Mode of delivery and risk of intracranial haemorrhage in newborns with severe haemophilia A: a multicentre study in Gulf region.

INTRODUCTION: The optimum mode of delivery in a known carrier of a haemophilia A is still an issue of debate. AIM: This study was conducted to report a multicentre experience in Gulf Cooperation Council (GCC) on the incidence of intracranial haemorrhage (ICH) in newborns with severe haemophilia A delivered by different modalities. METHODS: We have conducted a retrospective/prospective multicentre cohort study including a total of seven hospitals distributed in four GCC countries between 1998 and Jan 2015. A total of 163 patient with severe haemophilia A (factor VIII <1%) were enrolled in this study, age ranged between 2 weeks to 18 years. RESULTS: Most of the patients were born by spontaneous vaginal delivery (SVD) (131, 80.4%), whereas 26 patients (16%) were born by CS and only six patients were born by instrumental delivery (3.7%), five of them by vacuum and one was delivered using forceps. Five out of 163 patients developed ICH during the first 2 weeks of life (3.1%). Two of them were born by SVD (2/131; 1.5%) and two were born by instrumental delivery (2/6; 33.3%). Only one patient among those who were born by caesarean section developed ICH (1/26; 3.8%). Assisted vaginal delivery was associated with a significant risk of ICH, in comparison to SVD and CS (P = 0.0093). CONCLUSION: Normal vaginal delivery is still considered a safe journey through the birth canal for haemophilic newborns particularly in this area of the world. Larger prospective studies might be needed to define an evidence-based optimal mode of delivery for the haemophilia carrier expecting an affected child.

Silicone oil emulsions: strategies to improve their stability and applications in hair care products.

Silicone oils have wide range of applications in personal care products due to their unique properties of high lubricity, non-toxicity, excessive spreading and film formation. They are usually employed in the form of emulsions due to their inert nature. Until now, different conventional emulsification techniques have been developed and applied to prepare silicone oil emulsions. The size and uniformity of emulsions showed important influence on stability of droplets, which further affect the application performance. Therefore, various strategies were developed to improve the stability as well as application performance of silicone oil emulsions. In this review, we highlight different factors influencing the stability of silicone oil emulsions and explain various strategies to overcome the stability problems. In addition, the silicone deposition on the surface of hair substrates and different approaches to increase their deposition are also discussed in detail.

Role of neck dissection in management of patients with clinically apparent parotid metastatic melanoma - systematic review.

Patients with cutaneous melanoma with metastatic deposits in the parotid gland have poor prognosis due to the high risk of developing distant metastasis. In the era of effective immunotherapy, there is no consensus amongst head and neck surgeons about the extent of neck dissection required for patients presenting with clinically apparent parotid metastasis. This review aims to determine the incidence and pattern of occult neck disease for patients with parotid metastasis reported in the literature to help guide clinicians on the extent of neck dissection required. The systematic review search was conducted using PubMed, EMBASE and Medline, using PRISMA guidelines. The inclusion criteria include cases treated with parotidectomy and neck dissection for patients with parotid melanoma metastasis. A narrative synthesis was carried out due to heterogeneity of studies. A total of 14 studies was included. We found no study reporting on outcomes with surgery and adjuvant immunotherapy in this cohort of patients. The incidence of distant metastasis reported was variable but remains high for patients with parotid metastasis. Patients with parotid and neck involvement have poorer prognosis than patients with parotid only metastatic disease. The effect and extent of neck dissection in patients with clinically apparent parotid nodes remains unclear in the era of effective immunotherapy. There is a need for further well-designed studies evaluating the outcomes for such patients following surgery and adjuvant immunotherapy.

Evaluating feasibility and acceptability of a group WHO trans-diagnostic intervention for women with common mental disorders in rural Pakistan: a cluster randomised controlled feasibility trial.

AIMS: The aim of this feasibility trial was to evaluate the feasibility and acceptability of the locally adapted Group Problem Management Plus (PM+) intervention for women in the conflict affected settings in Swat, Pakistan. METHODS: This mixed-methods study incorporated a quantitative component consisting of a two arm cluster randomised controlled feasibility trial, and qualitative evaluation of the acceptability of the Group PM+ to a range of stakeholder groups. For the quantitative component, on average from each of the 20 Lady Health Workers (LHWs) catchment area (20 clusters), six women were screened and recruited for the trial with score of >2 on the General Health Questionnaire and score of >16 on the WHO Disability Assessment Schedule. These LHW clusters were randomised on a 1 : 1 allocation ratio using a computer-based software through a simple randomisation method to the Group PM+ intervention or Enhanced Usual Care. The Group PM+ intervention consisted of five weekly sessions of 2 h duration delivered by local non-specialist females under supervision. The primary outcome was individual psychological distress, measured by levels of anxiety and depression on the Hospital Anxiety and Depression Scale at 7th week after baseline. Secondary outcomes include symptoms of depression, post-traumatic stress disorder (PTSD), general psychological profile, levels of functioning and generalised psychological distress. Intervention acceptability was explored through in-depth interviews. RESULTS: The results show that lay-helpers with no prior mental health experience can be trained to achieve the desired competency to successfully deliver the intervention in community settings under supervision. There was a good intervention uptake, with Group PM+ considered useful by participants, their families and lay-helpers. The outcome evaluation, which was not based on a large enough study to identify statistically significant results, indicated statistically significant improvements in depression, anxiety, general psychological profile and functioning. The PTSD symptoms and depressive disorder scores showed a trend in favour of the intervention. CONCLUSION: This trial showed robust acceptance in the local settings with delivery by non-specialists under supervision by local trained females. The trial paves the way for further adaptation and exploration of the outcomes through larger-scale implementation and definitive randomised controlled trials in the local settings.

Patients' experience of the monitoring of free flaps after reconstruction for oral cancer.

Regular monitoring of free flaps is essential after microvascular free tissue transfer, but the frequency and duration of the observations vary between units and there is no consensus nationally. Best practice can be informed by the feedback of patients, but as we know of no such studies, we did a cross-sectional survey of a consecutive group of patients after free tissue transfer to find out what they thought about monitoring. We designed a study-specific questionnaire after consultation with the patient and carer forum, and sent it to 150 patients who had had free tissue transfer in the maxillofacial department at Aintree University Hospital during 2015 and 2016. A total of 106 (71%) responded, and a quarter (30/106, 28%) would have liked more information about monitoring. Generally, patients were worried little by the observations (91/106, 86%), but one-third (34/106, 32%) reported disturbed sleep. Just over half (n=55/104, 53%) were relieved when the monitoring changed from hourly to four-hourly, and almost all (99/101, 98%) were not worried by this. Nearly half (47/105, 45%) would have preferred fewer observations when asleep. In conclusion, our findings could help to inform a leaflet for patients about monitoring. Consideration could be given to reducing its frequency, for example, the checks at 1, 3, and 5am could be omitted during the second night, which could make a substantial difference to the patient. However, its impact on salvage needs to be audited.

WHO Parents Skills Training (PST) programme for children with developmental disorders and delays delivered by Family Volunteers in rural Pakistan: study protocol for effectiveness implementation hybrid cluster randomized controlled trial.

BACKGROUND: Development disorders and delays are recognised as a public health priority and included in the WHO mental health gap action programme (mhGAP). Parents Skills Training (PST) is recommended as a key intervention for such conditions under the WHO mhGAP intervention guide. However, sustainable and scalable delivery of such evidence based interventions remains a challenge. This study aims to evaluate the effectiveness and scaled-up implementation of locally adapted WHO PST programme delivered by family volunteers in rural Pakistan. METHODS: The study is a two arm single-blind effectiveness implementation-hybrid cluster randomised controlled trial. WHO PST programme will be delivered by 'family volunteers' to the caregivers of children with developmental disorders and delays in community-based settings. The intervention consists of the WHO PST along with the WHO mhGAP intervention for developmental disorders adapted for delivery using the android application on a tablet device. A total of 540 parent-child dyads will be recruited from 30 clusters. The primary outcome is child's functioning, measured by WHO Disability Assessment Schedule - child version (WHODAS-Child) at 6 months post intervention. Secondary outcomes include children's social communication and joint engagement with their caregiver, social emotional well-being, parental health related quality of life, family empowerment and stigmatizing experiences. Mixed method will be used to collect data on implementation outcomes. Trial has been retrospectively registered at ClinicalTrials.gov (NCT02792894). DISCUSSION: This study addresses implementation challenges in the real world by incorporating evidence-based intervention strategies with social, technological and business innovations. If proven effective, the study will contribute to scaled-up implementation of evidence-based packages for public mental health in low resource settings. TRIAL REGISTRATION: Registered with ClinicalTrials.gov as Family Networks (FaNs) for Children with Developmental Disorders and Delays. Identifier: NCT02792894 Registered on 6 July 2016.