West Cumberland Hospital

Background: Uterine rupture is a severe obstetric complication traditionally associated with a past history of caesarean section or other factors causing uterine scarring. However, instances of atypical uterine rupture in patients have been reported. This case report present an atypical instance of uterine rupture in a patient with no known risk factors, emphasising the need for high suspicion for uterine rupture even in absence of risk factors. Case Presentation: The case discusses a gravida 3, para 2 female with no significant history, except for treatment for cervical intraepithelial neoplasia. No history of caesarean section or uterine scarring. Presented with light vaginal bleeding and later diagnosed with a miscarriage at 20+1 weeks of gestation. Managed with misoprostol per trust guidelines, the patient developed severe pain, signs of sepsis, and shock. An ultrasound revealed a heterogeneous mass in the lower uterine segment and free fluid in the pelvis. ACT scan confirmed a ruptured uterus with the foetus and placenta lying anteriorly and hemoperitoneum present. Alaparotomy was performed under general anaesthesia and the uterus was repaired. Postoperatively, the patient developed ileus and a pulmonary embolism, which were treated, leading to gradual recovery. Conclusion: This atypical case of uterine rupture highlights the need to maintain a high level of suspicion for uterine rupture, even in the absence of traditional risk factors. It also underscores the importance of careful patient management during labour induction with misoprostol, especially when complications arise. This case serves as a reminder to clinicians to consider all possible diagnoses when a patient's condition deteriorates, even in the absence of conventional risk factors. More research is needed on the use of labour-inducing drugs, particularly misoprostol, in the management of intrauterine foetal death.

Please confirm that an ethics committee approval has been applied for or granted: Not relevant (see information at the bottom of this page)Application for ESRA Prizes: I apply as an Anesthesiologist (Aged 35 years old or less)Background and AimsIPAH corresponds to sporadic disease without any family history of PH or known triggering factor with mPAP > 25 mm Hg or more at rest after excluding left sided heart disease and certain other disorders[1].Pregnancy in IPAH patients is associated with very high peri-partum mortality and conception is not advised and if detected early in pregnancy, then termination is advised[2].MethodsParturient,37years,at 35 weeks gestation,in premature labour was referred to us being diagnosed as IPAH;NYHA Class III,on Tab.Sildenafil 12.5mg BD and Inj.Enoxaparin 40mg s.c. Post high risk consent,LSCS done under lumbar epidural anaesthesia with 0.25% Bupivacaine+Fentanyl,with standard monitoring and intra arterial line,maintaining hemodynamic stability.Intra-op BP decreased twice,treated with Phenylephrine 50mcg iv bolus & rest was uneventful.Patient monitored in CCU for 48hours;on continuous epidural 0.125% Bupivacaine infusion,with uneventful post operative period.ResultsDuring pregnancy the circulatory and haematological changes which occur can lead to increased peri-op mortality and morbidity in patients of IPAH.The anaesthetic goals are Maintenance of adequate Systemic Vascular Resistance (SVR);Maintenance of intra-vascular volume and venous return;Avoidance of aorto-caval compression;Prevention of pain, hypoxemia,hypercarbia and acidosis which may increase Pulmonary Vascular Resistance(PVR) and avoidance of myocardial depression.The choice of anaesthesia for LSCS in patients with IPAH is controversial as there is no established anaesthetic protocols to manage such patients and varied reports make it difficult to come to a well-established decision.ConclusionsEpidural anesthesia can be safely administered during LSCS in a selected group of patients with IPAH,using a multi-disciplinary team approach and extreme vigilance leading to a good maternal and fetal outcome.

Abstract Introduction: For a test to be of value, it needs to demonstrate that it is changing clinical decisions, improving clinical confidence and of economic benefit. This trial looked at the use of Oncotype DX Breast Recurrence Score ® (RS) assay against these criteria in 680 women with hormone receptor positive (HR+), HER2 negative early breast cancer with 1 to 3 lymph nodes positive (LN+) in the UK National Health Service (NHS) (5 teaching and 9 district general hospitals) between 2017 and 2022. Methods: Patients with LN+ early breast cancer who were willing and fit to receive chemotherapy (CT) were consented to join the trial. At the initial oncologists’ appointment, physicians were asked to state their preference for or against CT and their level of confidence in their decision on a scale of 1 to 5. Following receipt of the RS result physicians were asked to make a final decision for or against CT and similarly record their level of confidence. Descriptive analyses were used to characterize (1) patient and tumour characteristics, (2) change in treatment recommendations post-RS testing (by RS result and nodal status), and (3) change in physicians’ level of confidence post-RS testing (by RS result and nodal status). Average cost for chemotherapy and RS test price were used to estimate overall cost savings. Results: A total of 680 patients were recruited. 16 patients were excluded (5 failed samples, 5 withdrew consent, 3 HER2 positives, 2 with advanced disease, and 1 specimen delayed in transit), leaving 664 assessable patients. The median age was 58 years and 77.1% of women were post-menopausal. Most patients had a RS of 0-17 (n=400, 60.2%); while 206 (31%) had a RS of 18-30 and 58 (8.7%) had a RS of 31-100. Using post-RxPONDER cutoffs, 566 (85.2%) had an RS of 0-25; 98 (14.8%) had an RS of 26-100. Decision impact results: The decision impact results broken down by RS result and nodal status are detailed in Table 1. Of the 662 patients with complete decision impact data, in 359 (54.2%) the recommendation by the physician changed from CT+ hormone therapy (HT) to HT alone. In 286 (43.2%) cases the decision was unchanged and in 17 (2.6%) the recommendation changed from HT alone to CT+HT. Overall 342 (51.7%) cases were spared chemotherapy. Decision conflict results: The change in the physicians’ level of confidence by RS result and nodal status are detailed in Table 2. Of the 660 cases with complete decision conflict data, physicians reported an increase in confidence in their recommendations after receiving the RS in 363 (55.0%), confidence was unchanged in 219 (33.2%) and decreased confidence in 78 (11.8%) cases. Economic analysis: Using the estimates of Burdanov et al, the average costs of a course of chemotherapy in the UK is £6,000 to £7,000. An estimate of the overall cost saving of 342 courses is £2,064,00 to £2,408,000 and the overall cost of 664 RS assays at the list price of about £2580 (although an undisclosed discount applies to the NHS) is £1,713,120. This suggests that the use of RS assay represents a significant saving to the NHS. Conclusion: The use of Oncotype DX assay in node positive early breast cancer leads to about half of women being spared chemotherapy, a significant improvement in clinical confidence for oncologists and an economic saving to the health care system. Table 1 Pre- vs Post-Oncotype DX Treatment Recommendation by Physician According to Recurrence Score and Nodal Status Table 2 Change in Physicians’ Level of Confidence Post-Oncotype DX Testing According to Recurrence Score and Nodal Status Citation Format: Simon D. Holt, Priyadharshini Sai-Giridhar, Mark Verrill, Laura Pettit, Anna Rigg, Tamas Hickish, Caroline D. Archer, Anshu Wadhawan, Marianne Dillon, Jo Dent, Mark R. Nathan, Ludger Barthelmes, Shazza rehman, Paige Innis, Saira Khawaja. A UK prospective multicentre decision impact, decision conflict and economic evaluation of the use of Oncotype DX® to guide chemotherapy in 680 women with hormone receptor positive, HER2 negative breast cancer and 1 to 3 nodes involved [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-01-11.

Immigrant nurses make up a large percentage of the Australian nursing workforce. Since the support in the workplace is expected to be inclusive for all nurses, the aim of this article is to explore how support and opportunities for professional growth, learning and development are distributed across different categories of nurses working in a neonatal intensive care unit (NICU). An ethnographic approach has opened an examination of the everyday workplace practices in the NICU to gain insight into how nurses made sense of the social and power relations occurring between themselves and their senior colleagues and how they experienced the support and opportunities they received in their workplace. As today's workplaces such as the NICU are diverse in races, culture and experiences, the concepts of intersectionality and cultural safety assisted in identifying inequality and injustice related to such diversity. The results showed how patronage relations rendered nurses with immigrant status with major disadvantage and left them clinically and culturally vulnerable. Such inequity defeats the reasons for encouraging skilled migration of nurses and poses questions on the cultural competency of recruiting organisations. Considering how cultural safety might guide staff development offers opportunities for authentic support to culturally diverse nurses.

Background and aims Ovarian cancer is the leading cause of female reproductive cancer death. It is estimated that dietary habits accounts for 30% of all cancers. This review sets out what we know about the food, nutrition and lifestyle factors that cause ovarian cancer, affect women with ovarian cancer and the problems associated with study design that may affect its prevention and patient survival. Methods Studies reporting lifestyle, diet, nutritional benefits in ovarian cancer patients from 1980 to date were examined and insights into the potential problems related with study design evaluated. Results Poor diet and nutrition are associated with ovarian cancer and exacerbated by poor lifestyle choices. Although improvements in disease prevention and patient survival can be made through nutritional, dietary and lifestyle interventions uncertain evidence, resulting directly or indirectly from inadequate study design may negate this. Conclusions Lifestyle, dietary and nutrition interventions may prevent and improve survival of ovarian cancer patients. However, inadequate clarity and gaps exists within the literature, eg., study design, data interpretation, absence of cohesive questions and scoring systems. Future directions that emphasize high quality studies and clinical trials should be encouraged.

I am writing in order to stress upon the correct and safe rate of propofol infusion in intensive care unit (ICU) as a high rate of infusion can easily be missed and can lead to serious consequences. Propofol infusion syndrome (PRIS) is a well-known entity, which has been reported in both children and adults and is related to its high rates. First death due to PRIS was reported in 1990. The term was originally coined in 1998 by Bray to describe the adverse effects with its use in pediatric population. Though the first case was reported in a child, it has now been increasingly reported in adult ICU patients too.

ObjectivesTo assess the effectiveness of analgesia used in mountain rescue (MR) in casualties with moderate or severe pain. To determine if a verbal numeric pain score is practical in this environment. To describe the analgesic strategies used by MR.DesignProspective, descriptive study.SettingFifty-one MR teams in England and Wales. The study period was 1 September 2008 to 31 August 2010.Participants92 MR casualties with a pain scoreof 4/10 or greater.Main outcome38% of casualties achieved a pain reduction of 50% or greater in their initial score at 15 min and 60.2% had achieved this at handover.ResultsThe initial pain score was 8 (median), reducing to 5 at 15 min and 3 at handover. The mean pain reduction was 2.5±2.4 at 15 min and 3.9±2.5 at handover. 80 casualties (87%) were treated with an opioid and seven had two different opioids administered. Seven main strategies were identified in which the principal agent was entonox, intramuscular opioid, oral analgesia, fentanyl lozenge, intranasal or intravenous opioid. The choice of strategy varied with the skills of the casualty carer.ConclusionsPain should be assessed using a pain score. When possible, intravenous opioid is the gold standard to achieve early and continuing pain control in patients with moderate or severe pain. Entonox and oral analgesics, as sole agents, have limited use in moderate or severe pain. Intranasal opioid and fentanyl lozenge are effective, and appropriate in MR. Research priorities include bioavailability in different environmental conditions and patient's satisfaction with their pain management.

A retrospective study to investigate the effectiveness of topical manuka honey in the treatment of chronic or recurrent pilonidal sinus disease (PSD), assessing the ability of this simple dressing technique to achieve complete wound healing, the time taken to achieve healing and the recurrence rate. All patients who received manuka honey dressing therapy following surgical intervention for chronic or recurrent PSD were identified over a 4-year period. In a retrospective review of case notes, data were collected on patient sex, age, nature of surgical procedures performed, time to achieve complete wound healing, and recurrences after completion of honey therapy. Seventeen patients were eligible for inclusion in the study. Mean time to commence honey therapy post-surgery was 93 days (5-517 days; median 33 days); 15 patients achieved complete wound healing, in a mean time of 65 days (14-264 days; median 49 days). Honey was discontinued in one patient due to an adverse event, and two patients experienced recurrence several months after completing honey therapy. Manuka honey dressing therapy provides an effective topical treatment for chronic/recurrent PSD. Further research is necessary to determine the optimum dressing protocol. The authors have no conflicts of interest to declare. There were no external sources of funding for this study.