Learning from a Rapid Health Impact Assessment of a proposed maternity service reconfiguration in the English NHS

<p>Abstract</p> <p>Background</p> <p>Within many parts of the country, the NHS is undertaking reconfiguration of services. Such proposals can prove a tipping point and provoke public protest, often with significant involvement of local and national politicians. We undertook a rapid Health Impact Assessment (HIA) of a proposed reconfiguration of maternity services in Huddersfield and Halifax in England. The aim of the HIA was to help the PCT Boards to assess the reconfiguration's possible consequences on access to maternity services, and maternal and infant health outcomes across different socio-economic groups in Kirklees. We report on the findings of the HIA and the usefulness of the process to decision making.</p> <p>Methods</p> <p>This HIA used routine maternity data for 2004–2005 in Huddersfield, in addition to published evidence. Standard HIA techniques were used.</p> <p>Results</p> <p>We re-highlighted the socio economic differences in smoking status at booking and quitting during pregnancy. We focused on the key concerns of the public, that of adverse obstetric events on a Midwife Led Unit (MLU) with distant obstetric cover. We estimate that twenty percent of women giving birth in a MLU may require urgent transfer to obstetric care during labour. There were no significant socio economic differences. Much of the risk can be mitigated though robust risk management policies. Additional travelling distances and costs could affect lower socio-economic groups the greatest because of lower car ownership and geographical location in relation to the units. There is potential that with improved community antenatal and post natal care, population outcomes could improve significantly, the available evidence supports this view.</p> <p>Conclusion</p> <p>Available evidence suggests that maternity reconfiguration towards enhanced community care could have many potential benefits but carries risk. Investment is needed to realise the former and mitigate the latter.</p> <p>The usefulness of this Health Impact Assessment may have been impeded by its timing, and the politically charged environment of the proposals. Nonetheless, the methods used are readily applicable to assess the impact of other service reconfigurations. The analysis was simple, not time intensive and used routinely available data. Careful consideration should be given to both the timing and the political context in which an analysis is undertaken.</p

Impact of risk factors on the timing of first postpartum venous thromboembolism: a population-based cohort study from England

For women with preeclampsia, BMI &gt;30 kg/m2, infection, or those having cesarean delivery, VTE risk remained elevated for 6 weeks postpartum.For women with postpartum hemorrhage or preterm birth, the relative rate of VTE was only increased for the first 3 weeks postpartum.Impact on the timing of first postpartum venous thromboembolism (VTE) for women with specific risk factors is of crucial importance when planning the duration of thromboprophylaxis regimen. We observed this using a large linked primary and secondary care database containing 222 334 pregnancies resulting in live and stillbirth births between 1997 and 2010. We assessed the impact of risk factors on the timing of postpartum VTE in term of absolute rates (ARs) and incidence rate ratios (IRRs) using a Poisson regression model. Women with preeclampsia/eclampsia and postpartum acute systemic infection had the highest risk of VTE during the first 3 weeks postpartum (ARs ≥2263/100 000 person-years; IRR ≥2.5) and at 4-6 weeks postpartum (AR ≥1360; IRR ≥3.5). Women with body mass index (BMI) &gt;30 kg/m2 or those having cesarean delivery also had elevated rates up to 6 weeks (AR ≥1425 at 1-3 weeks and ≥722 at 4-6 weeks). Women with postpartum hemorrhage or preterm birth, had significantly increased VTE rates only in the first 3 weeks (AR ≥1736; IRR ≥2). Our findings suggest that the duration of the increased VTE risk after childbirth varies based on the type of risk factors and can extend up to the first 3 to 6 weeks postpartum

Short term culture of breast cancer tissues to study the activity of the anticancer drug taxol in an intact tumor environment

BACKGROUND: Sensitivity of breast tumors to anticancer drugs depends upon dynamic interactions between epithelial tumor cells and their microenvironment including stromal cells and extracellular matrix. To study drug-sensitivity within different compartments of an individual tumor ex vivo, culture models directly established from fresh tumor tissues are absolutely essential. METHODS: We prepared 0.2 mm thick tissue slices from freshly excised tumor samples and cultivated them individually in the presence or absence of taxol for 4 days. To visualize viability, cell death, and expression of surface molecules in different compartments of non-fixed primary breast cancer tissues we established a method based on confocal imaging using mitochondria- and DNA-selective dyes and fluorescent-conjugated antibodies. Proliferation and apoptosis was assessed by immunohistochemistry in sections from paraffin-embedded slices. Overall viability was also analyzed in homogenized tissue slices by a combined ATP/DNA quantification assay. RESULTS: We obtained a mean of 49 tissue slices from 22 breast cancer specimens allowing a wide range of experiments in each individual tumor. In our culture system, cells remained viable and proliferated for at least 4 days within their tissue environment. Viability of tissue slices decreased significantly in the presence of taxol in a dose-dependent manner. A three-color fluorescence viability assay enabled a rapid and authentic estimation of cell viability in the different tumor compartments within non-fixed tissue slices. CONCLUSION: We describe a tissue culture method combined with a novel read out system for both tissue cultivation and rapid assessment of drug efficacy together with the simultaneous identification of different cell types within non-fixed breast cancer tissues. This method has potential significance for studying tumor responses to anticancer drugs in the complex environment of a primary cancer tissue

WHO systematic review of maternal morbidity and mortality: the prevalence of severe acute maternal morbidity (near miss)

AIM: To determine the prevalence of severe acute maternal morbidity (SAMM) worldwide (near miss). METHOD: Systematic review of all available data. The methodology followed a pre-defined protocol, an extensive search strategy of 10 electronic databases as well as other sources. Articles were evaluated according to specified inclusion criteria. Data were extracted using data extraction instrument which collects additional information on the quality of reporting including definitions and identification of cases. Data were entered into a specially constructed database and tabulated using SAS statistical management and analysis software. RESULTS: A total of 30 studies are included in the systematic review. Designs are mainly cross-sectional and 24 were conducted in hospital settings, mostly teaching hospitals. Fourteen studies report on a defined SAMM condition while the remainder use a response to an event such as admission to intensive care unit as a proxy for SAMM. Criteria for identification of cases vary widely across studies. Prevalences vary between 0.80% – 8.23% in studies that use disease-specific criteria while the range is 0.38% – 1.09% in the group that use organ-system based criteria and included unselected group of women. Rates are within the range of 0.01% and 2.99% in studies using management-based criteria. It is not possible to pool data together to provide summary estimates or comparisons between different settings due to variations in case-identification criteria. Nevertheless, there seems to be an inverse trend in prevalence with development status of a country. CONCLUSION: There is a clear need to set uniform criteria to classify patients as SAMM. This standardisation could be made for similar settings separately. An organ-system dysfunction/failure approach is the most epidemiologically sound as it is least open to bias, and thus could permit developing summary estimates

Adverse events from spinal manipulation in the pregnant and postpartum periods: a critical review of the literature

<p>Abstract</p> <p>Background</p> <p>The safety of spinal manipulation during pregnancy and the postpartum periods has been a matter of debate among manual therapists. Spinal manipulative therapy during these periods is a commonly performed intervention as musculoskeletal pain is common in these patients. To date there has not been an evaluation of the literature on this topic exclusively.</p> <p>Methods</p> <p>A literature search was conducted on PubMed, CINAHL and the Index to Chiropractic Literature along with reference searching for articles published in English and French in the peer-reviewed literature that documented adverse effects of spinal manipulation during either pregnancy or postpartum. Case reports, case series, and any other clinical study designs were deemed acceptable for inclusion, as were systematic reviews. The appropriate Scottish Intercollegiate Guidelines Network (SIGN) tools were used to rate included articles for quality when applicable.</p> <p>Results</p> <p>Five articles identifying adverse events in seven subjects following spinal manipulation were included in this review, along with two systematic reviews. The articles were published between 1978 and 2009. Two articles describing adverse effects from spinal manipulation on two postpartum patients were included, while the remaining three articles on five patients with adverse effects following spinal manipulation were on pregnant patients. Injury severity ranged from minor injury such as increasing pain after treatment that resolved within a few days to more severe injuries including fracture, stroke, and epidural hematoma. SIGN scores of the prospective observational cohort study and systematic reviews indicated acceptable quality.</p> <p>Conclusions</p> <p>There are only a few reported cases of adverse events following spinal manipulation during pregnancy and the postpartum period identified in the literature. While improved reporting of such events is required in the future, it may be that such injuries are relatively rare.</p