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Approaches to improving the health outcomes for Aboriginal and Torres Strait Islander women and their babies in pregnancy include the following: • systems-based approaches to address socioeconomic disadvantage discount prochlorperazine 5mg with visa medications not to crush, education and health literacy (Boyle & Eades 2016) • health services approaches to provide trusted prochlorperazine 5 mg generic symptoms 8 days after iui, welcoming and culturally appropriate health services in both community-controlled and government sectors cheap 5mg prochlorperazine mastercard medications xanax, facilitate better communication between primary and hospital-based services and utilise initiatives such as continuous quality improvement practices that lead to improved services, particularly where staff turnover is high (Boyle & Eades 2016) • families-based approaches, to address social and lifestyle factors (eg smoking prevention and quitting (Boyle & Eades 2016), drinking alcohol, social and emotional wellbeing and nutrition) (Gibson-Helm et al 2016a) • clinical guidelines to address specific needs of Aboriginal and Torres Strait Islander women in pregnancy (eg screening for infection in young women and women from areas where risk is high) (Boyle & Eades 2016) • supports for the particular needs of rural and remote women in accessing care (eg access to ultrasound services) (Boyle & Eades 2016) • strengthened systems to ensure workforce support, retention and recruitment; patient-centred care; and community capacity, engagement and mobilisation (Gibson-Helm et al 2016a). Bertilone C & McEvoy S (2015) Success in Closing the Gap: favourable neonatal outcomes in a metropolitan Aboriginal Maternity Group Practice Program. Gibson-Helm M, Bailie J, Matthews V et al (2016a) Priority Evidence-Practice Gaps in Aboriginal and Torres Strait Islander Maternal Health Care Final Report. Kildea S, Tracy S, Sherwood J et al (2016) Improving maternity services for Indigenous women in Australia: moving from policy to practice. Melbourne: Royal Australian College of General Practitioners National Faculty of Aboriginal and Torres Strait Islander Health. Reibel T, Wyndow P, Walker R (2016) From Consultation to Application: Practical Solutions for Improving Maternal and Neonatal Outcomes for Adolescent Aboriginal Mothers at a Local Level. While the diversity of circumstances and experiences is acknowledged, this chapter highlights general considerations in improving the experience of antenatal care for migrant and refugee women. The term ‘migrant and refugee’ is used in these Guidelines to refer both to women who are voluntary migrants and women who come to Australia as refugees, humanitarian entrants or asylum seekers. Migrants and refugees are also often referred to as people of culturally and linguistically diverse background, people from non- English–speaking backgrounds or people who speak a language other than English. National data suggest similar rates of perinatal death among babies of women born in Australia and those born overseas (Li et al 2012). However, retrospective studies suggest that outcomes vary with country of birth (Drysdale et al 2012) and use of interpreters, but not refugee status (Thomas et al 2010). There is significant heterogeneity among migrant and refugee women and their experience of antenatal care. For example, more than half (57%) of women giving birth in New South Wales in 2004 who were originally from a developing country first attended for antenatal care later than 12 weeks in the pregnancy (Trinh & Rubin 2006). Expectations of the birth experience are also strongly influenced by cultural views and practices (Hoang et al 2009). An increasing proportion of refugee and humanitarian entrants to Australia come from Africa, the Middle East and Southeast Asia; about 30% are women aged 12–44 years (Correa-Velez & Ryan 2012). Refugee women are more likely than other women to have complex medical and psychosocial problems and may face additional barriers in accessing antenatal care (Correa-Velez & Ryan 2012). As well as cultural background, women’s experiences differ with migration status, educational level and prior experience of pregnancy and birth. However, there are some common issues that can affect uptake of antenatal care by migrant and refugee women. These include (McCarthy & Barnett 1996; Carolan & Cassart 2010; Phiri et al 2010; Murray et al 2011; Boerleider et al 2013): • migration factors: lack of knowledge of or information about the Western healthcare system (including rights in relation to tests and treatments); arriving in the new country late in pregnancy; history of grief, loss and/or trauma in addition to migration • cultural factors: adherence to cultural and religious practices, poor language proficiency, lack of assertiveness, partner/family perception of antenatal care, perceiving pregnancy as not requiring health professional involvement, belief that antenatal care is more a burden than a benefit, belief that antenatal classes are not necessary, fear of coming into contact with government agencies • position in host country: financial problems, unemployment, low or intermediate educational level, social inequality (education, economic resources and residence [rural or urban]), lack of time, lack of childcare, no medical leave from work • social network: lack of usual female family and community support systems, isolated community 37 • accessibility: inappropriate timing and incompatible opening hours, transport and mobility problems, indirect discrimination, lack of suitable resources (eg female interpreters) • expertise: health professional lacking knowledge of cultural practices • personal treatment and communication: poor communication, perception of having been badly treated by a health professional. While overseas students are required to maintain Overseas Student Health Cover for the duration of their time in Australia, pregnancy-related services may not be covered in the first 12 months of membership. Even when care can be accessed, women who have no previous experience with a western health care system may have limited understanding of reasons for antenatal visits, medical procedures and use of technology. They may not feel confident to ask questions or participate in discussions about their care plan or birth options. Different cultural beliefs may also influence aspects of antenatal care such as involvement of the father in pregnancy and childbirth, acceptance of tests and interventions, willingness to be cared for by a midwife rather than a doctor or a woman rather than a man, understanding of dates and times of appointments, and knowledge about medical aspects of pregnancy. Increased awareness of such issues and the differences between groups will help to promote better antenatal care of women from migrant and refugee backgrounds. These experiences cause significant psychological distress, manifesting in symptoms of anxiety, depression, post- traumatic stress, poor sleep and concentration.

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These include inhibition of geal surgery cheap prochlorperazine 5 mg 5 medications post mi, particularly those undergoing esophagoscopy endothelial–leukocyte interactions [206 buy prochlorperazine 5 mg low price treatment 4 pimples, 207] purchase prochlorperazine 5 mg with visa symptoms 3 months pregnant, transendothe- and minimally invasive laparoscopic or thoracoscopic surgical lial migration of neutrophils [208], and vascular fluid flux procedures. The primary colloid solutions available in the United tomy procedures will be discussed later. In most cases, dosing of an ance in patients with impaired renal function [210], and reduced indwelling thoracic epidural catheter is well tolerated during 30. Anesthesia for Esophageal Surgery 429 wound closure as the intravenous or inhalational anesthetic is Anesthetic Considerations for Specific reduced. Placing the patient in a 30° head-up position may Esophagoscopy improve pulmonary ventilation and decrease aspiration risk. Esophagoscopy may be performed with either a rigid or flex- If a gastric drain is indicated for the procedure, it should be ible endoscope and is used for a number of specific diagnostic secured prior to emergence and extubation. In general, most diagnostic esopha- Hypotension occurs not infrequently after esophageal sur- goscopies are performed using flexible endoscopes, often in gery. Causes include inadequate intraoperative plasma vol- awake sedated patients and frequently in a gastroenterology ume expansion, hemorrhage, cardiac dysrhythmias, most suite without the care of an anesthesiologist. Careful hemodynamic assess- tion of an endoscopist, usually a gastroenterologist, is most ment of the postoperative patient should permit the distinction often accomplished with the use of a benzodiazepine such as between hypovolemia and other causes. Urine output and diazepam or midazolam with or without the addition of an chest drain output should be carefully followed and hemoglo- opioid such as meperidine. Patient acceptance of the proce- bin concentration monitored in patients suspected of ongoing dure without sedation, even with ultrathin esophagoscopes, bleeding. Often, a local anesthetic such as lido- in patients undergoing transthoracic or transhiatal procedures caine or benzocaine is applied topically to facilitate patient and when postoperative cardiovascular or respiratory compli- acceptance and reduce gagging during the procedure. Flex- reducing the concentration of local anesthetic in the epidural ible esophagoscopy is also routinely performed by thoracic infusion. Occasionally, hemodynamically fragile patients may surgeons immediately prior to esophageal surgery to assess require substitution of epidural local anesthetic solution with the location and extent of esophageal lesions and the degree an opioid such as hydromorphone or morphine, though pain of esophageal obstruction. Most of these patients have known control with this regimen is usually suboptimal. These patients are usually at elevated risk surgical procedures, including esophageal surgeries and for regurgitation and aspiration and should be treated appro- may result in significant hemodynamic instability due to a priately. The airway should be secured prior to instrumenta- rapid ventricular response and/or myocardial ischemia. Myocar- extraction of esophageal foreign bodies, often in children, dial ischemia, congestive heart failure, and pulmonary throm- as well as for the removal of retained food items. As with boembolic complications are also possible though appropriate laryngoscopy, this is a very stimulating procedure and not patient selection, preoperative cardiovascular evaluation, and likely to be well tolerated without general anesthesia. Often, retractions guidelines, it may be appropriate to consider deeper levels of due to upper airway obstruction can be observed. Inadequate pain control after thoracotomy or laparotomy for rigid esophagoscopy include the extreme neck extension can also result in splinting with reduced tidal volumes and desired by surgeons for alignment of the oral–esophageal hypoventilation. Typically, adequate treatment of incisional axis, the risk of aspirating objects once extracted from the pain leads to a dramatic improvement in respiratory function. The latter need can be performed immediately in any patient with acute respiratory achieved with deep levels of inhalational anesthetic or with decompensation after thoracic surgery. Rarely, alternative approaches for oxygenation strictures [221, 222], and perforation [14, 223].

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If oophorectomy (removal of the ovaries) is performed at the time of hysterectomy prochlorperazine 5mg medications that interact with grapefruit, menopausal-like symptoms occur order prochlorperazine 5 mg visa treatment 32 for bad breath. Clinical outcomes and costs with the levonorgestrel- releasing intrauterine system or hysterectomy for treatment of menorrhagia: randomized trial 5-year follow-up discount 5 mg prochlorperazine fast delivery symptoms of. Hysterectomy versus expanded medical treatment for abnormal uterine bleeding: Clinical outcomes in the medicine or surgery trial. Hysteroscopic endometrial resection versus laparoscopic supracervical hysterectomy for menorrhagia: a prospective randomized trial. Uterine fibroids: uterine artery embolization versus abdominal hysterectomy for treatment – a prospective, randomized, and controlled clinical trial. Menorrhagia can occur by itself or in combination with other symptoms, such as menstrual pain (dysmenorrhoea). Heavy bleeding does not necessarily mean there is anything seriously wrong, but it can affect a woman physically, emotionally and socially, and can cause disruption to everyday life. Eligibility Criteria Diagnostic Hysteroscopy for Menorrhagia is not routinely commissioned. More than 70,000 knee replacements are carried out in England and Wales each year, and the number is rising. For most people, a replacement knee lasts over 20 years, especially if the new knee is cared for properly and not put under too much strain. These patients should be counselled regarding these risks prior to any surgical intervention. Patients suffering with persistent symptoms, despite appropriate non-operative management, should be given the option to choose decompression surgery. Page | 76 Criteria Arthroscopic subacromial decompression for pure subacromial shoulder impingement should only offered in appropriate cases. To be clear, ‘pure subacromial shoulder impingement’ means subacromial pain not caused by associated diagnoses such as rotator cuff tears, acromio-clavicular joint pain, or calcific tendinopathy. Non-operative treatment such as physiotherapy and exercise programmes are effective and safe in many cases. For patients who have persistent or progressive symptoms, in spite of adequate non-operative treatment, surgery should be considered. The latest evidence for the potential benefits and risks of subacromial shoulder decompression surgery should be discussed with the patient and a shared decision reached between surgeon and patient as to whether to proceed with surgical intervention. Rationale Recruiting patients with pure subacromial impingement and no other associated diagnosis, a recent randomised, pragmatic, parallel group, placebo-controlled trial investigated whether subacromial decompression compared with placebo (arthroscopy only) surgery improved pain and function1. While statistically better scores were reached by patients who had both types of surgery compared to no surgery, the differences were not clinically significant, which questions the value of this type of surgery. On the other hand, a more recent prospective randomised trial comparing the long term outcome (10 year follow up) of surgical or non-surgical treatment of sub acromial impingement showed surgery to be superior to non-surgical treatment. Subacromial Decompression Yields a Better Clinical Outcome Than Therapy Alone: A Prospective Randomized Page | 77 Study of Patients With a Minimum 10-Year Follow-up. Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomised controlled study. Arthroscopic subacromial decompression is effective in selected patients with shoulder impingement syndrome. Description of the intervention Recurrent sore throats are a very common condition that present a considerable health burden. In some cases, where there are recurrent, documented episodes of acute tonsillitis that are disabling to normal function, then tonsillectomy is beneficial, but it should only be offered when the frequency of episodes set out by the Scottish Intercollegiate Guidelines Network criteria are met. Summary of Intervention This guidance relates to surgical procedures to remove the tonsils as a treatment for recurrent sore throats in adults and children.

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Methods of termination of pregnancy Termination of pregnancy can be performed surgically before 15 weeks of pregnancy cheapest generic prochlorperazine uk medications questions, when uterine evacuation can usually be achieved by vacuum aspiration with an appropriate-sized curette after cervical preparation with misoprostol or gemeprost cheap 5mg prochlorperazine visa medicine vs medication. After this gestational age prochlorperazine 5mg without a prescription treatment juvenile rheumatoid arthritis, fetal size precludes complete aspiration and dilatation and evacuation (D&E) becomes necessary. Risks of termination increase with gestational age, particularly with medical termination; complication rates (haemorrhage, uterine perforation and/or sepsis up to the time of discharge from the place of termination) increase from 5/1000 medical procedures at 10–12 weeks to 16/1000 at 20 weeks of gestation and over. The situation is very different when only terminations performed under Ground E are considered (Figure 3). This may reflect the value placed on having an intact fetus to perform postmortem examination, especially in euploid cases. Almost all second-trimester abortions in Scotland, for whatever reason, are carried out medically rather than surgically. Medical termination offers the opportunity for pathological examination of an intact fetus. Feticide When undertaking a termination of pregnancy, the intention is that the fetus should not survive and that the process of abortion should achieve this. Death may also occur after birth either because of the severity of the abnormality for which termination was performed or because of extreme prematurity (or both). In the Epicure study, 11% of 2122 fetuses believed to be 20–22 weeks of gestation were born alive, of which two (0. For those born at 23 weeks, live birth and survival rates increased to 39% and 4%, respectively. The number and proportion of live births at or over 22 weeks decreased over the period of study from 10% to 16% in 1995–1997 to 2% in 2004. Livebirth rates after termination of pregnancy for fetal abnormality in West Midlands, 1995–2004 30 Gestation Live births (weeks) (n) (%) (95% confidence interval) 20 404 3. The proportion of abortions performed under Ground E preceded by feticide for the years 2005– 2008 is shown in Table 8. From this it can be seen that feticide is undertaken for a significant number of abortions before 22 weeks of gestation. It is not known whether this relates to a decision not to offer the procedure on the part of the clinician or whether the procedure was offered but declined by the woman. Because of the Office for National Statistics guidance on disclosure of abortion statistics, whereby information from ‘unsafe’ cells (those with less than ten cases) is suppressed,35 it is not known what proportion of these late abortions were performed for anomalies where early neonatal death was thought to be inevitable. Proportion of terminations for fetal abnormality preceded by feticide (residents of England and Wales, 2005–2008) Year Totala Gestation (weeks) < 16 16–19 20 21 22 23 ≥ 24 2005 1916 2 3 17 35 72 81 –b 2006 2036 1 3 13 30 72 88 –b 2007 1939 2 –b 9 23 74 82 –b 2008 1988 2 –b 11 25 65 88 92 a All terminations for fetal abnormality b Percentages are suppressed where based on totals less than 10 Attitudes to feticide There has been little research on health professionals’ and parents’ views on feticide as part of termination of pregnancy for fetal anomaly. While many professionals will find the procedure stressful, most agree that feticide will prevent parents and labour ward staff from facing the agony of neonatal distress and pain. However, both studies identified specialists who were more flexible about offering feticide after 21+6 weeks of gestation where the anomaly was considered to be incom- 31 patible with survival. Feticide should be performed by an appropriately trained practitioner (and always under consultant supervision) under aseptic conditions and continuous ultrasound guidance. A repeat injection may be required if asystole has not occurred after 30–60 seconds. Asystole should be documented for at least 2 minutes and a scan repeated after 30–60 minutes to ensure fetal demise. In a series of 239 cases of feticide using this technique, between 20+5 and 37+5 weeks of gestation, there were no failures (live births);40 asystole was confirmed in all cases within 2 minutes of the initial injection, with no woman requiring a second needle insertion and no maternal complications. In addition, acute haemorrhage of the survivor into the dead co-twin can result in death or neurological injury.

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