Development and validation of GLVS (Generic Laparoscopic Video Scoring System), a tool for assessment of laparoscopic skills in gynaecology using videotaped procedures: Are edited videos representative of their full-length version?

Background: Anonymized videotaped endoscopic procedures can be used for the assessment of surgical competence, but a reliable non-procedure-specific scoring system is needed for gynaecology. Objectives: To design and evaluate the validity of the Generic Laparoscopic Video Scoring System (GLVS), a novel tool in the assessment of various gynaecological laparoscopic procedures. Materials and Methods: Seventeen anonymized unedited video recordings of various gynaecological laparoscopic procedures and the 4-minute-long edited versions of the same videos were independently scored by two experts, twice, using GLVS. Main outcome measures: Internal consistency reliability, test-retest, and inter-rater reliability of GLVS. We also compared the scored achieved by edited videos with those of the full-length version of the same videos. Results: The mean score achieved by 4-minute-long edited videos was similar to that of the unedited version (p= 0.13 - 0.19). There was excellent correlation between the pooled scores for edited and unedited versions (intra-class correlation coefficient = 0.86). GLVS had excellent internal consistency reliability (Cronbach's alpha 0.92-0.97). Test-retest and inter-rater reliability were generally better for edited 4-minute-long videos compared to their full-length version. Test-retest reliability for edited videos was excellent for scorer 1 and good for scorer 2 with intra-class correlation coefficient (ICC) of 0.88 and 0.62 respectively. Inter-rater reliability was good for edited videos (ICC=0.64) but poor for full-length versions (ICC= -0.24). Conclusion: GLVS allows for objective surgical skills assessment using anonymized shortened self-edited videos of basic gynaecological laparoscopic procedures. Shortened video clips of procedures seem to be representative of their full-length version for the assessment of surgical skills. What's new?: We devised and undertook a validation study for a novel tool to assess surgical skills using surgical video clips. We believe this addition clearly delineates the unique contributions of our study.

Development and validation of the communication and language assessment questionnaire for persons with multiple sclerosis (CLAMS).

BACKGROUND: There is growing recognition that communication and language can be compromised in persons with multiple sclerosis (MS). However, patient-reported outcome measures (PROMs) designed to measure communication and language function in MS are currently lacking. OBJECTIVES: This study aimed to develop and validate a novel PROM, the Communication and Language Assessment questionnaire for persons with Multiple Sclerosis (CLAMS). METHODS: One-hundred and ninety-nine participants were recruited internationally through online channels. Participants completed an online questionnaire consisting of 41-items generated from the: (1) La Trobe Communication Questionnaire (LCQ), (2) Speech pathology-specific questionnaire for persons with Multiple Sclerosis (SMS), and (3) published research describing communication and language in MS. These items were then submitted to preliminary psychometric evaluation, including principal component analysis, internal consistency, test-retest reliability, criterion validity, and analyses of floor and ceiling effects. Criterion validity was assessed by comparing the CLAMS with the Communication Participation Item Bank (CPIB). RESULTS: The final CLAMS contained 11-items. Internal consistency was high (α = 0.944) and test-retest reliability. All items produced an intra-class correlation coefficient ≥ 0.70. No floor or ceiling effects were present. A statistically significant strong correlation between the CLAMS and the CPIB was identified (r = -0.750, p = ≤ 0.001). CONCLUSION: The CLAMS is a reliable and valid PROM that assesses self-perceived communication and language function in MS. This tool can be used for research and clinical purposes to measure intervention outcomes, monitor symptom evolution, evaluate service delivery, facilitate patient-centred care, and as an adjunct to clinical assessment.

Automated speech analysis tools for children's speech production: A systematic literature review.

PURPOSE: A systematic search and review of published studies was conducted on the use of automated speech analysis (ASA) tools for analysing and modifying speech of typically-developing children learning a foreign language and children with speech sound disorders to determine (i) types, attributes, and purposes of ASA tools being used; (ii) accuracy against human judgment; and (iii) performance as therapeutic tools. METHOD: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were applied. Across nine databases, 32 articles published between January 2007 and December 2016 met inclusion criteria: (i) focussed on children's speech; (ii) tools used for speech analysis or modification; and (iii) reporting quantitative data on accuracy. RESULT: Eighteen ASA tools were identified. These met the clinical threshold of 80% agreement with human judgment when used as predictors of intelligibility, impairment severity, or error category. Tool accuracy was typically <80% accuracy for words containing mispronunciations. ASA tools have been used effectively to improve to children's foreign language pronunciation. CONCLUSION: ASA tools show promise for automated analysis and modification of children's speech production within assessment and therapeutic applications. Further work is needed to train automated systems with larger samples of speech to increase accuracy for assessment and therapeutic feedback.

Establishing an integrated human milk banking approach to strengthen newborn care.

The provision of donor human milk can significantly reduce morbidity and mortality among vulnerable infants and is recommended by the World Health Organization as the next best option when a mother's own milk is unavailable. Regulated human milk banks can meet this need, however, scale-up has been hindered by the absence of an appropriate model for resource-limited settings and a lack of policy support for human milk banks and for the operational procedures supporting them. To reduce infant mortality, human milk banking systems need to be scaled up and integrated with other components of newborn care. This article draws on current guidelines and best practices from human milk banks to offer a compilation of universal requirements that provide a foundation for an integrated model of newborn care that is appropriate for low- and high-resource settings alike.

Effect of passive polarizing three-dimensional displays on surgical performance for experienced laparoscopic surgeons.

BACKGROUND: Although the potential benefits of stereoscopic laparoscopy have been recognized for years, the technology has not been adopted because of poor operator tolerance. Passive polarizing projection systems, which have revolutionized three-dimensional (3D) cinema, are now being trialled in surgery. This study was designed to see whether this technology resulted in significant performance benefits for skilled laparoscopists. METHODS: Four validated laparoscopic skills tasks, each with ten repetitions, were performed by 20 experienced laparoscopic surgeons, in both two-dimensional (2D) and 3D conditions. The primary outcome measure was the performance error rate; secondary outcome measures were time for task completion, 3D motion tracking (path length, motion smoothness and grasping frequency) and workload dimension ratings of the National Aeronautics and Space Administration (NASA) Task Load Index. RESULTS: Surgeons demonstrated a 62 per cent reduction in the median number of errors and a 35 per cent reduction in median performance time when using the passive polarizing 3D display compared with the 2D display. There was a significant 15 per cent reduction in median instrument path length, an enhancement of median motion smoothness, and a 15 per cent decrease in grasper frequency with the 3D display. Participants reported significant reductions in subjective workload dimension ratings of the NASA Task Load Index following use of the 3D displays. CONCLUSION: Passive polarizing 3D displays improved both the performance of experienced surgeons in a simulated setting and surgeon perception of the operative field. Although it has been argued that the experience of skilled laparoscopic surgeons compensates fully for the loss of stereopsis, this study indicates that this is not the case. Surgical relevance The potential benefits of stereoscopic laparoscopy have been known for years, but the technology has not been adopted because of poor operator tolerance. The first laparoscopic operation was carried out using a prototype passive polarizing laparoscopic system in 2010. This is new three-dimensional (3D) technology offers a real option for 3D laparoscopic surgery where previous systems have failed. This study is the first to have been carried out using this technology. It is essential that new technologies are adopted only when there is robust evidence to support their use. Currently, there are concerns about the use of robotic technologies and whether advantages exist for patient care. If there are advantages, 3D must be playing a significant role. If so, perhaps the technology under investigation here offers potential to a greater spectrum of surgeons, as well as being a more affordable option.

Continuous infusion of local anaesthetic following laparoscopic hysterectomy--a randomised controlled trial.

OBJECTIVE: To estimate whether a continuous infusion of intraperitoneal local anaesthetic for 48 hours following laparoscopic hysterectomy reduced the need for opioids delivered with a patient-controlled analgesia pump. DESIGN: Double-blind randomised placebo-controlled trial. SETTING: District general hospital in the UK. POPULATION: Women undergoing a laparoscopic hysterectomy for a benign indication. METHODS: Women were randomised to receive either 0.5% levobupivicaine or 0.9% normal saline via an ON-Q elastomeric pump for 48 hours postoperatively. The amount of opioids used via the patient-controlled analgesia pump was recorded and pain was measured using an 11-point Box Scale. MAIN OUTCOME MEASURES: The primary outcome was the amount of patient-administered morphine used over the first 48 postoperative hours. Secondary outcomes were length of hospital stay, oral analgesia use and level of patient-reported pain. RESULTS: Sixty women participated and completed the trial. There was no difference (P = 0.59) in the median amount of patient-administered morphine used between the levobupivicaine (23 mg) and placebo (18.5 mg) groups; median group difference 3.0 (95% CI -7.0 to 14.0). There was also no difference in the length of hospital stay with 40% of the treatment group remaining in hospital >48 hours compared with 30% of the placebo group (P = 0.08). Pain scores at all postoperative time points remained similar, with a median group difference in pain scores of 1.0 (95% CI -1.0 to 2.0) at the end of the first postoperative day. CONCLUSIONS: Continuous infusion of 0.5% levobupivicaine into the peritoneal cavity following laparoscopic hysterectomy does not have any opioid-sparing effects.

Provision of individualised obstetric risk advice to increase health facility usage by women at risk of a complicated delivery: a cohort study of women in the rural highlands of West Ethiopia.

OBJECTIVE: To determine whether the provision of individualised obstetric risk advice would increase health facility usage in women at life-threatening risk of a complicated delivery in Ethiopia, where maternal mortality has remained high and static for a decade and where, although the government has increased the number of health facilities, 90% of women deliver their babies at home. DESIGN: A prospective cohort study. SETTING: Rural Ethiopian highlands. POPULATION: A total of 294 pregnant women at 32 weeks or more of gestation. METHODS: Before being provided with individualised risk advice, women were asked about their birth plans, and in particular, their planned delivery place. Those identified as being at risk of a complicated delivery were followed up to find out whether they altered their birth plans. MAIN OUTCOME MEASURE: A change in birthplace. RESULTS: Women identified as being at high risk of a complicated delivery significantly changed their plans (P < 0.01), with 34 (89%) women delivering in hospital. Women with a medium risk did not significantly change their birth plans (P = 0.082), with 35 (36%) delivering at home. Women with a high parity were less likely to change their birth plans compared with primigravid women (odds ratio 0.53; 95% confidence interval 0.34-0.83) and high-risk women were more likely to change their plans compared with medium-risk women (odds ratio 6.2; 95% confidence interval 1.8-21.6). CONCLUSIONS: Providing simple, individualised advice about the risks of a complicated delivery leads to high-risk women delivering in hospital. Embedding this into the current antenatal care system in Ethiopia could significantly decrease maternal mortality.

Primary repair of obstetric uterine rupture can be safely undertaken by non-specialist clinicians in rural Ethiopia: a case series of 386 women.

We report 386 consecutive cases of uterine rupture over a 10-year period, revealing a case fatality rate of 4.8%, which is significantly less than the 16-37% fatality rate published in the literature. Primary uterine repair, which was carried out by non-specialised doctors in 43% of cases, was the treatment for 98% of women, and appears to be simple and effective. The main predictor of death from uterine rupture was a treatment delay of more than 12 hours from the presumed time of rupture (OR 7.7; 95% CI 1.02-58.4).

Advanced stereoscopic projection technology significantly improves novice performance of minimally invasive surgical skills.

BACKGROUND: Three-dimensional (3D) surgical imaging systems provide stereoscopic depth cues that are lost in conventional two-dimensional (2D) display systems. Recent improvements in stereoscopic projection technology using passive polarising displays may improve performance of minimally invasive surgical skills. This study aims to identify the effect of passive polarising stereoscopic displays on novice surgeon performance of minimally invasive surgical skills. METHODS: 20 novice surgeons performed 10 repetitions of 4 surgical skills tasks using a new passive polarising stereoscopic display under 3D and 2D conditions. The previously validated tasks used were rope pass, paper cut, needle capping and knot tying. Outcome measures included total error rate and time for task completion. RESULTS: Novice surgeons demonstrated a significant reduction in error rates for sequential repetitions of each task using the passive polarising stereoscopic display compared with the 2D display. Mean errors for the 3D versus the 2D mode were 2.0 versus 4.3 for rope pass (P ≤ 0.001), 0.8 versus 1.6 for paper cut (P = 0.001), 1.3 versus 4.2 for needle capping (P ≤ 0.001) and 2.8 versus 8.0 for knot tying (P ≤ 0.001). Novice surgeons demonstrated a significant improvement in mean time for completion for all four tasks when using the 3D system. Mean time (in seconds) for 3D versus 2D were 106.5 versus 134.4 for rope pass (P ≤ 0.001), 116.1 versus 176.3 for paper cut (P ≤ 0.001), 76.3 versus 141.6 for needle capping (P ≤ 0.001) and 153.4 versus 252.6 for knot tying (P ≤ 0.001). CONCLUSION: Passive polarising stereoscopic displays significantly improve novice surgeon performance during acquisition of minimally invasive surgical skills.

Clinical and plasma proteomic markers correlating with chronic kidney disease after liver transplantation.

Chronic kidney disease (CKD) occurs frequently after liver transplantation (LT) and is associated with significant morbidity and mortality. Thus, there is a pressing need to identify characteristics and biomarkers diagnostic of CKD to enable early diagnosis allowing preemptive interventions, as well as mechanistic insights into the progression from kidney injury to irreversible kidney failure. We analyzed 342 patients who had baseline glomerular filteration rate (GFR) >60 at the time of LT and are now >3 years post-LT. Risk factors for post-LT CKD were compared between three different groups defined by current GFR: >90 (n = 40), 60-90 (n = 146) and <60 (n = 156) mL/min. Age, cyclosporine use and pre-LT GFR were independently associated with new onset CKD. A subset (n = 64) without viral/immune disease or graft dysfunction underwent multianalyte plasma proteomic evaluations for correlation with CKD. Plasma proteomic analysis of two independent cohorts, test (n = 22) and validation (n = 42), identified 10 proteins highly associated with new onset CKD. In conclusion, we have identified clinical characteristics and a unique plasma proteomic signature correlating with new onset CKD after LT. These preliminary results are currently being validated in a prospective, multicenter study to determine if this signature precedes the onset of CKD and resolves with early interventions aimed at preserving kidney function.

Transvaginal sonography vs. clinical examination in the preoperative diagnosis of deep infiltrating endometriosis.

OBJECTIVE: The aim of this study was to compare the diagnostic performance of clinical vaginal examination with that of transvaginal sonography (TVS) in the presurgical diagnosis of deep infiltrating endometriosis. METHODS: One-hundred and fifty-five women with symptoms suggestive of endometriosis were included. One-hundred and twenty-nine patients met the inclusion criteria and were prospectively and independently assessed by vaginal examination and TVS prior to a diagnostic laparoscopy and, where appropriate, radical resection and histological confirmation of endometriosis was performed. Sensitivity, specificity, positive predictive values (PPV), negative predictive values (NPV) and positive and negative likelihood ratios (LR+ and LR-) were calculated for each test method. RESULTS: In total, 83 (64%) women had histological confirmation of endometriosis, 52 (40%) of whom had deep infiltrating endometriosis. The prevalence of endometriosis on the uterosacral ligaments, pouch of Douglas, vagina, bladder, rectovaginal space and rectosigmoid was 23.3%, 16.3%, 8.5%, 3.1%, 6.9% and 24%. PPV, NPV, LR+ and LR- for vaginal examination were 92%, 87%, 41.56 and 0.60 for ovarian endometriosis; 43%, 84%, 2.48 and 0.63 for uterosacral ligament disease; 64%, 95%, 9.14 and 0.26 for involvement of the pouch of Douglas; 80%, 97%, 42.91 and 0.28 for vaginal endometriosis; 78%, 98%, 46.67 and 0.23 for endometriosis of the rectovaginal space; 100%, 98%, 75.60 and 0.75 for bladder involvement; 86%, 84%, 18.97 and 0.63 for rectosigmoidal endometriosis. Values for TVS were similar with regard to vaginal and rectovaginal space endometriosis, but were clearly superior to vaginal examination in cases of ovarian (87%, 99%, 24.56 and 0.04), uterosacral ligament (91%, 90%, 31.35 and 0.37) and rectosigmoidal (97%, 97%, 88.51 and 0.1) endometriosis. CONCLUSIONS: TVS is a more useful test than is vaginal examination in detecting endometriosis in the ovaries and rectosigmoid.

Expressive language skills in Chinese Singaporean preschoolers with nonsyndromic cleft lip and/or palate.

OBJECTIVE: The main objective of the present study was to examine THE EXPRESSIVE LANGUAGE SKILLS and obtain a prevalence estimate of expressive language IMPAIRMENT (not skills) in Chinese Singaporean preschoolers with nonsyndromic cleft lip and/or palate (CLP). METHODS: A group of 43 Chinese Singaporean preschoolers aged 3 to 6 years with a diagnosis of nonsyndromic CLP was assessed using the Singapore English Action Picture Test (SEAPT). The SEAPT is an English Language screening tool standardised on typically developing English-Mandarin Chinese Singaporean preschoolers that assesses expressive vocabulary and grammatical usage. A grammar and/or information score below the 20(th) percentile on the SEAPT is indicative of an expressive language impairment. In addition, the medical records of this cohort were examined retrospectively for documentation of surgical timings, audiological history, articulation and resonance. RESULTS: Based on the results of the SEAPT, 33% of the preschoolers with CLP were identified as having a-possible expressive language impairment. Hence, the likelihood that a child with CLP with normal cognitive functioning will have an expressive language impairment is between 3.9 to 12.7 times more likely than in the general population. There was no statistical significance when comparisons were made between dominant language groups or CLP groups on SEAPT measures of information and grammar content. Significantly more males than females were identified with language difficulties, relative to the sex ratio in the sample. No significance was found for the other participant variables. CONCLUSIONS: The findings of this study suggest that Chinese Singaporean preschoolers with CLP have more difficulty in the expressive use of grammar and vocabulary than their peers of typical development, with significantly more males affected than females. As language performance was not related to hearing, articulation or resonance; these early results suggest that a comprehensive investigation of cognition, literacy and family aggregation of communication disorders is urgently warranted to study other possible aetiologies for language impairment in children with CLP in Singapore.

Why military personnel fail to keep medical appointments.

OBJECTIVES: Failure to keep medical appointments, commonly referred to as 'Did Not Attend' (DNA), is a frequent problem in both primary and secondary health care and leads to a waste of valuable resources. Although the reasons for DNA within the general population are well documented, little is known about this behaviour amongst people serving in the armed forces. In this paper we report the findings of a questionnaire-based study investigating the reasons why military personnel fail to keep hospital appointments. METHOD: A postal questionnaire asking questions about the reasons for not attending the appointment and how they perceived the condition for which treatment had been sought, were sent to 167 military patients known to have missed appointments in either a hospital outpatient department or regional rehabilitation unit. 162 controls, who attended appointments, were also sent a questionnaire asking them about factors leading to their appointment and how they perceived the condition that they attended the appointment for. Illness perception was measured using a previously validated Illness perception Questionnaire (IPQ-R). The controls were matched by rank, gender and corps. RESULTS: The overall response rate was 51.5%, with 46% response in the DNA group and 55% in the controls. A previous history of hospital DNA (though not DNA in primary care) and attempting to change the appointment date were associated with DNA (p = 0.01). Those who received a reminder about the appointment were less likely to DNA (p < or = 0.001). Although patients who perceived their condition to be less important were more likely to fail to attend their appointment (p = 0.01), illness perception as measured on the IPQ-R, was not associated with appointment attendance. The most frequent reasons cited for missed appointments were due to administrative problems, with many (38%) respondents being simply unaware that they had an appointment at all or believing that they had cancelled it (14%). Forgetting the appointment (8%) or mixing up the date (21%) were also cited by respondents as reasons for not attending. Only 11% of respondents gave reasons that were specific to a military population, most frequently being on exercise at the time of their appointment. Demographic differences such as age and gender, and practical factors such as appointment day, distance travelled, method of appointment notification, or type of hospital were not found to be associated with attendance. CONCLUSION: The most common reasons for not attending appointments were due to administrative error and an inability amongst patients to recall the correct date of the appointment. Whilst efforts to improve attendance through various reminder systems have been found to be effective in the short term at least, improvements in the efficiency of appointment administration is likely to generate a reduction in DNA and in turn will reduce the wastage of resources.

Long-term outcomes following laparoscopic supracervical hysterectomy.

OBJECTIVE: Evaluation of long-term outcomes following laparoscopic supracervical hysterectomy (LSH). DESIGN: Retrospective postal questionnaire. SETTING: Norwegian university teaching hospital. POPULATION: A total of 315 consecutive patients. METHODS: A questionnaire sent to all patients who underwent a LSH during 2004 and 2005. MAIN OUTCOME MEASURES: Persistent vaginal bleeding and pelvic pain, patient acceptability of such symptoms and patient satisfaction following LSH. RESULTS: A total of 240 women (78%) completed the questionnaire. About 24% reported experiencing vaginal bleeding up to 3 years following their hysterectomy, although this was rated as minimal in 90% of cases, resulting in a mean bothersome score of 1.1 (SD 2.0) on a 10-point visual analogue scale (VAS). Women operated on by less experienced surgeons were more likely to report vaginal bleeding following surgery (P = 0.02). About 74% of women reported having menstrual pain prior to surgery, with a mean score of 6.8 (SD 2.1) (10-point VAS). Up to 3 years following surgery, 38% continued to experience menstrual pain, although this was significantly less intense with a mean score of 3.5 (SD 2.2) (P < 0.01). While all women reported a decrease in the amount of pain experienced following the hysterectomy, those having a hysterectomy because of endometriosis reported significantly higher levels of menstrual/cyclical pain after surgery compared with women who had a hysterectomy for other reasons (P < 0.01). Ninety per cent of women reported being satisfied with their surgery. CONCLUSION: Although vaginal bleeding and pelvic pain are frequently observed following LSH, these symptoms are significantly reduced and patient satisfaction is high.

Endometriosis and its coexistence with irritable bowel syndrome and pelvic inflammatory disease: findings from a national case-control study--Part 2.

OBJECTIVE: To investigate whether the increased chances of having a diagnosis of irritable bowel syndrome (IBS) and pelvic inflammatory disease (PID) in women with endometriosis is due to misdiagnosis or co-morbidity. DESIGN: A case-control study of women aged 15-55 years with endometriosis and matched controls. SETTING: Data from the UK's General Practice Research Database for the years 1992-2001. SAMPLE: A total of 5540 women aged 15-55 years, diagnosed with endometriosis, each matched to four controls without endometriosis. The index date was defined as the date of diagnosis. METHODS: Data were analysed to determine whether women with endometriosis were more likely to receive a diagnosis of PIDor IBS than women without endometriosis. Odds ratios were calculated for endometriosis associated with IBS and PID before and after the index date. MAIN OUTCOME MEASURES: Diagnosis of IBS or PID before and after the index date. RESULTS: Compared with the controls, women with endometriosis were 3.5 times more likely to have received a diagnosis of IBS (OR 3.5 [95% CI: 3.1-3.9]). Even after women had been diagnosed with endometriosis, they were still two and a half times more likely to receive a new diagnosis of IBS when compared with the controls (OR 2.5 [95% CI: 2.2-2.8]). Similarly, women with endometriosis were more likely than those without endometriosis to have been treated for PID both before (OR 5.9 [95% CI: 5.1-6.9]) and after (OR 3.8 [95% CI: 3.1-4.6]) being diagnosed with endometriosis. CONCLUSIONS: Women with endometriosis are more likely to be diagnosed with IBS and PID than controls, even after a definitive diagnosis of endometriosis has been reached.

Can symptomatology help in the diagnosis of endometriosis? Findings from a national case-control study--Part 1.

OBJECTIVE: To determine the value of patient-reported symptoms in diagnosing endometriosis. DESIGN: A national case-control study. SETTING: Data from the UK General Practice Research Database for years 1992-2001. SAMPLE: A total of 5540 women aged 15-55 years, diagnosed with endometriosis, each matched to four controls without endometriosis. METHODS: Data were analysed to determine whether specific symptoms were highly indicative of endometriosis. Odds ratios for these symptoms were derived by conditional logistic regression analysis. MAIN OUTCOME MEASURES: Symptoms associated with endometriosis. RESULTS: The prevalence of diagnosed endometriosis was 1.5%. A greater proportion of women with endometriosis had abdominopelvic pain, dysmenorrhoea or menorrhagia (73%) compared with controls (20%). Compared with controls, women with endometriosis had increased risks of abdominopelvic pain (OR 5.2 [95% CI: 4.7-5.7]), dysmenorrhoea (OR 8.1 [95% CI: 7.2-9.3]), menorrhagia (OR 4.0 [95% CI: 3.5-4.5]), subfertility (OR 8.2 [95% CI: 6.9-9.9]), dyspareunia and/or postcoital bleeding (OR 6.8 [95% CI: 5.7-8.2]), and ovarian cysts (OR 7.3 [95% CI: 5.7-9.4]), and of being diagnosed with irritable bowel syndrome (IBS) (OR 1.6 [95% CI: 1.3-1.8]) or pelvic inflammatory disease (OR 3.0 [95% CI: 2.5-3.6]). Women with endometriosis were also found to consult the doctor more frequently than the controls and were twice as likely to have time off work. CONCLUSIONS: Specific symptoms and frequent medical consultation are associated with endometriosis and appear useful in the diagnosis. Endometriosis may coexist with or be misdiagnosed as pelvic inflammatory disease or IBS.

Systematic Review of Quality of Life following Laparoscopic and open colorectal surgery.

OBJECTIVE: To compare the health-related quality of life (HRQoL) of patients following laparoscopic and open colorectal surgery. METHODS: A systematic review was performed according to Quorum guidelines. Prospective studies comparing the HRQoL of patients after laparoscopic and open colorectal surgery were identified. The primary outcome measure was postoperative quality of life; performance status and cosmesis were secondary outcome measures. RESULTS: 23 studies were identified that satisfied the inclusion criteria; 18 assessed HRQoL, 4 performance status, and 3 cosmesis. It was not possible to perform a meta-analysis due to study heterogeneity. The studies reported outcomes for 2946 patients. The most frequent HRQoL instruments employed were SF-36, EORTC, and GIQLI. 6 studies, using a total of 12 separate measures, evaluated QoL during the first 3 post-operative months: 10 of these measures showed no significant difference, and 2 showed an improved HRQoL with laparoscopy. Twelve further studies evaluated HRQoL up to 5 years post-operatively: 9 showed no difference between the 2 groups, and 3 demonstrated a benefit for laparoscopy. Three of 4 studies assessing performance status on discharge, and all 3 studies assessing cosmesis, reported benefits with the laparoscopic approach. CONCLUSIONS: The current evidence suggests there is no significant difference in HRQoL following laparoscopic and open colorectal surgery, although there is a lack of good quality data. There is a trend towards improved quality of life outcomes and performance status with laparoscopy in the early post-operative period. There is a need for further research, particularly assessing quality of life in the early post-operative period.

"What else is there to do?"--A qualitative study of the barriers to soldiers stopping smoking.

OBJECTIVES: To investigate the impact of Army life on soldiers' motivation for stopping smoking. METHOD: A two stage study using a questionnaire to identify smokers in a British Army infantry battalion of 560 soldiers based in the United Kingdom with either a low or high intention to quit smoking, followed by semi-structured interviews of a purposive sample of 18 respondents. RESULTS: 31.3% of soldiers were current smokers. In addition to recognised barriers to stopping smoking, the interview data revealed structural and cultural barriers, some of which are unique to the Army. Structural barriers included an increased opportunity to smoke in terms of time, place, and cost. Cultural barriers included peer pressure, the smoking norm, and a lack of discouragement from the 'regimental family'. These barriers to stopping smoking often arise from established British Army values and standards. For example, the need for punctuality requires early arrival at destinations, which in turn, provides an increased time opportunity to smoke. Other attitudes that the Army wishes to encourage, such as building teamwork and interdependence, can also be enhanced through smoking. CONCLUSION: Whilst the numerous, previously identified barriers to stopping smoking exist within and outside the armed forces, specific additional barriers arise from the structure and culture of the Army. Changes in the structure of daily life within the Army may reduce the barriers to stop smoking. Army clinicians also play an important part in soldiers' stopping smoking and an increased understanding of the specific barriers to stopping smoking may help them to support soldiers more effectively.