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).

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.

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.

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.

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.

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.

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.

A rare malignant Brenner tumor of the ovary in a 77-year-old woman: a case report.

BACKGROUND: A malignant Brenner tumor is a rare form of invasive epithelial ovarian cancer and is extremely uncommon in women > 65 years of age. We present a case of an invasive Brenner tumor of the ovary in a woman greater than age 70. CASE: A 77-year-old woman presented with a rare, invasive Brenner tumor of the ovary. She was referred for evaluation of a complex pelvic mass and elevated serum CA-125. Treatment included complete surgical resection and staging procedure. Pathology revealed a malignant Brenner tumor. Immunohistochemical staining with cytokeratin 7 was positive, with cytokeratin 20 was negative, and was positive for uroplakin III and thrombomodulin. CONCLUSION: The histologic appearance of malignant Brenner tumor is similar to that of transitional cell cancer of the ovary and transitional epithelium of the urinary bladder. Immunohistochemical staining of malignant Brenner tumor often demonstrates positivity for uroplakin III, thrombomodulin and cytokeratin 7 and negativity to cytokeratin 20. The mainstay of treatment is surgical resection, but the exact regimen and benefit of adjuvant therapy remain unknown.

Healthcare seeking in gastro-oesophageal reflux disease: a qualitative study.

BACKGROUND: Gastro-oesophageal reflux disease (GORD) is a common problem in the community, and many patients do not seek medical attention despite potential morbidity and the availability of effective therapeutic interventions. The factors which determine healthcare seeking in GORD are not well understood. AIM: To examine the symptom experience and health and illness beliefs in people with GORD, who had either been diagnosed with the condition, or were dealing with the symptoms themselves. METHODS: A total of 12 focus groups and 65 face-to-face interviews were conducted in the USA, UK, France and Germany, and involved 164 participants, who had either been diagnosed with GORD or were identified as having GORD in the community, using a random digit dialling telephone method. Transcripts of focus groups and interviews were analysed thematically, using a constant comparative approach, to identify key factors associated with healthcare seeking. RESULTS: Patients' descriptions of GORD symptoms were often vivid, with the use of unexpected imagery and unusual beliefs about causality. We were able to identify four factors associated with healthcare seeking for GORD which were: the characteristics of symptoms (intensity and control), the perceived seriousness of symptoms, interference by symptoms with daily life and views about medicines and the medical profession. CONCLUSION: Patients with GORD, using both self care and formal medical care, have a surprising range of ideas about the causes and best treatments of their symptoms. Physicians' awareness of these beliefs, coupled with an understanding of the factors associated with healthcare seeking for GORD, is likely to be important in enhancing clinical management and in patient and public education.

Management of endometriosis in general practice: the pathway to diagnosis.

BACKGROUND: The prevalence of endometriosis is estimated to be around 10%. Diagnosis is through visualisation of the lesions, mostly via laparoscopy. Studies reveal that there is an average delay in the diagnosis of endometriosis of between 8 and 12 years. Little is known about the reasons for delays in diagnosis women's experiences of primary care prior to diagnosis. AIM: To investigate women's experiences of endometriosis from first presentation to diagnosis. DESIGN OF STUDY: Retrospective analysis of data collected from primary care records in four general practices. SETTING: General practice in south-east England. METHOD: Women with a Read Code diagnosis of endometriosis were recruited to the study. Details of consultations, investigations, and referrals related to endometriosis were recorded from the notes. Data were analysed using descriptive statistics. RESULTS: The prevalence of endometriosis in women aged over 16 years was 1.44%. A third of women had consulted their GP six or more times before being diagnosed. Ultrasound was frequently requested by GPs, but was helpful in diagnosing endometriosis in only 10.6% of women who underwent a scan. Thirty-nine per cent of women were referred to gynaecologists two or more times before a positive diagnosis was made. The median time from first presentation with symptoms to diagnosis was 9.0 years (interquartile range = 4.5-13.5 years). CONCLUSION: Repeated consultations and negative investigations contribute to a median delay of 9.0 years before diagnosis of endometriosis. Further research into GPs' interpretation of symptoms and patients' experiences of negative investigations and consultations may lead to a more positive outcome for women with this condition.

Adult cystic fibrosis patients' experiences of primary care consultations: a qualitative study.

BACKGROUND: "Expert patient" programmes have been introduced in the UK as a new approach to chronic disease management for the 21st century. The average survival age of those with cystic fibrosis (CF) has steadily increased such that the majority of those with the condition now live into adulthood. Currently, specialist CF centres deliver the core of medical care, with primary care providing access to prescribed medicines, referral to other services, and care of non-CF needs, however, it is necessary to provide a more comprehensive service for adult CF patients, involving both specialist centres and primary care. To date, little is known about these expert patients' experiences of primary care. AIM: To investigate how young adults with CF perceive and experience primary healthcare services. DESIGN OF STUDY: Qualitative study. SETTING: One specialist CF centre in southeast England. METHOD: Interview study of 31 patients with CF, aged 18 years or over. RESULTS: Adults with CF consult in primary care on two distinct levels: as lay and expert patients. When consulting as experts, patients tend to operate as consumers of health care and perceive a satisfactory doctor-patient relationship to be influenced by three factors: GPs' understanding of how people live with CF, GPs' ability to prescribe certain specialist medications, and sensitive management of the cost of health care for adults with CF. A doctor-patient relationship based on trust and understanding is seen as desirable, but requires that these factors are addressed both by the GP and the patient. CONCLUSION: Expert patient policy has focused on the role of patients with common chronic conditions in secondary and tertiary care, with little consideration of how adults with rare chronic illness and their GPs manage health problems that can be addressed in primary care. Enabling easy access to holistic care, as well as establishing successful trusting relationships with people with long-term rare conditions, is a necessary foundation for expert patients to take an active role in their care.

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.

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.

What is being assessed in the MRCGP oral examination? A qualitative study.

BACKGROUND: Oral examinations are a popular method of assessment within medicine, being capable of measuring candidates' ability to carry out tasks or develop skills (operational knowledge). One example of this is the oral examination for membership of the Royal College of General Practitioners (RCGP), which is designed to assess candidates' decision-making skills and the professional values that underpin these decisions. While the reliability of oral examinations has been investigated, to date, little is known about their ability to measure what they set out to measure (validity). AIM: To investigate the content validity of the MRCGP oral examination, with particular focus on its ability to assess the process of decision-making. DESIGN OF STUDY: An evaluation of oral examination video recordings, using qualitative methods. METHOD: The MRCGP oral examinations are video recorded as part of an ongoing quality assurance programme. Fifty of the recordings carried out in 2002 were selected randomly and analysed for content and dialogue patterns reflecting the assessment of the decisionmaking process. RESULTS: All examiners used the specified contexts outlined in the examination objectives to present candidates with dilemmas. The assessment of decision-making skills, however, was limited by a tendency among examiners to present the candidate with new, more complex dilemmas rather than giving them the opportunity to discuss the implications, make choices and ultimately, justify their decision. Moreover, while examiners frequently asked candidates questions relating to professional values, they rarely asked them to demonstrate how those values support their decisions. CONCLUSION: In order that the benefits of oral examination can be fully realised, questions need to be structured in a way that encourages candidates to discuss all stages of the decision-making process.

Variations in antibiotic prescribing and consultation rates for acute respiratory infection in UK general practices 1995-2000.

BACKGROUND: Antibiotic prescribing by GPs in the UK has declined since 1995. AIM: We investigated whether general practices that issue fewer antibiotic prescriptions to patients presenting with acute respiratory infections had lower consultation rates for these conditions. DESIGN OF STUDY: Retrospective data analysis. SETTING: UK general practice. METHOD: We analysed data from the General Practice Research Database, including all registered patients from 108 practices between 1995 and 2000. For each practice, numbers of consultations for acute respiratory tract infections and the proportion of consultations resulting in an antibiotic prescription were obtained. An age- and sex-standardised consultation ratio (SCR) and standardised prescription ratio (SPR) were calculated for each practice. We evaluated whether SPR and SCR values were associated. RESULTS: For the mid-year data (1997), the crude consultation rate for all acute respiratory infections ranged from 125-1,110 per 1,000 registered patients at different practices; the proportion of consultations with antibiotics prescribed ranged from 45-98%. After standardising for varying age and sex structure of practice populations, practices with lower SPR values had lower SCR values (r = 0.41; P<0.001). This association was observed in each study year. Moreover, practices that demonstrated reductions in SPR between 1995 and 2000 also showed reductions in SCR (r = 0.27; P = 0.005). CONCLUSION: Practices that prescribe antibiotics to a smaller proportion of patients presenting with acute respiratory infections have lower consultation rates for these conditions. Practices that succeed, over time, in reducing antibiotic prescribing also experience reductions in consultation rates for these conditions. Although our methodology cannot prove that these two findings are causally related, they imply that patients alter their illness behaviour and that this may be a response to previous consultation experience. In consequence, respiratory illness in the community may be undergoing a process of de-medicalisation.