ObjectiveThe objective of this study is to determine demographic and diagnostic distributions of physical pain recorded in clinical notes of a mental health electronic health records database by ...using natural language processing and examine the overlap in recorded physical pain between primary and secondary care.Design, setting and participantsThe data were extracted from an anonymised version of the electronic health records of a large secondary mental healthcare provider serving a catchment of 1.3 million residents in south London. These included patients under active referral, aged 18+ at the index date of 1 July 2018 and having at least one clinical document (≥30 characters) between 1 July 2017 and 1 July 2019. This cohort was compared with linked primary care records from one of the four local government areas.OutcomeThe primary outcome of interest was the presence of recorded physical pain within the clinical notes of the patients, not including psychological or metaphorical pain.ResultsA total of 27 211 patients were retrieved. Of these, 52% (14,202) had narrative text containing relevant mentions of physical pain. Older patients (OR 1.17, 95% CI 1.15 to 1.19), females (OR 1.42, 95% CI 1.35 to 1.49), Asians (OR 1.30, 95% CI 1.16 to 1.45) or black (OR 1.49, 95% CI 1.40 to 1.59) ethnicities, living in deprived neighbourhoods (OR 1.64, 95% CI 1.55 to 1.73) showed higher odds of recorded pain. Patients with severe mental illnesses were found to be less likely to report pain (OR 0.43, 95% CI 0.41 to 0.46, p<0.001). 17% of the cohort from secondary care also had records from primary care.ConclusionThe findings of this study show sociodemographic and diagnostic differences in recorded pain. Specifically, lower documentation across certain groups indicates the need for better screening protocols and training on recognising varied pain presentations. Additionally, targeting improved detection of pain for minority and disadvantaged groups by care providers can promote health equity.
The time of cord clamping in intrauterine growth–restricted (IUGR) neonates remains an area of uncertainty. This assessor-blinded randomized controlled trial compared the effects of delayed cord ...clamping (DCC) with early cord clamping (ECC) on the systemic blood flow (SBF) and cerebral hemodynamics in IUGR neonates of gestational age ≥28 weeks, not requiring resuscitation. Eligible newborns were randomized to DCC (cord clamping after 60 s;
n
=55) or ECC (cord clamping within 30 s;
n
=55) group immediately after delivery. The primary outcome variable was superior vena cava (SVC) blood flow at 24±2 h. The secondary outcome variables were right ventricular output (RVO), anterior cerebral artery (ACA) blood flow velocity (BFV), superior mesenteric artery (SMA)-BFV and venous hematocrit at 24±2 h, peak total serum bilirubin (TSB), incidences of polycythemia, intraventricular hemorrhage, respiratory distress, feeding intolerance, and necrotizing enterocolitis, outcome, duration of hospital stay, screening audiometry, and serum ferritin levels at the postnatal age of 3 months. Compared to ECC, DCC was associated with significantly higher SVC flow (101.22±21.02 and 81.27±19.12 mL/kg/min, in DCC and ECC groups, respectively;
p
<0.0001), and significantly increased RVO, SMA-BFV, venous hematocrit, and serum ferritin levels. Though peak TSB was significantly higher with DCC, duration of phototherapy was comparable. ACA-BFV, incidence of polycythemia, and other outcomes were comparable between the groups.
Conclusions
: DCC was a safe and beneficial intervention in IUGR infants with an improved SBF and SMA-BFV and an increased hematocrit and serum ferritin levels without higher incidences of polycythemia and requirement of phototherapy for significant hyperbilirubinemia.
Trial registration
: Clinical Trials Registry of India (CTRI/2019/05/018904)
What is Known:
•
Delayed cord clamping (DCC) increases superior vena cava (SVC) blood flow in preterm neonates.
• DCC increases hematocrit and serum ferritin in intrauterine growth–restricted (IUGR) neonates, but there may be an associated risk of polycythemia and neonatal hyperbilirubinemia.
What is New:
•
DCC increases SVC blood flow, right ventricular output, superior mesenteric artery blood flow velocity, venous hematocrit, and serum ferritin in IUGR neonates
.
•
Incidences of polycythemia and duration of phototherapy for significant neonatal hyperbilirubinemia do not increase with DCC.
Objective: To compare laparoscopic pectopexy with the standard laparoscopic sacropexy in women with symptomatic apical prolapse. Material and Methods: An interim analysis of an exploratory randomized ...controlled trial with the primary objective of comparing mesh fixation time and secondary objectives were to compare total operating time, blood loss, and intra-operative and post-operative complications. Additionally, patients completed the Prolapse Quality of Life (P-QOL) and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) questionnaires before surgery and during six months follow-up visit to evaluate the overall improvement in quality of life and sexual function. Patient Global Impression of Improvement (PGI-I) score was calculated on the 7-10th day post-operatively and then at six months to assess the level of improvement. Results: The study included 30 patients; 15 underwent laparoscopic sacropexy, and 15 underwent laparoscopic pectopexy. Baseline characteristics were comparable in both groups. The mean duration of mesh fixation was significantly less with laparoscopic pectopexy (45.00±11.34 minutes) than laparoscopic sacropexy (54.67±9.35 minutes) (p=0.019). The total operating time and blood loss tended to be less in the pectopexy group, but not significantly so. Only one patient in the pectopexy group had a bladder injury. No patient in either group had any post-operative complications. One case in each group had a relapse of apical prolapse. All the domains of PISQ-12, P-QOL, and PGI-I scores improved significantly after both procedures. Conclusion: Laparoscopic pectopexy is a safe, feasible, and comfortable alternative procedure to the standard sacropexy for apical prolapse. We noted significantly less mesh fixation time and less operating time, while blood loss tended to be less with laparoscopic pectopexy than with laparoscopic sacropexy. Post-operative parameters were comparable between techniques. Both corrective techniques for prolapse improved the PGI-I, P-QOL, and PISQ-12 scores.
Cervical agenesis is a rare congenital Mullerian anomaly. Its association with vaginal agenesis is further rare, reported in 39% of cases of cervical agenesis. The conventional treatment for this ...condition was hysterectomy. However, with evolving surgical skills and assisted reproductive techniques, conservative surgery could be considered as the first-line treatment in the current era. We report one such case of cervicovaginal agenesis in a 13-year-old adolescent girl managed successfully with cervicovaginoplasty. The patient was relieved of cyclical pain abdomen and resumed menstrual cycles postoperatively.
To ascertain whether extra-peritoneal approach is superior to conventional trans-peritoneal approach of cesarean section in terms of fetus delivery time, intra-operative and postoperative outcomes, ...including return of bowel activity and pain.
An open-label randomized controlled trial conducted over one year and six months at a tertiary care center in India. As per sample size calculation, 68 women enrolled in the study; 34 underwent extra-peritoneal, and another 34 underwent trans-peritoneal cesarean section after randomization. Statistical analysis was done with independent sample 't' test, chi-squared test, and fisher's exact test.
Baseline characteristics were comparable in both groups. Fetus delivery time was significantly higher in extra-peritoneal than trans-peritoneal cesarean section (14.26 ± 1.26 vs. 9.38 ± 1.83 min; p = <0.001). Total operation time was also higher in extra-peritoneal than trans-peritoneal approach (63.24 ± 12.74 vs. 57.41 ± 8.62 min; p = 0.027). Whereas average blood loss was comparable in both groups (733.82 ± 219.06 vs. 694.12 ± 351.57 ml; p = 0.063). Postoperatively, return of bowel activity was significantly earlier in extra-peritoneal than trans-peritoneal approach (4.59 ± 0.56 vs. 8.65 ± 1.23 h; p = <0.001). Mean time taken for passage of flatus was also significantly less in extra-peritoneal cesarean section (8.56 ± 0.99 vs. 12.76 ± 2.05 h; p = <0.001). Pain score at 6, 12, and 18 h was significantly lower in extra-peritoneal approach. No patient in extra-peritoneal approach had nausea, vomiting, and abdominal distension. Whereas 11.8 % of patients had nausea, 5.9 % had constipation, and 14.7 % had abdominal distension in trans-peritoneal cesarean section. Requirement of injectable antibiotics and analgesics, and hospital stay was less with extra-peritoneal approach.
Extra-peritoneal cesarean section is associated with better postoperative outcomes with respect to return of bowel functions, pain, and requirement of injectable analgesics and antibiotics than the routine trans-peritoneal cesarean section. However, the significantly higher fetus delivery time questions its feasibility in patients with acute fetal distress. Additionally, it is technically difficult and has a longer learning curve.
Research suggests that an increased risk of physical comorbidities might have a key role in the association between severe mental illness (SMI) and disability. We examined the association between ...physical multimorbidity and disability in individuals with SMI.
Data were extracted from the clinical record interactive search system at South London and Maudsley Biomedical Research Centre. Our sample (n = 13,933) consisted of individuals who had received a primary or secondary SMI diagnosis between 2007 and 2018 and had available data for Health of Nations Outcome Scale (HoNOS) as disability measure. Physical comorbidities were defined using Chapters II-XIV of the International Classification of Diagnoses (ICD-10).
More than 60 % of the sample had complex multimorbidity. The most common organ system affected were neurological (34.7%), dermatological (15.4%), and circulatory (14.8%). All specific comorbidities (ICD-10 Chapters) were associated with higher levels of disability, HoNOS total scores. Individuals with musculoskeletal, skin/dermatological, respiratory, endocrine, neurological, hematological, or circulatory disorders were found to be associated with significant difficulties associated with more than five HoNOS domains while others had a lower number of domains affected.
Individuals with SMI and musculoskeletal, skin/dermatological, respiratory, endocrine, neurological, hematological, or circulatory disorders are at higher risk of disability compared to those who do not have those comorbidities. Individuals with SMI and physical comorbidities are at greater risk of reporting difficulties associated with activities of daily living, hallucinations, and cognitive functioning. Therefore, these should be targeted for prevention and intervention programs.
Female sexual dysfunction (FSD) is an important health issue and its relationship with menopausal symptoms needs special attention.
To identify the frequency of FSD in middle aged women and assess ...its relationship with obesity and menopausal symptoms.
This was a cross sectional study performed at a tertiary care centre in North India over a period of one year from June 2022 to May 2023. Sexually active women aged 40–55 years were included in the study sample. Exclusion criteria included those not willing to participate, having pregnancy, malignancy, mental illness or history of pelvic surgery. Baseline demographic and anthropometric details were noted. Sexual function and menopausal symptoms were assessed using Menopause Rating Scale (MRS) and Female Sexual Function Index Scale (FSFI) questionnaire respectively.
Among one hundred and forty three sexually active middle aged women, 43 women had FSD (30.06%). FSD was observed in 9.09%, 22.73% and 45.45% in- 40–45 years, 46–50 years and 51–55 years respectively. No significant difference was seen in desire (p value=0.281), arousal (p value=0.424), lubrication (p value=0.143), orgasm (p value=0.637), satisfaction (p value=0.675), pain (p value=0.833), total score (p value=0.601) between body mass index (kg/m²). A significant strong negative correlation of somatic, urogenital, psychological and total MRS scores with female sexuality domains was observed excepting non-significant mild negative correlation between somatic with pain and psychological with orgasm and pain.
Female sexual dysfunction are quite common and has negative correlation with menopausal symptoms. Health care providers need to focus on this issue as part of their routine assessment for better quality of life.
Background:
Discontinuation of treatment in people with first episode psychosis (FEP) is common, but the extent to which this is related to specific adverse effects of antipsychotic medications is ...unclear.
Objectives:
To investigate whether antipsychotic discontinuation is associated with the prescription of particular antipsychotics and particular adverse effects.
Design:
Retrospective cohort study.
Methods:
We assembled de-identified electronic health record (EHR) data from 2309 adults with FEP who received care from the South London and Maudsley NHS Foundation Trust between 1st April 2008 and 31st March 2019. Associations between antipsychotic medications, clinician-recorded side effects and treatment discontinuation were investigated across a mean follow-up period of 34.2 months using Cox regression.
Results:
The mean age of patients was 26.7 years and 1492 (64.6%) were male. Among first prescribed antipsychotic medications, discontinuation occurred earlier with haloperidol hazard ratio (HR) = 2.78, 95% CI = 1.69–4.60 and quetiapine (HR = 1.43, 95% CI = 1.16–1.80) than with olanzapine. Discontinuation occurred sooner when there was evidence of extrapyramidal symptoms (HR = 1.33, 95% CI = 1.08–1.64) or sexual dysfunction (HR = 1.59, 95% CI = 1.03–2.46). Among antipsychotics prescribed at any point during treatment, lurasidone (HR = 1.40, 95% CI = 1.10–1.78) and aripiprazole (HR = 1.09, 95% CI = 1.01–1.19) were associated with earlier discontinuation than olanzapine. Conversely, clozapine (HR = 0.55, 95% CI = 0.41–0.73) and paliperidone 1-monthly (PP1M) long-acting injectable (HR = 0.80, 95% CI = 0.68–0.94) were associated with later discontinuation. Unexpectedly, for antipsychotics prescribed at any stage of treatment, sedation (HR = 0.89, 95% CI = 0.81–0.97), weight gain (HR = 0.73, 95% CI = 0.64–0.83), and multiple side effects (HR = 0.83, 95% CI = 0.76–0.90) were associated with later discontinuation.
Conclusion:
Earlier treatment discontinuation associated with sexual or extrapyramidal side effects could be related to their rapid onset and poor tolerability. Later treatment discontinuation associated with clozapine and PP1M could be related to the relative efficacy of these treatments. These findings merit consideration when selecting antipsychotic therapy for people with FEP.
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