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Duprez F, Mol B, Lesire B, Cotils M, Michotte JB, Mashayekhi S, de Terwangne C. FiO 2 prediction formula during low flow oxygen therapy in an adult model: a bench study. J Clin Monit Comput 2024; 38:455-461. [PMID: 38155340 DOI: 10.1007/s10877-023-01109-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 11/17/2023] [Indexed: 12/30/2023]
Abstract
During low-flow oxygen therapy, the true value of inspired oxygen fraction (FiO2) is generally unknown. Knowledge of delivered FiO2 values may be useful as well as to adjust oxygen therapy, as well as to predict patient deterioration. This study proposes a New FiO2 Prediction Formula (NFiO2) for low-flow oxygenation and compares its predictive value to precedent formulas. In a bench study, the O2 Flow rate was delivered through a T-piece connected to a dual-compartment artificial lung controlled by a mechanical ventilator. To test the NFiO2 formula, a set of ventilatory parameters were tested: Tidal Volume was set from 400 to 600 ml, Respiratory Rate (RR) was set from 18 to 30 CPM, Ti/Ttot was set at 0.33 and 0.25, and O2 flow rates from 3 to 10 L/min. A data acquisition system measured all parameters. To quantify the accuracy of the NFiO2 compared to other FiO2 prediction formulas, Bland and Altman agreement analyses were performed. To make use of the Duprez Formula 2018 in clinical practice, we simplified the formula to estimate the FiO2 during oxygenation at low flow. This NFiO2 formula makes use of only O2 Flow Rate and RR. Bias and limits of agreement between predicted FiO2 and benchtop FiO2 highlighted consistent differences between different FiO2 prediction formulas. The NFiO2 and the Duprez Formula 2018 seemed to be the most accurate formulas, followed by the Vincent Formula, and lastly the Shapiro Formula. A New FiO2 Prediction Formula was developed using clinical readily available variables (RR and O2 Flow rate) which showed good accuracy in predicting FiO2 during oxygenation at low flow.
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Affiliation(s)
- F Duprez
- Research Unit and Innovation Condorcet Epicura, Epicura Hospital, 63 rue de Mons, 7301, Hornu, Belgium.
- Laboratory of Motion and Respiratory Physiology, Condorcet School, 75 rue Paul Pastur, 7500, Tournai, Belgium.
| | - B Mol
- Research Unit and Innovation Condorcet Epicura, Epicura Hospital, 63 rue de Mons, 7301, Hornu, Belgium
| | - B Lesire
- Pulmonary department, Epicura Hospital, Hornu, Belgium
| | - M Cotils
- Pulmonary department, Epicura Hospital, Hornu, Belgium
| | - J B Michotte
- School of Health Sciences, University of Applied Sciences and Arts Western Switzerland, Lausanne, Switzerland
| | - S Mashayekhi
- Research Unit and Innovation Condorcet Epicura, Epicura Hospital, 63 rue de Mons, 7301, Hornu, Belgium
| | - C de Terwangne
- Department of Internal Medicine, Cliniques Universitaires Saint Luc, Avenue Hippocrate 10, 1200, Woluwe, Brussels, Belgium.
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2
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de Wit K, van Doorn DJ, Mol B, van Vught LA, Nevens F, Beuers U, Ponsioen CY, Teunissen CE, Takkenberg RB. Neurofilament light chain but not glial fibrillary acidic protein is a potential biomarker of overt hepatic encephalopathy in patients with cirrhosis. Ann Hepatol 2024; 29:101496. [PMID: 38460714 DOI: 10.1016/j.aohep.2024.101496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 12/04/2023] [Accepted: 01/04/2024] [Indexed: 03/11/2024]
Abstract
INTRODUCTION AND OBJECTIVES Hepatic encephalopathy (HE) is a frequent complication of cirrhosis and may cause cerebral damage. Neurodegenerative diseases can induce the release of neuroproteins like neurofilament light chain (NfL) and glial fibrillary acidic protein (GFAP) in body fluids, including blood plasma. We investigated whether NfL and GFAP could serve as potential diagnostic plasma biomarkers for overt HE (oHE). MATERIALS AND METHODS We included 85 patients from three prospective cohorts with different stages of liver disease and HE severity. The following patients were included: 1) 34 patients with primary sclerosing cholangitis (PSC) with compensated disease; 2) 17 patients with advanced liver disease without oHE before elective transjugular intrahepatic portosystemic shunt (TIPS) placement; 3) 17 intensive care unit (ICU) patients with oHE and 17 ICU patients without cirrhosis or oHE. Plasma NfL and GFAP were measured using single molecule assays. RESULTS ICU oHE patients had higher NfL concentrations compared to pre-TIPS patients or ICU controls (p < 0.05, each). Median GFAP concentrations were equal in the ICU oHE and pre-TIPS patients or ICU controls. Plasma NfL and GFAP concentrations correlated with Model for End-Stage Liver Disease (MELD) scores (R = 0.58 and R = 0.40, p < 0.001, each). CONCLUSIONS Plasma NfL deserves further evaluation as potential diagnostic biomarker for oHE and correlates with the MELD score.
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Affiliation(s)
- Koos de Wit
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam, The Netherlands
| | - Diederick J van Doorn
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam, The Netherlands
| | - Bregje Mol
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam, The Netherlands
| | - Lonneke A van Vught
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Center of Experimental and Molecular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Frederik Nevens
- Department of Gastroenterology and Hepatology, University Hospitals KU Leuven, Leuven, Belgium
| | - Ulrich Beuers
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam, The Netherlands
| | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam, The Netherlands
| | - Charlotte E Teunissen
- Neurochemistry Laboratory, Department of Clinical Chemistry, Amsterdam Neuroscience, Neurodegeneration, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - R Bart Takkenberg
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam, The Netherlands.
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van Munster KN, Mol B, Goet JC, van Munster SN, Weersma RK, de Vries AC, van der Meer AJ, Inderson A, Drenth JP, van Erpecum KJ, Boonstra K, Beuers U, Dijkgraaf MGW, Ponsioen CY. Disease burden in primary sclerosing cholangitis in the Netherlands: A long-term follow-up study. Liver Int 2023; 43:639-648. [PMID: 36328957 DOI: 10.1111/liv.15471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/31/2022] [Accepted: 10/19/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND & AIMS Primary sclerosing cholangitis (PSC) is a progressive, cholestatic liver disease which greatly impacts the lives of individuals. Burden of disease due to shortened life expectancy and impaired quality of life is ill-described. The aim of this study was to assess long-term disease burden in a large population-based registry with regard to survival, clinical course, quality adjusted life years (QALYs), medical consumption and work productivity loss. METHODS All PSC patients living in a geographically defined area covering ~50% of the Netherlands were included, together with patients from the three liver transplant centres. Survival was estimated by competing risk analysis. Proportional shortfall of QALYs during disease course was measured relative to a matched reference cohort using validated questionnaires. Work productivity loss and medical consumption were evaluated over time. RESULTS A total of 1208 patients were included with a median follow-up of 11.2 year. Median liver transplant-free survival was 21.0 years. Proportional shortfall of QALYs increased to 48% >25 years after diagnosis. Patients had on average 12.4 hospital contact days among which 3.17 admission days per year, annual medical costs were €12 169 and mean work productivity loss was 25%. CONCLUSIONS Our data quantify for the first time disease burden in terms of QALYs lost, clinical events, medical consumption, costs as well as work productivity loss, and show that all these are substantial and increase over time.
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Affiliation(s)
- Kim N van Munster
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, location AMC, Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, The Netherlands
| | - Bregje Mol
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, location AMC, Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, The Netherlands
| | - Jorn C Goet
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Sanne N van Munster
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, location AMC, Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, The Netherlands
| | - Rinse K Weersma
- Department of Gastroenterology and Hepatology, University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Annemarie C de Vries
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Adriaan J van der Meer
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Akin Inderson
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Joost P Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Karel J van Erpecum
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Kirsten Boonstra
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, location VUmc, Amsterdam Gastroenterology & Metabolism, Amsterdam, The Netherlands
| | - Ulrich Beuers
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, location AMC, Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, The Netherlands
| | - Marcel G W Dijkgraaf
- Department of Epidemiology and Data Science, Amsterdam University Medical Center, location University of Amsterdam, Amsterdam Public Health, Amsterdam, The Netherlands
| | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, location AMC, Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, The Netherlands
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Mol B, van Munster KN, Bogaards JA, Weersma RK, Inderson A, de Groof EJ, Rossen NGM, Ponsioen W, Turkenburg M, van Erpecum KJ, Poen AC, Spanier BWM, Beuers UHW, Ponsioen CY. Health-related quality of life in patients with primary sclerosing cholangitis: A longitudinal population-based cohort study. Liver Int 2023; 43:1056-1067. [PMID: 36779848 DOI: 10.1111/liv.15542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 02/09/2023] [Accepted: 02/10/2023] [Indexed: 02/14/2023]
Abstract
BACKGROUND & AIMS Data regarding health-related quality of life (HRQoL) in primary sclerosing cholangitis (PSC) are sparse and have only been studied cross-sectionally in a disease which runs a fluctuating and unpredictable course. We aim to describe HRQoL longitudinally by using repeated measurements in a population-based cohort. METHODS Every 3 months from May 2017 up to August 2020, patients received digital questionnaires at home. These included the EQ-5D, 5-D Itch, patient-based SCCAI and patient-based HBI. The SF-36, measuring HRQoL over eight dimensions as well as a physical component summary (PCS) and mental component summary (MCS) score, was sent annually. Data were compared with Dutch reference data and a matched IBD disease control from the population-based POBASIC cohort. Mixed-effects modelling was performed to identify factors associated with HRQoL. RESULTS Three hundred twenty-eight patients completed 2576 questionnaires. A significant reduction of small clinical relevance in several mean HRQoL scores was found compared with the Dutch reference population: 46.4 versus 48.0, p = .018 for PCS and 47.5 versus 50.5, p = .004 for MCS scores. HRQoL outcomes were significantly negatively associated with coexisting active IBD (PCS -12.2, p < .001 and MCS -12.0, p < .001), which was not the case in case of quiescent IBD. Decreasing HRQoL scores were also negatively associated with increasing age (PCS -0.1 per 10 years, p = .002), female sex (PCS -2.8, p < .001), diagnosis of AIH overlap (PCS -3.7, p = .059), end-stage liver disease (PCS -3.7, p = .015) and presence of itch (PCS -9.2, p < .001 and MCS -3.1, p = .078). The odds of reporting a clinically relevant reduction in EQ-5D scores showed seasonal variation, being lowest in summer (OR = 0.48 relative to spring, p = .037). In patients with liver transplant, HRQoL outcomes were comparable to the Dutch general population. CONCLUSIONS PSC patients report impaired HRQoL of small clinical relevance compared with the general population. After liver transplantation, HRQoL scores are at comparable levels to the general population. HRQoL scores are associated with potentially modifiable factors such as itch and IBD activity.
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Affiliation(s)
- Bregje Mol
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, Location AMC, Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, the Netherlands
| | - Kim N van Munster
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, Location AMC, Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, the Netherlands
| | - Johannes A Bogaards
- Department of Epidemiology and Data Science, Amsterdam University Medical Centre, location AMC, Amsterdam, the Netherlands
| | - Rinse K Weersma
- Department of Gastroenterology and Hepatology, University Medical Centre Groningen, Groningen, the Netherlands
| | - Akin Inderson
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - E Joline de Groof
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, Location AMC, Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, the Netherlands
| | - Noortje G M Rossen
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, Location AMC, Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, the Netherlands
| | - Willemijn Ponsioen
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, Location AMC, Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, the Netherlands
| | - Maud Turkenburg
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, Location AMC, Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, the Netherlands
| | - Karel J van Erpecum
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Alexander C Poen
- Department of Gastroenterology and Hepatology, Isala Hospital, Zwolle, the Netherlands
| | - B W Marcel Spanier
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Arnhem, the Netherlands
| | - Ulrich H W Beuers
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, Location AMC, Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, the Netherlands
| | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, Location AMC, Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, the Netherlands
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5
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Wessels C, Vollenhoven B, Hammarberg K, Lensen S, Mol B. O-200 Women’s understanding of their personal chance of success with IVF. Hum Reprod 2022. [DOI: 10.1093/humrep/deac105.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Study question
How well informed are Australian women who undergo In Vitro Fertilisation (IVF) about their treatment and their chances of having a baby?
Summary answer
Only one in four women accurately estimated their individual chance of success with IVF and most women overestimated their chance.
What is known already
IVF is the cornerstone of infertility treatment, and high quality, transparent and reliable treatment information is essential for patient-centred care. A recent review into IVF practice in Victoria, Australia has highlighted deficiencies in information-provision. Similar findings have also been reported internationally. An assessment of women’s understanding of various aspects of the treatment is needed to identify information gaps that should be addressed by clinicians. While limited knowledge about infertility and infertility treatment in the general population is well-documented, little is known about the level of knowledge about infertility treatment among women undergoing IVF treatment.
Study design, size, duration
We conducted an anonymous online survey of women who had started IVF since 2018 in Australia. The survey aimed to assess how well-informed women feel about their treatment, and was advertised on social media, enabling women from across Australia to participate. Responses were collected from 3 to 21 June 2021.
Participants/materials, setting, methods
The survey included questions on demographic characteristics and IVF history. It also asked how well-informed participants felt about their treatment, what they thought their chance of having a baby from one IVF treatment cycle was, how they rated their knowledge about chance of success, and about their experience of receiving IVF-related information. Participants’ beliefs about chance of success were compared with their chance as calculated by the Society for Assisted Reproductive Technology’s (SART) online calculator.
Main results and the role of chance
The survey was completed by 225 women. Only about a quarter (25.8%) of participants accurately estimated their chance of success within 20% relative to their SART calculated chance, and more than half (52.4%) overestimated their chance. Among women who rated their understanding of their chance of success as ‘high’ (7-10/10), less than one third (31.6%) accurately estimated their chance of success. Older age and having undergone several cycles were associated with women being more likely to overestimate their chance of success (odds ratios of 3.2 and 2.5, respectively). Ninety percent of women indicated that their preferred source of treatment information was a consultation with their doctor, despite many women reporting that doctors only explained the probability of having a baby with IVF moderately well (mean 5.9/10). Women also reported that they wished they had been given more realistic information about IVF and their chance of success. It is difficult to determine to what extent women’s lack of understanding of what is possible with IVF is due to poor information-provision by clinicians and the clinic, and how much can be explained by optimism bias.
Limitations, reasons for caution
The dissemination method precludes calculation of response rate, and it is not possible to know if participants are representative of all women undergoing IVF. There is inherent imprecision in the way understanding of chance of success was estimated. The potential impact of recall bias could neither be quantified nor excluded.
Wider implications of the findings
The poor understanding of personal chance of success amongst women undergoing IVF in Australia, highlights the need for systematic and evidence-based improvement in the way clinics inform patients about the probability of having a baby with IVF. Further research into how information-provision in IVF can be improved is needed.
Trial registration number
Not applicable
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Affiliation(s)
- C Wessels
- Monash University, Department of Obstetrics and Gynaecology , Melbourne, Australia
| | - B Vollenhoven
- Monash University, Department of Obstetrics and Gynaecology , Melbourne, Australia
| | - K Hammarberg
- Monash University, School of Public Health and Preventive Medicine - Global and Women's Health , Melbourne, Australia
| | - S Lensen
- University of Melbourne, Department of Obstetrics and Gynaecology , Parkville, Australia
| | - B Mol
- Monash University, Department of Obstetrics and Gynaecology , Melbourne, Australia
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Van Kessel M, Pham C, Tros R, Oosterhuis J, Kuchenbecker W, Bongers M, Mol B, Koks C. P-750 The cost-effectiveness of transvaginal hydrolaparoscopy versus hysterosalpingography in the work-up for subfertility. Hum Reprod 2022. [DOI: 10.1093/humrep/deac106.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Study question
Is transvaginal hydrolaparoscopy (THL) cost-effective compared to hysterosalpingography (HSG) in the work-up for subfertility in a population at low-risk for tubal pathology?
Summary answer
THL is cost-effective compared to HSG in a preselected group of women at low-risk of tubal pathology.
What is known already
Tubal pathology is a common cause of subfertility and tubal patency testing plays an important part in the work-up of the subfertile couple and the subsequent counseling for fertility treatment. THL is an out-patient procedure. After access through the pouch of Douglas, the tubes and pelvic cavity are directly observed using hydroflotation, whereas HSG is a radiographic evaluation of the uterine cavity and patency of the tubes with injection of contrast medium in the uterine cavity. Both methods are safe and feasible for subfertile women at low-risk of tubal pathology.
Study design, size, duration
We performed an economic analysis as part of a randomized controlled trial comparing THL and HSG in the work-up for subfertility. Women were eligible if they had an indication for evaluation of tubal patency. Primary outcome was a conception leading to live birth in 24 months. We randomly assigned 300 subfertile women to THL or HSG between May 2013 and October 2016.
Participants/materials, setting, methods
This study was performed in four Dutch teaching hospitals. The economic evaluation was performed from a health care perspective. Costs were either derived from literature or calculated. The mean costs and outcomes for each treatment group were compared. Costs were combined with effectiveness by calculating ICER, and bootstrap resampling was performed. We generated a cost-effectiveness plane and cost-effectiveness acceptability curves.
Main results and the role of chance
After 24 months of follow-up there was a 3% difference in live birth rate in favour of the THL group (58.5% in the THL group versus 55.4% in the HSG group (83/142 versus 82/148 difference 3.0% (95% CI: -8.3 – 14.4)). Multiple pregnancy and miscarriage rate were low and did not differ between groups. Ectopic pregnancy occurred in two women in the HSG group and not in the THL group. The mean cost was lower in the THL group, compared to the HSG group (THL group 4,927 EUR versus 5,197 EUR in the HSG group, difference -270 EUR). Although the costs of the diagnostic procedure itself were higher in the THL group (425 EUR versus 289 EUR, difference 136 EUR), the costs for fertility treatments are higher in the HSG group. The base case outcome is that THL costs less and is more effective than HSG, making THL the dominant strategy. The spread of the bootstrap indicates that there is uncertainty regarding the effectiveness of THL over HSG but less uncertainty regarding the cost difference between THL and HSG.
Limitations, reasons for caution
This trial was conducted in the Netherlands, using price calculations of the Dutch healthcare system in Euro’s. Since prices of fertility treatments and especially ART or fertility enhancing surgery can vary widely worldwide, it is possible that the outcomes of our study are not generalizable to other countries.
Wider implications of the findings
The findings of our trial suggest that in a preselected group of women with low risk for tubal pathology, a diagnostic strategy starting with THL is cost-effective compared to a diagnostic strategy starting with HSG in the workup for subfertility.
Trial registration number
NTR3462
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Affiliation(s)
- M Van Kessel
- Dr. Horacio E. Oduber Hospitaal, Obstetrics and gynecology , Oranjestad Aruba, The Netherlands
| | - C Pham
- Flinders Health and Medical Research Institute, College of Medicine & Public Health , Adelaide, Australia
| | - R Tros
- Amsterdam UMC, Obstetrics and gynecology , Amsterdam, The Netherlands
| | - J Oosterhuis
- St. Antonius Hospital, Obstetrics and gynecology , Nieuwegein, The Netherlands
| | - W Kuchenbecker
- Isala klinieken, Obstetrics and gynecology , Zwolle, The Netherlands
| | - M Bongers
- GROW – School for Oncology and Developmental Biology- Maastricht University Medical Centre, Obstetrics and gynecology , Maastricht, The Netherlands
| | - B Mol
- Monash University Monash Medical Centre, Obstetrics and gynecology , Clayton, Australia
| | - C Koks
- Maxima Medical Center, Obstetrics and Gynecology , Veldhoven, The Netherlands
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7
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Mazi M, Temple-Smith P, Mol B. P-743 Is the use of IVF in Australia appropriate? Hum Reprod 2022. [DOI: 10.1093/humrep/deac107.688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Study question
How often is ART treatment necessary and what is the true demand of ART treatment in Australia, as opposed to the published ART use?
Summary answer
The use of ART in Australia, as reported by ANZARD, exceeds the estimated demand of couples requiring ART treatment by 59%.
What is known already
ART has gained increasing attention over the years in high resourced settings allowing easier access to this technology. The use of IVF and ICSI has become a standard treatment for infertility, with Australia having a high utilisation rate of ART. During the last decade, infertility treatments have been applied to all types of infertility, including unexplained subfertility.
This trend has resulted in the possible over-treatment of couples that have a reasonable chance of natural conception. We used modelling to determine whether over- or under-servicing of ART is occurring.
Study design, size, duration
A model-based approach in which we estimated the annual demand for ART based on a calculated population suffering from infertility. This estimate number of couples requiring ART was then compared to Australia’s reported ART usage, to determine if over- or under-servicing is present in the country. The demand for ART was estimated using demographic data from the Australian New Zealand Assisted Reproduction Database (ANZARD), Australian government databases and literature.
Participants/materials, setting, methods
The initial assumptions included an estimate of the total infertile population in Australia based on demographic data, with an infertility rate of 10% or 16% (sensitivity) and the prevalence of infertility types obtained from literature. A treatment model was based on three categories (couples with “absolute indications requiring ART”, anovulatory and unexplained infertility).The sum of couples that conceived without ART and those unable to requiring ART was estimated and compared to the ANZARD report.
Main results and the role of chance
Following the model calculations and based on 305,800 live births and 15,150 ART deliveries, and assuming an infertility rate of 10%, the total infertile population was approximately 40,700 couples. It was estimated that an average of 27,300 couples was calculated to need ART treatment in Australia in 2019. Out of these couples, 58% indicated absolute indications for ART (including uni- and bilateral tubal obstruction and severe male infertility), 14% were couples with anovulatory infertility (couples diagnosed with ovulation disorders) and 28% were couples with ovulatory infertility (including couples suffering from endometriosis and unexplained infertility). The reported number from the ANZARD 2019 report stated that 46,000 couples underwent ART treatment in Australia (59% overuse), with approximately 81,000 completed ART cycles. When comparing the reported number with the estimated number of cycles from the model, we found a 68% overutilisation of ART in Australia.
When in the sensitivity analysis, the infertility rate for was adjusted to 16%, and it was estimated that 43,200 couples required ART treatment in Australia in 2019 which seems comparable to 46,000 people that actually received ART treatment in 2019 (6% overuse).
Limitations, reasons for caution
This model was developed using variables obtained from literature and the calculations were based on a hypothetical population. The model did not include possible combination of infertility causes that ART reports do, and if included, the estimated number of couples would be lower
Wider implications of the findings
Assuming infertility rates of 10% to 16%, Australia shows clear to limited overuse of IVF. Global ART schemes and funding policies need to be revisited to avoid ART overtreatment and to improve clinical pathways that direct the use of ART.
Trial registration number
Not applicable
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Affiliation(s)
- M Mazi
- School of Clinical Sciences- Monash University, Department of Obstetrics and Gynaecology , OAKLEIGH SOUTH, Australia
| | - P Temple-Smith
- Monash University, Department of Obstetrics and Gynaecology , Melbourne, Australia
| | - B Mol
- Monash University, Department of Obstetrics and Gynaecology , Melbourne, Australia
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8
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Solangon A, Van Wely M, Van Mello N, Mol B, Jurkovic D. P-400 Methotrexate versus expectant management for treatment of tubal ectopic pregnancy: an individual participant data meta-analysis (IPD-MA). Hum Reprod 2022. [DOI: 10.1093/humrep/deac107.377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Study question
Is medical management with methotrexate superior over expectant management in the resolution of tubal ectopic pregnancy in clinically stable women and low serum hCG?
Summary answer
In women with tubal ectopic pregnancy and low serum hCG, methotrexate was not better than expectant management. There were no subgroups benefiting from methotrexate.
What is known already
Women with tubal pregnancy who are clinically stable and have low hCG concentrations can be treated medically with methotrexate, an anti-folate drug that has a range of adverse effects and requires women to avoid conceiving three months after administration due to teratogenic effects. Expectant management with close monitoring is as effective compared to methotrexate in this subgroup of women. There are three randomised controlled trials (RCTs) not showing a statistically significant difference in uneventful resolution of ectopic pregnancy between methotrexate and expectant management. These studies were too small to define if certain subgroups could benefit from either treatment.
Study design, size, duration
We performed an individual participant data meta-analysis (IPD-MA) of RCTs based on a search of international scientific databases. We selected RCTs comparing methotrexate and expectant management in women with suspected tubal ectopic pregnancy. The primary outcome was treatment success, defined as resolution of clinical symptoms and decline in level of serum hCG to < 20 IU/L or a negative urine pregnancy test by the initial intervention strategy, without any additional treatment.
Participants/materials, setting, methods
Analyses were performed on an intention-to-treat basis. A one-stage IPDMA was performed to assess overall treatment effects of methotrexate and expectant management to generate a pooled intervention effect. This included a random intercept (for baseline differences between studies) and random slope (for differences in treatment effect between studies). A log-binomial model for dichotomous outcomes yielded a risk ratio (RR) with 95% confidence interval (CI). Subgroup analyses were undertaken according to baseline serum β-hCG levels.
Main results and the role of chance
We obtained data from two relevant trials reporting on 153 women with suspected tubal ectopic pregnancy who were randomised to expectant management or methotrexate. The third RCT was excluded as their inclusion criteria required declining titres of hCG 48 hours prior to treatment.
The success rate was 65/82 (79.3%) after methotrexate and 48/70 (68.6%) after expectant management (IPD RR 1.16, 95%CI 0.71-2.38). 9/82 (11%) in the methotrexate group and 9/70 (12.8%) after expectant required additional methotrexate. 8/82 (9.8%) in the methotrexate group and 13/70 (18.6%) in the expectant group required surgical intervention (RR 0.65, 95%CI 0.66-3.54). The mean time to success was 21.2 days (95%CI 17.4 to 25.6) after expectant management and 19.7 days (95%CI 17.1-22.2) after methotrexate (p = 0.25).
There was no interaction with treatment of maternal age, parity, previous ectopic pregnancy, and serum β-hCG on success rate. Serum hCG <1000 IU/l was associated with a higher success rate in both groups. Only one woman in the expectant group required a blood transfusion. Methotrexate users had side effects (N = 7/49) including vomiting, diarrhoea, mucositis, conjunctivitis and photosensitivity that were not seen in the expectant group (N = 0/49).
Limitations, reasons for caution
One of the trials had a higher proportion of pregnancy of unknown location (PUL) which were presumed to be tubal ectopic pregnancies due to plateauing serum hCG levels and caution is therefore advised on the application of these findings to ectopic pregnancies visualised on ultrasound.
Wider implications of the findings
Initial expectant management might be the preferred strategy for women with suspected tubal ectopic pregnancy in clinically stable women with lower hCG levels in view of less adverse effects, less cost and enabling women who wish to conceive soon after resolution of ectopic pregnancy to do so.
Trial registration number
Prospero ID: CRD42021214093
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Affiliation(s)
- A Solangon
- University College London Hospital, Gynaecology Diagnostics and Treatment Unit , London, United Kingdom
- University College London, Institute for Women's Health , London, United Kingdom
| | - M Van Wely
- Amsterdam Universitair Medische Centra, Center for Reproductive Medicine , Amsterdarm, The Netherlands
| | - N Van Mello
- Amsterdam Universitair Medische Centra, Center for Reproductive Medicine , Amsterdarm, The Netherlands
| | - B Mol
- Monash University, Monash Medical Centre , Victoria, Australia
| | - D Jurkovic
- University College London Hospital, Gynaecology Diagnostics and Treatment Unit , London, United Kingdom
- University College London, Institute for Women's Health , London, United Kingdom
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9
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Hammond E, Liu Y, Xu F, Liu G, Xi H, Xue L, Bai X, Liao H, Xue S, Zhao S, Zhang A, Kemper J, Afnan M, Mol B, Morbeck D. P–138 When is low quality really low? Should we transfer low-grade blastocysts? Hum Reprod 2021. [DOI: 10.1093/humrep/deab130.137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Study question
What is the live birth rate after single, low-grade blastocyst (LGB) transfer?
Summary answer
The live birth rate for LGBs is 28%, ranging between 15–31% for the different inner cell mass (ICM) and trophectoderm (TE) subgroups of LGBs.
What is known already
Live birth rates following LGB transfer are varied and have been reported to be in the range of 5–39%. However, these estimates are inaccurate as studies investigating live birth rates following LGB transfer are inherently limited by sample size (n = 10–440 for LGB transfers) due to LGBs being ranked last for transfer. Further, these studies are heterogenous with varied LGB definitions and design. Collating LGB live birth data from multiple clinics is warranted to obtain sufficient numbers of LGB transfers to establish reliable live birth rates, and to allow for delineation of different LGB subgroups, including blastocyst age and female age.
Study design, size, duration
We performed a multicentre, multinational retrospective cohort study in 9 IVF centres in China and New Zealand from 2012 to 2019. We studied the outcome of 6966 single blastocyst transfer cycles on days 5–7 (fresh and frozen) according to blastocyst grade, including 875 transfers from LGBs (<3bb, this being the threshold typically applied to LGB studies). Blastocysts with expansion stage 1 or 2 (early blastocysts) were excluded.
Participants/materials, setting, methods
The main outcome measured was live birth rate. Blastocysts were grouped according to quality grade: good-grade blastocysts (GGBs; n = 3849, aa, ab and ba), moderate-grade blastocysts (MGBs; n = 2242, bb) and LGBs (n = 875, ac, ca, bc, cb and cc) and live birth rates compared using the Pearson Chi-squared test. A logistic regression analysis explored the relationship between blastocyst grade and live birth after adjustment for the confounders: clinic, female age, expansion stage, and blastocyst age.
Main results and the role of chance
The live birth rates for GGBs, MGBs and LGBs were 45%, 36% and 28% respectively (p < 0.0001). Within the LGB group, the highest live birth rates were for grade c TE (30%) and the lowest were for grade c ICM (19%). The lowest combined grade (cc) maintained a 15% live birth rate (n = 7/48). After accounting for confounding factors, including female age and blastocyst characteristics, the odds of live birth were 2.33 (95% CI = 1.88–2.89) for GGBs compared to LGBs and 1.56 (95% CI = 1.28–1.92) for MGBs compared to LGBs following fresh and frozen blastocyst transfers (p < 0.0001, odds ratios confirmed in exclusively frozen blastocyst transfer cycles). When stratified by individual ICM and TE grade, the odds of live birth according to ICM grade were 1.31 (a versus b; 95% CI = 1.15–1.48), 2.82 (a versus c; 95% CI = 1.91–4.18) and 2.16 (b versus c; 95% CI = 1.48–3.16; all p < 0.0001). The odds of live birth according to TE grade were 1.33 (a versus b; 95% CI = 1.17–1.50, p < 0.0001), 1.85 (a versus c; 95% CI = 1.45–2.34, p < 0.0001) and 1.39 (b versus c; 95% CI = 1.12–1.73, p = 0.0024).
Limitations, reasons for caution
Despite the large multicentre design of the study, analyses of transfers occurring within the smallest subsets of the LGB group were limited by sample size. The study was not randomised and had a retrospective character.
Wider implications of the findings: LGBs maintain satisfactory live birth rates (averaging 28%) in the general IVF population. Even those in the lowest grading tier maintain modest live birth rates (15%; cc). It is recommended that LGBs not be universally discarded, and instead considered for subsequent frozen embryo transfer to maximize cumulative live birth rates.
Trial registration number
Not applicable
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Affiliation(s)
- E Hammond
- Fertility Associates, Embryology, Auckland, New Zealand
| | - Y Liu
- Monash IVF Group- Southport- Australia, Embryology, Queensland, Australia
| | - F Xu
- Tianjin First Central Hospital, Reproductive Medicine Center, Tianjin, China
| | - G Liu
- Tianjin Aiwei Hospital, Reproductive Center, Tianjin, China
| | - H Xi
- The second affiliated hospital of WenZhou Medical University, Department of Obstetrics and Gynecology, Wenzhou, China
| | - L Xue
- People’s Hospital of Guangxi Zhuang Autonomous Region, Reproductive Medical and Genetic Center, Nanning, China
| | - X Bai
- General Hospital of Tianjin Medical University, Department of Obstetrics and Gynecology, Tianjin, China
| | - H Liao
- The second affiliated hospital of South China University, Reproductive Medicine Center, Hengyang, China
| | - S Xue
- Shanghai East Hospital, Department of Assisted Reproduction, Shanghai, China
| | - S Zhao
- Zaozhuang Maternal and Child Health Care, Reproductive Center, Zaozhuang, China
| | - A Zhang
- Reproductive Medical Center of Ruijin Hospital- School of Medicine- Shanghai Jiao Tong University, Reproductive Medical Center, Shanghai, China
| | - J Kemper
- Monash Women’s- Monash Health- Clayton- Australia, Department of obstetrics and gynaecology, Melbourne, Australia
| | - M Afnan
- Qingdao United Family Hospital- Qingdao- China, Obstetrics and Gynecology, Qingdao, China
| | - B Mol
- Monash Women’s- Monash Health- Clayton- Australia, Obstetrics & Gynaecology Monash Health, Melbourne, Australia
| | - D Morbeck
- Fertility Associates, Embryology, Auckland, New Zealand
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10
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Ho T, Pham T, Le K, Ly T, Le H, Nguyen D, Ho V, Dang V, Phung T, Norman R, Mol B, Vuong L. O-233 Micronized progesterone plus dydrogesterone versus micronized progesterone alone for luteal phase support in frozen-thawed cycles: a prospective cohort study. Hum Reprod 2021. [DOI: 10.1093/humrep/deab128.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Study question
Does the addition of oral dydrogesterone to vaginal progesterone as luteal phase support improve pregnancy outcomes during frozen embryo transfer (FET) cycles compared with vaginal progesterone alone?
Summary answer
Luteal phase support with oral dydrogesterone added to vaginal progesterone improves live birth rates and reduces miscarriage rates compared with vaginal progesterone alone.
What is known already
Progesterone is an important hormone that triggers secretory transformation of the endometrium to allow implantation of the embryo. During in vitro fertilization (IVF), exogenous progesterone is administered for luteal phase support. However, there is wide inter-individual variation in absorption of progesterone via the vaginal wall. Oral dydrogesterone is effective and well tolerated when used to provide luteal phase support after fresh embryo transfer. However, there are currently no data on the effectiveness of luteal phase support with the combination of dydrogesterone with vaginal micronized progesterone compared with vaginal micronized progesterone after FET.
Study design, size, duration
Prospective cohort study conducted at an academic infertility center in Vietnam from 26 June 2019 to 30 March 2020.
Participants/materials, setting, methods
We studied 1364 women undergoing IVF with FET. The luteal support regimen was either vaginal micronized progesterone 400 mg twice daily plus oral dydrogesterone 10 mg twice daily (second part of the study) or vaginal micronized progesterone 400 mg twice daily (first 4 months of the study). The primary endpoint was live birth after the first FET of the started cycle, with miscarriage <12 weeks as one of the secondary endpoints.
Main results and the role of chance
The vaginal progesterone + dydrogesterone group and vaginal progesterone groups included 732 and 632 participants, respectively. Live birth rates were 46.3% versus 41.3%, respectively (rate ratio [RR] 1.12, 95% confidence interval [CI] 0.99–1.27, p = 0.06; multivariate analysis RR 1.30 (95% CI 1.01–1.68), p = 0.042), with a statistically significant lower rate of miscarriage at < 12 weeks (3.4% vs 6.6%; RR 0.51, 95% CI 0.32–0.83; p = 0.009). Birth weight of both singletons (2971.0 ± 628.4 vs. 3118.8 ± 559.2 g; p = 0.004) and twins (2175.5 ± 494.8 vs. 2494.2 ± 584.7; p = 0.002) was significantly lower in the progesterone plus dydrogesterone versus progesterone group.
Limitations, reasons for caution
The study were the open-label design and the non-randomized nature of the sequential administration of study treatments. However, our systematic comparison of the two strategies was able to be performed much more rapidly than a conventional randomized controlled trial. In addition, the single ethnicity population limits external generalizability.
Wider implications of the findings
Oral dydrogesterone in addition to vaginal progesterone as luteal phase support in FET cycles can reduce the miscarriage rate and improve the live birth rate. Carefully planned prospective cohort studies with limited bias could be used as an alternative to randomized controlled clinical trials to inform clinical practice.
Trial registration number
NCT03998761
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Affiliation(s)
- T Ho
- My Duc Hospital, IVFMD and HOPE Research Center, Ho Chi Minh, Vietnam
| | - T Pham
- My Duc Hospital, HOPE Research Center, Ho Chi Minh, Vietnam
| | - K Le
- My Duc Hospital, IVFMD Centre, Ho Chi Minh, Vietnam
| | - T Ly
- My Duc Hospital, IVFMD Centre, Ho Chi Minh, Vietnam
| | - H Le
- My Duc Hospital, IVFMD Centre, Ho Chi Minh, Vietnam
| | - D Nguyen
- My Duc Hospital, HOPE Research Center, Ho Chi Minh, Vietnam
| | - V Ho
- My Duc Hospital, IVFMD and HOPE Research Center, Ho Chi Minh, Vietnam
| | - V Dang
- My Duc Hospital, IVFMD and HOPE Research Center, Ho Chi Minh, Vietnam
| | - T Phung
- My Duc Hospital, IVFMD Centre, Ho Chi Minh, Vietnam
| | - R Norman
- The University of Adelaide, Robinson Research Institute and Adelaide Medical School, Adelaide, Australia
| | - B Mol
- Monash University, Department of Obstetrics & Gynaecology, Clayton, Australia
| | - L Vuong
- University of Medicine and Pharmacy at Ho Chi Minh City, Department of Obstetrics and Gynecology, Ho Chi Minh City, Vietnam
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11
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Townsend R, Sileo FG, Allotey J, Dodds J, Heazell A, Jorgensen L, Kim VB, Magee L, Mol B, Sandall J, Smith G, Thilaganathan B, von Dadelszen P, Thangaratinam S, Khalil A. Prediction of stillbirth: an umbrella review of evaluation of prognostic variables. BJOG 2020; 128:238-250. [PMID: 32931648 DOI: 10.1111/1471-0528.16510] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Stillbirth accounts for over 2 million deaths a year worldwide and rates remains stubbornly high. Multivariable prediction models may be key to individualised monitoring, intervention or early birth in pregnancy to prevent stillbirth. OBJECTIVES To collate and evaluate systematic reviews of factors associated with stillbirth in order to identify variables relevant to prediction model development. SEARCH STRATEGY MEDLINE, Embase, DARE and Cochrane Library databases and reference lists were searched up to November 2019. SELECTION CRITERIA We included systematic reviews of association of individual variables with stillbirth without language restriction. DATA COLLECTION AND ANALYSIS Abstract screening and data extraction were conducted in duplicate. Methodological quality was assessed using AMSTAR and QUIPS criteria. The evidence supporting association with each variable was graded. RESULTS The search identified 1198 citations. Sixty-nine systematic reviews reporting 64 variables were included. The most frequently reported were maternal age (n = 5), body mass index (n = 6) and maternal diabetes (n = 5). Uterine artery Doppler appeared to have the best performance of any single test for stillbirth. The strongest evidence of association was for nulliparity and pre-existing hypertension. CONCLUSION We have identified variables relevant to the development of prediction models for stillbirth. Age, parity and prior adverse pregnancy outcomes had a more convincing association than the best performing tests, which were PAPP-A, PlGF and UtAD. The evidence was limited by high heterogeneity and lack of data on intervention bias. TWEETABLE ABSTRACT Review shows key predictors for use in developing models predicting stillbirth include age, prior pregnancy outcome and PAPP-A, PLGF and Uterine artery Doppler.
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Affiliation(s)
- R Townsend
- Molecular and Clinical Sciences Research Institute, St George's, University of London and St George's University Hospitals NHS Foundation Trust, London, UK.,Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - F G Sileo
- Molecular and Clinical Sciences Research Institute, St George's, University of London and St George's University Hospitals NHS Foundation Trust, London, UK.,Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - J Allotey
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.,Pragmatic Clinical Trials Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - J Dodds
- Pragmatic Clinical Trials Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Centre for Women's Health, Institute of Population Health Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - A Heazell
- St Mary's Hospital, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, UK.,Faculty of Biology, Medicine and Health, Maternal and Fetal Health Research Centre, School of Medical Sciences, University of Manchester, Manchester, UK
| | | | - V B Kim
- The Robinson Institute, University of Adelaide, Adelaide, SA, Australia
| | - L Magee
- Faculty of Life Sciences and Medicine, School of Life Course Sciences, King's College London, London, UK
| | - B Mol
- Department of Obstetrics and Gynaecology, School of Medicine, Monash University, Melbourne, Vic., Australia
| | - J Sandall
- Health Service and Population Research Department, Centre for Implementation Science, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,Department of Women and Children's Health, Faculty of Life Sciences & Medicine, School of Life Course Sciences, King's College London, St Thomas' Hospital, London, UK
| | - Gcs Smith
- Department of Obstetrics and Gynaecology, University of Cambridge, NIHR Cambridge Biomedical Research Centre, Cambridge, UK.,Department of Physiology, Development and Neuroscience, Centre for Trophoblast Research (CTR), University of Cambridge, Cambridge, UK
| | - B Thilaganathan
- Molecular and Clinical Sciences Research Institute, St George's, University of London and St George's University Hospitals NHS Foundation Trust, London, UK.,Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - P von Dadelszen
- Faculty of Life Sciences and Medicine, School of Life Course Sciences, King's College London, London, UK
| | - S Thangaratinam
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.,Pragmatic Clinical Trials Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - A Khalil
- Molecular and Clinical Sciences Research Institute, St George's, University of London and St George's University Hospitals NHS Foundation Trust, London, UK.,Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
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12
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Stevens TW, Haasnoot ML, D'Haens GR, Buskens CJ, de Groof EJ, Eshuis EJ, Gardenbroek TJ, Mol B, Stokkers PCF, Bemelman WA, Ponsioen CY. Laparoscopic ileocaecal resection versus infliximab for terminal ileitis in Crohn's disease: retrospective long-term follow-up of the LIR!C trial. Lancet Gastroenterol Hepatol 2020; 5:900-907. [PMID: 32619413 DOI: 10.1016/s2468-1253(20)30117-5] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 04/02/2020] [Accepted: 04/03/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND The LIR!C trial showed that laparoscopic ileocaecal resection is a cost-effective treatment that has similar quality-of-life outcomes to treatment with infliximab, an anti-tumour necrosis factor (TNF) drug. We aimed to compare long-term outcomes of both interventions and identify baseline factors associated with the duration of treatment effect in each group. METHODS In this retrospective follow-up study, we collected data from patients who participated in the LIR!C trial, a multicentre randomised controlled trial that compared quality of life after surgical resection versus infliximab in adult patients with non-stricturing and immunomodulator-refractory ileocaecal Crohn's disease. From Jan 1 to May 1, 2018, we collected follow-up data from the time from enrolment in the LIR!C trial until the last visit at either the gastrointestinal surgeon or gastroenterologist. In this study, outcomes of interest were need for surgery or repeat surgery or anti-TNF therapy, duration of treatment effect, and identification of factors associated with the duration of treatment effect. Duration of treatment effect was defined as the time without need for additional Crohn's disease-related treatment (corticosteroids, immunomodulators, biologics, or surgery). FINDINGS We collected long-term follow-up data for 134 (94%) of 143 patients included in the LIR!C trial, of whom 69 were in the resection group and 65 were in the infliximab group. Median follow-up was 63·5 months (IQR 39·0-94·5). In the resection group, 18 (26%) of 69 patients started anti-TNF therapy and none required a second resection. 29 (42%) patients in the resection group did not require additional Crohn's disease-related medication, although 14 (48%) of these patients were given prophylactic immunomodulator therapy. In the infliximab group, 31 (48%) of 65 patients had a Crohn's disease-related resection, and the remaining 34 patients maintained, switched, or escalated their anti-TNF therapy. Duration of treatment effect was similar in both groups, with a median time without additional Crohn's disease-related treatment of 33·0 months (95% CI 15·1-50·9) in the resection group and 34·0 months (0·0-69·3) in the infliximab group (log-rank p=0·52). In both groups, therapy with an immunomodulator, in addition to the allocated treatment, was associated with duration of treatment effect (hazard ratio for resection group 0·34 [95% CI 0·16-0·69] and for infliximab group 0·49 [0·26-0·93]). INTERPRETATION These findings further support laparoscopic ileocaecal resection as a treatment option in patients with Crohn's disease with limited (affected segment ≤40 cm) and predominantly inflammatory terminal ileitis for whom conventional treatment is not successful. FUNDING None.
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Affiliation(s)
- Toer W Stevens
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Maria L Haasnoot
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Geert R D'Haens
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Christianne J Buskens
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - E Joline de Groof
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Emma J Eshuis
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Tjibbe J Gardenbroek
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Bregje Mol
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Pieter C F Stokkers
- Department of Gastroenterology and Hepatology, OLVG West, Amsterdam, Netherlands
| | - Willem A Bemelman
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.
| | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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13
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de Groof EJ, Stevens TW, Eshuis EJ, Gardenbroek TJ, Bosmans JE, van Dongen JM, Mol B, Buskens CJ, Stokkers PCF, Hart A, D'Haens GR, Bemelman WA, Ponsioen CY. Cost-effectiveness of laparoscopic ileocaecal resection versus infliximab treatment of terminal ileitis in Crohn's disease: the LIR!C Trial. Gut 2019; 68:1774-1780. [PMID: 31233395 DOI: 10.1136/gutjnl-2018-317539] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 12/27/2018] [Accepted: 01/04/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Evaluate the cost-effectiveness of laparoscopic ileocaecal resection compared with infliximab in patients with ileocaecal Crohn's disease failing conventional therapy. DESIGN A multicentre randomised controlled trial was performed in 29 centres in The Netherlands and the UK. Adult patients with Crohn's disease of the terminal ileum who failed >3 months of conventional immunomodulators or steroids without signs of critical strictures were randomised to laparoscopic ileocaecal resection or infliximab. Outcome measures included quality-adjusted life-years (QALYs) based on the EuroQol (EQ) 5D-3L Questionnaire and the Inflammatory Bowel Disease Questionnaire (IBDQ). Costs were measured from a societal perspective. Analyses were performed according to the intention-to-treat principle. Missing cost and effect data were imputed using multiple imputation. Cost-effectiveness planes and cost-effectiveness acceptability curves were estimated to show uncertainty. RESULTS In total, 143 patients were randomised. Mean Crohn's disease total direct healthcare costs per patient at 1 year were lower in the resection group compared with the infliximab group (mean difference €-8931; 95% CI €-12 087 to €-5097). Total societal costs in the resection group were lower than in the infliximab group, however not statistically significant (mean difference €-5729, 95% CI €-10 606 to €172). The probability of resection being cost-effective compared with infliximab was 0.96 at a willingness to pay (WTP) of €0 per QALY gained and per point improvement in IBDQ Score. This probability increased to 0.98 at a WTP of €20 000/QALY gained and 0.99 at a WTP of €500/point of improvement in IBDQ Score. CONCLUSION Laparoscopic ileocaecal resection is a cost-effective treatment option compared with infliximab. CLINICAL TRIAL REGISTRATION NUMBER Dutch Trial Registry NTR1150; EudraCT number 2007-005042-20 (closed on 14 October 2015).
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Affiliation(s)
- E Joline de Groof
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Toer W Stevens
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Emma J Eshuis
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Tjibbe J Gardenbroek
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Judith E Bosmans
- Department of Health Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - J M van Dongen
- Department of Health Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Bregje Mol
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Christianne J Buskens
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Pieter C F Stokkers
- Department of Gastroenterology and Hepatology, OLVG West, Amsterdam, The Netherlands
| | - Ailsa Hart
- Faculty of Medicine, Department of Surgery & Cancer, APRG, Imperial College, London, UK.,IBD Unit, St. Mark's Hospital, London, UK
| | - Geert R D'Haens
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Willem A Bemelman
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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14
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Reddy M, Costa FDS, Mol B. The COLLECT database: momentum to improve our research standards, methods, and culture. BJOG 2018; 126:11. [PMID: 30288883 DOI: 10.1111/1471-0528.15487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- M Reddy
- Department of Obstetrics and Gynaecology, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing, and Health Sciences, Monash University, Clayton, Vic., Australia
| | - F da Silva Costa
- Department of Obstetrics and Gynaecology, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing, and Health Sciences, Monash University, Clayton, Vic., Australia.,Department of Gynaecology and Obstetrics, Ribeirão Preto Medical School, Ribeirão Preto, São Paulo, Brazil
| | - B Mol
- Department of Obstetrics and Gynaecology, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing, and Health Sciences, Monash University, Clayton, Vic., Australia
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Ponsioen CY, de Groof EJ, Eshuis EJ, Gardenbroek TJ, Bossuyt PMM, Hart A, Warusavitarne J, Buskens CJ, van Bodegraven AA, Brink MA, Consten ECJ, van Wagensveld BA, Rijk MCM, Crolla RMPH, Noomen CG, Houdijk APJ, Mallant RC, Boom M, Marsman WA, Stockmann HB, Mol B, de Groof AJ, Stokkers PC, D'Haens GR, Bemelman WA. Laparoscopic ileocaecal resection versus infliximab for terminal ileitis in Crohn's disease: a randomised controlled, open-label, multicentre trial. Lancet Gastroenterol Hepatol 2017; 2:785-792. [PMID: 28838644 DOI: 10.1016/s2468-1253(17)30248-0] [Citation(s) in RCA: 164] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 07/09/2017] [Accepted: 07/24/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Treatment of patients with ileocaecal Crohn's disease who have not responded to conventional therapy is commonly scaled up to biological agents, but surgery can also offer excellent short-term and long-term results. We compared laparoscopic ileocaecal resection with infliximab to assess how they affect health-related quality of life. METHODS In this randomised controlled, open-label trial, in 29 teaching hospitals and tertiary care centres in the Netherlands and the UK, adults with non-stricturing, ileocaecal Crohn's disease, in whom conventional therapy has failed were randomly allocated (1:1) by an internet randomisation module with biased-coin minimisation for participating centres and perianal fistula to receive laparoscopic ileocaecal resection or infliximab. Eligible patients were aged 18-80 years, had active Crohn's disease of the terminal ileum, and had not responded to at least 3 months of conventional therapy with glucocorticosteroids, thiopurines, or methotrexate. Patients with diseased terminal ileum longer than 40 cm or abdominal abscesses were excluded. The primary outcome was quality of life on the Inflammatory Bowel Disease Questionnaire (IBDQ) at 12 months. Secondary outcomes were general quality of life, measured by the Short Form-36 (SF-36) health survey and its physical and mental component subscales, days unable to participate in social life, days on sick leave, morbidity (additional procedures and hospital admissions), and body image and cosmesis. Analyses of the primary outcome were done in the intention-to-treat population, and safety analyses were done in the per-protocol population. This trial is registered at the Dutch Trial Registry (NTR1150). FINDINGS Between May 2, 2008, and October 14, 2015, 73 patients were allocated to have resection and 70 to receive infliximab. Corrected for baseline differences, the mean IBDQ score at 12 months was 178·1 (95% CI 171·1-185·0) in the resection group versus 172·0 (164·3-179·6) in the infliximab group (mean difference 6·1 points, 95% CI -4·2 to 16·4; p=0·25). At 12 months, the mean SF-36 total score was 112·1 (95% CI 108·0-116·2) in the resection group versus 106·5 (102·1-110·9) in the infliximab group (mean difference 5·6, 95% CI -0·4 to 11·6), the mean physical component score was 47·7 (45·7-49·7) versus 44·6 (42·5-46·8; mean difference 3·1, 4·2 to 6·0), and the mean mental component score was 49·5 (47·0-52·1) versus 46·1 (43·3-48·9; mean difference 3·5, -0·3 to 7·3). Mean numbers of days of sick leave were 3·4 days (SD 7·1) in the resection group versus 1·4 days (4·7) in the infliximab group (p<0·0001), days not able to take part in social life were 1·8 days (6·3) versus 1·1 days (4·5; p=0·20), days of scheduled hospital admission were 6·5 days (3·8) versus 6·8 days (3·2; p=0·84), and the number of patients who had unscheduled hospital admissions were 13 (18%) of 73 versus 15 (21%) of 70 (p=0·68). Body-image scale mean scores in the patients who had resection were 16·0 (95% CI 15·2-16·8) at baseline versus 17·8 (17·1-18·4) at 12 months, and cosmetic scale mean scores were 17·6 (16·6-18·6) versus 18·6 (17·6-19·6). Surgical intervention-related complications classified as IIIa or worse on the Clavien-Dindo scale occurred in four patients in the resection group. Treatment-related serious adverse events occurred in two patients in the infliximab group. During a median follow-up of 4 years (IQR 2-6), 26 (37%) of 70 patients in the infliximab group had resection, and 19 (26%) of 73 patients in the resection group received anti-TNF. INTERPRETATION Laparoscopic resection in patients with limited (diseased terminal ileum <40 cm), non-stricturing, ileocaecal Crohn's disease in whom conventional therapy has failed could be considered a reasonable alternative to infliximab therapy. FUNDING Netherlands Organisation for Health Research and Development.
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Affiliation(s)
- Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, Netherlands
| | - E Joline de Groof
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, Netherlands; Department of Surgery, Academic Medical Centre, Amsterdam, Netherlands
| | - Emma J Eshuis
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, Netherlands
| | | | - Patrick M M Bossuyt
- Department of Clinical Epidemiology and Biostatistics, Academic Medical Centre, Amsterdam, Netherlands
| | - Ailsa Hart
- Inflammatory Bowel Disease Unit, St Mark's Hospital, London, UK
| | | | | | - Ad A van Bodegraven
- Department of Gastroenterology and Hepatology, Zuyderland Hospital, Sittard, Netherlands; VU University Medical Centre, Amsterdam, Netherlands
| | - Menno A Brink
- Department of Gastroenterology and Hepatology, Meander Medical Centre, Amersfoort, Netherlands
| | | | | | - Marno C M Rijk
- Department of Gastroenterology and Hepatology, Amphia Hospital, Breda, Netherlands
| | | | - Casper G Noomen
- Department of Gastroenterology and Hepatology, Medical Centre Alkmaar, Alkmaar, Netherlands
| | | | - Rosalie C Mallant
- Department of Gastroenterology and Hepatology, Flevo Hospital, Almere, Netherlands
| | - Maarten Boom
- Department of Surgery, Flevo Hospital, Almere, Netherlands
| | - Willem A Marsman
- Department of Gastroenterology, Kennemer Gasthuis, Haarlem, Netherlands
| | | | - Bregje Mol
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, Netherlands
| | - A Jeroen de Groof
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, Netherlands
| | - Pieter C Stokkers
- Department of Gastroenterology and Hepatology, OLVG West, Amsterdam, Netherlands
| | - Geert R D'Haens
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, Netherlands
| | - Willem A Bemelman
- Department of Surgery, Academic Medical Centre, Amsterdam, Netherlands.
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Lan L, Misso M, Harrison C, Hill B, Teede H, Mol B, Moran L. Systematic review and meta-analysis of the impact of preconception lifestyle interventions in females and males. Journal of Nutrition & Intermediary Metabolism 2017. [DOI: 10.1016/j.jnim.2017.04.187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Duffy JMN, Bhattacharya S, Herman M, Mol B, Vail A, Wilkinson J, Farquhar C. Reducing research waste in benign gynaecology and fertility research. BJOG 2017; 124:366-369. [DOI: 10.1111/1471-0528.14438] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2016] [Indexed: 01/08/2023]
Affiliation(s)
- JMN Duffy
- Balliol College University of Oxford Oxford UK
- Primary Care Health Sciences University of Oxford Oxford UK
| | - S Bhattacharya
- The Institute of Applied Health Sciences University of Aberdeen Aberdeen UK
| | - M Herman
- Department of Obstetrics and Gynaecology Máxima Medical Centre Veldhoven the Netherlands
| | - B Mol
- Robinson Research Institute University of Adelaide Adelaide SA Australia
| | - A Vail
- Centre for Biostatistics University of Manchester Manchester UK
| | - J Wilkinson
- Centre for Biostatistics University of Manchester Manchester UK
| | - C Farquhar
- Cochrane Gynecology and Fertility Group University of Auckland Auckland New Zealand
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Kersten F, Nelen W, Goddijn M, Braat D, Mol B, Hermens R. P198 Adherence To Infertility Guidelines With Regard To Treatment Policy. BMJ Qual Saf 2013. [DOI: 10.1136/bmjqs-2013-002293.202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Pariente-Khayat A, Conard J, Lemardeley G, Merlet F, Creusvaux H, Bissonnette F, Phillips S, Holzer H, Mahutte N, St-Michel P, Gunby J, Kadoch IJ, Wetzels A, Hendriks J, Cleine J, Curfs M, Kastrop P, Consten D, Woodward BJ, Norton WJ, Almeida P, Gilling-Smith C, Mol B, Van den Boogaard NM, Bruhl SW, Hompes PGA, Kremer JAM, Van der Veen F, Nelen WLDM, Emerson G, Hughes C, Mocanu E, Halliday J, Wilson C, Fisher JR, Hammarberg K, Sanson A, McBain J, McLachlan R. SELECTED ORAL COMMUNICATION SESSION, SESSION 71: QUALITY MANAGEMENT IN ART Wednesday 6 July 201114:00 - 15:45. Hum Reprod 2011. [DOI: 10.1093/humrep/26.s1.71] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Iyengar S, Koopmans C, Zamora J, Ismail K, Mol B, Kalid K, Thangaratinam S. O406 Accuracy of liver function tests in predicting maternal and fetal complications in women with pre-eclampsia: A systematic review. Int J Gynaecol Obstet 2009. [DOI: 10.1016/s0020-7292(09)60779-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Oates-Whitehead RM, D'Angelo A, Mol B. WITHDRAWN: Anticoagulant and aspirin prophylaxis for preventing thromboembolism after major gynaecological surgery. Cochrane Database Syst Rev 2007; 2010:CD003679. [PMID: 17636729 PMCID: PMC10680427 DOI: 10.1002/14651858.cd003679.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The reported overall risk of deep venous thrombosis in gynaecological surgery ranges from 7 to 45%. Fatal pulmonary embolism is estimated to occur in nearly 1% of these women. Pharmaceutical interventions are one possible prophylactic measure for preventing emboli in women undergoing major gynaecological surgery. Agents include unfractionated heparin (low -dose and adjusted-dose), low-molecular-weight heparins, heparinoids and warfarin. OBJECTIVES The objective of this review was to evaluate the effectiveness of warfarin, heparin and aspirin in preventing thromboembolism after major gynaecological surgery. SEARCH STRATEGY We searched the Cochrane Menstrual Disorders and Subfertility Group trials register (searched 15 August 2003), the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library issue 2, 2003), MEDLINE (1966 to April 2003), EMBASE (1985 to April 2003), and CINAHL (1982 to April 2003). References from relevant articles were searched and authors contacted where necessary. In addition we contacted experts in the field for unpublished works. SELECTION CRITERIA Randomised controlled trials of heparins, warfarin or aspirin to prevent thromboembolism after major gynaecological surgery were eligible for inclusion. DATA COLLECTION AND ANALYSIS Thirty-three trials were identified in the initial search. On careful inspection only eight of these met the inclusion criteria. Trials were data extracted and assessed for quality by at least two reviewers. Data were combined for meta-analysis using odds ratios for dichotomous data or weighted mean difference for continuous data. A random effects statistical model was used. MAIN RESULTS The meta-analysis of heparin versus placebo found a statistically significant decrease in the number of DVTs in both the all women group (including those with and without malignancy) (OR 0.30, 95% CI 0.12 to 0.76) and the subgroup of only women with malignancy (OR 0.30, 95% CI 0.10 to 0.89). There was no significant difference in the incidence of PE. Oral warfarin reduced DVT when compared to placebo in all women (OR 0.22, 95% CI 0.06 to 0.86) and in women with malignancy (OR 0.18, 95% CI 0.04 to 0.87). Meta-analyses of UH and LMWH showed no statistical difference in any comparison. No studies compared aspirin alone to placebo, heparin or warfarin. There was a statistically significant increase in injection site haematomas associated with heparin compared to placebo (OR 0.30, 95% CI 0.10 to 0.89). AUTHORS' CONCLUSIONS Women, undergoing major gynaecological surgery and without contraindications to anticoagulants should be offered thromboprophylaxis. Evidence suggests that UH and LMWH are equally as effective in preventing DVT and the one trial available suggests that warfarin is as effective as UH. There is no evidence as yet to suggest that warfarin, heparin or aspirin reduce incidence of PE.
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Abstract
BACKGROUND Premenstrual Syndrome (PMS) is the term for severe symptoms experienced by about 5% of menstruating women up to two weeks before their menstrual periods, but not at other times. Treatment with progesterone may restore a deficiency, or balance the level of progesterone with other menstrual hormones. Progesterone therapy may reduce the effects of falling progesterone levels on the brain or on electrolytes in the blood. OBJECTIVES The objectives were to determine if progesterone has been found to be an effective treatment for all or some premenstrual symptoms, and if adverse events associated with this treatment have been reported. SEARCH STRATEGY We last searched the Cochrane Menstrual Disorders and Subfertility Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 1, 2005), MEDLINE (1966 to 2005) and EMBASE (1980 to 2005) in March 2005, and PsycINFO (1806 to 2006) in April 2006. We contacted pharmaceutical companies for information about unpublished trials. SELECTION CRITERIA We included randomised double-blind, placebo-controlled trials of progesterone on women with PMS diagnosed by at least two prospective cycles, without current psychiatric disorder. DATA COLLECTION AND ANALYSIS Two reviewers (BM and OF) extracted data independently, and decided on the trials to be included. OF wrote to the trial investigators to ask for missing data. MAIN RESULTS We considered 17 studies. We included two trials totaling 280 participants aged from 18 to 45 years. Of these 115 yielded analysable results. Both studies measured outcomes using subjective scales of symptom severity but made calculations as if they were interval data. The two studies differed in design, participants, dose of progesterone, how and when the dose was administered and in outcome measures. It was impossible to combine data in a meta-analysis. Adverse events which may or may not have been the side effects of the treatment, were generally described as mild. Both trials intended to exclude women whose symptoms continued after their periods; unfortunately the larger multicentre study had some ineligible participants. Overall, participants benefited more from progesterone than placebo. This was statistically significant in per protocol analysis but not in the intention-to-treat analysis, except for the first cycle. The smaller, crossover study found no statistically significant difference between oral progesterone, vaginally absorbed progesterone and placebo. AUTHORS' CONCLUSIONS We could not say that progesterone helped women with PMS, nor that it was ineffective. Neither trial distinguished a subgroup of women who benefited.
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Affiliation(s)
- O Ford
- Sunnybank, Over stratton, South Petherton, Somerset, UK.
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Ford O, Mol B, Roberts H. Progesterone for premenstrual syndrome. Hippokratia 2006. [DOI: 10.1002/14651858.cd003415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
BACKGROUND The reported overall risk of deep venous thrombosis in gynaecological surgery ranges from 7 to 45%. Fatal pulmonary embolism is estimated to occur in nearly 1% of these women. Pharmaceutical interventions are one possible prophylactic measure for preventing emboli in women undergoing major gynaecological surgery. Agents include unfractionated heparin (low -dose and adjusted-dose), low-molecular-weight heparins, heparinoids and warfarin. OBJECTIVES The objective of this review was to evaluate the effectiveness of warfarin, heparin and aspirin in preventing thromboembolism after major gynaecological surgery. SEARCH STRATEGY We searched the Cochrane Menstrual Disorders and Subfertility Group trials register (searched 15 August 2003), the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library issue 2, 2003), MEDLINE (1966 to April 2003), EMBASE (1985 to April 2003), and CINAHL (1982 to April 2003). References from relevant articles were searched and authors contacted where necessary. In addition we contacted experts in the field for unpublished works. SELECTION CRITERIA Randomised controlled trials of heparins, warfarin or aspirin to prevent thromboembolism after major gynaecological surgery were eligible for inclusion. DATA COLLECTION AND ANALYSIS Thirty-three trials were identified in the initial search. On careful inspection only eight of these met the inclusion criteria. Trials were data extracted and assessed for quality by at least two reviewers. Data were combined for meta-analysis using odds ratios for dichotomous data or weighted mean difference for continuous data. A random effects statistical model was used. MAIN RESULTS The meta-analysis of heparin versus placebo found a statistically significant decrease in the number of DVTs in both the all women group (including those with and without malignancy) (OR 0.30, 95% CI 0.12 to 0.76) and the subgroup of only women with malignancy (OR 0.30, 95% CI 0.10 to 0.89). There was no significant difference in the incidence of PE. Oral warfarin reduced DVT when compared to placebo in all women (OR 0.22, 95% CI 0.06 to 0.86) and in women with malignancy (OR 0.18, 95% CI 0.04 to 0.87). Meta-analyses of UH and LMWH showed no statistical difference in any comparison. No studies compared aspirin alone to placebo, heparin or warfarin. There was a statistically significant increase in injection site haematomas associated with heparin compared to placebo (OR 0.30, 95% CI 0.10 to 0.89). REVIEWER'S CONCLUSIONS Women, undergoing major gynaecological surgery and without contraindications to anticoagulants should be offered thromboprophylaxis. Evidence suggests that UH and LMWH are equally as effective in preventing DVT and the one trial available suggests that warfarin is as effective as UH. There is no evidence as yet to suggest that warfarin, heparin or aspirin reduce incidence of PE.
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Affiliation(s)
- R M Oates-Whitehead
- Research Division, Royal College of Paediatrics and Child Health, 50 Hallam Street, London, UK, W1W 6DE
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Tuerlings JH, Mol B, Kremer JA, Looman M, Meuleman EJ, te Meerman GJ, Buys CH, Merkus HM, Scheffer H. Mutation frequency of cystic fibrosis transmembrane regulator is not increased in oligozoospermic male candidates for intracytoplasmic sperm injection. Fertil Steril 1998; 69:899-903. [PMID: 9591500 DOI: 10.1016/s0015-0282(98)00050-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To examine the frequency of anomalies of the vas deferens and the frequency of mutations of the cystic fibrosis transmembrane regulator (CFTR) gene in male candidates for intracytoplasmic sperm injection (ICSI) who had severe oligoasthenoteratozoospermia. DESIGN The clinical data for male candidates for ICSI were studied. The three most frequent cystic fibrosis (CF)-causing CFTR mutations in the Dutch population (deltaF508, A455E, and G542X) and the three most frequent CFTR mutations potentially causing congenital bilateral absence of the vas deferens (CBAVD) in the Dutch population (deltaF508, R117H, and IVS8-5T) were analyzed. Delta I507 is also detected by the deltaF508 test. Samples of DNA from patients identified as CFTR mutation carriers were subjected to denaturing gradient gel electrophoresis analysis with use of a two-dimensional electrophoretic technique. SETTING University-based center for reproductive medicine and clinical genetics. PATIENT(S) Male candidates for ICSI who had oligoasthenoteratozoospermia and no history of operative sterilization and refertilization. Males with a chromosomal aberration or a Y-chromosome microdeletion were excluded. INTERVENTION(S) Semen and blood samples were collected from the patients at their first visit to the clinic. MAIN OUTCOME MEASURE(S) Frequency of anomalies of the vas deferens and frequency of mutations of the CFTR gene in male candidates for ICSI who had oligoasthenoteratozoospermia. RESULT(S) None of the patients had abnormalities of the vas deferens at physical examination. In 4 of the 150 chromosomes (75 patients), a CFTR mutation was found, yielding a CFTR mutation frequency of 2.7% (95% confidence interval, 1.0-6.7%). None of the patients had two CFTR mutations. CONCLUSION(S) The frequency of congenital abnormalities of the vas deferens in patients with oligoasthenoteratozoospermia is low. The frequencies of the CFTR mutations identified in this cohort did not differ significantly from the frequencies found in the normal Dutch population.
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