A virtual reality environment for supporting mental wellbeing of students on remote clinical placement: A multi-methods evaluation.

BACKGROUND: Nursing and Allied Health Profession (NAHP) students undertake clinical placements as part of their pre-registration training. The remote nature of some placement sites, shiftwork and the emotionally challenging nature of the workload has led to mental wellbeing issues in many students. AIM: This project aimed to evaluate a novel 3D immersive virtual reality environment that supports mental wellbeing for NAHP students on clinical placement. It comprises a calming 3D tropical beach environment where students and tutors can meet for reflection and mutual support. DESIGN: A multi-methods design gathered quantitative impact data with validated measurement tools and qualitative output related to the lived experience of students. SETTINGS AND PARTICIPANTS: All 600 pre-registration NAHP students within the institution undertaking clinical placements were invited to participate, irrespective of mental wellbeing status. Students were randomly assigned to either a VR or Conventional cohort; all participants received the control support mechanism in a subsequent placement. METHODS: All participants completed an initial demographic and Readiness for Therapy survey followed by weekly Beck Anxiety and Depression Inventories during placement. All participants were invited to a semi-structured interview. RESULTS: Overall, 32 participants engaged with the application; although the VR cohort demonstrated improved scores on both Beck inventories, these were not statistically significant. This is probably due to the low response rate for the control cohort. A total of 15 interviews were conducted and several themes emerged from the data in relation. to both experiential outcomes (escapism, anonymity and sense of community) and instrumental outcomes (calming, mindfulness and combatting loneliness). CONCLUSIONS: User feedback indicates that a VR environment can provide a calming escape from the pressures and anxiety arising from clinical placement for healthcare students. The relaxing beach environment facilitated mindfulness meditation and the additional opportunities for pseudo-anonymous interactions with peers and tutors were wellreceived by students.

Medical student wellbeing during COVID-19: a qualitative study of challenges, coping strategies, and sources of support.

BACKGROUND: Medical students face challenges to their mental wellbeing and have a high prevalence of mental health problems. During training, they are expected to develop strategies for dealing with stress. This study investigated factors medical students perceived as draining and replenishing during COVID-19, using the 'coping reservoir' model of wellbeing. METHODS: In synchronous interactive pre-recorded webinars, 78 fourth-year medical students in the UK responded to reflective prompts. Participants wrote open-text comments on a Padlet site. Responses were analysed using reflexive thematic analysis. RESULTS: Analysis identified five themes. COVID-19 exacerbated academic pressures, while reducing the strategies available to cope with stress. Relational connections with family and friends were affected by the pandemic, leading to isolation and reliance on housemates for informal support. Relationships with patients were adversely affected by masks and telephone consultations, however attending placement was protective for some students' wellbeing. Experiences of formal support were generally positive, but some students experienced attitudinal and practical barriers. CONCLUSIONS: This study used a novel methodology to elicit medical students' reflections on their mental wellbeing during COVID-19. Our findings reinforce and extend the 'coping reservoir' model, increasing our understanding of factors that contribute to resilience or burnout. Many stressors that medical students typically face were exacerbated during COVID-19, and their access to coping strategies and support were restricted. The changes to relationships with family, friends, patients, and staff resulted in reduced support and isolation. Recognising the importance of relational connections upon medical students' mental wellbeing can inform future support.

National action plans on antimicrobial resistance in Latin America: an analysis via a governance framework.

In 2015, the World Health Assembly adopted a global action plan (GAP) on antimicrobial resistance (AMR). Member states were encouraged to develop their own national action plans (NAPs) in alignment with the GAP. To-date, in systematic assessments of NAPs, the Latin American specific context has not been previously analysed. Here we examined 11 Latin American NAPs published between 2015 and 2021 using content analysis. We focused on two approaches: (1) alignment between the strategic objectives and actions defined in the GAP, and those outlined in the NAPs via a content indicator; and (2) assessment of the NAPs via a governance framework covering 'policy design', 'implementation tools' and 'monitoring and evaluation' areas. We observed a high alignment with the strategic objectives of the GAP; however, the opposite was observed for the corresponding actions. Our results showed that the governance aspects contained within coordination and participation domains were addressed by every Latin American NAP, whereas monitoring and assessment areas, as well as incorporating the environment, would need more attention in subsequent NAPs. Given that AMR is a global health threat and collective efforts across regions are necessary to combat it, our findings can benefit member states by highlighting how to strengthen the AMR strategies in Latin America, while also supporting global policy formulation.

Biochar application to temperate grasslands: challenges and opportunities for delivering multiple ecosystem services.

Grasslands (natural, semi-natural and improved) occupy approximately one-third of the terrestrial biosphere and are key for global ecosystem service provision, storing up to 30% of soil organic carbon (SOC). To date, most research on soil carbon (C) sequestration has focused on croplands where the levels of native soil organic matter (SOM) are typically low and significant potential exists to replenish SOM stocks. However, with the renewed push to achieve "net zero" C emissions by 2050, grasslands may offer an additional C store, utilising tools such as biochar. Here, we critically evaluate the potential for biochar as a technology for increasing grassland C stocks, identifying a number of practical, economic, social and legislative challenges that need to be addressed before the widescale adoption of biochar may be achieved. We critically assess the current knowledge within the field of grassland biochar research in the context of ecosystem service provision and provide opinions on the applicability of biochar as an amendment to different types of grassland (improved, semi-improved and unimproved) and the potential effect on ecosystem provision using a range of application techniques in the topsoil and subsoil. We concluded that the key question remains, is it possible for managed grasslands to store more C, without causing a loss in additional ecosystem services? To address this question future research must take a more multidisciplinary and holistic approach when evaluating the potential role of biochar at sequestering C in grasslands to mitigate climate change. Supplementary Information: The online version contains supplementary material available at 10.1007/s42773-023-00232-y.

Antimicrobial resistance in dairy slurry tanks: A critical point for measurement and control.

Waste from dairy production is one of the largest sources of contamination from antimicrobial resistant bacteria (ARB) and genes (ARGs) in many parts of the world. However, studies to date do not provide necessary evidence to inform antimicrobial resistance (AMR) countermeasures. We undertook a detailed, interdisciplinary, longitudinal analysis of dairy slurry waste. The slurry contained a population of ARB and ARGs, with resistances to current, historical and never-used on-farm antibiotics; resistances were associated with Gram-negative and Gram-positive bacteria and mobile elements (ISEcp1, Tn916, Tn21-family transposons). Modelling and experimental work suggested that these populations are in dynamic equilibrium, with microbial death balanced by fresh input. Consequently, storing slurry without further waste input for at least 60 days was predicted to reduce ARB spread onto land, with > 99 % reduction in cephalosporin resistant Escherichia coli. The model also indicated that for farms with low antibiotic use, further reductions are unlikely to reduce AMR further. We conclude that the slurry tank is a critical point for measurement and control of AMR, and that actions to limit the spread of AMR from dairy waste should combine responsible antibiotic use, including low total quantity, avoidance of human critical antibiotics, and choosing antibiotics with shorter half-lives, coupled with appropriate slurry storage.

Effect of clinician information sessions on diagnostic testing for Chagas disease.

BACKGROUND: Chagas disease is a potentially life-threatening neglected disease of poverty that is endemic in continental Latin America. Caused by Trypanosoma cruzi (T. cruzi), it is one of six parasitic diseases in the United States targeted by the Centers for Disease Control as a public health problem in need of action. An estimated 300,000 people are infected with T. cruzi in the United States (US). Although its morbidity, mortality and economic burden are high, awareness of Chagas disease is lacking among many healthcare providers in the US. The purpose of this analysis is to determine if the number of diagnostic tests performed at a community health center serving an at-risk population for Chagas disease increased after information sessions. A secondary aim was to determine if there was a difference by provider type, i.e., nurse practitioner vs. physician, or by specialty in the number of patients screened. METHODOLOGY/PRINCIPAL FINDINGS: We conducted a retrospective data analysis of the number of Chagas serology tests performed at a community health center before and after information sessions for clinicians. A time series analysis was conducted focusing on the Adult and Family Medicine Departments at East Boston Neighborhood Health Center (EBNHC). Across all departments there were 1,957 T. cruzi tests performed before the sessions vs. 2,623 after the sessions. Interrupted time series analysis across departments indicated that testing volume was stable over time prior to the sessions (pre-period slope = +4.1 per month; p = 0.12), followed by an immediate shift after the session (+51.6; p = 0.03), while testing volume remained stable over time after the session (post-period slope = -6.0 per month; p = 0.11). CONCLUSION/SIGNIFICANCE: In this study, Chagas testing increased after information sessions. Clinicians who began testing their patients for Chagas disease after learning of the importance of this intervention added an extra, potentially time-consuming task to their already busy workdays without external incentives or recognition.

Sorption, separation and recycling of ammonium in agricultural soils: A viable application for magnetic biochar?

Recent research on the magnetisation of biochar, a carbon-based material that can be used as a sorbent, has opened novel opportunities in the field of environmental remediation, as incorporating magnetic particles into biochar can simplify subsequent separation. This could offer a sustainable circular economy-based solution in two areas of waste management; firstly, pyrolysis of agricultural waste for magnetic biochar synthesis could reduce greenhouse gas emissions derived from traditional agricultural waste processing, such as landfill and incineration, while secondly, application of magnetic biochar to remove excess nitrogen from soils (made possible through magnetic separation) could provide opportunities for this pollutant to be used as a recycled fertiliser. While sorption of pollutants by magnetic biochar has been researched in wastewater, few studies have investigated magnetic biochar use in polluted soils. Nitrogen pollution (e.g. NH4+), stemming from agricultural fertiliser management, is a major environmental and economic issue that could be significantly reduced before losses from soils occur. This review demonstrates that the use of magnetic biochar tailored to NH4+ adsorption has potential to remove (and recycle for reuse) excess nitrogen from soils. Analysis of research into recovery of NH4+ by sorption/desorption, biochar magnetisation and biochar-soil interactions, suggests that this is a promising application, but a more cohesive, interdisciplinary approach is called for to elucidate its feasibility. Furthermore, research shows variable impacts of biochar upon soil chemistry and biology, such as pH and microbial diversity. Considering wide concerns surrounding global biodiversity depletion, a more comprehensive understanding of biochar-soil dynamics is required to protect and support soil ecosystems. Finally, addressing research gaps, such as optimisation and scaling-up of magnetic biochar synthesis, would benefit from systems thinking approaches, ensuring the many complex considerations across science, industry, policy and economics are connected by circular-economy principles.

Antimicrobial Resistance Patterns of Escherichia coli Isolated from Sheep and Beef Farms in England and Wales: A Comparison of Disk Diffusion Interpretation Methods.

Little data exist on the levels of antimicrobial resistance from bacteria isolated from British sheep and beef cattle. The aim of this study was to investigate antimicrobial resistance patterns on sheep and beef farms in England and Wales using multiple interpretation methods. Fecal samples (n = 350) from sheep and beef cattle were collected from 35 farms. Disk diffusion antimicrobial susceptibility testing against ten antimicrobials was carried out for 1115 (699 sheep, 416 beef) ß-glucuronidase-positive Escherichia coli isolates. Susceptibility was interpreted using clinical breakpoints, which determine clinically resistant bacteria, and epidemiological and livestock-specific cut-off values, which determine microbiological-resistant bacteria (non-wild type). Using livestock-specific cut-off values, a high frequency of wild type for all ten antimicrobials was observed in isolates from sheep (90%) and beef cattle (85%). Cluster analysis was performed to identify patterns in antimicrobial resistance. Interpretation of susceptibility using livestock-specific cut-off values showed a cluster of isolates that were non-wild type to cefotaxime and amoxicillin/clavulanic acid, whereas clinical breakpoints did not. A multilevel logistic regression model determined that tetracycline use on the farm and soil copper concentration were significantly associated with tetracycline non-wild type isolates. The results suggest that using human clinical breakpoints could lead to both the under-reporting and over-reporting of antimicrobial resistance in sheep and beef cattle.

Perceived barriers to Chagas disease screening among a diverse group of prenatal care providers.

BACKGROUND: Chagas disease is a vector borne infection of poverty endemic to Latin America which affects an estimated 40,000 women of child-bearing age in the United States (US). In the US Chagas disease is concentrated among individuals who have lived in endemic areas. Prenatal diagnosis and treatment are needed to prevent congenital transmission. The objective of this study was to assess perceived barriers to Chagas disease screening among prenatal care providers in Obstetrics/Gynecology and Family Medicine Departments of a tertiary care safety-net hospital caring for a significant at-risk population. METHODOLOGY/PRINCIPAL FINDINGS: An anonymous survey was distributed to 178 Obstetrics/Gynecology and Family Medicine practitioners. Of the 66 respondents, 39% thought Chagas screening was very important, and 48% somewhat important as a public health initiative. One third judged screening patients during clinic visits as very important. Most respondents (64%) reported being familiar with Chagas disease. However, only 32% knew how to order a test and only 22% reported knowing what to do if a test was positive. CONCLUSIONS/SIGNIFICANCE: These findings will be incorporated into measures to facilitate full implementation of Chagas screening, and can inform initiatives at other centers who wish to address this deeply neglected infection among their patient families. Greater integration of information on Chagas disease screening and treatment in medical and nursing education curricula can contribute to addressing this disease with the focus that its potentially fatal sequelae merit.

Carers Create: Carer perspectives of a creative programme for people with dementia and their carers on the relationship within the (carer and cared-for) dyad.

INTRODUCTION: Relationships between people with dementia and their carers can prove challenging over the trajectory of the disease. Interventions with a potential to address this include arts and music-based activities. This research project aimed to evaluate a community engagement programme (Carers Create) where both people with dementia and their carers participate together in singing and other activities. A specific focus was on the impact of the sessions on the dyadic relationship. METHODS: A grounded theory approach involved conducting three focus group interviews with carers of people with dementia (n = 16) facilitated by members of a local U3A (University of the Third Age) who were trained and supported by university researchers. Recorded conversations were transcribed and analysed using a three-stage coding and thematic development technique. RESULTS: Four overarching themes were identified from the discourse: remembering the positive qualities of the cared-for, the physical and emotional demands of caring, Carers Create as a shared, beneficial activity and the enduring value of Carers Create. CONCLUSION: Carers found the sessions to positively influence the relationship with the person they cared for through offering some relief from the day-to-day pressures of caring and, in some cases, restoring elements of a previously strong relationship. Crucial to the experience was the fact that the sessions included both carer and cared-for, offering activities to do together, and that they took place within a group, thereby offering a degree of mutual support. In addition, some carers were able to build on learning which had taken place and use certain techniques, such as singing, to help manage care, thus extending the improved relationship.

Whole-Genome Sequence of a Plant Growth-Promoting Strain, Serratia marcescens BTL07, Isolated from the Rhizoplane of Capsicum annuum L.

Serratia marcescens strain BTL07, which has the ability to promote growth and suppress plant diseases, was isolated from the rhizoplane of a chili plant. The draft genome sequence data of the strain will contribute to advancing our understanding of the molecular mechanisms underlying plant growth promotion and tolerance to different stresses.

Integrated phytobial heavy metal remediation strategies for a sustainable clean environment - A review.

Heavy metal contamination in the environment is a global threat which accelerated after the industrial revolution. Remediation of these noxious elements has been widely investigated and multifarious technologies have been practiced for many decades. Phytoremediation has attracted much attention from researchers. Under this technology, heavy metal hyperaccumulator plants have been extensively employed to extract extraordinary concentrations of heavy metals but slow growth, limited biomass and stresses caused by heavy metals imperil the efficiency of hyperaccumulators. Plant growth promoting rhizobacteria (PGPR) can help overcome/lessen heavy metal-induced adversities. PGPR produce several metabolites, including growth hormones, siderophores and organic acids, which aid in solubilization and provision of essential nutrients (e.g. Fe and Mg) to the plant. Hyperaccumulator plants may be employed to remediate metal contaminated sites. Use of PGPR to enhance growth of hyperaccumulator plant species may enhance their metal accumulating capacity by increasing metal availability and also by alleviating plant stress induced by the heavy metals. Combined use of hyperaccumulator plants and PGPR may prove to be a cost effective and environmentally friendly technology to clean heavy metal contaminated sites on a sustainable basis. This review discusses the current status of PGPR in improving the growth and development of hyperaccumulator plants growing in metal contaminated environments. The mechanisms used by these rhizosphere bacteria in increasing the availability of heavy metals to plants and coping with heavy metal stresses are also described.

Endophytic Bacillus spp. from medicinal plants inhibit mycelial growth of Sclerotinia sclerotiorum and promote plant growth.

Plant growth-promoting bacteria that are also capable of suppressing plant pathogenic fungi play an important role in sustainable agriculture. There is a critical need for conducting research to discover, characterize and evaluate the efficacy of new strains of such bacteria in controlling highly aggressive plant pathogens. In this study, we isolated endophytic bacteria from medicinal plants of Bangladesh and evaluated their antagonistic capacity against an important phytopathogenic fungus Sclerotinia sclerotiorum. Growth-promoting effects of those isolates on cucumber and rice seedlings were also assessed. Among 16 morphologically distinct isolates, BDR-2, BRtL-2 and BCL-1 significantly inhibited the growth of S. sclerotiorum through induction of characteristic morphological alterations in hyphae and reduction of mycelial dry weight. When cucumber and rice seeds were treated with these endophytic bacteria, seven isolates (BCL-1, BDL-1, BRtL-2, BRtL-3, BDR-1, BDR-2 and BBoS-1) enhanced seed germination, seedling vigor, seedling growth and number of roots per plant at a varying level compared to untreated controls. All isolates produced high levels of indole-3-acetic acid (6 to 63 µg/mL) in vitro. Two most potential isolates, BDR-2 and BRtL-2, were identified as Bacillus amyloliquefaciens and B. subtilis, respectively, based on the 16S rRNA gene sequencing. These results suggest that endophytic Bacillus species from native medicinal plants have great potential for being used as natural plant growth promoter and biopesticides in sustainable crop production.

Pseudomonas and Burkholderia inhibit growth and asexual development of Phytophthora capsici.

The objective of this study was to isolate and characterize antagonistic rhizobacteria from chili against a notorious phytopathogen Phytophthora capsici. Among the 48 bacteria isolated, BTLbbc-02, BTLbbc-03, and BTLbbc-05 were selected based on their inhibitory activity against P. capsici. They were tentatively identified as Burkholderia metallica BTLbbc-02, Burkholderia cepacia BTLbbc-03, and Pseudomonas aeruginosa BTLbbc-05, respectively, based on their 16S rRNA gene sequencing. All inhibited the growth of P. capsici at varying levels by inducing characteristic morphological alterations of P. capsici hyphae. The cell-free culture supernatant of all three isolates impaired motility (up to 100%) and caused lysis (up to 50%) of the halted zoospores. Bioassays revealed that Pseudomonas sp. had higher antagonism and zoospore motility-inhibitory effects against P. capsici compared with two other isolates, Burkholderia spp. and B. metallica, which caused vacuolation in mycelium. All three bacteria suppressed sporangium formation and zoosporogenesis of P. capsici, and improved the seed germination and growth of cucumber. Our findings suggest that epiphytic bacteria, B. metallica, B. cepacia, and P. aeruginosa, could be used as potential biocontrol agents against P. capsici. A further study is required to ensure conformity with the existing regulations for soil, plant, and human health.

Safety of Outpatient Parenteral Antimicrobial Therapy in Children.

BACKGROUND AND OBJECTIVE: Outpatient parenteral antimicrobial therapy (OPAT) provides numerous benefits but may pose unique risks in children. We aimed to determine rates of OPAT antimicrobial- and intravenous access-related complications and their associations with specific antimicrobials and type of intravenous access in pediatric patients. METHODS: Observational cohort study of patients receiving OPAT from August 2008 to May 2015 cared for by the Infectious Diseases service at a tertiary children's hospital. Primary outcome was antimicrobial discontinuation (AD) because of OPAT-associated complications. Secondary outcomes were unplanned outpatient healthcare visits and readmissions from OPAT-associated complications. RESULTS: Seven hundred and seven intravenous antimicrobials were prescribed in 540 cases. Nondevice-associated musculoskeletal infection was the most common diagnosis (39%). Ceftriaxone (30%), cefazolin (27%) and vancomycin (22%) were the most commonly used antimicrobials. Complications led to AD, ≥1 unplanned outpatient healthcare visit and ≥1 readmission in 23%, 30% and 17% of cases, respectively. Compared with use of ceftriaxone, use of oxacillin was associated with a significantly higher risk of AD because of any antimicrobial-related complication [hazard ratio (HR), 3.3; 95% confidence interval (CI): 1.2-9.7) and because of hepatic transaminitis (HR, 32.8; 95% CI: 4.02-268.2). Subjects treated with intravenous clindamycin (HR, 2.6; 95% CI: 1.1-5.8) and with a peripherally inserted central catheter (HR, 2.6; 95% CI: 1.04-6.3) were more likely to have unplanned outpatient visits. CONCLUSIONS: Use of oxacillin during OPAT was associated with higher rate of AD. Patients treated with clindamycin and those with a peripherally inserted central catheter had higher rates of unplanned outpatient visits. Providers should strongly consider alternative treatment options when possible.

No difference in knowledge obtained from infographic or plain language summary of a Cochrane systematic review: three randomized controlled trials.

OBJECTIVES: The aim of this study was to test the usefulness of an infographic in the translation of knowledge about health information from a Cochrane systematic review to lay and professional populations in comparison to a plain language summary (PLS) and scientific abstract (SA). STUDY DESIGN AND SETTING: We conducted three parallel randomized trials with university students (n = 171), consumers (n = 99), and doctors (n = 64), to examine the effect of different summary formats of a Cochrane systematic review on the knowledge about health information presented in the review, reading experience, and perceived user-friendliness. In the trials involving students and doctors, an infographic was compared to a PLS and a SA, while in those with consumers, an infographic was compared to a PLS. RESULTS: We found no difference in knowledge between the infographic and the text-based PLS in any of the trials or in the whole participant sample. All three participant groups preferred the infographic and gave it higher ratings for reading experience (d = 0.48 in the overall sample) and user-friendliness (d = 0.46 in the overall sample). CONCLUSION: Although the infographic format was perceived as more enjoyable for reading, it was not better than a traditional, text-based PLS in the translation of knowledge about findings from a Cochrane systematic review.

Techniques of monitoring blood glucose during pregnancy for women with pre-existing diabetes.

BACKGROUND: Self-monitoring of blood glucose (SMBG) is recommended as a key component of the management plan for diabetes therapy during pregnancy. No existing systematic reviews consider the benefits/effectiveness of various techniques of blood glucose monitoring on maternal and infant outcomes among pregnant women with pre-existing diabetes. The effectiveness of the various monitoring techniques is unclear. OBJECTIVES: To compare techniques of blood glucose monitoring and their impact on maternal and infant outcomes among pregnant women with pre-existing diabetes. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2016), searched reference lists of retrieved studies and contacted trial authors. SELECTION CRITERIA: Randomised controlled trials (RCTs) and quasi-RCTs comparing techniques of blood glucose monitoring including SMBG, continuous glucose monitoring (CGM) or clinic monitoring among pregnant women with pre-existing diabetes mellitus (type 1 or type 2). Trials investigating timing and frequency of monitoring were also included. RCTs using a cluster-randomised design were eligible for inclusion but none were identified. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed study eligibility, extracted data and assessed the risk of bias of included studies. Data were checked for accuracy. The quality of the evidence was assessed using the GRADE approach. MAIN RESULTS: This review update includes at total of 10 trials (538) women (468 women with type 1 diabetes and 70 women with type 2 diabetes). The trials took place in Europe and the USA. Five of the 10 included studies were at moderate risk of bias, four studies were at low to moderate risk of bias, and one study was at high risk of bias. The trials are too small to show differences in important outcomes such as macrosomia, preterm birth, miscarriage or death of baby. Almost all the reported GRADE outcomes were assessed as being very low-quality evidence. This was due to design limitations in the studies, wide confidence intervals, small sample sizes, and few events. In addition, there was high heterogeneity for some outcomes.Various methods of glucose monitoring were compared in the trials. Neither pooled analyses nor individual trial analyses showed any clear advantages of one monitoring technique over another for primary and secondary outcomes. Many important outcomes were not reported.1. Self-monitoring versus standard care (two studies, 43 women): there was no clear difference for caesarean section (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.40 to 1.49; one study, 28 women) or glycaemic control (both very low-quality), and not enough evidence to assess perinatal mortality and neonatal mortality and morbidity composite. Hypertensive disorders of pregnancy, large-for-gestational age, neurosensory disability, and preterm birth were not reported in either study.2. Self-monitoring versus hospitalisation (one study, 100 women): there was no clear difference for hypertensive disorders of pregnancy (pre-eclampsia and hypertension) (RR 4.26, 95% CI 0.52 to 35.16; very low-quality: RR 0.43, 95% CI 0.08 to 2.22; very low-quality). There was no clear difference in caesarean section or preterm birth less than 37 weeks' gestation (both very low quality), and the sample size was too small to assess perinatal mortality (very low-quality). Large-for-gestational age, mortality or morbidity composite, neurosensory disability and preterm birth less than 34 weeks were not reported.3. Pre-prandial versus post-prandial glucose monitoring (one study, 61 women): there was no clear difference between groups for caesarean section (RR 1.45, 95% CI 0.92 to 2.28; very low-quality), large-for-gestational age (RR 1.16, 95% CI 0.73 to 1.85; very low-quality) or glycaemic control (very low-quality). The results for hypertensive disorders of pregnancy: pre-eclampsia and perinatal mortality are not meaningful because these outcomes were too rare to show differences in a small sample (all very low-quality). The study did not report the outcomes mortality or morbidity composite, neurosensory disability or preterm birth.4. Automated telemedicine monitoring versus conventional system (three studies, 84 women): there was no clear difference for caesarean section (RR 0.96, 95% CI 0.62 to 1.48; one study, 32 women; very low-quality), and mortality or morbidity composite in the one study that reported these outcomes. There were no clear differences for glycaemic control (very low-quality). No studies reported hypertensive disorders of pregnancy, large-for-gestational age, perinatal mortality (stillbirth and neonatal mortality), neurosensory disability or preterm birth.5.CGM versus intermittent monitoring (two studies, 225 women): there was no clear difference for pre-eclampsia (RR 1.37, 95% CI 0.52 to 3.59; low-quality), caesarean section (average RR 1.00, 95% CI 0.65 to 1.54; I² = 62%; very low-quality) and large-for-gestational age (average RR 0.89, 95% CI 0.41 to 1.92; I² = 82%; very low-quality). Glycaemic control indicated by mean maternal HbA1c was lower for women in the continuous monitoring group (mean difference (MD) -0.60 %, 95% CI -0.91 to -0.29; one study, 71 women; moderate-quality). There was not enough evidence to assess perinatal mortality and there were no clear differences for preterm birth less than 37 weeks' gestation (low-quality). Mortality or morbidity composite, neurosensory disability and preterm birth less than 34 weeks were not reported.6. Constant CGM versus intermittent CGM (one study, 25 women): there was no clear difference between groups for caesarean section (RR 0.77, 95% CI 0.33 to 1.79; very low-quality), glycaemic control (mean blood glucose in the 3rd trimester) (MD -0.14 mmol/L, 95% CI -2.00 to 1.72; very low-quality) or preterm birth less than 37 weeks' gestation (RR 1.08, 95% CI 0.08 to 15.46; very low-quality). Other primary (hypertensive disorders of pregnancy, large-for-gestational age, perinatal mortality (stillbirth and neonatal mortality), mortality or morbidity composite, and neurosensory disability) or GRADE outcomes (preterm birth less than 34 weeks' gestation) were not reported. AUTHORS' CONCLUSIONS: This review found no evidence that any glucose monitoring technique is superior to any other technique among pregnant women with pre-existing type 1 or type 2 diabetes. The evidence base for the effectiveness of monitoring techniques is weak and additional evidence from large well-designed randomised trials is required to inform choices of glucose monitoring techniques.

Methods of term labour induction for women with a previous caesarean section.

BACKGROUND: Women with a prior caesarean delivery have an increased risk of uterine rupture and for women subsequently requiring induction of labour it is unclear which method is preferable to avoid adverse outcomes. This is an update of a review that was published in 2013. OBJECTIVES: To assess the benefits and harms associated with different methods used to induce labour in women who have had a previous caesarean birth. SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register (31 August 2016) and reference lists of retrieved studies. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing any method of third trimester cervical ripening or labour induction, with placebo/no treatment or other methods in women with prior caesarean section requiring labour induction in a subsequent pregnancy. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for inclusion and trial quality, extracted data, and checked them for accuracy. MAIN RESULTS: Eight studies (data from 707 women and babies) are included in this updated review. Meta-analysis was not possible because studies compared different methods of labour induction. All included studies had at least one design limitation (i.e. lack of blinding, sample attrition, other bias, or reporting bias). One study stopped prematurely due to safety concerns. Vaginal PGE2 versus intravenous oxytocin (one trial, 42 women): no clear differences for caesarean section (risk ratio (RR) 0.67, 95% confidence interval (CI) 0.22 to 2.03, evidence graded low), serious neonatal morbidity or perinatal death (RR 3.00, 95% CI 0.13 to 69.70, evidence graded low), serious maternal morbidity or death (RR 3.00, 95% CI 0.13 to 69.70, evidence graded low). Also no clear differences between groups for the reported secondary outcomes. The GRADE outcomes vaginal delivery not achieved within 24 hours, and uterine hyperstimulation with fetal heart rate changes were not reported. Vaginal misoprostol versus intravenous oxytocin (one trial, 38 women): this trial stopped early because one woman who received misoprostol had a uterine rupture (RR 3.67, 95% CI 0.16 to 84.66) and one had uterine dehiscence. No other outcomes (including GRADE outcomes) were reported. Foley catheter versus intravenous oxytocin (one trial, subgroup of 53 women): no clear difference between groups for vaginal delivery not achieved within 24 hours (RR 1.47, 95% CI 0.89 to 2.44, evidence graded low), uterine hyperstimulation with fetal heart rate changes (RR 3.11, 95% CI 0.13 to 73.09, evidence graded low), and caesarean section (RR 0.93, 95% CI 0.45 to 1.92, evidence graded low). There were also no clear differences between groups for the reported secondary outcomes. The following GRADE outcomes were not reported: serious neonatal morbidity or perinatal death, and serious maternal morbidity or death. Double-balloon catheter versus vaginal PGE2 (one trial, subgroup of 26 women): no clear difference in caesarean section (RR 0.97, 95% CI 0.41 to 2.32, evidence graded very low). Vaginal delivery not achieved within 24 hours, uterine hyperstimulation with fetal heart rate changes, serious neonatal morbidity or perinatal death, and serious maternal morbidity or death were not reported. Oral mifepristone versus Foley catheter (one trial, 107 women): no primary/GRADE outcomes were reported. Fewer women induced with mifepristone required oxytocin augmentation (RR 0.54, 95% CI 0.38 to 0.76). There were slightly fewer cases of uterine rupture among women who received mifepristone, however this was not a clear difference between groups (RR 0.29, 95% CI 0.08 to 1.02). No other secondary outcomes were reported. Vaginal isosorbide mononitrate (IMN) versus Foley catheter (one trial, 80 women): fewer women induced with IMN achieved a vaginal delivery within 24 hours (RR 2.62, 95% CI 1.32 to 5.21, evidence graded low). There was no difference between groups in the number of women who had a caesarean section (RR 1.00, 95% CI 0.39 to 2.59, evidence graded very low). More women induced with IMN required oxytocin augmentation (RR 1.65, 95% CI 1.17 to 2.32). There were no clear differences in the other reported secondary outcomes. The following GRADE outcomes were not reported: uterine hyperstimulation with fetal heart rate changes, serious neonatal morbidity or perinatal death, and serious maternal morbidity or death. 80 mL versus 30 mL Foley catheter (one trial, 154 women): no clear difference between groups for the primary outcomes: vaginal delivery not achieved within 24 hours (RR 1.05, 95% CI 0.91 to 1.20, evidence graded moderate) and caesarean section (RR 1.05, 95% CI 0.89 to 1.24, evidence graded moderate). However, more women induced using a 30 mL Foley catheter required oxytocin augmentation (RR 0.81, 95% CI 0.66 to 0.98). There were no clear differences between groups for other secondary outcomes reported. Several GRADE outcomes were not reported: uterine hyperstimulation with fetal heart rate changes, serious neonatal morbidity or perinatal death, and serious maternal morbidity or death. Vaginal PGE2 pessary versus vaginal PGE2 tablet (one trial, 200 women): no difference between groups for caesarean section (RR 1.09, 95% CI 0.74 to 1.60, evidence graded very low), or any of the reported secondary outcomes. Several GRADE outcomes were not reported: vaginal delivery not achieved within 24 hours, uterine hyperstimulation with fetal heart rate changes, serious neonatal morbidity or perinatal death, and serious maternal morbidity or death. AUTHORS' CONCLUSIONS: RCT evidence on methods of induction of labour for women with a prior caesarean section is inadequate, and studies are underpowered to detect clinically relevant differences for many outcomes. Several studies reported few of our prespecified outcomes and reporting of infant outcomes was especially scarce. The GRADE level for quality of evidence was moderate to very low, due to imprecision and study design limitations.High-quality, adequately-powered RCTs would be the best approach to determine the optimal method for induction of labour in women with a prior caesarean birth. However, such trials are unlikely to be undertaken due to the very large numbers needed to investigate the risk of infrequent but serious adverse outcomes (e.g. uterine rupture). Observational studies (cohort studies), including different methods of cervical ripening, may be the best alternative. Studies could compare methods believed to provide effective induction of labour with low risk of serious harm, and report the outcomes listed in this review.