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Background: Preoperative risk factor identification and optimisation are widely accepted as the gold standard of care for elective surgery and are essential for reducing morbidity and mortality. COVID-19 public health restrictions required a careful balance between ensuring best medical practices and maintaining safety by minimising patient face-to-face attendance in the hospital. Based on the successful implementation of telemedicine (TM) in other medical specialties and its feasibility in the preoperative context, this study aimed to develop, implement and evaluate a high-quality virtual preoperative anaesthetic assessment process., Methods: The three-step model for improvement was used. The specific, measurable, actionable, relevant, time aim (step 1) and measures for improvement (step 2) were defined at the onset of the project. The plan-do-study-act tool was used for the structured implementation of improvement interventions (step 3) in three phases. Data relating to virtual and in-person referrals, assessments, did-not-attend (DNA) rate, consultation time, day of surgery delays and cancellations, and service-user and provider experience surveys were recorded prospectively., Results: A total of 2805 patients were assessed in the preoperative anaesthetic assessment clinic between July 2020 and March 2021. The mean rate of virtual preoperative assessments was 50% (SD ±10) (1390/2805). 0.1% (30/2805) were inappropriately referred on the alternative pathway. The DNA rate was 0.4% (8/1398) and 3% (43/1458) for virtual and in-person pathways, respectively. The mean consultation times for virtual and in-person attendance were 19 (SD ±7) and 31 (SD ±13) min, respectively. There were five same-day surgery cancellations and one delay due to medical reasons. When asked about their experience with the virtual assessment, both service users and providers reported high satisfaction, minimal technical difficulties and shared concerns about limited opportunities for physical examination., Conclusion: This is one of the first implementational studies to comprehensively outline the feasibility of TM in preoperative anaesthetic assessment during COVID-19., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Capturing 'near miss' and severe maternal morbidity using standard definitions is challenging. Information about levels of care required by ill pregnant or recently pregnant women may be more informative. The aim of this study was to prospectively audit incidence, causes, categorisation of maternal morbidity and level of care required by patients admitted to a labour ward high dependency unit (HDU) in a stand-alone obstetric hospital., Study Design: All women admitted to HDU from May 5th to November 5th 2014 were identified prospectively and morbidity was categorised according to the Scottish Audit of Severe Maternal Morbidity (SAMM) and World Health Organisation (WHO) definitions of 'near miss' (NM), and 'severe maternal complications' (SMC). Level of care was determined by the RCOG Maternal critical care working group recommendations [1]., Results: There were 128 admissions to HDU with 4502 live births (2.8%) during this period. There were 16 (12.5%) cases of NM; 83 (64.8%) of SMC and 29 'others' not meeting either criteria. Direct obstetric causes accounted for 79% of admissions. NM cases were more likely to be caused by haemorrhage (56.3%, p=0.009), postpartum (75%, p<0.05) and require blood transfusion (56.4%) compared to SMC cases, more likely to result from hypertension (39.8%, p=0.018) and be admitted antenatally (66.3%, p=0.039). Those admitted in the beneath NM and SMC group were more likely to be admitted antenatally (89.7%, p=0.039) and require specialist consultation (31%, p=0.022). Mean duration of HDU stay was 26.6 (±17 SD) hours. The perinatal mortality rate was 39/1000 total births. There were no maternal deaths. Level 2 care was required by 40 women (NM 25%; SMC 39% and others 14%) and two women required ICU transfer for Level 3 care., Conclusions: Approximately one quarter of women requiring HDU care 'lie beneath' criteria for near miss or severe maternal complications. One third of women admitted to the HDU require Level 2 care and the remainder require higher levels of monitoring only. The majority of cases are antepartum and delivery is integral in their care. HDU care in a labour ward setting is a good model for care of the ill pregnant or recently pregnant woman., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Quantitative ultrasound (QUS) of the calcaneus quickly introduced itself as a useful diagnostic tool in osteoporosis. The purpose of this study was to assess its diagnostic value in postmenopausal women as compared to DXA of vertebral bodies. 100 postmenopausal women (mean age 48 years) were included and underwent calcaneal QUS (Lunar Achilles+ device) and dual-energy X-ray absorptiometry of the vertebral bodies (Hologic QDR 4500 A unit). Mean QUS T-score was -2.38, and mean DXA T-score was -2.06 standard deviations. Both measurements classified equal proportions of women as normal (4 versus 12%), osteopenic (55% in both cases), and osteoporotic (41 versus 33%). In detecting osteoporosis QUS showed 58% sensitivity and 47% specificity. When assessing fracture risk (osteoporosis and osteopenia) QUS showed 100% sensitivity and 92% specificity. The negative predictive value of QUS always exceeded the positive one. QUS is a valuable tool in primary screening for increased fracture risk. Alerting results require further examinations.

In the second half of the twentieth century different patterns of bone mass changes in young women were described in association with pregnancy and lactation. Pregnancy-associated osteoporosis may present as predominant bone loss from the hip; there is a second form with vertebral involvement; and it may present with fractures at atypical sites such as the sacrum. Long-term lactation is also associated with increased bone loss. In our work we describe a clinical case of a 34-year old lactating woman, presenting at the fourth month after unremarkable childbearing with vertebral fractures and overt osteoporosis. We described the diagnostic procedures and therapeutic interventions. A literature review is also presented. In conclusion, osteoporosis of pregnancy and lactation should not stay out of the clinician's focus and requires a multi-disciplinary approach.

The age of menopause in women is a key point, because early menopause is associated with increased risk for many diseases. The purpose of this study was to collect data on age of menopause in Bulgarian women and to detect possible changes in it. 6017 women aged 50 years and over were included, 5363 of them were postmenopausal. Mean age of menopause in the whole study group was 49.3 years. In younger menopausal women (age 51-59 yrs.) mean age of menopause was 47.7 yrs., whereas in elderly women (71-79 yrs.) it was 49.2 yrs. This shift down of the menopausal transition is due also to the increasing part of women with early or premature menopause, including iatrogenic causes. The main consequence is the "growing younger" of many common and socially important diseases among Bulgarian women, which require active prevention.

Fine needle aspiration biopsy (FNA) is a morphological method, which may bridge the diagnostic gap between initial clinical and sonographic examination and histological diagnosis in thyroid disease. Our study was aimed at a review of 3-year aspiration cytology of the thyroid gland in clinical practice. 175 FNA were assessed (165 in females and 10 in males). Aspiration biopsy was performed using 20 to 23 G needles and aspirates were stained after Pappenheim. The highest number of performed FNA was between 40 and 60 yrs of age. The most commonly observed clinical diagnosis requiring FNA included multinodular goiter, Hashimoto thyroiditis and thyroid adenoma. These were also the most common cytological findings. Unsatisfactory specimens were found in 21% of aspirates. Most pitfalls were found in cases of multinodular goiter and Hashimoto thyroiditis. Our results are comparable to those of other clinical centers. They reflect the age-adjusted incidence of thyroid disease. We conclude that combination of ultrasound tomography, aspiration puncture, and cytological evaluation improves the diagnosis of thyroid disease and reduces the duration of the examination.

The early menopause is well known to have deleterious effects on bone mass. Trabecular bone is thought to be mainly affected. Aim of this study was to produce evidence on charges in forearm total, cortical and trabecular bone density in women with early menopause. The study included 40 women menopaused before the age of 43 years and 44 age- and size-matched healthy controls, menopaused after the age of 45 years. Bone densitometry was carried out on a single X-ray DTX-100 densitometer. A special calculation procedure was used to determine bone density of cortical and trabecular bone. The early menopaused women had low bone density both at the Distal (mainly trabecular) bone. We conclude that early-onset menopause affects mainly trabecular bone and causes premature ageing of bone.

Ten female patients with manifested climacteric syndrome (CS) were treated by acupuncture according to the traditional east methodology, the basic therapy making use of the points--Năi-Guan, Gun-Sun, Hă-Gu and Zsu-San-Li and for the determination of the severity of CS and the effect of its treatment --five of the most often applied menopause indices (MI) in the hormonal treatment of CS were used. Copperman, Blatt--modification of Neugarten and Kreins: Jones, Marshall and Nordin: Wenderlein and Striker. The favourable clinical results observed from the acupuncture treatment, determined by MI, are similar to the results, reported by the authors, making use of MI in the hormonal treatment of CS. That provided grounds to admit that they are suitable criteria also for the objectivization of the effect of the acupuncture treatment of climacteric syndrome.

The following parameters were studied in 27 newly diagnosed and not treated patients with primary hypothyroidism: TTH, creatine kinase (CK) with MB isoenzyme, lactate dehydrogenase (LDH) with isoenzymes LDH1 and LDH5, aspartate aminotransferase (ASAT) and alanine aminotransferase (ALAT) before and after 20-day substitutive therapy. It has been established that the enzymes were increased in about 60% of the untreated patients, and the typical enzyme constellation for hypothyroidism consisted of CK with MB isoenzymes, ASAT and LDH1. The myocardial isoenzymes were normalized within the period of substitutive therapy. The enzymes were established to be elevated only in the patients that had increased CK. The follow up of the above enzyme constellation before and during the initial phases of the treatment of hypothyroidism could provide considerable possibilities of differential diagnosis with ischemic heart disease, often manifested during that period. The determination of CK in advance would be a screening determining the necessity of studies on the enzyme constellation.