WeeksCesarean deliveryPregnanciesPrematurityFetalObstetricPregnancyInfantsVaginal deliverySingleton1000 liveInfectionPlacentaGestational agePerinatalPreterm laborHigh maternal ageTwinsMultipleTripletsOutcomesSpontaneousNeonatal mortalityPostpartumMothersLastsRiskAntepartumBabiesDependsPeriodBirthLaborPremature deliveryDeathsFindingsCaesarean section
Weeks49
- Analysis of preterm deliveries below 35 weeks' gestation in a tertiary referral hospital in the UK. (biomedcentral.com)
- 274 deliveries between 23-35 weeks' gestation (preterm group), were compared to 559 randomly selected control deliveries at term (37-42 weeks) using standard statistical procedures. (biomedcentral.com)
- my baby average gestation at 15 weeks. (medhelp.org)
- This study shows outcomes including mode of delivery were not significantly different in those labouring spontaneously following PROM over 36 weeks gestation, and those who required induction. (bmj.com)
- The cat gestation period lasts 9 weeks on average, or about 63 days. (vetinfo.com)
- After the delivery, the cat will start lactating and there will be a vaginal discharge for up to 3 weeks after delivery. (vetinfo.com)
- If the cat has vaginal bleeding in the weeks prior to the delivery date, you need to visit the vet and find the cause of bleeding and if a cesarean section is recommended. (vetinfo.com)
- Preterm birth (delivery before 37 weeks and 0/7 days of gestation) is a leading cause of infant morbidity and mortality in the United States. (cdc.gov)
- Rare cases have been reported before 20 weeks' gestation or as late as 23 days' postpartum. (medscape.com)
- Preterm birth is childbirth occurring at less than 37 completed weeks or 259 days of gestation, is a major determinant of neonatal mortality and morbidity and has long-term adverse consequences for health. (sciencerepository.org)
- the present study was planned to find the association between cervical length at 18 to 23 weeks of gestation done as a routine during all second level scans and spontaneous preterm delivery. (sciencerepository.org)
- A total of 205 women presenting with singleton pregnancies between 18-23 weeks of gestations were assessed by transvaginal ultrasound for the measurement of cervical length. (sciencerepository.org)
- The mean gestation age at the time of enrollment was 20.72 ± 1.00 weeks with 33% of women showing a cervical length of 26-30 mm. (sciencerepository.org)
- Spontaneous preterm birth occurs before 37 weeks' gestation in 7-11% of pregnancies, and before 34 weeks' gestation in 3-7% of pregnancies [6, 7]. (sciencerepository.org)
- Delivery before 34 weeks' gestation, however, accounts for three-quarters of neonatal mortality and one half of long-term neurological impairment in children. (sciencerepository.org)
- Considering the high rate of preterm delivery and its adverse consequences and with hypothesis that short cervical length may predict the preterm delivery, the present study was planned to find the association between cervical length at 18 to 23 weeks of gestation done as a routine during all second level scans and spontaneous preterm delivery. (sciencerepository.org)
- Planned Delivery for Pre-eclampsia between 34 and 37 weeks of gestation: the PHOENIX randomised controlled trial. (ox.ac.uk)
- Women with non-severe hypertensive disorders of pregnancy between 34 and 37 weeks of gestation were randomly allocated to either induction of labour or caesarean section within 24 h (immediate delivery) or a strategy aimed at prolonging pregnancy until 37 weeks of gestation (expectant monitoring). (elsevierpure.com)
- Interpretation For women with non-severe hypertensive disorders at 34-37 weeks of gestation, immediate delivery might reduce the already small risk of adverse maternal outcomes. (elsevierpure.com)
- 37 weeks gestation). (cdc.gov)
- Lactating mothers and their VPI (delivery at or before 32 0 weeks of gestation) admitted to the Neonatal Unit between January 2018 and January 2020 were consecutively approached for inclusion in the study when milk production exceeded enteral feeding requirements. (nature.com)
- To examine the clinical significance of the relationship between ritodrine hydrochloride and escape enzymes in the preterm infants, we reviewed all patients who were delivered at less than 36 weeks of gestation with preterm birth in the Perinatal Center of Social Insurance Funabashi Central Hospital between July 1, 2005, and June 30, 2008. (hindawi.com)
- Preterm labor was defined as demonstrated progressive dilation of the cervix with uterine contractions before 36 weeks of gestation. (hindawi.com)
- Gestational age was estimated based on menstrual dates and an ultrasound examination performed before 20 weeks of gestation. (hindawi.com)
- Although not all studies agree on the exact range, experts believe the fetus is particularly vulnerable to periventricular leukomalacia somewhere between 26 weeks and 34 weeks of gestation. (cerebralpalsy.org)
- Infants who are born before 32 weeks of gestation and are mechanically ventilated are at greatest risk for periventricular leukomalacia. (cerebralpalsy.org)
- Aplastic anaemia may develop during was of general weakness, loss of appetite pregnancy and sometimes improve sponta- and easy bruising at 16 weeks gestation. (who.int)
- This area is fragile and prone to injury, especially before 32 weeks of gestation. (medlineplus.gov)
- Between-hospital variations in active treatment explain much of the difference seen in infants born at 22 to 24 weeks of gestation. (uab.edu)
- Maternal mood symptoms were documented at 36 weeks gestation. (unboundmedicine.com)
- Preterm birth is defined as delivery before completion of 37 weeks gestation. (scienceblog.com)
- It was time for delivery … at 28 weeks and three days. (kevinmd.com)
- Median duration of gestation was 39 (38.6-40) weeks. (bmj.com)
- Doctors ordered an emergency delivery at 34 weeks of gestation. (ksfr.org)
- In uncomplicated dichorionic twin pregnancies, delivery should be considered at 37 weeks' gestation to minimize perinatal death, and no clear evidence supports delivery of monochorionic twins before 36 weeks, according to a meta-analysis published online September 6 in the BMJ . (medscape.com)
- Current recommendations vary from 34 to 37 weeks' gestation in monochorionic pregnancies that share a placenta, and 37 to 39 weeks in dichorionic pregnancies that have two placentas, according to background information in the article. (medscape.com)
- Then they performed a meta-analysis to evaluate the risk for stillbirth and neonatal complications in weekly intervals for monochorionic and dichorionic twin pregnancies, starting from 34 weeks' gestation. (medscape.com)
- After 37 weeks' gestation, the risk for still birth significantly outweighed the risk for neonatal death from delivery. (medscape.com)
- Timing of delivery for multiple pregnancies should be always be individualised, however, the current evidence-base suggests that in uncomplicated dichorionic twin pregnancies delivery should be considered at 37 weeks' gestation and in monochorionic pregnancies delivery should be considered from 36 weeks," he continued. (medscape.com)
- Most stillbirths were 31 weeks gestation or less and almost all occurred at home. (confex.com)
- METHODS: This retrospective cohort study included 339,123 deliveries at 35 weeks' gestation or greater. (healthpartners.com)
- Main outcome measures Proportion of babies born at less than 37 weeks' completed gestation for each year in the overall population and in a standard population at low risk. (bmj.com)
- Recent data show an increase in the proportion of pre-term births (live infants born before 37 weeks' completed gestation out of all live born infants) in the United States (11.0% in 1995 v 12.1% in 2002) and Norway (7.5% in 1995 v 8.5% in 2002). (bmj.com)
- When we stratified preterm deliveries in the total population into extremely preterm (22-28 completed weeks of gestation), very preterm (28-32), and moderately preterm (32-36), we found increases of 41%, 22%, and 22% between 1995 and 2005 ( table 1 ). (bmj.com)
- Preterm Infants An infant born before 37 weeks gestation is considered preterm. (msdmanuals.com)
- Preterm Labor Labor (contractions resulting in cervical change) that begins before 37 weeks gestation is considered preterm. (msdmanuals.com)
- Cesarean delivery rates decreased more than 5% among births at 38 weeks of gestation, but increased 4% among births at 39 weeks. (cdc.gov)
- Decreases in cesarean delivery rates for births at 38 weeks occurred for non-Hispanic white, non-Hispanic black, and Hispanic women, as well as for all maternal age groups. (cdc.gov)
- the cesarean delivery rate at 39 weeks increased in 23 states. (cdc.gov)
Cesarean delivery9
- Cesarean delivery 5. (wikipedia.org)
- Maternal or fetal complications can often result in preterm birth because of medically indicated induction of labor or cesarean delivery (30%-35% of preterm births) ( 3 ). (cdc.gov)
- Most cases of endometritis, including those following cesarean delivery, should be treated in an inpatient setting. (medscape.com)
- Following cesarean delivery, the incidence ranges from 13-90%, depending on the risk factors present and whether perioperative antibiotic prophylaxis had been given. (medscape.com)
- Cesarean delivery is recommended for twins unless the presenting twin is in vertex presentation. (msdmanuals.com)
- Check for other possible complications, such as preeclampsia and gestational diabetes, and prepare for preterm delivery, cesarean delivery, and postpartum hemorrhage. (msdmanuals.com)
- The total U.S. cesarean delivery rate reached a high of 32.9% of all births in 2009, rising 60% from the most recent low of 20.7 in 1996. (cdc.gov)
- Since 2009, the U.S. cesarean delivery rate has not increased. (cdc.gov)
- NCHS's report explores cesarean delivery rates by gestational age for 1996-2011, focusing on 2009-2011. (cdc.gov)
Pregnancies7
- Our study provides comprehensive estimates comparing risks of stillbirth and neonatal mortality at various gestational ages, which is required for the planning of delivery in uncomplicated twin pregnancies," write Fiona Cheong-See, MBBS, from Queen Mary University of London, United Kingdom, and colleagues with the Global Obstetrics Network Collaboration. (medscape.com)
- Although uncomplicated twin pregnancies are often scheduled for early delivery to prevent stillbirth, preterm birth can increase neonatal complications. (medscape.com)
- Yet, the optimal age for delivery of twin pregnancies has not been established. (medscape.com)
- Our estimates of fetal and neonatal outcomes at various gestational ages in twin pregnancies should be taken into account when decisions are made on timing of delivery," the authors conclude. (medscape.com)
- During the same period, known risk factors for preterm delivery such as in vitro fertilisation, multiple pregnancies, and elective deliveries also increased, and logistic regression analyses showed that these factors were associated with an increased risk of preterm delivery. (bmj.com)
- We used data from the Danish national registers to calculate the proportion of preterm deliveries in low risk pregnancies from 1995 to 2004. (bmj.com)
- In multifetal pregnancies, the overdistended uterus tends to stimulate preterm labor, resulting in preterm delivery. (msdmanuals.com)
Prematurity3
- Growing awareness of the complications of prematurity has prompted careful evaluation of the indications for and timing of delivery ( 5 ). (cdc.gov)
- IFA supplements have also been found to reduce the preterm delivery rate and neonatal mortality attributable to prematurity and birth asphyxia. (biomedcentral.com)
- Maternal age below 25 years, prematurity, and multiple gestation all significantly increased the odds of perinatal death. (confex.com)
Fetal2
- Medically indicated preterm deliveries were associated with hypertension and fetal growth restriction. (biomedcentral.com)
- The most common reasons for C-sections are labor dystocia, fetal heart rate abnormalities, fetal malpresentation, and multiple gestations. (kevinmd.com)
Obstetric7
- In this study we have carried out a detailed comparison of preterm and term deliveries in a relatively homogeneous obstetric population attending a tertiary referral maternity hospital, to highlight areas where further research or intervention is needed in order to prevent preterm birth and improve perinatal outcome. (biomedcentral.com)
- For more accurate estimates of the preterm birth rate, CDC's National Center for Health Statistics transitioned from using the date of last normal menstrual period to the obstetric estimate of gestation at delivery, starting with 2014 births and revising data back to 2007 ( 6 ). (cdc.gov)
- Since 2007, the first year that data using the obstetric estimate of gestation at delivery were available, the overall rate declined, from 10.4% in 2007 to 9.6% in 2014. (cdc.gov)
- During March 1-May 30, 2020, as part of Vaccine Safety Datalink (VSD) † surveillance of COVID-19 hospitalizations, 105 hospitalized pregnant women with SARS-CoV-2 infection were identified, including 62 (59%) hospitalized for obstetric reasons (i.e., labor and delivery or another pregnancy-related indication) and 43 (41%) hospitalized for COVID-19 illness without an obstetric reason. (cdc.gov)
- Patients were interviewed and their demographic data such as age, obstetric index(GPALD), obstetric history such last menstrual period (LMP), estimated delivery date (EDD) and current pregnancy details such as BP, pulse rate, pallor, period of gestation, were recorded in a predesigned pro forma. (sciencerepository.org)
- Chronic endometritis in the obstetric population is usually associated with retained products of conception after delivery or elective abortion. (medscape.com)
- I was having an obstetric emergency, and I needed a C-section to get my baby and myself through delivery in the safest way possible. (kevinmd.com)
Pregnancy11
- Dates fruit consumption during late pregnancy has been shown to positively affect the outcome of labour and delivery. (nih.gov)
- 39 years), socioeconomic problems, smoking during pregnancy, hypertension, psychiatric disorders and uterine abnormalities were significantly associated with preterm deliveries. (biomedcentral.com)
- Pregnancy related protection against breast cancer depends on length of gestation. (abortionbreastcancer.com)
- Most cases of eclampsia present in the third trimester of pregnancy, with about 80% of eclamptic seizures occurring intrapartum or within the first 48 hours following delivery. (medscape.com)
- Prevalences of prepregnancy obesity and gestational diabetes were higher among pregnant women hospitalized for COVID-19-related illness (e.g., worsening respiratory status) than among those admitted for pregnancy-related treatment or procedures (e.g., delivery) and found to have COVID-19. (cdc.gov)
- Pregnancy and delivery are not benign processes. (kevinmd.com)
- Purpose To provide an update on the delivery outcomes achieved in congenital heart disease (CHD) patients by the Cuban National Programme for Pregnancy and Heart Disease. (bmj.com)
- The LVEF did not change throughout pregnancy or after the delivery in either group. (nih.gov)
- Although the Tei index of the controls did not change throughout the pregnancy, in the ToF group it was significantly increased in the 2nd and 3rd trimester and then decreased after delivery. (nih.gov)
- We also studied the proportion of spontaneous preterm deliveries in multiparous women at low risk (20-40 year old white European multiparous women with a singleton spontaneous pregnancy) using the same methods as for primiparous women. (bmj.com)
- Multifetal (multiple) pregnancy occurs in up to 1 of 30 deliveries. (msdmanuals.com)
Infants1
- Data comprised case based information from four national registries on 99.8% of live births in Denmark from 1995 to 2004 (646 144 deliveries and 659 154 infants). (bmj.com)
Vaginal delivery4
- For mild cases following vaginal delivery, oral antibiotics in an outpatient setting may be adequate (see Treatment and Management, as well as Medication). (medscape.com)
- Prenatal SSRI exposure significantly increased serum CBG levels in neonates after vaginal delivery (p ≤ 0.038), even when controlling for maternal depression. (unboundmedicine.com)
- Neonatal serum cortisol levels did not vary with SSRI exposure or antenatal maternal mood, but were significantly higher following vaginal delivery (p ≤ 0.003). (unboundmedicine.com)
- Besides providing analgesia in labor, regional analgesia may facilitate atraumatic vaginal delivery of twins, preterm neonates, and neonates with breech presentation. (medscape.com)
Singleton1
- We studied women with singleton deliveries at St Michael's Hospital, Bristol during 2002 and 2003. (biomedcentral.com)
1000 live1
- The perinatal mortality rate was 39 deaths/1000 deliveries, stillbirth rate 23/1000 deliveries, and END rates 16/1000 live births. (confex.com)
Infection2
- infection around the time of delivery also increases likelihood. (cerebralpalsy.org)
- Infection around the time of delivery may also play a role in causing PVL. (medlineplus.gov)
Placenta1
- The uterus may contract after delivery of the first child, shearing away the placenta and increasing risk for the remaining fetuses. (msdmanuals.com)
Gestational age1
- Rates of neonatal morbidity, including assisted ventilation, respiratory distress syndrome, admission to the neonatal intensive care unit, and septicemia, consistently decreased as gestational age increased in both monochorionic and dichorionic gestations. (medscape.com)
Perinatal2
- Preterm birth remains a major cause of perinatal mortality and morbidity and efforts to predict and prevent its occurrence are difficult because of our lack of understanding of the biochemical mechanism of labour and the multiplicity of medical and socioeconomic factors associated with preterm delivery [ 1 ]. (biomedcentral.com)
- Preterm delivery is the main cause of perinatal mortality and morbidity [6]. (sciencerepository.org)
Preterm labor1
- If preterm labor leads to an early delivery, the premature newborn is at risk for problems related to incomplete development of its organ systems. (sciencerepository.org)
High maternal age1
- 1 2 The prevalence of several risk factors for preterm delivery, such as in vitro fertilisation (IVF) high maternal age, primiparity, and elective delivery before term, have changed in recent years and this may explain the increase in the proportion of preterm deliveries. (bmj.com)
Twins1
- The authors point out that current policies for planned elective delivery of twins before term could have decreased the number of twins born at term, which may have underestimated the risk for stillbirth near term. (medscape.com)
Multiple3
- Multiple gestation 4. (wikipedia.org)
- Conclusions The overall proportion of preterm deliveries increased significantly from 1995 to 2004 and primiparity and multiple birth were the most important contributing factors. (bmj.com)
- Most of the and ratio of live births in triplet and other higher order increase was among births to white mothers, particularly multiple deliveries from 1971 to 1994 by maternal race, age, among married and more educated mothers. (cdc.gov)
Triplets1
- The report also examines the one-third of the increase in triplet birthing among white birth outcomes of triplets compared with singletons, including mothers between 1989 and 1994 could be attributed to changes overall gestation specific, and birthweight specific infant mor- in the maternal age distribution. (cdc.gov)
Outcomes3
- Further, adverse birth outcomes, such as preterm delivery and stillbirth, might be more common among pregnant women infected with SARS-CoV-2, the virus that causes COVID-19 ( 2 , 3 ). (cdc.gov)
- We investigated the effect of immediate delivery versus expectant monitoring on maternal and neonatal outcomes in such women. (elsevierpure.com)
- Midwives may employ sophisticated delivery room management technologies to improve birth outcomes and reduce maternal anxiety and depression, and it is something that should be extensively promoted in clinic. (hindawi.com)
Spontaneous5
- 53% of preterm deliveries were spontaneous, and were strongly associated with episodes of threatened preterm labour. (biomedcentral.com)
- Preterm premature rupture of the membranes, vaginal bleeding, anaemia and oligohydramnios were significantly increased in both spontaneous and indicated preterm deliveries compared to term controls. (biomedcentral.com)
- Spontaneous preterm deliveries in primiparous women at low risk rose 51% (from 3.8% to 5.7%) during this time compared with 20% (2.7% to 3.2%) in multiparous women at low risk. (bmj.com)
- The rise in spontaneous preterm deliveries in the standard population of primiparous women at low risk was greater than in the total population. (bmj.com)
- We calculated the proportion of spontaneous preterm deliveries by dividing the number of spontaneous preterm deliveries (excluding elective caesarean section and induction of labour) by the total number of deliveries in this population. (bmj.com)
Neonatal mortality1
- They also analyzed studies for risk for bias and representativeness and defined neonatal mortality as death up to 28 days after delivery. (medscape.com)
Postpartum3
- [ 4 , 5 ] It typically occurs during or after the 20th week of gestation or in the postpartum period. (medscape.com)
- The incidence of postpartum endometritis in the United States varies depending on the route of delivery and the patient population. (medscape.com)
- Antepartum, delivery, and postpartum hospitalizations were evaluated separately and reported in 4-year increments. (cdc.gov)
Mothers1
- Serum cortisol and CBG levels were assayed from SSRI-exposed and non-exposed mothers and their neonates at delivery. (unboundmedicine.com)
Lasts1
- In many species of deer , the period of gestation (the time during which a doe is pregnant) lasts between approximately 200 and 205 days. (worlddeer.org)
Risk8
- The aim of this study was to identify current risk factors associated with preterm delivery and highlight areas for further research. (biomedcentral.com)
- Preterm delivery and risk of breast cancer. (abortionbreastcancer.com)
- 9. Hsieh C-c, Wuu J, Lambe M, Trichopoulos D, et al Delivery of premature newborns and maternal breast-cancer risk. (abortionbreastcancer.com)
- Risk factors for preterm delivery include social, behavioral, clinical, and biologic characteristics ( Box ). (cdc.gov)
- 2) the absence of reliable criteria for the selection of a high-risk population for preterm delivery [10]. (sciencerepository.org)
- However, it significantly increases the risk of neonatal respiratory distress syndrome, therefore, routine immediate delivery does not seem justified and a strategy of expectant monitoring until the clinical situation deteriorates can be considered. (elsevierpure.com)
- Midwives use an intelligent delivery room management system to optimise medical staff work efficiency, improve childbirth quality, control childbirth risk, and collect delivery room data management information [ 4 , 6 ]. (hindawi.com)
- There are many risk factors that parents need to be aware of that can be a contributing factor in premature delivery. (nspt4kids.com)
Antepartum2
- On our labor and delivery board, we listed our active laborers in green marker, our triage patients in blue marker, and our antepartum patients in black marker. (kevinmd.com)
- The antepartum patients were the ones who were admitted remotely from delivery (or so we hoped) in the 20-something or early 30-something week range. (kevinmd.com)
Babies1
- We went on to successfully delivery four babies (three boys and one girl) by c-section. (smfm.org)
Depends1
- The deer gestation period depends on its species. (worlddeer.org)
Period11
- Fundal height of the uterus marrow of patients with aplastic anaemia corresponded with the period of gestation. (who.int)
- Housing: Rodents were group-housed as practical, up to 3 animals of the same group per cage (during the mating and gestation/delivery period, they were paired or individually housed, respectively). (europa.eu)
- Females were dosed for 14 days pre-mating, for up to 16 days mating period, through gestation and up to and including the day before necropsy, 4 days post-partum dosing. (europa.eu)
- So, How Long is the Deer Gestation Period? (worlddeer.org)
- The gestation period for whitetail deer is approximately 200 days. (worlddeer.org)
- The gestation period of red deer is around 236 days. (worlddeer.org)
- Its gestation period is usually about 290 days in length. (worlddeer.org)
- The gestation period for mule deer is about seven months in length. (worlddeer.org)
- The Fallow Deer doe's gestation period is between 230 and 245 days in length. (worlddeer.org)
- As the period of gestation draws to its end, the front legs and head will turn towards the back of the uterus. (worlddeer.org)
- The LVEDD in the controls increased throughout the gestation period, then decreased after delivery. (nih.gov)
Birth2
- In preparation for delivery, keepers will add a large amount of playground mulch to two giraffe stalls, to provide a cushion for when the baby drops, as well as provide traction when the calf stands up shortly after birth. (greenvillezoo.com)
- Triplet and other singletons, but had a survival advantage over singletons at higher order birth ratios for most variables are computed by lower gestations and birthweights. (cdc.gov)
Labor10
- Complications of labor and/or delivery 263-278 f. (cdc.gov)
- The top of your pubic hair will be clipped when you arrive to labor and delivery. (bidmc.org)
- You will arrive to labor and delivery (10th floor) about 2 hours prior to the start time of your scheduled procedure. (bidmc.org)
- Your primary nurse and anesthesiologist will walk you to the Labor and Delivery operating room, or you will be transferred by stretcher. (bidmc.org)
- A clinic urgently needs a set of management system software to solve the problem of labor shortage in the delivery room. (hindawi.com)
- Electronic delivery record sheet can be realized, doctors can view all maternal actual labor process on a computer and can meet the needs of information, mobile monitoring function, electronic files, and so on [ 4 , 5 ]. (hindawi.com)
- Labor & Delivery Services: Why Choose Carle? (carle.org)
- Carle Health provides labor and delivery services at four of its hospitals - Carle BroMenn, Carle Foundation, Carle Health Methodist, and Carle Richland. (carle.org)
- I had worked a Saturday 24-hour call shift, and as soon as I got home on Sunday morning, I began having symptoms that made me turn around and head right back to the labor and delivery unit where I worked … as a patient. (kevinmd.com)
- Delivery of a quadruplet mother in the county of Kirinyaga as the medical officer in-charge of the labor ward unit. (smfm.org)
Premature delivery1
- This is more common during premature delivery. (cerebralpalsy.org)
Deaths1
- These results combined indicate that IFA supplements in populations of iron-deficient pregnant women could lead to a decrease in the number of neonatal deaths mediated by reduced rates of preterm delivery. (biomedcentral.com)
Findings1
- Findings Between March 1, 2009, and Feb 21, 2013, 897 women were invited to participate, of whom 703 were enrolled and randomly assigned to immediate delivery (n=352) or expectant monitoring (n=351). (elsevierpure.com)
Caesarean section1
- Mode of delivery in these 57 women was by vaginal route in 74%, while 26% were delivered by a Caesarean section. (bmj.com)