Tubal disease and fertility outcome.

A consequence of assisted reproduction technology in infertility management has been a decline in tubal surgery. Microsurgery to correct localized damage has the advantage of long-standing restoration of fertility. A simple prognostic classification is lacking. The severity of the tubal damage and the health of the mucosa is key in determining outcome. Visualization of the tube by hysterosalpingography (HSG) or by hysterocontrastsonography (HyCoSy) has limitations. Laparoscopy has the advantage of inspecting the tube and its relation to other pelvic organs. Differentiating between anatomical obstruction or spasm at the uterine end of the tube might be achieved by selective salpingography and tubal catheterization (SSTC) and should precede IVF. Microsurgery should be provided, if the skills are available, where cannulation has failed. Assessment of mucosal health by fertiloscopy is claimed to be less invasive. Fertiloscopy includes hydrolaparoscopy, tubal patency testing by dye hydrotubation, salpingoscopy and demonstration if the mucosa is healthy. Where the mucosa is unhealthy, surgery is not justified; early referral for IVF is indicated. In the management of ectopic pregnancy, there is a paucity of objective data of the relative merits of medical regimens and various surgical procedures.

Learning from litigation. The role of claims analysis in patient safety.

Claims for malpractice and medical negligence are a potentially important source of information on the causes of harm to patients and have provided valuable lessons in the past. However today, with many additional sources of information and methods of analysis, the role of claims analysis needs to be reappraised. We consider the role of claims analysis in relation to other methods of studying adverse outcomes, review previous studies of claims and summarize the findings of four recent British specialty claims reviews. Claims analysis has a number of inherent limitations. We suggest that there is now no case for ad hoc claims reviews which rely on data that have been assembled for legal purposes only. Claims review is still potentially useful for rare events or in cases where other sources of data are not available. However, future claims reviews need to meet basic criteria before being undertaken; these include prospective identification of the relevant questions and variables, adequacy and completeness of the data set, availability of expert reviewers and clear protocols for review.

Prospective semistructured observational study to identify risk attributable to staff deployment, training, and updating opportunities for midwives.

OBJECTIVE: To identify potential risk or mishap in the system of intrapartum care, relating to the deployment of midwives. DESIGN: Prospective semistructured observational study. SETTING: Labour wards of seven maternity units in the north west of England. PARTICIPANTS: All midwives working on the labour ward during the observation period in 2000. MAIN OUTCOME MEASURE: "Latent failures" within the system relating to midwifery staffing levels, deployment, and training or updating opportunities. RESULTS: Despite the exemplary dedication of midwives, potential risk of mishap due to their deployment occurred within the system of care. A shortfall of midwives existed in all seven maternity units and was most acute in the largest units. Six units relied on bank midwives to maintain minimum staffing levels. High risk practices (oxytocin administration and epidural blockades) continued during midwifery shortfalls in all units. Some adverse events and "near misses" were attributable to midwifery shortages in all units, and near misses remained unreported in all units. Uptake of opportunities for training or updating in interpretation of cardiotocographs and obstetric emergency management remained low owing to midwifery shortages in all units. A poor skill mix of midwives occurred at times in all units. In six units midwives spent time away from clinical areas performing clerical duties. In three units team midwifery systems were reported to erode labour ward skills and confidence. CONCLUSION: Midwives are fundamental components in the system of intrapartum care, and the system cannot operate safely and effectively when the number of midwives is inadequate, midwives are poorly deployed, and they are unable to engage in opportunities for training and updating.

Oestrogen therapy for prevention of reinfarction in postmenopausal women: a randomised placebo controlled trial.

BACKGROUND: Results of observational studies suggest that hormone replacement therapy (HRT) could reduce the risk of coronary heart disease (CHD), but those of randomised trials do not indicate a lower risk in women who use oestrogen plus progestagen. The aim of this study was to ascertain whether or not unopposed oestrogen reduces the risk of further cardiac events in postmenopausal women who survive a first myocardial infarction. METHODS: The study was a randomised, blinded, placebo controlled, secondary prevention trial of postmenopausal women, age 50-69 years (n=1017) who had survived a first myocardial infarction. Individuals were recruited from 35 hospitals in England and Wales. Women received either one tablet of oestradiol valerate (2 mg; n=513) or placebo (n=504), daily for 2 years. Primary outcomes were reinfarction or cardiac death, and all-cause mortality. Analyses were by intention-to-treat. Secondary outcomes were uterine bleeding, endometrial cancer, stroke or other embolic events, and fractures. FINDINGS: Frequency of reinfarction or cardiac death did not differ between treatment groups at 24 months (rate ratio 0.99, 95% CI 0.70-1.41, p=0.97). Similarly, the reduction in all-cause mortality between those who took oestrogen and those on placebo was not significant (0.79, 0.50-1.27, p=0.34). The relative risk of any death (0.56, 0.23-1.33) and cardiac death (0.33, 0.11-1.01) was lowest at 3 months post-recruitment. INTERPRETATION: Oestradiol valerate does not reduce the overall risk of further cardiac events in postmenopausal women who have survived a myocardial infarction.