsociable 'on-call' periods, however there is an extreme range of activity within each midwifery roster. Prompt escalation plans remain essential for maternity services to manage unexpected increases in demand and complexity. WHAT IS ALREADY KNOWN ON THIS TOPIC: Shortfalls in staffing and inadequate workforce planning have been frequently cited in recent maternity safety reports as barriers to sustainable and safe maternity care. WHAT THIS STUDY ADDS: Our study shows that the mean number of births in a large tertiary center are consistent across day and night rosters. However, there are large fluctuations in activity during which births can exceed the number of available midwives. HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY: Our study reflects the sentiments of the Ockenden review and APPG report on safe maternity staffing. Investment in services and the workforce to aid recruitment and reduce attrition is essential to establish robust escalation plans, including the deployment of additional staff in the event of extreme service pressures.

The duration of labor in spontaneous preterm deliveries: A retrospective observational study in a tertiary Irish maternity hospital.

BACKGROUND: Preterm deliveries account for 10% of all births, and are the most important cause of neonatal mortality globally. Despite their frequency, there is a paucity of information known about usual patterns of preterm labor, as previous studies which critically defined the normal progression of labor excluded preterm gestations. OBJECTIVE: To compare the durations of the first, second and third stages of spontaneous preterm labor in nulliparous and multiparous women at varying preterm gestations. METHODS: A retrospective observational study was undertaken of women admitted in spontaneous preterm labor from January 2017 to December 2020 with viable singleton gestations between 24 and 36 + 6 weeks' gestation who then proceeded to have a vaginal delivery. There were 512 cases following exclusion of preterm inductions of labor, instrumental vaginal deliveries, provider-initiated pre-labor Caesarean sections and emergency intrapartum Caesarean sections. The data was then examined to determine our outcomes of interest including the durations of the first, second and third stages of preterm labor, analyzing results by parity and gestation. For comparison, we reviewed data of term spontaneous labors and spontaneous vaginal deliveries during the same study period, identifying 8339 cases. FINDINGS: 97.6% of participants achieved a spontaneous cephalic vaginal delivery with the remainder undergoing an assisted breech birth. 5.7% of gestations delivered spontaneously between 24 + 0 and 27 + 6 weeks, with most births at gestations greater than 34 weeks (74%). The second stage duration (mean 15 vs 32 vs 32 mins respectively) was significantly different across the three gestation periods (p < 0.05), but was notably much quicker in extremely preterm labors. The first and third stage durations were similar between all gestational age groups with no statistically significant differences in results. There was a significant influence of parity on the first and second stages of labor, with multiparous women progressing more quickly than nulliparae (p < 0.001). CONCLUSION: The duration of spontaneous preterm labor is described. Multiparous women progress more quickly in the first and second stages of preterm labor than nulliparous women.

Barriers and facilitators of weight bearing after hip fracture surgery among older adults. A scoping review.

PURPOSE: This scoping review aimed to synthesise the available evidence on barriers and facilitators of weight bearing after hip fracture surgery in older adults. METHODS: Published (Cochrane Central, MEDLINE, EMBASE, CINAHL, and PEDro) and unpublished (Global Health, EThOS, WorldCat dissertation and thesis, ClinicalTrials.gov , OpenAIRE, DART-Europe) evidence was electronically searched from database inception to 29 March 2022. Barriers and facilitators of weight bearing were extracted and synthesised into patient, process (non-surgical), process (surgical), and structure-related barriers/facilitators using a narrative review approach. RESULTS: In total, 5594 were identified from the primary search strategy, 1314 duplicates were removed, 3769 were excluded on title and abstract screening, and 442 were excluded on full-text screening. In total, 69 studies (all from published literature sources) detailing 47 barriers and/or facilitators of weight bearing were included. Of barriers/facilitators identified, 27 were patient-, 8 non-surgical process-, 8 surgical process-, and 4 structure-related. Patient facilitators included anticoagulant, home discharge, and aid at discharge. Barriers included preoperative dementia and delirium, postoperative delirium, pressure sores, indoor falls, ventilator dependence, haematocrit < 36%, systemic sepsis, and acute renal failure. Non-surgical process facilitators included early surgery, early mobilisation, complete medical co-management, in-hospital rehabilitation, and patient-recorded nurses' notes. Barriers included increased operative time and standardised hip fracture care. Surgical process facilitators favoured intramedullary fixations and arthroplasty over extramedullary fixation. Structure facilitators favoured more recent years and different healthcare systems. Barriers included pre-holiday surgery and admissions in the first quarter of the year. CONCLUSION: Most patient/surgery-related barriers/facilitators may inform future risk stratification. Future research should examine additional process/structure barriers and facilitators amenable to intervention. Furthermore, patient barriers/facilitators need to be investigated by replicating the studies identified and augmenting them with more specific details on weight bearing outcomes.

Demographic changes in primiparae of Irish ethnicity between 2000 and 2020.

BACKGROUND: Trends in maternal demographic changes linked to lifestyle and socio-economic conditions reflect greatly on maternal, perinatal and infant mortality rates. Hospital data reflect a heterogenous population where specific demographic changes may not be obvious. OBJECTIVES: To report yearly demographic changes in Irish primiparae from 2000 to 2020, specifically looking at age, BMI, smoking and marital status of patients attending the Coombe Women and Infant's University Hospital (CWIUH). METHODS: Retrospective report of demographic details contemporaneously documented on the CWIUH data base. FINDINGS: In the years 2000 to 2020 inclusive there were 47,659 primiparous women of Irish ethnicity delivered at the CWIUH (70.2% of the total primiparae), of those 99.3% were Caucasian. There was a significant rise in mean age at first delivery in Irish mothers; 26.0 years old in the 2000 to 30.9 years old in 2020 associated with a rise in mean BMI of 9.1%. Smoking rates (ever smoked) showed a significant reduction from 53.9% in 2000 to 39.3% in 2020. There was a significant decrease in rates of marriage, with 61.9% married in 2000 compared to 46.3% in 2020. Birth weight and prematurity rates remained unchanged, with fall in mean gestational age at first delivery from 279.3 days in 2000 to 275.8 days in 2020. CONCLUSION: This study highlights that Irish primiparae are older, heavier, less likely to smoke and to be married than they were 20 years ago. These trends are an interesting glimpse into changing economic and cultural climate over just the past 2 decades.

Prognostic factors of depression and depressive symptoms after hip fracture surgery: systematic review.

BACKGROUND: Patients with hip fracture and depression are less likely to recover functional ability. This review sought to identify prognostic factors of depression or depressive symptoms up to 1 year after hip fracture surgery in adults. This review also sought to describe proposed underlying mechanisms for their association with depression or depressive symptoms. METHODS: We searched for published (MEDLINE, Embase, PsychInfo, CINAHL and Web of Science Core Collection) and unpublished (OpenGrey, Greynet, BASE, conference proceedings) studies. We did not impose any date, geographical, or language limitations. Screening (Covidence), extraction (Checklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies, adapted for use with prognostic factors studies Checklist), and quality appraisal (Quality in Prognosis Studies tool) were completed in duplicate. Results were summarised narratively. RESULTS: In total, 37 prognostic factors were identified from 12 studies included in this review. The quality of the underlying evidence was poor, with all studies at high risk of bias in at least one domain. Most factors did not have a proposed mechanism for the association. Where factors were investigated by more than one study, the evidence was often conflicting. CONCLUSION: Due to conflicting and low quality of available evidence it is not possible to make clinical recommendations based on factors prognostic of depression or depressive symptoms after hip fracture. Further high-quality research investigating prognostic factors is warranted to inform future intervention and/or stratified approaches to care after hip fracture. TRIAL REGISTRATION: Prospero registration: CRD42019138690 .

Reconsidering fear of birth: Language matters.

Interest in fear of childbirth has grown exponentially since the 1980s, but the landscape of birth has shifted considerably since then, with evolving feminism; moving from a patriarchal environment in a biomedical model of care to a holistic model which recognizes the birth and sexuality rights of women and birthing people. Distinguishing the spectrum of fear from low to high and severe is important rather than aggregating all individuals with fear of childbirth. However, the terms 'fear of childbirth' and 'tocophobia' have been used interchangeably. In this paper we urge clinicians to use the term 'tocophobia' with caution since it may be construed negatively and there is a limited understanding of the underpinning aetiology of tocophobia. Furthermore, using the label may be disempowering for women and birthing people making decisions about their birth. Further research is warranted to better understand the experience, refine and define the issue and meet the individual needs of people with fear of childbirth and tocophobia.

Anakinra for recalcitrant pyoderma gangrenosum.

Pyoderma gangrenosum (PG) is an autoinflammatory neutrophilic dermatosis characterized by rapidly enlarging, painful ulcers. Anakinra is a recombinant interleukin (IL)-1 receptor antagonist that blocks the activity of IL-1α and IL-1ß by competitively inhibiting IL-1 binding to the IL-1 type 1 receptor. We present a series of two patients with recalcitrant PG, who had limited therapeutic options and multiple comorbidities and multiple previous treatment failures, who obtained 100% healing with anakinra. Compared with conventional first-line therapies for PG, the safety profile of anakinra may be preferable for patients with multiple comorbidities. Further research is needed to assess the safety and efficacy of anakinra for PG.

Bare necessities? The utility of full skin examination in the COVID-19 era.

Full skin examination (FSE) may improve the detection of malignant melanoma (MM). The objective of this study was to assess the safety of targeted lesion examination (TLE) compared with FSE in our Pigmented Lesion Clinic (PLC). Patients attending the PLC were randomized in a 2 : 1 ratio to FSE (intervention) or TLE (standard care). Demographic details and risk factors were documented, and the time taken to perform FSE and TLE was noted. Of 763 participants, 520 were assigned to FSE and 243 were assigned to TLE. On average, FSE took 4.02 min and TLE took 30 s to perform. Of the 520 participants assigned to FSE, 37 (7.1%) had incidental findings, of whom 12 patients (2.3%) had additional lesions biopsied. No additional melanomas were detected that would have been missed by use of the standard protocol. This study suggests that in low-risk patients referred to a PLC with a lesion of concern, the possibility of missing incidental cutaneous malignancies using lesion-directed examination is low.

Tokophobia and fear of birth: a workshop consensus statement on current issues and recommendations for future research.

Objective: To discuss and develop a statement on the current state of the evidence and opinion in Fear of Childbirth (FoC) and Tokophobia (Tocophobia), and to provide recommendations. Background: A group met in 2019 to discuss the state of clinical and academic knowledge relating to FoC/Tokophobia. Five key areas were agreed as the focus of the meeting. Methods: 12 internationally acknowledged experts, in this or a closely related area (e.g. PTSD) met to discuss their understanding of the evidence for FoC/ Tokophobia and current practice. The consensus described in this paper constitutes the expression of the general opinion of the participants and does not necessarily imply unanimity. Keys points: Work focussed on tokophobia is recent and there remains a wide range of issues, which were addressed in the workshop including complexity in defining prevalence, a theoretical lack of understanding, which creates challenge for robust assessment and the identification of risk factors. An improved aetiological and developmental understanding of the tokophobia is required to underpin appropriate, effective and evidence-based interventions. Evaluation of pathways of care and relevant interventions, should be a focus of future research. Conclusion: Significant gaps remain within the FoC/tokophobia knowledge base. Further research is necessary.

Investigating the role of hallucinatory experiences in the transition from suicidal thoughts to attempts.

OBJECTIVE: Psychotic experiences, including auditory hallucinatory experiences (HEs), are strongly associated with both suicidal thoughts and behaviour. This study examined their role in the ideation-to-attempt transition in adolescents, including their direct and indirect effect via potential mediators. METHOD: Participants were from an Australian prospective longitudinal cohort of 1669 adolescents (12-17 years); of which a subsample endorsing baseline suicidal ideation (n = 216) was the focus of most analyses. Suicidal thoughts and behaviours were measured using the Self-Harm Behaviour Questionnaire. The Diagnostic Interview Schedule for Children was used to assess auditory HEs. Potential mediators of interest were psychological distress and Interpersonal Theory of Suicide (IPTS) constructs. RESULTS: Among adolescents reporting suicidal ideation at baseline (n = 216), 6.5% had attempted suicide during follow-up. The size of auditory HEs' univariate effect suggests a possible strong relationship with increased risk of incident suicide attempts (OR = 2.40; 95%CI = 0.76-7.56); however, there was inadequate statistical power to produce a precise estimate. When HEs were accompanied by distress there was a nine-fold increased risk of acting on suicidal thoughts. Distress was independently associated with risk of attempt transition (OR = 4.09), whereas IPTS constructs were poor explanatory variables in most models. CONCLUSION: Adolescents with psychological distress and auditory HEs are at high risk of incident suicide attempts. Further investigations on the role of negative/distressing content of hallucinations in the ideation-to-attempt transition are warranted.

Experience of patients and practitioners with a team and technology approach to chronic back disorder management.

PURPOSE: Although rural and remote residents face general challenges accessing health care in comparison to urban dwellers, care for musculoskeletal conditions like chronic back disorders (CBD) is particularly challenging for rural and remote residents due to lack of access to physical yherapists. Telerehabilitation such as secure videoconferencing offers one solution to this disparity in rural care delivery, but incorporating the perspectives of health practitioners and patients is important when developing new sustainable care models. PATIENTS AND METHODS: This study investigated the experiences of practitioners and patients during a novel interprofessional model of assessment where an urban-based physical therapist used videoconferencing to virtually join a rural nurse practitioner and a rural patient with CBD. Patient surveys and semi-structured interviews of practitioners and patients were analyzed quantitatively and qualitatively. RESULTS: Most patients were "very satisfied" (62.1%) or "satisfied" (31.6%) with the overall experience, and "very" (63.1%) or "somewhat (36.9%) confident" with the assessment. Thematic analysis of interviews revealed that this novel assessment method identified: access to care for CBD, effective interprofessional practice, enhanced clinical care for CBD, and technology considerations. CONCLUSION: Patient satisfaction with the telerehabilitation model of care was high. Patients and practitioners reported their experiences were impacted by access to care, interprofessional practice, enhanced care for CBD and technology. These findings will be useful in the development of patient-centered models of care utilizing telehealth strategies.

Incidence of incisional hernias following single-incision versus traditional laparoscopic surgery: a meta-analysis.

PURPOSE: To compare, using a meta-analysis of randomized controlled trials, the risk of incisional hernia in patients undergoing single-incision laparoscopic surgery to those undergoing traditional laparoscopic surgery. METHODS: MEDLINE and EMBASE databases were searched. Randomized controlled trials comparing single-incision laparoscopic surgery to traditional laparoscopic surgery and which reported incisional hernias over a minimum 6-month follow-up period were eligible. Risk of bias was assessed as outlined in the Cochrane Handbook. Pooled odds ratios were calculated using RevMan. RESULTS: Of 309 identified studies, 22 were included in this meta-analysis. Pooled results showed higher odds of incisional hernia following single-incision laparoscopic surgery relative to traditional laparoscopic surgery (odds ratio 2.83, 95% CI 1.34-5.98, p = 0.006, I2 = 0%). There was no difference in the odds of incisional hernias requiring surgical repair (p = 0.10). Subgroup analysis found no difference in the odds of incisional hernias based on procedure type (p = 0.69) or method of follow-up (p = 0.85). The quality of evidence was determined to be moderate. CONCLUSION: Single-incision laparoscopic surgery is associated with a threefold increase in the odds of incisional hernia compared with traditional laparoscopic surgery.

Systematic review and meta-analysis: Efficacy of patented probiotic, VSL#3, in irritable bowel syndrome.

BACKGROUND: VSL#3 is a patented probiotic for which several clinical trials suggest benefits on motor function, bloating, and symptoms of irritable bowel syndrome (IBS). OBJECTIVES: To quantify effects of VSL#3 on abdominal pain, stool consistency, overall response, abdominal bloating, and quality of life (QOL) in IBS through meta-analysis. METHODS: MEDLINE (OvidSP and PubMed), EMBASE, Web of Science, and Scopus were searched up to May 2017. Using a fixed effects model, we pooled data from intention-to-treat analyses of randomized trials (RCTs) comparing VSL#3 to placebo in IBS. Data were reported as relative risk (RR), overall mean difference (MD), or standardized MD (SMD) with 95% confidence intervals (CI). Quality of evidence was rated using the GRADE approach. KEY RESULTS: Among 236 citations, 5 RCTs (243 patients) were included. No significant differences were observed for abdominal pain (SMD = -0.03; 95% CI -0.29 to 0.22), bloating (SMD = -0.15; 95% CI -0.40 to 0.11), proportion of bowel movements with normal consistency (overall MD = 0; 95% CI -0.09 to 0.08), or IBS-QOL (SMD = 0.08; 95% CI -0.22 to 0.39). VSL#3 was associated with a nearly statistically significant increase in overall response (RR = 1.39; 95% CI 0.99-1.98). CONCLUSIONS & INFERENCES: In this systematic review and meta-analysis, there was a trend toward improvement in overall response with VSL#3, but no clear evidence effectiveness for IBS. However, the number and sample sizes of the trials are small and the overall quality of evidence for 3 of the 5 outcomes was low. Larger trials evaluating validated endpoints in well-defined IBS patients are warranted.

Why are psychotic experiences associated with self-injurious thoughts and behaviours? A systematic review and critical appraisal of potential confounding and mediating factors.

Psychotic experiences (PEs), including hallucination- and delusion-like experiences, are robustly associated with self-injurious thoughts and behaviours (SITB) in the general population. However, it remains unclear as to why there is an association. The purpose of this systematic review was to elucidate the role of other factors that influence the association between PEs and SITB and, in doing so, highlight potential mechanisms underlying the relationship. A search of electronic international databases was undertaken, including PubMed, PsycINFO and EMBASE, and eligible studies were grouped according to seven confounder categories: sociodemographics, mental disorders, alcohol and substance use, environmental, psychological, intervention and family history/genetic factors. The systematic search strategy identified 41 publications reporting on 1 39 427 participants from 16 different countries. In the majority of studies, where adjustment for other variables occurred, the association between PEs and SITB persisted, suggesting PEs have an independent role. Common mental disorders, psychological distress and negative environmental exposures explained a substantial amount of the variance and therefore need to be considered as potential underlying mechanisms. There was high variability in the variables adjusted for in these studies, and so the question still remains as to whether the association between PEs and self-harm/suicidality can be attributed (fully or in part) to confounding and mediating factors or directly causal mechanisms. Regardless of causality, the now extensive literature reporting an association between these two clinical phenomena supports the broad usefulness of PEs as an indicator of risk for SITB.