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• W4253313299 abstract "Coomarasamy and his colleagues from Birmingham have contributed some interesting ideas to the debate on the treatment of preterm labour (pages 1045–1049), but their methods are new to BJOG and doctors will want to read more before they alter practice. The members of the Birmingham group were interested in extracting information from trials to compare two tocolytics, nifedipine and atosiban. They soon discovered that although there had been no direct randomised comparisons, nine nifedipine and four atosiban trials had use β-agonists as the comparator. This, they argue, opens the way to an indirect comparison of the two drugs. If for example drug A was twice as effective as β-agonists, but drug B only 25% better, it seems reasonable to conclude, all else being equal, that A is better than B. However, we have to be careful when following our intuition in this sort of area. Just adding the endpoints from the two groups of trials would lose the benefits of the original randomisation. The correct method, which the Birmingham group followed, is to compare the pooled odds ratios from each set of trials. Their results suggest that nifedipine is more effective than atosiban in reducing respiratory distress syndrome, and that there is also a trend towards greater prolongation of gestation with nifedipine. Such results should be taken seriously. In other areas of medicine indirect comparison like this has later been shown to agree with the results of direct comparative randomised trials. However, in the present study, the nifedipine trials were of lower methodological quality and less likely to be blinded than the atosiban ones. As the authors acknowledge, both factors may have exaggerated the size of the nifedipine treatment effect. Many other details of trial design may also have influenced the results. For example, if rescue treatment with the alternative drug was instigated earlier in, say, the atosiban than the nifedipine trials, this would exaggerate the apparent size of the nifedipine treatment effect. I predict that we will hear more, both about these specific tocolytics and about indirect treatment comparisons in general. Many years ago, surgeons performing hysterectomy for benign conditions by the abdominal route usually left the cervix alone. The operation was easier, there was an idea that cervical secretions were involved in vaginal lubrication during sex and some even believed that retention of the cervix might prevent post-operative prolapse. However, when reports came in of continued bleeding or even cancer in the cervical stump, and sexologists like Masters and Johnson demonstrated that most sexual lubrication was a vaginal wall transudate, the operation of total hysterectomy, in which the cervix was removed with the uterine body, became the norm. Things changed again about 20 years ago when surgeons in Denmark revived the idea that leaving the cervical stump in situ might improve sexual function. Initial reports were susceptible to bias but there have now been some randomised trials of the two methods. We report the latest on pages 1088–1098. Like most previous trials, there were no important differences in sexual function between the operations but to the authors' surprise, urinary incontinence post-operatively was more common in the subtotal group. This is interesting and needs explaining, and undoubtedly a systematic review of the trials will soon appear, but in the meantime I doubt that it is sufficient to change practice. After all, no less than 20% of those allocated to the subtotal operation had continued vaginal bleeding, and eventually many of them are likely to demand that their cervix be removed. We do not normally report the baseline characteristics of patients in a randomised trial separately from the main trial results, but we have made an exception for women entered into the endometrial subprotocol arm of the Arimadex, Tamoxifen Alone or in Combination (ATAC) study (Duffy et al. pages 1099–1106;). This trial compares two anti-oestrogens for the adjuvant treatment of breast cancer, and participants underwent endometrial biopsy and hysteroscopy as part of the pretrial assessment. Although they had recently diagnosed breast cancer, the women had no specific gynaecological symptoms, and the study therefore provides an accurate measure of the range of endometrial pathology in asymptomatic women. Only 82% of participants had a completely ‘normal’ endometrial cavity. Either endometrial pathology is underdiagnosed or more likely, some so-called ‘abnormalities’ are common in asymptomatic women and should be reclassified as normal. Many women attribute stress incontinence after delivery to the trauma of the birth process. However, when Dolan and colleagues from Manchester (pages 1107–1114) followed up a series of women, who had been originally studied during their first pregnancy 15 years earlier, they found that the only group with a significantly raised prevalence of stress incontinence was those who had had stress incontinence antenatally. Among that group, the risk was substantial, two-thirds had developed stress incontinence. Surprisingly, postnatal stress incontinence, which could be related to difficult vaginal delivery, was not associated with the same problem 15 years later. Nor was there a relationship with birthweight, parity, length of the second stage of labour or even nerve damage as measured by motor unit potential duration. We should not rush to blame birth trauma for stress incontinence. Some other pregnancy-related factor might be a more important cause." @default.
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• W4253313299 date "2003-05-01" @default.
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• W4253313299 title "Editor's Choice" @default.
• W4253313299 doi "https://doi.org/10.1046/j.1471-0528.2003.51107.x" @default.
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