ObjectiveTo estimate the incidence of severe maternal sepsis due to group B Streptococcus (GBS) in the UK, and to investigate the associated outcomes for mother and infant.DesignNational case–control study.SettingAll UK consultant-led maternity units.Participants30 women with confirmed or suspected severe GBS sepsis, and 757 control women.Main outcome measuresDisease incidence, additional maternal morbidity, critical care admission, length of stay, infant infection, mortality.ResultsThe incidences of confirmed and presumed severe maternal GBS sepsis were 1.00 and 2.75 per 100 000 maternities, respectively, giving an overall incidence of 3.75 per 100 000. Compared with controls, severe GBS sepsis was associated with higher odds of additional maternal morbidity (OR 12.35, 95% CI 3.96 to 35.0), requiring level 2 (OR 39.3, 95% CI 16.0 to 99.3) or level 3 (OR 182, 95% CI 21.0 to 8701) care and longer hospital stay (median stay in cases and controls was 7 days (range 3–29 days) and 2 days (range 0–16 days), respectively, p<0.001). None of the women died. Severe maternal GBS sepsis was associated with higher odds of infant sepsis (OR 32.7, 95% CI 8.99 to 119.0); 79% of infants, however, did not develop sepsis. There were no associated stillbirths or neonatal deaths.ConclusionsSevere maternal GBS sepsis is a rare occurrence in the UK. It is associated with adverse maternal and neonatal outcomes.

Background Even when resting pulse oximetry is normal in the patient with acute Covid-19, hypoxia can manifest on exertion. We summarise the literature on the performance of different rapid tests for exertional desaturation and draw on this evidence base to provide guidance in the context of acute Covid-19. Main research questions What exercise tests have been used to assess exertional hypoxia at home or in an ambulatory setting in the context of Covid-19 and to what extent have they been validated? What exercise tests have been used to assess exertional hypoxia in other lung conditions, to what extent have they been validated and what is the applicability of these studies to acute Covid-19? Method AMED, CINAHL, EMBASE MEDLINE, Cochrane and PubMed using LitCovid, Scholar and Google databases were searched to September 2020. Studies where participants had Covid-19 or another lung disease and underwent any form of exercise test which was compared to a reference standard were eligible. Risk of bias was assessed using QUADAS 2. A protocol for the review was published on the Medrxiv database. Results Of 47 relevant papers, 15 were empirical studies, of which 11 described an attempt to validate one or more exercise desaturation tests in lung diseases other than Covid-19. In all but one of these, methodological quality was poor or impossible to fully assess. None had been designed as a formal validation study (most used simple tests of correlation). Only one validation study (comparing a 1-min sit-to-stand test [1MSTST] with reference to the 6-min walk test [6MWT] in 107 patients with interstitial lung disease) contained sufficient raw data for us to calculate the sensitivity (88%), specificity (81%) and positive and negative predictive value (79% and 89% respectively) of the 1MSTST. The other 4 empirical studies included two predictive studies on patients with Covid-19, and two on HIV-positive patients with suspected pneumocystis pneumonia. We found no studies on the 40-step walk test (a less demanding test that is widely used in clinical practice to assess Covid-19 patients). Heterogeneity of study design precluded meta-analysis. Discussion Exertional desaturation tests have not yet been validated in patients with (or suspected of having) Covid-19. A stronger evidence base exists for the diagnostic accuracy of the 1MSTST in chronic long-term pulmonary disease; the relative intensity of this test may raise safety concerns in remote consultations or unstable patients. The less strenuous 40-step walk test should be urgently evaluated.

Background: Following a pandemic-driven shift to remote service provision, UK general practices offer telephone, video or online consultation options alongside face-to-face. This study explores practices’ varied experiences over time as they seek to establish remote forms of accessing and delivering care. Methods: This protocol is for a mixed-methods multi-site case study with co-design and national stakeholder engagement. 11 general practices were selected for diversity in geographical location, size, demographics, ethos, and digital maturity. Each practice has a researcher-in-residence whose role is to become familiar with its context and activity, follow it longitudinally for two years using interviews, public-domain documents and ethnography, and support improvement efforts. Research team members meet regularly to compare and contrast across cases. Practice staff are invited to join online learning events. Patient representatives work locally within their practice patient involvement groups as well as joining an online patient learning set or linking via a non-digital buddy system. NHS Research Ethics Approval has been granted. Governance includes a diverse independent advisory group with lay chair. We also have policy in-reach (national stakeholders sit on our advisory group) and outreach (research team members sit on national policy working groups). Results (anticipated): We expect to produce rich narratives of contingent change over time, addressing cross-cutting themes including access, triage and capacity; digital and wider inequities; quality and safety of care (e.g. continuity, long-term condition management, timely diagnosis, complex needs); workforce and staff wellbeing (including non-clinical staff, students and trainees); technologies and digital infrastructure; patient perspectives; and sustainability (e.g. carbon footprint). Conclusion: By using case study methods focusing on depth and detail, we hope to explain why digital solutions that work well in one practice do not work at all in another. We plan to inform policy and service development through inter-sectoral network-building, stakeholder workshops and topic-focused policy briefings.

Background: The value of continuity in primary care has been demonstrated for multiple outcomes. However, little is known about how the expansion of remote and digital care models have impacted continuity. Aim: To conduct a mixed-methods systematic review to explore how expansion of remote and digital care models have impacted continuity. Design and Setting: A systematic search of electronic databases with snowball sampling to identify relevant qualitative and quantitative studies. Methods: 17 English-language studies (any country, 2000-2022) exploring remote or digital approaches in primary care and continuity were identified. Relevant data were extracted, analysed using GRADE-CERQual, and narratively synthesised. Results: The specific impact of remote approaches on continuity was rarely overtly addressed. Some patients expressed a preference for relational continuity depending on circumstance, problem, and context, whilst others prioritised access. Clinicians valued continuity with some viewing remote consultations more suitable for patients where there was high episodic or relational continuity. With lower continuity, patients and clinicians considered remote consultations harder, higher risk, and poorer quality. Some evidence suggested remote approaches, and/or their implementation risked worsening inequalities and causing harm by reducing continuity where it was valuable. However, if deployed strategically and flexibly, remote approaches could improve continuity. Conclusion: The dearth of evidence around continuity in a remote and digital context is troubling. Further research should explore the links between the shift to remote care, continuity and equity, using real-world evaluation frameworks to ascertain when and for whom continuity adds most value and how this can be enabled or maintained.