Updates on thyroid disorders in pregnancy and the postpartum period.

ABSTRACT: NPs play a pivotal role in caring for pregnant people. This article provides an overview of gestational and postpartum thyroid disorders, including their assessment, management, and indications for referral. The goal of this article is to help providers better assess and manage thyroid disorders during pregnancy and improve patient outcomes.

Implementing routine use of self-removed ureteric stents on extraction strings: prospective patient-reported outcome measures and complications.

PURPOSE: Ureteric stents placed after ureteroscopy typically require cystoscopy for removal. Stent extraction strings allow the option of patient self-removal. This facilitates shorter stent dwell time, and cost-savings. Concerns regarding safety and limited evidence regarding patient acceptability are speculated reasons for infrequent clinical use of extraction strings. This study investigates our recent experience using routine self-removal of stents on extraction strings to provide evidence to address these concerns. METHODS: In February 2020, our hospital adopted a policy for self-removal of stents on extraction strings to be routine following ureteroscopy. This was influenced by motivation to improve service capacity for diagnostic flexible cystoscopy, hospital avoidance during the pandemic, perceived improvement for the patient experience, and cost-saving. Prospective clinical and patient-reported outcome data were collected and evaluated. RESULTS: There were 168 patients who had stents on extraction strings. Mean stent dwell time was 5.2 ± 1.8 days. Primary ureteroscopy was performed in 40.5%, and 59.5% had procedures using an access sheath. Self-removal at home was successful for 79% of patients. Stent dislodgement rate was 3.0% (5/168) and retained stents due to string detachment occurred in 1.8% (3/168). Almost all indicated they "would remove the stent on string again" (90%, 128/142) and the majority reported stent removal as "very easy" (61%, 87/142). Cost modelling estimates a total saving of AUD $148,869 per annum for routine use of extraction strings at our hospital. CONCLUSION: Our experience reflects that stent extraction strings may be used routinely with acceptable low complication rates, favourable patient experiences and associated cost savings.

Effectiveness and safety of inpatient versus extended venous thromboembolism (VTE) prophylaxis with heparin following major pelvic surgery for malignancy: protocol for a systematic review.

BACKGROUND: Venous thromboembolism (VTE) is a common postoperative complication associated with significant morbidity and mortality. The use of prophylactic heparin postoperatively reduces this risk, and the use of extended duration prophylaxis is becoming increasingly common. Malignancy and pelvic surgery both independently further increase the risk of postoperative VTE and patients undergoing major pelvic surgery for malignancy are at particularly high risk of VTE. However, the optimum duration of prophylaxis specifically in this population currently remains unclear. METHODS: We will conduct a systematic review of literature in accordance with the Cochrane Handbook for Systematic Reviews of Interventions (Higgins JPT, Green S. Cochrane Handbook for Systematic Reviews of Interventions version 5.1.0.,2011) to evaluate current evidence of the effectiveness and safety of inpatient versus extended VTE prophylaxis with heparin (all forms) following major pelvic surgery for malignancy. We will search PubMed, EMBASE, and the Cochrane Library. Regarding safety, Food and Drug Administration (FDA), and Therapeutic Goods Administration (TGA) websites will be searched, including all levels of evidence. Results will be the postoperative timeframe in which a VTE event can be considered to have been provoked by the surgery, and the number of patients needed to treat with both inpatient and extended prophylaxis to prevent a VTE event in this timeframe, comparing these to determine if there is a significant benefit from extended prophylaxis. DISCUSSION: This systematic review will aim to identify the postoperative period in which patients undergoing major pelvic surgery for malignancy are at further increased risk of VTE as a result of their surgery and the optimum duration of heparin VTE prophylaxis with heparin to reduce this risk. Determining this will allow evidence-based recommendations to be made for the optimum duration of heparin VTE prophylaxis post major pelvic surgery for malignancy, leading to improved standards of care that are consistent between different providers and institutions. SYSTEMATIC REVIEW REGISTRATION: In accordance with guidelines, our systematic review was submitted to PROSPERO for consideration of registration on 16/12/17 and was registered on 12/1/18 with the registration number CRD42018068961 , and it was last updated on December 1, 2018.

Fournier's gangrene: not as lethal as previously thought? A case series.

BACKGROUND: Fournier's gangrene (FG) is a necrotizing fasciitis involving the perineum, external genitalia or perianal area. A rare condition with a historically high mortality rate (20-40%), our objective was to provide an up to date mortality rate for patients treated with multimodal therapy in a tertiary referral centre. METHODS: A retrospective review of a prospective database of FG patients treated at our tertiary referral centre was conducted. The primary end point was survival. Secondary end points included total hospital and intensive care unit (ICU) length of stay (LOS), number and type of procedures as well as considering co-morbidities at presentation as potential predisposing factor. Results were compared to those in current literature. RESULTS: Between 2012 and 2017, 15 patients were diagnosed with FG at our tertiary referral centre. One was excluded as decision to palliate was made at presentation. Of the remaining 14 patients, 13 survived representing a mortality rate of 7%. In surviving patients, total LOS was between 10 and 71 days, with a mean LOS of 36 days and median LOS of 34 days. Eight required ICU with ICU LOS between 1 and 42 days, with a mean of 10 and median of 4. Number of debridement procedures ranged from 3 to 17 with a mean and median of 6. Six patients required adjunctive procedures and 10 required reconstructive procedures. CONCLUSION: While a prolonged admission and multiple operations are expected, early diagnosis and aggressive multimodal treatment may result in a significantly better survival outcome than those quoted in previous literature.

Clostridium difficile multidisciplinary team root cause analysis: impact on clinical care and circumvention of financial penalties posed by clinical commissioning groups, but at what cost?

BACKGROUND: In Hampshire Hospitals NHS Foundation Trust, in addition to an on-the-spot investigation into hospital-onset Clostridium difficile infection (CDI) by the infection prevention team, a multidisciplinary team root cause analysis (MDT-RCA) forum has been developed. The MDT-RCA aims to deliver a more thorough investigation into individual cases and the recommendation of cases to the clinical commissioning groups (CCG) appeals panel against potential financial penalties (£10,000 per breached case). We mainly aimed to investigate the financial impact of MDT-RCAs to the Trust. METHODOLOGY: Over two years, 84 cases of hospital-onset CDI cases were reviewed by the MDT-RCA forum. RESULTS: Among this cohort, no additional learning outcomes were identified by the MDT-RCAs over those that were found by on-the-spot investigations. In total, 543 staff members attended the MDT-RCAs at a potential cost to the Trust of £23,795.74-£51,670.10. The Trust appealed against financial penalties for 27 cases and 14 were successful, i.e. £140,000 would have been avoided had targets been breached by 14 cases. However, targets were only breached by two cases, meaning only £20,000 in fines was avoided. Deducting this from the total costs of the MDT-RCA meant the Trust lost £3,795.74-£31,670.10. CONCLUSION: Over the two years reviewed, the MDT-RCA proved to be costly to the Trust, with no additional learning or quality improvement measures identified.

Can rapid negative exclusion of blood cultures by a molecular method, enzyme template generation and amplification technique (Cognitor® Minus), aid antimicrobial stewardship?

OBJECTIVES: Antimicrobial review is an important part of antimicrobial stewardship. A novel enzyme template generation and amplification technique (ETGA), the Cognitor® Minus (Momentum Bioscience, Long Hanborough, UK) test, has a 99.5% negative predictive value for bacteraemia and fungaemia. This observational study asked two questions: (1) Does a negative ETGA, indicating no bacteraemia or fungaemia, aid antimicrobial review within 48 h of admission; (2) In this real-life clinical setting, does a negative ETGA mean no bacteraemia or fungaemia? METHODS: Consecutive blood cultures in patients with clinical infection were tested by ETGA. Negative results indicating an absence of bacteraemia or fungaemia were reviewed by the clinical infection team. Antibiotics were reviewed in these patients, and the role of the ETGA result in antibiotic change was recorded. Patients were followed up for a week. KEY FINDINGS: A total of 197 of 246 samples gave a negative result by ETGA. This led to a positive stewardship outcome (antimicrobials changed) in 145 (73.6%) and negative stewardship outcome (empirical antimicrobials continued) in 47 (23.9%). Of the positive stewardship outcomes, the ETGA result supported the decision not to start antimicrobials in 21 (10.7%) patients, to stop antimicrobials in 21 (10.7%), to switch from IV to oral antimicrobials in 103 (52.2%) or to discharge or leave the patient at home in 58 cases (29.4%). CONCLUSIONS: Enzyme template generation and amplification supports antimicrobial stewardship decisions and may have cost advantages in reducing unnecessary empirical antibiotics and antifungal agents and in discharging patients from hospital earlier. ETGA result was consistent with blood culture findings and gave an earlier negative result.

Electronic prescribing system design priorities for antimicrobial stewardship: a cross-sectional survey of 142 UK infection specialists.

Background: The implementation of electronic prescribing and medication administration (EPMA) systems is a priority for hospitals and a potential component of antimicrobial stewardship (AMS). Objectives: To identify software features within EPMA systems that could potentially facilitate AMS and to survey practising UK infection specialist healthcare professionals in order to assign priority to these software features. Methods: A questionnaire was developed using nominal group technique and transmitted via email links through professional networks. The questionnaire collected demographic data, information on priority areas and anticipated impact of EPMA. Responses from different respondent groups were compared using the Mann-Whitney U -test. Results: Responses were received from 164 individuals (142 analysable). Respondents were predominantly specialist infection pharmacists (48%) or medical microbiologists (37%). Of the pharmacists, 59% had experience of EPMA in their hospitals compared with 35% of microbiologists. Pharmacists assigned higher priority to indication prompt ( P < 0.001), allergy checker ( P = 0.003), treatment protocols ( P = 0.003), drug-indication mismatch alerts ( P = 0.031) and prolonged course alerts ( P = 0.041) and lower priority to a dose checker for adults ( P = 0.02) and an interaction checker ( P < 0.05) than microbiologists. A 'soft stop' functionality was rated essential or high priority by 89% of respondents. Potential EPMA software features were expected to have the greatest impact on stewardship, treatment efficacy and patient safety outcomes with lowest impact on Clostridium difficile infection, antimicrobial resistance and drug expenditure. Conclusions: The survey demonstrates key differences in health professionals' opinions of potential healthcare benefits of EPMA, but a consensus of anticipated positive impact on patient safety and AMS.

Increased epidermal growth factor receptor gene copy number is associated with poor prognosis in head and neck squamous cell carcinomas.

PURPOSE: High epidermal growth factor receptor (EGFR) gene copy number is associated with poor prognosis in lung cancer, but such findings have not been reported for HNSCC. A better understanding of the EGFR pathway may improve the use of EGFR inhibitors in HNSCC. PATIENTS AND METHODS: EGFR status was analyzed in 86 tumor samples from 82 HNSCC patients by fluorescent in situ hybridization (FISH) to determine EGFR gene copy number, by polymerase chain reaction and direct sequencing for activating mutations, and by DNA microarray and immunohistochemistry for RNA and protein expression. The results were associated with patient characteristics and clinical end points. RESULTS: Forty-three (58%) of 75 samples with FISH results demonstrated EGFR high polysomy and/or gene amplification (FISH positive). The FISH-positive group did not differ from the FISH-negative group with respect to age, sex, race, tumor grade, subsites and stage, or EGFR expression by analyses of RNA or protein. No activating EGFR mutations were found. However, the FISH-positive group was associated with worse progression-free and overall survival (P < .05 and P < .01, respectively; log-rank test). When microarray data were interrogated using the FISH results as a supervising parameter, ECop (which is known to coamplify with EGFR and regulate nuclear factor-kappa B transcriptional activity) had higher expression in FISH-positive tumors. CONCLUSION: High EGFR gene copy number by FISH is frequent in HNSCC and is a poor prognostic indicator. Additional investigation is indicated to determine the biologic significance and implications for EGFR inhibitor therapies in HNSCC.