Geographic variation in the rate and route of hysterectomy for benign disease in the USA: A retrospective cross-sectional study.

OBJECTIVES: To describe population rate of hysterectomy for benign disease in the USA, including geographic variation across states and Hospital Service Areas (HSAs; areas defined by common patient flows to healthcare facilities). DESIGN: Cross-sectional study. SETTING: Four US states including 322 HSAs. POPULATION: A total of 316 052 cases of hysterectomy from 2012 to 2016. METHODS: We compiled annual hysterectomy cases, merged female populations, and adjusted for reported rates of previous hysterectomy. We assessed small-area variation and created multi-level Poisson regression models. MAIN OUTCOME MEASURES: Prior-hysterectomy-adjusted population rates of hysterectomy for benign disease. RESULTS: The annual population rate of hysterectomy for benign disease was 49 per 10 000 hysterectomy-eligible residents, declining slightly over time, mostly among reproductive-age populations. Rates peaked among residents ages 40-49 years, and declined with increasing age, apart from an increase with universal coverage at age 65 years. We found large differences in age-standardised population rates of hysterectomy across states (range 42.2-69.0), and HSAs (range: overall 12.9-106.3; 25th-75th percentile 44.0-64.9). Among the non-elderly population, those with government-sponsored insurance had greater variation than those with private insurance (coefficient of variation 0.61 versus 0.32). Proportions of minimally invasive procedures were similar across states (71.0-74.8%) but varied greatly across HSAs (27-96%). In regression models, HSA population characteristics explained 31.8% of observed variation in annual rates. Higher local proportions of government-sponsored insurance and non-White race were associated with lower population rates. CONCLUSIONS: We found substantial variation in rate and route of hysterectomy for benign disease in the USA. Local population characteristics explained less than one-third of observed variation.

Open issues in management of carbon monoxide poisoning in pregnancy: practical suggestions.

Carbon monoxide (CO) poisoning during pregnancy may cause deleterious effects to the fetus. Hyperbaric oxygen therapy (HBO) in pregnancy is proven to be safe and it is considered to be beneficial, reducing the severity of the fetal injuries. However, a number of issues are still to be discussed, among them the question of the carboxyhemoglobin (COHb) levels that trigger HBO therapy in pregnant CO poisoned patients. In this letter we report some practical suggestions for organizations wishing to develop their own protocols.

A review of modern and Vedic practices on use of umbilical cord.

Stromal cells possess unique properties to regenerate themselves and cure various chronic illnesses. An easily available and ethical source for procurement of stromal cells is umbilical cord blood which is now being stored for future use. Vedic texts also describe the cord blood as a source of life. However, Indian traditions seem to preserve one more alternative for storage and procurement of stromal cells. Traditionally, in many parts of India, the umbilical cord stump is dried and stored for future use. It is used as a medicine for some illness and to treat infertility. Since Indian traditions are an excerpt of Vedic science, it points towards the possible emergence of dried stump as an easy and cost-effective means for stromal cell procurement and storage. The present review compiles the literature available on these traditional practices and stresses upon the need of rigorous experimental and theoretical research in the area.

Evaluation of the frequency of coitus interruptus and the effect of contraception counselling on this frequency.

In this prospective study, the aim was to determine the frequency and effectiveness of the coitus interruptus method, to compare the demographic characteristics of women using modern contraception methods and those using the coitus interruptus method and to demonstrate how effective contraceptive counselling is in choosing a contraception method. The researchers collected data from 1000 sexually active women in their reproductive period at the gynaecological clinic of a university hospital in Turkey. The researchers used an introductory information contraceptive counselling form, which they prepared for the data collection tool. The rate of the coitus interruptus method use among the interviewed women was 42.8%. There was a statistically significant difference between the coitus interruptus group and the group using modern contraceptive methods regarding mean age, educational status, smoking, awareness of last menstrual period, number of pads used during the menstrual period, and information sources. Following effective contraception counselling, the rate of switching to a modern and proven contraceptive method was found to be 73.8%.Impact statementWhat is already known on this subject? Although the traditional method of coitus interruptus has been used for many years, its incidence is not clearly known. What we know about the subject is based on ancient research. All the studies on the subject are very old and need to be updated.What do the results of this study add? With the help of the data obtained from this study, it is understood that withdrawal method is still widely used today, it is still not known that it is not a modern contraceptive method and the rate of transition to modern methods with effective contraception counselling is very high.What are the implications of these findings for clinical practice and/or further research? In the outpatient clinic conditions, even a very short period of time for contraception counselling will be very beneficial for women and will contribute to family planning and prevent unwanted pregnancies.

Severe morbidity with ectopic pregnancy is associated with late presentation.

This article investigates if severe morbidity associated with ectopic pregnancy (EP) is related to patient characteristics or the quality of patient care after presentation. This is a retrospective study of women who had surgical management of tubal EP between 2008 and 2012. Severe maternal morbidity was defined as a blood loss ≥800 mL. Women of a white ethnicity were statistically more likely to have a blood loss of <800 mL (p = .0228). The patient related risk factors were significantly higher in the women with a blood loss of <800 mL (p = .0139). The incidence of substandard care was low in both groups although a substandard care due to a misdiagnosis of EP was significantly higher in the patients with a blood loss ≥800 mL (p = .0150). We found that a severe morbidity from EP is multifactorial involving patient awareness of risk factors and timely diagnosis by healthcare professionals. IMPACT STATEMENT What is already known on the subject? Ectopic pregnancy (EP) can be associated with severe maternal morbidity with up to a third of women with EP being managed after the pregnancy has ruptured. To try and reduce severe maternal morbidity and improve management for these women it is vital to identify the important risk factors associated with severe maternal morbidity. What do the results of this study add? We found ethnicity to be a predictive factor of severe maternal morbidity, with women of white ethnicity significantly more likely to have reduced severe maternal morbidity compared to other ethnicities. We also found multiple risk factors for an EP were statistically protective of severe maternal morbidity. We found the rate of substandard care to be low in our study but identified that where there was substandard care it was associated with diagnostic and therapeutic delays. Our findings lead us to conclude that a severe maternal morbidity from EP is multifactorial, and an improvement will involve both a patient awareness of risk factors and a timely diagnosis by health care professionals. What are the implications of these findings for clinical practice and/or further research? We believe that this to be an important article as it identifies the importance of the increasing knowledge both of women in the community but also educating health care professionals on the signs and symptoms of EP. These steps are vital to improve severe maternal morbidity associated with EP.

An exploration of attitudes towards female genital mutilation (FGM) in men and women accessing FGM clinical services in London: a pilot study.

This pilot study researched the attitudes towards and the knowledge of female genital mutilation (FGM) in adult women with FGM and their partners. The participant population consisted of English-speaking women and men over 18 years old attending specialist FGM clinics in two London hospitals. The participants completed a questionnaire on the attitudes and the knowledge of FGM, which were adapted with permission from the United Nations Children's Fund and the United States Agency for International Development household surveys. 54 participants (51 women, 3 men) took part in the surveys. 89% of participants thought that FGM should be stopped (95%CI: 0.81-0.97) and 72% said they knew FGM is illegal in the United Kingdom (UK). 15% reported that FGM caused no danger, or were unaware of any danger to women's health. This study demonstrates the opposition to FGM by participants, but some lack of knowledge regarding the legal and health implications. The exploration of attitudes in diaspora community groups is often cited as key to safeguarding girls from FGM. This is one of the first UK studies of individuals from FGM-practising communities, and we recommend use of the study questionnaires for a multicentre, cross-community study. Impact statement What is already known about this subject? Women and children are affected by female genital mutilation (FGM) globally and in the United Kingdom (UK). The majority of knowledge on practices and the attitudes towards FGM comes from UNICEF and USAID research in Africa and there is scant data on FGM practices in diaspora communities in the UK. What do the results of this study add? This study provides an appropriate questionnaire and protocol for use in community-based national research to improve healthcare for women by collecting up-to-date data on the attitudes towards FGM among the members of FGM-practising communities in the UK. What are the implications of these findings for clinical practice and further research? The implications of the results of this study are that health professionals need to understand that patients do not always know the law on FGM, even after a consultation. Health and social care professionals are placed in a unique position to work with community members to educate men and women to end FGM.

Non-indicated use of prophylactic antibiotics in gynaecological surgery at an academic tertiary medical centre.

Surgical site infections (SSI) are the most common surgical complication. Perioperative antibiotics can reduce SSI when used properly. Despite guidelines from The American College of Obstetrics and Gynecology, non-indicated antibiotic use is widespread which exposes women to unnecessary risks. This study represents a quality improvement analysis assessing surgeon compliance with established guidelines regarding antibiotic use in gynaecological surgery. This is a single centre, retrospective study examining gynaecological procedures over two years. Cases were identified using Current Procedure Terminology codes. Perioperative antibiotics were used contrary to published guidelines in 199 of 1046 cases. Three variables were independently associated with inappropriate administration of perioperative antibiotics: entrance into abdominal cavity, higher EBL, and longer procedures. Impact statement Overuse of antibiotics has unintended consequences including allergic sequelae, extended length of hospital stay, increased healthcare costs, and the formation of antibiotic-resistant organisms. Antibiotic stewardship programmes have been shown to reduce the number of resistant pathogens, decrease incidence of Clostridium difficile colitis, and decrease length of hospital stay without increasing infection rates. Further outcomes-based research is needed regarding the use of antibiotic stewardship programmes in gynaecological surgery.

OAB epidemiological survey of general gynaecology outpatients and its effects on patient quality of life.

AIMS: To survey the prevalence rate of overactive bladder (OAB) among general gynaecology outpatients, it's connection to common benign gynaecological diseases and its effects on patient quality of life (QOL). METHOD: A questionnaire survey on urination and its effects on QOL was administered to 2500 general gynaecology outpatients aged ≥18 who visited our hospital which is in Peking between October and November 2012. Additionally, their menstrual history and diseases were documented, according to their medical records. RESULTS: In total, 2161 effective questionnaires (86.4%) were collected from the respondents, who were aged 18-97 years. The overall OAB prevalence rate was 8.8% (191/2161), and the OAB prevalence rate in women >50 years was significantly higher (X(2) = 7.656, P < 0.05). Moreover, the OAB prevalence rate (25.8%) among patients suffering from pelvic organ prolapse was significantly higher than the rate (8.6%) among patients without pelvic organ prolapse (X(2) = 11.238, P < 0.05). Multi-factor logistic regression indicated that age (OR = 1.504, 95% CI = 1.072-2.111) and pelvic organ prolapse (OR = 2.512, 95% CI = 1.109-5.688) were risk factors for OAB among the respondents. Additionally, with the rise of OAB severity, its effects on the QOL of OAB patients, like urinary urgency, nocturia, frequency and urge incontinence increased accordingly. CONCLUSIONS: The OAB prevalence rate among general gynaecology outpatients was 8.8%, and the effects of OAB on QOL increased with the worsening of the disease.

Efficacy and safety of ferrous asparto glycinate in the management of iron deficiency anaemia in pregnant women.

The aim of the present investigation was to compare the efficacy and safety of oral ferrous asparto glycinate and ferrous ascorbate in pregnant women with iron deficiency anaemia (IDA). We performed a double blind, prospective, randomised, multicentre, parallel group comparative clinical study at three different centres in India. A total of 73 pregnant women at 12-26 weeks' gestation were divided into two arms. While one group received ferrous ascorbate, another group was treated with ferrous asparto glycinate for a period of 28 days. The mean rise in haemoglobin and ferritin levels on day 14 and 28 was evaluated. At both time points, significantly higher levels of haemoglobin and ferritin were noticed with ferrous asparto glycinate treatment as compared with ferrous ascorbate. Our results showed that ferrous asparto glycinate is an effective iron-amino acid chelate in the management of IDA in pregnant women as compared with ferrous ascorbate. Nevertheless, additional large scale prospective, randomised trials are warranted to confirm the findings of the present efficacy trial, and also to find out the anaemia eradication rate.

CT scan does not predict optimal debulking in stage III-IV epithelial ovarian cancer: a multicentre validation study.

Our aim was to design and validate a model of CT findings that predict suboptimal cytoreduction in primary surgery (PS) for Stage III-IV epithelial ovarian cancer (EOC). We performed a retrospective review of preoperative CT scans of patients undergoing PS for EOC in a cancer centre in London, UK, between November 1995 and October 2003 (n = 91). Radiological features predictive of suboptimal cytoreduction were identified and the model tested in a second cohort undergoing PS in Manchester, June 2005 - March 2007 (n = 35). In the London cohort, liver surface disease and infrarenal para-aortic lymph node involvement predicted suboptimal cytoreduction with 80% accuracy. Accuracy of these predictors dropped to 63% when applied to the Manchester cohort. We concluded that CT prediction of suboptimal cytoreduction is unreliable and may not be reproducible. In the absence of favourable data from larger, prospective trials, it should not be used to guide management.

Delivering quality care: what can emergency gynaecology learn from acute obstetrics?

Emergency obstetric care in the UK has been systematically developed over the years to high quality standards. More recently, advances have been made in the organisation and delivery of care for women presenting with acute gynaecological problems, but a lot remains to be done, and emergency gynaecology has a lot to learn from the evolution of its sister special interest area: acute obstetric care. This paper highlights areas such as consultant presence, risk management, patient flow pathways, out-of-hours care, clinical guidelines and protocols, education and training and facilities, where lessons from obstetrics are transferrable to emergency gynaecology.

Establishment and application of the "electronic follow-up platform for endometriosis" during the COVID-19 pandemic.

The management of endometriosis has been complicated by the COVID-19 pandemic. We aimed to introduce the establishment and application of a new follow-up method during the COVID-19 pandemic-the electronic follow-up (e-follow-up) platform for endometriosis-and to test the applicability of the platform-based follow-up management model and patient satisfaction. We used the platform for information entry and post-operative follow-up of 152 patients with endometriosis from January 2021 to August 2022, and compared patients' Zung's Self-Rating Depression Scale (SDS), Self-Rating Anxiety Scale (SAS), and Visual Analogue Score (VAS) (range: 0 - 10, indicating: no pain-extreme pain) scores preoperatively and after 6-month of follow-up, together with recording patients' follow-up satisfaction and number of recurrence of lesions. Eventually, the SDS, SAS, and VAS scores were significantly lower than those at pre-surgery (p < .001), and the follow-up satisfaction rate reached 100%, with 91.41% expressing great satisfaction. The cumulative number of recurrences was 2 out of 138. Follow-up using this platform reduce the risk of COVID-19 transmission, enabled more efficient access to healthcare resources for patients with endometriosis, improved the efficiency of follow-up management, met the mental health needs of the patients.

Silent voices that must be heard - women's perceptions of gynecologic examinations.

PURPOSE: To analyze the perception of gynecologic examination from the patients' point of view. MATERIALS AND METHODS: This anonymous electronic cross-sectional survey aimed to evaluate the subjective experiences of women during gynecologic examinations (levels of pain, embarrassment and trauma), the manner the examination was conducted, and women's suggestions for improving their experience. RESULTS: Overall, 6,508 women answered the survey. The examination was considered an embarrassing event by 47%, painful by 35% and traumatic by 19%. Importantly, only 43% of the respondents stated they would notify the gynecologist in case of physical discomfort or pain during the examination. The quality of physician-to-patient communication was rated as the most important aspect of gynecologic examination, and showed a significant association with the general quality of the experience (levels of pain, embarrassment, and trauma). Matters relating to women's privacy during gynecologic examination were also considered important. An option for a companion was rated as important by 64% of the respondents. Significant differences with large effect-sizes were found between the respondents' preferences and their reports of the observed situation. CONCLUSION: The findings highlight the need for establishing guidelines for gynecologic examinations, according to a patient-centered care approach. This study constitutes a first discourse on the subject of gynecologic examinations in Israel in order to provide an overview and initial insights, serving as a starting point for further specific and more in-depth research.

Impact of different educational interventions on psychosocial well-being of women with a positive high-risk human papillomavirus and normal cervical cytology: a randomised trial.

INTRODUCTION: The aim of this study was to compare the effect of two educational interventions on the psychosocial well-being of Hong Kong Chinese women who have a positive high-risk human papillomavirus (HPV) test and normal cervical cytology. METHODS: Participants were randomised into either leaflet group, in which a written HPV factsheet was provided; or counselling group, in which a didactic HPV presentation in person in addition to the factsheet was provided. Women's psychological conditions were assessed by self-administered questionnaires at pre, post (within one week) and 6 months after the educational interventions. Main outcome measures were psychosocial well-being (cervical cancer worry, anxiety and depression, screening-related anxieties, HPV-related shame) and knowledge of cervical screening and HPV. RESULTS: Data from 121 women (52 in leaflet group; 69 in counselling group) were analysed. There was no significant difference in the psychosocial well-being between the two groups at alltime points. Irrespective of the two educational interventions, cervical cancer worry and anxiety decreased over time. The counselling group had a significantly higher score in knowledge of cervical screening and HPV compared with leaflet group (mean score 4.65 ± 0.19 versus 3.71 ± 0.23, p = 0.002) at post-educational intervention, but there was no significant difference (mean score 4.14 ± 0.22 versus 3.58 ± 0.24, p = 0.084) at 6 months. DISCUSSION: Both educational interventions were comparable in relieving adverse HPV-related psychosocial effects. Combination of counselling and leaflet were more effective than leaflet only in improving women's knowledge on cervical screening and HPV soon after educational interventions but the benefit was not apparent after 6 months.