Objective To ascertain whether a clinically important difference exists in the incidence of gynaecological infection between surgical management and expectant or medical management of miscarriage. Design Randomised controlled trial comparing medical and expectant management with surgical management of first trimester miscarriage. Setting Early pregnancy assessment units of seven hospitals in the United Kingdom. Participants Women of less than 13 weeks' gestation, with a diagnosis of early fetal demise or incomplete miscarriage. Interventions Expectant management (no specific intervention); medical management (vaginal dose of misoprostol preceded, for women with early fetal demise, by oral mifepristone 24-48 hours earlier); surgical management (surgical evacuation). Main outcome measures Confirmed gynaecological infection at 14 days and eight weeks; need for unplanned admission or surgical intervention. Results 1200 women were recruited: 399 to expectant management, 398 to medical management, and 403 to surgical management. No differences were found in the incidence of confirmed infection within 14 days between the expectant group (3%) and the surgical group (3%) (risk difference 0.2%, 95% confidence interval − 2.2% to 2.7%) or between the medical group (2%) and the surgical group (0.7%, − 1.6% to 3.1%). Compared with the surgical group, the number of unplanned hospital admissions was significantly higher in both the expectant group (risk difference − 41%, − 47% to − 36%) and the medical group ( − 10%, − 15% to − 6%). Similarly, when compared with the surgical group, the number of women who had an unplanned surgical curettage was significantly higher in the expectant group (risk difference − 39%, − 44% to − 34%) and the medical group ( − 30%, − 35% to − 25%). Conclusions The incidence of gynaecological infection after surgical, expectant, and medical management of first trimester miscarriage is low (2-3%), and no evidence exists of a difference by the method of management. However, significantly more unplanned admissions and unplanned surgical curettage occurred after expectant management and medical management than after surgical management. Trial registration National Research Register: N0467011677/N0467073587.

Objective To review trials of nurse led interventions for hypertension in primary care to clarify the evidence base, establish whether nurse prescribing is an important intervention, and identify areas requiring further study. Design Systematic review and meta-analysis. Data sources Ovid Medline, Cochrane Central Register of Controlled Trials, British Nursing Index, Cinahl, Embase, Database of Abstracts of Reviews of Effects, and the NHS Economic Evaluation Database. Study selection Randomised controlled trials of nursing interventions for hypertension compared with usual care in adults. Data extraction Systolic and diastolic blood pressure, percentages reaching target blood pressure, and percentages taking antihypertensive drugs. Intervention effects were calculated as relative risks or weighted mean differences, as appropriate, and sensitivity analysis by study quality was undertaken. Data synthesis Compared with usual care, interventions that included a stepped treatment algorithm showed greater reductions in systolic blood pressure (weighted mean difference −8.2 mm Hg, 95% confidence interval −11.5 to −4.9), nurse prescribing showed greater reductions in blood pressure (systolic −8.9 mm Hg, −12.5 to −5.3 and diastolic −4.0 mm Hg, −5.3 to −2.7), telephone monitoring showed higher achievement of blood pressure targets (relative risk 1.24, 95% confidence interval 1.08 to 1.43), and community monitoring showed greater reductions in blood pressure (weighted mean difference, systolic −4.8 mm Hg, 95% confidence interval −7.0 to −2.7 and diastolic −3.5 mm Hg, −4.5 to −2.5). Conclusions Nurse led interventions for hypertension require an algorithm to structure care. Evidence was found of improved outcomes with nurse prescribers from non-UK healthcare settings. Good quality evidence from UK primary health care is insufficient to support widespread employment of nurses in the management of hypertension within such healthcare systems.

Conclusion-This multidimensional labour satisfaction instrument has good validity and internal reliability. It could be used to assess care in labour across diVerent models of maternity care, or as a prelude to in depth exploration of specific areas of concern. Its external reliability and transferability to care outside the South West region needs further evaluation, particularly in terms of ethnicity and social class.

This paper explores the special nature of bereavement in the case of first trimester miscarriage. It is theoretically informed by the sociological literature concerning death and bereavement and is empirically grounded in interviews with 79 women. We argue that the 'scientisation of death' in modern societies contributes to the uncertainty and isolation which distinguish early miscarriage as a unique form of loss. In the absence of clear cultural scripts to draw upon, many women interviewed gave meaning to their loss as 'what might have been' or what we call 'the loss of possibility'. Some women juxtaposed the failure of their pregnancy with that of modern medicine either to prevent the loss or provide a credible explanation for their miscarriage. Little research has been conducted in this area, since the pioneering work of Lovell (1983) andCecil (1984). Our research draws on one of the largest and most systematic bodies of data ever collected on early miscarriage, and provides continued evidence of the traumas of miscarriage. The strategies employed by women to make sense of, and come to terms with, their experience of miscarriage are explored, employing a typology of pre-modern, modern and postmodern responses.

In an internal combustion engine, twin entry turbine operates under different unequal admission conditions by feeding the turbine with a dissimilar amount of flow in each entry for a majority of the time. Despite of the impact on turbine performance, normal characteristic maps of these turbines are usually available only for full admission conditions. The current study

Age-specific centile charts of heart rates expected at different temperatures should be used by clinicians in the initial assessment of children with acute infections. The charts will identify children who have a heart rate higher than expected for a given temperature and facilitate the interpretation of changes in heart rate on reassessment. Further research on the predictive value of the centile charts is needed to optimise their diagnostic utility.

There is some evidence for improved blood pressure outcomes with nurse-led interventions for hypertension in people with diabetes compared with doctor-led care. Nurse-based interventions require an algorithm to structure care and there is some preliminary evidence for better outcomes with nurse prescribing. Further work is needed to elucidate which nurse-led interventions are most effective.

Objectives  To compare the cost‐effectiveness of alternative management methods of first‐trimester miscarriage. Design  Economic evaluation conducted alongside a large randomised controlled trial (the MIST trial). Setting  Early pregnancy assessment units of seven participating hospitals in southern England. Sample  A total of 1200 women with a confirmed pregnancy of less than 13 weeks of gestation with a diagnosis of incomplete miscarriage or missed miscarriage. Methods  Random allocation to expectant management, medical management or surgical management. Collection of health service and broader resource use data, unit costs for each resource item and clinical outcomes. Main outcome measures  Costs (£, 2001–02 prices) to the health service, social services, women, carers and wider society during the first 8 weeks postrandomisation. Cost‐effectiveness estimates, expressed in terms of incremental cost per gynaecological infection prevented; cost‐effectiveness acceptability curves presented at alternative willingness‐to‐pay thresholds for preventing gynaecological infection. Results  There was no significant difference in the incidence of gynaecological infection between groups. The net societal cost per woman was estimated at £1086.20 in the expectant group, £1410.40 in the medical group and £1585.30 in the surgical group. Expectant management had a 97.8% probability of being the most cost‐effective management method at a willingness‐to‐pay threshold of £10,000 for preventing one gynaecological infection, while medical management had a 2.2% probability of being the most cost‐effective management method. Expectant management retained the highest probability of being the most cost‐effective management method at all willingness‐to‐pay thresholds of less than £70,000 for preventing one gynaecological infection. Conclusions  Expectant and medical management of first‐trimester miscarriage possess significant economic advantages over traditional surgical management.