Complex interventions in midwifery care: Reflections on the design and evaluation of an algorithm for the diagnosis of labour

Randomised controlled trials are the ‘gold standard’ for evaluating the effectiveness of interventions in health-care settings. However, in midwifery care, many interventions are ‘complex’, comprising a number of different elements which may have an effect on the impact of the intervention in health-care settings. In this paper we reflect on our experience of designing and evaluating a complex intervention (a decision tool to assist with the diagnosis of labour in midwifery care), examining some of the issues that our study raises for future research in complex interventions

What characteristics of primary care and patients are associated with early death in patients with lung cancer in the UK?

Background: The UK has poor lung cancer survival rates and high early mortality, compared to other countries. We aimed to identify factors associated with early death, and features of primary care that might contribute to late diagnosis. Methods: All cases of lung cancer diagnosed between 2000 and 2013 were extracted from The Health Improvement Network database. Patients who died within 90 days of diagnosis were compared with those who survived longer. Standardised chest X-ray (CXR) and lung cancer rates were calculated for each practice. Results: Of 20 142 people with lung cancer, those who died early consulted with primary care more frequently prediagnosis. Individual factors associated with early death were male sex (OR 1.17; 95% CI 1.10 to 1.24), current smoking (OR 1.43; 95% CI 1.28 to 1.61), increasing age (OR 1.80; 95% CI 1.62 to 1.99 for age ≥80 years compared to 65–69 years), social deprivation (OR 1.16; 95% CI 1.04 to 1.30 for Townsend quintile 5 vs 1) and rural versus urban residence (OR 1.22; 95% CI 1.06 to 1.41). CXR rates varied widely, and the odds of early death were highest in the practices which requested more CXRs. Lung cancer incidence at practice level did not affect early deaths. Conclusions: Patients who die early from lung cancer are interacting with primary care prediagnosis, suggesting potentially missed opportunities to identify them earlier. A general increase in CXR requests may not improve survival; rather, a more timely and appropriate targeting of this investigation using risk assessment tools needs further assessment

Risk assessment and decision making about in-labour transfer from rural maternity care: a social judgment and signal detection analysis

Background: The importance of respecting women's wishes to give birth close to their local community is supported by policy in many developed countries. However, persistent concerns about the quality and safety of maternity care in rural communities have been expressed. Safe childbirth in rural communities depends on good risk assessment and decision making as to whether and when the transfer of a woman in labour to an obstetric led unit is required. This is a difficult decision. Wide variation in transfer rates between rural maternity units have been reported suggesting different decision making criteria may be involved; furthermore, rural midwives and family doctors report feeling isolated in making these decisions and that staff in urban centres do not understand the difficulties they face. In order to develop more evidence based decision making strategies greater understanding of the way in which maternity care providers currently make decisions is required. This study aimed to examine how midwives working in urban and rural settings and obstetricians make intrapartum transfer decisions, and describe sources of variation in decision making. Methods: The study was conducted in three stages. 1. 20 midwives and four obstetricians described factors influencing transfer decisions. 2. Vignettes depicting an intrapartum scenario were developed based on stage one data. 3. Vignettes were presented to 122 midwives and 12 obstetricians who were asked to assess the level of risk in each case and decide whether to transfer or not. Social judgment analysis was used to identify the factors and factor weights used in assessment. Signal detection analysis was used to identify participants' ability to distinguish high and low risk cases and personal decision thresholds. Results: When reviewing the same case information in vignettes midwives in different settings and obstetricians made very similar risk assessments. Despite this, a wide range of transfer decisions were still made, suggesting that the main source of variation in decision making and transfer rates is not in the assessment but the personal decision thresholds of clinicians. Conclusions: Currently health care practice focuses on supporting or improving decision making through skills training and clinical guidelines. However, these methods alone are unlikely to be effective in improving consistency of decision making

Speech Communication

Contains table of contents for Part V, table of contents for Section 1, reports on six research projects and a list of publications.C.J. Lebel FellowshipDennis Klatt Memorial FundNational Institutes of Health Grant R01-DC00075National Institutes of Health Grant R01-DC01291National Institutes of Health Grant R01-DC01925National Institutes of Health Grant R01-DC02125National Institutes of Health Grant R01-DC02978National Institutes of Health Grant R01-DC03007National Institutes of Health Grant R29-DC02525National Institutes of Health Grant F32-DC00194National Institutes of Health Grant F32-DC00205National Institutes of Health Grant T32-DC00038National Science Foundation Grant IRI 89-05249National Science Foundation Grant IRI 93-14967National Science Foundation Grant INT 94-2114

Alcohol brief interventions in Scottish antenatal care:a qualitative study of midwives' attitudes and practices

Background: Infants exposed to alcohol in the womb are at increased risk of experiencing health problems. However, mixed messages about the consequences of prenatal alcohol consumption have resulted in inconsistent attitudes and practices amongst some healthcare practitioners. Screening and alcohol brief interventions (ABIs) can reduce risky drinking in various clinical settings. Recently, a program of screening and ABIs have been implemented in antenatal care settings in Scotland. However, current evidence suggests that midwives' involvement in alcohol brief interventions activities is patchy. This study explored midwives' attitudes and practices regarding alcohol screening and ABIs in order to understand why they are relatively underutilized in antenatal care settings compared to other clinical settings. Methods: This was a qualitative study, involving semi-structured interviews with 15 midwives and a focus group with a further six midwifery team leaders (21 participants in total) in Scotland. Interview transcripts were analysed using thematic analysis. Results: Midwives were positive about their involvement in the screening and ABI program. However, they were not completely convinced about the purpose and value of the screening and ABIs in antenatal care. In the midst of competing priorities, the program was seen as having a low priority in their workload. Midwives felt that the rapport between them and pregnant women was not sufficiently established at the first antenatal appointment to allow them to discuss alcohol issues appropriately. They reported that many women had already given up drinking or were drinking minimal amounts prior to the first antenatal appointment. Conclusions: Midwives recognised the important role they could play in alcohol intervention activities in antenatal care. As the majority of women stop consuming alcohol in pregnancy, many will not need an ABI. Those who have not stopped are likely to need an ABI, but midwives were concerned that it was this group that they were most likely to alienate by discussing such concerns. Further consideration should be given to pre-pregnancy preventative measures as they are more likely to reduce alcohol-exposed pregnancies

Impacts of fire and prospects for recovery in a tropical peat forest ecosystem

Uncontrolled fires place considerable burdens on forest ecosystems, compromising our ability to meet conservation and restoration goals. A poor understanding of the impacts of fire on ecosystems and their biodiversity exacerbates this challenge, particularly in tropical regions where few studies have applied consistent analytical techniques to examine a broad range of ecological impacts over multiyear time frames. We compiled 16 y of data on ecosystem properties (17 variables) and biodiversity (21 variables) from a tropical peatland in Indonesia to assess fire impacts and infer the potential for recovery. Burned forest experienced altered structural and microclimatic conditions, resulting in a proliferation of nonforest vegetation and erosion of forest ecosystem properties and biodiversity. Compared to unburned forest, habitat structure, tree density, and canopy cover deteriorated by 58 to 98%, while declines in species diversity and abundance were most pronounced for trees, damselflies, and butterflies, particularly for forest specialist species. Tracking ecosystem property and biodiversity datasets over time revealed most to be sensitive to recurrent high-intensity fires within the wider landscape. These megafires immediately compromised water quality and tree reproductive phenology, crashing commercially valuable fish populations within 3 mo and driving a gradual decline in threatened vertebrates over 9 mo. Burned forest remained structurally compromised long after a burn event, but vegetation showed some signs of recovery over a 12-y period. Our findings demonstrate that, if left uncontrolled, fire may be a pervasive threat to the ecological functioning of tropical forests, underscoring the importance of fire prevention and long-term restoration efforts, as exemplified in Indonesia

Obesity and normal birth: A qualitative study of clinician’s management of obese pregnant women during labour

Background: Currently one-fifth of women in the UK are obese. Obese, pregnant woman are at an increased risk of experiencing complications of labour and serious morbidity. However, they are also more likely to undergo medical interventions such as induction of labour and caesarean section which in themselves confer additional health risks for obese women such as wound infection and deep vein thrombosis. Reducing unnecessary interventions and increasing normal birth rates for obese women would substantially improve their postnatal health and wellbeing and reduce the burden of NHS resources required to care for them post operatively. This research aimed to explore practitioners’ experiences of and strategies for providing intrapartum care to obese women.  Method: A qualitative methodology was adopted, focus groups and individual interviews were conducted with health professionals. Audio recordings were transcribed verbatim and data analysed using a framework approach.  Results: Twenty-four health professionals participated; Six Consultant Obstetricians two Consultant Anaesthetists and 16 midwives. Three key themes emerged from the data: medicalisation of obese birth; promotion of normal obese birth; and the complexities and contradictions in staff attitudes and behaviours. The overall interpretation is that positive approaches to obese birth offer opportunities to promote normal birth. However, many health professionals find the provision of intrapartum care to obese women challenging, and attitudes and behaviours towards the promotion of normal birth are heterogeneous, complex and contradictory.  Conclusion: The care of obese women during labour is generally medicalised and focussed on the associated risks. However, although there are conflicting views on how to care for obese women, some practitioners do strive to promote normality and optimise the potential for normal birth by challenging current practices and utilise some ‘interventions’ in order to facilitate normality and mobility during childbirth. Obesity is a major and growing health problem and a major cause of morbidity and mortality for pregnant women. It is essential that more positive proactive guidelines are available to maximise normal birth if the postnatal health of obese women is to be improved

The evolution of non-small cell lung cancer metastases in TRACERx

Metastatic disease is responsible for the majority of cancer-related deaths. We report the longitudinal evolutionary analysis of 126 non-small cell lung cancer (NSCLC) tumours from 421 prospectively recruited patients in TRACERx who developed metastatic disease, compared with a control cohort of 144 non-metastatic tumours. In 25% of cases, metastases diverged early, before the last clonal sweep in the primary tumour, and early divergence was enriched for patients who were smokers at the time of initial diagnosis. Simulations suggested that early metastatic divergence more frequently occurred at smaller tumour diameters (less than 8 mm). Single-region primary tumour sampling resulted in 83% of late divergence cases being misclassified as early, highlighting the importance of extensive primary tumour sampling. Polyclonal dissemination, which was associated with extrathoracic disease recurrence, was found in 32% of cases. Primary lymph node disease contributed to metastatic relapse in less than 20% of cases, representing a hallmark of metastatic potential rather than a route to subsequent recurrences/disease progression. Metastasis-seeding subclones exhibited subclonal expansions within primary tumours, probably reflecting positive selection. Our findings highlight the importance of selection in metastatic clone evolution within untreated primary tumours, the distinction between monoclonal versus polyclonal seeding in dictating site of recurrence, the limitations of current radiological screening approaches for early diverging tumours and the need to develop strategies to target metastasis-seeding subclones before relapse

Genomic–transcriptomic evolution in lung cancer and metastasis

Intratumour heterogeneity (ITH) fuels lung cancer evolution, which leads to immune evasion and resistance to therapy. Here, using paired whole-exome and RNA sequencing data, we investigate intratumour transcriptomic diversity in 354 non-small cell lung cancer tumours from 347 out of the first 421 patients prospectively recruited into the TRACERx study. Analyses of 947 tumour regions, representing both primary and metastatic disease, alongside 96 tumour-adjacent normal tissue samples implicate the transcriptome as a major source of phenotypic variation. Gene expression levels and ITH relate to patterns of positive and negative selection during tumour evolution. We observe frequent copy number-independent allele-specific expression that is linked to epigenomic dysfunction. Allele-specific expression can also result in genomic–transcriptomic parallel evolution, which converges on cancer gene disruption. We extract signatures of RNA single-base substitutions and link their aetiology to the activity of the RNA-editing enzymes ADAR and APOBEC3A, thereby revealing otherwise undetected ongoing APOBEC activity in tumours. Characterizing the transcriptomes of primary–metastatic tumour pairs, we combine multiple machine-learning approaches that leverage genomic and transcriptomic variables to link metastasis-seeding potential to the evolutionary context of mutations and increased proliferation within primary tumour regions. These results highlight the interplay between the genome and transcriptome in influencing ITH, lung cancer evolution and metastasis