Fertility-sparing surgical interventions for low-risk, non-metastatic gestational trophoblastic neoplasia.

BACKGROUND: The primary treatment approach for addressing low-risk nonmetastatic gestational trophoblastic neoplasia (LR-NMGTN) in women desiring fertility preservation involves chemotherapy. An alternative option for treatment is fertility-sparing surgical interventions, either alone or in combination with adjuvant chemotherapy. The hypothesised advantages of choosing fertility-sparing surgery in cases of LR-NMGTN include potential avoidance of adverse effects associated with chemotherapy, potential reduction in the number of chemotherapy cycles required to achieve complete remission, and potential reduction in time to remission. OBJECTIVES: To measure the benefits and harms of fertility-sparing surgical interventions, with or without adjuvant chemotherapy, compared to primary chemotherapy alone, for the treatment of women with low-risk, non-metastatic gestational trophoblastic neoplasia (LR-NMGTN). SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, Web of Science, ClinicalTrials.gov and WHO ICTRP on 31 January 2024. We also searched abstracts of scientific meetings and reference lists of included studies. SELECTION CRITERIA: We included all randomised controlled trials (RCTs) comparing fertility-sparing surgical interventions, with or without subsequent adjuvant chemotherapy, versus primary chemotherapy as standard care for the treatment of women with LR-NMGTN. DATA COLLECTION AND ANALYSIS: We employed standard Cochrane methodological procedures. We used the GRADE approach to assess the certainty of evidence for each outcome, if available. We focused on the following outcomes: treatment success rate, relapse, disease-specific mortality, death due to treatment, pregnancy rate, quality of life, and any adverse events. MAIN RESULTS: We included two RCTs, with a total of 151 participants contributing data to our analyses. Both studies used uterine curettage as the fertility-sparing surgical intervention. Fertility-sparing surgical intervention without subsequent adjuvant chemotherapy versus primary chemotherapy alone One RCT involving 62 participants with varying hCG (human chorionic gonadotrophin) levels evaluated this comparison. Most of our outcomes of interest were not measured in this study. The relative risk of experiencing any adverse event could not be estimated as chemotherapy adverse effects were not reported. The study reported that there were no surgical complications. Chemotherapy was administered to 50% of participants in the intervention group after curettage because their hCG levels increased. Fertility-sparing surgical intervention with subsequent adjuvant chemotherapy versus primary chemotherapy alone One RCT involving 89 participants with hCG levels < 5000 IU/L evaluated this comparison. We judged the risk of bias in the study to be high. The evidence was very uncertain about the effect of uterine curettage with subsequent adjuvant chemotherapy on treatment success rate (RR 1.03, 95% CI 0.86 to1.23; 86 participants), relapse (RR 0.5, 95% CI 0.05 to 5.31; 86 participants), pregnancy rate (RR 0.86, 95% CI 0.31 to 2.34; 86 participants), and rate of adverse events (RR 1.15, 95% CI 0.63 to 2.13; 86 participants), all very low certainty evidence. The relative risks of disease-specific mortality and death due to treatment could not be estimated as there were no deaths in either group. There were no results for quality of life as this outcome was not reported. AUTHORS' CONCLUSIONS: Uterine curettage is the only fertility-sparing surgical intervention for LR-NMGTN that has been evaluated in a randomised controlled trial. The evidence is very uncertain about the benefits and harms of uterine curettage, with or without subsequent adjuvant chemotherapy, compared to primary chemotherapy alone. The two available studies are small with a high risk of bias, and future research may find substantially different results for all reported outcomes. Larger RCTs, with appropriate clinical outcome measures, would be required to determine the benefits or harms of fertility-sparing surgical interventions for this population.

Association of body composition and survival in patients with locally advanced breast cancer: a historical cohort study.

BACKGROUND: Altered body composition has been attributed to major health problems globally, particularly in patients with cancer. To date, there have not been sufficient indices for body compositions in predicting the survival of locally advanced breast cancer (LABC). PURPOSE: To assess the association between body composition and overall survival (OS) as well as disease-free survival (DFS) in patients with LABC. MATERIAL AND METHODS: A retrospective study was conducted of patients with LABC diagnosed between 2010 and 2018. Body composition parameters, including skeletal muscle and adiposity parameters, were measured using computed tomography at the L3 vertebra using in-house software developed by MATLAB and freeware Python 3.6.13. The association between body composition and OS and DFS were analyzed using a log-rank test and multivariate Cox-proportional hazard regression. RESULTS: Of 199 patients, 72 (36%) died during the follow-up period (range = 3.8-150.7 months). Median survival was 101 months. Low visceral-to-subcutaneous ratio ≤0.3 (adjusted hazard ratio [aHR] = 2.57, 95% confidence interval [CI] = 1.51-4.37; aHR = 2.46, 95% CI = 1.33-4.56), and high composite fat (aHR = 3.26, 95% CI = 1.69-6.29; aHR = 2.19, 95% CI = 1.11-4.3) were associated with lower OS and DFS. Positive lymph nodes ≥3, progesterone receptor negative, and total radiation dose >5000 cGy significantly decreased both OS and DFS. A history of previous treatment before body composition assessment and surgery had a protective effect on OS and DFS. No association of sarcopenia, body mass index, and adiposity areas with survival outcomes was observed. CONCLUSION: Low visceral-to-subcutaneous ratio and high composite fat were independent prognostic factors for OS and DFS in patients with LABC. However, other body composition parameters showed no effect on survival.

Changes in Modified Raymond-Roy Classification Occlusion Classes and Predictors of Recurrence-Free Survival in Patients with Intracranial Aneurysms after Endovascular Coil Embolization.

PURPOSE: To assess changes in modified Raymond-Roy classification (MRRC) occlusion classes and recurrence rates over time and evaluate recurrence-free survival after coil embolization and its predictors. MATERIALS AND METHODS: During 2007-2016, 201 patients (mean age, 57.1 ± 13.4 years; 75.5% women) with 240 aneurysms treated with coil embolization were enrolled. MRRC Class I (n = 210), Class II (n = 14), Class IIIa (n = 10), and Class IIIb (n =6) closures were assessed. Recurrence was defined as recanalization in MRRC Class I closures or an increase of at least 20% in any of the dimensions of the remnants of the other classes. Recurrence-free survival and its predictors were analyzed using survival analysis. RESULTS: Most changes in MRRC class occurred in the first year after treatment. MRRC Class I closures had a slightly lower probability of change than that associated with other classes within 1-5 years, whereas Class IIIb closures remained unchanged. Rates of recurrence or regression for all classes were highest within the first year. The median recurrence-free survival times among patients with Class IIIa and Class IIIb closures were 11.56 and 5.55 months, respectively. Significant predictors of recurrence included aneurysm size of 13-24 mm, ruptured or wide-necked aneurysms, and MRRC Class IIIa or IIIb closures. CONCLUSIONS: Class changes and recurrence rates for all MRRC classes were highest in the first year. MRRC Class IIIb closures had the highest recurrence rate and the shortest recurrence-free survival. Recurrence risk increased in Classes IIIa and IIIb and with large, ruptured or wide-necked aneurysms.

The related factors to the re-thrombosis of hemodialysis arteriovenous graft after endovascular salvage.

BACKGROUND: Only a few issues of the related factors to hemodialysis access dysfunction have been evaluated, and the effects of antiplatelets to improve the patency of hemodialysis access remained controversial. Hence, this study aimed to determine the related factors to the re-thrombosis of arteriovenous grafts (AVGs) after endovascular treatment. METHODS: This retrospective study was conducted at a university-affiliated teaching hospital in Southern Thailand. All patients who underwent hemodialysis with thrombosed AVG, who had pharmacomechanical thrombolysis from January 2016 to December 2018, were enrolled. Post-intervention primary patency was analyzed by the Kaplan-Meier method, and the related factors to the re-thrombosis of AVG were evaluated using logistic regression. RESULTS: A total of 157 patients with thrombosed hemodialysis AVG were enrolled. The most common graft location and configuration was a forearm loop graft (65%). Post-intervention primary patency rate at 1, 3, and 6 months were 79.0%, 67.1%, and 54.0%, respectively. Diabetes mellitus (DM) was a significant related factor for re-thrombosis (hazard ratio [HR], 1.89; 95% confidence interval [CI], 1.20-2.98; p = 0.006). A single antiplatelet after the procedure was a protective factor for re-thrombosis (HR, 0.58; 95% CI, 0.38-0.89; p = 0.013). The median post-intervention primary patency was 15.7 months in the group of single antiplatelet usage, which was better than that of the non-antiplatelet group (p = 0.012). CONCLUSION: DM and antiplatelet usage were significant related factors to the re-thrombosis of hemodialysis AVG after endovascular salvage.

Cost-utility analysis of separated continuous renal replacement therapy systems versus intermittent hemodialysis in critically ill patients with acute kidney injury in a low-resource setting.

BACKGROUND: The aim of this study is to perform a cost-utility analysis of separated continuous renal replacement therapy (CRRT) compared with intermittent hemodialysis (IHD) in critically ill patients with acute kidney injury (AKI). METHODS: Cost and clinical data were gathered from adult patients with AKI who received separated CRRT or IHD at a tertiary hospital in Thailand. We applied a Markov model in this study. Our primary outcome was the incremental cost-effectiveness ratio (ICER). We performed sensitivity analysis to assess the influence of parameter uncertainty. RESULTS: We enrolled 199 critically ill patients with AKI. Of these patients, 129 underwent separated CRRT, and the rest underwent IHD. The mortality rate and dialysis dependence status were not significantly different between the groups. The total costs of separated CRRT were lower than IHD ($73 042.20 vs. $89 244.37). We estimated that separated CRRT increased quality-adjusted life years (QALYs) by 0.21 compared with IHD. The ICER of -74 035.16 USD/QALY gained in the case-based analysis indicated that separated CRRT is superior to IHD due to the lower cost and more cumulative QALYs. After performing sensitivity analysis by varying parameter ranges, separated CRRT remained a cost-saving approach. CONCLUSIONS: Separated CRRT is a cost-saving modality compared with IHD in critically ill patients with AKI. This approach can be applied in resource-limited settings.

Relationship of anthropometric measurements with glycated hemoglobin and 1-h blood glucose after 50 g glucose challenge test in pregnant women: A longitudinal cohort study in Southern Thailand.

AIMS: To assess correlations of anthropometric measurements with glycated hemoglobin (HbA1c) and 1-h blood glucose after a 50 g glucose challenge test during the first and late second trimesters and explore their relationships of anthropometric measurements with neonatal birth weight. METHODS: A longitudinal study was conducted among pregnant Thai women with gestational age ≤14 weeks. Anthropometric measurements, using body mass index, body compositions, and circumferences, and skinfold thickness, were measured at four-time points: ≤14, 18-22, 24-28, and 30-34 weeks of gestation. HbA1c and 1-h blood glucose were examined at ≤14 and 24-28 weeks. Neonatal birth weight was recorded. RESULTS: Of 312 women, HbA1c was more correlated with anthropometric measurements during pregnancy than 1-h blood glucose. At 24-28 weeks, women with high/very high body fat percentage were more likely to have higher HbA1c. Women with high subscapular skinfold thickness were more likely to have higher 1-h blood glucose at ≤14 and 24-28 weeks. High hip circumference significantly increased neonatal birth weights. CONCLUSION: Anthropometric measurements were longitudinally correlated with HbA1c and 1-h blood glucose, higher in the late second than first trimesters, as well as neonatal birth weight. The mechanisms to explain the relationship of different anthropometric measurements are required to be further studied.

Changes in health-related quality of life and the associated factors among Myanmar migrants with tuberculosis: a cohort study.

BACKGROUND: Migrants are known to be predominantly poor population which are predisposing to social and health problems, particularly infectious diseases including tuberculosis (TB). TB itself and effect of treatment may further result in substantial morbidity and lowering the quality of life. This study aimed to assess the changes in health-related quality of life (HRQOL) within six months of anti-TB treatment initiation, and the associated factors in Myanmar migrants under anti-TB treatment within this border area. METHODS: This was a prospective cohort study of adult Myanmar migrants with new TB who were within two months of treatment initiation in two TB clinics in Mae Sot, a Thai-Myanmar border area between September 2019 and July 2020. Eight individual domain scores of the HRQOL and Physical and Mental Component Summary (PCS and MCS) scores measured by SF-36 were calculated at month-2 (T1) as baseline, and at the month-4 (T2) and month-6 follow-up visits (T3). Generalized estimation equation models were used to assess the longitudinal changes in PCS and MCS scores of HRQOL. RESULTS: Of the 155 patients recruited, 93 (60.0%) and 65 (69.9%) completed the month-4 and month-6 follow-ups, respectively. Both the PCS (+ 6.1) and MCS (+ 6.3) scores significantly improved between T1 and T3, with the lowest scores being general health, with the least improvement in social function (+ 1.5) compared with the other domains. Migrants with ethnic origin of Burmese or other were associated with higher PCS and MCS. Those living with family and having higher numbers of initial TB symptoms were associated with lower PCS and MCS scores. Those diagnosed during routine medical checkup were positively associated with PCS scores, whereas patients diagnosed during active case findings were negatively associated with MCS scores. Patients who received residential TB care had higher PCS scores than those with OPD-based TB care. CONCLUSIONS: Continuous improvement in quality of life was found among Myanmar migrants with TB during treatment but their quality of life is still low. Patients with low mental health, especially in the social domain, requires further attention. Active screening policy and supportive strategies during treatment are essential to TB migrants.

Economic Evaluations of Gestational Diabetes Mellitus Screening: A Systematic Review.

BACKGROUND: This study aims to find evidence of the cost-effectiveness of gestational diabetes mellitus (GDM) screening and assess the quality of current economic evaluations, which have shown different conclusions with a variation in screening methods, data sources, outcome indicators, and implementation in diverse organizational contexts. METHODS: Embase, Medline, Web of Science, Health Technology Assessment, database, and National Health Service Economic Evaluation Database databases were searched through June 2019. Studies on economic evaluation reporting both cost and health outcomes of GDM screening programs in English language were selected, and the quality of the studies was assessed using Drummond's checklist. The general characteristics, main assumptions, and results of the economic evaluations were summarized. RESULTS: Our search yielded 10 eligible economic evaluations with different screening strategies compared in different settings and perspectives. The selected papers scored 81% (68-97%) on the items in Drummond's checklist on average. In general, a screening program is cost-effective or even dominant over no screening. The one-step screening, with more cases detected, is more likely to be cost-effective than the two-step screening. Universal screening is more likely to be cost-effective than screening targeting the high-risk population. Parameters affecting cost-effectiveness include: diagnosis criteria, epidemiological characteristics of the population, efficacy of screening and treatment, and costs. CONCLUSIONS: Most studies found GDM screening to be cost-effective, though uncertainties remain due to many factors. The quality assessment identified weaknesses in the economic evaluations in terms of integrating existing data, measuring costs and consequences, analyzing perspectives, and adjusting for uncertainties.

Associations between symptom severity and well-being among Thai patients with schizophrenia: a cross-sectional analytical study.

BACKGROUND: Severity of symptoms in patients with schizophrenia is a determinant of patient's well-being, but evidence in low- and middle-income countries is limited. We aimed to measure the symptom severity using objective measurements, the Brief Psychiatric Rating Scale (BPRS) and Clinical Global Impression-Severity scale (CGI-S), and their associations with well-being in patients with schizophrenia. METHODS: Patients with schizophrenia aged ≥18 years, without active psychosis including no history of hospitalization within the last 6 months, were included. Symptom severity was measured by the clinicians using BPRS and CGI-S. The patients' well-being was assessed by self-report using the Subjective Well-being under Neuroleptic treatment scale (SWN) as continuous and binary outcomes (categorized into adequate or poor well-being). Correlations between symptom severity (BPRS and CGI-S scores) and well-being (SWN score) were analyzed using Pearson's correlation. Association between well-being status and BPRS was analyzed using multivariate logistic regression. RESULTS: Of 150 patients, BPRS and CGI-S were inversely correlated with SWN score (r = - 0.47; p < 0.001 and - 0.21; p < 0.01, respectively). BPRS Affect domain had the highest correlation with SWN (r = - 0.51, p < 0.001). In multivariate logistic regression, BPRS score and being unemployed were associated with poor well-being status (adjusted OR 1.08; 95%CI 1.02-1.14; p = 0.006, and 4.01; 95%CI 1.38-11.7; p = 0.011, respectively). CONCLUSION: Inverse relationships between symptom severity and well-being score were found. Higher BPRS Affect domain was significantly associated with lower patients' well-being. The use of BPRS tool into routine clinical practice could serve as an adjunct to physician's clinical evaluation of patients' symptoms and may help improve patient's well-being. Further research on negative symptoms associated with well-being is required.

Clinical Outcomes of Children Diagnosed Dengue-Associated Acute Liver Failure with or without N-Acetylcysteine Treatment: A Retrospective Cohort Study.

OBJECTIVES: N-acetylcysteine (NAC) has been shown to prevent hepatic damage and improve microcirculatory blood flow and oxygen delivery to the tissue. Previous studies have proposed the benefit of NAC in dengue-associated acute liver failure (ALF). However, most studies are descriptive and lack comparison between groups. We aimed to compare the ALF resolution rate and mortality rate of those who received and did not receive NAC treatment. METHODS: A retrospective cohort study was conducted among children aged <15 years who were diagnosed with dengue-associated ALF at a tertiary hospital in Thailand, between January 2002 and July 2019. Demographic and clinical information were collected. Main outcomes were ALF resolution and mortality rate. RESULTS: Thirty-three patients were included of which 16 received NAC treatment (48.5%). Mean ages were 8.5 years (SD 3.7) and mean onset of ALF was 6.3 days (SD 1.6) after onset of fever. The grading of hepatic encephalopathy (HE) and organ failure was not significantly different between the two groups. In the NAC group, 13/16 children were prescribed 100 mg/kg/day of NAC until INR <2 without HE or <1.5 with HE. NAC was initiated 1.1 days (SD 0.3) after the ALF diagnosis. The NAC group showed a higher rate of ALF resolution (75% vs. 53% in the non-NAC group, p = 0.34) with a lower mortality rate (31% vs. 53%, p = 0.36). Side effects of NAC were not found. CONCLUSION: NAC may be beneficial in dengue-associated pediatric ALF. Further well-designed randomized control trials should be carried out.

Does the Psychiatrist's Use of Subjective Well-Being Measurement in People with Schizophrenia Provide a Better Alignment with the Patient's Well-Being Perception than Clinical Judgement Alone?

To examine the agreement between patient and psychiatrist ratings of subjective well-being in people with schizophrenia using three well-being measurements: Satisfaction with Life, Subjective Happiness, and Subjective Well-being under Neuroleptic Treatment (SWN), including the SWN-subscale, and to investigate whether the psychiatrist's judgement or the psychiatrist-rated SWN is better at defining patient well-being. Patients with schizophrenia (n = 150) completed the three well-being measurements, then met psychiatrists, and their well-being was judged as either 'poor' or 'adequate' via the usual clinical assessment before being assessed again by the psychiatrist using the same measurements. Intra-class correlation was used to analyze the absolute agreement between 'patient-rated' and 'psychiatrist-rated' scores. Agreements on 'adequate' well-being status between patient-rated SWN (≥ 80; gold standard), psychiatrist-rated SWN, and psychiatrist's judgement were calculated using Kappa coefficients. We also calculated the sensitivity and specificity of the psychiatrist's judgement and the psychiatrist-rated SWN to define adequate well-being. SWN showed the strongest absolute agreement between patient-psychiatrist ratings (ICC = 0.7, p = 0.005), with physical functioning yielding the highest and self-control the lowest coefficients. The psychiatrist-rated SWN showed a better Kappa coefficient (0.4, p < 0.001) than the psychiatrist's judgement. Clinical judgement showed a 67% sensitivity and a 64% specificity, whereas the psychiatrist-rated SWN (score 93, AUC 81.4%) showed a 74% sensitivity and a 74% specificity for well-being prediction. The use of SWN by psychiatrists yielded a better alignment of well-being than the psychiatrist's judgement alone. The SWN subscale could help fill the gap between clinician and patient views on well-being. Psychiatrists should upskill in assessing patient wellbeing for appropriate treatment provision.

Hormone replacement therapy after surgery for epithelial ovarian cancer.

BACKGROUND: Women who have undergone surgical treatment for epithelial ovarian cancer (EOC) may develop menopausal symptoms due to immediate loss of ovarian function following surgery and chemotherapy. Women may experience vasomotor symptoms, sleep disturbance, difficulty concentrating, sexual dysfunction, vaginal symptoms and accelerated osteoporosis. Although hormone replacement therapy (HRT) is the most effective treatment to relieve these symptoms, its safety has been questioned for women with EOC. OBJECTIVES: To assess the safety and efficacy of HRT for menopausal symptoms in women surgically treated for EOC. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 6), MEDLINE via Ovid (1946 to 12 June 2019) and Embase via Ovid (1980 to 2019, week 23). We also handsearched conference reports and trial registries. There was no language restriction. SELECTION CRITERIA: We included randomized controlled trials (RCTs) with participants of any age and menopausal status who had undergone surgery for EOC and, after diagnosis and treatment, used any regimen and duration of HRT compared with placebo or no hormone therapy. We also included trials comparing different regimens or duration of administration of HRT. DATA COLLECTION AND ANALYSIS: Two review authors independently identified studies that met the inclusion criteria. They used Covidence to extract study characteristics, outcome data and to assess methodological quality of the included studies. MAIN RESULTS: Our search strategy identified 2617 titles, of which 2614 titles were excluded. Three studies, involving 350 women, met our inclusion criteria. Two of the studies included pre and postmenopausal women, and the third only included premenopausal women. The overall age range of those women included in the studies was 20 to 89.6 years old, with a median follow-up ranging from 31.4 months to 19.1 years. The geographical distribution of participants included Europe, South Africa and China. All stages and histological subtypes were included in two of the studies, but stage IV disease had been excluded in the third. The three included studies used a variety of HRT regimens (conjugated oestrogen with or without medroxyprogesterone and with or without nylestriol) and HRT administrations (oral, patch and implant), In all studies, the comparisons were made versus women who had not received HRT. The studies were at low or unclear risk of selection and reporting bias, and at high risk of performance, detection and attrition bias. The certainty of the evidence was low for overall survival and progression-free survival, and very low for quality-of-life assessment, incidence of breast cancer, transient ischaemic attack (TIA), cerebrovascular accident (CVA) and myocardial infarction (MI). Meta-analysis of these studies showed that HRT may improve overall survival (hazard ratio (HR) 0.71, 95% confidence interval (CI) 0.54 to 0.93; 350 participants, 3 studies; low-certainty evidence). Quality-of-life assessment by use of the EORTC-C30 questionnaire was performed only in one study. We are uncertain whether HRT improves or reduces quality of life as the certainty of the evidence was assessed as very low (mean difference (MD) 13.67 points higher, 95% CI 9.26 higher to 18.08 higher; 1 study; 75 participants; very low-certainty evidence). Likewise, HRT may make little or no difference to progression-free survival (HR 0.76, 95% CI 0.57 to 1.01; 275 participants, 2 studies; low-certainty evidence). We are uncertain whether HRT improves or reduces the incidence of breast cancer (risk ratio (RR) 2.00, 95% CI 0.19 to 21.59; 225 participants, 2 studies; very low-certainty evidence); TIA (RR 5.00, 95% CI 0.24 to 102.42; 150 participants, 1 study; very low-certainty evidence); CVA (RR 0.67, 95% CI 0.11 to 3.88; 150 participants, 1 study; very low-certainty evidence); and MI (RR 0.20, 95% CI 0.01 to 4.10; 150 participants, 1 study; very low-certainty evidence). The incidence of gallstones was not reported in the included studies. AUTHORS' CONCLUSIONS: Hormone replacement therapy may slightly improve overall survival in women who have undergone surgical treatment for EOC, but the certainty of the evidence is low. HRT may make little or no difference to quality of life, incidence of breast cancer, TIA, CVA and MI as the certainty of the evidence has been assessed as very low. There may be little or no effect of HRT use on progression-free survival. The evidence in this review is limited by imprecision and incompleteness of reported relevant outcomes and therefore the results should be interpreted with caution. Future well-designed RCTs are required as this is an important area to women experiencing menopausal symptoms following surgical treatment for ovarian cancer, especially as doctors are often reluctant to prescribe HRT in this scenario. The evidence in this review is too limited to support or refute that HRT is very harmful in this population.

Antibiotic prophylaxis for operative vaginal delivery.

BACKGROUND: Vacuum and forceps assisted vaginal deliveries are reported to increase the incidence of postpartum infections and maternal readmission to hospital compared to spontaneous vaginal delivery. Prophylactic antibiotics may be prescribed to prevent these infections. However, the benefit of antibiotic prophylaxis for operative vaginal deliveries is still unclear. This is an update of a review last published in 2017. OBJECTIVES: To assess the effectiveness and safety of antibiotic prophylaxis in reducing infectious puerperal morbidities in women undergoing operative vaginal deliveries including vacuum or forceps delivery, or both. SEARCH METHODS: For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (5 July 2019), and reference lists of retrieved studies. SELECTION CRITERIA: All randomised controlled trials comparing any prophylactic antibiotic regimens with placebo or no treatment in women undergoing vacuum or forceps deliveries were eligible. Participants were all pregnant women without evidence of infections or other indications for antibiotics of any gestational age. Interventions were any antibiotic prophylaxis (any dosage regimen, any route of administration or at any time during delivery or the puerperium). DATA COLLECTION AND ANALYSIS: Two review authors assessed trial eligibility and risk of bias. Two review authors extracted the data independently using prepared data extraction forms. Any discrepancies were resolved by discussion and a consensus reached through discussion with all review authors. We assessed methodological quality of the two included studies using the GRADE approach. MAIN RESULTS: Two studies, involving 3813 women undergoing either vacuum or forceps deliveries, were included. One study involving 393 women compared the antibiotic intravenous cefotetan after cord clamping compared with no treatment. The other study involving 3420 women compared a single dose of intravenous amoxicillin and clavulanic acid with placebo using 20 mL of intravenous sterile 0.9% saline. The evidence suggests that prophylactic antibiotics reduce superficial perineal wound infection (risk ratio (RR) 0.53, 95% confidence interval (CI) 0.40 to 0.69; women = 3420; 1 study; high-certainty evidence), deep perineal wound infection (RR 0.46, 95% CI 0.31 to 0.69; women = 3420; 1 study; high-certainty evidence) and probably reduce wound breakdown (RR 0.52, 95% CI 0.43 to 0.63; women = 2593; 1 study; moderate-certainty evidence). We are unclear about the effect on organ or space perineal wound infection (RR 0.11, 95% CI 0.01 to 2.05; women = 3420; 1 study) and endometritis (average RR 0.32, 95% CI 0.04 to 2.64; 15/1907 versus 30/1906; women = 3813; 2 studies) based on low-certainty evidence with wide CIs that include no effect. Prophylactic antibiotics probably lower serious infectious complications (RR 0.44, 95% CI 0.22 to 0.89; women = 3420; 1 study; high-certainty evidence). They also have an important effect on reduction of confirmed or suspected maternal infection. The two included studies did not report on fever or urinary tract infection. It is unclear, based on low-certainty evidence, whether prophylactic antibiotics have any impact on maternal adverse reactions (RR 2.00, 95% CI 0.18 to 22.05; women = 2593; 1 study) and maternal length of stay (MD 0.09 days, 95% CI -0.23 to 0.41; women = 393; 1 study) as the CIs were wide and included no effect. Prophylactic antibiotics slightly improve perineal pain and health consequences of perineal pain and probably reduce costs. Prophylactic antibiotics did not have an important effect on dyspareunia (difficult or painful sexual intercourse) or breastfeeding at six weeks. Antibiotic prophylaxis may slightly improve maternal hospital re-admission and maternal health-related quality of life. Neonatal adverse reactions were not reported in any included trials. AUTHORS' CONCLUSIONS: Prophylactic intravenous antibiotics are effective in reducing infectious puerperal morbidities in terms of superficial and deep perineal wound infection or serious infectious complications in women undergoing operative vaginal deliveries without clinical indications for antibiotic administration after delivery. Prophylactic antibiotics slightly improve perineal pain and health consequences of perineal pain, probably reduce the costs, and may slightly reduce the maternal hospital re-admission and health-related quality of life. However, the effect on reduction of endometritis, organ or space perineal wound infection, maternal adverse reactions and maternal length of stay is unclear due to low-certainty evidence. As the evidence was mainly derived from a single multi-centre study conducted in a high-income setting, future well-designed randomised trials in other settings, particularly in low- and middle-income settings, are required to confirm the effect of antibiotic prophylaxis for operative vaginal delivery.

Association of maternity waiting home utilization with women's perceived geographic barriers and delivery complications in Ethiopia.

OBJECTIVES: The aim of this study is to identify the influence of perceived geographic barriers to the utilization of maternity waiting homes (MWHs) and to explore factors associated with current delivery complications among MWH users and nonusers. METHODS: An observational cross-sectional study was conducted between December 2017 and June 2018 in eight health facilities with MWH in the Gurage zone of Ethiopia. The associated factors were identified by using the combination of a directed acyclic graph (DAG) concept and multiple logistic regression for data analysis. RESULTS: A total of 716 women were included in the study, of whom 358 were MWH users. MWH users had lower odds of having delivery complications. Lower odds of delivery complications were found among women who gave birth in non-cesarean section (CS) facilities. Women with pregnancy complications and did not used MWH were more likely to develop delivery complications. Women with delivery complications had higher odds of undergoing cesarean delivery and neonatal death. CONCLUSIONS: Geographic barriers influenced the utilization of MWH. The women who used MWH had lower delivery complications. This study strengthens the evidence of MWH utilization as a useful strategy to overcome geographic barriers and lower delivery complications.

Risk of adverse pregnancy outcomes and seroprevalence for brucellosis in pregnant women exposed to goats or raw goat products in southern Thailand: a prospective cohort study.

BACKGROUND: Pregnant women infected with brucellosis have been shown to have higher odds of having been exposed to goats and raw goat products and adverse pregnancy outcomes. However, information on these associations in asymptomatic pregnant women is limited, particularly in the brucellosis-endemic areas. This study aimed to assess the association of a history of exposure to goats and/or raw goat products and the serological status of anti-Brucella abortus immunoglobulin G (IgG) with adverse pregnancy outcomes among pregnant women, and explore factors associated with having exposure to goats and/or raw goat products. METHODS: A prospective cohort study was conducted among pregnant women from July 2015 to July 2016 at Songkhla province in southern Thailand. All pregnant women who came for antenatal care (ANC) visits were approached. Blood samples from the women who agreed to participate were randomly tested for anti-Brucella abortus IgG. The women were then followed for adverse pregnancy outcomes. RESULTS: Of 666 pregnant women, the majority (74.4%) were aged 20-34 years and Muslim (89.2%), 30.6% indicated exposure to goats or raw goat products, and 17.3% had adverse pregnancy outcomes. Women rearing goats at home or having neighbors rearing goats were more likely to be exposed to goats or raw goat products by cutaneous contact. Of 465 women having a blood test, 3.7% had seropositive results for anti-Brucella abortus IgG. No association with adverse pregnancy outcomes was found in the women reporting any exposure to goat and raw goat products. Having the first ANC visit at the first trimester and history of preterm birth or low birth weight newborn were independent risk factors of adverse pregnancy outcomes. Women who had positive serological results were more likely to have a history of drinking raw goat milk than those who had negative results significantly. CONCLUSIONS: Although no association between past exposure with goats and raw goat products and adverse pregnancy outcomes was found, women with past exposure showed positive anti-Brucella abortus IgG. Counseling on avoiding consumption of raw goat milk would be beneficial to prevent goat-related infection in pregnant women in this area.

Health care expenditure for delivery care between maternity waiting home users and nonusers in Ethiopia.

OBJECTIVE: To compare the health care expenditures between maternity waiting home (MWH) users and nonusers in Ethiopia. METHODS: A cross-sectional study was done in Ethiopia between December 2017 and June 2018. The study setting included eight health facilities in the Gurage zone of Ethiopia. Health expenditure for delivery care was the outcome variable that was then classified into out-of-pocket (OOP) payments, women's costs, total costs, and overall costs. Those health expenditures were then compared among MWH users and nonusers. OOP payments were further analyzed using quantile regression to explore associated factors. RESULTS: A total of 812 postpartum women were included in this study of whom half were MWH users. Significantly higher OOP payment, women's costs, total costs, and overall cost were found among MWH users compared with nonusers regardless of duration of MWH stay. The MWH users were more likely to have higher OOP payment compared with MWH nonusers in linear and quantile regressions for both unadjusted and adjusted analyses. Higher OOP payments were observed for longer distance traveled and cesarean section (CS) delivery women at the 75th and 90th quantiles of expenditure. Using public transportation was significantly associated with higher OOP payment in all quantile levels. CONCLUSION: Utilization of MWH incurred higher OOP payments, total costs, women's costs, and overall costs compared with MWH nonusers. Higher OOP payments for delivery care among MWH users were observed in all quantiles of expenditure.

Type of health care workers and quality of antenatal and delivery care in communities of Myanmar: An experience- and vignette-based study.

BACKGROUND: Understanding who provides antenatal and delivery care services and the quality of care in communities with high maternal deaths is essential for planning the efficient utilization of a limited health care workforce. OBJECTIVES: To identify the types of health care workers for antenatal and delivery care in these communities, and assess the quality of care using vignettes of women with hypertensive disorder in pregnancy (HDP) and postpartum hemorrhage (PPH) from the provider's perspectives in Myanmar. METHODS: A cross-sectional study was conducted in three townships of Myanmar during May to September 2016. Health assistants, lady health visitors, midwives, and auxiliary midwives rated the type of providers and quality of care based on four HDP vignettes and four PPH vignettes. The agreements of their assessments were analysed using prevalence-adjusted bias-adjusted kappa and Cramer's V coefficient. RESULTS: Almost perfect agreement was found that midwives were the providers who provided and who should provide all routine antenatal and delivery care services. Less than 80% of the participants perceived good quality antenatal care (ANC) and delivery care for HDP and PPH, particularly in vignettes featuring cases of pre-existing hypertension or PPH with history of hospitalization. More than 85% of the participants rated quality of care for managing complications as good. Variations of ratings among the providers ranged from small to medium (Cramer's V = .22-.40). CONCLUSION: Midwives were key providers of ANC and delivery care in the local communities in Myanmar, but the quality of ANC for women with HDP and PPH was poor and needs improvement.

Improving detection of tuberculosis among household contacts of index tuberculosis patients by an integrated approach in Myanmar: a cross-sectional study.

BACKGROUND: Contact tracing for tuberculosis (TB) is a recommended measure to improve the case detection rate; however, actual implementation in Myanmar is limited and low detection rates have been reported. Household contacts of a known index TB case are at high risk of infection, thus a more strategic action for contact tracing is required to achieve the goal of the World Health Organization End TB Strategy. This study aimed to assess TB case detection rates among household contacts by an integrated approach and identify risk factors for TB. METHODS: A cross-sectional study was conducted in Mandalay City, Myanmar. Household contacts of index TB cases who had been receiving treatment for at least 3 months were prospectively investigated by an integrated approach which included modification of screening methods and active facilitation of screening investigations as follows. Initial chest x-ray (CXR) was performed for all contacts at the responsible facilities followed by sputum specimen collection for those aged ≥15 years and gene Xpert MTB/RIF examination. Transportation of all household contacts to health facilities and transportation of sputum samples for smear and gene Xpert MTB/RIF examination at centers were arranged by the research team to ensure that all household contacts received all investigations. Risk factors for TB among household contacts were identified by multiple logistic regression models. RESULTS: Of 174 household contacts, 115 were ≥ 15 years and 59 were < 15 years. The percentage of TB cases detected among the household contacts was 13.8%. There were 14 (12.2%) positive TB cases among the 115 contacts aged ≥15 years while 10 (16.9%) of those aged < 15 years had clinical signs and symptoms of TB with an abnormal CXR. Risk factors among household contacts for TB were being a caretaker of an index case, active and passive smoking, and drinking alcohol. CONCLUSIONS: The integrated approach of TB contact tracing by special arrangement for CXR, sputum and gene Xpert MTB/RIF examination yielded a high TB detection rate in a high TB prevalence area. Logistic and financial administration is needed to strengthen contact tracing. Further research on high-risk household contacts should be considered for increasing TB detection rates.

Inequity in the utilization of antenatal and delivery care in Yangon region, Myanmar: a cross-sectional study.

BACKGROUND: Equity of access to and utilization of healthcare across socio-economic groups is important to achieve universal health coverage. Although the utilization of antenatal and delivery care has been increasing in low- and middle-income countries, inequities in the utilization of antenatal and delivery care have been reported in many countries, but have not yet been studied in Myanmar. This study aimed to determine whether inequities in the utilization of antenatal and delivery care existed in Yangon region, Myanmar. METHODS: A community-based cross-sectional survey using multistage sampling was conducted from October to November 2016. A wealth index was selected as the main socioeconomic parameter for measuring inequities with respect to early initiation of antenatal care (ANC), number of antenatal care visits, delivery by a skilled birth attendant (SBA) and delivery by cesarean section (CS). Inequities were evaluated using concentration curves and concentration indexes. RESULTS: Of the 762 women who gave birth within the 12-month survey period, there was no evidence of inequity in utilization of ANC; however, inequity of at least one antenatal visit among women aged less than 20 years was found with a concentration index of 0.04. The concentration indexes for delivery by SBA and CS were 0.05 and 0.14, respectively. Delivery by CS was disproportionately higher in adolescents and women with higher education than middle school. CONCLUSION: There was no overall inequity in the utilization of ANC but substantial inequities in delivery by CS and SBA were shown. Social determinants of health, particularly age and education, were associated with inequities in the utilization of delivery care. Adolescent pregnant women were found to be particularly vulnerable, and thus should be a target group for strategic plans to reduce inequities in utilization of delivery care.

Mechanical dilatation of the cervix during elective caeserean section before the onset of labour for reducing postoperative morbidity.

BACKGROUND: During elective (planned) caesarean sections, some obstetricians routinely dilate the cervix intraoperatively, using sponge forceps, a finger, or other instruments, because the cervix of women not in labour may not be dilated, and this may cause obstruction of blood or lochia drainage. However, mechanical cervical dilatation during caesarean section may result in contamination by vaginal micro-organisms during dilatation, and increase the risk of infection or cervical trauma. OBJECTIVES: To determine the effects of mechanical dilatation of the cervix during elective caesarean section on postoperative morbidity. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) and reference lists of retrieved studies on 20 September 2017. SELECTION CRITERIA: We included all randomised, quasi-randomised, and cluster-randomised controlled trials comparing intraoperative cervical dilatation using a finger, sponge forceps, or other instruments during elective caesarean section versus no mechanical dilatation. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS: We included eight studies with a total of 2227 women undergoing elective caesarean section. Of these, 1097 underwent intraoperative cervical dilatation with a double-gloved index finger or Hegar dilator inserted into the cervical canal to dilate, and 1130 did not undergo intraoperative cervical dilatation. Six of the eight included trials had high risk of bias for some of the risk of bias domains.Very low-quality evidence suggested it was unclear whether cervical dilatation had any impact on postpartum haemorrhage (estimated blood loss greater than 1000 mL; risk ratio (RR) 1.97, 95% confidence interval (CI) 0.48 to 8.13; 5/205 versus 3/242; one study, 447 women).Low- or very low-quality evidence showed no clear difference for the need for blood transfusion (RR 3.54, 95% CI 0.37 to 33.79; two studies, 847 women); postoperative haemoglobin (mean difference (MD -0.05, 95% CI -0.15 to 0.06; three studies, 749 women), or haematocrit (MD 0.01%, 95% CI -0.18 to 0.20; one study, 400 women); the incidence of drop from baseline haemoglobin above 0.5 g/dL (RR 0.92, 95% CI 0.64 to 1.31; two studies, 722 women), or amount of haemoglobin drop (MD -0.01 g/dL, 95% -0.14 to 0.13; three studies, 796 women); the incidence of secondary postpartum haemorrhage within six weeks (RR 1.18, 95% CI 0.07 to 18.76; one study, 447 women); febrile morbidity (RR 1.18, 95% CI 0.76 to 1.85; seven studies, 2126 women); endometritis (RR 0.94, 95% CI 0.35 to 2.52; four studies, 1536 women); or uterine subinvolution (RR 0.34, 95% CI 0.08 to 1.36; two studies, 654 women); the results crossed the line of no effect for all of the outcomes. There were no data for cervical trauma.We found a slight improvement with mechanical dilatation for these secondary outcomes, not prespecified in the protocol: mean blood loss, endometrial cavity thickness, retained products of conception, distortion of uterine incision, and healing ratio. The evidence for these outcomes was based on one or two studies. Cervical dilatation did not have a clear effect on these secondary outcomes, not prespecified in the protocol: wound infection, urinary tract infection, operative time, infectious morbidity, and integrity of uterine scar. AUTHORS' CONCLUSIONS: At this time, the evidence does not support or refute the use of mechanical dilatation of the cervix during elective caesarean section for reducing postoperative morbidity.Further large, well-designed studies are required to compare the effect of intraoperative mechanical dilatation of the cervix with no intraoperative mechanical cervical dilatation for reducing postoperative morbidity.