Preconception indicators and associations with health outcomes reported in UK routine primary care data: a systematic review.

BACKGROUND: Routine primary care data may be a valuable resource for preconception health research and informing provision of preconception care. AIM: To review how primary care data could provide information on the prevalence of preconception indicators and examine associations with maternal and offspring health outcomes. DESIGN AND SETTING: Systematic review of observational studies using UK routine primary care data. METHOD: Literature searches were conducted in five databases (March 2023) to identify observational studies that used national primary care data from individuals aged 15-49 years. Preconception indicators were defined as medical, behavioural and social factors that may impact future pregnancies. Health outcomes included those that may occur during and after pregnancy. Screening, data extraction and quality assessment were conducted by two reviewers. RESULTS: From 5,259 records screened, 42 articles were included. The prevalence of 30 preconception indicators was described for female patients, ranging from 0.01% for sickle cell disease to >20% for each of advanced maternal age, previous caesarean section (among those with a recorded pregnancy), overweight, obesity, smoking, depression and anxiety (irrespective of pregnancy). Few studies reported indicators for male patients (n=3) or associations with outcomes (n=5). Most studies had low risk of bias, but missing data may limit generalisability. CONCLUSION: Findings demonstrate that routinely collected UK primary care data can be used to identify patients preconception care needs. Linking primary care data with health outcomes collected in other datasets is underutilised but could help quantify how optimising preconception health and care can reduce adverse outcomes for mothers and children.

Legislating for a Pandemic: Exposing the Stateless State.

Initially the subject of widespread consensus, legislative and policy responses to COVID-19 are increasingly provoking predictable reactions. Right and left are united by concern that essential freedoms are being eroded by a state utilizing the opportunity of the pandemic to make a power grab. Focused on the Coronavirus Act 2020, this article takes a more cautious approach, suggesting that the law should be understood not as the product of a hierarchical state but as a demonstration of the 'statelessness' of the contemporary state. It examines the Act with particular focus on open justice, adult social care, and Business Improvement Districts. Reading this unique piece of legislation through the lens of the stateless state reveals the complexities, ambiguities, and contestations within contemporary policy making. Dismissing the Act as unnecessarily authoritarian is an insufficiently nuanced response; furthermore, this exploration of the law allows us to develop and complicate scholarship on the stateless state.

Apex Pro-care mattress: How can this advanced mattress assist in prevention of pressure injuries?

Avalon Nursing Home is fully aware of the potential for pressure ulcers in immobile residents and were keen to undertake an evaluation to ensure their residents have the most appropriate care possible. They selected Apex Pro-care to evaluate as there were concerns for residents heels in those with any arterial insufficiency. The Apex Pro-care mattress has a heel section where one or more of the bottom five cells can be deflated under the patient's heel to create a void, which will enable the heel to "float" so that there is no pressure in contact with the heel area. The mattress would reduce the cost of nursing care as repositioning times can be optimised according to need. The three residents who agreed to evaluate the mattress found it to be extremely comfortable and they remained free of any pressure injury.

Improving care and outcomes of inpatients with syndrome of inappropriate antidiuresis (SIAD): a prospective intervention study of intensive endocrine input vs. routine care.

PURPOSE: The syndrome of inappropriate antidiuresis is often undertreated with most patients discharged with persistent hyponatraemia. This study tested the hypothesis that an endocrine input is superior to routine care in correcting hyponatraemia and can improve patient outcomes. METHODS: This single-centre prospective-controlled intervention study included inpatients admitted at a UK teaching hospital, with serum sodium ≤ 127 mmol/l, due to syndrome of inappropriate antidiuresis over a 6-month period. The prospective intervention group (18 subjects with mean serum sodium 120.7 mmol/l) received prompt endocrine input, while the historical control group (23 patients with mean serum sodium 124.1 mmol/l) received routine care. The time needed for serum sodium increase ≥ 5 mmol/l was the primary endpoint. RESULTS: The intervention group achieved serum sodium rise by ≥5 mmol/l in 3.5 vs. 7.1 days in the control group (P = 0.005). In the intervention group, the mean total serum sodium increase was 12 mmol/l with only 5.8 % of patients discharged with serum sodium < 130 vs. 6.3 mmol/l increase (P < 0.001) and 42.1 % of the subjects discharged with serum sodium < 130 mmol/l in the control group (P = 0.012). The mean length of hospital stay in the intervention group (10.9 days) was significantly shorter than in the control group (14.5 days; P = 0.004).The inpatient mortality rate was 5.5 % in intervention arm vs. 17.4 % in control arm, but this difference was not statistically significant. CONCLUSIONS: Since the endocrine input improved time for correction of hyponatraemia and shortened length of hospitalisation, widespread provision of endocrine input should be considered.

Real-life experience of tolvaptan use in the treatment of severe hyponatraemia due to syndrome of inappropriate antidiuretic hormone secretion.

OBJECTIVE: European guidelines do not recommend tolvaptan for treatment of syndrome of inappropriate antidiuretic hormone secretion (SIADH), principally owing to concerns about risk of overly rapid correction of hyponatraemia. This study evaluated the real-life effectiveness and safety of tolvaptan. DESIGN: Consecutive case series. PATIENTS: Inpatients treated with tolvaptan for SIADH in 2 UK hospitals over a 3-year period. MEASUREMENTS: The primary outcome measures were serum sodium (sNa) correction at 24 and 48 h after tolvaptan therapy. RESULTS: This case series included 61 patients aged 74·4 ± 15·3 years with (mean ± SD) sNa 119·9 ± 5·5 mmol/l. The mean sNa increase 24 h after tolvaptan initiation was 9 ± 3·9 mmol/l. Excessive correction of hyponatraemia was observed in 23% of patients with all these patients having baseline sNa <125 mmol/l, but no cases of osmotic demyelination syndrome were recorded. At the end of tolvaptan therapy, sNa increase was 13·5 ± 5·9 mmol/l with 96·7% of patients having sNa increase ≥5 mmol/l in 48 h. There was a negative significant correlation (P = 0·012) between baseline sNa and 24-h change; for every 1 mmol/l reduction in baseline value, sNa increased by an additional 0·23 mmol/l (95% CI 0·05-0·41). CONCLUSIONS: Tolvaptan is effective in correcting hyponatraemia. Without rigorous electrolyte monitoring, tolvaptan carries a significant risk of overly rapid sodium correction, especially in patients with starting sNa <125 mmol/l. Tolvaptan should be used with great caution under close electrolyte monitoring.

Unexpected consequences: women's experiences of a self-hypnosis intervention to help with pain relief during labour.

BACKGROUND: Self-hypnosis is becoming increasingly popular as a means of labour pain management. Previous studies have produced mixed results. There are very few data on women's views and experiences of using hypnosis in this context. As part of a randomized controlled trial of self-hypnosis for intra-partum pain relief (the SHIP Trial) we conducted qualitative interviews with women randomized to the intervention arm to explore their views and experiences of using self-hypnosis during labour and birth. METHODS: Participants were randomly selected from the intervention arm of the study, which consisted of two antenatal self-hypnosis training sessions and a supporting CD that women were encouraged to listen to daily from 32 weeks gestation until the birth of their baby. Those who consented were interviewed in their own homes 8-12 weeks after birth. Following transcription, the interviews were analysed iteratively and emerging concepts were discussed amongst the authors to generate organizing themes. These were then used to develop a principal organizing metaphor or global theme, in a process known as thematic networks analysis. RESULTS: Of the 343 women in the intervention group, 48 were invited to interview, and 16 were interviewed over a 12 month period from February 2012 to January 2013. Coding of the data and subsequent analysis revealed a global theme of 'unexpected consequences', supported by 5 organising themes, 'calmness in a climate of fear', 'from sceptic to believer', 'finding my space', 'delays and disappointments' and 'personal preferences'. Most respondents reported positive experiences of self-hypnosis and highlighted feelings of calmness, confidence and empowerment. They found the intervention to be beneficial and used a range of novel strategies to personalize their self-hypnosis practice. Occasionally women reported feeling frustrated or disappointed when their relaxed state was misinterpreted by midwives on admission or when their labour and birth experiences did not match their expectations. CONCLUSION: The women in this study generally appreciated antenatal self-hypnosis training and found it to be beneficial during labour and birth. The state of focused relaxation experienced by women using the technique needs to be recognized by providers if the intervention is to be implemented into the maternity service.

Defining dimensions of research readiness: a conceptual model for primary care research networks.

BACKGROUND: Recruitment to research studies in primary care is challenging despite widespread implementation of electronic patient record (EPR) systems which potentially make it easier to identify eligible cases. METHODS: Literature review and applying the learning from a European research readiness assessment tool, the TRANSFoRm International Research Readiness instrument (TIRRE), to the context of the English NHS in order to develop a model to assess a practice's research readiness. RESULTS: Seven dimensions of research readiness were identified: (1) Data readiness: Is there good data quality in EPR systems; (2) Record readiness: Are EPR data able to identify eligible cases and other study data; (3) Organisational readiness: Are the health system and socio-cultural environment supportive; (4) Governance readiness: Does the study meet legal and local health system regulatory compliance; (5) Study-specific readiness; (6) Business process readiness: Are business processes tilted in favour of participation: including capacity and capability to take on extra work, financial incentives as well as intangibles such as social and intellectual capital; (7) Patient readiness: Are systems in place to recruit patients and obtain informed consent? CONCLUSIONS: The model might enable the development of interventions to increase participation in primary care-based research and become a tool to measure the progress of practice networks towards the most advanced state of readiness.

Comparing exercise interventions to increase persistence with physical exercise and sporting activity among people with hypertension or high normal blood pressure: study protocol for a randomised controlled trial.

BACKGROUND: Increasing physical activity is known to have health benefits for people with hypertension and related conditions. Current general practitioner referrals for gym-based exercise increase physical activity but meta-analyses show that while these are effective the absolute health risk reduction is small due to patients failing to maintain activity levels over time. This study assesses the effectiveness of two sports-oriented interventions that are intended to bridge the intention-behaviour gap and thus increase the likelihood of sustained increases in physical activity. METHODS/DESIGN: Four-arm randomised controlled trial. The study tests two types of intervention that are intended to increase physical activity among currently inactive 18- to 74-year-old people with hypertension or high-normal blood pressure. This study will assess the effectiveness of a 12-week sports-oriented exercise programme, the efficacy of a web-delivered self-help tool to promote and support sports participation and healthy behaviour change and the effect of these interventions in combination. The control arm will be a standard care general practitioner referral for gym-based exercise. Participants will be allocated using block randomisation. The first author and primary analyst is blinded to participant allocation. The primary outcome measures will be time spent in physical activity assessed in metabolic equivalent minutes per week using the International Physical Activity Questionnaire 1 year after commencement of the intervention. Secondary outcomes include increased involvement in sporting activity and biomedical health outcomes including change in body mass index, and waist and hip measurement and reductions in blood pressure. DISCUSSION: If proven to be superior to general practitioner referrals for gym-based exercise, these sports-oriented interventions would constitute low-cost alternatives. The next stage would be a full economic evaluation of the interventions. TRIAL REGISTRATION: Current Controlled Trials ISRCTN71952900 (7 June 2013).

Diabetes screening after gestational diabetes in England: a quantitative retrospective cohort study.

BACKGROUND: The National Institute for Health and Care Excellence (NICE) recommends postpartum and annual monitoring for diabetes for females who have had a diagnosis of gestational diabetes mellitus (GDM). AIM: To describe the current state of follow-up after GDM in primary care, in England. DESIGN AND SETTING: A retrospective cohort study in 127 primary care practices. The total population analysed comprised 473 772 females, of whom 2016 had a diagnosis of GDM. METHOD: Two subgroups of females were analysed using electronic general practice records. In the first group of females (n = 788) the quality of postpartum follow-up was assessed during a 6-month period. The quality of long-term annual follow-up was assessed in a second group of females (n = 718), over a 5-year period. The two outcome measures were blood glucose testing performed within 6 months postpartum (first group) and blood glucose testing performed annually (second group). RESULTS: Postpartum follow-up was performed in 146 (18.5%) females within 6 months of delivery. Annual rates of long-term follow-up stayed consistently around 20% a year. Publication of the Diabetes in Pregnancy NICE guidelines, in 2008, had no effect on long-term screening rates. Substantial regional differences were identified among rates of follow-up. CONCLUSION: Monitoring of females after GDM is markedly suboptimal despite current recommendations.

Baby massage.

Having initially trained as a nurse and then a midwife, massage for me was back to hands on care. In 1992, as part of my continuing professional development, I undertook an anatomy, physiology and massage course. My aim was to acquire skills that could benefit the mothers I cared for. My journey with baby massage began when I had my first son in 1993. At that time there were no courses or sessions on baby massage available but I did adapt some of the massage techniques I had learnt during my massage course to benefit me and my son.

Juggling the dual role of practitioner and educator: practice teachers' perceptions.

This paper reports on a study exploring the role (caseload manager; practitioner; educator) of Specialist Community Public Health Nursing (SCPHN) Practice Teachers (PTs) and mentors for Specialist Practice Community (SPC) district nursing students. Methodological triangulation was used, comprising questionnaires completed by 15 PTs and mentors, followed by six semistructured interviews, to provide quantitative and qualitative data. The results of the study identify that post-registration students demanded considerable time due to their need to develop leadership and higher cognitive skills in practice. PTs and mentors identified feeling undervalued by the organisation and colleagues as they tried to maintain their dual role with limited time or resources allocated. Respondents reported that they often worked over their hours to maintain both roles which impacted on their work life balance. They reported that both peer and university support groups were valuable and suggested that increased contact from lecturers and greater flexibility in university courses would accommodate their continuing professional development. It is, therefore, concluded that further support is needed by both the organisation and the university to enable this dual role.

Enabling practice development and research through partnerships with higher education.

This paper reports on a study that aimed to review a Practice Development and Research Partnership (PDRP) that was formed between an NHS community trust and a higher education institute (HEI) in 2008. Specific objectives were to focus on exploring stakeholders' views and experiences of the PDRP and to identify opportunities, barriers or challenges that were encountered. The ultimate goal of the PDRP was to promote partnership working between practitioners and academics in creating a culture of research and innovation in improving patient care, experiences and services. A qualitative research design was employed. Five lead practitioners, six academics and five senior managers from the PDRP steering group participated in semi-structured interviews. All were recorded and transcribed verbatim and a thematic approach to data analysis adopted. The PDRP provided opportunities for professional development for practitioners and academics, enhanced partnership working and recognised the need for a dedicated partnership coordinator. The evaluation recognised ambiguity with regard to roles, responsibilities and expectations. PDRPs can provide a vehicle for local NHS services to work collaboratively with HEls in developing a productive research environment that addresses local gaps in service and education in improving the quality of the patient experience.