South West Thames Region Research Articles

Effect of monochorionicity on perinatal outcome and growth discordance in triplet pregnancy: collaborative multicenter study in England, 2000-2013.

To compare perinatal outcome and growth discordance between trichorionic triamniotic (TCTA) and dichorionic triamniotic (DCTA) or monochorionic triamniotic (MCTA) triplet pregnancies. This was a multicenter cohort study using population-based data on triplet pregnancies from 11 Northern Survey of Twin and Multiple Pregnancy (NorSTAMP) maternity units and the Southwest Thames Region of London Obstetric Research Collaborative (STORK) multiple pregnancy cohort, for 2000-2013. Perinatal outcomes (from ≥ 24 weeks' gestation to 28 days of age), intertriplet fetal growth and birth-weight (BW) discordance and neonatal morbidity were analyzed in TCTA compared with DCTA/MCTA pregnancies. Monochorionic placentation of a pair or trio in triplet pregnancy (n = 72) was associated with a significantly increased risk of perinatal mortality (risk ratio, 2.7 (95%CI, 1.3-5.5)) compared with that in TCTA pregnancies (n = 68), due mainly to a much higher risk of stillbirth (risk ratio, 5.4 (95%CI, 1.6-18.2)), with 57% of all stillbirth cases resulting from fetofetal transfusion syndrome, while there was no significant difference in neonatal mortality (P = 0.60). The associations with perinatal mortality and stillbirth persisted when considering only pregnancies not affected by a major congenital anomaly. DCTA/MCTA triplets had lower BW and demonstrated greater BW discordance than did TCTA triplets (P = 0.049). Severe BW discordance of > 35% was 2.5-fold higher in DCTA/MCTA compared with TCTA pregnancies (26.1% vs 10.4%), but this difference did not reach statistical significance (P = 0.06), presumably due to low numbers. Triplets in both groups were delivered by Cesarean section in over 95% of cases, at a similar gestational age (median, 33 weeks' gestation). The rate of respiratory (P = 0.28) or infectious (P = 0.08) neonatal morbidity was similar between the groups. Despite close antenatal surveillance, monochorionic placentation of a pair or trio in triamniotic triplet pregnancy was associated with a significantly increased stillbirth risk, mainly due to fetofetal transfusion syndrome, and with greater size discordance. In liveborn triplets, there was no adverse effect of monochorionicity on neonatal outcome. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Prevalence, antenatal management and perinatal outcome of monochorionic monoamniotic twin pregnancy: a collaborative multicenter study in England, 2000-2013.

To determine the prevalence of monochorionic monoamniotic (MCMA) twin pregnancy and to describe perinatal outcome and clinical management of these pregnancies. In this multicenter cohort study, the prevalence of MCMA twinning was estimated using population-based data on MCMA twin pregnancies, collected between 2000 and 2013 from 11 Northern Survey of Twin and Multiple Pregnancy (NorSTAMP) maternity units. Pregnancy outcome at < 24 weeks' gestation, antenatal parameters and perinatal outcome (from ≥ 24 weeks to the first 28 days of age) were analyzed using combined data on pregnancies confirmed to be MCMA from NorSTAMP and the Southwest Thames Region of London Obstetric Research Collaborative (STORK) multiple pregnancy cohort for 2000-2013. The estimated total prevalence of MCMA twin pregnancies in the North of England region was 8.2 per 1000 twin pregnancies (59/7170), and the birth prevalence was 0.08 per 1000 pregnancies overall (singleton and multiple). Using combined data from NorSTAMP and STORK, the rate of fetal death (at < 24 weeks' gestation), including terminations of pregnancy and selective feticide, was 31.8% (54/170); the overall perinatal mortality rate was 14.7% (17/116), ranging from 69.2% at < 30 weeks to 4.5% at ≥ 33 weeks' gestation. MCMA twins that survived in utero beyond 24 weeks were delivered, usually by Cesarean section, at a median of 33 (interquartile range, 32-34) weeks of gestation. In MCMA twins surviving beyond 24 weeks of gestation, there was a higher survival rate compared with in previous decades, presumably due to early diagnosis, close surveillance and elective birth around 32-34 weeks of gestation. High perinatal mortality at early gestations was attributed mainly to extreme prematurity due to preterm spontaneous labor. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

PTU-042 Appropriately Trained Registrars Are As Good As Consultants In Endoscopic Management Of Moderate-severe Upper Gastrointestinal Haemorrhage

IntroductionThe South West Thames region operates a unique regional gastrointestinal service covering 4 hospitals. Registrar endoscopists are assessed and signed off as competent in providing endoscopic haemostatic therapy before taking...

Second‐trimester discordance and adverse perinatal outcome in twins: the STORK multiple pregnancy cohort

The aim of this study was to determine the association between biometry discordance at the time of the anomaly scan and adverse perinatal outcomes in twin pregnancies. Retrospective cohort study. Nine hospitals in the Southwest Thames Region of London Obstetric Research Collaborative (STORK). Population multicentre retrospective study of all twin pregnancies booked for antenatal care in nine hospitals over a period of 10 years. Methods Logistic regression and receiver operating characteristic (ROC) curve analyses were performed to evaluate the association between abdominal circumference (AC) and estimated fetal weight (EFW) discordance, recorded between 20 and 22weeks of gestation, and adverse pregnancy outcomes. Stillbirth, neonatal mortality, preterm birth (PTB) at <34weeks of gestation, and birthweight (BW) discordance ≥25%. A total of 2399 twin pregnancies [457 monochorionic (MC) and 1942 dichorionic (DC)] were included in the study. The predictive accuracy of the EFW discordance was poor for fetal loss after 22weeks of gestation (area under the curve, AUC0.54, 95%CI 0.46-0.64), fetal loss beyond 28weeks of gestation (AUC0.42, 95%CI 0.31-0.52), perinatal loss (AUC0.51, 95%CI 0.44-0.57), BW discordance (AUC0.63, 95%CI 0.56-0.65), and PTB before 34weeks of gestation (AUC0.52, 95%CI 0.49-0.55). There was no significant difference in the prediction of these outcomes when using EFW discordance or AC discordance. Once structural malformations, chromosomal abnormalities, and twin-to-twin transfusion syndrome have been excluded, second-trimester EFW and AC discordance have poor predictive value for adverse perinatal outcomes in twin pregnancy.

Ocular loiasis in London 2008–2009: a case series

To report three cases of Loa loa infestation presenting over the course of 12 months to ophthalmology departments in the South West Thames region around London. Case series (three case histories are described) and literature review. All three patients had a history of travel to West Africa. All had worms surgically removed and were referred to an infectious diseases hospital, where these were confirmed as adult Loa loa nematodes and treatment was initiated. Although ocular loiasis is endemic in West Africa, European ophthalmologists in areas of diverse ethnicity should be aware that it is presenting increasingly frequently, that there is often no history of recent travel abroad, and that loiasis is a differential diagnosis for any 'at-risk' patient with an unexplained foreign body sensation.

Failed tracheal intubation in obstetrics: no more frequent but still managed badly

In the South-West Thames region of the United Kingdom, during a 5-year period from 1999 to 2003, there were 20 failed tracheal intubations occurring in 4768 obstetric general anaesthetics (incidence 1 : 238). In half of the 16 cases for which the patient's notes could be examined there was a failure to follow an accepted protocol for failed tracheal intubation.

Some immediate serious complications of obstetric epidural analgesia and anaesthesia: a prospective study of 145 550 epidurals

Inadvertent intravascular, intrathecal or subdural injection in obstetric regional analgesia are potentially life-threatening, so following a catastrophic complication it was decided to collect data regionally. Obstetric anaesthetists from 14, later 12 maternity units in the South West Thames Region collected and pooled data on obstetric anaesthetic interventions and complications from 1987 to 2003. During the 17-year period, 145,550 epidurals (26.3%) were administered to 553,905 mothers. The incidence of intravascular injection was 1 in 5,000 epidurals (0.02% [95%CI 0.014-0.029%]), of intrathecal injection 1 in 2,900 epidurals (0.035% [95%CI 0.027-0.046%]), of subdural injection 1 in 4,200 epidurals (0.024% [95%CI 0.017-0.033%]) and of high or total spinal block 1 in 16,200 epidurals (0.006% [95%CI 0.003-0.012%]). The incidence of serious complications did not change during the course of the study, nor was there any difference in the incidence of serious complications in obstetric units of different sizes or in obstetric units with different rates of epidural analgesia. The incidence of intravascular, intrathecal and subdural injection and of high or total spinal block was similar to that found in previous prospective studies in obstetric and non-obstetric patients. The incidence of these complications has not changed and is not related to the number of deliveries or the epidural rate in obstetric units.

Anaesthesia for Caesarean section: a survey in a UK region from 1992 to 2002.

Data are presented for anaesthesia for Caesarean section (CS) in the South-west Thames region of the UK. The CS rate rose from 12.7% in 1987 to 24.2% in 2002. The rate of increase shows no sign of slowing. The rate of regional anaesthesia (RA) for elective CS rose from 69.4% in 1992 to 94.9% in 2002, when spinal anaesthesia was used for 86.6% of cases. This may limit the opportunities to teach other anaesthetic techniques. The rate of RA for emergency CS rose from 49.3% in 1992 to 86.7% in 2002. There is an unacceptable rate of failure of RA for both elective and emergency CS, 1.3% of RAs for elective CS and 4.9% of RAs for emergency CS were converted to general anaesthesia.

Asthma and allergy: a worldwide problem of meanings and management?

Asthma and allergy: a worldwide problem of meanings and management?

An audit of the application of care aims across the south west Thames region.

Care aims are a means of defining the purpose of intervention of health care. The Malcomess care aims model uses these labels to guide the planning, delivery and outcome measurement of care. Within speech and language therapy (SLT) this involves the use of one of seven labels which clarify and make explicit the purpose of each episode of care undertaken with a client. This relatively simple application has been shown to change the way SLTs work, clarifying expectations of many who use the service. In the South West Thames Region, a project was put in place for SLTs which included undertaking training, audit and support. The outcome of the audit showed that care aims had been adopted across the region in a sufficiently flexible way to meet local needs and offered therapists the tools to reflect on the types of interventions provided to clients.

Using a Markov reward model to estimate spend-down costs for a geriatric department

A Markov model is used to describe movements of geriatric patients within a hospital system where the states of the Markov chain are acute/rehabilitative, long-stay care, discharge or death. By assigning costs to the states of this model, we can estimate the spend-down costs of running down services given that there are no more admissions and different costs are assigned to acute/rehabilitative and long-stay care. The model is used to estimate the spend-down costs using data previously validated for three Departments of Geriatric Medicine in the South West Thames Region of England. Our approach allows hospital planners to identify cost-effective strategies which take into account the fact that some geriatric patients remain in long-stay care for very long periods of time.

Security needs of South West Thames Special Hospital patients: 1992 and 1993. No way out?

Abstract Two audit surveys were carried out, one in 1992 and the other in 1993, to examine the security needs of South West Thames Region (SWTR) Special Hospital patients. Special Hospital responsible medical officers (RMOs) were surveyed regarding need for security, appropriate placement and reasons for transfer delay for South West Thames patients. Results from both audits were strikingly similar and were also consistent with previous studies based on RMO surveys. They suggest that there are large numbers of Special Hospital patients who do not require maximum security. Assessed need for medium- and long-stay (greater than 2 years) medium secure care in the region highlighted current deficiencies in medium secure provision within South West Thames, which falls short of both Department of Health and Home Office specifications. The most frequently cited reason for postponement of transfer was Home Office delays. The consistent findings of this and previous studies emphasize the ongoing problem of overcont...

Genetic analysis of 20 families with autosomal dominant adult polycystic kidney disease from South West Thames Region

Twenty families with autosomal dominant polycystic kidney disease from S. W. Thames Region were analysed using markers for chromosome 16p13.3, the site of the common mutation (PKD1). Six families gave a negative lod-score for 3'HVR, the most informative distal marker. This could be explained in four cases by recombination events. Of the two families where this was not an explanation, one, of Italian origin, was unequivocally unlinked for all markers, and the other was more likely to be non-PKD1 than linked to 16p13.3. The Italian family was ascertained through the Blood Pressure Unit, and the other via the Genetic Clinic. No members of either family had ever attended a renal clinic. The remaining 18 families either came via renal clinics, or had at least one member attending such a centre.

Evaluating self-managed learning--Part 2: Accelerating management development in an NHS region.

Evaluates the use of self-managed learning (SML) in management development processes in health-care settings. Focuses on the application of SML to region-wide management development initiatives in the South West Thames Region of the UK National Health Service (NHS) from the late 1980s onwards.

Is Friday the 13th bad for your health?

To examine the relation between health, behaviour, and superstition surrounding Friday 13th in the United Kingdom. Retrospective study of paired data comparing driving and shopping patterns and accidents. Drivers, shoppers, and residents. South West Thames region. Numbers of vehicles on motorways; numbers of shoppers in supermarkets; and hospital admissions due to accidents. There were consistently and significantly fewer vehicles on the southern section of the M25 on Friday the 13th compared with Friday the 6th. The numbers of shoppers were not significantly different on the two days. Admissions due to transport accidents were significantly increased on Friday 13th (total 65 v 45; p < 0.05). Friday 13th is unlucky for some. The risk of hospital admission as a result of a transport accident may be increased by as much as 52%. Staying at home is recommended.

An outbreak of Salmonella mikawasima associated with doner kebabs.

During October 1992 an increase in the number of isolates of Salmonella mikawasima, a rare serotype, was noted including a cluster of nine cases in the South West Thames region. A case control study was conducted and univariate analysis showed a statistical association between illness and eating at take-away A for cases compared with household controls (P = 0.003) and with neighbourhood controls (P = 0.0245). Cases were also more likely to have eaten kebabs than were controls or average take-away A customers, implicating doner kebabs as the most likely vehicle of infection. Plasmid profile analysis of the nine cases' isolates showed them to be indistinguishable and to be characterized by a single plasmid of approximately 60 MDa. The original source of the Salmonella mikawasima contamination was not determined, but food preparation practices for kebabs at take-away A were insufficient to protect against illness if contaminated. This outbreak was only recognized because of the unusual serotype, but could be an indication of a more widespread problem with doner kebabs.

Cataract surgery in South West Thames Region: An analysis of age-adjusted surgery rates and length of stay by district

Although the frequency of cataract surgery has increased in the UK, the demand is still not being met. There is no evidence of whether Regional Health Authorities are meeting the national target of 150 cataract operations per 100,000 population. This paper describes variations in age-standardised rates of cataract surgery and lengths of hospital stay (LOS) between the 13 health districts in South West Thames Regional Health Authority (SWTRHA). A retrospective analysis of cataract surgery performed on South West Thames (SW Thames) residents during 1990 was undertaken using the Korner hospital activity data system. The residents of SW Thames Region had 6,729 cataract operations in 1990, producing an overall surgery rate of 266 per 100,000 resident population. Two-thirds of the operations were performed on women, and the greatest number of operations were in the 75-79 and 80-84 year age bands. Women aged over 75 had significantly higher age-specific surgery rates than their male counterparts. The mean age for women was 76.6 years and for men 71.9 years; 12% of cases had a length of stay less than a day (day cases) and 49% were discharged within two days. There were substantial variations in LOS between health districts. Age-adjusted rates revealed significant variations between districts, four of which had rates below the regional average. The crude cataract surgery rate for SW Thames residents has increased threefold since 1975. Women have a significantly higher rate of surgery, which may be due to social factors. Variations in LOS between districts cannot be explained by difference in age structure and may be caused by local custom and practice. It is possible for national, regional and district cataract rates to be calculated, and they are a useful indicator of how the need for cataract surgery is being met in the population.

A study of the provision of health checks and health‐promotion clinics in 18 general practices

Summary The objective of this study was to describe the variation in provision of health checks and health‐promotion clinics operating under the regulations of the 1990 Contract for general practice in the UK. Eighteen group practices in three Family Health Service Authority (FHSA) areas of England (two in the South West Thames region and one in the Yorkshire region) were selected for the study. The nurses, largely responsible for the implementation of the health checks at these practices, were interviewed using semi‐structured interview schedules. They were asked about age‐groups targeted, means of recruiting patients for clinics, duration of clinic appointments, and procedures carried out in clinics. All practices offered health checks, and 55% had started doing so before introduction of the 1990 Contract. Recruitment for health checks took place in a number of ways: self‐referral (83% of practices); opportunistically in those with coronary heart disease risk factors (78%); opportunistically during attendance for cervical smears (62%); screening in at least one patient group (78%). Blood pressure, height, weight, urinalysis and life‐style advice were included by all practices. Stress management and quit smoking strategies were offered only by a minority of practices. Duration of first health‐check appointment ranged between 15 and 30 minutes. The basic content of health checks, and life‐style advice given appeared consistent between the widely varying practices. However, the resources available for intervention and follow up showed more variation.

Coronary artery surgery: are women discriminated against?

To determine whether the sex differences in access to cardiac surgery observed in the United States exist in the United Kingdom. Retrospective analysis of routinely collected data. South West Thames and North West Thames regional health authorities. 8564 patients discharged from hospital with a principal diagnosis of coronary heart disease in 1987-8 in South West Thames region and 15243 discharges in North West Thames region in 1990-1. Performance of angiography or coronary artery bypass surgery. In all age groups and among patients with a principal diagnosis of either angina or chronic ischaemia men were significantly more likely than women to undergo revascularisation in both regions. Using multiple logistic regression to control for potential clinical and demographic confounders, the male to female odds ratio for revascularisation among all cases was 1.59 (95% confidence interval 1.25 to 2.03) in South West Thames region and 1.47 (1.32 to 1.63) in North West Thames region. There appears to be a systematic difference in the treatment received by men and women in the United Kingdom. The reasons for this are uncertain.

Are haematological tests warranted prior to tonsillectomy?

The use of phlebotomy for a full blood count (FBC) and group and serum storage (G&S) prior to tonsillectomy with or without adenoidectomy was assessed by means of a postal questionnaire sent to consultant otolaryngologists within the South West Thames region. This was compared with 'countrywide' practice assessed by means of questions to attenders at an otolaryngology course. A postal response rate of 86 per cent was obtained with 67 per cent within the region requesting a FBC prior to tonsillectomy and 50 per cent to adenoidectomy alone. This was much greater than for the 'countrywide' group with 24 per cent and 6 per cent respectively. Requests for pre-operative G&S were 17 per cent and 6 per cent respectively. This large difference in practice suggests that in the clinically healthy patient with no specific indications, pre-operative haematological investigations may be non-contributory, which has important financial implications. The maintenance of post-operative intravenous access is considered to be much safer, less traumatic and cheaper.