3D laparoscopy does not reduce operative duration or errors in day-case laparoscopic cholecystectomy: a randomised controlled trial.

BACKGROUND: Contemporary 3D platforms have overcome past deficiencies. Available trainee and laboratory studies suggest stereoscopic imaging improves performance but there is little clinical data or studies assessing specialists. We aimed to determine whether stereoscopic (3D) laparoscopic systems reduce operative time and number of intraoperative errors during specialist-performed laparoscopic cholecystectomy (LC). METHODS: A parallel arm (1:1) randomised controlled trial comparing 2D and 3D passive-polarised laparoscopic systems in day-case LC using was performed. Eleven consultant surgeons that had each performed > 200 LC (including > 10 3D LC) participated. Cases were video recorded and a four-point difficulty grade applied. The primary outcome was overall operative time. Subtask time and the number of intraoperative consequential errors as identified by two blinded assessors using a hierarchical task analysis and the observational clinical human reliability analysis technique formed secondary endpoints. RESULTS: 112 patients were randomised. There was no difference in operative time between 2D and 3D LC (23:14 min (± 10:52) vs. 20:17 (± 9:10), absolute difference - 14.6%, p = 0.148) although 3D surgery was significantly quicker in difficulty grade 3 and 4 cases (30:23 min (± 9:24), vs. 18:02 (± 7:56), p < 0.001). No differences in overall error count was seen (total 47, median 1, range 0-4 vs. 45, 1, 0-3, p = 0.62) although there were significantly fewer 3D gallbladder perforations (15 vs. 6, p = 0.034). CONCLUSION: 3D laparoscopy did not reduce overall operative time or error frequency in laparoscopic cholecystectomies performed by specialist surgeons. 3D reduced Calot's dissection time and operative time in complex cases as well as the incidence of iatrogenic gallbladder perforation (NCT01930344).

Can a community-based maternal care package in rural Ethiopia increase the use of health facilities for childbirth and reduce the stillbirth rate?

OBJECTIVE: To measure the impact of a maternal health package on health facility delivery and stillbirth rates. METHODS: This is a cross-sectional study in Ethiopia where a maternal package was integrated into eight health centers across three regions. The package included trained midwives with a mentoring program, transport for referral, and equipment and accommodation for the midwives. Ten health centers without the package but in the same districts as the intervention centers and eight without the package in different districts were randomly selected as the comparison groups. Women living in the catchment areas of the 26 health centers, who delivered a baby in the past 12 months, were randomly selected to complete a face-to-face survey about maternal health experiences. RESULTS: The maternal package did not significantly affect the stillbirth or facility delivery rates. Women were positively influenced to deliver in a health facility if their husbands were involved in the decision concerning the place of birth and if they had prior maternal experience in the health center. Barriers to delivering in a health facility included distance and ability to read and write. CONCLUSION: Women served by health centers with a maternal health package did not have significantly fewer stillbirths and were not more likely to deliver their babies in a health facility. Husbands played an important role in influencing the decisions to deliver in a health facility.

The changing face of obstetric fistula surgery in Ethiopia.

OBJECTIVE: To examine the incidence and type of obstetric fistula presenting to Hamlin Fistula Ethiopia over a 4-year period. STUDY DESIGN: This is a 4-year retrospective survey of obstetric fistula treated at three Hamlin Fistula Hospitals in Ethiopia, where approximately half of all women in the country are treated. The operation logbook was reviewed to identify all new cases of obstetric fistula presenting from 2011 to 2015. New cases of urinary fistula were classified by fistula type (high or low), age, and parity of the woman. RESULTS: In total, 2,593 new cases of urinary fistulae were identified in the study period. The number of new cases fell by 20% per year over the 4 years (P<0.001). A total of 1,845 cases (71.1%) were low (ischemic) fistulae, and 804 cases (43.6%) of these had an extreme form of low circumferential fistula. A total of 638 (24.6%) women had a high bladder fistula, which predominantly occurs following surgery, specifically cesarean section or emergency hysterectomy, and 110 (4.2%) women had a ureteric fistula. The incidence of high fistulae increased over the study period from 26.9% to 36.2% (P<0.001). A greater proportion of multiparous women had a high bladder fistula (70.3%) compared with primigravid women (29.7%) (P<0.001). Conversely, a greater proportion of primiparous women experienced a low circumferential fistulae (68.6%) compared with multiparous women (31.4%) (P<0.001). CONCLUSION: There appears to be a decline in the number of Ethiopian women being treated for new obstetric urinary fistulae. However, the type of fistula being presented for treatment is changing, with a rise in high fistulae that very likely occurred following cesarean section and a decline in the classic low fistulae that arise following obstructed childbirth.

The effect of prenatal and intrapartum care on the stillbirth rate among women in rural Ethiopia.

OBJECTIVE: To determine whether community-based prenatal and intrapartum care in Ethiopia results in a lower stillbirth rate. METHODS: Between May and December 2014, a randomly selected sample of women in northern and eastern Ethiopia who had delivered a neonate in the preceding 12months completed a face-to-face survey about their experiences of maternal services and the fetal outcome for each delivery. The stillbirth rates among women delivering at home and at health facilities were compared. RESULTS: Overall, 4442 women completed surveys. Stillbirth was reported by 42 (1.7%) of the 2437 women who had received prenatal care and 53 (2.8%) of the 1921 women who did not receive prenatal care (P=0.01). The stillbirth rate was similar among women who delivered in a health center (27/1417 [1.9%]), in a hospital (6/126 [4.8%]), and at home (62/2725 [2.3%]; P=0.13). However, women experiencing an intrapartum emergency were twice as likely to deliver in a health facility (odds ratio 2.6, 95% confidence interval 2.2-3.0). Satisfaction with health-center care was moderately good (median score 77.5/100). CONCLUSION: The stillbirth rate was reduced among women receiving prenatal care, although delivering in a health facility did not reduce the risk of stillbirth. Improving the quality of health-center care could lead to their planned use for childbirth, which might reduce stillbirth rates.

Prevalence of obstetric fistula and symptomatic pelvic organ prolapse in rural Ethiopia.

INTRODUCTION AND OBJECTIVE: Little is known about the extent to which women in low- and middle-income countries suffer with urological and urogynaecological complications of childbirth. This study measured the prevalence of obstetric fistula and symptomatic pelvic organ prolapse (POP) in east and north Ethiopia. METHODS: We randomly selected 23,023 women of reproductive age (15-49 years) from 113 villages in East Harraghe, South Gondar and West Gojjam, Ethiopia. Trained local health workers administered a validated face-to-face survey and a team of researchers verified data by readministering a random selection (5 %) of the survey. All suspected fistulae were followed up to confirm a clinical diagnosis. RESULTS: Mean age was 29.5 [standard deviation (SD) 8.05] years. Only 22 % of women were knowledgeable about the symptoms of fistula. The prevalence of all obstetric fistulae was 6:10,000 reproductive-aged women [95 % confidence interval (CI) 3-8], of untreated fistula 2:10,000 (95 % CI 0-4) and of symptomatic POP 100:10,000 (95 % CI 86-114). CONCLUSION: The prevalence of obstetric fistula in these rural zones of Ethiopia is relatively low and reflects a substantial reduction from previous reports. Significant numbers of women suffer with symptomatic POP, for which surgical and nonsurgical treatments would be beneficial. Obstetric fistula in north and east Ethiopia is relatively low; however, the many women with symptomatic pelvic organ prolapse could benefit from treatment.

Quality of life in the first 6 weeks following laparoscopic and open colorectal surgery.

OBJECTIVES: Evidence of how health-related quality of life (HRQOL) changes following laparoscopic and open colorectal surgery in the first 6 weeks of postoperative recovery is needed to inform cost-effectiveness evaluations. METHODS: Pragmatic prospective cohort study design. Consecutive patients requiring elective colorectal surgery were allocated to either laparoscopic or open surgery by administrative staff in a district general hospital in England, 2006-2007. Patients completed two validated, generic measures of HRQOL at baseline (preoperatively) and on multiple occasions in the first 6 weeks postsurgery using diaries (EuroQol five-dimensional [EQ-5D] questionnaire: 16 times; short-form 36 health survey [SF-36]: 4 times; HRQOL was compared between groups at each time point, and overall using repeated-measures analysis. RESULTS: Of 201 consecutive patients recruited, 32 (15.1%) were unable to complete diaries. Of the remaining 169 patients, 120 (71%) returned completed diaries at 28 days and 105 (62.1%) at 42 days. There was no difference in preoperative HRQOL scores between surgical groups, but the postoperative EQ-5D questionnaire and SF-36 scores were significantly higher in the laparoscopic group (EQ-5D questionnaire P = 0.005, SF-36 P = 0.007). Subgroup analysis showed that patients with a stoma have worse HRQOL than those without. HRQOL did not differ between the laparoscopic and open stoma patients. CONCLUSIONS: This study presents unique prospective data demonstrating that laparoscopic surgery confers HRQOL benefits for patients in the early recovery period following colorectal surgery, compared with open surgery. Consideration of these data in the context of a cost-effectiveness analysis will be reported separately.

Is single-port laparoscopy for benign adnexal disease less painful than conventional laparoscopy? A single-center randomized controlled trial.

OBJECTIVE: To determine whether laparo-endoscopic single-site surgery (LESS) results in less postoperative pain and a better cosmetic surgical scar compared with conventional laparoscopy. DESIGN: Prospective randomized controlled trial. SETTING: A county hospital in Norway. PATIENT(S): Forty women with benign adnexal disease or a hereditary cancer risk scheduled for laparoscopic adnexal surgery. INTERVENTION(S): LESS or conventional laparoscopy. MAIN OUTCOME MEASURE(S): Postoperative pain 24 hours after surgery. RESULT(S): There was no difference in pain at 24 hours after surgery, with a mean score of 3.0 (SD 2.1) in the LESS group and 2.5 (SD 1.5) in the conventional laparoscopy group. Significantly more shoulder tip pain was reported by women undergoing LESS compared with those having conventional surgery at 6 and 24 hours after surgery. A high satisfaction with the cosmetic result was reported in both groups, with no significant difference in the Manchester scar scale score. CONCLUSION(S): Although similar levels of postoperative pain are experienced by women having LESS and conventional laparoscopic surgery, women having LESS report significantly more shoulder tip pain compared to those having conventional laparoscopic surgery. This may relate to a significantly longer operation time in the LESS group. CLINICAL TRIAL REGISTRATION NUMBER: NCT01288599.

A randomized trial of day-case vs inpatient laparoscopic supracervical hysterectomy.

OBJECTIVE: To determine whether women having day-case laparoscopic supracervical hysterectomy are more or less satisfied with the length of hospital stay compared with women who stayed overnight after the procedure. STUDY DESIGN: An randomized control trial of 49 women randomized to day-case or overnight hospital stay after laparoscopic supracervical hysterectomy. Satisfaction with length of hospitalization and quality of life were compared using the Mann-Whitney U test. RESULTS: No group differences were found in satisfaction with length of hospital stay (P = .13). There was a nonsignificant trend toward greater anxiety in the day-case group (P = .06 on day 1 postoperative). Quality of life was lower in the day-case group on days 2 (P = .02) and 4 (P = .03), postoperatively. CONCLUSION: Women having a day-case hysterectomy were discharged after median of 5 hours postoperative and were similarly satisfied as women hospitalized overnight. Quality of life, however, does appear to be compromised by day-case surgery.

Patients' experiences and satisfaction with out-of-hours GP home visiting provided by a GP cooperative.

BACKGROUND: Within the UK, patients place a fairly high value on the out-of-hours GP home visiting service. Although satisfaction with the range of out-of-hours services has been found to be high, little is known about patients' specific experiences of the home visiting services. OBJECTIVE: To investigate the satisfaction with, and experiences of, patients receiving a GP out-of-hours (OOH) home visit from a GP cooperative. METHODS: A postal questionnaire study sent to all patients receiving a home visit from a single cooperative. The questionnaire asked patients a range of questions about their experiences of the home visiting service that they received and also contained a validated satisfaction measure. RESULTS: The OOH home visiting services largely provide care for an older population, most of whom consider that they are either too ill to travel or have limited mobility. The majority (43%) of home visits are made during the daytime at weekends, with just 25% of visits made during the night-time. If the home visit was not available, 67% of patients stated that they would have phoned for an ambulance or gone directly to hospital. The majority of patients (87%) were satisfied with the overall home visiting service that they received; however, 32% of patients were dissatisfied with the time it took for them to see a doctor or a nurse. CONCLUSIONS: Although the OOH services have received considerable criticism over the past 5 years, this study reveals that patients remain largely satisfied with the service and would have called 999 or gone directly to hospital if there had been no service.

Nurse administrators: leading environmental change.

Evidence is building about the impact of environmental contaminants on patients and health care providers. The nurse administrator has a professional responsibility to provide leadership in assuring that the health care organization does not have a negative impact on health. This article presents critical environmental health concerns and an overview of the nursing profession efforts to improve the environment, which includes development of the American Nurses Association's Principles of Environmental Health for Nursing Practice with Implementation Strategies. An example is provided as to how the nurse administrator can use Appreciative Inquiry to harness the nurses collaborative energy for an environmentally healthy organization.

The impact of the environment on health.

Increasingly science is providing evidence linking the disease burden of people with exposure to toxins in their environments. The quality of one's health is determined by physical, chemical, biological, social, and psychological problems in the environment. This article provides an overview of the current science on how environmental pollution is impacting upon the chronic disease burden in people, how toxic chemicals are traveling globally and entering the food chain, and the impact of changes in climate upon one's health.

Potential barriers to the laparoscopic management of ectopic pregnancies: a regional UK study.

In this regional UK study across seven hospitals, we examined the potential barriers to undertaking a laparoscopic approach to the surgical management of ectopic pregnancies. Across the region 84% of surgically managed ectopic pregnancies were undertaken laparoscopically, although out of hours operating resulted in a higher rate of laparotomies. Trainees perceived themselves to be competent in carrying out laparoscopy for ectopic pregnancies and reported their training as adequate. Perceived barriers to training were a lack of operating time, service commitments, reduced working hours arising from the European working directive, and a lack of laboratory training facilities. In order to maintain and improve the laparoscopic rate for the management of ectopic pregnancies, it is necessary to ensure that trainees have more supervised operating time and better access to laboratory training facilities.

Secondary cervical cancer in a patient with chronic lymphocytic leukemia and recurrent chronic lymphocytic leukemia mimicking recurrent cervical dysplasia: a case report.

BACKGROUND: Patients with chronic lymphocytic leukemia (CLL) have up to a 3-fold risk of site-specific secondary cancers. The only exception is a lower incidence of cervical cancer in this population. CASE: A 70-year-old, white woman with stage IV CLL was diagnosed 2 years prior to presentation with stage Ia1 squamous cell carcinoma of the cervix. Following an abnormal Pap smear, a colposcopy and biopsies were performed. Initial pathologic impression of the cervical biopsies was high grade dysplasia. The final review was consistent with CLL without cervical dysplasia. CONCLUSION: Cervical cancer in patients with CLL is a rare occurrence. The pathologic changes on cervical epithelium caused by CLL can mimic dysplastic cellular changes. Expert pathologic review of cervical biopsies is warranted to distinguish between the diagnoses, thus altering management.

Embryonal rhabdomyosarcoma: adjuvant and ex vivo assay-directed chemotherapy.

The aim of this retrospective study was to evaluate differences in treatment of embryonal rhabdomyosarcoma (RMS) of the uterus in 2 premenopausal women. We discuss adjuvant chemotherapy and use of ChemoFx Assay (Precision Therapeutics, Pittsburgh, PA) to guide choice of active chemotherapeutic agents. Two premenopausal patients were identified with a pathologic diagnosis of embryonal RMS of the uterus. Both met inclusion criteria for the study. A 21-year-old woman underwent a staging abdominal hysterectomy for a variant of embryonal RMS. Vincristine, actinomycin D, and cyclophosphamide were given adjunctively for a complete response. A 20-year-old woman underwent a diagnostic dilation and curettage revealing embryonal RMS. Initial treatment included an abdominal hysterectomy and nodal sampling. Presentation to a subsequent gynecologic oncologist 7 months later revealed recurrence. Carboplatin, doxorubicin, and paclitaxel provided a partial response. After a second surgical resection, ChemoFx Assay identified ifosfamide and mitomycin C as active agents and resulted in a complete response. Recommended treatment includes surgery and chemotherapy with possible radiation therapy if deemed necessary. The benefit of adding neoadjuvant or adjuvant chemotherapy and radiation therapy allows for a conservative surgical approach and improved survival. Choosing active chemotherapy agents can be aided by ChemoFx Assay. The chemotherapy most commonly used for treatment of embryonal RMS is a combination of vincristine, actinomycin D, and cyclophosphamide.

Endometrial carcinoma in vitro chemosensitivity testing of single and combination chemotherapy regimens using the novel microculture kinetic apoptosis assay: implications for endometrial cancer treatment.

OBJECTIVE: The in vitro microculture kinetic (MiCK) apoptosis assay has been used to predict single or combination chemotherapy response in leukemia patients. This feasibility study addressed MiCK in endometrial cancer specimens. METHODS: Endometrial cancer specimens from total abdominal hysterectomies were processed at a central laboratory. Single cell suspensions of viable endometrial cancer cells were plated in individual wells. Single and combination regimens were tested: combinations of doxorubicin, cisplatin, and paclitaxel and carboplatin and paclitaxel (Gynecologic Oncology Group [GOG] 209 endometrial cancer phase III trial arms) as well as single agent testing with paclitaxel, carboplatin, doxorubicin, cisplatin, ifosfamide, and vincristine (active agents in GOG trials). Apoptosis was measured continuously over 48 hours. RESULTS: Fifteen of nineteen patients had successful assays. The highest mean chemo sensitivity was noted in the combination of cisplatin, doxorubicin, and paclitaxel with lower mean chemosensitivity for carboplatin and paclitaxel. Combination chemotherapy had higher chemosensitivity than single drug chemotherapy. However, in 25% of patients a single drug had higher chemosensitivity than combination chemotherapy. As single agents, ifosfamide, cisplatin, and paclitaxel had the highest kinetic unit values. CONCLUSION: Using a panel of agents simulating clinical dose regimens, the MiCK assay was feasible in evaluating in vitro chemosensitivity of endometrial cancer. MiCK assay results correlated with GOG clinical trial results. However, 25% of patients might be best treated with single agent chemotherapy selected by MiCK. Ifosfamide, cisplatin, and paclitaxel appear to have high activity as single agents. MiCK may be useful in future new drug testing and individualizing endometrial cancer patient's chemotherapy management.

Can specific pain symptoms help in the diagnosis of endometriosis? A cohort study of women with chronic pelvic pain.

OBJECTIVE: To investigate whether different dimensions of chronic pelvic pain are useful in the diagnosis of endometriosis. DESIGN: A prospective questionnaire-based study of 185 women. SETTING: Southeast of England. PATIENT(S): Women undergoing a diagnostic laparoscopy for chronic pelvic pain. INTERVENTION(S): Preoperative questionnaire. MAIN OUTCOME MEASURE(S): Descriptions of pain, areas of pain, and pain intensity. RESULT(S): One hundred thirteen women (61%) had histologically confirmed endometriosis. Three pain descriptors were reported more commonly by women with endometriosis: throbbing, gnawing, and dragging pain to the legs. Compared with women with superficial endometriosis, those with deep disease were more likely to report shooting rectal pain and a sense of their insides being pulled down. Individual pain areas were unrelated to the surgical diagnosis. Area of pain was unrelated to area of endometriosis. Pain intensity was unrelated to the surgical diagnosis. Dyschezia was more severe in women with endometriosis. CONCLUSION(S): Women with endometriosis are more likely to report their pain as throbbing and experience dyschezia when compared with women with an apparently normal pelvis. These dimensions of pain may usefully contribute to the diagnostic picture.