Tests for predicting complications of pre-eclampsia: A protocol for systematic reviews

Background Pre-eclampsia is associated with several complications. Early prediction of complications and timely management is needed for clinical care of these patients to avert fetal and maternal mortality and morbidity. There is a need to identify best testing strategies in pre eclampsia to identify the women at increased risk of complications. We aim to determine the accuracy of various tests to predict complications of pre-eclampsia by systematic quantitative reviews. Method We performed extensive search in MEDLINE (1951–2004), EMBASE (1974–2004) and also will also include manual searches of bibliographies of primary and review articles. An initial search has revealed 19500 citations. Two reviewers will independently select studies and extract data on study characteristics, quality and accuracy. Accuracy data will be used to construct 2 × 2 tables. Data synthesis will involve assessment for heterogeneity and appropriately pooling of results to produce summary Receiver Operating Characteristics (ROC) curve and summary likelihood ratios. Discussion This review will generate predictive information and integrate that with therapeutic effectiveness to determine the absolute benefit and harm of available therapy in reducing complications in women with pre-eclampsia

Development of a clockwork light source to enable cervical inspection by village health workers

BACKGROUND: Cervical cancer can often be prevented by screening and may be curable if identified and treated in its early stages. However, 80% of new cases occur in less-developed countries where cervical cancer screening programmes are small-scale or non-existent. This is a human tragedy of great proportion, with many of those affected being young mothers. There is some evidence that cancerous or precancerous lesions may be detected by visual inspection with acetic acid (VIA) and field studies indicate that this technique is effective, safe and acceptable to women. However, the provision of a light source for inspection of the cervix presents a major problem in less-developed countries, where candles and torches often provide the only means of illumination. Our objective was to develop a light source based on clockwork technology, that required no batteries or external power source. METHODS: We adapted the design of a commercially available clockwork torch to provide a light source for cervical inspection. The light source was then tested under laboratory conditions in a comparison with other illumination methods typically used in this application. RESULTS: The light source gave illuminance levels greater than those produced by any other method tested, and also had considerable advantages in terms of ease of use and safety. CONCLUSION: This design is small, compact, effective and safe to use and promises a better and more affordable means of visualising the cervix. Further field trials of VIA are now required which incorporate this light source

Estimation of proteinuria as a predictor of complications of pre-eclampsia: a systematic review

Background Proteinuria is one of the essential criteria for the clinical diagnosis of pre-eclampsia. Increasing levels of proteinuria is considered to be associated with adverse maternal and fetal outcomes. We aim to determine the accuracy with which the amount of proteinuria predicts maternal and fetal complications in women with pre-eclampsia by systematic quantitative review of test accuracy studies. Methods We conducted electronic searches in MEDLINE (1951 to 2007), EMBASE (1980 to 2007), the Cochrane Library (2007) and the MEDION database to identify relevant articles and hand-search of selected specialist journals and reference lists of articles. There were no language restrictions for any of these searches. Two reviewers independently selected those articles in which the accuracy of proteinuria estimate was evaluated to predict maternal and fetal complications of pre-eclampsia. Data were extracted on study characteristics, quality and accuracy to construct 2 × 2 tables with maternal and fetal complications as reference standards. Results Sixteen primary articles with a total of 6749 women met the selection criteria with levels of proteinuria estimated by urine dipstick, 24-hour urine proteinuria or urine protein:creatinine ratio as a predictor of complications of pre-eclampsia. All 10 studies predicting maternal outcomes showed that proteinuria is a poor predictor of maternal complications in women with pre-eclampsia. Seventeen studies used laboratory analysis and eight studies bedside analysis to assess the accuracy of proteinuria in predicting fetal and neonatal complications. Summary likelihood ratios of positive and negative tests for the threshold level of 5 g/24 h were 2.0 (95% CI 1.5, 2.7) and 0.53 (95% CI 0.27, 1) for stillbirths, 1.5 (95% CI 0.94, 2.4) and 0.73 (95% CI 0.39, 1.4) for neonatal deaths and 1.5 (95% 1, 2) and 0.78 (95% 0.64, 0.95) for Neonatal Intensive Care Unit admission. Conclusion Measure of proteinuria is a poor predictor of either maternal or fetal complications in women with pre-eclampsia

Prediction of complications in early-onset pre-eclampsia (PREP): development and external multinational validation of prognostic models.

BACKGROUND: Unexpected clinical deterioration before 34 weeks gestation is an undesired course in early-onset pre-eclampsia. To safely prolong preterm gestation, accurate and timely prediction of complications is required. METHOD: Women with confirmed early onset pre-eclampsia were recruited from 53 maternity units in the UK to a large prospective cohort study (PREP-946) for development of prognostic models for the overall risk of experiencing a complication using logistic regression (PREP-L), and for predicting the time to adverse maternal outcome using a survival model (PREP-S). External validation of the models were carried out in a multinational cohort (PIERS-634) and another cohort from the Netherlands (PETRA-216). Main outcome measures were C-statistics to summarise discrimination of the models and calibration plots and calibration slopes. RESULTS: A total of 169 mothers (18%) in the PREP dataset had adverse outcomes by 48 hours, and 633 (67%) by discharge. The C-statistics of the models for predicting complications by 48 hours and by discharge were 0.84 (95% CI, 0.81-0.87; PREP-S) and 0.82 (0.80-0.84; PREP-L), respectively. The PREP-S model included maternal age, gestation, medical history, systolic blood pressure, deep tendon reflexes, urine protein creatinine ratio, platelets, serum alanine amino transaminase, urea, creatinine, oxygen saturation and treatment with antihypertensives or magnesium sulfate. The PREP-L model included the above except deep tendon reflexes, serum alanine amino transaminase and creatinine. On validation in the external PIERS dataset, the reduced PREP-S model showed reasonable calibration (slope 0.80) and discrimination (C-statistic 0.75) for predicting adverse outcome by 48 hours. Reduced PREP-L model showed excellent calibration (slope: 0.93 PIERS, 0.90 PETRA) and discrimination (0.81 PIERS, 0.75 PETRA) for predicting risk by discharge in the two external datasets. CONCLUSIONS: PREP models can be used to obtain predictions of adverse maternal outcome risk, including early preterm delivery, by 48 hours (PREP-S) and by discharge (PREP-L), in women with early onset pre-eclampsia in the context of current care. They have a potential role in triaging high-risk mothers who may need transfer to tertiary units for intensive maternal and neonatal care. TRIAL REGISTRATION: ISRCTN40384046 , retrospectively registered

Training tomorrow's doctors in the preoperative clinic

Background: The reduction in the length of hospital stay for surgical patients at a time of expanding medical student numbers has created challenges in the provision of adequate exposure to surgical patients. This has required the use of surgical learning opportunities in the ambulatory setting, including the preoperative assessment clinic. At Keele University, fourth-year medical students follow patient journeys through the preoperative assessment process, gaining experience of history taking, examination, prescribing and practical skills. This is followed by group discussion with a clinical teaching fellow, focusing on management and clinical reasoning. We audited the experience our students gained in the preoperative assessment clinic against the relevant Tomorrow's Doctors outcomes. Methods: An audit tool was created by reviewing the patient journey to identify potential learning opportunities. These were then mapped to the relevant Tomorrow's Doctors outcomes. Audit pro formas were completed for each student at the end of the clinic by the clinical educator, with a total of 42 sessions audited. Results: Our findings show that it is possible for students to gain experience in all nine of the identified Tomorrow's Doctors outcomes in the preoperative assessment clinic. Practical procedure experience was gained by 92 per cent of students, and 70 per cent demonstrated clinical judgment and decision skills. Discussion: This study shows that students can gain experience in multiple Tomorrow's Doctors outcomes in the preoperative assessment clinic. In particular, it is a useful environment to learn and teach practical procedures, clinical reasoning and decision-making skills

Instruments for assisted vaginal birth

BACKGROUND : Assisted vaginal births are carried out to expedite birth for the benefit of mothers and babies but are sometimes associated with significant morbidity for both. Various instruments are available, broadly divided into forceps and vacuum cups, and choice may be influenced by clinical circumstances, operator preference, experience and availability. OBJECTIVES : To evaluate the different instruments in terms of success in achieving a vaginal birth, and the risk of morbidity for mother and baby. SEARCH METHODS : We searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (14 May 2021), and reference lists of retrieved studies. SELECTION CRITERIA : We selected randomised controlled trials of assisted vaginal birth using different instruments. The review did not include quasi-randomised trials, cluster-randomised trials or cross-over designs. The review included trials for which abstracts alone were available as long as there was sufficient information to assess eligibility. Data collection analysis We used standard Cochrane methods. We used the GRADE approach to assess the certainty of evidence. The main outcomes assessed included failed delivery with allocated instrument, any maternal trauma, third- and fourth-degree tears, postpartum haemorrhage, any neonatal trauma, low Apgar and low umbilical artery pH. MAIN RESULTS : We included 31 studies involving a total of 5754 women. Risk of bias criteria were largely assessed as 'unclear', due to a lack of detail in trial reports. Blinding would have been challenging for all trials due to their inability to conceal the type of instrument used from either the woman or the operator, which is reflected in the risk of bias assessment.http://www.thecochranelibrary.com2022-09-24am2022Obstetrics and Gynaecolog

Twelve tips for creating a medical education society

University societies are student-led organisations which provide excellent opportunities for students to collaborate in a shared interest. Peer teaching is gaining recognition as an effective method of medical education. Peer teaching also provides student tutors with core educational skills and provides students with approachable peer mentors. This article offers practical guidance on organising, planning, executing and sustaining peer teaching via a medical education society at university and outlines the supporting literature

Non-contraceptive oestrogen-containing preparations for controlling symptoms of premenstrual syndrome

Premenstrual syndrome (PMS) is a psychological and somatic disorder of unknown aetiology, with symptoms typically including irritability, depression, mood swings, bloating, breast tenderness and sleep disturbances. About 3% to 10% of women who experience these symptoms may also meet criteria for premenstrual dysphoric disorder (PMDD). PMS symptoms recur during the luteal phase of the menstrual cycle and reduce by the end of menstruation. PMS results from ovulation and may be due to ovarian steroid interactions relating to neurotransmitter dysfunction. Premenstrual disorders have a devastating effect on women, their families and their work. Several treatment options have been suggested for PMS, including pharmacological and surgical interventions. The treatments thought to be most effective tend to fall into one of two categories: suppressing ovulation or correcting a speculated neuroendocrine anomaly. Transdermal oestradiol by patch, gel or implant effectively stops ovulation and the cyclical hormonal changes which produce the cyclical symptoms. These preparations are normally used for hormone therapy and contain lower doses of oestrogen than found in oral contraceptive pills. A shortened seven-day course of a progestogen is required each month for endometrial protection but can reproduce premenstrual syndrome-type symptoms in these women. Objectives To determine the effectiveness and safety of non-contraceptive oestrogen-containing preparations in the management of PMS. Search methods On 14 March 2016, we searched the following databases: the Cochrane Gynaecology and Fertility Group (CGF) Specialised Register; Cochrane Central Register of Studies (CRSO); MEDLINE; Embase; PsycINFO; CINAHL; ClinicalTrials.gov; metaRegister of Controlled trials (mRCT); and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) Search Portal. In addition, we checked the reference lists of articles retrieved. Selection criteria We included published and unpublished randomized placebo or active controlled trials on the efficacy of the use of non-contraceptive oestrogen-containing preparations in the management of premenstrual syndrome in women of reproductive age with PMS diagnosed by at least two prospective cycles without current psychiatric disorder. Data collection and analysis Two review authors independently selected studies, assessed risk of bias, extracted data on premenstrual symptoms and adverse effects and entered data into Review Manager 5 software. Where possible, intention-to-treat or modified intention-to-treat analysis was used. Studies were pooled using a fixed-effect model, analysing cross-over trials as parallel trials. Standardised mean differences (SMDs) with 95% confidence intervals (CIs) were calculated for premenstrual symptom scores. Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated for dichotomous outcomes. The overall quality of the evidence was assessed using the GRADE working group methods. Main results The search resulted in 524 potentially relevant articles. Five eligible randomized controlled trials (RCTs) were identified (305 women). Trials using oral tablets, transdermal patches and implants were identified. No trial used gels. One small cross-over trial (11 women, effective sample size 22 women considering cross-over trials) compared oral luteal-phase oestrogen versus placebo. Data were very low quality and unsuitable for analysis, but study authors reported that the intervention was ineffective and might aggravate the symptoms of PMS. They also reported that there were no adverse events. Three studies compared continuous oestrogen with progestogen versus placebo (with or without progestogen). These trials were of reasonable quality, although with a high risk of attrition bias and an unclear risk of bias due to potential carry-over effects in two cross-over trials. Continuous oestrogen had a small to moderate positive effect on global symptom scores (SMD −0.34, 95% CI −0.59 to −0.10, P = 0.005, 3 RCTs, 158 women, effective sample size 267 women, I² = 63%, very low quality evidence). The evidence was too imprecise to determine if the groups differed in withdrawal rates due to adverse effects (RR 0.64, 95% CI 0.26 to 1.58, P = 0.33, 3 RCTs, 196 women, effective sample size 284 women, I² = 0%, very low quality evidence). Similarly, the evidence was very imprecise in measures of specific adverse events, with large uncertainties around the true value of the relative risk. None of the studies reported on long-term risks such as endometrial cancer or breast cancer. One study compared patch dosage (100 vs 200 µg oestrogen, with progestogen in both arms) and had a high risk of performance bias, detection bias and attrition bias. The study did not find evidence that dosage affects global symptoms but there was much uncertainty around the effect estimate (SMD −1.55, 95% CI −8.88 to 5.78, P = 0.68, 1 RCT, 98 women, very low quality evidence). The evidence on rates of withdrawal for adverse events was too imprecise to draw any conclusions (RR 0.70, 95% CI 0.34 to 1.46, P = 0.34, 1 RCT, 107 women, low-quality evidence). However, it appeared that the 100 µg dose might be associated with a lower overall risk of adverse events attributed to oestrogen (RR 0.51, 95% Cl 0.26 to 0.99, P = 0.05, 1 RCT, 107 women, very low quality evidence) with a large uncertainty around the effect estimate. The overall quality of the evidence for all comparisons was very low, mainly due to risk of bias (specifically attrition), imprecision, and statistical and clinical heterogeneity. Authors' conclusions We found very low quality evidence to support the effectiveness of continuous oestrogen (transdermal patches or subcutaneous implants) plus progestogen, with a small to moderate effect size. We found very low quality evidence from a study based on 11 women to suggest that luteal-phase oral unopposed oestrogen is probably ineffective and possibly detrimental for controlling the symptoms of PMS. A comparison between 200 µg and 100 µg doses of continuous oestrogen was inconclusive with regard to effectiveness, but suggested that the lower dose was less likely to cause side effects. Uncertainty remains regarding safety, as the identified studies were too small to provide definite answers. Moreover, no included trial addressed adverse effects that might occur beyond the typical trial duration of 2-8 months. This suggests the choice of oestrogen dose and mode of administration could be based on an individual woman’s preference and modified according to the effectiveness and tolerability of the chosen regimen