Management of hypertension in pregnancy

Hypertensive disorders of pregnancy are common and can result in maternal and fetal morbidity and mortality. Women may have chronic hypertension, or develop hypertension during pregnancy. Management involves close maternal and fetal surveillance. If an antihypertensive drug is needed, prescribe one that is safe in pregnancy. Pre-eclampsia is a hypertensive disorder of pregnancy. Women at high risk of pre-eclampsia should start aspirin 150 mg daily at 12-16 weeks gestation and continue until 36 weeks gestation, to reduce the risk of preterm delivery. There are long-term cardiovascular and mortality risks associated with pregnancies complicated by gestational hypertension and pre-eclampsia. Ongoing cardiovascular and metabolic risk surveillance should be undertaken by the woman's general practitioner.

Prevalence of autoimmune conditions in pregnant women in a tertiary maternity hospital: A cross-sectional survey and maternity database review

Background

Autoimmune conditions are associated with adverse pregnancy and offspring outcomes; however, the prevalence in pregnant women is not well understood. Estimates based on administrative data alone may underestimate prevalence.

Methods

A cross-sectional survey of women attending a tertiary referral hospital for antenatal care in December 2018-February 2019 and review of the hospital's maternity database of women giving birth from October 2017-June 2018 to estimate autoimmune disease prevalence.

Results

A total of 400 women completed surveys (78% response rate) and 41 (10.3%) reported an autoimmune disease, most commonly Hashimoto's thyroiditis (2.8%) and psoriasis (2.5%). From the maternity database, 112 of 2756 women giving birth (4.1%) had a recorded autoimmune disease, most commonly Hashimoto's thyroiditis (1.3%) followed by coeliac disease, Graves' disease, and immune thrombocytopenic purpura (all 0.4%).

Conclusion

Autoimmune disease prevalence in pregnant women is higher when self-reported and may be more common than previously reported using administrative data.

Natural language processing of radiology reports for the identification of patients with fracture

Text-search software can be used to identify people at risk of re-fracture. The software studied identified a threefold higher number of people with fractures compared with conventional case finding. Automated software could assist fracture liaison services to identify more people at risk than traditional case finding.

PURPOSE

Fracture liaison services address the post-fracture treatment gap in osteoporosis (OP). Natural language processing (NLP) is able to identify previously unrecognized patients by screening large volumes of radiology reports. The aim of this study was to compare an NLP software tool, XRAIT (X-Ray Artificial Intelligence Tool), with a traditional fracture liaison service at its development site (Prince of Wales Hospital [POWH], Sydney) and externally validate it in an adjudicated cohort from the Dubbo Osteoporosis Epidemiology Study (DOES).

METHODS

XRAIT searches radiology reports for fracture-related terms. At the development site (POWH), XRAIT and a blinded fracture liaison clinician (FLC) reviewed 5,089 reports and 224 presentations, respectively, of people 50 years or over during a simultaneous 3-month period. In the external cohort of DOES, XRAIT was used without modification to analyse digitally readable radiology reports (n = 327) to calculate its sensitivity and specificity.

RESULTS

XRAIT flagged 433 fractures after searching 5,089 reports (421 true fractures, positive predictive value of 97%). It identified more than a threefold higher number of fractures (421 fractures/339 individuals) compared with manual case finding (98 individuals). Unadjusted for the local reporting style in an external cohort (DOES), XRAIT had a sensitivity of 70% and specificity of 92%.

CONCLUSION

XRAIT identifies significantly more clinically significant fractures than manual case finding. High specificity in an untrained cohort suggests that it could be used at other sites. Automated methods of fracture identification may assist fracture liaison services so that limited resources can be spent on treatment rather than case finding.

Blood pressure postpartum (BP2) RCT protocol: Follow-up and lifestyle behaviour change strategies in the first 12 months after hypertensive pregnancy

OBJECTIVES

Women who had hypertensive disorders of pregnancy (HDP) are twice as likely to experience maternal cardiovascular disease later in life. The primary aim of this study (BP²) is to compare outcomes of 3 different management strategies, including lifestyle behaviour change (LBC), in the first 12 months postpartum in women who had HDP in their preceding pregnancy. Secondary aims include assessing the effects on other cardiometabolic parameters.

STUDY DESIGN

Three-arm multicentre randomised trial in metropolitan Australian hospitals, (registration: ACTRN12618002004246) target sample size 480. Participants are randomised to one of three groups: 1) Optimised usual care: information package and family doctor follow-up 6 months postpartum 2) Brief intervention: information package as per group 1, plus assessment and brief LBC counselling at a specialised clinic with an obstetric physician and dietitian 6 months postpartum 3) Extended intervention: as per group 2 plus enrolment into a 6 month telephone-based LBC program from 6 to 12 months postpartum. All women have an outcome assessment at 12 months.

MAIN OUTCOME MEASURES

Primary outcomes: (a) BP change or (b) weight change and/or waist circumference change.

SECONDARY OUTCOMES

maternal health-related quality of life, engagement and retention in LBC program, biochemical markers, vascular function testing, infant weight trajectory, incremental cost-effectiveness ratios. The study is powered to detect a 4 mmHg difference in systolic BP between groups, or a 4 kg weight loss difference/2cm waist circumference change.

CONCLUSIONS

BP² will provide evidence regarding the feasibility and effectiveness of postpartum LBC interventions and structured clinical follow-up in improving cardiovascular health markers after HDP.

OR29-02 Natural Language Processing of Radiology Reports Improves Identification of Patients with Fracture

Fracture liaison services (FLS) address the treatment gap for those with osteoporosis (OP) who fracture and are not treated. Given the limited human resources in FLS, screening high volumes of radiology reports for fractures with Natural Language Processing (NLP) could identify patients that have not been recognized or treated. This study is an analytical and clinical validation of X-Ray Artificial Intelligence Tool software (XRAIT) at its development site (a tertiary hospital) and external validation in an adjudicated cohort from the Dubbo Osteoporosis Epidemiology Study (DOES).Methods: XRAIT uses NLP to perform a Boolean search of radiology reports for fracture and related terms. It can be trained for site-specific reporting styles and use rules to refine identification (e.g. age>50y; bone involved; etc). At the development site, XRAIT was used to search the emergency patient presentations of people over 50 years of age and compared to referrals to FLS (usual care) during the same 3-month period. XRAIT analyzed all plain radiographs and CT scans (n = 5089) while n = 224 were referred to FLS for usual care. External validation: XRAIT was used to analyze digitally readable radiology reports in an untrained cohort from DOES (n = 327) to calculate sensitivity and specificity.Results: XRAIT identified a 5-fold higher number of potential significant fractures (349/5089) compared to manual case finding (70/224). 339/349 were confirmed fractures (97.1%). Only 29% of those eligible were started or recommended anti-resorptive therapy, including those seen by the fracture liaison service. XRAIT unadjusted for the local radiology reporting styles in DOES had a sensitivity of 69.6% and specificity of 95%. Conclusion: XRAIT identifies clinically significant fractures efficiently with minimal additional human resources. Its high specificity in an untrained cohort suggests it could be used at other sites. Automated methods of patient identification may assist fracture liaison services to identify fractures that still remain largely untreated.

SOMANZ position paper on the management of nausea and vomiting in pregnancy and hyperemesis gravidarum

This is a brief summary of the Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) evidence-based guideline for the management of nausea and vomiting of pregnancy (NVP) and hyperemesis gravidarum (HG). The full guideline and executive summary including auditable outcomes are freely available on the SOMANZ website [https://www.somanz.org/guidelines.asp]. The guideline includes a proposed SOMANZ definition of NVP and HG and evidence-based practical advice regarding the investigation and management of NVP, HG and associated conditions including thyroid dysfunction. A practical algorithm for assessment and management as well as an individual patient management plan and self-assessment tools are included.

Halitosis as a product of hepatic disease

OBJECTIVES

This study evaluated halitosis in patients suffering from hepatic disease.

MATERIAL AND METHODS

Twenty-five patients (12 males and 13 females) aged between 16 and 73 years who had undergone treatment for liver disease were included in this study. Three halimeter recordings were performed to measure methyl mercarptan and hydrogen sulphite. Mean values were calculated and compared with normal values (75-120 ppb). The level of significance was set at P < .05. Results: Thirteen of the 25 subjects (52%) had normal Volatile Sulphur Compound (VSC) values (75-120 ppb). Twelve subjects (48%) recorded values ranging from 132 to 1112 ppb. There was no correlation between hepatic pathology and halitosis. Fifty-two percent of all subjects had poor oral hygiene, strongly correlated with high VSC values (P<0.05) whereas the remaining 48% with good hygiene had normal levels of VSC.

CONCLUSIONS

Within the limitations of this study, high values of VSC were not associated with the presence of hepatic disease.

A Prospective Randomised Controlled Trial of VNUS Closure versus Surgery for the Treatment of Recurrent Long Saphenous Varicose Veins

OBJECTIVE

This study aimed to assess the outcome of endoluminal thermal ablation (VNUS) and traditional redo groin surgery (RGS) and long saphenous vein (LSV) stripping in patients with bilateral recurrent long saphenous varicose veins.

METHODS

This was a randomised patient controlled double blind study. Sample size calculations required 16 patients. Their median age was 54 and 11 were women. The median CEAP class was 3. At operation one leg, chosen at random, was treated with VNUS and avulsions using intra-operative duplex control. The other leg was treated with traditional RGS, exposure of the femoral vein, stripping of the LSV and multiple avulsions. Post-operatively patients completed 10 cm visual analogue scales for pain and bruising. Digital Image analysis was used to objectively assess bruising. Statistical analysis was done using Wilcoxon signed rank test for paired data. Results are expressed as median values (inter-quartile ranges).

RESULTS

Time to perform VNUS was 25.5 (20.5-31.3) min compared with 40 (34.5-45.5) min it took for RGS (p=0.02). Pain score for VNUS was 1.7 (0.2-4), significantly lower than that for RGS 3.8 (0.6-6.3) (p=0.02). Bruise score for VNUS was 1.7 (0.4-4.4), and that for RGS was 5.2 (2.6-7) (p=0.03). All LSVs were sealed by VNUS at duplex follow up. Three legs in the RGS group and two in the VNUS group had a minor complication.

CONCLUSIONS

VNUS caused less pain and bruising and was performed more quickly than RGS. VNUS should be considered the treatment of choice for recurrent long saphenous varicose veins.

Developing a one-stop clinic for leg ulcer patients

Leg ulceration may be caused by a variety of different factors and specialist assessment is required. Patients with complex leg ulcers in Nottingham are assessed at a one-stop dermatology/vascular clinic. Nurses undertake assessments, provide education and support and liaise with the community nursing services.

An exploration of child sexual abusers' sexual fantasies before and after treatment

Although there is a substantial literature looking at the relationship between deviant sexual fantasies and child sexual abuse, there is scant previous work that focuses upon the actual content of such fantasies. The present study looks at child sexual abusers' deviant fantasies both pre- and postintervention. Using both qualitative and quantitative methodologies, a description of the frequency and content of, and triggers for, child sexual abusers' deviant fantasies is reported both pre- and postintervention. The implications of this information for subsequent intervention programs is explored.

Vascular surgical society of great britain and ireland: randomized controlled trial of heparin plus graduated compression stocking for the prophylaxis of deep venous thrombosis in general surgical patients

BACKGROUND: A randomized controlled study was undertaken to compare heparin with heparin plus graduated compression stockings (Brevet Tx, Seton Healthcare) in the prophylaxis of deep vein thrombosis (DVT) following abdominal surgery. METHODS: Sixty high-risk patients were recruited if they met at least two of the following criteria identified as predisposing to DVT: age greater than 39 years, malignancy, varicose veins, cardiac disease or hypertension, diabetes mellitus, obesity or previous thromboembolic episode. All patients received subcutaneous heparin and were randomized to receive Brevet Tx to either the right or left leg before surgery. The stocking was worn for 2 weeks after surgery. The patients underwent duplex imaging before surgery, and at 3, 6 and 14 days after operation. All scans were performed by one sonographer. The policy was to perform a venogram where a positive result was indicated by duplex scanning. RESULTS: Fifty-six patients completed the study. Six patients (11 per cent) suffered a DVT in the non-stockinged leg, but none in the stockinged leg (P = 0.016, McNemar's test). The DVTs occurred on days 3, 6, 7, 8, 9 and 12 following surgery. CONCLUSION: Brevet Tx in addition to low-dose subcutaneous heparin significantly reduced the incidence of DVT in high-risk patients undergoing abdominal surgery.

Individual differences in cognitive processes: towards an explanation of schizophrenic symptomatology

A study is reported that examined the relationship between a measure of schizophrenic-like characteristics (schizotypy) in normal subjects and cognitive inhibition. Both repetitive and semantic measures of priming were used. It was found that low schizotypes showed negative priming (i.e. longer reaction times to the re-presentation of initially ignored stimuli) while high schizotypes did not; high schizotypes exhibited semantic facilitation (i.e. shorter reaction times to previously ignored stimuli) but low schizotypes did not. A model is suggested, including both inhibitory and facilitatory processes, which can account for these findings. Theorizing about these processes is of interest as it may shed some light on the mechanisms involved in the specifically cognitive symptoms of schizophrenia.

Evidence of reduced 'cognitive inhibition' in schizophrenia

An experiment is described which investigated cognitive inhibition in schizophrenia. It is noted that both the abnormal and cognitive literatures use the concept of inhibition. Frith (1979) suggests that the more cognitive symptoms of schizophrenia may be due to the failure to limit the current contents of consciousness due to a failure adequately to inhibit the output of preconscious processes. Current thinking in cognitive psychology suggests that in the process of selective attention there is active inhibition of distractor information. A technique used to investigate this is termed negative priming (Tipper, 1985). The general nature of this paradigm is as follows: if a distractor, which has been previously ignored, is response, due to inhibition of the information when it was originally a distractor. It was found that inhibition of such distracting information was reduced in schizophrenics. This finding is seen as providing some support for Frith's (1979) theory that the cognitive symptoms of schizophrenia are due to awareness of processes that normally occur preconsciously.

Individual differences in schizotypy as reflected in measures of cognitive inhibition

Three experiments are reported using the 'negative priming' paradigm to investigate cognitive differences in normal schizotypal subjects. Lists of Stroop colour words were presented at different display times in a number of priming and non-priming conditions, in one of which the ignored colour name predicted the colour of the next target item. The increased RT latencies to the target normally found in this condition were reduced, or even reversed, in high schizotypal subjects selected on the basis of a new schizotypy scale (STA). This effect was confined to a very short presentation time (100 ms), suggesting that schizotypy is associated with weakened inhibition operating in the early (automatic) stages of information processing. The familiar Stroop (interference) effect was related overall to negative priming, but was not responsible for the schizotypy differences.

Individual differences in negative priming: relations with schizotypal personality traits

A study is reported of normal subjects, selected for degree of schizotypal personality traits, on a cognitive task designed to measure, in a negative priming paradigm, the extent to which they differed in interference and presumed inhibitory effects on performance. The main individual differences measure used--a new scale of schizotypy--showed, as predicted, a significant correlation with negative priming. The correlation with a measure of 'interference' was non-significant but in the expected direction. The results are judged relevant to research implicating a weakening of inhibitory selective mechanisms in schizophrenia and to models in abnormal psychology proposing a continuum between normal and abnormal cognitive function. As such, they suggest a soundly based theoretical approach to the analysis of the individual variations in information processing commonly observed in general cognitive psychology.