Survey of maternal sleep practices in late pregnancy in a multi-ethnic sample in South Auckland, New Zealand.

BACKGROUND: The Auckland Stillbirth study demonstrated a two-fold increased risk of late stillbirth for women who did not go to sleep on their left side. Two further studies have confirmed an increased risk of late stillbirth with supine sleep position. As sleep position is modifiable, we surveyed self-reported late pregnancy sleep position, knowledge about sleep position, and views about changing going-to-sleep position. METHODS: Participants in this 2014 survey were pregnant women (n = 377) in their third trimester from South Auckland, New Zealand, a multi-ethnic and predominantly low socio-economic population. An ethnically-representative sample was obtained using random sampling. Multivariable logistic regression was performed to identify factors independently associated with non-left sided going-to-sleep position in late pregnancy. RESULTS: Respondents were 28 to 42 weeks' gestation. Reported going-to-sleep position in the last week was left side (30%), right side (22%), supine (3%), either side (39%) and other (6%). Two thirds (68%) reported they had received advice about sleep position. Non-left sleepers were asked if they would be able to change to their left side if it was better for their baby; 87% reported they would have little or no difficulty changing. Women who reported a non-left going-to-sleep position were more likely to be of Maori (aOR 2.64 95% CI 1.23-5.66) or Pacific (aOR 2.91 95% CI 1.46-5.78) ethnicity; had a lower body mass index (BMI) (aOR 0.93 95% CI 0.89-0.96); and were less likely to sleep on the left-hand side of the bed (aOR 3.29 95% CI 2.03-5.32). CONCLUSIONS: Maternal going-to-sleep position in the last week was side-lying in 91% of participants. The majority had received advice to sleep on their side or avoid supine sleep position. Sleeping on the left-hand side of the bed was associated with going-to-sleep on the left side. Most non-left sleepers reported their sleeping position could be modified to the left side suggesting a public health intervention about sleep position is likely to be feasible in other multi-ethnic communities.

Exploratory study of bed-sharing and maternal-infant bonding.

AIM: Bed-sharing with an infant is controversial due to the increased risk of sudden unexpected death in infancy versus postulated benefits of the practice such as enhanced breastfeeding and maternal-infant bonding. This study evaluated the association between bed-sharing and maternal-infant bonding. METHODS: Four hundred randomly selected mothers who had delivered in a large maternity unit in Auckland and whose infants were between the ages of 6 weeks and 4 months were sent a postal questionnaire asking about their bed-sharing practices last night, usually, and in the last 2 weeks. Included in the questionnaire were factors 1 and 2 questions from the Postpartum Bonding Questionnaire to assess maternal-infant bonding. RESULTS: Responders totalled 172 (43%), and infants were a mean age of 11 weeks. Fourteen per cent of infants slept in a bed-sharing situation last night, 8% usually, and 41% had slept with an adult in the last 2 weeks. Nine per cent of mothers scored above the cut-off for factor 1 for impaired maternal-infant bonding. Infants of these mothers were more likely to bed-share last night, usually, and in the last 2 weeks, and were less likely to use a pacifier and to breastfeed. Bed-sharing mothers scored more highly on individual questions relating to being annoyed or irritated by their baby. CONCLUSION: There is an inverse association between bed-sharing and maternal-infant bonding, which is contrary to the often expressed belief that bed-sharing enhances maternal-infant bonding.

A postal survey of maternal sleep in late pregnancy.

BACKGROUND: Sleep disturbances in late pregnancy are common. This study aimed to survey sleep problems in third trimester pregnant women and to compare sleep in the pre-pregnancy period with the third trimester. METHODS: Third-trimester women (n=650) were sent a postal survey containing questions relating to sleep experience, including perceived sleep quality, sleep difficulties, night waking, sleep environment, snoring, daytime tiredness and daytime napping. Time periods reported on were before pregnancy and in the last week. RESULTS: Respondents numbered 244 (38%). Before pregnancy, the mean reported duration of night-time sleep was 8.1 (SD 1.1) hours; in the last week this had decreased to 7.5 (SD 1.8) hours (p<.0001). Only 29% rated their sleep quality in the last week as very good or fairly good, compared with 82% rating their sleep this way before the pregnancy. The main reasons for sleeping difficulties were discomfort (67%) and pain (36%). Snoring increased significantly over the course of the pregnancy, with 37% reporting snoring often or every night in the last week. Those with a pre-pregnancy body mass index of greater than 25 were significantly more likely to snore (p=.01). Only 4% of women had an abnormal Epworth Sleepiness Scale score (i.e. >10) prior to pregnancy, whereas in the last week 33% scored in the abnormal range. Likewise, 5% had regularly napped during the daytime before pregnancy, compared with 41% in the last week. CONCLUSIONS: Sleep problems are common in women in late pregnancy, and increase markedly compared with before pregnancy.

Serial developmental assessments in infants with deformational plagiocephaly.

AIM: An association between positional plagiocephaly and developmental problems has previously been noted, but whether delays persist over time has not been established. This study aimed to determine developmental outcomes for children with deformational plagiocephaly over 1 year of follow up. METHODS: This was a longitudinal cohort study of 126 infants with deformational plagiocephaly recruited at an outpatient clinic. Development was assessed with the parent-completed Ages and Stages Questionnaires at recruitment and repeated at follow-up assessments in the home 3, 6 and 12 months later. Questionnaires were scored according to cut-off scores from the Ages and Stages Questionnaires, Third Edition. RESULTS: Ninety-six percent of children were followed up for the full 12 months. The existence of one or more delays initially was 30%; this rose to 42% at the 3-month follow up then dropped back to 23% by the 12-month follow up. Delays were predominantly in the gross motor domain. Ten percent had > 4 delays in total over the four assessments. Mothers with tertiary education were more likely to have infants showing delays that persisted over time. CONCLUSIONS: Infants with deformational plagiocephaly exhibited marked delays especially in early infancy. These delays were largely gross motor in type but had reduced to approach the expected level by the time of the 12-month follow up, at a mean age of 17 months.

Sudden unexpected infant death in Auckland: a retrospective case review.

AIM: To review autopsy reports of all SUDI deaths in the Auckland region, New Zealand, from October 2000 to December 2009. METHODS: Information on all SUDI cases from 2000 to 2009 was extracted from autopsy and police reports from the National Forensic Pathology Service at Auckland Hospital. RESULTS: Of the 332 post-mortems in this period, 221 were classified as SUDI. Of these, 83% were Maori or Pacific infants. The median age at death was 11 weeks and 11% occurred in 7- to 28-day-olds. At the time of death, 64% overall were bedsharing; this was more common in 7-28 day olds (92%). Bedsharing infants were significantly younger at death than non-bedsharing infants (p=0.008). Where sleep position was known, 57% were placed in non-supine at the last sleep. There was no evidence of diagnostic shift and the prevalence of bedsharing did not change over the decade. CONCLUSIONS: Bedsharing was associated with a high proportion of SUDI cases, especially in the youngest infants, and non-supine sleep positions were common. There is a need to enhance SUDI prevention messages and consider innovative ways of promoting safe sleeping environment and supine sleep position in Maori and Pacific communities.

The prevalence of cobedding and SIDS-related child care practices in twins.

UNLABELLED: Sudden unexplained and unexpected death in twins has not been well studied, particularly in relation to the common practice of sleeping twin infants together in the same cot (cobedding). Postal surveys of 109 mothers of twins were undertaken when the infants were 6 weeks, 4 months, and 8 months of age to determine the prevalence of cobedding, infant care practices related to sudden infant death syndrome (SIDS), and the mother's knowledge of SIDS risk factors. SIDS risk factor knowledge was similar to an earlier survey of singletons in 2005. At 6 weeks, 76% of infants usually slept on the back; this changed to 86% at 4 months and 73% at 8 months. At 6 weeks, 52% usually cobedded with their twin all or part of the time. At 4 and 8 months, this had reduced to 31% and 10%, respectively. Side-by-side cobedding configurations were predominant at 6 weeks, with feet-to-feet configurations increasing as the infants grew older. Breastfeeding was reported in 83%, 61% and 31% of infants at 6 weeks, 4 months and 8 months, respectively. Pacifier use was reported in 38%, 50% and 33% at the respective surveys. As the age of the twins increased, mothers were significantly more likely to be concerned about deformational plagiocephaly in Twin 1 than in Twin 2. CONCLUSION: Despite a lack of evidence of the risks or benefits of cobedding, this practice was very popular, especially in the younger infants. More research is needed to establish the safety of cobedding in relation to the risk of SIDS.

A randomized controlled trial of positioning treatments in infants with positional head shape deformities.

BACKGROUND: Randomized controlled trials of treatment for deformational plagiocephaly and brachycephaly have been lacking in the literature. METHODS: Infants (n = 126) presenting to a plagiocephaly clinic were randomized to either positioning strategies or to positioning plus the use of a Safe T Sleep™ positioning wrap. Head shape was measured using a digital photographic technique, and neck function was assessed. They were followed up at home 3, 6 and 12 months later. RESULTS: There was no difference in head shape outcomes for the two treatment groups after 12 months of follow-up, with 42% of infants having head shapes in the normal range by that time. Eighty per cent of children showed good improvement. Those that had poor improvement were more likely to have both plagiocephaly and brachycephaly and to have presented later to clinic. CONCLUSIONS: Most infants improved over the 12-month study period, although the use of a sleep positioning wrap did not increase the rate of improvement.

Characteristics, head shape measurements and developmental delay in 287 consecutive infants attending a plagiocephaly clinic.

AIM: To describe the characteristics, developmental status and severity of head shape deformation in infants presenting to a plagiocephaly clinic. METHODS: Head shape was measured and neck function assessed in 287 consecutive infants presenting to a plagiocephaly outpatient clinic. Information was obtained on demographic and obstetric factors, plagiocephaly history and current positioning strategies. Development was assessed by the Ages and Stages Questionnaire (ASQ). RESULTS: After clinical examination, craniosynostosis was suspected in seven infants (2%) and a skull computed tomography (CT) scan was performed; five showed suture abnormalities. Fifty-eight percent of cases had a history of limitation of neck function; this was more likely in plagiocephalic infants than brachycephalic infants. Males, firstborn infants, instrument-delivered infants, supine sleep position and right-sided flattening were predominant. One or more delays on the ASQ were seen in 36% of infants. CONCLUSION: Physical examination of infants with head shape deformities is essential in order to rule out craniosynostosis. Infants with deformational plagiocephaly frequently have neck muscle dysfunction. We postulate that the higher than expected number of developmental delays may be related to the effects of supine sleep position, low or variable tone, lower activity levels, male gender and neck muscle dysfunction.

Where would you turn for help? Older adults' awareness of community support services.

Previous findings on older adults' awareness of community support services (CSSs) have been inconsistent and marred by acquiescence or over-claiming bias. To address this issue, this study used a series of 12 vignettes to describe common situations faced by older adults for which CSSs might be appropriate. In telephone interviews, 1,152 adults aged 50 years and over were read a series of vignettes and asked if they were able to identify a community organization or agency that they may turn to in that situation. They were also asked about their most important sources of information about CSSs. The findings show that, using a vignette methodology, awareness of CSSs is much lower than previously thought. The most important sources of information about CSSs included information and referral sources, the telephone book, doctors' offices, and word of mouth.

Infant care practices related to sudden unexpected death in infancy: a 2013 survey.

AIM: This survey aimed to evaluate mothers' knowledge of, and practices related to, risk factors for sudden unexpected death in infancy (SUDI) and to compare results with a similar survey conducted in 2005. METHOD: 400 randomly selected women with infants between the ages of 6 weeks and 4 months were sent a postal questionnaire asking about their knowledge and infant care practices related to SUDI risk factors. Included were questions on sleep position, bed sharing, room sharing, smoking, and breastfeeding. Results were compared with a similar survey conducted in 2005. RESULTS: There were 172 (43%) responses. Compared with 2005, more women in this survey cited avoiding bed sharing, keeping the face clear, avoiding soft bedding, and room sharing as SUDI prevention factors. Compared with 2005, more mothers usually used the supine sleep position and shared the parental bedroom, while fewer mothers reported smoking. Eight percent said the infant usually shared a bed, down from 15% in 2005. Of the five main protective factors promoted by New Zealand's Ministry of Health (supine sleep, own bed, room sharing, smoke free, breastfeeding), 43% were implementing all of these practices. CONCLUSION: There has been an increased knowledge of SUDI risk factors. Also evident are an increase in supine positioning and room sharing and a decrease in smoking and bed sharing. These results suggest possible reasons for the falling rate of SUDI in New Zealand.

HLA-DR and -DQ genotyping in anti-GBM disease.

Anti-GBM disease has been associated with the HLA genes of the major histocompatibility complex (MHC) in previous serological studies, with an increased incidence of HLA-DR2 in patients. In this study, 36 patients with anti-GBM disease were genotyped by restriction fragment length polymorphism (RFLP) analysis using cDNA probes for DRB, DQA, and DQB. The frequency of HLA-DRw15(Dw2), a split of DR2, was significantly increased in the patients compared with the controls (63.9 per cent versus 23.3 per cent, chi 2 = 22.4, p(corr) less than 0.0001), and all but one of the patients were positive for either DRw15(Dw2) or DR4 (p less than 0.0001). The frequencies of the remaining DR antigens were not decreased randomly, with a significant decrease in DR7 in the patient group (chi 2 = 8.6, p(corr) less than 0.05). The closely linked gene HLA-DQw6 was found to be significantly increased in frequency in the patients compared with the controls (p(corr) less than 0.0001). No correlations could be made between the genetic data and clinical features of the disease.

Agreement among reviewers of review articles.

OBJECTIVE: To assess the consistency of an index of the scientific quality of research overviews. DESIGN: Agreement was measured among nine judges, each of whom assessed the scientific quality of 36 published review articles. ITEM SELECTION: An iterative process was used to select ten criteria relative to five key tasks entailed in conducting a research overview. SAMPLE: The review articles were drawn from three sampling frames: articles highly rated by criteria external to the study; meta-analyses; and a broad spectrum of medical journals. JUDGES: Three categories of judges were used: research assistants; clinicians with research training; and experts in research methodology; with three judges in each category. RESULTS: The level of agreement within the three groups of judges was similar for their overall assessment of scientific quality and for six of the nine other items. With four exceptions, agreement among judges within each group and across groups, as measured by the intraclass correlation coefficient (ICC), was greater than 0.5, and 60% (24/40) of the ICCs were greater than 0.7. CONCLUSIONS: It was possible to achieve reasonable to excellent agreement for all of the items in the index, including the overall assessment of scientific quality. The implications of these results for practising clinicians and the peer review system are discussed.

Selective opportunistic screening for hypercholesterolemia in primary care practice.

OBJECTIVES: To assess the performance of selective opportunistic screening in a primary care group practice. DESIGN: Cross-sectional survey of coronary heart disease risk factors and retrospective chart audit of cholesterol testing. SETTING: Capitation-funded primary care group practice in Ontario, Canada. SUBJECTS: 7785 enrolled patients between the ages of 20 and 69 years. INTERVENTION: Protocol-based selective opportunistic screening program for hypercholesterolemia of 45 months duration. MAIN OUTCOME MEASURES: Targeting (proportion of screening tests that were appropriate), coverage (proportion of those meeting screening criteria who had a screening test performed), over-screening (proportion of those not meeting screening criteria who had a screening test performed), and screening ratio (likelihood that a screening test was performed on an individual who met screening criteria rather than one who failed to meet screening criteria). RESULTS: 64.7% of patients tested met the practice criteria for screening. 37.7% of patients who met the practice screening criteria were tested and 24.9% of those not meeting practice screening criteria had a cholesterol test performed. The screening ratio was 1.52. CONCLUSION: Our findings bring into question the effectiveness of opportunistic approaches to preventive care.

The regulation of calcitriol by parathyroid hormone and absorbed dietary phosphorus in subjects with moderate chronic renal failure.

The two best-recognized stimuli for calcitriol production are parathyroid hormone (PTH) and dietary phosphorus deprivation. We studied the relative importance of these two stimuli in subjects with moderate chronic renal failure (MCRF). We recruited 10 subjects with MCRF aged 49 +/- 13 years (mean +/- SD) and having a creatinine clearance rate of 31 +/- 24 mL/min. After an overnight fast, they received 400 IU human PTH 1-34 subcutaneously, and blood and urine samples were collected over the subsequent 24 hours. They then took aluminum hydroxide 30 mmol/d for 2 months to reduce gut phosphorus absorption, at the end of which the PTH stimulation test was repeated. Responses were compared with those obtained in 11 normal subjects aged 44 +/- 16 years and having a creatinine clearance rate of 102 +/- 37 mL/min who were only studied while on their normal diet. Following PTH stimulation in the normal subjects but not the MCRF subjects, there was a significant increase in plasma calcium and calcitriol levels, with a significant decrease in renal phosphorus threshold. In both groups there was a similar and significant increase in urine cyclic adenosine monophosphate (cAMP) levels. Following restriction of absorption of dietary phosphorus in MCRF subjects, plasma calcitriol levels increased compared with baseline values. This study shows that these MCRF subjects were unable to respond with an increase in calcitriol to a PTH stimulus that produced a similar urine cAMP response in normal subjects. However, they were capable of responding to a reduction in phosphorus absorption with an increase in calcitriol.(ABSTRACT TRUNCATED AT 250 WORDS)

Primary care in Canada: so much innovation, so little change.

The development of Canadian primary care has been shaped by a series of policy legacies that continue to affect the possibilities for change in primary care through their cumulative effects on the health care system and the process of health policy development. The pursuit of radical systemwide change in the face of unfavorable circumstances (created in large part by those legacies) has resulted in missed opportunities for cumulative incremental change. While major changes in primary care policy seem unlikely in the near future, significant incremental change is possible, but it will require a reorientation of the policy development process.

Do socioeconomic characteristics modify the short term association between air pollution and mortality? Evidence from a zonal time series in Hamilton, Canada.

STUDY OBJECTIVE: To assess the short term association between air pollution and mortality in different zones of an industrial city. An intra-urban study design is used to test the hypothesis that socioeconomic characteristics modify the acute health effects of ambient air pollution exposure. DESIGN: The City of Hamilton, Canada, was divided into five zones based on proximity to fixed site air pollution monitors. Within each zone, daily counts of non-trauma mortality and air pollution estimates were combined. Generalised linear models (GLMs) were used to test mortality associations with sulphur dioxide (SO(2)) and with particulate air pollution measured by the coefficient of haze (CoH). MAIN RESULTS: Increased mortality was associated with air pollution exposure in a citywide model and in intra-urban zones with lower socioeconomic characteristics. Low educational attainment and high manufacturing employment in the zones significantly and positively modified the acute mortality effects of air pollution exposure. DISCUSSION: Three possible explanations are proposed for the observed effect modification by education and manufacturing: (1) those in manufacturing receive higher workplace exposures that combine with ambient exposures to produce larger health effects; (2) persons with lower education are less mobile and experience less exposure measurement error, which reduces bias toward the null; or (3) manufacturing and education proxy for many social variables representing material deprivation, and poor material conditions increase susceptibility to health risks from air pollution.

Defining the practice population in fee-for-service practice.

OBJECTIVE: To develop and validate a technique for defining a practice population of discrete individuals based on multiyear family practice fee-for-service billings data. DATA SOURCES/STUDY SETTING: Nineteen family physicians in Ontario, Canada who converted from fee-for-service to capitation payment. Data sources were fee-for-service billings data for the three-year period prior to the conversion from fee-for-service to capitation payment and the rosters of enrolled patients for the first and third years after the change to capitation payment. STUDY DESIGN: The billings-based definition of the physician's practice population was compared against the Year 1 roster. We also compared the billings-based practice population and the Year 1 roster to the physician's Year 3 roster to identify patients who might have been missed during the roster development process. Our principal analyses were an assessment of the sensitivity of the billings-based definition of the practice population (EPP), the positive predictive value of EPP, and the agreement between EPP and the rostered patient population (RPP). We also examined the ratio between EPP and RPP to determine EPP's accuracy in estimating the practice denominator. DATA COLLECTION/EXTRACTION METHODS: The practice population for each physician at the time of conversion from fee-for-service to capitation payment was defined as (a) all persons for whom the physician billed the provincial health insurance plan for at least one visit during the year immediately prior to joining the capitation-funded program; and (b) all additional patients for whom the physician billed the plan for at least one service in each of the two preceding years. Data extraction was carried out within the Ministry of Health in order to preserve the anonymity of patients and physicians. Data were provided to the investigators stripped of patient and physician identifiers. PRINCIPAL FINDINGS: The mean sensitivity and positive predictive value of EPP were 95.3 percent and 87.4 percent, respectively. The level of agreement between EPP and RPP averaged 84.4 percent. The mean ratio of EPP to RPP was 1.21 (95 percent C.I. 1.030-1.213). Correction for roster false-negatives increased the sensitivity, positive predictive value, and agreement between EPP and the practice population, and reduced the mean ratio of EPP to the practice population to 1.068 (95 percent C.I. 1.010-1.127). CONCLUSIONS: The practice population can usefully be defined in fee-for-service family practice on the basis of multiyear fee-for-service billings data. Further research examining alternative encounter-based practice population definitions would be valuable.

A needs-based methodology for allocating health care resources in Ontario, Canada: development and an application.

In an attempt to limit its health care expenditures, Ontario is, as one option, exploring the possibilities of a capitated system for service delivery payments as opposed to the present mixture of global budgets and fee-for-service. After reviewing the literatures on capitation (primarily American) and on resource allocation (primarily British), the paper sets out to establish a capitation rate, based on 'need' and not prior use, for a range of health services in the northern Ontarian community of Fort Frances-Rainy River. The difficulties and limitations of the needs-based approach are explored. The results reported show the setting of the local population characteristics against provincial average health care utilization data to generate expected use rates, which are then adjusted for need and other factors, particularly relative costs and sparsity. Finally these adjusted rates are applied to current provincial expenditures to derive a target share. This target is then expressed in relation to the planning population to derive the capitation rate.

A pilot home-based geriatric health screening project in primary care.

Regular multidimensional screening of the elderly for undetected health problems has the potential for delaying functional deterioration and improving the quality of life, but has not been evaluated rigorously. This pilot study examined the amount and type of unmet health care need discovered by home-based screening of 100 family practice patients aged 75 and over. Although 96 per cent of patients had some health problems, only 71 per cent had problems that needed further intervention. Of these, the majority were problems in the area of psychosocial function, independence, and lifestyle. Age, sex, and frequency of attendance at the practice in the previous year were not found to be useful markers for targeting screening efforts. Although it is potentially beneficial for detecting unmet need, home-based screening is resource-intensive and requires further examination in randomized trials in the North American context.

Casting the screening net: separating big fish from little fish.

Screening tests are a rapidly growing part of medical practice. If we are going to make the best use of resources, screening tests need to be considered in terms of effectiveness, efficiency and equity. We present a framework as a way to think about screening programmes. The framework expands on existing literature that recognizes two categories of screening: universal and opportunistic. By adding the dimension of 'selectivity', we identify four categories of screening: active non-selective (universal or mass screening), active selective, opportunistic non-selective and opportunistic selective. We illustrate the framework by categorizing screening recommendations for high serum cholesterol levels. We conclude there is no one ideal strategy for screening that simultaneously satisfies criteria of effectiveness, efficiency and equity. However, our framework allows a systematic consideration and balancing of these objectives in the development and assessment of screening programs. In this way, it may assist decision-makers by making this trade-off more explicit.