Professor Ian Symonds

Objective: To investigate whether use of ST analysis of the fetal electrocardiogram (STan) as an adjunct to continuous cardiotocography (CTG) reduces the rate of emergency Cesarean section (EmCS) compared with CTG alone. Methods: This was a randomized controlled trial of patients with a singleton fetus in cephalic presentation at = 36 weeks' gestation, requiring continuous electronic fetal monitoring during labor at a tertiary maternity hospital in Adelaide, Australia, between January 2018 and July 2021. Participants were randomized to undergo CTG + STan or CTG alone. The calculated sample size was 1818 participants. The primary outcome was EmCS. Secondary outcomes included metabolic acidosis, a composite adverse perinatal outcome, and other maternal and neonatal morbidity and safety outcomes. Results: The present study enrolled 970 women, of whom 967 were included in the primary analysis. EmCS occurred in 107/482 (22.2%) deliveries in the CTG + STan arm and in 107/485 (22.1%) in the CTG arm (adjusted relative risk, 1.02 (95% CI, 0.81¿1.27); P = 0.89). There was no difference in the rate of adverse maternal or neonatal outcomes between arms. Conclusions: The addition of STan as an adjunct to continuous CTG did not reduce the EmCS rate. The smaller-than-anticipated sample size meant that this study was underpowered to detect absolute differences of = 5% and, therefore, this negative finding could be due to a Type-2 error. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Machine learning may assist in medical student evaluation. This study involved scoring short answer questions administered at three centres. Bidirectional encoder representations from transformers were particularly effective for professionalism question scoring (accuracy ranging from 41.6% to 92.5%). In the scoring of 3-mark professionalism questions, as compared with clinical questions, machine learning had a lower classification accuracy (P < 0.05). The role of machine learning in medical professionalism evaluation warrants further investigation.

To utilise effectively tools that employ machine learning (ML) in clinical practice medical students and doctors will require a degree of understanding of ML models. To evaluate current levels of understanding, a formative examination and survey was conducted across three centres in Australia, New Zealand and the United States. Of the 245 individuals who participated in the study (response rate¿=¿45.4%), the majority had difficulty with identifying weaknesses in model performance analysis. Further studies examining educational interventions addressing such ML topics are warranted.

Issue addressed: The aim of this study was to assess potential barriers to the implementation of clinical guideline recommendations regarding maternal alcohol consumption by antenatal clinicians and managers. Methods: Cross-sectional surveys of antenatal clinicians and managers employed in a New South Wales Local Health District were undertaken. Survey items were developed based on 11 domains of the Theoretical Domains Framework. Consistent with previous studies, a cut point of less than 4 was applied to mean values of survey items (range: 1-5) to identify domains representing barriers to the implementation. Results: Thirty-three antenatal clinicians and eight managers completed the surveys. For clinicians, the domains with the lowest mean values included "environmental context and resources" (ie, complexity of appointments and availability of supporting systems) (mean: 3.13, SD: 0.93); "social influences" (ie, expectations of others that alcohol will be addressed) (mean: 3.33, SD: 0.68); "beliefs about capabilities" (ie, confidence in providing guideline recommendations) (mean: 3.51, SD: 0.67); and "behavioural regulation" (ie, planning and responding to feedback) (mean: 3.53, SD: 0.64). For managers, "emotion regulation" (ie, stress in managing change) (mean: 2.13, SD: 0.64) and "environmental context and resources" (ie, complexities of managing change) (mean: 3.13, SD: 0.83) were the lowest scoring domains. Conclusions: The antenatal service environment and availability of resources appear to be primary barriers to both clinicians and managers implementing guidelines for maternal alcohol consumption. So what?: In the development of interventions to support the delivery of clinical guideline recommendations addressing alcohol consumption during pregnancy, a broad range of potential barriers at both the clinician and manager levels need to be considered and targeted by effective implementation strategies.

Background: Ageing, socioeconomic level, obesity, fertility, relaxed natural selection and urbanization have been postulated as the risk factors of ovarian cancer (OC56). We sought to identify which factor plays the most significant role in predicting OC56 incidence rate worldwide. Methods: Bivariate correlation analysis was performed to assess the relationships between country-specific estimates of ageing (measured by life expectancy), GDP PPP (Purchasing power parity), obesity prevalence, fertility (indexed by the crude birth rate), opportunity for natural selection (Ibs) and urbanization. Partial correlation was used to compare contribution of different variables. Fisher A-to-Z was used to compare the correlation coefficients. Multiple linear regression (Enter and Stepwise) was conducted to identify significant determinants of OC56 incidence. ANOVA with post hoc Bonferroni analysis was performed to compare differences between the means of OC56 incidence rate and residuals of OC56 standardised on fertility and GDP respectively between the six WHO regions. Results: Bivariate analyses revealed that OC56 was significantly and strongly correlated to ageing, GDP, obesity, low fertility, Ibs and urbanization. However, partial correlation analysis identified that fertility and ageing were the only variables that had a significant correlation to OC56 incidence when the other five variables were kept statistically constant. Fisher A-to-Z revealed that OC56 had a significantly stronger correlation to low fertility than to ageing. Stepwise linear regression analysis only identified fertility as the significant predictor of OC56. ANOVA showed that, between the six WHO regions, multiple mean differences of OC56 incidence were significant, but all disappeared when the contributing effect of fertility on OC56 incidence rate was removed. Conclusions: Low fertility may be the most significant determining predictor of OC56 incidence worldwide.

Background: Detection and management of antenatal risk factors is critical for quality care. Aims: To determine (1) women's views about when they should be asked about antenatal health factors as recommended in the Australian antenatal guidelines; and (2) the time required to provide recommended care using a clinical scenario. Methods: In Phase 1, pregnant women attending an outpatient obstetrics clinic at a public hospital were surveyed about preferred screening for antenatal risk factors during visit(s). In Phase 2, a hypothetical clinical scenario of a woman attending her first antenatal visit with a practising midwife was video-recorded to extrapolate the time taken to ask about and offer assistance to manage clinical, screening and lifestyle risk factors. Findings: Most women (96%) perceived they should be asked about each of the risk factors at least once (i.e. at first visit). Total time taken to ask about all risk factors was 52 min. More time was spent discussing clinical (11 min) than lifestyle factors (4 min). Adjusting for the estimated prevalence of each risk factor, the time taken to offer assistance was 8 min per woman. Average time required for detecting and offering assistance to manage risk factors is 60 min per average risk woman. Conclusion: Women are willing to be asked about risk factors; however this process is time-consuming. Strategies to streamline visits and prioritise recommendations so time-efficient yet comprehensive care can be delivered are needed, particularly when factors require monitoring over time and for those who may be 'at-risk' for multiple factors.

Objectives: This study was designed to elucidate why students from backgrounds of lower socio-economic status (SES) and who may be first in their family (FIF) to enter university continue to be under-represented in medical schools. Methods: Academically able high school students (n = 33) from a range of socio-economic backgrounds participated in focus groups. School careers advisors (n = 5) were interviewed. Students discussed their career and education plans and ideas about a medical career. Careers advisors discussed enablers and barriers to a medical career for their students. Results: Students of lower SES and of FIF status attending schools situated in poorer geographic locations had limited access to suitable work experience and, despite their participation in gifted and talented classes, were considered to be at greater risk of not achieving the high level of academic achievement required for admission to medical school. Conclusions: There is utility in exploring intersecting differences and Appardurai's theory of the 'capacity to aspire' for the purpose of understanding the causes of the under-representation of disadvantaged students in medical schools. A focused materialist approach to building the aspirations of disadvantaged students, particularly those attending schools located in poorer areas, is required if effective pre-entry equity programmes are to be developed and evaluated. Alternatively, medical schools might rethink their reliance on very high academic attainment in the admission process. Discuss ideas arising from the article at www.mededuc.com discuss.

Problem: Susceptibility to Chlamydia trachomatis infection is increased by oral contraceptives and modulated by sex hormones. We therefore sought to determine the effects of female sex hormones on the innate immune response to C. trachomatis infection. Method of study: ECC-1 endometrial cells, pre-treated with oestradiol or progesterone, were infected with C. trachomatis and the host transcriptome analysed by Illumina Sentrix HumanRef-8 microarray. Primary endocervical epithelial cells, prepared at either the proliferative or secretory phase of the menstrual cycle, were infected with C. trachomatis and cytokine gene expression determined by quantitative RT-PCR analysis. Results: Chlamydia trachomatis yield from progesterone-primed ECC-1 cells was significantly reduced compared with oestradiol-treated cells. Genes upregulated in progesterone-treated and Chlamydia-infected cells only included multiple CC and CXC chemokines, IL-17C, IL-29, IL-32, TNF-a, DEFB4B, LCN2, S100A7-9, ITGAM, NOD2, JAK1, IL-6ST, type I and II interferon receptors, numerous interferon-stimulated genes and STAT6. CXCL10, CXCL11, CX3CL1 and IL-17C, which were also upregulated in infected secretory-stage primary cells, and there was a trend towards higher levels of immune mediators in infected secretory-phase compared with proliferative-phase cells. Conclusion: Progesterone treatment primes multiple innate immune pathways in hormone-responsive epithelial cells that could potentially increase resistance to chlamydial infection. © 2013 John Wiley & Sons Ltd.

Well-organized cervical screening programmes have reduced the mortality from cervical cancer by up to 50% in the developed world. Despite the successful development of human papillomavirus vaccines there is likely to remain a need for cervical screening for the foreseeable future. In contrast, the value of mass screening for other gynaecological cancers remains unproven, although current screening methods can detect early stage ovarian cancer in asymptomatic individuals. Breast screening does appear to be associated with a reduction in mortality in women aged 50-69 years but disagreement remains about its value in younger and older women. Testing for sexually transmitted infections is effective in reducing morbidity but tends to be selective at present because of concerns over the cost and psychosocial implications of general population screening. © 2012.