Sara Wickham

Bio: Sara Wickham is an academic researcher from Anglia Ruskin University. The author has contributed to research in topics: MEDLINE & Evidence-based medicine. The author has an hindex of 6, co-authored 48 publications receiving 129 citations.

The art of questioning.

Abstract: A physician once saved my life with a question, or more precisely, with two questions. I had been short of breath for several months. Because I had had some cardiac problems in the past—an episode of pericarditis seven years pre-viously—I called my cardiologist. He thought it sounded like a slight worsening of my generally mild asthma, and reassured me. As the weeks passed, I had good days and bad days, and sometimes I worried more and sometimes less. At some point I organized a chest X-ray and an ECG for myself, and I also saw my GP. The tests were normal, there were no physical signs of anything, and the message was one of unconcerned uncertainty. Then one day I could not walk to the shops at the end of the road without stopping. My wife thought that my lips were now slightly blue. She insisted that my GP should send me to hospital. In the back of my mind I had a nagging fear that I was having pulmonary emboli. In any logical sense, this seemed absurd. I had no pain in my chest or legs, no cough and no haemoptysis. I was generally fit, and had not gone on any long flights that year. But my mother had died of a pulmonary embolus during a hospital admission. Also, for the first time in my life, I was unaccountably having dreams about her brother, who was murdered by the Nazis as a teenager—almost certainly by cyanide asphyxiation in Auschwitz. I had not known him, and she had virtually never talked about him. I saw a consultant chest physician who could not have been more thorough, but it was clear from her questions that pulmonary emboli did not figure remotely in her thinking. All the same, when she had finished examining me, she asked: 'Have you come up with any diagnosis yourself?' Sheepishly, and with the slight fear of ridicule that comes with not being a specialist, I told her of my specific anxiety. She then asked one further question: 'Does that mean you'd like a V/Q scan to reassure you?' I said yes. Three days later it was done, and showed I had already lost 25% of my lungs to multiple infarcts. 'You're a very good diagnostician' she said, graciously. I never told her about the bad dreams. At medical school, we are taught meticulously about the importance of …

Immersion in water during labour and birth

Abstract: Background Enthusiasts suggest that labouring in water and waterbirth increase maternal relaxation, reduce analgesia requirements and promote a midwifery model of care. Critics cite the risk of neonatal water inhalation and maternal/neonatal infection. Objectives To assess the evidence from randomised controlled trials about immersion in water during labour and waterbirth on maternal, fetal, neonatal and caregiver outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2011) and reference lists of retrieved studies. Selection criteria Randomised controlled trials comparing immersion in any bath tub/pool with no immersion, or other non-pharmacological forms of pain management during labour and/or birth, in women during labour who were considered to be at low risk of complications, as defined by the researchers. Data collection and analysis We assessed trial eligibility and quality and extracted data independently. One review author entered data and the other checked for accuracy. Main results This review includes 12 trials (3243 women): eight related to just the first stage of labour: one to early versus late immersion in the first stage of labour; two to the first and second stages; and another to the second stage only. We identified no trials evaluating different baths/pools, or the management of third stage of labour. Results for the first stage of labour showed there was a significant reduction in the epidural/spinal/paracervical analgesia/anaesthesia rate amongst women allocated to water immersion compared to controls (478/1254 versus 529/1245; risk ratio (RR) 0.90; 95% confidence interval (CI) 0.82 to 0.99, six trials). There was also a reduction in duration of the first stage of labour (mean difference -32.4 minutes; 95% CI -58.7 to -6.13). There was no difference in assisted vaginal deliveries (RR 0.86; 95% CI 0.71 to 1.05, seven trials), caesarean sections (RR 1.21; 95% CI 0.87 to 1.68, eight trials), use of oxytocin infusion (RR 0.64; 95%CI 0.32 to 1.28,five trials), perineal trauma or maternal infection. There were no differences for Apgar score less than seven at five minutes (RR 1.58; 95% CI 0.63 to 3.93, five trials), neonatal unit admissions (RR 1.06; 95% CI 0.71 to 1.57, three trials), or neonatal infection rates (RR 2.00; 95% CI 0.50 to 7.94, five trials). Of the three trials that compared water immersion during the second stage with no immersion, one trial showed a significantly higher level of satisfaction with the birth experience (RR 0.24; 95% CI 0.07 to 0.80). A lack of data for some comparisons prevented robust conclusions. Further research is needed. Authors' conclusions Evidence suggests that water immersion during the first stage of labour reduces the use of epidural/spinal analgesia and duration of the first stage of labour. There is limited information for other outcomes related to water use during the first and second stages of labour, due to intervention and outcome variability. There is no evidence of increased adverse effects to the fetus/neonate or woman from labouring in water or waterbirth. However, the studies are very variable and considerable heterogeneity was detected for some outcomes. Further research is needed.

Sudden Deaths and Severe Apparent Life-Threatening Events in Term Infants Within 24 Hours of Birth

Abstract: OBJECTIVE AND DESIGN: To determine the incidence of and possible risk factors for unexpected sudden infant deaths (SID) and severe apparent life-threatening events (S-ALTE) that occurred within 24 hours of birth. This was a monthly epidemiologic survey. PATIENTS AND METHODS: Throughout 2009, every pediatric department in Germany was asked to report such cases of unexplained SID or S-ALTE in term infants after a good postnatal adaptation (10-minute Apgar score ≥ 8) to the Surveillance Unit for Rare Pediatric Conditions in Germany. The latter has a capture rate of > 95%. S-ALTE was defined as acute cyanosis/pallor and unconsciousness, requiring bagging, intubation and/or cardiac compressions. Hospitals that reported a case were asked to return an anonymized questionnaire and discharge letter as well as the autopsy protocol in SID cases. RESULTS: Of 43 cases reported, 17 fulfilled entry criteria, yielding an incidence of 2.6 in 100 000 live births. There were 7 deaths (ie, 1.1/100 000); 6 of the 10 S-ALTE infants were neurologically abnormal at discharge. Twelve infants were found lying on their mother9s chest or abdomen, or very close to and facing her. Nine events occurred in the first 2 hours after birth; 7, were only noticed by a health professional despite the mother being present and awake. CONCLUSIONS: SID or S-ALTE may occur in the first 24 hours after birth, particularly within the first 2 hours. Events seem often related to a potentially asphyxiating position. Parents may be too fatigued or otherwise not able to assess their infant9s condition correctly. Closer observation during these earliest hours seems warranted.

Unexpected collapse in apparently healthy newborns - a prospective national study of a missing cohort of neonatal deaths and near-death events

Abstract: Background Sudden and unexpected postnatal collapse (SUPC) of a healthy newborn infant is a rare event, which carries a high risk of mortality and significant neurodisability in survivors. An underlying condition can be found in 60% of cases who undergo detailed postmortem but in the remainder there are important associations with prone position, breast feeding and primiparous status. The authors undertook a prospective study to ascertain the population incidence of SUPC in the UK. Methods Cases were referred through the British Paediatric Surveillance Unit reporting scheme over a 13-month period. Infants were at ≥37 weeks of gestation, had an Apgar score of ≥8 at 5 min, collapsed within 12 h in hospital requiring positive pressure ventilation and either died or received ongoing intensive care. Data were collected on maternal and infant characteristics, clinical investigations and 1-year outcome. Findings 45 cases were reported, an incidence of 0.05/1000 live births of whom 12 infants died. In 15/45 infants, an underlying disease/abnormality was determined. In 30/45 cases (0.035/1000 live births), no such cause was found, but in 24, the clinical/pathological diagnosis was airway obstruction during breast feeding or in prone position. Mothers were commonly primiparous and unattended by clinical staff before collapse was recognised. Approach to investigation was highly disparate and frequently very limited. Of the 30 infants with no underlying disease/abnormality, 22 (73%) developed a postasphyxial encephalopathy and 10 had a poor outcome (33%) – 5 died and 5 had neurological sequelae at 1 year. Interpretation SUPC is rare in any one centre and there is no standard approach to investigation. In those cases where collapse is not due to an underlying abnormality, breast feeding and prone position are important associations. Guidelines for safe postnatal care of infants should include appropriate vigilance of infants particularly where mothers are primiparous or where ability to assess the baby may be impaired.

Developing Higher Level Thinking.

Abstract: This paper identifies an interdisciplinary, five-step process, built upon existing theory and best practices in cognitive development, effective learning environments, and outcomes-based assessment. The Process for the Development of Higher Level Thinking Skills provides teachers with an easy to implement method of moving toward a more purposeful and active-learning environment, which encourages higher level thinking.