Editor’s Choice


More innovations at BJOG

When our journal started in 1902, articles were commonly written in a conversational style, often in the first person. They frequently contained interesting details that would now be regarded as irrelevant, such as ‘I had the idea for this study as I was walking down the corridor at the hospital talking to Mr …’. This made them very readable. However, as the ‘publish or perish’ ethos steadily took hold during the past half-century, the number of submissions to journals rose and the pressure on page space increased. Accordingly, articles became long on data but short on chat. Many scientific journals became increasingly dry and more of an archive than a newspaper. It became more important for an article to be cited by fellow researchers than for it to be read by the clinical or scientific community at large (academics needed to demonstrate that their articles had a high citation index if they were to gain promotion). Changes in the research environment and the growth of electronic publishing over the past 10 years appear set to change things once again. There has been a major increase in controls on clinical research, including the need for approval from institutional ethics and research and development committees, medico-legal indemnity, full economic costing, and the European clinical trials directive requiring projects to be sponsored. The process of applying for grant funding has become increasingly complex, probably in an attempt to control demand for decreasing resources. These constraints are resulting in a diminution of the ‘own account research’ that had formerly comprised a considerable proportion of published studies in obstetrics and gynaecology. Pharmaceutical companies, which fund so much research in the rest of medicine, are reluctant to invest in product development in such a medico-legally risky specialty as maternity care. Moreover, in a parallel development, most active researchers now access the literature via electronic media, particularly the internet and PubMed coupled with publishers’ websites, rather than by reference to the printed page. Accordingly, we are seeing a gradual divergence in the content of the printed journal and the web-based archive. Journals are increasingly carrying a higher proportion of editorial material and a lower number of original articles. On the other hand, the web-based archive is increasingly expanding to include additional material such as extra figures or tables, original data, PowerPoint slides, and even interviews with the authors and other relevant authorities. This month’s BJOG illustrates these trends. In future, we will be publishing slightly fewer articles but supplementing them with more editorial material (representing ‘added value’ in the printed journal). Since I have become editor-in-chief I have been very impressed by the quality of many of the reports on submitted articles provided to us by referees and editors. I consider that more of these deserve to be shared with our readers, and this month, we have on page 985 an editorial by Doug Tincello commenting on three articles assessing open colposuspension, on page 988 a commentary by editor Patrick Chien on a case report of laparoscopically assisted correction of uterine inversion, and on page 989 a commentary by referee Andrew Carlin and co-author Zarko Alfirevic on an article reporting a study of the haemodynamics of pregnancy. We hope that these commentaries will be interesting in their own right and enhance readers’ ability to interpret the articles to which they refer. In another ‘first’ for BJOG, the web version of the case report on uterine inversion by Vijayaraghavan and Sujatha on page 1100 contains a fascinating web-streamed video, which can be viewed using Windows media player. It shows the laparoscopic view of a uterine inversion being corrected, which will be particularly useful for teaching.

Is there still a place for open colposuspension?

As I have mentioned before in my editor’s choice, we need to be aware of the element of fashion in the surgeon’s choice of procedure for any particular condition. New procedures that involve advanced technology can sometimes take over from well established but ‘boringly straightforward’ techniques before their evidence base is established. When I was still doing general gynaecology, open colposuspension was one of my favourite operations because it was straightforward to perform and appeared to produce good results. It was overtaken by laparoscopic techniques which offer the benefits of shorter inpatient stay, although the extended learning curve and the length of the procedures sometimes lead to them being called ‘foreveroscopies’ by the medical students. On page 985, one of our editors, Doug Tincello, reviews three articles in this issue (see pages 999, 1007, 1014) that show that in terms of outcome, the two techniques are equivalent but that the laparoscopic approach is more cost effective. Given that both techniques have been largely supplanted by the use of tension-free tape and mesh insertion, does this mean that such comparisons are no longer important? Tincello does not think so, arguing that we now need equivalent data on the newer techniques. If the use of tape or mesh turns out to have unforeseen long-term complications, we may yet need to go back to laparoscopic colposuspension as the treatment of choice.

Prognosis for the co-twin following single-twin death

My researches into the components contributing to the impact factor of journals have highlighted the popularity of reviews. Indeed, many journals that are now ‘top of the Pops’ are largely or entirely review based. However, as Ong et al. point out on page 992, there are reviews and reviews. The traditional review has been written either by a senior clinician who marshals the evidence to support a particular point of view or by a junior researcher who lists a series of articles on a topic, often with little attempt to synthesise a coherent theme. Recent years have seen the development of ‘systematic reviews’ into what might almost be called an industry. Sometimes called ‘research into research’, systematic reviews have developed a specific methodology to capture and integrate information scattered throughout the literature. This can make them daunting to read. However, when carried out with a very specific objective, done by experts, and written clearly and concisely, they can inform practice with a level of reliability not otherwise available. For anyone not familiar with systematic reviews, the article by Ong et al. is a good place to start. They conclude that following the death of one twin after 14 weeks of gestation, the remaining monochorionic twin has a 12% risk of demise and survivors have an 18% risk of neurological abnormality. This compares with 4 and 1%, respectively, for dichorionic twins. This highlights the much higher complication rate in monochorionic twins. However, the preterm birth rates were not so different, 68 and 57%, respectively. These data are very valuable for counselling. We would like to publish more such systematic reviews, so if any reader has one completed or in process, we would be delighted to see it. My only concern is that we should continue to do enough ‘original’ research to keep the systematic reviewers of the future occupied.

Scientific assessment of the ‘hot water bottle’ effect on pelvic pain

Most of us will be familiar with the soothing effects of heat applied to the skin, which taken to extremes leads to the appearance of ‘erythema ab igne’. But does it have a place in gynaecology? Bertalanffy et al. on page 1031 have investigated the use of an electric heating blanket for the emergency treatment of pelvic pain. They concluded that its use halves the amount of pain experienced while women are being transferred to hospital. They suggest that this might have important medical benefits in reducing stress and thus improving the patient’s condition on arrival at hospital.

The value of fetal pulse oximetry in labour

I have always been sceptical about the value of pulse oximetry in labour because it represents assessment of a stressor (low oxygen tension) rather than a response to stress. Because babies vary enormously in their ability to withstand intrapartum stress (growth-restricted babies being, for example, much more susceptible to the harmful effects of hypoxia than well-grown babies), I have viewed measures of fetal response (such as the development of acidosis) as more likely to indicate the ability of the fetus to cope with the effects of labour. The recently reported FOREMOST trial (East et al. Am J Obstet Gynecol 2006;194:606.e1–16) appeared to support the use of pulse oximetry because they reported a reduction in the incidence of operative delivery for nonreassuring fetal status from 32.2 to 24.9% associated with its use in a randomised trial. However, the incidence of operative delivery for dystocia was increased from 15.6 to 24.3%, resulting in no overall significant difference in the incidence of operative delivery (including other indications as well, 70.8 versus 73.4%), nor was there any difference in neonatal condition between the two groups. However, East et al. on page 1080 of this issue have put forward the thesis that the reduction in operative delivery for nonreassuring fetal status has an economic impact, saving 813 Australian dollars per operative delivery. This conclusion relies on their argument that the increase in operative delivery for dystocia is an independent finding unrelated to their primary hypothesis of a reduction in operative delivery for fetal indications and that therefore correcting for the increased cost of delivery for dystocia would be an inappropriate post hoc analysis. Read the article on page 1080 and see if you agree with them.

Putting the Staphylococcus to good use

All of us are familiar with the ubiquitous Staphylococcus aureus, especially its variety that is multiresistant to antibiotics. On page 1039, Aggarwal and Prabha report that the vaginal instillation of a sperm-agglutinating factor derived from Staphylococcus aureus had a 100% contraceptive efficacy without having any measurable effect on the vaginal epithelium. Where did this factor come from? It was derived from a strain of Staphylococcus aureus isolated from the cervix of a woman in Chandigarh, India, who had unexplained infertility. The concept that it was this particular strain of Staphylococcus aureus that was causing her problem is a remarkable leap of intuition, and the finding of 100% contraceptive efficacy when the sperm-agglutinating factor was instilled in the vagina is a remarkable result. However, before we get too excited, we need to remember that this result was obtained from studies in 36 female mice, only eight of which were treated and allowed to be impregnated. Referees and editors considering this article were concerned that publishing at such a preliminary stage might be misleading. However, clearly this is an approach that needs to be validated in further tests not only by the primary investigators but also by other research groups; therefore, we thought that publishing the article at this stage could encourage the process of further evaluation. Some surprising reports in the past have turned out to be less exciting than thought at the time, for example, we now know that the cause of pre-eclampsia is not worms in the placenta. However, who would have thought that the gastric and duodenal ulcers that we all knew were due to hypersecretion of hydrochloric acid were actually due to the effects of a bacterium, Helicobacter pylori? It is a good job that at least one person did.