Publications by authors named "Sarah Hillman"

25 Publications

  • Page 1 of 1

The impact of disasters on contraception in OECD member countries: a scoping review.

Eur J Contracept Reprod Health Care 2021 Oct 15;26(5):429-438. Epub 2021 Jun 15.

Warwick Medical School, University of Warwick, Coventry, UK.

Objectives: Review evidence is lacking about how contraception is affected by severe social disruption, such as that caused by the COVID-19 pandemic. The purpose of this scoping review was to explore the impact of natural and man-made disasters on contraception in OECD member countries.

Methods: Manual searches and systematic searches in six electronic databases were conducted with no language restrictions. All articles were screened by at least two researchers. The data were analysed thematically.

Results: 108 articles were included. Most focussed on the Zika virus outbreak ( = 50) and the COVID-19 pandemic ( = 28). Four key themes were identified: importance of contraception during disasters, impact of disasters on contraceptive behaviour, barriers to contraception during disasters and ways of improving use of contraception during disasters. Despite efforts to increase access to contraception including by transforming ways of delivery, barriers to use meant that unmet need persisted.

Conclusions: To prevent adverse health outcomes and reduce health costs as a result of failure to have access to contraception during disasters, there is a need to intensify efforts to remove barriers to use. This should include increasing access and information on methods of contraception and their side effects (e.g., menstrual suppression) and making contraception freely available.
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http://dx.doi.org/10.1080/13625187.2021.1934440DOI Listing
October 2021

Remote by default general practice: must we, should we, dare we?

Br J Gen Pract 2021 06 27;71(707):254. Epub 2021 May 27.

Unit of Academic Primary Care, University of Warwick, Coventry.

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http://dx.doi.org/10.3399/bjgp21X715925DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8163481PMC
June 2021

Guidance impact on primary care prescribing rates of simple analgesia: an interrupted time series analysis in England.

Br J Gen Pract 2021 25;71(704):e201-e208. Epub 2021 Feb 25.

Warwick Medical School, University of Warwick, Coventry.

Background: In March 2018, NHS England published guidance for clinical commissioning groups (CCGs) to encourage implementation of policy to reduce primary care prescriptions of over-the-counter medications, including simple analgesia.

Aim: To investigate the impact of guidance publication on prescribing rates of simple analgesia (oral paracetamol, oral ibuprofen, and topical non-steroidal anti-inflammatory drugs) in primary care; CCG guidance implementation intentions; and whether the guidance has created health inequality based on socioeconomic status.

Design And Setting: Interrupted time series analysis of primary care prescribing data in England.

Method: Practice-level prescribing data from January 2015 to March 2019 were obtained from NHS Digital. Interrupted time series analyses were used to assess the association of guidance publication with prescribing rates. The association between practice-level prescribing rates and Index of Multiple Deprivation scores before and after publication was quantified using multivariable Poisson regression. Freedom of information requests were submitted to all CCGs.

Results: There was a statistically significant 4.4% reduction in prescribing of simple analgesia following guidance publication (adjusted incidence rate ratio 0.96, 95% CI = 0.92 to 0.99, = 0.027), adjusting for underlying time trend and seasonality. There was considerable diversity across CCGs in whether or how they chose to implement the guidance. Practice-level prescribing rates were greater in more deprived areas.

Conclusion: Guidance publication was associated with a small reduction in the prescribing rates of simple analgesia across England, without evidence of creating additional health inequality. Careful implementation by CCGs would be required to optimise cost saving to the NHS.
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http://dx.doi.org/10.3399/bjgp20X714101DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7906621PMC
June 2021

Associations between socioeconomic deprivation and pharmaceutical prescribing in primary care in England.

Postgrad Med J 2020 Dec 11. Epub 2020 Dec 11.

Warwick Medical School, University of Warwick, Coventry, UK

Background: Socioeconomic deprivation is associated with health inequality. Previous studies have described associations between primary care prescribing rates and deprivation for individual drugs or drug classes. We explore the correlation between socioeconomic deprivation and the rate of prescribing of individual pharmaceutical drugs, and drug classes, in primary care in England, to identify prescribing inequalities that would require further investigation.

Methods: In this cross-sectional study, national primary care prescribing data, by primary care practice, were retrieved for the calendar year 2019 in England. Socioeconomic deprivation was quantified using the Index of Multiple Deprivation (IMD) score. Correlations were calculated using Spearman's rank correlation coefficient (ρ), adjusting for practice list size and demographics, with a Bonferroni-corrected p value threshold of 5×10.

Results: We included 1.05 billion prescription items dispensed from 6896 England practices. 142/206 (69%) drug classes and 505/774 (65%) drugs were significantly correlated with IMD score (p<5×10). Of the 774 included drugs, 31 (4%) were moderately positively associated with IMD score (ρ>0.4). Only one was moderately negatively correlated with IMD score (ρ<-0.4), suggesting higher prescribing rates in more affluent areas. The drug classes most strongly associated with IMD score included opioid and non-opioid analgesics, antipsychotics and reflux medications. Drug classes most strongly associated with affluence included epinephrine, combined oral contraceptives and hormone replacement therapy.

Conclusion: We identify novel associations of prescribing with deprivation. Further work is required to identify the underlying reasons for these associations so that appropriate interventions can be formulated to address drivers of inequality.
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http://dx.doi.org/10.1136/postgradmedj-2020-138944DOI Listing
December 2020

Falling through the cracks: the impact of COVID-19 on postnatal care in primary care.

Br J Gen Pract 2020 12 26;70(701):578-579. Epub 2020 Nov 26.

Clinical Trials Unit, Warwick Medical School, Coventry.

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http://dx.doi.org/10.3399/bjgp20X713573DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7679148PMC
December 2020

Socioeconomic status and HRT prescribing: a study of practice-level data in England.

Br J Gen Pract 2020 11 29;70(700):e772-e777. Epub 2020 Oct 29.

Unit of Academic Primary Care.

Background: Concerns have been raised that women from deprived backgrounds are less likely to be receiving hormone replacement therapy (HRT) treatment and its benefits, although evidence in support of this is lacking.

Aim: To investigate general practice HRT prescription trends and their association with markers of socioeconomic deprivation.

Design And Setting: Cross-sectional study of primary care prescribing data in England in 2018.

Method: Practice-level prescribing rate was defined as the number of items of HRT prescribed per 1000 registered female patients aged ≥40 years. The association between Index of Multiple Deprivation (IMD) score and HRT prescribing rate was tested using multivariate Poisson regression, adjusting for practice proportions of obesity, smoking, hypertension, diabetes, coronary heart disease and cerebrovascular disease, and practice list size.

Results: The overall prescribing rate of HRT was 29% lower in practices from the most deprived quintile compared with the most affluent (incidence rate ratio [IRR] = 0.71; 95% confidence interval [CI] = 0.68 to 0.73). After adjusting for all cardiovascular disease outcomes and risk factors, the prescribing rate in the most deprived quintile was still 18% lower than in the least deprived quintile (adjusted IRR = 0.82; 95% CI = 0.77 to 0.86). In more deprived practices, there was a significantly higher tendency to prescribe oral HRT than transdermal preparations (<0.001).

Conclusion: This study highlights inequalities associated with HRT prescription. This may reflect a large unmet need in terms of menopause care in areas of deprivation. Further research is needed to identify the factors from patient and GP perspectives that may explain this.
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http://dx.doi.org/10.3399/bjgp20X713045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7523922PMC
November 2020

GP home visits: essential patient care or disposable relic?

Br J Gen Pract 2020 Jun 28;70(695):306-307. Epub 2020 May 28.

Warwick Medical School, University of Warwick, Coventry.

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http://dx.doi.org/10.3399/bjgp20X710345DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7241922PMC
June 2020

Women's experiences of diagnosis and management of polycystic ovary syndrome: a mixed-methods study in general practice.

Br J Gen Pract 2020 05 30;70(694):e322-e329. Epub 2020 Apr 30.

Unit of Academic Primary Care, Warwick Medical School, University of Warwick, Coventry.

Background: Polycystic ovary syndrome (PCOS) is a common lifelong metabolic condition with serious associated comorbidities. Evidence points to a delay in diagnosis and inconsistency in the information provided to women with PCOS.

Aim: To capture women's experiences of how PCOS is diagnosed and managed in UK general practice.

Design And Setting: This was a mixed-methods study with an online questionnaire survey and semi-structured telephone interviews with a subset of responders.

Method: An online survey to elicit women's experiences of general practice PCOS care was promoted by charities and BBC Radio Leicester. The survey was accessible online between January 2018 and November 2018. A subset of responders undertook a semi-structured telephone interview to provide more in-depth data.

Results: A total of 323 women completed the survey (average age 35.4 years) and semi-structured interviews were conducted with 11 women. There were five key themes identified through the survey responses. Participants described a variable lag time from presentation to PCOS diagnosis, with a median of 6-12 months. Many had experienced mental health problems associated with their PCOS symptoms, but had not discussed these with the GP. Many were unable to recall any discussion about associated comorbidities with the GP. Some differences were identified between the experiences of women from white British backgrounds and those from other ethnic backgrounds.

Conclusion: From the experiences of the women in this study, it appears that PCOS in general practice is not viewed as a long-term condition with an increased risk of comorbidities including mental health problems. Further research should explore GPs' awareness of comorbidities and the differences in PCOS care experienced by women from different ethnic backgrounds.
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http://dx.doi.org/10.3399/bjgp20X708881DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7065681PMC
May 2020

We need to improve postnatal care, starting with the maternal six week postnatal check.

BMJ 2020 01 24;368:m252. Epub 2020 Jan 24.

Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK.

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http://dx.doi.org/10.1136/bmj.m252DOI Listing
January 2020

Polycystic ovarian syndrome: an under-recognised problem?

Br J Gen Pract 2018 05;68(670):244

Primary Care, Medical School, University of Warwick, Coventry.

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http://dx.doi.org/10.3399/bjgp18X696101DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5916073PMC
May 2018

Genomics in general practice: Generation Genome.

Br J Gen Pract 2017 12;67(665):540-541

Warwick Primary Care, Warwick Medical School, University of Warwick, Coventry.

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http://dx.doi.org/10.3399/bjgp17X693533DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5697527PMC
December 2017

Parental experiences of prenatal whole exome sequencing (WES) in cases of ultrasound diagnosed fetal structural anomaly.

Prenat Diagn 2017 12 10;37(12):1225-1231. Epub 2017 Nov 10.

Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.

Objective: To explore parental experiences of whole exome sequencing (WES) for prenatal diagnosis and ascertain what influenced their decision-making to undergo testing.

Method: Twelve women comprised a purposeful sample in a series of semistructured interviews. All had received a fetal anomaly diagnosis on ultrasound. A topic guide was used, and transcripts were thematically analyzed to elicit key themes.

Results: Five main themes (parental experiences of prenatal WES, need for information, consent/reasons for prenatal WES, sources of support for prenatal WES, and return of WES findings to families) emerged, some with multiple subthemes.

Conclusions: Parents desired as much information as possible and appreciated information being repeated and provided in various formats. Many struggled with clinical uncertainty relating to the cause and prognosis following a fetal anomaly diagnosis and found it difficult to balance the risks of invasive testing against their need for more definitive information. Parents trusted their clinicians and valued their support with decisions in pregnancy. Testing was sometimes pursued to reassure parents that their baby was "normal" rather than to confirm an underlying genetic problem. Parents were motivated to undergo WES for personal and altruistic reasons but disliked waiting times for results and were uncertain about what findings might be returned.
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http://dx.doi.org/10.1002/pd.5172DOI Listing
December 2017

Prenatal whole exome sequencing: the views of clinicians, scientists, genetic counsellors and patient representatives.

Prenat Diagn 2016 Oct 18;36(10):935-941. Epub 2016 Sep 18.

Fetal Medicine Centre, Birmingham Women's NHS Foundation Trust, Birmingham, UK.

Objective: Focus groups were conducted with individuals involved in prenatal diagnosis to determine their opinions relating to whole exome sequencing in fetuses with structural anomalies.

Method: Five representatives of patient groups/charities (PRGs) and eight clinical professionals (CPs) participated. Three focus groups occurred (the two groups separately and then combined). Framework analysis was performed to elicit themes. A thematic coding frame was identified based on emerging themes.

Results: Seven main themes (consent, analysis, interpretation/reinterpretation of results, prenatal issues, uncertainty, incidental findings and information access) with subthemes emerged. The main themes were raised by both groups, apart from 'analysis', which was raised by CPs only. Some subthemes were raised by PRGs and CPs (with different perspectives). Others were raised either by PRGs or CPs, showing differences in patient/clinician agendas.

Conclusions: Prenatal consent for whole exome sequencing is not a 'perfect' process, but consent takers should be fully educated regarding the test. PRGs highlighted issues involving access to results, feeling that women want to know all information. PRGs also felt that patients want reinterpretation of results over time, whilst CPs felt that interpretation should be performed at the point of testing only. © 2016 John Wiley & Sons, Ltd.
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http://dx.doi.org/10.1002/pd.4916DOI Listing
October 2016

Intrahepatic cholestasis of pregnancy.

BMJ 2016 Apr 21;353:i1236. Epub 2016 Apr 21.

Centre for Women's and New-born Health, Institute of Metabolism and Systems Research, College of Medical Sciences, University of Birmingham, Birmingham, B15 2TT, UK Fetal Medicine Centre, Birmingham Women's Foundation Trust, Birmingham, UK.

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http://dx.doi.org/10.1136/bmj.i1236DOI Listing
April 2016

BAC chromosomal microarray for prenatal detection of chromosome anomalies in fetal ultrasound anomalies: an economic evaluation.

Fetal Diagn Ther 2014 13;36(1):49-58. Epub 2014 Jun 13.

School of Clinical and Experimental Medicine, College of Medicine and Dentistry, Birmingham, UK.

Introduction: To determine the cost-effectiveness of prenatal chromosomal microarray (CMA) when performed for structural anomalies on fetal ultrasound scan over conventional techniques.

Method: A decision tree was populated using data from a prospective cohort of women undergoing testing when a fetal ultrasound scan showed a structural abnormality. Nine strategies of testing were modeled including combinations of the tests: QFPCR, G-band karyotyping, CMA and FISH for DiGeorge (22q) microdeletion.

Results: When CMA costs GBP 405 and using a 1-Mb BAC array it would cost GBP 24,600 for every additional case detected by CMA over a combination of QFPCR, followed by G-band karyotype, followed lastly by FISH (for DiGeorge syndrome). If CMA is performed instead of conventional karyotyping alone it costs GBP 33,000 for every additional case detected. However, if the cost of CMA is reduced to GBP 360 than when CMA is performed instead of conventional karyotyping alone it would cost GBP 9,768 for every additional case detected.

Discussion: The use of a prenatal BAC CMA is not currently cost-effective when compared to other testing strategies. However, as CMA costs decrease and resolution (and detection rates) increase it is likely to become the cost-effective option of the future.
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http://dx.doi.org/10.1159/000358387DOI Listing
March 2015

Exome sequencing improves genetic diagnosis of structural fetal abnormalities revealed by ultrasound.

Hum Mol Genet 2014 Jun 29;23(12):3269-77. Epub 2014 Jan 29.

Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridgeshire CB10 1SA, UK.

The genetic etiology of non-aneuploid fetal structural abnormalities is typically investigated by karyotyping and array-based detection of microscopically detectable rearrangements, and submicroscopic copy-number variants (CNVs), which collectively yield a pathogenic finding in up to 10% of cases. We propose that exome sequencing may substantially increase the identification of underlying etiologies. We performed exome sequencing on a cohort of 30 non-aneuploid fetuses and neonates (along with their parents) with diverse structural abnormalities first identified by prenatal ultrasound. We identified candidate pathogenic variants with a range of inheritance models, and evaluated these in the context of detailed phenotypic information. We identified 35 de novo single-nucleotide variants (SNVs), small indels, deletions or duplications, of which three (accounting for 10% of the cohort) are highly likely to be causative. These are de novo missense variants in FGFR3 and COL2A1, and a de novo 16.8 kb deletion that includes most of OFD1. In five further cases (17%) we identified de novo or inherited recessive or X-linked variants in plausible candidate genes, which require additional validation to determine pathogenicity. Our diagnostic yield of 10% is comparable to, and supplementary to, the diagnostic yield of existing microarray testing for large chromosomal rearrangements and targeted CNV detection. The de novo nature of these events could enable couples to be counseled as to their low recurrence risk. This study outlines the way for a substantial improvement in the diagnostic yield of prenatal genetic abnormalities through the application of next-generation sequencing.
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http://dx.doi.org/10.1093/hmg/ddu038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4030780PMC
June 2014

Placenta chorioangioma: a rare case and systematic review of literature.

J Matern Fetal Neonatal Med 2014 Jul 17;27(10):1055-63. Epub 2013 Oct 17.

Fetal Medicine Centre, Birmingham Women's Foundation Trust , Birmingham , UK .

Objectives: Placental chorioangioma is a relatively rare condition that often results in serious prenatal complications and adverse pregnancy outcome. We report a case of a large chorioangioma that was prenatally diagnosed at 23 weeks with polyhydramnios and fetal anemia. With prenatal monitoring, transplacental therapy with a COX-2 inhibitor and intrauterine transfusion, the pregnancy resulted in the live birth at 30 weeks. Due to the paucity of evidence relating to the management protocols in cases of placental chorioangiomas, we have conducted a systematic review of the literature.

Methods: All reported cases in the English language were captured using the electronic databases. Bibliographies of relevant articles were manually searched.

Results: Sixty-four articles were included reporting 112 cases of placental chorioangioma. In 79, there was no prenatal treatment and in 33 there was in-utero treatment. A systematic comparison of antenatal complications and pregnancy outcomes was performed. No strong conclusion could be made due to the low number and quality of the reported cases.

Conclusion: Placenta chorioangioma represents a challenge with its potentially serious complications adversely affecting pregnancy outcome. An international registry of pregnancies with this rare complication and documentation of pregnancy outcomes will improve the evidence base for prospective management.
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http://dx.doi.org/10.3109/14767058.2013.847424DOI Listing
July 2014

Exome Sequencing in Fetuses with Structural Malformations.

J Clin Med 2014 Jul 8;3(3):747-62. Epub 2014 Jul 8.

Centre of Women's and Children's Health & School of Clinical and Experimental Medicine, College of Medicine and Dentistry, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK.

Prenatal diagnostic testing is a rapidly advancing field. An accurate diagnosis of structural anomalies and additional abnormalities in fetuses with structural anomalies is important to allow "triage" and designation of prognosis. This will allow parents to make an informed decision relating to the pregnancy. This review outlines the current tests used in prenatal diagnosis, focusing particularly on "new technologies" such as exome sequencing. We demonstrate the utility of exome sequencing above that of conventional karyotyping and Chromosomal Microarray (CMA) alone by outlining a recent proof of concept study investigating 30 parent-fetus trios where the fetus is known to have a structural anomaly. This may allow the identification of pathological gene anomalies and consequently improved prognostic profiling, as well as excluding anomalies and distinguishing between de novo and inherited mutations, in order to estimate the recurrence risk in future pregnancies. The potential ethical dilemmas surrounding exome sequencing are also considered, and the future of prenatal genetic diagnosis is discussed.
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http://dx.doi.org/10.3390/jcm3030747DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4449643PMC
July 2014

Single-twin demise: pregnancy outcome.

Best Pract Res Clin Obstet Gynaecol 2014 Feb 3;28(2):249-63. Epub 2013 Dec 3.

Centre for Women's and Children's Health, School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, UK; Fetal Medicine Centre, Birmingham Women's Foundation NHS Trust, Edgbaston, Birmingham, UK.

Single-twin demise can pose substantial risks for the surviving co-twin, including increased risk of fetal loss, preterm delivery, neurovascular injury, and end-organ damage. In this chapter, we summarise recently published research on the causes of single twin demise, the pathophysiology of injury to the surviving co-twin, and the evidence for current management strategies. The gestation at which single intrauterine fetal demise occurs, and the chorionicity of the multiple pregnancies, are the two most important factors when considering the risks to the surviving twin. Management should include fortnightly ultrasound scans for growth, umbilical artery Doppler studies, and liquor volume. In monochorionic twins, more complex Doppler assessment with middle cerebral artery Doppler velocimetry and a magnetic resonance imaging of the survivor's brain at least 3 weeks after single intrauterine fetal demise occurs should be carried out to look for evidence of neurological morbidity. With no other obstetric complications, dichorionic pregnancies can be delivered at term. Monochorionic pregnancies are more difficult to manage, and are often delivered between 34 and 36 weeks.
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http://dx.doi.org/10.1016/j.bpobgyn.2013.11.003DOI Listing
February 2014

A systematic review and thematic synthesis of qualitative studies on maternal emergency transport in low- and middle-income countries.

Int J Gynaecol Obstet 2013 Sep 24;122(3):192-201. Epub 2013 Jun 24.

School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.

Background: Most maternal deaths are preventable with emergency obstetric care; therefore, ensuring access is essential. There is little focused information on emergency transport of pregnant women.

Objectives: The literature on emergency transport of pregnant women in low- and middle-income countries (LMICs) was systematically reviewed and synthesized to explore current practices, barriers, and facilitators for transport utilization.

Search Strategy: MEDLINE, EMBASE, BNI, Cochrane Library, CINAHL, African Index Medicus, ASSIA, QUALIDATA, RHL, and Science Citation Index (inception to April 2012) were searched without language restriction.

Selection Criteria: Studies using qualitative methodology and reporting on emergency transportation in LMICs were included.

Data Collection And Analysis: Thematic framework and synthesis through examination and translation of common elements were used to analyze and synthesize the data.

Main Results: Twenty-nine articles were included. Eight major themes were identified: time for transport; transport options; geography; local support; autonomy; culture; finance; and ergonomics. Key issues were transport availability; transport speed; terrain; meteorology; support; dependence for decision making; cultural issues; cost; and lack of safe, comfortable positioning during transport.

Conclusion: Themes should be appreciated within local contexts to illuminate barriers and facilitators. Potential solutions include motorcycle ambulance programs, collaboration with taxi services, community education, subsidies, and vehicle maintenance.
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http://dx.doi.org/10.1016/j.ijgo.2013.03.030DOI Listing
September 2013

"If it helps..." the use of microarray technology in prenatal testing: patient and partners reflections.

Am J Med Genet A 2013 Jul 21;161A(7):1619-27. Epub 2013 May 21.

School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, UK.

The objective was to gain insight into the experiences of women and their partners diagnosed with a fetal abnormality on prenatal ultrasound examination and receiving genetic testing including microarray. Twenty-five semi-structured interviews were performed with women +/- their partners after receiving the results of prenatal genetic testing. Framework analysis was performed to elicit themes and subthemes. Five main themes were recognized; diagnosis, genetic testing, family and support, reflections of the treatment received and emotions. Our results showed that women recall being told about QFPCR for trisomy 13, 18, and 21 but often no further testing. Women expected the conventional karyotype and microarray result would be normal following a normal QFPCR result. There were frequent misconceptions by couples regarding aspects of counseling/testing. Communication of variants of unknown (clinical) significance (VOUS) presents a particularly difficult challenge. Good clear communication by health care professionals is paramount. When counseling women and their partners for fetal chromosomal testing it should be reinforced that although the most common, trisomy 13, 18, and 21 only account for some of the chromosomal changes resulting in abnormal scan findings. Couples should have literature to take home summarizing scan anomalies and reinforcing information about genetic testing.
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http://dx.doi.org/10.1002/ajmg.a.35981DOI Listing
July 2013

Co-twin prognosis after single fetal death: a systematic review and meta-analysis.

Obstet Gynecol 2011 Oct;118(4):928-40

School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK.

Objective: To perform a systematic review and meta-analysis of the effects on the surviving twin of single fetal death comparing monochorionic to dichorionic twins to report the rates of co-twin death, preterm delivery, and neurologic morbidity in the surviving fetus.

Data Sources: MEDLINE (inception-December 2010), EMBASE (inception-December 2010), The Cochrane library (inception-December 2010), Web of Science (inception-December 2010), and British Nursing Index (inception-December 2010) were searched electronically.

Methods Of Study Selection: Selected studies had more than five cases of single fetal death with reports of co-twin death, neurologic morbidity, or both co-twin death and neurologic morbidity. They also must have defined the gestational age of single fetal death and chorionicity.

Tabulation, Integration, And Results: The search yielded 1,386 citations. Full manuscripts were retrieved for 204 and 22 were included in the review and meta-analysis. Twenty manuscripts were used to calculate overall summary statistics for monochorionic and dichorionic twins showing rates of co-twin death after single fetal death (15% compared with 3%), rates of preterm delivery after single fetal death (68% compared with 54%), the rate of abnormal postnatal cranial imaging after single fetal death (34% compared with 16%), and the rate of neurodevelopmental impairment after single fetal death (26% compared with 2%). Odds ratios (ORs) were calculated from 16 manuscripts. There was no significant difference reported between preterm delivery of monochorionic or dichorionic twins (OR 1.1, 95% confidence interval [CI] 0.34-3.51, P=.9). After single fetal death, monochorionic twins had higher odds of an abnormal cranial imaging after delivery, this was not significant (OR 3.25, 95% CI 0.66-16.1, P=.12). After single fetal death, monochorionic twins were 4.81-times more likely to have neurodevelopmental morbidity (95% CI 1.39-16.6, P<.05).

Conclusion: Monochorionic twins are at significantly increased odds of co-twin demise and neurodevelopmental morbidity after single fetal death.
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http://dx.doi.org/10.1097/AOG.0b013e31822f129dDOI Listing
October 2011
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