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1.
J Dent Res ; : 220345221128226, 2022 Oct 30.
Artigo em Inglês | MEDLINE | ID: mdl-36314491

RESUMO

Patients with persistent orofacial pain (POFP) can go through complex care pathways to receive a diagnosis and management, which can negatively affect their pain. This study aimed to describe 44-y trends in attendances at Welsh medical practices for POFP and establish the number of attendances per patient and referrals associated with orofacial pain and factors that may predict whether a patient is referred. A retrospective observational study was completed using the nationwide Secure Anonymised Information Linkage Databank of visits to general medical practices in Wales (UK). Data were extracted using diagnostic codes ("Read codes"). Orofacial and migraine Read codes were extracted between 1974 and 2017. Data were analyzed using descriptive statistics and univariate and multivariable logistic regression. Over the 44-y period, there were 468,827 POFP and migraine diagnostic codes, accounting for 468,137 patient attendances, or 301,832 patients. The overall attendance rate was 4.22 attendances per 1,000 patient-years (95% confidence interval [CI], 4.21-4.23). The attendance rate increased over the study period. Almost one-third of patients (n = 92,192, 30.54%) attended more than once over the study period, and 15.83% attended more than once within a 12-mo period. There were 20,103 referral codes that were associated with 8,183 patients, with over half these patients being referred more than once. Odds of receiving a referral were highest in females (odds ratio [OR], 1.23; 95% CI, 1.17-1.29), in those living in rural locations (OR, 1.17; 95% CI, 1.12-1.22), and in the least deprived quintile (OR, 1.39; 95% CI, 1.29-1.48). Odds also increased with increasing age (OR, 1.03; 95% CI, 1.03-1.03). The increasing attendance may be explained by the increasing incidence of POFP within the population. These patients can attend on a repeated basis, and very few are referred, but when they are, this may occur multiple times; therefore, current care pathways could be improved.

2.
JDR Clin Trans Res ; 7(1): 16-24, 2022 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33323035

RESUMO

BACKGROUND: For health care services to address the health care needs of populations and respond to changes in needs over time, workforces must be planned. This requires quantitative models to estimate future workforce requirements that take account of population size, oral health needs, evidence-based approaches to addressing needs, and methods of service provision that maximize productivity. The aim of this scoping review was to assess whether and how these 4 elements contribute to existing models of oral health workforce planning. METHODS: A scoping review was conducted. MEDLINE, Embase, HMIC, and EconLit were searched, all via OVID. Additionally, gray literature databases were searched and key bodies and policy makers contacted. Workforce planning models were included if they projected workforce numbers and were specific to oral health. No limits were placed on country. A single reviewer completed initial screening of abstracts; 2 independent reviewers completed secondary screening and data extraction. A narrative synthesis was conducted. RESULTS: A total of 4,009 records were screened, resulting in 42 included articles detailing 47 models. The workforce planning models varied significantly in their use of data on oral health needs, evidence-based services, and provider productivity, with most models relying on observed levels of service utilization and demand. CONCLUSIONS: This review has identified quantitative workforce planning models that aim to estimate future workforce requirements. Approaches to planning the oral health workforce are not always based on deriving workforce requirements from population oral health needs. In many cases, requirements are not linked to population needs, while in models where needs are included, they are constrained by the existence and availability of the required data. It is critical that information systems be developed to effectively capture data necessary to plan future oral health care workforces in ways that relate directly to the needs of the populations being served. KNOWLEDGE TRANSFER STATEMENT: Policy makers can use the results of this study when making decisions about the planning of oral health care workforces and about the data to routinely collect within health services. Collection of suitable data will allow for the continual improvement of workforce planning, leading to a responsive health service and likely future cost savings.


Assuntos
Mão de Obra em Saúde , Saúde Bucal , Atenção à Saúde , Planejamento em Saúde , Recursos Humanos
3.
J Dent Res ; 101(4): 407-413, 2022 04.
Artigo em Inglês | MEDLINE | ID: mdl-34582311

RESUMO

One-third of the UK population is composed of problem-oriented dental attenders, seeking dental care only when they have acute dental pain or problems. Patients seek urgent dental care from a range of health care professionals, including general medical practitioners. This study aimed to identify trends in dental attendance at Welsh medical practices over a 44-y period, specifically in relation to dental policy change and factors associated with repeat attendance. A retrospective observational study was completed via the nationwide Secure Anonymised Information Linkage (SAIL) Databank of visits to general medical practice in Wales. Read codes associated with dental diagnoses were extracted for patients attending their general medical practitioner between 1974 and 2017. Data were analyzed with descriptive statistics and univariate and multivariable logistic regression. Over the 44-y period, there were 439,361 dental Read codes, accounting for 288,147 patient attendances. The overall attendance rate was 2.60 attendances per 1,000 patient-years (95% CI, 2.59 to 2.61). The attendance rate was negligible through 1987 but increased sharply to 5.0 per 1,000 patient-years in 2006 (95% CI, 4.94 to 5.09) before almost halving to 2.6 per 1,000 in 2017 (95% CI, 2.53 to 2.63) to a pattern that coincided with changes to National Health Service policies. Overall 26,312 patients were repeat attenders and were associated with living in an area classified as urban and deprived (odds ratio [OR], 1.22; 95% CI, 1.19 to 1.25; P < 0.0001) or rural (OR, 0.84; 95% CI, 0.83 to 0.85; P < 0.0001). Repeat attendance was associated with greater odds of having received an antibiotic prescription (OR, 2.53; 95% CI, 2.50 to 2.56; P < 0.0001) but lower odds of having been referred to another service (OR, 0.75; 95% CI, 0.70 to 0.81; P < 0.0001). Welsh patients' reliance on medical care for dental problems was influenced by social deprivation and health policy. This indicates that future interventions to discourage dental attendance at medical practitioners should be targeted at those in the most deprived urban areas or rural areas. In addition, health policy may influence attendance rates positively and negatively and should be considered in the future when decisions related to policy change are made.


Assuntos
Encaminhamento e Consulta , Medicina Estatal , Pessoal de Saúde , Humanos , Estudos Retrospectivos , País de Gales/epidemiologia
5.
BJOG ; 126(10): 1243-1250, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31066982

RESUMO

OBJECTIVE: To identify the most cost-effective policy for detection and management of fetal macrosomia in late-stage pregnancy. DESIGN: Health economic simulation model. SETTING: All English NHS antenatal services. POPULATION: Nulliparous women in the third trimester treated within the UK NHS. METHODS: A health economic simulation model was used to compare long-term maternal-fetal health and cost outcomes for two detection strategies (universal ultrasound scanning at approximately 36 weeks of gestation versus selective ultrasound scanning), combined with three management strategies (planned caesarean section versus induction of labour versus expectant management) of suspected fetal macrosomia. Probabilities, costs and health outcomes were taken from literature. MAIN OUTCOME MEASURES: Expected costs to the NHS and quality-adjusted life-years (QALYs) gained from each strategy, calculation of net benefit and hence identification of most cost-effective strategy. RESULTS: Compared with selective ultrasound, universal ultrasound increased QALYs by 0.0038 (95% CI 0.0012-0.0076), but also costs by £123.50 (95% CI 99.6-149.9). Overall, the health gains were too small to justify the cost increase given current UK thresholds cost-effective policy was selective ultrasound coupled with induction of labour where macrosomia was suspected. CONCLUSIONS: The most cost-effective policy for detection and management of fetal macrosomia is selective ultrasound scanning coupled with induction of labour for all suspected cases of macrosomia. Universal ultrasound scanning for macrosomia in late-stage pregnancy is not cost-effective. TWEETABLE ABSTRACT: Universal late-pregnancy ultrasound screening for fetal macrosomia is not warranted.


Assuntos
Análise Custo-Benefício , Técnicas de Apoio para a Decisão , Macrossomia Fetal/diagnóstico , Macrossomia Fetal/economia , Paridade , Cuidado Pré-Natal/economia , Cuidado Pré-Natal/métodos , Ultrassonografia Pré-Natal/economia , Adulto , Inglaterra , Feminino , Macrossomia Fetal/diagnóstico por imagem , Pesquisa sobre Serviços de Saúde , Humanos , Seleção de Pacientes , Gravidez , Terceiro Trimestre da Gravidez
6.
BJOG ; 126(9): 1157-1167, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30576053

RESUMO

OBJECTIVE: To determine whether a novel therapy for placental insufficiency could achieve orphan drug status by estimating the annual incidence of placental insufficiency, defined as an estimated fetal weight below the 10th centile in the presence of abnormal umbilical artery Doppler velocimetry, per 10 000 European Union (EU) population as part of an application for European Medicines Agency (EMA) orphan designation. DESIGN: Incidence estimation based on literature review and published national and EU statistics. SETTING AND POPULATION: European Union. METHODS: Data were drawn from published literature, including national and international guidelines, international consensus statements, cohort studies and randomised controlled trials, and published national and EU statistics, including birth rates and stillbirth rates. Rare disease databases were also searched. RESULTS: The proportion of affected pregnancies was estimated as 3.17% (95% CI 2.93-3.43%), using a weighted average of the results from two cohort studies. Using birth rates from 2012 and adjusting for a pregnancy loss rate of 1/100 gave an estimated annual incidence of 3.33 per 10 000 EU population (95% CI 3.07-3.60 per 10 000 EU population). This fell below the EMA threshold of 5 per 10 000 EU population. CONCLUSIONS: Maternal vascular endothelial growth factor gene therapy for placental insufficiency was granted EMA orphan status in 2015 after we demonstrated that it is a rare, life-threatening or chronically debilitating and currently untreatable disease. Developers of other potential obstetric therapies should consider applying for orphan designation, which provides financial and regulatory benefits. TWEETABLE ABSTRACT: Placental insufficiency meets the European Medicines Agency requirements for orphan disease designation.


Assuntos
Insuficiência Placentária/epidemiologia , Doenças Raras/epidemiologia , Europa (Continente)/epidemiologia , União Europeia/estatística & dados numéricos , Feminino , Terapia Genética/classificação , Humanos , Incidência , Produção de Droga sem Interesse Comercial/classificação , Insuficiência Placentária/classificação , Gravidez , Doenças Raras/classificação , Fator A de Crescimento do Endotélio Vascular/uso terapêutico
7.
Br Dent J ; 225(9): 815-819, 2018 11 09.
Artigo em Inglês | MEDLINE | ID: mdl-30412550

RESUMO

The paper highlights the pros and cons of a national programme for screening for oral cancer. It provides an overview of screening methods and the metrics used to evaluate a screening programme. It then reviews the evidence for mouth cancer screening against the criteria of the United Kingdom National Screening Committee.


Assuntos
Detecção Precoce de Câncer , Neoplasias Bucais , Humanos , Programas de Rastreamento , Reino Unido
8.
Br Dent J ; 224(3): 136-139, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29391605

RESUMO

The transfer of evidence into clinical practice is the ultimate aim of those engaged in health research. But is this a process that occurs naturally? Can health researchers take it for granted that the evidence they produce will be embraced by clinicians and incorporated into their everyday practice? In this article, we use the example of oral healthcare in dependent older people and the issue of antibiotic prescribing by GDPs to illustrate the fact that successful knowledge transfer between researchers and practitioners cannot be automatically assumed. What is needed, so we argue, are certain tools to facilitate the knowledge transfer, exchange and implementation process. These tools may take the form of human intermediaries, who can occupy the space in between the worlds of research and practice, acting as brokers to mobilise knowledge, or through the establishment of communities of practice. We outline both of these approaches here as a potential solution to the problem of knowledge mobilisation in dentistry.


Assuntos
Odontologia , Odontologia Baseada em Evidências , Atenção à Saúde , Humanos
9.
BJOG ; 125(8): 965-971, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29193647

RESUMO

OBJECTIVE: The aim of this study was to estimate the incidence of anaphylaxis in pregnancy and describe the management and outcomes in the UK. DESIGN: A population-based descriptive study using the UK Obstetric Surveillance System (UKOSS). SETTING: All consultant-led maternity units in the UK. POPULATION: All pregnant women who had anaphylaxis between 1 October 2012 and 30 September 2015. Anaphylaxis was defined as a severe, life-threatening generalised or systemic hypersensitivity reaction. METHODS: Prospective case notification using UKOSS. MAIN OUTCOME MEASURES: Maternal mortality, severe maternal morbidity, neonatal mortality and severe neonatal morbidity. RESULTS: There were 37 confirmed cases of anaphylaxis in pregnancy, giving an estimated incidence of 1.6 (95% CI: 1.1-2.2) per 100 000 maternities. Four cases of anaphylaxis were in women with known penicillin allergies: two received co-amoxiclav and two cephalosporins. Twelve women had anaphylaxis following prophylactic use of antibiotics at the time of a caesarean delivery. Prophylactic use of antibiotics for Group B streptococcal infection accounted for anaphylaxis in one woman. Two women died (5%), 14 (38%) women were admitted to intensive care and seven women (19%) had one or more additional severe maternal morbidities, which included three haemorrhagic events, two cardiac arrests, one thrombotic event and one pneumonia. No infants died; however, in those infants whose mother had anaphylaxis before delivery (n = 18) there were seven (41%) neonatal intensive care unit admissions, three preterm births and one baby was cooled for neonatal encephalopathy. CONCLUSIONS: Anaphylaxis is a rare severe complication of pregnancy and frequently the result of a reaction to antibiotic administration. This study highlights the seriousness of the outcomes of this condition for the mother. The low incidence is reassuring given the large proportion of the pregnant population that receive prophylactic antibiotics during delivery. TWEETABLE ABSTRACT: Anaphylaxis is a rare severe complication of pregnancy and frequently the result of a reaction to antibiotic administration.


Assuntos
Anafilaxia/mortalidade , Vigilância da População , Complicações na Gravidez/mortalidade , Adulto , Feminino , Humanos , Incidência , Recém-Nascido , Mortalidade Materna , Mortalidade Perinatal , Gravidez , Complicações na Gravidez/imunologia , Resultado da Gravidez , Estudos Prospectivos , Reino Unido/epidemiologia , Adulto Jovem
10.
Eye (Lond) ; 32(1): 74-80, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-28752837

RESUMO

PurposeTo investigate whether the observed international differences in retinopathy of prematurity (ROP) treatment rates within the Benefits of Oxygen Saturation Targeting (BOOST) II trials might have been caused by international variation in ROP disease grading.MethodsGroups of BOOST II trial ophthalmologists in UK, Australia, and New Zealand (ANZ), and an international reference group (INT) used a web based system to grade a selection of RetCam images of ROP acquired during the BOOST II UK trial. Rates of decisions to treat, plus disease grading, ROP stage grading, ROP zone grading, inter-observer variation within groups and intra-observer variation within groups were measured.ResultsForty-two eye examinations were graded. UK ophthalmologists diagnosed treat-requiring ROP more frequently than ANZ ophthalmologists, 13.9 (3.49) compared to 9.4 (4.46) eye examinations, P=0.038. UK ophthalmologists diagnosed plus disease more frequently than ANZ ophthalmologists, 14.1 (6.23) compared to 8.5 (3.24) eye examinations, P=0.021. ANZ ophthalmologists diagnosed stage 2 ROP more frequently than UK ophthalmologists, 20.2 (5.8) compared to 12.7 (7.1) eye examinations, P=0.026. There were no other significant differences in the grading of ROP stage or zone. Inter-observer variation was higher within the UK group than within the ANZ group. Intra-observer variation was low in both groups.ConclusionsWe have found evidence of international variation in the diagnosis of treatment-requiring ROP. Improved standardisation of the diagnosis of treatment-requiring ROP is required. Measures might include improved training in the grading of ROP, using an international approach, and further development of ROP image analysis software.


Assuntos
Recém-Nascido Prematuro , Oftalmoscopia/métodos , Consumo de Oxigênio/fisiologia , Oxigenoterapia/métodos , Oxigênio/metabolismo , Retinopatia da Prematuridade/terapia , Austrália/epidemiologia , Canadá/epidemiologia , Feminino , Seguimentos , Idade Gestacional , Humanos , Incidência , Recém-Nascido , Masculino , Nova Zelândia , Estudos Prospectivos , Reprodutibilidade dos Testes , Retinopatia da Prematuridade/epidemiologia , Retinopatia da Prematuridade/metabolismo , Reino Unido/epidemiologia , Estados Unidos/epidemiologia
11.
BMC Pregnancy Childbirth ; 17(1): 439, 2017 12 28.
Artigo em Inglês | MEDLINE | ID: mdl-29282072

RESUMO

BACKGROUND: Few data are available to guide biological sample collection around the time of birth for large-scale birth cohorts. We are designing a large UK birth cohort to investigate the role of infection and the developing immune system in determining future health and disease. We undertook a pilot to develop methodology for the main study, gain practical experience of collecting samples, and understand the acceptability of sample collection to women in late pregnancy. METHODS: Between February-July 2014, we piloted the feasibility and acceptability of collecting maternal stool, baby stool and cord blood samples from participants recruited at prolonged pregnancy and planned pre-labour caesarean section clinics at University College London Hospital. Participating women were asked to complete acceptability questionnaires. RESULTS: Overall, 265 women were approached and 171 (65%) participated, with ≥1 sample collected from 113 women or their baby (66%). Women had a mean age of 34 years, were primarily of white ethnicity (130/166, 78%), and half were nulliparous (86/169, 51%). Women undergoing planned pre-labour caesarean section were more likely than those who delivered vaginally to provide ≥1 sample (98% vs 54%), but less likely to provide maternal stool (10% vs 43%). Pre-sample questionnaires were completed by 110/171 women (64%). Most women reported feeling comfortable with samples being collected from their baby (<10% uncomfortable), but were less comfortable about their own stool (19% uncomfortable) or a vaginal swab (24% uncomfortable). CONCLUSIONS: It is possible to collect a range of biological samples from women around the time of delivery, and this was acceptable for most women. These data inform study design and protocol development for large-scale birth cohorts.


Assuntos
Fezes , Sangue Fetal , Testes para Triagem do Soro Materno/métodos , Aceitação pelo Paciente de Cuidados de Saúde , Gravidez Prolongada/diagnóstico , Cuidados Pré-Operatórios/métodos , Manejo de Espécimes/métodos , Adulto , Coleta de Amostras Sanguíneas/métodos , Coleta de Amostras Sanguíneas/psicologia , Cesárea , Estudos de Viabilidade , Feminino , Humanos , Estudos Longitudinais , Testes para Triagem do Soro Materno/psicologia , Projetos Piloto , Gravidez , Gravidez Prolongada/psicologia , Cuidados Pré-Operatórios/psicologia , Manejo de Espécimes/psicologia , Reino Unido
12.
Br Dent J ; 223(9): 729-732, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29097795

RESUMO

All clinicians in medicine and dentistry aim to deliver evidence-based practice; however, it is widely recognised that the current evidence base for interventions in oral medicine, as with many other specialties, is of a low quality. The highest level of evidence is considered to be the systematic review and meta-analysis. The Cochrane Collaboration and the Cochrane Oral Health group produce high quality systematic reviews, however, despite the large number of trials carried out for treatments in oral medicine, the results are often not able to be utilised to guide clinical care due to the various methodological limitations of the trials including the heterogeneity of outcome measures used. To improve the strength of the evidence base this will need to change. The Comet initiative aims to support the development of core outcome sets which are used to allow homogeneity of outcome measures in trials and therefore will allow pooling of data for meta-analysis in future systematic reviews. This paper explores the complexities involved in producing evidence for oral medicine interventions and introduces an approach for developing core outcome sets in oral medicine.


Assuntos
Odontologia Baseada em Evidências , Saúde Bucal , Medicina Baseada em Evidências , Prática Clínica Baseada em Evidências , Metanálise como Assunto , Medicina Bucal , Avaliação de Resultados em Cuidados de Saúde , Literatura de Revisão como Assunto
13.
Community Dent Health ; 34(2): 102-106, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28573841

RESUMO

OBJECTIVES: To assess the efficiency of service provision in the Community Dental Services and its determinants in the North-West of England. SETTING AND SAMPLE: 40 Community Dental Services sites operating across the North-West of England. BASIC RESEARCH DESIGN: A data envelopment analysis was undertaken of inputs (number of surgeries, hours worked by dental officers, therapists, hygienists and others) and outputs (treatments delivered, number of courses of treatment and patients seen) of the Community Dental Services to produce relative efficiency ratings by health authority. These were further analyzed in order to identify which inputs (determined within the Community Dental Services) or external factors outside the control of the Community Dental Services are associated with efficiency. MAIN OUTCOME MEASURE: Relative efficiency rankings in Community Dental Services production of dental healthcare. RESULTS: Using the quantity of treatments delivered as the measure of output, on average the Community Dental Services in England is operating at a relative efficiency of 85% (95% confidence interval 77%- 99%) compared to the best performing services. Average efficiency is lower when courses of treatment and unique patients seen are used as output measures, 82% and 68% respectively. Neither the input mix nor the patient case mix explained variations in the efficiency across Community Dental Services. CONCLUSIONS: Although large variations in performance exist across Community Dental Services, the data available was not able to explain these variations. A useful next step would be to undertake detailed case studies of several best and under-performing services to explore the factors that influence relative performance levels.


Assuntos
Serviços de Saúde Comunitária/organização & administração , Serviços de Saúde Bucal/organização & administração , Eficiência Organizacional , Inglaterra , Humanos
14.
Br Dent J ; 222(9): 721-726, 2017 May 12.
Artigo em Inglês | MEDLINE | ID: mdl-28496211

RESUMO

This practical paper explains how to design an randomised controlled trial (RCT) for those who have little prior knowledge of the topic. It covers the basics of radomisation, statistical testing, sample size caluclations, bias and the role of Clinical Trial Units.


Assuntos
Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Projetos de Pesquisa , Viés , Humanos , Distribuição Aleatória , Tamanho da Amostra , Estatística como Assunto/métodos
15.
Br Dent J ; 222(5): 331-335, 2017 Mar 10.
Artigo em Inglês | MEDLINE | ID: mdl-28281585

RESUMO

In a world where evidence-based practice is see as the foundation of modern healthcare, this paper asks when and how should we be accounting for the input of patients, the public, dental professionals, commissioners and policy-makers in the evidence generation process?


Assuntos
Prática Clínica Baseada em Evidências , Ensaios Clínicos como Assunto , Humanos , Projetos de Pesquisa
16.
Br Dent J ; 221(11): 717-721, 2016 Dec 09.
Artigo em Inglês | MEDLINE | ID: mdl-27932822

RESUMO

Background The oral health of the adult population has been improving in the United Kingdom decade upon decade. Over half of dental service activity in the National Health Service (NHS) is limited to a check-up without any further treatment. This raises a question as to whether check-ups could be provided by dental hygienist-therapists, rather than general dental practitioners. The aim of this study was to assess the feasibility of a definitive trial to evaluate the costs and effects of using dental hygienist-therapists to undertake the check-up.Methods/design Adult NHS patients were randomised into three arms in two dental practices: patients who only saw dental hygienist-therapists for a check-up, those that saw the general dental practitioner and dental hygienist-therapist alternatively and a control, where patients only saw the general dental practitioner for their check-up. The study ran for 15 months. The primary outcome measures of the study were patient recruitment, retention and fidelity. A parallel and embedded qualitative study was undertaken which recorded the views of participating patients to determine the social acceptability of the intervention.Results Sixty patients participated in the study. The initial recruitment rate for the study was 33.7%. This figure increased to over 82.1% when telephone calls or face-to-face recruitment was utilised. The retention rates were 60% for both the dental hygienist-therapist only group and the alternate general dental practitioner and dental hygienist-therapist group, compared to 70% for the general dental practitioner only group. Fifteen patients were interviewed in the qualitative study and supported a team approach to the provision of check-ups in the NHS. Conclusion This study demonstrates the feasibility of a definitive trial to evaluate the costs and effects of using dental-hygienist-therapists to undertake the check-up.


Assuntos
Assistência Odontológica , Higienistas Dentários , Medicina Estatal , Custos e Análise de Custo , Estudos de Viabilidade , Humanos , Papel Profissional , Reino Unido
17.
Lancet ; 388(10039): 62-72, 2016 Jul 02.
Artigo em Inglês | MEDLINE | ID: mdl-27155903

RESUMO

BACKGROUND: The CORONIS trial reported differences in short-term maternal morbidity when comparing five pairs of alternative surgical techniques for caesarean section. Here we report outcomes at 3 years follow-up. METHODS: The CORONIS trial was a pragmatic international 2 × 2 × 2 × 2× 2 non-regular fractional, factorial, unmasked, randomised controlled trial done at 19 sites in Argentina, Chile, Ghana, India, Kenya, Pakistan, and Sudan. Pregnant women were eligible if they were to undergo their first or second caesarean section through a planned transverse abdominal incision. Women were randomly assigned by a secure web-based allocation system to one intervention from each of the three assigned pairs. All investigators, surgeons, and participants were unmasked to treatment allocation. In this follow-up study, we compared outcomes at 3 years following blunt versus sharp abdominal entry, exteriorisation of the uterus for repair versus intra-abdominal repair, single versus double layer closure of the uterus, closure versus non-closure of the peritoneum, and chromic catgut versus polyglactin-910 for uterine repair. Outcomes included pelvic pain; deep dyspareunia; hysterectomy and outcomes of subsequent pregnancies. Outcomes were assessed masked to the original trial allocation. This trial is registered with the Current Controlled Trials registry, number ISRCTN31089967. FINDINGS: Between Sept 1, 2011, and Sept 30, 2014, 13,153 (84%) women were followed-up for a mean duration of 3·8 years (SD 0·86). For blunt versus sharp abdominal entry there was no evidence of a difference in risk of abdominal hernias (adjusted RR 0·66; 95% CI 0·39-1·11). We also recorded no evidence of a difference in risk of death or serious morbidity of the children born at the time of trial entry (0·99, 0·83-1·17). For exteriorisation of the uterus versus intra-abdominal repair there was no evidence of a difference in risk of infertility (0·91, 0·71-1·18) or of ectopic pregnancy (0·50, 0·15-1·66). For single versus double layer closure of the uterus there was no evidence of a difference in maternal death (0·78, 0·46-1·32) or a composite of pregnancy complications (1·20, 0·75-1·90). For closure versus non-closure of the peritoneum there was no evidence of a difference in any outcomes relating to symptoms associated with pelvic adhesions such as infertility (0·80, 0·61-1·06). For chromic catgut versus polyglactin-910 sutures there was no evidence of a difference in the main comparisons for adverse pregnancy outcomes in a subsequent pregnancy, such as uterine rupture (3·05, 0·32-29·29). Overall, severe adverse outcomes were uncommon in these settings. INTERPRETATION: Although our study was not powered to detect modest differences in rare but serious events, there was no evidence to favour one technique over another. Other considerations will probably affect clinical practice, such as the time and cost saving of different approaches. FUNDING: UK Medical Research Council and the Department for International Development.


Assuntos
Cesárea/métodos , Peritônio/cirurgia , Complicações Pós-Operatórias/epidemiologia , Hemorragia Pós-Parto/epidemiologia , Útero/cirurgia , Técnicas de Fechamento de Ferimentos , Adulto , Categute , Dissecação/métodos , Dispareunia/epidemiologia , Feminino , Humanos , Histerectomia/estatística & dados numéricos , Dor Pélvica/epidemiologia , Poliglactina 910 , Gravidez , Resultado da Gravidez
18.
Eye (Lond) ; 30(4): 577-81, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-26795413

RESUMO

PURPOSE: Retinopathy of prematurity (ROP) is a disorder of developing retinal blood vessels in preterm infants. The purpose of this nested study was to investigate the effects of higher (91-95%) and lower (85-89%) oxygen saturation (SpO2) targeting on retinal blood vessel growth in preterm infants. METHODS: Retinal blood vessel growth in the higher (91-95%) and lower (85-89%) oxygen saturation (SpO2) targeting groups was compared. Suitable RetCam (Clarity, Pleasanton, CA, USA) images collected in the BOOST-II UK trial were used. The distances between the centre of the optic disc and the ROP ridge in the temporal and nasal retina were measured in pixel units. RESULTS: Images from 38 infants were studied, 20 from the higher SpO2 target group and 18 from the lower SpO2 target group. On average, temporal blood vessels extended further from the optic disc than nasal blood vessels, mean (standard deviation (SD)) 463.39 (55.05) pixels compared with 360.13 (44.47) pixels, respectively, P<0.0001. Temporal blood vessels extended less far from the optic disc in the higher SpO2 target group than in the lower SpO2 target group: mean (SD) 449.83 (56.16) pixels compared with 480.02 (49.94), respectively, P=0.055. Nasal retinal blood vessel measurements were broadly similar in the higher and lower SpO2 target groups; mean (SD) 353.96 (41.95) compared with 370.00 (48.82) pixels, respectively, P=0.38. CONCLUSIONS: Relatively high oxygen saturation targeting (91-95%) was associated with a trend (P=0.055) towards reduced retinal blood vessel growth in this study of preterm infants.


Assuntos
Oxigenoterapia , Oxigênio/sangue , Neovascularização Retiniana/fisiopatologia , Vasos Retinianos/patologia , Retinopatia da Prematuridade/fisiopatologia , Bases de Dados Factuais , Feminino , Idade Gestacional , Humanos , Lactente , Recém-Nascido , Recém-Nascido Prematuro , Recém-Nascido de muito Baixo Peso , Masculino , Variações Dependentes do Observador , Oximetria , Reino Unido
19.
BJOG ; 123(7): 1123-32, 2016 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-26213223

RESUMO

OBJECTIVE: To compare vaginal birth rates in women planning vaginal birth after caesarean (VBAC) at home versus in an obstetric unit (OU) and explore transfer rates in women planning home VBAC. DESIGN: Prospective cohort study. SETTING: OUs and planned home births in England. POPULATION: 1436 women planning VBAC in the Birthplace cohort, including 209 planning home VBAC. METHODS: We used Poisson regression to calculate relative risks adjusted for maternal characteristics. MAIN OUTCOMES: (i) vaginal birth and (ii) transfer from planned home birth to OU during labour or immediately after birth. SECONDARY OUTCOMES: (i) composite of maternal blood transfusion or admission to higher level care, (ii) stillbirth or Apgar score <7 at 5 minutes, (iii) neonatal unit admission. RESULTS: Planned VBAC at home was associated with a statistically significant increase in the chances of having a vaginal birth compared with planned VBAC in an OU (adjusted relative risk 1.15, 95% confidence interval 1.06-1.24). The risk of an adverse maternal outcome was around 2-3% in both settings, with a similar risk of an adverse neonatal outcome. Transfer rates were high (37%) and varied markedly by parity (para 1, 56.7% versus para 2+, 24.6%). CONCLUSION: Women in the cohort who planned VBAC at home had an increased chance of a vaginal birth compared with those planning VBAC in an OU, but transfer rates were high, particularly for women with only one previous birth, and the risk of an adverse maternal or perinatal outcome was around 2-3%. No change in guidance can be recommended. TWEETABLE ABSTRACT: Higher vaginal birth rates in planned VBAC at home versus in OU but 2-3% adverse outcomes and high transfer rate.


Assuntos
Resultado da Gravidez/epidemiologia , Nascimento Vaginal Após Cesárea/estatística & dados numéricos , Adulto , Índice de Apgar , Transfusão de Sangue/estatística & dados numéricos , Inglaterra/epidemiologia , Feminino , Parto Domiciliar/estatística & dados numéricos , Maternidades/estatística & dados numéricos , Humanos , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Transferência de Pacientes/estatística & dados numéricos , Gravidez , Estudos Prospectivos , Fatores de Risco , Natimorto/epidemiologia , Adulto Jovem
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