Is there an association between parity and urinary incontinence in women during pregnancy and the first year postpartum?: A systematic review and meta-analysis.

AIMS: To systematically review the literature on possible associations between parity and urinary incontinence (UI) during pregnancy and in the first year postpartum. METHODS: We searched the databases Pubmed, CINAHL, Embase, the Cochrane Library, PsycINFO, MIDIRS, ClinicalTrials.gov (inception-18 April 2020). One reviewer screened all titles. Two reviewers independently selected studies by abstract and full text. Risk of bias was assessed using the Quality In Prognosis Studies tool. Findings were synthesised in meta-analysis or narratively. We assessed the certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluation Working Group approach adopted for prognostic studies. RESULTS: We identified 16 643 records and 39 were included. Thirty studies examined UI during pregnancy and 12 examined UI postpartum. Multiparity was associated with UI at any point in the last pregnancy (odds ratio [OR]: 1.59 [1.26-2.00], 5 studies, 1565 participants) and in the third trimester when measured by ICIQ-SF (OR: 2.67 [1.53-4.67], 4 studies, 1150 participants), but not when studies measured the UI point prevalence (OR: 2.48 [0.91-6.79], 4 studies, 52 976 participants), or if they measured the prevalence at one point in any trimester (OR: 1.09 (0.60-1.95), 3 studies, 872 participants). At 3 months postpartum, UI was associated with multiparity (OR: 2.03 [1.35-3.06], 4 studies, 6781 participants). CONCLUSIONS: Increased parity was associated with UI in the first year postpartum, but studies on UI during pregnancy had conflicting results. The evidence was (very) uncertain. Future studies should use comparable definitions and further explore UI sub-types.

Prevention and treatment of peripartum urinary incontinence-a survey of hospital-based maternity services in Ireland.

INTRODUCTION AND HYPOTHESIS: Considerable proportions of pregnant and postpartum women experience urinary incontinence, but to our knowledge, there are no national data on the preventative and treatment services available in Ireland's 19 maternity hospitals. METHODS: Ethical approval was granted. A national benchmarking survey on the range and type of services on prevention and treatment of urinary incontinence during pregnancy and postpartum was developed. Directors of Midwifery and Nursing in each hospital identified midwives and women's health physiotherapists to complete the survey. Data were analysed descriptively, and results presented as proportions. RESULTS: Responses were received from 17 hospitals. Women were asked about urinary incontinence during their first booking visit in 6 hospitals, during all antenatal visits in 2 and the onus was on women self-reporting symptoms in 9. Pelvic floor muscle exercises were taught in antenatal classes in 14 hospitals and management of urinary incontinence in 9. In hospital postpartum, midwives in 13 hospitals asked women about urinary incontinence. All women were seen by a physiotherapist in 7 hospitals and only those who were referred in 6. Women could access the hospital's physiotherapy services up to 6 weeks postpartum in 3 hospitals, up to 6 months or 1 year in 5 and beyond 1 year in 6. CONCLUSIONS: Geographical inequity exists in the services offered to pregnant and postpartum women nationally. This indicates that many pregnant and postpartum women, both continent and incontinent, cannot avail themselves of preventative and treatment services within the maternity hospital system and points to the need to review, reconfigure and resource services.

The characteristics and effectiveness of pregnancy yoga interventions: a systematic review and meta-analysis.

BACKGROUND: Yoga is a popular mind-body medicine frequently recommended to pregnant women. Gaps remain in our understanding of the core components of effective pregnancy yoga programmes. This systematic review and meta-analysis examined the characteristics and effectiveness of pregnancy yoga interventions, incorporating the FITT (frequency, intensity, time/duration and type) principle of exercise prescription. METHODS: Nine electronic databases were searched: MEDLINE, PsycINFO, EMBASE, CINAHL, WHOLiS, AMED, ScieLo, ASSIA and Web of Science. Randomised control trials and quasi-experimental studies examining pregnancy yoga interventions were eligible. Covidence was used to screen titles, abstracts, and full-text articles. Outcomes of interest were stress, anxiety, depression, quality of life, labour duration, pain management in labour and mode of birth. The Cochrane Collaboration's Risk of Bias Assessment tool was used to assess methodological quality of studies and GRADE criteria (GRADEpro) evaluated quality of the evidence. Meta-analysis was performed using RevMan 5.3. RESULTS: Of 862 citations retrieved, 31 studies met inclusion criteria. Twenty-nine studies with 2217 pregnant women were included for meta-analysis. Pregnancy yoga interventions reduced anxiety (SMD: -0.91; 95% CI: - 1.49 to - 0.33; p = 0.002), depression (SMD: -0.47; 95% CI: - 0.9 to - 0.04, P = 0.03) and perceived stress (SMD: -1.03; 95% CI: - 1.55 to - 0.52; p < 0.001). Yoga interventions also reduced duration of labour (MD = - 117.75; 95% CI - 153.80 to - 81.71, p < 0.001) and, increased odds of normal vaginal birth (OR 2.58; 95% CI 1.46-4.56, p < 0.001) and tolerance for pain. The quality of evidence (GRADE criteria) was low to very low for all outcomes. Twelve or more yoga sessions delivered weekly/bi-weekly had a statistically significant impact on mode of birth, while 12 or more yoga sessions of long duration (> 60 min) had a statistically significant impact on perceived stress. CONCLUSION: The evidence highlights positive effects of pregnancy yoga on anxiety, depression, perceived stress, mode of birth and duration of labour. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42019119916. Registered on 11th January 2019.

Trajectories of Postpartum Recovery: What is Known and Not Known.

Women's postpartum health is a public health issue that has lifelong consequences. Timely recognition and treatment of physical and mental health issues can have positive health consequences while lack of access to effective treatments or health care services can lead to long-term health problems. To advance knowledge of priority health symptoms and trajectories of postpartum recovery from women's health perspectives, we share findings from the Maternal health And Maternal Morbidity in Ireland (MAMMI) study. Data from 3047 first-time mothers recruited to a longitudinal maternal health study in Ireland from 2012 to 2017 reveal the trajectories of maternal health and health problems experienced up to 12 months postpartum. Morbidities explored include urinary incontinence, pelvic girdle pain, and sexual and mental health issues. Viewed together, and over time, the scale and persistent nature of many physical and mental health problems become apparent, yet considerable proportions of women were not asked directly about health problems by health care professionals. When women do not know what is and is not normal postpartum, they may suffer in silence and the consequence is that health problems/issues that are preventable, and treatable, are likely to become chronic. To make positive contributions to women's health, maternity care systems must be truly woman-centered and structured in ways that place emphasis on women's own health needs. In systems where women's voices and concerns are acknowledged and central, women are likely to thrive and flourish in motherhood.

Preliminary Classification of Selected Farmland Habitats in Ireland Using Deep Neural Networks.

Ireland has a wide variety of farmlands that includes arable fields, grassland, hedgerows, streams, lakes, rivers, and native woodlands. Traditional methods of habitat identification rely on field surveys, which are resource intensive, therefore there is a strong need for digital methods to improve the speed and efficiency of identification and differentiation of farmland habitats. This is challenging because of the large number of subcategories having nearly indistinguishable features within the habitat classes. Heterogeneity among sites within the same habitat class is another problem. Therefore, this research work presents a preliminary technique for accurate farmland classification using stacked ensemble deep convolutional neural networks (DNNs). The proposed approach has been validated on a high-resolution dataset collected using drones. The image samples were manually labelled by the experts in the area before providing them to the DNNs for training purposes. Three pre-trained DNNs customized using the transfer learning approach are used as the base learners. The predicted features derived from the base learners were then used to train a DNN based meta-learner to achieve high classification rates. We analyse the obtained results in terms of convergence rate, confusion matrices, and ROC curves. This is a preliminary work and further research is needed to establish a standard technique.

Cost-Effectiveness Analysis of a National Pre-Exposure Prophylaxis (PrEP) Program in Ireland.

OBJECTIVES: To estimate the cost-effectiveness of introducing a publicly funded pre-exposure prophylaxis (PrEP) program in Ireland. METHODS: We constructed a state-transition Markov model. This was a cross-sectional population model that tracked all HIV-negative men who have sex with men (MSM) in Ireland over their lifetime. Access to a publicly funded PrEP program (medications + frequent monitoring) in high-risk MSM was compared with no PrEP. The primary outcome measure was the incremental cost-effectiveness ratio (ICER). RESULTS: In the base case, introducing a PrEP program was considered cost saving and provided significant health benefits to the population. Univariate sensitivity analysis demonstrated that PrEP efficacy and HIV incidence had the greatest impact on cost-effectiveness. Including an increase in sexually transmitted infections had a negligible impact on the results. Efficacy was a significant driver in the model. PrEP was cost saving at all efficacy values above 60%, and at the lowest reported efficacy in MSM (44% in the iPrEX trial), the ICER was €4711/QALY (highly cost-effective). Event-based dosing (administration during high-risk periods only) was associated with additional cost savings. We estimated that 1705 individuals (95% CI: 617-3452) would join the program in year 1. The incremental budget impact was €1.5m (95% CI: €0.5m to €3m) in the first year and €5.4m over 5 years (95% CI: €1.8m to €11.5m), with 173 cases of HIV averted over 5 years. CONCLUSION: We found that the introduction of a PrEP program would be considered cost saving in the first cost-effectiveness analysis of its kind in Ireland.

A systematic review of utility-based and disease-specific quality of life measurement instruments for women with urinary incontinence.

AIM: This systematic review aims to identify disease-specific and generic quality of life (QoL) outcome measurement instruments used in populations of women with urinary incontinence (UI) and to determine the most psychometrically robust and appropriate disease-specific and generic tools for measuring the quality of life in this population. METHODS: A systematic search was conducted of PubMed, Embase, SCIELO, and CINAHL databases for studies evaluating measurement properties of QoL instruments in women with UI. The methodological quality of studies and the quality of measurement properties were evaluated using the COnsensus-based Standards for the selection of health status Measurement INtruments (COSMIN) checklist and quality criteria. Overall, evidence for measurement properties was graded using the modified grading of recommendations, assessment, development & evaluation approach. RESULTS: A total of 73 studies were included, and 27 specific and 6 generic instruments were identified. The Incontinence QoL questionnaire (IQoL) had the highest overall psychometric quality for English-speaking populations and was the most widely translated tool. Evidence for generic QoL tools in this population is limited. Few studies evaluated measurement error or cross-cultural validity. CONCLUSION: The IQoL is the most psychometrically robust disease-specific tool for use in this population. More research is needed to determine the most psychometrically robust generic tool. Future studies should also evaluate measurement error and cross-cultural validity as evidence for these properties is particularly lacking.

VEGF/PKD-1 signaling mediates arteriogenic gene expression and angiogenic responses in reversible human microvascular endothelial cells with extended lifespan.

Microvascular ECs (MVECs) are an ideal model in angiogenesis research. The aim of this study was to determine vascular endothelial growth factor (VEGF)/protein kinase D1 (PKD-1) signaling in expression of arteriogenic genes in human MVECs. To achieve this aim, we transduced specific SV40 large T antigen and telomerase into primary human dermal MVECs (HMVEC-D) to establish reversible HMVECs with extended lifespan (HMVECi-D). HMVECi-D was then exposed to VEGF/VEGF-inducer GS4012 or transduced with constitutively active protein kinase PKD-1 (PKD-CA). Quantitative RT-PCR was performed to detect arteriogenic gene expression. Furthermore, the angiogenic capacity in response to VEGF pathway was evaluated by Matrigel tube-formation and proliferation assays. We observed that VEGF/PKD-1 signaling axis significantly stimulated the expression of arteriogenic genes and promoted EC proliferation, along with downregulation of CD36 expression. Intriguingly, overexpression of PKD-CA also resulted in formation of tip cell morphology, accompanied by increased mRNA of delta-like ligand 4 (DLL4). In conclusion, we have successfully established and characterized HMVECi-D, and showed that VEGF/PKD-1 signaling axis increases angiogenic and arteriogenic gene expression. These studies suggest that the axis may regulate arteriolar differentiation through changing MVEC gene expression.

The HIQA's Health Technology Assessment of Breast Screening: Highlighting Some of the Challenges Posed by Evaluations of Screening Programs.

A review of the Health Information and Quality Authority's (HIQA) assessment of breast cancer surveillance cancer criticized how the results were presented and interpreted. The health technology assessment (HTA) investigated surveillance options for women aged less than 50 years who were at elevated risk of breast cancer. Surveillance strategies using digital mammography, magnetic resonance imaging, or a combination of the two modalities were modeled on the basis of diagnostic test accuracy. The HTA faced a number of issues, including the use of diagnostic test accuracy as a surrogate for long-term outcomes; modeling interventions that were not considered acceptable to clinicians; and extrapolating for screening intervals and age ranges not directly supported by available evidence. The evaluation of screening programs gives rise to challenges in terms of balancing an adequate exploration of the possible options while also being cognizant of what is appropriately supported by evidence. In this article, the authors of the HIQA report discuss the challenges posed by this particular HTA.

CONTRIBUTION OF STAKEHOLDER ENGAGEMENT TO THE IMPACT OF A HEALTH TECHNOLOGY ASSESSMENT: AN IRISH CASE STUDY.

OBJECTIVES: The aim of this study was to illustrate the contribution of stakeholder engagement to the impact of health technology assessment (HTA) using an Irish HTA of a national public access defibrillation (PAD) program. BACKGROUND: In response to draft legislation that proposed a PAD program, the Minister for Health requested that Health Information and Quality Authority undertake an HTA to inform the design and implementation of a national PAD program and the necessary underpinning legislation. The draft legislation outlined a program requiring widespread installation and maintenance of automatic external defibrillators in specified premises. METHODS: Stakeholder engagement to optimize the impact of the HTA included one-to-one interviews with politicians, engagement with an Expert Advisory Group, public and targeted consultation, and positive media management. RESULTS: The HTA quantified the clinical benefits of the proposed PAD program as modest, identified that substantial costs would fall on small/medium businesses at a time of economic recession, and that none of the programs modeled were cost-effective. The Senator who proposed the Bill actively publicized the HTA process and its findings and encouraged participation in the public consultation. Participation of key stakeholders was important for the quality and acceptability of the HTA findings and advice. Media management promoted public engagement and understanding. The Bill did not progress. CONCLUSIONS: The HTA informed the decision not to progress with legislation for a national PAD program. Engagement was tailored to ensure that key stakeholders including politicians and the public were informed of the HTA process, the findings, and the advice, thereby maximizing acceptance. Appropriate stakeholder engagement optimizes the impact of HTA.

Tolerance of the eriophyid mite Aceria salsolae to UV-A light and implications for biological control of Russian thistle.

Aceria salsolae (Acari: Eriophyidae) is being evaluated as a candidate biological control agent of Russian thistle (Salsola tragus, Chenopodiaceae), a major invasive weed of rangelands and dryland crops in the western USA. Prior laboratory host range testing under artificial lighting indicated reproduction on non-native Bassia hyssopifolia and on a native plant, Suaeda calceoliformis. However, in field tests in the native range, mite populations released on these 'nontarget' plants remained low. We hypothesized that UV-A light, which can affect behavior of tetranychid mites, would affect populations of the eriophyid A. salsolae differently on the target and nontarget plant species, decreasing the mite's realized host range. Plants were infested with A. salsolae under lamps that emitted UV-A, along with broad-spectrum lighting, and the size of mite populations and plant growth was compared to infested plants exposed only to broad-spectrum light. Russian thistle supported 3- to 55-fold larger mite populations than nontarget plants regardless of UV-A treatment. UV-A exposure did not affect mite populations on Russian thistle or S. calceoliformis, whereas it increased populations 7-fold on B. hyssopifolia. Main stems on nontarget plants grew 2- to 6-fold faster than did Russian thistle under either light treatment. The two nontarget plants attained greater volume under the control light regime than UV-A, but Russian thistle was unaffected. Although Russian thistle was always the superior host, addition of UV-A light to the artificial lighting regime did not reduce the ability of A. salsolae to reproduce on the two nontarget species, suggesting that UV-B or other environmental factors may be more important in limiting mite populations in the field.

Cost-Effectiveness of a National Opportunistic Screening Program for Atrial Fibrillation in Ireland.

OBJECTIVES: To evaluate the cost-effectiveness of a national atrial fibrillation screening program in Ireland involving annual opportunistic pulse palpation of all those older than 65 years during general practitioner consultations, with an electrocardiogram being performed if an irregular pulse is detected. METHODS: A probabilistic Markov model was used to simulate costs and clinical outcomes in a hypothetical cohort of men and women with and without screening over the course of 25 years, using a societal perspective. RESULTS: Screening was associated with an incremental cost-effectiveness ratio of €23,004/quality-adjusted life-year compared with routine care. Nevertheless, if the relative risk of stroke and systematic embolism in screen-detected patients is more than 12% lower than that in patients with atrial fibrillation identified through routine practice, then screening would not be considered cost-effective at a willingness-to-pay threshold of €45,000/quality-adjusted life-year. An analysis comparing alternative combinations of start age and screening interval found that less frequent screening with a later start age may be more cost-effective than an annual screening from age 65 years. CONCLUSIONS: Annual opportunistic screening of men and women aged 65 years and older in primary care in Ireland is likely to be cost-effective using conventional willingness-to-pay thresholds, assuming that those detected through screening have a comparable stroke risk profile as those detected through routine practice. Raising the start age of screening or increasing the screening interval may improve the cost-effectiveness of a prospective screening program.

Systematic screening for the detection of atrial fibrillation.

BACKGROUND: Atrial fibrillation (AF), the most common arrhythmia in clinical practice, is a leading cause of morbidity and mortality. Screening for AF in asymptomatic patients has been proposed as a way of reducing the burden of the disease by detecting people who would benefit from prophylactic anticoagulation therapy before the onset of symptoms. However, for screening to be an effective intervention, it must improve the detection of AF and provide benefit for those detected earlier as a result of screening. OBJECTIVES: This review aims to answer the following questions.Does systematic screening increase the detection of AF compared with routine practice? Which combination of screening population, strategy and test is most effective for detecting AF compared with routine practice? What safety issues and adverse events may be associated with individual screening programmes? How acceptable is the intervention to the target population? What costs are associated with systematic screening for AF? SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid) and EMBASE (Ovid) up to 11 November 2015. We searched other relevant research databases, trials registries and websites up to December 2015. We also searched reference lists of identified studies for potentially relevant studies, and we contacted corresponding authors for information about additional published or unpublished studies that may be relevant. We applied no language restrictions. SELECTION CRITERIA: Randomised controlled trials comparing screening for AF with routine practice in people 40 years of age and older were eligible. Two review authors (PM and CT) independently selected trials for inclusion. DATA COLLECTION AND ANALYSIS: Two review authors (PM and CT) independently assessed risk of bias and extracted data. We used odds ratios (ORs) and 95% confidence intervals (CIs) to present results for the primary outcome, which is a dichotomous variable. As we identified only one study for inclusion, we performed no meta-analysis. We used the GRADE (Grades of Recommendation, Assessment, Development and Evaluation Working Group) method to assess the quality of the evidence and GRADEPro to create a 'Summary of findings' table. MAIN RESULTS: One cluster-randomised controlled trial met the inclusion criteria for this review. This study compared systematic screening (by invitation to have an electrocardiogram (ECG)) and opportunistic screening (pulse palpation during a general practitioner (GP) consultation for any reason, followed by an ECG if pulse was irregular) versus routine practice (normal case finding on the basis of clinical presentation) in people 65 years of age or older.Results show that both systematic screening and opportunistic screening of people over 65 years of age are more effective than routine practice (OR 1.57, 95% CI 1.08 to 2.26; and OR 1.58, 95% CI 1.10 to 2.29, respectively; both moderate-quality evidence). We found no difference in the effectiveness of systematic screening and opportunistic screening (OR 0.99, 95% CI 0.72 to 1.37; low-quality evidence). A subgroup analysis found that systematic screening and opportunistic screening were more effective in men (OR 2.68, 95% CI 1.51 to 4.76; and OR 2.33, 95% CI 1.29 to 4.19, respectively) than in women (OR 0.98, 95% CI 0.59 to 1.62; and OR 1.2, 95% CI 0.74 to 1.93, respectively). No adverse events associated with screening were reported.The incremental cost per additional case detected by opportunistic screening was GBP 337, compared with GBP 1514 for systematic screening. All cost estimates were based on data from the single included trial, which was conducted in the UK between 2001 and 2003. AUTHORS' CONCLUSIONS: Evidence suggests that systematic screening and opportunistic screening for AF increase the rate of detection of new cases compared with routine practice. Although these approaches have comparable effects on the overall AF diagnosis rate, the cost of systematic screening is significantly greater than the cost of opportunistic screening from the perspective of the health service provider. Few studies have investigated effects of screening in other health systems and in younger age groups; therefore, caution needs to be exercised in relation to transferability of these results beyond the setting and population in which the included study was conducted.Additional research is needed to examine the effectiveness of alternative screening strategies and to investigate the effects of the intervention on risk of stroke for screened versus non-screened populations.

A systematic review of intermittent pneumatic compression for critical limb ischaemia.

Intermittent pneumatic compression (IPC) is designed to aid wound healing and limb salvage for patients with critical limb ischaemia who are not candidates for revascularisation. We conducted a systematic review of the literature to identify and critically appraise the evidence supporting its use in this population. A search was conducted in Embase, MEDLINE and clinical trial registries up to the end of March 2013. No date or language restrictions were applied. Quality assessment was performed by two people independently. Quality was assessed using the Cochrane risk of bias tool and the NICE case-series assessment tool. Two controlled before-and-after (CBA) studies and six case series were identified. One retrospective CBA study involving compression of the calf reported improved limb salvage and wound healing (OR 7.00, 95% CI 1.82 to 26.89, p<0.01). One prospective CBA study involving sequential compression of the foot and calf reported statistically significant improvements in claudication distances and SF-36 quality of life scores. No difference in all-cause mortality was found. Complications included pain associated with compression, as well as skin abrasion and contact rash as a result of the cuff rubbing against the skin. All studies had a high risk of bias. In conclusion, the limited available results suggest that IPC may be associated with improved limb salvage, wound healing and pain management. However, in the absence of additional well-designed analytical studies examining the effect of IPC in critical limb ischaemia, this treatment remains unproven.

Using prediction intervals from random-effects meta-analyses in an economic model.

OBJECTIVES: When incorporating treatment effect estimates derived from a random-effect meta-analysis it is tempting to use the confidence bounds to determine the potential range of treatment effect. However, prediction intervals reflect the potential effect of a technology rather than the more narrowly defined average treatment effect. Using a case study of robot-assisted radical prostatectomy, this study investigates the impact on a cost-utility analysis of using clinical effectiveness derived from random-effects meta-analyses presented as confidence bounds and prediction intervals, respectively. METHODS: To determine the cost-utility of robot-assisted prostatectomy, an economic model was developed. The clinical effectiveness of robot-assisted surgery compared with open and conventional laparoscopic surgery was estimated using meta-analysis of peer-reviewed publications. Assuming treatment effect would vary across studies due to both sampling variability and differences between surgical teams, random-effects meta-analysis was used to pool effect estimates. RESULTS: Using the confidence bounds approach the mean and median ICER was €24,193 and €26,731/QALY (95%CI: €13,752 to €68,861/QALY), respectively. The prediction interval approach produced an equivalent mean and median ICER of €26,920 and €26,643/QALY (95%CI: -€135,244 to €239,166/QALY), respectively. Using prediction intervals, there is a probability of 0.042 that robot-assisted surgery will result in a net reduction in QALYs. CONCLUSIONS: Using prediction intervals rather than confidence bounds does not affect the point estimate of the treatment effect. In meta-analyses with significant heterogeneity, the use of prediction intervals will produce wider ranges of treatment effect, and hence result in greater uncertainty, but a better reflection of the effect of the technology.

Multiple lines of evidence point to pesticides as stressors affecting invertebrate communities in small streams in five United States regions.

Multistressor studies were performed in five regions of the United States to assess the role of pesticides as stressors affecting invertebrate communities in wadable streams. Pesticides and other chemical and physical stressors were measured in 75 to 99 streams per region for 4 weeks, after which invertebrate communities were surveyed (435 total sites). Pesticides were sampled weekly in filtered water, and once in bed sediment. The role of pesticides as a stressor to invertebrate communities was assessed by evaluating multiple lines of evidence: toxicity predictions based on measured pesticide concentrations, multivariate models and other statistical analyses, and previously published mesocosm experiments. Toxicity predictions using benchmarks and species sensitivity distributions and statistical correlations suggested that pesticides were present at high enough concentrations to adversely affect invertebrate communities at the regional scale. Two undirected techniques-boosted regression tree models and distance-based linear models-identified which pesticides were predictors of (respectively) invertebrate metrics and community composition. To put insecticides in context with known, influential covariates of invertebrate response, generalized additive models were used to identify which individual pesticide(s) were important predictors of invertebrate community condition in each region, after accounting for natural covariates. Four insecticides were identified as stressors to invertebrate communities at the regional scale: bifenthrin, chlordane, fipronil and its degradates, and imidacloprid. Fipronil was particularly important in the Southeast region, and imidacloprid, bifenthrin, and chlordane were important in multiple regions. For imidacloprid, bifenthrin, and fipronil, toxicity predictions were supported by mesocosm experiments that demonstrated adverse effects on naïve aquatic communities when dosed under controlled conditions. These multiple lines of evidence do not prove causality-which is challenging in the field under multistressor conditions-but they make a strong case for the role of insecticides as stressors adversely affecting invertebrate communities in streams within the five sampled regions.

Effectiveness of systematic screening for the detection of atrial fibrillation.

BACKGROUND: Atrial fibrillation (AF) is the most common arrhythmia in clinical practice and is a leading cause of morbidity and mortality. Screening for AF in asymptomatic patients has been proposed as a way of reducing the burden of the disease by detecting people who would benefit from prophylactic anticoagulation therapy prior to the onset of symptoms. However, for screening to be an effective intervention it must improve the detection of AF and provide benefit for those who are detected earlier as a result of screening. OBJECTIVES: The primary objective of this review was to examine whether screening programmes increase the detection of new cases of AF compared to routine practice. The secondary objectives were to identify which combination of screening strategy and patient population is most effective, as well as assessing any safety issues associated with screening, its acceptability within the target population and the costs involved. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library, MEDLINE (Ovid) and EMBASE (Ovid) up to March 2012. Other relevant research databases, trials registries and websites were searched up to June 2012. Reference lists of identified studies were also searched for potentially relevant studies and we contacted corresponding authors for information about additional published or unpublished studies that may be relevant. No language restrictions were applied. SELECTION CRITERIA: Randomised controlled trials, controlled before and after studies and interrupted time series studies comparing screening for AF with routine practice in people aged 40 years and over were eligible. Two authors (PM, CT or MF) independently selected the trials for inclusion. DATA COLLECTION AND ANALYSIS: Assessment of risk of bias and data extraction were performed independently by two authors (PM, CT). Odds ratios (OR) and 95% confidence intervals (CI) were used to present the results for the primary outcome, which is a dichotomous variable. Since only one included study was identified, no meta-analysis was performed. MAIN RESULTS: One cluster randomised controlled trial met the inclusion criteria for this review. This study compared systematic screening (by invitation to have an electrocardiogram (ECG)) and opportunistic screening (pulse palpation during a general practitioner (GP) consultation for any reason followed by an ECG if pulse was irregular) to routine practice (normal case finding on the basis of clinical presentation) in people aged 65 years or older. The risk of bias in the included study was judged to be low.Both systematic and opportunistic screening of people over the age of 65 years are more effective than routine practice (OR 1.57, 95% CI 1.08 to 2.26 and OR 1.58, 95% CI 1.10 to 2.29, respectively). The number needed to screen in order to detect one additional case compared to routine practice was 172 (95% CI 94 to 927) for systematic screening and 167 (95% CI 92 to 806) for opportunistic screening. Both systematic and opportunistic screening were more effective in men (OR 2.68, 95% CI 1.51 to 4.76 and OR 2.33, 95% CI 1.29 to 4.19, respectively) than in women (OR 0.98, 95% CI 0.59 to 1.62 and OR 1.2, 95% CI 0.74 to 1.93, respectively). No data on the effectiveness of screening in different ethnic or socioeconomic groups were available. There were insufficient data to compare the effectiveness of screening programmes in different healthcare settings.Systematic screening was associated with a better overall uptake rate than opportunistic screening (53% versus 46%) except in the ≥ 75 years age group where uptake rates were similar (43% versus 42%). In both screening programmes men were more likely to participate than women (57% versus 50% in systematic screening, 49% versus 41% in opportunistic screening) and younger people (65 to 74 years) were more likely to participate than people aged 75 years and over (61% versus 43% systematic, 49% versus 42% opportunistic). No adverse events associated with screening were reported.The incremental cost per additional case detected by opportunistic screening was GBP 337, compared to GBP 1514 for systematic screening. All cost estimates were based on data from the single included trial, which was conducted in the UK between 2001 and 2003. AUTHORS' CONCLUSIONS: Systematic and opportunistic screening for AF increase the rate of detection of new cases compared with routine practice. While both approaches have a comparable effect on the overall AF diagnosis rate, the cost of systematic screening is significantly more than that of opportunistic screening from the perspective of the health service provider. The lack of studies investigating the effect of screening in other health systems and younger age groups means that caution needs to be exercised in relation to the transferability of these results beyond the setting and population in which the included study was conducted.Additional research is needed to examine the effectiveness of alternative screening strategies and to investigate the effect of the intervention on the risk of stroke for screened versus non-screened populations.

Robot-assisted hysterectomy compared to open and laparoscopic approaches: systematic review and meta-analysis.

PURPOSE: To review the safety and effectiveness of robot-assisted hysterectomy compared to traditional open and conventional laparoscopic surgery, differentiating radical, simple total with node staging, and simple total hysterectomy. METHODS: Medline, Embase, the Cochrane library, and the Journal of Robotic Surgery were searched for controlled trials and observational studies with historic or concurrent controls. Data were pooled using random effects meta-analysis. RESULTS: Compared to open surgery, robot-assisted radical hysterectomy is associated with reduced hospital stay and blood transfusions. For simple total hysterectomy with node staging, robot-assisted surgery is associated with reduced hospital stay, complications, and blood transfusions compared to open surgery. Compared to conventional laparoscopic surgery, robot-assisted simple total hysterectomy with node staging is associated with complications and conversions. CONCLUSIONS: Compared to open surgery, robot-assisted hysterectomy offers benefits for reduced length of hospital stay and blood transfusions. The best evidence of improved outcomes is for simple total hysterectomy with node staging. Study quality was poor.