Invasive Procedures in the First Trimester

Objective: The purpose of this study is to show distribution of risk in pregnancies which underwent first trimester combined tests, and investigate general demographic and clinical characteristics of patients, underwent invasive diagnostic tests after screening tests. Methods: Combined test data of first trimester screening in 20082011 were evaluated retrospectively and cross-sectional. After the measurement of nuchal translucency (NT), double test was applied to complete combined test within the same day. Invasive diagnostic procedures were compared in terms of rate, indications, karyotype and postnatal outcomes. Results: A total of 1109 pregnant women were included. Their mean age was 31.07±3.73 years. Free-βhCG was 1.26±0.94 MoM and PAPPA was 1.16±0.65 MoM. Mean NT value was 1.60±0.67 mm. With threshold of 1/250, screening test was positive in 3.1% of the cases. Additional 22 cases due to first trimester screening and 19 cases due to second trimester screening had invasive procedures (6.4% in total). Invasive procedures revealed karyotype anomaly in 11.3%. Karyotype anomalies were more frequent in group (20%) with positive combined test compared to ones performed for other reasons like maternal anxiety. Conclusion: Although false positive rate is 3.1% in first trimester combined test, rate of total invasive procedures is more than double (6.4%). Number of invasive diagnostic procedures increased due to maternal anxiety of age and physicians evaluating only NT or double tests. With diagnostic procedures, chromosome anomalies reaches 11% and termination need reaches 10%. Invasive procedures performed due to anxiety of mother or physician revealed no chromosomal anomaly requiring termination.

Behavioral coping strategies used by 44 pediatric oncology patients during invasive medical procedures were assessed with a structured interview. The behavioral strategies were subsequently categorized into the following global coping styles: information seeking, information avoiding, and mixed. Coping style was unrelated to age and gender but was significantly related to measures of disease chronicity -time since diagnosis and number of previous procedures. No differences were found among children who had different coping styles on subjective ratings of anticipatory fear and degree of pain experienced or on behavioral observations of distress during invasive procedures. The results suggested that children's preferred styles of coping with invasive procedures may change with preferred styles of coping with invasive procedures may change with time and experience; however, a longitudinal study is needed to address this hypothesis prospectively.

Introduction Consent of patients for any medical procedure is an essential part of good practice (1). Verbal consent is increasingly sought for invasive anaesthetic procedures and documentation of this is an important feature of risk management. Paediatric consent is a complex issue and although it is common practice to explain things to the child, written consent is generally still sought from the parent (2). Recent guidelines from the Royal College (3) are quite specific about having a ‘child centred approach’. They clearly state that ‘where special techniques (e.g. epidurals, other regional blocks including caudal, and invasive monitoring or blood transfusion) are used there should generally be written evidence that these have been discussed with the child (when appropriate) and the parents’.Our aim was to discover the current amount of documentation on invasive procedures in our paediatric anaesthetic notes and to subsequently agree on a local standard.Method We looked retrospectively at anaesthetic records of children aged 10, 11 and 12 years undergoing general anaesthesia for elective surgery over a 2‐month period. We specifically looked for documentation of who was present at the pre‐operative discussion and where an invasive anaesthetic technique was planned. written evidence that it had been discussed.Results 73 anaesthetic records were examined. The case mix was as follows: 37% ENT, 28% Plastic Surgery, 24% General Surgery, 11 % Orthopaedic and Oral Surgery. A Consultant was present for 98% of the anaesthetics and was accompanied by a trainee in half of those cases. In 82% (60 patients) there was no documentation of who was present at the pre‐operative discussion. In 2 cases (3%) the child was seen alone, in 8 cases (11 %) both a parent and child were documented to have been involved in the discussion and in 3 cases (4%) only the parents appeared to have been involved. Of the 73 anaesthetic records, 11 did not have invasive procedures planned or performed and the following data is from the remaining 62 anaesthetic records 83.5% of invasive procedures were documented pre‐operatively 12 patients (19%) had more than one procedure. Only 7 notes (11 %) had a record of the procedure being specifically discussed with the child. 2 out of the 4 caudal (50%) were done without documentatior, of discussion about the procedure 7 out of 48 suppositories (14%) were given without record of verbal consent 5 out of 16 (31 %) of the local anaesthetic techniques were performed without documentation of discussion. Discussion This pre‐audit survey demonstrates that in 82% of cases there was no record of exactly who was present at the preoperative discussion and that some invasive procedures were carried out without any record of a discussion having taken place. We feel that this level of documentation is insufficient. We looked at the age range 10–12 years as this might be regarded as approximately the age at which agreement should be sought for relatively simple procedures such as those chosen in this survey. This is not to imply that children below this age should not be involved in a plan of management or that all children of this age will be fully competent to participate in decisions. We deliberately chose to look at elective surgery, as there should be better documentation in these cases. One reason for such poor results may be that most anaesthetists do not realise the importance of documentation. Our current chart provides no means of prompting the anaesthetist to record who was present at pre‐operative discussions. There is also a lack of a clear standard as to an age when invasive procedures should generally be discussed. We feel that this is probably a common problem and hope this surveys increases awareness on this important topic.Conclusions The results of this survey are to be brought to the attention of the local department. Having identified the problem we hope to agree on a local standard and audit against these standards.

Variables affecting the decision for numbers of embryos transferred

ObjectiveAntibiotic prophylaxis has been recommended for patients at increased risk of infective endocarditis (IE) undergoing specific invasive procedures (IPs) despite a lack of data supporting its use. Therefore, antibiotic prophylaxis...

BackgroundBreach of neonatal skin by obstetric procedures during delivery increases risk of neonatal herpes among infants of women with genital HSV infections. We hypothesised that knowledge of genital HSV infection...

Assessing Risks and Benefits of Invasive Cardiac Procedures in Patients with Advanced Multimorbidity

The Diagnosis of Pneumonia in Renal Transplant Recipients Using Invasive and Noninvasive Procedures

Parental presence during painful or invasive procedures in neonatology: A survey of healthcare professionals

The study compares the cost analysis of ultrasound versus computed tomography guidance for nonvascular invasive procedures. Ultrasound and computed tomography-guided invasive procedures are performed routinely in all radiology departments. However, in many departments computed tomography guidance is preferred to ultrasound, sometimes without valid medical indication, aside from personal preference or training. In the authors' department, all requests for imaging-guided nonvascular procedures initially are evaluated for the possibility of ultrasound guidance. This retrospective study included 2971 patients who underwent invasive procedures with ultrasound and computed tomography guidance during a 4-year period (1994-1997). Outcomes were compared to those of another community-based hospital in the same area. The cost analysis was made based on Health Care Financing Administration/ Medicare reimbursements. The results show that approximately 10% of patients can be redirected from computed tomography-guided procedures to ultrasound guidance.

In the 1960s or 1970s, gynecology residency training emphasized vaginal hysterectomy as the preferred technique for treating many conditions now managed by less invasive alternatives. This led gynecologists to become very skilled at operating through very small incisions. More recently, as these less invasive procedures are rapidly becoming the standard of care, and women are having fewer babies, vaginal surgery is performed less often. Because our young colleagues are acquiring less experience with this technique, the skill of operating through a very small incision is becoming a lost art. Of the 600,000 hysterectomies done in the United States each year—a number which has remained stable for the past 20 years—65% to 75% are done through large abdominal incisions.1 Rates in the Kaiser Permanente Northern California (KPNC) Region are somewhat better: The rate of abdominal hysterectomy is 68%, the rate of vaginal hysterectomy is 21%, and 11% of these procedures are done laparoscopically. Although laparoscopic hysterectomy offers a minimally invasive alternative when vaginal hysterectomy is contraindicated or considered too difficult by the surgeon, laparoscopic hysterectomy has many drawbacks. The procedure is very costly because of its requirements for equipment and time in the operating suite and because the procedure has a very steep learning curve. However, when length of hospital stay and postoperative utilization of medical services are taken into account, laparoscopic hysterectomy in the KPNC Region is less expensive than abdominal hysterectomy but substantially more expensive than vaginal hysterectomy. In addition, compared with patients who have the more invasive (ie, abdominal) procedure, our patients who undergo vaginal or laparoscopic hysterectomy have better postoperative quality of life.2 Minilaparotomy is technically less difficult to perform than laparoscopic myomectomy … Development of Minilaparotomy Techniques Use of minilaparotomy in surgery for benign gynecologic disease has been well established.3 Laparoscopically assisted myomectomy was first reported by Nezhat et al in 1994.4 In their review of 57 cases, these authors concluded that the use of the minilaparotomy incision is a safe alternative to myomectomy done by laparotomy. Minilaparotomy is technically less difficult to perform than laparoscopic myomectomy, allows better closure of the uterine defect, and may require less time to perform. Most women in the series reported by Nezhat et al4 returned to normal activity within three weeks. In 2002, we adopted the Pelosi minilaparotomy hysterectomy technique as an effective alternative to laparoscopic hysterectomy and standard open laparotomy hysterectomy. First presented at the Global Congress of Gynecologic Endoscopy in 2002 and described in OBG Management in April 2003,5 the procedure relies on traditional open techniques learned by all Ob/Gyn residents and relies also on use of an inexpensive, soft, sleeve-type self-retaining abdominal retractor. Minilaparotomy is a minimally invasive procedure ideal for gynecologists who are less skilled in vaginal or laparoscopic surgery and who are more comfortable with the (standard) abdominal approach. In addition to combining the surgical principles and techniques of vaginal and laparoscopic surgery, minilaparotomy requires the same postoperative care as less invasive procedures. Detailed description of the surgical technique would be more appropriate for an obstetrics/gynecology journal; here I describe some of the most important technical principles of minilaparotomy.

BACKGROUNDFibreoptic bronchoscopy (FOB) is the usual initial investigation of choice in patients with suspected endobronchial carcinoma, but it is often non-diagnostic. Once a positive diagnosis has been made, many patients...

Objective: family-centered care during invasive procedures has been endorsed by many professional health care organizations. The aim of this study was to evaluate the health professionals’ attitudes towards parental presence during their child’s invasive procedure. Method: pediatric healthcare providers (divided in professional categories and range of ages) from one of the Spain’s largest hospitals were asked to complete a questionnaire and write free-text comments. Results: 227 responded the survey. Most (72%) participants, in their answers, reported that parents are sometimes present during interventions, although there were differences between professional categories in this respect. The procedures in which the parents were present were those considered “less invasive” (96% of cases), while only 4% were present in those considered “more invasive”. The older the professional, the less necessary parental presence was considered. Conclusion: the attitudes towards parental presence during pediatric invasive procedure are influenced by the professional category, the age of the healthcare provider and the invasiveness of the procedure.

Excess mortality from heart disease is observed in patients with severe mental disorder. This excess mortality may be rooted in adverse effects of pharmacological or psychotropic treatment, lifestyle factors, or inadequate somatic care. To examine whether persons with severe mental disorder, defined as persons admitted to a psychiatric hospital with bipolar affective disorder, schizoaffective disorder, or schizophrenia, are in contact with hospitals and undergoing invasive procedures for heart disease to the same degree as the nonpsychiatric general population, and to determine whether they have higher mortality rates of heart disease. A population-based cohort of 4.6 million persons born in Denmark was followed up from 1994 to 2007. Rates of mortality, somatic contacts, and invasive procedures were estimated by survival analysis. Incidence rate ratios of heart disease admissions and heart disease mortality as well as probability of invasive cardiac procedures. The incidence rate ratio of heart disease contacts in persons with severe mental disorder compared with the rate for the nonpsychiatric general population was only slightly increased, at 1.11 (95% confidence interval, 1.08-1.14). In contrast, their excess mortality rate ratio from heart disease was 2.90 (95% confidence interval, 2.71-3.10). Five years after the first contact for somatic heart disease, the risk of dying of heart disease was 8.26% for persons with severe mental disorder (aged <70 years) but only 2.86% in patients with heart disease who had never been admitted to a psychiatric hospital. The fraction undergoing invasive procedures within 5 years was reduced among patients with severe mental disorder as compared with the nonpsychiatric general population (7.04% vs 12.27%, respectively). Individuals with severe mental disorder had only negligible excess rates of contact for heart disease. Given their excess mortality from heart disease and lower rates of invasive procedures after first contact, it would seem that the treatment for heart disease offered to these individuals in Denmark is neither sufficiently efficient nor sufficiently intensive. This undertreatment may explain part of their excess mortality.

Aim: This study aimed to investigate the impact of Gebauer’s Pain Ease® (Gebauer Company, Cleveland, OH) topical refrigerant spray on the disinfection of skin sites, focusing on the volar wrist and lower back. The primary objective was to determine whether the application of Pain Ease would compromise the disinfection of these sites, potentially making it a suitable alternative to injectable lidocaine for invasive medical procedures. Methods: This prospective, blinded, controlled study was conducted at Henry Ford Hospital in Detroit, MI. Healthy adult hospital employees were recruited, and written consent was obtained. Swabs were taken from the volar wrist and lower back sites before and after treatment with ChloraPrep™ (BD, Franklin Lakes, NJ) and Pain Ease. Microbial cultures were performed, and microbial growth levels were assessed and categorized. Data analysis included comparisons of microbial growth between untreated samples, ChloraPrep-treated samples, and ChloraPrep + Pain Ease-treated samples. Results: Data were collected from 72 participants, with 6 samples per participant (2 locations, 3 treatments each). For wrist samples, there were no statistically significant differences in microbial growth between ChloraPrep and ChloraPrep + Pain Ease. Similarly, for lower-back samples, microbial growth did not significantly differ between these 2 treatment groups. Conclusions: This study demonstrates that the application of Gebauer’s Pain Ease to ChloraPrep disinfected skin areas does not negatively affect the reduction of the bacterial load, supporting its potential as an alternative to injectable lidocaine and other superficial anesthetics for vascular access or invasive medical procedures. However, further research is warranted to explore the application of Pain Ease in various clinical scenarios and optimize patient comfort during longer and more invasive procedures.