Diagnosis and management of endometrial hyperplasia: A UK national audit of adherence to national guidance 2012-2020

BACKGROUND

Endometrial hyperplasia (EH) is a precusor lesion for endometrial cancer (EC), the commonest gynaecological malignancy in high-income countries. EH is a proliferation of glandular tissue, classified as either non-atypical endometrial hyperplasia (NEH) or, if the cytological features are abnormal, atypical endometrial hyperplasia (AEH). The clinical significance of AEH is that patients face both a high risk of having occult EC and a high risk of progression to EC if untreated. Recommendations on the care of women with EH were introduced by United Kingdom-wide guidance (Green-top Guide No. 67, 2016). National adherence to guidance is unknown. We aimed to describe the care of patients with EH; to compare the patterns of care for those with EH with national guidance to identify opportunities for quality improvement; and to compare patterns of care prior to and following the introduction of national guidance to understand its impact.

METHODS AND FINDINGS

In this UK-wide patient-level clinical audit, we included 3,307 women who received a new histological diagnosis of EH through a gynaecology service between 1 January 2012 and 30 June 2020. We described first-line management, management at 2 years, and surgical characteristics prior to and following national guidance for EH using proportions and 95% confidence intervals (CIs) and compared process measures between time periods using multilevel Poisson regression. Of the 3,307 patients, 1,570 had NEH and 1,511 had AEH between 2012 and 2019. An additional 85 patients had NEH and 141 had AEH during 2020. Prior to national guidance, 9% (95% CI [6%, 15%]) received no initial treatment for NEH compared with 3% (95% CI [1%, 5%]) post-guidance; 31% (95% CI [26%, 36%]) and 48% (95% CI [43% 53%]) received an intrauterine progestogen, respectively, in the same periods. The predominant management of women with AEH did not differ, with 68% (95% CI [61%, 74%]) and 67% (95 CI [63%, 71%]) receiving first-line hysterectomy, respectively. By 2 years, follow-up to histological regression without hysterectomy increased from 38% (95% CI [33%, 43%]) to 52% (95% CI [47%, 58%]) for those with NEH (rate ratio (RR) 1.38, 95% CI [1.18, 1.63] p < 0.001). We observed an increase in the use of total laparoscopic hysterectomy among those with AEH (RR 1.26, 95% CI [1.04, 1.52]). In the later period, 37% (95% CI [29%, 44%]) of women initially diagnosed with AEH who underwent a first-line hysterectomy, received an upgraded diagnosis of EC. Study limitations included retrospective data collection from routine clinical documentation and the inability to comprehensively understand the shared decision-making process where care differed from guidance.

CONCLUSIONS

The care of patients with EH has changed in accordance with national guidance. More women received first-line medical management of NEH and were followed up to histological regression. The follow-up of those with AEH who do not undergo hysterectomy must be improved, given their very high risk of coexistent cancer and high risk of developing cancer.

Ezrin and Its Phosphorylated Thr567 Form Are Key Regulators of Human Extravillous Trophoblast Motility and Invasion

The protein ezrin has been shown to enhance cancer cell motility and invasion leading to malignant behaviours in solid tumours, but a similar regulatory function in the early physiological reproduction state is, however, much less clear. We speculated that ezrin may play a key role in promoting first-trimester extravillous trophoblast (EVT) migration/invasion. Ezrin, as well as its Thr567 phosphorylation, were found in all trophoblasts studied, whether primary cells or lines. Interestingly, the proteins were seen in a distinct cellular localisation in long, extended protrusions in specific regions of cells. Loss-of-function experiments were carried out in EVT HTR8/SVneo and Swan71, as well as primary cells, using either ezrin siRNAs or the phosphorylation Thr567 inhibitor NSC668394, resulting in significant reductions in both cell motility and cellular invasion, albeit with differences between the cells used. Our analysis further demonstrated that an increase in focal adhesion was, in part, able to explain some of the molecular mechanisms involved. Data collected using human placental sections and protein lysates further showed that ezrin expression was significantly higher during the early stage of placentation and, importantly, clearly seen in the EVT anchoring columns, further supporting the potential role of ezrin in regulating migration and invasion in vivo.

Synthetic osmotic dilators (Dilapan-S) or dinoprostone vaginal inserts (Propess) for inpatient induction of labour: A UK cost-consequence model

OBJECTIVE

To estimate the costs of synthetic osmotic dilators (Dilapan-S) compared to dinoprostone vaginal inserts (Propess) for inpatient induction of labour (IOL).

STUDY DESIGN

A population-level, Markov model-based cost-consequence analysis was developed to compare the impact of using Dilapan-S versus Propess. The time horizon was modelled from admission to birth. The target population was women requiring inpatient IOL from 37 weeks with an unfavourable cervix in the UK. Mean population characteristics reflected those of the SOLVE (NCT03001661) trial. No patient data were included in this analysis. The care pathways and staff workload were modelled using data from the SOLVE trial and clinical experience. Cost and clinical inputs were sourced from the SOLVE trial and peer-reviewed literature. Costs were inflated to 2020 British pounds (GBP, £). Outcomes were reported as an average per woman for total costs and required staff time (minutes) from admission for IOL until birth. The model robustness was assessed using a probabilistic, multivariate sensitivity analysis of 2,000 simulations with results presented as the median (interquartile range, IQR).

RESULTS

Dilapan-S was cost neutral compared to Propess. Midwife and obstetrician times were decreased by 146 min (-11%) and 11 min (-54%), respectively. Sensitivity analysis showed that in 78% of simulations, use of Dilapan-S reduced midwife time with a median of -160 min (IQR -277 to -24 min). Costs were reduced in 54% of simulations (median -£33, IQR -£319 to £282).

CONCLUSIONS

The model indicates that adoption of Dilapan-S is likely to be cost-neutral and reduce staff workload in comparison to Propess. Results require support from real-world data and further exploration of Dilapan-S is to be encouraged.

A randomized trial of synthetic osmotic cervical dilator for induction of labor vs dinoprostone vaginal insert

BACKGROUND

Induction of labor is a commonly performed obstetrical intervention. Vaginal prostaglandin E2 (dinoprostone) is a first-choice agent. Mechanical methods of induction are slower in achieving cervical ripening but have a lower risk of adverse effects.

OBJECTIVE

This study aimed to compare the efficacy, maternal and neonatal safety, and maternal satisfaction of a synthetic osmotic cervical dilator (Dilapan-S) with those of dinoprostone.

STUDY DESIGN

This was an open-label superiority randomized controlled trial in 4 English hospitals. Eligible participants were women ≥16 years of age undergoing induction of labor for a singleton pregnancy at ≥37 weeks' gestation with vertex presentation and intact membranes. The women were randomly assigned to receive either Dilapan-S or dinoprostone using a telephone randomization system minimized by hospital, parity, body mass index, and maternal age. The induction agent was replaced as required until the cervix was assessed as favorable for labor by the Bishop score. The primary outcome was failure to achieve vaginal delivery (ieor a cesarean delivery being performed). The secondary outcome measures included maternal and neonatal adverse events. Analysis was by intention-to-treat, adjusting for design variables where possible.

RESULTS

Between December 19, 2017 and January 26, 2021, 674 women were randomized (337 to Dilapan-S, and 337 to dinoprostone). The trial did not reach its planned sample size of 860 participants because of restrictions on research during the COVID-19 pandemic. The primary outcome was missing for 2 women in the dinoprostone group. Failure to achieve vaginal delivery (or a cesarean delivery being performed) occurred in 126 women (37.4%) allocated to Dilapan-S and in 115 (34.3%) women allocated to dinoprostone (adjusted risk difference, 0.02; 95% confidence interval, -0.05 to 0.10). There were similar maternal and neonatal adverse events between the groups.

CONCLUSION

Women undergoing induction of labor with Dilapan-S have similar rates of cesarean delivery and maternal and neonatal adverse events compared with dinoprostone.

The feasibility, safety, and effectiveness of hysteroscopic sterilization compared with laparoscopic sterilization

BACKGROUND

In contrast to conventional laparoscopic sterilization, newer hysteroscopic approaches avoid the need for hospital admission, general anesthesia, and prolonged recovery. However, there are concerns that the feasibility, safety, and efficacy of hysteroscopic sterilization may be lower than established laparoscopic sterilization.

OBJECTIVE

We sought to evaluate the outcomes of hysteroscopic sterilization compared with laparoscopic sterilization in routine clinical practice in a comparative observational cohort study.

STUDY DESIGN

This study was carried out at University of Birmingham, United Kingdom, National Health Service teaching hospital, office hysteroscopy clinics, and day-case hospital unit. In all, 1085 women underwent hysteroscopic sterilization and 2412 had laparoscopic sterilization. Hysteroscopic sterilization was carried out using the tubal implant permanent birth control system in the office setting and laparoscopic sterilization using the tubal ligation system as a day-case under general anesthesia. Outcome data were collected regarding feasibility (technical completion of the sterilization procedure, satisfactory radiological confirmation at 3 months-hysterosalpingogram or transvaginal pelvic ultrasound scan), safety events within 30 days of procedures, reoperations, and unintended pregnancies within 1 year of procedures.

RESULTS

Hysteroscopic sterilization was successful in 992/1085 (91.4%; 95% confidence interval, 89.6-93.0%) at the first attempt. In comparison, bilateral tubal ligation was successfully performed in 2400/2412 (99.5%; 95% confidence interval, 99.2-99.8%) of patients who underwent laparoscopic sterilizations (odds ratio, 18.8; 95% confidence interval, 10.2-34.4). In all, 902/1085 (83.1%; 95% confidence interval, 80.8-85.2%) of successfully performed hysteroscopic procedures attended for radiological confirmation testing were considered satisfactory. The rate of adverse events within 30 days were similar: 2/1085 (0.2%) vs 3 (0.12%; 95% confidence interval, 0.04-0.36%). There were 3/1085 (0.3%; 95% confidence interval, 0.1-0.8%) unintended pregnancies after hysteroscopic sterilization compared with 5/2412 (0.2%; 95% confidence interval, 0.1-0.5%) laparoscopic sterilization (odds ratio, 1.3; 95% confidence interval, 0.3-5.6). Median length of follow-up for pregnancy outcome was 5 years. Hysteroscopic sterilization was associated with a higher risk of reoperation at 1 year compared to laparoscopic sterilization (odds ratio, 6.2; 95% confidence interval, 2.8-14.0) and the commonest reintervention was unilateral salpingectomy (12/22, 54.5%).

CONCLUSION

Hysteroscopic sterilization has been introduced as a more convenient, office-based method of permanent fertility control. However, while the small risk of unintended pregnancy is comparable to conventional laparoscopic sterilization, women should also be counselled regarding its lower success rate in successfully completing the procedure and its higher rate of failed reoperation.

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.

Position in the second stage of labour for women without epidural anaesthesia

BACKGROUND

For centuries, there has been controversy around whether being upright (sitting, birthing stools, chairs, squatting, kneeling) or lying down (lateral (Sim's) position, semi-recumbent, lithotomy position, Trendelenburg's position) have advantages for women giving birth to their babies. This is an update of a review previously published in 2012, 2004 and 1999.

OBJECTIVES

To determine the possible benefits and risks of the use of different birth positions during the second stage of labour without epidural anaesthesia, on maternal, fetal, neonatal and caregiver outcomes.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (30 November 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised, quasi-randomised or cluster-randomised controlled trials of any upright position assumed by pregnant women during the second stage of labour compared with supine or lithotomy positions. Secondary comparisons include comparison of different upright positions and the supine position. Trials in abstract form were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and assessed trial quality. At least two review authors extracted the data. Data were checked for accuracy. The quality of the evidence was assessed using the GRADE approach.

MAIN RESULTS

Results should be interpreted with caution because risk of bias of the included trials was variable. We included eleven new trials for this update; there are now 32 included studies, and one trial is ongoing. Thirty trials involving 9015 women contributed to the analysis. Comparisons include any upright position, birth or squat stool, birth cushion, and birth chair versus supine positions.In all women studied (primigravid and multigravid), when compared with supine positions, the upright position was associated with a reduction in duration of second stage in the upright group (MD -6.16 minutes, 95% CI -9.74 to -2.59 minutes; 19 trials; 5811 women; P = 0.0007; random-effects; I² = 91%; very low-quality evidence); however, this result should be interpreted with caution due to large differences in size and direction of effect in individual studies. Upright positions were also associated with no clear difference in the rates of caesarean section (RR 1.22, 95% CI 0.81 to 1.81; 16 trials; 5439 women; low-quality evidence), a reduction in assisted deliveries (RR 0.75, 95% CI 0.66 to 0.86; 21 trials; 6481 women; moderate-quality evidence), a reduction in episiotomies (average RR 0.75, 95% CI 0.61 to 0.92; 17 trials; 6148 women; random-effects; I² = 88%), a possible increase in second degree perineal tears (RR 1.20, 95% CI 1.00 to 1.44; 18 trials; 6715 women; I² = 43%; low-quality evidence), no clear difference in the number of third or fourth degree perineal tears (RR 0.72, 95% CI 0.32 to 1.65; 6 trials; 1840 women; very low-quality evidence), increased estimated blood loss greater than 500 mL (RR 1.48, 95% CI 1.10 to 1.98; 15 trials; 5615 women; I² = 33%; moderate-quality evidence), fewer abnormal fetal heart rate patterns (RR 0.46, 95% CI 0.22 to 0.93; 2 trials; 617 women), no clear difference in the number of babies admitted to neonatal intensive care (RR 0.79, 95% CI 0.51 to 1.21; 4 trials; 2565 infants; low-quality evidence). On sensitivity analysis excluding trials with high risk of bias, these findings were unchanged except that there was no longer a clear difference in duration of second stage of labour (MD -4.34, 95% CI -9.00 to 0.32; 21 trials; 2499 women; I² = 85%).The main reasons for downgrading of GRADE assessment was that several studies had design limitations (inadequate randomisation and allocation concealment) with high heterogeneity and wide CIs.

AUTHORS' CONCLUSIONS

The findings of this review suggest several possible benefits for upright posture in women without epidural anaesthesia, such as a very small reduction in the duration of second stage of labour (mainly from the primigravid group), reduction in episiotomy rates and assisted deliveries. However, there is an increased risk blood loss greater than 500 mL and there may be an increased risk of second degree tears, though we cannot be certain of this. In view of the variable risk of bias of the trials reviewed, further trials using well-designed protocols are needed to ascertain the true benefits and risks of various birth positions.

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.

The relationship between pelvic vein incompetence and chronic pelvic pain in women: systematic reviews of diagnosis and treatment effectiveness

BACKGROUND

Pelvic congestion syndrome (PCS) is described as chronic pelvic pain (CPP) arising from dilated and refluxing pelvic veins, although the causal relationship between pelvic vein incompetence (PVI) and CPP is not established. Non-invasive screening methods such as Doppler ultrasound and magnetic resonance venography are used before confirmation by venography. Percutaneous embolisation has become the principal treatment for PCS, with high success rates often cited.

OBJECTIVES

Our proposal aimed to systematically and critically review the definitions and diagnostic criteria of PCS, the association between PVI and CPP, the accuracy of various non-invasive imaging techniques and the effectiveness of embolisation for PVI; and to identify factors associated with successful outcome. We also wished to survey clinicians and patients to assess awareness and management of PCS and gauge the enthusiasm for further research.

DATA SOURCES

A comprehensive search strategy encompassing various terms for pelvic congestion, pain, imaging techniques and embolisation was deployed in 17 bibliographic databases, including MEDLINE, EMBASE and Web of Science. There was no restriction on study design.

METHODS

Methodological quality was assessed using appropriate tools. Online surveys were sent to clinicians and patients. The quality and heterogeneity generally precluded meta-analysis and so results were tabulated and described narratively.

RESULTS

We identified six association studies, 10 studies involving ultrasound, two studies involving magnetic resonance venography, 21 case series and one poor-quality randomised trial of embolisation. There were no consistent diagnostic criteria for PCS. We found that the associations between CPP and PVI were generally fairly similar, with three of five studies with sufficient data showing statistically significant associations (odds ratios of between 31 and 117). The prevalence of PVI ranged widely, although the majority of women with PVI had CPP. Transvaginal ultrasound with Doppler and magnetic resonance venography are both useful screening methods, although the data on accuracy are limited. Early substantial relief from pain symptoms was observed in approximately 75% of women undergoing embolisation, a figure which generally increased over time and was sustained. Reintervention rates were generally low. Transient pain was a common occurrence following foam embolisation, while there was a < 2% risk of coil migration. Confidence in the embolisation technique is reasonably high, although there is a desire to strengthen the evidence base. Even among women with CPP, fewer than half had any knowledge about PCS.

CONCLUSIONS

The data supporting the diagnosis and treatment of PCS are limited and of variable methodological quality. There is some evidence to tentatively support a causative association, but it cannot be categorically stated that PVI is the cause of CPP in women with no other pathology, as the six most pertinent drew on clinically disparate populations and defined PVI inconsistently. Embolisation appears to provide symptomatic relief in the majority of women and is safe. However, the majority of included studies of embolism were relatively small case series and only the randomised controlled trial was considered at risk of potential biases. There is scope and demand for considerable further research. The question of the association of PVI and CPP requires a well-designed and well-powered case-control study, which will also provide data to derive a diagnostic standard. An adequately powered randomised trial is essential to provide evidence on the effectiveness of embolisation, but this faces methodological challenges.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42012002237 and CRD42012002238.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Effectiveness of Embolization or Sclerotherapy of Pelvic Veins for Reducing Chronic Pelvic Pain: A Systematic Review

PURPOSE

Chronic pelvic pain (CPP) in the presence of dilated and refluxing pelvic veins is often described as pelvic congestion syndrome (PCS), although the causal relationship between pelvic vein incompetence and CPP has not been established. Percutaneous embolization is the principal treatment for PCS, with high success rates cited. This study was undertaken to systematically and critically review the effectiveness of embolization of incompetent pelvic veins.

MATERIALS AND METHODS

A comprehensive search strategy encompassing various terms for pelvic congestion, pelvic pain, and embolization was deployed in 17 bibliographic databases, with no restriction on study design. Methodologic quality was assessed. The quality and heterogeneity generally precluded meta-analysis. Results were tabulated and described narratively.

RESULTS

Twenty-one prospective case series and one poor-quality randomized trial of embolization (involving a total of 1,308 women) were identified. Early substantial relief from pain was observed in approximately 75% of women undergoing embolization, and generally increased over time and was sustained. Significant pain reductions following treatment were observed in all studies that measured pain on a visual analog scale. Repeat intervention rates were generally low. There were few data on the impact on menstruation, ovarian reserve, or fertility, but no concerns were noted. Transient pain was common following foam embolization, and there was a < 2% risk of coil migration.

CONCLUSIONS

Embolization appears to provide symptomatic relief of CPP in the majority of women and is safe, although the quality of the evidence is low.

A randomised controlled trial of the clinical effectiveness and cost-effectiveness of the levonorgestrel-releasing intrauterine system in primary care against standard treatment for menorrhagia: the ECLIPSE trial

BACKGROUND

Heavy menstrual bleeding (HMB) is a common problem, yet evidence to inform decisions about initial medical treatment is limited.

OBJECTIVES

To assess the clinical effectiveness and cost-effectiveness of the levonorgestrel-releasing intrauterine system (LNG-IUS) (Mirena®, Bayer) compared with usual medical treatment, with exploration of women's perspectives on treatment.

DESIGN

A pragmatic, multicentre randomised trial with an economic evaluation and a longitudinal qualitative study.

SETTING

Women who presented in primary care.

PARTICIPANTS

A total of 571 women with HMB. A purposeful sample of 27 women who were randomised or ineligible owing to treatment preference participated in semistructured face-to-face interviews around 2 and 12 months after commencing treatment.

INTERVENTIONS

LNG-IUS or usual medical treatment (tranexamic acid, mefenamic acid, combined oestrogen-progestogen or progesterone alone). Women could subsequently swap or cease their allocated treatment.

OUTCOME MEASURES

The primary outcome was the patient-reported score on the Menorrhagia Multi-Attribute Scale (MMAS) assessed over a 2-year period and then again at 5 years. Secondary outcomes included general quality of life (QoL), sexual activity, surgical intervention and safety. Data were analysed using iterative constant comparison. A state transition model-based cost-utility analysis was undertaken alongside the randomised trial. Quality-adjusted life-years (QALYs) were derived from the European Quality of Life-5 Dimensions (EQ-5D) and the Short Form questionnaire-6 Dimensions (SF-6D). The intention-to-treat analyses were reported as cost per QALY gained. Uncertainty was explored by conducting both deterministic and probabilistic sensitivity analyses.

RESULTS

The MMAS total scores improved significantly in both groups at all time points, but were significantly greater for the LNG-IUS than for usual treatment [mean difference over 2 years was 13.4 points, 95% confidence interval (CI) 9.9 to 16.9 points; p < 0.001]. However, this difference between groups was reduced and no longer significant by 5 years (mean difference in scores 3.9 points, 95% CI -0.6 to 8.3 points; p = 0.09). By 5 years, only 47% of women had a LNG-IUS in place and 15% were still taking usual medical treatment. Five-year surgery rates were low, at 20%, and were similar, irrespective of initial treatments. There were no significant differences in serious adverse events between groups. Using the EQ-5D, at 2 years, the relative cost-effectiveness of the LNG-IUS compared with usual medical treatment was £1600 per QALY, which by 5 years was reduced to £114 per QALY. Using the SF-6D, usual medical treatment dominates the LNG-IUS. The qualitative findings show that women's experiences and expectations of medical treatments for HMB vary considerably and change over time. Women had high expectations of a prompt effect from medical treatments.

CONCLUSIONS

The LNG-IUS, compared with usual medical therapies, resulted in greater improvement over 2 years in women's assessments of the effect of HMB on their daily routine, including work, social and family life, and psychological and physical well-being. At 5 years, the differences were no longer significant. A similar low proportion of women required surgical intervention in both groups. The LNG-IUS is cost-effective in both the short and medium term, using the method generally recommended by the National Institute for Health and Care Excellence. Using the alternative measures to value QoL will have a considerable impact on cost-effectiveness decisions. It will be important to explore the clinical and health-care trajectories of the ECLIPSE (clinical effectiveness and cost-effectiveness of levonorgestrel-releasing intrauterine system in primary care against standard treatment for menorrhagia) trial participants to 10 years, by which time half of the cohort will have reached menopause.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN86566246.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 88. See the NIHR Journals Library website for further project information.

Uterine artery embolization for symptomatic uterine fibroids

BACKGROUND

Uterine fibroids cause heavy prolonged bleeding, pain, pressure symptoms and subfertility. The traditional method of treatment has been surgery as medical therapies have not proven effective. Uterine artery embolization has been reported to be an effective and safe alternative to treat fibroids in women not desiring future fertility. There is a significant body of evidence that is based on case controlled studies and case reports. This is an update of the review previously published in 2012.

OBJECTIVES

To review the benefits and risks of uterine artery embolization (UAE) versus other medical or surgical interventions for symptomatic uterine fibroids.

SEARCH METHODS

We searched sources including the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and trial registries. The search was last conducted in April 2014. We contacted authors of eligible randomised controlled trials to request unpublished data.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of UAE versus any medical or surgical therapy for symptomatic uterine fibroids. The primary outcomes of the review were patient satisfaction and live birth rate (among women seeking live birth).

DATA COLLECTION AND ANALYSIS

Two of the authors (AS and JKG) independently selected studies, assessed quality and extracted data. Evidence quality was assessed using GRADE methods.

MAIN RESULTS

Seven RCTs with 793 women were included in this review. Three trials compared UAE with abdominal hysterectomy, two trials compared UAE with myomectomy, and two trials compared UAE with either type of surgery (53 hysterectomies and 62 myomectomies).With regard to patient satisfaction rates, our findings were consistent with satisfaction rates being up to 41% lower or up to 48% higher with UAE compared to surgery within 24 months of having the procedure (odds ratio (OR) 0.94; 95% confidence interval (CI) 0.59 to 1.48, 6 trials, 640 women, I(2) = 5%, moderate quality evidence). Findings were also inconclusive at five years of follow-up (OR 0.90; 95% CI 0.45 to 1.80, 2 trials, 295 women, I(2) = 0%, moderate quality evidence). There was some indication that UAE may be associated with less favourable fertility outcomes than myomectomy, but it was very low quality evidence from a subgroup of a single study and should be regarded with extreme caution (live birth: OR 0.26; 95% CI 0.08 to 0.84; pregnancy: OR 0.29; 95% CI 0.10 to 0.85, 1 study, 66 women).Similarly, for several safety outcomes our findings showed evidence of a substantially higher risk of adverse events in either arm or of no difference between the groups. This applied to intra-procedural complications (OR 0.91; 95% CI 0.42 to 1.97, 4 trials, 452 women, I(2) = 40%, low quality evidence), major complications within one year (OR 0.65; 95% CI 0.33 to 1.26, 5 trials, 611 women, I(2) = 4%, moderate quality evidence) and major complications within five years (OR 0.56; CI 0.27 to 1.18, 2 trials, 268 women). However, the rate of minor complications within one year was higher in the UAE group (OR 1.99; CI 1.41 to 2.81, 6 trials, 735 women, I(2) = 0%, moderate quality evidence) and two trials found a higher minor complication rate in the UAE group at up to five years (OR 2.93; CI 1.73 to 4.93, 2 trials, 268 women).UAE was associated with a higher rate of further surgical interventions (re-interventions within 2 years: OR 3.72; 95% CI 2.28 to 6.04, 6 trials, 732 women, I(2) = 45%, moderate quality evidence; within 5 years: OR 5.79; 95% CI 2.65 to 12.65, 2 trials, 289 women, I(2) = 65%). If we assumed that 7% of women will require further surgery within two years of hysterectomy or myomectomy, between 15% and 32% will require further surgery within two years of UAE.The evidence suggested that women in the UAE group were less likely to require a blood transfusion than women receiving surgery (OR 0.07; 95% CI 0.01 to 0.52, 2 trials, 277 women, I(2) = 0%). UAE was also associated with a shorter procedural time (two studies), shorter length of hospital stay (seven studies) and faster resumption of usual activities (six studies) in all studies that measured these outcomes; however, most of these data could not be pooled due to heterogeneity between the studies.The quality of the evidence varied, and was very low for live birth, moderate for satisfaction ratings, and moderate for most safety outcomes. The main limitations in the evidence were serious imprecision due to wide confidence intervals, failure to clearly report methods, and lack of blinding for subjective outcomes.

AUTHORS' CONCLUSIONS

When we compared patient satisfaction rates at up to two years following UAE versus surgery (myomectomy or hysterectomy) our findings are that there is no evidence of a difference between the interventions. Findings at five year follow-up were similarly inconclusive. There was very low quality evidence to suggest that myomectomy may be associated with better fertility outcomes than UAE, but this information was only available from a selected subgroup in one small trial.We found no clear evidence of a difference between UAE and surgery in the risk of major complications, but UAE was associated with a higher rate of minor complications and an increased likelihood of requiring surgical intervention within two to five years of the initial procedure. If we assume that 7% of women will require further surgery within two years of hysterectomy or myomectomy, between 15% and 32% will require further surgery within two years of UAE. This increase in the surgical re-intervention rate may balance out any initial cost advantage of UAE. Thus although UAE is a safe, minimally invasive alternative to surgery, patient selection and counselling are paramount due to the much higher risk of requiring further surgical intervention.

Uterine fibroids: current perspectives

Uterine fibroids are a major cause of morbidity in women of a reproductive age (and sometimes even after menopause). There are several factors that are attributed to underlie the development and incidence of these common tumors, but this further corroborates their relatively unknown etiology. The most likely presentation of fibroids is by their effect on the woman's menstrual cycle or pelvic pressure symptoms. Leiomyosarcoma is a very rare entity that should be suspected in postmenopausal women with fibroid growth (and no concurrent hormone replacement therapy). The gold standard diagnostic modality for uterine fibroids appears to be gray-scale ultrasonography, with magnetic resonance imaging being a close second option in complex clinical circumstances. The management of uterine fibroids can be approached medically, surgically, and even by minimal access techniques. The recent introduction of selective progesterone receptor modulators (SPRMs) and aromatase inhibitors has added more armamentarium to the medical options of treatment. Uterine artery embolization (UAE) has now been well-recognized as a uterine-sparing (fertility-preserving) method of treating fibroids. More recently, the introduction of ultrasound waves (MRgFUS) or radiofrequency (VizAblate™ and Acessa™) for uterine fibroid ablation has added to the options of minimal access treatment. More definite surgery in the form of myomectomy or hysterectomy can be performed via the minimal access or open route methods. Our article seeks to review the already established information on uterine fibroids with added emphasis on contemporary knowledge.

Predictive ability of estrogen receptor (ER), progesterone receptor (PR), COX-2, Mlh1, and Bcl-2 expressions for regression and relapse of endometrial hyperplasia treated with LNG-IUS: a prospective cohort study

OBJECTIVE

To test the predictive ability of immunohistochemical estrogen receptor(ER), progesterone receptor (PR), COX-2, Mlh1, and Bcl-2 expressions for predicting the outcomes of regression and relapse in women with endometrial hyperplasia treated with the Levonorgestrel-releasing intrauterine system (LNG-IUS).

METHODS

We recruited prospectively all women diagnosed with complex or atypical complex hyperplasia that underwent treatment with LNG-IUS from August 1998 until September 2008. Immunohistochemistry was performed with conventional methods and recorded using a semi-quantitative score (Q score) by two blinded assessors. Women were followed with endometrial biopsies to record regression and relapse. The biomarker predictive ability was analysed using the Cox proportional hazards model.

RESULTS

The median follow-up was 72.1 months (IQR 59.1-89.8). The Q score agreement between assessors was 82.6% (K statistic=0.801 ± 0.036). The majority of study participants initially regressed to normal endometrium following LNG-IUS therapy (n = 164 regressed; n = 10 persisted). From the 164 women that regressed with LNG-IUS we were able to assess 152 women for relapse from which 18 relapsed. We found a weak association for persisted endometrial hyperplasia with ER and PR expressions with Q score on the 5th and 10th centiles. No associations were found for COX-2, Mlh1 and Bcl-2 protein expressions for regression and for any of the biomarkers for relapse.

CONCLUSION

We found that poor expression of ER and PR is weakly associated with persisting endometrial hyperplasia and COX-2, Mlh1, and Bcl-2 expressions are not predictive. None of the biomarkers is predictive for relapse in women with endometrial hyperplasia treated with LNG-IUS.

Relapse of endometrial hyperplasia after conservative treatment: a cohort study with long-term follow-up

STUDY QUESTION

What is the risk of relapse for women with endometrial hyperplasia treated with levonorgestrel-releasing intrauterine system (LNG-IUS) or oral progestogens?

SUMMARY ANSWER

Relapse of complex endometrial hyperplasia after initial regression occurs often and it occurs less often in women treated with LNG-IUS than with oral progestogens.

WHAT IS KNOWN ALREADY

The LNG-IUS and oral progestogens are used to treat women with endometrial hyperplasia and achieve regression. There is uncertainty over whether further surveillance for these women is necessary as the risk for relapse is unknown.

STUDY DESIGN, SIZE, DURATION

A cohort study of 219 women with complex non-atypical or atypical endometrial hyperplasia who were treated and achieved initial regression with LNG-IUS (n = 153) or oral progestogens (n = 66) from August 1998 until December 2007 and followed up for >5 years. The mean length of follow-up was 74.7 ± SD 31.8 months for the LNG-IUS versus 87.6 ± SD 42.2 months for the oral progestogen group.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We evaluated the proportion of women who relapsed or had hysterectomy after initial regression with LNG-IUS compared with oral progestogens by logistic regression and adjusting for confounding. The time from regression to relapse was explored through a survival analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

Relapse of hyperplasia occurred in 13.7% (21/153) of women treated with LNG-IUS compared with 30.3% (20/66) of women treated with oral progestogens [adjusted odds ratio (OR) = 0.34, 95% confidence interval (CI): 0.17-0.7, P = 0.005]. Relapse rates over long-term follow-up were lower for complex non-atypical hyperplasia compared with atypical hyperplasia for both LNG-IUS (12.7%, 18/142 versus 27.3%, 3/11, respectively; P ≤ 0.001) and oral progestogens (28.3%, 17/60 versus 50%, 3/6, respectively; P ≤ 0.001). The survival analysis indicates that relapse occurred less often with LNG-IUS at 12, 24, 36, 48, 60 and >60 months of follow-up (hazard ratio 0.37, 95% CI: 0.2-0.7, P = 0.0013). There were no events of relapse after 48 months from regression with oral progestogens, but 5 women treated with LNG-IUS relapsed after 60 months when treatment was discontinued. Hysterectomy rates were lower in the LNG-IUS than oral progestogen group during follow-up (19.6%, 30/153 versus 31.8%, 21/66, respectively, OR = 0.52, 95% CI: 0.27-1, P = 0.05). Endometrial cancer was diagnosed in 2 (11.8%) women who had hysterectomy (n = 17) because of relapse.

LIMITATIONS, REASONS FOR CAUTION

We are unable to accurately estimate the cancer risk in women who relapse during follow-up as only 17 out of 41 who relapsed underwent hysterectomy.

WIDER IMPLICATIONS OF THE FINDINGS

Relapse of endometrial hyperplasia after initial regression occurs often and long-term follow-up is advised.

STUDY FUNDING/COMPETING INTEREST(S)

Ioannis D. Gallos and this study were funded through a grant from Wellbeing of Women (ELS022). No competing interests.

Uterine artery embolization for symptomatic uterine fibroids

BACKGROUND

Uterine fibroids cause heavy prolonged bleeding, pain, pressure symptoms and subfertility. The traditional method of treatment has been surgery as medical therapies have not proven effective. Uterine artery embolization (UAE) has been reported to be an effective and safe alternative to treat fibroids in women not desiring future fertility. There is a significant body of evidence based on case controlled studies and case reports. This is an update of the review previously published in 2006.

OBJECTIVES

To review the benefits and risks of uterine artery embolization (UAE) versus other medical or surgical interventions for symptomatic uterine fibroids.

SEARCH METHODS

We searched the Cochrane Menstrual Disorders & Subfertility Group Trials register (searched November 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, 4th Quarter 2011), MEDLINE (1950 to November 2011) and EMBASE (January 1980 to November 2011). We also contacted authors of eligible RCTs for unpublished data.

SELECTION CRITERIA

Randomised controlled trials (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.

MAIN RESULTS

Five RCTs were included in this review. Three trials compared UAE with abdominal hysterectomy in 291 women. A fourth trial included 157 women and compared UAE with surgery (43 hysterectomies and 8 myomectomies). The fifth trial included 121 women and compared UAE with myomectomy in women wishing to preserve fertility.There was moderately good evidence that there is no significant difference between UAE and surgery in patient satisfaction rates at two years (OR 0.69, 0.40 to 1.21, 516 women, 5 trials) nor at five years (OR 0.90, 95% CI 0.45 to 1.80, 295 women, 2 trials). There was very low level evidence suggesting that myomectomy may be associated with better fertility outcomes than UAE, but this analysis was restricted to the limited cohort of women (n=66) who tried to conceive in the single study of UAE versus myomectomy (live birth: OR 0.33, 95% CI 0.11 to 1.00; pregnancy: OR 0.29, 95% CI 0.10 to 0.85). There was no significant difference between the two interventions in the rate of major complications. Compared to surgery, UAE significantly reduced the length of the procedure, length of hospital stay and time to resumption of routine activities and also decreased the likelihood of needing a blood transfusion. However, UAE was associated with higher rates of minor short term and long term complications, more unscheduled readmissions after discharge and an increased surgical reintervention rate. This increase in the surgical reintervention rate may balance out the initial cost advantage of UAE (reinterventions within 2 years: OR 5.64, 95% CI 2.92 to 10.90, 486 women, 4 trials; within 5 years: OR 5.79, 95% CI 2.65 to 12.65. 289 women, 2 trials). There was no significant difference in ovarian failure rates at long term follow-up.

AUTHORS' CONCLUSIONS

UAE appears to have an overall patient satisfaction rate similar to hysterectomy and myomectomy and offers an advantage with regards to a shorter hospital stay and a quicker return to routine activities. However, UAE is associated with a higher rate of minor complications and an increased likelihood of requiring surgical intervention within two to five years of the initial procedure. There is very low level evidence suggesting that myomectomy may be associated with better fertility outcomes than UAE, but more research is needed.

Position in the second stage of labour for women without epidural anaesthesia

BACKGROUND

For centuries, there has been controversy around whether being upright (sitting, birthing stools, chairs, squatting, kneeling) 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 uterine cervix).

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (28 February 2012).

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials of any upright or lateral position assumed by pregnant women during the second stage of labour compared with supine or lithotomy positions. Secondary comparisons include comparison of different upright positions and the lateral position.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and assessed trial quality. At least two review authors extracted the data. Data were checked for accuracy.

MAIN RESULTS

Results should be interpreted with caution as the methodological quality of the 22 included trials (7280 women) was variable.In all women studied (primigravid and multigravid) there was a non-significant reduction in duration of second stage in the upright group (mean difference (MD) -3.71 minutes; 95% confidence interval (CI) -8.78 to 1.37 minutes; 10 trials, 3485 women; random-effects, I(2) = 94%), a significant reduction in assisted deliveries (risk ratio (RR) 0.78; 95% CI 0.68 to 0.90; 19 trials, 6024 women, I(2)= 27%), a reduction in episiotomies (average RR 0.79, 95% CI 0.70 to 0.90, 12 trials, 4541 women; random-effects, I(2) = 7%), an increase in second degree perineal tears (RR 1.35; 95% CI 1.20 to 1.51, 14 trials, 5367 women), increased estimated blood loss greater than 500 ml (RR 1.65; 95% CI 1.32 to 2.60; 13 trials, 5158 women, asymmetric funnel plot indicating publication bias), fewer abnormal fetal heart rate patterns (RR 0.46; 95% CI 0.22 to 0.93; two trials, 617 women). In primigravid women the use of any upright compared with supine positions was associated with: non-significant reduction in duration of second stage of labour (nine trials: mean 3.24 minutes, 95% CI 1.53 to 4.95 minutes) - this reduction was largely due to women allocated to the use of the birth cushion.

AUTHORS' CONCLUSIONS

The findings of this review suggest several possible benefits for upright posture in women without epidural, but with the possibility of increased risk of blood loss greater than 500 mL. Until such time as the benefits and risks of various delivery positions are estimated with greater certainty, when methodologically stringent data from trials are available, women should be allowed to make choices about the birth positions in which they might wish to assume for birth of their babies.

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.

Oral progestogens vs levonorgestrel-releasing intrauterine system for endometrial hyperplasia: a systematic review and metaanalysis

OBJECTIVE

To conduct a systematic review and metaanalysis of studies evaluating the regression rate of endometrial hyperplasia with oral progestogens and levonorgestrel-releasing intrauterine system.

STUDY DESIGN

Searches were conducted on Medline, Embase, Cochrane Library, and Web of Science, and reference lists of relevant articles were examined. The methodologic index for nonrandomized studies was used for quality assessment. Metaanalysis was performed with random effects model.

RESULTS

There were 24 observational studies (1001 women), of low methodologic quality, evaluating the outcome of regression of endometrial hyperplasia with oral progestogens or levonorgestrel-releasing intrauterine system. Metaanalysis showed that oral progestogens achieved a lower pooled regression rate compared with levonorgestrel-releasing intrauterine system for complex (pooled rate, 66% vs 92%; P < .01) and atypical hyperplasia (pooled rate, 69% vs 90%; P = .03). There was no statistical difference in simple hyperplasia (pooled rate, 89% vs 96%; P = .41).

CONCLUSION

Oral progestogens appear to induce a lower disease regression rate than Levonorgestrel-releasing intrauterine system in the treatment of endometrial hyperplasia.

Outpatient Thermachoice endometrial balloon ablation: long-term, prognostic and quality-of-life measures

STUDY OBJECTIVE

To evaluate short- and long-term treatment outcomes of outpatient local anaesthetic thermal balloon endometrial ablation (LA-TBEA) and identify any prognostic factors.

STUDY DESIGN

Prospective observational study in a UK teaching hospital involving 102 menorrhagic women undergoing LA-TBEA between 2001 and 2005. Women underwent either Gynecare® Thermachoice I (n = 51) or Thermachoice III (n = 51) TBEA performed in the outpatient setting under local anaesthesia without conscious sedation. The main outcome measures were: treatment completion, pain and analgesia, duration of stay (from admission to discharge), duration of follow-up, primary treatment success and nature of any secondary treatment, menstrual symptoms and amenorrhoea, patient satisfaction, and quality of life.

RESULTS

TBEA was completed in 97% of women. Mean duration of stay was 8.0 h (95% CI 6.6-9.3). Mean follow-up was 30 months (95% CI 26-32). Secondary treatment with the levonorgestrel intrauterine system, repeat TBEA or hysterectomy occurred in 19/102 (19%). Overall, 50% of surgical re-interventions occurred by 19 months. There were high rates of amenorrhoea (29%) and treatment satisfaction (76%). Higher mean intrauterine ablation pressure was associated with increased treatment satisfaction.

CONCLUSION

TBEA can be successfully performed in the outpatient setting. Higher endometrial ablation pressure may improve long-term treatment outcome.

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.

Evidence for preventing infection in abortion care

There is controversy of whether prophylaxis treatment or a ''screen and treat'' policy should be adopted for preventing infective complications when women undergo abortion. There is currently compelling evidence that indicates that a universal policy of prophylaxis treatment to all women undergoing abortion should receive antibiotics. It is also a cost-effective policy.

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.

Hysteroscopic myomectomy for menorrhagia using Versascope bipolar system: efficacy and prognostic factors at a minimum of one year follow up

OBJECTIVE

To evaluate the effectiveness of hysteroscopic submucous myomectomy for women with heavy menstrual bleeding (HMB) over a minimum 1-year period and assess prognostic factors associated with treatment success.

STUDY DESIGN

Prospective observational study set in a university teaching hospital in UK involving 92 women symptomatic of HMB with submucous myomas consecutively recruited between June 2003 and November 2006. Hysteroscopic myomectomy was performed under outpatient local anaesthetic (n=35, 38%) or daycase general anaesthesia (n=57, 62%) using Gynecare Versascope bipolar system. The main outcome measures were: the need for secondary surgical or medical re-intervention, menstrual improvement and patient satisfaction. Other outcome measures include: successful completion of primary resection, type of secondary treatment.

RESULT

Mean follow up was 2.6 years (95% CI 2.3-2.9). Complete fibroid excision was achieved in 66%. Secondary surgical re-intervention was required in 27 (29%) of which 11 (12%) were repeat hysteroscopic myomectomy and 10 (11%) were hysterectomy procedures. Multiple uterine fibroids and adenomyosis were identified in 80% of hysterectomies. At follow up, improved menstrual symptoms and patient satisfaction were reported by 91% and 86%, respectively. Irregular cycle HMB and incomplete fibroid excision were associated with secondary retreatment. Size of the submucous fibroid resected, presence of intramural and subserosal fibroids, or LA vs. GA setting were unrelated to treatment success.

CONCLUSION

HMB with submucous myomas may be successfully treated by completely removing the intracavity myoma component, irrespective of co-existent intramural or subserosal fibroids or size of fibroid resected. This effect remains sustained over at least a 1-2 year period.

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.

Predicting negligence in female sterilization failure using time interval to sterilization failure: analysis of 131 cases

BACKGROUND

Sterilization failure due to 'tubal non-occlusion' or 'wrong structure sterilization' is considered negligent, whereas 'spontaneous tubal recanalization' or 'fistula formation' is considered non-negligent. We examined whether interval to pregnancy failure was predictive of a negligent rather non-negligent failure mechanism. We aim to test this hypothesis in a selected population series of known mechanisms of sterilization failure and their time interval to failure.

METHODS

Analyses of 131 failed sterilizations pooled from UK (NHS Litigation Authority, Medical Protection Society and our hospital), Australia and a qualitative systematic review.

RESULTS

We identified 88 negligent and 43 non-negligent sterilization failures. Filshie and ring methods failed earlier than diathermy and Pomeroy methods. Sterilization failure occurred significantly earlier in negligent than non-negligent failure mechanisms [median failure intervals 7.0 versus 12.0 months; Hazard ratio (2.35 95% CI 1.31-4.21)]. Knowing that sterilization failure occurred early, increased the probability that the failure mechanism was likely to be negligent rather than non-negligent.

CONCLUSIONS

A short interval to failure is suggestive of a negligent failure mechanism. There is less certainty in the predictive value of longer time intervals on the mechanism of failure due to a paucity of cases. A national register of failed sterilizations that have been systematically investigated is needed to improve our understanding of negligent and non-negligent failure mechanisms.

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.

Do screening-preventative interventions in asymptomatic pregnancies reduce the risk of preterm delivery—A critical appraisal of the literature

Recent research has suggested that women who experience preterm delivery (PTD) may be identified earlier in pregnancy and before onset of symptoms. Interventions commenced at this earlier asymptomatic stage may offer an opportunity to prevent PTD or lengthen gestation sufficiently to reduce adverse perinatal outcome. Our objective was to examine the evidence that supports or refutes this approach to preventing PTD. We therefore conducted a systematic search and critical appraisal of the identified literature. We found evidence that introducing screening-preventative strategies for asymptomatic pregnancies may reduce the rate of PTD. Evidence for screening and selective treatment exists for: asymptomatic bacteriuria; bacterial vaginosis in low-risk population groups; elective cervical cerclage in high-risk pregnancies; indicated cervical cerclage in women with short cervical length on ultrasound; prophylactic progesterone supplementation in high-risk pregnancies, and smoking cessation. However, for most other strategies, such as increased antenatal attendance, or routine administration of prophylactic micronutrients, the evidence is inconsistent and conflicting. Information on neonatal outcomes apart from PTD (such as serious neonatal morbidity and mortality) was found to be lacking in most studies. It was therefore not possible to establish whether preventing PTD or prolonging gestation would correlate to improved perinatal outcome, and this lessened the potential clinical usefulness of any proposed preventative strategy. No studies were found that evaluated the effectiveness of combining screening-preventative strategies. The review concludes with a suggested an antenatal management plan designed to prevent PTD based on current practice and the evidence presented in this article.