Estimated versus measured blood loss during dilation and evacuation: an observational study

Objective

To compare estimated versus measured blood loss at the time of dilation and evacuation (D&E).

Adherence to antiparkinsonian medication: an in-depth qualitative study

BackgroundAdherence to prescribed medication is low. It is a major problem as following practitioners’ recommendations is strongly associated with good patient outcomes. Little research has been undertaken with people in the early stages of Parkinson's disease although achieving symptom control depends on regularly timing doses.Research questionsHow do people with Parkinson's disease adhere to prescribed medication, and what are the antecedents of non-adherence to antiparkinsonian medication?DesignExploratory qualitative study using semi-structured interviews.SettingSpecialist Parkinson's disease clinic in one National Health Service hospital in England.ParticipantsFifteen consecutive patients not yet in the advanced stages of Parkinson's disease living at home and responsible for managing their own medication or managing medication with the help of their carer.MethodsSemi-structured interviews with open questions.FindingsEach respondent demonstrated at least one type and in most cases several different types of non-adherent behaviour. Inadvertent minor non-adherence occurred because patients forgot to take tablets or muddled doses. Minor deliberate deviations occurred when patients took occasional extra tablets or brought forward doses to achieve better symptom control, often to cater for situations that were anticipated as especially demanding. Deliberate major non-adherence was very common and always related to over-use of medication. The experiences of parkinsonism were particular to the individual. The specific circumstances that prompted an episode of non-adherence varied between patients. Nevertheless there was evidence of negotiation between respondents and the Parkinson's disease nurse specialist; medication regimes were altered in conjunction with the patient during formal consultations and by telephone.ConclusionNon-adherence to prescribed medication for people with chronic conditions is complex and for people with Parkinson's disease it was possible to identify different types of non-adherence. The possible existence of a typology of non-adherence for people with other chronic conditions merits investigation. Further research is needed to establish whether the findings of this small scale qualitative study can be replicated with a larger, more representative sample and establish how people with Parkinson's disease might be encouraged to adhere to medication regimes to improve symptom control.     

The frailty syndrome in general practitioner care

Background

Knowledge about frailty among patients seen by general practitioners (GP) is currently limited.

Patients and methods

Frailty assessment by the criteria of Fried and additional documentation was performed at a GP??s office.

Results

Out of 119?participating patients, 14.3% were classified as frail, 52.1% as prefrail, and 33.6% as not frail. Frailty was associated with comorbidity, the number of drugs prescribed, depressive symptoms, cognitive function, and frequency of falls.

Conclusion

The prevalence of frailty is high among the cohort of elderly persons seen by a GP. Routine frailty assessment will help to direct preventive and therapeutic interventions.     

The relationship between continuing professional education and commitment to nursing

Nurses have a responsibility to undertake continuing professional development to enable them to keep abreast with changes in health care. Acquiring new knowledge and skills is essential for nurses to practice safely in new and extended roles. Opportunities for continuing professional development are thought to increase retention. The aim of this study was to explore the relationship between undertaking continuing professional development and commitment to the profession and the employing National Health Service trust and to explore any differences between nurses in standard and extended roles. A questionnaire survey was undertaken with 451 nurses employed in three contrasting trusts. The questionnaire incorporated a validated scale to measure organisational and professional commitment. Three hundred and eighteen (70.5%) of the nurses had undertaken continuing professional development over the previous 12 months. Ninety nine nurses (22%) had received only mandatory training over the same period. There was no evidence of a relationship between professional and organisational commitment and undertaking continuing professional development. There was no evidence that specialist nurses in extended roles had undertaken the developmental continuing professional development that would be expected in order for them to acquire new competencies and skills.     

Risk factors associated with presenting for abortion in the second trimester

OBJECTIVE: To determine factors associated with delay of induced abortion into the second trimester of pregnancy. METHODS: Using audio computer-assisted self-interviewing, 398 women from 5 to 23 weeks of gestation at an urban hospital described steps and reasons that could have led to a delayed abortion. Multivariable logistic regression identified independent contributors to delay. RESULTS: Half of the 70-day difference between the average gestational durations in first- and second-trimester abortions is due to later suspicion of pregnancy and administration of a pregnancy test. Delays in suspecting and testing for pregnancy cumulatively caused 58% of second-trimester patients to miss the opportunity to have a first-trimester abortion. Women presenting in the second trimester experienced more delaying factors (3.2 versus 2.0, P < .001), with logistical delays occurring more frequently for these women (63.3% versus 30.4%, P < .001). Factors associated with second-trimester abortion in logistic regression were prior second-trimester abortion, delay in obtaining state insurance, difficulty locating a provider, initial referral elsewhere, and uncertainty about last menstrual period. Factors associated with decreased likelihood of second-trimester abortion were presence of nausea or vomiting, prior abortion, and contraception use. CONCLUSION: Abortion delay results from myriad factors, many of them logistical, such as inappropriate or delayed referrals and delays in obtaining public insurance. Public health interventions could promote earlier recognition of pregnancy, more timely referrals, more easily obtainable public funding, and improved abortion access for indigent women. However, accessible second-trimester abortion services will remain necessary for the women who present late due to delayed recognition of and testing for pregnancy. LEVEL OF EVIDENCE: II-2.     

The City MISS: development of a scale to measure stigma of perinatal mental illness

Objective: This study aimed to develop and validate a scale to measure perceived stigma for perinatal mental illness in women.

Background: Stigma is one of the most frequently cited barriers to seeking treatment and many women with perinatal mental illness fail to get the treatment they need. However, there is no psychometric scale that measures how women may experience the unique aspects of perinatal mental illness stigma.

Method: A draft scale of 30 items was developed from a literature review. Women with perinatal mental illness (n = 279) were recruited to complete the City Mental Illness Stigma Scale. Concurrent validity was measured using the Internalised Stigma of Mental Illness Scale. Factor analysis was used to create the final scale.

Results: The final 15-item City Mental Illness Stigma Scale has a three-factor structure: perceived external stigma, internal stigma and disclosure stigma. The scale accounted for 54% of the variance and had good internal reliability and concurrent validity.

Conclusion: The City Mental Illness Stigma Scale appears to be a valid measure which provides a potentially useful tool for clinical practice and research in stigma and perinatal mental illness, including assessing the prevalence and characteristics of stigma. This research can be used to inform interventions to reduce or address the stigma experienced by some women with perinatal mental illness.     

Fetal pain: a systematic multidisciplinary review of the evidence

Context  Proposed federal legislation would require physicians to inform women seeking abortions at 20 or more weeks after fertilization that the fetus feels pain and to offer anesthesia administered directly to the fetus. This article examines whether a fetus feels pain and if so, whether safe and effective techniques exist for providing direct fetal anesthesia or analgesia in the context of therapeutic procedures or abortion. Evidence Acquisition  Systematic search of PubMed for English-language articles focusing on human studies related to fetal pain, anesthesia, and analgesia. Included articles studied fetuses of less than 30 weeks’ gestational age or specifically addressed fetal pain perception or nociception. Articles were reviewed for additional references. The search was performed without date limitations and was current as of June 6, 2005. Evidence Synthesis  Pain perception requires conscious recognition or awareness of a noxious stimulus. Neither withdrawal reflexes nor hormonal stress responses to invasive procedures prove the existence of fetal pain, because they can be elicited by nonpainful stimuli and occur without conscious cortical processing. Fetal awareness of noxious stimuli requires functional thalamocortical connections. Thalamocortical fibers begin appearing between 23 to 30 weeks’ gestational age, while electroencephalography suggests the capacity for functional pain perception in preterm neonates probably does not exist before 29 or 30 weeks. For fetal surgery, women may receive general anesthesia and/or analgesics intended for placental transfer, and parenteral opioids may be administered to the fetus under direct or sonographic visualization. In these circumstances, administration of anesthesia and analgesia serves purposes unrelated to reduction of fetal pain, including inhibition of fetal movement, prevention of fetal hormonal stress responses, and induction of uterine atony. Conclusions  Evidence regarding the capacity for fetal pain is limited but indicates that fetal perception of pain is unlikely before the third trimester. Little or no evidence addresses the effectiveness of direct fetal anesthetic or analgesic techniques. Similarly, limited or no data exist on the safety of such techniques for pregnant women in the context of abortion. Anesthetic techniques currently used during fetal surgery are not directly applicable to abortion procedures.