Comparing the efficacy of vaginal micronized progesterone gel and capsule for prevention of preterm birth in singleton pregnancies with short cervical length at midtrimester: an indirect comparison meta-analysis.

Objective: To evaluate the effectiveness of vaginal progesterone in preventing preterm birth in women with a singleton gestation and short cervical length and to determine which of the two formulations, micronized progesterone vaginal capsule versus vaginal gel containing micronized progesterone, is more effective for preventing preterm birth. Data sources: A systematic search was performed in the following databases: EMBASE, PubMed (MEDLINE), The Cochrane Library, and the Clinical Trials Registry (clinicaltrials.gov). Study eligibility criteria: Randomized controlled trials (RCTs), prospective and retrospective observational studies were included. We searched for progesterone administration to prevent preterm birth in asymptomatic women with a shortened cervix (<25 mm) measured by ultrasound in the second trimester of singleton pregnancy. Study appraisal and synthesis methods: Assessments of the risk of bias of RCTs were performed by applying the Cochrane Collaboration's Risk of Bias Tool; non-randomized control trials were evaluated with the Newcastle-Ottawa Scale (NOS). The primary outcome was preterm birth ≤33 weeks of gestation. Pooled relative risks (RR) and 95% CI's were calculated for dichotomous outcomes. Heterogeneity of treatment effect was assessed with the I2 statistic. We pooled results of the primary outcome for individual studies using a random-effect model. We then performed a network meta-analysis to pool indirect comparisons between the two formulations (gel vs capsule). This analysis was performed using the network meta-analysis package within the R environment. Results: Five studies met the inclusion criteria (4 RCTs, one cohort study) including 1,048 women. The meta-analysis demonstrated that vaginal micronized progesterone significantly reduces preterm birth risk, Risk Ratio = 0.63; 95% CI, 0.48-0.82; p = 0.0006; with no heterogeneity between the studies: I 2 = 0%. In the network meta-analysis, no significant difference was demonstrated (OR = 0.85; 95% CI, 0.43-1.69) between the effect of the two formulations of vaginal micronized progesterone (vaginal gel versus vaginal capsules) on the risk of PTB. Conclusion: Vaginal progesterone is associated with a decreased risk of premature birth in women with a shortened cervix in the second trimester of pregnancy. No differences were found between vaginal micronized progesterone in gel or capsule formulations. Systematic Review Registration: PROSPERO, identifier CRD42020165198.

The role of secure instant messaging applications in medical education: Evaluating student satisfaction in a case-based learning program using Siilo.

Background: Instant messaging applications for mobile phones have recently grown in popularity among medical personnel, including both physicians and medical students. During the COVID-19 pandemic, medical education was largely transferred to virtual platforms, making such applications an increasingly important tool for medical education. "Siilo" is a secure instant messaging application that was designed for medical professionals, and offers several advantages over other instant messaging services that are vital for its use in medical settings, including information security, data encryption, and a built-in blurring tool to maintain patient privacy. In addition, Siilo allows for the creation of individual folders for each case, enabling users to conduct separate discussions about multiple patients simultaneously. Objective: To evaluate student satisfaction in a case-based learning program using Siilo as a medical education tool in improving student learning outcomes and motivation. Methods: A case-based learning program was conducted with 24 fifth-year medical students using Siilo to evaluate its effectiveness as a medical education tool. The program was evaluated through the use of pre- and post-program questionnaires and focus group discussions to assess student satisfaction. Results: The majority of students (83.3%) were highly satisfied with the Siilo platform and felt that it enhanced their learning experience, and a majority of students (79.1%) reported that the program was highly effective. Students reported that the platform was easy to use and provided a clear and organized way to follow discussions about cases. The focus group discussions further revealed that students appreciated the real-time communication and felt that the use of Siilo helped to improve the quality of communication and collaboration during the learning process. The use of Siilo as a medical education tool was found to contribute to positive relationships between doctors and students and improve student motivation for learning and outcomes. Conclusion: These findings suggest that Siilo can be a valuable resource for medical education, particularly due to its secure and convenient features, which are well-suited for use in medical settings. The use of Siilo in a case-based learning program was found to be effective in improving student satisfaction and learning outcomes and contributed to positive relationships between doctors and students. These results highlight the potential for utilizing mobile instant messaging apps as a tool for enhancing clinical teaching in medical education.

The role of vaginal progesterone for preterm birth prevention in women with threatened labor and shortened cervix diagnosed after 24 weeks of pregnancy.

OBJECTIVE: To determine whether vaginal progesterone treatment for women with a short cervix, diagnosed after 24 weeks of pregnancy, reduces preterm birth rates. METHODS: A retrospective cohort study that included women with a singleton pregnancy, threatened preterm labor, and a short cervix measured between 24+0 and 33+6 weeks. Women who received vaginal progesterone were compared with women who did not receive progesterone. The primary outcome was spontaneous preterm birth before 37 weeks of pregnancy. RESULTS: Patients who received vaginal progesterone had a lower rate of preterm delivery at less than 37 weeks of pregnancy (18.2% [22/121] versus 28.9% [73/253]; adjusted hazard ratio 0.50; 95% confidence interval 0.28-0.73, P = 0.001). The diagnosis-to-delivery interval was significantly greater in patients who received progesterone than in those who did not-median time to delivery in weeks: 8.2 (interquartile range [IQR] 6.2-9.8) versus 6.6 (4.8-8.8), (P < 0.001). The frequency of neonatal intensive care unit admission was significantly lower in patients who received progesterone than in those who did not (8.3% [10/121] versus 16.2% [41/253], P = 0.04). CONCLUSIONS: The administration of vaginal progesterone to patients with an episode of threatened premature labor and a short cervix presenting after 24 weeks of pregnancy was associated with lower rates of premature births.

Trial of labor after cesarean in primiparous women with fetal macrosomia.

KEY MESSAGE: Spontaneous labor onset, epidural anesthesia and prior cesarean for non-arrest disorders are strong predictors of successful vaginal birth after cesarean in women delivering a macrosomic fetus. PURPOSE: Lower rates of successful vaginal birth after cesarean in association with increasing birthweight were previously reported. We aimed to determine the factors associated with successful trial of labor after cesarean (TOLAC) among primiparous women with fetal macrosomia. METHODS: A retrospective cohort study conducted during 2005-2019 at two university hospitals, including all primiparous women delivering a singleton fetus weighing ≥ 4000 g, after cesarean delivery at their first delivery. A multivariate analysis was performed to evaluate the characteristics associated with TOLAC success (primary outcome). RESULTS: Of 551 primiparous women who met the inclusion criteria, 50.1% (n = 276) attempted a TOLAC and 174 (63.0%) successfully delivered vaginally. In a multivariate analysis, spontaneous onset of labor (aOR [95% CI] 3.68 (2.05, 6.61), P < 0.001), epidural anesthesia (aOR [95% CI] 2.38 (1.35, 4.20), P = 0.003) and history of cesarean delivery due to non-arrest disorder (aOR [95% CI] 2.25 (1.32, 3.85), P = 0.003) were the only independent factors associated with TOLAC success. Successful TOLAC was achieved in 82.0% (82/100) in the presence of all three favorable factors, 61.3% (65/106) in the presence of two factors and 38.6% (27/70) in the presence of one or less of these three factors (P < 0.001). CONCLUSION: Spontaneous onset of labor, epidural anesthesia and prior cesarean delivery due to non-arrest disorders were independently associated with higher vaginal birth after cesarean rate among women with fetal macrosomia, with an overall favorable success rate in the presence of these factors. These findings should be implemented in patient counseling in those contemplating a vaginal birth in this setting.

A model based on routine liver tests can reliably exclude intrahepatic cholestasis of pregnancy.

OBJECTIVES: Serum bile acid (BA) levels testing is used for the diagnosis of intrahepatic cholestasis of pregnancy (ICP). We aimed to determine the performance of routine liver tests in the evaluation of ICP. METHODS: A retrospective cohort study conducted at a university hospital, including all pregnant women who underwent serum BA levels testing due to suspected ICP during 2007-2019. Liver tests were performed in all women including: aspartate aminotransferase (AST), alanine transaminase (ALT), alkaline phosphatase (ALK), gamma-glutamyl transferase (GGT), and total bilirubin (TB). The optimal combination of laboratory values was determined by an algorithm developed in the Python programming language. RESULTS: Of 640 women who met the inclusion criteria, 22% (n = 142) were diagnosed with ICP (serum BA>10 µmol/L). A combined laboratory score of: (TB>11 µmol/L) or (ALK>255 U/L) or (GGT>32 U/L) or (AST>31 U/L), had a sensitivity of 94%, negative predictive value (NPV) of 97%, specificity of 50%, positive predictive value of 35%, and a negative likelihood ratio of 0.11 for the diagnosis of ICP. The AUC of the laboratory model alone was 0.72 (95% CI: 0.69-0.75). The addition of history of ICP to the suggested laboratory score resulted in a sensitivity of 97%, NPV of 98% and a negative likelihood ratio of 0.06. The AUC of the final model was 0.76 (95% CI: 0.72-0.79). CONCLUSIONS: A combined laboratory score incorporating AST, GGT, ALK and TB was shown to reliably exclude the diagnosis of ICP. This may be particularly useful in settings with limited access to BA levels testing.

Recurrence risk of preterm birth in a subsequent singleton pregnancy after a spontaneous preterm triplet delivery.

OBJECTIVE: History of prior preterm birth (PTB) represents one of the strongest risk factors for recurrent PTB. Nevertheless, whether the occurrence of PTB in multifetal gestation is associated with increased risk of PTB in subsequent pregnancies remains unclear. We aimed to determine the recurrence risk of PTB in a subsequent singleton pregnancy after a previous spontaneous preterm triplet delivery. STUDY DESIGN: A retrospective matched case-control study. The study group comprised all women with spontaneous preterm trichorionic triplet delivery who had a subsequent singleton pregnancy during 2006-2017 at two university hospitals. A control group of women with spontaneous preterm dichorionic twin delivery and a subsequent singleton pregnancy, was established by matching, four-to-one, according to maternal age, parity, gestational age at delivery, and delivery year. RESULTS: Data from 170 women were analyzed, 34 with preterm triplet delivery and 136 matched control women with preterm twin delivery. Gestational age at the subsequent singleton delivery was higher in those with preterm triplet delivery than in those with preterm twin delivery (median 39 vs 38 weeks, P = 0.02). Women with prior triplet PTB had a significantly lower rate of recurrent PTB as compared with women with prior twin PTB (5.9 % vs. 25.0 %; OR [95 % CI]: 0.19 (0.04, 0.82), P = 0.02) with lower proportions of low-birth weight infants (<2500 g) (0 % vs. 11.8 %, P = 0.04). CONCLUSIONS: The risk of recurrent PTB following spontaneous PTB in triplet pregnancy was low compared to preterm twin delivery. These data provide reassurance for those who experienced preterm triplet delivery and suggest the need for further studies to understand the mechanisms contributing to PTB in multifetal pregnancies.

Nonlinear Optical Phenomena in a Silicon-Smectic A Liquid Crystal (SALC) Waveguide.

Liquid crystals (LCs) are organic materials characterized by the intermediate properties between those of an isotropic liquid and a crystal with a long range order. The LCs possess strong anisotropy of their optical and electro-optical properties. In particular, LCs possess strong optical nonlinearity. LCs are compatible with silicon-based technologies. Due to these unique properties, LCs are promising candidates for the development of novel integrated devices for telecommunications and sensing. Nematic liquid crystals (NLCs) are mostly used and studied. Smectic A liquid crystals (SALCs) have a higher degree of long range order forming a layered structure. As a result, they have lower scattering losses, specific mechanisms of optical nonlinearity related to the smectic layer displacement without the mass density change, and they can be used in nonlinear optical applications. We theoretically studied the nonlinear optical phenomena in a silicon-SALC waveguide. We have shown theoretically that the stimulated light scattering (SLS) and cross-phase modulation (XPM) caused by SALC nonlinearity can occur in the silicon-SALC waveguide. We evaluated the smectic layer displacement, the SALC hydrodynamic velocity, and the slowly varying amplitudes (SVAs) of the interfering optical waves.