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IntroductionPatient numbers in paediatric emergency departments (PED) are steadily increasing. Parental perception of waiting time and reasons for attending a PED with non-emergencies have been investigated in the UK, Australia, Korea, Canada and the USA. We sought to examine which factors influence parental satisfaction with waiting time in a tertiary Swiss PED and whether these differed from other countries.MethodsPaper surveys were administered to parents of children presenting to our interdisciplinary PED from February to May 2015. Primary outcome was parental satisfaction with waiting time, secondary outcomes were satisfaction with treatment, parental reasons for presentation with non-emergencies, parental perception of times to triage, first physician contact and disposition from ED, level of physician training, understanding of various anticrowding strategies and comparison of perceived and true waiting times to triage and physician contact.Results739 out of 750 surveys were returned (57 complete, 298 with 1 or 2 missing answers). Satisfaction with waiting time (on a 5-point-Likert-scale; 1 being the best possible answer) was higher in groups with shorter waiting time until triage (+0.41, p=0.001), first physician contact (+1.43, pConclusionTo counteract parental dissatisfaction associated with waiting time, we suggest the implementation of feasible measures including entertainment while waiting, early first medical review and timely discharge from the PED.

Introduction: Dysbaric osteonecrosis (DON) in people working under increased atmospheric pressure is well documented. It is generally less common in military and commercial divers than in caisson workers, except in some high-risk groups, such as in many indigenous diving industries where workers have little or no understanding of decompression principles. With the increasing popularity within the recreational diving community of deep air and mixed-gas decompression diving (‘technical diving’), it is likely that diving physicians may see an increase in the prevalence of DON in this group in the future. Methods: The case report is presented of a technical diving instructor, with a 30-year history of deep diving, who developed bilateral humeral head DON and required a right shoulder hemi-arthroplasty. A focused literature search was also undertaken to identify published cases of DON in recreational divers. Results: The frequency, duration and depth of exposure to pressure, inadequate decompression, the occurrence of DCS and increasing age have been common features associated with DON in both divers and caisson workers. Many of these features were present in this technical diver. Conclusions: Whilst DON is uncommon in recreational air scuba divers, all the above risk factors are present to a greater degree in technical diving. It is suggested that medical review for DON is merited from time to time in this potentially high-risk group of recreational divers.

Chronic right-sided salpingitis. Periophorium. Apoplexia and cystic degeneration of the right ovary. Gluttony. Recovery.

Clinical Handover has been identified as one of the most high-risk processes within medicine. Inadequate handover is a significant cause of avoidable adverse events across many hospitals. A likert-survey of the weekend handover system at a district general hospital demonstrated significant dissatisfaction amongst junior doctors. Intending to improve patient safety and reduce stress for on-call junior doctors, a weekend handover proforma was compiled according to the Royal College of Physicians and Surgeons guidelines. The proforma was trialed on six medical wards for six months with a before and after questionnaire being sent to doctors on the wards involved to determine the proforma’s merits on a scale of 1 (least effective) to 10 (most effective). Reports subsequent to implementation demonstrated a 67% increase ease of identifying outstanding weekend jobs. 57% of doctors reported better understanding of their patient’s diagnosis and management plan and 53% stated it was easier to identify the patients that required regular medical review over the weekend. Results also highlighted a 55% reported an increase in safety of weekend handovers (p, Highlights • Weekend handovers are a valuable tool to increase patient safety. • Weekend handovers can reduce stress levels in junior doctors. • Weekend handovers have been shown to reduce the financial and operational burden.

Mrs. Duong had coronary artery disease, ischemic cardiomyopathy, and mildly altered mental status when her case was presented before an advanced heart therapy medical review board. She was accepted for left ventricular assist device placement pending additional insight into her cognitive state. Before the LVAD could be implanted, however, Mrs. Duong went into cardiogenic shock, and her heart failure team placed an intra-aortic balloon pump in her subclavian artery. Within two weeks, Mrs. Duong became IABP dependent and deconditioned. The attending deemed her as lacking capacity to make complex medical decisions, and the medical review board officially declined her for LVAD placement. The heart failure and CICU teams feel that Mrs. Duong is not being helped by the care they are giving her. They recommend terminal weaning of the IABP and initiation of comfort care. Her family disagrees, pointing to activities like continued eating and interacting with family. At an impasse after yet another family meeting, the attending for the heart failure team asks the clinical ethics consultant, "Do we have to replace the balloon pump when it fails?"

INTRODUCTION: Exposure to high G force is a known safety hazard in military aviation as well as civilian aerobatic flight. Tolerance to high G forces has been well studied in military pilots, but there is little research directed at civilian pilots who may have medications or medical conditions not permitted in military pilots.METHODS: In this case-control study, we identified 89 fatal high-G aerobatic accidents and 4000 fatal control accidents from 1995 through 2018 from the NTSB accident database and the FAA autopsy database. We retrieved medications and medical conditions from the FAA's pilot medical databases. Logistic regression models were used to explore the associations of drugs, medical conditions, height, and medical waivers with high-G accidents.RESULTS: Seven drugs (alprazolam, clonidine, ethanol, meclizine, phentermine, triamterene, and zolpidem) reached statistical significance in our models, but had such small case counts that we consider these findings to be uncertain, except for ethanol, which was found in seven cases. Of these, only triamterene was known to the FAA. Statistically significant medical predictors included only alcohol abuse (seven cases) and liver disease (only two cases).DISCUSSION: Our analysis found that the drug ethanol and the condition alcohol abuse are significantly associated with high-G accidents. Seven other factors were statistically significant, but should only be considered as hypothesis generating due to very low case counts. Our study does not suggest that restricting pilots with otherwise permissible medications or medical conditions from aerobatics is warranted.Mills WD, Greenhaw RM, Wang JMP. A medical review of fatal high-G U.S. aerobatic accidents. Aerosp Med Hum Perform. 2019; 90(11):959–965.

The IMPaCT (Integrated Mersey Palliative Care Team) model of care is designed to improve access for patients, their families, and professionals. The COVID-19 pandemic enabled implementation more quickly than envisaged. Waiting times for medical appointments in our integrated palliative medicine service were in excess of two weeks, restricting the clinic system’s ability to deal with acute problems. The team recognised that routine medical review of patients is often unnecessary, and with this in mind, all the referrals for outpatients are now assessed by a nurse specialist triage coordinator and those requiring routine follow-up are now fed into the nurse-led telephone assessment clinics for monitoring. There is a junior and a senior palliative medicine doctor assigned to the ambulatory medical clinic in the IMPaCT hub at Woodlands Hospice from Monday to Friday. There are a small number of pre-planned appointment slots for follow up, but the rest are used for urgent assessment of patients in person, by video consultation or by phone. Domiciliary visits can be undertaken if needed on the day. All admission requests and advice calls to the ward now come to the hub which means that the calls come into doctors with the necessary time to deal with issues as they arise, co-ordinating with other members of the team as needed. This also means the medical team on the inpatient unit have more time to see their patients. Co-location of the ambulatory medical clinics with the nurse triage coordinators has improved working relationships and means that all settings have an awareness of which patients are most complex. Admissions to the hospice are now appropriately more complex and the waiting time reduced to within 24 hours in the majority of cases in December 2020. Waiting times for medical assessments has reduced to within 24 hours of the request.

Aims In-hospital cardiac arrests are often preceded by a period of physiological deterioration that has often gone unnoticed. We proposed that the same might be true for out-of-hospital cardiac arrests (OHCAs) where ambulance crews leave patients at home who then subsequently go on to suffer a cardiac arrest. Methods and results We identified all OHCA over a 12-month period that had been seen and assessed by an ambulance crew within the 48 h preceding their cardiac arrest. We retrospectively calculated the patient’s NEWS2 score at the time of their initial assessment as a marker of their physiological status and need for hospital admission. Of 1960 OHCA patients, 184 (9.4%) had been assessed by ambulance crews within the preceding 48 h. Excluding those who had been taken to hospital (and then discharged), declined hospital conveyance or were on end-of-life care pathways, 79 (56% of total) were left at home through crew discretion. Thirty-four out of 79 (43%) patients not conveyed had either a NEWS score of 3 in a single parameter or a score of ≥5, which in hospital would mandate an urgent medical review. The most overlooked observation was respiratory rate. Conclusions In total, 1.7% of all OHCA had been assessed in the previous 48 h and inappropriately left at home by ambulance crews. This represents a missed opportunity to avert cardiac arrest. NEWS scoring has the potential to improve pre-hospital triage of these patients and avoid missing the deteriorating patient.

For the past several decades, medical malpractice claims in the state of Louisiana have been screened by a pretrial medical review panel (MRP). Composed of 3 physicians and 1 attorney, these panels are a method of filtering nonmeritorious lawsuits while expediting creditable claims. Currently, 14 jurisdictions in the United States require medical liability/malpractice cases be heard by an MRP or screening panel prior to trial. In this article, we review the MRP process in Louisiana and compare it to those in other states. Data are presented for the past 10 yr of malpractice claims in Louisiana with an emphasis on the neurosurgery specialty. Finally, the benefits and challenges of pretrial screening panels are discussed.

Objective To evaluate the implementation of an intervention for parents to escalate care if concerned about their child's clinical condition. Design Mixed-methods health-care improvement approach guided by the Theoretical Domains Framework. Methods Implementation of the 'Calling for Help' (C4H) intervention was informed by previously identified barriers and facilitators. Evaluation involved audit, review of clinical deterioration incidents, interviews and focus groups. Setting Australian specialist paediatric hospital. Participants Convenience sample of 75 parents from inpatient areas during the audit, interviews with ten parents who had expressed concern about their child's clinical condition; five focus groups with 35 ward nurses. Main outcome measures Parent awareness and utilization of C4H, parent and nurse views of factors influencing implementation. Results Parent awareness of C4H improved to 35% (25/75). Parent concern was documented prior to 21/174 (12%) clinical deterioration events. All interviewed parents and nurses who participated in focus groups were positive about C4H. Parents preferred to be informed about C4H by nurses, but nurses described this as time-consuming and selectively chose parents who they believed would benefit most. Parents and nurses described frustrations with and trepidation in escalating care. Nurses had used C4H to expedite urgent medical review. Conclusions There was an improvement in the level of parent awareness of C4H, which was viewed positively by parents and nurses alike. To achieve a high level of parent awareness in a sustainable way, a multifaceted approach is required. Further strategies will be required for parents to feel confident enough to use C4H and to address interprofessional communication barriers.

Objectives To provide an introduction to the role of audiological evaluations with special reference to patients with skull base disease. Design Review article with case-based overview of the current state of the practice of diagnostic audiology through highlighting the multifaceted clinical toolbox and the value of mechanism-based audiological evaluations that contribute to otologic differential diagnosis. Setting Current state of the practice of diagnostic audiology. Main Outcome Measures Understanding of audiological evaluation results in clinical practice and value of contributions to interdisciplinary teams to identify and quantify dysfunction along the auditory pathway and its subsequent effects. Results Accurate auditory information is best captured with a test battery that consists of various assessment crosschecks and mechanism-driven assessments. Conclusion Audiologists utilize a comprehensive clinical toolbox to gather information for assessment, diagnosis, and management of numerous pathologies. This information, in conjunction with thorough medical review, provides mechanism-specific contributions to the otologic and lateral skull base differential diagnosis.

A substantial proportion of individuals with newly diagnosed epilepsy report prior seizures, suggesting a missed opportunity for early epilepsy care and management. Consideration of the causes and outcomes of diagnostic delay is needed to address this issue. We aimed to review the literature pertaining to delay to diagnosis of epilepsy, describing the components, characteristics, and risk factors for delay. We undertook a systematic search of the literature for full-length original research papers with a focus on diagnostic delay or seizures before diagnosis, published 1998-2020. Findings were collated, and a narrative review was undertaken. Seventeen papers met the inclusion criteria. Studies utilized two measures of diagnostic delay: seizures before diagnosis and/or a study-defined time between first seizure and presentation/diagnosis. The proportion of patients with diagnostic delay ranged from 16% to 77%; 75% of studies reported 38% or more to be affected. Delays of 1 year or more were reported in 13%-16% of patients. Seizures prior to diagnosis were predominantly nonconvulsive, and usually more than one seizure was reported. Prior seizures were often missed or mistaken for symptoms of other conditions. Key delays in the progression to specialist review and diagnosis were (1) "decision delay" (the patient's decision to seek/not seek medical review), (2) "referral delay" (delay by primary care/emergency physician referring to specialist), and (3) "attendance delay" (delay in attending specialist review). There were few data available relevant to risk factors and virtually none relevant to outcomes of diagnostic delay. This review found that diagnostic delay consists of several components, and progression to diagnosis can stall at several points. There is limited information relating to most aspects of delay apart from prevalence and seizure types. Risk factors and outcomes may differ according to delay characteristics and for each of the key delays, and recommendations for future research include examining each before consideration of interventions is made.

Background: Prescribing errors are quite common and according to one estimate out of 100 patients admitted into UK hospitals 15 will have some form of prescribing error in their records. It is a general understanding that most of the time these errors are made due to lack of awareness. Severity of these errors can range from minor to major mistakes that can lead to fatal results. Materials and Methods: A simplified anonymous approach of identifying these errors and then using a step wise approach to educate the prescribers’ especially junior doctors can be quite fruitful in reducing these errors. Unfortunately there are not many studies or projects available to back our proposal however these seems a logical way forward and is exactly what we have shown in our study. Results: We performed a prospective snapshot study involving 100 inpatients to get baseline measurements. The errors and mistakes were identified and fed back to the junior doctors in an anonymous manner. Clear & legible writing, frequency of use, responsible consultant name, allergy box filled, VTE assessment, oxygen prescribing and labeling of medication discontinuation were the most common negligence identified. At the same time junior doctors were reminded of local prescription standards and guidelines which usually don’t form part of induction. Conclusion: Multiple deficient areas were identified during this audit like legible writing, dosage frequency, VTE prophylaxis and oxygen prescription. It was highlighted to junior doctors how important are these components as they play a key role in patient getting better after medical review. Above mentioned steps did improve prescription errors to an extent, but aim should be to achieve 100% results. Repeated reminders are important in this case as that helps to improve practice and avoid clinical accidents.

AimsTo establish the improvements in the quality of seclusion medical review after introducing a template to complete the review.BackgroundThe Mental Health Act – Code of Practice outlines the standards of patient care while in seclusion. It also emphasis that supportive engagement/observation schedules should be reviewed in person and continued at the point an episode of seclusion was initiated.Furthermore, NICE also set up standards to monitor side effect profile while prescribing psychotropic for such patients and regular management review. It also gives importance to staff training to ensure these standards.To improve the quality of the seclusion medical review, we completed an audit in July 2019 to ascertain whether medics are following Trust Policy.We identified good results (above 90%) in the following areas:Time of seclusion reviewRecord keepingManagement planGood documentation of risk, mental state examination and physical health.We also noticed that the following areas can be improved:Prescribed Medications. (60%)Medication side effects. (40%)Physical Observations (40%)We used the following audit standards for our audit after our last audit and a template was designed and after discussion with medics incorporated into the existing documentation template.Time of reviewReason and duration for seclusionPsychiatric diagnosisMental State Examination/BehaviourPhysical health (including physical observations)/EnvironmentMedication (prescribed, rapid tranquilisation, side effects, or adverse effects)Risk (to self-DSH or accidental) (risks to others)Plan :(frequency of physical obs./medical review, management, restrictions, exit plan for terminating seclusion, patient's capacity to understand it)MethodWe considered the following aspects:Retrospective data collection from 01.03.2020 to 30.08.2020.Sample selection: random selection of mixture of clinicians on different times and days of the week.Data analysis was carried out by using Microsoft Excel.ResultWe noticed a marked improvement in the quality of seclusion medical review (between 95% and 100%) after introducing a template for it. There were no major concerns identified during the re-audit.ConclusionTo continue to use the template for Seclusion Medical Review which has shown significant improvement in the quality of the reviews which will improve patient care.It also helped us to deliver person centred care and safe practice.To continue teaching and training of doctors.This QIP project motivated nurses to do an audit on nursing seclusion review and made necessary changes.

AimsWhilst patient psychiatric health is the primary focus in the acute psychiatric inpatient setting, there has been a recent focus on ensuring a greater integration with physical health to address the physical health outcome inequalities between patients with psychiatric conditions and those without. Despite the ward having a robust physical health clerking proforma, there were issues with its completion; at initial clerking patients often aren't able, or refuse, to consent to physical examination or investigations. This lead to the trust's electronic physical health form, designed to collate these results, not always being completed. Our aim was to increase the rates of completion.MethodChanges to ward handover sheets were made in an effort to increase rates of physical health form completion and improve 24 and 72 hour completion rates. Columns were added delineating which parts of the physical clerking were outstanding, ensuring the MDT were aware of which jobs needed actioning. Data for two months prior and post intervention were analysed.Result266 admissions were analysed for the two months prior and post the intervention. Form completion rose from July (88%) to October (100%), with 24 and 72 hour completion rate increasing from 47% & 55% respectively, to 84% & 96%, during the same time period. Greater completion rates of physical health forms led to increased knowledge of patients’ physical health issues. Having 96% of patients physical health issues within three days of admission (cf. 55%, July), led to a 'physical health huddle' being held during the MDT. This provided a platform to discuss relevant physical health treatment plans with the whole team. These findings were summarised under a new column on the handover sheet and updated biweekly during the MDT meeting. Placement on the handover sheet ensured daily visibility to all staff.ConclusionSimple structural changes can bring physical health to the fore in psychiatric care. Timely and more complete physical health data enabled biweekly reviews of physical health issues and allowed input across the MDT. Increased knowledge and awareness of physical health issues led to an increase in medical review requests. These are currently performed on an ad hoc basis, which can be quite disorganised and inefficient. The results above, of improved physical health outcomes based on a structured approach, have led to a recommendation of a biweekly physical health clinic, with specific staffing allocation, to ensure a more thorough and efficient way to address physical health.

Aim This Quality Improvement project aimed to increase the usefulness of ward rounds in a busy Special Care Baby Unit (SCBU; i.e. low dependency neonatal unit). Most babies’ primary reasons for remaining inpatient in SCBU are to gain weight and establish oral feeds. Despite this taking weeks for some, they were seen daily on ward round. Baseline data showed that 86% ward round plans for these low risk babies made no changes to management. My aim was to halve this number in four months. Method Babies that required daily medical review (table 1) were identified and excluded from the project, leaving only low risk infants. The medical team were instructed to actively seek out babies of concern by discussion with nurses before ward round. The first PDSA cycle introduced the project to colleagues. Subsequent cycles reduced the frequency of ward round to three times per week, trialling different days. Data was collected from clinical notes. Balancing measures were details of babies that became unwell in the data collection period. Results The frequency of ward round plans making no changes to management of low risk babies dropped from 86% to 17%, which surpassed the aim. Doctors felt they had more time to help colleagues on the postnatal ward, complete discharge paperwork further in advance (thus facilitating morning discharges) and for projects. Medical and nursing teams were satisfied that well babies were not examined and disturbed daily. Conclusion Medical and nursing teams are more satisfied with ward rounds occurring three times per week instead of daily for low risk babies in SCBU. More work is needed to look into ways to empower nursing staff to lead on care in low risk babies on their journey to discharge. This project would have had more impact if a reliable measure could be found for staff efficiency.

The application of teledermatology for evaluating acne patients has yielded comparable therapeutic outcomes with traditional face-to-face evaluation, but follow-up compliance between these modalities is not well-studied. Our objective is to compare the rate and duration of follow-up between acne patients initially evaluated by teledermatology versus in-person outpatient consultation. Electronic medical review of acne patients, 18-35 years-old seen via teledermatology and face-to-face evaluation at the University of Pittsburgh Medical Center between 2010-2018 was performed. Teledermatology patients were less likely to follow-up in the first 90 days (13.0% versus 31.0%, Plt;0.001) compared to patients seen face-to-face with overall follow-up rates of 22% among both modalities. The median time to follow-up was 45.5 days (IQR: 13/57) in the teledermatology group compared to 64 days (IQR: 56/77) in the face-to-face group (Plt;0.001). Teledermatology patients were more likely to be treated with oral antibiotics (43.0% versus 28.5%) or oral spironolactone (18.5% versus 12.5%) compared to patients seen face-to-face (Plt;0.001). Teledermatology poses a promising solution to extend dermatologic care with earlier access to follow-up. Our data demonstrates a need to improve teledermatology follow-up education to improve follow-up care.

Background There are cases where epidural analgesia is initially effective but subsequently fails and needs to be resited. We evaluated the rate of normal vaginal delivery and operative delivery among parturients who had resited epidurals compared to parturients with epidurals that were not resited. Methods A retrospective electronic medical review of parturients with a singleton gestation attempting normal vaginal delivery under epidural analgesia between the years 2012-2016 was conducted. Resited epidurals were defined as epidurals that were considered effective but subsequently removed and reinserted. For each resited epidural, two previous and two consecutive deliveries of parturients with normally functioning epidural catheter inserted by the same anesthesiologist were matched controls (non-resited epidurals). Results There were 35,984 attempted vaginal deliveries with 118 resited epidurals and 472 non-resited epidurals. When adjusted for nulliparity, oxytocin administration, sex and weight of the baby, and maternal BMI, labor epidural catheter replacement was not associated with need for instrumental or caesarean delivery, (OR 1.5, 95% CI 0.91-2.49, P = .11). Conclusions Need for labor epidural catheter replacement does not appear to be associated with need for operative delivery based on this single-centre cohort analysis.

The long-term traveler can be defined as those traveling or residing overseas for more than 6 months and includes those going on extended holidays (gap year/backpackers/visiting friends and relatives) and those residing overseas (expatriates). Screening involves a medical review to identify possible exposure to risk of infections that may have implications for the health of the traveler. The type and extent of risk to the health of long-term travelers, and the screening of them on return, vary considerably according to the individual, their destinations, duration, and purpose of travel. The clinician must make a risk assessment, including a detailed history, in order to assess the likelihood of exposure to infectious and non-infectious travel-associated risks and assess the potential impact of that risk, for example, exposure to schistosomula, sexually transmitted and blood-borne infections, tuberculosis, and malaria, bearing in mind that infections may be asymptomatic or latent at screening.

OBJECTIVE: To examine the effects of Medicare's Medical Review (MR) program on short‐stay inpatient hospitalization. DATA SOURCES/STUDY SETTING: One Hundred percent of Medicare Part A and Part B claims and the Master Beneficiary Summary File (2007–2010). STUDY DESIGN: Retrospective observational study using a difference‐in‐differences approach. We examined six primary intake diagnoses, we believed likely to be targeted by MR. We stratified by hospital profit structure, bed size, system membership, and inpatient admission rate to test for differential effects. The comparison group was hospital visits occurring in those MACs that had yet to implement, as well as those that did not implement during the period of interest. DATA COLLECTION: None. PRINCIPAL FINDINGS: Medical Review significantly reduced the likelihood of inpatient admission for patients with an intake diagnosis of “Non‐Specific Chest Pain” by 1.29 percentage points (p

Background: Seizures in tuberous sclerosis complex (TSC) tend to be intractable over time and become a subsequent psychological burden for the patients. The purpose of the current study was to describe the onset, phenotype, and factors associated with seizure remission in patients with TSC. Methods: Patients diagnosed with TSC between 2009 and 2015 completed a questionnaire interview and underwent a systematic evaluation, including a medical review of their epilepsy history and neurobehavioral disorder assessment. Results: Of the 61 patients, 50 patients (82.0%) had a positive seizure history. The active (n = 34) and seizure remission (n = 16) groups showed significant differences in age, neurobehavioral disorder, history of refractory epilepsy, and onset age (p

Zusammenfassung Einleitung Mit dem Krankenhausstrukturgesetz wurde der § 275a SGB V dem Sozialgesetzbuch eingefügt. Er präzisiert und erweitert die rechtlichen Voraussetzungen für Qualitätskontrollen in Krankenhäusern durch den Medizinischen Dienst der Krankenversicherung (MDK). Diese sollen dazu beitragen, eine qualitativ hochwertige, patienten- und bedarfsgerechte Versorgung der Bevölkerung sicher zu stellen. Anhand der mittlerweile 10-jährigen Praxis des MDK Hessen soll die Praktikabilität der Qualitätsprüfungen aufgezeigt werden. Methode Die bislang in den Krankenhäusern durchgeführten Qualitätsprüfungen betreffen die Überprüfung der Strukturqualität auf der Basis von Bestimmungen des G-BA zur Qualitätssicherung spezieller Versorgungskomplexe/Verfahren bzw. des DIMDI zu Komplexbehandlungen. Sämtliche Qualitätsprüfungen in den hessischen Kliniken werden von einem darauf spezialisierten Team des MDK durchgeführt. 2 fachärztliche Prüfer führen diese in Form von Begehungen vor Ort durch. Neben Verantwortlichen der Fachebene sind auch Mitglieder der Führungsebene aus dem Krankenhausmanagement bei den Qualitätsprüfungen vor Ort beteiligt. Ergebnisse In den Jahren 2006–2016 wurden 357 Qualitätsprüfungen gemäß den Bestimmungen des G-BA zu 10 verschiedenen Versorgungskomplexen/Verfahren durchgeführt. In rund 20% der Fälle wurden die vorgeschriebenen Anforderungen nicht erfüllt. Im selben Zeitraum wurden 1624 Qualitätsprüfungen gemäß den Vorgaben des DIMDI zu 33 verschiedenen Komplexkodes durchgeführt. In rund 40% der Fälle wurden die vorgeschriebenen Anforderungen nicht erfüllt. Schlussfolgerung Die bei den Prüfungen erhobenen Defizite belegen die Notwendigkeit von Qualitätskontrollen durch eine unabhängige und qualifizierte Instanz. Die Qualitätsprüfungen tragen zur Qualitätssicherung und damit zur Struktur-, Prozess- und Ergebnisqualität in den Krankenhäusern bei. Die in Hessen etablierte Prüfpraxis ist auf die zukünftig bundesweit durchzuführenden Qualitätskontrollen übertragbar.

The purpose of this study was to analyze the relationship between academic success and functional and dysfunctional families. A non-experimental, cross-sectional, descriptive correlational design was used. A convenience sample of 200 children between 6 and 13 years old, primary and junior high school students was conducted (32.3% were female and 67.7% were male). To assess the relationship, a study case of 21 reagents was designed to empty the obtained information from medical review records from a psychopedagogic clinic. Academic success was measured as from the revision of informal tests and standardized tests. Results showed that the population levels of academic success were average. However, a significant relationship between the age of the parents and the level of academic success was found, indicating that these variables are associated with this problem. Besides that, it was found that there is a tendency in children with cognitive, emotional and sensory problems reflected in low academic success. The findings provide information that could be considered for the development of programs of psychopedagogic intervention to treat children with learning disabilities and low academic success.

Married and childless. She never had a month, but every month her usual peeling of the cuticle of her entire body intensified, and her head hurt for 3-4 days. Sexual intercourse has always been indifferent.

The author cites the history of the illness of one patient with manifestations of cortical epilepsy: convulsions began on the face, then passed on to the arm and leg, for the most part the seizure was limited to one left side. Left n. facialis was paralyzed; in the left extremities - paresis with reduced rigidity and increased tendon reflexes, while in the arms paresis and rigidity were almost the same, and rigidity prevailed in the legs. After the seizure, the paralysis intensified sharply. Some seizures were preceded by a motor aura: clonic convulsions in the paralyzed limbs. Left side sensitivity was decreased; muscle feeling weakened, stronger in the arms, less in the legs. The patient died of tuberculous pneumonia. When opened, found in the right hemisphere softening, which occupied the lower third of the posterior central gyrus. Gyrus marginalis in the anterior part was destroyed. The softening into the depths did not extend equally. In the rear part, it went quite deep; the radiant end in the supramargi nalis area is softened, the system of long connecting paths, apparently, is not affected; small focus in the superior parietal gyrus In the middle of the focus, destruction is limited to the cortex. In the front part, the softening was located under the cortical layer and reached the inner capsule. Deep-lying gray masses, corpus callosum and cingulum have survived from destruction. Microscopic examination showed extensive degeneration in connective and adhesive pathways; the descending rebirth was barely expressed and was found only in Marchi.

Patient 31 years old, multiparous. She was ill after childbirth, she threw it out 2 times, and suffered from monthly disorders, pain and leucorrhoea. The patient is hysterical, and her aphony was of hysterical origin.

Each of the existing methods of caring for the umbilical cord has known advantages and disadvantages. So, the previous method of the author (powdering with a mixture of 10 hours of magisterii bismuthi and 1 hour of iodoform), having the property of causing dry mummification of the umbilical cord, the remainder, not accompanied by either irritation or separation, is the inconvenience that the remnant does not disappear before 7 days, and it slowly drags on to 10, due to which all the time mothers have to be released with the unreported umbilical cord residue from the fetus.

Patient 67 years old, does not wear blood since 50 years of age, suffers from 5 years of umbilical hernia and progressive enlargement of the abdomen. The hernia cannot be adjusted, the abdomen is greatly increased in volume. Above the hernia, the sound, when tapped, tympanic, with the sides - dull, passing at a distance of 4 fingers from the spine, in tympanic; below the hernia, the sound is dull. In the area of a dull sound, there is a ripple.

On February 24, 1893, a bourgeois woman, 27 years old, was admitted to the hospital, almost pulseless, at t 40 C., with complaints of dizziness, severe pain in the lower abdomen, bloody discharge from the genital parts during the last month, and so on. From the spread, it turned out that she gave birth once at the age of 20; after giving birth was sick 3 months. 21/2 months ago, the regulations stopped, pain in the lower abdomen appeared, and afterwards bloody effusion from the genitals joined; 2 days before admission to the hospital, bleeding appeared, the patient lost strength. Objectively: the abdomen is sore at the bottom, the left groin area is swollen; the uterus is enlarged, dense, sensitive, almost immobile; the length of the uterine cavity is 8 cm. The vaults are flattened. The left tube and ovary are palpated in the form of a solid tumor with an unclear fluctuation. On the right and behind the uterus, the tumor is dense, immobile, eat the head of the newborn. - Diagnosis: extrauterine pregnancy, rupture of the fetal baby.

Background In MYSTIC, an open-label, phase 3 trial of first-line D (anti-PD-L1) ± T (anti-CTLA-4) vs CT, while not statistically significant, a clinically meaningful improvement in overall survival (OS) was seen with D vs CT in patients with tumour cell PD-L1 expression ≥25% (TC ≥ 25% [primary analysis population]; D vs CT, HR 0.76 [97.54% CI 0.56–1.02]; D+T vs CT, HR 0.85 [98.77% CI 0.61–1.17]). Here we report results in a subpopulation of Asian patients. Methods Immunotherapy/CT-naive patients with metastatic NSCLC were randomized (1:1:1) to D (20 mg/kg q4w); D (20 mg/kg q4w) + T (1 mg/kg q4w ≤4 doses); or CT. In this analysis in a subpopulation of Asian patients, efficacy outcomes were evaluated in patients with PD-L1 TC ≥25%; safety was evaluated in all treated patients (regardless of PD-L1 expression). Results Of the 488 patients in the primary analysis population (PD-L1 TC ≥25%), 156 (32%) were Asian (D, 59; D+T, 50; CT, 47). Baseline characteristics in the Asian population were balanced between treatment arms. OS was improved in Asian patients (PD-L1 TC ≥25%) with D vs CT (HR 0.69 [95% CI 0.43–1.09]) and D+T vs CT (HR 0.64 [95% CI 0.40-1.03]); more patients receiving D or D+T remained in response at 6 months vs CT (Table). Grade ≥3 treatment-related adverse events (TRAEs) and any grade TRAEs leading to discontinuation occurred in 19.7% and 9.0% (D); 23.9% and 14.5% (D+T); 23.4% and 7.2% (CT) patients in the Asian subpopulation, respectively.Table474OTableDurvalumabDurvalumab + tremelimumabChemotherapyOverall (n = 163)Asian (n = 59)Overall (n = 163)Asian (n = 50)Overall (n = 162)Asian (n = 47)Median OS, mo16.3 (12.2–20.8)18.8 (9.2–28.4)11.9 (9.0–17.7)17.7 (11.6–27.3)12.9 (10.5–15.0)10.6 (7.0–14.6)24-mo OS rate, %38.343.835.442.022.722.3OS HR vs CT (95% CI)0.76 (0.56–1.02)*0.69 (0.43–1.09)0.85 (0.61–1.17)†0.64 (0.40–1.03)––ORR, n (%)58 (35.6)19 (32.2)56 (34.4)18 (36)61 (37.7)17 (36.2)Patients remaining in response (%) at6 mo66.968.467.652.732.434.312 mo61.362.254.926.318.0NROverall and Asian populations include patients with PD-L1 TC ≥25%;.*97.54% CI; †98.77% CI; ORR occurred on June 1, 2017; DoR, duration of response; NR, not reached; ORR, objective response rate; OS, overall survival. Conclusions Durvalumab resulted in a favourable HR for OS compared to CT in patients with PD-L1 TC≥25% in the Asian subpopulation, which was consistent with the primary analysis population. OS HR for D+T vs CT appeared to be more favourable in the Asian subpopulation compared to the primary analysis population, although results should be interpreted with caution due to small sample sizes. The safety profile of D±T in the subpopulation of Asian patients was manageable and consistent with the primary analysis population. Clinical trial identification NCT02453282. Editorial acknowledgement Medical writing support, which was in accordance with Good Publication Practice (GPP3) guidelines, was provided by Beena John, PhD of Cirrus Communications (Macclesfield, UK), an Ashfield company, and was funded by AstraZeneca. Legal entity responsible for the study AstraZeneca. Funding AstraZeneca. Disclosure B.C. Cho: Advisory / Consultancy, Research grant / Funding (institution): AstraZeneca; Advisory / Consultancy, Research grant / Funding (institution): Novartis; Research grant / Funding (institution): Bayer; Research grant / Funding (institution): MOGAM Institute; Advisory / Consultancy: Boehringer Ingelheim; Advisory / Consultancy: Roche; Advisory / Consultancy: BMS; Advisory / Consultancy, Research grant / Funding (institution): Ono; Advisory / Consultancy, Research grant / Funding (institution): Yuhan; Advisory / Consultancy, Research grant / Funding (institution): Janssen; Research grant / Funding (institution): Champions Oncology; Research grant / Funding (institution): Dong-A ST; Research grant / Funding (institution): Dizal Pharma; Advisory / Consultancy, Research grant / Funding (institution): MSD; Advisory / Consultancy: Pfizer; Advisory / Consultancy: Eli Lilly; Advisory / Consultancy: Takeda; Shareholder / Stockholder / Stock options: TheraCanVac Inc. K.H. Lee: Honoraria (self), Advisory / Consultancy: AstraZeneca; Honoraria (self), Advisory / Consultancy: MSD; Honoraria (self), Advisory / Consultancy: BMS. S. Lucien Geater: Honoraria (self), Research grant / Funding (institution): AstraZeneca; Honoraria (self), Research grant / Funding (institution): Roche; Honoraria (self), Advisory / Consultancy, Research grant / Funding (institution): Boehringer Ingelheim; Research grant / Funding (institution): Novartis; Research grant / Funding (institution): Samsung. T.V. Ngoc: Research grant / Funding (institution): AstraZeneca; Research grant / Funding (institution): GSK; Research grant / Funding (institution): Novartis. S. Clarke: Advisory / Consultancy, Travel / Accommodation / Expenses: AstraZeneca. S. Kuyama: Speaker Bureau / Expert testimony, Lecture fees: AstraZeneca; Speaker Bureau / Expert testimony, Lecture fees: Pfizer; Speaker Bureau / Expert testimony, Lecture fees: Eli Lilly; Speaker Bureau / Expert testimony, Lecture fees: Boehringer Ingelheim; Speaker Bureau / Expert testimony, Lecture fees: MSD; Speaker Bureau / Expert testimony, Lecture fees: Taiho; Speaker Bureau / Expert testimony, Lecture fees: Chughai. K. Nakagawa: Honoraria (institution), Research grant / Funding (institution): MSD / Takeda / SymBio Pharmaceuticals / Daiichi Sankyo; Honoraria (self), Research grant / Funding (institution): Eli Lilly Japan; Honoraria (self), Research grant / Funding (institution): BMS; Honoraria (self), Research grant / Funding (institution): Taiho /Ono / Chughai; Honoraria (self), Research grant / Funding (institution): AstraZeneca / Astellas Pharma / Novartis / Nippon Boehringer Ingelheim / Pfizer Japan; Research grant / Funding (institution): Merck Serono / ICON Japan /PAREXEL / IQVIA Services Japan / A2 Healthcare / AbbVie; Research grant / Funding (institution): EP-CRSU / Linical / Otsuka Pharmaceuticals / EPS International / Quintiles / CMIC Shift Zero / Eisai / Kissei Pharmaceutical ; Research grant / Funding (institution): Kyowa Hakko Kirin / EPS Corporation / Bayer Yakuhin / inVentiv Health Japan / Gritstone Oncology / GSK / Yakult Honsha / Covance ; Honoraria (self): Kyorin Pharmaceutical / CareNet / Nichi-Iko Pharmaceutical / Hisamitsu Pharmaceutical / Yodosha / Clinical Trial / Reno Medical / Nanzando / Medical Review; Honoraria (self): Medicus Shuppan / Ayumi Pharmaceutical / Thermo Fisher Scientific / Yomiuri Telecasting Corporation / Nikkei Business Publications. F. Liu: Full / Part-time employment, Full-time employee: AstraZeneca. D. Clemett: Full / Part-time employment, Full-time employee: AstraZeneca. U. Scheuring: Full / Part-time employment, Full-time employee: AstraZeneca. S. Peters: Honoraria (self), Advisory / Consultancy: AbbVie; Honoraria (self), Advisory / Consultancy, Research grant / Funding (institution): Amgen; Honoraria (self), Advisory / Consultancy, Speaker Bureau / Expert testimony, Research grant / Funding (institution): AstraZeneca / Pfizer; Honoraria (self), Advisory / Consultancy, Research grant / Funding (institution): Bayer / Seattle Genetics and Takeda; Honoraria (self), Advisory / Consultancy: Biocartis; Honoraria (self), Advisory / Consultancy, Speaker Bureau / Expert testimony, Research grant / Funding (institution): Boehringer Ingelheim; Honoraria (self), Advisory / Consultancy, Speaker Bureau / Expert testimony, Research grant / Funding (institution): BMS; Honoraria (self), Advisory / Consultancy, Research grant / Funding (institution): Clovis; Honoraria (self), Advisory / Consultancy: Daiichi Sankyo / Regeneron / Sanofi; Honoraria (self), Advisory / Consultancy: Debiopharm; Honoraria (self), Advisory / Consultancy, Speaker Bureau / Expert testimony: Eli Lilly; Honoraria (self), Advisory / Consultancy, Speaker Bureau / Expert testimony, Research grant / Funding (institution): F Hoffmann-La Roche; Honoraria (self), Advisory / Consultancy: Foundation Medicine; Honoraria (self), Advisory / Consultancy, Research grant / Funding (institution): Illumina; Honoraria (self), Advisory / Consultancy: Janssen; Honoraria (self), Advisory / Consultancy, Speaker Bureau / Expert testimony, Research grant / Funding (institution): Merck Sharp & Dohme; Honoraria (self), Advisory / Consultancy, Research grant / Funding (institution): Merck Serono; Honoraria (self), Advisory / Consultancy: Merrimack; Honoraria (self), Advisory / Consultancy, Speaker Bureau / Expert testimony, Research grant / Funding (institution): Novartis; Honoraria (self), Advisory / Consultancy: Pharma Mar. N. Rizvi: Advisory / Consultancy: AstraZeneca; Advisory / Consultancy: Genentech/Roche; Advisory / Consultancy: Novartis; Advisory / Consultancy: Merck Sharp & Dohme; Advisory / Consultancy: BMS; Advisory / Consultancy: Pfizer; Advisory / Consultancy: Lilly; Advisory / Consultancy: AbbVie; Advisory / Consultancy: Regeneron; Advisory / Consultancy: Janssen; Leadership role, Shareholder / Stockholder / Stock options: ARMO BioSciences; Shareholder / Stockholder / Stock options: Gritstone Oncology. All other authors have declared no conflicts of interest.

Background Recurrent or refractory infections can be a warning sign of primary immunodeficiency diseases (PID). Such mimicking PID (mPID) can occur in patients with Langerhans cell histiocytosis (LCH). Because some cases with refractory molluscum contagiosum-like lesions and persistent otorrhea are finally diagnosed with LCH, we wondered whether such mPID can occur in LCH children and affect on their prognosis. Methods We retrospectively reviewed all children with LCH at our institute from 2001 to 2018. A complete medical review of sex, age, symptoms, treatment course, and outcome comparison was performed. Results Of 39 enrolled LCH patients, three had persistent otorrhea and one had refractory molluscum contagiosum-like lesions despite aggressive antibiotic therapy. These four cases with mPID had significantly higher rates of multi-system involvement, recurrence and 5-month more lag time, but no risk organ (liver, spleen and bone marrow) involvement compared to those without mPID, although bone and skin were the most involved in both groups. Overall, the lag-time in multi-system was longer than that in single-system involvement (median 2.5 vs. 1.0 months; p = 0.003). The diagnosis-age of risk organ involvement was younger than those without (median 8 vs. 43 months; p = 0.004). There were no significant differences in diagnosis-age, single/multi-system and risk organ involvement between remission and recurrence groups. All were alive excluding four who were lost to follow-up. Conclusions The LCH children with mPID had greater lag time, multi-system involvement, recurrence and more refractory treatment including transplantation despite the ratio of bone and skin lesions equal to those without mPID.

Background: Oxygen is often administered to patients without a prescription, potentially increasing mortality, morbidity and hospital stay. When we implemented an EMC in 2018, oxygen prescription by our medical officers (MOs) dropped. Our MOs should change the medical review criteria according to target oxygen saturations. Aim and Objectives: We hypothesised that education on oxygen therapy improves its EMC prescription. We investigated the effect of education on EMC oxygen prescription, review criteria and oxygen delivery. Methods: We collected baseline data from inpatients on oxygen over 6 weeks, spanning 2 rotations of MOs. We then delivered a brief education program to MOs and nurses, focussing on oxygen prescription, devices and saturation targets based on TSANZ guidelines. In the next 10 weeks, we collected outcome data and provided monthly feedback to our MOs. Outcome data are EMC oxygen prescription (device, flow rate/FiO2 & target saturation) and appropriate changes to the medical review criteria. We assessed if oxygen delivery on patients matched the prescription. Results: Oxygen was not prescribed before education. EMC oxygen prescription improved after education, but the rate was low (36%), and the higher rate of review criteria change was not significant. When prescribed, nurses accurately administered oxygen. Conclusion: EMC Oxygen prescription is improved with a brief education program, but more research is needed to improve prescription rates and investigate sustainability.

Background Over recent years we have had increasing numbers of acute admissions, with potentially reversible conditions, as well as noticing increasing use of intravenous antibiotics, without any structured monitoring of progress. We have introduced an Acute Illness Management Plan (AIMP) including regular observations with triggers for medical review, based on the Royal College of Physicians National Early Warning Score (NEWS). This change was introduced alongside improving oxygen prescribing and administration, and an education programme, and is being followed with ongoing quality improvement work. It is important to ensure staff feel a change is worthwhile and important to ensure they are motivated to develop this further. We aimed to assess acceptability of an acute illness management plan in a hospice setting. Methods We undertook a mixed survey with both quantitative and qualitative sections. This was analysed using a narrative approach. Results All respondents feel the AIMP represents an improvement in the care offered to acutely ill patients in the hospice setting. The Majority (60%) felt the AIMP is acceptable in the hospice setting and (40%) felt it is sometimes acceptable. No staff felt it was inappropriate in a hospice setting. Additional comments include: Concerns about stopping treatment when a patient is felt to be clearly in the last days of life; Concerns about documenting individualised goals or triggers for medical review, to avoid frequent observations not leading to changes in treatment; A need for improved recording of urine output; A desire for more training in acute illness management. Conclusions The AIMP acceptable in a hospice setting. Future work will include incorporating NEWS2 guidance, and an ongoing quality improvement programme to look at areas where it could be used more effectively. This will allow us to determine the efficacy of the AIMP along with ensuring staff feel empowered in the process of its introduction.

Primigravid 23 years (5th month of pregnancy). Along the middle line of the abdominal wall, 4 fingers below the navel, annular, covered with integuments, a hole with a diameter of 8-9 cm. The uterus that had fallen into the ring did not adjust and showed signs of incipient infringement. Pains in the abdomen and back of a forced character appeared. During the womb, the uterus was repositioned, and the hernial ring was sutured. Pregnancy ended at the time of the birth of a living baby. The hernia did not return.

Background Good vision is essential for safe driving and studies have associated visual impairment with an increased crash risk. Currently, there is little information about the medical review of drivers with visual field loss. This study examines the prevalence of visual field loss among drivers referred for medical review in one Australian jurisdiction and investigates factors associated with licence outcome in this group. Methods A random sample of 10,000 (31.25 per cent) medical review cases was extracted for analysis from the Victorian licensing authority. Files were screened for the presence of six visual field‐related medical conditions. Data were captured on a range of variables, including referral source, age, gender, health status, crash history and licence outcome. Prevalence analyses were univariate and descriptive. Logistic regression was used to assess factors associated with licence outcomes in the visual field loss group. Results Approximately 1.9 per cent of the 10,000 medical review cases screened had a visual field loss condition identified (n = 194). Among the visual field loss group, 57.2 per cent were permitted to continue driving (conditional/unconditional licence). Primary referral sources were the police, self‐referrals and general medical practitioners. Key factors associated with licence test outcomes were visual field condition, age group, crash involvement and referral to the Driver Licensing Authority's Medical Advisors. Those who were younger had a crash involvement triggering referral and those who were referred to the Medical Advisors were more likely to have a positive licensing outcome. Conclusion The evidence base for making licensing decisions is complicated by the variable causes, patterns, progressions and measuring technologies for visual field loss. This study highlighted that the involvement of an expert medical advisory service in Victoria resulted in an increased likelihood that drivers with visual field loss will be allowed to continue driving. Further research is warranted to explore issues relating to severity of field loss and the capacity for compensation.

To investigate the incidence of adverse reactions after corneal transplantation, reported to the Eye Bank Association of America.Incidence of adverse reactions from January 1, 2007, to December 31, 2014, was analyzed.Of the 354,930 transplants performed in the United States, adverse reactions were reported in 494 cases (0.139%). Primary graft failure (PGF) predominated (n = 319; 0.09%) followed by endophthalmitis (n = 99; 0.028%) and keratitis (n = 66; 0.019%). The procedure type predominantly associated with PGF was endothelial keratoplasty (EK) in 56% (n = 180; 11 per 10,000 grafts), followed by penetrating keratoplasty (PK) in 42% (n = 135; 6.9 per 10,000 grafts). The procedure type predominantly associated with endophthalmitis and keratitis was EK in 63% (n = 104; 6.3 per 10,000 grafts) followed by PK in 34% (n = 56; 2.8 per 10,000 grafts), anterior lamellar keratoplasty in 1% (n = 2; 2.7 per 10,000 grafts), and keratoprosthesis in 1% (n = 2; 12.4 per 10,000 grafts). Although the incidence of PGF and endophthalmitis between PK and EK was noteworthy, the difference was not statistically significant (P = 0.098). Endophthalmitis-associated pathogens were isolated in 78% of cases: predominantly Candida species (65%), gram-positive organisms (33%), and gram-negative rods (2%). Keratitis-associated pathogens were isolated in 64% of cases: predominantly Candida species (81%), Herpes simplex virus (7%), gram-negative organisms (7%), and gram-positive organisms (5%).PGF was the most commonly reported adverse reaction, disproportionately associated with EK. An increasingtrend in the rate of endophthalmitis and keratitis was observed, disproportionately associated with EK and Candida species.

Objectives: Patients with suspected Neutropenic sepsis require rapid antibiotic administration, but despite extensive education, only 67% of patients received antibiotics within 60 minutes. Methods: A Neutropenic Sepsis Alert Card was created, as a Patient Specific Directive – this allows nurses to administer antibiotics to specific patients without prior medical review. Results: Since the intervention, 301 patients presented with suspected neutropenic sepsis. 277 patients (92%) received their first dose of intravenous antibiotics within 1 hour of arrival into hospital, compared to 95 out of 143 patients (67%) presenting between January and June of 2014 (p=0.036). Conclusion: The Neutropenic Sepsis Alert Card can significantly improve door to antibiotic needle time for chemotherapy patients with suspected neutropenic sepsis. This intervention is inexpensive and easily replicable in other health care organisations.

1st case: peasant woman 24 y. A tumor in the region of the right inguinal canal, about the size of a goose egg, soft-elastic, not decreasing under pressure, not moving away from the place and not guided into the inguinal canal, which also cannot be penetrated with a finger.

Judging by the description given by Richelot, the course of his operation seems to be the same as that of Schrder, only ligatures are used instead of tweezers in the last day. The idea of using the tweezers belongs to Pan proper. Seeing the speed of the operation as a guarantee of its success, the author decided to try Richelot's way mainly, in view of the speed that should belong to this method. 1st patient. 24 years old. Cervical ulcer and infiltration in the left parameters. 2 tweezers were applied, which lasted for 2 days, causing severe pain. Operation 30 minutes.

33 years old, multiparous. The last childbirth, three days ago, quickly (within 2 hours).

The uterus is mobile and elastic, and retains its position and configuration with some of its ligaments, but most of all with the tension of the abdominal press. Diseases of the uterus itself and the organs surrounding it change its figure and its position in the pelvis. Changing her figure changes blood circulation, her nutrition and causes disorder throughout the body, affecting by a mass of painful phenomena. Particularly severe seizures cause posterior folds of the uterus. The suffering of the uterus and its appendages cause irritation of the peritoneum, more or less significant adhesions with the surrounding organs are obtained, which even more changes the blood circulation and nutrition of the pelvic organs, and this even more leads to bending.

The author describes ten cases of chronic inflammatory processes in the appendages, in which he removed these appendages. Indications were used in every case of local pain and general nervous phenomena, which were not inferior to any therapeutic effects before.

The author, listing the methods of faradization and galvanization, used by different authors, indicating the places of application of the electrodes, their form, the combination of their action, the current strength and the duration of the sessions.

Purpose There is a lack of data regarding the outcomes of patients who were subjectively assessed to have advanced heart failure (AdvHF) and therefore offered evaluation for left ventricular assist devices (LVADs) only to be determined to be “too well”. Methods We retrospectively reviewed all referrals to our Advanced Heart Failure outpatient clinic for LVAD evaluation from 1/1/13 to 12/31/17. Those individuals who were above the age of 18, subjectively determined to have a syndrome of AdvHF as assessed by a HF Faculty, but deemed “too well” for implantation after formal VAD evaluation and multidisciplinary Medical Review Board (MRB) discussion were included for analysis. Results 62 patients met inclusion criteria. 75% were male, median age at time of presentation to MRB was 57.5 years. Median time to MRB presentation from initial out-patient consultation was 33.5 days. Medication titration was recommended to nearly all (98%), while concomitant evaluation for stem cell therapy and inotropic support was recommended in 17% and 15% respectively. Median time to initial follow-up after MRB presentation was 29.5 days. Beyond initial follow-up 26% were lost to follow-up. Men were 31% more likely than women to be lost to follow up (p = 0.019). Of those who continued to follow in our system, survival 1 year after MRB presentation was 94%, during which time 28% required at least one unscheduled clinic visit, 25% required ED treatment and 27% required at least one hospitalization. 10 patients ultimately were represented to the MRB at a median time of 391 days after initial presentation. Of these, 3 patients were ultimately implanted with an LVAD. 26% of patients given the label of “too well” were noted to have relative contraindications precluding them from consideration. Conclusion Patients determined to be “too well” for LVAD despite a subjective assessment suggestive of a syndrome of AdvHF have good 1 year survival. However, the rates of follow-up and MRB re-discussion, as well as rates of implantation at later dates for “too well” patients is relatively low, despite the known progressive nature of HF. The “too well” label may diminish the perceived need for these patients to have close follow-up with an advanced heart failure team. Additionally, its use may be inaccurate and therefore should be avoided.

BackgroundThrough extra genital screening methods, Health Departments and community clinics can increase detection of sexually transmitted diseases (STDs) through the application of urethral testing. The Long Beach Department of Health and Human Services (LBDHHS) works on preventing cases of chlamydia (CT) and gonorrhea (GC) from being undiagnosed, by providing extra genital screening.MethodsRetrospective medical review of 1,571 patient health records, who received CT/GC testing, based on at least 1-visit to the Long Beach Department of Health & Human Services, STD Clinic, between 2012 to 2015. All male patients ages 18 years or older with positive CT/GC results (242 cases) for any of the three sites (e.g. urethral, rectal, and pharyngeal); regardless of their sexual behaviors, were included in the study. Females, those under the age of 18, and patients who tested negative for all three anatomical sites were excluded (1,412 controls).ResultsAt time of collection, study participants had a mean age of 37 years. Reported ethnicity indicated 56% Caucasian, 21% Hispanic or Latino, 9% Asian or Pacific Islander, 7% Other, 5% Black, and 2% More than one race. The use of extra genital screening detected 15% (242) of the 1,571 patients tested positive for at least 1-type of CT/GC infection. Our findings demonstrated that if urine was the only specimen collected, then over 29.7% of CT and 46.8% of GC cases would have been missed.ConclusionsTesting of all three anatomical sites should continue to be performed for CT/GC detection. Cases of CT/GC are underreported if performing urethral screening alone. These results highlight the need for clinicians to perform extra genital screening among male patients for prevention and control. These testing measures may reduce the potential for missing a diagnosis and mitigating transmission.Short SummaryThe number of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) infections missed were determined using extra genital screening procedures among male patients from the Long Beach Department of Health and Human Services (LBDHHS), STD/Family Planning Clinic. This method tests urethral, pharyngeal, and rectal sites for CT and GC infection. In this retrospective review of 1,571 patient files, of which 242 tested positive, we determined the proportion of cases that would have remained undetected if only using urethral screening.

Background Accurate information about treatment is needed to evaluate cervical cancer prevention efforts. We studied completeness and validity of reporting cervical treatments in the Cancer Registry of Norway (CRN). Material and methods We identified 47,423 (92%) high-grade cervical dysplasia patients with and 3983 (8%) without recorded treatment in the CRN in 1998-2013. We linked the latter group to the nationwide registry of hospital discharges in 1998-2015. Of patients still without treatment records, we randomly selected 375 for review of their medical history. Factors predicting incomplete treatment records were assessed by multiple imputation and logistic regression. Results Registry linkage revealed that 10% (401/3983) of patients received treatment, usually conization, within one year of their initial high-grade dysplasia diagnosis. Of those, 11% (n = 44) were missing due to unreporting and 89% (n = 357) due to misclassification at the CRN. Of all cases in medical review, patients under active surveillance contributed almost 60% (223/375). Other reasons of being without recorded treatment were uncertain dysplasia diagnosis, invasive cancer or death. Coding error occurred in 19% (73/375) of randomly selected cases. CRN undercounted receipt of treatment by 38% (n = 1526) among patients without recorded treatment which translates into 97% overall completeness of treatment data. Incomplete treatment records were particularly associated with public laboratories, patients aged 40-54 years, and the latest study years. Conclusions CRN holds accurate information on cervical treatments. Completeness and particularly validity can be further improved through the establishment of new internal routines and regular linkage to hospital discharges.

Exacerbations of chronic obstructive pulmonary disease (ECOPD) remain a common cause of hospital admission in the UK, despite the huge amount of effort and resources that have been invested in COPD services in recent years, and in-hospital mortality has been unchanged at around 4%.1 Clinical teams looking after patients with ECOPD need well-validated tools to assess mortality risk at admission and detect clinical deterioration in a timely manner. Several such tools have been developed to predict in-hospital mortality, of which the Dyspnoea, Eosinopenia, Consolidation, Acidaemia and atrial Fibrillation (DECAF) score has received the greatest attention2 3 indeed, the 2014 UK National COPD Audit report recommended the DECAF score for all patients hospitalised for ECOPD, in part to enable adjustment for mortality risk in a mixed cohort. Yet despite being robustly derived and validated, the DECAF score has not been widely adopted into clinical practice; in the 2019 National COPD Audit report, DECAF was recorded in only 17.5% of admissions1 and it is therefore worthwhile to consider alternatives. Introduced in 2012, the National Early Warning Score (NEWS) was designed to standardise the clinical response to the deteriorating patient. Derived from routinely measured physiological parameters, it was validated as an indicator of clinical deterioration and mortality in several acute medical conditions. Despite its widespread use, questions were raised over its safety in the management of patients at risk of hypercapnic respiratory failure, for whom the addition of supplemental oxygen might lower their NEWS, but inadvertently place them at risk of worsening hyperoxic hypercapnia.4 Furthermore, patients with chronic hypoxaemia and on long-term oxygen therapy may have inappropriately elevated scores by virtue of their being on supplementary oxygen even when their acute illness has stabilised, resulting in inappropriate escalation for medical review. In response, the Royal College of Physicians introduced …