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Concept: Obstetrics and gynaecology

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The aim of this study was to determine the impact of prognostic factors in primary fallopian tube carcinoma (PFTC). All cases of PFTC diagnosed between 1990 and 2010 were retrieved from the files of 6 academic centers. The cases were staged according to a modification of the International Federation of Obstetrics and Gynecology staging system proposed by Alvarado-Cabrero et al (Gynecol Oncol 1999; 72: 367-379). One hundred twenty-seven PFTC cases were identified. The mean age of the patients was 64.2 years. Stage distribution was as follows: 72 (57%), stage I; 19 (15%), stage II; 28 (22%), stage III; and 8 (6.2%), stage IV. Depth of infiltration of the tubal wall was an independent prognostic factor in stage I cases (P < .001). Carcinomas located in the fimbriated end even without invasion had a worse prognosis than did carcinomas involving the tubal portion of the organ. The presence of vascular space invasion correlated with the depth of tubal wall invasion (P = .001) and the presence of lymph node metastases (P = .003). Tumor grade significantly correlated with survival (P < .0001), but histologic type was of marginal significance and only if it was grouped as nonserous/non-clear cell vs serous/clear cell (P = .04). The depth of invasion of the tubal wall and the presence of carcinoma in the fimbriated end even without invasion are important prognostic indicators. The modified International Federation of Obstetrics and Gynecology staging system should be used on a routine basis in all carcinomas of the fallopian tube.

Concepts: Cancer, Lung cancer, Cancer staging, Lymph node, Gynecology, Prognosis, Fallopian tube cancer, Obstetrics and gynaecology

28

Follicle flushing has been proved to be ineffective in polyfollicular in-vitro fertilization. To analyse the effect of flushing in monofollicular in-vitro fertilisation we aspirated and then flushed the follicles in 164 cycles. Total oocyte yield/aspiration was 44.5% in the aspirate, 20.7% in the 1(st) flush, 10.4% in the 2(nd) flush and 4.3% in the 3(rd) flush. By flushing, the total oocyte yield increased (p<0.01) by 80.9% from 44.5% to 80.5%. The total transfer rate increased (p<0.01) by 91.0% from 20.1% to 38.4%. The results indicate that the oocyte yield and the number of transferable embryos can be significantly increased by flushing. © 2012 The Authors Acta Obstetricia et Gynecologica Scandinavica © 2012 Nordic Federation of Societies of Obstetrics and Gynecology.

Concepts: Pregnancy, Obstetrics, In vitro fertilisation, Gynecology, Flushing, Fertilisation, Obstetrics and gynaecology, Embryo transfer

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INTRODUCTION AND HYPOTHESIS: Vaginal pessaries may offer symptomatic improvement for women with pelvic organ prolapse (POP) or urinary incontinence (UI). This study aimed to investigate multidisciplinary perspectives on vaginal pessary use in clinical practice and to understand the service organisation of vaginal pessary care for women with these conditions. METHODS: A pretested, anonymous survey was e-mailed to members of the Royal College of Obstetrics and Gynaecology, the Association for Continence Advice and the Association of Chartered Physiotherapists in Women’s Health in the UK. RESULTS: A total of 678 respondents, from medical, nursing and physiotherapy professions, consented to survey participation and provided useable data (response rate 20.7 %). Doctors were significantly more likely to report involvement in pessary care than nurses or physiotherapists. Respondents were optimistic about the success of pessary treatment; however, a lower proportion reported using pessaries for UI than for prolapse. The majority of respondents used ring pessaries and shelf pessaries, most recipients were older women, and commonly an indication for fitting a pessary was that the woman was unfit for surgery. More than 15 % of respondents providing pessary care had not received training. Follow-up services for women with pessaries varied considerably. CONCLUSIONS: The variation in pessary care delivery and organisation requires further study in order to maximise efficiency and effectiveness. The development of nurse- or physiotherapist-led models of care may be appropriate, but the effectiveness of such models requires testing. Furthermore, to potentially improve outcomes of pessary care, a greater understanding of the availability, content and process of training may be warranted.

Concepts: Childbirth, Uterus, Urinary incontinence, Woman, Gynaecology, Obstetrics and gynaecology, Pessary, Kegel exercise

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We enjoyed reading the Editorial by Jan Deprests' group from Leuven in Belgium on laser treatment for TTTS. Although we agree on most of their statements, and that there is an obvious room for further improvements, we would like to stress that an inherent problem, when comparing results from different institutions, is the selection of cases on which to operate on. So far there are no population-based studies, and this is urgently needed for evaluating this procedure. © 2012 The Authors Acta Obstetricia et Gynecologica Scandinavica © 2012 Nordic Federation of Societies of Obstetrics and Gynecology.

Concepts: Obstetrics, Sociology, Syndromes, Twin-to-twin transfusion syndrome, Gynaecology, Obstetrics and gynaecology, Fetoscopy, Bell Labs

21

To explore incidents of bullying and undermining among obstetrics and gynaecology (O&G) consultants in the UK, to add another dimension to previous research and assist in providing a more holistic understanding of the problem in medicine.

Concepts: Medicine, Obstetrics, Gynecology, Consultant, Gynaecology, Obstetrics and gynaecology, Tertiary education, Subjects taught in medical school

18

Ultrasound imaging has become integral to the practice of obstetrics and gynecology. With increasing educational demands and limited hours in residency programs, dedicated time for training and achieving competency in ultrasound has diminished substantially. The American Institute of Ultrasound in Medicine assembled a multisociety task force to develop a consensus-based, standardized curriculum and competency assessment tools for obstetric and gynecologic ultrasound training in residency programs. The curriculum and competency assessment tools were developed based on existing national and international guidelines for the performance of obstetric and gynecologic ultrasound examinations and thus are intended to represent the minimum requirement for such training. By expert consensus, the curriculum was developed for each year of training, criteria for each competency assessment image were generated, the pass score was established at, or close to, 75% for each, and obtaining a set of 5 ultrasound images with pass score in each was deemed necessary for attaining each competency. Given the current lack of substantial data on competency assessment in ultrasound training, the task force expects that the criteria set forth in this document will evolve with time. The task force also encourages use of ultrasound simulation in residency training and expects that simulation will play a significant part in the curriculum and the competency assessment process. Incorporating this training curriculum and the competency assessment tools may promote consistency in training and competency assessment, thus enhancing the performance and diagnostic accuracy of ultrasound examination in obstetrics and gynecology.

Concepts: Pregnancy, Obstetrics, Gynecology, Medical ultrasonography, Gynaecology, Obstetrics and gynaecology, Obstetric ultrasonography, Gynecologic ultrasonography

18

The Beyond Ultrasound First Forum was conceived to increase awareness that the quality of obstetric and gynecologic ultrasound can be improved, and is inconsistent throughout the country, likely due to multiple factors, including the lack of a standardized curriculum and competency assessment in ultrasound teaching. The forum brought together representatives from many professional associations; the imaging community including radiology, obstetrics and gynecology, and emergency medicine among others; in addition to government agencies, insurers, industry, and others with common interest in obstetric and gynecologic ultrasound. This group worked together in focus sessions aimed at developing solutions on how to standardize and improve ultrasound training at the resident level and beyond. A new curriculum and competency assessment program for teaching residents (obstetrics and gynecology, radiology, and any other specialty doing obstetrics and gynecology ultrasound) was presented, and performance measures of ultrasound quality in clinical practice were discussed. The aim of this forum was to increase and unify the quality of ultrasound examinations in obstetrics and gynecology with the ultimate goal of improving patient safety and quality of clinical care. This report describes the proceedings of this conference including possible approaches to resident teaching and means to improve the inconsistent quality of ultrasound examinations performed today.

Concepts: Medicine, Improve, Obstetrics, Gynecology, Medical ultrasonography, Gynaecology, Obstetrics and gynaecology, Obstetric ultrasonography

7

Previous reviews examining the effect of participation in trials on outcomes have not consistently shown benefit. Obstetrics and gynaecology is a unique disease area posing challenges for both researchers and patients.

Concepts: Medicine, Epidemiology, Clinical trial, Medical statistics, Effectiveness, Meta-analysis, Gynaecology, Obstetrics and gynaecology

5

Evidence-based medicine aims to translate scientific research into good medical practice. The Royal College of Obstetricians and Gynaecologists publishes recommendations and guidelines to guide clinicians in decision-making. In this study, the evidence base underlying the ‘Green-top Guidelines’ has been analysed in order to establish the quality of research underlying recommendations. During this descriptive study of 1,682 individual recommendations, the authors found that only 9-12% of the guidelines were based on the best quality (Grade A) evidence. The authors believe that this type of analysis serves to provide greater clarity for clinicians and patients using guidelines and recommendations in the field of obstetrics and gynaecology to make collaborative clinical decisions.

Concepts: Medicine, The Canon of Medicine, Evidence-based medicine, Systematic review, Avicenna, Alternative medicine, Obstetrics and gynaecology, Medical literature

4

Objectives. We determined the effectiveness of primary care-based, and pre- and postnatal interventions to increase breastfeeding. Methods. We conducted 2 trials at obstetrics and gynecology practices in the Bronx, New York, from 2008 to 2011. The Provider Approaches to Improved Rates of Infant Nutrition & Growth Study (PAIRINGS) had 2 arms: usual care versus pre- and postnatal visits with a lactation consultant (LC) and electronically prompted guidance from prenatal care providers (EP). The Best Infant Nutrition for Good Outcomes (BINGO) study had 4 arms: usual care, LC alone, EP alone, or LC+EP. Results. In BINGO at 3 months, high intensity was greater for the LC+EP (odds ratio [OR] = 2.72; 95% confidence interval [CI] = 1.08, 6.84) and LC (OR = 3.22; 95% CI = 1.14, 9.09) groups versus usual care, but not for the EP group alone. In PAIRINGS at 3 months, intervention rates exceeded usual care (OR = 2.86; 95% CI = 1.21, 6.76); the number needed to treat to prevent 1 dyad from nonexclusive breastfeeding at 3 months was 10.3 (95% CI = 5.6, 50.7). Conclusions. LCs integrated into routine care alone and combined with EP guidance from prenatal care providers increased breastfeeding intensity at 3 months postpartum. (Am J Public Health. Published online ahead of print December 19, 2013: e1-e9. doi:10.2105/AJPH.2013.301360).

Concepts: Pregnancy, Childbirth, Infant, Prolactin, Obstetrics, Breastfeeding, Obstetrics and gynaecology, The Bronx