Fiona L. R. Williams

Randomised controlled trial of cardiotocography versus Doppler auscultation of fetal heart at admission in labour in low risk obstetric population

Abstract Objective: To compare the effect of admission cardiotocography and Doppler auscultation of the fetal heart on neonatal outcome and levels of obstetric intervention in a low risk obstetric population. Design: Randomised controlled trial. Setting: Obstetric unit of teaching hospital Participants: Pregnant women who had no obstetric complications that warranted continuous monitoring of fetal heart rate in labour. Intervention: Women were randomised to receive either cardiotocography or Doppler auscultation of the fetal heart when they were admitted in spontaneous uncomplicated labour. Main outcome measures: The primary outcome measure was umbilical arterial metabolic acidosis. Secondary outcome measures included other measures of condition at birth and obstetric intervention. Results: There were no significant differences in the incidence of metabolic acidosis or any other measure of neonatal outcome among women who remained at low risk when they were admitted in labour. However, compared with women who received Doppler auscultation, women who had admission cardiotocography were significantly more likely to have continuous fetal heart rate monitoring in labour (odds ratio 1.49, 95% confidence interval 1.26 to 1.76), augmentation of labour (1.26, 1.02 to 1.56), epidural analgesia (1.33, 1.10 to 1.61), and operative delivery (1.36, 1.12 to 1.65). Conclusions: Compared with Doppler auscultation of the fetal heart, admission cardiotocography does not benefit neonatal outcome in low risk women. Its use results in increased obstetric intervention, including operative delivery. What is already known on this topic The admission cardiotocogram is a short recording of the fetal heart rate immediately after admission to the labour ward Opinion varies about its value in identifying a potentially compromised fetus In low risk women, the incidence of intrapartum fetal compromise is low What this study adds Compared with Doppler auscultation of the fetal heart, admission cardiotocography has no benefit on neonatal outcome in low risk women Admission cardiotocography results in increased obstetric intervention, including operative delivery

Reducing door-to-antibiotic time in community-acquired pneumonia: controlled before-and-after evaluation and cost-effectiveness analysis

Background: Practice guidelines suggest that all patients hospitalised with community-acquired pneumonia (CAP) should receive antibiotics within 4 h of admission. An audit at our hospital during 1999–2000 showed that this target was achieved in less than two thirds of patients with severe CAP. Methods: An experienced multidisciplinary steering group designed a management pathway to improve the early delivery of appropriate antibiotics to patients with CAP. This was implemented using a multifaceted strategy. The effect of implementation was evaluated using a controlled before-and-after study design over two winter seasons (November–April 2001–2 and 2002–3). Cost-effectiveness analyses were performed from the hospital’s perspective. Results: The proportion of patients receiving appropriate antibiotics within 4 h of admission to hospital increased from 33% to 56% at the intervention site, and from 32% to 36% at the control site (absolute change adjusted for differences in severity of illness 17%, p = 0.035). The cost per additional patient receiving appropriate antibiotics within 4 h was £132 with no post-implementation evaluation, and £456 for a limited post-implementation evaluation. Simple modelling from the results of a large observational study suggests that the cost per death prevented could be £3003 with no post-implementation evaluation, or £16 632 with a limited post-implementation evaluation. Conclusions: The intervention markedly improved door-to-antibiotic time, albeit at considerable cost. It might still be a cost-effective strategy, however, to reduce mortality in CAP. Uncertainty about the cost effectiveness of such interventions is likely to be resolved only by a well-designed, cluster randomised trial.

Impact of vector control on a dengue fever outbreak in Trinidad, West Indies, in 1998.

In 1998, Trinidad experienced its first major outbreak of dengue haemorrhagic fever. Data from the Trinidad Public Health Laboratory, the National Surveillance Unit and Insect Vector Control Division, Ministry of Health, Trinidad and Tobago were analysed to determine the impact of vector control measures on the dengue outbreak. Geographical Information Systems (GIS)/Global Positioning Systems (GPS) were used to map cases and to distinguish epidemiological clusters. The Aedes aegypti population densities were higher than the 5% transmission threshold in all counties. The spatial distribution of dengue fever cases was significantly correlated with the heavily populated east–west corridor in the north and several distinctly separate clusters in the western part of the island. The temporal distribution patterns showed significantly more dengue fever cases occurring during the rainy season than during the dry season. This study documents the importance of vector control in the prevention of dengue transmission since no vaccine is currently available, and emphasizes the urgent need to understand better the environmental factors which contribute to the proliferation of this disease vector Ae. aegypti.

Levels of Neonatal Thyroid Hormone in Preterm Infants and Neurodevelopmental Outcome at 5½ Years: Millennium Cohort Study

CONTEXT Transient hypothyroxinemia is the commonest thyroid dysfunction of premature infants, and recent studies have found adverse associations with neurodevelopment. The validity of these associations is unclear because the studies adjusted for a differing range of factors likely to influence neurodevelopment. OBJECTIVE The aim was to describe the association of transient hypothyroxinemia with neurodevelopment at 5.5 yr corrected age. DESIGN We conducted a follow-up study of a cohort of infants born in Scotland from 1999 to 2001 ≤34 wk gestation. MAIN OUTCOME MEASURES We measured scores on the McCarthy scale adjusted for 26 influences of neurodevelopment including parental intellect, home environment, breast or formula fed, growth retardation, and use of postnatal drugs. RESULTS A total of 442 infants ≤34 wk gestation who had serum T(4) measurements on postnatal d 7, 14, or 28 and 100 term infants who had serum T(4) measured in cord blood were followed up at 5.5 yr. Infants with hypothyroxinemia (T(4) level ≤ 10th percentile on d 7, 14, or 28 corrected for gestational age) scored significantly lower than euthyroid infants (T(4) level greater than the 10th percentile and less than the 90th percentile on all days) on all McCarthy scales, except the quantitative. After adjustment for confounders of neurodevelopment, hypothyroxinemic infants scored significantly lower than euthyroid infants on the general cognitive and verbal scales. CONCLUSIONS Our findings do not support the view that the hypothyroxinemic state, in the context of this analysis, is harmless in preterm infants. Many factors contribute both to the etiology of hypothyroxinemia and neurodevelopment; strategies for correction of hypothyroxinemia should acknowledge its complex etiology and not rely solely on one approach.

UK study of intrapartum care for low risk primigravidas: a survey of interventions.

STUDY OBJECTIVE: To determine the extent of intrapartum intervention received by primigravidas. DESIGN: Cross sectional survey of NHS hospitals in the UK. SETTING: One hundred and one randomly selected hospital maternity units. PARTICIPANTS: Forty consecutive primigravid women, judged to be at low risk at the start of labour, in each hospital. MAIN OUTCOME MEASURES: Seven groups of interventions or monitoring procedures were identified from the first, second, and third stages of labour: fetal monitoring, vaginal examinations, artificial rupture of membranes, augmentation of labour, pain relief, type of delivery, and episiotomy. Data were collected during 1993. MAIN RESULTS: Ninety eight hospitals took part in the study and data were collected on 3160 low risk primigravidas. Seventy four per cent of these women had continuous cardiotocography. The proportion of women having restrictive or invasive fetal monitoring showed appreciable geographical variation for both the first and second stages of labour. Using the criterion of a vaginal examination every four hours and allowing for the length of each womans labour, 72% had more vaginal examinations than expected; there was a significant geographical variation in the number of women receiving more than five examinations. Fifty three per cent had artificial rupture of membranes; the procedure was performed over a wide range of cervical dilatations (0 cm-10 cm). Thirty eight per cent of labours were augmented, most commonly by intravenous syntocinon; the procedure showed significant geographical variation. Twenty eight per cent had a spinal block or epidural analgesia for the relief of pain; this intervention varied by geographical region only for the second stage of labour. Over one quarter of the women required instrumental delivery. Forty six per cent had an episiotomy; the frequency of this intervention varied substantially by region. There were no infant deaths. Twelve babies were recorded at birth as having a congenital anomaly. CONCLUSIONS: The rates of several interventions seem high for this low risk group and there was substantial geographical variation in the use of six interventions. Clinical trials are needed to evaluate the optimum criteria for using these interventions from which guidelines should be drawn up by local groups and the Royal College.

Twinning in human populations and in cattle exposed to air pollution from incinerators.

Human populations and animals are often exposed to the airborne pollutants in plumes from incinerators. The incineration of chemical and other waste may release polychlorinated hydrocarbons, some of which have oestrogenic properties. Increased numbers of twins had been reported anecdotally in cattle at risk from plumes from two incinerators near the town of Bonnybridge in central Scotland and also in cattle near a chemical factory in Eire. It was decided to follow up these reports in central Scotland and also to test the hypothesis that the frequency of human twinning might be increased there. Data on human twin and single births in hospitals in central Scotland were obtained for the years 1975-83. The twinning rates in areas exposed to airborne pollution from incinerators were compared with the background rates present in neighbouring areas. Farmers provided information on calving among the herds of two farms close to the incinerators. The frequency of human twinning was increased, particularly after 1979, in the areas most at risk from air pollution from the incinerators. Among the dairy cattle, there was a dramatic increase in twinning at about the same time.

Multiprofessional education in undergraduate curricula can work

A multiprofessional educational programme about labour was introduced into the undergraduate curriculum for medical students and the diploma course for midwifery students. The students gained knowledge about labour and a better understanding of each others role in the care of the labouring women. The change in awareness of professional responsibility was greatest for medical students; it was evident in medical students taught in medical-student-only groups and also in those taught alongside midwives. Differences in professional attitudes between the medical and midwifery students at the start of the course were less marked following completion of the course. The programme was well received by both students and tutors; both groups advocated the use of mixed medical/midwifery teaching in other areas of the curricula.We conclude that multiprofessional learning has a role in medical and nursing education when the intended educational objectives are clearly defined and the educational strategy and learning op...

Sex ratios of births, mortality, and air pollution: can measuring the sex ratios of births help to identify health hazards from air pollution in industrial environments?

OBJECTIVES--To compare the sex ratios of births and mortality in 12 Scottish localities with residential exposure to pollution from a variety of industrial sources with those in 12 nearby and comparable localities without such exposure. METHODS--24 localities were defined by postcode sectors. SMRs for lung cancer and for all causes of death and sex ratios of births were calculated for each locality for the years 1979-83. Log linear regression was used to assess the relation between exposure, sex ratios, and mortality. RESULTS--Mortalities from all causes were consistently and significantly higher in the residential areas exposed to air pollution than in the non-exposed areas. A similar, but less consistently significant, excess of mortality from lung cancer in the exposed areas was also found. The associations between exposure to the general air pollution and abnormal sex ratios, and between abnormal sex ratios and mortality, were negligible. CONCLUSIONS--Sex ratios were not consistently affected when the concentrations or components of the air pollution were insufficiently toxic to cause substantially increased death rates. Monitoring of the sex ratio does not provide a reliable screening measure for detecting cryptic health hazards from industrial air pollution in the general residential environment.

Use of Indicators to Evaluate the Quality of Community-Acquired Pneumonia Management

Quality-assessment indicators for community-acquired pneumonia (CAP) founded on health care structure, process, and outcome have been recommended as a potential audit tool to evaluate the delivery of care. We prospectively audited the treatment of 205 patients admitted with CAP to 2 hospitals in Dundee against some of these key standards. Patients with severe CAP were more likely to die (mortality rate, 42% versus 7%) and to receive antibiotics by the intravenous route (relative risk [RR], 1.81; 95% confidence interval [CI], 1.38-2.37) and within 4 hours of admission to the hospital (RR, 1.22; 95% CI, 0.92-1.62). There was a lack of uniformity regarding the amount of oxygen prescribed, with evidence of poor case record and drug prescription chart documentation related to oxygen therapy. Adherence to the recommended antibiotic policy was associated with reduced risk of death or readmission to the hospital (RR, 0.58; 95% CI, 0.34-1.00). However, in a multivariate analysis, severity of pneumonia was the strongest predictor of death or readmission (P=.004), and adherence to the antibiotic policy was not statistically significant (P=.154). Our study has confirmed the value of quality indicators in evaluating our CAP management and has stimulated the development and implementation of a local hospital-based integrated care pathway.

Mild maternal thyroid dysfunction at delivery of infants born <34 weeks and neurodevelopmental outcome at 5.5 years

CONTEXT Mild maternal thyroid dysfunction during early pregnancy is associated with poor neurodevelopment in affected offspring. Most studies are population based or are smaller populations of term/late preterm infants. No studies were found that focused on more preterm infants. OBJECTIVE Our objective was to describe the relationship between mild maternal thyroid dysfunction at delivery of infants born ≤34 wk and neurodevelopment at 5.5 yr. DESIGN The study design was follow-up of women and children recruited in Scotland between 1998 and 2001. MAIN OUTCOME We evaluated delivery levels of maternal TSH, free T(4) (FT(4)), and T(4) and the association with McCarthy Scale scores adjusted for 26 confounders of neurodevelopment. RESULTS Maternal serum levels and McCarthy scores were available for 143 women and 166 children. After adjustment for confounders, there were significant 3.2, 2.1, and 1.8 point decrements, respectively, in general cognitive index, verbal subscale, and the perceptual performance subscale for each milliunit per liter increment in maternal TSH. Maternal FT(4) levels were variably associated with neurodevelopment. After adjustment, significant associations were found for the general cognitive index, motor scale, and quantitative subscale; each picomole per liter decrease in FT(4) was associated with an increase of 1.5, 1.7, and 0.9 points, respectively. Maternal T(4) levels showed little relationship with neurodevelopment. None of the women in this analysis had overt hypothyroidism, but mild hypothyroidism was evident in 27%; thyroglobulin antibody (TgAb) was ≥ 40 U/ml in 28% of the women. CONCLUSIONS Higher maternal levels of TSH at delivery of infants born preterm were associated with significantly lower scores on the general cognitive index at 5.5 yr.