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Biomedical subjects

M Maresh

Publications and source records attributed to M Maresh.

At least 19 recordsLinked to original sources
PubMed2005

Screening for gestational diabetes mellitus.

The term 'gestational diabetes mellitus' is unsatisfactory as it refers to a heterogeneous group of women, including those with minimal abnormality of carbohydrate metabolism and those with undiagnosed type II diabetes. However, perinatal morbidity is increased even in the group of women who have only impaired glucose tolerance; the mothers are at increased risk of subsequent development of diabetes, and there may also be long-term implications for the offspring. Current research is aiming to define the blood glucose levels at which risks increase so that clinical management can be appropriately directed. When available, the criteria required to justify population screening in pregnancy should be satisfied. The glucose challenge and fasting glucose tests are the leading contenders as appropriate screening tests to determine who should have the diagnostic glucose tolerance test. However, until this is reviewed, the widely used scheme of risk factors as a screening method should continue, as it detects at least 50% of women with gestational diabetes.

Diabetes, Gestational↗
PubMed2005

Self-reported bladder function five years post-hysterectomy.

We have examined the contribution of hysterectomy, compared with less invasive surgery, for dysfunctional uterine bleeding (DUB) on the prevalence of bladder problems five years after surgery. We report a prospective cohort study of over 25,000 women treated for benign cause menorrhagia by three types of surgery - transcervical endometrial resection/ablation and hysterectomy with or without bilateral oophorectomy. Postal questionnaires were sent five years after surgery investigating satisfaction with surgery and bladder function. When adjusted for confounders the odds of severe urinary incontinence (OR = 1.59, CI 95%, 1.35 - 1.87), urinary frequency (1.23 (1.04 - 1.45)), and nocturia (1.19, (1.03 - 1.38)) - were increased for women who had a hysterectomy compared with endometrial ablation. Hysterectomy with bilateral oophorectomy was not as strongly associated with severe bladder problems. Women who had the LAVH were most likely to report severe urinary incontinence (2.02, CI 95% 1.32 - 3.07), but not severe frequency or nocturia.

Adult↗
PubMed2005

Intrauterine programming of urinary calcium and magnesium excretion in children born to mothers with insulin dependent diabetes mellitus.

BACKGROUND: Offspring of diabetic rats have reduced urinary calcium and magnesium excretion compared with offspring of controls; these differences persist up to 16 weeks after birth, a time equivalent to young adulthood in humans. OBJECTIVES: To test the hypothesis that urinary calcium and magnesium excretion would be lower in children born to mothers with insulin dependent diabetes mellitus (ChMIDDM) than those born to non-diabetic mothers. METHODS: Concentrations of calcium, magnesium, sodium, and creatinine were measured in first void spot urine samples collected from 45 (28 male; median age 9.6 years) ChMIDDM and 127 (58 male; median age 11.3 years) controls. Analysis of covariance was used to test for differences in urinary calcium to creatinine ratios (UCa/Cr), magnesium to creatinine ratios (UMg/Cr), and log sodium to creatinine ratios (logUNa/Cr) between controls and ChMIDDM after allowing for the effects of sex and age. RESULTS: UCa/Cr (difference -0.10, 95% confidence interval (CI) -0.19 to -0.01; p = 0.03) and UMg/Cr (difference -0.15, 95% CI -0.22 to -0.08; p<0.0001) were lower in ChMIDDM than controls. However, logUNa/Cr did not differ between ChMIDDM and controls (difference -0.14, 95% CI -0.33 to 0.05; p = 0.1). The daily estimated intake of magnesium, sodium, and protein were significantly higher and that of calcium non-significantly higher in ChMIDDM than controls. In ChMIDDM, UCa/Cr and UMg/Cr were not related to diabetic control of mothers. CONCLUSIONS: Results of this study provide the first evidence that in humans, as in rats, there is modification of renal Ca and Mg handling in ChMIDDM, which persists well into childhood.

Adolescent↗
PubMed2005

Readmission to hospital 5 years after hysterectomy or endometrial resection in a national cohort study.

OBJECTIVES: To investigate the readmission experience of a large national prospective cohort of women up to 5 years after undergoing either transcervical resection of the endometrium (TCRE) or hysterectomy to assess reasons for readmission and whether TCRE can be viewed as a definitive substitute for hysterectomy. DESIGN AND PARTICIPANTS: Data are from the VALUE/MISTLETOE prospective national cohort studies of hysterectomy and TCRE respectively. 5294 women who underwent hysterectomy for dysfunctional uterine bleeding in 1994/5 and 4032 women who underwent TCRE in 1993/4 and who responded to postal questionnaires were included. Surgeons gathered operative details. Women completed postal follow up questionnaires at 3 and 5 years after surgery asking about readmission to hospital and reasons for readmission. Adjusted proportional hazard ratios were calculated for likelihood of readmission in each category comparing types of surgery. RESULTS: 41.7% of women undergoing hysterectomy and 44.6% of women undergoing TCRE experienced one or more readmissions to hospital overall within 5 years (adjusted hazard ratio for all readmissions (AHR) 0.87 (95% confidence interval (CI) 0.80 to 0.95)). 12.6% of hysterectomy patients and 30.3% of TCRE patients were readmitted for gynaecological reasons (AHR 0.40 (95% CI 0.33 to 0.48)). Rates of readmission for gynaecological reasons were similar up to 6 months but were markedly reduced for hysterectomy compared with TCRE patients towards the end of the follow up period (AHR for readmission at 3-5 years 0.28 (95% CI 0.20 to 0.39)). CONCLUSIONS: There are differences in the pattern of readmission to hospital after hysterectomy and TCRE for dysfunctional uterine bleeding. Women undergoing a hysterectomy are less likely to be readmitted to hospital up to 5 years after their operation overall, and are significantly less likely to be readmitted for reasons related to their operation, particularly for gynaecological reasons. Hysterectomy appears to be a more definitive operation. The different options for surgery for dysfunctional uterine bleeding are not interchangeable; they represent different patterns of care. Information should be available to women and practitioners to inform choices between these options.

Adult↗
PubMed2004

Severe complications of hysterectomy: the VALUE study.

OBJECTIVES: To model the determinants of serious operative and post-operative complications of hysterectomy and their potential risk factors. DESIGN: A prospective cohort of women undergoing hysterectomies for benign indications in 1994/1995, with a six-week postsurgery follow up. POPULATION AND SETTING: A total of 37,512 women from 276 NHS and 145 private hospitals in England, Wales and Northern Ireland, originally recruited to compare the outcomes of endometrial destruction with those of hysterectomy. METHODS: Gynaecologists reported hysterectomies for non-malignant indications carried out during a 12-month period beginning in October 1994 and follow up data were obtained at outpatient follow up six weeks postsurgery. Odds ratios of severe complications by indication and method, adjusting for measured intrinsic risk factors, were calculated. MAIN OUTCOME MEASURES: Severe operative and post-operative complications. RESULTS: Severe operative complications occurred in 3%. The risk decreased with age and increased with greater parity and history of serious illness. Women with symptomatic fibroids (4.4%, 95% CI 3.9-4.9) experienced more complications than women with dysfunctional uterine bleeding (3.6%, 3.2-3.8), adjusted odds ratio (OR) = 1.3 (95% CI 1.1-1.6). Laparoscopic procedures (6.1%) doubled the risk of operative complications of abdominal hysterectomy (3.6%) (adjusted OR = 1.9, 1.5-2.5). Post-operative complications occurred in around 1% of women, with a slight decrease with increasing age, and the strongest risk factor was a history of operative complications. Relative to dysfunctional uterine bleeding (1.0%), a higher risk for fibroids (1.2%) persisted after adjustments (RR = 1.5, 1.1-2.0). Both vaginal (1.2%) and laparoscopic (1.7%) techniques had significantly higher adjusted risks than abdominal operations (0.9%), RR = 1.4 (1.0-1.9) and RR = 1.6 (1.0-2.7). There were no operative deaths; 14 women died within the six-week postsurgery (a crude mortality rate of 3.8/1000, 2.5-6.4). CONCLUSIONS: Hysterectomy is a common, routine surgery with comparatively rare serious complications. However, younger women, women with more vascular pelvis, who undergo hysterectomy, especially laparoscopically assisted vaginal surgery for symptomatic fibroids, are at most risk of experiencing severe complications both operatively and post-operatively. Therefore, a less invasive alternative treatment for symptomatic fibroids could particularly benefit this group of women, while less invasive treatments for dysfunctional uterine bleeding, such as various methods of endometrial ablations or resections, would need to meet the current low levels of clinical complications in order to replace hysterectomy.

Adolescent↗
PubMed2002

Grandmultiparae in a modern setting.

OBJECTIVE: To compare the incidence of antenatal and intrapartum complications and neonatal outcomes among women who had previously delivered five or more times (grandmultiparous) with that of age-matched control women who had previously delivered two or three times (multiparous). DESIGN: A matched cohort study. SETTING: An inner city university maternity hospital in the United Kingdom. SAMPLE: Three hundred and ninety-seven grandmultiparous women were compared with three hundred and ninety-seven age-matched multiparous women. METHODS: Data on the subjects were obtained from a computerised maternity information system (SMMIS). Characteristics and complications occurring in the two groups were compared. Data validation was performed with a 10% randomised sample of the casenotes in both groups. Nineteen relevant data fields were abstracted and compared with the matched SMMIS record. Results The overall incidence of intrapartum complications for grandmultiparous women was 16% compared with 18% in the control multiparous women (odds ratio 0.9, 95% CI 0.6-1.3). Grand multiparity was associated with a significantly higher body mass index at booking (P < 0.01) and the last antenatal clinic (P < 0.05), an increased incidence of antenatal anaemia (22% vs 16%, odds ratio 1.8, 95% CI 1.2-2.8) and a decreased incidence of elective caesarean section (6% vs 11%, odds ratio 0.5, 95% CI 0.3-0.9). Agreement was greater than 95% in all the data fields reviewed except three. In the 14 categorical variables reviewed the Cohen's kappa results were in excess of 0.6. CONCLUSION: This study suggests that in a developed country with satisfactory health care conditions, grandmultiparity should not be considered dangerous,and risk assessment should be based on past and present history and not simply on the basis of parity.

Cohort Studies↗
PubMed2001

Clinical, provider and sociodemographic determinants of the number of antenatal visits in England and Wales.

The objective of this study was to measure the independent effects of clinical factors and non-clinical factors, such as provider and sociodemographic characteristics, on the number of antenatal visits made by women in England and Wales. The study was based on a survey of the secondary case records of 20,771 women with singleton pregnancies who were delivered between 1 August 1994 and 31 July 1995. The women in the survey attended one of nine maternity units in Northern England and North Wales selected within those areas to reflect geographical variations, as well as variations in the size and teaching status of the institution. A multivariate Poisson regression model was developed to examine differences in the number of antenatal visits made by women with different clinical and non-clinical characteristics. After controlling for non-clinical factors, primiparous women identified as high risk at booking made 1.0% more visits than primiparous women identified as low risk at booking (p = 0.196). Multiparous women identified as high risk at booking made 3.5% more visits than their low risk counterparts (p<0.001). High risk-defining criteria during antenatal care led to a 0.3% weekly increase in the number of antenatal visits amongst primiparous women (p <0.001) and a 0.4% weekly increase in the number of antenatal visits amongst multiparous women (p < 0.001). Several notable results, not reported elsewhere in the literature, were revealed by the regression analyses. After all independent variables were controlled for, women who were booked into urban teaching hospitals made 10% fewer antenatal visits than the women who were booked into the urban non-teaching hospitals. Women of Pakistani origin made 9.1% fewer antenatal visits than women of white British origin. Similar results were revealed for women of Indian origin and women from other ethnic groups. Non-smokers made 6.0% more antenatal visits than smokers. The planned pattern of antenatal care, number of carers seen, gestation at first presentation and maternal age also had significant independent impacts on the number of antenatal visits. The study highlights the sizeable impact of non-clinical factors on the antenatal care delivery process and indicates ways in which variations in antenatal care might be reduced.

Adult↗
PubMed2001

Diabetes in pregnancy.

The following review considers briefly most aspects of the care of the woman with established diabetes, gestational diabetes and impaired glucose tolerance. Where possible, reference is made to recent publications, but much of our current practice is based on old research and opinions. However, a review of current practice clearly shows that existing research is not being put into practice. The controversies surrounding the relevance of impaired glucose tolerance are discussed, and the results of existing clinical trials are eagerly awaited.

Delivery, Obstetric↗
PubMed1999

Indicators of quality of antenatal care: a pilot study.

OBJECTIVE: To pilot a list of indicators of quality of antenatal care across a range of maternity care settings. For each indicator to determine what is achieved in current clinical practice, to facilitate the setting of audit standards and calculation of appropriate sample sizes for audit. DESIGN: A multicentre retrospective observational study. SETTING: Nine maternity units in the United Kingdom. POPULATION: 20,771 women with a singleton pregnancy, who were delivered between 1 August 1994 and 31 July 1995. RESULTS: Nine of the eleven suggested indicators were successfully piloted. Two indicators require further development. In seven of the nine hospitals external cephalic version was not commonly performed. There were wide variations in the proportions of women screened for asymptomatic bacteriuria. Screening of women from ethnic minorities for haemoglobinopathy was more likely in hospitals with a large proportion of non-caucasian women. A large number of Rhesus negative women did not have a Rhesus antibody check performed after 28 weeks of gestation and did not receive anti-D immunoglobulin after a potentially sensitising event during pregnancy. As a result of the study appropriate sample sizes for future audit could be calculated. CONCLUSIONS: Measuring the extent to which evidence-based interventions are used in routine clinical practice provides a more detailed picture of the strengths and weaknesses in an antenatal service than traditional outcomes such as perinatal mortality rates. Awareness of an appropriate sample size should prevent waste of time and resources on inconclusive audits.

Delivery, Obstetric↗
PubMed1999

Colposcopy and treatment of cervical intra-epithelial neoplasia: are national standards achievable?

OBJECTIVE: To assess whether consensus based national standards for colposcopy and treatment of cervical intra-epithelial neoplasia are achievable in practice. DESIGN: Identification of 100 consecutive cases of first assessment colposcopy from each gynaecological unit in the former North West region from 1 January 1994 and follow up of their outcome after one year. SETTING: All 19 gynaecological colposcopy clinics in the former North West region. SAMPLE: In one hospital data were available on only 39 women and therefore information was analysed on 1839 women. MAIN OUTCOME MEASURES: Waiting times for colposcopy, different modalities of treatment used for premalignant conditions of the cervix and type of anaesthesia used for treatments. With regard to follow up, time of occurrence, whether or not colposcopy was performed and efficacy of treatment as judged by cervical cytology. RESULTS: Waiting times for colposcopy varied in the individual hospitals studied, but overall 56% of patients were seen within eight weeks. Diathermy loop excision was the most popular treatment modality accounting for 44% of cases. At six months after treatment, 9.98% of patients had a smear of mild dyskaryosis or worse. Colposcopy, as well as cytology, was used at the first follow up visit in 43% of cases. CONCLUSION: At a local level individual hospitals can identify areas where improvements in the service they provide need to be made. The practicality of the current guidelines in today's health service needs questioning.

Anesthesia↗
PubMed1998

Quality in obstetrics and gynaecology: the example of the enquiries into maternal mortality.

For nearly 50 years there has been an independent system for monitoring all maternal deaths in the United Kingdom. Validation exercises suggest that about 99% of cases are successfully identified and reviewed. The analysis is published every 3 years and includes independent assessment as to whether substandard care was present. As the proportion of cases where substandard care is present remains constant at about 40-50%, it is claimed that these reports do little to improve the quality of care. Review of particular causes of deaths suggests that the regular stating of the problem areas, developing management guidelines relating to these, and re-auditing practice, almost certainly has improved standards. However, more remains to be done.

Anesthesia, Obstetrical↗
PubMed1997

A national survey of the complications of endometrial destruction for menstrual disorders: the MISTLETOE study. Minimally Invasive Surgical Techniques--Laser, EndoThermal or Endorescetion.

OBJECTIVES: To study the frequency of complications of endometrial resection and ablation for menstrual disturbances and the influence of the experience of the operators. DESIGN: Prospective survey with additional retrospective reporting by theatre staff. SETTING: 300 National Health Service and independent hospitals in the United Kingdom (excluding Scotland). POPULATION: 10,686 women registered by 690 doctors (1-222 cases/doctor) from April 1993 to October 1994. METHODS: Mailings were sent to relevant medical and non medical staff at every hospital to ascertain who performed the operations. These doctors were asked to complete a questionnaire detailing their previous experience. Completed patient registration forms were returned each month. Theatre contacts returned lists of cases reported in theatre registers. MAIN OUTCOME MEASURES: Perioperative, post-operative and delayed complications by method of surgery and experience of operator. RESULTS: Two directly related deaths were reported. Laser and rollerball ablations were associated with least operative and post-operative complications. Combined loop and rollerball diathermy was associated with a higher rate, but with fewer immediate operative complications than loop resection alone. Endometrial thinning agents were not associated with decreased complications. Fibroids were associated with increased operative haemorrhage. Early post-operative complication rates ranged from 0.77% to 1.51%. Six-week follow up in 82.5% of the women revealed few complications (1.25% to 4.58%). Increasing operative experience was associated with fewer uterine perforations in the loop resection alone group (chi 2 for trend, P < 0.001), but had no effect on operative haemorrhage in any group. CONCLUSIONS: These procedures were used widely in 1993 to 1994 with low morbidity and mortality. The techniques may be relatively easily learned in the apprenticeship system without compromising safety. Combined diathermy resection appears safer than loop resection alone, but laser and rollerball ablation were safest.

Adult↗