Self-reported alcohol consumption in doctors.

BACKGROUND: The UK government has prioritized reducing the harmful effects of excessive alcohol consumption on mental and physical well-being. AIMS: To assess self-reported alcohol consumption amongst doctors at an acute London Trust. METHODS: An opportunistic, anonymous, survey was conducted by Postgraduate Education Fellows over 2 weeks in December 2018. This included all grades of doctors from Foundation Year One to Consultant. The survey consisted of nine questions, modified from the alcohol use disorders identification test (AUDIT) and CAGE questionnaire. RESULTS: Of 446 doctors within our institution, 109 completed the survey (24%). Fourteen per cent of those surveyed abstained from alcohol, 21% drank monthly or less, 31% drank between two to four times per month, 25% drank two to three times per week and 9% drank greater than four times per week. In the preceding 2 years, 9% reported being unable to do what was expected of them on at least one occasion due to alcohol. Five per cent were concerned about alcohol affecting their performance. Two per cent were annoyed by criticism of their drinking, 9% felt guilty about drinking and 4% needed an eye-opener. Eighteen per cent wanted to reduce their alcohol consumption; however, 43% of the 109 doctors surveyed were uncertain where to seek help. CONCLUSIONS: Twenty per cent of surveyed doctors reported consuming potentially hazardous levels of alcohol and 18% of respondents wanted to cut down. Forty-three per cent were unaware of sources of support. Our findings suggest a role for collaboration between Occupational Health departments and Postgraduate Education teams to support doctors misusing alcohol.

Venous thromboprophylaxis in pregnancy: the implications of changing to the 2010 RCOG guidelines.

The latest Confidential Enquiry into Maternal Deaths (2006-2008) shows that venous thromboembolism (VTE) is now the third leading cause of direct maternal mortality, behind sepsis and hypertension. This is likely to be because of improved risk assessment of patients and adequate thromboprophylaxis both antenatally and postnatally. Given the importance of this area, compliance with the departmental VTE guidelines (which were based on previous RCOG guidelines) was reviewed prior to transferring to a revised guideline based on the recent RCOG guideline (2010). The results obtained highlighted the difficulties in achieving good VTE risk assessment, with only 60% of patients being adequately assessed and managed antenatally, and 68% postnatally. The findings led to a revised guideline, and it was anticipated that this change would facilitate improved compliance. Other units are likely to be facing similar difficulties, and therefore these results also aim to encourage others to consider review and assessment of their own VTE risk assessment protocols.

How good are obstetric and gynaecology trainees at reviewing and debriefing their patients following operative deliveries?

High levels of obstetric involvement are associated with psychological morbidity in patients postnatally. Operative deliveries contribute to up to 40% of deliveries. Given this, we decided to assess how well patients were being reviewed and debriefed following operative deliveries within our unit. A total of 53 notes following operative deliveries were analysed. To assess the quality of debriefing, the notes were reviewed for evidence of documentation on discussion for reason, procedure and complications of mode of delivery, advised plan for next delivery and contraception advice. Feedback questionnaires were given to patients on discharge to complete, regarding their understanding on the events surrounding their delivery. To assess how well doctors reviewed their own deliveries, we searched the notes for documented evidence of primary operator review. Our results identify significant deficiencies in doctors reviewing and debriefing patients following operative deliveries.

Uterine compression suture without hysterotomy--why a non-absorbable suture should be avoided.

We describe 2 cases of uterine compression suture without hysterotomy, only described once in the literature previously (Hayman et al. 2002). We consider in detail the suture material used for this technique and show photos of the compression suture at laparoscopy 4 weeks after insertion to demonstrate why it is inappropriate to use a non-absorbable suture. Modified compression sutures are being used increasingly and a wide variety of suture materials are being chosen, including vicryl, PDS and nylon (verbal communications). We feel it important to report our findings so that others can avoid the use of non or slowly absorbable sutures.

Obstetricians say yes to maternal request for elective caesarean section: a survey of current opinion.

AIM: To determine what proportion of obstetricians would agree to elective pre-labour CS for 'maternal request'. METHODS: Every fifth consultant on an alphabetical list of obstetricians in England and Wales obtained from the RCOG (243) was surveyed by post and asked (a) "Would you agree to perform an elective CS on a woman with an uncomplicated singleton cephalic pregnancy at term for 'maternal request?"' and (b) if yes, in relation to this 'Has your practice changed over recent years?" RESULTS: 155 questionnaires were returned (63% response rate -- four unanswered, leaving 151 for analysis). One hundred and four (69%) consultants said they would agree to 'maternal request' for CS. Of the 'yes' respondents, 62 (60%) claimed their practice had changed recently. CONCLUSION: This survey demonstrates that a majority of obstetricians are now prepared to agree to maternal request for CS in the absence of obstetric indications.

Does an inflatable obstetric belt facilitate spontaneous vaginal delivery in nulliparae with epidural analgesia?

OBJECTIVE: To assess whether an inflatable obstetric belt, synchronised to apply uniform fundal pressure during a uterine contraction, reduces operative delivery rates when used in the second stage of labour. DESIGN: Randomised controlled trial. METHODS: Five hundred nulliparae with a singleton cephalic pregnancy at term and with an epidural in labour were recruited during the first stage and randomised at full dilatation. Standard care involved one hour passive second stage and one hour active pushing after which instrumental delivery was performed if delivery was not imminent. Those randomised to the belt group, in addition to standard care, had the inflatable obstetric belt for the whole second stage of labour. MAIN OUTCOME MEASURE: Mode of delivery. RESULTS: One hundred and eleven of the 260 women in the belt group (42.7%) compared with 94 of the 240 in the control group (39.2%) had a spontaneous vertex delivery (P = 0.423). The lift-out instrumental delivery rate was similar between the two groups: 108 belts (41.5%), compared with 101 controls (42.1%) (P = 0.902), whereas rotational instrumental deliveries in the belt group were 26 belts (10%) compared with 36 controls (15%) (P = 0.09). Fifteen women (5.8%) in the belt group and nine women (3.8%) in the control group had a caesarean section in the second stage (P = 0.292). An intact perineum was more likely in the belt group (16.5% compared with 9.6%, P = 0.022) as was a third degree tear (6.5% compared with 0.4%, P = 0.001). CONCLUSION: The inflatable obstetric belt did not significantly reduce operative delivery rates when used in this clinical setting in the second stage of labour.

Ventouse: use, cup placement and success.

Sixty ventouse deliveries were analysed prospectively with specific attention paid to cup placement and its influence on successful or failed delivery. There was an 18.3% failure rate and 21.7% of all ventouse deliveries attempted had the cup inaccurately positioned. Cup placement was significantly more likely to be inaccurate when there was malposition of the fetal head. Significantly more tractions were needed when the cup was incorrectly positioned, but although there was a trend toward more failed attempts with the ventouse when the cup was inaccurately placed (23% vs 17%), this was not significant.

General practitioners' requirements from a hospital cardiology department.

The requirements of 500 general practitioners from a hospital department of cardiology were sought and assessed from a questionnaire. One hundred and twenty two general practitioners caring for 766,384 patients responded. The most important inpatient service requirement was that cardiologists should be responsible for the management of patients with acute myocardial infarction and other acute cardiac conditions. The expertise and reputation of the consultant cardiologist and the waiting time for an appointment were the two most important outpatient service requirements. The least important aspect was the time patients waited in clinic to see a doctor. Fundholders considered price of outpatient consultations to be unimportant. Waiting times for cardiac catheterisation and non-invasive cardiac investigations together with the quality of the investigation equipment and the technical staff were all considered to be important requirements. Most general practitioners wanted protocols for managing common cardiac conditions. The majority wanted an open access investigation service to reduce outpatient waiting times. Those who did not want an open access service explained that they would not be confident in interpreting the results or deciding subsequent management. An understanding of the requirements of general practitioners is helpful in planning and developing hospital services.

Vascular and electromyographic responses evoked in forearm muscle by isometric contraction of the contralateral forearm.

There is controversy over whether isometric contraction of the forearm evokes vasoconstriction or vasodilatation in the muscles of the contralateral forearm. In the present study we have investigated in normal man, the effects of isometric contraction of one arm at 75, 50 and 25% maximum voluntary contraction (MVC) on arterial pressure, heart rate, blood flow and vascular resistance of the contralateral forearm and on electromyographic (EMG) activity recorded from that same arm with sensitive, surface electrodes. When EMG activity was not being recorded from the 'resting' arm, isometric contraction of the contralateral arm for 2 min evoked increases in arterial pressure and heart rate whose magnitudes were graded with % MVC and an increase in forearm blood flow and a decrease in forearm vascular resistance at 75, 50 and 25% MVC, indicating vasodilatation. Further experiments in which EMG activity was recorded from the 'resting' arm demonstrated that the decrease in forearm vascular resistance evoked by 75% MVC was associated with a substantial increase in EMG activity of the extensor and flexor muscles of that arm. By contrast, when forearm contraction was performed at 75% MVC whilst subjects viewed the EMG activity in the 'resting' arm on an oscilloscope and kept EMG activity minimal, vascular resistance increased in that arm, indicating vasoconstriction. Further, when subjects performed contraction at 25% MVC whilst showing minimal EMG activity in the contralateral arm, vascular resistance in that same arm increased (from 78 +/- 16 to 124 +/- 29 mmHg/ml/min/100 ml tissue). These results are discussed in relation to those of previous studies. We propose, that in normal man, isometric contraction of the forearm evokes primary vasoconstriction in the muscles of the contralateral forearm, but that this response may be overcome by muscle vasodilatation occurring secondary to unintended muscle contraction or as part of the alerting response to acute stress.

Differential effects of isometric exercise on the cutaneous circulation of different regions.

Studies have been made in healthy human subjects of the changes evoked by isometric hand grip in arterial pressure, heart rate and cutaneous red cell flux, the latter being recorded using a laser Doppler meter. Hand grip for 2 min evoked increases in arterial pressure and heart rate, the magnitude of which were graded with the force of contraction (75, 50, or 25% maximum voluntary contraction). Cutaneous red cell flux in the contralateral forearm decreased significantly during 25 and 50% maximum voluntary contraction, while the cutaneous vascular resistance (arterial pressure/cutaneous red cell flux) increased to extents that were graded with the maximum voluntary contraction, indicating graded vasoconstriction. By contrast, cutaneous red cell flux in the face tended to increase, this reaching significance at 75% maximum voluntary contraction. Cutaneous vascular resistance in the face increased in some subjects, but decreased in others, vasodilator responses being most common during 75% maximum voluntary contraction when sweating commonly appeared on the face. In the dorsum of the foot, red cell flux did not change during 75% maximum voluntary contraction, although foot cutaneous vascular resistance increased significantly by the end of the first minute of contraction. At 50 and 25% maximum voluntary contraction most subjects showed an increase in foot cutaneous vascular resistance, but the remainder showed a decrease. We propose that isometric hand grip causes vasoconstriction in the cutaneous circulation of the contralateral forearm, the face and foot, that this response is strongest in the forearm and weakest in the face, and that in the face and foot, the vasoconstriction may be overcome by vasodilatation secondary to sweating.