Acoustic shock: an update review.

BACKGROUND: This paper discusses the concept of acoustic shock based on a literature review and the results of our own research into cases seen in both clinical and medicolegal practice. With the demise of traditional 'metal bashing' and 'smoke stack' heavy industries, there has been a decline in the incidence of noise-induced hearing loss and tinnitus in this form of employment. However, with the increasing establishment of call centre work, the emergence of acoustic shock has been noted. Acoustic shock is recognised as a clinical entity distinct from noise-induced hearing loss and acoustic trauma. OBJECTIVE: This article discusses clinical implications, medicolegal considerations in light of a recent high-profile court case and proposed criteria for diagnosis.

Classification systems in Gestational trophoblastic neoplasia - Sentiment or evidenced based?

The classification system for Gestational trophoblastic neoplasia (GTN) has proved a controversial topic for over 100years. Numerous systems simultaneously existed in different countries, with three main rival classifications gaining popularity, namely histological, anatomical and clinical prognostic systems. Until 2000, prior to the combination of the FIGO and WHO classifications, there was no worldwide consensus on the optimal classification system, largely due to a lack of high quality data proving the merit of one system over another. Remarkably, a validated, prospectively tested classification system is yet to be conducted. Over time, increasing criticisms have emerged regarding the currently adopted combined FIGO/WHO classification system, and its ability to identify patients most likely to develop primary chemotherapy resistance or disease relapse. This is particularly pertinent for patients with low-risk disease, whereby one in three patients are resistant to first line therapy, rising to four out of five women who score 5 or 6. This review aims to examine the historical basis of the GTN classification systems and critically appraise the evidence on which they were based. This culminates in a critique of the current FIGO/WHO prognostic system and discussion surrounding clinical preference versus evidence based practice.

A Randomised Assessment of Trainee Doctors' Understanding and Interpretation of Diagnostic Test Results.

INTRODUCTION: Doctors are unfamiliar with diagnostic accuracy parameters despite routine clinical use of diagnostic tests to estimate disease probability. METHODS: Trainee doctors completed a questionnaire exploring their understanding of diagnostic accuracy parameters; ability to calculate post-test probability of a common surgical condition (appendicitis) and their perceptions on training in this area. To determine whether the method of information provision altered interpretation, trainees were randomised to receive diagnostic test information in three ways: positive test only; positive test with specificity and sensitivity; positive test with positive likelihood ratio in layman terms. RESULTS: 326 candidates were recruited across 30 training sessions. Trainees scored a median of three out of seven in questions concerning knowledge of diagnostic accuracy parameters. This was affected neither by training level (P = 0.737) nor by experience in acute general surgery (P = 0.738). 30 (11.8%) candidates correctly estimated post-test probability; with 86.6% overestimating this value. Neither level of training (P = 0.180) nor experience (P = 0.242) influenced the accuracy of the estimate. Provision of the ultrasound scan results in different ways was not associated with likelihood of a correct response (P = 0.857). CONCLUSION: This study highlights the deficiencies in trainee doctors' understanding and application of diagnostic tests results. Most trainees over-estimated disease probability, increasing the risk of unnecessary intervention and treatment.

Do we understand the pathophysiology of endometrial cancer?

Endometrial carcinoma is the fourth most common cancer in U.K. women. Previous literature describes local, haematological or lymphatic dissemination to common sites including vaginal vault, lungs, liver, bones and brain. The authors present two unusual cases of endometrial cancer metastases to the psoas major muscle and laparoscopic port sites. Case 1 involves a 71-year-old female who underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy and peritoneal washings (TAH, BSO, PW) for Grade 1 endometrial cancer, Stage lB. Three years later she represented with lower back and right hip pain, with MRI imaging revealing psoas muscle metastases. Case 2 describes a 60-year-old female who underwent laparoscopic-assisted vaginal hysterectomy (LAVH), BSO+ PW for Grade 1 endometrial cancer, Stage 1B. Three years postoperatively she presented with a lateral abdominal mass overlying the laparoscopic port site scar, which was Grade 1 endometrial cancer on biopsy. These rare metastatic locations question our traditional understanding of the pathophysiology of endometrial carcinoma.

Post-menopausal presentation of yolk sac germ cell tumour.

•Yolk sac germ cell tumours are rare in post-menopausal patients.•Most involve mixed yolk sac tumours•Consider diagnosis in patients with a pelvic-abdominal mass and raised AFP.