An examination of women experiencing obstetric complications requiring emergency care: perceptions and sociocultural consequences of caesarean sections in Bangladesh

Little is known about the physical and socioeconomic postpartum consequences of women who experience obstetric complications and require emergency obstetric care (EmOC), particularly in resource-poor countries such as Bangladesh where historically there has been a strong cultural preference for births at home. Recent increases in the use of skilled birth attendants show socioeconomic disparities in access to emergency obstetric services, highlighting the need to examine birthing preparation and perceptions of EmOC, including caesarean sections. Twenty women who delivered at a hospital and were identified by physicians as having severe obstetric complications during delivery or immediately thereafter were selected to participate in this qualitative study. Purposive sampling was used for selecting the women. The study was carried out in Matlab, Bangladesh, during March 2008-August 2009. Data-collection methods included in-depth interviews with women and, whenever possible, their family members. The results showed that the women were poorly informed before delivery about pregnancy-related complications and medical indications for emergency care. Barriers to care-seeking at emergency obstetric facilities and acceptance of lifesaving care were related to apprehensions about the physical consequences and social stigma, resulting from hospital procedures and financial concerns. The respondents held many misconceptions about caesarean sections and distrust regarding the reason for recommending the procedure by the healthcare providers. Women who had caesarean sections incurred high costs that led to economic burdens on family members, and the blame was attributed to the woman. The postpartum health consequences reported by the women were generally left untreated. The data underscore the importance of educating women and their families about pregnancy-related complications and preparing families for the possibility of caesarean section. At the same time, the health systems need to be strengthened to ensure that all women in clinical need of lifesaving obstetric surgery access quality EmOC services rapidly and, once in a facility, can obtain a caesarean section promptly, if needed. While greater access to surgical interventions may be lifesaving, policy-makers need to institute mechanisms to discourage the over-medicalization of childbirth in a context where the use of caesarean section is rapidly rising.     

探讨选择性与急症子宫切除术在产科临床中的应用

目的：探究选择性和进行子宫切除术在产科中的应用效果。方法选取我院2011年1月-2013年1月收治的42例行产科子宫切除术的患者作为研究对象，按照患者行子宫切除术的类型分为选择性组和急症组，其中选择性组有28例患者，急症组有14例患者，对两组患者的应用效果进行分析。结果两组产妇全子宫切除和次全子宫切除比例无差异（P＞0.05）。选择性组患者早产儿的发生率、新生儿的重度窒息率、新生儿死亡率明显高于急症组患者，两组之间的差异具有统计学意义（P〈0.05）。其中选择性组早产儿比例14.3%，死亡率为10.7%，急症组早产儿比例为7.14%，死亡率为0；选择性组新生儿重度窒息率为10.7%，急症组为7.14%；选择性组新生儿的畸形率（3.6%）以及并发症发生率（3.6%）明显低于急症组患者的（分别为28.6%和35.7%），两组之间的差异具有统计意义（P〈0.05）。结论选择性和急症子宫切除术在临床应用的效果各有利弊，在实际的应用中应该根据患者的具体情况有选择的行子宫切除术，以降低不必要的负面影响。     

Serum albumin and clinical outcome in pediatric cardiac surgery

OBJECTIVE: We evaluated the behavior of serum albumin concentrations in response to metabolic stress that is associated with cardiac surgery and the role of this protein as a predictor of clinical outcome in children at high surgical risk who undergo operative correction of congenital heart defects. METHODS: Serum albumin concentrations were measured in 30 children who had heart disease and were at high surgical risk. Analyses were performed before surgery, on the second postoperative day, and on discharge from the intensive care unit. Preoperative serum concentrations of albumin were compared with those of a control group that consisted of 20 healthy and well-nourished children. RESULTS: Preoperative albumin concentrations of patients were lower than those of the control group (3.4+/-0.25 g/dL versus 4.0+/-0.18 g/dL, P<0.05). Serum levels decreased on the second postoperative day and at discharge from the intensive care unit (3.1+/-0.65 g/dL and 3.2+/-0.44 g/dL, P<0.05) compared with preoperative concentrations. Preoperative concentrations lower than 3.0 g/dL were associated with increased postsurgical infection (P=0.0026) and with increased mortality (P=0.0138). Patients whose postoperative levels were lower than 3.0 g/dL had longer hospital stays compared with those whose concentrations were higher than 3.0 g/dL (14.5+/-1.3 d versus 10+/-2.2 d, P<0.05). CONCLUSION: The results suggest that hypoalbuminemia is common among children who have heart disease and are at high surgical risk, and serum albumin concentrations lower than 3 g/dL may be related to outcome in the period after cardiac surgery.     

Audit of cost and clinical outcome of cataract surgery

An audit of routine cataract surgery in our hospital was carried out by examining records of 340 adult patients who underwent such surgery during October 1990. The category of intended accommodation (day case or inpatient), operative details, post-operative course and management were recorded, along with the outcome measures of visual acuity (unaided and corrected) and refractive error (spherical equivalent and cylinder). The costs of treatment, including post-operative management, were calculated for each patient. The results indicate that day case surgery under local anaesthesia was the most cost-effective method of cataract surgery, with no detrimental effect on clinical outcome.     

Perioperative administration of parenteral fish oil supplements in a routine clinical setting improves patient outcome after major abdominal surgery

BACKGROUND & AIMS: It is hypothesized that provision of pre- and/or postoperative omega-3 fatty acids to surgical patients in clinical routine improves clinical outcome. METHODS: Retrospective evaluation of a 2-year-longitudinal data base of ICU patients (n=249) elected for major abdominal surgery. Group I (n=110): postoperative standard parenteral nutrition (1.2 g amino acids, 0.3 g glutamine dipeptide, 0.6 g lipids, 4 g/kg glucose; energy ratio glucose to lipid 2:1); group II (n=86): part of postoperative lipid emulsion replaced by fish oil; group III (n=53): in addition 2-3 days preoperative fish oil supplementation (max. 100 ml/d). RESULTS: A decrease in mortality was observed in group III compared to group I (P=0.02). The number of patients requiring mechanical ventilation was lower with perioperative fish oil (n=34 in groups I and II. 10 in III, P<0.05). The number of days in ICU was not different (group I: 7.6 days, group II: 7.0, group III: 7.3), the length of hospital stay was shorter in group I (group I: 29.2 days, group II: 24.9, group III: 22.2, P<0.05 vs I). CONCLUSIONS: In a retrospective evaluation, perioperative provision of parenteral fish oil (ca. 10 g/day) beneficially influences patient outcome probably by modulating the immune response.     

不同国家院前急救医疗服务发展概况及启示

不同国家因地理、政治、文化、语言、历史和医学背景的不同,院前急救医疗服务模式有各自不同的发展模式。分析了不同国家院前急救服务发展概况及现状,借鉴国外发展经验,对国内院前医疗急救服务现状进行思考。认为我国应该通过完善急救立法、加强部门合作、探索院前急救分级诊疗模式、加强专业化人才队伍建设、探索智慧医疗院前急救模式、普及公众院前急救知识等措施,大力发展院前急救医疗服务。     

Optimal distribution of medical backpacks and health surveillance assistants in Malawi

Despite recent progress, Malawi continues to perform poorly on key health indicators such as child mortality and life expectancy. These problems are exacerbated by a severe lack of access to health care. Health Surveillance Assistants (HSAs) help bridge this gap by providing community-level access to basic health care services. However, the success of these HSAs is limited by a lack of supplies and long distances between HSAs and patients. To address this issue, we used large-scale weighted p-median and capacitated facility location problems to create a scalable, three-tiered plan for optimal allocation of HSAs, HSA designated medical backpacks, and backpack resupply centers. Our analysis uses real data on the location and characteristics of hospitals, health centers, and the general population. In addition to offering specific recommendations for HSA, backpack, and resupply center locations, it provides general insights into the scope of the proposed HSA backpack program scale-up. In particular, it demonstrates the importance of local health centers to the resupply network. The proposed assignments are robust to changes in the underlying population structure, and could significantly improve access to medical supplies for both HSAs and patients.     

Measurement and determinants of tuberculosis outcome in Karonga District, Malawi.

Evaluation of disease outcome is central to the assessment of tuberculosis (TB) control programmes. In the study reported in this article we examined the factors influencing the measurement of outcome, survival rates during and after treatment, smear conversion rates, and relapse rates for patients diagnosed with TB in a rural area of Malawi between 1986 and mid-1994. Patients with less certain diagnoses of TB were more likely to die than those with confirmed TB, both among those who were seropositive and those who were seronegative to human immunodeficiency virus (HIV). The mortality rate among smear-positive patients with a separate culture-positive specimen was half that of patients with no such diagnostic confirmation. Patients not registered by the Ministry of Health had much higher mortality and default rates than did registered patients. Among smear-positive patients, HIV serostatus was the most important influence on mortality both during and after treatment (crude hazard ratios (95% confidence intervals) = 5.6 (3.0-10) and 7.7 (3.4-17), resp.), but HIV serostatus did not influence smear conversion rates. The initial degree of smear positivity influenced smear conversion rates, but not mortality rates. No significant predictors of relapse were identified. Unless considerable care is taken to include all TB patients, and to exclude nontuberculous patients, recorded TB outcome statistics are difficult to interpret and may be misleading. In populations with high rates of HIV infection, TB target cure rates of 85% are unrealistic. When new interventions are assessed it cannot be assumed that factors which influence the smear conversion rate will also influence the mortality rate.     

Availability, distribution and use of emergency obstetric care in northern Tanzania

The objective of this study is to determine the availability, distribution and quality of facilities providing delivery services, as well as their use by pregnant women. The study is a survey of all facilities providing delivery services (n = 129) in six districts in northern Tanzania. The framework provided by the UNICEF/UNFPA/WHO (UN) Guidelines is applied. An attempt is made to answer the first three questions in this audit outline: are there enough emergency obstetric care (EmOC) facilities? Are they well distributed? And are enough women using them? The results show that there is a very low availability of basic emergency obstetric care (BEmOC) units (1.6/500,000), and a relatively high availability of comprehensive emergency obstetric care (CEmOC) units (4.6/500,000), both with large urban/rural variation. The percentage of expected deliveries in EmOC facilities is 36%, compared with the UN Guidelines minimum accepted threshold of 15%. Nevertheless, the distribution shows a much higher utilization in urban districts compared with rural, indicating that mothers have to travel long distances to receive adequate services when in need of them. The paper also discusses the provisional context of the services in terms of level of facilities providing them and their public/private mix. Most facility deliveries are conducted at CEmOC facilities. Pregnant women tend to utilize the services of voluntary agencies to a greater degree than government services in rural areas, while the government services have a higher burden of the workload in urban areas. A majority (86%) of the deliveries occurring in voluntary agency facilities occur in a qualified EmOC facility. Against a backdrop of a large availability of any facility regardless of their emergency obstetric care status (41.9/500,000), this paper argues that given the large number of potential BEmOC facilities, it seems more efficient to shift resources within the BEmOC level, compared with from CEmOC level down to BEmOC level, to improve access to quality services. There is a large potential for quality improvement, in particular at dispensary and health centre levels. We argue that the main barrier to access to quality care is not the mother's ignorance or their ability to get to a facility, but the actual quality of care meeting them at the facility.     

Sources of job satisfaction and psychological distress in GPs and medical house officers

The psychological health and job satisfaction of 285 GPs and 89 medical house officers from Leeds was compared using standardized self-report measures. Forty-eight per cent of the GPs and 20% of the house officers scored as 'cases' of psychiatric disorder. The GPs were less satisfied with the recognition they received for their work and their hours of work, but more satisfied with their job variety and job autonomy. Further research examining the sources of work-related distress in different medical settings could help inform future organizational changes.     

乡镇医疗机构产科围手术期抗菌药物临床应用现状分析

目的:了解基层卫生院妇产科围手术期抗菌药物的应用情况,为合理应用抗菌药物提供参考.方法:通过2011年医疗质量监督考核对24个乡镇卫生院产科手术病历进行回顾分析,每个医院抽取20份,共480份,根据抗菌药物临床应用指导原则等相关资料评价妇产科围手术期抗菌药物用药指征、时间、剂量、禁忌证、预后、不良反应及联合应用比率.结果:抗菌药物应用率为100％,共4类9个品种.以术后预防用药为主,注射用抗菌药物前5位为硝唑注射液(76.4％)、注射用头孢他啶(42.1％)、注射用头孢匹胺(34.6％)、注射用阿奇霉素(10.0％)、注射用头孢曲松钠(5.8％),联合应用头孢菌素类和硝咪唑类占96.4％.结论:基层产科围手术期预防性应用抗菌药物不合理,用药时机及疗程不当、联合用药不合理、应用孕妇及哺乳期禁用的抗菌药物,需加强基层医疗机构抗菌药物临床应用管理.     

Perceptions of voluntary medical male circumcision among circumcising and non-circumcising communities in Malawi

Three randomised controlled trials in Africa indicated that voluntary medical male circumcision (VMMC) is an effective method to reduce a man's risk of becoming infected through sex with an HIV-positive female partner. The success of recent public health initiatives to increase numbers of circumcised men in Malawi has been very limited. We conducted in-depth interviews and focus group discussions (FGDs) with men, women and male adolescents from non-circumcising and circumcising communities in southern Malawi to better understand their beliefs about male circumcision and the promotion of VMMC for HIV prevention. Results revealed that beliefs about male circumcision, in general, are strongly mediated by Malawian culture and history. Participants have attempted to develop a new meaning for circumcision in light of the threat of HIV infection and the publicised risk reduction benefits of VMMC. Several study participants found it difficult to distinguish VMMC from traditional circumcision practices (jando and lupanda), despite awareness that the new form of circumcision was an expression of (western) modern medicine performed largely for public health purposes. Greater recognition of background cultural beliefs and practices could inform future efforts to promote medical male circumcision as an HIV prevention strategy in this context.     

营养支持对内科患者营养状况和临床结局的影响

目的 评价营养支持对有营养风险内科住院患者营养状况和临床结局的影响.方法 营养风险筛查2002筛查有营养风险的148例患者根据入院时间顺次排序,依单双号进行分组,分为常规治疗组75例和个体化营养干预组73例.干预措施包括鼓励患者进食、设计饮食计划、确保膳食处方的落实.评价住院期间能量、蛋白质入量、体质量、住院时间、住院费用及并发症发生率.结果 营养干预组有更高的蛋白质摄入量[(45.1±2.2)g/d比(54.8±2.5) g/d,P=0.004)],能量摄入干预组有增高的趋势[(4 180.0±227.4) kJ/d比(4 589.6±150.5) kJ/d,P=0.135)],但差异无统计学意义.46.6％的干预组患者摄入量超过需求量的75％,对照组只有30.7％,差异有统计学意义(P =0.047).干预组比对照组更能保持自身体质量[(-0.4±0.2) kg比(-1.1±0.2)kg,P=0.025].对照组与干预组的住院时间[(13.5±0.9)d比(12.4±0.6)d,P=0.310)]、住院费用[(17834±1 824)元比(16 099±1 243)元,P=0.435)]、并发症发生率(12.8％比8.1％,P=0.184)差异均无统计学意义.结论 营养干预对内科住院患者蛋白质摄入量及住院期间体质量的保持有意义,大样本随机对照试验研究营养干预对有营养风险的内科住院患者临床结局的影响是必要的.     

急性开放性眼外伤患者早期玻璃体手术治疗的时机及临床效果

目的探讨急性开放性眼外伤患者早期玻璃体手术治疗的时机及临床效果。 方法随机抽取2013年6月至2014年6月我院收治的开放性眼外伤患者65例(65只眼),按手术方式,将接受常规时间II期玻璃体手术治疗的32例(32只眼)患者作为对照组,将接受早期玻璃体手术治疗的33例(33只眼)作为观察组,对比两组患者的手术效果,并统计记录术后并发症发生情况。 结果两组患者术前玻璃体积血、视网膜脱离、晶状体破裂、角膜裂伤发生率比较差异均无统计学意义(P>0.05)。观察组功能治愈28例,解剖治愈4例,未愈1例,治愈率为96.97%。对照组功能治愈16例,解剖治愈10例,未愈6例,治愈率为81.25%,差异有统计学意义(P<0.05)。观察组术后并发症发生率为9.09%,对照组为25.00%,差异有统计学意义(P<0.05)。 结论对开放性急诊眼外伤患者,早期玻璃体手术治疗的临床效果显著,同时可减少术后并发症的发生。     

Pregestational obesity,maternal morbidity and risk of caesarean delivery in a country in an advanced stage of obstetric transition

ObjectiveTo evaluate whether pregestational obesity is associated with the risk of caesarean section in pregnant women living in a country in an advanced stage of the obstetric transition.MethodsRetrospective cohort study. Data were collected from prenatal and hospital records. Pregestational obesity was defined as: body mass index, [weight(k)/height (m²)] ≥30, and caesarean sections were categorized as elective, emergency, or non-emergency/medically necessary. Biodemographic and sociodemographic characteristics, obstetric and perinatal pathologies, and maternal anthropometric variables were assessed. Chi-square and t-tests were used to compare qualitative and quantitative variables, respectively. Simple and adjusted generalized linear models were used to evaluate the association between pregestational obesity and caesarean delivery. Finally, population attributable risk was calculated. Data analysis was performed using STATA.v.14.0.Participants2309 pregnant women with a singleton pregnancy who gave birth at a public hospital in the Metropolitan Region of Santiago, Chile in 2015.ResultsThe prevalence of pregestational obesity was 21.4%, and the incidence of caesarean deliveries was 34.8% (33% of which corresponded to elective, 46% to emergency, and 21% to non-emergency/medically necessary caesarean deliveries). Pregestational obesity increased the risk of caesarean delivery (aRR = 1.46; 95%CI. [1.19–1.79] as well as the risk of elective (aRR = 1.74; 95%CI. [1.23–2.45]) and emergency caesarean delivery (aRR = 1.44; 95%CI. [1.03–2.00]). The population attributable risk of pregestational obesity for caesarean section was 32%.ConclusionGiven the significant association between pregestational obesity and caesarean delivery, it is necessary to develop strategies to decrease obesity among women of childbearing age in order to decrease obstetric intervention.     

The clinical and educational experiences of pre-registration house officers in general practice

AIMS: To describe aspects of the clinical experience and educational supervision gained by pre-registration house officers (PRHOs) in general practice, and to relate these to the current General Medical Council (GMC) aims for general clinical training in general practice. DESIGN: Qualitative evaluation, part of which involved semistructured interviews with 12 PRHOs who were experiencing a general practice rotation. Interviews were conducted at the beginning and the end of the pre-registration year, and following return to hospital work after completion of the general practice placement. SETTINGS: Three teaching hospitals, two district general hospitals and six general practices in south-east England. PARTICIPANTS: 12 PRHOs who were involved in rotations incorporating a general practice placement. RESULTS: To varying degrees, the GMC aims for training in general practice were met for all the participants. All PRHOs recognized the value of the clinical experience and educational supervision they received in general practice. They particularly valued aspects such as having an individual training programme based on their own needs, and the interlinking of theory and practice, which aided learning. Most felt that having responsibility for their own patients acted as an important incentive for learning, and in general, PRHOs appreciated having the time to learn which general practice allowed. CONCLUSIONS: For the majority of PRHOs, the time spent in general practice was seen as a positive clinical and educational experience. In a variety of ways, the general practice placement encouraged PRHOs to develop the self-directed learning skills seen as essential to the lifelong learning advocated by the GMC. A number of recommendations are made to help improve the integration of the hospital and general practice components of these rotations.