Determining sample size for progression criteria for pragmatic pilot RCTs: the hypothesis test strikes back!

Background

The current CONSORT guidelines for reporting pilot trials do not recommend hypothesis testing of clinical outcomes on the basis that a pilot trial is under-powered to detect such differences and this is the aim of the main trial. It states that primary evaluation should focus on descriptive analysis of feasibility/process outcomes (e.g. recruitment, adherence, treatment fidelity). Whilst the argument for not testing clinical outcomes is justifiable, the same does not necessarily apply to feasibility/process outcomes, where differences may be large and detectable with small samples. Moreover, there remains much ambiguity around sample size for pilot trials.

Methods

Many pilot trials adopt a ‘traffic light’ system for evaluating progression to the main trial determined by a set of criteria set up a priori. We construct a hypothesis testing approach for binary feasibility outcomes focused around this system that tests against being in the RED zone (unacceptable outcome) based on an expectation of being in the GREEN zone (acceptable outcome) and choose the sample size to give high power to reject being in the RED zone if the GREEN zone holds true. Pilot point estimates falling in the RED zone will be statistically non-significant and in the GREEN zone will be significant; the AMBER zone designates potentially acceptable outcome and statistical tests may be significant or non-significant.

Results

For example, in relation to treatment fidelity, if we assume the upper boundary of the RED zone is 50% and the lower boundary of the GREEN zone is 75% (designating unacceptable and acceptable treatment fidelity, respectively), the sample size required for analysis given 90% power and one-sided 5% alpha would be around n = 34 (intervention group alone). Observed treatment fidelity in the range of 0–17 participants (0–50%) will fall into the RED zone and be statistically non-significant, 18–25 (51–74%) fall into AMBER and may or may not be significant and 26–34 (75–100%) fall into GREEN and will be significant indicating acceptable fidelity.

Discussion

In general, several key process outcomes are assessed for progression to a main trial; a composite approach would require appraising the rules of progression across all these outcomes. This methodology provides a formal framework for hypothesis testing and sample size indication around process outcome evaluation for pilot RCTs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00770-x.

Characteristics and perspectives of night-eating behaviour in a severely obese population

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

Night-eating syndrome (NES) can be a feature of severe obesity. NES is a dysfunction of circadian rhythm and is associated with impaired sleep.

WHAT THIS STUDY ADDS

Night eaters with severe obesity are more likely to be low in mood and unemployed compared with non-night eaters. Night eaters with severe obesity describe compulsive and uncontrolled eating. Research interest in night-eating syndrome (NES) has grown in recent years in line with increased rates of obesity. This study used a mixed-methods approach to investigate its characteristics in severe obesity. Eighty-one individuals (mean [standard deviation] age 44.6 [11.6] years, [body mass index] 50.0 [10.7] kg m(-2) ; 43% men) from a hospital-based UK obesity clinic were interviewed for NES based on 2003 criteria. Full and partial NES were combined into one night-eating behaviour (NEB) group (n = 31). Demographic and clinical characteristics were compared with those of non-NEB individuals (n = 50). NEB characteristics were also identified through exploratory thematic analysis of interview data. NEB individuals had lower mood (P = 0.01) and were less likely to be employed (P = 0.03). Differences in mean age and reported sleep duration were not significant. Thematic analysis of patient perceptions of NEB highlighted the potential heterogeneity of NEB development: NEB developed in childhood, adolescence and adulthood. Individuals reported long-standing and current sleep difficulties, negative affect and conflictful relationships. Night eating was solitary, compulsive and uncontrolled, and daytime eating patterns were chaotic. Accounts of awareness of night eating were conflicting. Severely obese night eaters are characterized by low mood and lack of employment. Further studies are required to explore behavioural and cognitive influences on night eating in severe obesity.

Treatment of urinary incontinence after stroke in adults

BACKGROUND

Urinary incontinence can affect 40-60% of people admitted to hospital after a stroke, with 25% still having problems on hospital discharge and 15% remaining incontinent at one year.

OBJECTIVES

To determine the optimal methods for treatment of urinary incontinence after stroke in adults.

SEARCH STRATEGY

We searched the Cochrane Incontinence and Stroke Groups specialised registers (searched 15 March 2007 and 5 March 2007 respectively), CINAHL (January 1982 to January 2007), national and international trial databases for unpublished data, and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials evaluating the effects of interventions designed to promote continence in people after stroke.

DATA COLLECTION AND ANALYSIS

Data extraction and quality assessment were undertaken by two reviewers working independently. Disagreements were resolved by a third reviewer.

MAIN RESULTS

Twelve trials with a total of 724 participants were included in the review. Participants were from a mixture of settings, age groups and phases of stroke recovery. BEHAVIOURAL INTERVENTIONS: Three trials assessed behavioural interventions, such as timed voiding and pelvic floor muscle training. All had small sample sizes and confidence intervals were wide. SPECIALISED PROFESSIONAL INPUT INTERVENTIONS: Two trials assessed variants of professional input interventions. Results tended to favour the intervention groups: in a small trial in early rehabilitation, fewer people had incontinence at discharge from hospital after structured assessment and management than in a control group (1/21 vs. 10/13; RR 0.06, 95% CI 0.01 to 0.43); in the second trial, assessment and management by Continence Nurse Advisors was associated with fewer participants having urinary symptoms (48/89 vs. 38/54; RR 0.77, 95% CI 0.59 to 0.99) and statistically significantly more being satisfied with care. COMPLEMENTARY THERAPY INTERVENTIONS: Three small trials all reported fewer participants with incontinence after acupuncture therapy (overall RR 0.44; 95% 0.23 to 0.86), but there were particular concerns about study quality. PHARMACOTHERAPY AND HORMONAL INTERVENTIONS: There were three small trials that included groups allocated meclofenoxate, oxybutinin or oestrogen. There were no apparent differences other than in the trial of meclofenoxate where fewer participants had urinary symptoms in the active group than in the control group (9/40 vs. 27/40; RR 0.33, 95% CI 0.18 to 0.62).

AUTHORS' CONCLUSIONS

Data from the available trials are insufficient to guide continence care of adults after stroke. However, there was suggestive evidence that professional input through structured assessment and management of care and specialist continence nursing may reduce urinary incontinence and related symptoms after stroke. Better quality evidence is required of the range of interventions that have been suggested for continence care after stroke.

Repetitive task training for improving functional ability after stroke

BACKGROUND

The active practice of task-specific motor activities is a component of current approaches to stroke rehabilitation.

OBJECTIVES

To determine if repetitive task training after stroke improves global, upper or lower limb function, and if treatment effects are dependent on the amount, type or timing of practice.

SEARCH STRATEGY

We searched the Cochrane Stroke Trials Register (October 2006), The Cochrane Library, MEDLINE, EMBASE, CINAHL, AMED, SportDiscus, Science Citation Index, Index to Theses, ZETOC, PEDro, and OT Seeker (to September 2006), and OT search (to March 2006). We also searched for unpublished/non-English language trials, conference proceedings, combed reference lists, requested information on bulletin boards, and contacted trial authors.

SELECTION CRITERIA

Randomised/quasi-randomised trials in adults after stroke, where the intervention was an active motor sequence performed repetitively within a single training session, aimed towards a clear functional goal, and where the amount of practice could be quantified.

DATA COLLECTION AND ANALYSIS

Two authors independently screened abstracts, extracted data and appraised trials. Assessment of methodological quality was undertaken for allocation concealment, blinding, loss to follow up and equivalence of treatment. We contacted trial authors for additional information.

MAIN RESULTS

Fourteen trials with 17 intervention-control pairs and 659 participants were included.

PRIMARY OUTCOMES

results were statistically significant for walking distance (mean difference (MD) 54.6, 95% CI 17.5 to 91.7); walking speed (standardised mean difference (SMD) 0.29, 95% CI 0.04 to 0.53); sit-to-stand (standard effect estimate 0.35, 95% CI 0.13 to 0.56); and of borderline statistical significance for functional ambulation (SMD 0.25, 95% CI 0.00 to 0.51), and global motor function (SMD 0.32, 95% CI -0.01 to 0.66). There were no statistically significant differences for hand/arm function, or sitting balance/reach.

SECONDARY OUTCOMES

results were statistically significant for activities of daily living (SMD 0.29, 95% CI 0.07 to 0.51), but not for quality of life or impairment measures. There was no evidence of adverse effects. Follow-up measures were not significant for any outcome at six or twelve months. Treatment effects were not modified by intervention amount or timing, but were modified by intervention type for lower limbs.

AUTHORS' CONCLUSIONS

Repetitive task training resulted in modest improvement in lower limb function, but not upper limb function. Training may be sufficient to impact on daily living function. However, there is no evidence that improvements are sustained once training has ended. The review potentially investigates task specificity rather more than repetition. Further research should focus on the type and amount of training, and how to maintain functional gain.

Disease and psychological status in ankylosing spondylitis

OBJECTIVES

Psychological factors may be important in the assessment and management of ankylosing spondylitis (AS). Our primary objective was to describe associations between disease and psychological status in AS, using AS-specific assessment tools and questionnaires. Our secondary objectives were to identify patient subgroups based on such associations and to determine the stability of the measures over time.

METHODS

A total of 110 patients were assessed at 6-monthly intervals up to four times using tools to measure disease [Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI) and the Bath Ankylosing Spondylitis Metrology Index (BASMI)], psychological [Hospital Anxiety and Depression Questionnaire (HADS), Health Locus of Control-Form C Questionnaire (HLC-C)] and generic health [Short form (SF)-36] status.

RESULTS

Eighty-nine participants completed all four assessments. Throughout the study, BASDAI, BASFI and BASMI scores correlated significantly with anxiety, depression, internality and health status, but not with levels of belief in chance or powerful others. Clinically anxious or depressed subgroups had significantly worse BASDAI and BASFI, but not BASMI, scores. BASMI scores were the least closely linked to psychological status. Mean scores for disease, psychological and health status were clinically stable over the 18 months period.

CONCLUSIONS

Disease status scores in AS correlated significantly with anxiety, depression, internality and health status. Interpretation of AS disease scores should take an account of psychological status and the choice of measures used. These findings have important potential applications in AS management and monitoring, including the identification of patients for biological therapies.

Ethnic aspects of acute primary angle closure in a UK mulicultural conurbation

AIM

To investigate the incidence and ethnic distribution of patients with symptomatic acute primary angle closure (APAC) who presented to a UK hospital serving a multicultural conurbation by a population-wide case series investigation.

METHODS

Case series chart review of patients aged 30 years and above, who required laser peripheral iridotomy (LPI) for a primary acute angle closure event over a 7-year period. Demographic data for cases were compared to the local resident census data.

RESULTS

A total of 46 local residents aged > or =30 years required LPI for APAC. In all, 96% of patients were Caucasian compared to the local resident population of 89% Caucasian. The overall annual APAC rate for Bolton was 4.14 cases per 100 000 population (95% CI 3.03-5.52). The standardised incidence ratio for the South Asian population was 0.78 (95% CI 0.02-4.34) and 26.6 (95% CI 0.67-148.40) for the Chinese population.

CONCLUSIONS

APAC incidence in South Asians was similar to that among Caucasians. The incidence of APAC patients treated in this UK department is consistent with international experience. Individuals of Chinese ethnicity were at an enhanced risk of APAC. However, these results should be interpreted with caution, as patient numbers are small.

Levels of the DNA adduct, N7-methyldeoxyguanosine, are associated with increased risk of failure of treatment of cervical intraepithelial neoplasia

OBJECTIVE

To determine whether exposure to methylating agents was a risk factor for treatment failure in women undergoing colposcopic examination.

METHODS

Nine hundred fifty-eight women attending for colposcopic examination after abnormal cervical smear test results were recruited into the study cohort. Information on demographic factors, smoking and other risk factors was obtained and a pre-treatment biopsy was taken and stored at -70 degrees C. After follow-up, cases who had treatment failure of cervical intraepithelial neoplasia (CIN) within 2 years following treatment were identified (n = 77) and matched to women with no treatment failure of CIN in this time period (controls, n = 154). DNA was extracted from the pre-treatment biopsies and levels of N7-methyl-deoxyguanosine (N7-MedG), a marker of exposure to methylating agents, were quantified as the ring-opened form of the base damage by a validated immunoslotblot assay.

RESULTS

Sufficient DNA for N7-MedG analysis was extracted from 61 subjects corresponding to 20 matched case control pairs. N7-MedG was detected in cervical DNA with levels ranging from non-detected (<0.1 micromol/mol dG) to 4.83 micromol/mol dG. N7-MedG levels were significantly higher in cases (geometric mean 0.99 micromol/mol dG) than controls (0.33 micromol/mol dG; P = 0.01). There were no associations between N7-MedG levels and HPV or smoking status. Log N7-MedG content, after adjustment for HPV status at time of treatment, was found to be significantly associated with increased risk of treatment failure (OR 5.74, 95% CI 1.05-31.23).

CONCLUSIONS

The association between pre-treatment levels of DNA damage induced by methylating agents and subsequent treatment failure implicates methylating agent exposure as a causative factor in treatment failure.

A study of breast cancers detected in the incident round of the UK NHS Breast Screening Programme: the importance of early detection and treatment of ductal carcinoma in situ

One hundred and seventy eight cancers detected on incident round screening in the UK National Health Service Breast Screening Programme were reviewed. Critical review of the immediately preceding screening films (from 3 years previously) found abnormalities at the site of the subsequently detected cancer in 93 cases (52%). Forty-eight of these (27% of the total) had microcalcification as the sole abnormality. All of these 48 women had invasive ductal carcinoma and/or ductal carcinoma in situ (DCIS) (including four cases in which DCIS was associated with another type of primary invasive breast cancer). The finding of microcalcification on the previous mammograms at the site of a subsequently detected cancer was a strong predictor for the presence of DCIS (with or without associated invasive disease) (P<0.0001). Of the women with invasive ductal carcinoma, those with microcalcification on previous films were significantly more likely to have intermediate or high grade (grade 2 or 3) tumours than those women without microcalcification on previous films (P=0.0015). Previous films were also read blind by two independent experienced breast radiologists. Cancers were correctly identified by one or both readers in 39 cases. However, 35 of the remaining 139 cases showed microcalcification which was not detected or considered significant by the readers. If only these 139 'true negative' screens are analysed, similar associations are seen between microcalcification on previous films and subsequent finding of DCIS (P=0.03) and between microcalcification on previous films and high grade invasive ductal carcinomas (P=0.015). These findings provide support for the hypothesis that microcalcification seen on previous screening films at the site of a subsequently detected invasive ductal carcinoma represents ductal carcinoma in situ. In this series, 19 of 82 women (23%) with invasive ductal carcinoma in the 'true negative' screen group had microcalcification suggestive of DCIS on mammograms taken, on average, 3 years previously. Significant microcalcification is often overlooked using current detection criteria. Early detection and treatment of DCIS is essential in order to prevent the development of aggressive invasive disease. Revision of the NHSBSP targets for DCIS detection is recommended.

Long-term follow-up of a controlled trial of laser laparoscopy for pelvic pain

BACKGROUND AND OBJECTIVES

The purpose of this study was to assess the long-term efficacy of laparoscopic laser surgery in the treatment of painful pelvic endometriosis.

METHODS

We conducted a long-term follow-up of 56 patients who had participated in a randomized, double-blind controlled study at a tertiary referral center for the laparoscopic treatment of endometriosis. The patients had pelvic pain, minimal-to-moderate endometriosis, and underwent laser laparoscopy. We asked patients whether they had now achieved satisfactory symptom relief or whether they had received any further medical intervention for their endometriosis. The main outcome measure was continued symptom relief after treatment and subsequent medical history.

RESULTS

Of the original 56 patients, we were able to contact 38 (67.9%). The mean (range) time since operation was 73 months. Painful symptoms had recurred in 28/38 (73.7%) patients at some point since their operation. The median (range) time for recurrence was 19.7 (5-60) months. At the time of follow-up, satisfactory symptom relief was reported in 21/38 (55.3%) patients. The remaining 17/38 (44.7%) patients continued to experience painful symptoms, and eight eventually had a hysterectomy.

CONCLUSIONS

This study suggests that operative laparoscopy can have long-term benefits for the majority of women with pelvic pain due to endometriosis, but because of the small numbers, this study lacks the power to demonstrate this conclusively.

Laparoscopic management of ovarian endometriomas: a critical review of current practice

Endometriomas are a common cause of gynaecological morbidity, but their aetiology and management remain controversial This review focuses on identifying the evidence from published literature for the laparoscopic management of ovarian endometriomas. A critical appraisal shows that laparoscopic surgery is equivalent to laparotomy. There is no evidence to suggest that one minimal access surgical technique is clearly superior to another. However, this may be related to the inconsistencies in study design. In view of this we describe and justify our own management strategy for dealing with endometriomas.

Does transcervical resection of the endometrium for menorrhagia really avoid hysterectomy? Life table analysis of a large series

STUDY OBJECTIVE

To determine long-term success and complication rates of transcervical resection of endometrium (TCRE) for menorrhagia.

DESIGN

Retrospective audit of a continuous case series with a minimum of 2 and a maximum of 5 years' follow-up (Canadian Task Force classification II-2).

SETTING

District general hospital and tertiary referral center for gynecologic endoscopy.

PATIENTS

Three hundred eighty consecutive women with menorrhagia.

INTERVENTION

TCRE performed as a day case or with overnight stay between August 1988 and December 1992.

MEASUREMENTS AND MAIN RESULTS

Complications occurred in 6.8% of patients, with a perforation rate of 3.2%. Life table analysis showed a cumulative hysterectomy rate of 12.4% at 1 year, reaching a plateau of 27.4% after 4 years. The rate at 5 years was higher for women under age 45 years (35%) than for those 45 and over (14.9%, p <0.01, Mantel's test x(2)). Women whose operation was performed by a senior surgeon had a lower cumulative hysterectomy rate (12.6%) than those whose surgery was performed at least in part by trainees (38%, p <0.01, Mantel's text x(2)). There was no significant difference in cumulative hysterectomy rates between women who had uterine fibroids and those who did not. Ninety-six percent of hysterectomies were performed in the first 3 years after initial TCRE.

CONCLUSION

Although TCRE for menorrhagia did not avoid hysterectomy in all women, for those considering hysterectomy, it was a conservative procedure with low morbidity and high chance of avoiding the need for major surgery, especially when performed in women over age 45, by an experienced surgeon.

Follow-up report on a randomized controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal to moderate endometriosis

OBJECTIVE

To assess the longer term efficacy of laparoscopic laser surgery in the treatment of painful pelvic endometriosis and to observe the natural history of the disease at second-look laparoscopy in a control group.

DESIGN

One-year follow-up of a prospective, randomized, double-blind controlled trial.

SETTING

A referral center for the laparoscopic laser treatment of endometriosis.

PATIENT(S)

Sixty-three patients with pelvic pain and minimal to moderate endometriosis.

INTERVENTION(S)

After the 6-month follow-up visit, the randomization code was broken, and follow-up was continued to 1 year. Symptomatic patients were offered second-look laser laparoscopy.

MAIN OUTCOME MEASURE(S)

Continued symptom relief at 1 year after treatment and findings at second-look laparoscopy in symptomatic controls.

RESULT(S)

Symptom relief continued at 1 year in 90% of those who initially responded. All symptomatic controls had a second-look procedure, with 7 (29%) showing disease progression, 7 (29%) showing disease regression, and 10 (42%) having static disease.

CONCLUSION(S)

The benefits of laser laparoscopy for painful pelvic endometriosis are continued in the majority of patients at 1 year. Untreated painful endometriosis will progress or remain static in the majority of patients but will spontaneously improve in others.

Thermoregulated radiofrequency endometrial ablation

OBJECTIVE

To test the hypothesis that treating dysfunctional uterine bleeding by automated application of electrothermal energy to the uterine cavity, with precise regional control, might yield results equivalent to those reported for hysteroscopically directed laser and electrosurgical endometrial ablations.

MATERIALS AND METHODS

Patients with life style compromising menorrhagia, referred to six gynecologic surgical centers for hysterectomy or endometrial ablation, were admitted to the study if they had normal cervical cytology, a benign endometrial biopsy, no defined cause for their bleeding, and consented to participate in the evaluation of a newly developed Vesta DUB Treatment System. The device consists of a silicone-inflatable electrode carrier to be inserted into the uterine cavity and a controller to monitor and distribute current from a matched electrosurgical generator. Treatment involved a 3-minute or shorter warm-up period and a 4-minute treatment phase.

RESULTS

Three- to 24-month follow-up data were available for 187 patients, with a mean follow-up of 14.8 months. The amenorrhea rate was 38%. Bleeding was reduced in 95% of patients. Actuarially, 88 +/- 3% of patients should expect to be free of menorrhagia, dissatisfaction, or need for a second procedure out to 24 months.

CONCLUSIONS

The unique regional feed-back control offered by this system causes thorough, evenly distributed, thermal destruction 4-5 mm into the myometrium that reduces bleeding with durability equivalent to published reports of hysteroscopic endometrial ablation.

Laser laparoscopic surgery in the treatment of ovarian endometriomas

STUDY OBJECTIVE

To assess the efficacy of laser laparoscopic photocoagulation of endometriomas (2-18 cm) in patients with pain, infertility, or a combination of the two.

DESIGN

Retrospective review of all patients with endometriomas from June 1, 1983, to December 31, 1993.

SETTING

Department of gynecology and obstetrics at a district general hospital and national training center in minimal access surgery.

PATIENTS

One hundred sixty-five women with large endometriomas present at the time of laser laparoscopy.

INTERVENTIONS

Carbon dioxide laser or potassium-titanyl-phosphate laser laparoscopic surgery.

MEASUREMENTS AND MAIN RESULTS

Ninety (74%) of 122 patients reported improvement or resolution of pain; and 30 of 66 achieved a pregnancy, for a cumulative conception rate of 45%.

CONCLUSION

Laser laparoscopy is a practical, safe, and effective technique for the management of large ovarian endometriomas.

Advantages of laparoscopic supra-cervical hysterectomy

The development of minimally invasive hysterectomy in gynaecology is clearly an exciting one, but these procedures need to be validated in prospective studies. If laparoscopic hysterectomy proves to be safe and more effective than abdominal hysterectomy, then it will definitely become established as a validated procedure in gynaecology. There are an increasing number of surgical options for women with menstrual problems-hysterectomy: abdominal, vaginal, laparoscopic, total, supra-cervical, Doderlein, with or without oophorectomy, or endometrial ablation or resection. One particular approach will not be suitable for all women and the choice needs to be individualized according to the particular clinical situation and to some extent patient choice. The true benefits of the supra-cervical approach are yet to be shown, but this may be the way that laparoscopic hysterectomy will develop in the future.

Prospective, randomized, double-blind, controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal, mild, and moderate endometriosis

OBJECTIVE

To assess the efficacy of laser laparoscopic surgery in the treatment of pain associated with minimal, mild, and moderate endometriosis.

DESIGN

A prospective, randomized, double-blind, and controlled clinical study.

SETTING

Royal Surrey County Hospital, Guildford, United Kingdom, a referral center for the laser laparoscopic treatment of endometriosis.

PATIENTS

Sixty-three patients with pain (dysmenorrhoea, pelvic pain, or dyspareunia) and minimal to moderate endometriosis.

INTERVENTIONS

The patients were randomized at the time of laparoscopy to laser ablation of endometriotic deposits and laparoscopic uterine nerve ablation or expectant management. Pain symptoms were recorded subjectively and by visual analogue scale. The women were unaware of the treatment allocated as was the nurse who assessed them at 3 and 6 months after surgery.

MAIN OUTCOME MEASURE

Improvement or resolution of pain symptoms assessed subjectively and by visual analogue score.

RESULTS

Laser laparoscopy results in statistically significant pain relief compared with expectant management at 6 months after surgery. Sixty-two and a half percent of the lasered patients reported improvement or resolution of symptoms compared with 22.6% in the expectant group. Results were poorest for minimal disease and, if patients with mild and moderate disease only are included, 73.7% of patients achieved pain relief. There were no operative or laser complications.

CONCLUSIONS

Laser laparoscopy is a safe, simple, and effective treatment in alleviating pain symptoms in women with stages I, II, and III endometriosis.

Patients with chronic pelvic pain and/or infertility: psychological differences pre- and post-treatment

This study investigated the psychological differences between gynecological clinic attenders with either pelvic pain or infertility, or with both pelvic pain and infertility both before and after laparoscopic investigation with concurrent treatment. Given the differing meaning attached to the procedure by these groups, it was hypothesized that infertility patients would be more anxious but with less evidence of psychopathology in comparison with the pain group prior to laparoscopic surgery. Postsurgery and in the short term, pain reduction was expected to be associated with decreased pathology for the pain group. Contrary to the hypotheses, pain patients obtained higher anxiety scores in comparison with the infertility group both pretreatment as well as post-treatment. The latter group's scores were comparable to normative data. Other results were generally in line with the hypotheses, pain reduction for both pain groups being associated with a reduction in psychopathology. Patients with pain plus infertility resembled pain patients at pretreatment, while at post-treatment, they bore a closer resemblance to infertility patients in their psychological profile. This was despite the fact that for both pain groups, pain relief was similar. This reinforces the notion that in the patient groups studied anxiety is associated with pain rather than with infertility.

Initial experience with supracervical laparoscopic hysterectomy and removal of the cervical transformation zone

OBJECTIVE

To assess the feasibility and outcome of laparoscopic supracervical hysterectomy with removal of the cervical transformation zone.

DESIGN

A prospective clinical study.

SETTING

The department of Gynaecology, Royal Surrey County Hospital, Guildford.

SUBJECTS

Eleven consecutive women who were on the waiting list for abdominal hysterectomy and fulfilled the selection criteria.

INTERVENTION

Laparoscopic supracervical hysterectomy using a modification of the classical abdominal supracervical hysterectomy technique with removal of the cervical transformation zone.

MAIN OUTCOME MEASURES

Operating time, blood loss, duration of hospital stay, time to full recovery and complications.

RESULTS

All 11 procedures were successfully completed laparoscopically. The mean operating time was 111 min, and mean blood loss was 185 ml. The mean duration of hospital stay was three days, and the mean time to full recovery was 20 days. There were no major complications.

CONCLUSIONS

Laparoscopic supracervical hysterectomy appears to result in a shorter hospital stay and more rapid recovery than total abdominal hysterectomy. This shortened convalescence is of benefit to the patient. The operation appears to be safe when carried out by surgeons experienced in laparoscopic surgery. A randomised comparative study with total abdominal hysterectomy is currently being undertaken.

Death after marital bereavement--is the risk increased?

Previous studies on the effect of marital bereavement on mortality have suggested various time periods during which the risk of mortality is increased. As many of the studies compared the widowed group with national mortality statistics for the married, there has been no opportunity to adjust for confounders which might themselves be responsible for this increased risk after bereavement. In this paper the various hypotheses proposed are reviewed and then modelled on a dataset of 344 elderly persons who were living with a spouse and who were part of a survey of a population of people aged 75 years and over. The 344 index-cases and their spouses were followed up for seven years and the times of death (for those who died) of the index-case and spouse were noted. The data were analysed by fitting a proportional hazards model to the subject's survival time after adjustment for other factors such as mental and physical health which had already been shown to be associated with mortality. The bereavement effects were fitted as time-dependent covariates. The best fitting model for females and males indicated an increased relative risk of mortality which lasted for approximately six months after bereavement. In the case of widows this relative risk was significantly increased, being 3.8 with 95 per cent confidence interval (1.4, 10.3) while for widowers the risk was 0.03 with 95 per cent confidence interval (0.00, 37.3).

Diagnostic significance of octadeca-9,11-dienoic acid in cervical neoplasia

The percentage molar ratio (%MR) of the 9,11 and 9,12 isomers of octadecadienoic acid was determined in cervical exfoliated cells from 148 subjects, of whom 27 had cytologically proven intraepithelial neoplasia and in cervical biopsy specimens from 43 subjects, of whom 24 had histologically diagnosed cervical intraepithelial neoplasia. The %MR in both cervical biopsy specimens and exfoliated cells did not significantly differ in subjects with or without cervical intraepithelial neoplasia. The measurement of the %MR of 9,11:9,12 octadecadienoic acid has no role in the detection of cervical intraepithelial neoplasia.

Production of interferons during experimental African trypanosomiasis

African trypanosomiasis is associated with profound changes in the function of the immune system. In this study we find that alpha/beta and gamma interferon (IFN) are released into the serum of mice infected with Trypanosoma brucei. The parasite-induced rise in serum IFNs is associated with a detectable parasitaemia, but the serum IFN peak precedes the peak parasitaemia in some cases. Unlike other protozoan interferon inducers, no parasite-dependent IFN production was observed in the pre-patent period of infection; while the most virulent clone induced very high IFN levels, no clear difference in stimulation was noted in the first waves of semi-acute and chronic T. brucei clones. However, subsequent IFN augmentation more closely reflected the host parasite load and virulence of infection. The nature of the stimulatory parasite component is as yet unknown, and the parasite surface glycoprotein had no effect on serum IFN. Injection of large quantities of lethally irradiated, but intact organisms did not stimulate IFN production; however this treatment significantly impaired antibody responses to the heterologous antigen SRBC. This suggests that the more severe effects of an actual trypanosome infection are required for induction of IFN synthesis, and that the presence of measurable serum IFN is not a prerequisite for parasite-induced suppression of host antibody responses.