W. Harper Gilmour

Randomised, controlled trial of efficacy of midwife-managed care

BACKGROUND Midwife-managed programmes of care are being widely implemented although there has been little investigation of their efficacy. We have compared midwife-managed care with shared care (ie, care divided among midwives, hospital doctors, and general practitioners) in terms of clinical efficacy and womens satisfaction. METHODS We carried out a randomised controlled trial of 1299 pregnant women who had no adverse characteristics at booking (consent rate 81.9%). 648 women were assigned midwife-managed care and 651 shared care. The research hypothesis was that compared with shared care, midwife-managed care would produce fewer interventions, similar (or more favourable) outcomes, similar complications, and greater satisfaction with care. Data were collected by retrospective review of case records and self-report questionnaires. Analysis was by intention to treat. FINDINGS Interventions were similar in the two groups or lower with midwife-managed care. For example, women in the midwife-managed group were less likely than women in shared care to have induction of labour (146 [23.9%] vs 199 [33.3%]; 95% CI for difference 4.4-14.5). Women in the midwife-managed group were more likely to have an intact perineum and less likely to have had an episiotomy (p = 0.02), with no significant difference in perineal tears. Complication rates were similar. Overall, 32.8% of women were permanently transferred from midwife-managed care (28.7% for clinical reasons, 3.7% for non-clinical reasons). Women in both groups reported satisfaction with their care but the midwife-managed group were significantly more satisfied with their antenatal (difference in mean scores 0.48 [95% CI 0.41-0.55]), intrapartum (0.28 [0.18-0.37]), hospital-based postnatal care (0.57 [0.45-0.70]), and home-based postnatal care (0.33 [0.25-0.42]). INTERPRETATION We conclude that midwife-managed care for healthy women, integrated within existing services, is clinically effective and enhances womens satisfaction with maternity care.

Prevalence of dental fluorosis in children from non-water-fluoridated Halmstad, Sweden: fluoride toothpaste use in infancy

Objectives. To determine the prevalence and severity of dental fluorosis in children aged 7–9 years from non-water-fluoridated Halmstad, Sweden, and to relate the results to their reported fluoride exposure history during infancy. Material and Methods. In Spring 2002, a questionnaire distributed to a cluster random sample of 1039 parents enquired into their childs early oral health behaviors and included a “photographic toothpaste menu”. The permanent upper anterior teeth (13–23) were examined clinically (+10% repeats) using a modified Thylstrup-Fejerskov Index. Results. Complete data were available for 53% (n=548) of the sampled children. The prevalence of fluorosis at any level was 49% (95% CI: 45–54%), and of fluorosis with esthetic concern (TF score ≥3) 4% (95% CI: 3–6%). Based on repeat observations, reliability was good (kappa=0.82). There was no statistically significant increased risk of dental fluorosis prevalence associated with any of the fluoride exposure risk factors examined, including reported usage of (1000 ppm) fluoride toothpaste from time of first deciduous tooth eruption. Conclusions. While there were low levels of dental fluorosis of esthetic concern, half the children had some degree of dental fluorosis. The prevalence of dental fluorosis was not explained by the risk factors, including fluoride toothpaste usage as explored in this study.

Tailored written invitations for second round breast cancer screening: a randomised controlled trial

Objectives– Firstly, to determine if attendance for second round mammography screening in those sent a tailored letter (that is, making reference to their screening history) is increased compared with those sent a standard letter; secondly, to investigate the acceptability of tailored letters. Setting– North West Glasgow Breast Screening Centre. Methods– A randomised controlled trial. Results – Overall attendance was unrelated to whether the women were sent a tailored or standard letter; 60% of those sent the standard letter attended (922/1531) compared with 62% of those sent the tailored letter (956/1552) (χ2 = 0·61, P = 0·4) (difference 2%; 95% confidence interval − 2% to 5%). There were no significant differences in percentage attendance within each of the study subgroups: women who attended previously and received an all clear result, women who attended previously and received a false positive result, women who were invited previously and failed to attend, and women who were previously too young to be invited for screening. However, there was a statistically significant difference in percentage attendance between these four groups, independent of letter type (χ2 = 510, P<0·00001). Although women found the letters acceptable and understandable, they did not seem to pay close attention to the content. Conclusions– Tailoring invitation letters does not have a significant effect on uptake rates for breast screening and does not justify the additional workload required.

Does writing a list help cancer patients ask relevant questions

We examined the use of written lists to give patients an opportunity to have their questions answered. Patients undergoing radical radiotherapy for cancer were given a sheet of paper with the simple prompt to write questions and give to the hospital doctor at their appointment 3 weeks later. At 3 months, patients were asked about their use and opinions of the written list. About half of the 478 patients attended with a written list. Fewer patients living in deprived areas used the list compared to more affluent areas. Doctors thought that 34% of patients would not otherwise have asked those questions and 91% of prompted discussions were a worthwhile use of time.

Changes to leave of absence in Scotland: the views of patients

Sixty-four patients were interviewed about changes to leave of absence brought about by the Mental Health (Patients in the Community) Act 1995 in the context of their views about services and medication. Few patients were clear about the change in the law,which suggests that more has to be done to inform patients of their rights and legal status. A number of patients reported difficulty in negotiating preferred medication with their psychiatrists and felt compelled to take medication that resulted in debilitating side-effects. A third of patients eligible to be interviewed agreed to an interview and ethical and practical difficulties in accessing patients for this type of research are discussed.

Impact of prenatal screening and diagnosis on the epidemiology of structural congenital anomalies.

Objective — To assess the impact of prenatal screening on the birth prevalence of three categories of structural congenital anomaly: abdominal wall defects (omphalocele and gastroschisis), renal agenesis/dysgenesis, and limb reduction defects. Setting — Glasgow, Scotland, United Kingdom. Methods — Data on the selected defects were obtained retrospectively from the population based Glasgow Register of Congenital Anomalies for the period 1980–91 inclusive. The register records all clinical or laboratory diagnoses of congenital anomaly in live births, stillbirths, and induced abortions occurring in women resident within the boundaries of the Greater Glasgow Health Board. The secular trends in the proportions of the defects diagnosed prenatally and terminated after screening, and in their prevalence at birth and during pregnancy, were examined. A total of 154845 births were surveyed: 309 cases were identified in the selected anomaly categories. Results — 83 cases of omphalocele/gastroschisis (5·4/10000 births), 92 cases of renal agenesis/dysgenesis (5·9/10000 births), and 134 cases of limb reduction defects (8·7/10000 births) were found. Marked increases occurred over the study period in the proportions of cases diagnosed prenatally but not in the proportions terminated. The greatest difference between the prevalence at birth and during pregnancy was found for omphalocele. There were no significant secular trends in the prevalence of the selected defects. Conclusions — Prenatal screening has made a limited epidemiological impact on the prevalence of these defects. It has been moderately (but inconsistently) effective in the avoidance of births of infants with omphalocele/gastroschisis and renal agenesis/dysgenesis but not of limb reduction defects. Future efforts should be directed towards improving the technical aspects of the ultrasonographic detection of fetal abnormalities and exploring in detail, locally, the reasons for the varying pattern of decision making about termination of pregnancy among prospective parents.

Photographic assessment of fluorosis in children from naturally fluoridated Kungsbacka and non-fluoridated Halmstad, Sweden.

Objectives. To assess levels of fluorosis and fluorosis of esthetic concern in children from a naturally fluoridated and a non-fluoridated area of Sweden, and to determine the relative contributions of fluoridated water, parental educational level, and infant oral health-related behaviors. Methods. A parental questionnaire collected information concerning child F-supplement and F-dentifrice usage histories, and socio-economic status. Photographic examination of 1336 subjects (F=791; N-F=545) was undertaken. Fluorosis was assessed (blind to F-exposure) in a random sample (n=250) of 35 mm slides by four dental and two lay “jurors” (with 10% random repeat-viewing for inter-observer and intra-observer agreement). Four outcomes were assessed on each slide: fluorosis at any level, fluorosis of esthetic concern, acceptability of appearance, and treatment needs. Ordinal logistic regression models were used to determine significant determinants. Results. For presence of fluorosis of esthetic concern, majority jury agreements (>3 of 6) were seen in only 2.3% (N-F) and 13.4% (F) pupils (p<0.001), albeit jurors unanimously scored only 13 F and 2 N-F exposed children as having esthetically unacceptable fluorosed teeth (p<0.001). The over-riding significant factor in terms of fluorosis of esthetic concern was exposure to water fluoridation in infancy in both unadjusted and adjusted models. Conclusions. The important factor in relation to fluorosis of esthetic concern was explained by exposure to fluoridated water in infancy, and was not explained by age, sex, level of parental education or early childhood oral health behaviors. However, prevalence of this condition was relatively low. These findings should inform policies on appropriate total fluoride exposure levels during infancy.

Computer-based learning in statistics: a problem solving approach

Summary. Software which allows interactive textual and graphical material to be created relatively easily has now existed for several years. This has promoted considerable interest in computerbased learning. This paper describes an approach which uses these tools to create problem-based material for use in laboratory sessions in association with courses in statistics. Illustrations are given, and the presentation of one particular problem, based on the design and analysis of a simple clinical trial, is developed in detail. Important issues of design, construction and evaluation are also discussed. It is argued that, although it is expensive to produce, material of this type can provide real benefits as a teaching resource.

Views of consultant psychiatrists and mental health officers in Scotland on the Mental Health (Patients in the Community) Act 1995

In 1995 new legislation was introduced in Scotland limiting Leave of Absence to 12 months and introducing Community Care Orders (CCOs). Consultant psychiatrists and mental health officers in Scotland were surveyed by postal questionnaire to ascertain their views on the impact of this new legislation. The reduced powers for psychiatrists to ensure compliance with medication in the community and the introduction of a new form of supervision of patients (CCOs) that does not include compulsory treatment orders are unpopular with both groups of professionals but significantly more unpopular with consultants than mental health officers. This is examined in relation to a previous survey of professional attitudes. The place of the Care Programme Approach and the possible shortage of community care resources in relation to this group of patients are also discussed. The results are further discussed in the context of current reviews of mental health legislation.