Summary Objectives This paper summarises the findings of a national audit of mastectomy and breast reconstruction surgery carried out in England. It describes patterns of treatment, and the clinical ...and patient-reported quality of life outcomes associated with these types of procedure. Design Prospective cohort study. Setting All 150 National Health Service hospital groups (NHS trusts) in England that provided mastectomy or breast reconstruction surgery, along with six NHS trusts in Wales and Scotland and 114 independent hospitals. Participants Women aged 16 years and over undergoing mastectomy with or without immediate breast reconstruction, or primary delayed breast reconstruction, between 1st January 2008 and 31st March 2009. Main outcome measures Reconstructive utilisation, post-operative complications and sequelae, and patient-reported satisfaction and quality of life. Results Overall, 21% of the 16,485 women who had mastectomy underwent immediate reconstruction. However, the proportion varied between regions from 9% to 43% ( p < 0.001). Levels of patient satisfaction with information, choice and the quality of care were high. The proportion of women who experienced local complications was 10.30% (95% CI 9.78–10.84) for mastectomy surgery, ranged from 11.02% (9.31–12.92) to 18.24% (14.80–22.10) for different immediate reconstructive procedures, and from 5.00% (2.76–8.25) to 19.86% (16.21–23.94) for types of delayed reconstruction. Breast appearance and overall well-being scores reported 18 months after surgery were higher among women having immediate breast reconstruction compared to mastectomy only. Postoperative outcomes were similar across providers.. Conclusions The Audit found women were highly satisfied with their peri-operative care, with hospital providers achieving similar outcomes. English providers should examine how to reduce the variation in rates of immediate reconstruction.
The COVID-19 pandemic has had a profound impact on health-care systems and potentially on pregnancy outcomes, but no systematic synthesis of evidence of this effect has been undertaken. We aimed to ...assess the collective evidence on the effects on maternal, fetal, and neonatal outcomes of the pandemic.
We did a systematic review and meta-analysis of studies on the effects of the pandemic on maternal, fetal, and neonatal outcomes. We searched MEDLINE and Embase in accordance with PRISMA guidelines, from Jan 1, 2020, to Jan 8, 2021, for case-control studies, cohort studies, and brief reports comparing maternal and perinatal mortality, maternal morbidity, pregnancy complications, and intrapartum and neonatal outcomes before and during the pandemic. We also planned to record any additional maternal and offspring outcomes identified. Studies of solely SARS-CoV-2-infected pregnant individuals, as well as case reports, studies without comparison groups, narrative or systematic literature reviews, preprints, and studies reporting on overlapping populations were excluded. Quantitative meta-analysis was done for an outcome when more than one study presented relevant data. Random-effects estimate of the pooled odds ratio (OR) of each outcome were generated with use of the Mantel-Haenszel method. This review was registered with PROSPERO (CRD42020211753).
The search identified 3592 citations, of which 40 studies were included. We identified significant increases in stillbirth (pooled OR 1·28 95% CI 1·07–1·54; I2=63%; 12 studies, 168 295 pregnancies during and 198 993 before the pandemic) and maternal death (1·37 1·22–1·53; I2=0%, two studies both from low-income and middle-income countries, 1 237 018 and 2 224 859 pregnancies) during versus before the pandemic. Preterm births before 37 weeks' gestation were not significantly changed overall (0·94 0·87–1·02; I2=75%; 15 studies, 170 640 and 656 423 pregnancies) but were decreased in high-income countries (0·91 0·84–0·99; I2=63%; 12 studies, 159 987 and 635 118 pregnancies), where spontaneous preterm birth was also decreased (0·81 0·67–0·97; two studies, 4204 and 6818 pregnancies). Mean Edinburgh Postnatal Depression Scale scores were higher, indicating poorer mental health, during versus before the pandemic (pooled mean difference 0·42 95% CI 0·02–0·81; three studies, 2330 and 6517 pregnancies). Surgically managed ectopic pregnancies were increased during the pandemic (OR 5·81 2·16–15·6; I2=26%; three studies, 37 and 272 pregnancies). No overall significant effects were identified for other outcomes included in the quantitative analysis: maternal gestational diabetes; hypertensive disorders of pregnancy; preterm birth before 34 weeks', 32 weeks', or 28 weeks' gestation; iatrogenic preterm birth; labour induction; modes of delivery (spontaneous vaginal delivery, caesarean section, or instrumental delivery); post-partum haemorrhage; neonatal death; low birthweight (<2500 g); neonatal intensive care unit admission; or Apgar score less than 7 at 5 min.
Global maternal and fetal outcomes have worsened during the COVID-19 pandemic, with an increase in maternal deaths, stillbirth, ruptured ectopic pregnancies, and maternal depression. Some outcomes show considerable disparity between high-resource and low-resource settings. There is an urgent need to prioritise safe, accessible, and equitable maternity care within the strategic response to this pandemic and in future health crises.
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Linkage of longitudinal administrative data for mothers and babies supports research and service evaluation in several populations around the world. We established a linked mother-baby cohort using ...pseudonymised, population-level data for England.
Retrospective linkage study using electronic hospital records of mothers and babies admitted to NHS hospitals in England, captured in Hospital Episode Statistics between April 2001 and March 2013.
Of 672,955 baby records in 2012/13, 280,470 (42%) linked deterministically to a maternal record using hospital, GP practice, maternal age, birthweight, gestation, birth order and sex. A further 380,164 (56%) records linked using probabilistic methods incorporating additional variables that could differ between mother/baby records (admission dates, ethnicity, 3/4-character postcode district) or that include missing values (delivery variables). The false-match rate was estimated at 0.15% using synthetic data. Data quality improved over time: for 2001/02, 91% of baby records were linked (holding the estimated false-match rate at 0.15%). The linked cohort was representative of national distributions of gender, gestation, birth weight and maternal age, and captured approximately 97% of births in England.
Probabilistic linkage of maternal and baby healthcare characteristics offers an efficient way to enrich maternity data, improve data quality, and create longitudinal cohorts for research and service evaluation. This approach could be extended to linkage of other datasets that have non-disclosive characteristics in common.
The current treatment choice for men with localized prostate cancer lies between active surveillance and radical therapy. The difference between these two extremes of care is 5% in terms of ...cancer-related absolute mortality at 8 years. It is generally accepted that this small difference will decrease for men diagnosed in the prostate-specific-antigen era. Radical therapy is associated with considerable adverse effects (e.g. incontinence, impotence, rectal problems) because it treats the whole gland, and damages surrounding structures in up to half of men. Men are being diagnosed at a younger age with lower-risk disease, and many have unifocal or unilateral disease. We propose a new concept whereby only the tumor focus and a margin of normal tissue are treated. This paradigm might decrease adverse effects whilst, at the same time, retaining effective cancer control. The arguments for and against active surveillance and radical therapy are reviewed in this article, with focal therapy presented as a means for bridging these two approaches.
Introduction
Mastectomy patients’ satisfaction with reconstructive options has not been examined.
Methods
A national study measured 18‐month satisfaction with reconstructive options and collected ...case‐mix and reconstructive offer and uptake data on breast cancer patients having mastectomy with or without immediate reconstruction (IR) in England between January 2008 and March 2009. Multivariable logistic regression examined the relationship between satisfaction, age, IR offer and uptake, and clinical suitability.
Results
Of 4796 patients, 1889 were not offered IR, 1489 declined an offer and 1418 underwent it. Women not offered IR were more likely older, obese or smokers and had higher ASA grades, ECOG scores, tumour burdens and adjuvant chemotherapy and radiotherapy likelihoods (9% of lowest suitability group offered IR; 81% in highest suitability group). 83.7% were satisfied with their reconstructive options, varying significantly by IR offer and uptake (76.1% for those not offered IR; 85.8% for those who declined IR; 91.7% following IR). Older women and women deemed more suitable for IR were more often satisfied (p‐values <0.001).
Conclusions
Satisfaction varied by offer and uptake status, age and suitability score. Clinicians should target equity for women deemed unsuitable by exploring their needs and desired outcomes, standardising operative fitness assessments and utilising shared decision‐making aids.
Under commercial conditions, weaning of piglets is associated with social, environmental and dietary stress. Consequently, small-intestinal barrier and absorptive functions deteriorate within a short ...time after weaning. Most studies that have assessed small-intestinal permeability in pigs after weaning used either Ussing chambers or orally administered marker probes. Paracellular barrier function and active absorption decrease when pigs are weaned at 3 weeks of age or earlier. However, when weaned at 4 weeks of age or later, the barrier function is less affected, and active absorption is not affected or is increased. Weaning stress is a critical factor in relation to the compromised paracellular barrier function after weaning. Adequate feed intake levels after weaning prevent the loss of the intestinal barrier function. Transcellular transport of macromolecules and passive transcellular absorption decrease after weaning. This may reflect a natural intestinal maturation process that is enhanced by the weaning process and prevents the pig from an antigen overload. It seems that passive and active absorption after weaning adapt accurately to the new environment when pigs are weaned after 3 weeks of age. However, when weaned at 3 weeks of age or earlier, the decrease in active absorption indicates that pigs are unable to sufficiently adapt to the new environment. To improve weaning strategies, future studies should distinguish whether the effect of feed intake on barrier function can be directed to a lack of a specific nutrient, i.e. energy or protein.
Background and Aims
Identifying international differences in utilization and outcomes of liver transplantation (LT) after donation after circulatory death (DCD) donation provides a unique opportunity ...for benchmarking and population‐level insight.
Methods
Adult (≥18 years) LT data between 2008 and 2018 from the UK and US were used to assess mortality and graft failure after DCD LT. We used time‐dependent Cox‐regression methods to estimate hazard ratios (HR) for risk‐adjusted short‐term (0–90 days) and longer‐term (90 days–5 years) outcomes.
Results
One‐thousand five‐hundred‐and‐sixty LT receipts from the UK and 3426 from the US were included. Over the study period, the use of DCD livers increased from 15.7% to 23.9% in the UK compared to 5.1% to 7.6% in the US. In the UK, DCD donors were older (UK:51 vs. US:33 years) with longer cold ischaemia time (UK: 437 vs. US: 333 min). Recipients in the US had higher Model for End‐stage Liver Disease (MELD) scores, higher body mass index, higher proportions of ascites, encephalopathy, diabetes and previous abdominal surgeries. No difference in the risk‐adjusted short‐term mortality or graft failure was observed between the countries. In the longer‐term (90 days–5 years), the UK had lower mortality and graft failure (adj.mortality HR:UK: 0.63 (95% CI: 0.49–0.80); graft failure HR: UK: 0.72, 95% CI: 0.58–0.91). The cumulative incidence of retransplantation was higher in the UK (5 years: UK: 11.9% vs. 4.6%; p < .001).
Conclusions
For those receiving a DCD LT, longer‐term post‐transplant outcomes in the UK are superior to the US, however, significant differences in recipient illness, graft quality and access to retransplantation were seen between the two countries.
Objectives
To assess the complications of transrectal (TR) compared to transperineal prostate (TP) biopsies.
Patients and Methods
Men diagnosed with prostate cancer between 1 April 2014 and 31 March ...2017 in England were identified in the National Prostate Cancer Audit. Administrative hospital data were then used to categorize the type of prostate biopsy and subsequent complications requiring hospital admission. Administrative hospital data were used to identify patients staying overnight immediately after biopsy and those readmitted separately for hospital admissions because of sepsis, urinary retention or haematuria. Procedure‐related mortality and total length of hospital stay within 30 days were also recorded. Generalized linear models were used to calculate adjusted risk differences (aRDs).
Results
A total of 73 630 patients undergoing prostate biopsy were identified. Those undergoing TP biopsy (n = 13 723) were more likely to have an overnight hospital stay (12.3% vs 2.4%; aRD 9.7%, 95% confidence interval CI 7.1–12.3), were less likely to be readmitted because of sepsis (1.0% vs 1.4%; aRD −0.4%, CI −0.6 to −0.2), and were more likely to be readmitted with urinary retention (1.9% vs 1.0%; aRD 1.1%, CI 0.7–1.4) than those undergoing a TR biopsy (n = 59 907). There were no significant differences in the risk of haematuria or mortality.
Conclusions
Our results showed that TP biopsy had a lower risk of readmission for sepsis but a higher risk of readmission for urinary retention than TR biopsy. Use of the TP route would prevent one readmission for sepsis in 278 patients at the cost of three additional patients readmitted for urinary retention.
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