Search

Background\ud The position of invasive urodynamic testing (IUT) in diagnostic pathways for urinary incontinence is unclear, and systematic reviews have called for further trials evaluating clinical utility. The objective of this study was to inform the decision whether to proceed to a definitive randomised trial of IUT compared to clinical assessment with non-invasive tests, prior to surgery in women with stress urinary incontinence (SUI) or stress-predominant mixed urinary incontinence (MUI).\ud \ud Methods\ud A mixed methods study comprising a pragmatic multicentre randomised pilot trial, a qualitative face-to face interview study with patients eligible for the trial, an exploratory economic evaluation including value of information study, a survey of clinicians’ views about IUT, and qualitative telephone interviews with purposively sampled survey respondents. Only the first and second of these elements are reported here.\ud \ud Trial participants were randomised to either clinical assessment with non-invasive tests (control arm) or clinical assessment with non-invasive tests plus IUT (intervention arm).\ud \ud The main outcome measures of these feasibility studies were confirmation that units can identify and recruit eligible women, acceptability of investigation strategies and data collection tools, and acquisition of outcome data to determine the sample size for a definitive trial. The primary outcome proposed for a definitive trial was ICIQ-FLUTS (total score) 6 months after surgery or the start of nonsurgical treatment.\ud \ud Results\ud Of 284 eligible women, 222 (78 %) were recruited, 165/219 (75 %) returned questionnaires at baseline, and 125/200 returned them (63 %) at follow-up. Most women underwent surgery; management plans were changed in 19 (19 %) participants following IUT.\ud \ud Participants interviewed were positive about the trial and the associated documentation.\ud \ud Conclusions\ud All elements of a definitive trial were rehearsed. Such a trial would require between 232 and 922 participants, depending on the target difference in the primary outcome. We identified possible modifications to our protocol for application in a definitive trial including clarity over inclusion/exclusions, screening processes, reduction in secondary outcomes, and modification to patient questionnaire booklets and bladder diaries. A definitive trial of IUT versus clinical assessment prior to surgery for SUI or stress predominant MUI is feasible and remains relevant.\ud \ud Trial registration\ud Current Controlled Trials: ISRCTN71327395, registered 7 June 2010.

A survey was distributed among new breastfeeding mothers in northern England to gain insight into their experiences with different forms of neonatal vitamin K prophylaxis. Two-thirds of mothers were knowledgeable about the reasons for giving vitamin K and a quarter felt that they had not received adequate information on the subject. The importance of neonatal vitamin K prophylaxis must be fully explained by healthcare workers to all expectant parents.

Background:\ud A paucity of antenatal alcohol consumption prevalence rates in the UK and limited guidance around the implementation of antenatal screening practices led to the inception of my research within the field. In particular, the need to raise awareness of the risks of Prenatal Alcohol Exposure (PAE) and FASD with UK health professionals and the wider public. As a midwife researcher I identified that addressing this gap in knowledge was urgently required to evaluate and improve antenatal alcohol practices and services.\ud \ud Introduction:\ud My published papers follow a logical and sustained sequence of investigations to address this deficit, and consequently make an independent and original contribution to knowledge and understanding. Adopting an inductive approach, I initially examined the utility of self-report in relation to blood biomarkers to improve existing screening methods. Expanding the scope of my research to examine patient and healthcare professional’s expectations, knowledge and experience in relation to alcohol in pregnancy and the condition of Fetal Alcohol Spectrum Disorder (FASD). Finally, I consolidated this work by evaluating existing practices and services across the North-east and North Cumbria to inform future policy and make service recommendations.\ud \ud Aim:\ud The aim of my PhD was to investigate the feasibility and clinical effectiveness of antenatal alcohol screening for pregnant women, their partners and clinicians; and to evaluate a regional antenatal alcohol service provision in maternity practice.\ud \ud Design and Methodology:\ud I have taken a pragmatic approach and utilised a variety of methods to fully address my research objectives. A systematic review was undertaken comparing the diagnostic accuracy of blood biomarker analysis to maternal self-report in the detection of antenatal alcohol consumption. Retrospective anonymous surveillance using clinical audit methodology and blood biomarker analysis was employed to obtain epidemiological prevalence data regarding antenatal alcohol use. Surveys were used to understand patient understanding and attitudes to antenatal alcohol screening and healthcare professionals’ knowledge and experience of alcohol and FASD in practice. An evaluation of current alcohol prevention, screening and treatment service provision in maternity care practices and services in the North East and North Cumbria using content analysis was undertaken to inform strategic planning for the Local Maternity System.\ud \ud Results:\ud The six publications present a logical and inductive progression of enquiry, culminating in the presentation of a body of evidence which validates antenatal alcohol screening as feasible, acceptable and a recognised public health priority which should be integral to routine clinical practice. However, the effectiveness of the screening methods varied, and more research is required into blood biomarker analysis in pregnancy. Training and education requirements were also identified in healthcare professionals and the public. In response, the prioritisation of antenatal alcohol screening and the standardisation of best practices are recognised needs in UK maternity services. As a measure of success, I have received national and local recognition of my research which is now informing and changing clinical practice.\ud \ud Discussion:\ud \ud My main knowledge contributions are:\ud \ud • Production of empirical evidence that antenatal alcohol screening can effectively identify women at risk, thereby facilitating intervention to improve both maternal and infant health outcomes.\ud \ud • The demonstrated feasibility and acceptability of establishing routine antenatal alcohol screening also has the potential to determine reliable UK alcohol in pregnancy prevalence rates to inform future healthcare strategies.\ud \ud • Self-report is the cheapest and most accessible method of screening, but blood biomarkers may also be beneficial and cost-effective in the long-term.\ud \ud • FASD and alcohol in pregnancy training is urgently required for UK healthcare professionals. \ud \ud • Alcohol reduction in pregnancy should be made an urgent public health priority in UK maternity services to improve health outcomes across the life-course.\ud \ud • Standardised UK patient pathways involving alcohol screening and management practices are required, and the sharing of best practices will facilitate referrals and support regardless of location.\ud \ud • The implementation of these recommendations requires appropriate leadership, commissioning and training strategies.\ud \ud Conclusions:\ud My research has helped raised awareness and improved current practices relating to alcohol in pregnancy in the UK. The findings include original regional prevalence rates and have identified potential antenatal alcohol screening and management strategies. My evidence-based recommendations are already informing national Public Health England recommendations, NICE consultations, multidisciplinary training and service improvement initiatives. This new evidence has demonstrated the need for further inquiry into the challenging and complex issues surrounding alcohol harm reduction in pregnancy.