Chemotherapy versus surgery for initial treatment in advanced ovarian epithelial cancer.

BACKGROUND: Epithelial ovarian cancer presents at an advanced stage in the majority of patients. These women require chemotherapy and surgery for optimal treatment. Conventional treatment is to perform surgery first and then give chemotherapy. However, it is important to determine whether there is any advantage to using chemotherapy prior to surgery. OBJECTIVES: To assess whether there is an advantage to treating women with advanced epithelial ovarian cancer with chemotherapy prior to debulking surgery (neoadjuvant chemotherapy) compared with conventional treatment where chemotherapy follows maximal debulking surgery. SEARCH STRATEGY: RCTs were identified by searching The Cochrane Central Register of Controlled Trials (CENTRAL, Issue 3, 2006), MEDLINE (Silver Platter, from 1966 to 1st Sept 2006), EMBASE via Ovid (from 1980 to 1st Sept 2006), CANCERLIT (from 1966 to 1st Sept 2006), PDQ (search for open and closed trials) and MetaRegister (most current search Sept 2006). SELECTION CRITERIA: Women with advanced epithelial ovarian cancer (Federation of International Gynaecologists and Obstetricians (FIGO) stage III-IV); randomized allocation to treatment groups which compared platinum-based chemotherapy before debulking surgery with platinum-based chemotherapy following debulking surgery. DATA COLLECTION AND ANALYSIS: Data were extracted by three independent authors, and the quality of included trials was assessed by three independent authors. MAIN RESULTS: One RCT was identified as meeting the inclusion criteria. This trial randomized 85 women and compared standard debulking surgery followed by eight cycles of platinum-based chemotherapy with pre-operative intra-arterial platinum-based chemotherapy and ovarian artery embolization followed by debulking surgery and seven cycles of platinum-based chemotherapy. There was no statistical difference in median overall survival (OS) between the two treatment groups. Three on-going RCTs were identified and their results are awaited. AUTHORS' CONCLUSIONS: There is as yet no good evidence that neoadjuvant chemotherapy prior to debulking surgery for women with advanced epithelial ovarian cancer is superior to conventional debulking surgery and platinum-based chemotherapy.

Inter-rater reliability of distal ureteral diameter ratio compared to grade of VUR.

INTRODUCTION AND OBJECTIVE: Management of vesicoureteral reflux (VUR) remains controversial, and reflux grade constitutes an important prognostic factor. Recent work has suggested that distal ureteral diameter ratio (UDR) is a predictive factor relative to clinical outcome independent of grade. Previous studies have noted significant inter-rater variability with grading of VUR. The present study compared inter-rater reliability of reflux grade and UDR in children with primary VUR. STUDY DESIGN: Four pediatric urologists independently reviewed, in a blinded fashion, voiding cystourethrograms. For each renal unit, grade was assigned according to the standardized international scale. The UDR was calculated by dividing the largest ureteral diameter within the false pelvis by the distance between L1-L3 vertebral bodies. Correlation within each rater was determined using Pearson's correlation coefficient. Reliability of VUR grade and UDR were calculated using two-way ANOVA model inter-rater agreement. RESULTS: Four independent raters reliably measured VUR grade (ICC = 0.87, 95% CI = 0.78-0.93) and UDR (ICC = 0.95, 95% CI = 0.92-0.97). While UDR and grade were equally reliable measures, UDR had a tighter confidence interval. For each rater, grade and UDR were well correlated (r = 0.73-0.84; P < 0.0001). For higher-grade reflux, grade was more variable than UDR (Summary Figure). Using empirical thresholds, the increased variability of grade compared with UDR may lead to significant differences in clinical decision-making among physicians (P = 0.022). DISCUSSION: Known discordance with grading reflux emphasizes the need for a more objective VUR measurement, as clinicians and parents often opt for clinical intervention based on both clinical course and the likelihood of spontaneous resolution. While ICC for UDR and grade were not significantly different, the confidence intervals for grade were wider due to greater variability among grade measurements. This suggests that using UDR measurements may lead to more accurate characterization of VUR and ultimately more consistent clinical decision-making across providers. CONCLUSIONS: Ureteral diameter ratio has good inter-rater reliability among pediatric urologists, with less clinically relevant variability than VUR grade. Ureteral diameter ratio is a more objective and reliable measure than grade, and may be more useful in clinical decision-making.

Characteristics of Fatal Agricultural Injuries by Production Type.

Although agriculture is recognized as a hazardous industry, it is unclear how fatal agricultural injuries differ by production type. The purpose of this study was to characterize fatal occupational injuries in agriculture, comparing crop and animal production, and determine which risk factors are specifically associated with each production type. A cross-sectional study was conducted among crop and animal pro ducers using data from the Census of Fatal Occupational Injuries in the Midwest region from 2005 to 2012. Rates offatal injury by production type were estimated. The frequency of fatal injury in each production type was also reported by demographic and injury characteristics. Finally, a logistic regression was performed to determine whether age, gender, injury timing, or injury event/exposure type were associated with crop or animal production. A total of 1,858 fatal agriculture-related injuries were identified, with 1,341 in crop production and 517 in animal production. The estimated rate of fatal injury was higher in crop production than in animal production (15.9 vs. 10.8 per 100,000 workers). Fatal injuries among young and elderly agricultural workers were significantly associated with crop production compared to animal production. Animal assaults, falls, and exposure to harmful substances or environments were significantly associated with animal production. Fatal agricultural injury is more common in crop production. However, the characteristics and risk factors of fatal injuries differ by production type. Intervention strategies may be guided by considering the production-specflc risk factors.

Diagnosis, treatment and follow up of women undergoing conscious pain mapping for chronic pelvic pain: a prospective cohort study.

OBJECTIVE: To assess the efficacy of conscious pain mapping in diagnosing and treating chronic pelvic pain (CPP). DESIGN: Prospective cohort study. Setting Gynaecology Department, UK District General Hospital. POPULATION: Forty-three women diagnosed with CPP. METHODS: The cohort was followed up for 18-24 months after diagnosis and treatment based on conscious pain mapping. MAIN OUTCOME MEASURES: Improvement of pain assessed by using visual analogue scale (VAS) pain scores at 6-month follow up. RESULTS: Thirty-nine women had successful conscious pain mapping. Pelvic pathology was identified in 18, pelvic congestion in 13 and 8 women had normal pelvic organs. In 35 women (90%), conscious pain mapping identified the cause of pain. Five out of eight women (63%) who were judged to have a normal pelvis had positive findings at pain mapping. VAS scores fell significantly from pre-treatment to post-treatment values at 6-month follow up (P < 0.01). Overall, 26 women (74%) felt that their symptoms had improved after treatment based on findings at pain mapping. However, we concluded that pain mapping only contributed to the diagnosis and treatment in seven women (27%), who may not have received appropriate diagnosis and treatment if they had a laparoscopy under general anaesthetic. Conclusions CONSCIOUS: pain mapping is a useful additional investigation in the management of women with CPP. It can be employed in women with a negative laparoscopy or with visible pathology where the conventional treatment has failed.

Gynaecological surgery in the older population: a comparative study between two 3-year samples over a decade.

This study aimed to assess the increase, if any, of the number of operations being performed in older women and try to determine the reasons behind any such increase.