Which women should be tested for Chlamydia trachomatis?

Objective To assess the prevalence of genitourinary Chlamydia trachomatis infection among women in different clinical settings, with a view to making decisions about who should be tested routinely.
Design Cross sectional study.
Setting One regional hospital and family planning clinic serving an urban centre.
Population Two thousand thirty-five sexually active women attending various outpatient settings.
Main outcome measures Prevalence of positivity by clinical setting, stratified by age.
Results Overall, prevalence of lower genital tract chlamydial infection was similar in a variety of clinical settings. Infertile women were the only exception, demonstrating a much lower prevalence. Stratifying the study population by age found a clear trend towards high prevalence in teenagers and virtually no infection in women over the age of 30 years.
Conclusions The prevalence of chlamydial infection in women is related to age, regardless of clinical presentation. In practice, opportunistic screening should target sexually active women under 30 years of age.     

Rotational forceps: should these procedures be abandoned?

Forceps delivery remains an important part of the obstetric armamentarium. When applied by practitioners skilled in their use, forceps delivery can quickly and safely deliver a fetus at risk. Unfortunately, forceps can also be an instrument of harm for the women or her infant. This is particularly true of rotational forceps. The goal of this monograph is to review in detail the indications, contraindications, technique, as well as risks and complications of forceps delivery, with particular attention to rotational forceps. We conclude by asking the question: Should rotational forceps be abandoned altogether?     

Patient-friendly IVF: how should it be defined?

"Patient-friendly" IVF must be associated with a healthy newborn achieved in a safe, cost-effective, and timely manner. Patients are best served when physicians provide honest appraisal of treatment techniques and outcomes using the evidence available from scientific study.     

Which stem cells should be used for transplantation?

In view of the ever-increasing demand for human stem cells for transplantation, we initiated in vitro and in vivo studies of human fetal bone marrow stem/progenitor cells derived from lost pregnancies at 16-20 weeks. Utilizing non-human primates as models, we demonstrated that fetal tissue has distinctive biological and therapeutic properties that are optimal for transplantation. Subsequently, we tested and compared the phenotypic and functional characteristics of fetal bone marrow (FBM), adult bone marrow (ABM), and cord blood (CB) and peripheral blood (PB) sources of the most primitive stem/progenitor cells. A striking ontogenic difference in the proportion of CD34+ cells in FBM, ABM, PB and CB was observed (24.6 vs. 2.1 vs. 0.5 vs. 2%). The clonogenic potential, as measured by the CFU-c assay, was also higher in FBM when compared with ABM, PB and CB (202.5 vs. 73.5 vs. 40.8 vs. 65.5 colonies/10(5 )cells). Moreover, there was a significant decrease in proliferative responsiveness in the mixed lymphocyte reaction (MLR) assay of FBM and CB as compared to ABM and PB. The cytokinetic profiles of the cells from the four sources were also analyzed. This study revealed that both FBM and ABM had a higher proportion of S-phase (21.7 and 11.5%, respectively), compared to PB and CB cells (1.2 and 2.8%, respectively). FBM and ABM also showed a higher proportion of cells in the G(2)-M phase (6.4 and 2.6%, respectively) compared with PB and CB (1.7 and 1.2%, respectively). These data show that FBM has the highest number of proliferating cells. We have also investigated the ontogenic differences in stromal cells derived from FBM, ABM and CB, with a special focus on the expression of selected cytokines, such as CSF, GM-CSF, G-CSF, M-CSF, IL-3, IL-6, IL-10 and IL-11. FBM showed the highest levels of expression of CSF, IL-6 and IL-11 when compared to the other sources. These cytokines may have an important role in engraftment and homing of stem cells. The levels of expression of the other cytokines were similar in all sources of stromal cells, with the exception of G-CSF, which was not detected in CB. Moreover, the number of colonies FBM and ABM cells was higher when inoculated with fetal stromal cells. These results suggested an important regulatory role of cytokines in ontogeny of hematopoiesis. In summary, the foregoing observations indicate that each source of hematopoietic and stromal cells has different intrinsic properties, closely correlated with ontogenetic age, which is a vital determinant for phenotypic characteristics, lineage commitments, immunogenicity as well as proliferative potentials. Our data clearly indicate that FBM is the best source of stem cells for engraftment and therapeutic reconstitution due to its very high proliferative capacity, low immunogenicity and highest number of primitive stem/progenitor cells. It should also be stressed that FBM stem cells retrieved at their optimal stage of hematopoiesis (16-20 weeks) may be the cells of choice for both therapeutic cellular reconstitution and gene targeting.     

Long-term outcomes: what should the focus be?

The neonatal intervention trials of the 1980s and early 1990s focused primarily on short-term outcomes. Contemporary clinical trials have recognized the importance of longer-term outcomes but have rarely been powered to achieve that aim. This review discusses important and clinically relevant outcomes that future trials should be powered to address and identifies the challenges facing the neonatal clinical trials community. These challenges include consensus definitions of relevant outcomes that are objective and validated, variability among centers in populations and practices, and the need for predictive surrogate markers of long-term outcomes. Future trials must be designed and powered to address the potential for harm as well as the prospect of benefit.     

How should randomised trials including multiple pregnancies be analysed?

Objective   To compare the effects of four methods of analysis on the results of randomised controlled trials that recruit women with multiple pregnancies and measure outcomes on their babies.
Design   Analysis of one real and two simulated data sets.
Setting   Secondary analysis of perinatal randomised controlled trials.
Population   Randomised controlled trials including women with multiple pregnancies.
Methods   The analytical methods compared were (a) assuming independence among babies, (b) analysing outcomes per women, counting a woman as having an outcome if any of her babies had it (equivalent to selecting the worst outcome among any of a woman's babies), (c) randomly selecting one baby from each set of multiples for inclusion in the analysis, (d) adjustment of the analysis to take account of non-independence of babies from multiple pregnancies, using methods developed for analysis of cluster randomised trials.
Main outcome measures   Odds ratios for trials' main outcomes.
Results   Results from application of cluster trial methods were similar to those from assuming independence among babies, but with slightly wider confidence intervals, reflecting the reduced effective sample size caused by non-independence between babies from the same pregnancy. Results were more variable using the other two methods, and in some cases, departed markedly from the results of the cluster trial methods.
Conclusions   Cluster trial methods provide a simple way of adjusting the analysis to take account of non-independence between babies from the same pregnancy. Random selection and analysis by pregnancy (methods (b) and (c)) have disadvantages and do not report outcomes for all of the babies in the trial. This may cause problems with incorporating trials analysed using these methods into systematic reviews.     

What prenatal diagnosis should be offered in multiple pregnancy?

The issues surrounding prenatal diagnosis in multiple pregnancy are complex. Accurate determination of chorionicity is vital and an inability to determine this should trigger consideration for referral to a specialist. The choice of screening method for detection of chromosomal abnormality is limited, and existing data demonstrates the advantages of nuchal translucency screening. The possibility of obtaining discordant results and options for management should be discussed in advance. Invasive tests are technically more difficult and associated with a higher risk of procedure-related pregnancy loss than less invasive methods. Repeat invasive testing is required more often in multiple pregnancies than in singleton pregnancies. Selective termination is technically feasible in both mono- and dichorionic pregnancies, although the risks are higher with the former. It is likely to be more acceptable than high-order multifetal reduction performed in the absence of fetal abnormality.     

At what age should we be vaccinating for human papillomavirus?

Human papillomavirus (HPV) infections cause high disease burden. Primary prevention by vaccination is a major breakthrough. HPV vaccines are well tolerated and safe. Vaccines protect unexposed individuals against high-grade CIN and VIN/VaIN caused by the vaccine HPV types. Vaccines also provide protection against related oncogenic HPV types. The primary target population is young adolescents before their sexual debut. Catch-up vaccination policy up to age 26 may facilitate long-term health benefits but should not divert resources from vaccinating the primary target population or from effective cervical cancer screening programmes. Health benefits of vaccinating older age groups beyond age 26 are unknown.     

Post Magpie: how should we be managing severe preeclampsia?

PURPOSE OF REVIEW: Preeclampsia is a common complication of pregnancy and a significant cause of fetal and maternal morbidity and mortality. The purpose of this review is to highlight and discuss aspects of some of the more recent clinical management papers published in the field of preeclampsia and eclampsia. The title explains the clinical nature of this paper and a detailed review of the basic science literature is beyond the scope of this article. RECENT FINDINGS: Several controversial areas still exist in the current management of severe preeclampsia/eclampsia. We present a number of interesting papers dealing with practical management questions and discuss the optimum treatment regimen for preventing eclampsia. The findings of the MAGPIE study are discussed. Opinions are expressed as to the current management of preterm severe preeclampsia, and we outline a new hypothesis on the etiology of eclampsia. SUMMARY: Preeclampsia/eclampsia remains a disease without a clear etiology. Despite this, clinical management issues are being addressed and maternal morbidity and mortality continue to fall.     

Genetic screening for infertility: When should it be done?

Depending on the clinical findings, the infertile male patient needs genetic evaluation. Karyotype analysis and Y-chromosomal microdeletion screening should be performed in patients with azoospermia or severe oligozoospermia in order to rule out structural chromosomal abnormalities, Klinefelter syndrome and Y chromosome microdeletions. Infertile patients with obstructive azoospermia need cystic fibrosis transmembrane receptor gene screening, while in patients with hypogonadotropic hypogonadism mutation screening may be performed according to clinical features. All genetic analyses should be accompanied by expert counseling by a clinical genetist both in male and female patients.Primary amenorrhea should be investigated by karyotype analysis and selected mutation screening according to the patient's clinical features. Karyotype analyses and FMR1 gene screening is recommended in cases of POF. At present the infertility of patients with POF cannot be restored if the diagnosis is made after complete follicular depletion, but in some cases, early diagnosis by genetic investigation may instead lead to the advice of early conception or oocyte harvesting and preservation. In addition, the accumulation and annotation of array comparative genomic hybridization data might, in the near future, lead to the identification of pathogenetic copy number variations and genes involved in POF. Karyotype analysis of both partners is recommended in all couples with recurrent pregnancy loss. No routine genetic test can be recommended so far in patients with PCOS.     

Antenatal care in developing countries. What should be done?

Development of antenatal care from the beginning of the 20th century and its relation to perinatal mortality in developed countries is presented. The role of socioeconomic factors, new diagnostic and therapeutic procedures, extended indications for cesarean section and of neonatal intensive care is also stressed. In the West- and Middle-European countries by the introduction of antenatal care the perinatal mortality (PNM) rate decreased from about 60.0@1000 in the years 1920-1930 to about 40.0@1000 in 1950s. Further decrease to about 25.0@1000 in the 1970s was conditioned by an increase of number of antenatal visits and by extended indications for cesarean section. New technologies (amnioscopy, pH.metry, cardiotocography and ultrasound examinations) decreased the PNM rate to about 13.0@1000 in the year 1980. Regional organization with neonatal intensive care units decreased PNM rate to low values of 5.0-9.0@1000. The echo of the number of antenatal visits to PNM rate is illustrated on 36,855 deliveries at the University Clinic in Zagreb. In developing countries maternal and perinatal mortality is very high. The reason for that is a bad socioeconomic background and a lack of organized antenatal and perinatal health care system. The policy to decrease maternal and perinatal mortality is presented: the improvement of antenatal booking and of the number of prenatal visits of pregnant women; their childbearing under professional assistance. The organizing of maternity health care should be different from country to country, from region to region, respectively.