Ureteric injuries during hysterectomy-A Norwegian retrospective study of occurrence and claims for compensation over an 11-year period.

INTRODUCTION: Ureteric injury is a rare but serious, iatrogenic complication of hysterectomy. The risk depends on indication for surgery, predisposing risk factors, and peroperative conditions. Our aims were to evaluate and learn from compensation claims to The Norwegian System of Patient Injury Compensation (NPE) for ureteric injury occurring during hysterectomies to predict risk factors, time of identification, symptoms, and consequences, and to relate these cases to injuries registered in The Norwegian Patient Registry. MATERIAL AND METHODS: A retrospective study of ureteric injuries occurring during hysterectomies, reported to NPE and the Norwegian Patient Registry from 2009 through 2019. RESULTS: During the study period, 53 096 hysterectomies were registered in The Norwegian Patient Registry, of which ureteric injury was documented in 643 (1.2%). More ureteric injuries were registered in large hospital trusts than in small trusts (1.3% vs. 0.7%, p < 0.05). NPE received 69 claims due to ureteric injury occurring during hysterectomy, comprising 11% of all injuries in the study period. Compensation was approved for 15%. Women who claimed compensation were younger (48.1 ± 8.9 years vs. 55.1 ± 13.6 years, p < 0.01), more likely to have had a benign diagnosis (89.9% vs. 52.1%, p < 0.01), and more likely to have had the ureteric injury recognized after discharge (58.0% vs. 33.0%, p < 0.001) compared with non-complainants. Identification of the ureters during the hysterectomy was documented in 30% of the NPE patient files. Additional information for the NPE cases included the following. The most common symptoms of unidentified injury were pain (77%), fever (12%), urinary leakage (13%), and anuria (8%). Re-operation was necessary in 77% of the cases, and 10% of the women lost one kidney. Long-term consequences after repair, such as loss of a kidney or persistent pain, were seen in 17%. No women died because of the injury. CONCLUSIONS: The incidence of ureteric injury occurring during hysterectomy in Norway was 1.2%; 11% involved a claim for compensation, and 15% of these had their case approved. Most ureteric injuries were not recognized during the hysterectomy. Documentation of peroperative identification of the ureters during hysterectomy was often missing. Vigilance to pain as a postoperative symptom of peroperative unrecognized ureteric injury may result in earlier diagnosis and treatment.

New developments in the treatment of osteoporosis.

The last 25 years have seen the development of a plethora of new, effective agents for the treatment of osteoporosis. These agents reduce the risk of spine fractures by up to 70%, hip fractures by 40-50% and non-vertebral fractures by up to 50-80%. Amino-bisphosphonates, taken orally or intravenously, remain the dominant treatment modalities for osteoporosis. These so-called anti-resorptive or anti-catabolic agents stabilize the skeleton and reduce fracture risk in osteoporotic as well as osteopenic individuals. A monoclonal antibody against receptor activator of nuclear factor κB ligand, Denosumab, constitutes a new anti-resorptive agent recently approved worldwide. In younger postmenopausal women, low-dose estrogen or estrogen/progestin still has a place for short-term (up to 5 years) preservation of bone mass, especially in women with menopausal symptoms. Likewise, selective estrogen receptor modulators should be considered in younger postmenopausal women, especially those at increased risk of breast cancer. Anabolic (bone forming) regimens, of which parathyroid hormone is the only agent currently available, aid in the build up of new bone, increase bone mass and improve bone architecture. In cancellous bone, 30-60% increases of bone mass have been documented, but cortical bone thickness also increases. These improvements lead to profound reduction in fracture rates in both the axial and appendicular skeleton. Owing to cost and the need for parenteral administration, in most countries these agents are reserved for severe osteoporosis with multiple fractures.

Life after a diagnosis with endometriosis - a 15 years follow-up study.

OBJECTIVE: Previous studies have elucidated the negative impact of endometriosis on life, but the patient selection may have contributed to a skewed picture. The aim of this study was to investigate longitudinally the consequences of the disease in women diagnosed with endometriosis 15 years ago. DESIGN: Retrospective descriptive. SETTING: Trondheim 2007. SAMPLE: One hundred thirty women diagnosed with endometriosis at St. Olav's Hospital in Trondheim between 1991 and 1993. METHODS: Questionnaires. Response rate of 60%. MAIN OUTCOME MEASURES: Consequences of living with endometriosis. RESULTS: Of the women, 19.2% never experienced pelvic pain and 21.8% did not have any further visits to the gynecological department after being diagnosed. Almost 70% had received pharmaceutical treatment and positive effect on pain was reported by 41% for NSAIDs and oral contraceptives, and by 62% for progestins and GnRH-analogues. Satisfactory effect on pain after surgical interventions at the time of diagnosis was reported by 60.9%, and by 89.9% after later surgeries. Of the infertile patients, 75.6% succeeded in delivering one or more biological children. Half of the women reported that endometriosis had some negative impact on their lives. After menopause, 96.9% were free from pain. CONCLUSION: This study confirms that endometriosis is a condition that often has considerable impact on a woman's life. However, the study also found that endometriosis does not always cause pain, that treatment in many cases is effective, that infertility may be overcome, and that almost all postmenopausal women were free from endometriosis-associated pain.

Breastfeeding in polycystic ovary syndrome.

BACKGROUND: To investigate the breastfeeding rate in new mothers with polycystic ovary syndrome (PCOS). METHODS: Case-control study. Thirty-six women with PCOS and 99 controls matched for age, gestational length and parity, answered a questionnaire. Breastfeeding at one-, three- and six-months postpartum was registered and the two groups were compared. In the women with PCOS, androgen levels through pregnancy were analysed and related to breastfeeding rate. RESULTS: At one-month postpartum, 27 (75%) of the women with PCOS were breastfeeding exclusively, whereas five (14%) did not breastfeed at all. Among controls, 88 (89%) were breastfeeding exclusively and two (2%) did not breastfeed (p=0.001). At three- and six-months postpartum, breastfeeding was equal in the two groups. Problems with sore nipples and seeking professional lactation support were also equal. Dehydroepiandrosterone-sulphate levels at gestational week 32 and 36 showed a weak negative association with breastfeeding in PCOS women. Breastfeeding rate was not associated with maternal gestational levels of androstenedione, testosterone, sex-hormone binding globulin, or free testosterone index in PCOS. CONCLUSIONS: Women with PCOS appear to have a reduced breastfeeding rate in the early postpartum period. Possibly, gestational dehydroepiandrosterone-sulphate might negatively influence breastfeeding rate in women with the syndrome.

Impact of recent studies on attitudes and use of hormone therapy among Scandinavian gynaecologists.

BACKGROUND: Climacteric medicine has been in focus during the last 2 decades, and an intensive debate has been ongoing regarding the positive and negative aspects of postmenopausal hormone therapy (HT). Recent randomised controlled studies have been unable to confirm data from observational studies of primary or secondary preventive effects of HT on coronary heart disease, and other studies have indicated an increased risk of breast cancer, stroke and venous thromboembolism among HT users. In 2001, we reported on knowledge, attitudes, management strategies and use of HT among Scandinavian gynaecologists. The aim of the present study was to re-assess the same parameters concerning HT among Scandinavian gynaecologists in 2002-2003, and compare the results with the data collected in 1995-1997. METHODS: All practicing gynaecologists in Denmark, Sweden and Norway were invited by letter to complete and return a questionnaire regarding their knowledge, attitudes and management strategies concerning HT. Female gynaecologists were questioned if they were currently using HT, and the same question was posed concerning spouses of male gynaecologists. RESULTS: The questionnaire was completed and returned by 60, 76 and 72%, respectively of gynaecologists in Denmark, Sweden and Norway. Of the 1,591 physicians who responded, 13% thought that all women should be offered HT provided there were no contraindications, while 86% recommended HT only to selected women after considering the individual advantages and disadvantages of the treatment. Of the gynaecologists, 37% considered HT to be without relevance in the primary prevention of osteoporosis in healthy women. As for duration of the treatment, 40% of the gynaecologists would recommend HT for <5 years for the treatment of climacteric complaints, and only 8% would recommend HT for >10 years. The prevalence of HT use among the menopausal female gynaecologists varied between 71 and 74%. Among the menopausal spouses of male gynaecologists, 68-72% were current users of HT. CONCLUSION: During the last years of ongoing debate, gynaecologists from Denmark, Sweden and Norway have become more modest in their recommendations of postmenopausal HT. Scandinavian specialists are more cautious in prescribing hormones for women with symptomatic CVD or previously treated for breast cancer, however, their personal use of HT has not changed dramatically and still reflects a positive attitude.

Inflammatory markers in endometriosis: reduced peritoneal neutrophil response in minimal endometriosis.

BACKGROUND: Inflammation is considered to play a role in the pathogenesis of endometriosis. Inflammatory activation in endometriosis was tested based on the hypothesis that pain and endometriosis stage are related to the degree of local and systemic inflammation. METHODS: Eighteen patients with endometriosis and 14 controls without endometriosis were studied. Cancer antigen 125 and C-reactive protein were analyzed in blood, and in aspirated peritoneal fluid, lactoferrin, myeloperoxidase (neutrophil granulocyte activation marker), sC5b-9 (terminal complement complex), soluble intercellular adhesion molecule 1 (marker for extent of endometriotic tissue), neopterin, and tumor necrosis factor alpha (monocyte/macrophage activation) were evaluated and related to pain, endometriosis stage, and clinical data. RESULTS: None of the measured markers were different between control and endometriosis patients, or in women with or without menstrual pain, dyspareunia, or other types of pelvic pain. Lactoferrin and myeloperoxidase concentrations were significantly lower in patients with endometriosis stage I compared to control patients and endometriosis patients with stage III/IV disease. As expected, cancer antigen 125 concentrations were increased in endometriosis patients of stage III/IV. CONCLUSIONS: Neutrophil granulocytes in endometriosis patients may have a lowered ability to respond to weak activation signals, while in more extensive endometriosis stronger neutrophil activation may be related to a proinflammatory effect of endometriotic tissue.

[Use of estrogen replacement therapy and alternative therapies among Norwegian women aged 50-69]. / Bruk av østrogen og alternativ behandling blant norske kvinner 50-69 år.

BACKGROUND: Several large studies have showed higher risk and less benefit from hormone replacement therapy (HRT) than assumed, and sales figures have been reduced by almost a half. Several non-hormonal treatment alternatives for climacteric complaints are available. The object of this study was to determine the occurrence of climacteric complaints, and to study the use and efficacy of hormonal and alternative therapies among Norwegian women. MATERIAL AND METHODS: 150 participants in the Norwegian Mammography Screening Programme in Trondheim were interviewed about climacteric symptoms, use of HRT, and of alternative therapies. RESULTS: 81% of the participants had experienced vasomotor symptoms. The prevalence was highest among women aged 55-59 years. 23% of the women were current users of HRT, 27% were past users. 75% of the HRT users reported good effect. 25% of the participants were current users of alternative therapies, while 17% were past users. Soy was most frequently used as an alternative therapy. 42% of the alternative therapies were reported to be effective. INTERPRETATION: Half of the participants had used HRT, and most of these reported good effect. A corresponding number of women had used various alternative therapies, but the perceived efficacy of these was significantly poorer.