Targeted Protein O-GlcNAcylation Using Bifunctional Small Molecules

Protein O-linked β-N-acetylglucosamine modification (O-GlcNAcylation) plays a crucial role in regulating essential cellular processes. The disruption of the homeostasis of O-GlcNAcylation has been linked to various human diseases, including cancer, diabetes, and neurodegeneration. However, there are limited chemical tools for protein- and site-specific O-GlcNAc modification, rendering the precise study of the O-GlcNAcylation challenging. To address this, we have developed heterobifunctional small molecules, named O-GlcNAcylation TArgeting Chimeras (OGTACs), which enable protein-specific O-GlcNAcylation in living cells. OGTACs promote O-GlcNAcylation of proteins such as BRD4, CK2α, and EZH2 in cellulo by recruiting FKBP12F36V-fused O-GlcNAc transferase (OGT), with temporal, magnitude, and reversible control. Overall, the OGTACs represent a promising approach for inducing protein-specific O-GlcNAcylation, thus enabling functional dissection and offering new directions for O-GlcNAc-targeting therapeutic development.

Quality assessment of online patient information on upper gastrointestinal endoscopy using the modified Ensuring Quality Information for Patients tool

INTRODUCTION

Websites and online resources are increasingly becoming patients' main source of healthcare information. It is paramount that high quality information is available online to enhance patient education and improve clinical outcomes. Upper gastrointestinal (UGI) endoscopy is the gold standard investigation for UGI symptoms and yet little is known regarding the quality of patient orientated websites. The aim of this study was to assess the quality of online patient information on UGI endoscopy using the modified Ensuring Quality Information for Patients (EQIP) tool.

METHODS

Ten search terms were employed to conduct a systematic review. for each term, the top 100 websites identified via a Google search were assessed using the modified EQIP tool. High scoring websites underwent further analysis. Websites intended for professional use by clinicians as well as those containing video or marketing content were excluded.

FINDINGS

A total of 378 websites were eligible for analysis. The median modified EQIP score for UGI endoscopy was 18/36 (interquartile range: 14-21). The median EQIP scores for the content, identification and structure domains were 8/18, 1/6 and 9/12 respectively. Higher modified EQIP scores were obtained for websites produced by government departments and National Health Service hospitals (p=0.007). Complication rates were documented in only a fifth (20.4%) of websites. High scoring websites were significantly more likely to provide balanced information on risks and benefits (94.6% vs 34.4%, p<0.001).

CONCLUSIONS

There is an immediate need to improve the quality of online patient information regarding UGI endoscopy. The currently available resources provide minimal information on the risks associated with the procedure, potentially hindering patients' ability to make informed healthcare decisions.

Quality indicators for the diagnosis and treatment of breast cancer integrated assistance: A critical appraisal

INTRODUCTION

Quality indicators (QIs) are essential for adequate control of the health care management process, recognizing areas of improvement and providing solutions. We aimed to evaluate the Integrated Breast Cancer (BC) Care Process QIs.

METHODS

We studied 487 consecutive BC cases diagnosed from November 1st, 2013, to November 30th, 2019, in a Spanish healthcare area, and we estimated the associated QIs.

RESULTS

Four indicators did not meet the standards and were analysed based on related sociodemographic and clinical variables. The surgical delay after a multidisciplinary team discussion (mean 64%, IQR 59.6-68.5) was lower in elder people (p=0.027), and early histological grades (p=0.019) and stages (p=0.008). The adjuvant treatment delay (mean 55.7%, IQR 51.1-60.3) was lower in advance stages (p=0.002) and when there was no reoperation (p=0.001). The surgical delay after inclusion (mean 83.2%, IQR 79.3-87.2) was lower in early histological grades (p=0.048). The immediate reconstruction (mean 42.3%, IQR 34.0-50.5) reached 72.3% in young women compared to 11.8% in older than 70 years (p=0.001) and it was higher in early stages (45.3% vs 36.2%; p=0.049).

CONCLUSION

The study of QIs evaluated their compliance and analysed the variables influencing them to propose improvement measures. Not all the indicators were equally valuable. Some depended on the available resources, and others on the mix of patients or complementary treatments. It would be essential to identify the specific target populations to estimate the indicators or provide standards stratified by the related variables.

Obesity and female sexual dysfunctions: A systematic review of prevalence with meta-analysis

Obesity represents a major global health challenge. Female sexual dysfunctions have a negative impact on quality of life and overall health balance. A higher rate of female sexual dysfunctions in obese women has been suggested. This systematic review summarized the literature on female sexual dysfunction prevalence in obese women. The review was registered (Open Science Framework OSF.IO/7CG95) and a literature search without language restrictions was conducted in PubMed, Embase and Web of Science, from January 1990 to December 2021. Cross-sectional and intervention studies were included, the latter if they provided female sexual dysfunction rate data in obese women prior to the intervention. For inclusion, studies should have used the female sexual function index or its simplified version. Study quality was assessed to evaluate if female sexual function index was properly applied using six items. Rates of female sexual dysfunctions examining for differences between obese vs class III obese and high vs low quality subgroups were summarized. Random effects meta-analysis was performed, calculating 95% confidence intervals (CI) and examining heterogeneity with I2 statistic. Publication bias was evaluated with funnel plot. There were 15 relevant studies (1720 women participants in total with 153 obese and 1567 class III obese women). Of these, 8 (53.3%) studies complied with >4 quality items. Overall prevalence of female sexual dysfunctions was 62% (95% CI 55-68%; I2 85.5%). Among obese women the prevalence was 69% (95% CI 55-80%; I2 73.8%) vs 59% (95% CI 52-66%; I2 87.5%) among those class III obese (subgroup difference p=0.15). Among high quality studies the prevalence was 54% (95% CI 50-60%; I2 46.8%) vs 72% (95% CI 61-81%; I2 88.0%) among low quality studies (subgroup difference p=0.002). There was no funnel asymmetry. We interpreted that the rate of sexual dysfunctions is high in obese and class III obese women. Obesity should be regarded as a risk factor for female sexual dysfunctions.

[Longitudinality in Primary Care and Polypharmacy. A Systematic Review]

The aim of this work was to collect, evaluate and interpret the available evidence on the relationship between continuity in primary care (i.e., longitudinality), and the prevalence of polypharmacy and its associated problems. Following the PRISMA reporting statement, we carried out a systematic review of the literature searching PubMed and Scopus databases. The screening of titles and summaries and the review of references carried out independently by two authors detected 16 works of potential interest, of which 4 were discarded after the independent review of all the originals because they did not meet inclusion criteria. The 12 papers selected studied the relationship between Longitudinality, measured with various quantitative indices, and the rate of polypharmacy or various associated problems, such as duplicate drugs, inadequate prescriptions or drug interactions. They all showed a significant relationship, often strong (RR>2 or<0.5), between longitudinality indicators and the various dependent variables. Although our knowledge could be improved by prospective studies that more directly evaluate longitudinality and its impact on problems due to excess medication, with the existing evidence, we can affirm that the protection and promotion of continuity in primary care can be a key element for the control of polypharmacy and associated problems.

Evidence-based medicine needs patient and public involvement to remain relevant: A proposal for a new curriculum

INTRODUCTION

Public partnerships, a route to sharing expertise, networks and resources anchored in the United Nations Sustainable Development Goals, has been championed by multiple stakeholders.

OBJECTIVE

To propose a new evidence-based medicine (EBM) curriculum for harnessing patient and public expertise to ensure that EBM teaching and learning can become more relevant and impactful.

METHODS

A curriculum development group comprising of EBM teachers, patient and public involvement representatives, clinicians, clinical epidemiologists, public health experts and educationalists, with experience of delivering and evaluating face-to-face and online EBM courses across many countries and continents, prepared a new EBM course.

RESULTS

A student-centred, problem-based and clinically integrated course for teaching and learning EBM was developed. In the spirit of shared decision-making, practitioners can learn to support patients, articulate their perspectives, recognise the need for their contribution and ensure community involvement when generating and applying evidence. With end users in mind, the application of research findings, delivery of care and EBM effectiveness in the workplace would carry increased priority.

CONCLUSIONS

Embracing patients as EBM collaborators can help deliver cognitive diversity and inspire different ways of thinking and working. Adopting the proposed approach in EBM education lays the foundations for a joint practitioner-patient partnership to ask, acquire, appraise and apply EBM in a more holistic context which will strengthen the EBM proposition.

[Systematic reviews in five steps: V. Interpreting the findings]

The last step in a systematic review is the interpretation of the findings. The important findings need to be explicitly identified. A level of strength of evidence should be assigned to support each key finding, based on factors such as study design, methodological quality and risk of publication bias. Variations in the magnitude of associations observed also need to be explored. The aim of this analysis is to determine in which clinical groups the intervention is more or less effective, the impact of exposure is greater or lesser, or a diagnostic test is more useful. At this stage, for better interpretation of the findings, the magnitude of the association can be estimated either globally or stratified according to the characteristics of the participants. All this is helpful in formulating recommendations for clinical practice and policy.

Inguinal hernia repair: a systematic analysis of online patient information using the Modified Ensuring Quality Information for Patients tool

BACKGROUND

Online resources are a fundamental source of healthcare information due to the increasing popularity of the internet. Ensuring accuracy and reliability of websites is crucial to improving patient education and enhancing patient outcomes. Inguinal hernia repair is the most commonly performed general surgical procedure worldwide. This study analyses the quality of online patient information about inguinal hernia repair using the Modified Ensuring Quality Information for Patients (EQIP) tool.

METHODS

A systematic review of online information on inguinal hernia repair was conducted using four search terms: 'inguinal hernia', 'groin hernia', 'inguinal hernia repair' and 'inguinoscrotal hernia'. The top 100 websites for each term identified using Google were assessed using the modified EQIP tool (score 0-36). Websites for the paediatric population or intended for medical professional use were excluded from analysis.

FINDINGS

A total of 142 websites were eligible for analysis, 52.8% originating from the UK. The median EQIP score for all websites was 17/36 (interquartile range 14-21). The median EQIP scores for content, identification and structure were 8/18, 2/8 and 8/12, respectively. Complications of inguinal hernia repair were included in 46.5% of websites, with only 9.2% providing complication rates and 14.1% providing information on how complications are handled.

CONCLUSION

This study highlights that the current quality of online patient information on inguinal hernia repair is poor, with minimal information available on complications, hindering patients' ability to make informed decisions regarding their healthcare. To improve patient education, there is an immediate need for improved quality online resources to meet international standards.

Early cryoprecipitate transfusion versus standard care in severe postpartum haemorrhage: a pilot cluster-randomised trial

There is a lack of evidence evaluating cryoprecipitate transfusion in severe postpartum haemorrhage. We performed a pilot cluster‐randomised controlled trial to evaluate the feasibility of a trial on early cryoprecipitate delivery in severe postpartum haemorrhage. Pregnant women (>24 weeks gestation), actively bleeding within 24 h of delivery and who required at least one unit of red blood cells were eligible. Women declining transfusion in advance or with inherited clotting deficiencies were not eligible. Four UK hospitals were randomly allocated to deliver either the intervention (administration of two pools of cryoprecipitate within 90 min of first red blood cell unit requested plus standard care), or the control group treatment (standard care, where cryoprecipitate is administered later or not at all). The primary outcome was the proportion of women who received early cryoprecipitate (intervention) vs. standard care (control). Secondary outcomes included consent rates, acceptability of the intervention, safety outcomes and preliminary clinical outcome data to inform a definitive trial. Between March 2019 and January 2020, 199 participants were recruited; 19 refused consent, leaving 180 for analysis (110 in the intervention and 70 in the control group). Adherence to assigned treatment was 32% (95%CI 23–41%) in the intervention group vs. 81% (95%CI 70–90%) in the control group. The proportion of women receiving cryoprecipitate at any time‐point was higher in the intervention (60%) vs. control (31%) groups; the former had fewer red blood cell transfusions at 24 h (mean difference −0.6 units, 95%CI −1.2 to 0); overall surgical procedures (odds ratio 0.6, 95%CI 0.3–1.1); and intensive care admissions (odds ratio 0.4, 95%CI 0.1–1.1). There was no increase in serious adverse or thrombotic events in the intervention group. Staff interviews showed that lack of awareness and uncertainty about study responsibilities contributed to lower adherence in the intervention group. We conclude that a full‐scale trial may be feasible, provided that protocol revisions are put in place to establish clear lines of communication for ordering early cryoprecipitate in order to improve adherence. Preliminary clinical outcomes associated with cryoprecipitate administration are encouraging and merit further investigation.

Famotidine inhibits toll-like receptor 3-mediated inflammatory signaling in SARS-CoV-2 infection

Apart from prevention using vaccinations, the management options for COVID-19 remain limited. In retrospective cohort studies, use of famotidine, a specific oral H2 receptor antagonist (antihistamine), has been associated with reduced risk of intubation and death in patients hospitalized with COVID-19. In a case series, nonhospitalized patients with COVID-19 experienced rapid symptom resolution after taking famotidine, but the molecular basis of these observations remains elusive. Here we show using biochemical, cellular, and functional assays that famotidine has no effect on viral replication or viral protease activity. However, famotidine can affect histamine-induced signaling processes in infected Caco2 cells. Specifically, famotidine treatment inhibits histamine-induced expression of Toll-like receptor 3 (TLR3) in SARS-CoV-2 infected cells and can reduce TLR3-dependent signaling processes that culminate in activation of IRF3 and the NF-κB pathway, subsequently controlling antiviral and inflammatory responses. SARS-CoV-2-infected cells treated with famotidine demonstrate reduced expression levels of the inflammatory mediators CCL-2 and IL6, drivers of the cytokine release syndrome that precipitates poor outcome for patients with COVID-19. Given that pharmacokinetic studies indicate that famotidine can reach concentrations in blood that suffice to antagonize histamine H2 receptors expressed in mast cells, neutrophils, and eosinophils, these observations explain how famotidine may contribute to the reduced histamine-induced inflammation and cytokine release, thereby improving the outcome for patients with COVID-19.

Simeprevir Potently Suppresses SARS-CoV-2 Replication and Synergizes with Remdesivir

The outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a global threat to human health. Using a multidisciplinary approach, we identified and validated the hepatitis C virus (HCV) protease inhibitor simeprevir as an especially promising repurposable drug for treating COVID-19. Simeprevir potently reduces SARS-CoV-2 viral load by multiple orders of magnitude and synergizes with remdesivir in vitro. Mechanistically, we showed that simeprevir not only inhibits the main protease (Mpro) and unexpectedly the RNA-dependent RNA polymerase (RdRp) but also modulates host immune responses. Our results thus reveal the possible anti-SARS-CoV-2 mechanism of simeprevir and highlight the translational potential of optimizing simeprevir as a therapeutic agent for managing COVID-19 and future outbreaks of CoV.

995 Clinical Outcomes Following Incomplete Colonoscopy

Introduction

Following incomplete colonoscopy (IC) it is reported that there is up to five-fold increased risk of colorectal cancer. Our aim was to determine the final clinical outcome for patients with a prior IC.

Method

A multi-centre retrospective observational study involving three endoscopy units. All consecutive patients having colonoscopy from over 18 months were analysed. Exclusion criteria included IC was due to obstructing cancer, follow up was not performed due to non-attendance at clinic or investigation and incomplete data set. Electronic notes were analysed to determine patient’s final clinical outcome. All patients were followed up for minimum of six months.

Results

Of the 8,490 colonoscopies, 733 (8.6%) were IC. 86 (11.7%) were excluded. Of the 647 included, 469 (72.4%) were females and 473 (73.1%) has further colonic investigations. Secondary investigations were: CT colonography 169 (35.7%), repeat colonoscopy 161 (34.0%), barium enema 95 (20.1%) and others 48 (10.1%). The repeat colonoscopy group achieved a complete colonoscopy in 111 (68.9%) patients. For those who had further investigations 15 (3.2%) had colorectal cancer and 12 (2.5%) has polyps ≥1cm.

Conclusions

There is significant risk of missing colorectal malignancy and large polyps following IC. Further colonic investigations should be carried out in this cohort of patients.

930 Impact of the COVID-19 Pandemic on Higher General Surgical Training – A West of Scotland Experience

Introduction

COVID-19 pandemic has caused significant disruption in all aspects of training. Our aim was to explore the degree of impact caused by the pandemic on higher general surgical trainees.

Method

All higher general surgical trainees in a single UK deanery were invited to participate in an online, voluntary, anonymous survey via SurveyMonkey.

Results

64 (72.7%) of the trainees responded. 39.1% were ST3/4, 29.7% were ST5/6, 20.3% were ST7/8 and 10.9% were out of training (maternity & research). Thirty-five (55.6%) worked in district general hospitals. Forty (68.9%) trainees felt that they had fewer opportunities to be primary surgeon. Forty-two (67.7%) trainees did not have access to laparoscopic simulation trainers. Fifty-two (88.1%) trainees had their courses and 2 (3.4%) had their FRCS part 2 exam postponed. 16 (27.1%) trainees reported they had been off-sick, with a median of 7 days off (range 3-35 days). Thirty-three (55.9%) trainees felt more stressed due to the pandemic and 35 (59.4%) had symptoms of burnout.

Conclusions

The COVID-19 pandemic has had an unprecedented impact on all aspects of higher surgical training. The most noticeable impact has been on the reduction in the confidence in laparoscopic and endoscopic skills.

Sensory and motor axonal excitability testing in early diabetic neuropathy

OBJECTIVE

The aim of the present study was to gain insight into the pathophysiology of diabetic polyneuropathy (DPN) and examine the diagnostic value of sensory and motor axonal excitability testing.

METHODS

One hundred and eleven type 2 diabetics with and without DPN (disease duration: 6.36 ± 0.25 years) and 60 controls were included. All participants received a thorough clinical examination including Michigan Neuropathy Screening Instrument (MNSI) score, nerve conduction studies (NCS), and sensory and motor excitability tests. Patients were compared by the likelihood of neuropathy presence, ranging from no DPN (17), possible/probable DPN (46) to NCS-confirmed DPN (48).

RESULTS

Motor excitability tests showed differences in rheobase and depolarizing threshold electrotonus measures between NCS-confirmed DPN group and controls but no changes in hyperpolarising threshold electrotonus or recovery cycle parameters. Sensory excitability showed even less changes despite pronounced sensory NCS abnormalities. There were only weak correlations between the above motor excitability parameters and clinical scores.

CONCLUSIONS

Changes in excitability in the examined patient group were subtle, perhaps because of the relatively short disease duration.

SIGNIFICANCE

Less pronounced excitability changes than NCS suggest that axonal excitability testing is not of diagnostic value for early DPN and does not provide information on the mechanisms.

Does nosocomial COVID-19 result in increased 30-day mortality? A multi-centre observational study to identify risk factors for worse outcomes in patients with COVID-19

This study aimed to determine whether nosocomial coronavirus disease 2019 (COVID-19) has a worse outcome compared with community-acquired COVID-19. This was a prospective cohort study of all hospitalized patients with confirmed COVID-19 in three acute hospitals on 9th April 2020. Patients were followed-up for at least 30 days. Nosocomial infection was defined as a positive swab after 7 days of admission. In total, one hundred and seventy-three patients were identified, and 19 (11.0%) had nosocomial infection. Thirty-two (18.5%) patients died within 30 days (all cause) of a positive swab test; there were no significant differences in 30-day all-cause mortality rates between the three groups (i.e. patients admitted with suspected COVID-19, patients with incidental COVID-19 and patients with nosocomial COVID-19): 21.1% vs 17.6% vs 21.6% (P=0.755). Nosocomial COVID-19 is not associated with increased mortality compared with community-acquired COVID-19.

Myths and conspiracy theories on vaccines and COVID-19: Potential effect on global vaccine refusals

The current coronavirus disease 2019 (COVID-19) pandemic is one of the international crises and researchers are working collaboratively to develop a safe and effective COVID-19 vaccine. The World Health Organization recognizes vaccine hesitancy as the world's top threat to public health safety, particularly in low middle-income countries. Vaccine hesitancy can be due to a lack of knowledge, false religious beliefs, or anti-vaccine misinformation. The current situation regarding anti-vaccine beliefs is pointing towards dreadful outcomes. It raises the concern that will people believe and accept the new COVID-19 vaccines despite all anti-vaccine movements and COVID-19-related myths and conspiracy theories. This review discusses the possible detrimental impacts of myths and conspiracy theories related to COVID-19 and vaccine on COVID-19 vaccine refusals as well as other vaccine programs.

Nucleic Acid-Based Technologies Targeting Coronaviruses

The coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is currently creating a global health emergency. This crisis is driving a worldwide effort to develop effective vaccines, prophylactics, and therapeutics. Nucleic acid (NA)-based treatments hold great potential to combat outbreaks of coronaviruses (CoVs) due to their rapid development, high target specificity, and the capacity to increase druggability. Here, we review key anti-CoV NA-based technologies, including antisense oligonucleotides (ASOs), siRNAs, RNA-targeting clustered regularly interspaced short palindromic repeats-CRISPR-associated protein (CRISPR-Cas), and mRNA vaccines, and discuss improved delivery methods and combination therapies with other antiviral drugs.

Coronavirus RNA Proofreading: Molecular Basis and Therapeutic Targeting

The coronavirus disease 2019 (COVID-19) that is wreaking havoc on worldwide public health and economies has heightened awareness about the lack of effective antiviral treatments for human coronaviruses (CoVs). Many current antivirals, notably nucleoside analogs (NAs), exert their effect by incorporation into viral genomes and subsequent disruption of viral replication and fidelity. The development of anti-CoV drugs has long been hindered by the capacity of CoVs to proofread and remove mismatched nucleotides during genome replication and transcription. Here, we review the molecular basis of the CoV proofreading complex and evaluate its potential as a drug target. We also consider existing nucleoside analogs and novel genomic techniques as potential anti-CoV therapeutics that could be used individually or in combination to target the proofreading mechanism.

MScanFit motor unit number estimation and muscle velocity recovery cycle recordings in diabetic polyneuropathy

OBJECTIVE

Motor Unit Number Estimation (MUNE) methods may be valuable in tracking motor unit loss in diabetic polyneuropathy (DPN). Muscle Velocity Recovery Cycles (MVRCs) provide information about muscle membrane properties. This study aimed to examine the utility of the MScanFit MUNE in detecting motor unit loss and to test whether the MVRCs could improve understanding of DPN pathophysiology.

METHODS

Seventy-nine type-2 diabetic patients were compared to 32 control subjects. All participants were examined with MScanFit MUNE and MVRCs in anterior tibial muscle. Lower limb nerve conduction studies (NCS) in peroneal, tibial and sural nerves were applied to diagnose large fiber neuropathy.

RESULTS

NCS confirmed DPN for 47 patients (DPN + ), with 32 not showing DPN (DPN-). MScanFit showed significantly decreased MUNE values and increased motor unit sizes, when comparing DPN + patients with controls (MUNE = 71.3 ± 4.7 vs 122.7 ± 3.8), and also when comparing DPN- patients (MUNE = 103.2 ± 5.1) with controls. MVRCs did not differ between groups.

CONCLUSIONS

MScanFit is more sensitive in showing motor unit loss than NCS in type-2 diabetic patients, whereas MVRCs do not provide additional information.

SIGNIFICANCE

The MScanFit results suggest that motor changes are seen as early as sensory, and the role of axonal membrane properties in DPN pathophysiology should be revisited.

Accuracy of imaging modalities for adnexal torsion: a systematic review and meta-analysis

BACKGROUND

Adnexal torsion (AT), a serious gynaecological emergency, often presents with non-specific symptoms leading to delayed diagnosis.

OBJECTIVE

To compare the test accuracy of ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI) to diagnose AT.

SEARCH STRATEGY

We searched EMBASE, MEDLINE and Cochrane CENTRAL until December 2019.

SELECTION CRITERIA

Studies reporting on the accuracy of any imaging modality (Index Test) in female patients (paediatric and adult) suspected of AT compared with surgical diagnosis and/or standard clinical/radiological follow-up period until resolution of symptoms (Reference Standard).

DATA COLLECTION AND ANALYSIS

We assessed study quality using QUADAS-2. We conducted test accuracy meta-analysis using a univariate model or a hierarchical model.

MAIN RESULTS

We screened 3836 citations, included 18 studies (1654 women, 665 cases), and included 15 in the meta-analyses. Ultrasound pooled sensitivity (n = 12, 1187 women) was 0.79 (95% CI 0.63-0.92) and specificity was 0.76 (95% CI 0.54-0.93), with negative and positive likelihood ratios of 0.29 (95% CI 0.13-0.66) and 4.35 (95% CI 2.03-9.32), respectively. Using Doppler with ultrasound (n = 7, 845 women) yielded similar sensitivity (0.80, 95% CI 0.67-0.93) and specificity (0.88, 95% CI 0.72-1.00). For MRI (n = 3, 99 women), the pooled sensitivity was 0.81 (95% CI 0.63-0.91) and specificity was 0.91 (95% CI 0.80-0.96). A meta-analysis for CT was not possible with two case-control studies and one cohort study (n = 3, 232 women). Its sensitivity range was 0.74-0.95 and specificity was 0.80-0.90.

CONCLUSIONS

Ultrasound has good performance as a first-line diagnostic test for suspected AT. Magnetic resonance imaging could offer improved specificity to investigate complex ovarian morphology, but more evidence is needed.

TWEETABLE ABSTRACT

To investigate adnexal torsion, ultrasound is a good first-line diagnostic test with a pooled sensitivity of 0.79 and specificity of 0.76.

Virtual reality for acute pain in outpatient hysteroscopy: a randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of virtual reality as a distraction technique in the management of acute pain and anxiety during outpatient hysteroscopy.

DESIGN

Parallel group, prospective randomised controlled trial.

SETTING

UK University Hospital.

METHODS

Forty consenting, eligible women were randomised to virtual reality intervention (immersive video content as a distraction method) or standard care during outpatient hysteroscopy from August to October 2018.

MAIN OUTCOME MEASURES

Pain and anxiety outcomes were measured as a numeric rating score (scale 0-10).

RESULTS

Compared with standard care, women with virtual reality intervention experienced less average pain (score 6.0 versus 3.7, mean difference 2.3, 95% CI 0.61-3.99, P = 0.009) and anxiety (score 5.45 versus 3.3, mean difference 2.15, 95% CI 0.38-3.92, P = 0.02).

CONCLUSION

Virtual reality was effective in reducing pain and anxiety during outpatient hysteroscopy in a mixed-methods randomised control trial. Its wide potential role in ambulatory gynaecological procedures needs further evaluation.

TWEETABLE ABSTRACT

Virtual reality can be used as a part of a multimodal strategy to reduce acute pain and anxiety in patients undergoing outpatient hysteroscopy.

Pravastatin for early-onset pre-eclampsia: a randomised, blinded, placebo-controlled trial

Objective

Women with pre‐eclampsia have elevated circulating levels of soluble fms‐like tyrosine kinase‐1 (sFlt‐1). Statins can reduce sFlt‐1 from cultured cells and improve pregnancy outcome in animals with a pre‐eclampsia‐like syndrome. We investigated the effect of pravastatin on plasma sFlt‐1 levels during pre‐eclampsia.

Design

Blinded (clinician and participant), proof of principle, placebo‐controlled trial.

Setting

Fifteen UK maternity units.

Population

We used a minimisation algorithm to assign 62 women with early‐onset pre‐eclampsia (24⁺⁰–31⁺⁶ weeks of gestation) to receive pravastatin 40 mg daily (n = 30) or matched placebo (n = 32), from randomisation to childbirth.

Primary outcome

Difference in mean plasma sFlt‐1 levels over the first 3 days following randomisation.

Results

The difference in the mean maternal plasma sFlt‐1 levels over the first 3 days after randomisation between the pravastatin (n = 27) and placebo (n = 29) groups was 292 pg/ml (95% CI −1175 to 592; P = 0.5), and over days 1–14 was 48 pg/ml (95% CI −1009 to 913; P = 0.9). Women who received pravastatin had a similar length of pregnancy following randomisation compared with those who received placebo (hazard ratio 0.84; 95% CI 0.50–1.40; P = 0.6). The median time from randomisation to childbirth was 9 days (interquartile range [IQR] 5–14 days) for the pravastatin group and 7 days (IQR 4–11 days) for the placebo group. There were three perinatal deaths in the placebo‐treated group and no deaths or serious adverse events attributable to pravastatin.

Conclusions

We found no evidence that pravastatin lowered maternal plasma sFlt‐1 levels once early‐onset pre‐eclampsia had developed. Pravastatin appears to have no adverse perinatal effects.

Tweetable abstract

Pravastatin does not improve maternal plasma sFlt‐1 or placental growth factor levels following a diagnosis of early preterm pre‐eclampsia #clinicaltrial finds.

Pravastatin does not improve maternal plasma sFlt‐1 or placental growth factor levels following a diagnosis of early preterm pre‐eclampsia #clinicaltrial finds.

C-reactive protein level as a predictor of difficult emergency laparoscopic cholecystectomy

Background

Studies focused on C‐reactive protein (CRP) as a marker of difficult laparoscopic cholecystectomy are limited to small case series. The aim of this study was to evaluate the association between preoperative CRP concentration and difficulty of laparoscopic cholecystectomy in patients admitted with a biliary emergency presentation.

Methods

Patients with an emergency admission for biliary disease treated between 2012 and 2017 with a documented preoperative CRP level were analysed. Elective patients and those with other concurrent causes of increased CRP concentration were excluded. The intraoperative difficulty grade was based on the Nassar scale. Statistical analysis was conducted to determine the association of preoperative CRP level with difficulty grading, adjusted for the interval to surgery.

Results

A total of 804 emergency patients were included. The mean preoperative peak CRP level was 64·7 mg/l for operative difficulty grade I, 69·6 mg/l for grade II, 98·2 mg/l for grade III, 217·5 mg/l for grade IV and 193·1 mg/l for grade V, indicating a significant association between CRP concentration and Nassar grade (P < 0·001). Receiver operating characteristic (ROC) curve analysis showed an area under the curve of 0·78 (95 per cent c.i. 0·75 to 0·82), differentiating patients with grade I–III from those with grade IV–V operative difficulty. ROC curve analysis found a cut‐off CRP value of 90 mg/l, with 71·5 per cent sensitivity and 70·5 per cent specificity in predicting operative difficulty of grade IV or V. Logistic regression analysis found preoperative peak CRP level to be predictive of Nassar grade I–III versus grade IV–V operative difficulty, also when adjusted for timing of surgery (odds ratio 5·90, 95 per cent c.i. 2·80 to 12·50).

Conclusion

Raised preoperative CRP levels are associated with greater operative difficulty based on Nassar scale grading.

Breastfeeding avoidance following psychological intimate partner violence during pregnancy: a cohort study and multivariate analysis

OBJECTIVE

To evaluate if the experience of psychological intimate partner violence (IPV) adversely affects breastfeeding rates.

DESIGN

A cohort study.

SETTING

Maternities in 15 public hospitals, drawn using cluster sampling of obstetric services in Andalusia, Spain.

POPULATION

A total of 779 consecutive mothers receiving antenatal care including ultrasound and giving birth during February-June 2010.

METHODS

Trained midwives gathered IPV data using the Index of Spouse Abuse validated in the Spanish language (score ranges: 0-100, higher scores reflect more severe IPV; cut-off: psychological IPV = 25). Sociodemographic data including lack of kin support, and obstetric and neonatal outcomes were collected. Multivariate logistic regression estimated adjusted odds ratios (aOR), with 95% confidence intervals (CI), of the relationship between psychological IPV and breastfeeding, controlling for sociodemographic characteristics and obstetric complications.

MAIN OUTCOME MEASURE

Breastfeeding avoidance defined as lack of breastfeeding or pumping of breast milk to feed the new baby in the immediate post-partum period.

RESULTS

Response rate was 92.2%. A total of 70% (n = 545) of women initiated breastfeeding. Psychological IPV, reported by 21.0% (n = 151), increased the odds of breastfeeding avoidance (aOR = 2.0; 95% CI = 1.2-3.3) adjusting for the presence of obstetric complications (aOR = 1.6; 95% CI = 1.0-2.4).

CONCLUSIONS

Mothers with psychological IPV avoid breastfeeding. Clinicians should be aware of the risks to infant arising from this deficiency due to IPV in pregnancy.

TWEETABLE ABSTRACT

Psychological intimate partner violence, reported by one in five mothers in this study, on average doubles the avoidance of breastfeeding.

Inattentiveness and Language Abilities in Preschoolers: A Latent Profile Analysis

Growing evidence suggests that early symptoms of inattentiveness may affect the language development and academic success of young children. In the present study, we examined the extent to which profiles of inattentiveness and language could be discerned within a heterogeneous group of preschoolers attending early childhood special education programs (n = 461). Based on parent-reported observations of children's symptoms of inattentiveness and direct assessments of children's language skills (grammar, vocabulary, and narrative ability), three distinct profiles were identified. The three groups, representing levels of severity (at risk, almost average, above average), differed not only by their end of year performance, but also with respect to which their abilities changed over the course of the academic year. Children in the poorest performing profile had poorer mean scores in the spring of their preschool year on all measures, but exhibited patterns of gain that exceeded or equaled their peers in higher-performing groups, in the domains of vocabulary and grammar. Examination of subsequent kindergarten reading skills suggested that profile differences remained consistent. Findings underscore the associations between early symptoms of inattentiveness and language difficulties, and further indicate that these relations extend to the acquisition of early reading skills. Future research is needed to corroborate these findings with more robust measures of attention, and to understand the long-term associations between inattentiveness, language and literacy, and potential effects on these associations from early intervention.

Inadequate safety reporting in pre-eclampsia trials: a systematic evaluation

BACKGROUND

Randomised trials and their syntheses in meta-analyses offer a unique opportunity to assess the frequency and severity of adverse reactions.

OBJECTIVE

To assess safety reporting in pre-eclampsia trials.

SEARCH STRATEGY

Systematic search using bibliographic databases, including Cochrane Central Register of Controlled Trials, Embase, and MEDLINE, from inception to August 2017.

SELECTION CRITERIA

Randomised trials evaluating anticonvulsant or antihypertensive medication for pre-eclampsia.

DATA COLLECTION AND ANALYSIS

Descriptive statistics appraising the adequacy of adverse reaction and toxicity reporting.

MAIN RESULTS

We included 60 randomised trials. Six trials (10%) were registered with the International Clinical Trials Registry Platform, two registry records referred to adverse reactions, stating 'safety and toleration' and 'possible side effects' would be collected. Twenty-six trials (43%) stated the frequency of withdrawals within each study arm, and five trials (8%) adequately reported these withdrawals. Adverse reactions were inconsistently reported across eligible trials: 24 (40%) reported no serious adverse reactions and 36 (60%) reported no mild adverse reactions. The methods of definition or measurement of adverse reactions were infrequently reported within published trial reports.

CONCLUSIONS

Pre-eclampsia trials regularly omit critical information related to safety. Despite the paucity of reporting, randomised trials collect an enormous amount of safety data. Developing and implementing a minimum data set could help to improve safety reporting, permitting a more balanced assessment of interventions by considering the trade-off between the benefits and harms.

FUNDING

National Institute for Health Research (DRF-2014-07-051), UK; Maternity Forum, Royal Society of Medicine, UK.

TWEETABLE ABSTRACT

Developing @coreoutcomes could help to improve safety reporting in #preeclampsia trials. @NIHR_DC.

Factors associated with insomnia in pregnancy: A prospective Cohort Study

OBJECTIVE

To quantify insomnia and their components in a longitudinal cohort of pregnant women and factors associated with insomnia.

STUDY DESIGN

A prospective cohort of 486 healthy singleton pregnancies assembled before the 14th gestational week (February 2013 to March 2016). Insomnia data were collected pre-gestationally, in each trimester and six months post-partum, analysing five different moments. Multiple logistic regression analysis was performed to generate adjusted Odds Ratios (aOR) with 95% confidence intervals (CI) of determinants of insomnia in each trimester, defined using Athens Insomnia Scale (AIS) as score ≥8.

RESULTS

Insomnia prevalence was 6.1% (3.9-8.9) pre-gestational, 44.2% (39.3-49.6) in first trimester (T1), 46.3% (41.9-51.3) in second (T2) and 63.7% (57.7-67.8) in third trimester (T3). Post-gestational insomnia was 33.2% (28.2-37.9) (p < 0.001 pre-gestational vs T1, T2 vs T3 and T3 vs after pregnancy). There was worsening mean AIS score, from: 2.34 before pregnancy to 9.87 in T3 because the deterioration of nighttime sleep, in absolute terms, but daytime impact was higher in T1. Previous trimester insomnia was associated with insomnia in T2 (aOR = 4.21, 95% CI 2.78-6.37) and T3 (aOR = 4.43, 95% CI 2.77-7.08). Pre-gestational insomnia was determinant of insomnia in T1 (aOR 12.50, 95% CI 3.58-43.60) and obesity was associated with insomnia in T3 (aOR = 2.30, 95% CI 0.99-5.32). On the contrary, moderate physical activity reduced the odds of insomnia in T3 (aOR 0.65, 95% CI 0.40-1.03).

CONCLUSIONS

Insomnia prevalence was high from the beginning of pregnancy, associated with pre-gestational insomnia. In late pregnancy, two out of three pregnant women suffering insomnia. Insomnia prevention should be targeted particularly to those with high body mass index and pre-gestational insomnia.

Serum ferritin thresholds for the diagnosis of iron deficiency in pregnancy: a systematic review

The aim of this review was to understand the landscape of serum ferritin in diagnosing iron deficiency in the aetiology of anaemia in pregnancy. Iron deficiency in pregnancy is a major public health problem leading to the development of anaemia. Reducing the global prevalence of anaemia in women of reproductive age is a 2025 global nutrition target. Bone marrow aspiration is the gold standard test for iron deficiency but requires an invasive procedure; therefore, serum ferritin is the most clinically useful test. We undertook a systematic search of electronic databases and trial registers from inception to January 2016. Studies of iron or micronutrient supplementation in pregnancy with pre‐defined serum ferritin thresholds were included. Two independent reviewers selected studies, extracted data and assessed quality. There were 76 relevant studies mainly of observational study design (57%). The most commonly used thresholds of serum ferritin for the diagnosis of iron deficiency were <12 and <15 ng mL⁻¹ (68%). Most primary studies provided no justification for the choice of serum ferritin threshold used, but 25 studies (33%) used thresholds defined by expert consensus in a guideline development process. There were five studies (7%) using a serum ferritin threshold defining iron deficiency derived from primary studies of bone marrow aspiration. Unified international thresholds of iron deficiency for women throughout pregnancy are required for accurate assessments of the global disease burden and for evaluating effectiveness of interventions addressing this problem.

Maternal and perinatal mortality and morbidity associated with tuberculosis during pregnancy and the postpartum period: a systematic review and meta-analysis

BACKGROUND

There is a dearth of data on the clinical features and outcomes of active tuberculosis (TB) in pregnancy. Studies have shown varied results and the relationship between TB and adverse pregnancy outcomes remains unclear.

OBJECTIVES

We conducted a systematic review and meta-analysis to evaluate pregnancy outcomes associated with TB.

SEARCH STRATEGY

Major databases were searched from inception until December 2015 without restrictions using the terms: 'TB', 'pregnancy', 'maternal morbidity', 'mortality' and 'perinatal morbidity', 'mortality'.

SELECTION CRITERIA

We included studies that compared the outcomes of pregnant women with and without active TB.

DATA COLLECTION AND ANALYSIS

We computed odds ratios for maternal and perinatal complications, and pooled them using a random effects model. We assessed for heterogeneity using chi-squared tests and evaluated its magnitude using the I2 statistic. We used the Newcastle-Ottawa scale for quality assessment.

MAIN RESULTS

Thirteen studies, including 3384 pregnancies with active TB and 119 448 without TB were included. Compared with pregnant women without TB, pregnant women with active TB was associated with increased odds of maternal morbidity [odds ratio (OR) 2.8, 95% CI 1.7-4.6; I2  = 60.3%], anaemia (OR 3.9, 95% CI 2.2-6.7; I2  = 29.8%), caesarean delivery (OR 2.1, 95% CI 1.2-3.8; I2  = 61.1%), preterm birth (OR 1.7, 95% CI 1.2-2.4; I2  = 66.5%), low birth weight (OR 1.7, 95% CI 1.2-2.4; I2  = 53.7%), birth asphyxia (OR 4.6, 95% CI 2.4-8.6; I2  = 46.3), and perinatal death (OR 4.2, 95% CI 1.5-11.8; I2  = 57.2%).

AUTHOR'S CONCLUSION

Active TB in pregnancy is associated with adverse maternal and fetal outcomes. Early diagnosis of TB is important to prevent significant maternal and perinatal complications.

TWEETABLE ABSTRACT

Active tuberculosis in pregnancy is associated with adverse maternal and perinatal outcomes.

On-site test to detect syphilis in pregnancy: a systematic review of test accuracy studies

BACKGROUND

Syphilis in pregnancy can lead to fetal and neonatal death or congenital anomalies. Accurate on-site tests are an essential part of effective prevention of mother-to-child transmission of the disease.

OBJECTIVE

This systematic review assessed the accuracy of on-site tests to detect infection with Treponema pallidum in pregnant women.

SEARCH STRATEGY

Major databases were searched from inception to January 2016 using terms: 'pregnancy', 'antenatal', 'syphilis', 'Treponema pallidum' with their variations, and the search limit for the relevant study design.

SELECTION CRITERIA

We included studies that used dual reference standard (non-treponemal and treponemal tests) to detected syphilis in pregnancy.

DATA COLLECTION AND ANALYSIS

Extracted accuracy data were tabulated and pooled using hierarchical, bivariate random effects model.

MAIN RESULTS

Seven studies (combined sample 17 546) reporting the accuracy of four on-site tests met the eligibility criteria. On average, Determine™ and SD BioLine Syphilis 3.0 had the highest sensitivity of all the evaluated tests: 0.83 (95% CI 0.58, 0.98) and 0.86 (95% CI 0.82, 0.89), respectively, with a high specificity 0.96 (95% CI 0.89, 1.00) and 0.99 (95% CI 0.94, 1.00), respectively. The Qualitative Rapid Plasma Reagin card commonly used in clinical practice had a pooled sensitivity of 0.70 (95% CI 0.54, 0.88) and specificity of 0.97 (95% CI 0.96, 0.99).

CONCLUSION

Immunochromatographic tests such as Determine™ and SD BioLine Syphilis 3.0 seem to be acceptable options in antenatal testing for syphilis, especially in resource-limited settings. Future research should seek more evidence to strengthen this claim.

TWEETABLE ABSTRACT

On-site test to detect syphilis-options during antenatal care.

Threats to reliability risk erroneous conclusions: a survey of prospective registration and sample sizes of randomised trials in women's health

OBJECTIVE

Prospective registration of clinical trials has been required since 2005. We aimed to assess concordance between registered and reported sample sizes among prospectively registered randomised controlled trials (RCTs) in obstetrics and gynaecology.

DESIGN

Analysis of prospectively registered and published data.

SETTING

Women's health.

SAMPLE

Obstetrics and gynaecology RCTs published in eight journals in 2015.

METHODS

Specialist (Acta Obstet Gynecol Scand, BJOG, Obstet Gynecol and Am J Obstet Gynecol) and general (BMJ, N Engl J Med, JAMA and Lancet) journals were searched from 1 January to 31 December 2015 for main reports of obstetrics and gynaecology RCTs. Their corresponding registries and protocols were sought and data were extracted. Proportions and 95% CI were calculated using exact methods.

MAIN OUTCOME MEASURES

Prospective registration of RCT and sample size concordance between RCTs and their registries within those where registration took place before patients were recruited.

RESULTS

Of the 75 relevant RCTs, 51 (68%, 95% CI 56-78%, P < 0.001 using a null hypothesis requiring 100% compliance) were prospectively registered, a feature found to be more common in general journals versus specialist journals (21/22 versus 30/53, 95% versus 57%, P = 0.001). Of the 51 prospectively registered RCTs, 31 (61%, 95% CI 46-74%, P = 0.003 using a null hypothesis requiring 40% of studies to achieve their stated sample size) did not reach the target sample size.

CONCLUSIONS

There are gaps in universal adoption of the prospective trial registration rule. Inability to meet target sample size risks deficiencies in statistical power with unreliability in results.

TWEETABLE ABSTRACT

Only two-thirds of RCTs in women's health are prospectively registered, and over half fail to achieve target sample sizes.

Development of a core outcome set for epilepsy in pregnancy (E-CORE): a national multi-stakeholder modified Delphi consensus study

OBJECTIVE

To develop a set of core outcomes for studies on pregnant women with epilepsy.

DESIGN

Delphi consensus study.

POPULATION

Healthcare professionals, and patient representatives with lived experience of epilepsy in the UK.

METHODS

We used a modified Delphi method and a consultation meeting to achieve consensus. Potential outcomes were identified by systematic review, and were scored using a Likert scale anchored between 1 (least important) and 5 (most important). We included outcomes that scored ≥4 by >70% of participants, and outcomes that scored ≤2 by <15% of participants.

MAIN OUTCOME MEASURES

Outcomes in studies on epilepsy in pregnancy.

RESULTS

Seventy-five healthcare professionals completed the first round, 48 (64%) completed the second round, and 37 (49%) completed the third round of the survey. Twenty-four patient representatives participated. The final core outcome set included 31 outcomes in three domains: neurological, offspring, and obstetric. Outcomes in the neurological domain were seizure control in pregnancy and postpartum, status epilepticus, maternal mortality, drowning, sudden unexpected death in epilepsy, postnatal depression, and quality of life. Offspring domain included congenital abnormalities (major and minor), fetal anticonvulsant syndrome, neurodevelopment, autism disorder, neonatal clinical complications, admission to a neonatal intensive care unit, and anthropometric measurements. The obstetric domain included live birth, stillbirth, miscarriage, ectopic, termination of pregnancy, admission to a high dependency or intensive care unit, breastfeeding, mode of delivery, preterm birth, pre-eclampsia, and eclampsia. Outcomes specific for studies on anti-epileptic drugs (AEDs) included maternal AED toxicity, AED compliance, neonatal withdrawal symptoms, and neonatal haemorrhagic disease.

CONCLUSION

Embedding this core set in future clinical trials will promote the standardisation of reporting to inform clinical practice.

TWEETABLE ABSTRACT

A Delphi method identifying core outcomes for epilepsy in pregnancy. Final core set includes 31 outcomes.

Diagnostic accuracy of cancer antigen 125 for endometriosis: a systematic review and meta-analysis

BACKGROUND

The development of a non-invasive and accurate diagnostic biomarker for endometriosis is urgently needed.

OBJECTIVE

Evaluate the diagnostic accuracy of serum cancer antigen 125 (CA 125) for endometriosis.

SEARCH STRATEGY

We searched EMBASE, MEDLINE, and Web of Science from inception to January 2016.

SELECTION CRITERIA

Diagnostic accuracy studies of serum CA 125 (index test) for histologically confirmed endometriosis (reference standard) were included.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials, extracted study characteristics and data. Methodological quality was assessed using Quality Assessment of Comparative Diagnostic Accuracy Studies (QUADAS-2) checklist.

MAIN RESULTS

Twenty-two studies (16 cohort, six case-control), 3626 participants, were identified. Bivariate hierarchical models were used to pool accuracy data of 14 studies (2920 participants) using CA 125 ≥ 30 units/ml. Pooled specificity was 93% (95% CI 89-95%) and sensitivity 52% (95% CI 38-66%). CA 125 was significantly more sensitive for the diagnosis of moderate or severe endometriosis compared with minimal disease (63%, 95% CI 47-77% versus 24%, 95%CI 19-32%, P-value = 0.001).

CONCLUSIONS

CA 125 performs well as a rule-in test facilitating expedited diagnosis and ensuring investigation and treatment can be confidently tailored for the management of endometriosis. Unfortunately, a negative test, CA 125 < 30 units/ml, is unable to rule out endometriosis.

TWEETABLE ABSTRACT

Blood test CA 125: a rule-in test for the diagnosis of women presenting with symptoms of endometriosis.

Educational effectiveness of gynaecological teaching associates: a multi-centre randomised controlled trial

OBJECTIVE

To evaluate, among medical students learning the female pelvic examination, the added benefits of training by gynaecological teaching associates compared with training involving a manikin only.

DESIGN

Randomised controlled trial.

SETTING

Nine university teaching hospitals.

POPULATION

Ninety-four medical students recruited prior to commencing a 4-week obstetrics and gynaecology rotation.

METHODS

The control training consisted of lectures, demonstration of the pelvic examination on a manikin, and opportunities to practise on this low-fidelity simulation (n = 40). The experimental group received additional gynaecological teaching associate training, delivered by pairs of experienced associates to groups of four medical students (n = 54).

MAIN OUTCOME MEASURES

Outcomes measured at the end of the rotation included knowledge of the correct order of examination components (Yes/No), and student comfort [Likert scales anchored between 1 (very uncomfortable) and 4 (very comfortable) on four items] and confidence [Likert scales anchored between 1 (No) and 3 (Yes) on six items]. The primary outcome, measured at the end of the academic year, was the objective structured clinical examination of a female pelvis (score range 0-54).

RESULTS

At baseline, the groups were similar in age, gender, and ethnicity. At the end of the clinical rotation, when compared with the control intervention, the experimental intervention had a moderate effect on student knowledge [difference 29.9% (95% CI 11.2-48.6%); P = 0.002] and confidence [difference 1 (95% CI 0-2); P < 0.001], and a large effect on student comfort [difference 1.8 (95% CI 0.6-3.0); P = 0.004]. At the end of the academic year, the experimental intervention had no impact on skills compared with the control [difference 2 (95% CI-1 to 4); P = 0.26].

CONCLUSIONS

Among medical students taught the female pelvic examination by low-fidelity simulation, additional training by gynaecology teaching associates improved knowledge, comfort, and confidence at the end of the clinical rotation but did not improve examination skills at end of the academic year.

Predictive accuracy of second-trimester uterine artery Doppler indices for stillbirth: a systematic review and meta-analysis

OBJECTIVE

To assess the predictive accuracy for stillbirth of second-trimester uterine artery Doppler.

METHODS

We searched MEDLINE, EMBASE and The Cochrane Library databases from inception until March 2015 without language restrictions. The included studies were those that assessed the association of abnormal uterine artery Doppler parameters and stillbirth. Two independent reviewers selected the studies, extracted data and assessed quality. Results for studies that were performed in the second trimester were pooled and summary estimates of sensitivity, specificity, likelihood ratios and their 95% confidence intervals were obtained. An overall summary of test accuracy was provided by the diagnostic odds ratio. Subgroup analysis was performed according to whether the study population was high risk or unselected.

RESULTS

Literature searches returned 338 relevant citations with 32 considered in full. Thirteen studies met our search criteria (85 845 women, 508 stillbirths) and were included in the review. Bivariate pooled estimate for sensitivity was 65% (95% CI, 38-85%) and for specificity 82% (95% CI, 72-88%). The positive likelihood ratio was 3.5 (95% CI, 2.3-5.5) and negative likelihood ratio 0.43 (95% CI, 0.22-0.85). The diagnostic odds ratio was 8.3 (95% CI, 3.0-22.4). Heterogeneity was high in the studies of high-risk women.

CONCLUSIONS

Abnormal uterine artery Doppler indices are associated with a three- to four-fold increase in the risk of stillbirth. The heterogeneity was particularly high in the high-risk group rendering it impossible to draw firm conclusions. In view of this, there is a role for individual patient data meta-analysis to define which Doppler parameter and threshold value should be measured.

An assessment of clinicians' and patients' experiences in the management of bladder pain syndrome

Current management of bladder pain syndrome (BPS) was evaluated through a prospective electronic questionnaire posted on three patient support groups and sent to all members on the British Society of Urogynaecology (BSUG) database. Methods of diagnosis and treatment were assessed. 133 patients and 69 clinicians participated in the survey. Patients reported their main symptom to be pain when their bladder was full in 80% (n = 107) and the most bothersome symptom was pelvic pain (22%, n = 29). 93% (n = 64) of clinicians made their diagnosis by history and cystoscopy. 78% (n = 54) of clinicians treated patients with amitriptyline and 75% (n = 52) by dietary modification while 77% (n = 102) of patients reported using simple analgesia, 74% (n = 98) dietary modification and 62% (n = 83) low-dose long-term antibiotics. There is wide variation in diagnostic methods and treatments of BPS used by clinicians and experienced by patients with no obvious consensus. National guidance is needed to help standardise care.

Outcome in fetal lower urinary tract obstruction: a prospective registry study

OBJECTIVE

To describe influences on decision-making and prognostic variables in the prenatal management of fetal lower urinary tract obstruction (LUTO).

METHODS

This was a prospective registry study of pregnant women with a male fetus with LUTO from centers within the British Isles and The Netherlands. Women and/or their clinicians were given the treatment option of either conservative management or vesicoamniotic shunting (VAS). Baseline characteristics of women in the registry, reasons for entry to the registry and pregnancy outcomes were assessed. The main study outcomes were survival to 28 days after delivery, further survival to 2 years and renal function. Logistic regression analysis was used to examine prognostic variables that affected outcome. Results were compared with those of women in a randomized controlled trial (RCT) who were allocated randomly to a treatment option.

RESULTS

Forty-five women were registered, of whom 78% (35/45) underwent conservative management. Twenty-seven women entered the registry owing to their clinician's preference for management and 18 because of their own preference. Compared to the conservative-management group of the RCT, a higher proportion of women in the registry opting for conservative management had a normal amniotic fluid volume at diagnosis (P = 0.05) and a diagnosis of LUTO ≥ 24 weeks' gestation (P = 0.003). On multivariable logistic regression analysis, these variables showed a significant association with perinatal survival (P < 0.001). Survival to 28 days after delivery was higher in the conservative-management group, at 69% (24/35), compared to 40% (4/10) in the VAS group (P = 0.02) but this difference had limited statistical significance owing to small study size (relative risk, 0.58 (95% CI, 0.26-1.29); P = 0.14).

CONCLUSION

In our prospective registry, the majority of fetuses with LUTO received conservative management, which was associated with better short- and long-term outcomes. A significant proportion of these pregnancies had normal amniotic fluid volume and a gestational age at diagnosis of ≥ 24 weeks, characteristics shown to be associated with improved survival.