Patient perceptions of cognitive screening in adult audiology services: A qualitative exploration

Introduction: Both hearing loss and dementia are extremely pervasive, especially amongst older adults. As hearing loss and dementia have common symptoms, misdiagnosis can be common, and failure to address hearing loss for people with dementia could accelerate cognitive decline. The timely detection of cognitive impairment is clinically important, however the use of cognitive assessments in adult audiology services is a hotly debated topic. Although the early detection of cognitive impairment may improve patient care and quality of life, patients attending audiology services for hearing assessment might not expect to be asked questions about their cognition. The aim of this study was to qualitatively explore patient and public perspectives and preferences on the use of cognitive screening within adult audiology services. Methods: Quantitative and qualitative data were gathered from an online survey and a workshop. Descriptive statistics were applied to quantitative data and an inductive thematic analysis was performed on free-text responses. Results: In total, 90 respondents completed the online survey. Overall, cognitive screening in audiology was reported to be acceptable to participants (92%). A reflexive thematic analysis of the qualitative data reported four themes: i) knowledge of cognitive impairment and screening, ii) implementation of cognitive screening, iii) impact of screening on patient and iv) contributions to future care and research. A workshop was held with five participants to discuss and reflect on the findings in more detail. Discussion: Participants found cognitive screening to be acceptable within adult audiology services providing audiologists had suitable training, and sufficient explanation and justification were provided. However, implications such as additional time and staff resource and supplementary training for audiologists would be required to address participants concerns

Which method is best for the induction of labour?: A systematic review, network meta-analysis and cost-effectiveness analysis

Background: More than 150,000 pregnant women in England and Wales have their labour induced each year. Multiple pharmacological, mechanical and complementary methods are available to induce labour. Objective: To assess the relative effectiveness, safety and cost-effectiveness of labour induction methods and, data permitting, effects in different clinical subgroups. Methods: We carried out a systematic review using Cochrane methods. The Cochrane Pregnancy and Childbirth Group’s Trials Register was searched (March 2014). This contains over 22,000 reports of controlled trials (published from 1923 onwards) retrieved from weekly searches of OVID MEDLINE (1966 to current); Cochrane Central Register of Controlled Trials (The Cochrane Library); EMBASE (1982 to current); Cumulative Index to Nursing and Allied Health Literature (1984 to current); ClinicalTrials.gov; the World Health Organization International Clinical Trials Registry Portal; and hand-searching of relevant conference proceedings and journals. We included randomised controlled trials examining interventions to induce labour compared with placebo, no treatment or other interventions in women eligible for third-trimester induction. We included outcomes relating to efficacy, safety and acceptability to women. In addition, for the economic analysis we searched the Database of Abstracts of Reviews of Effects, and Economic Evaluations Databases, NHS Economic Evaluation Database and the Health Technology Assessment database. We carried out a network meta-analysis (NMA) using all of the available evidence, both direct and indirect, to produce estimates of the relative effects of each treatment compared with others in a network. We developed a de novo decision tree model to estimate the cost-effectiveness of various methods. The costs included were the intervention and other hospital costs incurred (price year 2012–13). We reviewed the literature to identify preference-based utilities for the health-related outcomes in the model. We calculated incremental cost-effectiveness ratios, expected costs, utilities and net benefit. We represent uncertainty in the optimal intervention using cost-effectiveness acceptability curves. Results: We identified 1190 studies; 611 were eligible for inclusion. The interventions most likely to achieve vaginal delivery (VD) within 24 hours were intravenous oxytocin with amniotomy [posterior rank 2; 95% credible intervals (CrIs) 1 to 9] and higher-dose (≥ 50 μg) vaginal misoprostol (rank 3; 95% CrI 1 to 6). Compared with placebo, several treatments reduced the odds of caesarean section, but we observed considerable uncertainty in treatment rankings. For uterine hyperstimulation, double-balloon catheter had the highest probability of being among the best three treatments, whereas vaginal misoprostol (≥ 50 μg) was most likely to increase the odds of excessive uterine activity. For other safety outcomes there were insufficient data or there was too much uncertainty to identify which treatments performed ‘best’. Few studies collected information on women’s views. Owing to incomplete reporting of the VD within 24 hours outcome, the cost-effectiveness analysis could compare only 20 interventions. The analysis suggested that most interventions have similar utility and differ mainly in cost. With a caveat of considerable uncertainty, titrated (low-dose) misoprostol solution and buccal/sublingual misoprostol had the highest likelihood of being cost-effective. Limitations: There was considerable uncertainty in findings and there were insufficient data for some planned subgroup analyses. Conclusions: Overall, misoprostol and oxytocin with amniotomy (for women with favourable cervix) is more successful than other agents in achieving VD within 24 hours. The ranking according to safety of different methods was less clear. The cost-effectiveness analysis suggested that titrated (low-dose) oral misoprostol solution resulted in the highest utility, whereas buccal/sublingual misoprostol had the lowest cost. There was a high degree of uncertainty as to the most cost-effective intervention

Intraamniotic Pressures Following Vaginal Gemeprost Prior to 1st and 2nd Trimester Termination of Pregnancy

Intra-amniotic pressures were measured following 1 mg gemeprost for cervical preparation before first trimester vacuum aspiration (n = 10) and following 2 mg gemeprost before second trimester dilatation and evacuation (n = 15). Twenty-five women, matched for gestational age and parity, who did not receive gemeprost served as controls. Compared to control values (2-8 mmHg), basal intra-amniotic pressure (IAP) was significantly increased after 1 mg and 2 mg of gemeprost (median 20.0, range 4-45 mmHg, median 20.0, range 8-60 mmHg, respectively). Uterine contractions were recorded in 8 of 10 subjects after 1 mg (median DELTAIAP 28.0,95% CI 10.0-42.6 mmHg) and 14 of 15 subjects after 2 mg (median DELTAIAP 52.5, 95% CI 26.7-60.3 mmHg). Gemeprost produces an increase in uterine contractility which may be additional to cervical softening properties and which may be responsible for the adverse effects of pain and bleeding experienced by some women prior to termination

Endocrine pancreatic function in growth-retarded fetuses

Maternal-fetal glucose gradient and fetal plasma glucose, insulin, and glucagon were measured in 63 fetuses: 34 controls and 29 with growth retardation (nine with and 20 without end-diastolic frequencies in the umbilical artery). Maternal-fetal glucose gradient and fetal glucagon levels were higher in the growth-retarded group than in controls (P < .001), whereas fetal insulin and glucose concentrations were lower (P < .001). Although maternal-fetal glucose gradient, fetal glucose, and insulin concentrations were similar among the growth-retarded fetuses, fetuses without end-diastolic frequencies in the umbilical artery had higher fetal glucagon levels (P = .01) than those with end-diastolic frequencies. In growth-retarded fetuses, the increase in fetal glucagon might reflect a compensatory response to hypoglycemia and appears to be a better index of fetal compromise than is glucose or insulin

Fetal blood sampling from the intrahepatic vein: analysis of safety and clinical experience with 214 procedures

Transabdominal fetal blood sampling under ultrasonic guidance was performed at the intrahepatic vein on 214 occasions in 177 fetuses. In 72 cases, an intravascular transfusion was also attempted at the same site. In 91.1% of the samplings, more than 1 mL of pure fetal blood was obtained, and in 89.9% of transfusions, fetal hematocrit or platelet concentration was raised to a satisfactory level. Fetal bradycardia and intraperitoneal bleeding occurred in 2.3% of the cases. Among fetuses at low risk, there was only one intrauterine death, which occurred 3 weeks after the procedure, and one spontaneous abortion in a patient with twin pregnancy. In fetuses with Rh/Kell alloimmunization or perinatal alloimmune thrombocytopenia, the survival rate was 86%. Four liver enzyme were assayed in the blood of 13 fetuses that underwent transfusions at the intrahepatic vein and 13 controls in whom the site of sampling was the umbilical vein at the placental cord insertion. No differences were found between the groups at the subsequent transfusion 2-5 weeks later. The intrahepatic vein is an alternate site of sampling/transfusion when access is difficult or failure occurs at the placental cord insertion. This approach minimizes the risks of fetal blood loss, fetomaternal hemorrhage, arterial vasospasm, and cord tamponade