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Engjom HM, Ramakrishnan R, Vousden N, Bunch K, Morris E, Simpson N, Gale C, O'Brien P, Quigley M, Brocklehurst P, Kurinczuk JJ, Knight M. Perinatal outcomes after admission with COVID-19 in pregnancy: a UK national cohort study. Nat Commun 2024; 15:3234. [PMID: 38622110 PMCID: PMC11018846 DOI: 10.1038/s41467-024-47181-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 03/22/2024] [Indexed: 04/17/2024] Open
Abstract
There are few population-based studies of sufficient size and follow-up duration to have reliably assessed perinatal outcomes for pregnant women hospitalised with SARS-CoV-2 infection. The United Kingdom Obstetric Surveillance System (UKOSS) covers all 194 consultant-led UK maternity units and included all pregnant women admitted to hospital with an ongoing SARS-CoV-2 infection. Here we show that in this large national cohort comprising two years' active surveillance over four SARS-CoV-2 variant periods and with near complete follow-up of pregnancy outcomes for 16,627 included women, severe perinatal outcomes were more common in women with moderate to severe COVID-19, during the delta dominant period and among unvaccinated women. We provide strong evidence to recommend continuous surveillance of pregnancy outcomes in future pandemics and to continue to recommend SARS-CoV-2 vaccination in pregnancy to protect both mothers and babies.
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Affiliation(s)
- Hilde Marie Engjom
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, OX3 7LF, UK
- Division of Physical and Mental Health, Norwegian Institute of Public Health, 5015, Bergen, Norway
| | - Rema Ramakrishnan
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, OX3 7LF, UK
| | - Nicola Vousden
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, OX3 7LF, UK
| | - Kathryn Bunch
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, OX3 7LF, UK
| | - Edward Morris
- Norfolk and Norwich University Hospital, Colney Lane, Norwich, NR4 7UY, UK
| | - Nigel Simpson
- Department of Women's and Children's Health, School of Medicine, University of Leeds, Leeds, LS2 9JT, UK
| | - Chris Gale
- Neonatal Medicine, School of Public Health, Faculty of Medicine, London, London, UK, SW7 2BX and Centre for Paediatrics and Child Health, Imperial College, London, SW7 2AZ, UK
| | - Pat O'Brien
- Norfolk and Norwich University Hospital, Colney Lane, Norwich, NR4 7UY, UK
- Institute for Women's Health, University College London, London, UK
| | - Maria Quigley
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, OX3 7LF, UK
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Jennifer J Kurinczuk
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, OX3 7LF, UK
| | - Marian Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, OX3 7LF, UK.
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Kachapila M, Oppong R, Ademuyiwa AO, Bhangu A, Dauda R, Ghosh DN, Kamarajah SK, Lawani I, Medina ARDL, Monahan M, Morton DG, Omar O, Picciochi M, Tabiri S, Roberts TE, Brocklehurst P, Chakrabortee S, Glasbey J, Hardy P, Harrison E, Lillywhite R, Magill L, Nepogodiev D, Simoes J, Smith D, Kadir B, Pinkney T, Brant F, Li E, Runigamugabo E, Bahrami-Hessari M, Bywater E, Martinez L, Habumuremyi S, Ntirenganya F, Williams E, Fourtounas M, Melic BKC, Ghosh DN, Suroy A, Ahogni D, Ahounou A, Boukari KA, Gbehade O, Hessou TK, Nindopa S, Nontonwanou MB, Guessou NO, Sambo A, Tchati SV, Tchogo A, Tobome SR, Yanto P, Gandaho I, Hadonou A, Hinvo S, Hodonou MA, Tamou SB, Lawani S, Dossou FM, Gaou A, Goudou R, Kouroumta MC, Lawani I, Malade E, Dikao ASM, Nsilu JN, Ogouyemi P, Akpla M, Mitima NB, Kovohouande B, Loupeda SL, Agbangla MV, Hedefoun SE, Mavoha T, Ngaguene J, Rugendabanga J, Soton RR, Totin M, Agbadebo M, Dewamon H, Akpo I, Djeto M, Hada A, Hollo M, Houndji A, Houndote A, Hounsa S, Kpatchassou E, Yome H, Alidou MM, Bara EJ, Yovo BBD, Guinnou R, Hamadou S, Kola H, Moussa N, Cakpo B, Etchisse L, Hatangimana E, Muhindo M, Sanni K, Yevide AB, Agossou H, Musengo FB, Behanzin H, Seto DM, Alia BA, Alitonou A, Mehounou Y, Agbanda L, Attinon J, Hounsou NR, Gbassi M, Adagrah A, Alhassan BBA, Amoako-Boateng MP, Appiah AB, Asante-Asamani A, Boakye B, Debrah SA, Ganiyu RA, Enti D, Koggoh P, Kpankpari R, Opandoh INM, Manu MA, Manu MPO, Mensah S, Morna MT, Nortey M, Nkrumah J, Ofori EO, Quartson EM, Acquah AO, Adam-Zakariah LI, Asabre E, Boateng RA, Koomson B, Kusiwaa A, Twerefour EY, Ankomah J, Assah-Adjei F, Boakye AA, Fosu G, Serbeh G, Gyan KY, Nyarko IO, Robertson Z, Acheampong DO, Acquaye J, Adinku M, Agbedinu K, Agbeko AE, Amankwa EG, Amoah M, Amoah G, Appiah J, Arthur J, Ayim A, Ayodeji EK, Boakye-Yiadom J, Boateng EA, Dally C, Davor A, Gyasi-Sarpong CK, Hamidu NNN, Haruna I, Kwarley N, Lovi AK, Nimako B, Nyadu BB, Opoku D, Osabutey A, Sagoe R, Tuffour S, Tufour Y, Yamoah FA, Yefieye AC, Yorke J, Addo KG, Akosa EA, Boakye P, Coompson CL, Gyamfi B, Kontor BE, Kyeremeh C, Manu R, Mensah E, Solae FI, Toffah GK, Adu-Brobbey R, Coompson CL, Labaran AH, Owusu JA, Adobea V, Bennin A, Dankwah F, Doe S, Kantanka RS, Kobby E, Larnyor H, Owusu PY, Sie-Broni CA, Zume M, Abantanga FA, Abdulai DR, Acquah DK, Ayingayure E, Osman I, Kunfah S, Limann G, Mohammed SA, Mohammed S, Musah Y, Ofori B, Owusu EA, Saba AH, Seidu AS, Yakubu M, Yenli EMTA, Bhatti K, Dhiman J, Dhir K, Hans M, Haque PD, Jesudason EDM, Madankumar L, Mittal R, Nagomy I, Prasad S, Dasari A, Jacob P, Kurien E, Mathew A, Prakash D, Susan A, Varghese R, Ortiz RC, Gonzalez GH, Krauss RH, Miguelena LH, Romero MH, Gomez IB, Aguirre CC, Avendaño AC, Sansores LD, Mejia HO, Campo LUGD, Sánchez ID, Vazquez DG, Lara MM, Maldonado LMP, Fuente ANSDL, Medina ARDL, Adeleye V, Adeniyi O, Akinajo O, Akinboyewa D, Alasi I, Alakaloko F, Atoyebi O, Balogun O, Belie O, Bode C, Ekwesianya A, Elebute O, Ezenwankwo F, Fatuga A, Ihediwa G, Jimoh A, Kuku J, Ladipo-Ajayi O, Makanjuola A, Mokwenyei O, Nwokocha S, Ogein O, Ojewola R, Oladimeji A, Olajide T, Oluseye O, Seyi-Olajide J, Soibi-Harry A, Ugwu A, Williams E, Abdur-Rahman L, Adeleke N, Adesola M, Afolabi R, Agodirin S, Aremu I, Bello J, Lawal S, Lawal A, Raji H, Sayomi O, Shittu A, Acquah R, Banka C, Esssien D, Hussey R, Mustapha Y, Nunoo-Ghartey K, Yeboah G, Aniakwo LA, Adjei MNM, Adofo-Asamoah Y, Agyapong MM, Agyen T, Alhassan BAB, Amoako-Boateng MP, Appiah AB, Ashong J, Awindaogo JK, Brimpong BB, Dayie MSCJK, Enti D, Ghansah WW, Gyamfi JE, Koggoh P, Kpankpari R, Kudoh V, Mensah P, Opandoh INM, Morna MT, Nortey M, Odame E, Ofori EO, Quaicoo S, Quartson EM, Teye-Topey C, Yigah M, Yussif S, Adjei-Acquah E, Agyekum-Gyimah VO, Agyemang E, AkotoAmpaw A, Amponsah-Manu F, Arkorful TE, Dokurugu MA, Essel N, Ijeoma A, Obiri EL, Ofosu-Akromah R, Quarchey KND, Adam-Zakariah L, Andoh AB, Asabre E, Boateng RA, Koomson B, Kusiwaa A, Naah A, Oppon-Acquah A, Oppong BA, Agbowada EA, Akosua A, Armah R, Asare C, Awere-Kyere LKB, Bruce-Adjei A, Christian NA, Gakpetor DA, Kennedy KK, Mends-Odro J, Obbeng A, Ofosuhene D, Osei-Poku D, Robertson Z, Ciociano MCJMC, Valle CJZFD, Aziz HIAG, Calvillo MDCG, Iriarte DGIM, Namur LDCM, Medina ARDL, Mustapha BKLA, Utumatwishima AMJN, Abdul-Aziz IIA, Anasara GAG, Ogudi DKD, Quansah JIK, Kumar NAU, Mehraj IMA, Nayak SMP, Díaz KVA, Herrera VJA, Camacho FJB, Pérez IVB, Llamas MAC, Cardona GAC, Andrade LRC, Flores AOC, Torres EJC, Valadez TAC, Valadez AEC, Cardoza JAF, González LAG, Bojorquez JLG, Ponce FYG, Ramírez CSG, Barba JAG, Ramírez BGG, Ruvalcaba MJG, Alva DAH, Camargo SAI, Peña JCI, Pérez ZML, Tellez MPM, Ackerman RCM, Vallejo LRP, Bocanegra VHP, Navarro JVP, Posada FJP, Hernández MAQ, Gonzalez LRR, Elizalde EAR, Ascencio EVR, Velasco CBR, Martínez JAS, Pulido JIS, García AGS, Carreón LOS, Ávila JJT, Gastelum JOV, Ramirez MLV, Casas MFZ, Mata JAA, Vanegas MAC, Arias RGC, Barajas BVE, Angeles LOM, Lomeli AFM, Navarro JEO, Baolboa LGP, Dominguez ACG, Morales JFM, Pesquera JAA, Maldonado LMP, Fonseca RKC, Hernandez EEL, Ramirez JAR, Moscoso MRB, Duniya SAN, Adeleye GTC, Bakare TIB, Ohemu AA, Habumuremyi DUS, Seneza GNC, Haragirimana JDD, Ingabire AJC, Ekwunife OH, Acheampong DO, Agbeko AE, Gyamfi FE, Nyadu BB, Adu-Aryee NA, Amoako JK, Aperkor NT, Asman WK, Attepor GS, Bediako-Bowan AA, Brown GD, Etwire VK, Fenu BS, Kumassah PK, Larbi-Siaw LA, Olatola DO, Tsatsu SE, Barimah CG, Boateng GC, Kwabena PW, Kwarteng SM, Luri PT, Kantanka RS, Owusu PY, Acquah DK, Adams SM, Alhassan MS, Asirifi SA, Dery MK, Ofori BA, Sam NB, Seidu AS, Acquah EK, Coompson CL, Gyambibi AK, Kontor BE, Poonia DR, Rathod KK, Rodha MS, Soni SC, Varsheney VK, Vishnoi JR, Garnaik DK, Lokavarapu MJ, Seenivasagam RK, Kalyanapu JA, Gautham AK, Singh DS, Abraham ES, Gold CS, Joseph JN, Kurien EN, Mathew AJ, Mathew AE, Prakash DD, Hans MA, Haque PD, Sam VD, Thind RS, Veetil SK, Daniel ER, Jacob SE, Jesudason MR, Samuel VM, Sivakumar MV, Saluja SS, Attri AK, Pai MV, Prabhu PS, T SP, Alexander PV, Ismavel VA, Solomi CV, Alpheus RA, Choudhrie AV, Gunny RJ, Malik MA, Peters NJ, Chowdri NA, Dar RA, Parray FQ, Shah ZA, Wani RA, Villaseñor SA, Hernández AB, Ahumada EB, Cardiel GC, Guevara GC, Perez EC, Martinez EC, Barradas PD, Estrada IE, Becerril PF, Orozco CF, Reyna BG, Sánchez EG, Espinoza EG, Ojeda AG, Torres MI, Tornero JJ, País RM, Santana DM, Villela GM, Hinojosa RN, Escobar CN, Rodríguez IO, Flores OO, Barreiro AO, Rubio JO, Bravo CR, Villaseñor GS, Tinajero CC, Samano FD, Banuelos GG, Ortiz FI, Ramirez ML, Arroyo GL, Perez JO, Ramirez DO, Lozano JP, Reyes GY, Castillo MN, Mellado DH, Bozada-Gutierrez K, Casado-Zarate AF, Delano-Alonso R, Herrera-Esquivel J, Moreno-Portillo M, Trejo-Avila M, Quiros BC, Ambriz-González G, Cabrera-Lozano I, Calderón-Alvarado AB, León-Frutos FJ, Villanueva-Martínez EE, Aliyu MS, Balogun AO, Francis AA, Duromola KM, Gana SG, George MD, Iji LO, Jimoh AO, Koledade AK, Lawal AT, Nwabuoku SE, Ogunsua OO, Okafor IF, Okorie EI, Saidu IA, Sholadoye TT, Abdulkarim AA, Abdullahi LB, Tolani MA, Tukur AM, Umar AS, Umar AM, Yusuf SA, Ado KA, Aliyu NU, Anyanwu LJC, Daneji SM, Magashi MK, Mohammad MA, Muhammad AB, Muhammad SS, Muideen BA, Nwachukwu CU, Sallau SB, Sheshe AA, Takai IU, Umar GI, Adze JA, Airede LR, Bature SB, Galadima MC, Hamza BK, Kache SA, Kagomi WY, Kene IA, Makama JG, Mohammed-Durosinlorun AA, Taingson MC, Odunafolabi TA, Okereke CE, Oladele OO, Olaleye OH, Olubayo OO, Abiola OP, Abiyere HO, Adebara IO, Adeniyi AA, Adewara OE, Adeyemo OT, Adeyeye AA, Ariyibi AL, Awoyinka BS, Ayankunle OM, Babalola OF, Banjo OO, Egharevba PA, Fatudimu OS, Obateru JA, Odesanya OJ, Ojo OD, Okunlola AI, Okunlola CK, Olajide AT, Orewole TO, Salawu AI, Abdulsalam MA, Adelaja AT, Ajai OT, Atobatele KM, Bakare OO, Faboya OM, Imam ZO, Nwaenyi FC, Ogunyemi AA, Oludara MA, Omisanjo OA, Onyeka CU, Oshodi OA, Oshodi YA, Salami OS, Williams OM, Adeyeye VI, Agbulu MV, Akinajo OR, Akinboyewa DO, Alakaloko FM, Alasi IO, Atoyebi OA, Balogun OS, Bode CO, Busari MO, Duru NJ, Edet GB, Elebute OA, Ezenwankwo FC, Fatuga AL, Ihediwa GC, Inyang ES, Jimoh AI, Kuku JO, Ladipo-Ajayi OA, Lawal AO, Makwe CC, Mgbemena CV, Nwokocha SU, Ogunjimi MA, Ohazurike EO, Ojewola RW, Badedale ME, Okeke CJ, Okunowo AA, Oladimeji AT, Olajide TO, Oluseye OO, Orowale AA, Osinowo AO, Oyegbola CB, Seyi-Olajide JO, Soibi-Harry AP, Timo MT, Ugwu AO, Williams EO, Duruewuru IO, Egwuonwu OA, Emeka JJ, Modekwe VI, Nwosu CD, Obiechina SO, Obiesie AE, Okafor CI, Okonoboh TO, Okoye OA, Onu OA, Onyejiaka CC, Uche CF, Ugboajah JO, Ugwu JO, Adeleke AA, Adepiti AC, Aderounmu AA, Adesunkanmi AO, Adisa AO, Ajekwu SC, Ajenifuja OK, Alatise OI, Badmus TA, Mohammed TO, Salako AA, Sowande OA, Talabi AO, Wuraola FO, Adegoke PA, Eseile IS, Ogundoyin OO, Olulana DI, Adumah CC, Ajagbe AO, Akintunde OP, Asafa OQ, Eziyi AK, Fasanu AO, Ojewuyi OO, Ojewuyi AR, Oyedele AE, Taiwo OA, Abdullahi HI, Adewole ND, Agida TE, Ailunia EE, Akaba GO, Bawa KG, Chinda JY, Daluk EB, Eniola SB, Ezenwa AO, Garba SE, Mshelbwala PM, Ndukwe NO, Ogolekwu IP, Osagie OO, Sani SA, Tabuanu NO, Umar AM, Agbonrofo PI, Arekhandia AI, Edena ME, Eghonghon RA, Enaholo JE, Ideh SN, Iribhogbe OI, Irowa OO, Isikhuemen ME, Odutola OR, Okoduwa KO, Omorogbe SO, Osagie OT, Abdus-Salam RA, Adebayo SA, Ajagbe OA, Ajao AE, Ayandipo OO, Egbuchulem KI, Ekwuazi HO, Idowu OC, Irabor DO, Lawal TA, Lawal OO, Ogundoyin OO, Sanusi AT, Takure AO, Abdur-Rahman LO, Adebisi MO, Adeleke NA, Afolabi RT, Aremu II, Bello JO, Lawal SA, Raji HO, Igwe PO, Iweha IE, John RE, Okoro PE, Oriji VK, Oweredaba IT, Majyabere JP, Habiyakare JA, Nabada MG, Masengesho JP, Niyomuremyi JP, Uwimana JC, Maniraguha HL, Urimubabo CJ, Shyirakera JY, Adams MA, Ede CJ, Mathe MN, Nhlabathi NA, Nxumalo HS, Sethoana ME, Acquaye J, Appiah J, Arthur J, Boakye-Yiadom J, Abdulai S, Agboadoh N, Akoto E, Boakye-Yiadom K, Dedey F, Nsaful J, Wordui T, Abubakari F, Akunyam J, Ballu C, Ngaaso K, Adobea V, Bennin A, Doe S, Kobby E, Kyeremeh C, Osei E, Owusu F, Sie-Broni C, Zume M, Abdul-Hafiz S, Amadu M, Awe M, Azanlerigu M, Edwin Y, Limann G, Maalekuu A, Malechi H, Mohammed S, Mohammed I, Mumuni K, Yahaya S, Alhassan J, Boakye P, Jeffery-Felix A, Manu R, Mensah E, Naah G, Noufuentes C, Sakyi A, Chaudhary R, Misra S, Pareek P, Pathak M, Sharma N, Sharma N, Huda F, Mishra N, Ranjan R, Singh S, Solanki P, Verma R, Yhoshu E, John S, Kutma A, Philips S, Hepzibah A, Mary G, Chetana C, Dasari A, Dummala P, Jacob J, Mary P, Samuel O, Sukumar A, Syam N, Varghese R, Bhatt A, Bhatti W, Dhar T, Goyal A, Goyal S, Jain D, Jain R, Kaur S, Kumar K, Luther A, Mahajan A, Mandrelle K, Michael V, Mukherjee P, Rajappa R, Singh P, Suroy A, Williams R, D S, Kumari P, Mittal R, Prasad S, Shankar B, Sharma S, Surendran S, Thomas A, Trinity P, Kanchodu S, Leshiini K, Bansal I, Gupta S, Gureh M, Kapoor S, Aggarwal M, Kanna V, Kaur H, Kumar A, Singh S, Singh G, John V, Adnan M, Kumar P, S A, Sehrawat V, Singla D, Thami G, Kumar V, Mathew S, Akhtar N, Chaturvedi A, Gupta S, Kumar V, Prakash P, Rajan S, Singh M, Tripathi A, Thomas J, Zechariah P, Kichu M, Joseph S, Pundir N, Samujh R, Kour R, Saqib N, Raul S, Rautela K, Sharma R, Singh N, Vakil R, Chowdhury P, Chowdhury S, Roy B, Abdullahi A, Abubakar M, Awaisu M, Bakari F, Bashir M, Bello A, Daniyan M, Gimba J, Gundu I, Oyelowo N, Sufyan I, Umaru-Sule H, Usman M, Yahya A, Yakubu A, Abdullahi M, Soladoye A, Yahaya A, Abdulrasheed L, Aminu B, Bello-Tukur F, Chinyio D, Joshua S, Lawal J, Mohammed C, Nuwam D, Sale D, Sani A, Tabara S, Usam E, Yakubu J, Adegoke F, Ige O, Bakare A, Akande O, Anyanwu N, Eke G, Oyewole Y, Abunimye E, Adeoluwa A, Adesiyakan A, Amao M, Ashley-Osuzoka C, Gbenga-Oke C, Makanjuola A, Olanrewaju O, Olayioye O, Olutola S, Onyekachi K, Osariemen E, Osunwusi B, Owie E, Okoro C, Ugwuanyi K, Ugwunne C, Olasehinde O, Akinloye A, Akinniyi A, Ejimogu J, Okedare A, Omotola O, Sanwo F, Awodele K, Aisuodionoe-Shadrach O, Alfred J, Atim T, Mbajiekwe N, Olori A, Suleiman S, Sunday H, Ida G, Oruade D, Osemwegie O, Ajibola G, Elemile P, Fakoya A, Ojediran O, Olagunju N, Bello R, Lawal A, Ojajuni A, Oyewale S, Sayomi O, Shittu A, Abhulimen V, Okoi N, Mizero J, Mutimamwiza I, Nirere F, Niyongombwa I, Byaruhanga A, Dukuzimana R, Uwizeye M, Ruhosha M, Igiraneza J, Ingabire F, Karekezi A, Mpirimbanyi C, Mukamazera L, Mukangabo C, Imanishimwe A, Kanyarukiko S, Mukaneza F, Mukantibaziyaremye D, Munyaneza A, Ndegamiye G, Nyirangeri P, Tubasiime R, Dusabe M, Izabiriza E, Mpirimbanyi C, Mutuyimana J, Mwenedata O, Rwagahirima E, Zirikana J, Sibomana I, Rubanguka D, Umuhoza J, Uwayezu R, Uzikwambara L, Dieudonne A, Kabanda E, Mbonimpaye S, Mukakomite C, Muroruhirwe P, Butana H, Dusabeyezu M, Batangana M, Bucyibaruta G, Habumuremyi S, Imanishimwe A, Mukanyange V, Munyaneza E, Mutabazi E, Mwungura E, Ncogoza I, Ntirenganya F, Nyirahabimana J, Nyirasebura D, Dusabimana A, Kanyesigye S, Munyaneza R, Fourtounas M, Hyman G, Moore R, Sentholang N, Wondoh P, Ally Z, Domingo A, Munda P, Nyatsambo C, Ojo V, Pswarayi R, Cook J, Jayne D, Laurberg S, Brown J, Smart N, Cousens S. Routine sterile glove and instrument change at the time of abdominal wound closure to prevent surgical site infection (ChEETAh): a model-based cost-effectiveness analysis of a pragmatic, cluster-randomised trial in seven low-income and middle-income countries. Lancet Glob Health 2024; 12:e235-e242. [PMID: 38245114 DOI: 10.1016/s2214-109x(23)00538-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 10/17/2023] [Accepted: 11/07/2023] [Indexed: 01/22/2024]
Abstract
BACKGROUND Surgical site infection (SSI) is a major burden on patients and health systems. This study assessed the cost-effectiveness of routine change of sterile gloves and instruments before abdominal wall closure to prevent SSI. METHODS A decision-analytic model was built to estimate average costs and outcomes of changing gloves and instruments before abdominal wall closure compared with current practice. Clinical data were obtained from the ChEETAh trial, a multicentre, cluster-randomised trial in seven low-income and middle-income countries (LMICs), and costs were obtained from a study (KIWI) that assessed costs associated with SSIs in LMICs. Outcomes were measured as the percentage of surgeries resulting in SSIs. Costs were measured from a health-care provider perspective and were reported in 2021 US$. The economic analysis used a partially split single-country costing approach, with pooled outcomes data from all seven countries in the ChEETAh trial, and data for resource use and unit costs from India (KIWI); secondary analyses used resource use and costs from Mexico and Ghana (KIWI). FINDINGS In the base case, the average cost of the intervention was $259∙92 compared with $261∙10 for current practice (cost difference -$1∙18, 95% CI -4∙08 to 1∙33). In the intervention group, an estimated 17∙6% of patients had an SSI compared with 19∙7% of patients in the current practice group (absolute risk reduction 2∙10%, 95% CI 2∙07-2∙84). At all cost-effectiveness thresholds assumed ($0 to $14 000), the intervention had a higher likelihood of being cost-effective compared with current practice, indicating that the intervention was cost-effective. Similar results were obtained when the analysis using data from India was repeated using resource use and unit cost data from Mexico and Ghana. INTERPRETATION Routine sterile glove and instrument change before abdominal wall closure is effective and the costs are similar to those for current practice. Routine change of gloves and instruments before abdominal wall closure should be rolled out in LMICs. FUNDING National Institute for Health and Care Research (NIHR) Clinician Scientist Award, NIHR Global Health Research Unit Grant, and Mölnlycke Healthcare.
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Glasbey J, Ademuyiwa A, Bhatt A, Biccard B, Blazeby J, Brocklehurst P, Chakrabortee S, Allen Ingabire JC, Dossou FM, Durán I, Dutta R, Ghosh D, Gyamfi F, Haque P, Hardy P, Horton M, Hyman G, Jain R, Ladipo-Ajayi O, Lawani I, Lawani S, Kachapila M, Lillywhite R, Macefield R, Magill L, Martin J, Mathers J, McLean K, Mistry P, Mittal R, Monahan M, Moore R, Morton D, Ojo M, Ntirenganya F, Ofori E, Pearse R, Peón A, Pinkney T, de la Medina AR, Ronald T, Roman D, Runingamugabo E, Sitch A, Slade A, Tabiri S, Smith D, Bhangu A, Glasbey J, Sitch A, Slade A, To DK, Bhangu A, Hardy P, Ademuyiwa AO, Ismail L, Ghosh D, de la Medina AR, Moore R, Ntirenganya F, Tabiri S, Runingamugabo E, Patrawala S, Prah A, Oko C, Kroese K, Lawani I, Dossou FM, Dzemta C, Kandokponou CMB, Lawani S, Behanzin H, Kpangon C, Ofori BA, Tabiri S, Saba AH, Limann G, Acquah DK, Alhassan SM, Mohammed S, Emmanuel OA, Musah Y, Edwin Y, Kunfah S, Mustapha Y, Francis AA, Ayingayure E, Limann G, Amponsah-Manu F, Agyemang E, Agyekum V, Adjei-Acquah E, Twerefour EY, Koomson B, Boateng RA, Acquah AO, Ofosu-Akromah R, Adam-Zakariah LI, Adu-Aryee NA, Wordui T, Larbi CC, Enoch AA, Elijah M, Christian K, Kwame AG, Percy B, Bismark KE, Brian G, Ruth M, Hussey R, Dadzie S, Appiah AD, Yeboah G, Yeboah C, Amoako J, Acquah R, Sowah NA, Kusiwaa A, Asabre E, Ballu C, Barimah CG, Owusu F, Sie-Broni C, Adobea V, Owusu PY, Zume M, Labaran AH, Adu-Brobbey R, Morna MT, Debrah SA, Maison POM, Nortey M, Enti D, Amoako-Boateng MP, Appiah AB, Ofori EO, Kpankpari R, Boakye B, Quartson EM, Koggoh P, Agbeko AE, Gyamfi FE, Arthur J, Yorke J, Gyasi-Sarpong CK, Dally C, Lovi AK, Amoah M, Nimako B, Sagoe R, Davor A, Galley F, Adinku M, Boakye-Yiadom J, Acquaye J, Appiah J, Acheampong DO, Haruna I, Boateng EA, Ayodeji EK, Tuffuor S, Kwarley N, Tufuor Y, Abdulai RD, Dankwah F, Armah R, Ofosuhene D, Osei-Poku D, Temitope AE, Gakpetor DA, Gawu VS, Asare C, Tackie E, Ankomah J, Nyarko IO, Robertson Z, Godwin S, Boakye AA, Fosu G, Assah-Adjei F, Haque P, Jain R, Bhatt A, Dhiman J, Dutta R, Ghosh D, Daniel E, K P, Madankumar L, Mittal R, Nagomy I, Prasad S, Mathew AJ, Prakash D, Jacob P, Anachy JP, Mathew A, Thomas J, Alexander PV, Zechariah P, Aruldas ND, Mehraj A, Ahmed HI, Wani RA, Parray FQ, Chowdri NA, De la Medina AR, Maldonado LMP, Vazquez DSG, Sánchez IID, Lara MJM, de la Fuente ANS, Flores AOC, Gallo MEB, Ojeda AG, Velasco MEJ, Miguelena LH, Ortiz RJC, Gonzalez GIH, Romero MH, Krauss RIH, Sansores LAD, Avendaño AC, Aguirre CC, Gomez IB, Mejia HO, Ojeda AG, Flores OEO, González García de Rojas EA, Belmontes KJP, Camacho FJB, Hernández AB, Aguirre LR, Galaviz REM, Orozco CF, Bueno WGÁ, Marbello FSR, Acevedo DEL, Valadez MH, Arellano ALB, Ramírez-González LR, Ramírez BGG, Robles EV, García RIR, Navarro JVP, Torres EJC, Solano DRD, Peón AN, Menindez RDL, Gamez RR, Muñoz MCP, Belie O, Adeleye V, Ademuyiwa A, Adeniyi O, Akinajo O, Akinboyewa D, Alakaloko F, Atoyebi O, Balogun O, Bode C, Elebute O, Ezenwankwo F, Adedotun A, Ihediwa G, Kuku J, Ladipo-Ajayi O, Makanjuola A, Nwokocha S, Ogein O, Ojewola R, Oladimeji A, Olajide T, Alasi I, Oluseye O, Seyi-Olajide J, Soibi-Harry A, Williams E, Vincent AM, Duru NJ, Onyekachi KU, Ashley C, Mgbemena CV, Ojo M, Oluyemisi O, Ikuewunmi I, Adebunmi A, Bassey EG, Ohazurike EO, Amao OM, Oluwaseun OB, Doris E, Stephen O, Gbenga-Oke C, Olayioye O, Oluyemisi O, Oluremi K, Abunimye E, Oyegbola C, Kayode O, Orowale AA, Williams OM, Omisanjo OA, Faboya OM, Imam ZO, Oshodi OA, Oshodi YA, Ogunyemi AA, Ajai OT, Nwaenyi FC, Adisa AO, Aderounmu AA, Wuraola FO, Sowande O, Abdur-Rahman LO, Bello JO, Raji HO, Adeleke NA, Lawal SA, Afolabi RT, Lawal A, Ekwunife OH, Egwuonwu OA, Uche CF, Muhammad ABAB, Muhammad SS, Takai IUIU, Aliyu Salele MAS, Ukata OG, Magashi MKMK, Abdullahi LBLB, Muideen BABA, Ado KA, Anyawu LJCLJC, Olori S, Sani SA, Osagie OO, Mbajiekwe N, Aisuodionoe-Shadrach O, Akaba GO, Ameh L, Ameh L, Adebayo FO, Uanikhoba M, Ogbo FO, Tabuanu NO, Lawal TA, Abdus-Salam RA, Ajao AE, Takure AO, Ayandipo OO, Ekwuazi HO, Abayomi O, Lawal OO, Olagunju S, Egbuchulem KI, Adebayo SA, Elemile P, Usang UE, Udosen JE, Edet EE, Inyang AW, Olory EM, Udie GU, Chiejina GO, Marwa AD, Iseh FJ, Ogbeche SA, Isa MO, Ezomike UO, Ekenze SO, Eze MI, Izuka EO, Ede JK, Enemuo VC, Mbadiwe OM, Mbah NG, Imanishimwe A, Habumuremyi S, Ntirenganya F, Allen Ingabire JC, Ncogoza I, Munyaneza E, Haragirimana JDD, Urimubabo CJ, Mukanyange V, Nyirahabimana J, Mutabazi E, Mpirimbanyi C, Mwenedata O, Maniraguha HL, Izabiriza E, Dusabe M, Zirikana J, Uwizeyimana F, Mutuyimana J, Rwagahirima E, Imanishimwe A, Tubasiime R, Munyaneza A, Habumuremyi S, Kanyarukiko S, Ndegamiye G, Mukaneza F, Uwimana JC, Nyirangeri P, Mukantibaziyaremye D, Hirwa AD, Mbonimpaye S, Muroruhirwe P, Mukakomite C, Kabanda E, Moore R, Nhlabathi NA, Fourtounas M, Adams MA, Hyman G, Nxumalo HS, Sentholang N, Sethoana ME, Mathe MN, Ally Z, Flint M, Biccard B, Ademuyiwa AO, Adisa AO, Bhangu A, Brocklehurst P, Chakrabortee S, Hardy P, Harrison E, Allen Ingabire JC, Haque PD, Ismail L, Glasbey J, Ghosh D, Gyamfi FE, Li E, Lillywhite R, de la Medina AR, Moore R, Magill L, Morton D, Nepogodiev D, Ntirenganya F, Pinkney T, Omar O, Simoes J, Smith D, Tabiri S, Ademuyiwa AO, Ismail L, Ghosh D, de la Medina AR, Moore R, Ntirenganya F, Tabiri S, Ademuyiwa A, Bhangu A, Brant F, Brocklehurst P, Chakrabortee S, Ghosh D, Glasbey J, Hardy P, Harrison E, Heritage E, Ismail L, Kroese K, Lapitan C, Lillywhite R, Lissauer D, Magill L, de la Medina AR, Mistry P, Monahan M, Moore R, Morton D, Nepogodiev D, Ntirenganya F, Omar O, Pinkney T, Roberts T, Smith D, Tabiri S, Winkles N, Hardy P, Omar O, Runigamugabo E, Verjee A, Sodonougbo P, Assouto P, Fiogbe M, Koco H, Metchinhoungbe S, Sogbo H, Behanzin H, Seto DM, Tandje Y, Kangni S, Kpangon C, Akpla M, Chobli HH, Kovohouande B, Agboton G, Ahossi R, Ngabo RB, Bisimwa N, Kandokponou CMB, Dokponou M, Dossou FM, Dzemta C, Gaou A, Goudou R, Hedefoun E, Houtoukpe S, Kamga F, Kiki-Migan E, Lawani S, Lawani I, Loko R, Moutaïrou A, Ogouyemi P, Soumanou F, Tamadaho P, Zounon MA, Adagrah LA, Alhassan BBA, Amoako-Boateng MP, Appiah AB, Asante-Asamani A, Boakye B, Debrah SA, Enti D, Ganiyu RA, Koggoh P, Kpankpari R, Opandoh INM, Manu MA, Manu MPO, Mensah S, Morna MT, Nkrumah J, Nortey M, Ofori EO, Quartson EM, Adjei-Acquah E, Agyekum V, Agyemang E, Akesseh RA, Amponsah-Manu F, Ofosu-Akromah R, Acquah AO, Adam-Zakariah LI, Asabre E, Boateng RA, Koomson B, Kusiwaa A, Twerefour EY, Ankomah J, Assah-Adjei F, Boakye AA, Fosu G, Serbeh G, Gyan KY, Nyarko IO, Robertson Z, Armah R, Asare C, Gakpetor DA, Gawu VS, Obbeng A, Ofosuhene D, Osei-Poku D, Puozaa D, Tackie E, Temitope AE, Acquah R, Amoako J, Appiah AD, Aseti M, Banka C, Dadzie S, Essien D, Gyamfi FE, Hussey R, Kwarteng J, Sowah NA, Yeboah G, Yeboah C, Addo KG, Akosa EA, Boakye P, Coompson CL, Gyamfi B, Kontor BE, Kyeremeh C, Manu R, Mensah E, Solae FI, Toffah GK, Acheampong DO, Acquaye J, Adinku M, Agbedinu K, Agbeko AE, Amankwa EG, Amoah M, Amoah G, Appiah J, Arthur J, Ayim A, Ayodeji EK, Boakye-Yiadom J, Boateng EA, Dally C, Davor A, Gyasi-Sarpong CK, Hamidu NNN, Haruna I, Kwarley N, Lovi AK, Nimako B, Nyadu BB, Opoku D, Osabutey A, Sagoe R, Tuffour S, Tufour Y, Yamoah FA, Yefieye AC, Yorke J, Adu-Aryee NA, Adjei F, Akoto E, Ametefe E, Amoako JK, Attepor GS, Brown GD, Fenu B, Kumassah PK, Olayiwola DO, Wordui T, Agboadoh N, Abubakari F, Ballu C, Barimah CG, Boateng GC, Luri PT, Titigah A, Owusu F, Adu-Brobbey R, Coompson CL, Labaran AH, Owusu JA, Adobea V, Bennin A, Dankwah F, Doe S, Kantanka RS, Kobby E, Larnyor KKKH, Osei E, Owusu PY, Sie-Broni CA, Zume M, Abantanga FA, Abdulai DR, Acquah DK, Ayingayure E, Osman I, Kunfah S, Limann G, Mohammed SA, Mohammed S, Musah Y, Ofori B, Owusu EA, Saba AH, Seidu AS, Tabiri S, Yakubu M, Yenli EMT, Gautham A, Hepzibah A, Mary G, Singh D, Bhatti D, Bhatti W, Bir K, Daniel S, Dhar T, Dhiman J, Ghosh D, Goyal S, Ankush, Goyal, Hans M, Haque P, Konda S, Luther A, Mahajan A, Makkar S, Mandrelle K, Michael V, Mukherjee P, Rajappa R, Singh P, Suroy A, Thind R, Thomas A, Tuli A, Veetil S, Jesudason EDM, K P, Madankumar L, Mittal R, Nagomy I, Selvakumar R, Shankar B, Sivakumar M, Sridhar R, Thomas C, Titus D, Aggarwal M, Dhamija P, Gupta H, Kanna V, Kumar A, Singh G, Alexander P, Thomas J, Zechariah P, Dasari A, Jacob P, Kurien E, Mathew A, Prakash D, Susan A, Varghese R, Alpheus R, Choudhrie A, Kumar H, Peters N, Raul S, Sharma R, Vakil R, Bueno WÁ, Camacho FB, Hernández AB, Arellano AB, Torres EC, Orozco CF, de Rojas EGG, Ojeda AG, Ramírez BG, Valadez MH, Acevedo DL, Galaviz RM, Flores OO, Navarro JP, Belmontes KP, Marbello FR, Ramírez-González L, Aguirre LR, García RR, Robles EV, Ortiz RC, Gonzalez GH, Krauss RH, Miguelena LH, Romero MH, Gomez IB, Aguirre CC, Avendaño AC, Sansores LD, Mejia HO, del Campo LUG, Cerdan CC, Solano DD, Garcia RT, Gallo MB, Flores AC, Ojeda AG, Velasco MJ, Gamez RR, Menindez RL, Peón AN, Muñoz MP, Sánchez IID, Vázquez DSG, Lara MJM, Maldonado LMP, de la Fuente ANS, De la Medina AR, Abdullahi L, Ado K, Aliyu M, Anyanwu LJ, Magashi M, Muhammad A, Muhammad S, Muideen B, Takai I, Ukata O, Adesanya O, Awonuga D, Fasiku O, Ogo C, Abdulsalam M, Adeniran A, Ajai O, Akande O, Atobatele K, Eke G, Faboya O, Imam Z, Momson E, Nwaenyi F, Ogunyemi A, Oludara M, Omisanjo O, Oshodi O, Oshodi Y, Oyewole Y, Salami O, Williams O, Adeleye V, Ademuyiwa A, Adeniyi O, Akinajo O, Akinboyewa D, Alasi I, Alakaloko F, Atoyebi O, Balogun O, Belie O, Bode C, Ekwesianya A, Elebute O, Ezenwankwo F, Fatuga A, Ihediwa G, Jimoh A, Kuku J, LadipoAjayi O, Makanjuola A, Mokwenyei O, Nwokocha S, Ogein O, Ojewola R, Oladimeji A, Olajide T, Oluseye O, Seyi-Olajide J, Soibi-Harry A, Ugwu A, Williams E, Egwuonwu O, Ekwunife O, Modekwe V, Okoro C, Uche C, Ugwuanyi K, Ugwunne C, Adeleke A, Adenikinju W, Adeniyi O, Adepiti A, Aderounmu A, Adesunkanmi A, Adisa A, Ajekwu S, Ajenjfuja O, Akindojutimi J, Akinkuolie A, Alatise O, Allen O, Amosu L, Archibong M, Arowolo O, Ayantona D, Ayinde A, Badejoko O, Badmus T, Etonyeaku A, Igbodike E, Ijarotimi O, Lawal A, Nana F, Oduanafolabi T, Olasehinde O, Olayemi O, Omitinde S, Oni O, Onyeze C, Orji E, Rotimi A, Salako A, Solaja O, Sowemimo O, Talabi A, Tajudeen M, Wuraola F, Adebayo F, Aisuodionoe-Shadrach O, Akaba G, Ameh L, Mbajiekwe N, Ogbo F, Olori S, Osagie O, Sadiq A, Sani S, Tabuanu N, Uanikhoba M, Chiejina G, Edet E, Inyang A, Isa M, Iseh F, Marwa A, Ogbeche S, Olory E, Udie G, Udosen J, Usang U, Abayomi O, Abdus-Salam R, Adebayo S, Ajao A, Amusat O, Ayandipo O, Egbuchulem K, Ekwuazi H, Elemile P, Lawal T, Lawal O, Olagunju S, Osuala P, Suleman B, Takure A, Abdur-Rahman L, Adeleke N, Adesola M, Afolabi R, Agodirin S, Aremu I, Bello J, Lawal S, Lawal A, Raji H, Sayomi O, Shittu A, Ede J, Ekenze S, Enemuo V, Eze M, Ezomike U, Izuka E, Mbadiwe O, Mbah N, Ezinne U, Francis M, Ikechukwu I, Nnyonno O, Okoro P, Patrick I, Raphael J, Vaduneme O, Victor A, Kanyarukiko S, Mukaneza F, Mukantibaziyaremye D, Munyaneza A, Ndegamiye G, Tubasiime R, Dusabe M, Izabiriza E, Maniraguha HL, Mpirimbanyi C, Mutuyimana J, Mwenedata O, Rwagahirima E, Uwizeyimana F, Zirikana J, Hirwa AD, Kabanda E, Mbonimpaye S, Mukakomite C, Muroruhirwe P, Bucyibaruta G, Bunogerane GJ, Habumuremyi S, Haragirimana JDD, Imanishimwe A, Allen Ingabire JC, Mukanyange V, Munyaneza E, Mutabazi E, Ncogoza I, Ntirenganya F, Nyirahabimana J, Urimubabo C, Adams MA, Crawford R, Ede CJ, Fourtounas M, Hyman G, Khan Z, Kwati M, Mathe MN, Moore R, Nhlabathi NA, Nxumalo HS, Pattinson P, Sentholang N, Sethoana ME, Stassen ME, Thornley L, Wondoh P, Birtles C, Ivy M, Mbavhalelo C, Ally Z, Adewunmi AS, Cook J, Jayne D, Laurberg S, Brown J, Cousens S, Smart N. Accuracy of the Wound Healing Questionnaire in the diagnosis of surgical-site infection after abdominal surgery in low- and middle-income countries. Br J Surg 2024; 111:znad446. [PMID: 38747515 PMCID: PMC10895408 DOI: 10.1093/bjs/znad446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 09/07/2023] [Accepted: 10/12/2023] [Indexed: 05/19/2024]
Abstract
INTRODUCTION Telemedicine is being adopted for postoperative surveillance but requires evaluation for efficacy. This study tested a telephone Wound Healing Questionnaire (WHQ) to diagnose surgical site infection (SSI) after abdominal surgery in low- and middle-income countries. METHOD A multi-centre, international, prospective study was embedded in the FALCON trial; a factorial RCT testing measures to reduce SSI in seven low- and middle-income countries (NCT03700749). It was conducted according to a pre-registered protocol (SWAT126) and reported according to STARD guidelines. The reference test was in-person review by a trained clinician at 30 postoperative days according to US Centres for Disease Control criteria. The index test was telephone administration of an adapted WHQ at 27 to 30 postoperative days by a researcher blinded to the outcome of in-person review. The sum of item response scores generated an overall score between 0 and 29. The primary outcome was the diagnostic accuracy of the WHQ, defined as the proportion of SSI correctly identified by the telephone WHQ, and summarized using the area under the receiving operator characteristic curve (AUROC) and diagnostic test accuracy statistics. RESULTS Patients were included from three upper-middle income (396 patients, 13 hospitals), three lower-middle income (746 patients, 19 hospitals), and one low-income country (54 patients, 4 hospitals). 90.3% (1088 of 1196) patients were successfully contacted. Those with non-midline incisions (adjusted odds ratio: 0.36, 95% c.i. 0.17 to 0.73, P=0.005) or a confirmed diagnosis of SSI on in-person assessment (odds ratio: 0.42, 95% c.i. 0.20 to 0.92, P=0.006) were harder to reach. The questionnaire correctly discriminated between most patients with and without SSI (AUROC 0.869, 95% c.i. 0.824 to 0.914), which was consistent across subgroups. A representative cut-off score of ≥4 displayed a sensitivity of 0.701 (0.610-0.792), specificity of 0.911 (0.878-0.943), positive predictive value of 0.723 (0.633-0.814) and negative predictive value of 0.901 (0.867-0.935). CONCLUSION SSI can be diagnosed using a telephone questionnaire (obviating in-person assessment) in low resource settings.
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Subramanian A, Lee SI, Hemali Sudasinghe SPB, Wambua S, Phillips K, Singh M, Azcoaga-Lorenzo A, Cockburn N, Wang J, Fagbamigbe A, Usman M, Damase-Michel C, Yau C, Kent L, McCowan C, OReilly D, Santorelli G, Hope H, Kennedy J, Mhereeg M, Abel KM, Eastwood KA, Black M, Loane M, Moss N, Brophy S, Brocklehurst P, Dolk H, Nelson-Piercy C, Nirantharakumar K. Detection and evaluation of signals associated with exposure to individual and combination of medications in pregnancy: a signal detection study protocol. BMJ Open 2023; 13:e073162. [PMID: 37813531 PMCID: PMC10565241 DOI: 10.1136/bmjopen-2023-073162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 09/15/2023] [Indexed: 10/13/2023] Open
Abstract
INTRODUCTION Considering the high prevalence of polypharmacy in pregnant women and the knowledge gap in the risk-benefit safety profile of their often-complex treatment plan, more research is needed to optimise prescribing. In this study, we aim to detect adverse and protective effect signals of exposure to individual and pairwise combinations of medications during pregnancy. METHODS AND ANALYSIS Using a range of real-world data sources from the UK, we aim to conduct a pharmacovigilance study to assess the safety of medications prescribed during the preconception period (3 months prior to conception) and first trimester of pregnancy. Women aged between 15 and 49 years with a record of pregnancy within the Clinical Practice Research Datalink (CPRD) Pregnancy Register, the Welsh Secure Anonymised Information Linkage (SAIL), the Scottish Morbidity Record (SMR) data sets and the Northern Ireland Maternity System (NIMATS) will be included. A series of case control studies will be conducted to estimate measures of disproportionality, detecting signals of association between a range of pregnancy outcomes and exposure to individual and combinations of medications. A multidisciplinary expert team will be invited to a signal detection workshop. By employing a structured framework, signals will be transparently assessed by each member of the team using a questionnaire appraising the signals on aspects of temporality, selection, time and measurement-related biases and confounding by underlying disease or comedications. Through group discussion, the expert team will reach consensus on each of the medication exposure-outcome signal, thereby excluding spurious signals, leaving signals suggestive of causal associations for further evaluation. ETHICS AND DISSEMINATION Ethical approval has been obtained from the Independent Scientific Advisory Committee, SAIL Information Governance Review Panel, University of St. Andrews Teaching and Research Ethics Committee and Office for Research Ethics Committees Northern Ireland (ORECNI) for access and use of CPRD, SAIL, SMR and NIMATS data, respectively.
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Affiliation(s)
| | - Siang Ing Lee
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Steven Wambua
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Katherine Phillips
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Megha Singh
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Amaya Azcoaga-Lorenzo
- Division of Population and Behavioural Sciences, University of Saint Andrews School of Medicine, St. Andrews, Fife, UK
- Hospital Rey Juan Carlos. Research Network on Chronicity, Primary Care and Health Promotion-RICAPPS (RICORS), Instituto de Investigación Sanitaria Fundación Jimenez Diaz, Madrid, Spain
| | - Neil Cockburn
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Jingya Wang
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Adeniyi Fagbamigbe
- Division of Population and Behavioural Sciences, University of Saint Andrews School of Medicine, St. Andrews, Fife, UK
- Department of Epidemiology and Medical Statistics, University of Ibadan, Ibadan, Nigeria
| | - Muhammad Usman
- Division of Population and Behavioural Sciences, University of Saint Andrews School of Medicine, St. Andrews, Fife, UK
| | - Christine Damase-Michel
- Medical and Clinical Pharmacology, School of Medicine, Université Toulouse III, Toulouse, France
- Center for Epidemiology and Research in Population Health (CERPOP), INSERM, Toulouse, France
| | - Christopher Yau
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Lisa Kent
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Colin McCowan
- Division of Population and Behavioural Sciences, University of Saint Andrews School of Medicine, St. Andrews, Fife, UK
| | - Dermot OReilly
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | | | - Holly Hope
- Centre for Women's Mental Health, Faculty of Biology Medicine & Health, University of Manchester, Manchester, UK
| | | | | | - Kathryn Mary Abel
- Centre for Women's Mental Health, Faculty of Biology Medicine & Health, University of Manchester, Manchester, UK
- Manchester Mental Health & Social Care Trust, Manchester, UK
| | - Kelly-Ann Eastwood
- Centre for Public Health, Queen's University Belfast, Belfast, UK
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Mairead Black
- Aberdeen Centre for Women's Health Research, School of Medicine, Medical Science and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Maria Loane
- The Institute of Nursing and Health Research, University of Ulster, Belfast, UK
| | | | - Sinead Brophy
- Data Science, Medical School, Swansea University, Swansea, UK
| | - Peter Brocklehurst
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Helen Dolk
- The Institute of Nursing and Health Research, University of Ulster, Belfast, UK
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Antoun L, Middleton L, Smith P, Saridogan E, Cooper K, Brocklehurst P, McKinnon W, Bevan S, Woolley R, Jones L, Fullard J, Morgan M, Roberts T, Clark TJ. LAparoscopic Versus Abdominal hysterectomy (LAVA): protocol of a randomised controlled trial. BMJ Open 2023; 13:e070218. [PMID: 37669836 PMCID: PMC10481847 DOI: 10.1136/bmjopen-2022-070218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 06/27/2023] [Indexed: 09/07/2023] Open
Abstract
INTRODUCTION There is uncertainty about the advantages and disadvantages of laparoscopic hysterectomy compared with abdominal hysterectomy, particularly the relative rate of complications of the two procedures. While uptake of laparoscopic hysterectomy has been slow, the situation is changing with greater familiarity, better training, better equipment and increased proficiency in the technique. Thus, a large, robust, multicentre randomised controlled trial (RCT) is needed to compare contemporary laparoscopic hysterectomy with abdominal hysterectomy to determine the safest and most cost-effective technique. METHODS AND ANALYSIS A parallel, open, non-inferiority, multicentre, randomised controlled, expertise-based surgery trial with integrated health economic evaluation and an internal pilot with an embedded qualitative process evaluation. A within trial-based economic evaluation will explore the cost-effectiveness of laparoscopic hysterectomy compared with open abdominal hysterectomy. We will aim to recruit 3250 women requiring a hysterectomy for a benign gynaecological condition and who were suitable for either laparoscopic or open techniques. The primary outcome is major complications up to six completed weeks postsurgery and the key secondary outcome is time from surgery to resumption of usual activities using the personalised Patient-Reported Outcomes Measurement Information System Physical Function questionnaire. The principal outcome for the economic evaluation is to be cost per QALY at 12 months' postsurgery. A secondary analysis is to be undertaken to generate costs per major surgical complication avoided and costs per return to normal activities. ETHICS AND DISSEMINATION The study was approved by the West Midlands-Edgbaston Research Ethics Committee, 18 February 2021 (Ethics ref: 21/WM/0019). REC approval for the protocol version 2.0 dated 2 February 2021 was issued on 18 February 2021.We will present the findings in national and international conferences. We will also aim to publish the findings in high impact peer-reviewed journals. We will disseminate the completed paper to the Department of Health, the Scientific Advisory Committees of the RCOG, the Royal College of Nurses (RCN) and the BSGE. TRIAL REGISTRATION NUMBER ISRCTN14566195.
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Affiliation(s)
- Lina Antoun
- Department of Gynaecology, Birmingham Women's NHS Foundation Trust, Birmingham, UK
- University of Birmingham, Birmingham, UK
| | - Lee Middleton
- School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Paul Smith
- Department of Gynaecology, Birmingham Women's NHS Foundation Trust, Birmingham, UK
| | - Ertan Saridogan
- Department of Gynaecology, University College London Hospitals, London, UK
| | - Kevin Cooper
- Aberdeen Royal Infirmary, Aberdeen, UK
- University of Aberdeen, Aberdeen, UK
| | | | | | | | - Rebecca Woolley
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Laura Jones
- Public Health, Epidemiology & Biostatistics, University of Birmingham, Birmingham, UK
| | | | | | - Tracy Roberts
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | - T Justin Clark
- Department of Gynaecology, Birmingham Women's NHS Foundation Trust, Birmingham, UK
- University of Birmingham, Birmingham, UK
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Lee SI, Hanley S, Vowles Z, Plachcinski R, Moss N, Singh M, Gale C, Fagbamigbe AF, Azcoaga-Lorenzo A, Subramanian A, Taylor B, Nelson-Piercy C, Damase-Michel C, Yau C, McCowan C, O'Reilly D, Santorelli G, Dolk H, Hope H, Phillips K, Abel KM, Eastwood KA, Kent L, Locock L, Loane M, Mhereeg M, Brocklehurst P, McCann S, Brophy S, Wambua S, Hemali Sudasinghe SPB, Thangaratinam S, Nirantharakumar K, Black M. The development of a core outcome set for studies of pregnant women with multimorbidity. BMC Med 2023; 21:314. [PMID: 37605204 PMCID: PMC10441728 DOI: 10.1186/s12916-023-03013-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 07/27/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND Heterogeneity in reported outcomes can limit the synthesis of research evidence. A core outcome set informs what outcomes are important and should be measured as a minimum in all future studies. We report the development of a core outcome set applicable to observational and interventional studies of pregnant women with multimorbidity. METHODS We developed the core outcome set in four stages: (i) a systematic literature search, (ii) three focus groups with UK stakeholders, (iii) two rounds of Delphi surveys with international stakeholders and (iv) two international virtual consensus meetings. Stakeholders included women with multimorbidity and experience of pregnancy in the last 5 years, or are planning a pregnancy, their partners, health or social care professionals and researchers. Study adverts were shared through stakeholder charities and organisations. RESULTS Twenty-six studies were included in the systematic literature search (2017 to 2021) reporting 185 outcomes. Thematic analysis of the focus groups added a further 28 outcomes. Two hundred and nine stakeholders completed the first Delphi survey. One hundred and sixteen stakeholders completed the second Delphi survey where 45 outcomes reached Consensus In (≥70% of all participants rating an outcome as Critically Important). Thirteen stakeholders reviewed 15 Borderline outcomes in the first consensus meeting and included seven additional outcomes. Seventeen stakeholders reviewed these 52 outcomes in a second consensus meeting, the threshold was ≥80% of all participants voting for inclusion. The final core outcome set included 11 outcomes. The five maternal outcomes were as follows: maternal death, severe maternal morbidity, change in existing long-term conditions (physical and mental), quality and experience of care and development of new mental health conditions. The six child outcomes were as follows: survival of baby, gestational age at birth, neurodevelopmental conditions/impairment, quality of life, birth weight and separation of baby from mother for health care needs. CONCLUSIONS Multimorbidity in pregnancy is a new and complex clinical research area. Following a rigorous process, this complexity was meaningfully reduced to a core outcome set that balances the views of a diverse stakeholder group.
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Affiliation(s)
- Siang Ing Lee
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Stephanie Hanley
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Zoe Vowles
- Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | | | - Ngawai Moss
- Patient and public representative, London, UK
| | - Megha Singh
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Chris Gale
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Adeniyi Francis Fagbamigbe
- Division of Population and Behavioural Sciences, School of Medicine, University of St Andrews, St Andrews, UK
- Department of Epidemiology and Medical Statistics, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Amaya Azcoaga-Lorenzo
- Division of Population and Behavioural Sciences, School of Medicine, University of St Andrews, St Andrews, UK
- Hospital Rey Juan Carlos, Instituto de Investigación Sanitaria Fundación Jimenez Diaz, Madrid, Spain
| | | | - Beck Taylor
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Christine Damase-Michel
- Medical and Clinical Pharmacology, School of Medicine, Université Toulouse III, Toulouse, France
- Center for Epidemiology and Research in Population Health (CERPOP), INSERM, Toulouse, France
| | - Christopher Yau
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
- Health Data Research UK, London, UK
| | - Colin McCowan
- Division of Population and Behavioural Sciences, School of Medicine, University of St Andrews, St Andrews, UK
| | - Dermot O'Reilly
- Centre for Public Health, Queen's University of Belfast, Belfast, UK
| | | | - Helen Dolk
- Centre for Maternal, Fetal and Infant Research, Ulster University, Belfast, UK
| | - Holly Hope
- Centre for Women's Mental Health, Faculty of Biology Medicine & Health, The University of Manchester, Manchester, UK
| | - Katherine Phillips
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Kathryn M Abel
- Centre for Women's Mental Health, Faculty of Biology Medicine & Health, The University of Manchester, Manchester, UK
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Kelly-Ann Eastwood
- Centre for Public Health, Queen's University of Belfast, Belfast, UK
- St Michael's Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Lisa Kent
- Centre for Public Health, Queen's University of Belfast, Belfast, UK
| | - Louise Locock
- Health Services Research Unit, Health Sciences Building, Foresterhill, University of Aberdeen, Aberdeen, UK
| | - Maria Loane
- The Institute of Nursing and Health Research, Ulster University, Newtownabbey, UK
| | - Mohamed Mhereeg
- Data Science, Medical School, Swansea University, Swansea, UK
| | - Peter Brocklehurst
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Sharon McCann
- Health Services Research Unit, Health Sciences Building, Foresterhill, University of Aberdeen, Aberdeen, UK
| | - Sinead Brophy
- Data Science, Medical School, Swansea University, Swansea, UK
| | - Steven Wambua
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Shakila Thangaratinam
- WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Obstetrics and Gynaecology, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | | | - Mairead Black
- Aberdeen Centre for Women's Health Research, School of Medicine, Medical Science and Nutrition, University of Aberdeen, Aberdeen, UK
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Glasbey JC, Kadir B, Ademuyiwa AO, Adisa AO, Bhangu A, Brocklehurst P, Chakrabortee S, Hardy P, Harrison E, Ingabire JCA, Haque PD, Ismail L, Ghosh D, Gyamfi FE, Li E, Lillywhite R, de la Medina AR, Moore R, Magill L, Morton D, Nepogodiev D, Ntirenganya F, Pinkney T, Omar O, Simoes JFF, Smith D, Tabiri S, Runigamugabo E, Sodonougbo P, Behanzin H, Kangni S, Agboton G, Adagrah LA, Adjei-Acquah E, Acquah AO, Ankomah J, Armah R, Acquah R, Addo KG, Acheampong DO, Adu-Aryee NA, Abubakari F, Titigah A, Owusu F, Adu-Brobbey R, Adobea V, Abantanga FA, Gautham A, Bhatti D, Jesudason EDM, Aggarwal M, Alexander P, Dasari A, Alpheus R, Kumar H, Raul S, Bueno WÁ, Ortiz RC, Gomez IB, Cerdan CC, Gallo MB, Gamez RR, Sánchez ID, Abdullahi L, Adesanya O, Abdulsalam M, Adeleye V, Egwuonwu O, Adeleke A, Adebayo F, Chiejina G, Abayomi O, Abdur-Rahman L, Ede J, Ezinne U, Kanyarukiko S, Dusabe M, Hirwa AD, Bucyibaruta G, Adams MA, Birtles C, Ally Z, Adewunmi AS, Cook J, Brown J, Verjee A, Assouto P, Seto DM, Kpangon C, Ahossi R, Alhassan BBA, Agyekum V, Adam-Zakariah LI, Assah-Adjei F, Asare C, Amoako J, Akosa EA, Acquaye J, Adjei F, Ballu C, Coompson CL, Bennin A, Abdulai DR, Hepzibah A, Bhatti W, Paul PK, Dhamija P, Thomas J, Jacob P, Choudhrie A, Peters N, Sharma R, Camacho FB, Gonzalez GH, Aguirre CC, Solano DD, Flores AC, Menindez RL, Vazquez DG, Ado K, Awonuga D, Adeniran A, Ademuyiwa A, Ekwunife O, Adenikinju W, Aisuodionoe-Shadrach O, Edet E, Abdus-Salam R, Adeleke N, Ekenze S, Francis M, Mukaneza F, Izabiriza E, Kabanda E, Bunogerane GJ, Crawford R, Ivy M, Jayne D, Cousens S, Brant F, Fiogbe M, Tandje Y, Akpla M, Ngabo RB, Amoako-Boateng MP, Agyemang E, Asabre E, Boakye AA, Gakpetor DA, Appiah AD, Boakye P, Adinku M, Akoto E, Barimah CG, Labaran AH, Dankwah F, Acquah DK, Mary G, Bir K, Madankumar L, Gupta H, Zechariah P, Kurien E, Vakil R, Hernández AB, Krauss RH, Avendaño AC, Garcia RT, Ojeda AG, Peón AN, Lara MM, Aliyu M, Fasiku O, Ajai O, Adeniyi O, Modekwe V, Adeniyi O, Akaba G, Inyang A, Adebayo S, Adesola M, Enemuo V, Ikechukwu I, Mukantibaziyaremye D, Maniraguha HL, Mbonimpaye S, Habumuremyi S, Ede CJ, Mbavhalelo C, Laurberg S, Smart N, Koco H, Chobli HH, Bisimwa N, Appiah AB, Akesseh RA, Boateng RA, Fosu G, Gawu VS, Aseti M, Coompson CL, Agbedinu K, Ametefe E, Boateng GC, Owusu JA, Doe S, Ayingayure E, Singh D, Daniel S, Mittal R, Kanna V, Mathew A, Arellano AB, Miguelena LH, Sansores LD, Velasco MJ, Muñoz MP, Perez-Maldonado LM, Anyanwu LJ, Ogo C, Akande O, Akinajo O, Okoro C, Adepiti A, Ameh L, Isa M, Ajao A, Afolabi R, Eze M, Nnyonno O, Munyaneza A, Mpirimbanyi C, Mukakomite C, Haragirimana JDD, Fourtounas M, Chakrabortee S, Metchinhoungbe S, Kovohouande B, Kandokponou CMB, Asante-Asamani A, Amponsah-Manu F, Koomson B, Serbeh G, Obbeng A, Banka C, Gyamfi B, Agbeko AE, Amoako JK, Luri PT, Kantanka RS, Osman I, Dhar T, Nagomy I, Kumar A, Prakash D, Torres EC, Romero MH, Mejia HO, de la Fuente ANS, Magashi M, Atobatele K, Akinboyewa D, Uche C, Aderounmu A, Mbajiekwe N, Iseh F, Amusat O, Agodirin S, Ezomike U, Okoro P, Ndegamiye G, Mutuyimana J, Muroruhirwe P, Imanishimwe A, Hyman G, Sogbo H, Dokponou M, Boakye B, Ofosu-Akromah R, Kusiwaa A, Gyan KY, Ofosuhene D, Dadzie S, Kontor BE, Amankwa EG, Attepor GS, Kobby E, Kunfah S, Dhiman J, Selvakumar R, Singh G, Susan A, Orozco CF, del Campo LUG, de la Medina ARD, Muhammad A, Eke G, Alasi I, Ugwuanyi K, Adesunkanmi A, Ogbo F, Marwa A, Ayandipo O, Aremu I, Izuka E, Patrick I, Tubasiime R, Mwenedata O, Ingabire JCA, Khan Z, Dossou FM, Debrah SA, Enti D, Twerefour EY, Nyarko IO, Osei-Poku D, Essien D, Kyeremeh C, Amoah M, Brown GD, Larnyor KKKH, Limann G, Ghosh D, Shankar B, Varghese R, de Rojas EGG, Muhammad S, Faboya O, Alakaloko F, Ugwunne C, Adisa A, Olori S, Ogbeche S, Egbuchulem K, Bello J, Mbadiwe O, Raphael J, Rwagahirima E, Mukanyange V, Kwati M, Dzemta C, Ganiyu RA, Robertson Z, Puozaa D, Gyamfi FE, Manu R, Amoah G, Fenu B, Osei E, Mohammed SA, Goyal S, Sivakumar M, Ojeda AG, Muideen B, Imam Z, Atoyebi O, Ajekwu S, Osagie O, Olory E, Ekwuazi H, Lawal S, Mbah N, Vaduneme O, Uwizeyimana F, Munyaneza E, Mathe MN, Gaou A, Koggoh P, Tackie E, Hussey R, Mensah E, Appiah J, Kumassah PK, Owusu PY, Mohammed S, Goyal A, Sridhar R, Ramírez BG, Takai I, Momson E, Balogun O, Ajenjfuja O, Sadiq A, Udie G, Elemile P, Lawal A, Victor A, Zirikana J, Mutabazi E, Moore R, Heritage E, Goudou R, Kpankpari R, Temitope AE, Kwarteng J, Solae FI, Arthur J, Olayiwola DO, Sie-Broni CA, Musah Y, Goyal S, Thomas C, Valadez MHV, Ukata O, Nwaenyi F, Belie O, Akindojutimi J, Sani S, Udosen J, Lawal T, Raji H, Ncogoza I, Nhlabathi NA, Hedefoun E, Opandoh INM, Sowah NA, Toffah GK, Ayim A, Wordui T, Zume M, Ofori B, Hans M, Titus D, Acevedo DL, Ogunyemi A, Bode C, Akinkuolie A, Tabuanu N, Usang U, Lawal O, Sayomi O, Ntirenganya F, Nxumalo HS, Kroese K, Houtoukpe S, Manu MA, Yeboah G, Ayodeji EK, Agboadoh N, Owusu EA, Haque P, Galaviz RM, Oludara M, Ekwesianya A, Alatise O, Uanikhoba M, Olagunju S, Shittu A, Nyirahabimana J, Pattinson P, Lapitan C, Kamga F, Manu MPO, Yeboah C, Boakye-Yiadom J, Saba AH, Konda S, Flores OO, Omisanjo O, Elebute O, Allen O, Osuala P, Urimubabo C, Sentholang N, Kiki-Migan E, Mensah S, Boateng EA, Seidu AS, Luther A, Navarro JP, Oshodi O, Ezenwankwo F, Amosu L, Suleman B, Sethoana ME, Lissauer D, Lawani S, Morna MT, Dally C, Tabiri S, Mahajan A, Belmontes KP, Oshodi Y, Fatuga A, Archibong M, Takure A, Stassen ME, Lawani I, Nkrumah J, Davor A, Yakubu M, Makkar S, Marbello FR, Oyewole Y, Ihediwa G, Arowolo O, Thornley L, Loko R, Nortey M, Gyasi-Sarpong CK, Yenli EMTA, Mandrelle K, Ramírez-González L, Salami O, Jimoh A, Ayantona D, Wondoh P, Mistry P, Moutaïrou A, Ofori EO, Hamidu NNN, Michael V, Aguirre LR, Williams O, Kuku J, Ayinde A, Monahan M, Ogouyemi P, Quartson EMQ, Haruna I, Mukherjee P, García RR, Ladipo-Ajayi O, Badejoko O, Soumanou F, Kwarley N, Rajappa R, Robles EV, Makanjuola A, Badmus T, Tamadaho P, Lovi AK, Singh P, Mokwenyei O, Etonyeaku A, Zounon MA, Nimako B, Suroy A, Nwokocha S, Igbodike E, Nyadu BB, Thind R, Ogein O, Ijarotimi O, Opoku D, Thomas A, Ojewola R, Lawal A, Osabutey A, Tuli A, Oladimeji A, Nana F, Roberts T, Sagoe R, Veetil S, Olajide T, Oduanafolabi T, Tuffour S, Oluseye O, Olasehinde O, Tufour Y, Seyi-Olajide J, Olayemi O, Winkles N, Yamoah FA, Soibi-Harry A, Omitinde S, Yefieye AC, Ugwu A, Oni O, Yorke J, Williams E, Onyeze C, Orji E, Rotimi A, Salako A, Solaja O, Sowemimo O, Talabi A, Tajudeen M, Wuraola F. The importance of post-discharge surgical site infection surveillance: an exploration of surrogate outcome validity in a global randomised controlled trial (FALCON). Lancet Glob Health 2023; 11:e1178-e1179. [PMID: 37474222 DOI: 10.1016/s2214-109x(23)00256-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 04/05/2023] [Accepted: 05/26/2023] [Indexed: 07/22/2023]
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Kirk J, Reynolds F, Adey E, Boazman M, Brookes M, Brocklehurst P. Developing paediatric chief investigators within the NHS: the Clinical Trials Scholars programme. Arch Dis Child Educ Pract Ed 2023; 108:139-141. [PMID: 35193887 DOI: 10.1136/archdischild-2021-322186] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 08/06/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Jeremy Kirk
- Research and Development, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Fiona Reynolds
- Chief Medical Office, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Elizabeth Adey
- Research and Development, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Matthew Boazman
- Research and Development, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | | | - Peter Brocklehurst
- Institute of Applied Health Research, Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
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Anand A, Phillips K, Subramanian A, Lee SI, Wang Z, McCowan R, Agrawal U, Fagbamigbe AF, Nelson-Piercy C, Brocklehurst P, Damase-Michel C, Loane M, Nirantharakumar K, Azcoaga-Lorenzo A. Prevalence of polypharmacy in pregnancy: a systematic review. BMJ Open 2023; 13:e067585. [PMID: 36878655 PMCID: PMC9990613 DOI: 10.1136/bmjopen-2022-067585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 01/22/2023] [Indexed: 03/08/2023] Open
Abstract
OBJECTIVES The use of medications among pregnant women has been rising over the past few decades but the reporting of polypharmacy has been sporadic. The objective of this review is to identify literature reporting the prevalence of polypharmacy among pregnant women, the prevalence of multimorbidity in women taking multiple medications in pregnancy and associated effects on maternal and offspring outcomes. DESIGN MEDLINE and Embase were searched from their inception to 14 September 2021 for interventional trials, observational studies and systematic reviews reporting on the prevalence of polypharmacy or the use of multiple medications in pregnancy were included.Data on prevalence of polypharmacy, prevalence of multimorbidity, combinations of medications and pregnancy and offspring outcomes were extracted. A descriptive analysis was performed. RESULTS Fourteen studies met the review criteria. The prevalence of women being prescribed two or more medications during pregnancy ranged from 4.9% (4.3%-5.5%) to 62.4% (61.3%-63.5%), with a median of 22.5%. For the first trimester, prevalence ranged from 4.9% (4.7%-5.14%) to 33.7% (32.2%-35.1%). No study reported on the prevalence of multimorbidity, or associated pregnancy outcomes in women exposed to polypharmacy. CONCLUSION There is a significant burden of polypharmacy among pregnant women. There is a need for evidence on the combinations of medications prescribed in pregnancy, how this specifically affects women with multiple long-term conditions and the associated benefits and harms. TWEETABLE ABSTRACT Our systematic review shows significant burden of polypharmacy in pregnancy but outcomes for women and offspring are unknown. PROSPERO REGISTRATION NUMBER CRD42021223966.
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Affiliation(s)
- Astha Anand
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Katherine Phillips
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Siang Ing Lee
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Zhaonan Wang
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Utkarsh Agrawal
- Division of Population and Behavioural Sciences, University of Saint Andrews School of Medicine, St. Andrews, UK
| | - Adeniyi Frances Fagbamigbe
- Division of Population and Behavioural Sciences, University of Saint Andrews School of Medicine, St. Andrews, UK
- Epidemiology and Medical Statistics, University of Ibadan, Ibadan, Nigeria
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | | | - Peter Brocklehurst
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Maria Loane
- Institute of Nursing and Health Research, University of Ulster, Belfast, UK
| | | | - Amaya Azcoaga-Lorenzo
- Division of Population and Behavioural Sciences, University of Saint Andrews School of Medicine, St. Andrews, UK
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Lee SI, Hope H, O'Reilly D, Kent L, Santorelli G, Subramanian A, Moss N, Azcoaga-Lorenzo A, Fagbamigbe AF, Nelson-Piercy C, Yau C, McCowan C, Kennedy JI, Phillips K, Singh M, Mhereeg M, Cockburn N, Brocklehurst P, Plachcinski R, Riley RD, Thangaratinam S, Brophy S, Hemali Sudasinghe SPB, Agrawal U, Vowles Z, Abel KM, Nirantharakumar K, Black M, Eastwood KA. Maternal and child outcomes for pregnant women with pre-existing multiple long-term conditions: protocol for an observational study in the UK. BMJ Open 2023; 13:e068718. [PMID: 36828655 PMCID: PMC9972454 DOI: 10.1136/bmjopen-2022-068718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 02/07/2023] [Indexed: 02/26/2023] Open
Abstract
INTRODUCTION One in five pregnant women has multiple pre-existing long-term conditions in the UK. Studies have shown that maternal multiple long-term conditions are associated with adverse outcomes. This observational study aims to compare maternal and child outcomes for pregnant women with multiple long-term conditions to those without multiple long-term conditions (0 or 1 long-term conditions). METHODS AND ANALYSIS Pregnant women aged 15-49 years old with a conception date between 2000 and 2019 in the UK will be included with follow-up till 2019. The data source will be routine health records from all four UK nations (Clinical Practice Research Datalink (England), Secure Anonymised Information Linkage (Wales), Scotland routine health records and Northern Ireland Maternity System) and the Born in Bradford birth cohort. The exposure of two or more pre-existing, long-term physical or mental health conditions will be defined from a list of health conditions predetermined by women and clinicians. The association of maternal multiple long-term conditions with (a) antenatal, (b) peripartum, (c) postnatal and long-term and (d) mental health outcomes, for both women and their children will be examined. Outcomes of interest will be guided by a core outcome set. Comparisons will be made between pregnant women with and without multiple long-term conditions using modified Poisson and Cox regression. Generalised estimating equation will account for the clustering effect of women who had more than one pregnancy episode. Where appropriate, multiple imputation with chained equation will be used for missing data. Federated analysis will be conducted for each dataset and results will be pooled using random-effects meta-analyses. ETHICS AND DISSEMINATION Approval has been obtained from the respective data sources in each UK nation. Study findings will be submitted for publications in peer-reviewed journals and presented at key conferences.
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Affiliation(s)
- Siang Ing Lee
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Holly Hope
- Centre for Women's Mental Health, Faculty of Biology Medicine & Health, The University of Manchester, Manchester, UK
| | - Dermot O'Reilly
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Lisa Kent
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Gillian Santorelli
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Trust, Bradford, UK
| | | | - Ngawai Moss
- Patient and Public Representative, London, UK
| | - Amaya Azcoaga-Lorenzo
- Division of Population and Behavioural Sciences, University of St Andrews School of Medicine, St Andrews, UK
- Instituto de Investigación Sanitaria Fundación Jimenez Diaz, Hospital Rey Juan Carlos, Mostoles, Spain
| | - Adeniyi Francis Fagbamigbe
- Division of Population and Behavioural Sciences, University of St Andrews School of Medicine, St Andrews, UK
- Department of Epidemiology and Medical Statistics, University of Ibadan College of Medicine, Ibadan, Nigeria
| | | | - Christopher Yau
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
- Health Data Research UK, London, UK
| | - Colin McCowan
- Division of Population and Behavioural Sciences, University of St Andrews School of Medicine, St Andrews, UK
| | | | - Katherine Phillips
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Megha Singh
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Mohamed Mhereeg
- Data Science, Medical School, Swansea University, Swansea, UK
| | - Neil Cockburn
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Peter Brocklehurst
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Richard D Riley
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Shakila Thangaratinam
- WHO Collaborating Centre for Global Women's Health, University of Birmingham Institute of Metabolism and Systems Research, Birmingham, UK
- Department of Obstetrics and Gynaecology, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Sinead Brophy
- Data Science, Medical School, Swansea University, Swansea, UK
| | | | - Utkarsh Agrawal
- Division of Population and Behavioural Sciences, University of St Andrews School of Medicine, St Andrews, UK
| | - Zoe Vowles
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Kathryn Mary Abel
- Centre for Women's Mental Health, Faculty of Biology Medicine & Health, The University of Manchester, Manchester, UK
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | | | - Mairead Black
- Aberdeen Centre for Women's Health Research, University of Aberdeen School of Medicine Medical Sciences and Nutrition, Aberdeen, UK
| | - Kelly-Ann Eastwood
- Centre for Public Health, Queen's University Belfast, Belfast, UK
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
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Currie C, Palmer J, Stone S, Brocklehurst P, Aggarwal V, Dorman P, Pearce M, Durham J. Persistent Orofacial Pain Attendances at General Medical Practitioners. J Dent Res 2023; 102:164-169. [PMID: 36314491 PMCID: PMC9896262 DOI: 10.1177/00220345221128226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Patients with persistent orofacial pain (POFP) can go through complex care pathways to receive a diagnosis and management, which can negatively affect their pain. This study aimed to describe 44-y trends in attendances at Welsh medical practices for POFP and establish the number of attendances per patient and referrals associated with orofacial pain and factors that may predict whether a patient is referred. A retrospective observational study was completed using the nationwide Secure Anonymised Information Linkage Databank of visits to general medical practices in Wales (UK). Data were extracted using diagnostic codes ("Read codes"). Orofacial and migraine Read codes were extracted between 1974 and 2017. Data were analyzed using descriptive statistics and univariate and multivariable logistic regression. Over the 44-y period, there were 468,827 POFP and migraine diagnostic codes, accounting for 468,137 patient attendances, or 301,832 patients. The overall attendance rate was 4.22 attendances per 1,000 patient-years (95% confidence interval [CI], 4.21-4.23). The attendance rate increased over the study period. Almost one-third of patients (n = 92,192, 30.54%) attended more than once over the study period, and 15.83% attended more than once within a 12-mo period. There were 20,103 referral codes that were associated with 8,183 patients, with over half these patients being referred more than once. Odds of receiving a referral were highest in females (odds ratio [OR], 1.23; 95% CI, 1.17-1.29), in those living in rural locations (OR, 1.17; 95% CI, 1.12-1.22), and in the least deprived quintile (OR, 1.39; 95% CI, 1.29-1.48). Odds also increased with increasing age (OR, 1.03; 95% CI, 1.03-1.03). The increasing attendance may be explained by the increasing incidence of POFP within the population. These patients can attend on a repeated basis, and very few are referred, but when they are, this may occur multiple times; therefore, current care pathways could be improved.
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Affiliation(s)
- C.C. Currie
- School of Dental Sciences, Newcastle University, Newcastle upon Tyne, UK,Newcastle Upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK,C.C. Currie, School of Dental Sciences, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4BW, UK.
| | - J. Palmer
- School of Dental Sciences, Newcastle University, Newcastle upon Tyne, UK,Newcastle Upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - S.J. Stone
- School of Dental Sciences, Newcastle University, Newcastle upon Tyne, UK,Newcastle Upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | | | - P.J. Dorman
- Newcastle Upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - M.S. Pearce
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - J. Durham
- School of Dental Sciences, Newcastle University, Newcastle upon Tyne, UK,Newcastle Upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
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12
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Subramanian A, Azcoaga-Lorenzo A, Anand A, Phillips K, Lee SI, Cockburn N, Fagbamigbe AF, Damase-Michel C, Yau C, McCowan C, O'Reilly D, Santorelli G, Hope H, Kennedy JI, Abel KM, Eastwood KA, Locock L, Black M, Loane M, Moss N, Plachcinski R, Thangaratinam S, Brophy S, Agrawal U, Vowles Z, Brocklehurst P, Dolk H, Nelson-Piercy C, Nirantharakumar K. Polypharmacy during pregnancy and associated risk factors: a retrospective analysis of 577 medication exposures among 1.5 million pregnancies in the UK, 2000-2019. BMC Med 2023; 21:21. [PMID: 36647047 PMCID: PMC9843951 DOI: 10.1186/s12916-022-02722-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 12/23/2022] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND The number of medications prescribed during pregnancy has increased over the past few decades. Few studies have described the prevalence of multiple medication use among pregnant women. This study aims to describe the overall prevalence over the last two decades among all pregnant women and those with multimorbidity and to identify risk factors for polypharmacy in pregnancy. METHODS A retrospective cohort study was conducted between 2000 and 2019 using the Clinical Practice Research Datalink (CPRD) pregnancy register. Prescription records for 577 medication categories were obtained. Prevalence estimates for polypharmacy (ranging from 2+ to 11+ medications) were presented along with the medications commonly prescribed individually and in pairs during the first trimester and the entire pregnancy period. Logistic regression models were performed to identify risk factors for polypharmacy. RESULTS During the first trimester (812,354 pregnancies), the prevalence of polypharmacy ranged from 24.6% (2+ medications) to 0.1% (11+ medications). During the entire pregnancy period (774,247 pregnancies), the prevalence ranged from 58.7 to 1.4%. Broad-spectrum penicillin (6.6%), compound analgesics (4.5%) and treatment of candidiasis (4.3%) were commonly prescribed. Pairs of medication prescribed to manage different long-term conditions commonly included selective beta 2 agonists or selective serotonin re-uptake inhibitors (SSRIs). Risk factors for being prescribed 2+ medications during the first trimester of pregnancy include being overweight or obese [aOR: 1.16 (1.14-1.18) and 1.55 (1.53-1.57)], belonging to an ethnic minority group [aOR: 2.40 (2.33-2.47), 1.71 (1.65-1.76), 1.41 (1.35-1.47) and 1.39 (1.30-1.49) among women from South Asian, Black, other and mixed ethnicities compared to white women] and smoking or previously smoking [aOR: 1.19 (1.18-1.20) and 1.05 (1.03-1.06)]. Higher and lower age, higher gravidity, increasing number of comorbidities and increasing level of deprivation were also associated with increased odds of polypharmacy. CONCLUSIONS The prevalence of polypharmacy during pregnancy has increased over the past two decades and is particularly high in younger and older women; women with high BMI, smokers and ex-smokers; and women with multimorbidity, higher gravidity and higher levels of deprivation. Well-conducted pharmaco-epidemiological research is needed to understand the effects of multiple medication use on the developing foetus.
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Affiliation(s)
- Anuradhaa Subramanian
- Institute of Applied Health Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Amaya Azcoaga-Lorenzo
- Division of Population and Behavioural Sciences, School of Medicine, University of St Andrews, St Andrews, UK
| | - Astha Anand
- Institute of Applied Health Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Katherine Phillips
- Institute of Applied Health Research, University of Birmingham, Birmingham, B15 2TT, UK.
| | - Siang Ing Lee
- Institute of Applied Health Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Neil Cockburn
- Institute of Applied Health Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Adeniyi Francis Fagbamigbe
- Division of Population and Behavioural Sciences, School of Medicine, University of St Andrews, St Andrews, UK
- Department of Epidemiology and Medical Statistics, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Christine Damase-Michel
- Medical and Clinical Pharmacology, School of Medicine, Université Toulouse III, Toulouse, France
- INSERM, Center for Epidemiology and Research in Population Health (CERPOP), Toulouse, CIC 1436, France
| | - Christopher Yau
- Division of Informatics, Imaging and Data Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK
- Health Data Research UK, Oxford, UK
| | - Colin McCowan
- Division of Population and Behavioural Sciences, School of Medicine, University of St Andrews, St Andrews, UK
| | - Dermot O'Reilly
- Centre for Public Health, Queen's University of Belfast, Belfast, UK
| | | | - Holly Hope
- Centre for Women's Mental Health, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology Medicine & Health, The University of Manchester, Manchester, UK
| | | | - Kathryn M Abel
- Centre for Women's Mental Health, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology Medicine & Health, The University of Manchester, Manchester, UK
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Kelly-Ann Eastwood
- Centre for Public Health, Queen's University of Belfast, Belfast, UK
- St Michael's Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Louise Locock
- Health Services Research Unit, School of Medicine, Medical Science and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Mairead Black
- Aberdeen Centre for Women's Health Research, School of Medicine, Medical Science and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Maria Loane
- Centre for Maternal, Fetal and Infant Research, The Institute of Nursing and Health Research, Ulster University, Coleraine, UK
| | - Ngawai Moss
- Patient and Public Representative, London, UK
| | | | - Shakila Thangaratinam
- WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Obstetrics and Gynaecology, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Sinead Brophy
- Data Science, Medical School, Swansea University, Swansea, UK
| | - Utkarsh Agrawal
- Division of Population and Behavioural Sciences, School of Medicine, University of St Andrews, St Andrews, UK
| | - Zoe Vowles
- Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Peter Brocklehurst
- Institute of Applied Health Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Helen Dolk
- Centre for Maternal, Fetal and Infant Research, The Institute of Nursing and Health Research, Ulster University, Coleraine, UK
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13
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Chappell LC, Brocklehurst P, Green M, Hardy P, Hunter R, Beardmore-Gray A, Bowler U, Brockbank A, Chiocchia V, Cox A, Duhig K, Fleminger J, Gill C, Greenland M, Hendy E, Kennedy A, Leeson P, Linsell L, McCarthy FP, O'Driscoll J, Placzek A, Poston L, Robson S, Rushby P, Sandall J, Scholtz L, Seed PT, Sparkes J, Stanbury K, Tohill S, Thilaganathan B, Townend J, Juszczak E, Marlow N, Shennan A. Planned delivery for pre-eclampsia between 34 and 37 weeks of gestation: the PHOENIX RCT. Health Technol Assess 2022:10.3310/CWWH0622. [PMID: 36547875 PMCID: PMC10068586 DOI: 10.3310/cwwh0622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND In women with late preterm pre-eclampsia (i.e. at 34+0 to 36+6 weeks' gestation), the optimal delivery time is unclear because limitation of maternal-fetal disease progression needs to be balanced against infant complications. The aim of this trial was to determine whether or not planned earlier initiation of delivery reduces maternal adverse outcomes without substantial worsening of perinatal or infant outcomes, compared with expectant management, in women with late preterm pre-eclampsia. METHODS We undertook an individually randomised, triple non-masked controlled trial in 46 maternity units across England and Wales, with an embedded health economic evaluation, comparing planned delivery and expectant management (usual care) in women with late preterm pre-eclampsia. The co-primary maternal outcome was a maternal morbidity composite or recorded systolic blood pressure of ≥ 160 mmHg (superiority hypothesis). The co-primary short-term perinatal outcome was a composite of perinatal deaths or neonatal unit admission (non-inferiority hypothesis). Analyses were by intention to treat, with an additional per-protocol analysis for the perinatal outcome. The primary 2-year infant neurodevelopmental outcome was measured using the PARCA-R (Parent Report of Children's Abilities-Revised) composite score. The planned sample size of the trial was 900 women; the trial is now completed. We undertook two linked substudies. RESULTS Between 29 September 2014 and 10 December 2018, 901 women were recruited; 450 women [448 women (two withdrew consent) and 471 infants] were allocated to planned delivery and 451 women (451 women and 475 infants) were allocated to expectant management. The incidence of the co-primary maternal outcome was significantly lower in the planned delivery group [289 (65%) women] than in the expectant management group [338 (75%) women] (adjusted relative risk 0.86, 95% confidence interval 0.79 to 0.94; p = 0.0005). The incidence of the co-primary perinatal outcome was significantly higher in the planned delivery group [196 (42%) infants] than in the expectant management group [159 (34%) infants] (adjusted relative risk 1.26, 95% confidence interval 1.08 to 1.47; p = 0.0034), but indicators of neonatal morbidity were similar in both groups. At 2-year follow-up, the mean PARCA-R scores were 89.5 points (standard deviation 18.2 points) for the planned delivery group (290 infants) and 91.9 points (standard deviation 18.4 points) for the expectant management group (256 infants), both within the normal developmental range (adjusted mean difference -2.4 points, 95% confidence interval -5.4 to 0.5 points; non-inferiority p = 0.147). Planned delivery was significantly cost-saving (-£2711, 95% confidence interval -£4840 to -£637) compared with expectant management. There were nine serious adverse events in the planned delivery group and 12 in the expectant management group. CONCLUSION In women with late preterm pre-eclampsia, planned delivery reduces short-term maternal morbidity compared with expectant management, with more neonatal unit admissions related to prematurity but no indicators of greater short-term neonatal morbidity (such as need for respiratory support). At 2-year follow-up, around 60% of parents reported follow-up scores. Average infant development was within the normal range for both groups; the small between-group mean difference in PARCA-R scores is unlikely to be clinically important. Planned delivery was significantly cost-saving to the health service. These findings should be discussed with women with late preterm pre-eclampsia to allow shared decision-making on timing of delivery. LIMITATIONS Limitations of the trial include the challenges of finding a perinatal outcome that adequately represented the potential risks of both groups and a maternal outcome that reflects the multiorgan manifestations of pre-eclampsia. The incidences of maternal and perinatal primary outcomes were higher than anticipated on the basis of previous studies, but this did not limit interpretation of the analysis. The trial was limited by a higher loss to follow-up rate than expected, meaning that the extent and direction of bias in outcomes (between responders and non-responders) is uncertain. A longer follow-up period (e.g. up to 5 years) would have enabled us to provide further evidence on long-term infant outcomes, but this runs the risk of greater attrition and increased expense. FUTURE WORK We identified a number of further questions that could be prioritised through a formal scoping process, including uncertainties around disease-modifying interventions, prognostic factors, longer-term follow-up, the perspectives of women and their families, meta-analysis with other studies, effect of a similar intervention in other health-care settings, and clinical effectiveness and cost-effectiveness of other related policies around neonatal unit admission in late preterm birth. TRIAL REGISTRATION The trial was prospectively registered as ISRCTN01879376. FUNDING This project was funded by the National Institute for Health and Care Research ( NIHR ) Health Technology Assessment programme and will be published in Health Technology Assessment. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Lucy C Chappell
- School of Life Course Sciences, King's College London, London, UK
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | | | - Pollyanna Hardy
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Rachael Hunter
- Research Department of Primary Care and Population Health, University College London, London, UK
| | | | - Ursula Bowler
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Anna Brockbank
- School of Life Course Sciences, King's College London, London, UK
| | - Virginia Chiocchia
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Alice Cox
- School of Life Course Sciences, King's College London, London, UK
| | - Kate Duhig
- School of Life Course Sciences, King's College London, London, UK
| | | | - Carolyn Gill
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Melanie Greenland
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Eleanor Hendy
- School of Life Course Sciences, King's College London, London, UK
| | - Ann Kennedy
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Paul Leeson
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Louise Linsell
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Fergus P McCarthy
- Department of Obstetrics and Gynaecology, University of Cork, Cork, Ireland
| | - Jamie O'Driscoll
- School of Psychology and Life Sciences, Canterbury Christ Church University, Kent, UK
| | - Anna Placzek
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Lucilla Poston
- School of Life Course Sciences, King's College London, London, UK
| | - Stephen Robson
- Population Health Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Pauline Rushby
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jane Sandall
- School of Life Course Sciences, King's College London, London, UK
| | - Laura Scholtz
- School of Life Course Sciences, King's College London, London, UK
| | - Paul T Seed
- School of Life Course Sciences, King's College London, London, UK
| | - Jenie Sparkes
- School of Life Course Sciences, King's College London, London, UK
| | - Kayleigh Stanbury
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Sue Tohill
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Basky Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - Edmund Juszczak
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Neil Marlow
- Institute for Women's Health, University College London, London, UK
| | - Andrew Shennan
- School of Life Course Sciences, King's College London, London, UK
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14
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Andoh AB, Atindaana Francis A, Abdulkarim AA, Adesunkanmi AO, Salako AA, Soladoye A, Sheshe AA, Sani A, Lawal AO, Lawal A, Tripathi A, S A, Akinloye A, Olajumoke Balogun A, Ariyibi AL, Okunlola AI, Ojewuyi AR, Oyedele AE, Sakyi A, Oladimeji AT, Bala Muhammad A, Yahaya A, Soibi-Harry AP, Gyambibi AK, Adeniyi AA, Adeoluwa A, Olumide Osinowo A, Salawu AI, Fatuga AL, Adesiyakan A, Fakoya A, Naah A, Adeyeye AA, Talabi AO, Fasanu AO, Ayoola Orowale A, Ojajuni A, Adelaja AT, Ademuyiwa AO, Jimoh AI, Aderounmu AA, Adisa AO, Ajagbe AO, Olajide AT, Bakare A, Okunowo AA, Tchogo A, Koledade AK, Barthelemy Yevide A, Bello A, Shehu Umar A, Lawal AT, Obiesie AE, Dieudonne Hirwa A, Domingo A, Mustapha A, Abdullahi A, Hada A, Ijeoma A, Adeleke AA, Adepiti AC, Ajao AE, Sanusi AT, Houndji A, Bernal Hernández A, González Ojeda A, Serrano García AG, Ohemu AA, Arekhandia AI, Yakubu A, Hepzibah A, Bhatt A, Muhammad Tukur A, Ingabire AJC, Okechukwu Ugwu A, Karekezi A, Maalekuu A, Imanishimwe A, Bruce-Adjei A, Obbeng A, Akosua A, Jeffery-Felix A, Mohammed-Durosinlorun AA, Jimoh AO, Umar AM, Umar AM, Mahajan A, Eziyi AK, Bennin A, Dasari A, Okedare A, Mathew AE, Florencia Casado-Zarate A, Calderón-Alvarado AB, Dominguez ACG, Cortés Flores AO, Dusabimana A, Kutma A, Byaruhanga A, Houndote A, Cueto Valadez AE, Alvarez Villaseñor AS, Bhangu A, Ortega Barreiro A, Mortola Lomeli AF, Luther A, Yahya A, Eseenam Agbeko A, Thomas A, Goyal A, Mkoh Dikao AS, Appiah AB, Gaou A, Bediako-Bowan AA, Ramos De la Medina A, Seidu AS, Munyaneza A, Ahounou A, Akoto-Ampaw A, Hadonou A, Alitonou A, Sambo A, Mathew AJ, Chaturvedi A, Gautham AK, Choudhrie AV, Attri AK, Kumar A, Sukumar A, Mehraj A, Shittu A, Mukasine A, Oppon-Acquah A, Kusiwaa A, Suroy A, Ezenwa AO, Takure AO, Akinniyi A, Ogunyemi AA, Makanjuola A, Dossou Yovo BB, Alhassan BAB, Hamza BK, Awoyinka BS, Koomson B, Aminu B, Abodunde Muideen B, Osunwusi B, García Reyna B, Oppong BA, Brimpong BB, Fenu BS, Ofori BA, Guzmán Ramírez BG, Nyadu BB, Shankar B, Lawal BK, Armstrong Alia B, Roy B, Kontor BE, Kovohouande B, Cakpo B, Enriquez Barajas BV, Crocco Quiros B, Kadir B, Mohammed C, Nwachukwu CU, Colunga Tinajero C, Ruiz Velasco CB, Zuloaga Fernández del Valle CJ, Noufuentes C, Solomi CV, Okunlola CK, Seneza C, Okafor CI, Nuño Escobar C, Banka C, Barimah CG, Chetana C, Nyatsambo C, Okeke CJ, Jeffrey Ede C, Nwosu CD, Victoria Mgbemena C, Onyeka CU, Gold CS, Faith Uche C, Chigoze Makwe C, Urimubabo CJ, Coompson CL, Ashley-Osuzoka C, Gbenga-Oke C, Bidemi Oyegbola C, Mukakomite C, Mpirimbanyi C, Asare C, Bode CO, Ugwunne C, Onyejiaka CC, Okoro C, Okereke CE, Mukangabo C, Sie-Broni C, Ballu C, Fuentes Orozco C, Kyeremeh C, Adumah CC, Ruelas Bravo C, Bokossa Kandokponou CM, Guerrero Ramírez CS, Teye-Topey C, Kpangon C, Chinyio D, Orozco Ramirez D, Mora Santana D, Nyirasebura D, Hérnandez Alva DA, Acquah DK, Prakash DD, Sale D, Olulana DI, Oruade D, Jayne D, Morales Iriarte DGI, Ogudi DKD, Olatola DO, Akinboyewa DO, Irabor DO, Nuwam D, Mukantibaziyaremye D, Jain D, Singla D, Garnaik DK, Singh DS, Gakpetor DA, Esssien D, Rubanguka D, Poonia DR, Ghosh D, Ahogni D, Morton D, Umuhoza D, Morel Seto D, Nepogodiev D, Enti D, Smith D, Osei-Poku D, Acheampong DO, Mellado DH, Ofosuhene D, Cortes Torres EJ, Efren Lozada E, Gómez Sánchez E, González Espinoza E, Osei E, Mensah E, Rwagahirima E, Quartson EM, Li E, Kurien EN, Bonilla Ahumada E, Kabanda E, Odame E, Izabiriza E, Hatangimana E, Osariemen E, Reyes Elizalde EA, Agbowada EA, Usam E, Sylvester Inyang E, Owie E, Ojo Williams E, Munyaneza E, Mutabazi E, Kojo Acquah E, Obiri EL, Ofori EO, Runigamugabo E, Yhoshu E, Malade E, Cervantes Perez E, Kobby E, Okwudiri Ohazurike E, Jerry Bara E, Agyemang E, Akoto E, Villanueva-Martínez EE, Mwungura E, Cueva Martinez E, Asabre E, Adjei-Acquah E, Abunimye E, Daluk EB, Daniel ER, Ike Okorie E, Ailunia EE, Abraham ES, Romo Ascencio EV, Harrison E, Kpatchassou E, Bakari F, González Ponce FY, Huda F, Abubakari F, Ntirenganya F, Ingabire F, Parray FQ, Brant F, Alakaloko FM, Diaz Samano F, Duque Zepeda F, Bello-Tukur F, Basirwa Musengo F, Dedey F, Adegoke F, Amponsah-Manu F, Mukaneza F, Chinonso Ezenwankwo F, Sanwo F, Dossou FM, Nwaenyi FC, Ibanez Ortiz F, Barbosa Camacho FJ, León-Frutos FJ, Plascencia Posada FJ, Nirere F, Owusu F, Gyamfi FE, Wuraola FO, Cervantes Guevara G, Ntwari G, Ambriz-González G, Hyman G, Umar GI, Thami G, Adeleye GTC, Limann G, Ajibola G, Ida G, Ihediwa GC, Brown GD, Bucyibaruta G, Gallardo Banuelos G, Lopez Arroyo G, Ndegamiye G, Naah G, Morgan Villela G, Edet G, Attepor GS, Akaba GO, Aziz G, Yeboah G, Mary G, Eke G, Castillo Cardiel G, Yanowsky Reyes G, Sanchez Villaseñor G, Cervantes Cardona GA, Singh G, Boateng GC, Kola H, Abdullahi HI, Olaide Raji H, Ahmed HI, Umaru-Sule H, Kaur H, Malechi H, Sunday H, Abiyere HO, Butana H, Agossou H, Samkelisiwe Nxumalo H, Maniraguha HL, Dewamon H, Yome H, Behanzin H, Ekwuazi HO, Oweredaba IT, Mohammed I, Sufyan I, Saidu IA, Abdul-Aziz IIA, Eseile IS, Ogolekwu IP, Adebara IO, Usman Takai I, Fidelis Okafor I, Kene IA, Enyinnaya Iweha I, Mutimamwiza I, Mantoo I, Duruewuru IO, Akpo I, Niyongombwa I, Brancaccio Pérez IV, Esparza Estrada I, Gundu I, Morkor Opandoh IN, Ncogoza I, Sibomana I, Bansal I, Cabrera-Lozano I, Ishola Aremu I, Gandaho I, Lawani I, Ochoa Rodríguez I, Alasi IO, Alhassan J, Mends-Odro J, Osuna Rubio J, Orozco Perez J, González Bojorquez JL, Rodriguez Ramirez JA, Glasbey J, Emeka JJ, Lawal J, Acquaye J, Alfred J, Rugendabanga J, Mizero J, Ingabire JCA, Aimable Habiyakare J, Claude Uwimana J, de Dieu Haragirimana J, Yves Shyirakera J, Utumatwishima JN, Niyomuremyi JP, Majyabere JP, Masengesho JP, Nyirahabimana J, Vishnoi JR, Kalyanapu JA, Joseph JN, Makama JG, Pizarro Lozano J, Aguilar Mata JA, Morales JFM, Vega Gastelum JO, Oyekunle Bello J, Okechukwu Ugwu J, Amoako JK, Simoes J, Zirikana J, Nzuwa Nsilu J, Adze JA, Enaholo JE, Obateru JA, Chinda JY, Akunyam J, Boakye-Yiadom J, Cook J, Quansah JIK, Chejfec Ciociano JM, Jiménez Tornero J, Herrera-Esquivel J, Flores Cardoza JA, Sánchez Martínez JA, Guzmán Barba JA, Pesquera JAA, Orozco Navarro JE, Sandoval Pulido JI, Pérez Navarro JV, Igiraneza J, Ejimogu J, Awindaogo JK, Ugboajah JO, Ashong J, Nsaful J, Arthur J, Yakubu J, Mutuyimana J, Umuhoza J, Thomas J, Ibarrola Peña JC, Tijerina Ávila JJ, Oladayo Kuku J, Gyamfi JE, Brown J, Appiah J, Attinon J, Jacob J, Gimba J, Seyi-Olajide JO, Ngaguene J, Jyoti J, Leshiini K, Boukari KA, Kumar K, Mumuni K, Quarchey KND, Sanni K, Bozada-Gutierrez K, Mandrelle K, Atobatele KM, Awodele K, Bawa KG, Duromola KM, Egbuchulem KI, Ngaaso K, Onyekachi K, Ugwuanyi K, Okoduwa KO, Ado KA, Rathod KK, Nunoo-Ghartey K, Rautela K, Kennedy KK, Ascencio Díaz KV, Boakye-Yiadom K, Onahi Iji L, Magill L, Martinez Perez Maldonado L, Pena Baolboa LG, Montano Angeles LO, Barau Abdullahi L, Ismail L, Awere-Kyere LKB, Uzikwambara L, Adam-Zakariah L, Larbi-Siaw LA, Chukwuemeka Anyanwu LJ, Etchisse L, Abdulrasheed L, Agbanda L, García González LA, Suárez Carreón LO, Cifuentes Andrade LR, Pacheco Vallejo LR, Ramirez Gonzalez LR, Aniakwo LA, Olajide Abdur-Rahman L, Abdur-Rahman LO, Namur LDCM, Mukamazera L, Airede LR, Nontonwanou MB, Amoako-Boateng MP, Rodha MS, Kawu Magashi M, Abubakar M, Yigah M, Dayie MSCJK, Victorin Agbangla M, Pathak M, Aggarwal M, Lokavarapu MJ, Talla Timo M, Isikhuemen ME, Gbassi M, Uwizeye M, Akpla M, Adjei MNM, Picciochi M, Chávez M, Fourtounas M, Quirarte Hernández MA, Zarate Casas MF, Gloriose Nabada M, Kouroumta MC, De Cristo Gonzalez Calvillo M, Trejo-Avila M, Guzmán Ruvalcaba MJ, Monahan M, Jesudason MR, Zume M, Totin M, Djeto M, Awe M, Islas Torres M, Morna MT, Oluwadamilola Adebisi M, Adams MA, Oluwatobi Busari M, Lazo Ramirez M, Taingson MC, Ruhosha M, Dery MK, Batangana M, Mellado Tellez MP, Vicencio Ramirez ML, Agyapong MM, Nortey M, Amao M, Bahrami-Hessari M, Calderón Llamas MA, Calderon Vanegas MA, Azanlerigu M, Becerra Moscoso MR, Sethoana ME, Oludara MA, Moussa Alidou M, Mohammad MA, Bashir M, Usman M, Adnan M, Alhassan MS, Aliyu MS, Singh M, Muhindo M, Dusabeyezu M, Kichu M, Castillo MN, Gureh M, Hans MA, Hollo M, Hodonou MA, Sivakumar MV, Edena ME, Abdulsalam MA, Adebisi Ogunjimi M, Dusabe M, Dokurugu MA, Galadima MC, Agbulu MV, Agbadebo M, Eunice ME, Nosipho Mathe M, Moreno-Portillo M, Awaisu M, Daniyan M, Duke George M, Malik MA, Amadu M, Pai MV, Adetola Tolani M, Abdullahi M, Moussa N, Guessou NO, Saqib N, Christian NA, Essel N, Tabuanu NO, Olagunju N, Sam NB, Akhtar N, Oyelowo N, Bisimwa Mitima N, Adewole ND, Sharma N, Anthea Nhlabathi N, Mbajiekwe N, Mishra N, Pundir N, Winkles N, Smart N, Agboadoh N, Ndukwe NO, Aperkor NT, Adu-Aryee NA, Chowdri NA, Singh N, Peters NJ, Sharma N, Agrawal N, Syam N, Duru NJ, Sentholang N, Okoi N, Anyanwu N, Rene Hounsou N, Aliyu NU, Abiola Adeleke N, Egwuonwu OA, Okoye OA, Hyginus Ekwunife O, Olanrewaju O, Osagie OO, Adeyemo OT, Oshodi OA, Olaolu Ogundoyin O, Ogundoyin OO, Babalola OF, Olasehinde O, Ajai OT, Balogun OS, Lawal OO, Olayioye O, Sayomi O, Samuel O, Mwenedata O, Oluwaseyi Bakare O, Sowande OA, Ojewuyi OO, Omisanjo OA, Akintunde OP, Abiola OP, Abiola OP, Akande O, Elebute OA, Adewara OE, Ayankunle OM, Odesanya OJ, Alatise OI, Ajenifuja OK, Ogunsua OO, Banjo OO, Ojediran O, Oladele OO, Fatudimu OS, Ajagbe OA, Idowu OC, Ladipo-Ajayi OA, Taiwo OA, Olaleye OH, Oluseye OO, Ige O, Odutola OR, Atoyebi OA, Omar O, Ayandipo OO, Omotola O, Faboya OM, Williams OM, Irowa OO, Salami OS, Onu OA, Asafa OQ, Akinajo OR, Osemwegie O, Osagie OT, Olvera Flores O, Iribhogbe OI, Aisuodionoe-Shadrach O, Gbehade O, Ojo OD, Olubayo OO, Prabhu PS, Flores Becerril P, Kumar P, Yanto P, Mukherjee P, Haque PD, Koggoh P, Igwe PO, Trinity P, Aderemi Adegoke P, Wondoh P, Domínguez Barradas P, Ogouyemi P, Boakye P, Brocklehurst P, Elemile P, Egharevba PA, Agbonrofo PI, Okoro PE, Kumassah PK, Mensah P, Munda P, Mshelbwala PM, Alexander PV, Nyirangeri P, Muroruhirwe P, Hardy P, Kwabena PW, Zechariah P, Nayak P, Dummala P, Singh P, Solanki P, Yeboah Owusu P, Mary P, Chowdhury P, Luri PT, Pareek P, Prakash P, Kumari P, Lillywhite R, Moore R, Tinuola Afolabi R, Williams R, Alpheus RA, Sharma R, Seenivasagam RK, Vakil R, Armah R, Samujh R, Chaudhary R, John RE, Gunny RJ, Wani RA, Verma R, Thind RS, Dar RA, Eghonghon RA, Acquah R, Rajappa R, Kpankpari R, Ofosu-Akromah R, Romaric Soton R, Jain R, Guinnou R, Munyaneza R, Mares País R, Delano-Alonso R, Miranda Ackerman RC, Bello R, Kour R, Guadalupe Cano Arias RG, Uwayezu R, Nájar Hinojosa R, Mittal R, Ranjan R, Goudou R, Cethorth Fonseca RK, Hussey R, Tubasiime R, Dukuzimana R, Varghese R, Boateng RA, Pswarayi R, Ojewola RW, Abdus-Salam RA, Abdus-Salam RA, Sarfo Kantanka R, Manu R, Abdul-Hafiz S, Oyewale S, Yussif S, Abolade Lawal S, Kanyarukiko S, Abeku Yusuf S, Suleiman S, Tabara S, Mbonimpaye S, Kanyesigye S, Joshua S, Tamou SB, Gupta S, Muhammad SS, Abdulai S, Olori S, Mensah S, Asirifi SA, Sani SA, Ajekwu SC, Nwokocha SU, Quaicoo S, Tsatsu SE, Philips S, Gupta S, Misra S, Kaur S, Omorogbe SO, Eniola SB, Kwarteng SM, Tobome SR, Emmanuel Hedefoun S, Adams SM, Singh S, Duniya SAN, Yahaya S, Mohammed S, Rajan S, Adekola Adebayo S, Ibarra Camargo SA, Cousens S, Hinvo S, Kapoor S, Singh S, Nindopa S, Jacob SE, Laurberg S, Chakrabortee S, Chowdhury S, Mathai S, Prasad S, Tchati SV, Habumuremyi S, Habumuremyi S, Hamadou S, Lawani S, Veetil SK, D S, D S, Sharma S, Doe S, Mathew S, Emeka Nwabuoku S, Ideh SN, Laurent Loupeda S, Tabiri S, Olutola S, Kache SA, Bature SB, Garba SE, Gana SG, Soni SC, Raul S, Kanchodu S, Daneji SM, Sallau SB, P T S, Saluja SS, Goyal S, Surendran S, Joseph S, John S, Obiechina SO, Hounsa S, Lawal TA, Badmus TA, Bakare TIB, Mohammed TO, Cueto Valadez TA, Dhar T, Agida TE, Arkorful TE, Atim T, Orewole TO, Wordui T, Okonoboh TO, Mavoha T, Hessou TK, Agyen T, Pinkney T, Olajide TO, Odunafolabi TA, Sholadoye TT, Kumar U, Kingsley Oriji V, Varsheney VK, Samuel VM, Agyekum-Gyimah VO, Ifeanyichukwu Modekwe V, Ojo V, Abhulimen V, Pérez Bocanegra VH, Avalos Herrera VJ, Etwire VK, Ibukunoluwa Adeyeye V, Kumar V, Ismavel VA, John V, Sehrawat V, Kudoh V, Kanna V, Mukanyange V, Michael V, Adobea V, Sam VD, Ghansah WW, Asman WK, Bhatti W, Kagomi WY, Mehounou Y, Mustapha Y, Oyewole Y, Edwin Y, Oshodi YA, Adofo-Asamoah Y, Ally Z, Imam ZO, Shah ZA, Lara Pérez ZM, Robertson Z. Routine sterile glove and instrument change at the time of abdominal wound closure to prevent surgical site infection (ChEETAh): a pragmatic, cluster-randomised trial in seven low-income and middle-income countries. Lancet 2022; 400:1767-1776. [PMID: 36328045 DOI: 10.1016/s0140-6736(22)01884-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/06/2022] [Accepted: 09/21/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Surgical site infection (SSI) remains the most common complication of surgery around the world. WHO does not make recommendations for changing gloves and instruments before wound closure owing to a lack of evidence. This study aimed to test whether a routine change of gloves and instruments before wound closure reduced abdominal SSI. METHODS ChEETAh was a multicentre, cluster randomised trial in seven low-income and middle-income countries (Benin, Ghana, India, Mexico, Nigeria, Rwanda, South Africa). Any hospitals (clusters) doing abdominal surgery in participating countries were eligible. Clusters were randomly assigned to current practice (42) versus intervention (39; routine change of gloves and instruments before wound closure for the whole scrub team). Consecutive adults and children undergoing emergency or elective abdominal surgery (excluding caesarean section) for a clean-contaminated, contaminated, or dirty operation within each cluster were identified and included. It was not possible to mask the site investigators, nor the outcome assessors, but patients were masked to the treatment allocation. The primary outcome was SSI within 30 days after surgery (participant-level), assessed by US Centers for Disease Control and Prevention criteria and on the basis of the intention-to-treat principle. The trial has 90% power to detect a minimum reduction in the primary outcome from 16% to 12%, requiring 12 800 participants from at least 64 clusters. The trial was registered with ClinicalTrials.gov, NCT03700749. FINDINGS Between June 24, 2020 and March 31, 2022, 81 clusters were randomly assigned, which included a total of 13 301 consecutive patients (7157 to current practice and 6144 to intervention group). Overall, 11 825 (88·9%) of 13 301 patients were adults, 6125 (46·0%) of 13 301 underwent elective surgery, and 8086 (60·8%) of 13 301 underwent surgery that was clean-contaminated or 5215 (39·2%) of 13 301 underwent surgery that was contaminated-dirty. Glove and instrument change took place in 58 (0·8%) of 7157 patients in the current practice group and 6044 (98·3%) of 6144 patients in the intervention group. The SSI rate was 1280 (18·9%) of 6768 in the current practice group versus 931 (16·0%) of 5789 in the intervention group (adjusted risk ratio: 0·87, 95% CI 0·79-0·95; p=0·0032). There was no evidence to suggest heterogeneity of effect across any of the prespecified subgroup analyses. We did not anticipate or collect any specific data on serious adverse events. INTERPRETATION This trial showed a robust benefit to routinely changing gloves and instruments before abdominal wound closure. We suggest that it should be widely implemented into surgical practice around the world. FUNDING National Institute for Health Research (NIHR) Clinician Scientist Award, NIHR Global Health Research Unit Grant, Mölnlycke Healthcare.
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Alcazar CGM, Paes VM, Shao Y, Oesser C, Miltz A, Lawley TD, Brocklehurst P, Rodger A, Field N. The association between early-life gut microbiota and childhood respiratory diseases: a systematic review. Lancet Microbe 2022; 3:e867-e880. [PMID: 35988549 PMCID: PMC10499762 DOI: 10.1016/s2666-5247(22)00184-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 04/29/2022] [Accepted: 06/08/2022] [Indexed: 01/14/2023]
Abstract
Data from animal models suggest a role of early-life gut microbiota in lung immune development, and in establishing susceptibility to respiratory infections and asthma in humans. This systematic review summarises the association between infant (ages 0-12 months) gut microbiota composition measured by genomic sequencing, and childhood (ages 0-18 years) respiratory diseases (ie, respiratory infections, wheezing, or asthma). Overall, there was evidence that low α-diversity and relative abundance of particular gut-commensal bacteria genera (Bifidobacterium, Faecalibacterium, Ruminococcus, and Roseburia) are associated with childhood respiratory diseases. However, results were inconsistent and studies had important limitations, including insufficient characterisation of bacterial taxa to species level, heterogeneous outcome definitions, residual confounding, and small sample sizes. Large longitudinal studies with stool sampling during the first month of life and shotgun metagenomic approaches to improve bacterial and fungal taxa resolution are needed. Standardising follow-up times and respiratory disease definitions and optimising causal statistical approaches might identify targets for primary prevention of childhood respiratory diseases.
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Affiliation(s)
| | - Veena Mazarello Paes
- Institute for Child Health, University College London, London, UK; John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Yan Shao
- Host-Microbiota Interactions Laboratory, Wellcome Sanger Institute, Hinxton, UK
| | - Clarissa Oesser
- Institute for Global Health, University College London, London, UK
| | - Ada Miltz
- Institute for Global Health, University College London, London, UK
| | - Trevor D Lawley
- Host-Microbiota Interactions Laboratory, Wellcome Sanger Institute, Hinxton, UK
| | - Peter Brocklehurst
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Alison Rodger
- Institute for Global Health, University College London, London, UK; Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Nigel Field
- Institute for Global Health, University College London, London, UK
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Gupta JK, Maher A, Stubbs C, Brocklehurst P, Daniels JP, Hardy P. Corrigendum to A randomized trial of synthetic osmotic cervical dilator for induction of labor vs dinoprostone vaginal insert American Journal of Obstetrics & Gynecology MFM Volume 4, Issue 4, July 2022, 100628. Am J Obstet Gynecol MFM 2022; 4:100702. [PMID: 35961850 DOI: 10.1016/j.ajogmf.2022.100702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Janesh K Gupta
- Institute of Metabolism and Systems Biology, University of Birmingham, Birmingham, United Kingdom (Professor Gupta).
| | - Alisha Maher
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom (Ms Maher and Messrs Stubbs and Brocklehurst)
| | - Clive Stubbs
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom (Ms Maher and Messrs Stubbs and Brocklehurst)
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom (Ms Maher and Messrs Stubbs and Brocklehurst)
| | - Jane P Daniels
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, United Kingdom (Professor Daniels)
| | - Pollyanna Hardy
- National Perinatal Epidemiology Unit Clinical Trials Unit, University of Oxford, Oxford, United Kingdom (Ms Hardy)
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Hodgetts Morton V, Toozs-Hobson P, Moakes CA, Middleton L, Daniels J, Simpson NAB, Shennan A, Israfil-Bayli F, Ewer AK, Gray J, Slack M, Norman JE, Lees C, Tryposkiadis K, Hughes M, Brocklehurst P, Morris RK. Monofilament suture versus braided suture thread to improve pregnancy outcomes after vaginal cervical cerclage (C-STICH): a pragmatic randomised, controlled, phase 3, superiority trial. Lancet 2022; 400:1426-1436. [PMID: 36273481 DOI: 10.1016/s0140-6736(22)01808-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 08/23/2022] [Accepted: 09/16/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Miscarriage in the second trimester and preterm birth are significant global problems. Vaginal cervical cerclage is performed to prevent pregnancy loss and preterm birth. We aimed to determine the effectiveness of a monofilament suture thread compared with braided suture thread on pregnancy loss rates in women undergoing a cervical cerclage. METHODS C-STICH was a pragmatic, randomised, controlled, superiority trial done at 75 obstetric units in the UK. Women with a singleton pregnancy who received a vaginal cervical cerclage due to a history of pregnancy loss or premature birth, or if indicated by ultrasound, were centrally randomised (1:1) using minimisation to receive a monofilament suture or braided suture thread for their cervical cerclage. Women and outcome assessors were masked to allocation as far as possible. The primary outcome was pregnancy loss, defined as miscarriage, stillbirth, or neonatal death in the first week of life, analysed in the intention-to-treat population (ie, all women who were randomly assigned). Safety was also assessed in the intention-to-treat population. The trial was registered with ISRCTN, ISRCTN15373349. FINDINGS Between Aug 21, 2015, and Jan 28, 2021, 2049 women were randomly assigned to receive a monofilament suture (n=1025) or braided suture (n=1024). The primary outcome was ascertained in 1003 women in the monofilament suture group and 993 women in the braided suture group. Pregnancy loss occurred in 80 (8·0%) of 1003 women in the monofilament suture group and 75 (7·6%) of 993 women in the braided suture group (adjusted risk ratio 1·05 [95% CI 0·79 to 1·40]; adjusted risk difference 0·002 [95% CI -0·02 to 0·03]). INTERPRETATION Monofilament suture did not reduce rate of pregnancy loss when compared with a braided suture. Clinicians should use the results of this trial to facilitate discussions around the choice of suture thread to optimise outcomes. FUNDING National Institute of Health Research Health Technology Assessment Programme.
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Affiliation(s)
| | | | - Catherine A Moakes
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Lee Middleton
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | | | | | | | - Andrew K Ewer
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Jim Gray
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | | | | | | | | | - Max Hughes
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - R Katie Morris
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK; Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
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Wang X, Mobley AR, Tica O, Okoth K, Ghosh RE, Myles P, Williams T, Haynes S, Nirantharakumar K, Shukla D, Kotecha D, Mehta S, Breeze S, Lancaster K, Fordyce S, Allen N, Calvert M, Denniston A, Gkoutos G, Jayawardana S, Ball S, Baigent C, Brocklehurst P, Lester W, McManus R, Seri S, Valentine J, Camm AJ, Haynes S, Moore DJ, Rogers A, Stanbury M, Flather M, Walker S, Wang D. Systematic approach to outcome assessment from coded electronic healthcare records in the DaRe2THINK NHS-embedded randomized trial . Eur Heart J Digit Health 2022; 3:426-436. [PMID: 36712153 PMCID: PMC9708037 DOI: 10.1093/ehjdh/ztac046] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 08/15/2022] [Indexed: 02/01/2023]
Abstract
Aims Improving the efficiency of clinical trials is key to their continued importance in directing evidence-based patient care. Digital innovations, in particular the use of electronic healthcare records (EHRs), allow for large-scale screening and follow up of participants. However, it is critical these developments are accompanied by robust and transparent methods that can support high-quality and high clinical value research. Methods and results The DaRe2THINK trial includes a series of novel processes, including nationwide pseudonymized pre screening of the primary-care EHR across England, digital enrolment, remote e-consent, and 'no-visit' follow up by linking all primary- and secondary-care health data with patient-reported outcomes. DaRe2THINK is a pragmatic, healthcare-embedded randomized trial testing whether earlier use of direct oral anticoagulants in patients with prior or current atrial fibrillation can prevent thromboembolic events and cognitive decline (www.birmingham.ac.uk/dare2think). This study outlines the systematic approach and methodology employed to define patient information and outcome events. This includes transparency on all medical code lists and phenotypes used in the trial across a variety of national data sources, including Clinical Practice Research Datalink Aurum (primary care), Hospital Episode Statistics (secondary care), and the Office for National Statistics (mortality). Conclusion Co-designed by a patient and public involvement team, DaRe2THINK presents an opportunity to transform the approach to randomized trials in the setting of routine healthcare, providing high-quality evidence generation in populations representative of the community at risk.
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Affiliation(s)
- Xiaoxia Wang
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK,Health Data Research UK Midlands, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Alastair R Mobley
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK,Health Data Research UK Midlands, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Otilia Tica
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Kelvin Okoth
- Institute of Applied Health Sciences, University of Birmingham, Birmingham, UK
| | - Rebecca E Ghosh
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
| | - Puja Myles
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
| | - Tim Williams
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
| | | | | | - David Shukla
- Institute of Applied Health Sciences, University of Birmingham, Birmingham, UK,Primary Care Clinical Research, NIHR Clinical Research Network West Midlands, Birmingham, UK
| | - Dipak Kotecha
- Corresponding author. Heritage Building, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham, B15 2GW, UK. Tel: +44 121 3718122,
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Knight SR, Qureshi AU, Drake TM, Lapitan MCM, Maimbo M, Yenli E, Tabiri S, Ghosh D, Kingsley PA, Sundar S, Shaw C, Valparaiso AP, Bhangu A, Brocklehurst P, Magill L, Morton DG, Norrie J, Roberts TE, Theodoratou E, Weiser TG, Burden S, Harrison EM. The impact of preoperative oral nutrition supplementation on outcomes in patients undergoing gastrointestinal surgery for cancer in low- and middle-income countries: a systematic review and meta-analysis. Sci Rep 2022; 12:12456. [PMID: 35864290 PMCID: PMC9304351 DOI: 10.1038/s41598-022-16460-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 07/11/2022] [Indexed: 12/24/2022] Open
Abstract
Malnutrition is an independent predictor for postoperative complications in low- and middle-income countries (LMICs). We systematically reviewed evidence on the impact of preoperative oral nutrition supplementation (ONS) on patients undergoing gastrointestinal cancer surgery in LMICs. We searched EMBASE, Cochrane Library, Web of Science, Scopus, WHO Global Index Medicus, SciELO, Latin American and Caribbean Health Sciences Literature (LILACS) databases from inception to March 21, 2022 for randomised controlled trials evaluating preoperative ONS in gastrointestinal cancer within LMICs. We evaluated the impact of ONS on all postoperative outcomes using random-effects meta-analysis. Seven studies reported on 891 patients (446 ONS group, 445 control group) undergoing surgery for gastrointestinal cancer. Preoperative ONS reduced all cause postoperative surgical complications (risk ratio (RR) 0.53, 95% CI 0.46-0.60, P < 0.001, I2 = 0%, n = 891), infection (0.52, 0.40-0.67, P = 0.008, I2 = 0%, n = 570) and all-cause mortality (0.35, 0.26-0.47, P = 0.014, I2 = 0%, n = 588). Despite heterogeneous populations and baseline rates, absolute risk ratio (ARR) was reduced for all cause (pooled effect -0.14, -0.22 to -0.06, P = 0.006; number needed to treat (NNT) 7) and infectious complications (-0.13, -0.22 to -0.06, P < 0.001; NNT 8). Preoperative nutrition in patients undergoing gastrointestinal cancer surgery in LMICs demonstrated consistently strong and robust treatment effects across measured outcomes. However additional higher quality research, with particular focus within African populations, are urgently required.
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Affiliation(s)
- Stephen R. Knight
- grid.4305.20000 0004 1936 7988Centre for Medical Informatics, Usher Institute, Nine Bioquarter, University of Edinburgh, Edinburgh, EH16 4UX UK
| | - Ahmad U. Qureshi
- grid.415544.50000 0004 0411 1373Department of Surgery, Services Institute of Medical Sciences, Lahore, Pakistan
| | - Thomas M. Drake
- grid.4305.20000 0004 1936 7988Centre for Medical Informatics, Usher Institute, Nine Bioquarter, University of Edinburgh, Edinburgh, EH16 4UX UK
| | - Marie Carmela M. Lapitan
- grid.443239.b0000 0000 9950 521XDepartment of Surgery, National Institutes of Health, University of the Philippines, Manila, Philippines
| | - Mayaba Maimbo
- Department of General Surgery, Kitwe Teaching Hospital, Kitwe, Zambia
| | - Edwin Yenli
- grid.442305.40000 0004 0441 5393Department of Surgery, School of Medicine, University for Development Studies, Tamale, Ghana
| | - Stephen Tabiri
- grid.442305.40000 0004 0441 5393Department of Surgery, School of Medicine, University for Development Studies, Tamale, Ghana ,grid.442305.40000 0004 0441 5393Dean of School of Medicine, University for Development Studies, Tamale, Ghana
| | - Dhruva Ghosh
- grid.414306.40000 0004 1777 6366Department of Paediatric Surgery, Christian Medical College, Ludhiana, India
| | - Pamela A. Kingsley
- grid.414306.40000 0004 1777 6366Department of Radiation Oncology Department, Christian Medical College, Ludhiana, India
| | - Sudha Sundar
- grid.6572.60000 0004 1936 7486Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Catherine Shaw
- grid.4305.20000 0004 1936 7988Centre for Medical Informatics, Usher Institute, Nine Bioquarter, University of Edinburgh, Edinburgh, EH16 4UX UK
| | - Apple P. Valparaiso
- grid.443239.b0000 0000 9950 521XDepartment of Surgery, National Institutes of Health, University of the Philippines, Manila, Philippines
| | - Aneel Bhangu
- grid.6572.60000 0004 1936 7486Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Peter Brocklehurst
- grid.6572.60000 0004 1936 7486Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
| | - Laura Magill
- grid.6572.60000 0004 1936 7486Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Dion G. Morton
- grid.6572.60000 0004 1936 7486Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
| | - John Norrie
- grid.4305.20000 0004 1936 7988Centre for Global Health, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Tracey E. Roberts
- grid.6572.60000 0004 1936 7486Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Evropi Theodoratou
- grid.4305.20000 0004 1936 7988Centre for Global Health, Usher Institute, University of Edinburgh, Edinburgh, UK ,grid.4305.20000 0004 1936 7988Cancer Research UK Edinburgh Centre, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
| | - Thomas G. Weiser
- grid.168010.e0000000419368956Department of Surgery, Stanford University, Stanford, USA ,grid.4305.20000 0004 1936 7988Department of Clinical Surgery, University of Edinburgh, Edinburgh, UK
| | - Sorrel Burden
- grid.5379.80000000121662407School of Health Sciences, University of Manchester, Manchester, UK
| | - Ewen M. Harrison
- grid.4305.20000 0004 1936 7988Centre for Medical Informatics, Usher Institute, Nine Bioquarter, University of Edinburgh, Edinburgh, EH16 4UX UK
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20
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Gupta JK, Maher A, Stubbs C, Brocklehurst P, Daniels JP, Hardy P. A randomized trial of synthetic osmotic cervical dilator for induction of labor vs dinoprostone vaginal insert. Am J Obstet Gynecol MFM 2022; 4:100628. [PMID: 35358740 DOI: 10.1016/j.ajogmf.2022.100628] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 03/23/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Induction of labor is a commonly performed obstetrical intervention. Vaginal prostaglandin E2 (dinoprostone) is a first-choice agent. Mechanical methods of induction are slower in achieving cervical ripening but have a lower risk of adverse effects. OBJECTIVE This study aimed to compare the efficacy, maternal and neonatal safety, and maternal satisfaction of a synthetic osmotic cervical dilator (Dilapan-S) with those of dinoprostone. STUDY DESIGN This was an open-label superiority randomized controlled trial in 4 English hospitals. Eligible participants were women ≥16 years of age undergoing induction of labor for a singleton pregnancy at ≥37 weeks' gestation with vertex presentation and intact membranes. The women were randomly assigned to receive either Dilapan-S or dinoprostone using a telephone randomization system minimized by hospital, parity, body mass index, and maternal age. The induction agent was replaced as required until the cervix was assessed as favorable for labor by the Bishop score. The primary outcome was failure to achieve vaginal delivery (ieor a cesarean delivery being performed). The secondary outcome measures included maternal and neonatal adverse events. Analysis was by intention-to-treat, adjusting for design variables where possible. RESULTS Between December 19, 2017 and January 26, 2021, 674 women were randomized (337 to Dilapan-S, and 337 to dinoprostone). The trial did not reach its planned sample size of 860 participants because of restrictions on research during the COVID-19 pandemic. The primary outcome was missing for 2 women in the dinoprostone group. Failure to achieve vaginal delivery (or a cesarean delivery being performed) occurred in 126 women (37.4%) allocated to Dilapan-S and in 115 (34.3%) women allocated to dinoprostone (adjusted risk difference, 0.02; 95% confidence interval, -0.05 to 0.10). There were similar maternal and neonatal adverse events between the groups. CONCLUSION Women undergoing induction of labor with Dilapan-S have similar rates of cesarean delivery and maternal and neonatal adverse events compared with dinoprostone.
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Affiliation(s)
- Janesh K Gupta
- Institute of Metabolism and Systems Biology, University of Birmingham, Birmingham, United Kingdom (Dr Gupta).
| | - Alisha Maher
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom (Ms Maher and Messrs Stubbs and Brocklehurst)
| | - Clive Stubbs
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom (Ms Maher and Messrs Stubbs and Brocklehurst)
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom (Ms Maher and Messrs Stubbs and Brocklehurst)
| | - Jane P Daniels
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, United Kingdom (Dr Daniels)
| | - Pollyanna Hardy
- National Perinatal Epidemiology Unit Clinical Trials Unit, University of Oxford, Oxford, United Kingdom (Ms Hardy)
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21
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Šumilo D, Brocklehurst P. What is the relationship between mode of birth, antibiotics, and childhood health? BMJ 2022; 377:o1526. [PMID: 35732309 DOI: 10.1136/bmj.o1526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Dana Šumilo
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Peter Brocklehurst
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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22
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Šumilo D, Nirantharakumar K, Willis BH, Rudge GM, Martin J, Gokhale K, Thayakaran R, Adderley NJ, Chandan JS, Okoth K, Harris IM, Hewston R, Skrybant M, Deeks JJ, Brocklehurst P. Long-term impact of pre-incision antibiotics on children born by caesarean section: a longitudinal study based on UK electronic health records. Health Technol Assess 2022; 26:1-160. [PMID: 35781133 DOI: 10.3310/zyzc8514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Since changes in the national guidance in 2011, prophylactic antibiotics for women undergoing caesarean section are recommended prior to skin incision, rather than after the baby's umbilical cord has been clamped. Evidence from randomised controlled trials conducted outside the UK has shown that this reduces maternal infectious morbidity; however, the prophylactic antibiotics also cross the placenta, meaning that babies are exposed to them around the time of birth. Antibiotics are known to affect the gut microbiota of the babies, but the long-term effects of exposure to high-dose broad-spectrum antibiotics around the time of birth on allergy and immune-related diseases are unknown. OBJECTIVES We aimed to examine whether or not in-utero exposure to antibiotics immediately prior to birth compared with no pre-incisional antibiotic exposure increases the risk of (1) asthma and (2) eczema in children born by caesarean section. DESIGN This was a controlled interrupted time series study. SETTING The study took place in primary and secondary care. PARTICIPANTS Children born in the UK during 2006-18 delivered by caesarean section were compared with a control cohort delivered vaginally. INTERVENTIONS In-utero exposure to antibiotics immediately prior to birth. MAIN OUTCOME MEASURES Asthma and eczema in children in the first 5 years of life. Additional secondary outcomes, including other allergy-related conditions, autoimmune diseases, infections, other immune system-related diseases and neurodevelopmental conditions, were also assessed. DATA SOURCES The Health Improvement Network (THIN) and the Clinical Practice Research Datalink (CPRD) primary care databases and the Hospital Episode Statistics (HES) database. Previously published linkage strategies were adapted to link anonymised data on mothers and babies in these databases. Duplicate practices contributing to both THIN and the CPRD databases were removed to create a THIN-CPRD data set. RESULTS In the THIN-CPRD and HES data sets, records of 515,945 and 3,945,351 mother-baby pairs were analysed, respectively. The risk of asthma was not significantly higher in children born by caesarean section exposed to pre-incision antibiotics than in children whose mothers received post-cord clamping antibiotics, with an incidence rate ratio of 0.91 (95% confidence interval 0.78 to 1.05) for diagnosis of asthma in primary care and an incidence rate ratio of 1.05 (95% confidence interval 0.99 to 1.11) for asthma resulting in a hospital admission. We also did not find an increased risk of eczema, with an incidence rate ratio of 0.98 (95% confidence interval 0.94 to1.03) and an incidence rate ratio of 0.96 (95% confidence interval 0.71 to 1.29) for diagnosis in primary care and hospital admissions, respectively. LIMITATIONS It was not possible to ascertain the exposure to pre-incision antibiotics at an individual level. The maximum follow-up of children was 5 years. CONCLUSIONS There was no evidence that the policy change from post-cord clamping to pre-incision prophylactic antibiotics for caesarean sections during 2006-18 had an impact on the incidence of asthma and eczema in early childhood in the UK. FUTURE WORK There is a need for further research to investigate if pre-incision antibiotics have any impact on developing asthma and other allergy and immune-related conditions in older children. STUDY REGISTRATION This study is registered as researchregistry3736. FUNDING This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 30. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Dana Šumilo
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.,Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Krishnarajah Nirantharakumar
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.,Midlands Health Data Research UK, University of Birmingham, Birmingham, UK
| | - Brian H Willis
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Gavin M Rudge
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - James Martin
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Krishna Gokhale
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Rasiah Thayakaran
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Nicola J Adderley
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Joht Singh Chandan
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Kelvin Okoth
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Isobel M Harris
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | | | - Jonathan J Deeks
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.,NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, University of Birmingham, Birmingham, UK
| | - Peter Brocklehurst
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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23
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Šumilo D, Nirantharakumar K, Willis BH, Rudge GM, Martin J, Gokhale K, Thayakaran R, Adderley NJ, Chandan JS, Okoth K, Harris IM, Hewston R, Skrybant M, Deeks JJ, Brocklehurst P. Long term impact of prophylactic antibiotic use before incision versus after cord clamping on children born by caesarean section: longitudinal study of UK electronic health records. BMJ 2022; 377:e069704. [PMID: 35580876 PMCID: PMC9112858 DOI: 10.1136/bmj-2021-069704] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To investigate the impact on child health up to age 5 years of a policy to use antibiotic prophylaxis for caesarean section before incision compared with after cord clamping. DESIGN Observational controlled interrupted time series study. SETTING UK primary and secondary care. PARTICIPANTS 515 945 children born in 2006-18 with linked maternal records and registered with general practices contributing to two UK primary care databases (The Health Improvement Network and Clinical Practice Research Datalink), and 7 147 884 children with linked maternal records in the Hospital Episode Statistics database covering England, of which 3 945 351 were linked to hospitals that reported the year of policy change to administer prophylactic antibiotics for caesarean section before incision rather than after cord clamping. INTERVENTION Fetal exposure to antibiotics shortly before birth (using pre-incision antibiotic policy as proxy) compared with no exposure. MAIN OUTCOME MEASURES The primary outcomes were incidence rate ratios of asthma and eczema in children born by caesarean section when pre-incision prophylactic antibiotics were recommended compared with those born when antibiotics were administered post-cord clamping, adjusted for temporal changes in the incidence rates in children born vaginally. RESULTS Prophylactic antibiotics administered before incision for caesarean section compared with after cord clamping were not associated with a significantly higher risk of asthma (incidence rate ratio 0.91, 95% confidence interval 0.78 to 1.05) or eczema (0.98, 0.94 to 1.03), including asthma and eczema resulting in hospital admission (1.05, 0.99 to 1.11 and 0.96, 0.71 to 1.29, respectively), up to age 5 years. CONCLUSIONS This study found no evidence of an association between pre-incision prophylactic antibiotic use and risk of asthma and eczema in early childhood in children born by caesarean section.
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Affiliation(s)
- Dana Šumilo
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Populations, Evidence and Technologies, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Krishnarajah Nirantharakumar
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Midlands Health Data Research UK, University of Birmingham, Birmingham, UK
| | - Brian H Willis
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Gavin M Rudge
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - James Martin
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Krishna Gokhale
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Rasiah Thayakaran
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Nicola J Adderley
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Joht Singh Chandan
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Kelvin Okoth
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Isobel M Harris
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | | | - Jonathan J Deeks
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Peter Brocklehurst
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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24
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Ademuyiwa AO, Adisa AO, Bhangu A, Brocklehurst P, Chakrabortee S, Ghosh D, Glasbey J, Haque PD, Hardy P, Harrison E, Ingabire JCA, Ismail L, Kadir B, Lillywhite R, Magill L, de la Medina AR, Moore R, Monahan M, Morton D, Nepogodiev D, Ntirenganya F, Omar O, Pinkney T, Smith D, Tabiri S, Winkles N. Correction: Study protocol for a cluster randomised trial of sterile glove and instrument change at the time of wound closure to reduce surgical site infection in low- and middle-income countries (CHEETAH). Trials 2022; 23:320. [PMID: 35428269 PMCID: PMC9013136 DOI: 10.1186/s13063-022-06175-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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25
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Vousden N, Ramakrishnan R, Bunch K, Morris E, Simpson N, Gale C, O'Brien P, Quigley M, Brocklehurst P, Kurinczuk JJ, Knight M. Management and implications of severe COVID-19 in pregnancy in the UK: data from the UK Obstetric Surveillance System national cohort. Acta Obstet Gynecol Scand 2022; 101:461-470. [PMID: 35213734 PMCID: PMC9111211 DOI: 10.1111/aogs.14329] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 12/09/2021] [Accepted: 01/19/2022] [Indexed: 12/21/2022]
Abstract
Introduction There is a lack of population level data on risk factors and impact of severe COVID‐19 in pregnancy. The aims of this study were to determine the characteristics, and maternal and perinatal outcomes associated with severe COVID‐19 in pregnancy compared with those with mild and moderate COVID‐19 and to explore the impact of timing of birth. Material and methods This was a secondary analysis of a national, prospective cohort study. All pregnant women admitted to hospital in the UK with symptomatic SARS‐CoV‐2 from March 1, 2020 to October 31, 2021 were included. The severity of maternal infection (need for high flow or invasive ventilation, intensive care admission or died), pregnancy and perinatal outcomes, and the impact of timing of birth were analyzed using multivariable logistic regression. Results Of 4436 pregnant women, 13.9% (n = 616) had severe infection. Women with severe infection were more likely to be aged ≥30 years (adjusted odds ratio [aOR] aged 30–39 1.48, 95% confidence interval [CI] 1.20–1.83), be overweight or obese (aOR 1.73, 95% CI 1.34–2.25 and aOR 2.52 95% CI 1.97–3.23, respectively), be of mixed ethnicity (aOR 1.93, 95% CI 1.17–3.21) or have gestational diabetes (aOR 1.43, 95% CI 1.09–1.87) compared with those with mild or moderate infection. Women with severe infection were more likely to have a pre‐labor cesarean birth (aOR 8.84, 95% CI 6.61–11.83), a very or extreme preterm birth (28–31+ weeks’ gestation, aOR 18.97, 95% CI 7.78–14.85; <28 weeks’ gestation, aOR 12.35, 95% CI 6.34–24.05) and their babies were more likely to be stillborn (aOR 2.51, 95% CI 1.35–4.66) or admitted to a neonatal unit (aOR 11.61, 95% CI 9.28–14.52). Of 112 women with severe infection who were discharged and gave birth at a later admission, the majority gave birth ≥36 weeks (85.7%), noting that three women in this group (2.7%) had a stillbirth. Conclusions Severe COVID‐19 in pregnancy increases the risk of adverse outcomes. Information to promote uptake of vaccination should specifically target those at greatest risk of severe outcomes. Decisions about timing of birth should be informed by multidisciplinary team discussion; however, our data suggest that women with severe infection who do not require early delivery have mostly good outcomes but that those with severe infection at term may warrant rapid delivery.
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Affiliation(s)
- Nicola Vousden
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Rema Ramakrishnan
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Kathryn Bunch
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Edward Morris
- Royal College of Obstetricians and Gynaecologists, London, UK
| | - Nigel Simpson
- Department of Women's and Children's Health, School of Medicine, University of Leeds, Leeds, UK
| | - Christopher Gale
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Pat O'Brien
- Royal College of Obstetricians and Gynaecologists, London, UK.,Institute for Women's Health, University College London, London, UK
| | - Maria Quigley
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Jennifer J Kurinczuk
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Marian Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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26
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Kirk J, Willcocks J, Boyle P, Brocklehurst P, Morris K, Kearney R, Holden M, Brookes M. Developing chief investigators within the NHS: the West Midlands clinical trials scholars programme. Clin Med (Lond) 2022; 22:149-152. [PMID: 38589177 DOI: 10.7861/clinmed.2021-0606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Consecutive Royal College of Physicians' Research for all surveys have highlighted the challenges for doctors becoming involved in research. Local issues included under-representation of chief investigators (CIs) and reduction in dedicated research time. The West Midlands National Institute for Health Research (NIHR) Clinical Research Network (CRN) established a clinical trials scholarship (CTS) initiative in 2019 to develop research-active consultants in smaller trusts, with a dedicated day per week embedded in a local clinical trials unit. In the initial round of 41 applications from 13 partner organisations, 17 CTSs were appointed, including nine consultant physicians, with one subsequently deferring. After 2 years, the remaining 16 CTSs have been awarded 40 grants totalling £18.35 million as CI or co-CI, including 10 NIHR grants, plus >200 publications. These scholarships are a proven cost-effective way to develop CIs, provide academic leadership and promote a research culture, even in small, previously less research-active trusts.
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Affiliation(s)
- Jeremy Kirk
- National Institute for Health Research Clinical Research Network West Midlands, Birmingham, UK.
| | - Jane Willcocks
- National Institute for Health Research Clinical Research Network West Midlands, Birmingham, UK
| | - Pauline Boyle
- National Institute for Health Research Clinical Research Network West Midlands, Birmingham, UK
| | | | | | | | | | - Matthew Brookes
- National Institute for Health Research Clinical Research Network West Midlands, Birmingham, UK
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27
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Lee SI, Azcoaga-Lorenzo A, Agrawal U, Kennedy JI, Fagbamigbe AF, Hope H, Subramanian A, Anand A, Taylor B, Nelson-Piercy C, Damase-Michel C, Yau C, Crowe F, Santorelli G, Eastwood KA, Vowles Z, Loane M, Moss N, Brocklehurst P, Plachcinski R, Thangaratinam S, Black M, O'Reilly D, Abel KM, Brophy S, Nirantharakumar K, McCowan C. Epidemiology of pre-existing multimorbidity in pregnant women in the UK in 2018: a population-based cross-sectional study. BMC Pregnancy Childbirth 2022; 22:120. [PMID: 35148719 PMCID: PMC8840793 DOI: 10.1186/s12884-022-04442-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 01/24/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Although maternal death is rare in the United Kingdom, 90% of these women had multiple health/social problems. This study aims to estimate the prevalence of pre-existing multimorbidity (two or more long-term physical or mental health conditions) in pregnant women in the United Kingdom (England, Northern Ireland, Wales and Scotland). STUDY DESIGN Pregnant women aged 15-49 years with a conception date 1/1/2018 to 31/12/2018 were included in this population-based cross-sectional study, using routine healthcare datasets from primary care: Clinical Practice Research Datalink (CPRD, United Kingdom, n = 37,641) and Secure Anonymized Information Linkage databank (SAIL, Wales, n = 27,782), and secondary care: Scottish Morbidity Records with linked community prescribing data (SMR, Tayside and Fife, n = 6099). Pre-existing multimorbidity preconception was defined from 79 long-term health conditions prioritised through a workshop with patient representatives and clinicians. RESULTS The prevalence of multimorbidity was 44.2% (95% CI 43.7-44.7%), 46.2% (45.6-46.8%) and 19.8% (18.8-20.8%) in CPRD, SAIL and SMR respectively. When limited to health conditions that were active in the year before pregnancy, the prevalence of multimorbidity was still high (24.2% [23.8-24.6%], 23.5% [23.0-24.0%] and 17.0% [16.0 to 17.9%] in the respective datasets). Mental health conditions were highly prevalent and involved 70% of multimorbidity CPRD: multimorbidity with ≥one mental health condition/s 31.3% [30.8-31.8%]). After adjusting for age, ethnicity, gravidity, index of multiple deprivation, body mass index and smoking, logistic regression showed that pregnant women with multimorbidity were more likely to be older (CPRD England, adjusted OR 1.81 [95% CI 1.04-3.17] 45-49 years vs 15-19 years), multigravid (1.68 [1.50-1.89] gravidity ≥ five vs one), have raised body mass index (1.59 [1.44-1.76], body mass index 30+ vs body mass index 18.5-24.9) and smoked preconception (1.61 [1.46-1.77) vs non-smoker). CONCLUSION Multimorbidity is prevalent in pregnant women in the United Kingdom, they are more likely to be older, multigravid, have raised body mass index and smoked preconception. Secondary care and community prescribing dataset may only capture the severe spectrum of health conditions. Research is needed urgently to quantify the consequences of maternal multimorbidity for both mothers and children.
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Affiliation(s)
- Siang Ing Lee
- Institute of Applied Health Research, IOEM Building, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Amaya Azcoaga-Lorenzo
- Division of Population and Behavioural Sciences, School of Medicine, University of St Andrews, St Andrews, UK
| | - Utkarsh Agrawal
- Division of Population and Behavioural Sciences, School of Medicine, University of St Andrews, St Andrews, UK
| | | | - Adeniyi Francis Fagbamigbe
- Division of Population and Behavioural Sciences, School of Medicine, University of St Andrews, St Andrews, UK
- Department of Epidemiology and Medical Statistics, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Holly Hope
- Centre for Women's Mental Health, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology Medicine & Health, The University of Manchester, Manchester, UK
| | - Anuradhaa Subramanian
- Institute of Applied Health Research, IOEM Building, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Astha Anand
- Institute of Applied Health Research, IOEM Building, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Beck Taylor
- Institute of Applied Health Research, IOEM Building, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | | | - Christine Damase-Michel
- Medical and Clinical Pharmacology, School of Medicine, Université Toulouse III, Toulouse, France
- INSERM, Centre for Epidemiology and Research in Population Health (CERPOP), CIC 1436, Toulouse, France
| | - Christopher Yau
- Division of Informatics, Imaging and Data Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK
- Health Data Research, London, UK
| | - Francesca Crowe
- Institute of Applied Health Research, IOEM Building, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | | | - Kelly-Ann Eastwood
- Centre for Public Health, Queen's University of Belfast, Belfast, UK
- St Michael's Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Zoe Vowles
- Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Maria Loane
- The Institute of Nursing and Health Research, Ulster University, Newtownabbey, UK
| | - Ngawai Moss
- Patient and Public Representative, London, UK
| | - Peter Brocklehurst
- Institute of Applied Health Research, IOEM Building, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | | | - Shakila Thangaratinam
- WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Obstetrics and Gynaecology, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Mairead Black
- Aberdeen Centre for Women's Health Research, School of Medicine, Medical Science and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Dermot O'Reilly
- Centre for Public Health, Queen's University of Belfast, Belfast, UK
| | - Kathryn M Abel
- Centre for Women's Mental Health, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology Medicine & Health, The University of Manchester, Manchester, UK
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Sinead Brophy
- Data Science, Medical School, Swansea University, Swansea, UK
| | - Krishnarajah Nirantharakumar
- Institute of Applied Health Research, IOEM Building, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.
| | - Colin McCowan
- Division of Population and Behavioural Sciences, School of Medicine, University of St Andrews, St Andrews, UK
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Engjom HM, Ramakrishnan R, Vousden N, Bunch K, Morris E, Simpson NAB, Gale C, O'Brien P, Quigley M, Brocklehurst P, Kurinczuk JJ, Knight M. Severity of maternal SARS-CoV-2 infection and perinatal outcomes of women admitted to hospital during the omicron variant dominant period using UK Obstetric Surveillance System data: prospective, national cohort study. BMJ Med 2022; 1:e000190. [PMID: 36936599 PMCID: PMC10012856 DOI: 10.1136/bmjmed-2022-000190] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 06/22/2022] [Indexed: 12/15/2022]
Abstract
Objectives To describe the severity of maternal infection when the omicron SARS-CoV-2 variant (B.1.1.529) was dominant (15 December 2021 to 14 March 2022) and describe outcomes by symptoms and vaccination status. Design Prospective, national cohort study using the UK Obstetric Surveillance System. Setting 94 hospitals in the UK with a consultant led maternity unit. Participants Pregnant women admitted to hospital for any cause with a positive SARS-CoV-2 test. Main outcome measures Symptomatic or asymptomatic infection, vaccination status by doses before admission, and severity of maternal infection (moderate or severe infection according to modified World Health Organization's criteria). Results Of 3699 women who were admitted to hospital, 986 (26.7%, 95% confidence interval 25.3% to 28.1%) had symptoms; of these, 144 (14.6%, 12.5% to 17.0%) had a moderate to severe infection, 99 (10.4%, 8.6% to 12.5%) of 953 received respiratory support, and 30 (3.0%, 2.1% to 4.3%) were admitted to an intensive care unit. Covid-19 specific drug treatment was given to 13 (43.3%) of the 30 women in intensive care. Four women with symptoms died (0.4%, 0.1% to 1.1%). Vaccination status was known for 845 (85.6%) women with symptoms; 489 (58.9%) were unvaccinated and only 55 (6.5%) had three doses. Moderate to severe infection was reported for 93 (19.0%) of 489 unvaccinated women with symptoms, decreasing to three (5.5%) of 55 after three doses. Among the 30 women with symptoms who were admitted to intensive care, 23 (76.7%) were unvaccinated and none had received three doses. Conclusion Most women with severe covid-19 disease were unvaccinated and vaccine coverage among pregnant women admitted to hospital with SARS-CoV-2 was low. Ongoing action to prioritise and advocate for vaccine uptake in pregnancy is essential. A better understanding of the persistent low use of drug treatments is an urgent priority. Trial registration ISRCTN 40092247.
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Affiliation(s)
- Hilde M Engjom
- Division of Mental and Physical Health, Norwegian Institute of Public Health, Bergen, Bergen, Norway
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, Oxfordshire, UK
| | - Rema Ramakrishnan
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, Oxfordshire, UK
| | - Nicola Vousden
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, Oxfordshire, UK
| | - Kathryn Bunch
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, Oxfordshire, UK
| | - Eddie Morris
- Department of Obstetrics and Gynaecology, Norfolk and Norwich University Hospital NHS Trust, Norwich, Norfolk, UK
- Royal College of Obstetricians and Gynaecologists, London, London, UK
| | - Nigel A B Simpson
- Department of Women’s & Children’s Health, University of Leeds, Leeds, West Yorkshire, UK
| | - Chris Gale
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Patrick O'Brien
- Royal College of Obstetricians and Gynaecologists, London, London, UK
- Institute for Women's Health, University College London, London, UK
| | - Maria Quigley
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, Oxfordshire, UK
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, West Midlands, UK
| | - Jennifer J Kurinczuk
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, Oxfordshire, UK
| | - Marian Knight
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, Oxfordshire, UK
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Vousden N, Ramakrishnan R, Bunch K, Morris E, Simpson NAB, Gale C, O'Brien P, Quigley M, Brocklehurst P, Kurinczuk JJ, Knight M. Severity of maternal infection and perinatal outcomes during periods of SARS-CoV-2 wildtype, alpha, and delta variant dominance in the UK: prospective cohort study. BMJ Med 2022; 1:e000053. [PMID: 36936566 PMCID: PMC9978672 DOI: 10.1136/bmjmed-2021-000053] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 01/19/2022] [Indexed: 12/17/2022]
Abstract
Objective To compare the severity of maternal infection and perinatal outcomes during periods in which wildtype, alpha variant, and delta variant of SARS-CoV-2 were dominant in the UK. Design Prospective cohort study. Setting 194 obstetric units across the UK, during the following periods: between 1 March and 30 November 2020 (wildtype dominance), between 1 December 2020 and 15 May 2021 (alpha variant dominance), and between 16 May and 31 October 2021 (delta variant dominance). Participants 4436 pregnant women admitted to hospital with covid-19 related symptoms. Main outcome measures Moderate to severe maternal SARS-CoV-2 infection (indicated by any of the following: oxygen saturation <95% on admission, need for oxygen treatment, evidence of pneumonia on imaging, admission to intensive care, or maternal death), and pregnancy and perinatal outcomes (including mode and gestation of birth, stillbirth, live birth, admission to neonatal intensive care, and neonatal death). Results 1387, 1613, and 1436 pregnant women were admitted to hospital with covid-19 related symptoms during the wildtype, alpha, and delta dominance periods, respectively; of these women, 340, 585, and 614 had moderate to severe infection, respectively. The proportion of pregnant women admitted with moderate to severe infection increased during the subsequent alpha and delta dominance periods, compared with the wildtype dominance period (wildtype 24.5% v alpha 36.2% (adjusted odds ratio 1.98, 95% confidence interval 1.66% to 2.37%); wildtype 24.5% v delta 42.8% (2.66, 2.21 to 3.20)). Compared with the wildtype dominance period, women admitted during the alpha dominance period were significantly more likely to have pneumonia, require respiratory support, and be admitted to intensive care; these three risks were even greater during the delta dominance period (wildtype v delta: pneumonia, adjusted odds ratio 2.52, 95% confidence interval 2.06 to 3.09; respiratory support, 1.90, 1.52 to 2.37; and intensive care, 2.71, 2.06 to 3.56). Of 1761 women whose vaccination status was known, 38 (2.2%) had one dose and 16 (1%) had two doses before their diagnosis (of whom 14 (88%) had mild infection). The proportion of women receiving drug treatment for SARS-CoV-2 management was low, but did increase between the wildtype dominance period and the alpha and delta dominance periods (10.4% wildtype v 14.9% alpha (2.74, 2.08 to 3.60); 10.4% wildtype v 13.6% delta (2.54, 1.90 to 3.38)). Conclusions While limited by the absence of variant sequencing data, these findings suggest that during the periods when the alpha and delta variants of SARS-CoV-2 were dominant, covid-19 was associated with more severe maternal infection and worse pregnancy outcomes than during the wildtype dominance period. Most women admitted with SARS-CoV-2 related symptoms were unvaccinated. Urgent action to prioritise vaccine uptake in pregnancy is essential. Study registration ISRCTN40092247.
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Affiliation(s)
- Nicola Vousden
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Rema Ramakrishnan
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Kathryn Bunch
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Eddie Morris
- Royal College of Obstetricians and Gynaecologists, London, UK
| | - Nigel A B Simpson
- Department of Women’s & Children’s Health, University of Leeds, Leeds, UK
| | - Christopher Gale
- School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Patrick O'Brien
- Royal College of Obstetricians and Gynaecologists, London, UK
- Institute for Women's Health, University College London, London, UK
| | - Maria Quigley
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, West Midlands, UK
| | - Jennifer J Kurinczuk
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Marian Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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O’Malley L, Macey R, Allen T, Brocklehurst P, Thomson F, Rigby J, Lalloo R, Tomblin Murphy G, Birch S, Tickle M. Workforce Planning Models for Oral Health Care: A Scoping Review. JDR Clin Trans Res 2022; 7:16-24. [PMID: 33323035 PMCID: PMC8674798 DOI: 10.1177/2380084420979585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND For health care services to address the health care needs of populations and respond to changes in needs over time, workforces must be planned. This requires quantitative models to estimate future workforce requirements that take account of population size, oral health needs, evidence-based approaches to addressing needs, and methods of service provision that maximize productivity. The aim of this scoping review was to assess whether and how these 4 elements contribute to existing models of oral health workforce planning. METHODS A scoping review was conducted. MEDLINE, Embase, HMIC, and EconLit were searched, all via OVID. Additionally, gray literature databases were searched and key bodies and policy makers contacted. Workforce planning models were included if they projected workforce numbers and were specific to oral health. No limits were placed on country. A single reviewer completed initial screening of abstracts; 2 independent reviewers completed secondary screening and data extraction. A narrative synthesis was conducted. RESULTS A total of 4,009 records were screened, resulting in 42 included articles detailing 47 models. The workforce planning models varied significantly in their use of data on oral health needs, evidence-based services, and provider productivity, with most models relying on observed levels of service utilization and demand. CONCLUSIONS This review has identified quantitative workforce planning models that aim to estimate future workforce requirements. Approaches to planning the oral health workforce are not always based on deriving workforce requirements from population oral health needs. In many cases, requirements are not linked to population needs, while in models where needs are included, they are constrained by the existence and availability of the required data. It is critical that information systems be developed to effectively capture data necessary to plan future oral health care workforces in ways that relate directly to the needs of the populations being served. KNOWLEDGE TRANSFER STATEMENT Policy makers can use the results of this study when making decisions about the planning of oral health care workforces and about the data to routinely collect within health services. Collection of suitable data will allow for the continual improvement of workforce planning, leading to a responsive health service and likely future cost savings.
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Affiliation(s)
- L. O’Malley
- Division of Dentistry, School of Medical Sciences, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
| | - R. Macey
- Division of Dentistry, School of Medical Sciences, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
| | - T. Allen
- Centre for Health Economics, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
| | - P. Brocklehurst
- NWORTH Clinical Trials Unit, University of Bangor, Bangor, UK
| | - F. Thomson
- Division of Dentistry, School of Medical Sciences, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
| | - J. Rigby
- WHO/PAHO Collaborating Centre on Health Workforce Planning and Research, Dalhousie University, Halifax, Canada
- Research, Innovation and Discovery, Nova Scotia Health Authority, Halifax, Canada
| | - R. Lalloo
- School of Dentistry, The University of Queensland, Brisbane, Australia
| | - G. Tomblin Murphy
- WHO/PAHO Collaborating Centre on Health Workforce Planning and Research, Dalhousie University, Halifax, Canada
- Research, Innovation and Discovery, Nova Scotia Health Authority, Halifax, Canada
| | - S. Birch
- Centre for the Business and Economics of Health, Faculty of Business Economics and Law, The University of Queensland, Brisbane, Australia
| | - M. Tickle
- Division of Dentistry, School of Medical Sciences, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
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Memtsa M, Goodhart V, Ambler G, Brocklehurst P, Keeney E, Silverio SA, Anastasiou Z, Round J, Khan N, Hall J, Barrett G, Bender-Atik R, Stephenson J, Jurkovic D. Differences in the organisation of early pregnancy units and the effect of senior clinician presence, volume of patients and weekend opening on emergency hospital admissions: Findings from the VESPA Study. PLoS One 2021; 16:e0260534. [PMID: 34847201 PMCID: PMC8631630 DOI: 10.1371/journal.pone.0260534] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 11/11/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To determine whether the participation of consultant gynaecologists in delivering early pregnancy care results in a lower rate of acute hospital admissions. DESIGN Prospective cohort study and emergency hospital care audit; data were collected as part of the national prospective mixed-methods VESPA study on the "Variations in the organization of EPAUs in the UK and their effects on clinical, Service and PAtient-centred outcomes". SETTING 44 Early Pregnancy Assessment Units (EPAUs) across the UK randomly selected in balanced numbers from eight pre-defined mutually exclusive strata. PARTICIPANTS 6606 pregnant women (≥16 years old) with suspected first trimester pregnancy complications attending the participating EPAUs or Emergency Departments (ED) from December 2016 to July 2017. EXPOSURES Planned and actual senior clinician presence, unit size, and weekend opening. MAIN OUTCOME MEASURES Unplanned admissions to hospital following any visit for investigations or treatment for first trimester complications as a proportion of women attending EPAUs. RESULTS 205/6397 (3.2%; 95% CI 2.8-3.7) women were admitted following their EPAU attendance. The admission rate among 44 units ranged from 0% to 13.7% (median 2.8). Neither planned senior clinician presence (p = 0.874) nor unit volume (p = 0.247) were associated with lower admission rates from EPAU, whilst EPAU opening over the weekend resulted in lower admission rates (p = 0.027). 1445/5464 (26.4%; 95%CI 25.3 to 27.6) women were admitted from ED. There was little evidence of an association with planned senior clinician time (p = 0.280) or unit volume (p = 0.647). Keeping an EPAU open over the weekend for an additional hour was associated with 2.4% (95% CI 0.1% to 4.7%) lower odds of an emergency admission from ED. CONCLUSIONS Involvement of senior clinicians in delivering early pregnancy care has no significant impact on emergency hospital admissions for early pregnancy complications. Weekend opening, however, may be an effective way of reducing emergency admissions from ED.
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Affiliation(s)
- Maria Memtsa
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, United Kingdom
| | - Venetia Goodhart
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, United Kingdom
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, United Kingdom
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Edna Keeney
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Sergio A Silverio
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, United Kingdom.,Department of Women and Children's Health, King's College London, London, United Kingdom
| | - Zacharias Anastasiou
- Department of Statistical Science, University College London, London, United Kingdom
| | - Jeff Round
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom.,Institute of Health Economics, Edmonton, Canada
| | - Nazim Khan
- Modelling and Analytical Systems Solutions (MASS) Ltd, Edinburgh, United Kingdom
| | - Jennifer Hall
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, United Kingdom
| | - Geraldine Barrett
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, United Kingdom
| | | | - Judith Stephenson
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, United Kingdom
| | - Davor Jurkovic
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, United Kingdom
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Lee SI, Eastwood KA, Moss N, Azcoaga-Lorenzo A, Subramanian A, Anand A, Taylor B, Nelson-Piercy C, Yau C, McCowan C, O'Reilly D, Hope H, Kennedy JI, Abel KM, Locock L, Brocklehurst P, Plachcinski R, Brophy S, Agrawal U, Thangaratinam S, Nirantharakumar K, Black M. Protocol for the development of a core outcome set for studies of pregnant women with pre-existing multimorbidity. BMJ Open 2021; 11:e044919. [PMID: 34716152 PMCID: PMC8559099 DOI: 10.1136/bmjopen-2020-044919] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Increasingly more pregnant women are living with pre-existing multimorbidity (≥two long-term physical or mental health conditions). This may adversely affect maternal and offspring outcomes. This study aims to develop a core outcome set (COS) for maternal and offspring outcomes in pregnant women with pre-existing multimorbidity. It is intended for use in observational and interventional studies in all pregnancy settings. METHODS AND ANALYSIS We propose a four stage study design: (1) systematic literature search, (2) focus groups, (3) Delphi surveys and (4) consensus group meeting. The study will be conducted from June 2021 to August 2022. First, an initial list of outcomes will be identified through a systematic literature search of reported outcomes in studies of pregnant women with multimorbidity. We will search the Cochrane library, Medline, EMBASE and CINAHL. This will be supplemented with relevant outcomes from published COS for pregnancies and childbirth in general, and multimorbidity. Second, focus groups will be conducted among (1) women with lived experience of managing pre-existing multimorbidity in pregnancy (and/or their partners) and (2) their healthcare/social care professionals to identify outcomes important to them. Third, these initial lists of outcomes will be prioritised through a three-round online Delphi survey using predefined score criteria for consensus. Participants will be invited to suggest additional outcomes that were not included in the initial list. Finally, a consensus meeting using the nominal group technique will be held to agree on the final COS. The stakeholders will include (1) women (and/or their partners) with lived experience of managing multimorbidity in pregnancy, (2) healthcare/social care professionals involved in their care and (3) researchers in this field. ETHICS AND DISSEMINATION This study has been approved by the University of Birmingham's ethical review committee. The final COS will be disseminated through peer-reviewed publication and conferences and to all stakeholders.
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Affiliation(s)
- Siang Ing Lee
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Kelly-Ann Eastwood
- Centre for Public Health, Queen's University Belfast, Belfast, UK
- St Michael's Hospital, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Ngawai Moss
- Patient and Public Representative, London, UK
| | | | | | - Astha Anand
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Beck Taylor
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Christopher Yau
- Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Colin McCowan
- School of Medicine, University of St Andrews, St Andrews, UK
| | - Dermot O'Reilly
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Holly Hope
- Division of Psychology and Mental Health, Faculty of Biology Medicine and Health, Centre for Women's Mental Health, The University of Manchester, Manchester, UK
| | | | - Kathryn Mary Abel
- Division of Psychology and Mental Health, Faculty of Biology Medicine and Health, Centre for Women's Mental Health, The University of Manchester, Manchester, UK
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Louise Locock
- Health Service Research Unit, University of Aberdeen, Aberdeen, UK
| | - Peter Brocklehurst
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Sinead Brophy
- Data Science, Medical School, University of Swansea, Swansea, UK
| | - Utkarsh Agrawal
- School of Medicine, University of St Andrews, St Andrews, UK
| | - Shakila Thangaratinam
- WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Obstetrics and Gynaecology, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | | | - Mairead Black
- School of Medicine, Medical Science and Nutrition, University of Aberdeen, Aberdeen, UK
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Fleminger J, Duhig K, Seed PT, Brocklehurst P, Green M, Juszczak E, Marlow N, Shennan A, Chappell L. Factors influencing perinatal outcomes in women with preterm preeclampsia: A secondary analysis of the PHOENIX trial. Pregnancy Hypertens 2021; 26:91-93. [PMID: 34688088 DOI: 10.1016/j.preghy.2021.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/16/2021] [Accepted: 10/11/2021] [Indexed: 10/20/2022]
Abstract
This secondary analysis of the PHOENIX trial (evaluating planned delivery against expectant management in late preterm preeclampsia) demonstrates that in women who started induction of labour, 63% of women delivered vaginally (56% at 34 weeks' gestation). Compared to expectant management, planned delivery was associated with higher rates of neonatal unit admission for prematurity (but lower proportions of small-for-gestational age infants); length of neonatal unit stay and neonatal morbidity (including respiratory support) were similar across both intervention groups at all gestational windows. Neonatal unit admission was increased by earlier gestation at delivery, development of severe preeclampsia, and being small-for-gestational age.
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Affiliation(s)
- Jessica Fleminger
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Kate Duhig
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Paul T Seed
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | | | - Edmund Juszczak
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Neil Marlow
- ULC EGA Institute for Women's Health, University College London, London, UK
| | - Andrew Shennan
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Lucy Chappell
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK.
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Phrommintikul A, Nathisuwan S, Gunaparn S, Krittayaphong R, Wongcharoen W, Sehmi S, Mehta S, Winkles N, Brocklehurst P, Mathers J, Jowett S, Jolly K, Lane D, Thomas GN, Lip GYH. Prospective randomised trial examining the impact of an educational intervention versus usual care on anticoagulation therapy control based on an SAMe-TT 2R 2 score-guided strategy in anticoagulant-naïve Thai patients with atrial fibrillation (TREATS-AF): a study protocol. BMJ Open 2021; 11:e051987. [PMID: 34635526 PMCID: PMC8506852 DOI: 10.1136/bmjopen-2021-051987] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION The burden of atrial fibrillation (AF) in Thailand is high and associated with increased morbidity, mortality and healthcare costs. Vitamin K antagonists (eg, warfarin), commonly used for stroke prevention in patients with AF in Thailand, are effective but are often suboptimally controlled. We aim to evaluate the impact of an SAMe-TT2R2 score-guided strategy and educational intervention compared to usual care on anticoagulation control expressed by the time in therapeutic range (TTR) at 12 months, in anticoagulant-naïve Thai patients with AF. METHODS AND ANALYSIS Multicentre, open-label, parallel-group, randomised controlled trial conducted in Thailand among adult patients (age: 18 years) with AF who are anticoagulant naïve. Patients will be randomised to one of two groups; an SAMe-TT2R2 score-guided strategy with educational intervention and usual care versus usual care alone. The planned follow-up period is 12 months. The primary outcome is TTR at 12 months. Secondary outcomes include: (1) TTR at 6 months; (2) thromboembolic and bleeding events at 12 months; (3) composite major adverse cardiovascular events at 12 months; (4) change in patients' knowledge of AF between baseline and 6 months and 12 months; (5) cost effectiveness; (6) quality of life at baseline, 6 months and 12 months using EQ-5D-5L (Thai version) and (7) patient satisfaction/perceptions of the TREAT intervention. An embedded qualitative study will assess patient perceptions of the TREAT intervention. ETHICS AND DISSEMINATION The study has been approved by the Ethical Review Committee, Ministry of Public Health of Thailand, and registered in the Thai Clinical Trials Registry. The results of this trial will be submitted for publication in a peer-reviewed journal. Participants will be informed via a link to a preview of the publication. A lay summary will also be provided to all participants prior to publication. TRIAL REGISTRATION NUMBER TCTR20180711003.
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Affiliation(s)
- Arintaya Phrommintikul
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Center for Medical Excellence, Faculty of Medicine, Chiang Mai, Thailand
| | - Surakit Nathisuwan
- Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Siriluck Gunaparn
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | | | - Wanwarang Wongcharoen
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Sukhi Sehmi
- Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Samir Mehta
- Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Neil Winkles
- Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | | | - Jonathan Mathers
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Sue Jowett
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Kate Jolly
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Deirdre Lane
- Department of Cardiovascular Health, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - G Neil Thomas
- Department of Public Health and Epidemiology, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg Universitet, Aalborg, Denmark
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35
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Abstract
One-third of the UK population is composed of problem-oriented dental attenders, seeking dental care only when they have acute dental pain or problems. Patients seek urgent dental care from a range of health care professionals, including general medical practitioners. This study aimed to identify trends in dental attendance at Welsh medical practices over a 44-y period, specifically in relation to dental policy change and factors associated with repeat attendance. A retrospective observational study was completed via the nationwide Secure Anonymised Information Linkage (SAIL) Databank of visits to general medical practice in Wales. Read codes associated with dental diagnoses were extracted for patients attending their general medical practitioner between 1974 and 2017. Data were analyzed with descriptive statistics and univariate and multivariable logistic regression. Over the 44-y period, there were 439,361 dental Read codes, accounting for 288,147 patient attendances. The overall attendance rate was 2.60 attendances per 1,000 patient-years (95% CI, 2.59 to 2.61). The attendance rate was negligible through 1987 but increased sharply to 5.0 per 1,000 patient-years in 2006 (95% CI, 4.94 to 5.09) before almost halving to 2.6 per 1,000 in 2017 (95% CI, 2.53 to 2.63) to a pattern that coincided with changes to National Health Service policies. Overall 26,312 patients were repeat attenders and were associated with living in an area classified as urban and deprived (odds ratio [OR], 1.22; 95% CI, 1.19 to 1.25; P < 0.0001) or rural (OR, 0.84; 95% CI, 0.83 to 0.85; P < 0.0001). Repeat attendance was associated with greater odds of having received an antibiotic prescription (OR, 2.53; 95% CI, 2.50 to 2.56; P < 0.0001) but lower odds of having been referred to another service (OR, 0.75; 95% CI, 0.70 to 0.81; P < 0.0001). Welsh patients’ reliance on medical care for dental problems was influenced by social deprivation and health policy. This indicates that future interventions to discourage dental attendance at medical practitioners should be targeted at those in the most deprived urban areas or rural areas. In addition, health policy may influence attendance rates positively and negatively and should be considered in the future when decisions related to policy change are made.
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Affiliation(s)
- C C Currie
- School of Dental Sciences, Newcastle University, Newcastle upon Tyne, UK.,Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - S J Stone
- School of Dental Sciences, Newcastle University, Newcastle upon Tyne, UK.,Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - P Brocklehurst
- School of Health Sciences, Bangor University, Bangor, UK
| | - G Slade
- Division of Pediatric and Public Health, UNC Adams School of Dentistry, University of North Carolina, Chapel Hill, NC, USA
| | - J Durham
- School of Dental Sciences, Newcastle University, Newcastle upon Tyne, UK.,Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - M S Pearce
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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36
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Israfil-Bayli F, Morton VH, Hewitt CA, Ewer AK, Gray J, Norman J, Lees C, Simpson NAB, Shennan A, Tryposkiadis K, Hughes M, Daniels J, Brocklehurst P, Morris K, Middleton L, Toozs-Hobson P. C-STICH: Cerclage Suture Type for an Insufficient Cervix and its effect on Health outcomes-a multicentre randomised controlled trial. Trials 2021; 22:664. [PMID: 34583760 PMCID: PMC8479931 DOI: 10.1186/s13063-021-05629-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 09/15/2021] [Indexed: 11/10/2022] Open
Abstract
Background Preterm birth is associated with significant mortality and morbidity for mothers and babies. Women are identified as high risk for preterm birth based on either previous medical/pregnancy history or on ultrasound assessment of the cervix. Women identified as high risk can be offered a cervical cerclage (a purse string stitch) around the cervix (neck of the womb) to reduce the risk of preterm birth. In women who have a cervical cerclage, the procedure can be performed using either a monofilament (single-stranded) or braided (woven) suture material. Both suture materials are routinely used for cervical cerclage and there is uncertainty as to which is superior. Methods A multicentre, open, randomised controlled superiority trial of 2050 women presenting at obstetric units, deemed to be at risk of preterm birth and already scheduled to have a cervical cerclage as part of their standard care. Inclusion criteria include singleton pregnancies and an indication for cervical cerclage for either a history of three or more previous mid-trimester losses or premature births (≤ 28 weeks), insertion of cervical sutures in previous pregnancies, a history of mid trimester loss or premature birth with a (current) shortened (≤ 25 mm) cervix, or women whom clinicians deem to be at risk of preterm birth either by history or the results of an ultrasound scan. Exclusion criteria include women who have taken part in C-STICH previously, are aged less than 18 years old at the time of presentation, require a rescue cerclage, and are unwilling or unable to give informed consent and in whom a cerclage will be placed by any route other than vaginally (e.g. via an abdominal route). Following informed consent, women are randomised on a 1:1 basis to either monofilament or braided suture, by minimisation. The primary outcome is pregnancy loss (miscarriage and perinatal mortality, including any stillbirth or neonatal death in the first week of life), and secondary outcomes include the core outcome set for preterm birth trials. Discussion Optimising established interventions to prevent preterm birth is important in reducing perinatal mortality rates. Trial registration ISRCTN 15373349. Registered before recruitment on 03 December 2014 prior to first recruit.
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Affiliation(s)
| | | | | | | | - Jim Gray
- Birmingham Women's and Children's Hospital, Birmingham, UK
| | | | | | | | | | | | - Max Hughes
- University of Birmingham, Birmingham, UK
| | | | | | - Katie Morris
- Birmingham Women's and Children's Hospital, Birmingham, UK.,University of Birmingham, Birmingham, UK
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37
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Beard DJ, Campbell MK, Blazeby JM, Carr AJ, Weijer C, Cuthbertson BH, Buchbinder R, Pinkney T, Bishop FL, Pugh J, Cousins S, Harris I, Lohmander LS, Blencowe N, Gillies K, Probst P, Brennan C, Cook A, Farrar-Hockley D, Savulescu J, Huxtable R, Rangan A, Tracey I, Brocklehurst P, Ferreira ML, Nicholl J, Reeves BC, Hamdy F, Rowley SC, Lee N, Cook JA. Placebo comparator group selection and use in surgical trials: the ASPIRE project including expert workshop. Health Technol Assess 2021; 25:1-52. [PMID: 34505829 PMCID: PMC8450778 DOI: 10.3310/hta25530] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The use of placebo comparisons for randomised trials assessing the efficacy of surgical interventions is increasingly being considered. However, a placebo control is a complex type of comparison group in the surgical setting and, although powerful, presents many challenges. OBJECTIVES To provide a summary of knowledge on placebo controls in surgical trials and to summarise any recommendations for designers, evaluators and funders of placebo-controlled surgical trials. DESIGN To carry out a state-of-the-art workshop and produce a corresponding report involving key stakeholders throughout. SETTING A workshop to discuss and summarise the existing knowledge and to develop the new guidelines. RESULTS To assess what a placebo control entails and to assess the understanding of this tool in the context of surgery is considered, along with when placebo controls in surgery are acceptable (and when they are desirable). We have considered ethics arguments and regulatory requirements, how a placebo control should be designed, how to identify and mitigate risk for participants in these trials, and how such trials should be carried out and interpreted. The use of placebo controls is justified in randomised controlled trials of surgical interventions provided that there is a strong scientific and ethics rationale. Surgical placebos might be most appropriate when there is poor evidence for the efficacy of the procedure and a justified concern that results of a trial would be associated with a high risk of bias, particularly because of the placebo effect. CONCLUSIONS The use of placebo controls is justified in randomised controlled trials of surgical interventions provided that there is a strong scientific and ethics rationale. Feasibility work is recommended to optimise the design and implementation of randomised controlled trials. An outline for best practice was produced in the form of the Applying Surgical Placebo in Randomised Evaluations (ASPIRE) guidelines for those considering the use of a placebo control in a surgical randomised controlled trial. LIMITATIONS Although the workshop participants involved international members, the majority of participants were from the UK. Therefore, although every attempt was made to make the recommendations applicable to all health systems, the guidelines may, unconsciously, be particularly applicable to clinical practice in the UK NHS. FUTURE WORK Future work should evaluate the use of the ASPIRE guidelines in making decisions about the use of a placebo-controlled surgical trial. In addition, further work is required on the appropriate nomenclature to adopt in this space. FUNDING Funded by the Medical Research Council UK and the National Institute for Health Research as part of the Medical Research Council-National Institute for Health Research Methodology Research programme.
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Affiliation(s)
- David J Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Jane M Blazeby
- Centre for Surgical Research, NIHR Bristol and Weston Biomedical Research Centre, Population Health Sciences, University of Bristol, Bristol, UK
| | - Andrew J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Charles Weijer
- Departments of Medicine, Epidemiology and Biostatistics, and Philosophy, Western University, London, ON, Canada
| | - Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Thomas Pinkney
- Academic Department of Surgery, University of Birmingham, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Felicity L Bishop
- Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Jonathan Pugh
- The Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - Sian Cousins
- Centre for Surgical Research, NIHR Bristol and Weston Biomedical Research Centre, Population Health Sciences, University of Bristol, Bristol, UK
| | - Ian Harris
- Faculty of Medicine, South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - L Stefan Lohmander
- Department of Clinical Sciences Lund, Orthopedics, Clinical Epidemiology Unit, Lund University, Lund, Sweden
| | - Natalie Blencowe
- Centre for Surgical Research, NIHR Bristol and Weston Biomedical Research Centre, Population Health Sciences, University of Bristol, Bristol, UK
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Pascal Probst
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | | | - Andrew Cook
- Wessex Institute, University of Southampton, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Julian Savulescu
- The Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - Richard Huxtable
- Centre for Surgical Research, NIHR Bristol and Weston Biomedical Research Centre, Population Health Sciences, University of Bristol, Bristol, UK
| | - Amar Rangan
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Department of Health Sciences, University of York, York, UK
| | - Irene Tracey
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Manuela L Ferreira
- Faculty of Medicine and Health, Institute of Bone and Joint Research, Northern Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Jon Nicholl
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Barnaby C Reeves
- Clinical Trials Evaluation Unit Bristol Medical School, University of Bristol, Bristol Royal Infirmary, Bristol, UK
| | - Freddie Hamdy
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | | | - Naomi Lee
- Editorial Department, The Lancet, London, UK
| | - Jonathan A Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Hodgetts-Morton V, Hewitt CA, Jones L, Leighton L, Pilarski N, Molloy E, Hinshaw K, Norman J, Waugh J, Stock S, Thornton J, Toozs-Hobson P, Johnston T, Coomarasamy A, Thangaratinam S, Mol B, Pajkrt E, Marlow N, Roberts T, Middleton L, Brocklehurst P, Morris K. C-STICH2: emergency cervical cerclage to prevent miscarriage and preterm birth-study protocol for a randomised controlled trial. Trials 2021; 22:529. [PMID: 34380528 PMCID: PMC8356468 DOI: 10.1186/s13063-021-05464-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 07/16/2021] [Indexed: 11/30/2022] Open
Abstract
Background Cervical cerclage is a recognised treatment to prevent late miscarriage and pre-term birth (PTB). Emergency cervical cerclage (ECC) for cervical dilatation with exposed unruptured membranes is less common and the potential benefits of cerclage are less certain. A randomised control trial is needed to accurately assess the effectiveness of ECC in preventing pregnancy loss compared to an expectant approach. Methods C-STICH2 is a multicentre randomised controlled trial in which women presenting with cervical dilatation and unruptured exposed membranes at 16 + 0 to 27 + 6 weeks gestation are randomised to ECC or expectant management. Trial design includes 18 month internal pilot with embedded qualitative process evaluation, minimal data set and a within-trial health economic analysis. Inclusion criteria are ≥16 years, singleton pregnancy, exposed membranes at the external os, gestation 16 + 0–27 + 6 weeks, and informed consent. Exclusion criteria are contraindication to cerclage, cerclage in situ or previous cerclage in this pregnancy. Randomisation occurs via an online service in a 1:1 ratio, using a minimisation algorithm to reduce chance imbalances in key prognostic variables (site, gestation and dilatation). Primary outcome is pregnancy loss; a composite including miscarriage, termination of pregnancy and perinatal mortality defined as stillbirth and neonatal death in the first week of life. Secondary outcomes include all core outcomes for PTB. Two-year development outcomes will be assessed using general health and Parent Report of Children’s Abilities-Revised (PARCA-R) questionnaires. Intended sample size is 260 participants (130 each arm) based on 60% rate of pregnancy loss in the expectant management arm and 40% in the ECC arm, with 90% power and alpha 0.05. Analysis will be by intention-to-treat. Discussion To date there has been one small trial of ECC in 23 participants which included twin and singleton pregnancies. This small trial along with the largest observational study (n = 161) found ECC to prolong pregnancy duration and reduce deliveries before 34 weeks gestation. It is important to generate high quality evidence on the effectiveness of ECC in preventing pregnancy loss, and improve understanding of the prevalence of the condition and frequency of complications associated with ECC. An adequately powered RCT will provide the highest quality evidence regarding optimum care for these women and their babies. Trial registration ISRCTN Registry ISRCTN12981869. Registered on 13th June 2018.
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Affiliation(s)
| | | | | | | | | | | | - Kim Hinshaw
- City Hospitals Sunderland NHS Foundation Trust, Sunderland, UK
| | | | - Jason Waugh
- University of Auckland, Auckland, New Zealand
| | | | | | | | | | | | | | - Ben Mol
- University of Adelaide, Adelaide, UK
| | | | | | | | | | | | - Katie Morris
- Birmingham Clinical Trials Unit, Birmingham, UK. .,Institute of Applied Health Research, University of Birmingham, B15 2TT, Birmingham, UK.
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39
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Guo P, Xu D, Liew Z, He H, Brocklehurst P, Taylor B, Zhang C, Jin X, Gong W. Adherence to Traditional Chinese Postpartum Practices and Postpartum Depression: A Cross-Sectional Study in Hunan, China. Front Psychiatry 2021; 12:649972. [PMID: 34385937 PMCID: PMC8353075 DOI: 10.3389/fpsyt.2021.649972] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 06/25/2021] [Indexed: 12/02/2022] Open
Abstract
Background: The relationship between adherence to traditional Chinese postpartum practices (known as "doing-the-month") and postpartum depression (PPD) remains unknown. Practices including restrictions on diet, housework and social activity, personal hygiene, and cold contact, could introduce biological, psychological, and socio-environmental changes during postpartum. Methods: The cross-sectional study included 955 postpartum women in obstetric clinics in Hunan Province of China between September 2018 to June 2019. Thirty postpartum practices were collected by a self-report online structured questionnaire. Postpartum depression symptoms were assessed by the Chinese version of the Edinburgh Postnatal Depression Scale (EPDS). Multivariable linear regression was used to estimate the differences in EPDS scores according to adherence to postpartum practices. Firth's bias-reduced logistic regression was employed to analyze the binary classification of having PPD symptoms (EPDS ≥ 10). Results: Overall, both moderate and low adherence to postpartum practices appeared to be associated with higher EPDS scores (adjusted difference 1.07, 95% CI 0.20, 1.94 for overall moderate adherence; and adjusted difference 1.72, 95% CI 0.84, 2.60 for overall low adherence). In analyses by practice domain, low adherence to housework-related and social activity restrictions was associated with having PPD symptoms compared with high adherence (OR 1.61, 95% CI 1.07, 2.43). Conclusions: Low adherence to traditional Chinese postpartum practices was associated with higher EPDS scores indicating PPD symptoms, especially in the domain of housework-related and social activity restrictions. Psychosocial stress and unsatisfactory practical support related to low adherence to postpartum practices might contribute to PPD. Longitudinal study and clinical assessment would be needed to confirm these findings.
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Affiliation(s)
- Pengfei Guo
- School of Public Health, Sun Yat-sen University, Guangzhou, China
- Department of Environmental Health Sciences, Yale School of Public Health, New Haven, CT, United States
- Yale Center for Perinatal, Pediatric, and Environmental Epidemiology, Yale School of Public Health, New Haven, CT, United States
| | - Dong Xu
- School of Health Management, Southern Medical University, Guangzhou, China
- Center for WHO Studies, Southern Medical University, Guangzhou, China
- Institute for Health Management, Southern Medical University, Guangzhou, China
- ACACIA Labs, Institute for Global Health and Dermatology Hospital, Southern Medical University, Guangzhou, China
| | - Zeyan Liew
- Department of Environmental Health Sciences, Yale School of Public Health, New Haven, CT, United States
- Yale Center for Perinatal, Pediatric, and Environmental Epidemiology, Yale School of Public Health, New Haven, CT, United States
| | - Hua He
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, United States
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Beck Taylor
- Institute for Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Chao Zhang
- Xiangya School of Public Health, Central South University, Changsha, China
| | - Xin Jin
- Xiangya School of Public Health, Central South University, Changsha, China
| | - Wenjie Gong
- Xiangya School of Public Health, Central South University, Changsha, China
- Department of Psychiatry, University of Rochester, Rochester, NY, United States
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40
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Vousden N, Bunch K, Morris E, Simpson N, Gale C, O’Brien P, Quigley M, Brocklehurst P, Kurinczuk JJ, Knight M. The incidence, characteristics and outcomes of pregnant women hospitalized with symptomatic and asymptomatic SARS-CoV-2 infection in the UK from March to September 2020: A national cohort study using the UK Obstetric Surveillance System (UKOSS). PLoS One 2021; 16:e0251123. [PMID: 33951100 PMCID: PMC8099130 DOI: 10.1371/journal.pone.0251123] [Citation(s) in RCA: 115] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 04/20/2021] [Indexed: 12/24/2022] Open
Abstract
Background There is a lack of population level data on risk factors, incidence and impact of SARS-CoV-2 infection in pregnant women and their babies. The primary aim of this study was to describe the incidence, characteristics and outcomes of hospitalized pregnant women with symptomatic and asymptomatic SARS-CoV-2 in the UK compared to pregnant women without SARS-CoV-2. Methods and findings We conducted a national, prospective cohort study of all hospitalized pregnant women with confirmed SARS-CoV-2 from 01/03/2020 to 31/08/2020 using the UK Obstetric Surveillance System. Incidence rates were estimated using national maternity data. Overall, 1148 hospitalized women had confirmed SARS-CoV-2 in pregnancy, 63% of which were symptomatic. The estimated incidence of hospitalization with symptomatic SARS-CoV-2 was 2.0 per 1000 maternities (95% CI 1.9–2.2) and for asymptomatic SARS-CoV-2 was 1.2 per 1000 maternities (95% CI 1.1–1.4). Compared to pregnant women without SARS-CoV-2, women hospitalized with symptomatic SARS-CoV-2 were more likely to be overweight or obese (adjusted OR 1.86, (95% CI 1.39–2.48) and aOR 2.07 (1.53–2.29)), to be of Black, Asian or Other minority ethnic group (aOR 6.24, (3.93–9.90), aOR 4.36, (3.19–5.95) and aOR 12.95, (4.93–34.01)), and to have a relevant medical comorbidity (aOR 1.83 (1.32–2.54)). Hospitalized pregnant women with symptomatic SARS-CoV-2 were more likely to be admitted to intensive care (aOR 57.67, (7.80–426.70)) but the absolute risk of poor outcomes was low. Cesarean births and neonatal unit admission were increased regardless of symptom status (symptomatic aOR 2.60, (1.97–3.42) and aOR 3.08, (1.99–4.77); asymptomatic aOR 2.02, (1.52–2.70) and aOR 1.84, (1.12–3.03)). The risks of stillbirth or neonatal death were not significantly increased, regardless of symptom status. Conclusions We have identified factors that increase the risk of symptomatic and asymptomatic SARS-CoV-2 in pregnancy. Clinicians can be reassured that the majority of women do not experience severe complications of SARS-CoV-2 in pregnancy.
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Affiliation(s)
- Nicola Vousden
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- School of Population Health & Environmental Sciences, King’s College London, London, United Kingdom
| | - Kathryn Bunch
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Edward Morris
- Royal College of Obstetricians and Gynaecologists, London, United Kingdom
| | - Nigel Simpson
- Department of Women’s and Children’s Health, School of Medicine, University of Leeds, Leeds, United Kingdom
| | - Christopher Gale
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Patrick O’Brien
- Institute for Women’s Health, University College London, London, United Kingdom
| | - Maria Quigley
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Jennifer J. Kurinczuk
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Marian Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- * E-mail:
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41
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Moraitis AA, Bainton T, Sovio U, Brocklehurst P, Heazell AE, Thornton JG, Robson SC, Papageorghiou A, Smith GC. Fetal umbilical artery Doppler as a tool for universal third trimester screening: A systematic review and meta-analysis of diagnostic test accuracy. Placenta 2021; 108:47-54. [PMID: 33819861 DOI: 10.1016/j.placenta.2021.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 03/11/2021] [Accepted: 03/17/2021] [Indexed: 10/21/2022]
Abstract
The objective of this study was to investigate the accuracy of universal third trimester umbilical artery (UA) Doppler to predict adverse pregnancy outcome at term. We searched Medline, EMBASE, the Cochrane library and ClinicalTrials.gov from inception to October 2020 and we also analyzed previously unpublished data from a prospective cohort study of nulliparous women, the Pregnancy Outcome Prediction (POP) study. We included studies that performed a third-trimester ultrasound scan in unselected, low or mixed risk populations, excluding studies which only included high risk pregnancies. Meta-analysis was performed using the hierarchal summary receiver operating characteristic curve (HSROC) analysis and bivariate logit-normal models. We identified 13 studies (including the POP study) involving 67,764 pregnancies which met our inclusion criteria. The overall quality was variable and only six studies (N = 5777 patients) blinded clinicians to the UA Doppler result. The summary sensitivity and positive likelihood ratio (LR) for small for gestational age (SGA; birthweight <10th centile) were 21.7% (95% CI 13.2-33.6%) and 2.65 (95% CI 1.89-3.72) respectively. The summary positive LR for NICU admission and metabolic acidosis were 1.35 (95% CI 0.93-1.97) and 1.34 (95% CI 0.86-2.08) respectively. The results were similar in the POP study: associations with SGA (positive LR 2.66 [95% CI 2.11-3.36]) and severe SGA (birthweight <3rd centile; positive LR 3.27 [95% CI 2.29-4.68]) but no statistically significant association with neonatal morbidity. We conclude that third trimester UA Doppler has moderate predictive accuracy for small for gestational age but not for indicators of neonatal morbidity in unselected and low risk pregnancies.
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Affiliation(s)
- Alexandros A Moraitis
- Department of Obstetrics and Gynaecology, University of Cambridge; NIHR Cambridge Comprehensive Biomedical Research Centre, CB2 2SW, United Kingdom
| | - Thomas Bainton
- Department of Obstetrics and Gynaecology, University of Cambridge; NIHR Cambridge Comprehensive Biomedical Research Centre, CB2 2SW, United Kingdom
| | - Ulla Sovio
- Department of Obstetrics and Gynaecology, University of Cambridge; NIHR Cambridge Comprehensive Biomedical Research Centre, CB2 2SW, United Kingdom
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Alexander Ep Heazell
- Maternal and Fetal Health Research Centre, School of Medical Sciences, Faculty of Biological, Medical and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9WL, United Kingdom; St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, United Kingdom
| | - Jim G Thornton
- Division of Child Health, Obstetrics and Gynaecology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Stephen C Robson
- Reproductive and Vascular Biology Group, The Medical School, University of Newcastle, Newcastle, United Kingdom
| | - Aris Papageorghiou
- Nuffield Department of Obstetrics and Gynaecology, Oxford, United Kingdom
| | - Gordon Cs Smith
- Department of Obstetrics and Gynaecology, University of Cambridge; NIHR Cambridge Comprehensive Biomedical Research Centre, CB2 2SW, United Kingdom.
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42
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Schroeder E, Yang M, Brocklehurst P, Linsell L, Rivero-Arias O. Economic evaluation of computerised interpretation of fetal heart rate during labour: a cost-consequence analysis alongside the INFANT study. Arch Dis Child Fetal Neonatal Ed 2021; 106:143-148. [PMID: 32796054 PMCID: PMC7907561 DOI: 10.1136/archdischild-2020-318806] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 06/30/2020] [Accepted: 07/07/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Economic evaluation of computerised decision-support software intended to assist in the interpretation of a cardiotocography (CTG) during birth. DESIGN Individual patient level data from the INFANT study (an unmasked randomised controlled trial). SETTING Maternity units in the UK and Ireland. POPULATION Singleton or twin pregnancy women of 35 weeks' gestation or more and receiving continuous electronic fetal monitoring during labour. INTERVENTION Computerised decision-support software. METHODS Cost-consequence analysis presenting costs and outcomes with a time horizon of 2 years from a government healthcare perspective. Unit cost data collected from a combination of primary and secondary sources. MAIN OUTCOME MEASURES Primary clinical outcomes were (i) composite 'poor neonatal outcome' and (ii) developmental assessment at age 2 years in a subset of surviving children. Mean cost per mother and infant dyad from birth to hospital discharge, and from hospital discharge to 24 months follow-up. Maternal health-related quality of life was assessed at 12 and 24 months follow-up using the EuroQol three-level health-related quality of life instrument (EQ-5D-3L). RESULTS Data were analysed for 46 042 women and 46 614 infants. No statistically significant differences were detected between trial arms in any of the primary clinical outcomes or maternal quality of life. No statistically significant differences in costs were detected in maternal or infant costs from trial entry to hospital discharge or overall from hospital discharge to 2-year follow-up. CONCLUSIONS Decision-support software during labour is not associated with additional maternal or infant benefits and over a 2-year period the software did not lead to additional costs or savings to the National Health Service. TRIAL REGISTRATION NUMBER ISRCTN98680152.
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Affiliation(s)
- Elizabeth Schroeder
- Centre for the Health Economy, Macquarie University, Sydney, New South Wales, Australia
| | - Miaoqing Yang
- National Perinatal Epidemiology Unit (NPEU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Louise Linsell
- National Perinatal Epidemiology Unit (NPEU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Oliver Rivero-Arias
- National Perinatal Epidemiology Unit (NPEU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Smith GC, Moraitis AA, Wastlund D, Thornton JG, Papageorghiou A, Sanders J, Heazell AE, Robson SC, Sovio U, Brocklehurst P, Wilson EC. Universal late pregnancy ultrasound screening to predict adverse outcomes in nulliparous women: a systematic review and cost-effectiveness analysis. Health Technol Assess 2021; 25:1-190. [PMID: 33656977 PMCID: PMC7958245 DOI: 10.3310/hta25150] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Currently, pregnant women are screened using ultrasound to perform gestational aging, typically at around 12 weeks' gestation, and around the middle of pregnancy. Ultrasound scans thereafter are performed for clinical indications only. OBJECTIVES We sought to assess the case for offering universal late pregnancy ultrasound to all nulliparous women in the UK. The main questions addressed were the diagnostic effectiveness of universal late pregnancy ultrasound to predict adverse outcomes and the cost-effectiveness of either implementing universal ultrasound or conducting further research in this area. DESIGN We performed diagnostic test accuracy reviews of five ultrasonic measurements in late pregnancy. We conducted cost-effectiveness and value-of-information analyses of screening for fetal presentation, screening for small for gestational age fetuses and screening for large for gestational age fetuses. Finally, we conducted a survey and a focus group to determine the willingness of women to participate in a future randomised controlled trial. DATA SOURCES We searched MEDLINE, EMBASE and the Cochrane Library from inception to June 2019. REVIEW METHODS The protocol for the review was designed a priori and registered. Eligible studies were identified using keywords, with no restrictions for language or location. The risk of bias in studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Health economic modelling employed a decision tree analysed via Monte Carlo simulation. Health outcomes were from the fetal perspective and presented as quality-adjusted life-years. Costs were from the perspective of the public sector, defined as NHS England, and the costs of special educational needs. All costs and quality-adjusted life-years were discounted by 3.5% per annum and the reference case time horizon was 20 years. RESULTS Umbilical artery Doppler flow velocimetry, cerebroplacental ratio, severe oligohydramnios and borderline oligohydramnios were all either non-predictive or weakly predictive of the risk of neonatal morbidity (summary positive likelihood ratios between 1 and 2) and were all weakly predictive of the risk of delivering a small for gestational age infant (summary positive likelihood ratios between 2 and 4). Suspicion of fetal macrosomia is strongly predictive of the risk of delivering a large infant, but it is only weakly, albeit statistically significantly, predictive of the risk of shoulder dystocia. Very few studies blinded the result of the ultrasound scan and most studies were rated as being at a high risk of bias as a result of treatment paradox, ascertainment bias or iatrogenic harm. Health economic analysis indicated that universal ultrasound for fetal presentation only may be both clinically and economically justified on the basis of existing evidence. Universal ultrasound including fetal biometry was of borderline cost-effectiveness and was sensitive to assumptions. Value-of-information analysis indicated that the parameter that had the largest impact on decision uncertainty was the net difference in cost between an induced delivery and expectant management. LIMITATIONS The primary literature on the diagnostic effectiveness of ultrasound in late pregnancy is weak. Value-of-information analysis may have underestimated the uncertainty in the literature as it was focused on the internal validity of parameters, which is quantified, whereas the greatest uncertainty may be in the external validity to the research question, which is unquantified. CONCLUSIONS Universal screening for presentation at term may be justified on the basis of current knowledge. The current literature does not support universal ultrasonic screening for fetal growth disorders. FUTURE WORK We describe proof-of-principle randomised controlled trials that could better inform the case for screening using ultrasound in late pregnancy. STUDY REGISTRATION This study is registered as PROSPERO CRD42017064093. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 15. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Gordon Cs Smith
- Department of Obstetrics and Gynaecology, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - Alexandros A Moraitis
- Department of Obstetrics and Gynaecology, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - David Wastlund
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Jim G Thornton
- Division of Child Health, Obstetrics and Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Aris Papageorghiou
- Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Oxford, UK
| | - Julia Sanders
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - Alexander Ep Heazell
- Faculty of Biology, Medicine and Health, School of Medical Sciences, University of Manchester, Manchester, UK
| | - Stephen C Robson
- Reproductive and Vascular Biology Group, The Medical School, Newcastle University, Newcastle upon Tyne, UK
| | - Ulla Sovio
- Department of Obstetrics and Gynaecology, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Edward Cf Wilson
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, UK
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M, Koco H, Lawani S, Kassa MW, Santos Bezerra T, Gribnev P, Dimitrov D, Krastev P, Oum S, Bonghaseh DT, Al Farsi M, Alsharqawi N, Agarwal A, Acevedo V, Castillo Barbosa AC, Giron F, Leon Rodriguez JP, Kucan D, Rosko D, Barsic N, Župan D, Hegazi A, Truncíková V, Fryba V, Mohamed M, Sultan A, Nagi A, Rashad Temerik A, Elshawy ME, Mahmoud MI, Omar S, Anwar M, Rageh T, Elmokadem A, Gaballa K, Teppo S, Turunen A, Pengermä P, Ballouhey Q, Bergeat D, Weyl A, Hain E, Gyedu A, Yenli E, Osei-Poku D, Rompou VA, Zoikas A, Gaitanidis A, Koukis G, Perivoliotis K, Tavlas P, Galanos-Demiris K, Zografos G, Karavokyros I, Xanthopoulou G, Iordanidou E, Ayau F, Garcia A, Damján P, Wason D, B L A, Rangganata E, Kamath P, O'Connor DB, Pinto M, Perrone F, Tropeano FP, Troilo F, Bossi D, Scala D, Pulitanò L, Carella M, Pietrabissa A, Gori A, Giraudo G, De Simone V, Russo AA, Braccio B, Al-Taher R, Athamneh S, Parker A, Sawiee A, Kattia A, Salem M, Tababa O, Shaeeb Z, Syminas V, Jurgaitis J, Damuleviciene G, Svagzdys S, Poskus T, Razafimanjato NNM, Chieng Loo L, Tiong IC, Wan Muhmad WF, Vijeyan H, Li Ying T, Grech G, Arrangoiz R, Jimenez Ley VB, Arizpe D, Jimenez Ley VB, Lagunes Lara E, Castro López EV, Eaazim J, Gordinou de Gouberville M, Bastiaenen V, Rottier S, Nahab F, Ji MY, Seyoji M, Nwachukwu C, Emeghara O, Muhammed SE, Idowu A, Sowemimo O, Ogundoyin O, Akande O, Lott A, Nadeem M, Laghari AA, Loya A, Mushtaq H, Abdullah MT, Abuhilal B, Atawneh M, Hamdan H, Alhabil B, Srour A, Mousa I, Da Silva Medina L, Sacdalan MD, Lapitan MC, Sacdalan MD, Sacdalan MD, Bartosiak K, Ferreira P, Francisco V, Lemos R, Frutuoso L, Fernandes S, Fonseca T, Pereira J, Rachadell J, Torre A, Madeira Martins F, Carvalho AC, Rodrigues Ferreira J, Ribeiro da Silva B, Devesa H, Vieira A, Mónica I, Amaro M, Sousa D, Reia M, Louro J, Martins A, Dominguez J, Santos I, Freitas Oliveira NM, Pereira JC, Silva-Vaz P, Freire L, Escrevente R, Negoita VM, Shakhmatov D, Nezerwa Y, Radulovic R, Moore R, Obery G, Viljoen F, Mendes T, Suarez A, Moncada E, Fernandez-Hevia M, Curtis Martínez C, Gil Garcia JM, González Zunzarren M, Idris T, Eklöv K, Grahn O, Amin L, Blomqvist M, Ajani C, Kraus R, Seeger N, Willemin M, Rayya F, Ayash M, Msouti R, Kannas I, Abazid E, Esper A, Slim S, Kavcar AS, Aytac E, Dural AC, Ilker A, Eray IC, Kurnaz E, Altiner S, Tepe MD, Sahin C, Savli E, Innocent A, Babirye L, Diachenko A, Hordoskiy V, Curry H, Chau CYC, Robertson H, Mahmoud A, Lennon H, Loi L, Kirkham E, McCann C, Watts D, Gurung B, Wilson M, Tribedi T, Garofalo E, Zahra B, MacDonald S, Daniels I, Ng N, Khosla S, Olivier J, Yue SYP, Suresh G, Wellington J, Lorejo E, Mossaad M, Tryliskyy Y, Crutcher M, Alimi M, Baiu I, Abdou H, Conway A, Peck C, Wagner G, Perdomo Perez MA, Trostchansky I, Zulu S, Nakazwe M, Knight SR, Drake TM, Nepogodiev D, Fitzgerald JE, Ademuyiwa A, Alexander P, Ingabire JA, Al-Saqqa SW, Biccard BM, Borda-Luque G, Borowski DW, Burger S, Chu K, Clarke D, Costas-Chavarri A, Davies J, Donaldson R, Ede C, Garden OJ, Ghosh D, Glasbey J, Kingham TP, Salem HK, Anyomih TTK, Koto MZ, Lapitan MC, Lawani I, Lesetedi C, Aguilera-Arevalo ML, Mabedi C, Maimbo M, Magill L, Makinde Alakaloko F, Makupe A, Martin J, Ramos-De la Medina A, Monahan M, Moore R, Msosa V, Mulira S, Mutabazi AZ, Muller E, Musowoyo J, Adisa AO, Olory-Togbe JL, Pius R, Qureshi AU, Rayne S, Roberts T, Sacdalan MD, Shaw CA, Smart N, Smith M, Spence R, Van Straten S, Tabiri S, Tayler V, Weiser TG, Windsor J, Yorke J, Yepez R, Lilford R, Morton D, Bhangu A, Sundar S, Harrison EM, Runigamugabo E, Verjee A, Chen J, Daya L, El Aroussi N, Farina V, Gnintedeme Olivier T, Gonzales Nacarino M, Hammani A, Honjo S, Jacobs R, Kimura H, Litvin A, Nkoronko M, Nour I, Oscullo Yepez JJ, Pagano G, Pata F, Pin Hung W, Raj A, Romani Pozo A, Rommaneh M, Sassamela Fabiano SC, Shiroma Gago CM, Shu Yip S, Srinivas A, Sung CY, Tai A, Valle Aranda YC, Venturini S, Vervoort D, Wilguens Lartigue J. Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries. Lancet 2021; 397:387-397. [PMID: 33485461 PMCID: PMC7846817 DOI: 10.1016/s0140-6736(21)00001-5] [Citation(s) in RCA: 104] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 12/02/2020] [Accepted: 12/17/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. METHODS This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. FINDINGS Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70-8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39-8·80) and upper-middle-income countries (2·06, 1·11-3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26-11·59) and upper-middle-income countries (3·89, 2·08-7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. INTERPRETATION Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. FUNDING National Institute for Health Research Global Health Research Unit.
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Milton R, Sanders J, Barlow C, Brocklehurst P, Cannings-John R, Channon S, Gale C, Holmes A, Hunter B, Paranjothy S, Lugg-Widger FV, Milosevic S, Morantz L, Plachcinski R, Nolan M, Robling M. Establishing the safety of waterbirth for mothers and babies: a cohort study with nested qualitative component: the protocol for the POOL study. BMJ Open 2021; 11:e040684. [PMID: 33419905 PMCID: PMC7798679 DOI: 10.1136/bmjopen-2020-040684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 11/26/2020] [Accepted: 12/17/2020] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Approximately 60 000 (9/100) infants are born into water annually in the UK and this is likely to increase. Case reports identified infants with water inhalation or sepsis following birth in water and there is a concern that women giving birth in water may sustain more complex perineal trauma. There have not been studies large enough to show whether waterbirth increases these poor outcomes. The POOL Study (ISRCTN13315580) plans to answer the question about the safety of waterbirths among women who are classified appropriate for midwifery-led intrapartum care. METHODS AND ANALYSIS A cohort study with a nested qualitative component. Objectives will be answered using retrospective and prospective data captured in electronic National Health Service (NHS) maternity and neonatal systems. The qualitative component aims to explore factors influencing pool use and waterbirth; data will be gathered via discussion groups, interviews and case studies of maternity units. ETHICS AND DISSEMINATION The protocol has been approved by NHS Wales Research Ethics Committee (18/WA/0291) the transfer of identifiable data has been approved by Health Research Authority Confidentiality Advisory Group (18CAG0153).Study findings and innovative methodology will be disseminated through peer-reviewed journals, conferences and events. Results will be of interest to the general public, clinical and policy stakeholders in the UK and will be disseminated accordingly.
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Affiliation(s)
- Rebecca Milton
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Julia Sanders
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | | | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | | | - Sue Channon
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | | | - Abigail Holmes
- Maternity Services, Cardiff and Vale University Health Board, Cardiff, UK
| | - Billie Hunter
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - Shantini Paranjothy
- Aberdeen Health Data Science Research Centre, University of Aberdeen, Aberdeen, UK
| | | | | | | | | | - Mary Nolan
- Institute of Health and Society, University of Worcester, Worcester, UK
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Malouf RS, Tomlinson C, Henderson J, Opondo C, Brocklehurst P, Alderdice F, Phalguni A, Dretzke J. Impact of obstetric unit closures, travel time and distance to obstetric services on maternal and neonatal outcomes in high-income countries: a systematic review. BMJ Open 2020; 10:e036852. [PMID: 33318106 PMCID: PMC7735086 DOI: 10.1136/bmjopen-2020-036852] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVES To systematically review (1) The effect of obstetric unit (OU) closures on maternal and neonatal outcomes and (2) The association between travel distance/time to an OU and maternal and neonatal outcomes. DESIGN Systematic review of any quantitative studies with a comparison group. DATA SOURCES Embase, MEDLINE, PsycINFO, Applied Social Science Index and Abstracts, Cumulative Index to Nursing and Allied Health and grey literature were searched. METHODS Eligible studies explored the impact of closure of an OU or the effect of travel distance/time on prespecified maternal or neonatal outcomes. Only studies of women giving birth in high-income countries with universal health coverage of maternity services comparable to the UK were included. Identification of studies, extraction of data and risk of bias assessment were undertaken by at least two reviewers independently. The risk of bias checklist was based on the Cochrane Effective Practice and Organisation of Care criteria and the Newcastle-Ottawa scale. Heterogeneity across studies precluded meta-analysis and synthesis was narrative, with key findings tabulated. RESULTS 31 studies met the inclusion criteria. There was some evidence to suggest an increase in babies born before arrival following OU closures and/or associated with longer travel distances or time. This may be associated with an increased risk of perinatal or neonatal mortality, but this finding was not consistent across studies. Evidence on other maternal and neonatal outcomes was limited but did not suggest worse outcomes after closures or with longer travel times/distances. Interpretation of findings for some studies was hampered by concerns around how accurately exposures were measured, and/or a lack of adjustment for confounders or temporal changes. CONCLUSION It is not possible to conclude from this review whether OU closure, increased travel distances or times are associated with worse outcomes for the mother or the baby. PROSPERO REGISTRATION NUMBER CRD42017078503.
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Affiliation(s)
- Reem Saleem Malouf
- Nuffield Department of Population Health, Policy Research Unit in Maternal Health and Care, National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Claire Tomlinson
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Jane Henderson
- Nuffield Department of Population Health, Policy Research Unit in Maternal Health and Care, National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Charles Opondo
- Nuffield Department of Population Health, Policy Research Unit in Maternal Health and Care, National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Peter Brocklehurst
- Nuffield Department of Population Health, Policy Research Unit in Maternal Health and Care, National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Fiona Alderdice
- Nuffield Department of Population Health, Policy Research Unit in Maternal Health and Care, National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Angaja Phalguni
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Janine Dretzke
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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Memtsa M, Goodhart V, Ambler G, Brocklehurst P, Keeney E, Silverio S, Anastasiou Z, Round J, Khan N, Hall J, Barrett G, Bender-Atik R, Stephenson J, Jurkovic D. Variations in the organisation of and outcomes from Early Pregnancy Assessment Units: the VESPA mixed-methods study. Health Serv Deliv Res 2020. [DOI: 10.3310/hsdr08460] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background
Early pregnancy complications are common and account for the largest proportion of emergency work in gynaecology. Although early pregnancy assessment units operate in most UK acute hospitals, recent National Institute of Health and Care Excellence guidance emphasised the need for more research to identify configurations that provide the optimal balance between cost-effectiveness, clinical effectiveness and service- and patient-centred outcomes [National Institute for Health and Care Excellence (NICE). Ectopic Pregnancy and Miscarriage: Diagnosis and Initial Management. URL: http://guidance.nice.org.uk/CG154 (accessed 23 March 2016)].
Objectives
The primary aim was to test the hypothesis that the rate of hospital admissions for early pregnancy complications is lower in early pregnancy assessment units with high consultant presence than in units with low consultant presence. The key secondary objectives were to assess the effect of increased consultant presence on other clinical outcomes, to explore patient satisfaction with the quality of care and to make evidence-based recommendations about the future configuration of UK early pregnancy assessment units.
Design
The Variations in the organisations of Early Pregnancy Assessment Units in the UK and their effects on clinical, Service and PAtient-centred outcomes (VESPA) study employed a multimethods approach and included a prospective cohort study of women attending early pregnancy assessment units to measure clinical outcomes, an economic evaluation, a patient satisfaction survey, qualitative interviews with service users, an early pregnancy assessment unit staff survey and a hospital emergency care audit.
Setting
The study was conducted in 44 early pregnancy assessment units across the UK.
Participants
Participants were pregnant women (aged ≥ 16 years) attending the early pregnancy assessment units or other hospital emergency services because of suspected early pregnancy complications. Staff members directly involved in providing early pregnancy care completed the staff survey.
Main outcome measure
Emergency hospital admissions as a proportion of women attending the participating early pregnancy assessment units.
Methods
Data sources – demographic and routine clinical data were collected from all women attending the early pregnancy assessment units. For women who provided consent to complete the questionnaires, clinical data and questionnaires were linked using the women’s study number. Data analysis and results reporting – the relationships between clinical outcomes and consultant presence, unit volume and weekend opening hours were investigated using appropriate regression models. Qualitative interviews with women, and patient and staff satisfaction, health economic and workforce analyses were also undertaken, accounting for consultant presence, unit volume and weekend opening hours.
Results
We collected clinical data from 6606 women. There was no evidence of an association between admission rate and consultant presence (p = 0.497). Health economic evaluation and workforce analysis data strands indicated that lower-volume units with no consultant presence were associated with lower costs than their alternatives.
Limitations
The relatively low level of direct consultant involvement could explain the lack of significant impact on quality of care. We were also unable to estimate the potential impact of factors such as scanning practices, level of supervision, quality of ultrasound equipment and clinical care pathway protocols.
Conclusions
We have shown that consultant presence in the early pregnancy assessment unit has no significant impact on key outcomes, such as the proportion of women admitted to hospital as an emergency, pregnancy of unknown location rates, ratio of new to follow-up visits, negative laparoscopy rate and patient satisfaction. All data strands indicate that low-volume units run by senior or specialist nurses and supported by sonographers and consultants may represent the optimal early pregnancy assessment unit configuration.
Future work
Our results show that further research is needed to assess the potential impact of enhanced clinical and ultrasound training on the performance of all disciplines working in early pregnancy assessment units.
Trial registration
Current Controlled Trials ISRCTN10728897.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 46. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Maria Memtsa
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, UK
| | - Venetia Goodhart
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, UK
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, UK
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Edna Keeney
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sergio Silverio
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, UK
- Department of Women and Children’s Health, King’s College London, St Thomas’ Hospital, London, UK
| | | | - Jeff Round
- Institute of Health Economics, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Nazim Khan
- Modelling and Analytical Systems Solutions Ltd, Edinburgh, UK
| | - Jennifer Hall
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, UK
| | - Geraldine Barrett
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, UK
| | | | - Judith Stephenson
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, UK
| | - Davor Jurkovic
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, UK
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McKenna G, Janssens B, Srinivasan M, Brocklehurst P, Tsakos G. Who is caring for the oral health of dependent institutionalised elderly during the COVID‐19 pandemic? Gerodontology 2020; 37:315-316. [DOI: 10.1111/ger.12504] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- G. McKenna
- Centre for Public Health Queens University Belfast Belfast UK
| | - B. Janssens
- Department of Oral Health Sciences Ghent University Ghent Belgium
| | - M. Srinivasan
- Centre of Dental Medicine University of Zurich Zurich Switzerland
| | | | - G. Tsakos
- Department of Epidemiology and Public Health University College London London UK
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Moraitis AA, Shreeve N, Sovio U, Brocklehurst P, Heazell AEP, Thornton JG, Robson SC, Papageorghiou A, Smith GC. Universal third-trimester ultrasonic screening using fetal macrosomia in the prediction of adverse perinatal outcome: A systematic review and meta-analysis of diagnostic test accuracy. PLoS Med 2020; 17:e1003190. [PMID: 33048935 PMCID: PMC7553291 DOI: 10.1371/journal.pmed.1003190] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 09/09/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The effectiveness of screening for macrosomia is not well established. One of the critical elements of an effective screening program is the diagnostic accuracy of a test at predicting the condition. The objective of this study is to investigate the diagnostic effectiveness of universal ultrasonic fetal biometry in predicting the delivery of a macrosomic infant, shoulder dystocia, and associated neonatal morbidity in low- and mixed-risk populations. METHODS AND FINDINGS We conducted a predefined literature search in Medline, Excerpta Medica database (EMBASE), the Cochrane library and ClinicalTrials.gov from inception to May 2020. No language restrictions were applied. We included studies where the ultrasound was performed as part of universal screening and those that included low- and mixed-risk pregnancies and excluded studies confined to high risk pregnancies. We used the estimated fetal weight (EFW) (multiple formulas and thresholds) and the abdominal circumference (AC) to define suspected large for gestational age (LGA). Adverse perinatal outcomes included macrosomia (multiple thresholds), shoulder dystocia, and other markers of neonatal morbidity. The risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Meta-analysis was carried out using the hierarchical summary receiver operating characteristic (ROC) and the bivariate logit-normal (Reitsma) models. We identified 41 studies that met our inclusion criteria involving 112,034 patients in total. These included 11 prospective cohort studies (N = 9986), one randomized controlled trial (RCT) (N = 367), and 29 retrospective cohort studies (N = 101,681). The quality of the studies was variable, and only three studies blinded the ultrasound findings to the clinicians. Both EFW >4,000 g (or 90th centile for the gestational age) and AC >36 cm (or 90th centile) had >50% sensitivity for predicting macrosomia (birthweight above 4,000 g or 90th centile) at birth with positive likelihood ratios (LRs) of 8.74 (95% confidence interval [CI] 6.84-11.17) and 7.56 (95% CI 5.85-9.77), respectively. There was significant heterogeneity at predicting macrosomia, which could reflect the different study designs, the characteristics of the included populations, and differences in the formulas used. An EFW >4,000 g (or 90th centile) had 22% sensitivity at predicting shoulder dystocia with a positive likelihood ratio of 2.12 (95% CI 1.34-3.35). There was insufficient data to analyze other markers of neonatal morbidity. CONCLUSIONS In this study, we found that suspected LGA is strongly predictive of the risk of delivering a large infant in low- and mixed-risk populations. However, it is only weakly (albeit statistically significantly) predictive of the risk of shoulder dystocia. There was insufficient data to analyze other markers of neonatal morbidity.
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Affiliation(s)
- Alexandros A. Moraitis
- Department of Obstetrics and Gynaecology, University of Cambridge, NIHR Cambridge Comprehensive Biomedical Research Centre, Cambridge, United Kingdom
| | - Norman Shreeve
- Department of Obstetrics and Gynaecology, University of Cambridge, NIHR Cambridge Comprehensive Biomedical Research Centre, Cambridge, United Kingdom
| | - Ulla Sovio
- Department of Obstetrics and Gynaecology, University of Cambridge, NIHR Cambridge Comprehensive Biomedical Research Centre, Cambridge, United Kingdom
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Alexander E. P. Heazell
- Maternal and Fetal Health Research Centre, School of Medical Sciences, Faculty of Biological, Medical and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
- St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Jim G. Thornton
- Division of Child Health, Obstetrics and Gynaecology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Stephen C. Robson
- Reproductive and Vascular Biology Group, The Medical School, University of Newcastle, Newcastle, United Kingdom
| | - Aris Papageorghiou
- Nuffield Department of Obstetrics and Gynaecology, Oxford, United Kingdom
| | - Gordon C. Smith
- Department of Obstetrics and Gynaecology, University of Cambridge, NIHR Cambridge Comprehensive Biomedical Research Centre, Cambridge, United Kingdom
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Le Doare K, Heath PT, Plumb J, Owen NA, Brocklehurst P, Chappell LC. Uncertainties in Screening and Prevention of Group B Streptococcus Disease. Clin Infect Dis 2020; 69:720-725. [PMID: 30561556 PMCID: PMC6669315 DOI: 10.1093/cid/ciy1069] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 12/11/2018] [Indexed: 01/29/2023] Open
Abstract
In autumn 2016, the UK Department of Health (now Department of Health and Social Care) convened 2 meetings to discuss how to address research evidence gaps in order to minimize the impact of infant group B streptococcus (GBS) disease in the United Kingdom. At that meeting, a number of research priorities were highlighted, including improving the screening for GBS colonization in pregnant women, offering intrapartum antibiotic prophylaxis and point-of-care testing, and understanding the effect of widespread intrapartum antibiotic use on long-term infant health. Further discussions involved investigating the feasibility of a large prospective study of pregnant women and their infants in order to understand the role of antibodies in the protection against GBS disease in infancy following maternal exposure to GBS colonization. Here, we summarize the research uncertainties identified at that meeting.
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Affiliation(s)
- Kirsty Le Doare
- Paediatric Infectious Disease Research Group & Vaccine Institute, St George's University of London, London, United Kingdom
| | - Paul T Heath
- Paediatric Infectious Disease Research Group & Vaccine Institute, St George's University of London, London, United Kingdom
| | - Jane Plumb
- Group B Strep Support, London, United Kingdom
| | - Natalie A Owen
- Science, Research and Evidence, Department of Health and Social Care, London, United Kingdom
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, University of Birmingham, London, United Kingdom
| | - Lucy C Chappell
- Department of Obstetrics, King's College London, London, United Kingdom
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