A national cohort study and confidential enquiry to investigate ethnic disparities in maternal mortality.

BACKGROUND: Ethnic disparities in maternal mortality were first documented in the UK in the early 2000s but are known to be widening. This project aimed to describe the women who died in the UK during or up to a year after the end of pregnancy, to compare the quality of care received by women from different aggregated ethnic groups, and to identify any structural or cultural biases or discrimination affecting their care. METHODS: National surveillance data was used to identify all 1894 women who died during or up to a year after the end of pregnancy between 2009 and 18 in the UK. Their characteristics and causes of death were described. A Confidential Enquiry was undertaken to describe the quality of care women received. The care of a stratified random sample of 54 women who died during or up to a year after the end of pregnancy between 2009 and 18, (18 from the aggregated group of Black women, 19 from the Asian aggregated group and 17 from the White aggregated group) was re-examined specifically to describe any structural or cultural biases or discrimination identified. FINDINGS: There were no major differences causes of death between women from different aggregated ethnic groups, with cardiovascular disease the leading cause of death in all groups. Multiple areas of bias were identified in the care women received, including lack of nuanced care (notable amongst women from Black aggregated ethnic groups who died), microaggressions (most prominent in the care of women from Asian aggregated ethnic groups who died) and clinical, social and cultural complexity (evident across all ethnic groups). INTERPRETATION: This confidential enquiry suggests that multiple structural and other biases exist in UK maternity care. Further research on the role of microaggressions is warranted. FUNDING: This research is funded by the National Institute for Health Research (NIHR) Policy Research Programme, conducted through the Policy Research Unit in Maternal and Neonatal Health and Care, PR-PRU-1217-21,202. MK is an NIHR Senior Investigator. SK is part funded and FCS fully funded by the National Institute for Health Research (NIHR) Applied Research Centre (ARC) West Midlands. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

Risk of mortality: the relationship with associated injuries and fracture treatment methods in patients with unilateral or bilateral femoral shaft fractures.

BACKGROUND: The aim of the study was to determine the relative contributions to mortality of a unilateral or a bilateral femoral fracture in patients with or without injuries to other body regions. STUDY DESIGN: An observational cohort study of the prospectively recorded England and Wales Trauma Registry data (Trauma Audit Research Network) from 1989 to 2003. METHODS: Patients were divided into the following groups: UFi (isolated unilateral femur injury), BFi (isolated bilateral femur injury), and UFa and BFa, if an associated injury was present. Injury and treatment data were collected for each patient. Logistic regression data analysis was performed to determine variables that were associated with increased mortality. RESULTS: Patients in group BFa had an increased mortality rate (31.6% vs. 9.8%) than patients in isolated bilateral femur injury group. Group BFa patients had an increased number of associated injuries (80%) than group UFa patients. Bilateral fracture, even in isolation, significantly increased the odds of mortality by 3.07. Intramedullary nailing was the method of fracture fixation associated with the lowest patient mortality overall. When assessing patient mortality in the BFa group with an New Injury Severity Score of >40, seven other fracture fixation regimens were associated with a lower mortality. CONCLUSIONS: The increase in mortality with BFs is more closely associated with the presence of associated injuries and poor physiologic parameters than with the presence of the BF alone. The presence of BFs should alert the clinician to the very high likelihood (80%) of significant associated injuries in other body systems and their life-threatening potential. Damage control fixation options should be considered in the subgroup with a very high New Injury Severity Score.

Hip arthrography in the assessment of children with developmental dysplasia of the hip and Perthes' disease.

In our unit, children with developmental dysplasia of the hip or Perthes' disease, for whom an operation is considered, undergo examination under anaesthetic and a hip arthrogram. This prospective study assessed whether the arthrogram modified treatment and analysed the reliability of its interpretation. All children undergoing a hip arthrogram for developmental dysplasia of the hip and Perthes' disease over a 12-month period were included. Treatment plans before and after the arthrogram were compared for each of the three children's consultants. The preoperative and arthrographic appearances were blindly reviewed to monitor reproducibility. Twenty-one patients with developmental dysplasia of the hip and 19 with Perthes' disease were included. The treatment plan was modified in 12 of the 21 (57.1%) patients with developmental dysplasia of the hip as a consequence of the arthrogram and six of the 19 patients (31.6%) with Perthes' disease. Intraobserver consultant agreement was high but interobserver agreement was only moderate. Static and dynamic arthrography helps decision-making in patients with developmental dysplasia of the hip and Perthes' disease.

Cervical dynamic screening in spinal clearance: now redundant.

BACKGROUND: The safest and most effective method of early cervical spine clearance in unconscious patients is the subject of intense debate. We hypothesize that helical computed tomography (CT) is a sufficiently sensitive investigation to render dynamic screening redundant. METHOD: We retrospectively reviewed the records of 839 trauma patients admitted to the intensive care unit under the orthopedic surgeons from April 1994 to September 2004. Our protocol for cervical spinal clearance in the unconscious patient involves plain radiographs, CT scanning, and dynamic screening. We recorded the presence of any unstable cervical spine injury and any cases that were missed by CT but detected by dynamic screening. RESULTS: There were 87 patients with an unstable cervical spine. Of these, 85 were detected by CT. Two cases were missed by CT (sensitivity 97.7%, specificity 100%). In one of these patients, dynamic screening detected an unstable spine and in the other patient dynamic screening missed an atlanto-occipital dislocation (sensitivity 98.8%, specificity 100%). Critical analysis of this case revealed that a powers ratio calculation on the CT scan would have detected the injury. There were no complications as a result of dynamic screening. CONCLUSION: Dynamic screening is a safe procedure but has no real advantage over helical CT. Power's ratio calculation is essential to reduce the chance of a missing an upper cervical injury. The cervical spine can be reliably cleared using helical CT alone.

Dynamic ultrasound as a selection tool for reducing achilles tendon reruptures.

BACKGROUND: The optimal method of treatment for acute tendo-Achilles ruptures continues to be debated. HYPOTHESIS: The reported lower rerupture rate for operatively treated patients is an effect of tendon end apposition during the healing process, and patients in whom apposition can be demonstrated using ultrasound will have a similar rate of rerupture if treated nonoperatively. STUDY DESIGN: Cohort study; Level of evidence, 2. METHOD: The authors reviewed all patients with an Achilles tendon rupture who were treated to a standard protocol during a 5-year period (2000-2005). Patients with a gap of 5 mm or more in equinus on ultrasound underwent surgery; those with a gap of less than 5 mm received nonoperative treatment. All patients were followed up to a minimum of 12 months. RESULTS: After exclusions, 125 patients were included: 67 treated operatively and 58 nonoperatively. There were 2 reruptures in the nonoperative group and 1 with surgery. There was no significant difference between the groups for any complication. CONCLUSION: Reduction of rerupture and surgery risks may be possible using dynamic ultrasound case selection. Further studies are needed to show whether functional results are the same with surgical and nonsurgical treatment when dynamic ultrasound criteria are used for case selection.