[Feather--data acquisition in gynaecology and obstetrics]

Nowadays many types of medical documentation are based on computer facilities. Unfortunately, this involves the considerable disadvantage that almost every single department and specialty has its own software programs, with the physician having to learn a whole range of different programs. In addition, data sometimes have to be entered twice - since although open interfaces are often available, the elaborate programming required to transfer data from outside programs makes the financial costs too high. Since 1995 the University's of Frankfurt am Main Department of Gynecology and Obstetrics has therefore developed a consistent program of its own under Windows NT for in-patient facilities, as well as for some outpatient services. The program does not aim to achieve everything that is technically possible, but focuses primarily on user requirements. In addition to the general requirements for medical documentation in gynecology and obstetrics, the program can also handle perinatal inquiries and gynecological quality control (QSmed [Qualitätssicherung in der Medizin] of the BQS [Bundesgeschäftsstelle Qualitätssicherung]).

Graduate education in women's health care: where have all the young men gone?

The trend toward female gender-dominance in women's health care carries enormous implications for the specialty, patients, and the practice of medicine as a whole. It is unclear what "gates," if any, should be created/maintained to control gender dominance, but it is certain that a continued shift in specialty constituency will change the way health care is provided to women. It is doubtful that even the most thorough prognosticators will be able to identify these changes prospectively, but several concerns arise regarding the security of the specialty when current literature is reviewed.

What is the optimal medical management of infertility and minor endometriosis? Analysis and future prospects

By asking the question 'What is the optimal medical management of infertility and minor endometriosis?', it is assumed that endometriosis has a detrimental effect on fertility. The published data suggest that oocyte dysfunction may contribute to infertility associated with endometriosis. This is expressed as a reduction in fertilization and implantation rates; implantation rates to a lesser extent, though still significant. Other evidence for oocyte dysfunction exists, not all of which is consistent. Suppression of ovulation and menstruation to treat endometriosis-associated infertility is not effective. However, ovulation induction, perhaps with intrauterine insemination, does result in pregnancy rates higher than in control cycles, while stimulated IVF success rates are equivalent to those of other diagnostic groups. For the future, angiogenesis is critical to the support of endometriotic deposits and targeted therapies are promised; their role in improving fertility has not yet been explored.

Trends among gynecologic oncology inpatient deaths: is end-of-life care improving?

OBJECTIVE

The objective was to describe trends over time in key factors surrounding end-of-life care on a gynecologic oncology service at a tertiary cancer center.

METHODS

Patients with gynecologic cancers who were hospitalized and died at our institution between 1992 and 1997 were identified using institutional databases. The study group consisted of 176 patients. For analysis, patients were divided into two groups: those who died between 1992 and 1994 and those who died between 1995 and 1997. Data were abstracted from medical records regarding the interval between placement of do-not-resuscitate (DNR) orders and death; the interval between the patient's being informed of her terminal-stage disease and death; the types of interventions performed near the end-of-life; and other factors related to end-of-life care.

RESULTS

The average patient age on last admission to the hospital was 56 years, and the most common disease sites were ovary (47%), cervix (30%), and uterus (17%). Most deaths (82%) occurred on medical or surgical units, with the remainder occurring in the intensive care unit (12%) or emergency room (6%). The average interval between placement of DNR orders and death was longer among patients who died in 1995-1997 than among patients who died in 1992-1994 (49.6 days vs 19.2 days, P = 0.027). The average annual number of deaths (42.0 vs 16.7, P = 0.061) and the average length of hospital stay (13.3 vs 8.8 days; P = 0.079) decreased between 1992-1994 and 1995-1997, but the differences did not reach statistical significance. Changes between patients who died in 1992-1994 and those who died in 1995-1997 in the interval between the last cycle of chemotherapy and death (87 days and 49 days, respectively; P = 0.29), the proportion of patients with a DNR order on admission (39 and 45%, respectively; P = 0.59), the proportion of patients admitted for terminal care only (22 and 19%, respectively; P = 0.47), and the proportion of patients who died awaiting transfer to hospice (32 and 22%, respectively; P = 0.24) likewise did not reach statistical significance.

CONCLUSIONS

Our data indicate that discussions about DNR orders are occurring earlier in relation to terminal events. However, we could not detect significant changes in the other outcome measures we studied. Major opportunities remain for further enhancements in the realm of advance planning for end-of-life care. Educational opportunities should be offered to physicians regarding communicating with patients about disease progression and end-of-life decision-making.

Working with women experiencing mid-trimester termination of pregnancy: the integration of nursing and feminist knowledge in the gynaecological setting

1. Working with women experiencing a mid-trimester termination of pregnancy is part of clinical practice in many gynaecological services. In this paper recent research with nurses working in the gynaecological area is drawn on to explore the issues for nurses working with women experiencing mid-trimester termination. Mid-trimester terminations are those carried out between approximately 12 and 20 weeks. 2. Mid-trimester termination results in the delivery of a fetus and this event requires sensitive management as it is has the potential to cause distress for the women due to the psychological and physical impact of the procedure. However, health professionals involved can also find this a distressing clinical event due to the complex nature of the management and care required. 3. Consideration of this clinical event from a feminist perspective led to my exploring the way in which feminist theory could be applied in the situation of mid-trimester termination. Using notions from feminist theory can assist in the management of this process, and feminist concepts related to the centrality of women's experience can be integrated into actual practice. 4. A series of recommendations are provided in this paper to show the way in which feminist concepts can be integrated into clinical practice. Integrating feminist principles into practice can support both the woman experiencing the abortion and the nurse whose role in the event is sustained and intimate, and result in positive outcomes for both women. This can result in an environment that is safe and supportive for all women involved in mid-trimester terminations.

Statistics usage in the American Journal of Obstetrics and Gynecology: has anything changed?

OBJECTIVE

Our purpose was to compare statistical listing and usage between articles published in the American Journal of Obstetrics and Gynecology in 1994 with those published in 1999.

STUDY DESIGN

All papers included in the obstetrics, fetus-placenta-newborn, and gynecology sections and the transactions of societies sections of the January through June 1999 issues of the American Journal of Obstetrics and Gynecology (volume 180, numbers 1 to 6) were reviewed for statistical usage. Each paper was given a rating for the cataloging of applied statistics and a rating for the appropriateness of statistical usage, when possible. These results were compared with the data collected on a similar review of articles published in 1994.

RESULTS

Of the 238 available articles, 195 contained statistics and were reviewed. In comparison to the articles published in 1994, there were significantly more articles that completely cataloged applied statistics (74.3% vs 47.4%) (P <.0001), and there was a significant improvement in appropriateness of statistical usage (56.4% vs 30.3%) (P <.0001).

CONCLUSION

Changes in the Instructions to Authors regarding the description of applied statistics and probable changes in the behavior of researchers and Editors have led to an improvement in the quality of statistics in papers published in the American Journal of Obstetrics and Gynecology.

[Gynäkologisch-geburtshilfliche Rundschau -revisited, future directed and practice oriented]

After a long period of 15 years, the SGGG recognized the Gynäkologisch-geburtshilfliche Rundschau once again as their official organ. Herewith a sign is given for a more intense cooperation with the Austrian Society for Gynecology and Obstetrics. Eventually, the possibility that the Bavarian Society of Gynecology and Obstetrics will also join might be achieved. In a time of rapid developments in the field of print media, publishers and editors are now facing new and upcoming challenges. The concept of our journal will be adapted to the modern requirements of our readership. Besides the traditional original papers, important with regard to the impact factor, other topics will be published, e.g., medicine and law, management and health care, and congress reports. As recently introduced, articles in German as well as in English are welcome.

Focus for the future: tackling the 'pelvic pain' problem in gynecologic practice--an interactive session

OBJECTIVE

The clinical management of women with chronic pelvic pain (CPP) and endometriosis involves important issues that exist at the interface between these two conditions.

METHODS

To address these issues, an interactive session was convened to discuss an empiric algorithmic protocol for the clinical management of CPP and endometriosis presented during the Takeda-sponsored session as part of the XVI FIGO World Congress of Gynecology and Obstetrics and to monitor the audience response to this approach.

RESULTS

Approximately one-third of the audience responded that they would definitely try this method, approximately 18% were already using it, and approximately 21% would be fairly likely to try it. Thirty percent of the audience was not convinced that the empiric approach is the best management strategy.

CONCLUSION

The advantages of this management strategy should be carefully considered, and discussed with colleagues who do think it is the reasonable treatment approach in selected cases.

Practice trends in outpatient obstetrics and gynecology: findings of the Collaborative Ambulatory Research Network, 1995--2000

Historically, obstetrics and gynecology has been a medical/surgical specialty focusing on women's health and reproductive concerns during the childbearing years. Newer responsibilities-for example, in primary care, gerontology, and genetics-require Ob-Gyns to draw upon a base of medical knowledge that traditionally was not considered germane to their practices. Ob-Gyns are increasingly providing more primary care services to their patients; consequently, the field has expanded considerably. The Collaborative Ambulatory Research Network (CARN) was created in 1990 as a vehicle for investigating issues pertinent to women's health and to the practice of obstetrics and gynecology in the outpatient setting. This article summarizes the findings of CARN studies from 1995 to 2000, covering a range of topics related to women's health across the life cycle, including, but not limited to perinatal care. Topics include nutrition, infectious disease, hormone replacement therapy, psychosocial issues, and genetic testing in obstetric and gynecologic practice. Each study produced a picture of current practice patterns and knowledge of the physicians surveyed. Findings on knowledge, attitudes, and practices varied widely. Overall, Ob-Gyns were knowledgeable and consistent in more traditional areas of practice. Conversely, inconsistencies were observed in newer areas.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians

LEARNING OBJECTIVES

After completion of this article, the reader will be able to define what the Collaborative Ambulatory Research Network (CARN) involves, describe how CARN obtains its data, and summarize some of the findings of CARN from the years 1995 to 2000.

Declining trend in major gynaecological surgery in The Netherlands during 1991-1998. Is there an impact on surgical skills and innovative ability?

OBJECTIVES

To assess the number of major surgical procedures in gynaecology over a period of eight years in The Netherlands and to detect possible trends. Relevance of the trends and the possible impact on surgical skills and on innovative ability are discussed.

DESIGN

Observational study.

SETTING

Hospital care in The Netherlands.

SAMPLE

Data from a national hospital discharge database, from all 119 hospitals in The Netherlands.

METHODS

When a patient is discharged from the hospital. data on the diagnosis and treatment are registered by local medical officers and administrators. Registration of surgical procedures is based on the International Classification of Procedures in Medicine (ICPM, WHO 1978), the so-called WCC-standard. All hospitals but one (a cancer centre) in The Netherlands participate in this registration, resulting in 99.3% of all admissions. Data on gynaccological manpower were obtained from the Dutch College of Obstetricians and Gynaecologists. In order to standardise the frequency numbers per 1,000 women, yearly data of the female population according to age were obtained from the Central Office for Population Statistics.

RESULTS

The female population aged 20 years of age and older increased 3% between 1991 and 1998, from 5.8 million to 6.0 million. In the same period the number of gynaecologists grew from 604 to 625, also an increase of 3%. The total number of hysterectomies dropped from 21,433 in 1991 to 16,320 (-24 %) in 1998 (chi2 for trend 1,245.1. P < 0.001) Surgery of the uterine cavity, either performed hysteroscopically or blind, increased from 311 to 1,958 (+ 625%) cases per year (chi2 for trend 2,459.2, P < 0.001). No trend has been detected in the numbers of adnexal operations, including surgical treatment of tubal pregnancy (tubotomy or tubectomy). In 1998, 12% of all ovarian surgery and 28% of all surgery for ectopic pregnancies was performed laparoscopically. Surgery for female urinary incontinence experienced a strong decline of 46% in the studied period. The frequency of vaginal repair decreased with 1354 (-16%) cases. The abdominal prolapse surgery (abdominal sacral colpopexy, obliteration of the Douglas pouch) is steadily increasing, although the absolute numbers are small. In 1998 seven hundred and forty-three women underwent an abdominal approach of their prolapse repair, compared with 7239 that had the vaginal repair.

CONCLUSIONS

The declining trend of major gynaecological surgery in combination with the increasing number of gynaecologists will result in more difficulty for gynaecologists to acquire and maintain surgical skills and may therefore affect their ability to innovate within the surgical profession.

Implications of the Human Genome Project for obstetrics and gynecology

The initial sequencing of the human genome should be regarded as a milestone in a road that stretches years into the future; the full ramifications of the Human Genome Project are still only being theorized. Researchers will benefit from the catalog of human genes in studies of the genetics of disease susceptibility and the cell biology of gene interactions. Clinicians will increasingly offer genetic or biochemical testing to identify those at highest risk for a number of diseases. Drug discovery will eventually follow newly possible studies of gene expression and protein function. However the Human Genome Project eventually shapes medicine, it is certain that physicians, particularly obstetricians and gynecologists, will need to be well versed in the scientific and ethical issues involved, inasmuch as we will likely be at the center of the most heated debates.

[Liposuction for "body contouring" in gynecology]

OBJECTIVES

The aim of this study was to describe the possible use of the ultrasound-assisted liposuction and liposuction with the tumescent technique for the contouring and remodelling of superficial fat areas of women in the field of gynaecology.

PATIENTS AND METHODS

Between 1997 and 1999 85 healthy female patients underwent a liposuction in the department of gynaecology of the university of Essen. The patients were divided into two groups. Thirty patients (group 1) underwent an ultrasound-assisted liposuction whereas the remaining 55 patients (group 2) were operated using only the tumescent technique.

RESULTS

From the operated 582 body areas a large volume liposuction with the aspiration of more than 1,000 cc fat was performed in 48.2% of the cases. In the remaining 51.8% of the cases aspiration volumes between 300 and 1,000 cc fat were obtained. No statistically significant differences could be observed when comparing the aspirat volumes between both treatment groups (p > 0.05). Serious complications were not observed.

DISCUSSION

Our data could show, that liposuction is an extremely safe method for eliminating surperficial fat depots in the sense of body contouring in gynaecology, but that it should not be used for the reduction of obese body volumes. If ultrasound-assisted liposuction is really superior to liposuction with the tumescent technique remaining uncertain, no time gain could be observed due to this technique.

[Psychosocial aspects of the change of life]

In organ medicine the climacteric woman is frequently characterised by terms indicating a defect. The lack of hormones is viewed as an illness that requires treatment. The trend towards medicalizing the menopausal and postmenopausal years conflicts strongly with recent findings in psychosomatic research. Prospective studies show that pre- and postmenopausal complaints are considerably less severe than often described. Menopause represents a phase in life with an increased psychosocial vulnerability. This increased vulnerability and lowered resilience should be taken into account when treating menopausal women.

[Developments in surgical gynecology]

This farewell lecture presents an overview of the development of operative gynecology on the basis of oncological surgery, removal of the uterus with or without pelvic floor reconstruction as well as corrective surgery of the uterovaginal canal. Without doubt the significance of endoscopic surgery, especially involving the adnexa and the cavum uteri, has increased. Uterus extirpation should remain in the domain of the vaginal approach. An experienced 'vaginalist' has has hardly any need for parasocpic assistance which should influence the renaissa lance of the vaginal method. Emphasis should be put on vaginal reconstruction of the affected pelvic floor in the course of incontinence surgery. Thanks to new diagnostic means malformations of the uterus can be detected more frequently, and it appears essential to develop and improve these methods further if one is to prevent laparoscopic polypragmatism. The author's opinion about the insufficient surgical experience and training in medical specialist education will be discussed.

Obesity in adolescent girls. Emerging role of reproductive health professionals

Reproductive health professionals who care for adolescent girls are often confronted with the issue of obesity either through specialty reproductive health concerns or as the primary providers of gynecologic or obstetric health care for young women. There are some significant health concerns that result from obesity in girls; therefore, this review summarizes the epidemiology, evaluation and management of adolescent obesity, focusing on issues pertinent to young women's health care.

Gynaecology in the new millennium

Great challenges await the gynaecologist in the 21st century. While advances in medical technology necessitate that gynaecology move more towards a medical discipline than a surgical one, gynaecologists will be expected to play an increasingly important role in the modern woman's life. This fundamental change is influenced by four main factors, namely, the world's aging population, spread of information technology, advances in molecular based medical therapy, and the changing lifestyle of the woman in the next century. Our role cannot get any lesser as we continue to advise, educate and facilitate the lives of women, and we must aspire a new generation of responsible gynaecologists to continue this ambition.

Drugs for the gynecologist to prescribe in the prevention of breast cancer: current status and future trends

Tamoxifen was approved for breast cancer prevention in October 1998. Thus, for the first time, we as gynecologists are being asked to prescribe this drug to healthy women. In the past each one of us has cared for women with breast cancer who have been treated with tamoxifen by oncologists or breast surgeons for the malignancy. Effects of tamoxifen on the uterus resulting in carcinomas, hyperplasia, and polyps are well known. Furthermore, tamoxifen has estrogenic properties in the venous system, increasing the incidence of deep vein thrombosis and pulmonary emboli. A new SERM (selective estrogen receptor modulator), raloxifene, has been approved for prevention and treatment of osteoporosis in postmenopausal women. It does not have stimulatory effects on the endometrium; however, it is estrogenic in the venous system. Preclinical data, as well as the breast cancer incidence reported in studies of the skeleton, seem to indicate that its effects in the breast are similar to those of tamoxifen. This article reviews tamoxifen and the new SERM, raloxifene, in an attempt to help gynecologists better understand each compound and what data are currently known, what we hope to learn from future studies, and what currently makes sense for clinical practice.

[Renaissance of vaginal hysterectomy for cervical carcinoma. 100th anniversary of the first abdominal radical surgery of cervical carcinoma by Ernst Wertheim on November 16, 1898]

In the 100 year long history of the abdominal radical operation of collum carcinoma, due to the continued clinical surgical and scientific work of several generations of physicians, abdominal radical operation with standardized pelvic lymphonodectomy has become the method of choice for surgical treatment of collum carcinoma since 1970. Vaginal radical operation in its various forms has since played only a very restricted role in surgical treatment of collum carcinoma. According to the opinion of the majority of cancer surgeons vaginal radical operation had to be abandoned in view of discontinuous spreading of carcinoma into the regional pelvic lymph nodes. Because of its simplicity vaginal radical operation would still be useful today for very old high-risk patients and very young women with early invasive collum carcinoma detected in cancer screening. In view of our knowledge of the lymph node problem in collum carcinoma, however, this can no longer be the vaginal radical operation of past generations. In order to prevent critical objections to vaginal radical operation, the early attempts of Stoeckel, Suboth Mitra, Bastiaanse, Navratil, Inguilla, and Akashi were resumed. Since 1989 attempts have been made to combine vaginal radical operation of collum carcinoma with laparoscopic pelvic or para-aortic lymphonodectomy. The development has passed the following stages: the development of laparoscopic pelvic and para-aortic lymphonodectomy based on staging criteria the combination of laparoscopic lymphonodectomy with vaginal radical operation of collum carcinoma the combination of laparoscopic lymphonodectomy with complete laparoscopic radical hysterectomy and only subsequent vaginal removal of organs.