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Abstract Background The objective was to provide a systematic review of the effectiveness of community-level interventions to reduce maternal mortality. Methods We searched published papers using Medline, Embase, Cochrane library, CINAHL, BNI, CAB ABSTRACTS, IBSS, Web of Science, LILACS and African Index Medicus from inception or at least 1982 to June 2006; searched unpublished works using National Research Register website, metaRegister and the WHO International Trial Registry portal. We hand searched major references. Selection criteria were maternity or childbearing age women, comparative study designs with concurrent controls, community-level interventions and maternal death as an outcome. We carried out study selection, data abstraction and quality assessment independently in duplicate. Results We found five cluster randomised controlled trials (RCT) and eight cohort studies of community-level interventions. We summarised results as odds ratios (OR) and confidence intervals (CI), combined using the Peto method for meta-analysis. Two high quality cluster RCTs, aimed at improving perinatal care practices, showed a reduction in maternal mortality reaching statistical significance (OR 0.62, 95% CI 0.39 to 0.98). Three equivalence RCTs of minimal goal-oriented versus usual antenatal care showed no difference in maternal mortality (1.09, 95% CI 0.53 to 2.25). The cohort studies were of low quality and did not contribute further evidence. Conclusion Community-level interventions of improved perinatal care practices can bring about a reduction in maternal mortality. This challenges the view that investment in such interventions is not worthwhile. Programmes to improve maternal mortality should be evaluated using randomised controlled techniques to generate further evidence.

Abstract Background Quality assessment tools for primary studies of test accuracy are relatively well developed, although only one is validated (QUADAS), but very little work has been done to develop tools to quality-assess studies evaluating the impact of diagnostic testing on management of patients (diagnostic or therapeutic yield). The recent draft NICE Guide to the Methods of Technology Appraisal (2007) suggests QUADAS "as a useful starting point for appraising studies that evaluate the sensitivity and specificity of a test" but does not mention how to quality assess diagnostic or therapeutic yield studies, in particular diagnostic before-after studies. In the context of undertaking a rapid systematic review of structural neuroimaging in psychosis for NICE, we describe the modifications that we made to QUADAS, our experience of this in practice and in relation to published theory on diagnostic or therapeutic yield studies. Methods The QUADAS tool was assessed for use in the review by two systematic reviewers with in-depth knowledge of the clinical area being reviewed and the types of studies being found in the searches that could answer the clinical question. Modifications were made following discussion as considered appropriate. Results Two QUADAS questions were removed altogether and. four additional questions were developed to capture additional quality issues not addressed by QUADAS. However, the developed checklist only partially helped to discern implications of the study designs on the results given. Conclusion The division between topic-specific and more generic quality items of relevance to diagnostic before-after studies is important. With more time, further work could have been done to create a better quality assessment tool, for example by incorporating some of the issues mentioned in previous work in this area. This paper is a discussion around quality assessment and is intended to offer insights into the types of issues that should be assessed. A quality assessment tool for diagnostic before-after studies that incorporates items from QUADAS and published theory needs to be further developed and validated.

Abstract Background Very little is known about the physical health needs of lesbian and bisexual women in the UK; most research has looked at mental or sexual health only. This article reports the results of four surveys carried out in the West Midlands between 1995 and 2005. Methods The first two surveys were conducted in 1995–6 by a volunteer group, with participants from a lesbian health conference (n = 69) and in a convenience sample from a wide range of relevant groups and venues (n = 354). The second two surveys were commissioned by the West Midlands South Strategic Health Authority in partnership with the Gay Men's Health Network and were conducted in 2002 (n = 449) and 2005 (n = 166) and again used convenience sampling methods including the internet. Results The mean age of respondents varied between 29–33 years and 5–7% were from a non-white ethnic background. The smoking rates varied from 42% o 55%, being twice the West Midlands regional average of 21% for women aged 16 or more. Similarly, problems with alcohol were reported in 25–37% of respondents, higher than the West Midlands regional average of 7% for women aged 16+. The prevalence of any mental health problem varied between 31–35% and any suicide attempt between 20–31%. Only 29–45% had revealed their sexual orientation to their GP and of these, approximately 50% had experienced a positive reaction. Conclusion The results suggest health needs that current UK health services may not be meeting. There is a need to identify and target specific health measures for lesbians and bisexual women in order to ensure improved physical and mental health in the longer term.

Abstract Background Pre-eclampsia, a syndrome of hypertension and proteinuria, is a major cause of maternal and perinatal morbidity and mortality. Accurate prediction of pre-eclampsia is important, since high risk women could benefit from intensive monitoring and preventive treatment. However, decision making is currently hampered due to lack of precise and up to date comprehensive evidence summaries on estimates of risk of developing pre-eclampsia. Methods/Design A series of systematic reviews and meta-analyses will be undertaken to determine, among women in early pregnancy, the accuracy of various tests (history, examinations and investigations) for predicting pre-eclampsia. We will search Medline, Embase, Cochrane Library, MEDION, citation lists of review articles and eligible primary articles and will contact experts in the field. Reviewers working independently will select studies, extract data, and assess study validity according to established criteria. Language restrictions will not be applied. Bivariate meta-analysis of sensitivity and specificity will be considered for tests whose studies allow generation of 2 × 2 tables. Discussion The results of the test accuracy reviews will be integrated with results of effectiveness reviews of preventive interventions to assess the impact of test-intervention combinations for prevention of pre-eclampsia.

Background: The objective was to provide a systematic review of the effectiveness of community-level interventions to reduce maternal mortality.Methods: We searched published papers using Medline, Embase, Cochrane library, CINAHL, BNI, CAB ABSTRACTS, IBSS, Web of Science, LILACS and African Index Medicus from inception or at least 1982 to June 2006; searched unpublished works using National Research Register website, metaRegister and the WHO International Trial Registry portal. We hand searched major references.Selection criteria were maternity or childbearing age women, comparative study designs with concurrent controls, community-level interventions and maternal death as an outcome. We carried out study selection, data abstraction and quality assessment independently in duplicate.Results: We found five cluster randomised controlled trials (RCT) and eight cohort studies of community-level interventions. We summarised results as odds ratios (OR) and confidence intervals (CI), combined using the Peto method for meta-analysis. Two high quality cluster RCTs, aimed at improving perinatal care practices, showed a reduction in maternal mortality reaching statistical significance (OR 0.62, 95% CI 0.39 to 0.98). Three equivalence RCTs of minimal goal-oriented versus usual antenatal care showed no difference in maternal mortality (1.09, 95% CI 0.53 to 2.25). The cohort studies were of low quality and did not contribute further evidence.Conclusion: Community-level interventions of improved perinatal care practices can bring about a reduction in maternal mortality. This challenges the view that investment in such interventions is not worthwhile. Programmes to improve maternal mortality should be evaluated using randomised controlled techniques to generate further evidence. [ABSTRACT FROM AUTHOR]

Objective: Type 1 diabetes mellitus rates are rising worldwide. The health benefits of physical exercise in this condition are many, but more than 60% do not participate, mainly from fear of hypoglycemia. This systematic review explores the effects of physical exercise modes on blood glucose levels in adults for hypoglycemia prevention., Research Design and Methods: Predefined inclusion criteria were randomized or non-randomized cross-over trials of healthy non-obese adults with type 1 diabetes mellitus. Exercise interventions used standardized protocols of intensity and timing. Outcomes included hypoglycemia during or after exercise, and acute glycemic control. Medline, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine Database, SPORTDiscus, CochraneCENTRAL (1990 to 11 January 2018), and Embase (1988 to 9 April 2018) were searched using keywords and Medical Subject Heading (MeSH) terms. Inclusions, data extraction and quality assessment using the Critical Appraisal Skills Programme checklists were done by one researcher and checked by a second. Review Manager (V.5.3) was used for meta-analysis where four or more outcomes were reported., Results: From 5459 citations, we included 15 small cross-over studies (3 non-randomized), 13 assessing aerobic (intermittent high-intensity exercise (IHE) vs continuous, or continuous vs rest) and 2 assessing resistance exercise versus rest. Study quality was good, and all outcome measures were reported. Thirteen gave hypoglycemia results, of which five had no episodes. Meta-analysis of hypoglycemia during or after IHE compared with continuous exercise showed no significant differences (n=5, OR=0.68 (95% CI 0.16 to 2.86), I 2 =56%). For blood glucose there was little difference between groups at any time point., Conclusion: IHE may be safer than continuous exercise because of lesser decline in blood glucose, but more research needs to demonstrate if this would be reflected in hypoglycemic episode rates., Trial Registration Number: CRD42018068358., Competing Interests: Competing interests: None declared.

Aim: School-based smoking prevention programmes may delay the age of smoking initiation, but do not appear to achieve lasting reductions in smoking prevalence beyond school-leaving age. We explored whether delaying the age at which someone initiates smoking may have life-time benefits by increasing the likelihood of quitting in later life., Design and Setting: Data from the General Household Survey of Great Britain were used in a logistic regression model to examine the association between age at which someone initiates regular smoking and the probability that the person will quit smoking later in life. The effect of confounding variables (sex, ethnicity, socio-economic class, education and geographical location) was taken into account. The predicted relationship was used in a cohort model to estimate the life-time reduction in smoking prevalence and all-cause mortality of a school-based smoking prevention programme., Results: Age of regular smoking initiation was associated strongly with the probability of quitting later in life (coefficient -0.103, P < 0.001). The strength of the association was slightly reduced but still significant when confounding variables were included (coefficient -0.075, P < 0.001). An intervention that delays smoking initiation without decreasing smoking prevalence at age 18 may reduce adult smoking prevalence by 0.13-0.32% (depending on age) and all-cause mortality by 0.09% over the life-time of the sample., Conclusion: School-based smoking prevention programmes have potential for a beneficial effect over the life-time of the participants even if they have no apparent effect at school-leaving age.

Objective: To assess the clinical outcomes of types of exercise in the management of subacromial impingement syndrome., Design: Systematic review of randomized controlled trials., Methods: Studies were identified from databases searched to May 2009: MEDLINE, EMBASE, CINAHL, Sports Discus, PEDro, AMED, Cochrane Library, National Research Register, Index Chiropractic Literature. Two reviewers selected studies meeting inclusion criteria. The methodological quality of the included studies was independently assessed by two reviewers using the PEDro quality assessment tool., Results: Eight studies with sample sizes ranging from 14 to 125 were included in the systematic review and appraised for content. Four papers achieved a score of 6 or above indicating good quality, with the remaining four achieving 4 or lower, indicating poor quality. Synthesis showed only limited evidence to support the use of exercise in the treatment of subacromial impingement syndrome., Conclusion: There is a need for further well-defined clinical trials on specific exercise interventions for the treatment of shoulder dysfunction including subacromial impingement syndrome.

The aim of this article is to review the accuracy of tests purported to be predictive of pre-eclampsia, a major cause of maternal and perinatal mortality and morbidity worldwide. A review of systematic reviews was done. A total of 219 studies were evaluated for the accuracy of 27 tests for predicting pre-eclampsia. Study quality assessment and data abstraction were performed using piloted proformas. Bivariate meta-analyses were used to synthesize data. Levels of sensitivity and specificity were measured. There were deficiencies in many areas of methodology including blinding, test description, and reference standard adequacy. No test had a high level of both sensitivity and specificity of greater than 90%. Where multiple studies were available, only BMI > 34, alpha-fetoprotein, fibronectin (cellular and total), and uterine artery Doppler (bilateral notching) measurements reached specificity above 90%. Only Doppler (any/unilateral notching, resistance index, and combinations) measurements were over 60% sensitive. Studies were of variable quality and most tests performed poorly. Further research should focus on tests which offer much higher levels of sensitivity than tests currently available. High sensitivity is a more useful attribute in early detection of pre-eclampsia than specificity because consideration of benefits, harms and costs indicates a much greater preference for minimizing false negatives than false positives, although the ideal would be to avoid both.

Objectives: To investigate the accuracy of predictive tests for pre-eclampsia and the effectiveness of preventative interventions for pre-eclampsia. Also to assess the cost-effectiveness of strategies (test-intervention combinations) to predict and prevent pre-eclampsia., Data Sources: Major electronic databases were searched to January 2005 at least., Review Methods: Systematic reviews were carried out for test accuracy and effectiveness. Quality assessment was carried out using standard tools. For test accuracy, meta-analyses used a bivariate approach. Effectiveness reviews were conducted under the auspices of the Cochrane Pregnancy and Childbirth Group and used standard Cochrane review methods. The economic evaluation was from an NHS perspective and used a decision tree model., Results: For the 27 tests reviewed, the quality of included studies was generally poor. Some tests appeared to have high specificity, but at the expense of compromised sensitivity. Tests that reached specificities above 90% were body mass index greater than 34, alpha-foetoprotein and uterine artery Doppler (bilateral notching). The only Doppler test with a sensitivity of over 60% was resistance index and combinations of indices. A few tests not commonly found in routine practice, such as kallikreinuria and SDS-PAGE proteinuria, seemed to offer the promise of high sensitivity, without compromising specificity, but these would require further investigation. For the 16 effectiveness reviews, the quality of included studies was variable. The largest review was of antiplatelet agents, primarily low-dose aspirin, and included 51 trials (36,500 women). This was the only review where the intervention was shown to prevent both pre-eclampsia and its consequences for the baby. Calcium supplementation also reduced the risk of pre-eclampsia, but with some uncertainty about the impact on outcomes for the baby. The only other intervention associated with a reduction in RR of pre-eclampsia was rest at home, with or without a nutritional supplement, for women with normal blood pressure. However, this review included just two small trials and its results should be interpreted with caution. The cost of most of the tests was modest, ranging from 5 pounds for blood tests such as serum uric acid to approximately 20 pounds for Doppler tests. Similarly, the cost of most interventions was also modest. In contrast, the best estimate of additional average cost associated with an average case of pre-eclampsia was high at approximately 9000 pounds. The results of the modelling revealed that prior testing with the test accuracy sensitivities and specificities identified appeared to offer little as a way of improving cost-effectiveness. Based on the evidence reviewed, none of the tests appeared sufficiently accurate to be clinically useful and the results of the model favoured no-test/treat-all strategies. Rest at home without any initial testing appeared to be the most cost-effective 'test-treatment' combination. Calcium supplementation to all women, without any initial testing, appeared to be the second most cost-effective. The economic model provided little support that any form of Doppler test has sufficiently high sensitivity and specificity to be cost-effective for the early identification of pre-eclampsia. It also suggested that the pattern of cost-effectiveness was no different in high-risk mothers than the low-risk mothers considered in the base case., Conclusions: The tests evaluated are not sufficiently accurate, in our opinion, to suggest their routine use in clinical practice. Calcium and antiplatelet agents, primarily low-dose aspirin, were the interventions shown to prevent pre-eclampsia. The most cost-effective approach to reducing pre-eclampsia is likely to be the provision of an effective, affordable and safe intervention applied to all mothers without prior testing to assess levels of risk. It is probably premature to suggest the implementation of a treat-all intervention strategy at present, however the feasibility and acceptability of this to women could be explored. Rigorous evaluation is needed of tests with modest cost whose initial assessments suggest that they may have high levels of both sensitivity and specificity. Similarly, there is a need for high-quality, adequately powered randomised controlled trials to investigate whether interventions such as advice to rest are indeed effective in reducing pre-eclampsia. In future, an economic model should be developed that considers not just pre-eclampsia, but other related outcomes, particularly those relevant to the infant such as perinatal death, preterm birth and small for gestational age. Such a modelling project should make provision for primary data collection on the safety of interventions and their associated costs.

Uveitis (intraocular inflammation) is a potentially blinding group of, probably autoimmune, conditions predominantly occurring in the working age group. Although the aetiology is unknown in most cases, many patients have an associated underlying systemic disease. Central vision loss, in the form of cystoid macular oedema, is the commonest type of visual impairment. Although historical incidence and prevalence data exists, little is known about the degree of vision loss experienced, and the social and financial consequences of having temporary or permanent visual impairment in this age group. The literature is also full of uncontrolled studies and case reports of different modalities of drug therapy for uveitis. This article attempts to raise the awareness of uveitis as an important sight-threatening group of conditions by highlighting the paucity of evidence-based data on epidemiological, quality of life, socioeconomic, and therapeutic aspects., (Copyright 2004 S. Karger AG, Basel)