Background: : Alterations in waveforms in the uterine artery are associated with the development of pre-eclampsia and intrauterine growth restriction. We investigated the predictive accuracy of all uterine artery Doppler indices for both conditions in the first and second trimesters. Methods: :We identified relevant studies through searches of MEDLINE, EMBASE, the Cochrane Library and Medion databases (all records to April 2006) and by checking bibliographies of identified studies and consulting with experts. Four of us independently selected studies, extracted data and assessed study validity. We performed a bivariable meta-analysis of sensitivity and specificity and calculated likelihood ratios. Results:We identified 74 studies of pre-eclampsia (total 79 547 patients) and 61 studies of intrauterine growth restriction (total 41 131 patients). Uterine artery Doppler ultrasonography provided a more accurate prediction when performed in the second trimester than in the first-trimester. Most Doppler indices had poor predictive characteristics, but this varied with patient risk and outcome severity. An increased pulsatility index with notching was the best predictor of pre-eclampsia (positive likelihood ratio 21.0 among high-risk patients and 7.5 among low-risk patients). It was also the best predictor of overall (positive likelihood ratio 9.1) and severe (positive likelihood ratio 14.6) intrauterine growth restriction among low-risk patients.Interpretation: Abnormal uterine artery waveforms are a better predictor of pre-eclampsia than of intrauterine growth restriction. A pulsatility index, alone or combined with notching, is the most predictive Doppler index. These indices should be used in clinical practice. Future research should also concentrate on combining uterine artery Doppler ultrasonography with other tests. Abstract CMAJ 2008;178(6):701-11From the Departments of General Practice (Cnossen, ter Riet, Bindels), of Obstetrics and Gynaecology (Cnossen, Mol, van der Post) and
return on a separate occasion for the hepatitis B immunisation. Defaulting did not seem to be a contributing factor to the sharp drop off of hepatitis B vaccine coverage beyond the first dose. Abstract Objective-To establish whether there is evidence of the efficacy of homoeopathy from controlled trials in humans.Design-Criteria based meta-analysis. Assessment of the methodological quality of 107 controlled trials in 96 published reports found after an extensive search. Trials were scored using a list of predefined criteria of good methodology, and the outcome of the trials was interpreted in relation to their quality.Setting-Controlled trials published world wide. Main outcome measures-Results of the trials with the best methodological quality. Trials of classical homoeopathy and several modern varieties were considered separately.Results-In 14 trials some form of classical homoeopathy was tested and in 58 trials the same single homoeopathic treatment was given to patients with comparable conventional diagnoses. Combinations of several homoeopathic treatments were tested in 26 trials; isopathy was tested in nine trials. Most trials seemed to be of very low quality, but there were many exceptions. The results showed a positive trend regardless of the quality of the trial or the variety of homoeopathy used. Overall, of the 105 trials with interpretable results, 81 trials indicated positive results whereas in 24 trials no positive effects of homoeopathy were found. The results of the review may be complicated by publication bias, especially in such a controversial subject as homoeopathy.Conclusions-At the moment the evidence of clinical trials is positive but not sufficient to draw definitive conclusions because most trials are of low methodological quality and because of the unknown role of publication bias. This indicates that there is a legitimate case for further evaluation of homoeopathy, but only by means of well performed trials. IntroductionA survey of 293 general practitioners in The Netherlands showed that 45% of them think that homoeopathic remedies are efficacious in treating upper respiratory tract infections or hay fever.' On the other hand, many doctors do not believe that homoeopathy is an efficacious treatment as it is highly implausible that infinitesimally diluted substances retain their biological effects. It is also often stated that homoeopathy has not been evaluated using modern methods -that is, controlled trials. The first argument may be true, but the second is certainly not true. Reading an article about pollen C30 in hay fever increased our interest in homoeopathy.2 We could not believe the positive result (was it coincidence?) and therefore we started to search for further reports. Here we present 107 controlled trials of homoeopathy.Homoeopathic medicine is a system developed by Samuel Hahnemann from the similia concept: "similia similibus curantur." This implies that a diluted, "potentised" agent, which (when undiluted) in healthy 316 BMJ VOLUME 302 9 FEBRUARY 1991
Background: General Practitioners spend a disproportionate amount of time on frequent attenders. So far, trials on the effect of interventions on frequent attenders have shown negative results. However, these trials were conducted in short-term frequent attenders. It would be more reasonable to target intervention at persistent frequent attenders. Typical characteristics of persistent frequent attenders, as opposed to 1-year frequent attenders and non-frequent attenders, may generate hypotheses regarding modifiable factors on which new randomized trials may be designed.
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