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The Cochrane Database of Systematic... Feb 2012The admission cardiotocograph (CTG) is a commonly used screening test consisting of a short (usually 20 minutes) recording of the fetal heart rate (FHR) and uterine... (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
The admission cardiotocograph (CTG) is a commonly used screening test consisting of a short (usually 20 minutes) recording of the fetal heart rate (FHR) and uterine activity performed on the mother's admission to the labour ward.
OBJECTIVES
To compare the effects of admission CTG with intermittent auscultation of the FHR on maternal and infant outcomes for pregnant women without risk factors on their admission to the labour ward.
SEARCH METHODS
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (17 May 2011) (CENTRAL) (The Cochrane Library 2011 Issue 2 of 4), MEDLINE (1966 to 17 May 2011), CINAHL (1982 to 17 May 2011), Dissertation Abstracts (1980 to 17 May 2011) and the reference list of retrieved papers.
SELECTION CRITERIA
All randomised and quasi-randomised trials comparing admission CTG with intermittent auscultation of the FHR for pregnant women between 37 and 42 completed weeks of pregnancy and considered to be at low risk of intrapartum fetal hypoxia and of developing complications during labour.
DATA COLLECTION AND ANALYSIS
Two authors independently assessed trial eligibility and quality, and extracted data. Data were checked for accuracy.
MAIN RESULTS
We included four trials involving more than 13,000 women. All four studies included women in labour. Overall, the studies were at low risk of bias. Although not statistically significant using a strict P < 0.05 criterion, data are consistent with women allocated to admission CTG having, on average, a higher probability of an increase in incidence of caesarean section than women allocated to intermittent auscultation (risk ratio (RR) 1.20, 95% confidence interval (CI) 1.00 to 1.44, four trials, 11,338 women, T² = 0.00, I² = 0%). There was no significant difference in the average treatment effect across included trials between women allocated to admission CTG and women allocated to intermittent auscultation in instrumental vaginal birth (RR 1.10, 95% CI 0.95 to 1.27, four trials, 11,338 women, T² = 0.01, I² = 38%) and fetal and neonatal deaths (RR 1.01, 95% CI 0.30 to 3.47, four trials, 11339 infants, T² = 0.00, I² = 0%).Women allocated to admission CTG had, on average, significantly higher rates of continuous electronic fetal monitoring during labour (RR 1.30, 95% CI 1.14 to 1.48, three trials, 10,753 women, T² = 0.01, I² = 79%) and fetal blood sampling (RR 1.28, 95% CI 1.13 to 1.45, three trials, 10,757 women, T² = 0.00, I² = 0%) than women allocated to intermittent auscultation. There were no differences between groups in other secondary outcome measures.
AUTHORS' CONCLUSIONS
Contrary to continued use in some clinical areas, we found no evidence of benefit for the use of the admission cardiotocograph (CTG) for low-risk women on admission in labour.We found no evidence of benefit for the use of the admission CTG for low-risk women on admission in labour. Furthermore, the probability is that admission CTG increases the caesarean section rate by approximately 20%. The data lacked power to detect possible important differences in perinatal mortality. However, it is unlikely that any trial, or meta-analysis, will be adequately powered to detect such differences. The findings of this review support recommendations that the admission CTG not be used for women who are low risk on admission in labour. Women should be informed that admission CTG is likely associated with an increase in the incidence of caesarean section without evidence of benefit.
Topics: Adult; Cardiotocography; Diagnostic Tests, Routine; Echocardiography, Doppler; Female; Heart Auscultation; Heart Rate, Fetal; Humans; Labor, Obstetric; Pregnancy; Randomized Controlled Trials as Topic
PubMed: 22336808
DOI: 10.1002/14651858.CD005122.pub4 -
American Journal of Hypertension Nov 2011Screening for inter-arm difference (IAD) of blood pressure (BP) at each first visit is recommended by numerous guidelines whereas it is unclear whether the method by... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Screening for inter-arm difference (IAD) of blood pressure (BP) at each first visit is recommended by numerous guidelines whereas it is unclear whether the method by which IAD is measured has significant influence on the IAD value.
METHODS
A systematic review is made of the studies reporting on double-arm measurements and the association of IAD with procedure characteristics (Medline/PubMed, Embase, and Cochrane Library).
RESULTS
The mean absolute IAD was 5.4 ± 1.7 and 3.6 ± 1.2 mm Hg for systolic and diastolic BP, respectively. Of all subjects 14% had a systolic IAD ≥10 mm Hg, 4% a systolic IAD ≥20 mm Hg, and 7% a diastolic IAD ≥10 mm Hg. The relative risk (RR) of obtaining a systolic IAD ≥10 and 20 mm Hg and a diastolic IAD ≥10 mm Hg is higher when measuring sequentially instead of simultaneously (2.2 (95% CI: 1.4-3.6), P < 0.01; 4.8 (95% CI: 1.1-21.9), P < 0.05 and 2.5 (95% CI: 1.0-6.3) P < 0.05, respectively), when using a manual instead of an automated device (2.1 (95% CI: 1.1-3.9), P < 0.05; 4.4 (95% CI: 1.8-10.8), P < 0.01 and 3.7 (95% CI: 1.6-8.6), P < 0.01, respectively) and when performing only one BP measurement instead of multiple (2.0 (95% CI: 1.1-3.8), P < 0.05; 4.3 (95% CI: 1.6-11.4), P < 0.01 and 4.4 (95% CI: 1.7-11.4), P < 0.01, respectively).
CONCLUSION
Screening for IAD of BP is important but the measurement methodology has a major influence on IAD results. To prevent overestimation and observer bias IAD should be assessed simultaneously at both arms, with one or two automatic devices and multiple readings should be taken.
Topics: Adult; Aged; Arm; Auscultation; Automation; Blood Pressure Determination; Diastole; Female; Humans; Male; Middle Aged; Observer Variation; Oscillometry; Systole
PubMed: 21776035
DOI: 10.1038/ajh.2011.125 -
Respiratory Medicine Sep 2011The standardized use of a stethoscope for chest auscultation in clinical research is limited by its inherent inter-listener variability. Electronic auscultation and... (Meta-Analysis)
Meta-Analysis Review
RATIONALE
The standardized use of a stethoscope for chest auscultation in clinical research is limited by its inherent inter-listener variability. Electronic auscultation and automated classification of recorded lung sounds may help prevent some of these shortcomings.
OBJECTIVE
We sought to perform a systematic review and meta-analysis of studies implementing computerized lung sound analysis (CLSA) to aid in the detection of abnormal lung sounds for specific respiratory disorders.
METHODS
We searched for articles on CLSA in MEDLINE, EMBASE, Cochrane Library and ISI Web of Knowledge through July 31, 2010. Following qualitative review, we conducted a meta-analysis to estimate the sensitivity and specificity of CLSA for the detection of abnormal lung sounds.
MEASUREMENTS AND MAIN RESULTS
Of 208 articles identified, we selected eight studies for review. Most studies employed either electret microphones or piezoelectric sensors for auscultation, and Fourier Transform and Neural Network algorithms for analysis and automated classification of lung sounds. Overall sensitivity for the detection of wheezes or crackles using CLSA was 80% (95% CI 72-86%) and specificity was 85% (95% CI 78-91%).
CONCLUSIONS
While quality data on CLSA are relatively limited, analysis of existing information suggests that CLSA can provide a relatively high specificity for detecting abnormal lung sounds such as crackles and wheezes. Further research and product development could promote the value of CLSA in research studies or its diagnostic utility in clinical settings.
Topics: Auscultation; Diagnosis, Computer-Assisted; Humans; Lung Diseases; Respiratory Sounds; Sensitivity and Specificity; Signal Processing, Computer-Assisted; Stethoscopes
PubMed: 21676606
DOI: 10.1016/j.rmed.2011.05.007 -
Indian Pediatrics Mar 2011Scaling up of evidence based management of childhood acute respiratory infection/pneumonia, is a public health priority in India, and necessitates robust literature... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Scaling up of evidence based management of childhood acute respiratory infection/pneumonia, is a public health priority in India, and necessitates robust literature review, for advocacy and action.
OBJECTIVE
To identify, synthesize and summarize current evidence to guide scaling up of management of childhood acute respiratory infection/pneumonia in India, and identify existing knowledge gaps.
METHODS
A set of ten questions pertaining to the management (prevention, treatment, and control) of childhood ARI/pneumonia was identified through a consultative process. A modified systematic review process developed a priori was used to identify, synthesize and summarize, research evidence and operational information, pertaining to the problem in India. Areas with limited or no evidence were identified as knowledge gaps.
RESULTS
Childhood ARI/pneumonia is a significant public health problem in India, although robust epidemiological data is not available on its incidence. Mortality due to pneumonia accounts for approximately one-fourth of the total deaths in under five children, in India. Pneumonia affects children irrespective of socioeconomic status; with higher risk among young infants, malnourished children, non-exclusively breastfed children and those with exposure to solid fuel use. There is lack of robust nation-wide data on etiology; bacteria (including Pneumococcus, H. influenzae, S. aureus and Gram negative bacilli), viruses (especially RSV) and Mycoplasma, are the common organisms identified. In-vitro resistance to cotrimoxazole is high. Wheezing is commonly associated with ARI/pneumonia in children, but difficult to appreciate without auscultation. The current WHO guidelines as modified by IndiaCLEN Task force on Penumonia (2010), are sufficient for case-management of childhood pneumonia. Other important interventions to prevent mortality are oxygen therapy for those with severe or very severe pneumonia and measles vaccination for all infants. There is insufficient evidence for protective or curative effect of vitamin A; zinc supplementation could be beneficial to prevent pneumonia, although it has no therapeutic benefit. There is insufficient evidence on potential effectiveness and cost-effectiveness of Hib and Pneumococcal vaccines on reduction of ARI specific mortality. Case-finding and community-based management are effective management strategies, but have low coverage in India due to policy and programmatic barriers. There is a significant gap in the utilization of existing services, provider practices as well as family practices in seeking care.
CONCLUSION
The systematic review summarizes current evidence on childhood ARI and pneumonia management and provides evidence to inform child health programs in India.
Topics: Acute Disease; Child; Child Advocacy; Child, Preschool; Disease Management; Humans; India; Infant; Infant, Newborn; Pneumonia; Respiratory Tract Infections
PubMed: 21478555
DOI: 10.1007/s13312-011-0051-8 -
The International Journal of... Mar 2011To assess the accuracy of clinical symptoms and signs in predicting hypoxaemia among young children with acute respiratory infection (ARI). (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To assess the accuracy of clinical symptoms and signs in predicting hypoxaemia among young children with acute respiratory infection (ARI).
METHODS
We conducted a systematic review and meta-analysis of prospective diagnostic studies that evaluated the accuracy of individual or combined clinical symptoms and signs in predicting hypoxaemia among children aged <5 years with ARI. MEDLINE® was searched for articles published between 1950 and March 2010. Measurement of arterial haemoglobin oxygen saturation by pulse oximetry was used as reference standard. The hierarchical summary receiver operating characteristic model for meta-analyses was applied.
RESULTS
Eleven diagnostic studies with 5787 patients were included in the review. There was substantial variation in sensitivity and specificity between different symptoms and signs as well as across studies. Cyanosis, inability to feed, head nodding, respiratory rate > 70/min and unresponsiveness/impaired rousability had high specificity but low sensitivity. In contrast, reported rapid breathing and crepitations in lung auscultation had relatively high sensitivity but low specificity. Five models of a combination of symptoms and signs presented moderate sensitivity (range 0.60-0.84) and specificity (range 0.63-0.82).
CONCLUSIONS
Neither single nor combined symptoms and signs have satisfactory performance in predicting hypoxaemia among young children with ARI. Improved access to pulse oximetry is needed in developing countries.
Topics: Acute Disease; Child, Preschool; Hemoglobins; Humans; Hypoxia; Infant; Infant, Newborn; Models, Statistical; Oximetry; Oxygen; ROC Curve; Respiratory Tract Infections; Sensitivity and Specificity
PubMed: 21333097
DOI: No ID Found -
The Cochrane Database of Systematic... Jul 2007Electronic fetal monitoring (EFM) is used in the management of labor and delivery in nearly three of four pregnancies in the United States. The apparent contradiction... (Review)
Review
BACKGROUND
Electronic fetal monitoring (EFM) is used in the management of labor and delivery in nearly three of four pregnancies in the United States. The apparent contradiction between the widespread use of EFM and expert recommendations to limit routine use indicates that a reassessment of this practice is warranted.
OBJECTIVES
To compare the efficacy and safety of routine continuous EFM during labor with intermittent auscultation, using the results of published randomized controlled trials (RCTs).
SEARCH STRATEGY
We identified RCTs by searching MEDLINE and the register maintained by the Cochrane Pregnancy and Childbirth Group, and by contacting experts, and reviewing published references. Date of last search: January 2001.
SELECTION CRITERIA
Randomized controlled trials.
DATA COLLECTION AND ANALYSIS
Data were abstracted by one of us, and their accuracy was confirmed independently by a second person. A single reviewer assessed study quality based on criteria developed by others for RCTs. Data reported from similar studies were used to calculate a combined risk estimate for each of eight outcomes.
MAIN RESULTS
Our search identified 13 published RCTs addressing the efficacy and safety of EFM; no unpublished studies were found. Four trials that did not fulfil our selection criteria were excluded. The remaining nine trials included 18,561 pregnant women and their 18,695 infants in both high- and low-risk pregnancies from seven clinical centers in the United States, Europe, and Australia. Overall, a statistically significant decrease was associated with routine EFM for neonatal seizures (relative risk (RR) 0.51, 95% confidence interval (CI) 0.32-0.82). The protective effect for neonatal seizures was only evident in studies with high-quality scores. No significant differences were observed in 1-minute Apgar scores below four or seven, rate of admissions to neonatal intensive care units, perinatal deaths or cerebral palsy. An increase associated with the use of EFM was observed in the rate of cesarean delivery (RR 1.41, 95% CI 1.23-1.61) and operative vaginal delivery (RR 1.20, 95% CI 1.11-1.30).
AUTHORS' CONCLUSIONS
The only clinically significant benefit from the use of routine continuous EFM was in the reduction of neonatal seizures. In view of the increase in cesarean and operative vaginal delivery, the long-term benefit of this reduction must be evaluated in the decision reached jointly by the pregnant woman and her clinician to use continuous EFM or intermittent auscultation during labor.
Topics: Cardiotocography; Female; Humans; Infant, Newborn; Infant, Newborn, Diseases; Labor, Obstetric; Pregnancy; Randomized Controlled Trials as Topic; Seizures
PubMed: 17636581
DOI: 10.1002/14651858.CD000063.pub2 -
International Journal of Nursing Studies Aug 2007The aim of this review was to determine whether intrapartum admission cardiotocography (CTG) in women at low obstetric risk can improve neonatal outcome (in terms of... (Comparative Study)
Comparative Study Meta-Analysis Review
Admission cardiotocography versus intermittent auscultation of fetal heart rate: effects on neonatal Apgar score, on the rate of caesarean sections and on the rate of instrumental delivery--a systematic review.
OBJECTIVE
The aim of this review was to determine whether intrapartum admission cardiotocography (CTG) in women at low obstetric risk can improve neonatal outcome (in terms of Apgar score) and whether it is associated with an increase in the incidence of instrumental delivery and caesarean section.
REVIEW METHODS
The Cochrane Library, Medline (1966-November 2005), Embase (1980-November 2005) and the PubMed were searched for randomized control trials and systematic reviews of randomized control trials. Studies were assessed for quality. Outcomes considered the neonatal Apgar score at 5 min after delivery, caesarean section and instrumental delivery. A meta-analysis of the results of the randomized controlled trials was performed.
RESULTS
The pooled relative risk for having an Apgar score less than 7 points at 5 min after delivery was higher in the admission CTG group (RR 1.35, 95% CI 0.85-2.13) but it was not statistically significant. The pooled relative risks for having a caesarean section-delivery (RR 1.2 95% CI 1.00-1.41) and an instrumental delivery (RR 1.1 95% CI 1.00-1.18) were both higher in the admission CTG group. Both these were statistically significant.
CONCLUSION
Intrapartum admission cardiotocography in women at low obstetric risk increases the risk of caesarean section and instrumental delivery. In addition, there is no evidence for neonatal benefit in terms of Apgar score at 5 min after delivery. A larger sample size would be needed in order to answer this important question.
Topics: Apgar Score; Auscultation; Cardiotocography; Cesarean Section; Extraction, Obstetrical; Female; Humans; Infant, Newborn; Patient Admission; Pregnancy; Randomized Controlled Trials as Topic; Risk
PubMed: 16919279
DOI: 10.1016/j.ijnurstu.2006.06.002 -
The Cochrane Database of Systematic... Jul 2006Cardiotocography (sometimes known as electronic fetal monitoring), records changes in the fetal heart rate and their temporal relationship to uterine contractions. The... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Cardiotocography (sometimes known as electronic fetal monitoring), records changes in the fetal heart rate and their temporal relationship to uterine contractions. The aim is to identify babies who may be short of oxygen (hypoxic), so additional assessments of fetal well-being may be used, or the baby delivered by caesarean section or instrumental vaginal birth.
OBJECTIVES
To evaluate the effectiveness of continuous cardiotocography during labour.
SEARCH STRATEGY
We searched the Cochrane Pregnancy and Childbirth Group Trials Register (March 2006), CENTRAL (The Cochrane Library 2005, Issue 4), MEDLINE (1966 to December 2005), EMBASE (1974 to December 2005), Dissertation Abstracts (1980 to December 2005) and the National Research Register (December 2005).
SELECTION CRITERIA
Randomised and quasi-randomised controlled trials involving a comparison of continuous cardiotocography (with and without fetal blood sampling) with (a) no fetal monitoring, (b) intermittent auscultation (c) intermittent cardiotocography.
DATA COLLECTION AND ANALYSIS
Two authors independently assessed eligibility, quality and extracted data.
MAIN RESULTS
Twelve trials were included (over 37,000 women); only two were high quality. Compared to intermittent auscultation, continuous cardiotocography showed no significant difference in overall perinatal death rate (relative risk (RR) 0.85, 95% confidence interval (CI) 0.59 to 1.23, n = 33,513, 11 trials), but was associated with a halving of neonatal seizures (RR 0.50, 95% CI 0.31 to 0.80, n = 32,386, nine trials) although no significant difference was detected in cerebral palsy (RR 1.74, 95% CI 0.97 to 3.11, n = 13,252, two trials). There was a significant increase in caesarean sections associated with continuous cardiotocography (RR 1.66, 95% CI 1.30 to 2.13, n =18,761, 10 trials). Women were also more likely to have an instrumental vaginal birth (RR 1.16, 95% CI 1.01 to 1.32, n = 18,151, nine trials). Data for subgroups of low-risk, high-risk, preterm pregnancies and high quality trials were consistent with overall results. Access to fetal blood sampling did not appear to influence the difference in neonatal seizures nor any other prespecified outcome.
AUTHORS' CONCLUSIONS
Continuous cardiotocography during labour is associated with a reduction in neonatal seizures, but no significant differences in cerebral palsy, infant mortality or other standard measures of neonatal well-being. However, continuous cardiotocography was associated with an increase in caesarean sections and instrumental vaginal births. The real challenge is how best to convey this uncertainty to women to enable them to make an informed choice without compromising the normality of labour.
Topics: Cardiotocography; Cesarean Section; Female; Heart Auscultation; Humans; Infant Mortality; Infant, Newborn; Labor, Obstetric; Pregnancy; Randomized Controlled Trials as Topic
PubMed: 16856111
DOI: 10.1002/14651858.CD006066 -
BJOG : An International Journal of... Dec 2005To assess the effectiveness of the labour admission test in preventing adverse outcomes, compared with auscultation only, and to assess the test's prognostic value in... (Comparative Study)
Comparative Study Review
OBJECTIVE
To assess the effectiveness of the labour admission test in preventing adverse outcomes, compared with auscultation only, and to assess the test's prognostic value in predicting adverse outcomes.
DESIGN
Systematic review.
SETTING
Labour wards in hospitals.
POPULATION
Pregnant women in labour. Three randomised controlled trials including 11,259 women and 11 observational studies including 5831 women.
METHODS
Literature searches in Medline, EMBASE, CINAHL, SweMed, The Cochrane Central Register of Controlled Trials, reference lists from identified studies and contact with experts.
MAIN OUTCOME MEASURES
Obstetric interventions (augmentation of labour, continuous electronic fetal monitoring, epidural analgesia, fetal blood sampling and operative deliveries) and neonatal outcomes (perinatal mortality, Apgar score, seizures, resuscitation and admission to neonatal unit).
RESULTS
Meta-analyses of the controlled trials found that women randomised to the labour admission test were more likely to have minor obstetric interventions like epidural analgesia [relative risk (RR) 1.2, 95% confidence interval (95% CI) 1.1-1.4], continuous electronic fetal monitoring (RR 1.3, 95% CI 1.2-1.5) and fetal blood sampling (RR 1.3, 95% CI 1.1-1.5) compared with women randomised to auscultation on admission. There were no significant differences in any of the other outcomes. From the observational studies, prognostic value for various outcomes was found to be generally poor. Likelihood ratio (LR) for a positive test was above 10 in 2 of 28 single outcomes and between 5 and 10 in six outcomes.
CONCLUSIONS
There is no evidence supporting that the labour admission test is beneficial in low risk women.
Topics: Auscultation; Diagnostic Tests, Routine; Female; Humans; Obstetric Labor Complications; Pregnancy; Pregnancy Outcome; Prenatal Diagnosis; Prognosis; Randomized Controlled Trials as Topic
PubMed: 16305561
DOI: 10.1111/j.1471-0528.2005.00766.x -
Seminars in Nephrology Nov 2004The benefits of antihypertensive therapy in pregnancy remain uncertain. Blood pressure control to prevent or correct severe hypertension can avert maternal target organ... (Review)
Review
The benefits of antihypertensive therapy in pregnancy remain uncertain. Blood pressure control to prevent or correct severe hypertension can avert maternal target organ damage and may allow obstetricians to prolong pregnancy or avoid hospitalization. Several factors limit the conclusions derived from systematic review of the available studies, including failure to distinguish among women with preeclampsia, gestational hypertension, or whose hypertension antedated pregnancy. As well, the application of consensus guidelines is limited by the unfortunate tendency to measure blood pressure by use of oscillometric devices rather than auscultation. We review the basis for using specific antihypertensive drugs in pregnancy and highlight important shortcomings in therapeutic knowledge that should be addressed in future studies.
Topics: Antihypertensive Agents; Female; Humans; Hypertension; Pregnancy; Pregnancy Complications, Cardiovascular
PubMed: 15529297
DOI: 10.1016/s0270-9295(04)00133-0