Biomedical subjects
R Johanson
Publications and source records attributed to R Johanson.
Suggestions in maternal and child health for the National Technology Assessment Programme: a consideration of consumer and professional priorities.
In North Staffordshire, the Achieving Sustainable Quality in Maternity (ASQUAM) meetings provide the programme for clinical guidelines and audit over the following year. The ASQUAM clinical effectiveness programme has attempted to address a number of the issues identified as obstacles to informed democratic prioritization. For example, it became clear that a number of topics raised were actually research questions. The organizers therefore decided to split the fourth ASQUAM day into an 'audit' morning and a 'research' afternoon. The meeting organized by RJ, CR and PJ in partnership with the Midwives Information and Resource Service and the National Childbirth Trust, was timed to allow the research ideas to feed into the national Health Technology Assessment (HTA) programme. This meeting was designed to increase the profile of ASQUAM amongst consumers and to increase their representation at the meeting. Objectives were to choose a new set of research priorities for the year 2000, and to ascertain the voting pattern of comparison to health professionals. There was overall agreement in terms of priorities, with the consumer group prioritizing 8 of the 10 topics chosen by the professionals (or 10 of the 11). No significant differences between the proportions of voted cast for each topic by professionals and consumers were found apart from topic 20. The numbers of consumers were small which does limit the number the validity of statistical comparisons. Nevertheless, it is clear that voting patterns were similar. Overall the process suggests that democratic prioritization is a viable option and one that may become essential within the framework of clinical and research governance.
A randomised trial of an intervention package designed to promote external cephalic version at term.
OBJECTIVE: To evaluate the effectiveness of an intervention package to promote external cephalic version (ECV). STUDY DESIGN: (1) Design and Setting--A randomised-controlled trial of 20 consultant-based maternity units in the West Midlands NHS Region. (2) Intervention Units--One consultant obstetrician from each unit was encouraged to promote changes in clinical practice within their unit. A multifaceted package including a workshop, written material, guidelines and videos was delivered to these consultants. (3) Control Units--No intervention. (4) Main Outcome Measure--The percentage of women with breech presentation at term who were offered ECV in the antenatal clinic, before and after the intervention. RESULTS: Pre-intervention, there was no difference between the intervention and control units in the proportion of women offered ECV (20 and 19%, respectively). Post-intervention, the proportions were 15% in the control group and 36% in the intervention group (P=0.016). CONCLUSION: This type of intervention package can alter clinical practice and increase the proportion of women with breech presentation at term being offered ECV after the intervention.
Promoting normality in childbirth.
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A decision analytical cost analysis of offering ECV in a UK district general hospital.
OBJECTIVE: To determine the care pathways and implications of offering mothers the choice of external cephalic version (ECV) at term for singleton babies who present with an uncomplicated breech pregnancy versus assisted breech delivery or elective caesarean. DESIGN: A prospective observational audit to construct a decision analysis of uncomplicated full term breech presentations. SETTING: The North Staffordshire NHS Trust. SUBJECTS: All women (n = 176) who presented at full term with a breech baby without complications during July 1995 and June 1997. MAIN OUTCOME MEASURES: The study determined to compare the outcome in terms of the costs and cost consequences for the care pathways that resulted from whether a women chose to accept the offer of ECV or not. All the associated events were then mapped for the two possible pathways. The costs were considered only within the hospital setting, from the perspective of the health care provider up to the point of delivery. RESULTS: The additional costs for ECV, assisted breech delivery and elective caesarean over and above a normal birth were 186.70 pounds sterling, 425.36 pounds sterling and 1,955.22 pounds sterling respectively. The total expected cost of the respective care pathways for "ECV accepted" and "ECV not accepted" (including the probability of adverse events) were 1,452 pounds sterling and 1,828 pounds sterling respectively, that is the cost of delivery through the ECV care pathways is less costly than the non ECV delivery care pathway. CONCLUSIONS: Implementing an ECV service may yield cost savings in secondary care over and above the traditional delivery methods for breech birth of assisted delivery or caesarean section. The scale of these expected cost savings are in the range of 248 pounds sterling to 376 pounds sterling per patient. This converts to a total expected cost saving of between 43,616 pounds sterling and 44,544 pounds sterling for the patient cohort considered in this study.
Evidence-based medicine in obstetrics.
OBJECTIVES: The main objectives of this study were to determine: (a) the most popular sources of educational material for use in obstetrics, and the relative values assigned to these; (b) the relative importance of current evidence-based medicine (EBM) activities including use of guidelines and audits; and (c) worldwide practice in respect of 4 RCOG audit recommendations. METHODS: A postal questionnaire was distributed to 2472 obstetricians/gynecologists worldwide. RESULTS: A total of 1090 questionnaires were returned. The results found broad support for the principles of EBM, with most clinicians having access to electronic databases, and using guidelines and audits. There was wide interest in further research in suggested key areas. CONCLUSION: The traditional reliance on meetings, reviews and colleagues' opinion continues, indicating that further research must be undertaken to optimize these educational opportunities.
Techniques for performing caesarean section.
In many countries caesarean section has become the mode of delivery in over a quarter of all births. Safety of the mother and cost are the two main areas of concern. Various studies on the techniques of performing a caesarean section have focused on reducing the operating time, blood loss, wound infection and cost. Given the fact that caesarean section is the most commonly performed operation in obstetrics, it is important that trainers and trainees are familiar with the basic surgical techniques and that best practice is followed. At the same time surgeons should take necessary precautions to reduce their risk of exposure to Hepatitis B and HIV. The skin incision and entry into abdominal cavity is best achieved by the modified Cohen's incision. The lower segment transverse uterine incision has stood the test of time over a period of 75 years and remains the best way to enter the uterus. Closure of the uterus in single layer appears to be acceptable, whenever technically possible. Placental delivery should be by controlled cord traction after spontaneous expulsion. Closure of the visceral and parietal layers of the peritoneum no longer seems to be necessary. Obliteration of space in the subcutaneous layer, either by suture or by suction, seems to reduce wound disruption. These issues are being considered in the CAESAR randomized controlled trial of surgical techniques currently underway in England.Prophylactic antibiotics are mandatory in preventing post-operative morbidity. Many of the above mentioned steps have been tested in randomized trials. Further studies are needed to examine a wide range of questions arising from this review, e.g. best position of the patient, the value of exteriorization of the uterus whilst repairing the uterus, and the use of agents to relax the uterus in difficult deliveries.
Haemodynamic, invasive and echocardiographic monitoring in the hypertensive parturient.
AIM: To determine the clinical usefulness of invasive and non-invasive haemodynamic assessment in pre-eclampsia. METHOD: A systematic review of the literature was undertaken, using a MEDLINE electronic search using a combination of MESH headings and textwords. Over 1500 abstracts were perused; we obtained 156 full papers that were related to the subject matter. Of the full papers, 55 yielded relevant information. Hand-searching the reference lists of the retrieved papers completed the search. RESULTS: There are no data from randomized controlled clinical trials illustrating the clinical usefulness of pulmonary artery catheters or echocardiographic techniques in hypertensive pregnancy. There are a wealth of data illustrating the haemodynamic profiles of both untreated and treated pre-eclamptic women. Data are also available comparing right heart and left heart filling pressures, demonstrating a relatively poor correlation between the two values. The clinical impact of either measurement is unclear. Data are available illustrating the correlation between echocardiographic techniques and pulmonary artery catheterization.
Management of obstetric emergencies and trauma (MOET): regional questionnaire survey of obstetric practice among career obstetricians in the United Kingdom.
Across specialties in the UK concern exists that the shortened training time, combined with the restriction on hours of work, will result in trainees being short of the necessary depth and breadth of experience for independent practice at the end of their defined training period. In terms of risk management, it is recognised that high reliability organisations anticipate the worst and equip themselves to deal with it at all levels in the organisation. Alternative methods of assessment and training need to be utilised, including models and scenario teaching. While it is important for clinicians to learn common skills well before practising on the labour ward, it is correspondingly more important that rare complications be rehearsed with models. In the UK, the MOET (Managing Obstetric Emergencies and Trauma) course has been developed to allow specialist obstetricians to learn, or revise, how to undertake procedures on models, and then to have their skills tested in scenarios. This survey aimed to ascertain the views of career obstetricians in terms of their ability to respond to some of the course scenarios and how frequently the rarest procedures have been undertaken. A one-page questionnaire with 15 questions, based on clinical scenarios taught on the MOET (Managing Obstetric Emergencies and Trauma), course was sent to all career obstetricians in the West Midlands region. Participants were asked to indicate whether they thought a particular management was 'good practice', 'bad practice' or 'good practice but would prefer a caesarean section' and to indicate the number of such procedures they had undertaken in their obstetric career. The response rate was 40% (97/243). There was a broad spectrum in obstetric views about 'good' and 'bad' practice. Overall the respondents agreed with the literature in terms of practices that are regarded as 'good' and 'bad'. A large proportion of respondents, however, would rather undertake a caesarean section than carry out a 'good' practice. Twenty-six obstetricians had experience in the rare obstetric procedures. Of these, 16 (66%) had worked outside the UK, either in the Middle East, South East Asia, Africa or the Caribbean. This survey highlights the need for training courses to teach and revise operative procedures.
Management of massive postpartum haemorrhage: use of a hydrostatic balloon catheter to avoid laparotomy.
Postpartum haemorrhage remains a significant complication of childbirth in the UK and worldwide. The most common cause of postpartum haemorrhage is uterine atony, but placent accreta is becoming more frequent. In these situations tamponade may be required. The successful use of the inflated stomach balloon (300ml) of a Sengstaken-Blakemore tube has been reported previously. We describe an innovative method of 'tamponade' which is simple and effective, using the Rüsch urological hydrostatic balloon catheter. In two cases of failed medical therapy for PPH, where the catheter has been tried, further surgical interventions have been avoided.
Surface expression of the conserved C repeat region of streptococcal M6 protein within the Pip bacteriophage receptor of Lactococcus lactis.
The C repeat region of the M6 protein (M6c) from Streptococcus pyogenes was expressed within the Pip bacteriophage receptor on the surface of Lactococcus lactis. M6c was also detected in the culture medium. The pip-emm6c allele was integrated into the chromosome and stably expressed without antibiotic selection. The level of cell-associated surface expression of PipM6c was 0.015% of total cellular protein. The amount of PipM6c on the cell surface was increased about 17-fold by expressing pip-emm6c from a high-copy-number plasmid. Replacing the native pip promoter with stronger promoters isolated previously from Lactobacillus acidophilus increased surface expression of PipM6c from the high-copy-number plasmid up to 27-fold. Concomitantly, the amount of PipM6c in the medium increased 113-fold. The amount of PipM6c did not vary greatly between exponential- and stationary-phase cultures. Western blots indicated that the full-length PipM6c protein and most of the numerous proteolytic products were found only on the cell surface, whereas only one proteolytic fragment was found in the culture medium.
Reducing risk by improving standards of intrapartum fetal care.
Confidential Enquiries into Stillbirths and Deaths in Infancy (CESDI) have pointed to a high frequency of suboptimal intrapartum fetal care of a kind that, in the event of an adverse outcome, is hard to defend in court. In an effort to minimize liability, various strategies were applied in a district hospital labour ward--guidelines, cyclical audit, monthly feedback meetings and training sessions in cardiotocography (CTG). The effects of these interventions on quality of care was assessed by use of the CESDI system in all babies born with an Apgar score of 4 or less at 1 min and/or 7 or less at 5 min. 540 babies (4.3%) had low Apgar scores, and neither the percentage nor gestational age differed significantly between audit periods. In the baseline audit, care was judged suboptimal (grade II/III) in 14 (74%) of 19 cases, and in the next four periods it was 23%, 27%, 27% and 32%. In the latest audit period, after further educational interventions, it was 9%. Many of the failures to recognize or act on abnormal events were related to CTG interpretation. After the interventions there was a significant increase in cord blood pH measurement. There were no differences between audit periods in the proportion of babies with cord pH < 7.2. These results indicate that substantial improvements in quality of intrapartum care can be achieved by a programme of clinical risk management.
Pre-eclampsia, diagnosis and treatment.
Pre-eclampsia is a multisystem disorder of pregnancy usually associated with raised blood pressure (BP) and proteinuria. The pathogenesis is not understood despite decades of research. Abnormal placentation related to immune mechanisms and maladaptation of the placenta may be the first step in the development of the disease. Although there are a number of risk factors and new innovatory tests (e.g., uterine artery Doppler) which can be used to predict pre-eclampsia, none fulfils standard diagnostic criteria. Of possible prophylactic value are antiplatelet agents, calcium supplementation and vitamins C and E. Prevention of eclampsia with magnesium sulfate is the subject of a current international randomised controlled trial (RCT), known as MAGPIE. Therapeutic strategies include avoidance of hypertensive injury and delivery of the baby and placenta. Further research into specific antihypertensive agents and conservative management strategies is required.
A low dose ("Dhaka") magnesium sulphate regime for eclampsia.
BACKGROUND: Eclampsia remains a common cause of maternal death in Bangladesh. Early experience of magnesium sulphate use for eclampsia in Bangladesh was based on a lower dose regime, tailored for use in the smaller woman. OBJECTIVES: a) To determine the recurrent convulsion rate with the low dose "Dhaka" magnesium sulphate regime (recognizing the limitations of sample size). b) To identify whether toxicity occurs with this regime. c) To measure serum level of magnesium with this regime. METHODS: This prospective study included 65 eclamptic patients receiving lower dose magnesium sulphate therapy at Dhaka Medical College Hospital from 25 March 1998-15 June 1998. The loading dose of magnesium sulphate was 10 gm. Following this 2.5 gm was given intramuscularly 4 hourly, for 24 hours after administration of the first dose. Four blood samples were collected for serum magnesium levels. Patients were monitored hourly by observing their respiratory rate, knee jerks and urinary output. Findings were matched with serum magnesium levels. RESULTS: The range of serum magnesium levels was 1.74 to 6 mg/dl with mean (s.d.) values of 3.87 (0.78). Only five (9%) patients had diminished knee jerks 6, 10, 12, 12 and 15 hours after administration of the loading dose. But at those times the serum magnesium levels were 3.2 mg/dl, 3.8/dl, 3.4 mg/dl and 3.3 mg/dl respectively. Of the 65 patients, only one developed recurrent convulsions. This was 3 hours after the loading dose and was controlled by diazepam treatment and maintenance magnesium sulphate. CONCLUSION: Half of the standard dose of magnesium sulphate appeared to be sufficient to control convulsions effectively and serum levels of magnesium remained lower than levels which produce toxicity.
Perineal massage for prevention of perineal trauma in childbirth.
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Soft versus rigid vacuum extractor cups for assisted vaginal delivery.
BACKGROUND: The original cups used for vacuum extraction delivery of the fetus were rigid metal cups. Subsequently, soft cups of flexible materials such as silicone rubber or plastic were introduced. Soft cups are thought to have a poorer success rate than metal cups. However they are also thought to be less likely to be associated with scalp trauma and less likely to injure the mother. OBJECTIVES: The objective of this review was to assess the effects of soft versus rigid vacuum extractor cups on perineal injury, fetal scalp injury and success rate. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register. Date of last search: February 2000. SELECTION CRITERIA: Acceptably controlled comparisons of soft versus rigid vacuum extractor cups. DATA COLLECTION AND ANALYSIS: Two reviewers assessed trial quality and extracted data. Study authors were contacted for additional information. MAIN RESULTS: Nine trials involving 1375 women were included. The trials were of average quality. Soft cups are significantly more likely to fail to achieve vaginal delivery (odds ratio 1.65, 95% confidence interval 1.19 to 2.29). However, they were associated with less scalp injury (odds ratio 0.45, 95% confidence interval 0.15 to 0.60). There was no difference between the two groups in terms of maternal injury. REVIEWER'S CONCLUSIONS: Metal cups appear to be more suitable for 'occipito-posterior', transverse and difficult 'occipito-anterior' position deliveries. The soft cups seem to be appropriate for straightforward deliveries.
Informed choice? Evidence of the persuasive power of professionals.
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Democratic prioritization of maternity care: a rational basis for planning a clinical effectiveness programme.
BACKGROUND: The aim of the study was to evaluate the use of a democratic process for prioritizing the ASQUAM (Achieving Sustainable Quality in Maternity) clinical effectiveness programme. METHODS: Twenty-two improvements in the standards of maternity care were chosen as top-topic priorities at the 1996 and 1997 ASQUAM meetings. We wished to assess the relative priorities of local and national delegates, by comparing their voting patterns at the two meetings. The setting was North Staffordshire ASQUAM prioritization days, and the subjects were all the delegates at the 1996 and 1997 ASQUAM meetings. Main outcome measures were comparison of numbers of votes cast by local and national delegates for each of the 20 topics presented at the two ASQUAM meetings, and proportions of the 11 top-topics decided at each meeting that were chosen by local and national delegates. RESULTS: In 1996, significantly more local than national delegates voted for two topics related to maternal mortality or morbidity (incontinence and hypertensive diseases of pregnancy), but there were no statistically significant differences between the proportions of votes cast for any of the other 18 topics presented on the day. Indeed, local delegates had prioritized 11/11 of the final top-topics, and only one was omitted by the national delegates (10/11). In 1997, significantly more national than local delegates voted for three topics relating to professional stress levels, user involvement in working groups and antibiotic prophylaxis, but there were no statistically significant differences between the proportions of votes cast for any of the other 17 topics presented on the day. Again, local delegates had prioritized 11/11 of the final topics, with only one being omitted by the national delegates (10/11). CONCLUSION: There appeared to be a remarkable concordance between local and national delegates at both meetings, suggesting an underlying rationality to decision making. We believe this to be a reflection of the process of careful evaluation of outcome and intervention supported by the protection of a secret ballot, allowing free expression of individual's values.