A multi-centre randomised controlled trial comparing radiofrequency and mechanical occlusion chemically assisted ablation of varicose veins - final results of the Venefit versus Clarivein for varicose veins trial

BACKGROUND: Endovenous thermal ablation has revolutionised varicose vein treatment. New non-thermal techniques such as mechanical occlusion chemically assisted endovenous ablation (MOCA) allow treatment of entire trunks with single anaesthetic injections. Previous non-randomised work has shown reduced pain post-operatively with MOCA. This study presents a multi-centre randomised controlled trial assessing the difference in pain during truncal ablation using MOCA and radiofrequency endovenous ablation (RFA) with six months' follow-up. METHODS: Patients undergoing local anaesthetic endovenous ablation for primary varicose veins were randomised to either MOCA or RFA. Pain scores using Visual Analogue Scale and number scale (0-10) during truncal ablation were recorded. Adjunctive procedures were completed subsequently. Pain after phlebectomy was not assessed. Patients were reviewed at one and six months with clinical scores, quality of life scores and duplex ultrasound assessment of the treated leg. RESULTS: A total of 170 patients were recruited over a 21-month period from 240 screened. Patients in the MOCA group experienced significantly less maximum pain during the procedure by Visual Analogue Scale (MOCA median 15 mm (interquartile range 7-36 mm) versus RFA 34 mm (interquartile range 16-53 mm), p = 0.003) and number scale (MOCA median 3 (interquartile range 1-5) versus RFA 4 mm (interquartile range 3-6.5), p = 0.002). 'Average' pain scores were also significantly less in the MOCA group; 74% underwent simultaneous phlebectomy. Occlusion rates, clinical severity scores, disease specific and generic quality of life scores were similar between groups at one and six months. There were two deep vein thromboses, one in each group. CONCLUSION: Pain secondary to truncal ablation is less painful with MOCA than RFA with similar short-term technical, quality of life and safety outcomes

Type of obstetric anesthesia administered and complications in women with preeclampsia in low- and middle-income countries: A systematic review.

BACKGROUND: Delivery is often expedited with cesarean section, necessitating anesthesia, to prevent complications in women with preeclampsia. Anesthesia-associated risks in these women from low- and middle-income countries (LMICs) are not known. METHODS: We searched major databases (until February 2017) for studies on general vs. regional anesthesia in women with preeclampsia. We summarized the association between outcomes and type of anesthesia using a random effects model and reported as odds ratio (OR) with 95% confidence intervals (95% CIs). FINDINGS: We included 14 studies (10,411 pregnancies). General anesthesia was associated with an increase in the odds of maternal death sevenfold (OR 7.70, 95% CI 1.9 to 31.0, I2 = 58%) than regional anesthesia. The odds of pulmonary edema (OR 5.16, 95% CI 2.5 to 10.4, I2 = 0%), maternal intensive care unit admissions (OR 16.25, 95% CI 9.0 to 29.5, I2 = 65%), and perinatal death (OR 3.01, 95% CI 1.4 to 6.5, I2 = 56%) were increased with general vs. regional anesthesia. CONCLUSION: General anesthesia is associated with increased complications in women with preeclampsia undergoing cesarean section in LMIC

Prospective observational cohort study of the association between antiplatelet therapy, bleeding and thrombosis in patients with coronary stents undergoing noncardiac surgery

Background: The perioperative management of antiplatelet therapy in noncardiac surgery patients who have undergone previous percutaneous coronary intervention (PCI) remains a dilemma. Continuing dual antiplatelet therapy (DAPT) may carry a risk of bleeding, while stopping antiplatelet therapy may increase the risk of perioperative major adverse cardiovascular events (MACE). Methods: Occurrence of Bleeding and Thrombosis during Antiplatelet Therapy In Non-Cardiac Surgery (OBTAIN) was an international prospective multicentre cohort study of perioperative antiplatelet treatment, MACE, and serious bleeding in noncardiac surgery. The incidences of MACE and bleeding were compared in patients receiving DAPT, monotherapy, and no antiplatelet therapy before surgery. Unadjusted risk ratios were calculated taking monotherapy as the baseline. The adjusted risks of bleeding and MACE were compared in patients receiving monotherapy and DAPT using propensity score matching. Results: A total of 917 patients were recruited and 847 were eligible for inclusion. Ninety-six patients received no antiplatelet therapy, 526 received monotherapy with aspirin, and 225 received DAPT. Thirty-two patients suffered MACE and 22 had bleeding. The unadjusted risk ratio for MACE in patients receiving DAPT compared with monotherapy was 1.9 (0.93–3.88), P=0.08. There was no difference in MACE between no antiplatelet treatment and monotherapy 1.03 (0.31–3.46), P=0.96. Bleeding was more frequent with DAPT 6.55 (2.3–17.96) P=0.0002. In a propensity matched analysis of 177 patients who received DAPT and 177 monotherapy patients, the risk ratio for MACE with DAPT was 1.83 (0.69–4.85), P=0.32. The risk of bleeding was significantly greater in the DAPT group 4.00 (1.15–13.93), P=0.031. Conclusions: OBTAIN showed an increased risk of bleeding with DAPT and found no evidence for protective effects of DAPT from perioperative MACE in patients who have undergone previous PCI

Tackling childhood obesity in the community using a participatory action research project with local children and young people

Introduction: Co-production of health services is becoming more routine with young people but such involvement in research lags behind, especially in the field of health promotion research. Our aim was to co-design and test a community intervention with parents and children focused on changing lifestyle behaviours which might contribute to childhood obesity on a deprived local housing estate in London. Methods: Within the context of an established integrated care collaborative, we supported parent and child volunteers to co-design and deliver a health and well-being intervention for local children. This was in the form of a 6-week “sprint” of exercise and healthy living activities. The subsequent evaluation was carried out by two children who were trained in basic qualitative and quantitative research methods by us. They designed, conducted and analysed data from intervention participants with repeat follow-up and analysis at 2 years. Results: Twenty-six children were recruited with 12 completing the programme and 7 followed up for 2 years. Young people aged 12 and older universally felt they could communicate their views better in a focus group led by a local young person with established trust and agency. We observed the value of our peer evaluator’s contribution to the design process and their insights during analysis. Post programme there were improvements in physical activity and nutrition scores in participants using validated scores, and themes relating to healthy living which were retained at 2 years. Discussion: The use of participatory evaluation in a citizen-driven intervention allowed us to breakdown barriers such as ?? within hard to reach communities, as well as enabling more meaningful results. We have demonstrated the desirability and acceptability of participatory research with children and young people. This intervention also reinforces that small, community–designed and delivered initiatives have the power to effect behaviour change sustained at 2 years

Risks associated with anaesthesia in women with pre-eclampsia in low- and middle-income countries. Systematic review and mata-analysis

Poster presented at British Maternal & Fetal Medicine Society (BMFMS) 18th Annual Conference 2016, 21st–22nd April 2016, International Convention Centre (ICC), Birmingha

Anaesthesia-related maternal mortality in low- and middle-income countries (LMIC): A systematic review and meta-analysis

Abstract of presentation at RCOG World Congress 2016, 20–22 June 2016, ICC Birmingham, United Kingdo

Anaesthesia-related maternal mortality in low-income and middle-income countries: a systematic review and meta-analysis

Background: The risk factors contributing to maternal mortality from anaesthesia in low-income and middle-income countries and the burden of the problem have not been comprehensively studied up to now. We aimed to obtain precise estimates of anaesthesia-attributed deaths in pregnant women exposed to anaesthesia and to identify the factors linked to adverse outcomes in pregnant women exposed to anaesthesia in low-income and middle-income countries. Methods: In this systematic review and meta-analysis, we searched major electronic databases from inception until Oct 1, 2015, for studies reporting risks of maternal death from anaesthesia in low-income and middle-income countries. Studies were included if they assessed maternal and perinatal outcomes in pregnant women exposed to anaesthesia for an obstetric procedure in countries categorised as low-income or middle-income by the World Bank. We excluded studies in high-income countries, those involving non-pregnant women, case reports, and studies published before 1990 to ensure that the estimates reflect the current burden of the condition. Two independent reviewers undertook quality assessment and data extraction. We computed odds ratios for risk factors and anaesthesia-related complications, and pooled them using a random effects model. This study is registered with PROSPERO, number CRD42015015805. Findings: 44 studies (632 556 pregnancies) reported risks of death from anaesthesia in women who had an obstetric surgical procedure; 95 (32 149 636 pregnancies and 36 144 deaths) provided rates of anaesthesia-attributed deaths as a proportion of maternal deaths. The risk of death from anaesthesia in women undergoing obstetric procedures was 1·2 per 1000 women undergoing obstetric procedures (95% CI 0·8–1·7, I2=83%). Anaesthesia accounted for 2·8% (2·4–3·4, I2=75%) of all maternal deaths, 3·5% (2·9–4·3, I2=79%) of direct maternal deaths (ie, those that resulted from obstetric complications), and 13·8% (9·0–20·7, I2=84%) of deaths after caesarean section. Exposure to general anaesthesia increased the odds of maternal (odds ratio [OR] 3·3, 95% CI 1·2–9·0, I2=58%), and perinatal deaths (2·3, 1·2–4·1, I2=73%) compared with neuraxial anaesthesia. The rate of any maternal death was 9·8 per 1000 anaesthetics (5·2–15·7, I2=92%) when managed by non-physician anaesthetists compared with 5·2 per 1000 (0·9–12·6, I2=95%) when managed by physician anaesthetists. Interpretation: The current international priority on strengthening health systems should address the risk factors such as general anaesthesia and rural setting for improving anaesthetic care in pregnant women. Funding: Ammalife Charity and ELLY Appeal, Bart's Charity