Rapid testing for group B streptococcus during labour: a test accuracy study with evaluation of acceptability and cost-effectiveness

OBJECTIVE: To determine the accuracy, acceptability and cost-effectiveness of polymerase chain reaction (PCR) and optical immunoassay (OIA) rapid tests for maternal group B streptococcal (GBS) colonisation at labour. DESIGN: A test accuracy study was used to determine the accuracy of rapid tests for GBS colonisation of women in labour. Acceptability of testing to participants was evaluated through a questionnaire administered after delivery, and acceptability to staff through focus groups. A decision-analytic model was constructed to assess the cost-effectiveness of various screening strategies. SETTING: Two large obstetric units in the UK. PARTICIPANTS: Women booked for delivery at the participating units other than those electing for a Caesarean delivery. INTERVENTIONS: Vaginal and rectal swabs were obtained at the onset of labour and the results of vaginal and rectal PCR and OIA (index) tests were compared with the reference standard of enriched culture of combined vaginal and rectal swabs. MAIN OUTCOME MEASURES: The accuracy of the index tests, the relative accuracies of tests on vaginal and rectal swabs and whether test accuracy varied according to the presence or absence of maternal risk factors. RESULTS: PCR was significantly more accurate than OIA for the detection of maternal GBS colonisation. Combined vaginal or rectal swab index tests were more sensitive than either test considered individually [combined swab sensitivity for PCR 84% (95% CI 79-88%); vaginal swab 58% (52-64%); rectal swab 71% (66-76%)]. The highest sensitivity for PCR came at the cost of lower specificity [combined specificity 87% (95% CI 85-89%); vaginal swab 92% (90-94%); rectal swab 92% (90-93%)]. The sensitivity and specificity of rapid tests varied according to the presence or absence of maternal risk factors, but not consistently. PCR results were determinants of neonatal GBS colonisation, but maternal risk factors were not. Overall levels of acceptability for rapid testing amongst participants were high. Vaginal swabs were more acceptable than rectal swabs. South Asian women were least likely to have participated in the study and were less happy with the sampling procedure and with the prospect of rapid testing as part of routine care. Midwives were generally positive towards rapid testing but had concerns that it might lead to overtreatment and unnecessary interference in births. Modelling analysis revealed that the most cost-effective strategy was to provide routine intravenous antibiotic prophylaxis (IAP) to all women without screening. Removing this strategy, which is unlikely to be acceptable to most women and midwives, resulted in screening, based on a culture test at 35-37 weeks' gestation, with the provision of antibiotics to all women who screened positive being most cost-effective, assuming that all women in premature labour would receive IAP. The results were sensitive to very small increases in costs and changes in other assumptions. Screening using a rapid test was not cost-effective based on its current sensitivity, specificity and cost. CONCLUSIONS: Neither rapid test was sufficiently accurate to recommend it for routine use in clinical practice. IAP directed by screening with enriched culture at 35-37 weeks' gestation is likely to be the most acceptable cost-effective strategy, although it is premature to suggest the implementation of this strategy at present.

A Look at Restaurant Commissaries

Restaurant commissaries range the full spectrum from simple storage of food and supplies to multi-million-dollar processing plants. The author discusses the cost effectiveness of commissary units, including their operating costs, quality control, and scope.

The Collusion of Feminist and Postmodernist Impulses in E.L. Doctorow’s "Ragtime"

Many critics of Doctorow have classified him as a postmodernist writer, acknowledging that a wide number of thematic and stylistic features of his early fiction emanate from the postmodern context in which he took his first steps as a writer. Yet, these novels have an eminently social and ethical scope that may be best perceived in their intellectual engagement and support of feminist concerns. This is certainly the case of Doctorow’s fourth and most successful novel, Ragtime. The purpose of this paper will be two-fold. I will explore Ragtime’s indebtedness to postmodern aesthetics and themes, but also its feminist elements. Thus, on the one hand, I will focus on issues of uncertainty, indeterminacy of meaning, plurality and decentering of subjectivity; on the other hand, I will examine the novel’s attitude towards gender oppression, violence and objectification, its denunciation of hegemonic gender configurations and its voicing of certain feminist demands. This analysis will lead to an examination of the problematic collusion of the mostly white, male, patriarchal aesthetics of postmodernism and feminist politics in the novel. I will attempt to establish how these two traditionally conflicting modes coexist and interact in Ragtime.

Letter to S.D. Woodruff from R. J. Thompson

Letter (1 double sided page and a half, handwritten) to S.D. Woodruff from R. J. Thompson who claims that he was not paid what he was owed by Burton. He is now foreman for McArthur Bros. and used to be the foreman for Burton Bros. He says that he will be in St. Catharines and will call and see Mr. Woodruff, Feb. 19, 1880.

Letter to S.D. Woodruff from R.J. Thompson

Letter to S.D. Woodruff from R.J. Thompson saying that he cannot be in St. Catharines because McArthur Bros. is building a saw mill. A. Denver is the only man that he could recommend for the job, May 5, 1880.

Letter to S.D. Woodruff from R.J.T. [R.J. Thompson]

Letter (1 ½ pages, handwritten) to S.D. Woodruff from R.J.T. [R.J. Thompson]. Mr. Thompson says that his wife doesn’t want him to have anything to do with this job. He says he will send 2 men and pay their expenses. He also says that he would not like to appear in court against Burton, but if Mr. Woodruff cannot prove his claim, then Mr. Thompson will appear, July 26, 1880.

Postcard to S.D. Woodruff from R.J. Thompson

Postcard to S.D. Woodruff from R.J. Thompson stating that he will be in Burlington and wants to know if he can be of any service, July 30, 1880.

Letter to S.D. Woodruff from R. J. Thompson

Letter to S.D. Woodruff from R. J. Thompson saying that he spoke to Whistle and he merely said that you wanted a man to look over your land and see if there is any pine left. There was nothing said to connect Mr. Thompson to Mr. Whistle. This is accompanied by an envelope, Aug. 2, 1880.