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Al Wattar BH, Rogozińska E, Vale C, Fisher D, Petersen I, Nicum S, Bannington D, Talaulikar V, Freemantle N. Effectiveness and safety of menopause treatments: pitfalls of available evidence and future research need. Climacteric 2024; 27:154-158. [PMID: 38275167 DOI: 10.1080/13697137.2023.2297880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 12/14/2023] [Indexed: 01/27/2024]
Abstract
By 2050 more than 1.6 billion women worldwide will be of post-reproductive age, with >75% reporting severe menopausal symptoms. The last few years saw a gradual uplift in public awareness reaffirming the health needs of women with menopause. Still, effective translation of available evidence on menopause treatments is hindered by several methodological limitations and poor research conduct. We argue that a paradigm shift is required in menopause research to address the remaining knowledge gap and guide safe evidence-based care provision. A critical misconception across studies on menopause is the assumption that women represent a homogeneous group who respond similarly to a particular therapy irrespective of their exposure and individual risk factors. We highlight potential solutions to optimize the quality of future research in menopause including adopting robust trial methodology, standardize outcome reporting to capture quality-of-life measures, and improve lay patient and public involvement in future research.
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Affiliation(s)
- B H Al Wattar
- Beginnings Assisted Conception Unit, Epsom and St Helier University Hospitals, London, UK
- Institute for Clinical Trials and Methodology, University College London, London, UK
| | - E Rogozińska
- MRC CTU, Institute for Clinical Trials and Methodology, University College London, London, UK
| | - C Vale
- MRC CTU, Institute for Clinical Trials and Methodology, University College London, London, UK
| | - D Fisher
- MRC CTU, Institute for Clinical Trials and Methodology, University College London, London, UK
| | - I Petersen
- Primary Care & Population Health, Institute of Epidemiology & Health, University College London Hospitals, London, UK
| | - S Nicum
- Research Department of Oncology, Cancer Institute, University College London Hospitals, London, UK
| | | | - V Talaulikar
- Reproductive Medicine Unit, Institute for Women's Health, University College London Hospitals, London, UK
| | - N Freemantle
- Institute for Clinical Trials and Methodology, University College London, London, UK
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2
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Al Wattar BH, Parry-Smith W. International collaboration is needed to preserve the use of Kielland's forceps in modern obstetrics. BJOG 2023. [PMID: 37345421 DOI: 10.1111/1471-0528.17579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 06/11/2023] [Indexed: 06/23/2023]
Affiliation(s)
- B H Al Wattar
- Beginnings Assisted Conception Unit, Epsom and St Helier University Hospitals, London, UK
- Comprehensive Clinical Trials Unit, Institute for Clinical Trials and Methodology, University College London, London, UK
| | - W Parry-Smith
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Telford, UK
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H. Al Wattar B, M. Hussain N, S. Khan K. Lifestyle interventions in women with polycystic ovary syndrome: A scoping systematic review of randomised evidence. Semergen 2022; 48:186-194. [DOI: 10.1016/j.semerg.2021.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 10/06/2021] [Accepted: 10/08/2021] [Indexed: 10/19/2022]
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4
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Al Wattar BH, Vashisht A, Saridogan E. Vaginal natural orifice transluminal endoscopic gynaecological surgery: is it time to accept it as routine practice? BJOG 2021; 128:1792. [PMID: 34228898 DOI: 10.1111/1471-0528.16829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 06/25/2021] [Accepted: 07/04/2021] [Indexed: 11/29/2022]
Affiliation(s)
- B H Al Wattar
- Elizabeth Garrett Anderson Institute for Women's Health, University College London Hospital, London, UK.,Women's Health Division, University College London Hospital, London, UK
| | - A Vashisht
- Elizabeth Garrett Anderson Institute for Women's Health, University College London Hospital, London, UK
| | - E Saridogan
- Elizabeth Garrett Anderson Institute for Women's Health, University College London Hospital, London, UK.,Women's Health Division, University College London Hospital, London, UK
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5
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Gurney L, Al Wattar BH, Sher A, Echevarria C, Simpson H. Comparison of perinatal outcomes for all modes of second stage delivery in obstetric theatres: a retrospective observational study. BJOG 2020; 128:1248-1255. [PMID: 33142034 DOI: 10.1111/1471-0528.16589] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To compare rates of vaginal delivery and adverse outcomes of instrumental delivery trials in obstetric theatre compared to primary emergency full dilation caesarean section. DESIGN Retrospective cohort study. SETTING University teaching hospital. POPULATION Women with singleton, non-anomalous, pregnancy undergoing instrumental delivery trial in obstetric theatre. METHODS Data were collected from consecutive cases during 2014 until 2018 using clinical records. Multivariate regression analysis was used comparing outcomes per first delivery method. MAIN OUTCOME MEASURES Primary outcome was completion of vaginal delivery between all methods of instrumental delivery. Secondary outcome was a composite of immediate perinatal adverse outcomes for instrumental delivery modes and primary full dilation caesarean section. RESULTS From 971 deliveries analysed: ventouse delivery was significantly less likely to achieve vaginal delivery compared with Keilland's forceps delivery (odds ratio [OR] 0.42, 95% CI 0.22-0.79). Once confounding factors were adjusted for, adverse outcome rates were less frequent in the Keilland's forceps group than with primary full dilation caesarean section (OR 0.37, 95% CI 0.16-0.81); however, the receiver operating characteristic curve produced from this model demonstrated a low predictive value (AUC 0.64). CONCLUSIONS Attempting instrumental delivery in delivery suite theatre, as an alternative to primary emergency full dilation caesarean section, is both reasonable and safe. In this study, ventouse delivery performed poorly in comparison with other modes of instrumental delivery. Further research in the form of randomised controlled trials to identify the optimal mode of second stage delivery is paramount. TWEETABLE ABSTRACT Instrumental delivery trials in theatre are safe but use of ventouse was associated with a higher rate of failure.
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Affiliation(s)
- L Gurney
- West Midlands Fetal Medicine Centre, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - B H Al Wattar
- Warwick Medical School, University of Warwick, Coventry, UK
| | - A Sher
- Maternity Department, James Cook University Hospital, Middlesbrough, UK
| | - C Echevarria
- Respiratory Department, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - H Simpson
- Maternity Department, James Cook University Hospital, Middlesbrough, UK
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Wattar B, Rimmer M, Rogozinska E, Macmillian M, Khan KS, Al Wattar BH. Accuracy of imaging modalities for adnexal torsion: a systematic review and meta-analysis. BJOG 2020; 128:37-44. [PMID: 32570294 DOI: 10.1111/1471-0528.16371] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Adnexal torsion (AT), a serious gynaecological emergency, often presents with non-specific symptoms leading to delayed diagnosis. OBJECTIVE To compare the test accuracy of ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI) to diagnose AT. SEARCH STRATEGY We searched EMBASE, MEDLINE and Cochrane CENTRAL until December 2019. SELECTION CRITERIA Studies reporting on the accuracy of any imaging modality (Index Test) in female patients (paediatric and adult) suspected of AT compared with surgical diagnosis and/or standard clinical/radiological follow-up period until resolution of symptoms (Reference Standard). DATA COLLECTION AND ANALYSIS We assessed study quality using QUADAS-2. We conducted test accuracy meta-analysis using a univariate model or a hierarchical model. MAIN RESULTS We screened 3836 citations, included 18 studies (1654 women, 665 cases), and included 15 in the meta-analyses. Ultrasound pooled sensitivity (n = 12, 1187 women) was 0.79 (95% CI 0.63-0.92) and specificity was 0.76 (95% CI 0.54-0.93), with negative and positive likelihood ratios of 0.29 (95% CI 0.13-0.66) and 4.35 (95% CI 2.03-9.32), respectively. Using Doppler with ultrasound (n = 7, 845 women) yielded similar sensitivity (0.80, 95% CI 0.67-0.93) and specificity (0.88, 95% CI 0.72-1.00). For MRI (n = 3, 99 women), the pooled sensitivity was 0.81 (95% CI 0.63-0.91) and specificity was 0.91 (95% CI 0.80-0.96). A meta-analysis for CT was not possible with two case-control studies and one cohort study (n = 3, 232 women). Its sensitivity range was 0.74-0.95 and specificity was 0.80-0.90. CONCLUSIONS Ultrasound has good performance as a first-line diagnostic test for suspected AT. Magnetic resonance imaging could offer improved specificity to investigate complex ovarian morphology, but more evidence is needed. TWEETABLE ABSTRACT To investigate adnexal torsion, ultrasound is a good first-line diagnostic test with a pooled sensitivity of 0.79 and specificity of 0.76.
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Affiliation(s)
- B Wattar
- West Suffolk NHS Foundation Trust, Bury St Edmunds, Suffolk, UK
| | - M Rimmer
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - E Rogozinska
- MRC Clinical Trials Unit, University College London, London, UK
| | - M Macmillian
- MRC Centre for Regenerative Medicine, The University of Edinburgh, Edinburgh, UK
| | - K S Khan
- Department of Preventive Medicine and Public Health, University of Granada, Granada, Spain
| | - B H Al Wattar
- Warwick Medical School, University of Warwick, Coventry, UK
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Rimmer MP, Al Wattar BH. Provision of obstetrics and gynaecology services during the COVID-19 pandemic: a survey of junior doctors in the UK National Health Service. BJOG 2020; 127:1123-1128. [PMID: 32460422 PMCID: PMC7283977 DOI: 10.1111/1471-0528.16313] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2020] [Indexed: 01/29/2023]
Abstract
Objective The coronavirus disease 2019 (COVID‐19) pandemic is disrupting health services worldwide. We aimed to evaluate the provision of obstetrics and gynaecology services in the UK during the acute phase of the COVID‐19 pandemic. Design Interview‐based national survey. Setting Women's healthcare units in the National Health Service. Population Junior doctors in obstetrics and gynaecology. Methods Participants were interviewed by members of the UK Audit and Research in Obstetrics and Gynaecology trainees' collaborative between 28 March and 7 April 2020. We used a quantitative analysis for closed‐ended questions and a thematic framework analysis for open comments. Results We received responses from 148/155 units (95%), most of the participants were in years 3–7 of training (121/148, 82%). Most completed specific training drills for managing obstetric and gynaecological emergencies in women with COVID‐19 (89/148, 60.1%) and two‐person donning and doffing of Personal Protective Equipment (PPE) (96/148, 64.9%). The majority of surveyed units implemented COVID‐19‐specific protocols (130/148, 87.8%), offered adequate PPE (135/148, 91.2%) and operated dedicated COVID‐19 emergency theatres (105/148, 70.8%). Most units reduced face‐to‐face antenatal clinics (117/148, 79.1%) and suspended elective gynaecology services (131/148, 88.5%). The 2‐week referral pathway for oncological gynaecology was not affected in half of the units (76/148, 51.4%), but half reported a planned reduction in oncology surgery (82/148, 55.4%). Conclusion The provision of obstetrics and gynaecology services in the UK during the acute phase of the COVID‐19 pandemic seems to be in line with current guidelines, but strategic planning is needed to restore routine gynaecology services and ensure safe access to maternity care in the long term. Tweetable abstract Provision of obstetrics and gynaecology services during the acute phase of COVID‐19 is in line with current guidelines, strategic planning is needed to restore routine services and ensure safe access to care in the long term. Provision of obstetrics and gynaecology services during the acute phase of COVID‐19 is in line with current guidelines, strategic planning is needed to restore routine services and ensure safe access to care in the long term. This paper includes Author Insights, a video abstract available at https://vimeo.com/rcog/authorinsights16313
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Affiliation(s)
- M P Rimmer
- UK Audit and Research Collaborative in Obstetrics and Gynaecology, London, UK
| | - B H Al Wattar
- UK Audit and Research Collaborative in Obstetrics and Gynaecology, London, UK
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Al Wattar BH, Afifi Y. Untwist and keep: appraising evidence for conservative management of ovarian torsion. BJOG 2020; 127:966. [PMID: 32223054 DOI: 10.1111/1471-0528.16233] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 03/24/2020] [Indexed: 11/30/2022]
Affiliation(s)
- B H Al Wattar
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Y Afifi
- Birmingham Women's Hospital, Birmingham, UK
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Affiliation(s)
- B H Al Wattar
- Warwick Medical School, University of Warwick, Coventry, UK.,University Hospital of Coventry and Warwickshire, Coventry, UK
| | - S D Keay
- University Hospital of Coventry and Warwickshire, Coventry, UK
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10
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Al Wattar BH, Khan KS. Upgrading Bartholin's abscess management using novel technologies? A challenge for generating knowledge through research that translates well. BJOG 2020; 127:679. [PMID: 31977146 DOI: 10.1111/1471-0528.16114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2020] [Indexed: 11/30/2022]
Affiliation(s)
- B H Al Wattar
- Warwick Medical School, University of Warwick, Coventry, UK
| | - K S Khan
- Department of Preventive Medicine and Public Health, University of Granada, Granada, Spain
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Affiliation(s)
- B H Al Wattar
- Women's Health Research Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Warwick Medical School, University of Warwick, Coventry, UK
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Affiliation(s)
- B H Al Wattar
- Women's Health Research Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Warwick Medical School, University of Warwick, Coventry, UK
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13
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Abstract
We conducted a cross-sectional survey including specialist trainees in obstetrics and gynaecology in the Health Education West Midlands region, UK, to capture their views and assess training opportunities on the use of Kielland's forceps. Half of the trainees in the region completed the survey (87/172, 50%). Only 31% of our trainees worked in units that supported the training on these forceps (27/87, 31%). The majority reported that they did not get enough exposure to using Kielland's forceps (53/87, 60.9%). Only a minority (5.7%, 5/87) felt confident to perform a Kielland's rotational delivery independently. The majority (64.3%, 56/87) were keen to continue using Kielland's forceps in the future if competent. More than two-thirds (86.2%, 75/87) felt that simulation could aid their training. There was large enthusiasm for training on the safe use of Kielland's forceps among trainees in obstetrics and gynaecology in the West Midlands region. A national assessment of training resources is needed to better plan training recourses on this complex skill.
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Affiliation(s)
- B H Al Wattar
- a Women's Health Research Unit - Blizard Institute - Barts and the London School of Medicine and dentistry, Queen Mary University , London , UK
| | - A Mahmud
- b Birmingham Women's Hospital - Mindelsohn Way , Birmingham , UK.,c Birmingham Centre for Women's and Children's Health, School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham , Birmingham , UK
| | - A Janjua
- b Birmingham Women's Hospital - Mindelsohn Way , Birmingham , UK.,c Birmingham Centre for Women's and Children's Health, School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham , Birmingham , UK
| | - W Parry-Smith
- d The Maternity Centre, University Hospital of North Staffordshire , Stoke-On-Trent , UK.,e Clinical Education Centre, Keele University , Staffordshire , UK
| | - K M Ismail
- b Birmingham Women's Hospital - Mindelsohn Way , Birmingham , UK.,c Birmingham Centre for Women's and Children's Health, School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham , Birmingham , UK
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Al Wattar BH, Tamilselvan K, Khan R, Kelso A, Sinha A, Pirie AM, McCorry D, Khan KS, Thangaratinam S. Development of a core outcome set for epilepsy in pregnancy (E-CORE): a national multi-stakeholder modified Delphi consensus study. BJOG 2016; 124:661-667. [PMID: 27860117 DOI: 10.1111/1471-0528.14430] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To develop a set of core outcomes for studies on pregnant women with epilepsy. DESIGN Delphi consensus study. POPULATION Healthcare professionals, and patient representatives with lived experience of epilepsy in the UK. METHODS We used a modified Delphi method and a consultation meeting to achieve consensus. Potential outcomes were identified by systematic review, and were scored using a Likert scale anchored between 1 (least important) and 5 (most important). We included outcomes that scored ≥4 by >70% of participants, and outcomes that scored ≤2 by <15% of participants. MAIN OUTCOME MEASURES Outcomes in studies on epilepsy in pregnancy. RESULTS Seventy-five healthcare professionals completed the first round, 48 (64%) completed the second round, and 37 (49%) completed the third round of the survey. Twenty-four patient representatives participated. The final core outcome set included 31 outcomes in three domains: neurological, offspring, and obstetric. Outcomes in the neurological domain were seizure control in pregnancy and postpartum, status epilepticus, maternal mortality, drowning, sudden unexpected death in epilepsy, postnatal depression, and quality of life. Offspring domain included congenital abnormalities (major and minor), fetal anticonvulsant syndrome, neurodevelopment, autism disorder, neonatal clinical complications, admission to a neonatal intensive care unit, and anthropometric measurements. The obstetric domain included live birth, stillbirth, miscarriage, ectopic, termination of pregnancy, admission to a high dependency or intensive care unit, breastfeeding, mode of delivery, preterm birth, pre-eclampsia, and eclampsia. Outcomes specific for studies on anti-epileptic drugs (AEDs) included maternal AED toxicity, AED compliance, neonatal withdrawal symptoms, and neonatal haemorrhagic disease. CONCLUSION Embedding this core set in future clinical trials will promote the standardisation of reporting to inform clinical practice. TWEETABLE ABSTRACT A Delphi method identifying core outcomes for epilepsy in pregnancy. Final core set includes 31 outcomes.
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Affiliation(s)
- B H Al Wattar
- Women's Health Research Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - R Khan
- Barts Health NHS Trust, London, UK
| | - A Kelso
- Barts Health NHS Trust, London, UK
| | - A Sinha
- Barts Health NHS Trust, London, UK
| | - A M Pirie
- Birmingham Women's Hospital, Birmingham, UK.,University of Birmingham, Birmingham, UK
| | - D McCorry
- University of Birmingham, Birmingham, UK
| | - K S Khan
- Women's Health Research Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Multidisciplinary Evidence Synthesis Hub (mEsh), Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,The CROWN Initiative
| | - S Thangaratinam
- Women's Health Research Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Multidisciplinary Evidence Synthesis Hub (mEsh), Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Abstract
Ultrasound scan (USS) is an important tool for assessing and diagnosing early pregnancy and gynaecological emergencies. Providing an ultrasound scanning service at all hours would enable and ease prompt diagnosis and appropriate management. It would also help hospitals in reducing costs secondary to unnecessary admissions due to lack of ultrasound out of hours. We have conducted a retrospective observational study that looked into the out of hours admissions to a busy early pregnancy unit in a general district hospital, over a 3-month period. Our results highlight the important role and possible benefits of using ultrasound out of hours and prove it is a cost-effective approach. However, providing ultrasound scanning out of hours is affected by limitations of staff and resources at each unit. This could be avoided by following a multidisciplinary approach in acute services and providing more training for medical staff in ultrasound scanning.
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Affiliation(s)
- B H Al Wattar
- Department of Obstetrics and Gynaecology, Heart of England NHS Foundation Trust, Heartlands Hospital
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Papaioannou S, Aslam M, Al Wattar BH, Milnes RC, Knowles TG. User's acceptability of OvuSense: a novel vaginal temperature sensor for prediction of the fertile period. J OBSTET GYNAECOL 2014; 33:705-9. [PMID: 24127960 DOI: 10.3109/01443615.2013.817984] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Measuring changes in core body temperature provides a valid method to detect ovulation and increase fertility. 'OvuSense' is a novel vaginal sensor that can predict the fertility window by recording and analysing the changes in intravaginal temperature records. This study aimed to determine patients 'acceptability and satisfaction after using OvuSense'. We approached 13 women to complete a patient satisfaction survey after using OvuSense in a prospective, longitudinal, comparative study, to test its validity and accuracy in detecting ovulation over a minimum period of three cycles. All 13 women agreed to participate in this survey. The majority of the participants found the usage of the reader to be very easy; 76.9% of the women said it was extremely comfortable to use the device during the night and 76.9% found the idea of using the intravaginal reader to be very convenient. Overall, 69.2% of women were extremely satisfied using the device. The idea of detecting intravaginal core body temperature changes appears to be highly acceptable by women.
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Affiliation(s)
- S Papaioannou
- Department of Obstetrics and Gynaecology, Heartlands Hospital , Birmingham
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Abstract
Primary bone lymphoma (PBL) is a rare, malignant, neoplastic disorder of the skeleton that accounts for less than 5% of all primary bone tumours. We present an extremely rare case of PBL mimicking a pelvic abscess around the sacroiliac joint, which has never been reported in the medical literature, and discuss learning points highlighted from this case.
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Affiliation(s)
- R Singh
- University Hospital of Wales, Cardiff, UK.
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