Burden of disease from shingles and post-herpetic neuralgia in the over 80 year olds in the UK.

BACKGROUND: The current UK vaccination programme for herpes zoster (HZ) excludes people aged ≥80 years. This study aimed to quantify the number of individuals ≥80 years who missed HZ vaccination and the consequent epidemiological and economic burden of HZ and post-herpetic neuralgia (PHN). METHODS: Immunocompetent individuals aged ≥80 years between 1st September 2013 and 31st December 2017 in the Clinical Practice Research Datalink were selected and linked to Hospital Episodes Statistics, where available. Rates of HZ and PHN and healthcare resource utilisation were investigated for the overall study population and by age group (80-84, 85-89, ≥90 years old) and the burden of HZ and PHN was projected to the UK population. RESULTS: 4,858 HZ episodes and 464 PHN cases were identified in 255,165 individuals over 576,421 person-years (PY). Rates of HZ and PHN were 8.43 (95% confidence interval [CI] 8.19-8.66) and 0.80 (0.73-0.87) per 1,000 PY respectively and lowest in those aged ≥90 (HZ rate 7.37/1,000 PY; PHN rate 0.56/1,000 PY). Within HZ episodes, 10.27% of GP visits, 5.82% of prescribed medications and 21.65% of hospitalisations were related to HZ/PHN. Median length of hospitalisation increased from 7.0 days for all-cause to 10.5 days for HZ/PHN related hospitalisations. Individuals ≥90 stayed in hospital a median of 3-4 days longer than younger groups. Approximately 2.23 million individuals in the UK missed HZ vaccination since 2013 (1.86 million had never been eligible and 365,000 lost eligibility for HZ vaccination), resulting in an estimated 43,149 HZ episodes. CONCLUSION: This study highlights the impact of the 80-year upper age limit policy on the health system. Our study estimates that 2.23 million individuals in the UK may have lost the opportunity to be vaccinated and that their burden of HZ and PHN remains high, especially among the very elderly.

Mode of Delivery Does Not Influence Postpartum Hypercoagulability Measured by Thrombin Generation or Thromboelastometry.

Introduction Venous thromboembolism (VTE) is a significant cause of maternal mortality with the greatest risk postpartum. Mode of delivery influences VTE risk, with emergency caesarean section (CS) associated with the highest risk (CS). Thromboprophylaxis is recommended for selected women to reduce the risk of VTE. We aimed to investigate the impact of mode of delivery and thromboprophylaxis on hypercoagulability as measured by thromboelastometry (TEM) and thrombin generation (TG) in women at high VTE risk. Materials and Methods Blood was collected from 99 pregnant women with VTE risk factors at up to five time points from pre- (T1) and post (T2)-delivery to 6 weeks postpartum (T5). Multiple linear regression was utilised to compare TG and TEM between those with vaginal delivery (VD) and CS at each time point. Paired sample t -test with post hoc Bonferroni correction was utilised to compare laboratory markers over time. Results Women in both groups had a median of three postpartum VTE risk factors, with higher body mass index and parity post-VD. In both the groups, TG and TEM parameters suggested hypercoagulability at T2 compared with T1, with resolution at T5. There were minimal differences between groups, apart from T2 with shorter clot formation time and higher maximum clot firmness in the VD group. Conclusion TG and TEM illustrate hypercoagulability associated with pregnancy and delivery. The pattern of postpartum hypercoagulability seen in women with VTE risk factors was similar irrespective of mode of delivery. Further research is required to establish the effect of labour on TG/TEM in the absence of low molecular weight heparin use.

Women's views, adherence and experience with postnatal thromboprophylaxis.

INTRODUCTION: Based on current guidelines, many women qualify for postnatal thromboprophylaxis following childbirth, however, little information exists on how adherent women are and their experiences to both pharmacological and mechanical forms of thromboprophylaxis. MATERIALS AND METHODS: Women requiring postnatal thromboprophylaxis were given questionnaire packs exploring their beliefs about enoxaparin, anti-embolic stockings (AES) and intermittent pneumatic compression devices (IPCD). Women were also asked to complete a diary recording when doses of enoxaparin were injected, along with an estimation of the number of hours the AES were worn each day, if at all. Results were entered onto SPSS and analysed. RESULTS: Sixty-seven women completed the questionnaire packs. Adherence to enoxaparin therapy was relatively high (82.4%). Women self-reported sub-optimal adherence levels to the AES, with 24% stating they never wore them once home. Reasons for this included being mobile, feeling hot and feeling as if they were cutting circulation off in the legs. Women reported a high level of acceptance of IPCD post caesarean section and would be happy for IPCD to be applied again in future deliveries, if required. CONCLUSIONS: Although many women are adherent to postnatal TP, our findings suggest that adherence to AES is sub-optimal following discharge from hospital and therefore their usefulness is questionable. Front-line clinical staff should discuss the importance of adherence to postnatal TP, in order to avert preventable venous thromboembolic events.

The prevention of pregnancy-related venous thromboembolism.

Pregnancy-related venous thromboembolism (VTE) remains one of the leading causes of maternal mortality and morbidity in the developed world. There is a lack of high-level data surrounding the use of thromboprophylaxis in pregnancy. In the UK, following the publication of the first Royal College of Obstetricians and Gynaecologists (RCOG) guideline for VTE prophylaxis during pregnancy and the puerperium in 2004, a fall in maternal deaths secondary to VTE was observed during the subsequent triennium (2006-2008). For the first time since 1985, VTE was no longer the most common cause of maternal death. Low-molecular-weight-heparin (LMWH) is generally the agent of choice for thromboprophylaxis in this setting, and is considered safe and efficacious. The accurate risk stratification of women in order to allow the targeted provision of thromboprophylaxis is challenging. A number of international guidelines support risk assessment for pregnancy-related VTE and the provision of LMWH for those who are deemed at sufficiently high risk. This review describes the importance of VTE in pregnancy and the puerperium, the part played by different risk factors and the role of thromboprophylaxis in this group of patients.

Evaluation of healthcare professionals' understanding of eponymous maneuvers and mnemonics in emergency obstetric care provision.

OBJECTIVE: To evaluate whether eponymous maneuvers and mnemonics taught for the management of shoulder dystocia, vaginal breech delivery, and uterine inversion were remembered and understood in practice. METHODS: A questionnaire was distributed to obstetricians and midwives collecting information about the HELPERR and PALE SISTER mnemonics. Three extended matching questions evaluated participants' knowledge of the correct maneuvers, with their matching eponyms, used in the management of shoulder dystocia, vaginal breech delivery, and uterine inversion. RESULTS: Of the 112 participants, 90% were familiar with the HELPERR mnemonic, with 79% using it in their practice. Of those who used it, only 32% could correctly decipher it (P = 0.032). PALE SISTER was mostly unfamiliar. The percentages of correct maneuvers used for managing shoulder dystocia, breech delivery, and uterine inversion were 84.6%, 58.3%, and 28.6%, respectively. However, the eponyms were correctly matched to their maneuvers in only 33.3%, 14.3%, and 0% of cases, respectively (P < 0.01). CONCLUSION: The meanings of the mnemonics for obstetric emergencies were frequently recalled incorrectly. This, together with the poor correlation between knowledge of maneuvers and their eponyms, limits their usefulness and indicates that teaching should focus on learning without relying on mnemonics and eponyms.