Expense for Clinical Documentation of Inpatients: Extent and Hierarchal Differences for the Example of a Gynaecological Department in Switzerland.

Introduction: The majority of physicians consider administrative tasks to be a burden. The present questionnaire is intended to clarify the expense of time for documentation tasks in the treatment of inpatients in a gynaecological department of a Swiss hospital and to what extent differences occur between senior physicians and junior physicians. Materials and Methods: For three weeks physicians in the gynaecological department of a central Swiss hospital documented minute for minute predefined tasks during their duty periods. A questionnaire in tabular form served as survey instrument for this working time analysis. The minute for minute details for the individual participants were summed for each clinical task listed in the questionnaire in order to subsequently calculate the amounts of time spent for the respective task categories and to subject them to a subgroup analysis. Results: The participation rate of the physicians amounted to 87 %. 287 questionnaires were included in the evaluation. According to the responses, 25 % of the clinical working time for inpatients was used for documentation of clinical tasks. The subgroup analysis revealed a higher proportion for assistant physicians (30 %) than for senior physicians (18 %). Discussion: The present working time analysis reveals an unfavourable ratio between surgical and administrative tasks between junior and senior physicians. In addition there is a danger that the true burden for junior physicians is underestimated by their superiors due to hierarchal differences.

Prevention of preterm delivery with vaginal progesterone in women with preterm labour (4P): randomised double-blind placebo-controlled trial.

OBJECTIVE: To evaluate the effectiveness of 200 mg of daily vaginal natural progesterone to prevent preterm birth in women with preterm labour. DESIGN: Multicentre, randomised, double-blind, placebo-controlled trial. SETTING: Twenty-nine centres in Switzerland and Argentina. POPULATION: A total of 385 women with preterm labour (24(0/7) to 33(6/7) weeks of gestation) treated with acute tocolysis. METHODS: Participants were randomly allocated to either 200 mg daily of self-administered vaginal progesterone or placebo within 48 hours of starting acute tocolysis. MAIN OUTCOME MEASURES: Primary outcome was delivery before 37 weeks of gestation. Secondary outcomes were delivery before 32 and 34 weeks, adverse effects, duration of tocolysis, re-admissions for preterm labour, length of hospital stay, and neonatal morbidity and mortality. The study was ended prematurely based on results of the intermediate analysis. RESULTS: Preterm birth occurred in 42.5% of women in the progesterone group versus 35.5% in the placebo group (relative risk [RR] 1.2; 95% confidence interval [95% CI] 0.93-1.5). Delivery at <32 and <34 weeks did not differ between the two groups (12.9 versus 9.7%; [RR 1.3; 95% CI 0.7-2.5] and 19.7 versus 12.9% [RR 1.5; 95% CI 0.9-2.4], respectively). The duration of tocolysis, hospitalisation, and recurrence of preterm labour were comparable between groups. Neonatal morbidity occurred in 44 (22.8%) cases on progesterone versus 35 (18.8%) cases on placebo (RR: 1.2; 95% CI 0.82-1.8), whereas there were 4 (2%) neonatal deaths in each study group. CONCLUSION: There is no evidence that the daily administration of 200 mg vaginal progesterone decreases preterm birth or improves neonatal outcome in women with preterm labour.

Spontaneous rupture of an adrenal artery in pregnancy: a case report.

A spontaneous rupture of an adrenal artery is a rare cause of abdominal pain in pregnancy. We present a case of a pregnant woman who needed to be operated on because of a rupture of the right adrenal artery associated with a fetal bradycardia. An immediate caesarean section was performed. The intra-abdominal palpation identified an extensive retroperitoneal mass near the right kidney and a postoperative computer tomography confirmed an active bleeding near the kidney. For this reason our interventional radiology team, using a right femoral artery approach, performed a flush aortogram and identified the source of bleeding in the right adrenal artery. After two attempts, a coiling of the artery stopped the haemorrhage. The pathogenesis of arterial haemorrhage is still poorly understood although a possible cause could be the excess of hormones during pregnancy, which can lead to a significant arterial wall degeneration. In case of a retroperitoneal bleeding and if the patient is still haemodynamically stable, a transcatheter embolization using microcoils must be considered. This technique is nowadays safe and effective and can be performed within a short time with a lower risk of complications.

Chylomicronemia Syndrome in Pregnancy: a Case Report of an Acute Necrotizing Pancreatitis.

Introduction: Chylomicronemia syndrome (CS) is a rare disorder characterized by a high level of triglycerides in plasma. We present a case of a pregnant woman with a severe acute pancreatitis (AP) affected by a CS. Case: A 38-year-old gravida 2, para 0 with an uneventful course of pregnancy was referred with an AP at 37 0/7 weeks of gestation. This diagnosis was made from a nearby hospital where the chemical analysis showed elevated pancreatic enzymes with significant hypertriglyceridemia. Because of a pathological fetal heart tracing a caesarean delivery was performed. The APGAR score of the female newborn was 5/8/8 at 1, 5 and 10 minutes, respectively. The pH from the umbilical cord were 7.26 (artery) and 7.59 (vein). Once transferred to our intensive care unit a computer tomography scan confirmed an onset of a necrotizing AP. A conservative treatment was tried without success. For this reason a surgical debridement of the infected and necrosic parts was performed. After a long hospitalisation the patient could be dismissed after 2.5 months in good general condition. Discussion: Lipid profile changes in normal pregnancy are characterized by an elevation of total plasma cholesterol and triglyceride levels. This is normally caused by an increased liver synthesis of triglycerides in response to elevated estrogen levels. When a CS is diagnosed the main goal is to maintain fasting triglyceride levels at less than 500 mg/dL to reduce the risk for AP. Conclusion: Practitioners have an important role in evaluating chylomicronemic patients and implementing therapeutic lifestyle and pharmaceutic interventions aimed to reduce the risk for AP.

Pregnancy-associated spontaneous coronary artery dissection: impact of medical treatment. Case report and systematic review.

We report on a 22- year-old woman with postpartum dissection of the left anterior descending artery and the intermediate branch. The patient was treated with acetylsalicylic acid (ASA), clopidogrel, and betablocker only. Coronary angiography performed 20 months later revealed complete resolution of the dissection sites. The patient's cardiovascular risk factors included mild smoking and high total cholesterol and low-density-lipoprotein-cholesterol levels, which showed a marked fall after pregnancy without pharmacological cholesterol-modifying therapy raising the question whether pregnancy-related hypercholesterolemia contributed to the pathogenesis of pregnancy-associated spontaneous coronary artery dissection (P-SCAD). In a systematic review of the literature, 16 women [median age 34 (31-36.5) years] with P-SCAD and angiographic follow-up were identified. The majority (69%) of P-SCAD cases occurred postpartum [median time after delivery: 13 (7-21) days]. In 10/16 (63%) patients medical treatment including betablocker and antiplatelet therapy was given leading to complete resolution of the dissection in 5 of them (31% of all patients) at follow-up, whereas in the other 5 patients the dissections were persisting or even progressive. Of the medically treated patients, 80% were free of symptoms suggestive for ischemia at follow-up. In 5/16 patients percutaneous coronary intervention (PCI) was performed as first-line therapy. Three patients underwent coronary artery bypass grafting, which was performed primarily in one patient, and secondarily in two patients with persisting dissections and ongoing ischemic symptoms after previous medical treatment or PCI without stenting, respectively. In conclusion, medical treatment including ASA, clopidogrel and betablocker therapy results in an excellent clinical and angiographic result in approximately one third of patients with P-SCAD.

[Selfmedication during pregnancy]. / Selbstmedikation in der Schwangerschaft.

A growing publicity drives the growing market of OTC, also in pregnancy. A short overview from this giant market, composed of pharmaceutical drugs, herbal medicines and homeopathic medicaments for a selection of frequent health problems in pregnancy is presented.

[Is continuing medical education under suspicion of corruption? Contribution to the discussion by the Committee for Quality Preservation of the Swiss Society of Gynaecology and Obstetrics]. / Arztliche Fortbildung unter Korruptionsverdacht?. Diskussionsbeitrag der Kommission Qualitätssicherung der Schweizerischen Gesellschaft für Gynäkologie und Geburtshilfe.

The requirements laid down by law and by the medical profession itself with regard to continuing medical education have recently been tightened. The cost of good training is high, both in time and money. Sponsoring, especially by the pharmaceutical industry, has helped to keep costs down for individual participants. The question of a tariff system for the payment of compulsory training is now being raised. Rates have been set to ensure that, in the future, indirect costs are covered. In the event of a full tariff-based payment of costs being introduced, various disadvantages could be expected both for participants and the quality of the training. Changes in Swiss criminal law and the new medicines act do not forbid sponsoring, but they do call for rules of professional ethics and of personnel law in public hospitals governing behaviour in respect of funding by sponsors. Various sponsoring models are conceivable with differences in allocation to organizers, individual participants or distribution via a pool system. There are strong arguments in favour of continuing the existing practice of mixed funding by participants and sponsoring, provided that it is subject to certain rules of transparency. What is lacking to date is a political decision on the issue of funding for continuing medical education.

[Symposium "Prenatal diagnosis--clinical practice and counseling]. / Symposium "Pränataldiagnostik--Praxis und Beratung".

The growing demand for prenatal diagnosis appears to be making these technologies an increasingly normal part of care in pregnancy. Nevertheless, and in spite of an expanding lay literature on the subject, every expectant mother has an undiminished need for personal information and counselling by her physician. At a symposium staged by the Gynecological Clinic, St. Gall, on 1 April 1995 several experts highlighted the technical, ethical and psychological aspects of prenatal diagnosis as well as the practical problems involved in the counselling and care of women and couples in the prenatal situation.

[Midwives in Switzerland: a study of the work and recruitment status]. / Hebammen in der Schweiz: Eine Untersuchung zur Arbeits- und Nachwuchssituation.

The aim of this study was an analysis of the working conditions for midwives in- and outside of obstetric clinics. The study is based on a representative survey carried out among Swiss midwives in 1991 and on statistics of the Swiss Red Cross and the Swiss Federal Statistical Office. It could be shown that there is a high degree of professional satisfaction especially among midwives working on their own; of the negative aspects, the irregular work load and an inadequate income were among the most often named problems. Recruitment problems were evident, as there is a clear lack between the available places in the Swiss schools for midwifery and the need for midwives in this country, at least during periods of a relatively favorable economic situation.

[Management of mono-amnion twin pregnancy]. / Management monoamnioter Zwillingsschwangerschaften.

There have been only a few reports on monoamniotic twin pregnancies from the period of modern perinatology. Consequently, available recommendations about the management of these high-risk pregnancies are uncertain. In this study, we present the management and the outcome of three monoamniotic twin pregnancies and two further pregnancies with acardiac acephalus twin in comparison to other case reports and case series from the literature. Practical ways of caring for these high-risk pregnancies are outlined, emphasising the continuous search for entanglement of umbilical cord by ultrasound and cardiotocography. The special importance of intensified cardiotocographic monitoring is demonstrated.

[Magnesium sulfate 4% xylitol infusions solution for the treatment of hypertensive disorders in pregnancy]. / Magnesiumsulfat-4%-Xylitol-Infusionslösung zur Behandlung von hypertensiven Erkrankungen in der Schwangerschaft (HES).

A new magnesium sulphate solution with xylitol for the management of hypertensive disorders during pregnancy has been described. The solution contains 40 g MgSO4 and 16 g xylit in 1000 ml and is isoosmotic with blood serum. It can be sterilised for 15 min. at 121 degrees C without risk of decomposition of the ingredients during and after autoclaving. The solution has been proved in the clinical practice.

[The "HELLP syndrome" without fragmentocytes: do drug-induced antibodies play a role?]. / "HELLP-Syndrom" ohne Fragmentozyten: Spielen medikamenteninduzierte Antikörper eine Rolle?

This is a case report on a nulliparous women, who developed the HELLP syndrome following intravenous tocolysis. Contrary to our expectations, neither schistocytes nor signs of intravasal coagulation were apparent; however, we found Fenoterol-associated anti-erythrocyte antibodies. However, the low titre of these antibodies does not explain the massive haemolysis. It is suggested, that these antibodies represent a causal factor in developing the HELLP syndrome.

[Pregnancy and delivery in a mother with Ebstein's anomaly]. / Schwangerschaft und Entbindung bei einer Mutter mit Ebsteinscher Anomalie.

Ebstein's anomaly is characterized by abnormalities both in the basal and in the free attachments of the leaflets of the tricuspid valve. Fairly frequently the developmental defect is associated with a WPW syndrome (Type B). The main obstetric problems arise from tachyarrhythmias. Since tachycardias in these patients are due to physical stress, correct planning of delivery calls for lightening of the hemodynamic burden of labor, careful analysis of the cardiac status, meticulous preparation for optimum antiarrhythmic therapy and correct timing for induction of labor. The case of a young primipara with Ebstein's anomaly is presented to typify the need for cooperation of subspecialities.

[Doppler ultrasound studies before and following short-term maternal stress in late pregnancy]. / Doppler-sonographische Untersuchungen vor und nach mütterlicher Kurzzeitbelastung in der Spätschwangerschaft.

Ten gravidae with normal course of pregnancy in the third trimester underwent a bicycle stress test (semi-supine, 75 W, 3 min). By means of pulsed Doppler sonography, a lowering of the resistance index (RI) in the maternal femoral artery from 93% to 69% was ascertained, though also a rise in maximum systolic velocity (VMAX (syst)) from 73 cm/sec to 194 cm/sec, in maximum diastolic velocity (VMAX diast)) from 5 cm/sec to 61 cm/sec, and in the time-averaged maximum velocity (TAVMAX) from 20 cm/sec to 101 cm/sec. These changes are statistically significant. In the maternal common carotid artery these parameters remained stable or changed little, for example VMAX (diast), which dropped from 24 cm/sec before to 19 cm/sec after exercise, and the RI, which rose from 77% to 84%. Neither in the uteroplacental vessels nor in the umbilical artery were any changes in the RI found (40% to 42% and 58% to 57%, respectively). The fetal cardiotachograms were normal in all cases, while not all cases manifested a rise in fetal heart rate following maternal stress. These results indicate that uteroplacental perfusion and the umbilical circulation remain constant. Doppler sonography thus demonstrates directly and noninvasively that provided placental function is normal the uteroplacental and fetoplacental circulation are not influenced by moderate physical exertion.

Human calcitonin stimulates salivary amylase output in man.

Salivary amylase output in man increases after injection of synthetic human calcitonin. This effect is dose dependent.

[Calcitonin and salivary gland amylase secretion in vivo and in vitro. Preliminary report]. / Calcitonin und Speicheldrüsen-Amylase-sekretion in vivo und in vitro

Synthetic human calcitonin stimulates amylase secretion of salivary glands in man. The same effect has been demonstrated in isolated cells of rat salivary glands. In vitro experiments suggest that the stimulatory effect is a direct action of calcitonin on salivary cells. Salivary secretion is not affected by pancreozymin or secretin. Our findings afford another example of the difference in secretory behaviour between salivary glands and pancreas.