Showing papers by "Peter Brocklehurst published in 2005"

Invasive fungal infection in very low birthweight infants: national prospective surveillance study

Abstract: Objective: To describe the epidemiology of invasive fungal infection in very low birthweight (VLBW: Design: National prospective surveillance study between February 2003 and February 2004 using the British Paediatric Surveillance Unit reporting system reconciled with cases identified through routine laboratory reporting to the Health Protection Agency (England, Wales, and Northern Ireland), the Scottish Centre for Infection and Environmental Health, and the UK Mycology Reference Laboratory. Results: Ninety four confirmed cases of invasive fungal infection were identified during the surveillance period giving an incidence of estimated annual incidence of 10.0 (95% confidence interval (CI) 8.0 to 12.0) cases per 1000 VLBW live births. Eighty one (86%) of the infants were of extremely low birth weight (ELBW: Candida species, predominantly C albicans and C parapsilosis , were isolated in 93% of cases. Most organisms were isolated from the bloodstream and urinary tract. Death occurred in 41% of the infected infants before 37 weeks postconceptional age. Conclusions: The incidence of invasive fungal infection in VLBW and ELBW infants in the United Kingdom is lower than reported in previous studies from tertiary centres in North America and elsewhere. The associated late neonatal and post-neonatal death rates are substantially higher than expected in infants without invasive fungal infection. These data may inform decisions about the evaluation and use of antifungal infection control strategies.

Vitamin A supplementation for reducing the risk of mother‐to‐child transmission of HIV infection

Abstract: BACKGROUND: Mother-to-child transmission (MTCT) of HIV is the dominant mode of acquisition of HIV infection for children, currently resulting in about 1800 new paediatric HIV infections each day world-wide This is one of several reviews assessing the available evidence for preventing HIV transmission from an HIV-infected woman to her child The other reviews assess the effects of antiretroviral therapy, Caesarean section delivery, breast feeding, and vaginal lavage OBJECTIVES: To assess the effects of antenatal and intrapartum vitamin A supplementation, compared to an appropriate control group, on the risk of MTCT of HIV infection and infant and maternal mortality and morbidity, and the tolerability of vitamin A supplementation SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register, Cochrane Pregnancy and Childbirth Register, PubMed, EMBASE, AIDSLINE, LILACS, AIDSTRIALS, and AIDSDRUGS, using standardised methodological filters for identifying trials We also searched reference lists of identified articles, relevant editorials, expert opinions and letters to journal editors, and abstracts or proceedings of relevant conferences; and contacted subject experts, agencies, organisations, academic centres, and pharmaceutical companies There were no language restrictions SELECTION CRITERIA: Randomised trials comparing vitamin A supplementation with no vitamin A supplementation in known HIV infected pregnant women Trials had to include an estimate of the effect of vitamin A supplementation on MTCT of HIV and/or any other pre-specified adverse pregnancy outcome to be included DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial eligibility and quality and extracted data Odds ratios (OR) and 95% confidence intervals (CI) were estimated for binary data and pooled using a fixed effect (Mantel-Haenszel) method Heterogeneity between studies was examined by graphical inspection of results followed by a chi-square test of homogeneity MAIN RESULTS: We identified five eligible trials, only two of which included an estimated of the effect of vitamin A supplementation on at least one of the pre-specified outcomes Based on the two trials, with a total of 1813 participants, there is no evidence that vitamin A supplementation has an effect on MTCT of HIV (OR 109, 95% confidence interval (CI) 081 to 145) There is no evidence of heterogeneity between the trials (p = 037), and no evidence of an effect of vitamin A supplementation in HIV-infected pregnant women on stillbirths (OR 107, 95% CI 063 to 180), very preterm births, ie born less than 34 weeks gestation (OR 086, 95% CI 057 to 131), all preterm births, ie born less than 37 weeks gestation (OR 088, 95% CI 068 to 113), low birth weight, ie weighing less than 2500g (OR 086, 95% CI 064 to 117), very low birthweight, ie weighing less than 2000g (OR 071, 95% CI 040 to 128), and postpartum CD4 levels (weighted mean difference -400, 95% CI -5106 to 4306) The effect of vitamin A on maternal mortality could not be assesssed, as there were only three maternal deaths REVIEWER'S CONCLUSIONS: IMPLICATIONS FOR PRACTICE: At the present time there is no conclusive evidence that the antenatal and intrapartum use of vitamin A supplementation to reduce MTCT of HIV and adverse pregnancy outcomes among HIV-infected pregnant women should be recommended IMPLICATIONS FOR RESEARCH: The current review will be updated as soon as data from ongoing studies become available This review and the review in progress on vitamin A supplementation in pregnant women of seronegative/unknown HIV status (Kulier 2002) should be considered together in order to shed more light on the effect of vitamin A supplementation on non-HIV related adverse pregnancy outcomes

The effect of a monetary incentive on return of a postal health and development questionnaire: a randomised trial (ISRCTN53994660)

Abstract: Postal questionnaires are widely used to collect data in healthcare research but a poor response rate may reduce the validity and reliability of results. There was a lack of evidence available relating to use of a monetary incentive to improve the response rate in the healthcare setting. The MRC ORACLE Children Study is assessing the health and development of nearly 9000 seven year old children whose mothers' joined the MRC ORACLE Trial. We carried out a randomised controlled trial of inclusion of monetary incentive (five pound voucher redeemable at many high street stores) with the reminder questionnaire to parents. This trial took place between April 2002 and November 2003. When the parents were sent the reminder questionnaire about their child's health and development they were randomly assigned by concealed computer-generated allocation stratified by week of birthday to receive a five pound voucher or no incentive. The population were 722 non-responders to the initial mailing of a 12-page questionnaire. Main outcome measures: Difference in response rate between the two groups. Inclusion of the voucher with the reminder questionnaire resulted in a 11.7%(95% CI 4.7% to 18.6%) improvement in the response rate between the two groups. This improvement in response rate and hence the validity and reliability of results obtained appears to be justified ethically and financially.

Evidence based care

Abstract: The ethos of basing practice on the best available evidence is well established in perinatal medicine. The introduction to clinical practice of major interventions, such as antenatal corticosteroids and exogenous surfactant, was informed by evidence from seminal randomised controlled trials and systematic reviews. Equally important has been the development and evaluation of interventions that have been shown not to have major benefits for preterm infants. For example, strong evidence from preclinical research studies indicated that antenatal thyrotropin releasing hormone might act synergistically with corticosteroids to reduce the risk of respiratory distress syndrome in preterm infants. Despite the biological plausibility of this treatment and evidence of effect in animal models, randomised controlled trials (involving over 4500 women) did not show any improvement in outcomes, including mortality, for preterm infants. Also, antenatal thyrotropin releasing hormone was shown to be associated with adverse effects for mothers and infants, including a higher risk of infants needing mechanical ventilation. On the basis of this evidence, antenatal thyrotropin releasing hormone does not have a role in the management of threatened preterm birth. Effect of prenatal thyrotropin releasing hormone (TRH) for preterm birth on mortality before hospital discharge. Data from Crowther CA et al. Cochrane Database Syst Rev. 2003;(4): CD000019 Obtaining the best evidence to guide clinical practice is not always easy. In particular, undertaking clinical trials to evaluate interventions for preterm infants is difficult. Although about 3000 randomised controlled trials have been reported in the field of neonatology, many interventions have not yet been subjected to unbiased evaluation. This could be because the trials have not been attempted, or have been flawed methodologically, or have been too small to detect clinically important effects. Large perinatal trials have problems with recruitment. This could be related to the issues surrounding the public perception of perinatal trials and the …

Vaginal disinfection for preventing mother-to-child transmission of HIV infection.

Abstract: B a c k g r o u n dMother-to-child transmission (MTCT) of HIV infection is one of the most tragic consequences of the HIV epidemic, especially in resource-limited countries, resulting in about 650 000 new paediatric HIV infections each year worldwide. The paediatric HIV epidemic threatens to seriously undermine decade-old child survival programmes.O b j e c t i v e sTo estimate the effect of vaginal disinfection on the risk of MTCT of HIV and infant and maternal mortality and morbidity, as well as tolerability of vaginal disinfection in HIV-infected women.S e a r c h s t r a t e g yWe searched the Cochrane Controlled Trials Register, Cochrane Pregnancy and Childbirth Register, PubMed, EMBASE, AIDSLINE, LILACS, AIDSTRIALS, and AIDSDRUGS, using standardised methodological filters for identifying trials. We also searched reference lists of identified articles, relevant editorials, expert opinions and letters to journal editors, and abstracts and proceedings of relevant conferences, and contacted subject experts and pharmaceutical companies. There were no language restrictions.S e l e c t i o n c r i t e r i aRandomised trials or clinical trials comparing vaginal disinfection during labour with placebo or no treatment, in known HIV-infected pregnant women. Trials had to include an estimate of the effect of vaginal disinfection on MTCT of HIV and or infant and maternal mortality and morbidity.D a t a c o l l e c t i o n a n d a n a l y s i sThree authors independently assessed trial eligibility and quality, and extracted data. Meta-analysis was performed using the Yusuf-Peto modification of Mantel-Haenszel's fixed effect method.M a i n r e s u l t sOnly two trials that included 708 patients met the inclusion criteria. The effect of vaginal disinfection on the risk of MTCT of HIV (OR 0.93, 95% CI 0.65 to 1.33), neonatal death (OR 1.38, 95% CI 0.30 to 6.33), and death after the neonatal period (OR 1.45, 95% CI 0.47 to 4.45) is uncertain. There was no evidence that vaginal disinfection increased adverse effects in mothers (OR 1.15, 95% CI 0.41 to 3.22), and evidence from one trial showed that adverse effects decreased in neonates (OR 0.14, 95% CI 0.07 to 0.31).A u t h o r s ' c o n c l u s i o n sCurrently, there is no evidence of an effect of vaginal disinfection on the risk of MTCT of HIV. Given its simplicity and low cost, there is need for a large well-designed and well-conducted randomised controlled trial to assess the additive effect of vaginal disinfection on the risk of MTCT of HIV in antiretroviral treated women.

Effect on survey response rate of hand written versus printed signature on a covering letter: randomised controlled trial [ISRCTN67566265].

Abstract: It is important that response rates to postal surveys are as high as possible to ensure that the results are representative and to maximise statistical power. Previous research has suggested that any personalisation of approach helps to improve the response rate. This experiment tested whether personalising questionnaires by hand signing the covering letter improved the response rate compared with a non-personalised group where the investigator's signature on the covering letter was scanned into the document and printed. Randomised controlled trial. Questionnaires about surgical techniques of caesarean section were mailed to 3,799 Members and Fellows of the Royal College of Obstetricians and Gynaecologists resident in the UK. Individuals were randomly allocated to receive a covering letter with either a computer printed signature or a hand written signature. Two reminders were sent to non-respondents. The outcome measures were the proportion of questionnaires returned and their time to return. The response rate was 79.1% (1506/1905) in the hand-signed group and 78.4% (1484/1894) in the scanned and printed signature group. There was no detectable difference between the groups in response rate or time taken to respond. No advantage was detected to hand signing the covering letter accompanying a postal questionnaire to health professionals.

The UK Obstetric Surveillance System (UKOSS): an effective way to study rare disorders of pregnancy with anaesthetic, obstetric and midwifery input.

Abstract: effective way to study rare disorders of pregnancy with anaesthetic, obstetric and midwifery input M Knight, P Spark, JJ Kurinczuk, and P Brocklehurst National Perinatal Epidemiology Unit, University of Oxford Introduction: Rare disorders are difficult to study and therefore knowledge is poor and management rarely evidence-based The British Paediatric Surveillance Unit has developed a successful system to survey rare disorders in children This system was developed and modified to allow study of rare disorders of pregnancy through the UK Obstetric Surveillance System (UKOSS) The system was launched in February 2005 Method: Cases are collected through a monthly card mailing to nominated obstetric anaesthetists, obstetricians, midwives and risk managers in each UK hospital with a consultant-led maternity unit Data collection forms for each condition are subsequently sent to each clinician reporting a case Results: 100% of UK consultant-led obstetric units are participating in monthly case reporting (n=230) The average response rate to the monthly mailing over the first six months was 89% The regular UKOSS reporters in each hospital consisted of 24% obstetric anaesthetists, 375% obstetricians, 206% midwives and 179% risk managers 435 cases of the different conditions were reported over this time (table), with complete data collection for 89% of cases (168% of cases reported by obstetric anaesthetists, 308% reported by obstetricians, 264% reported by midwives and 26% reported by risk managers)