WITHDRAWN: Continuous electronic heart rate monitoring for fetal assessment during labor.

BACKGROUND: Electronic fetal monitoring (EFM) is used in the management of labor and delivery in nearly three of four pregnancies in the United States. The apparent contradiction between the widespread use of EFM and expert recommendations to limit routine use indicates that a reassessment of this practice is warranted. OBJECTIVES: To compare the efficacy and safety of routine continuous EFM during labor with intermittent auscultation, using the results of published randomized controlled trials (RCTs). SEARCH STRATEGY: We identified RCTs by searching MEDLINE and the register maintained by the Cochrane Pregnancy and Childbirth Group, and by contacting experts, and reviewing published references. Date of last search: January 2001. SELECTION CRITERIA: Randomized controlled trials. DATA COLLECTION AND ANALYSIS: Data were abstracted by one of us, and their accuracy was confirmed independently by a second person. A single reviewer assessed study quality based on criteria developed by others for RCTs. Data reported from similar studies were used to calculate a combined risk estimate for each of eight outcomes. MAIN RESULTS: Our search identified 13 published RCTs addressing the efficacy and safety of EFM; no unpublished studies were found. Four trials that did not fulfil our selection criteria were excluded. The remaining nine trials included 18,561 pregnant women and their 18,695 infants in both high- and low-risk pregnancies from seven clinical centers in the United States, Europe, and Australia. Overall, a statistically significant decrease was associated with routine EFM for neonatal seizures (relative risk (RR) 0.51, 95% confidence interval (CI) 0.32-0.82). The protective effect for neonatal seizures was only evident in studies with high-quality scores. No significant differences were observed in 1-minute Apgar scores below four or seven, rate of admissions to neonatal intensive care units, perinatal deaths or cerebral palsy. An increase associated with the use of EFM was observed in the rate of cesarean delivery (RR 1.41, 95% CI 1.23-1.61) and operative vaginal delivery (RR 1.20, 95% CI 1.11-1.30). AUTHORS' CONCLUSIONS: The only clinically significant benefit from the use of routine continuous EFM was in the reduction of neonatal seizures. In view of the increase in cesarean and operative vaginal delivery, the long-term benefit of this reduction must be evaluated in the decision reached jointly by the pregnant woman and her clinician to use continuous EFM or intermittent auscultation during labor.

The role of public health surveillance: information for effective action in public health.

Public health surveillance can provide the quantitative information needed for setting priorities and establishing rational health policy. Although there are many examples of the effective use of such information, the full potential for surveillance has not yet been realized. To a large degree, failure to achieve this potential has resulted from limited perspectives regarding the role and conduct of surveillance. Both practitioners (those who conduct surveillance) and users (those who apply surveillance data in a real-world setting) have fallen victim to such myopia. Public health surveillance must be advocated as an essential part of the global health agenda if we are to achieve international goals for improving health status. As we improve our appreciation of the variety of uses for public health surveillance data, we need to understand more fully the determinants of the decision-making process. Effective dissemination of information and effective communication are as important as data collection and analysis. No longer do we have--or should we have--the luxury of collecting information for its own sake. The information collected must have a demonstrated utility. Developing and training personnel to have expertise in public health surveillance will necessarily incur opportunity costs. Bridging gaps in data methodology and coverage will force us to weigh alternatives and to compromise. We hope that the International Symposium on Public Health Surveillance will accomplish several goals. First, we wish to foster international understanding of the definition, role, and importance of surveillance in reducing morbidity and mortality, in improving quality of life, and in setting effective health priorities. Second, we hope that this symposium will serve as a springboard for identifying issues and topics that can be addressed in greater depth at future international meetings. Finally, we see the symposium as an essential step in developing a firm commitment on the part of countries, donor agencies, and multilateral organizations to develop the essential capacity for public health surveillance throughout the world. Each country should have the capacity to measure and monitor changes in health status, risk factors, and health-service access and utilization among its people. All countries should have the means to detect emerging health problems and implement measures for their control, to evaluate the impact of health policies and programs, and to communicate health information in a meaningful fashion to policymakers and the public. If we are successful in these endeavors, the long-term effects on the public's health will be well worth the struggle required to achieve them.(ABSTRACT TRUNCATED AT 400 WORDS)

Characteristics of meta-analyses related to acceptance for publication in a medical journal.

Editors of medical journals select manuscripts for publication based, in part, on the perceived quality of the manuscript submitted. The objective of this study was to describe associations between acceptance for publication and quality-related methodologic characteristics of meta-analyses. This was a prospective observational study. The setting was editorial offices of JAMA and offices of external reviewers. The manuscripts reviewed were 112 consecutive meta-analyses submitted to JAMA during 1996 and 1997 whose authors agreed to participate. The main outcome measures were ratings of 16 methodologic characteristics reflecting quality of the meta-analysis and acceptance for publication. A "high" rating for one methodologic characteristic, whether the report of the meta-analysis provided sufficient detail to enable replication, was related significantly to publication (RR = 2.79, 95% CI = 1.13-6.89). This relationship persisted when other variables were controlled for in the model. Generally, rejected manuscripts had fewer factors rated "high," but differences were not significant. We found that inclusion of sufficient detail to allow a reader to replicate meta-analytic methods was the only characteristic related to acceptance for publication.

Persistence of influenza A by continuous close-contact transmission: the effect of non-random mixing.

The interaction of two populations has variable effects on the nature and duration of epidemic activity, depending on the transmissibility of the virus, the susceptibility of the population, migration, birth and death rates, and the initial number of cases. Under circumstances where transmission stops in a single population (the infectious contact number is less than or equal to one), transmission may continue indefinitely when two populations interact under many different parameter combinations. A mass-action model was constructed using difference equations for two populations that included parameters for migration between populations and variable transmissibility between and within these populations. The limitations of extrapolating the model to actual conditions in human populations result from assumptions inherent in these models, such as fractional infection of individuals.

Applied epidemiology for the 21st Century.

BACKGROUND: Critics argue that the modern epidemiologist seems more concerned with intricately modelling complex relationships among risk factors than understanding their origins and their implications for public health. Indeed, some contend that epidemiology has reached its limits as a discipline. To address such concerns, alternatives have been proposed that integrate biological, analytical, and social approaches to epidemiological practice and training. METHODS: The published literature was reviewed to examine critical issues in current epidemiological practice and training. In addition, we reviewed records of training programmes in applied epidemiology established in 20 countries. RESULTS: We describe an existing approach to preparing epidemiologists for the emerging challenges of public health in which epidemiological research and practice are applied toward the end of improving public health and health care. Training in applied epidemiology is based on a philosophy of 'learning while doing'. Under the supervision of an experienced epidemiologist, trainees conduct field investigations, analyse large data bases, evaluate surveillance systems, publish and present scientific research, and respond to public enquiries. More than 3000 people have received intensive formal training over the past 50 years in programmes in more than 20 countries; most graduates continued to use the tools of applied epidemiology in their work. CONCLUSION: Training in applied epidemiology anchors the discipline in population-based, relevant public health practice.

Hospitalizations in a southern rural community: an application of the 'ecology model'.

The purpose of this study is to re-examine the concepts of health services utilization presented by White and his colleagues in 'The Ecology of Medical Care'. We re-test their model in a rural population in the southern United States using longitudinal instead of cross-sectional data and find that the general principles of the 'Ecology' model do, indeed, apply to rural populations like Rougemont/Bahama. Use of this model has implications for modifying and improving the organization of the health care delivery system and for a fundamental change of emphasis in medical education.

An assessment of the use of Bayes' Theorem for forecasting in public health: the case of epidemic meningitis in China.

A mathematical model based upon Bayes' Theorem (BT) was used to forecast the occurrence of epidemic cerebrospinal meningitis (ECM) in ten communities in North China. Reports of ECM from each ten-day period during the meningitis season and records of special population movement during 1960-82 were analysed to establish forecast models. Calibration, split-sample, random-sample selection, as well as actual forecast tests, were used to check the efficiency of the models. For all the tests, the theoretical occurrence of ECM forecast by the BT method was compared with the observational data. Since the BT method offers efficiency and convenience, it is recommended for use in planning for the prevention and control of ECM in China.

Efficacy and safety of intrapartum electronic fetal monitoring: an update.

OBJECTIVE: To compare the efficacy and safety of routine electronic fetal monitoring (EFM) of labor with intermittent auscultation, using the results of published randomized controlled trials (RCTs). DATA SOURCES: We identified RCTs by searching the MED-LINE data base for the period 1966-1994, contacting experts, and reviewing published references. METHODS OF STUDY SELECTION: Our search identified 12 published RCTs addressing the efficacy and safety of EFM; no unpublished studies were found. The studies included 58,855 pregnant women and their 59,324 infants in both high- and low-risk pregnancies from ten clinical centers in the United States, Europe, Australia, and Africa. DATA EXTRACTION AND SYNTHESIS: Data were abstracted, and their accuracy was confirmed independently. A single reviewer assessed study quality based on criteria developed by others for RCTs. Data reported from similar studies were used to calculate a combined risk estimate for each of nine outcomes. Overall, a statistically significant decrease was associated with routine EFM for a 1-minute Apgar score less than 4 (relative risk [RR] 0.82, 95% confidence interval [CI] 0.65-0.98) and neonatal seizures (RR 0.5, 95% CI 0.30-0.82). The protective effect of EFM for a 1-minute Apgar score less than 4 was apparent only in the non-United States studies, and the protective effect for neonatal seizures was evident only in studies with high-quality scores. No significant differences were observed in 1-minute Apgar scores less than 7, rate of admissions to neonatal intensive care units, and perinatal death. An increase associated with the use of EFM was observed in the rate of cesarean delivery (RR 1.33, 95% CI 1.08-1.59) and total operative delivery (RR 1.23, 95% CI 1.15-1.31). Risk of cesarean delivery was greatest in low-risk pregnancies. CONCLUSION: The only clinically significant benefit from the use of routine EFM was in the reduction of neonatal seizures. Because of the increase in cesarean and operative vaginal deliveries, the long-term benefit of this reduction must be evaluated in the decision reached jointly by the pregnant woman and her clinician to use EFM or intermittent auscultation during labor.

Relative risks and benefits of long-term estrogen replacement therapy: a decision analysis.

OBJECTIVE: To evaluate the relative risks and benefits of exogenous estrogen use among women entering the climacteric and to consider estrogen use for relief of symptoms or prevention of disease. METHODS: Decision analysis was used to assess the value of estrogen replacement therapy in a hypothetical cohort of 10,000 women assumed to be age 50 years; health outcomes were extrapolated to age 75. Risk ratios for mortality and morbidity of health outcomes associated with the use of estrogen replacement therapy were based on longitudinal studies reported in the literature. RESULTS: Estrogen use for 25 years would decrease fatal coronary heart disease events by 48% (567 cases), decrease deaths from hip fracture by 49% (75), increase deaths from breast cancer by 21% (39), and increase deaths from endometrial cancer by 207% (29 excess deaths). On balance, 25 years of estrogen replacement therapy in a cohort of 10,000 women would prevent 574 deaths. Further, women using estrogens for 25 years would gain 3951 quality-adjusted life years compared with women not using estrogens. Sensitivity analysis suggests that the benefits of estrogen replacement therapy outweight the risks under most assumptions. CONCLUSION: In a hypothetical, population-based analysis, the health benefits of postmenopausal estrogen replacement exceed the health risks incurred. Nevertheless, clinicians must still evaluate each individual's risks and needs.

The incidence of diarrheal disease in a defined population of rural Egypt.

A prospective study of diarrheal illness was conducted for 2 years in 309 families who were part of an epidemiologic research center population in rural Egypt. The rates of illness peaked in the first year of life with between 5 and 6 episodes per person year at risk. Although no seasonal variation in reported diarrhea was demonstrated for the total population, age-specific differences in seasonal occurrence were noted. The incidence did not consistently vary by village size, nor did rates vary by sex.

Nonmedical doctoral-level scientists in the Centers for Disease Control and Prevention's Epidemic Intelligence Service, 1964-1997.

INTRODUCTION: Although historically a training program in applied epidemiology for physicians, veterinarians, and dentists, CDC's Epidemic Intelligence Service (EIS) has been attracting an increasing number of other doctoral-level scientists with prior experience and training in advanced analytic methods. METHODS: Using data from alumni records, we studied the participation of these nonmedical scientists in the EIS program and their subsequent employment. RESULTS: 160 nonmedical doctoral level scientists enrolled in EIS from 1964 through 1997; 135 had completed EIS as of July 1997. Of 160 enrolled, 94 (59%) had an advanced degree in epidemiology; other degrees included demography, anthropology, behavioral sciences, statistics, and other health areas; 66% were women. Most (112; 70%) were assigned to work in noninfectious disease areas. After completion of EIS, 113 (84%) of 135 officers continued to work in public health activities: 75 (56%) remained employed at CDC; 17 (13%) in academic institutions; 14 (10%) in local or state health departments; 3 (2%) in international health agencies; 2 (1%) in other federal health agencies; and 2 (1%) in public health foundations. Compared with trainees recruited during 1964-1989, greater proportions of those recruited during 1990-1995 remained employed at CDC (44/74 [59%] versus 31/61 [51%]) or at state or local health departments (10 [14%] versus 4 [7%]). Those training during EIS at a state or local health department (15/20, 75%) or in occupational health (17/24, 71%) were more likely than those in other assignments to work outside CDC following EIS. CONCLUSION: There is increasing participation and collaboration of persons trained in nonmedical sciences with those trained in traditional medical areas in the EIS training program and in careers in public health at all levels: local, state, and federal.

A controlled trial of disease surveillance strategies.

Active surveillance techniques using routine telephone contacts with providers improved the reporting of measles, rubella, salmonellosis, and hepatitis by a factor of 4.6 among private physicians in Monroe County, New York, and increased reporting for these target diseases from all sources by 51 percent. The timeliness of reporting was not improved by active surveillance. Reporting patterns varied by disease and source of report, suggesting the desirability of various approaches to surveillance based on local resources and priorities. Although reporting rates were higher for diseases among persons from census tracts of low socioeconomic status, physicians providing care to persons living in low-income areas responded no differently to active reporting than did those providing care to patients from middle- and high-income areas.

Alcohol and fatal injuries: temporal patterns.

Although alcohol use has been established as a risk factor for injuries associated with motor vehicle crashes, the role of alcohol for other unintentional and intentional injuries is less defined. A review of 102,401 deaths investigated by North Carolina medical examiners in the period 1973-1983 characterized the temporal patterns of ethyl alcohol in unintentional injury fatalities, suicides, homicides, and persons who died of natural or unknown causes. Victims of homicides (85.9%) and suicides (77.7%) were tested for alcohol more frequently than were fatalities resulting from unintentional injury (67.5%) or natural causes (61.6%). Alcohol was present in 62.8% of homicide victims, 48.6% of unintentional injury fatalities, 35.3% of suicides, and 14.4% of deaths from natural causes. The percentage of alcohol-associated deaths for each manner of death showed little yearly or seasonal variation. Alcohol was most frequently detected in persons fatally injured on the weekend and from 6 PM to 6 AM. This study highlights the magnitude of alcohol's role in intentional and unintentional injuries, especially for persons injured at night and on weekends.

The science of public health surveillance.

Improved public health surveillance can lead to earlier implementation of prevention and control measures. Better surveillance data lead to a more rational establishment of priorities. More timely and accurate data facilitate earlier epidemic detection and control. With better surveillance data, the impact of intervention activities and other public health programs can be evaluated more accurately. In this paper we describe how to improve the science of surveillance in terms of data collection, analysis, and dissemination and its application to public health practice. We then discuss the potential benefits and costs of such efforts and suggest methods for evaluating alternative approaches. The argument for science in surveillance, on the other hand, may be subject to excess. Surveillance is not an end unto itself, but rather a tool. This tool should be refined and modified to adapt to the goals of a particular public health program. It is the development of methods to apply creative ideas to surveillance, and the rigorous assessment of the process, that will benefit from the application of scientific principles.

Assessing the diagnostic accuracy and efficacy of selected antepartum fetal surveillance techniques.

Published studies on the contraction stress test (CST), the nonstress test (NST), and monitoring of fetal movement were reviewed to assess the accuracy and efficacy of these techniques. The false-negativity and false-positivity rates, sensitivity, and specificity of these tests were assessed with use of perinatal mortality and various measures of morbidity as outcomes. Both the CST and the NST generally demonstrated low sensitivity and high rates of false positivity. No randomized controlled trials have been conducted that are of sufficient size to demonstrate whether there is a significant difference in outcome following use of the CST or the NST. A single nonrandomized, controlled trial evaluating fetal-movement monitoring suggested clinical benefit. Direct costs of NSTs and CSTs in the United States were estimated to exceed $200 million per year. Yet the CST and the NST have not been demonstrated to be useful diagnostic tests. The CST, the NST, and fetal-movement monitoring are potentially useful screening tests. However, they require critical evaluation, with large randomized, controlled trials, to determine their efficacy and safety before their further diffusion into obstetrical practice.

Historical controversy in health technology assessment: the case of electronic fetal monitoring.

Electronic fetal monitoring (EFM) was introduced in the late 1950s as an alternative to traditional auscultation by stethoscope or fetoscope in the management of labor and delivery. The new technology was seen as a valuable tool in the prevention of cerebral palsy and other adverse fetal outcomes and diffused rapidly into clinical practice. In the late 1970s, some scepticism began to be voiced about the evidence for the effectiveness of EFM. The authors published a systematic review of the evidence in 1979 that concluded that there was insufficient evidence for the effectiveness of the routine use of EFM and a clear rise in the cesarean delivery rate associated with its use. The analysis was based on a thorough review of approximately 600 books and articles, but focused heavily on the evidence of four randomized clinical trials (RCTs) that had been published. An economic analysis further underscored the importance of this issue. The report was met with harsh ad hominem criticism from clinicians both in public venues and in the medical literature. Subsequently, additional RCTs were conducted and other analyzes were published, and in 1987 the American College of Obstetricians and Gynecologists recommended that auscultation was an acceptable alternative to EFM in routine labor and delivery. Yet, today EFM continues to be the standard of practice, used in 80% of labors in this country. The most important conclusion drawn from this experience is the need to evaluate new technologies before their widespread diffusion into clinical practice.

Benefits and risks of episiotomy: an interpretative review of the English language literature, 1860-1980.

The benefits and risks of episiotomy in labor and delivery as recorded in the English language literature in over 350 books and articles published since 1860 are reviewed and analyzed. Episiotomy is performed in over 60 per cent of all deliveries in the United States and in a much higher per cent of primigravidas. Yet, there is no clearly defined evidence for its efficacy, particularly for routine use. In addition, although poorly studied, there is evidence that postpartum pain and discomfort are accentuated after episiotomy, and serious complications, including maternal death, can be associated with the procedure. Therefore, carefully designed controlled trials of benefit and risk should be carried out on the use of episiotomy.

Continuous electronic heart rate monitoring for fetal assessment during labor.

BACKGROUND: Electronic fetal monitoring (EFM) has been widely adopted. There is debate about its overall effectiveness as well as the relative merits of routine application versus use for high-risk pregnancies only. OBJECTIVES: The objective of this review was to assess the effects of routine continuous electronic fetal monitoring during labour compared with intermittent auscultation. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register, Medline (1966 to 1994), and reference list of relevant articles. We also contacted experts in the field. SELECTION CRITERIA: Randomised trials comparing routine continuous electronic fetal monitoring with intermittent auscultation. DATA COLLECTION AND ANALYSIS: Data were extracted by one reviewer, and their accuracy was confirmed independently by a second person. A single reviewer assessed study quality based on criteria developed by others for randomised controlled trials. Data reported from similar studies were used to calculate a combined risk estimate for each of eight outcomes. MAIN RESULTS: Nine studies involving 18,561 women and their 18,695 infants were included. The trials were of variable quality. A statistically significant decrease was associated with routine continuous EFM for neonatal seizures (relative risk (RR) = 0. 51, confidence interval (CI) = 0.32,0.82). The protective effect for neonatal seizures was only evident in studies with high-quality scores. No significant differences were observed in 1-minute Apgar scores below 4, 1-minute Apgar scores below 7, rate of admissions to neonatal intensive care units, and perinatal death. An increase associated with the use of EFM was observed in the rate of cesarean delivery (RR = 1.41, CI = 1.23,1.61) and operative vaginal delivery (RR = 1.20, CI = 1.11,1.30). REVIEWER'S CONCLUSIONS: The only clinically significant benefit from the use of routine continuous EFM was in the reduction of neonatal seizures. In view of the increase in cesarean and operative vaginal deliveries, the long-term benefit of this reduction must be evaluated in the decision reached jointly by the pregnant woman and her clinician to use continuous EFM or intermittent auscultation during labor.

Continuous electronic heart rate monitoring for fetal assessment during labor.

BACKGROUND: Electronic fetal monitoring (EFM) is used in the management of labor and delivery in nearly three of four pregnancies in the United States. The apparent contradiction between the widespread use of EFM and expert recommendations to limit routine use indicates that a reassessment of this practice is warranted. OBJECTIVES: To compare the efficacy and safety of routine continuous EFM during labor with intermittent auscultation, using the results of published randomized controlled trials (RCTs). SEARCH STRATEGY: We identified RCTs by searching MEDLINE and the register maintained by the Cochrane Pregnancy and Childbirth Group, and by contacting experts, and reviewing published references. Date of last search: January 2001. SELECTION CRITERIA: Randomized controlled trials. DATA COLLECTION AND ANALYSIS: Data were abstracted by one of us, and their accuracy was confirmed independently by a second person. A single reviewer assessed study quality based on criteria developed by others for RCTs. Data reported from similar studies were used to calculate a combined risk estimate for each of eight outcomes. MAIN RESULTS: Our search identified 13 published RCTs addressing the efficacy and safety of EFM; no unpublished studies were found. Four trials that did not fulfil our selection criteria were excluded. The remaining nine trials included 18,561 pregnant women and their 18,695 infants in both high- and low-risk pregnancies from seven clinical centers in the United States, Europe, and Australia. Overall, a statistically significant decrease was associated with routine EFM for neonatal seizures (relative risk (RR) 0.51, 95% confidence interval (CI) 0.32-0.82). The protective effect for neonatal seizures was only evident in studies with high-quality scores. No significant differences were observed in 1-minute Apgar scores below four or seven, rate of admissions to neonatal intensive care units, perinatal deaths or cerebral palsy. An increase associated with the use of EFM was observed in the rate of cesarean delivery (RR 1.41, 95% CI 1.23-1.61) and operative vaginal delivery (RR 1.20, 95% CI 1.11-1.30). REVIEWER'S CONCLUSIONS: The only clinically significant benefit from the use of routine continuous EFM was in the reduction of neonatal seizures. In view of the increase in cesarean and operative vaginal delivery, the long-term benefit of this reduction must be evaluated in the decision reached jointly by the pregnant woman and her clinician to use continuous EFM or intermittent auscultation during labor.

The prevention of ankle sprains in sports. A systematic review of the literature.

To assess the published evidence on the effectiveness of various approaches to the prevention of ankle sprains in athletes, we used textbooks, journals, and experts in the field of sports medicine to identify citations. We identified 113 studies reporting the risk of ankle sprains in sports, methods to provide support, the effect of these interventions on performance, and comparison of prevention efforts. The most common risk factor for ankle sprain in sports is history of a previous sprain. Ten citations of studies involving athletes in basketball, football, soccer, or volleyball compared alternative methods of prevention. Methods tested included wrapping the ankle with tape or cloth, orthoses, high-top shoes, or some combination of these methods. Most studies indicate that appropriately applied braces, tape, or orthoses do not adversely affect performance. Based on our review, we recommend that athletes with a sprained ankle complete supervised rehabilitation before returning to practice or competition, and those athletes suffering a moderate or severe sprain should wear an appropriate orthosis for at least 6 months. Both coaches and players must assume responsibility for prevention of injuries in sports. Methodologic limitations of published studies suggested several areas for future research.