Effect of routine first-trimester combined screening for pre-eclampsia on small-for-gestational-age birth: secondary interrupted time series analysis.

OBJECTIVE: To evaluate the impact of a first-trimester combined screening program for pre-eclampsia, based on the Fetal Medicine Foundation (FMF) algorithm, on the rate of small-for-gestational age (SGA) at birth and adverse pregnancy outcome. METHODS: This was a retrospective cohort study of data obtained from a London tertiary hospital between January 2017 and March 2019. The data were derived from a secondary analysis of the cohort evaluated in a clinical-effectiveness study on the implementation of a first-trimester screening program for pre-eclampsia. The cohort included 7720 women screened according to the UK National Institute for Health and Care Excellence (NICE) risk-based approach and 4841 women screened by the FMF multimodal approach, which combines maternal risk factors, blood pressure, pregnancy-associated plasma protein-A and uterine artery Doppler indices. The care package for the FMF-screened group included 150-mg aspirin prophylaxis, ultrasound scans at 28 and 36 weeks' gestation and scheduled delivery at 40 weeks. Outcome measures included the rates of SGA neonates at birth, admission to the neonatal unit, intrauterine demise, neonatal death and hypoxic-ischemic encephalopathy assessed by interrupted time series analysis (ITSA). RESULTS: There was no significant difference in the rates of intrauterine demise, neonatal death and hypoxic-ischemic encephalopathy between the FMF-screened and NICE-screened cohorts. ITSA showed a significant reduction in the rate of term SGA birth < 10th percentile at 21 months following implementation of the FMF screening program, with a relative effect reduction of 45.1% (P = 0.004). However, there was no significant relative effect reduction in term SGA birth < 5th or < 3rd percentile. CONCLUSIONS: First-trimester combined screening for pre-eclampsia based on the FMF algorithm accompanied by a care package including serial ultrasound scans for growth evaluation and elective birth from 40 weeks' gestation resulted in a significant 45% relative effect reduction in term SGA birth < 10th percentile but did not affect term SGA birth < 5th or < 3rd percentile. Further screening strategies to detect and improve the outcome of cases with SGA birth < 5th percentile need to be considered. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Implementation of routine first trimester combined screening for pre-eclampsia: a clinical effectiveness study.

OBJECTIVE: Evaluate clinical effectiveness of the first trimester combined (FMF) pre-eclampsia screening programme when implemented in a public healthcare setting. DESIGN: Retrospective cohort study. SETTING: London tertiary hospital from January 2017 to March 2019. METHODS: 7720 women screened for pre-eclampsia according to National Institute for Health and Care Excellence (NICE) risk-based guidance and 4841 by the Fetal Medical Foundation (FMF) algorithm which combined maternal risk factors, blood pressure, PAPP-A and uterine artery Doppler indices in the first trimester. High risk was defined by standard NICE criteria in the pre-intervention cohort (prescribed 75 mg aspirin) or a risk of ≥1:50 for preterm pre-eclampsia from the FMF algorithm in the post-intervention cohort (prescribed 150 mg aspirin). MAIN OUTCOME MEASURES: Screening effectiveness, rates of pre-eclampsia. RESULTS: The FMF screening programme resulted in a significant reduction in the screen-positive rate (16.1 versus 8.2%, odds ratio [OR] 0.50, 95% confidence interval [CI] 0.41-0.53) with a concurrent increase in targeted aspirin use in women classified as high risk for pre-eclampsia (28.9 versus 99.0%, OR 241.6, 95% CI 89.6-652.0). Screening indices were uniformly improved for the FMF algorithm with receiver operating characteristic (ROC) analysis demonstrating excellent discrimination for preterm pre-eclampsia (area under the curve [AUC] = 0.846, 95% CI 0.778-0.915, P value <.001). Interrupted time series analysis showed that the FMF screening programme resulted in a significant 21-month relative effect reduction of 80% (P = .025) and 89% (P = .017), for preterm and early pre-eclampsia, respectively. CONCLUSIONS: First trimester combined screening for pre-eclampsia is both feasible and effective in a public healthcare setting. Such an approach results in a two-fold de-escalation of risk, doubling of pre-eclampsia detection, near total physician compliance of aspirin use and a significant reduction in the prevalence of preterm pre-eclampsia. TWEETABLE ABSTRACT: Implementation of 1st trimester combined pre-eclampsia screening effectively reduces prevalence of the disorder.

Evaluación del uso adecuado de la laparoscopia hepatobiliar en la colelitiasis sintomática / Assessing the appropriate use of hepatobiliary laparoscopy in symptomatic chol elithiasis

ANTECEDENTES. La colelitiasis es una de las patologías más frecuentes del tubo digestivo. A pesar de los ensayos clínicos realizados que comparan las técnicas de colecistectomía abierta o laparoscópica, falta una lista de indicaciones para los diferentes perfiles de pacientes. Desde la introducción de la cirugía laparoscópica se ha abierto un amplio abanico de indicaciones para este procedimiento. El objetivo de este estudio fue desarrollar estándares de uso adecuado de la cirugía laparoscópica en pacientes con colelitiasis. MÉTODO. Se siguió el método RAND para elaborar criterios de uso adecuado de la laparoscopia hepatobiliar en la colelitiasis sintomática. Un panel de 7 expertos puntuó el grado de uso adecuado de cada indicación en una escala de 1 (muy inadecuado) a 9 (muy adecuado). Las puntuaciones se realizaron dos veces, en la primera ronda, de forma independiente por cada experto, y en la segunda ronda, durante una reunión presencial. Según la mediana de las puntuaciones de los panelistas y su nivel de acuerdo, cada indicación se clasificó como adecuada, dudosa o inadecuada. RESULTADOS. Los expertos señalaron que para la cirugía laparotómica, 2 indicaciones (12,5%) fueron consideradas adecuadas, 12 (75%) dudosas y 2 (12,5%) inadecuadas; mientras que para la cirugía laparoscópica, 9 indicaciones (56,25%) fueron consideradas adecuadas, 3 (18,75%) dudosas y 4 (25%) inadecuadas. CONCLUSIONES. Todavía hay incertidumbre con respecto a la gestión de la colelitiasis, mostrando la necesidad de una mayor investigación. La metodología RAM ayuda a dilucidar la adecuación de las diferentes opciones de tratamiento en situaciones clínicas específicas (AU)

BACKGROUND. Cholelithiasis is one of the most common diseases of the digestive tract. Despite clinical trials comparing the techniques of laparotomy or laparoscopic cholecystectomy, there is a lack of a list of indications for different patient profiles. Since the introduction of laparoscopic surgery, a wide range of indications for this procedure have been started. The aim ofthis study was to develop standards for the appropriate use of laparoscopic surgery in patients with cholelithiasis. METHOD. We conducted a study following the RAND appropriateness method (RAM) to develop criteria for hepatobiliary laparoscopy in symptomatic cholelithiasis. A panel comprised of 7 experts rated the appropriateness of a set of indications, from 1 (very inappropriate) to 9 (very appropriate). The panelists performed ratings in 2 rounds. The first round was performed independently by every expert. The second round took place during a face-to-face meeting. According to the median ratings and agreement criteria, every indication was classified as appropriate, uncertain, or inappropriate. RESULTS. The experts indicated that for the laparotomy surgery, 2 (12.5%) indications were judged as appropriate, 12 (75%) as uncertain, and 2 (12.5%) as inappropriate; while for laparoscopic surgery, 9 indications (56.25%) were considered as appropriate, 3 (18.75%) as uncertain, and 4 (25%) as inappropriate CONCLUSIONS. There is still uncertainty with respect to the management of cholelithiasis, showing the necessity of further investigation. The RAM helps to elucidate appropriateness for the different treatment options in specific clinical settings (AU)

Assessing the appropriate use of laparoscopic surgery for hepatobiliary diseases.

BACKGROUND: The range of indications for laparoscopic surgery has widened since it was first introduced. The aim of the present study was to develop standards for the appropriate use of laparoscopic surgery in patients with choledocholithiasis or cholelithiasis. METHOD: We conducted a study following the RAND appropriateness method (RAM) to develop criteria for hepatobiliary laparoscopy. A panel comprised of 7 experts rated the appropriateness of a set of indications, from 1 (very inappropriate) to 9 (very appropriate). The panelists performed ratings in 2 rounds. The first round was performed independently by every expert. The second round took place during a face-to-face meeting. According to the median of panelists' ratings and agreement criteria, every indication was classified as appropriate, uncertain, or inappropriate. RESULTS: In the first round, 112 (46.7%) indications were judged as appropriate, 102 (42.5%) as uncertain, and 26 (10.8%) as inappropriate. In the second round, 99 indications (48.5%) were considered as appropriate, 81 (39.7%) as uncertain, and 24 (11.8%) as inappropriate. Disagreement between panelists decreased in the second round compared with the first round. Thirteen indications were rated as disagreement (6.4%), 125 as uncertain (61.3%), and 66 as agreement (32.3%), while in the first round, the results and proportions were 44 (18.3%), 132 (55.0%), and 64 (26.7%), respectively. CONCLUSIONS: By using RAM, the panel was able to develop detailed explicit appropriateness criteria for the proper application of hepatobiliary laparoscopy. The criteria may be used prospectively to help in making clinical decisions or retrospectively to assess the overuse of clinical procedures.