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Biomedical subjects

J Chapple

Publications and source records attributed to J Chapple.

At least 19 recordsLinked to original sources
PubMed2002

Admissions for critically ill children: where and why?

INTRODUCTION: Planning services for critically ill children requires identification of overall critical care activity as well as an assessment of population needs. METHOD AND OBJECTIVES: This prospective needs assessment took a census approach to estimating population-based admission rates for paediatric critical care irrespective of where care was provided. A survey form was completed for every child in the study population for all of their admissions. CRITERIA: The need for tracheal intubation was used as a proxy for defining need for intensive care in this study. Critical illness was defined by clinical criteria adapted from the Advanced Paediatric Life Support Guidelines. STUDY POPULATION: All children under 17 years resident in south-east England (Thames regions) who required care for a critical illness in any inpatient setting between 1 December 1996 and 30 November 1997. Critical illness was the presence of acute body-system or multi-system failure. RESULTS: A wide variation in the rates of critical care admission to different types of care settings was reported ranging from 1.2 admissions per 1000 resident children per year for PIC units (general and cardiothoracic units) to 0.02 admissions per 1000 children per year for children admitted from the community to neonatal units. The age of children and their rates of admission were directly related to the type of ward or unit where children received care. Tracheal intubation occurred in all care settings. The proportion of intubated children transferred to paediatric intensive care units (PICUs) or paediatric cardiothoracic intensive care units (PCICUs) varied according to the type of referring unit. The proportion of episodes involving tracheal intubation where the child was not transferred to a PICU or PCICU was 52% for children in stand-alone neurosurgical units, 41% for those in adult intensive care units (AICUs), and 4% for those in children's wards. CONCLUSIONS: This baseline study shows a significant number of critically ill children who are never cared for in PIC units. With national changes in UK policy to regionalise care for these children, monitoring care in all locations by cause of admission remains important. While the data were collected in 1997, the findings from this study remain relevant and provide the basis for planning regional critical care services for children. Results are also relevant to other geographical areas in that measuring the use of services for critically ill children must go beyond documenting admission to ICUs for children and adults. All settings for critical care must be identified, the activity documented, and the use of services measured against existing resources. Clear clinical criteria are needed to identify children who can be cared for appropriately on high dependency units.

Adolescent↗
PubMed1999

Towards effective obstetric anaesthetic audit in the UK.

Obstetric audit is multidisciplinary, but maternal mortality data represent the only national obstetric anaesthetic audit currently available in the UK. Maternity and neonatal audit is progressing towards the collection of both numerator and denominator data in order to compare local, regional and national figures. Obstetric anaesthetists as a professional group play a significant role in maternity care and have in the past developed a minimum data set. Such a set now requires revision of items, agreement on definitions and integration with national projects. Since local and regional obstetric anaesthesia data collection systems are available, albeit in various manual or computerized forms, this is an achievable target. A standard maternity and neonatal data set which incorporates obstetric anaesthetic clinical items could offer a qualitative comparison of process variables and outcome, but should be under professional anaesthetic control. In addition, the process may enable professional standards to be defined and tested so that high quality obstetric anaesthetic care can be maintained.

Journal Article↗
PubMed1997

47,XXY (Klinefelter syndrome) and 47,XYY: estimated rates of and indication for postnatal diagnosis with implications for prenatal counselling.

Cytogenetic surveys of neonates have found that approximately one boy in 500 is born with an extra sex chromosome. Some of these boys are now being diagnosed when prenatal karyotyping is done for the detection of Down syndrome and other major aneuploidies. This study estimates what proportion of those not detected prenatally will be diagnosed postnatally and what the indications for karyotyping are likely to be. We ascertained all 47,XXY and 47,XYY males detected prenatally and postnatally (during the 4 years 1990-1993) in the three cytogenetic laboratories in the North Thames (West) region. The age at diagnosis and indication for karyotyping were noted for cases diagnosed postnatally. Less than 10 per cent of the estimated number of affected fetuses were detected prenatally. This study suggests that most males born with these chromosome patterns will go through life without being karyotyped, that the commonest indication for a 47,XYY male to be karyotyped will be developmental delay and/or behaviour problems, and that the commonest indication for a Klinefelter male to be karyotyped will be hypogonadism and/or infertility. It would appear that most undiagnosed 47,XXY and 47,XYY males do not look or behave in a manner which prompts testing for a chromosome abnormality.

Abortion, Eugenic↗
PubMed1996

The standard primipara as a basis for inter-unit comparisons of maternity care.

OBJECTIVE: To assess the suitability of the standard primipara (a subset of the obstetric population that has relatively low risk or intervention and of adverse outcome) for making inter-unit comparisons of indicators of the process and outcome of maternity care. DESIGN: Inter-unit comparison of 10 indicators of obstetric intervention and adverse outcome derived from routinely collected computerised data held on the St Mary's Maternity Information System. SETTING: Fifteen maternity units in the former North West Thames Region. PARTICIPANTS: 15,463 primiparae who were delivered in 1992. MAIN OUTCOME MEASURES: Proportion of primiparae within the standard definition; degree to which standard primiparae are associated with lower rates of intervention and adverse outcome, as compared to other primiparae. RESULTS: Within the database, 42.6% of all primiparae were found to be standard, with rates varying between units from 25.9% to 57.7%. As expected, the standard primiparous woman is at less risk of intervention or adverse outcome than other primiparae. All but one component variable of the standard definition is a significant risk factor for at least four of the 10 indicators. Statistically significant differences in indicator rates are seen between standard and nonstandard primiparae within units. Within the standard group, significant differences in rates of intervention and adverse outcome are seen between units. Units with relatively high levels of intervention within the higher risk nonstandard group also have relatively high levels of intervention within the standard group. CONCLUSIONS: Use of the standard primipara, rather than the whole obstetric population, as the basis for inter-unit comparisons of maternity care will control for the substantial difference in case mix seen in different units, thereby increasing the validity of those comparisons. The technique has the additional benefit of clarifying the relationship between everyday clinical decision making and a unit's performance in comparative indicator reports. The approach must be combined with a separate study of the other groups in the case mix, such as multiparae and high risk primiparae. Additional nonoverlapping groups, homogeneous in terms of risk factors, should be defined and used to extend the basis on which comparisons may be made.

Adult↗
PubMed1994

What is the optimal caesarean section rate? An outcome based study of existing variation.

STUDY OBJECTIVE: To investigate the consequences of different levels of caesarean section (CS) rate in terms of fetal and maternal outcomes. DESIGN: Comparison of outcome variables between four categories of maternity units stratified according to CS rates. Data were collected concurrently. SETTINGS: All 17 maternity units in one health region. SUBJECTS: Data for the perinatal mortality analysis: all 221,867 deliveries in 1983-87 (excluding severe malformations) (1462 deaths); maternity information analysis system: all 36,727 women with singleton pregnancies who delivered in 1988. OUTCOME MEASURES: Perinatal mortality, Apgar scores at one and five minutes, onset of respiration after one minute, postnatal transfusion, postnatal infection, thromboembolism, low haemoglobin concentration at discharge, and puerperal psychosis were determined. RESULTS: Teaching hospitals with an increased proportion of high risk cases had the highest CS rate, but the other three categories were found to serve comparable populations. Perinatal mortality showed a birthweight specific pattern--for very low birthweight infants, but not for other deliveries, mortality rates were lower in units with higher CS rates. Apgar scores showed no trend, but the onset of respiration after one minute was significantly more frequent in units with a CS rate of less than 10%. Increased maternal postnatal blood transfusion was associated with higher CS rates but no trend was observed for the other maternal variables. CONCLUSIONS: CS rates in general maternity units should be 10 to 12% or lower in the singleton population as a whole, but a more interventionist approach is indicated for very low birthweight infants. If confirmed, these recommendations could easily be incorporated into clinical audit.

Apgar Score↗
PubMed1993

Room for improvement? Detecting autosomal trisomies without serum screening.

OBJECTIVE: To assess the efficacy of the prenatal screening and diagnostic programme for the detection of the common autosomal trisomies in the North West Thames region prior to the introduction of serum screening. DESIGN: A retrospective study based on reports made to the North West Thames Regional Health Authority Congenital Malformation Register. SUBJECTS: 235 pregnancies of women delivered in units in the North West Thames region over a two-year period (1990-91) whose babies or fetuses were diagnosed as having Down, Edwards or Patau syndrome. RESULTS: 33% of Down syndrome, 68% of Edwards syndrome and 52% of Patau syndrome were diagnosed prenatally (before 28 weeks) in the region without the use of serum screening. CONCLUSIONS: Using maternal age and routine ultrasound as screening methods, units in the region are prenatally diagnosing significantly fewer Down syndrome babies than are those in authorities using serum screening. The use of maternal age and ultrasound screening is more effective for the antenatal detection of the other autosomal trisomies than it is for the detection of Down syndrome. It is not yet clear to what extent serum screening might be expected to increase the detection rate for these conditions.

Adult↗
PubMed1993

Which maternity unit? Who makes the choice?

To investigate the factors determining the choice of maternity unit in an outer London district where half of all births occur outside the district, a self-administered questionnaire was distributed by community midwives at postnatal home visits. The main outcome measures were: (1) proportion of mothers able to deliver in unit of first choice; (2) proportion of mothers making a personal choice rather than taking advice from their GP; (3) reasons for not choosing district unit, by parity. It was found that 28/166 (17 per cent) of mothers were unable to deliver in their first choice of unit, and 3/166 (2 per cent) were unable to obtain their second choice. Of the women who did obtain their first choice, 84/136 (62 per cent) had made a personal decision rather than being advised or told by their GP; 58 of these 84 personal deciders went outside the district, but for 36/58 (62 per cent) this was either because the other unit was nearer their home or because they had delivered there before. It is concluded that, although GPs are theoretically free to refer to any maternity unit, a sizeable minority of women are unable to realize their own choices. GPs seem to regulate flows by advising women without strong personal views to attend the local unit. Differences in the quality of care as perceived either by women or their GPs do not seem particularly important in determining choices. The introduction of an internal market in maternity care seems unlikely to result in improved quality of care.

Adult↗
PubMed1992

Psychological and social consequences of community carrier screening programme for cystic fibrosis.

We have assessed the effect of screening for cystic fibrosis (CF) carrier status on anxiety levels, attitudes, knowledge and actions of participants in a pilot programme conducted through primary health care services. Over 3000 individuals were screened and 100 carriers with no previous family history were identified. Varying degrees of anxiety were found to be associated initially with a positive result, but most of this was allayed by genetic counselling, and we find no adverse long-term psychological consequences in carriers. Most discussed carrier status with their partner (89%), parents, other relatives and also with friends; 87% of partners to whom testing was suggested have been screened. Those testing positive indicated that knowledge of carrier status would be considered in future reproductive decisions, and after 6 months carriers retained a reasonable level of knowledge about CF and its inheritance. Carriers and non-carriers uniformly approve of screening and are glad to have been tested. Knowledge of CF in the sample of non-carriers has also increased after testing, suggesting screening may improve understanding of CF among the entire target population. Fears of possible social costs of screening may be ill-founded.

Adolescent↗
PubMed1992

Congenital hypothyroidism detected by neonatal screening: relationship between biochemical severity and early clinical features.

The relationships between biochemical severity of hypothyroidism (as judged by plasma thyroxine) and the clinical and radiographic findings at diagnosis were evaluated in 449 infants born in 1982-4 with congenital hypothyroidism identified by neonatal screening. Details of pregnancy, delivery, and the neonatal period were also examined and compared with the findings in a normal population of 36,727 infants born in 1988. Infants with plasma thyroxine values of 30 nmol/l or less had a significantly higher incidence of prolonged jaundice, feeding difficulties, lethargy, umbilical hernia and macroglossia, showed more severe delay of bone maturation on a knee radiograph, and had a higher proportion of thyroid agenesis on isotope scan. In contrast, an ectopic or hypoplastic gland was more common in infants with plasma thyroxine values above 30 nmol/l. Prevalence of illness in pregnancy and mode of delivery was not related to severity of hypothyroidism and were similar to figures for the normal population. Induction of labour, gestation over 40 weeks, and birth weight above 3500 g were significantly more common in the hypothyroid infants. Perinatal illness and congenital malformations were more common in the infants with low plasma thyroxine values at diagnosis.

Adult↗
PubMed1991

Screening for carriers of cystic fibrosis through primary health care services.

OBJECTIVE: To evaluate the uptake of cystic fibrosis carrier testing offered through primary health care services. DESIGN: Carrier testing for cystic fibrosis was offered to patients of reproductive age through primary health care services. SETTING: Three general practice surgeries and four family planning clinics in South West Hertfordshire District Health Authority. SUBJECTS: Over 1000 patients aged 16-44 attending two general practices and four family planning clinics and a stratified random sample of patients aged 16-44 from one general practice's age-sex register. RESULTS: When screening was offered opportunistically the uptake was 66% in general practice and 87% in family planning clinics. Ten per cent of those offered a screening appointment by letter took up the invitation. Of the screened population, 76% had previously heard of cystic fibrosis, 35% realised it is inherited, and 18% realised that carriers need not have any family history. If they found themselves in an "at risk" partnership 39% would consider not having children and 26% would consider terminating an affected pregnancy, but in each case most people were unsure how they would react. CONCLUSIONS: Most people offered a cystic fibrosis test opportunistically wish to be tested, and the responses of those tested indicate that knowledge of carrier state would be considered in future reproductive decisions.

Attitude to Health↗
PubMed1991

Attitudes to carrier screening for cystic fibrosis: a survey of health care professionals, relatives of sufferers and other members of the public.

The gene which is mutated in cystic fibrosis has now been identified, thus permitting the detection of carriers in the general population. This paper reports pilot surveys in the North West Thames region of the health service to assess knowledge of people about cystic fibrosis and their attitudes towards screening. Three groups were surveyed: a group of relatives of those with cystic fibrosis (n = 268), a sample of the community (school pupils and family planning clinic attenders, n = 363), and a group of health care professionals (general practitioners and family planning clinic staff, n = 227). The relatives of cystic fibrosis sufferers were unanimously in favour of the introduction of cystic fibrosis screening, and the results indicate that there is likely to be support from the relevant health professionals: approximately 75% of respondents in the group of health care professionals believe the introduction of screening would be worthwhile. Data from the community sample suggest that, although knowledge of cystic fibrosis within the general community is low (less than 50% of respondents realized that cystic fibrosis affects the lungs and that no cure is available), there is likely to be considerable demand for carrier testing from the general public. Approximately 75% of the community sample indicated that they would like to be tested. There was no clear consensus, either from the professionals or the public, as to the best time to offer screening.

Adolescent↗