Marine cyanobacterial biomass is an efficient feedstock for fungal bioprocesses

BACKGROUND

Marine cyanobacteria offer many sustainability advantages, such as the ability to fix atmospheric CO2, very fast growth and no dependence on freshwater for culture. Cyanobacterial biomass is a rich source of sugars and proteins, two essential nutrients for culturing any heterotroph. However, no previous study has evaluated their application as a feedstock for fungal bioprocesses.

RESULTS

In this work, we cultured the marine cyanobacterium Synechococcus sp. PCC 7002 in a 3-L externally illuminated bioreactor with working volume of 2 L with a biomass productivity of ~ 0.8 g L-1 day-1. Hydrolysis of the biomass with acids released proteins and hydrolyzed glycogen while hydrolysis of the biomass with base released only proteins but did not hydrolyze glycogen. Among the different acids tested, treatment with HNO3 led to the highest release of proteins and glucose. Cyanobacterial biomass hydrolysate (CBH) prepared in HNO3 was used as a medium to produce cellulase enzyme by the Penicillium funiculosum OAO3 strain while CBH prepared in HCl and treated with charcoal was used as a medium for citric acid by Aspergillus tubingensis. Approximately 50% higher titers of both products were obtained compared to traditional media.

CONCLUSIONS

These results show that the hydrolysate of marine cyanobacteria is an effective source of nutrients/proteins for fungal bioprocesses.

The Effect of Promoter and RBS Combination on the Growth and Glycogen Productivity of Sodium-Dependent Bicarbonate Transporter (SbtA) Overexpressing Synechococcus sp. PCC 7002 Cells

Sodium dependent bicarbonate transporter, SbtA is a high-affinity, inducible bicarbonate transporter in cyanobacterial cells. Our previous work has shown that overexpression of this transporter can significantly increase growth and glycogen accumulation in Synechococcus sp. PCC 7002 cells. In this work, we have tested the effect of two different RBS sequences (RBS1: GGAGGA and RBS2: AGGAGA) and three different promoters (P_cpcB, P_cpcB560, and P_rbcL2) on the growth and glycogen production in SbtA-overexpressing Synechococcus sp. PCC 7002 cells. Our results show that P_cpcB or P_cpcB560 were more effective than P_rbcL2 in increasing the growth and glycogen content. The choice of RBS sequence had relatively minor effect, though RBS2 was more effective than RBS1. The transformant E, with P_cpcB560 and RBS2, showed the highest growth. The biomass after 5 days of growth on air or 1% CO₂ was increased by about 90% in the strain E compared to PCC 7002 cells. All transformants overexpressing SbtA had higher glycogen content. However, growing the cells with bubbling of 1% CO₂ did not increase cellular glycogen content any further. The strain E had about 80% higher glycogen content compared to WT PCC 7002 cells. Therefore, the glycogen productivity of the strain E grown with air-bubbling was about 2.5-fold that of the WT PCC 7002 cells grown similarly. Additionally, some of the transformants had higher chlorophyll content while all the transformants had higher carotenoid content compared to the PCC 7002 cells, suggesting interaction between carbon transport and pigment levels. Thus, this work shows that the choice of photosynthetic promoters and RBSs sequences can impact growth and glycogen accumulation in SbtA-overexpressing cells.

Overexpression of bicarbonate transporters in the marine cyanobacterium Synechococcus sp. PCC 7002 increases growth rate and glycogen accumulation

BACKGROUND

Synechococcus sp. PCC 7002 is an attractive organism as a feedstock and for photoautotrophic production of biofuels and biochemicals due to its fast growth and ability to grow in marine/brackish medium. Previous studies suggest that the growth of this organism is limited by the HCO₃ ^- transport across the cytoplasmic membrane. Tools for genetic engineering are well established for this cyanobacterium, which makes it possible to overexpress genes of interest.

RESULTS

In this work, we overexpressed two different native Na⁺-dependent carbon transporters viz., SbtA and BicA in Synechococcus sp. PCC 7002 cells under the influence of a strong light-inducible promoter and a strong RBS sequence. The overexpression of these transporters enhanced biomass by about 50%, increased intracellular glycogen about 50%, and increased extracellular carbohydrate up to threefold. Importantly, the biomass and glycogen productivity of the transformants with air bubbling was even higher than that of WT cells with 1% CO₂ bubbling. The overexpression of these transporters was associated with an increased carotenoid content without altering the chl a content.

CONCLUSIONS

Our work shows the utility of increased carbon transport in improving the growth as well as product formation in a marine cyanobacterium and will serve to increase the utility of this organism as a potential cell factory.

Involvement of atrial natriuretic peptide in abrogated cardioprotective effect of ischemic preconditioning in ovariectomized rat heart

BACKGROUND

Nitric oxide (NO) is an effective mediator of ischemic preconditioning (IPC)-induced cardioprotection. Atrial natriuretic peptide (ANP) is downregulated after ovariectomy, which results in reduction in the level of NO. The present study deals with the investigation of the role of ANP in abrogated cardioprotective effect of IPC in the ovariectomized rat heart.

METHODS

Heart was isolated from ovariectomized rat and mounted on Langendorff's apparatus, subjected to 30 min of ischemia and 120 min of reperfusion. IPC was given by four cycles of 5 min of ischemia and 5 min of reperfusion with Krebs-Henseleit solution. The myocardial infract size was estimated employing triphenyltetrazolium chloride stain, and coronary effluent was analyzed for creatine kinase-MB (CK-MB) and lactate dehydrogenase (LDH) release to consider the degree of myocardial injury. The cardiac release of NO was estimated by measuring the level of nitrite in coronary effluent.

RESULTS

IPC-mediated cardioprotection was significantly attenuated in ovariectomized rat as compared to normal rat, which was restored by perfusion with ANP. However, this observed cardioprotection was significantly attenuated by perfusion with L-NAME, an endothelial nitric oxide synthase inhibitor, and Glibenclamide, a K_ATP channel blocker, alone or in combination noted in terms of increase in myocardial infract size, release of CK-MB and LDH, and also decrease in release of NO.

CONCLUSION

Thus, it is suggested that ANP restores the attenuated cardioprotective effect of IPC in the ovariectomized rat heart which may be due to increase in the availability of NO and consequent increase activation of mitochondrial K_ATP channels.

The effectiveness of gynaecology teaching associates in teaching pelvic examination to medical students: a randomised controlled trial

OBJECTIVES

To assess whether teaching female pelvic examinations using gynaecological teaching associates (GTAs); women who are trained to give instruction and feedback on gynaecological examination technique, improves the competence, confidence and communication skills of medical students compared to conventional teaching.

STUDY DESIGN

Randomised controlled trial.

SETTING

Ten University of Birmingham (UoB) affiliated teaching hospitals in the UK.

POPULATION

492 final year medical students.

METHODS

GTA teaching of gynaecological examination compared with conventional pelvic manikin based teaching at the start of a five week clinical placement in obstetrics and gynaecology (O&G).

MAIN OUTCOME MEASURES

Student's perception of their confidence was measured on a 10cm visual analogue scale (VAS). Domains of competence were measured by a senior clinical examiner using a standardised assessment tool which utilised 10cm VAS and by a GTA using a four point Likert scale. Assessors were blinded to the allocated teaching intervention.

RESULTS

407/492 (83%) students completed both the intervention and outcome assessment. Self-reported confidence was higher in students taught by GTAs compared with those taught on manikins (median score GTA 6.3; vs. conventional 5.8; p=0.03). Competence was also higher in those taught by GTAs when assessed by an examiner (median global score GTA 7.1 vs. conventional 6.0; p<0.001) and by a GTA (p<0.001).

CONCLUSIONS

GTA teaching of female pelvic examination at the start of undergraduate medical student O&G clinical placements improves their confidence and competence compared with conventional pelvic manikin based teaching. GTAs should be introduced into undergraduate medical curricula to teach pelvic examination.

In vitro and in vivo antitumor activity of a methanol extract of Dregea volubilis leaves with its antioxidant effect

CONTEXT

In India, Dregea volubilis (L.f.) Benth. ex Hook.f. (Asclepediaceae), a large twining shrub with a woody vine, is used to treat tumors traditionally.

OBJECTIVE

This study evaluated the in vitro and in vivo antitumor activity of the methanol extract of Dregea volubilis leaves (MEDV) and elucidated its possible mechanism of action.

MATERIALS AND METHODS

In vitro antitumor activity of MEDV was evaluated against Ehrlich ascites carcinoma (EAC) cell-line. In vivo antitumor and antioxidant activity of MEDV at three dose levels (50, 100, and 200 mg/kg) were determined against EAC tumor-bearing mice. After 24 h of EAC inoculation, the extract was administered for 9 consecutive days. After the administration of the last dose on the 9th day followed by 18 h fasting, mice from all groups were sacrificed to determine antitumor activity and hematological profiles along with liver related biochemical parameters like lipid peroxidation, antioxidant enzymatic activity, etc.

RESULTS

For in vitro antitumor activity, IC(50) value of MEDV for EAC tumor cells was 85.51 ± 4.07 µg/ml. The MEDV showed a decrease in tumor volume, packed cell volume and viable cell count and an increase in the non-viable cell count of the EAC tumor-bearing mice (p < 0.001). Hematological profile reverted near to normal level in extract treated mice. MEDV decreased the hepatic lipid peroxidation level and enhanced superoxide dismutase and catalase level in tumor-bearing mice (p < 0.001).

DISCUSSION AND CONCLUSION

MEDV exhibited in vitro and in vivo antitumor activity in EAC tumor-bearing mice mediated through augmenting antioxidant defense system.

Inhalation of expiratory droplets in aircraft cabins

Airliner cabins have high occupant density and long exposure time, so the risk of airborne infection transmission could be high if one or more passengers are infected with an airborne infectious disease. The droplets exhaled by an infected passenger may contain infectious agents. This study developed a method to predict the amount of expiratory droplets inhaled by the passengers in an airliner cabin for any flight duration. The spatial and temporal distribution of expiratory droplets for the first 3 min after the exhalation from the index passenger was obtained using the computational fluid dynamics simulations. The perfectly mixed model was used for beyond 3 min after the exhalation. For multiple exhalations, the droplet concentration in a zone can be obtained by adding the droplet concentrations for all the exhalations until the current time with a time shift via the superposition method. These methods were used to determine the amount of droplets inhaled by the susceptible passengers over a 4-h flight under three common scenarios. The method, if coupled with information on the viability and the amount of infectious agent in the droplet, can aid in evaluating the infection risk.

PRACTICAL IMPLICATIONS

The distribution of the infectious agents contained in the expiratory droplets of an infected occupant in an indoor environment is transient and non-uniform. The risk of infection can thus vary with time and space. The investigations developed methods to predict the spatial and temporal distribution of expiratory droplets, and the inhalation of these droplets in an aircraft cabin. The methods can be used in other indoor environments to assess the relative risk of infection in different zones, and suitable measures to control the spread of infection can be adopted. Appropriate treatment can be implemented for the zone identified as high-risk zones.

Antidiabetic Activity of the Ethanol Extract of Capparis sepiaria L Leaves

Capparis sepiaria L, a profusely branched hedge plant, is used in Indian traditional medicine. Capparis sepiaria leaves were extracted with ethanol and concentrated to dryness. The LD₅₀ value was determined as 894.43 mg/kg body weight by acute toxicity study. The ethanol extract was investigated for possible hypoglycemic effect produced by single oral administration at various dose levels 100, 200 and 300 mg/kg in the streptozotocin induced diabetic rats and compared against normal saline control and the standard glibenclamide. A maximum fall of plasma glucose level 9.40%; 13.57%; 15.25% and 18.80% was observed after 12 h of treatment when administered with ethanol extract of Capparis sepiaria at 100, 200 and 300 mg/kg, and glibenclamide 10 mg/kg dose, respectively. The findings from the study suggest that the Capparis sepiaria leaves may be prescribed as an adjunct to traditional formulation and drug treatment for controlling diabetes mellitus.

Flow dynamics and characterization of a cough

Airborne disease transmission has always been a topic of wide interests in various fields for decades. Cough is found to be one of the prime sources of airborne diseases as it has high velocity and large quantity of droplets. To understand and characterize the flow dynamics of a cough can help to control the airborne disease transmission. This study has measured flow dynamics of coughs with human subjects. The flow rate variation of a cough with time can be represented as a combination of gamma-probability-distribution functions. The variables needed to define the gamma-probability-distribution functions can be represented by some medical parameters. A robust multiple linear regression analysis indicated that these medical parameters can be obtained from the physiological details of a person. However, the jet direction and mouth opening area during a cough seemed not related to the physiological parameters of the human subjects. Combining the flow characteristics reported in this study with appropriate virus and droplet distribution information, the infectious source strength by coughing can be evaluated.

PRACTICAL IMPLICATIONS

There is a clear need for the scientific community to accurately predict and control the transmission of airborne diseases. Transportation of airborne viruses is often predicted using Computational Fluid Dynamics (CFD) simulations. CFD simulations are inexpensive but need accurate source boundary conditions for the precise prediction of disease transmission. Cough is found to be the prime source for generating infectious viruses. The present study was designed to develop an accurate source model to define thermo-fluid boundary conditions for a cough. The model can aid in accurately predicting the disease transmission in various indoor environments, such as aircraft cabins, office spaces and hospitals.

Quality of life instruments in studies of chronic pelvic pain: a systematic review

The use of quality of life (QoL) instruments in chronic pelvic pain (CPP) will allow a more objective assessment of patient-centred clinical outcomes. However, there is concern that not enough emphasis is placed on clinical face validity (i.e. issues which are of importance to patients and reflect their experiences and concerns). To explore this issue, we performed a systematic review of published research. Relevant papers were identified through electronic scanning of six electronic databases and by manual searching of bibliographies of known primary and review articles. Studies were selected if they assessed women with CPP for life quality, either developing QoL instruments or applying them as an outcome measure. Selected studies were assessed for the quality of their QoL instruments using a 17-item checklist, including 10 items for clinical face validity and seven items for measurement (psychometric) properties. A total of 19 articles were eligible for inclusion in the review. The generic Short Form 36 Health Survey Questionnaire (SF-36) was used most frequently, being employed in 10/19 (53%) of the studies. Three studies developed disease-specific QoL instruments for CPP complying with 59 - 77% of the quality criteria. Overall, quality assessment showed that only 4/18 (22.2%) studies complied with more than half the criteria for face validity, whereas 12/18 (66.6%) studies complied with more than half of the criteria for measurement properties (P = 0.0001). Among existing QoL instruments, compliance with the quality criteria for measurement properties is higher than for clinical face validity. There is a need to develop disease specific QoL instruments for CPP with face validity in addition to sound measurement properties.

Variation in practice of laparoscopic uterosacral nerve ablation: a European survey

To examine the variation in current indications and surgical techniques for performing laparoscopic uterosacral nerve ablation (LUNA) in Europe, all consultants on the databases of the UK Royal College of Obstetricians and Gynaecologists (1569) and the European Society of Gynaecological Endoscopy (301) were surveyed. The questionnaire was returned by 719 (38% of 1870) of the gynaecologists contacted and 173 (24%) performed LUNA. Indications for LUNA, which included chronic pelvic pain (68%), dysmenorrhoea (66%), dyspareunia (39%) and endometriosis (60%), were similar across the United Kingdom and the rest of Europe. The European group were more likely to perform LUNA (62% versus 21%), completely transect the uterosacral ligaments (56% versus 36%) and at a distance of more than 2 cm from its cervical insertion (50% versus 21%) than the UK group. There is variation in the surgical techniques of performing LUNA in Europe and the techniques vary according to operator experience.

Methods of prediction and prevention of pre-eclampsia: systematic reviews of accuracy and effectiveness literature with economic modelling

OBJECTIVES

To investigate the accuracy of predictive tests for pre-eclampsia and the effectiveness of preventative interventions for pre-eclampsia. Also to assess the cost-effectiveness of strategies (test-intervention combinations) to predict and prevent pre-eclampsia.

DATA SOURCES

Major electronic databases were searched to January 2005 at least.

REVIEW METHODS

Systematic reviews were carried out for test accuracy and effectiveness. Quality assessment was carried out using standard tools. For test accuracy, meta-analyses used a bivariate approach. Effectiveness reviews were conducted under the auspices of the Cochrane Pregnancy and Childbirth Group and used standard Cochrane review methods. The economic evaluation was from an NHS perspective and used a decision tree model.

RESULTS

For the 27 tests reviewed, the quality of included studies was generally poor. Some tests appeared to have high specificity, but at the expense of compromised sensitivity. Tests that reached specificities above 90% were body mass index greater than 34, alpha-foetoprotein and uterine artery Doppler (bilateral notching). The only Doppler test with a sensitivity of over 60% was resistance index and combinations of indices. A few tests not commonly found in routine practice, such as kallikreinuria and SDS-PAGE proteinuria, seemed to offer the promise of high sensitivity, without compromising specificity, but these would require further investigation. For the 16 effectiveness reviews, the quality of included studies was variable. The largest review was of antiplatelet agents, primarily low-dose aspirin, and included 51 trials (36,500 women). This was the only review where the intervention was shown to prevent both pre-eclampsia and its consequences for the baby. Calcium supplementation also reduced the risk of pre-eclampsia, but with some uncertainty about the impact on outcomes for the baby. The only other intervention associated with a reduction in RR of pre-eclampsia was rest at home, with or without a nutritional supplement, for women with normal blood pressure. However, this review included just two small trials and its results should be interpreted with caution. The cost of most of the tests was modest, ranging from 5 pounds for blood tests such as serum uric acid to approximately 20 pounds for Doppler tests. Similarly, the cost of most interventions was also modest. In contrast, the best estimate of additional average cost associated with an average case of pre-eclampsia was high at approximately 9000 pounds. The results of the modelling revealed that prior testing with the test accuracy sensitivities and specificities identified appeared to offer little as a way of improving cost-effectiveness. Based on the evidence reviewed, none of the tests appeared sufficiently accurate to be clinically useful and the results of the model favoured no-test/treat-all strategies. Rest at home without any initial testing appeared to be the most cost-effective 'test-treatment' combination. Calcium supplementation to all women, without any initial testing, appeared to be the second most cost-effective. The economic model provided little support that any form of Doppler test has sufficiently high sensitivity and specificity to be cost-effective for the early identification of pre-eclampsia. It also suggested that the pattern of cost-effectiveness was no different in high-risk mothers than the low-risk mothers considered in the base case.

CONCLUSIONS

The tests evaluated are not sufficiently accurate, in our opinion, to suggest their routine use in clinical practice. Calcium and antiplatelet agents, primarily low-dose aspirin, were the interventions shown to prevent pre-eclampsia. The most cost-effective approach to reducing pre-eclampsia is likely to be the provision of an effective, affordable and safe intervention applied to all mothers without prior testing to assess levels of risk. It is probably premature to suggest the implementation of a treat-all intervention strategy at present, however the feasibility and acceptability of this to women could be explored. Rigorous evaluation is needed of tests with modest cost whose initial assessments suggest that they may have high levels of both sensitivity and specificity. Similarly, there is a need for high-quality, adequately powered randomised controlled trials to investigate whether interventions such as advice to rest are indeed effective in reducing pre-eclampsia. In future, an economic model should be developed that considers not just pre-eclampsia, but other related outcomes, particularly those relevant to the infant such as perinatal death, preterm birth and small for gestational age. Such a modelling project should make provision for primary data collection on the safety of interventions and their associated costs.

The feasibility, success and patient satisfaction associated with outpatient hysteroscopic sterilisation

OBJECTIVE

To determine the feasibility and patient satisfaction of female sterilisation using the Essure system in an outpatient hysteroscopy clinic without conscious sedation or general anaesthesia.

DESIGN

Prospective cohort study.

SETTING

Outpatient hysteroscopy clinic in a large teaching hospital.

POPULATION

Women undergoing outpatient hysteroscopic sterilisation using the Essure system for permanent fertility control.

METHODS

Demographic and procedural data were prospectively collected from 112 consecutive women undergoing outpatient hysteroscopic sterilisation without sedation or general anaesthesia. A hysterosalpingogram (HSG) was performed routinely in all women 3 months after the procedure to confirm bilateral tubal occlusion. Postal questionnaires were sent at this time enquiring about patient satisfaction and experience with the outpatient procedure. Multivariable logistic regression was used to identify factors independently predictive of successful completion of the procedure.

MAIN OUTCOME MEASURES

Technical feasibility, predictive factors for technical success (operator, body mass index, uterine size, axis, menstrual phase and cervical stenosis), complications, tubal occlusion on HSG, patient satisfaction and procedure-related experience.

RESULTS

Successful bilateral tubal placement of the Essure microinserts was achieved in 103/112 (92%, 95% CI 85-96%) women. Nonsecretory phase of the menstrual cycle (P = 0.04) and a clinically normal-sized uterus (P = 0.003) were independently predictive for successful completion of the outpatient procedure on multivariable modelling. There were no major procedure-related complications recorded, but transient vasovagal reactions occurred in 5/112 (5%) women. Of the original cohort of 112 women with successful procedures, 84 women were 3 months postprocedure and had undergone a HSG. Bilateral tubal occlusion was confirmed in 83/84 (99%, 95% CI 94-100%) women at 3 months and in 100% at 6 months. Seventy-six of 84 (91%) had returned the questionnaires, and 70/73 (96%, 95% CI 88-99%) were satisfied with their overall experience of the procedure including radiological follow up, with most reporting being 'very satisfied' (64/73, 88%, 95% CI 78-94%).

CONCLUSIONS

Outpatient hysteroscopic sterilisation using the Essure system without sedation or general anaesthesia is a successful and safe procedure associated with high rates of patient satisfaction. If practical, women should be scheduled to have their procedures in the proliferative phase of the menstrual cycle to optimise successful placement of Essure devices, especially if the uterus is clinically enlarged.

Gynaecological oncology: Investigating postmenopausal bleeding for endometrial cancer: cost-effectiveness of initial diagnostic strategies

OBJECTIVE

To determine the most cost-effective outpatient testing strategy for diagnosing endometrial cancer in women with postmenopausal bleeding (PMB).

DESIGN

Decision analysis modelling.

POPULATION

Women with postmenopausal bleeding.

METHODS

A decision analytic model was constructed to reflect current service provision, which evaluated 12 diagnostic strategies using endometrial biopsy (EB), ultrasonography (USS) (4- and 5-mm endometrial thickness cutoff) and hysteroscopy. Diagnostic probability estimates were derived from systematic quantitative reviews, clinical outcomes from published literature and cost estimates from local and NHS sources.

MAIN OUTCOME MEASURES

The cost per additional life year gained (pound/LYG) was determined and compared for each diagnostic strategy, and sensitivity analyses were performed.

RESULTS

Compared with carrying out no initial investigation, a strategy based on initial diagnosis with USS using a 5-mm cutoff was the least expensive (11,470 pound/LYG). Initial investigation with EB or USS using a 4-mm cutoff was comparably cost-effective (less than 30,000 pound/LYG versus USS with a 5-mm cutoff) at their most favourable diagnostic performance and at disease prevalence of 10% or more. The strategies involving initial evaluation with test combinations or hysteroscopy alone were not cost-effective.

CONCLUSIONS

Women presenting for the first time with PMB should undergo initial evaluation with USS or EB.

Uterine artery embolization for symptomatic uterine fibroids

BACKGROUND

Uterine fibroids cause heavy and prolonged bleeding, pain, pressure symptoms and subfertility but are mostly benign. The traditional method of treatment has been surgery as long term medical therapies have not shown to be effective. Uterine artery embolization (UAE - complete occlusion of both the uterine arteries with particulate emboli) has been reported to be an effective and safe alternative in the treatment of menorrhagia and other fibroid-related symptoms in women not desiring future fertility, but thus far this evidence is based on case controlled studies and case reports.

OBJECTIVES

To review the benefits and/or harms from randomised controlled trials (RCTs) of uterine artery embolization (UAE) versus other interventions for symptomatic uterine fibroids.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders & Subfertility Group Trials register (searched 10 August 2005), the Cochrane Central Register of Controlled Trials (CENTRAL) on the Cochrane Library, Issue 3, 2004), MEDLINE (January 1966 to November 2005) and EMBASE (January 1980 to November 2005). We also contacted authors of potential ongoing studies.

SELECTION CRITERIA

RCTs of UAE versus any medical or surgical therapy for symptomatic uterine fibroids.

DATA COLLECTION AND ANALYSIS

Two of the authors (AS and JKG) assessed the trials and extracted the data independently. They also contacted the investigators of eligible RCTs for unpublished data.

MAIN RESULTS

Three trials were included in this review. Two RCTs compared UAE with abdominal hysterectomy in 234 women. Although the follow-up period was intended for two years, the available published results was only for six months follow-up. The second trial included 63 women comparing UAE with myomectomy in women who wished to preserve their fertility. The minimum follow-up reported was six months with a mean of 17 (+/- 9.3) months. The clinical success rate measured by improvement in fibroid-related symptoms e.g. menstrual loss was at least 85% in the UAE group from both trials. The mean dominant fibroid volume decreased by 30 to 46% in two trials. UAE significantly reduces length of hospital stay compared to surgery for either hysterectomy or myomectomy. Women undergoing UAE resumed routine activities sooner than those undergoing surgery. UAE was associated with a higher rate of minor post procedural complications such as vaginal discharge, post puncture haematoma and post embolization syndrome (pain, fever, nausea, vomiting), as well as higher unscheduled visits and readmission rates after discharge, compared with hysterectomy. There were no major complication differences between the two groups. Three women in the myomectomy trial had elevated FSH levels post UAE indicating possible ovarian dysfunction.

AUTHORS' CONCLUSIONS

UAE offers an advantage over hysterectomy with regards to a shorter hospital stay and a quicker return to routine activities. There is no evidence of benefit of UAE compared to surgery (hysterectomy / myomectomy) for satisfaction. The higher minor complications rate after discharge in the UAE group as well as the unscheduled visits and readmission rates require more longer term follow-up trials to comment on its effectiveness and safety profile. There is currently an ongoing trial (REST, U. K.) and EMMY trial yet to report on the long term follow up, the results of which are awaited with interest.

The accuracy of risk scores in predicting preterm birth--a systematic review

This review aims to determine the accuracy with which published risk scores predict spontaneous preterm birth in pregnant women. Studies were identified without language restrictions through nine different databases (up to June 2002), and manual searching of bibliographies of known primary and review articles. Two reviewers selected studies independently and extracted data on their characteristics, quality and accuracy. Accuracy data were used to form 2 x 2 contingency tables of the results of risk scoring with spontaneous preterm birth as the reference standard. Heterogeneity was assessed and its reasons were explored. Summary estimates of accuracy were produced within clinically appropriate subgroups. There were 19 primary accuracy articles that met the selection criteria, including a total of 67390 women. There are 12 different risk-scoring systems, the one developed by Creasy being the most commonly evaluated. Quality features of an ideal study, such as blinding and consecutive enrolment, were frequently missing from the included studies, no study fulfilled all criteria for high quality study, and there was heterogeneity between their accuracy estimates. The reference standard most often used was birth before 37 weeks' gestation. The point estimates for the likelihood ratios (LRs) varied widely among the studies. LRs for an abnormal score (LR+) ranged from 1.0 (95% confidence interval (CI) 0.6-1.4) to 38.8 (95% CI 23.5-63.9) while that for a normal score (LR-) ranged from 0.1 (95% CI 0.02-0.6) to 1.2 (95% CI 0.9-1.6). In otherwise asymptomatic women, risk scoring in early pregnancy has a wide range of accuracy in predicting spontaneous preterm birth before 37 weeks' gestation. The evidence is of a relatively poor quality and lacks clinically important reference standards.

Accuracy of absence of fetal breathing movements in predicting preterm birth: a systematic review

OBJECTIVE

To determine the accuracy with which the absence of fetal breathing movements on ultrasound examination predicts spontaneous preterm birth in women with threatened preterm labor.

METHODS

Data sources included Medline, Embase, Pascal, Biosis, Cochrane Library, Medion, National Research Register, SciSearch, conference papers, and manual searching of bibliographies of known primary and review articles. A study was selected if it used absence of fetal breathing movements on ultrasound to predict spontaneous preterm birth in women with threatened preterm labor but before advanced cervical dilatation. Two reviewers independently selected studies and extracted data on their characteristics, quality and accuracy. Accuracy data were used to form 2 x 2 contingency tables with birth within 48 h and within 7 days of testing as the reference standards. Likelihood ratios for a positive test (LR+) and negative test (LR-) were calculated as a measure of accuracy.

RESULTS

There were eight studies, which included a total of 328 women, evaluating the accuracy of absence of fetal breathing movements in predicting spontaneous preterm birth in women with threatened preterm labor. There were differences in the methodological quality among the included studies. All were lacking in one or more item that make up an ideal test accuracy study. For women presenting with threatened preterm labor, meta-analysis showed a summary LR+ of 14.80 (95% CI, 6.30-34.79) with a corresponding summary LR- of 0.46 (95% CI, 0.36-0.58) for predicting preterm birth within 7 days, and summary LR+ of 7.84 (95% CI, 1.12-54.99) and summary LR- of 0.25 (95% CI, 0.13-0.48) for predicting preterm birth within 48 h of testing.

CONCLUSION

Absence of fetal breathing movements has the potential to be a useful test in predicting preterm birth both within 7 days and within 48 h of testing. However, the available studies were deficient in their sample size and quality of methodology. Future research should be undertaken to evaluate this technology and to address the methodological deficiencies.

Patient anxiety and experiences associated with an outpatient ?one-stop? ?see and treat? hysteroscopy clinic

BACKGROUND

"One-stop" outpatient hysteroscopy clinics have become well established for the investigation and treatment of women with abnormal uterine bleeding. However, the advantages of these clinics may be offset by patient factors such as anxiety, pain, and dissatisfaction. This study aimed to establish patients' views and experiences of outpatient service delivery in the context of a one-stop diagnostic and therapeutic hysteroscopy clinic, to determine the amount of anxiety experienced by these women and compare this with other settings, and to determine any predictors for patient preferences.

METHODS

The 20-item State-Trait Anxiety Inventory was given to 240 women attending a one-stop hysteroscopy clinic: to 73 consecutive women before their appointment in a general gynecology clinic and to 36 consecutive women attending a chronic pelvic pain clinic. The results were compared with published data for the normal female population, for women awaiting major surgery, and for women awaiting a colposcopy clinic appointment. In addition, a questionnaire designed to ascertain patients' views and experiences was used. Logistic regression analysis was used to delineate the predictive values of diagnostic or therapeutic hysteroscopy, and to determine their effect on the preference of patients to have the procedure performed under general anesthesia in the future.

RESULTS

Women attending the hysteroscopy clinic in this study reported significantly higher levels of anxiety than those attending the general gynecology clinic (median, 45 vs 39; p = 0.004), but the levels of anxiety were comparable with those of women attending the chronic pelvic pain clinic (median, 45 vs 46; p = 0.8). As compared with the data from the normal female population (mean, 35.7) and those reported for women awaiting major surgery (mean, 41.2), the levels of anxiety experienced before outpatient hysteroscopy clinic treatment were found to be higher (mean, 45.7). Only women awaiting colposcopy (6-item mean score, 51.1 +/- 13.3) experienced significantly higher anxiety scores than the women awaiting outpatient hysteroscopy (6-item mean score, 47.3 +/- 13.9; p = 0.002). Despite their anxiety, most women are satisfied with the outpatient hysteroscopy "see and treat" service. High levels of anxiety, particularly concerning pain but not operative intervention, were significant predictors of patients desiring a future procedure to be performed under general anesthesia.

CONCLUSIONS

Outpatient hysteroscopy is associated with significant anxiety, which increases the likelihood of intolerance for the outpatient procedure. However, among those undergoing operative therapeutic procedures, dissatisfaction was not associated with the outpatient setting.

On-line monitoring for control of a pilot-scale sequencing batch reactor using a submersible UV/VIS spectrometer

A submersible UV/VIS spectrometer was used to monitor a pilot-scale sequencing batch reactor (SBR). The instrument utilises the whole UV/VIS range between 200 and 750 nm. With just one single instrument nitrate, organic matter and suspended solids can be measured simultaneously. The spectrometer is installed directly in the reactor, measures in real-time, and is equipped with an auto-cleaning system using pressured air. The paper shows the calibration results for measurements in the SBR tank, time series for typical SBR cycles, and proposes possible ways for optimisation of the operation by using these measurements.

Position for women during second stage of labour

BACKGROUND

For centuries, there has been controversy around whether being upright (sitting, birthing stools, chairs, squatting) or lying down have advantages for women delivering their babies.

OBJECTIVES

To assess the benefits and risks of the use of different positions during the second stage of labour (i.e. from full dilatation of the cervix).

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register (16 April 2003).

SELECTION CRITERIA

Trials that used randomised or quasi-randomised allocation and appropriate follow up and compared various positions assumed by pregnant women during the second stage of labour.

DATA COLLECTION AND ANALYSIS

We independently assessed the trials for inclusion and extracted the data.

MAIN RESULTS

Results should be interpreted with caution as the methodological quality of the 19 included trials (5764 participants) was variable. Use of any upright or lateral position, compared with supine or lithotomy positions, was associated with: reduced duration of second stage of labour (10 trials: mean 4.29 minutes, 95% confidence interval (CI) 2.95 to 5.64 minutes) - this was largely due to a considerable reduction in women allocated to the use of the birth cushion; a small reduction in assisted deliveries (18 trials: relative risk (RR) 0.84, 95% CI 0.73 to 0.98); a reduction in episiotomies (12 trials: RR 0.84, 95% CI 0.79 to 0.91); an increase in second degree perineal tears (11 trials: RR 1.23, 95% CI 1.09 to 1.39); increased estimated blood loss greater than 500 ml (11 trials: RR 1.68, 95% CI 1.32 to 2.15); reduced reporting of severe pain during second stage of labour (1 trial: RR 0.73, 95% CI 0.60 to 0.90); fewer abnormal fetal heart rate patterns (1 trial: RR 0.31, 95% CI 0.08 to 0.98).

REVIEWER'S CONCLUSIONS

The tentative findings of this review suggest several possible benefits for upright posture, with the possibility of increased risk of blood loss greater than 500 ml. Women should be encouraged to give birth in the position they find most comfortable. Until such time as the benefits and risks of various delivery positions are estimated with greater certainty, when methodologically stringent trials' data are available, women should be allowed to make informed choices about the birth positions in which they might wish to assume for delivery of their babies.

Accuracy of cervical transvaginal sonography in predicting preterm birth: a systematic review

This review investigates the accuracy with which transvaginal cervical sonography predicts spontaneous preterm birth. Published studies were identified without language restrictions through nine different databases and manual searching of bibliographies of known primary and review articles. Studies were selected if they undertook antenatal transvaginal sonographic cervical assessment among a population of pregnant women with known gestational age of delivery. There were 46 primary articles, which included a total of 31,577 women, consisting of 33 studies in asymptomatic and 13 studies in symptomatic women. Data were extracted for the studies' characteristics and quality. Accuracy data were used to form 2 x 2 contingency tables for various cervical length measurements with birth before 32, 34 and 37 weeks' gestation as the reference standards. Data were stratified according to singleton or twin pregnancy, gestational age at testing, cervical length threshold, and the various reference standards, and were pooled to produce summary estimates of likelihood ratios (LRs). Our review showed that transvaginal cervical sonography identifies women who are at higher risk of spontaneous preterm birth, although there was a wide variation amongst studies with respect to gestational age at testing, definition of threshold of abnormality and definition of reference standard. The most commonly reported sub-group was testing of asymptomatic women at < 20 weeks' gestation using a threshold cervical length of 25 mm with spontaneous preterm birth before 34 weeks' gestation as the reference standard. The summary LR+ for this group was 6.29 (95% CI, 3.29-12.02), with corresponding LR- of 0.79 (95% CI, 0.65-0.95). Both cervical length measurement and funneling, whether alone or in combination, appear to be useful (depending on the threshold chosen to define the abnormality) in predicting spontaneous preterm birth in asymptomatic women. For symptomatic women there was a paucity of data, although the degree of funneling appeared to be predictive of spontaneous preterm birth.

Risk factors associated with endometrial polyps in abnormal uterine bleeding

OBJECTIVES

To evaluate the significance of various risk factors associated with endometrial polyps in women with abnormal uterine bleeding.

METHODS

A prospective cohort study of 248 consecutive patients evaluated for abnormal uterine bleeding in a Rapid Access Ambulatory Diagnostic (RAAD) clinic was carried out from 1996 to 1997. Endometrial polyps were diagnosed using outpatient hysteroscopy and their histological nature was confirmed in all patients by performing inpatient polypectomy. Multivariate logistic regression modeling was used to evaluate the effects of age, parity, menopausal status, hormone replacement therapy and tamoxifen treatment on the occurrence of polyps.

RESULTS

In an analysis adjusted for the effects of age, parity and menopausal status, tamoxifen treatment was associated with endometrial polyps (adjusted odds ratio 11.21, 95% confidence interval 2.70-46.46, P=0.0009) but hormone replacement therapy was not (adjusted odds ratio 1.48, 95% confidence interval 0.68-3.20, P=0.32).

CONCLUSION

Our study confirmed that tamoxifen is associated with endometrial polyps. However, it rejects the hypothesis that hormone replacement therapy is a risk factor for endometrial polyps.

Accuracy of outpatient endometrial biopsy in the diagnosis of endometrial hyperplasia

BACKGROUND

To determine the accuracy of outpatient endometrial biopsy in diagnosing endometrial hyperplasia in women with abnormal uterine bleeding.

DESIGN

Systematic quantitative review of published medical literature.

DATA SOURCES

Relevant papers were identified through electronic scanning of MEDLINE (1980-1999) and EMBASE (1980-1999), manual searching of bibliography of known primary and review articles and contact with manufacturers.

REVIEW METHODS

Studies were selected if accuracy of outpatient endometrial biopsy, in women with abnormal pre or postmenopausal uterine bleeding, was estimated compared to a reference standard, which was endometrial histology obtained by tissue sampling under anesthesia. Quality assessment and data extraction were performed in duplicate. Diagnostic accuracy was determined by pooled likelihood ratios (LR) for positive and negative test results for endometrial hyperplasia.

RESULTS

There were 881 subjects in 8 diagnostic evaluations reported in 6 primary studies. Postmenopausal women represented 25% of the participants studied. There were 43 patients in whom outpatient sampling was inadequate. A positive test result on outpatient biopsy diagnosed endometrial hyperplasia with a pooled LR of 12.0 (95% CI 7.8-18.6) while a negative test result had a pooled LR of 0.2 (95% CI 0.1-0.3). With a positive test result, the posttest probability of endometrial hyperplasia was 57.7% (95% CI 41.1%-72.7%) while it was 2.2% (95% CI 0.9%-4.1%) with a negative test.

CONCLUSION

Outpatient endometrial biopsy has modest accuracy in diagnosing endometrial hyperplasia. Therefore, additional endometrial assessment should be undertaken, especially if symptoms persist or intrauterine structural abnormalities are suspected.

Hysterectomy with bilateral salpingo-oophorectomy: a survey of gynecological practice

BACKGROUND

Oophorectomy at the time of hysterectomy can be carried out by open and minimally invasive methods. The objective of this survey was to determine the current operative practice concerning oophorectomy at hysterectomy for benign gynecological disease in the UK, and to establish practitioners' views regarding the desirability of a randomized controlled clinical trial to compare various operative techniques for this procedure.

SETTING

Gynecologists associated with the British Society of Gynecological Endoscopy.

METHODS

A self-administered structured questionnaire was posted to 323 UK gynecologists to enquire about their surgical practice in performing oophorectomy at hysterectomy and their willingness to participate in a randomized trial.

RESULTS

The postal questionnaire was returned by 147 (46% response rate). For performing oophorectomy at hysterectomy, 84 (57%) routinely used laparotomy only. However, 67 (46%) in total were competent in all surgical methods i.e. laparotomy, vaginal and laparoscopical. Of these, 38 (57%) were willing to enter patients into a proposed clinical trial comparing vaginal and laparoscopically assisted oophorectomy at hysterectomy.

CONCLUSION

The current surgical approach to performing oophorectomy at hysterectomy varies widely. This suggests that opinion regarding the relative roles of abdominal, vaginal and laparoscopic methods is divided. Hence, a rigorous randomized trial comparing the efficacy and safety of these methods is practicable and urgently needed.

Maternal posture in labour

The position adopted naturally by women during birth has been described as early as 1882 by Engelmann. He observed that primitive woman, not influenced by Western conventions would try to avoid the dorsal position and was allowed to change position as and when she wished. Different upright positions could be achieved using posts, slung hammock, furniture, holding on to a rope, knotted piece of cloth, or the woman could kneel, crouch, or squat using bricks, stones, a pile of sand, or a birth stool. Today the majority of women in Western societies deliver in a dorsal, semi-recumbent or lithotomy position. It is claimed that the dorsal position enables the midwife/obstetrician to monitor the fetus better and thus to ensure a safe birth. This paper examines the historical background of the different positions used and its evolution throughout the decades. We have reviewed the available evidence about the effectiveness, benefits and possible disadvantages for the use of different positions during the first and second stage of labour.

Controlled analysis of factors associated with insufficient sample on outpatient endometrial biopsy

We examined the relative significance of hysteroscopic and ultrasonographic evidence of endometrial atrophy in relation to insufficient sample on outpatient endometrial biopsy in women with abnormal uterine bleeding. Multivariate logistic regression modelling was used to evaluate the independent effects of age, menopausal status, hysteroscopic findings and sonographic endometrial thickness on outpatient endometrial sampling (sufficient or insufficient) used as the binary dependent variable. Insufficient sample on endometrial biopsy was associated with hysteroscopic finding of endometrial atrophy (OR 4.79, 95% CI 1.05-21.91, P = 0.04) and sonographic endometrial thickness below 5 mm (OR 0- 19. 95% CI 0.07-0.53, P = 0.001). There was no association with patient's age and menopausal status. In conclusion, when reassuring women with insufficient sample on outpatient endometrial biopsy, one can be confident about absence of pathology provided the hysteroscopic and sonographic endometrial assessment is consistent with endometrial atrophy.

Surgical correction of congenital uterine anomalies

Congenital uterine abnormalities have been associated with poor reproductive outcome. Anatomical corrections utilizing open or endoscopic surgery has been recommended to improve these outcomes. This article assesses the available evidence.

The risk of premalignant and malignant pathology in endometrial polyps

OBJECTIVE

To evaluate the risk of premalignant and malignant pathology among endometrial polyps.

DESIGN

Prospective cohort study.

SETTING

Minimal Access Surgical Training (MAST) center in a large teaching hospital.

METHODS

Among 248 patients seen in outpatient hysteroscopy clinic (1996-97), 62 had endometrial polyps. All patients had endometrial sampling for histological assessment. To determine the magnitude of malignant potential among polyps, we compared the pathological findings in polyps (cases) with non-polypoidal specimens (controls).

RESULTS

Out of 62 polyps, histologically 53 (85.5%) were benign, seven (11.3%) had hyperplasia, and two (3.2%) were associated with malignancy. Hyperplasia was more frequent in endometrial specimens with polyps than in those without (11.3% vs 4.3%, p=0.04), but the incidence of carcinoma in the two groups was the same (3.2% vs 3.2%, p= 1.0).

CONCLUSION

In abnormal uterine bleeding, hyperplasia was, but cancer was not, more common in women with endometrial polyps compared to those without polyps.

Woman's position during second stage of labour

BACKGROUND

For centuries, there has been controversy around whether being upright (sitting, birthing stools, chairs, squatting) or lying down have advantages for women delivering their babies.

OBJECTIVES

The objective of this review was to assess the benefits and risks of the use of different positions during the second stage of labour (i. e. from full dilatation of the cervix).

SEARCH STRATEGY

Relevant trials are identified from the register of trials maintained by the Cochrane Pregnancy and Childbirth Group, and from the Cochrane Controlled Trials Register.

SELECTION CRITERIA

Trials were included which compared various positions assumed by pregnant women during the second stage of labour. Randomised and quasi-randomised trials with appropriate follow-up were included.

DATA COLLECTION AND ANALYSIS

Trials were independently assessed for inclusion, and data extracted, by the two authors. Disagreements would have been resolved by consensus with an editor. Meta-analysis of data is performed using the RevMan software.

MAIN RESULTS

Results should be interpreted with caution as the methodological quality of the 18 trials was variable. Use of any upright or lateral position, compared with supine or lithotomy positions, was associated with: 1. Reduced duration of second stage of labour (12 trials - mean 5.4 minutes, 95% confidence interval (CI) 3.9 - 6.9 minutes). This was largely due to a considerable reduction in women allocated to use of the birth cushion. 2. A small reduction in assisted deliveries (17 trials - odds ratio (OR) 0.82, 95% CI 0.69 - 0.98). 3. A reduction in episiotomies (11 trials - OR 0.73, 95% CI 0.64 - 0.84). 4. A smaller increase in second degree perineal tears (10 trials - OR 1.30, 95% CI 1.09 - 1.54). 5. Increased estimated risk of blood loss > 500ml (10 trials - OR 1.76, 95% CI 1.34 - 3.32). 6. Reduced reporting of severe pain during second stage of labour (1 trial - OR 0.59, 95% CI 0.41 - 0.83). 7. Fewer abnormal fetal heart rate patterns (1 trial - OR 0.31, 95% CI 0.11 - 0.91).

REVIEWER'S CONCLUSIONS

The tentative findings of this review suggest several possible benefits for upright posture, with the possibility of increased risk of blood loss > 500ml. Women should be encouraged to give birth in the position they find most comfortable. Until such time the benefits and risks of various delivery positions are estimated with greater certainty when methodologically stringent trials data are available, then women should be allowed to make informed choices about the birth positions in which they might wish to assume for delivery of their babies.

Laparoscopic management of ectopic pregnancy

The incidence of ectopic pregnancy has been rising over the last 20 years. The cause is multifactorial. The technical advancement in the field of minimal access surgery has greatly enhanced the possibility of both diagnosing and treating the condition effectively. The management of ectopic pregnancy can be expectant and surgical; the latter can be by open or laparoscopic methods. Laparoscopic surgery is usually performed when the patient is haemodynamically stable, the hCG is <6000 IU/L, the history is suggestive of minimal pelvic adhesions and when the pregnancy is confined within the tube. This procedure is, however, vastly dependent on the experience and expertise of the surgeon and the equipment facilities available. There are various means of treating ectopic pregnancy by laparoscopy. This includes laparoscopic salpingectomy, salpingotomy, and direct injection of cytotoxic agents. This article will present an overview to ascertain the effectiveness of minimal access surgery in managing ectopic pregnancy. There seems little doubt that laparoscopic management should be the first line of treatment. The way to realize its full potential is by formulating clear guidelines regarding the indication and implementation of laparoscopic surgery and emphasising the role of a fully structured training program to achieve the goals.

The diagnostic accuracy of ultrasound scan in predicting endometrial hyperplasia and cancer in postmenopausal bleeding

OBJECTIVE

To determine the accuracy of ultrasound scan in the diagnosis of endometrial hyperplasia and cancer in postmenopausal bleeding.

DESIGN

A prospective diagnostic accuracy study (1996-97).

SETTING

Minimal access surgical training centers in two large teaching hospitals.

METHODS

Ultrasound scan and outpatient endometrial sampling were performed on 96 patients with postmenopausal bleeding. Patients unable to have these outpatient procedures had a formal inpatient hysteroscopy and curettage. Test performance characteristics were computed for ultrasound scan comparing its estimate of endometrial thickness with histologic diagnosis that served as a 'gold' standard.

OUTCOME MEASURES

Accuracy of the ultrasonic endometrial thickness was estimated using sensitivity, specificity and predictive values for binary data. For multilevel data, the diagnostic accuracy was computed using likelihood ratios (LRs). An LR < decreased the probability that endometrial hyperplasia/cancer was present, whereas an LR > 1 increased the probability that such lesion was present.

RESULTS

Using endometrial thickness > or =4 mm, the sensitivity of ultrasound to detect the endometrial malignancy was 92.9%, the specificity was 500%, and the positive and negative predictive values were 24.1% and 97.6% respectively. Analysis using likelihood ratio (LR) revealed that LR was 0.14 for endometrial thickness > or =4.0 mm, 0.94 for endometrial thickness 4.1-9.0 mm, and 3.3 for endometrial thickness >9.0 mm.

CONCLUSION

In women with postmenopausal bleeding, malignancy can probably be safely excluded if sonographic endometrial thickness is < or = 4.0 mm. However, the probability of endometrial hyperplasia/cancer is not particularly altered by the knowledge that endometrial thickness on scan is >4.0 mm.

Abdominal, laparoscopic, and vaginal hysterectomy with bilateral salpingo-oophorectomy: a feasibility study for further evaluation in randomized trials

BACKGROUND

The abdominal route is the traditional method of performing hysterectomy with bilateral salpingo-oophorectomy. In a feasibility study, we compared a nonconventional (vaginal) route for bilateral salpingo-oophorectomy at the time of vaginal hysterectomy (VH + BSO) to similar forms of hysterectomy performed abdominally or with operative laparoscopy.

METHODS

Fifty-nine patients were subject to either total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH + BSO; n = 19), or laparoscopic-assisted vaginal hysterectomy and bilateral salpingo-oophorectomy (LAVH + BSO; n = 19) or VH + BSO (n = 21).

RESULTS

VH + BSO resulted in a shorter operating time compared to LAVH + BSO (p < 0.001), shorter hospital stay compared with TAH + BSO (p = 0.001), and quicker long-term recovery compared to the other two operations.

CONCLUSION

This preliminary but significant study shows that the vaginal route for salpingo-oophorectomy at the time of vaginal hysterectomy is superior to other methods of hysterectomy. A randomized trial is needed to confirm these initial findings.

The Gupta-Frank clamp for salpingo-oophorectomy at vaginal hysterectomy

BACKGROUND

When performing a vaginal hysterectomy, removal of the tubes and ovaries can be either necessary or desirable. We describe our experience with a new instrument called the Gupta-Frank clamp for performing vaginal salpingo-oophorectomy at the time of vaginal hysterectomy.

INSTRUMENT

The stainless steel Gupta-Frank clamp is 260 mm long, and its shanks are curved to avoid impedance from the vaginal walls. The 70-mm jaws have a smooth curve, which allows both the round and infundibulopelvic ligaments to be incorporated into a single clamp bite. Each jaw has three serrated grooves, which interlock with the corresponding jaw grooves to give a 6-mm-wide atraumatic nonslip area.

EXPERIENCE

We have used this instrument in 18 women undergoing bilateral salpingo-oophorectomy at the time of vaginal hysterectomy. A single clamp bite on each side was sufficient to accomplish salpingo-oophorectomy in all cases. There were no major complications.

CONCLUSION

Salpingo-oophorectomy performed vaginally at the time of vaginal hysterectomy with the Gupta-Frank clamp is feasible and is accomplished easily and safely.

To peritonealize or not to peritonealize? A randomized trial at abdominal hysterectomy

OBJECTIVES

Our purpose was to determine whether nonclosure of the visceral and parietal peritoneum alters the intraoperative or postoperative course at abdominal hysterectomy.

STUDY DESIGN

The setting was a gynecology unit in a university teaching hospital. A parallel-group, single-blind randomized controlled trial was performed on 144 women who underwent abdominal hysterectomy with or without salpingo-oophorectomy. Seventy-six women were allocated to the control "closed" group and 68 women to the study "open" group. The main outcome measures were operative time, estimated blood loss, postoperative pain assessed by visual analog scale, and amount of postoperative analgesia.

RESULTS

The mean operative time was shorter by 10 minutes (p < 0.001) and there was a 45 ml reduction of estimated blood loss in the nonclosure group (p=0.03). There were no differences in postoperative pain in the two groups.

CONCLUSIONS

Peritoneal closure at abdominal hysterectomy provides no immediate postoperative benefits while unnecessarily lengthening surgical time and anesthesia exposure. We suggest that the traditional practice of visceral and parietal peritoneal closure be abolished at abdominal hysterectomy.

Nucleolar organizer regions in neoplastic and non-neoplastic epithelium of the cervix

Argyrophilic nucleolar organizer regions (Ag NORs) were counted in biopsies from 203 cases of various lesions of the cervix. The mean number of Ag NORs per nucleus was significantly higher in CIN (4.05 +/- 0.04) and malignancy (5.50 +/- 0.65) as compared to squamous metaplasia (1.74 +/- 0.32) and chronic cervicitis (1.54 +/- 0.42). Adenocarcinomas had higher Ag NOR counts compared to other carcinomas. Estimation of Ag NORs can be helpful in distinguishing benign lesions from CIN and malignancy of the cervix.

How should we investigate women with postmenopausal bleeding?

OBJECTIVE

To evaluate the optimum method(s) of investigating women with postmenopausal bleeding.

DESIGN

Prospective study of 76 postmenopausal women.

SETTING

Teaching Hospital. Interventions. All women had pipelle endometrial biopsy in outpatient clinic. Prior to inpatient hysteroscopy and uterine curettage, each woman had pelvic ultrasonography to measure the endometrial thickness and to exclude ovarian pathology.

RESULTS

Pipelle biopsy was successful in 70% of cases and has a sensitivity of 70%. Hysteroscopy has superior diagnostic capabilities allowing direct visualisation of the endometrial cavity with directed biopsies. Endometrial thickness of > 5 mm used as an indicator of endometrial pathology compared to uterine curettage has a sensitivity of 83%, a specificity of 77%, and a positive predictive value of 54%. Ultrasound also detected five ovarian tumors, two of which were malignant and three missed by pelvic examination alone.

CONCLUSIONS

We recommend the routine use of pelvic ultrasonography in all women with postmenopausal bleeding as it is an invaluable diagnostic tool in excluding ovarian pathology. In addition, sampling of the endometrial cavity, preferably with outpatient hysteroscopy, is mandatory for histological diagnosis. Overall, the combination of ultrasound and outpatient endometrial sampling would spare hospital admission for at least 60% of women with postmenopausal bleeding.

Purification and properties of levanase from Rhodotorula sp

Levanase, a slime dissolving enzyme of Rhodotorula sp., was purified to approx. 26-fold by ammonium sulphate precipitation, DEAE and gel filtration (Sephacryl S-200) chromatography. The molecular mass of the enzyme was 39 kDa. The purified levanase showed maximum activity at pH 6.0 and 40 degrees C. Enzyme was quite stable at 4 degrees C and at pH 5.5 to 6.5. Hg2+ at a level of 10 mM completely inhibited the levanase activity, while 2-mercaptoethanol at the same concentration showed a 2.93-times increase in activity. In addition to levan, the enzyme also showed substrate specificity towards inulin.

Clinical significance of fetal choroid plexus cysts

Choroid plexus (CP) cysts are commonly detected on routine mid-trimester ultrasound scan. When associated anomalies are detected, the risk is sufficient to justify an invasive diagnostic test such as amniocentesis. However, the risk when no associated anomalies are detected is much less well defined. This information is required to determine the appropriate management in cases of apparently isolated CP cysts. We thought the only way to resolve the difficulties in counselling prospective parents was to conduct a prospective study in a large unselected population. A registry of fetal CP cysts detected over 3 years in the Yorkshire Region was compiled and we identified 524 CP cysts. These cases were then amalgamated and analysed with 1361 cases from prospective studies reported in the world English literature and a further 71 unpublished cases identified from a 2 year prospective series from Ninewells Hospital, Dundee. The risk of chromosomal abnormalities was 1 in 150 (95% CI 1 in 85, 1 in 261) when no fetal anatomic abnormalities, apart from the CP cysts themselves, were detected antenatally. The risk increased to approximately 1 in 3 if any other associated ultrasound abnormalities were detected antenatally. The risk did not appear to be related to whether or not cyst size diminished as gestation progresses, whether they were unilateral or bilateral, and whether they were small or large in size (60-80% < 10 mm). 76% of aneuploidic cases were trisomy 18 and 17% were trisomy 21. The risk of Down's syndrome in fetuses with CP cysts but no other anomalies detected antenatally is 1 in 880. The probability of a chromosomal abnormality is high when CP cysts are associated with any other antenatally detected anomaly, indicating a clear need to offering amniocentesis. The predictive value is much lower when no other anomalies are detected. In such cases, it is probably advisable to regard CP cysts as an indication for detailed ultrasound assessment, rather than invasive testing.

Assessment and management of fetal agenesis of the corpus callosum

Prenatal counselling for fetal agenesis of the corpus callosum is difficult as the prognosis until now has been so uncertain. We have reviewed the current world English literature to provide the best probabilistic information for prospective parents. In total, there are 70 cases where the diagnosis was made prenatally. The diagnosis of apparently isolated agenesis of the corpus callosum (in the absence of other sonographically detectable anomalies) appears to carry an excellent prognosis, with an 85 per cent chance of a normal developmental outcome and a 15 per cent risk of handicap. Fetal karyotyping is recommended as there is a 1 in 10 risk of aneuploidy. If other anomalies are detected prenatally, the outcome is very poor. Termination of pregnancy is advised in these circumstances.

Management of apparently isolated fetal ventriculomegaly

Early ultrasound examination can provide accurate antenatal diagnosis of many fetal congenital abnormalities but it is often difficult to translate this into prognosis because of the variable functional effects of similar anatomical changes. In the case of isolated fetal ventriculomegaly it is the prognosis that parents require in order to choose between continuing with the pregnancy or termination. The outcome for antenatally diagnosed ventriculomegaly seems to be worse than that reported in the neurosurgical literature for children treated with congenital hydrocephalus. Follow-up is available for 276 cases with apparently isolated ventriculomegaly who did not undergo termination of pregnancy. One hundred ninety-four (70 per cent) survived and of these 114 (59 per cent) had normal developmental quotient to follow-up. Intrapartum cephalocentesis to aid vaginal delivery is almost invariably associated with fetal/neonatal death. A favorable outcome of normal mental development is present in cases with borderline, stable (nonprogressive) isolated ventriculomegaly or cases in which ventriculomegaly has resolved in utero. Fetal surgery would seem to offer no benefit. The outcome is much worse when other associated congenital anomalies are present.