Does the mode of delivery predispose women to anal incontinence in the first year postpartum? A comparative systematic review

OBJECTIVES

To assess if mode of delivery is associated with increased symptoms of anal incontinence following childbirth.

DESIGN

Systematic review of all relevant studies in English.

DATA SOURCES

Medline, Embase, Cochrane Library, bibliographies of retrieved primary articles and consultation with experts.

STUDY SELECTION AND DATA EXTRACTION

Data were extracted on study characteristics, quality and results. Exposure to risk factors was compared between women with and without anal incontinence. Categorical data in 2 x 2 contingency tables were used to generate odds ratios.

RESULTS

Eighteen studies met the inclusion criteria with 12,237 participants. Women having any type of vaginal delivery compared with a caesarean section have an increased risk of developing symptoms of solid, liquid or flatus anal incontinence. The risk varies with the mode of delivery ranging from a doubled risk with a forceps delivery (OR 2.01, 95% CI 1.47-2.74, P < 0.0001) to a third increased risk for a spontaneous vaginal delivery (OR 1.32, 95% CI 1.04-1.68, P = 0.02). Instrumental deliveries also resulted in more symptoms of anal incontinence when compared with spontaneous vaginal delivery (OR 1.47, 95% CI 1.22-1.78). This was statistically significant for forceps deliveries alone (OR 1.5, 95% CI 1.19-1.89, P = 0.0006) but not for ventouse deliveries (OR 1.31, 95% CI 0.97-1.77, P = 0.08). When symptoms of solid and liquid anal incontinence alone were assessed, these trends persisted but were no longer statistically significant.

CONCLUSION

Symptoms of anal incontinence in the first year postpartum are associated with mode of delivery.

Methods of prediction and prevention of pre-eclampsia: systematic reviews of accuracy and effectiveness literature with economic modelling

OBJECTIVES

To investigate the accuracy of predictive tests for pre-eclampsia and the effectiveness of preventative interventions for pre-eclampsia. Also to assess the cost-effectiveness of strategies (test-intervention combinations) to predict and prevent pre-eclampsia.

DATA SOURCES

Major electronic databases were searched to January 2005 at least.

REVIEW METHODS

Systematic reviews were carried out for test accuracy and effectiveness. Quality assessment was carried out using standard tools. For test accuracy, meta-analyses used a bivariate approach. Effectiveness reviews were conducted under the auspices of the Cochrane Pregnancy and Childbirth Group and used standard Cochrane review methods. The economic evaluation was from an NHS perspective and used a decision tree model.

RESULTS

For the 27 tests reviewed, the quality of included studies was generally poor. Some tests appeared to have high specificity, but at the expense of compromised sensitivity. Tests that reached specificities above 90% were body mass index greater than 34, alpha-foetoprotein and uterine artery Doppler (bilateral notching). The only Doppler test with a sensitivity of over 60% was resistance index and combinations of indices. A few tests not commonly found in routine practice, such as kallikreinuria and SDS-PAGE proteinuria, seemed to offer the promise of high sensitivity, without compromising specificity, but these would require further investigation. For the 16 effectiveness reviews, the quality of included studies was variable. The largest review was of antiplatelet agents, primarily low-dose aspirin, and included 51 trials (36,500 women). This was the only review where the intervention was shown to prevent both pre-eclampsia and its consequences for the baby. Calcium supplementation also reduced the risk of pre-eclampsia, but with some uncertainty about the impact on outcomes for the baby. The only other intervention associated with a reduction in RR of pre-eclampsia was rest at home, with or without a nutritional supplement, for women with normal blood pressure. However, this review included just two small trials and its results should be interpreted with caution. The cost of most of the tests was modest, ranging from 5 pounds for blood tests such as serum uric acid to approximately 20 pounds for Doppler tests. Similarly, the cost of most interventions was also modest. In contrast, the best estimate of additional average cost associated with an average case of pre-eclampsia was high at approximately 9000 pounds. The results of the modelling revealed that prior testing with the test accuracy sensitivities and specificities identified appeared to offer little as a way of improving cost-effectiveness. Based on the evidence reviewed, none of the tests appeared sufficiently accurate to be clinically useful and the results of the model favoured no-test/treat-all strategies. Rest at home without any initial testing appeared to be the most cost-effective 'test-treatment' combination. Calcium supplementation to all women, without any initial testing, appeared to be the second most cost-effective. The economic model provided little support that any form of Doppler test has sufficiently high sensitivity and specificity to be cost-effective for the early identification of pre-eclampsia. It also suggested that the pattern of cost-effectiveness was no different in high-risk mothers than the low-risk mothers considered in the base case.

CONCLUSIONS

The tests evaluated are not sufficiently accurate, in our opinion, to suggest their routine use in clinical practice. Calcium and antiplatelet agents, primarily low-dose aspirin, were the interventions shown to prevent pre-eclampsia. The most cost-effective approach to reducing pre-eclampsia is likely to be the provision of an effective, affordable and safe intervention applied to all mothers without prior testing to assess levels of risk. It is probably premature to suggest the implementation of a treat-all intervention strategy at present, however the feasibility and acceptability of this to women could be explored. Rigorous evaluation is needed of tests with modest cost whose initial assessments suggest that they may have high levels of both sensitivity and specificity. Similarly, there is a need for high-quality, adequately powered randomised controlled trials to investigate whether interventions such as advice to rest are indeed effective in reducing pre-eclampsia. In future, an economic model should be developed that considers not just pre-eclampsia, but other related outcomes, particularly those relevant to the infant such as perinatal death, preterm birth and small for gestational age. Such a modelling project should make provision for primary data collection on the safety of interventions and their associated costs.

Gynaecologic surgery from uncertainty to science: evidence-based surgery is no passing fad

BACKGROUND

The randomized controlled trial (RCT) is the least biased measure of the effectiveness of interventions, including surgical interventions. The aim was to review the available evidence base in gynaecologic surgery, to assess what progress has been made and to determine gaps in the evidence for clinical decision-making.

METHODS

Systematic reviews involving gynaecological surgery interventions were extracted from the Cochrane Database of Systematic Reviews (Issue 2, 2007) and data were extracted for key primary outcomes from each of the randomized trials in the reviews. The reviews were categorized as to whether they had provided evidence of effectiveness for pre-defined outcomes of most relevance to patients.

RESULTS

Of 371 reviews or protocols published on the Cochrane Database of Systematic Reviews (Issue 2, 2007), only 30 were completed reviews assessing surgical interventions. Seven reviews concluded there was evidence of a significant effect (whether beneficial or harmful) of the interventions studied for pre-defined primary outcomes; 11 reviews concluded there was some evidence of significant effects for primary outcomes along with some gaps for primary outcomes; 12 reviews concluded insufficient evidence of effectiveness. Common themes of unique methodological challenges and pitfalls with trials of surgical interventions were apparent.

CONCLUSIONS

Cochrane reviews have gone a long way to establishing a sound evidence base in gynaecologic surgery: some gaps in the evidence have been eliminated and others highlighted. In general, gynaecology has been a specialty where surgical interventions have been well exposed to the scrutiny of RCTs compared with other surgical specialties.

Evaluation of diagnostic tests when there is no gold standard. A review of methods

OBJECTIVE

To generate a classification of methods to evaluate medical tests when there is no gold standard.

METHODS

Multiple search strategies were employed to obtain an overview of the different methods described in the literature, including searches of electronic databases, contacting experts for papers in personal archives, exploring databases from previous methodological projects and cross-checking of reference lists of useful papers already identified.

RESULTS

All methods available were classified into four main groups. The first method group, impute or adjust for missing data on reference standard, needs careful attention to the pattern and fraction of missing values. The second group, correct imperfect reference standard, can be useful if there is reliable information about the degree of imperfection of the reference standard and about the correlation of the errors between the index test and the reference standard. The third group of methods, construct reference standard, have in common that they combine multiple test results to construct a reference standard outcome including deterministic predefined rules, consensus procedures and statistical modelling (latent class analysis). In the final group, validate index test results, the diagnostic test accuracy paradigm is abandoned and research examines, using a number of different methods, whether the results of an index test are meaningful in practice, for example by relating index test results to relevant other clinical characteristics and future clinical events.

CONCLUSIONS

The majority of methods try to impute, adjust or construct a reference standard in an effort to obtain the familiar diagnostic accuracy statistics, such as sensitivity and specificity. In situations that deviate only marginally from the classical diagnostic accuracy paradigm, these are valuable methods. However, in situations where an acceptable reference standard does not exist, applying the concept of clinical test validation can provide a significant methodological advance. All methods summarised in this report need further development. Some methods, such as the construction of a reference standard using panel consensus methods and validation of tests outwith the accuracy paradigm, are particularly promising but are lacking in methodological research. These methods deserve particular attention in future research.

Systematic review: Accuracy of body mass index in predicting pre-eclampsia: bivariate meta-analysis

OBJECTIVE

The objective of this study was to determine the accuracy of body mass index (BMI) (pre-pregnancy or at booking) in predicting pre-eclampsia and to explore its potential for clinical application.

DESIGN

Systematic review and bivariate meta-analysis.

SETTING

Medline, Embase, Cochrane Library, MEDION, manual searching of reference lists of review articles and eligible primary articles, and contact with experts.

POPULATION

Pregnant women at any level of risk in any healthcare setting.

METHODS

Reviewers independently selected studies and extracted data on study characteristics, quality, and accuracy. No language restrictions.

MAIN OUTCOME MEASURES

Pooled sensitivities and specificities (95% CI), a summary receiver operating characteristic curve, and corresponding likelihood ratios (LRs). The potential value of BMI was assessed by combining its predictive capacity for different prevalences of pre-eclampsia and the therapeutic effectiveness (relative risk 0.90) of aspirin.

RESULTS

A total of 36 studies, testing 1,699,073 pregnant women (60,584 women with pre-eclampsia), met the selection criteria. The median incidence of pre-eclampsia was 3.9% (interquartile range 1.4-6.8). The area under the curve was 0.64 with 93% of heterogeneity explained by threshold differences. Pooled estimates (95% CI) for all studies with a BMI > or = 25 were 47% (33-61) for sensitivity and 73% (64-83) for specificity; and 21% (12-31) and 92% (89-95) for a BMI > or = 35. Corresponding LRs (95% CI) were 1.7 (0.3-11.9) for BMI > or = 25 and 0.73 (0.22-2.45) for BMI < 25, and 2.7 (1.0-7.3) for BMI > or = 35 and 0.86 (0.68-1.07) for BMI < 35. The number needed to treat with aspirin to prevent one case of pre-eclampsia ranges from 714 (no testing, low-risk women) to 37 (BMI > or = 35, high-risk women).

CONCLUSIONS

BMI appears to be a fairly weak predictor for pre-eclampsia. Although BMI is virtually free of cost, noninvasive, and ubiquitously available, its usefulness as a stand-alone test for risk stratification must await formal cost-utility analysis. The findings of this review may serve as input for such analyses.

Accuracy of fibronectin tests for the prediction of pre-eclampsia: a systematic review

The purpose of this study was to review systematically all studies that assessed the accuracy of maternal plasma fibronectin as a serum marker for early prediction of pre-eclampsia. We therefore assessed studies that reported on fibronectin as serum marker for pre-eclampsia before the 25th gestational week. For the selected studies, sensitivity and specificity were calculated and plotted in ROC-space. We included 12 studies, of which only 5 studies reported sufficient data to calculate accuracy estimates, such as sensitivity and specificity. These five studies reported on 573 pregnant women of whom 109 developed pre-eclampsia. At a sensitivity of at least 50%, specificities ranged between 72 and 96% for cellular fibronectin. For total fibronectin, these numbers were 42-94%. Fibronectin seems to be a promising marker for the prediction of pre-eclampsia, however, further studies are needed to determine whether the accuracy of this test is sufficient to be clinically relevant.

Vesicoamniotic shunting for fetal lower urinary tract obstruction: an overview

Efficacy and complications of prenatal in utero treatment

Surgical interruption of pelvic nerve pathways in dysmenorrhea: a systematic review of effectiveness

OBJECTIVES

To assess the effectiveness of surgical interruption of pelvic nerve pathways in primary and secondary dysmenorrhea. Data sources. The Cochrane Menstrual Disorders and Subfertility Group Trials Register (9 June 2004), CENTRAL (The Cochrane Library, Issue 2, 2004), MEDLINE (1966 to Nov. 2003), EMBASE (1980 to Nov. 2003), CINAHL (1982 to Oct. 2003), MetaRegister of Controlled Trials, the citation lists of review articles and included trials, and contact with the corresponding author of each included trial.

REVIEW METHODS

The inclusion criteria were randomized controlled trials of uterosacral nerve ablation or presacral neurectomy (both open and laparoscopic procedures) for the treatment of dysmenorrhea. The main outcome measures were pain relief and adverse effects. Two reviewers extracted data on characteristics of the study quality and the population, intervention, and outcome independently.

RESULTS

Nine randomized controlled trials were included in the systematic review. There were two trials with open presacral neurectomy; all other trials used laparoscopic techniques. For the treatment of primary dysmenorrhea, laparoscopic uterosacral nerve ablation at 12 months was better when compared to a control or no treatment (OR 6.12; 95% CI 1.78-21.03). The comparison of laparoscopic uterosacral nerve ablation with presacral neurectomy for primary dysmenorrhea showed that at 12 months follow-up, presacral neurectomy was more effective (OR 0.10; 95% CI 0.03-0.32). In secondary dysmenorrhea, along with laparoscopic surgical treatment of endometriosis, the addition of laparoscopic uterosacral nerve ablation did not improve the pain relief (OR 0.77; 95% CI 0.43-1.39), while presacral neurectomy did (OR 3.14; 95% CI 1.59-6.21). Adverse events were more common for presacral neurectomy than procedures without presacral neurectomy (OR 14.6; 95% CI 5-42.5).

CONCLUSION

The evidence for nerve interruption in the management of dysmenorrhea is limited. Methodologically sound and sufficiently powered randomized controlled trials are needed.

Ovarian reserve tests for predicting fertility outcomes for assisted reproductive technology: the International Systematic Collaboration of Ovarian Reserve Evaluation protocol for a systematic review of ovarian reserve test accuracy

BACKGROUND

The presence of a wide range of tests of ovarian reserve suggests that no single test provides a sufficiently accurate result. Many tests are used without reference to an evidence base. So far, individual studies conducted on these tests are too small to give precise estimates of prognostic accuracy.

OBJECTIVES

To systematically assess the accuracy of the available tests of ovarian reserve in terms of prediction of fertility outcomes.

SEARCH STRATEGY

The search will be conducted using the name of the respective index test being studied (as listed on the MESH database), if more than 2000 citations are listed, 'ovary' and or 'ovarian', 'fertility' and or 'reserve' will be combined with the original search term as required. Studies of the accuracy of tests of ovarian reserve will be obtained without language restrictions from 1980 to 2005 using the following electronic databases and Ovid software: MEDLINE, EMBASE, PUBmed, Biological extracts, Pascal, Cochrane Library (CDSR, DARE, CCTR, HTA), Best Evidence databases, SCISEARCH, Conference Proceedings (ISI Proceedings, Healthstar, Current Contents, Science Citation Index, Cancerlit and Econlit and NHS Economic Evaluation database. The National Research Register, the Medical Research Council's Clinical Trials Register, MEDION, DARE, and the US Clinical Trials register.

SELECTION CRITERIA

Studies will be selected if accuracy of tests are compared with a reference standard and include data that can be abstracted into a two-by-two table to calculate sensitivity and specificity. The studies to be included in this review will examine one of the following index 'tests' within a study population of women undergoing assisted reproductive technology: * Clinical variables--age, history of cancelled cycles. * Basal blood tests--follicle-stimulating hormone (FSH), lutenising hormone (LH), FSH:LH ratios, estradiol (E(2)), inhibin A and B, progesterone (P(4)), P(4):E(2) ratios, antimullerian hormone, testosterone, vascular endothelial growth factor, insulin-like growth factor-1:insulin-like growth factor binding protein-1 ratios. * Dynamic tests--clomiphene citrate challenge test, gonadotropin analogue stimulating test, exogenous FSH ovarian reserve test. * Ultrasound tests-antral follicle count, ovarian volume, ovarian stromal peak systolic velocity, including waveform and pulsatility index, ovarian follicular vascularity. * Histology--ovarian biopsy. Data collection and analysis Two independent reviewers will perform quality assessment and data extraction. Prognostic accuracy will be determined by calculating positive and negative likelihood ratios for the following outcomes or reference standards: live birth, ongoing pregnancy, clinical pregnancy, biochemical pregnancy, embryos available for transfer, eggs obtained at oocyte retrieval, cycles cancelled prior to oocyte retrieval. Main results and conclusions N/A.

Systematic reviews of qualitative evidence: what are the experiences of women with endometriosis?

Just as systematic reviews of quantitative research have developed over the last two decades, the use of a systematic review is also superseding narrative non-systematic reviews in qualitative research in an attempt to bring rigour to reviewing research evidence. Qualitative research is concerned with the subjective world and the way in which people interpret and make sense of the reality of their lives. This paper describes procedures for conducting a systematic review on qualitative research, and the methods for assessing the quality of qualitative research papers, using published qualitative research on endometriosis as an example to demonstrate these. The conclusion from the systematic review carried out is that the values and methods utilised for a systematic review can usefully be applied to qualitative research. The review of endometriosis research revealed that despite the impact of endometriosis on the lives of women sufferers, little qualitative research has been conducted, and much of that which exists lacks rigour in a number of key areas.

Systematic review of accuracy of fetal urine analysis to predict poor postnatal renal function in cases of congenital urinary tract obstruction

OBJECTIVE

To evaluate the clinical usefulness of analysis of fetal urine in the prediction of poor postnatal renal function in cases of congenital urinary tract obstruction.

METHODS

A systematic review was performed. We conducted extensive electronic searches (database inception-2006). The reference lists of articles obtained were searched for any further articles. Two reviewers independently selected the articles in which the accuracy of fetal urinalysis was evaluated to predict poor postnatal renal function. There were no language restrictions. Data were extracted on study characteristics, quality and results, to construct 2 x 2 tables. Likelihood ratios for positive (LR+) and negative (LR-) test results were generated for the different fetal urinary analytes at various thresholds.

RESULTS

There were 23 articles that met the selection criteria, including a total of 572 women and 63 2 x 2 tables. The two most accurate tests were calcium > 95th centile for gestation (LR + 6.65, 0.23-190.96; LR - 0.19, 0.05-0.74) and sodium > 95th centile for gestation (LR + 4.46, 1.71-11.6; LR - 0.39, 0.17-0.88). beta(2)-microglobulin was found to be less accurate (LR + 2.92, 1.28-6.69; LR - 0.53, 0.24-1.17).

CONCLUSION

The current evidence demonstrates that none of the analytes of fetal urine investigated so far can be shown to yield clinically significant accuracy to predict poor postnatal renal function.

In-utero pulmonary drainage in the management of primary hydrothorax and congenital cystic lung lesion: a systematic review

OBJECTIVE

To determine the effect of in-utero pulmonary drainage on perinatal survival in fetuses with primary hydrothoraces and/or congenital cystic lung lesions.

METHODS

Relevant papers were identified by searching MEDLINE (1966-2004), EMBASE (1988-2004) and the Cochrane Library (2004 issue 2). Studies were selected if the effect of prenatal pulmonary drainage (shunt, surgery or drainage) on perinatal survival was compared with no treatment, in fetuses with ultrasonic evidence of lung pathology. Study selection, quality assessment and data abstraction were performed independently and in duplicate.

RESULTS

Of a total number of 7958 articles, there were 16 controlled observational studies involving 608 fetuses. Study characteristics and quality were recorded for each study. Data were abstracted to generate 2 x 2 tables to compare the effect of pulmonary drainage vs. no drainage on perinatal survival. Pooled odds ratios (ORs) were used as summary measures of effect and the results were stratified according to predicted fetal prognoses. Pulmonary drainage did not improve perinatal survival in cystic lung lesions compared with no drainage (OR 0.56, 95% CI 0.32-0.97, P = 0.04) overall. However there was a marked improvement with this therapy in a subgroup of fetuses with fetal hydrops fetalis (OR 19.28, 95% CI 3.67-101.27, P = 0.0005) but not in the subgroup uncomplicated by fetal hydrops fetalis (OR 0.04, 95% CI 0.01-0.32, P = 0.002).

CONCLUSION

Percutaneous, in-utero pulmonary drainage in fetuses with ultrasonic evidence of congenital pulmonary cystic malformations was associated with improved perinatal survival among fetuses with hydrops fetalis and therefore poor predicted survival.

Guidelines for the management of pelvic pain associated with endometriosis: a systematic appraisal of their quality

BACKGROUND

Guidelines exist for the management of endometriosis. Validated and reliable appraisal tools exist to assess the quality of guidelines.

OBJECTIVES

To systematically appraise the quality of guidelines for the management of pelvic pain associated with endometriosis.

SEARCH STRATEGY

Guidelines were identified using a prospective protocol through a systematic search of MEDLINE (1951-2005), EMBASE (1974-2005), the Cochrane Library (2005, issue 2), known guideline websites and the World Wide Web.

SELECTION CRITERIA

Type of document: guideline, consensus statement, care protocol or healthcare technology assessment produced by national or international professional organisations and societies or governmental agencies; subject: management of pelvic pain associated with endometriosis.

DATA COLLECTION AND ANALYSIS

Two validated appraisal tools, Cluzeau and The Appraisal of Guidelines and Research and Evaluation (AGREE), were used to quantitatively assess the quality of guidelines. Areas evaluated included 'rigour of development', 'context and content' and 'application.'

MAIN RESULTS

Eight of 596 potentially relevant citations identified met our inclusion criteria. The Cluzeau instrument quality score were the following: rigour of development, 53% (range 5-65%); context and content, 69% (range 29-79%) and application 20% (range 0-20%). The application dimension achieved significantly lower quality scores (P = 0.026 versus rigour of development and P = 0.017 versus context and content). The AGREE instrument quality scores were the following: scope and purpose, 68% (range 17-89%); stakeholder involvement, 33% (range 13-63%); rigour of development, 49% (range 10-81%); clarity of presentation, 55% (range 42-67%); applicability, 14% (range 0-28%) and editorial independence, 28% (range 8-67%). The applicability domain achieved significantly lower quality scores (P = 0.001 versus scope and purpose and P = 0.009 versus rigour of development).

AUTHOR'S CONCLUSIONS

Guidelines for the management of pelvic pain associated with endometriosis do not comply with the recommendations for high-quality standards.

Prognosis for the co-twin following single-twin death: a systematic review

BACKGROUND

Following single-twin death, the perinatal mortality and morbidity for the surviving co-twin is increased but difficult to quantify. We present data on prognosis from a systematic review.

OBJECTIVES

We aimed to determine the incidence of a) co-twin death, b) neurological abnormality and c) preterm delivery for the surviving co-twin following single-twin death after 14 weeks of gestation.

SEARCH STRATEGY

Literature was identified by searching two bibliographical databases and specialist journals between 1990 and 2005.

SELECTION CRITERIA

The selected studies of > or = 5 cases reported on perinatal death and/or neurodevelopmental delay of the surviving co-twin.

DATA COLLECTION AND ANALYSIS

Studies were assessed for quality and data extracted to allow computation of rates. The data were inspected for heterogeneity using a Forrest plot and examined statistically using the chi-square test. Data from individual studies were pooled within subgroups defined by prognosis.

MAIN RESULTS

The search strategy yielded 632 potentially relevant citations. Full manuscripts were retrieved for 54 citations and 28 studies were finally included in the review. Following the death of one twin, the risk of monochorionic and dichorionic co-twin demise was 12% (95% CI 7-11) and 4% (95% CI 2-7), respectively. The risk of neurological abnormality in the surviving monochorionic and dichorionic co-twin was 18% (95% CI 11-26) and 1% (95% CI 0-7), respectively. The risk of preterm delivery was 68% (95% CI 56-78) and 57% (95% CI 34-77), respectively. Where there was comparative data within studies, the odds of monochorionic co-twin intrauterine death was six times that of dichorionic twins (OR 6.04 [95% CI 1.84-19.87]). Neurological abnormality was also higher in monochorionic compared with dichorionic pregnancies (OR 4.07 [95% CI 1.32-12.51]).

AUTHOR'S CONCLUSIONS

More prospective research is required to inform decision making on this subject, especially with data that allow stratification based upon chorionicity.

A systematic review of the accuracy of first-trimester ultrasound examination for detecting major congenital heart disease

OBJECTIVE

To evaluate the accuracy of first-trimester ultrasound examination in detecting major congenital heart disease (CHD) using a systematic review of the literature.

METHODS

General bibliographic and specialist computerized databases along with manual searching of reference lists of primary and review articles were used to search for relevant citations. Studies were included if a first-trimester ultrasound scan was carried out to detect CHD that was subsequently verified by a reference standard. Data were extracted on study characteristics and quality, and 2 x 2 tables were constructed to calculate sensitivity and specificity.

RESULTS

Ten studies (involving 1243 patients) were suitable for inclusion. Of these, four used transabdominal ultrasonography, four used transvaginal and two used a combination. Pooled sensitivity and specificity were 85% (95% CI, 78-90%) and 99% (95% CI, 98-100%), respectively.

CONCLUSION

Ultrasound examination of the fetus in the first trimester is feasible for accurately detecting major CHD. It may be offered to women at high risk of having children with CHD.

Gynaecological oncology: Investigating postmenopausal bleeding for endometrial cancer: cost-effectiveness of initial diagnostic strategies

OBJECTIVE

To determine the most cost-effective outpatient testing strategy for diagnosing endometrial cancer in women with postmenopausal bleeding (PMB).

DESIGN

Decision analysis modelling.

POPULATION

Women with postmenopausal bleeding.

METHODS

A decision analytic model was constructed to reflect current service provision, which evaluated 12 diagnostic strategies using endometrial biopsy (EB), ultrasonography (USS) (4- and 5-mm endometrial thickness cutoff) and hysteroscopy. Diagnostic probability estimates were derived from systematic quantitative reviews, clinical outcomes from published literature and cost estimates from local and NHS sources.

MAIN OUTCOME MEASURES

The cost per additional life year gained (pound/LYG) was determined and compared for each diagnostic strategy, and sensitivity analyses were performed.

RESULTS

Compared with carrying out no initial investigation, a strategy based on initial diagnosis with USS using a 5-mm cutoff was the least expensive (11,470 pound/LYG). Initial investigation with EB or USS using a 4-mm cutoff was comparably cost-effective (less than 30,000 pound/LYG versus USS with a 5-mm cutoff) at their most favourable diagnostic performance and at disease prevalence of 10% or more. The strategies involving initial evaluation with test combinations or hysteroscopy alone were not cost-effective.

CONCLUSIONS

Women presenting for the first time with PMB should undergo initial evaluation with USS or EB.

Accuracy of serum uric acid in predicting complications of pre-eclampsia: a systematic review

BACKGROUND

Pre-eclampsia is one of the largest causes of maternal and fetal mortality and morbidity. Hyperuricemia is often associated with pre-eclampsia.

OBJECTIVE

To determine the accuracy with which serum uric acid predicts maternal and fetal complications in women with pre-eclampsia.

STUDY DESIGN

Systematic quantitative review of test accuracy studies.

SEARCH STRATEGY

We conducted electronic searches in MEDLINE (1951-2004), EMBASE (1980-2004), the Cochrane Library (2004:4) and the MEDION database to identify relevant articles. A hand-search of selected specialist journals and reference lists of articles obtained was then carried out. There were no language restrictions for any of these searches.

SELECTION CRITERIA

Two reviewers independently selected the articles in which the accuracy of serum uric acid was evaluated to predict maternal and fetal complications of pre-eclampsia.

DATA COLLECTION AND ANALYSIS

Data were extracted on study characteristics, quality and accuracy to construct 2 x 2 tables with maternal and fetal complications as reference standard. Summary likelihood ratios for positive (LR+) and negative LR(-) test results are generated for various threshold levels of uric acid.

MAIN RESULTS

There were 18 primary articles that met the selection criteria, including a total of 3913 women and forty-one 2 x 2 tables. In women with pre-eclampsia, a positive test result of uric acid greater than or equal to a 350-micromol/l threshold predicted eclampsia with a pooled likelihood ratio (LR) of 2.1 (95% CI 1.4-3.5), while a negative test result had a pooled LR of 0.38 (95% CI 0.18-0.81). For severe hypertension as the outcome measure, the LRs were 1.7 (95% CI 1.3-2.2) and 0.49 (95% CI 0.38-0.64) for positive and negative test results, respectively, and for caesarean section the LRs were 2.4 (95% CI 1.3-4.7) and 0.39 (95% CI 0.20-0.76). For stillbirths and neonatal deaths the respective LRs were 1.5 (95% CI 0.91-2.6) and 0.51 (95% CI 0.20-1.3). For the prediction of small-for-gestational-age fetus, the pooled LRs were 1.3 (95% CI 1.1-1.7) and 0.60 (95% CI 0.43-0.83) for positive and negative results, respectively. AUTHOR'S CONCLUSION: Serum uric acid is a poor predictor of maternal and fetal complications in women with pre-eclampsia.

Prevalence of anal incontinence according to age and gender: a systematic review and meta-regression analysis

CONTEXT

Anal incontinence is increasingly being recognised as a significant cause of physical and psychological morbidity with implications for healthcare provision within the community. There is controversy about which population groups are most disadvantaged by this chronic condition.

OBJECTIVES

The aim of this study was to evaluate the prevalence of this condition in the community according to age and gender, a systematic review was performed.

DATA SOURCES

Data were from Embase, Medline, bibliographies of known articles and contact with experts.

STUDY SELECTION

Studies were selected if data on anal incontinence could be extracted for participants over 15 years of age and living in the community.

DATA EXTRACTION

Data were extracted using a piloted form on participants' characteristics, study quality and incontinence rates.

DATA SYNTHESIS

Meta-analysis was used to combine data from multiple studies, and meta-regression evaluated the variation in rates according to age and gender in an analysis adjusted for study quality.

RESULTS

There were 29 studies (69,152 participants), of which 5 met over half of the high quality criteria. The rate of solid and liquid faecal incontinence among people aged 15-60 years was 0.8% [95% confidence interval (CI) 0.3-1.9] in men and 1.6% (95% CI 0.8-3.1) in women. In those aged over 60, this increased to 5.1% (95% CI 3.4-7.6) in men and 6.2% (95% CI 4.9-8.0) in women. Meta-regression showed that age had a significant influence on rates of solid and liquid faecal incontinence (p = 0.007), but not gender (p = 0.368) or study quality (p = 0.085).

CONCLUSIONS

The rate of solid and liquid faecal incontinence in older people is significantly higher than their younger counterparts. Gender differences in rates did not reach statistical significance.

Surgical interruption of pelvic nerve pathways for primary and secondary dysmenorrhoea

BACKGROUND

Dysmenorrhoea is the occurrence of painful menstrual cramps of uterine origin and is a very common gynaecological complaint with negative effect on a sufferer's quality of life. Medical therapy for dysmenorrhoea includes oral contraceptive pills (OCP) and nonsteroidal anti-inflammatory drugs (NSAIDs) which both act by suppressing prostaglandin levels. While these treatments are very successful there is still a 20 to 25% failure rate and surgery has been an option for such cases. Uterine nerve ablation (UNA) and presacral neurectomy (PSN) are two surgical treatments that have become increasingly utilised in recent years due to advances in laparoscopic procedures. These procedures both interrupt the majority of the cervical sensory pain nerve fibres. Observational studies have supported the use of these procedures for primary dysmenorrhoea. However, both operations only partially interrupt the cervical sensory nerve fibres in the pelvic area and, therefore, this type of surgery may not always benefit women with dysmenorrhoea.

OBJECTIVES

To assess the effectiveness of surgical interruption of pelvic nerve pathways as treatment for primary and secondary dysmenorrhoea, and to determine the most effective surgical treatment.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (searched 9 June 2004), CENTRAL (The Cochrane Library Issue 2, 2004), MEDLINE (1966 to Nov 2003), EMBASE (1980 to Nov 2003), and CINAHL (1982 to Oct 2003). Attempts were also made to identify trials from the metaRegister of Controlled Trials and the citation lists of review articles and included trials. In most cases the first or corresponding author of each included trial was contacted for additional information.

SELECTION CRITERIA

The inclusion criteria were randomised comparisons of surgical techniques of interruption of the pelvic nerve pathways (using both open and laparoscopic procedures) for the treatment of primary and secondary dysmenorrhoea. The main outcome measures were pain relief and adverse effects.

DATA COLLECTION AND ANALYSIS

Eleven randomised controlled trials (RCTs) were identified that initially appeared to fulfil the inclusion criteria for this review. Two trials were subsequently excluded (Garcia Leon 2003; Sutton 1991). Of the remaining nine trials, eight were included in the meta-analysis. The results of one trial were included in the text of the review for discussion because the data were not available in a form that allowed them to be combined in the meta-analysis. Five trials investigated laparoscopic uterine nerve ablation (LUNA), two trials laparoscopic presacral neurectomy (LPSN) and two open presacral neurectomy (PSN).

MAIN RESULTS

For the treatment of primary dysmenorrhoea there was some evidence of the effectiveness of laparoscopic uterine nerve ablation (LUNA) when compared to a control or no treatment. The comparison between LUNA and laparoscopic presacral neurectomy (LPSN) for primary dysmenorrhoea showed no significant difference in pain relief in the short term; however, long-term LPSN was shown to be significantly more effective than LUNA. For the treatment of secondary dysmenorrhoea six identified RCTs addressed endometriosis and one included women with uterine myomas. The treatment of LUNA combined with surgical treatment of endometrial implants versus surgical treatment of endometriosis alone showed that the addition of LUNA did not aid pain relief. For PSN combined with endometriosis treatment versus endometriosis treatment alone there was an overall difference in pain relief although the data suggests this may be specific to laparoscopy and for midline abdominal pain only. Adverse events were significantly more common for presacral neurectomy; however, the majority were complications such as constipation, which may spontaneously improve.

AUTHORS' CONCLUSIONS

There is insufficient evidence to recommend the use of nerve interruption in the management of dysmenorrhoea, regardless of cause. Future methodologically sound and sufficiently powered RCTs should be undertaken.

A systematic review of the accuracy of diagnostic tests for inguinal lymph node status in vulvar cancer

OBJECTIVE

To determine the accuracy of minimally and non-invasive tests to assess the groin node status in squamous cell vulvar cancer.

METHODS

A systematic review of published research from 1979 to 2004 that compares the results of tests to determine groin node status with histology at inguinofemoral lymphadenectomy was made. Studies included in the review were those that compared the index test to the standard surgical intervention of inguinofemoral lymphadenectomy and allowed the construction of two-by-two tables. From these tables, sensitivity, specificity, and the likelihood ratios (with 95% confidence intervals) were reported and, where feasible, meta-analysis was used to pool results for each test separately. Sentinel node biopsy using technetium-99m-labelled nanocolloid ((99m)Tc) had a pooled sensitivity and negative LR of 97% (91-100 95% CI) and 0.12 (0.053-0.28 95% CI), respectively, and was the most accurate test reviewed.

CONCLUSION

Five diagnostic tests were identified in a total of 29 studies (961 groins). Although the studies were small and the design often poor, this represents the best summary of the data to date. Sentinel node identification using (99m)Tc appeared to be the most promising test for accurately excluding lymph node metastases in squamous cell vulvar cancer and potentially reducing the radicality of surgery. Its efficacy as a tool in reducing the need for radical surgery and associated patient morbidity without reducing survival needs further assessment probably in a randomised control trial.

Postgraduate journal club as a means of promoting evidence-based obstetrics and gynaecology

We assessed the feasibility of a new educational programme to teach critical appraisal of the medical literature to postgraduate trainees. The new programme used a journal club format where selection of topics and articles was driven by clinical problems arising in day-to-day practice. Papers were appraised critically according to validated guidelines using computer software for appraisal, electronic storage and retrieval. Over the initial 4-month period the journal club produced 17 critically appraised topics, two of which were published in peer-reviewed journals. During the study, trainees' reading time improved from a median of 2.0 hours (range 1-5 hours) to 3.5 hours (range 2-8 hours) (P = 0.026) and their knowledge scores improved from a mean of 50.8 (SD 4.0) to 62.9 (SD 4.3) (P = 0.003). We conclude that a journal club supported by electronic means of critical appraisal and dissemination of appraised information can be used to encourage the practice of evidence-based medicine.