Labor induction information leaflets-Do women receive evidence-based information about the benefits and harms of labor induction?

Objectives: To determine the extent to which a sample of NHS labor induction leaflets reflects evidence on labor induction. Setting: Audit of labor induction patient information leaflets-local from WILL trial (When to Induce Labor to Limit risk in pregnancy hypertension) internal pilot sites or national-level available online. Methods: Descriptive analysis [n = 21 leaflets, 19 (one shared) in 20 WILL internal pilot sites and 2 NHS online] according to NHS "Protocol on the Production of Patient Information" criteria: general information (including indications), why and how induction is offered (including success and alternatives), and potential benefits and harms. Results: All leaflets described an induction indication. Most leaflets (n = 18) mentioned induction location and 16 the potential for delays due to delivery suite workloads and competing clinical priorities. While 19 leaflets discussed membrane sweeping (17 as an induction alternative), only 4 leaflets mentioned balloon catheter as another mechanical method. Induction success (onset of active labor) was presented by a minority of leaflets (n = 7, 33%), as "frequent" or in the "majority", with "rare" or "occasional" failures. Benefits, harms and outcomes following induction were not compared with expectant care, but rather with spontaneous labor, such as for pain (n = 14, with nine stating more pain with induction). Potential benefits of induction were seldom described [n = 7; including avoiding stillbirth (n = 4)], but deemed to be likely. No leaflet stated vaginal birth was more likely following induction, but most stated Cesarean was not increased (n = 12); one leaflet stated that Cesarean risks were increased following induction. Women's satisfaction was rarely presented (n = 2). Conclusion: Information provided to pregnant women regarding labor induction could be improved to better reflect women's choice between induction and expectant care, and the evidence upon which treatment recommendations are based. A multiple stakeholder-involved and evidence-informed process to update guidance is required.

Validation of the BPro radial pulse waveform acquisition device in pregnancy and gestational hypertensive disorders.

OBJECTIVE: To validate the BPro blood pressure (BP) wrist device for use in pregnancy and preeclampsia according to the Universal Standard protocol. PARTICIPANTS AND METHODS: BP was measured sequentially in 45 pregnant women (including 15 with preeclampsia, 15 with gestational hypertension and 15 who remained normotensive) alternating between a mercury sphygmomanometer and BPro device. RESULTS: The BPro is accurate in pregnancy with a mean device-observer difference of -1.7 ± 6.1 and 0.1 ± 4.6 mmHg for SBP and DBP, respectively. In women with preeclampsia, BPro also met the validation criteria for the Universal Standard protocol with a mean device-observer difference of -2.7 ± 7.1 and 0.3 ± 4.7 mmHg for SBP and DBP, respectively. However, the number of absolute BP differences within 5 mmHg was considerably fewer in those with preeclampsia when compared to the other two subgroups. CONCLUSION: The BPro device can be recommended for BP measurement in pregnancy but should be used with caution in those with confirmed preeclampsia.

Detection of additional abnormalities or co-morbidities in women with suspected intrahepatic cholestasis of pregnancy.

BACKGROUND: Current guidelines recommend viral, autoimmune, coagulation and liver ultrasound testing in intrahepatic cholestasis of pregnancy to exclude alternative diagnoses. METHODS: Electronic health records were searched for investigations and diagnoses in women with raised bile acid concentrations (>10 µmol/L) between January 2016 and December 2017 at two UK maternity units. RESULTS: Five hundred and thirty-one women had a raised bile acid concentration (median (IQR): 18 (13-32 µmol/L)) at a median gestation of 35.1 (IQR 31.8-37.0) weeks. Out of 531 women, 250 (47.1%) had full virology, autoimmune and ultrasound tests, and 348 (65.5%) had coagulation performed. Positive hepatitis B and C results were previously known. No new Epstein-Barr virus, cytomegalovirus or hepatitis A diagnoses were made. There were 11 positive autoimmune results, but no new diagnoses. No woman had an unexplained prolonged prothrombin time. No ultrasound liver (n = 38) or gallbladder (n = 85) abnormalities were of acute clinical significance. CONCLUSION: Intrahepatic cholestasis of pregnancy investigations provided no new diagnoses that influenced clinical management during pregnancy.

Mismatches between health service delivery and community expectations in the provision of secondary prophylaxis for rheumatic fever in New Zealand.

OBJECTIVE: Rheumatic fever (RF) recurrence prevention requires secondary prophylaxis for at least ten years. However, recurrences of rheumatic fever (RRF) persist disproportionately affecting Maori and Pacific youth. Reasons for recurrence rates are not well understood and commonly attributed to patient non-adherence. This research explored Maori and Pacific family experiences of RRF to better understand barriers to accessing secondary prophylaxis to inform health service improvements. METHODS: Participants were Maori and Pacific patients who had RRF or unexpected rheumatic heart disease and their family; and health professionals working in RF contexts. Kaupapa Maori, Talanga and Kakala Pacific qualitative methodologies were employed. Data were thematically analysed using a general inductive approach. RESULTS: Data collection included 38 interviews with patients and families (n=80), six focus group interviews and nine interviews with health providers (n=33) from seven geographic regions. Three key themes were identified where mismatches occurred between services and community needs: 1. Model of delivery; 2. Interpersonal approaches to care; and 3. Adolescent care. Conclusions and Public health implications: Successful RRF prevention requires interventions to address structural causes of inequity, appropriate clinical guidelines and quality health services. Service-delivery models should provide regular prophylaxis in an accessible manner through culturally-safe, community-based, age-appropriate care.

Measuring the success of Medical Emergency Teams: potentially preventable deaths versus total cardiac arrest deaths. A single centre observational study.

BACKGROUND: Rapid response systems have been implemented with the aim of preventing patient deterioration, in-hospital cardiac arrests (IHCA) and related deaths. Not all 'unexpected deaths' are preventable, thus compromising the use of unexpected deaths as an outcome measure. AIMS: To assess temporal trends in potentially preventable deaths as a subset of total unexpected death rates over a 4-year period. METHODS: A single centre, cohort study of all unexpected deaths between 1 January 2010 and 31 December 2013. Unexpected deaths were identified from the rapid response systems database and patients' case histories were reviewed to reclassify the deaths into one of three categories: potentially preventable: if earlier MET activation may have prevented death; missed not for resuscitation opportunity; and not preventable. Total bed days were obtained from the hospital's patient administration system. RESULTS: The rate of potentially preventable deaths decreased from 5.3 to 0.7 per 100 000 bed days (incident rate ratio (IRR) 0.53 (95% CI 0.31-0.90), P = 0.02). The rate of total unexpected deaths was unchanged (IRR 0.96 (0.80-1.16), P = 0.70), as were the rates of non-preventable deaths (IRR 1.06 (0.78-1.42), P = 0.72) and missed NFR deaths (IRR 1.1 (0.83-1.42), P = 0.56). CONCLUSION: The rate of potentially preventable deaths has decreased by 47% per year over a 4-year period without any change in the overall rate of unexpected deaths. Distinguishing between potentially preventable deaths in contrast to total unexpected deaths enables more targeted evaluation of rapid response systems.

A critical exploration of a collaborative Kaupapa Maori consistent research project on physician-assisted dying.

AIM: This paper critically explores the research approach undertaken by Maori and tauiwi researchers working alongside kaumatua within the context of physician-assisted dying. We critically explore the collaborative process we undertook in framing the research context and discuss the rewards and challenges that emerged. METHOD: The research this critical discussion draws on undertook a qualitative Kaupapa Maori consistent research approach and drew on the principles of an Interface Research approach. The paper focuses on the collaborative approach taken between the 10 researchers involved in the study. RESULTS: Challenges identified within the collaborative Kaupapa Maori consistent research process included: determining appropriate authority and representation of researchers and participants; maintaining clear communication; time and logistical management. The key strengths that emerged from this research design were: establishing a culturally safe and robust research process; an ability to build and maintain relationships between researchers and participants; and the opportunity to develop academic research skills between researchers and participants. CONCLUSION: Collaborative Kaupapa Maori consistent research approaches to research can enable accountability, control and representation throughout the entire research process. Given the rich research results achieved and personal rewards gained from this study design, we would advocate for the application of such approaches within health research contexts.

'It's not all just about the dying'. Kaumatua Maori attitudes towards physician aid-in dying: A narrative enquiry.

AIM: To explore kaumatua attitudes towards physician aid-in dying, to gain a clear understanding of how such attitudes may influence and shape their expectations of medical care at the end of life and to assist health professionals in Aotearoa/New Zealand to address the healthcare needs of older Maori near the end of life. DESIGN: A kaupapa Maori consistent approach was undertaken. A systematic narrative technique was employed for the qualitative data analysis. Data were triangulated through independent data coding by three researchers (two of whom identified as Maori researchers), to ensure a robust and consistent method of analysis as well as adhering to a kaupapa Maori research approach. SETTING/PARTICIPANTS: Recruitment of participants was through kaumatua of Te Kupenga Hauora Maori (Maori leadership within the Faculty of Medical and Health Sciences), University of Auckland and local Auckland marae. Focus group or individual interviews (as per their preference) were undertaken with 20 Kaumatua from the Auckland region. RESULTS: Five closely interrelated themes were identified from kaumatua narratives regarding physician aid-in dying. These were (1) attitudes and understandings of physician aid-in dying, (2) influence of power, (3) significance of kawa, (4) whanau relationships and the (5) significance of wairua. CONCLUSION: The study demonstrated that for these kaumatua, medical practices that hasten death such as physician aid-in dying are 'not all just about the dying'. Tikanga and kawa are important processes and concepts to understand during death and dying, and whanau are central to such processes being respected by those involved in the dying process. These factors are so closely intertwined that they cannot be considered in separation of each other.

Combined activity of oridonin and wogonin in advanced-stage ovarian cancer cells: sensitivity of ovarian cancer cells to phyto-active chemicals.

The initial response rates of advanced-stage epithelial ovarian cancer to the chemotherapeutic agents carboplatin and paclitaxel are high. However, once drug resistance develops, further chemotherapy is less effective. The objective of this study is to investigate the anti-proliferative activity of the phyto-active chemicals (PACs) oridonin and wogonin in chemo-resistant epithelial ovarian cancer cells. Primary cell cultures from the ascitic fluid of three patients at diagnosis, two patients chemo-resistant to carboplatin and paclitaxel, and one patient treated with letrozole for breast cancer were studied and compared to the ovarian cancer cell lines A2780 and PTX10, by cell viability assay (MTS). Effects on cell cycle modulation and apoptosis were examined by flow cytometry and Western blot analysis (WB). WB was further conducted to investigate protein expressions altered by PACs. The results show that IC(50) of the primary cultures ranged from 0.6 to 5.4 µg/ml for oridonin and 0.3-12.7 µg/ml for wogonin. The paclitaxel-resistant cell line PTX10 was more sensitive to each of the PACs than the chemo-sensitive cell line A2780. Of particular interest is that in combination, the two PACs were synergistic in their cytotoxicity to five of six of the primary cultures and to both the cell lines (combination indices of 0.39-0.95). The inhibition is attributable to apoptosis and cell cycle modulation induced by the PACs as demonstrated in A2780 and PTX10. Up-regulation of the functional p53 protein in A2780 and down-regulation of Akt protein in PTX10 have in part contributed to the apoptosis. These findings suggest that oridonin and wogonin may have activity in ovarian cancer following its development of resistance to carboplatin and paclitaxel.