QUALITY IMPROVEMENT: Supporting a hospital in difficulty: -experience of a '-buddying' agreement to implement a new medical pathway.

Increased NHS regulation has identified many healthcare organisations with operational and/or financial difficulties. Although the causes are often complex, most cases are effectively managed internally with limited input from external agencies. How best to support the few organisations needing additional support has not been established.

Hospital at night: an organizational design that provides safer care at night.

The reduction in the working hours of doctors represents a challenge to the delivery of medical care to acutely sick patients 24 hours a day. Increasing the number of doctors to support multiple specialty rosters is not the solution for economic or organizational reasons. This paper outlines an alternative, economically viable multidisciplinary solution that has been shown to improve patient outcomes and provides organizational consistency.

Creating teams for acute clinical services.

This article discusses how a project group at Guy's and St Thomas' NHS Foundation Trust, London, developed four multiprofessional teams that can provide first responses for acutely ill inpatients on both of the trust's hospital sites, 24 hours a day, seven days a week.

Managing miscarriage in early pregnancy assessment units.

For most women, pregnancy is a significant life event and the prospect of losing a baby causes anxiety, stress and grief. Modern treatment of miscarriage should provide rapid sympathetic diagnosis and adequate counselling. Early pregnancy assessment units benefit patients, staff and the NHS.

Obesity and female reproductive function.

Obesity has consistently been demonstrated to have a detrimental effect upon the female reproductive system. This review explores the common association of obesity with polycystic ovary syndrome (PCOS), the effect of obesity on the clinical and endocrinological parameters, and the role of insulin resistance in the expression of this disorder. An improvement in menstrual function, a decrease in the clinical androgenic profile, and significant increase in spontaneous pregnancy rates have been reported following weight loss.

Diurnal variation of sex hormone binding globulin and insulin-like growth factor binding protein-1 in women with polycystic ovary syndrome.

Objectives: The aim of this study was to examine (1) the diurnal variation in SHBG and (2) the inter-relationships of insulin, IGF-I, SHBG and IGFBP-1 over 24 hours in 10 women with anovulatory PCOS and compare them with weight-matched ovulatory controls.

Patients And Methods: The two groups comprised 10 anovulatory women with PCOS (as defined by clinical, ultrasound and biochemical criteria) and 10 weight matched controls. Serum samples were taken at two-hourly intervals for 24 hours and stored for measurement of SHBG, IGFBP-1, insulin and IGF-I.

Sex hormone-binding globulin and female reproductive function.

Although sex steroids have long been known to influence serum concentrations of SHBG, it is now recognized that nutritional factors may be more important in the regulation of SHBG in women. Thus, SHBG concentrations are negatively correlated with body mass index (BMI) and, more particularly, to indices of central adiposity. Polycystic ovary syndrome (PCOS), the most common cause of anovulatory infertility, is associated with truncal obesity, hyperandrogenism and hyperinsulinaemia.

[The role of body weight and metabolic anomalies in ovulation induction].

Obese women with polycystic ovary syndrome require higher doses of gonadotrophin for induction of ovulation than their lean counterparts. They also have a lower rate of ovulation and higher prevalence of miscarriage.

Response of sex hormone binding globulin and insulin-like growth factor binding protein-1 to an oral glucose tolerance test in obese women with polycystic ovary syndrome before and after calorie restriction.

Objective: We determined the relationship of short-term changes in circulating insulin concentrations, resulting from an oral glucose load, to those in both sex hormone binding globulin (SHBG) and insulin-like growth factor binding protein 1 (IGFBP-1) and assessed the effect of a short-term low calorie diet on the levels of SHBG and IGFBP-1 during an oral glucose tolerance test.

Design: A within-group comparison of biochemical indices during an oral glucose tolerance test before and after calorie restriction.

Patients And Methods: Six obese women with polycystic ovary syndrome with mean (SD) BMI 34.

Hypersecretion of luteinizing hormone and ovarian steroids in women with recurrent early miscarriage.

Polycystic ovary syndrome is associated with hypersecretion of luteinizing hormone (LH) which has been implicated in the aetiology of early pregnancy loss. Although 82% of women with recurrent early loss have polycystic ovaries on ultrasound imaging, random serum LH concentrations are normal. In the present study, we have obtained further information from serial samples concerning the cyclical patterns of gonadotrophin and sex steroid secretion in these women.

Association of moderate obesity with a poor pregnancy outcome in women with polycystic ovary syndrome treated with low dose gonadotrophin.

Objective: To assess the effect of moderate obesity on the outcome of induction of ovulation with low dose gonadotrophin in women with polycystic ovary syndrome (PCOS).

Design: Retrospective analysis of women with PCOS treated consecutively. An analysis of the impact of obesity on outcome of pregnancy using data from the North West Thames Regional (NWTR) obstetric database was included for comparison.

Improvement in endocrine and ovarian function during dietary treatment of obese women with polycystic ovary syndrome.

Objective: Obese women with polycystic ovary syndrome have a greater frequency of menstrual disturbance and of hirsutism than lean women with the syndrome. Initial studies have demonstrated a marked improvement in endocrine function following a short-term, very low calorie diet. The purpose of this study was to examine the effect of long-term calorie restriction on clinical as well as biochemical abnormalities in obese women with polycystic ovary syndrome.

The role of nutrition and insulin in the regulation of sex hormone binding globulin.

In an analysis of 263 women with polycystic ovary syndrome (PCOS), 91 (35%) of whom were obese (body mass index greater than 25 kg/m2), it was found that obese women with PCOS were more likely to be anovulatory and had a higher prevalence of hirsutism than the non-obese subgroup. Although serum concentrations of gonadotrophins, androstenedione and total testosterone were similar in obese and lean women with PCO, sex hormone binding globulin (SHBG) levels were significantly lower, and free testosterone correspondingly higher, in obese women. Serum concentrations of SHBG were inversely correlated with those of both fasting and glucose-stimulated insulin.

Low-dose gonadotrophin therapy for induction of ovulation in 100 women with polycystic ovary syndrome.

Women with anovulation due to polycystic ovary syndrome are likely to develop multiple follicles during gonadotrophin therapy and therefore have a high risk of multiple pregnancy. We have developed a low-dose regimen for use in these women; 100 women with clomiphene-resistant polycystic ovary syndrome were treated. Ninety-five of the women ovulated at least once, 72% of the 401 cycles induced were ovulatory and the majority (73%) of these were uni-ovulatory.

Obesity and polycystic ovary syndrome.

Our studies show that obese women with polycystic ovary syndrome are more likely to have hirsutism and menstrual disturbances than are lean women with PCOS. The most obvious biochemical differences between obese and lean women with PCOS is that SHBG concentrations are much lower in women with obesity. The SHBG levels are inversely related to insulin, and insulin has been shown to have a direct inhibitory action on SHBG secretion.

A comparative, randomized study of low-dose human menopausal gonadotropin and follicle-stimulating hormone in women with polycystic ovarian syndrome.

Treatment with low-dose follicle-stimulating hormone (FSH) is associated with a high rate of ovulation in anovulatory women with polycystic ovarian syndrome (PCOS), but it is not clear whether the success of treatment is because of the use of pure FSH or the low dose of gonadotropin. We undertook a randomized controlled study to compare the effects of urinary FSH and human menopausal gonadotropin (hMG) using a low-dose regimen in 30 women with PCOS. Each subject received a maximum of three cycles of either FSH or hMG.

Common problems in induction of ovulation.

There are many groups of women with anovulatory infertility who respond abnormally to conventional treatment. It is important to diagnose the underlying disorder correctly before commencing treatment. In this chapter we have discussed the various treatment modalities available and how they may be adapted to fit the particular clinical needs.