A national cohort study to investigate the association between ethnicity and the provision of care in obstetric anaesthesia in England between 2011 and 2021.

There is evidence that ethnic inequalities exist in maternity care in the UK, but those specifically in relation to UK obstetric anaesthetic care have not been investigated before. Using routine national maternity data for England (Hospital Episode Statistics Admitted Patient Care) collected between March 2011 and February 2021, we investigated ethnic differences in obstetric anaesthetic care. Anaesthetic care was identified using OPCS classification of interventions and procedures codes. Ethnic groups were coded according to the hospital episode statistics classifications. Multivariable negative binominal regression was used to model the relationship between ethnicity and obstetric anaesthesia (general and neuraxial anaesthesia) by calculating adjusted incidence ratios for the following: differences in maternal age; geographical residence; deprivation; admission year; number of previous deliveries; and comorbidities. Women giving birth vaginally and by caesarean section were considered separately. For women undergoing elective caesarean births, after adjustment for available confounders, general anaesthesia was 58% more common in Caribbean (black or black British) women (adjusted incidence ratio [95%CI] 1.58 [1.26-1.97]) and 35% more common in African (black or black British) women (1.35 [1.19-1.52]). For women who had emergency caesarean births, general anaesthesia was 10% more common in Caribbean (black or black British) women (1.10 [1.00-1.21]) than British (white) women. For women giving birth vaginally (excluding assisted vaginal births), Bangladeshi (Asian or Asian British), Pakistani (Asian or Asian British) and Caribbean (black or black British) women were, respectively, 24% (0.76 [0.74-0.78]), 15% (0.85 [0.84-0.87]) and 8% (0.92 [0.89-0.94]) less likely than British (white) women to receive neuraxial anaesthesia. This observational study cannot determine the causes for these disparities, which may include unaccounted confounders. Our findings merit further research to investigate potentially remediable factors such as inequality of access to appropriate obstetric anaesthetic care.

Pandemics and maternal health: the indirect effects of COVID-19.

Infectious diseases can directly affect women and men differently. During the COVID-19 pandemic, higher case fatality rates have been observed in men in most countries. There is growing evidence, however, that while organisational changes to healthcare delivery have occurred to protect those vulnerable to the virus (staff and patients), these may lead to indirect, potentially harmful consequences, particularly to vulnerable groups including pregnant women. These encompass reduced access to antenatal and postnatal care, with a lack of in-person clinics impacting the ability to screen for physical, psychological and social issues such as elevated blood pressure, mental health issues and sex-based violence. Indirect consequences also encompass a lack of equity when considering the inclusion of pregnant women in COVID-19 research and their absence from vaccine trials, leading to a lack of safety data for breastfeeding and pregnant women. The risk-benefit analysis of these changes to healthcare delivery remains to be fully evaluated, but the battle against COVID-19 cannot come at the expense of losing existing quality standards in other areas of healthcare, especially for maternal health.

Sea Level Budgets Should Account for Ocean Bottom Deformation.

The conventional sea level budget (SLB) equates changes in sea surface height with the sum of ocean mass and steric change, where solid-Earth movements are included as corrections but limited to the impact of glacial isostatic adjustment. However, changes in ocean mass load also deform the ocean bottom elastically. Until the early 2000s, ocean mass change was relatively small, translating into negligible elastic ocean bottom deformation (OBD), hence neglected in the SLB equation. However, recently ocean mass has increased rapidly; hence, OBD is no longer negligible and likely of similar magnitude to the deep steric sea level contribution. Here, we use a mass-volume framework, which allows the ocean bottom to respond to mass load, to derive a SLB equation that includes OBD. We discuss the theoretical appearance of OBD in the SLB equation and its implications for the global SLB.

The identification of key indicators to drive quality improvement in obstetric anaesthesia: results of the Obstetric Anaesthetists' Association/National Perinatal Epidemiology Unit collaborative Delphi project.

A three-stage Delphi survey process was undertaken to identify the quality indicators considered the most relevant to obstetric anaesthesia. The initial quality indicators assessed were derived from national peer-reviewed publications and were divided into service provision, service quality and clinical outcomes. A range of stakeholders were invited to participate and divided into three panels: obstetric anaesthetists; other maternity care health professionals; and women who had used maternity services. In total, 133 stakeholders registered to participate with 80% completing all three phases of the survey process. Participants ranked indicators for their relative importance using the grading of recommendations assessment, development and evaluation scale. From an initial list of 31 quality indicators, 11 indicators were rated as extremely important by > 90% of participants in at least two panels. These 11 indicators were presented to stakeholders; they were asked to vote for the five indicators they considered most relevant and useful for assessing and benchmarking the quality of obstetric anaesthesia provided. The indicators chosen were: the percentage of women who had an epidural/combined spinal-epidural for labour analgesia with accidental dural puncture; the presence of guidelines for the referral of patients to an anaesthetist for antenatal review; whether there are dedicated elective caesarean section lists; the availability of point-of-care testing for estimation of haemoglobin concentration; and the percentage of epidurals for labour analgesia that provided adequate pain relief within 45 min of the start of epidural insertion. These indicators may be used for quality improvement and national benchmarking to support the implementation of quality standards in obstetric anaesthesia.

Calving fluxes and basal melt rates of Antarctic ice shelves.

Iceberg calving has been assumed to be the dominant cause of mass loss for the Antarctic ice sheet, with previous estimates of the calving flux exceeding 2,000 gigatonnes per year. More recently, the importance of melting by the ocean has been demonstrated close to the grounding line and near the calving front. So far, however, no study has reliably quantified the calving flux and the basal mass balance (the balance between accretion and ablation at the ice-shelf base) for the whole of Antarctica. The distribution of fresh water in the Southern Ocean and its partitioning between the liquid and solid phases is therefore poorly constrained. Here we estimate the mass balance components for all ice shelves in Antarctica, using satellite measurements of calving flux and grounding-line flux, modelled ice-shelf snow accumulation rates and a regional scaling that accounts for unsurveyed areas. We obtain a total calving flux of 1,321 ± 144 gigatonnes per year and a total basal mass balance of -1,454 ± 174 gigatonnes per year. This means that about half of the ice-sheet surface mass gain is lost through oceanic erosion before reaching the ice front, and the calving flux is about 34 per cent less than previous estimates derived from iceberg tracking. In addition, the fraction of mass loss due to basal processes varies from about 10 to 90 per cent between ice shelves. We find a significant positive correlation between basal mass loss and surface elevation change for ice shelves experiencing surface lowering and enhanced discharge. We suggest that basal mass loss is a valuable metric for predicting future ice-shelf vulnerability to oceanic forcing.

BedMachine v3: Complete Bed Topography and Ocean Bathymetry Mapping of Greenland From Multibeam Echo Sounding Combined With Mass Conservation.

Greenland's bed topography is a primary control on ice flow, grounding line migration, calving dynamics, and subglacial drainage. Moreover, fjord bathymetry regulates the penetration of warm Atlantic water (AW) that rapidly melts and undercuts Greenland's marine-terminating glaciers. Here we present a new compilation of Greenland bed topography that assimilates seafloor bathymetry and ice thickness data through a mass conservation approach. A new 150 m horizontal resolution bed topography/bathymetric map of Greenland is constructed with seamless transitions at the ice/ocean interface, yielding major improvements over previous data sets, particularly in the marine-terminating sectors of northwest and southeast Greenland. Our map reveals that the total sea level potential of the Greenland ice sheet is 7.42 ± 0.05 m, which is 7 cm greater than previous estimates. Furthermore, it explains recent calving front response of numerous outlet glaciers and reveals new pathways by which AW can access glaciers with marine-based basins, thereby highlighting sectors of Greenland that are most vulnerable to future oceanic forcing.

A prospective survey of blood products transferred with patients during inter-hospital transfers in the East of England.

OBJECTIVES: A prospective survey was undertaken of blood products transferred with patients during inter-hospital transfers by ambulance in the East of England (population six million) BACKGROUND: There is little published information on the number and fate of blood products transferred with patients during inter-hospital transfers, although there are concerns about quality assurance and traceability of these blood products. Recent national guidance has been issued, but adherence to this guidance is uncertain. METHODS: A 6-month survey was undertaken of all inter-hospital transfers of blood products with patients within the East of England using routine data captured by established transfer of blood documentation. RESULTS: There were 45 transfer episodes of which 44 involved the transfer of red blood cells. In total, 148 units of red blood cells were transferred, of which 6% were transfused en route, 3% transfused at the destination hospital, 35% were wasted and for 18% the fate could not be established. The remainder were transferred into the blood stock of the destination hospital. CONCLUSION: The small proportion of blood products that were transfused raises questions about the necessity of the transfer of blood products with some patients particularly considering the higher percentage of wasted or untraced products. When transfers occur, there should be better communication between hospital transfusion laboratories assisted by adherence to national and regionally agreed policies.

Tumour biomechanical response to the vascular disrupting agent ZD6126 in vivo assessed by magnetic resonance elastography.

BACKGROUND: Magnetic resonance elastography (MRE) is an emerging imaging technique that affords non-invasive quantitative assessment and visualization of tissue mechanical properties in vivo. METHODS: In this study, MRE was used to quantify (kPa) the absolute value of the complex shear modulus |G*|, elasticity Gd and viscosity Gl of SW620 human colorectal cancer xenografts before and 24 h after treatment with either 200 mg kg(-1) of the vascular disrupting agent ZD6126 (N-acetylcolchinol-O-phosphate) or vehicle control, and the data were compared with changes in water diffusivity measured by diffusion-weighted magnetic resonance imaging. RESULTS: A heterogeneous distribution of |G*|, Gd and Gl was observed pre-treatment with an intertumoral coefficient of variation of 13% for |G*|. There were no significant changes in the vehicle-treated cohort. In contrast, ZD6126 induced a significant decrease in the tumour-averaged |G*| (P<0.01), Gd (P<0.01) and Gl (P<0.05), and this was associated with histologically confirmed central necrosis. This reduction in tumour viscoelasticity occurred at a time when no significant change in tumour apparent diffusion coefficient (ADC) was observed. CONCLUSIONS: These data demonstrate that MRE can provide early imaging biomarkers for treatment-induced tumour necrosis.

Observational study of peripheral skin temperature changes following spinal anaesthesia for caesarean birth.

BACKGROUND: Spinal anaesthesia is widely used in obstetric anaesthesia practice but there is limited knowledge about the development of sympathetic blockade following spinal anaesthesia for caesarean birth. This study investigated the characteristics of sympathetic blockade by measuring peripheral skin temperature changes in the feet of patients given spinal anaesthesia for elective caesarean birth. METHODS: A prospective observational study was conducted involving 60 eligible parturients scheduled for elective caesarean birth with spinal anaesthesia. Skin temperature probes were attached to the dorsum of both feet, and temperature measurements were recorded every minute. The dose of spinal anaesthesia given, and other relevant patient data, were collected. RESULTS: All participants had successful spinal anaesthesia. Following spinal anaesthesia, a sustained rise in skin temperature of both feet was observed, indicating the presence of sympathetic blockade. The maximum rate of temperature increase occurred between 6 and 15 min after the intrathecal injection and plateaued from 22 min after the injection. Control participants did not show any changes in foot temperature. CONCLUSIONS: This study demonstrates that successful spinal anaesthesia for caesarean birth results in a consistent and reliable rise in skin temperature of the feet that is evident after six minutes from intrathecal injection. The observed temperature changes provide indirect objective evidence of bilateral sympathetic blockade. Measurement of feet skin temperatures may serve as an additional objective indicator of successful spinal anaesthesia, along with tests of lower limb motor block and sensory block height. These findings contribute to the understanding of sympathetic blockade during spinal anaesthesia.

EFSUMB guidelines and recommendations on the clinical use of ultrasound elastography. Part 1: Basic principles and technology.

The technical part of these Guidelines and Recommendations, produced under the auspices of EFSUMB, provides an introduction to the physical principles and technology on which all forms of current commercially available ultrasound elastography are based. A difference in shear modulus is the common underlying physical mechanism that provides tissue contrast in all elastograms. The relationship between the alternative technologies is considered in terms of the method used to take advantage of this. The practical advantages and disadvantages associated with each of the techniques are described, and guidance is provided on optimisation of scanning technique, image display, image interpretation and some of the known image artefacts.

EFSUMB guidelines and recommendations on the clinical use of ultrasound elastography. Part 2: Clinical applications.

The clinical part of these Guidelines and Recommendations produced under the auspices of the European Federation of Societies for Ultrasound in Medicine and Biology EFSUMB assesses the clinically used applications of all forms of elastography, stressing the evidence from meta-analyses and giving practical advice for their uses and interpretation. Diffuse liver disease forms the largest section, reflecting the wide experience with transient and shear wave elastography . Then follow the breast, thyroid, gastro-intestinal tract, endoscopic elastography, the prostate and the musculo-skeletal system using strain and shear wave elastography as appropriate. The document is intended to form a reference and to guide clinical users in a practical way.

The delivery of obstetric anaesthetic care in UK maternity units: a survey of practice in 2021.

BACKGROUND: Anaesthetists are crucial members of the maternity unit team, providing peri-operative analgesia and anaesthesia, and supporting the delivery of medical care to high-risk women. The effective contribution from obstetric anaesthetists to safety in maternity units depends on how anaesthesia services are organised and resourced. There is a lack of information on how obstetric anaesthetic care is resourced in the UK. METHODS: The Obstetric Anaesthetists' Association surveyed UK clinical leads for their hospital's obstetric anaesthetic service and examined compliance with national recommendations. RESULTS: There were 153 responses by lead obstetric anaesthetists from 184 maternity units in the UK (83%). The number of consultants per 1000 deliveries was 2.2 [1.6-2.7] (median [IQR]). In 20% of units, there was a dedicated on-call rota (on-call only for obstetric anaesthesia), whilst the remainder had a 'combined' on-call rota (on-call for other clinical areas in addition to obstetrics). Multidisciplinary ward rounds were held in 83% of units. Twenty-five (16%) units reported having no regular multidisciplinary ward rounds, of which nine (6%) did not have any multidisciplinary ward rounds. Planned operating lists for elective caesarean sections were provided in 77% of units. CONCLUSIONS: In the largest survey of obstetric anaesthesia workload to be reported for any health system, we found significant disparities between obstetric anaesthesia service provision and current national recommendations for areas including consultant staffing, support for elective caesarean section lists, antenatal anaesthetic clinics, and consultant support for service development. Wide national variation in service provision was identified.