The safe use of transvaginal sonography in patients with placenta previa has been confirmed, and has revolutionized precise placental localization. The aim of our study was to evaluate the efficacy of transvaginal sonography and color-coded blood flow in the prediction of placenta accreta. Twenty-one patients with persistent placenta previa were scanned using transvaginal sonography and color-coded flow. Suspicion for placenta accreta consisted of total placenta previa at term with several placental lacunae exhibiting marked or turbulent blood flow, as seen with color Doppler transvaginal sonography from within the placenta, extending into the surrounding tissues. Five of the patients exhibited sonographic placental patterns suspicious for placenta accreta and one patient exhibited placental and cervical blood flow described as lacunar. Five Cesarean hysterectomies were performed for placenta accreta. Every placenta accreta was correctly diagnosed sonographically by the use of color flow studies. One patient with suspicion of placenta accreta delivered at another institution, a Cesarean hysterectomy was performed, and the pathology was confirmed. The one placenta previa exhibiting turbulent lacunar flow in the cervical area only was not confirmed to be an accreta at Cesarean section, although hemostasis was difficult at the placental bed. The remaining 15 patients with placenta previa and who on sonography were not suspicious for placenta accreta underwent uncomplicated Cesarean section. Transvaginal sonography and color Doppler imaging improve the diagnostic accuracy in the prediction of placenta accreta in patients with persistent placenta previa. A pattern of turbulent blood flow extending from the placenta into the surrounding tissues should alert the physician to the possibility of placenta accreta.

Obese children have more respiratory symptoms than their normal weight peers and respiratory related pathology increases with increasing weight. Some will need specialist assessment (box 1). Obesity produces mechanical effects on respiratory system performance. Breathlessness, wheeze, and cough are not related to increased airway responsiveness and may respond more to weight loss than bronchodilator therapy. A significant number of obese children have signs and symptoms of obstructive sleep apnoea largely related to the effect of obesity on upper airway dimensions. It seems likely that unless action is taken soon, increasing numbers of children will experience preventable respiratory morbidity as a result of nutritional obesity.

No abstract

No abstract

Introduction: Dysphagia is common after acute stroke. Variability in predicting who will require a gastrostomy tube (G-tube) prior to discharge can prolong length of hospital stay (LOS) and increase costs. Objectives: We propose a novel protocol to standardize speech therapy evaluation and G-tube recommendations among acute stroke patients with dysphagia to reduce LOS and costs. Methods: A cohort of acute stroke patients with dysphagia was identified through an administrative data set using ICD-10 codes for ischemic stroke and CPT codes for speech therapy evaluation, and if applicable, CPT code for G-tube placement. Patients with tracheostomy, comfort care orders, or discharge to hospice were excluded. A multidisciplinary team from speech therapy, neurology, and radiology applied quality improvement principles to design and implement a G-tube indicator score (Figure 1) to address variability in dysphagia evaluation. Median LOS and duration from initial speech therapy evaluation to final diet recommendation were compared between the pre- and post-intervention period. Cost savings were calculated using LOS and average daily institutional bed cost. Results: Between January 2016 to January 2017, 174/278 (62%) of acute stroke patients had dysphagia and 61/174 (35%) of these patients received G-tubes. Their median LOS was 21.7 days compared to 5 days for stroke patients without G-tube. In the post-implementation period from Feb-May 2017, 25/45 (55%) of acute stroke patients had dysphagia and 5/25 (20%) received G-tubes. Their median LOS was 16.4 days following the protocol implementation. This resulted in cost savings of $14,654 per G-tube patient. Conclusions: This novel G-tube indicator score standardized speech therapy evaluation and reduced LOS by more than 5 days among acute stroke patients requiring G-tube prior to discharge. Future studies will prospectively validate the score. Increased adoption would result in significant cost savings.