Transition to Permitless Open Carry and Association with Firearm-Related Suicide

BACKGROUND

Firearm-related death rates continue to rise in the US. As some states enact more permissive firearm laws, we sought to assess the relationship between a change to permitless open carry (PLOC) and subsequent firearm-related death rates, a currently understudied topic.

STUDY DESIGN

Using state-level data from 2013 to 2021, we performed a linear panel analysis using a state fixed-effects model. We examined total firearm-related death, suicide, and homicide rates separately. If a significant association between OC law and death rate was found, we then performed a difference-in-difference (DID) analysis to assess for a causal relationship between changing to PLOC and increased death rate. For significant DID results, we performed confirmatory DID separating firearm and nonfirearm death rates.

RESULTS

Nineteen states maintained a no OC or permit-required law, whereas 5 changed to permitless and 26 had a PLOC before 2013. The fixed-effects model indicated more permissive OC law that was associated with increased total firearm-related deaths and suicides. In DID, changing law to PLOC had a significant average treatment effect on the treated of 1.57 (95% CI 1.05 to 2.09) for total suicide rate but no significant average treatment effect for the total firearm-related death rate. Confirmatory DID results found a significant average treatment effect on the treated of 1.18 (95% CI 0.90 to 1.46) for firearm suicide rate.

CONCLUSIONS

OC law is associated with total firearm-related death and suicide rates. Based on our DID results, changing to PLOC is indeed strongly associated with increased suicides by firearm.

Cirrhosis Increases the Rate of Failure of Nonoperative Management in Blunt Liver Injuries

Pre-existing cirrhosis is associated with increased mortality in blunt liver injury. Despite widespread use of nonoperative management (NOM) for blunt liver injury, there is a relative paucity of data regarding how pre-existing cirrhosis impacts the success of NOM. Herein, we perform a retrospective cohort study using ACS TQIP 2017-2020 data to assess the relationship between cirrhosis and failure of NOM for adult patients with blunt liver injury. 37,176 patients were included (342 cirrhosis and 36,834 without cirrhosis). After propensity-score matching, patients with pre-existing cirrhosis had higher rates of failure of NOM (32.2 vs 14.1%, p < 0.01) and in-hospital mortality (36.3 vs 10.8%, p < 0.01) than patients without cirrhosis. Hesitancy to operate on patients with pre-existing cirrhosis and trauma, as well as significant underlying coagulopathy, may explain these findings.

Initial Experience Using Laparoscopic HIPEC for Gastric Cancer with Peritoneal Metastasis: Safety and Outcomes

BACKGROUND

Peritoneal metastases (PM) develop in approximately 20% of patients with gastric cancer (GC). For selected patients, treatment of PM with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has shown promising results. This report aims to describe the safety and perioperative outcomes of laparoscopic HIPEC for GC/PM.

METHODS

This retrospective cohort study evaluated patients who had GC and PM treated with laparoscopic HIPEC (2018-2022). The HIPEC involved cisplatin and mitomycin C (MMC) or MMC alone. The primary end point was perioperative safety.

RESULTS

The 22 patients in this study underwent 27 procedures. The mean age was 58 ± 13 years. All the patients were Eastern Cooperative Oncology Group (ECOG) 0 or 1 (55 and 45%, respectively). Five patients underwent a second laparoscopic HIPEC, with a median of 126 days (interquartile range [IQR], 117-166 days) between procedures. The median peritoneal carcinomatosis index (PCI) was 4 (IQR, 2-9), and the median hospital stay was 2 days (IQR, 1-3 days). No 30-day readmissions or complications occurred. Eight patients (36%) underwent gastrectomy (CRS ± HIPEC). After an average follow-up period of 11 months, 7 (32%) of the 22 patients were alive. The median overall survival was 11 months (IQR, 195-739 days) from the initial procedure and 19.3 months (IQR, 431-1204 days) from the diagnosis.

CONCLUSIONS

Laparoscopic HIPEC appears to be safe with minimal perioperative complications. Approximately one third of the patients undergoing initial laparoscopic HIPEC ultimately proceeded to cytoreduction and gastrectomy. Preliminary survival data from this highly selected cohort suggest that the addition of laparoscopic HIPEC to systemic chemotherapy does not compromise other treatment options. These initial results suggest that laparoscopic HIPEC may offer benefit to patients with GC and PM and aid in the selection of patients who may benefit from curative-intent resection.

Is nonoperative management of appendicitis inferior in the COVID-19 era?

BACKGROUND

Previous studies on nonoperative management (NOM) of acute appendicitis (AA) indicated comparable outcomes to surgery, but the effect of COVID-19 infection on appendicitis outcomes remains unknown. Thus, we evaluate appendicitis outcomes during the COVID-19 pandemic to determine the effect of COVID-19 infection status and treatment modality. We hypothesized that active COVID-19 patients would have worse outcomes than COVID-negative patients, but that outcomes would not differ between recovered COVID-19 and COVID-negative patients. Moreover, we hypothesized that outcomes would not differ between nonoperative and operative management groups, regardless of COVID-19 status.

METHODS

We queried the National COVID Cohort Collaborative from 2020 to 2023 to identify adults with AA who underwent operative or NOM. COVID-19 status was denoted as follows: COVID-negative, COVID-active, or COVID-recovered. Intention to treat was used for NOM. Propensity score-balanced analysis was performed to compare outcomes within COVID groups, as well as within treatment modalities.

RESULTS

A total of 37,868 patients were included: 34,866 COVID-negative, 2,540 COVID-active, and 460 COVID-recovered. COVID-active and recovered less often underwent operative management. Unadjusted, there was no difference in mortality between COVID groups for operative management. There was no difference in rate of failure of NOM between COVID groups. Adjusted analysis indicated, compared with operative, NOM carried higher odds of mortality and readmission for COVID-negative and COVID-active patients.

CONCLUSION

This study demonstrates higher odds of mortality among NOM of appendicitis and near equivalent outcomes for operative management regardless of COVID-19 status. We conclude that NOM of appendicitis is associated with worse outcomes for COVID-active and COVID-negative patients. In addition, we conclude that a positive COVID test or recent COVID-19 illness alone should not preclude a patient from appendectomy for AA. Surgeon clinical judgment of a patient's physiology and surgical risk should, of course, inform the decision to proceed to the operating room.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

The continued financial effect of COVID: Increasing costs for non-elective major lower extremity amputations

Background

The COVID-19 pandemic necessitated changes in processes of care, which significantly impacted surgical care. This study evaluated the impact of these changes on patient outcomes and costs for non-elective major lower extremity amputations (LEA).

Methods

The 2019-2021 Florida Agency for Health Care Administration database was queried for adult patients who underwent non-elective major LEA. Per-patient inflation-adjusted costs were collected. Patient cohorts were established based on Florida COVID-19 mortality rates: COVID-heavy (CH) included nine months with the highest mortality, COVID-light (CL) included nine months with the lowest mortality, and pre-COVID (PC) included nine months before COVID (2019). Outcomes included in-hospital patient outcomes and hospitalization cost.

Results

6132 patients were included (1957 PC, 2104 CH, and 2071 CL). Compared to PC, there was increased patient acuity at presentation, but morbidity (31%), mortality (4%), and length of stay (median 12 [8-17] days) were unchanged during CH and CL. Additionally, costs significantly increased during the pandemic; median total cost rose 9%, room costs increased by 16%, ICU costs rose by 15%, and operating room costs rose by 15%. When COVID-positive patients were excluded, cost of care was still significantly higher during CH and CL.

Conclusions

Despite maintaining pre-pandemic standards, as evidenced by unchanged outcomes, the pandemic led to increased costs for patients undergoing non-elective major LEA. This was likely due to increased patient acuity, resource strain, and supply chain shortages during the pandemic.

Key message

While patient outcomes for non-elective major lower extremity amputations remained consistent during the COVID-19 pandemic, healthcare costs significantly increased, likely due to increased patient acuity and heightened pressures on resources and supply chains. These findings underscore the need for informed policy changes to mitigate the financial impact on patients and healthcare systems for future public health emergencies.

The downtrending cost of robotic bariatric surgery: a cost analysis of 47,788 bariatric patients

The surgical robot is assumed to be a fixed, indirect cost. We hypothesized rising volume of robotic bariatric procedures would decrease cost per patient over time. Patients who underwent elective, initial gastric bypass (GB) or sleeve gastrectomy (SG) for morbid obesity were selected from Florida Agency for Health Care Administration database from 2017 to 2021. Inflation-adjusted cost per patient was collected. Cost-over-time ($/patient year) and change in cost-over-time were calculated for open, laparoscopic, and robotic cases. Linear regression on cost generated predictive parameters. Density plots utilizing area under the curve demonstrated cost overlap. Among 76 hospitals, 11,472 bypasses (223 open, 6885 laparoscopic, 4364 robotic) and 36,316 sleeves (26,596 laparoscopic, 9724 robotic) were included. Total cost for robotic was approximately 1.5-fold higher (p < 0.001) than laparoscopic for both procedures. For GB, laparoscopic had lower total ($15,520) and operative ($6497) average cost compared to open (total $17,779; operative $9273) and robotic (total $21,756; operative $10,896). For SG, laparoscopic total cost was significantly less than robotic ($10,691 vs. $16,393). Robotic GB cost-over-time increased until 2021, when there was a large decrease in cost (-$944, compared with 2020). Robotic SG total cost-over time fluctuated, but decreased significantly in 2021 (-$490 compared with 2020). While surgical costs rose significantly in 2020 for bariatric procedures, our study suggests a possible downward trend in robotic bariatric surgery as total and operative costs are decreasing at a higher rate than laparoscopic costs.

Nonelective coronary artery bypass graft outcomes are adversely impacted by Coronavirus disease 2019 infection, but not altered processes of care: A National COVID Cohort Collaborative and National Surgery Quality Improvement Program analysis

Objective

The effects of Coronavirus disease 2019 (COVID-19) infection and altered processes of care on nonelective coronary artery bypass grafting (CABG) outcomes remain unknown. We hypothesized that patients with COVID-19 infection would have longer hospital lengths of stay and greater mortality compared with COVID-negative patients, but that these outcomes would not differ between COVID-negative and pre-COVID controls.

Methods

The National COVID Cohort Collaborative 2020-2022 was queried for adult patients undergoing CABG. Patients were divided into COVID-negative, COVID-active, and COVID-convalescent groups. Pre-COVID control patients were drawn from the National Surgical Quality Improvement Program database. Adjusted analysis of the 3 COVID groups was performed via generalized linear models.

Results

A total of 17,293 patients underwent nonelective CABG, including 16,252 COVID-negative, 127 COVID-active, 367 COVID-convalescent, and 2254 pre-COVID patients. Compared to pre-COVID patients, COVID-negative patients had no difference in mortality, whereas COVID-active patients experienced increased mortality. Mortality and pneumonia were higher in COVID-active patients compared to COVID-negative and COVID-convalescent patients. Adjusted analysis demonstrated that COVID-active patients had higher in-hospital mortality, 30- and 90-day mortality, and pneumonia compared to COVID-negative patients. COVID-convalescent patients had a shorter length of stay but a higher rate of renal impairment.

Conclusions

Traditional care processes were altered during the COVID-19 pandemic. Our data show that nonelective CABG in patients with active COVID-19 is associated with significantly increased rates of mortality and pneumonia. The equivalent mortality in COVID-negative and pre-COVID patients suggests that pandemic-associated changes in processes of care did not impact CABG outcomes. Additional research into optimal timing of CABG after COVID infection is warranted.

Patient outcomes and cost in robotic emergency general surgery

The use of robotic technology in general surgery continues to increase, though its utility for emergency general surgery remains under-studied. This study explores the current trends in patient outcomes and cost of robotic emergency general surgery (REGS). The Florida Agency for Healthcare Administration database (2018-2020) was queried for adult patients undergoing intra-abdominal emergency general surgery within 24 h of admission and linked to CMS Cost Reports/Hospital Compare, American Hospital Association, and Rand Corporation Hospital datasets. Patients from the four most common REGS procedures were propensity matched to laparoscopic equivalents for hospital cost analysis. A telephone survey was performed with the top 10 REGS hospitals to identify key qualities for successful REGS programs. 181 hospitals (119 REGS, 62 non-REGS) performed 60,733 emergency surgeries. Six-percent were REGS. The most common REGS were cholecystectomy, appendectomy, inguinal and ventral hernia repairs. Before and after propensity matching, total cost for these four procedures were significantly higher than their laparoscopic equivalents, which was due to higher surgical cost as the non-operative costs did not differ. There were no differences in mortality, individual complications, or length of stay for most of the four procedures. REGS volume significantly increased each year. The survey found that 8/10 hospitals have robotic-trained staff available 24/7. Although REGS volume is increasing in Florida, cost remains significantly higher than laparoscopy. Given higher costs and lack of significantly improved outcomes, further study should be undertaken to better inform which specific patient populations would benefit from REGS.

Causal analysis of socioeconomic influence on cost of care: The emergency general surgery model

BACKGROUND

This study characterizes the relationship between SES and cost of emergency general surgery (EGS).

METHODS

Utilizing Florida AHCA (2016-2020), patients undergoing the 7 most common EGS were identified. Distressed Community Index (DCI) was linked, which quantifies SES through unemployment, poverty, and other factors. Zipcodes are assigned DCI 0 (no distress) to 100 (severe distress). Linear regression with stepwise elimination was conducted. Top and bottom DCI quintiles were propensity matched for demographics, comorbidities, and procedure.

RESULTS

144,924 admissions were included. Linear regression eliminated 5 of 28 variables, including DCI. Top cost contributors were discharge-43%; comorbidities-14%; age-9%. Distressed patients received less home health and inpatient rehab. Distressed patients utilized 4-/5-star hospitals less and had higher odds of mortality.

CONCLUSION

Discharge, mortality, and hospital characteristics differ significantly between DCI communities. Total cost was similar, and is strongly influenced by discharge status, while DCI had no effect.

COVID-Induced Alterations in Surgical Care and Outcomes in Perforated Diverticulitis

BACKGROUND

COVID-19 caused healthcare systems to significantly alter processes of care. Literature on the pandemic's effect on healthcare processes and resulting surgical outcomes is lacking. This study aims to determine outcomes of open colectomy in patients with perforated diverticulitis during the pandemic.

METHODS

Using CDC data, the highest and lowest COVID mortality rates were calculated and used to establish 9-month COVID-heavy (CH) and COVID-light (CL) timeframes, respectively. Nine-months of 2019 were assigned as pre-COVID (PC) control. Florida AHCA database was utilized for patient-level data. Primary outcomes were length of stay (LOS), morbidity, and in-hospital mortality. Stepwise regression with 10-fold cross-validation determined factors most impacting outcomes. A parallel analysis excluding COVID-positive patients was performed to differentiate COVID-infection from processes of care.

RESULTS

There were 3862 patients in total. COVID-positive patients had longer LOS, more intensive care unit admissions, and higher morbidity and mortality. After excluding 105 COVID-positive patients, individual outcomes were not different per timeframe. Regression showed timeframe did not affect primary outcomes.

DISCUSSION

Outcomes following colectomy for perforated diverticulitis were worse for COVID-positive patients. Despite increased stress on the healthcare system during the pandemic, major outcomes were unchanged for COVID-negative patients. Our results indicate that despite COVID-associated changes in processes of care, acute care surgery can still be performed in COVID-negative patients without increased mortality and minimal change in morbidity.

Association of state-level factors with rate of firearm-related deaths

BACKGROUND

Over 48,000 people died by firearm in the United States in 2021. Firearm violence has many inciting factors, but the full breadth of associations has not been characterized. We explored several state-level factors including factors not previously studied or insufficiently studied, to determine their association with state firearm-related death rates.

METHODS

Several state-level factors, including firearm open carry (OC) and concealed carry (CC) laws, state rank, partisan lean, urbanization, poverty rate, anger index, and proportion of college-educated adults, were assessed for association with total firearm-related death rates (TFDR). Secondary outcomes were firearm homicide (FHR) and firearm suicide rates (FSR). Exploratory data analysis with correlation plots and ANOVA was performed. Univariable and multivariable linear regression on the rate of firearm-related deaths was also performed.

RESULTS

All 50 states were included. TFDR and FSR were higher in permitless OC and permitless CC states. FHR did not differ based on OC or CC category. Open carry and CC were eliminated in all three regression models due to a lack of significance. Significant factors for each model were: 1) TFDR - partisan lean, urbanization, poverty rate, and state ranking; 2) FHR - poverty rate; 3) FSR - partisan lean and urbanization.

CONCLUSIONS

Neither open nor concealed carry is associated with firearm-related death rates when socioeconomic factors are concurrently considered. Factors associated with firearm homicide and suicide differ and will likely require separate interventions to reduce firearm-related deaths.

KEY MESSAGE

Neither open carry nor concealed carry law are associated with total firearm-related death rate, but poverty rate, urbanization, partisan lean, and state ranking are associated. When analyzing firearm homicide and suicide rates separately, poverty rate is strongly associated with firearm homicide rate, while urbanization and partisan lean are associated with firearm suicide rate.

Analysis of temporal trends in robotic surgery costs using the outpatient inguinal hernia repair model

BACKGROUND

Robotic technology is increasingly utilized despite increased costs compared with laparoscopic procedures. As the robot is a fixed, indirect cost, we hypothesized increased volume of robotic procedures will decrease operative costs per patient. The model of same-day, unilateral, primary inguinal hernia surgery in males was chosen.

METHODS

The Florida Agency for Health Care Administration database was queried for inguinal hernia repairs from 2015 to 2020. Inflation adjusted total and operative costs per patient were collected. Cost-over-time and change in cost-over-time were calculated for open, laparoscopic, and robotic cases. Linear regression using cost as the dependent variable generated predictive parameters.

RESULTS

In the study, 36,393 cases (19,364 open, 12,322 laparoscopic, 4,707 robotic) among 86 hospitals were included. In addition, 18 hospitals were "high volume," defined as total robotic inguinal hernia volume of >100 (range, 107-368) during the study period, and included 8,604 cases (3,915 open, 1,786 laparoscopic, 2,903 robotic). Compared with laparoscopic, total robotic cost and cost over time were 1.22- (P < .001) and 1.5-fold higher (P < .002). The change in cost-over-time was increased significantly in robotic cases: 358, 420, 548, 691, and 1,542 cost-over-time for 2015 to 2020, respectively. Positive contributors to total hospital robotic costs were total robotic inguinal hernia volume (17.3), total laparoscopic inguinal hernia volume (12.6), and number of hospital beds (1.9). Total open inguinal hernia volume was a negative contributor (-10).

CONCLUSION

We conclude, in the short term, robotic surgical costs are not behaving as traditional fixed costs in outpatient, unilateral inguinal hernia surgeries. Hospital methodology for cost assignment and increased robotic fixed costs such as purchase of additional instruments may explain these results.

Survivor of Right Atrial Appendage Rupture Following Blunt Chest Trauma

A 20-year-old woman presented to our trauma center with cardiac rupture after a motor vehicle collision. Our patient was the restrained driver in a high-speed collision. She arrived without external evidence of trauma but in obvious distress with tachycardia, tachypnea, and hypotension. Initial FAST was negative and chest x-ray; however, second FAST was equivocal for pericardial fluid. Computed tomography demonstrated a large hemopericardium, suspicious for cardiac injury. She underwent emergent operative exploration with a median sternotomy. A 1 cm right atrial appendage avulsion was identified and repaired primarily. She recovered uneventfully and was discharged home. Survival of blunt cardiac rupture is extremely rare and can occur in the absence of any external signs of trauma. Surgeons should maintain clinical suspicion for blunt cardiac injury in unstable trauma patients with deceleration injuries. Injury to the low-pressure right atrium likely contributed to her ability to survive transport to a trauma center.

Can an advanced nurse practitioner take on the role of senior house officer within a specialised area of practice: an evaluation

This study looked at the impact of advanced nurse practitioners (ANPs) taking on the role of senior house officer (SHO) within obstetrics and gynaecology. It was anticipated that such a change would have benefits for patients and for service delivery. The project took place in the gynaecology department of a district general hospital. All patients who would normally be under the care of the SHOs with one medical team received this care from one or other of two ANPs. Focus groups were used to look at the impact of the changes on other staff within the unit. Patient questionnaires were used to assess the opinions of patients about the care they received. Length of stay, readmissions and cancellations were used to assess the impact on patient care. The change in role of the ANPs has had lasting benefits in terms of better communication and multidisciplinary working and the development of an informal referral system that allowed patients to be seen more quickly and appropriately. There were no ill effects on patient care.

Influence of early discharge after hysterectomy on patient outcome and GP workloads

This paper examines the impact of early discharge following hysterectomy on patient outcome and GP workload. Results are presented from a survey of patient attitudes on care and recovery, pain relief and contacts overall with their general practitioner (GP) surgery. The findings are compared with those of a previous study where a policy of early discharge had been shown to increase GP workloads. The paper discusses the importance of preparing patients adequately for their surgery and postoperative recovery, and highlights the beneficial effects on patient attitudes of the introduction of patient information leaflets, a preadmission clinic and a telephone advice service following discharge.

Current practice for induction of labour in the United Kingdom: time for a review?

This paper presents the results of postal survey of protocols for induction of labour. The drug regimes used for the induction of labour in NHS hospitals in England and Wales have been compared to both RCOG guidelines and to the drug manufacturer's recommendations. A wide variation in practice was found, with many units using dosages that are different from those recommended. The implications of such departures from the norm are discussed in terms of the importance of evidence-based practice and the role of national guidelines in ensuring optimum care.

Outpatient endometrial assessment

Over the past 10 years, outpatient endometrial assessment has largely replaced traditional dilatation and curettage, offering a quick, reliable and cost-effective alternative which avoids the need for general anaesthesia. The techniques available and their scope are discussed in detail.

Efficacy and safety of large-loop excision of the transformation zone

Large-loop excision of the transformation zone (LLETZ) has become a popular treatment for women with cervical intraepithelial neoplasia (CIN) before long-term effectiveness and safety have been fully evaluated. Women who took part in a 1990 study of the procedure have been followed-up by cervical cytology for longer than 2 years. The rate of recurrences and residual lesions was 5.0% in the first year and 0.6% in the second year. LLETZ was also effective when used as a repeat procedure, although the negative histology rate was much higher (4.7% for initial procedures and 20% for repeat procedures). 250 women from the original study group of 1000 answered a questionnaire on fertility and menstrual symptoms 3 years after LLETZ. We found no differences between these women and controls of the same age, living in the same geographical area, with a history of negative cervical smears. LLETZ is a safe and effective procedure with no effect on menstruation or fertility.

Management of women referred to early pregnancy assessment unit: care and cost effectiveness

OBJECTIVE

To assess the efficiency of an early pregnancy assessment unit in the care of women with bleeding or pain in early pregnancy.

DESIGN

Analysis of women attending in the first year of the unit's operation and in the six months immediately before its introduction.

SETTING

Early pregnancy assessment unit in a district general hospital serving a population of 310,000.

PATIENTS

1141 women referred with bleeding or pain in early pregnancy.

MAIN OUTCOME MEASURES

Length of stay in hospital required for diagnosis and treatment.

RESULTS

Before the unit was established the mean admission time was one and a half (range half to three) days for women who required no treatment and three (one and a half to five) days in women requiring evacuation of uterus. These times were reduced to two hours as an outpatient and one day respectively for most women after the unit was established. Between 318 and 505 women were estimated to have been saved from unnecessary admission, and 233 had their stay reduced; the associated saving was between pounds 95,000 and pounds 120,000 in one year.

CONCLUSIONS

The early pregnancy assessment unit improved the quality of care and also produced considerable savings in financial and staff resources.

Colposcopic diagnosis and treatment of cervical dysplasia at a single clinic visit. Experience of low-voltage diathermy loop in 1000 patients

In a study of 1000 women referred over 20 months with abnormal smears and in whom the entire transformation zone could be seen the aim was to test the feasibility of colposcopic assessment and treatment at one visit to the clinic. 897 women needed only one visit. This was achieved by using a modification of the large loop diathermy excision technique and by careful attention to the timing of the clinic visit. 103 required further visits, for the following reasons: incomplete excision on histology and/or subsequently abnormal smear (85), secondary haemorrhage (6), microinvasion or invasive carcinoma (9), biopsy specimens unusable (3). Further treatment was given in 4.1% of the cervical dysplasias. All patients treated in a single visit preferred this approach to the alternative of colposcopic assessment and biopsy followed, after histological examination, by local ablation by laser, excision by loop biopsy technique, or cone biopsy.

A comparison of the efficacy of gemeprost vaginal pessaries and extra-amniotic prostaglandin E2 gel in the induction of middle trimester abortion

In an open random allocation trial of 50 patients, 25 had abortion induced vaginally with gemeprost (16.16-dimethyl-trans-delta squared- prostaglandin E1 methyl ester; PGE) 1 mg pessaries inserted into the posterior fornix. The remainder received 7.5 mg PGE2 in a gel inserted into the extraamniotic space. Following the administration of 2 doses of PGE2 gel, abortion was achieved in 100% of the cases within 24 hours, whereas the group treated with a maximum of 3 gemeprost pessaries administered at 3-hour intervals only achieved abortion within 24 hours in 76% of the cases. 3 doses of gemeprost pessaries are the cost equivalent of 2 doses of PGE2 gel.

The use of a calcium antagonist (nifedipine) to suppress preterm labour

The efficacy of an orally administered calcium antagonist, nifedipine, in suppressing premature uterine activity, was compared with intravenous ritodrine and no treatment. Nifedipine was found to be significantly more effective than ritodrine or withholding therapy, and was almost devoid of side-effects.

Epidural pethidine for relief of episiotomy pain

Epidural pethidine was compared with epidural saline for relief of pain from episiotomy wounds. Pethidine 25 mg administered by the lumbar epidural route produced significant analgesia. However, the incidence and severity of episiotomy pain are so variable that routine use of the technique is not recommended.

Characteristic fetal heart rate changes in severe rhesus isoimmunization

A case of pregnancy complicated by severe rhesus isoimmunization is described. The finding of a sequence of fetal heart pattern changes on daily cardiotocography offers a simple method of detecting the severely compromised fetus, which appears to be related to the underlying pathological process, and is more sensitive than other tests of fetal well-being currently used.

Iron prophylaxis in pregnancy--is it useful?

Iron deficiency anaemia in pregnancy is not a common problem among Black patients in the Durban area, and prophylactic iron supplements do not lead to an increase in haemoglobin values. Prophylactic iron therapy should give way to investigation and appropriate treatment of patients with low haemoglobin values.

Variations in sperm count in oligozoospermic or asthenozoospermic patients

Using a Coulter Counter, sperm density and total sperm population per ejaculate has been measured repeatedly in a series of oligozoospermic and asthenozoospermic patients. Marked variations in these parameters were found with repeated sampling from the same patient. The implications of such findings are discussed.

Radioisotope dilution technique for measurement of blood loss associated with lower segment caesarean section

Using a 51Cr-labelled red cell dilution technique, the blood loss associated with elective lower segment Caesarean section was measured in 30 patients, half of whom had a previous history of Caesarean section. The blood loss (mean +/- SD) was 1290 +/- 240 ml for first Caesarean sections and 1012 +/- 380 ml for repeat operations.

Neonatal jaundice--a comparison between intravenous oxytocin and oral prostaglandin E2

The total serum bilirubin levels at two and occasionally five days after birth were studied in 162 infants whose mothers received either intravenous oxytocin or oral Prostaglandin te2 during labour, and the results were compared with those obtained in forty-two control patients. Following labour of spontaneous onset, whether the mother received intravenous oxytocin or oral Prostaglandin E2, neonatal total serum bilirubin levels were not different from those in controls. After induction by amniotomy and an active agent, higher mean total serum bilirubin levels were found in infants whose mothers received intravenous oxytocin than in those given oral prostaglandin E2; a significant rise in the total serum bilirubin level appeared to occur when mothers received a total of more than 12,000 milliunits of oxytocin or more than 4,000 milliunits per kg birthweight of the infant.