Linda P. Hunt

Psychosocial stress in pregnancy and its relation to low birth weight

The relation of low birth weight to psychosocial stress in pregnancy was examined using a life events inventory and a state anxiety index. Two hundred and fifty women were randomly selected and interviewed three times during pregnancy and shortly after delivery. Twenty six were excluded. Of the remaining 224 women, nine miscarried, 195 had healthy term babies, and 20 gave birth to babies that were either premature or of low birth weight at term. Low birth weight and prematurity were significantly associated with objective major life events but not state anxiety. The occurrence of objective major life events in the third trimester may be important in precipitating preterm labour. Cigarette smoking was the best predictor and objective major life events the second best predictor of low birth weight. The result was not dependent on social class. These findings suggest that cigarette smoking may be an important mediator of stress on the fetus. Antenatal care should take greater account of stress in pregnancy, and social support systems should be evaluated.

Training for shoulder dystocia: a trial of simulation using low-fidelity and high-fidelity mannequins.

OBJECTIVE: To evaluate the effectiveness of simulation training for shoulder dystocia management and compare training using a high-fidelity mannequin with that using traditional devices. METHODS: Training was undertaken in six hospitals and a medical simulation center in the United Kingdom. Midwives and obstetricians working for participating hospitals were eligible for inclusion. One hundred forty participants (45 doctors, 95 midwives) were randomized to training with a high-fidelity training mannequin (incorporating force perception training) or traditional low-fidelity mannequins. Performance was assessed pre- and posttraining, using a videoed, standardized shoulder dystocia simulation. Outcome measures were delivery, head-to-body delivery time, use of appropriate and inappropriate actions, force applied, and communication. RESULTS: One hundred thirty-two participants completed the posttraining assessment. All training was associated with improved performance: use of basic maneuvers 114 of 140 (81.4%) to 125 of 132 (94.7%) (P=.002), successful deliveries 60 of 140 (42.9%) to 110 of 132 (83.3%) (P<.001), good communication with the patient 79 of 139 (56.8%) to 109 of 132 (82.6%) (P<.001), pre- and posttraining, respectively. Training with the high-fidelity mannequin was associated with a higher successful delivery rate than training with traditional devices: 94% compared with 72% (odds ratio 6.53, 95% confidence interval 2.05–20.81; P=.002). Total applied force was significantly lower for those who had undergone force training (2,030 Newton seconds versus 2,916 Newton seconds; P=.006) but there was no significant difference in the peak applied force 102 Newtons versus 112 Newtons (P=.242). CONCLUSION: This study verifies the need for shoulder dystocia training; before training only 43% participants could achieve delivery. All training with mannequins improved the management of simulated shoulder dystocia. Training on a high-fidelity mannequin, including force perception teaching, offered additional training benefits. LEVEL OF EVIDENCE: I

What reduction in BMI SDS is required in obese adolescents to improve body composition and cardiometabolic health

Objective To study the impact of body mass index (BMI) SD score (SDS) improvement through lifestyle modification on metabolic risk and body composition over 12 months. Design Prospective cohort study. Setting Hospital outpatient weight management clinic in the UK. Patients 88 adolescents (40 males, 86% Caucasian) of median age 12.4 years (range 9.1–17.4) and mean (SD) BMI SDS 3.23 (0.49). Main outcome measures BMI at baseline and 12 months was adjusted for age and gender providing BMI SDS using British 1990 growth reference data. Body composition was measured by bioimpedance. A standard oral glucose tolerance test (OGTT) examined glucose metabolism. Fasting lipid profiles, high sensitivity C-reactive protein (HsCRP) and blood pressure (BP) were measured. Results Reducing BMI SDS by ≥0.5 achieved significant improvements in important measures of body composition with mean waist circumference SDS reducing by 0.74 units and body fat SDS by 0.60 units, while also leading to significant reductions in key metabolic risk factors (triglycerides (−30%), low-density lipoprotein-cholesterol (−15%), HsCRP (−45%)). A lesser reduction of ≥0.25 improved insulin sensitivity, total cholesterol/high-density lipoprotein ratio and BP. The greater the BMI SDS reduction, the better the improvement seen in insulin sensitivity. The most insulinsensitive individuals at baseline were most likely to achieve BMI SDS changes of ≥0.5 regardless of baseline BMI SDS. Conclusions Improvement in body composition and cardiometabolic risk can be seen with BMI SDS reductions of ≥0.25 in obese adolescents, while greater benefits accrue from losing at least 0.5 BMI SDS. The most insulin-sensitive individuals seem best able to effect these changes.

Change in knowledge of midwives and obstetricians following obstetric emergency training: a randomised controlled trial of local hospital, simulation centre and teamwork training

Objectives  To explore the effect of obstetric emergency training on knowledge. Furthermore, to assess if acquisition of knowledge is influenced by the training setting or teamwork training.

90-day mortality after 409,096 total hip replacements for osteoarthritis, from the National Joint Registry for England and Wales: a retrospective analysis.

BACKGROUND Death within 90 days after total hip replacement is rare but might be avoidable dependent on patient and treatment factors. We assessed whether a secular decrease in death caused by hip replacement has occurred in England and Wales and whether modifiable perioperative factors exist that could reduce deaths. METHODS We took data about hip replacements done in England and Wales between April, 2003, and December, 2011, from the National Joint Registry for England and Wales. Patient identifiers were used to link these data to the national mortality database and the Hospital Episode Statistics database to obtain details of death, sociodemographics, and comorbidity. We assessed mortality within 90 days of operation by Kaplan-Meier analysis and assessed the role of patient and treatment factors by Cox proportional hazards model. FINDINGS 409,096 primary hip replacements were done to treat osteoarthritis. 1743 patients died within 90 days of surgery during 8 years, with a substantial secular decrease in mortality, from 0·56% in 2003 to 0·29% in 2011, even after adjustment for age, sex, and comorbidity. Several modifiable clinical factors were associated with decreased mortality according to an adjusted model: posterior surgical approach (hazard ratio [HR] 0·82, 95% CI 0·73-0·92; p=0·001), mechanical thromboprophylaxis (0·85, 0·74-0·99; p=0·036), chemical thromboprophylaxis with heparin with or without aspirin (0·79, 0·66-0·93; p=0·005), and spinal versus general anaesthetic (0·85, 0·74-0·97; p=0·019). Type of prosthesis was unrelated to mortality. Being overweight was associated with lower mortality (0·76, 0·62-0·92; p=0·006). INTERPRETATION Postoperative mortality after hip joint replacement has fallen substantially. Widespread adoption of four simple clinical management strategies (posterior surgical approach, mechanical and chemical prophylaxis, and spinal anaesthesia) could, if causally related, reduce mortality further. FUNDING National Joint Registry for England and Wales.

Hospital, simulation center, and teamwork training for eclampsia management: a randomized controlled trial.

OBJECTIVE: To compare the effectiveness of training for eclampsia in local hospitals and a regional simulation center, with and without teamwork theory. METHODS: This study is a randomized controlled trial of training in local hospitals and in a simulation center in the United Kingdom. Midwives and obstetricians working at participating hospitals were randomly assigned to 24 teams. Teams were randomly allocated to training in local hospitals or at a simulation center, and to teamwork theory or not. Performance was evaluated before and after training with a standardized eclampsia scenario captured on video. Outcome measures were completion of tasks, time to completion of tasks, administration of magnesium sulfate, and quality of teamwork. RESULTS: Training was associated with an increase in completion of basic tasks; 87% before training and 100% afterward. Basic tasks were completed more quickly; 55 seconds compared with 27 seconds, P=.012. The magnesium sulfate loading dose was administered by 61% of teams before training and by 92% afterward (P=.040). There was a shorter median time to administration (116 seconds less; P=.011). Training at the simulation center was not associated with additional improvement. Teamwork generally improved (median global score rose from 2.5 to 4.0; P<.001) but there was no additional benefit from teamwork training. CONCLUSION: Training resulted in enhanced performance with higher rates of completion for basic tasks, shorter times to administration of magnesium sulfate, and improved teamwork. There was no additional benefit from training in a simulation center, and none from teamwork theory. CLINICAL TRIAL REGISTRATION: ISRCTN, http://isrctn.org, ISRCTN67906788, reference number 0270030 LEVEL OF EVIDENCE: I

Management of Shoulder Dystocia : Skill Retention 6 and 12 Months After Training

OBJECTIVE: To assess skill retention 6 and 12 months after shoulder dystocia training. METHODS: Midwives and doctors from six United Kingdom hospitals attended a 40-minute workshop on shoulder dystocia management. Participants managed a standardized simulation before and 3 weeks, 6 months, and 12 months afterward. Outcome measures were delivery, head-to-body delivery time, performance of appropriate actions, force applied, and quality of communication. RESULTS: A total of 122 participants were recruited. One hundred eighteen were evaluated 3 weeks posttraining, for whom follow-up was available for 95 (81%) at 6 months and 82 (70%) at 12 months. Before training, 60 of 122 (49%) achieved delivery, 97 of 118 (82%) were able to deliver after initial training, 80 of 95 (84%) were able to deliver at 6 months, and 75 of 82 (85%) were able to deliver at 12 months. Twenty-one (18%) who could not deliver 3 weeks after training were offered additional training; of these, 11 of 14 (79%) achieved delivery at 12 months. Among those who could deliver 3 weeks posttraining, there was no deterioration in the performance of basic actions, delivery interval, force application, and patient communication. Those who were proficient before initial training performed best at follow-up, but skill retention was also good in those who learned to deliver during initial training. Eighteen percent could not deliver after initial training and required additional individualized tuition; the large majority retained their newly acquired skills at 6 and 12 months. CONCLUSION: Overall, training resulted in a sustained improvement in performance. Annual training seems adequate for those already proficient before training, but more frequent rehearsal is advisable for those initially lacking competency until skill acquisition is achieved. LEVEL OF EVIDENCE: II

Treatment of childhood obesity by retraining eating behaviour: randomised controlled trial

Objective To determine whether modifying eating behaviour with use of a feedback device facilitates weight loss in obese adolescents. Design Randomised controlled trial with 12 month intervention. Setting Hospital based obesity clinic. Participants 106 newly referred obese young people aged 9-17. Interventions A computerised device, Mandometer, providing real time feedback to participants during meals to slow down speed of eating and reduce total intake; standard lifestyle modification therapy. Main outcome measures Change in body mass index (BMI) standard deviation score (SDS) over 12 months with assessment 18 months after the start of the intervention. Secondary outcomes were body fat SDS, metabolic status, quality of life evaluation, change in portion size, and eating speed. Results Using the last available data on all participants (n=106), those in the Mandometer group had significantly lower mean BMI SDS at 12 months compared with standard care (baseline adjusted mean difference 0.24, 95% confidence interval 0.11 to 0.36). Similar results were obtained when analyses included only the 91 who attended per protocol (baseline adjusted mean difference 0.27, 0.14 to 0.41; P<0.001), with the difference maintained at 18 months (0.27, 0.11 to 0.43; P=0.001) (n=87). The mean meal size in the Mandometer group fell by 45 g (7 to 84 g). Mean body fat SDS adjusted for baseline levels was significantly lower at 12 months (0.24, 0.10 to 0.39; P=0.001). Those in the Mandometer group also had greater improvement in concentration of high density lipoprotein cholesterol (P=0.043). Conclusions Retraining eating behaviour with a feedback device is a useful adjunct to standard lifestyle modification in treating obesity among adolescents. Trial registration ClinicalTrials.gov NCT00407420.

Clinical efficiency in a simulated emergency and relationship to team behaviours: a multisite cross‐sectional study

Please cite this paper as: Siassakos D, Bristowe K, Draycott T, Angouri J, Hambly H, Winter C, Crofts J, Hunt L, Fox R. Clinical efficiency in a simulated emergency and relationship to team behaviours: a multisite cross‐sectional study. BJOG 2011;118:596–607.

The Association Between Developmental Coordination Disorder and Other Developmental Traits

OBJECTIVE: To explore associations between developmental coordination disorder (DCD) and attention, language, social skills, and academic ability in a population-based cohort. METHODS: We analyzed data (N = 6902) from the Avon Longitudinal Study of Parents and Children (ALSPAC). Probable DCD was defined as children below the 15th centile of the ALSPAC Coordination Test aged 7 years with functional impairment in activities of daily living or handwriting, excluding children with neurologic difficulties or an IQ of <70. Four developmental domains were assessed by using standardized tests between the ages of 7.5 and 9 years: attention; language skills (expressive language, comprehension, short-term memory); social skills (nonverbal skills and social communication); and academic ability (reading and spelling). The worst 5% of each trait was used to define impairment. We used multiple logistic regression models to assess the association between probable DCD and each trait. Our final model controlled for IQ, socioeconomic factors, and other developmental traits not in the domain assessed. RESULTS: A total of 346 (5.0%) children met criteria for probable DCD. Probable DCD was associated with difficulties in attention (odds ratio [OR]: 1.94 [95% confidence interval (CI): 1.17–3.24]), nonword repetition (OR: 1.83 [95% CI: 1.26–2.66]), social communication (OR: 1.87 [95% CI: 1.15–3.04]), reading (OR: 3.35 [95% CI: 2.36–4.77]), and spelling (OR: 2.81 [95% CI: 2.03–3.90]). CONCLUSIONS: Children with probable DCD had an increased risk of difficulties in attention, social skills, reading, and spelling. These additional difficulties need to be screened for during assessment and considered when formulating interventions.