Objectives To study the frequency of complications of endometrial resection and ablation for menstrual Design Prospective survey with additional retrospective reporting by theatre staff.Setting 300 National Health Service and independent hospitals in the United Kingdom (excluding disturbances and the influence of the experience of the operators. Scotland),Population 10,686 women registered by 690 doctors (1-222 cases/doctor) from April 1993 to October 1994. MethodsMailings were sent to relevant medical and non medical staff at every hospital to ascertain who performed the operations. These doctors were asked to complete a questionnaire detailing their previous experience. Completed patient registration forms were returned each month. Theatre contacts returned lists of cases reported in theatre registers.Main outcome measures Perioperative, post-operative and delayed complications by method of surgery and experience of operator.Results Two directly related deaths were reported. Laser and rollerball ablations were associated with least operative and post-operative complications. Combined loop and rollerball diathermy was associated with a higher rate, but with fewer immediate operative complications than loop resection alone. Endometrial thinning agents were not associated with decreased complications. Fibroids were associated with increased operative haemorrhage. Early post-operative complication rates ranged from 0.77% to 1.51%. Six-week follow up in 82.5% of the women revealed few complications (1.25% to 4.58%). Increasing operative experience was associated with fewer uterine perforations in the loop resection alone group (x2 for trend, P < 0.001), but had no effect on operative haemorrhage in any group. ConclusionsThese procedures were used widely in 1993 to 1994 with low morbidity and mortality. The techniques may be relatively easily learned in the apprenticeship system without compromising safety. Combined diathermy resection appears safer than loop resection alone, but laser and rollerball ablation were safest.

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OBJECTIVE To quantify the impact of cash transfer and microfinance interventions on a selected list of tuberculosis (TB) risk factors and assess their potential role in supporting TB control. DATA SOURCE Published and unpublished references identified from clinical and social electronic databases, grey literature and web sites. METHODS Eligible interventions had to be conducted in middle- or low-income countries and document an impact evaluation on any of the following outcomes: 1) TB or other respiratory infections; 2) household socio-economic position; and 3) factors mediating the association between low household socio-economic position and TB, including inadequate health-seeking behaviours, food insecurity and biological TB risk factors such as human immunodeficiency virus (HIV) and adult malnutrition. Interventions targeting special populations were excluded. RESULTS Fifteen cash transfer schemes (four unconditional and 11 conditional) and seven microfinance programmes met the eligibility criteria. No intervention addressed TB or any other respiratory infection. Of 11 cash transfer and four microfinance interventions, respectively seven and four reported a positive impact on indicators of economic well-being. A positive impact on household food security was documented in respectively eight of nine and three of five cash transfer and microfinance interventions. Improved health care access was documented respectively in 10 of 12 cash transfer and four of five microfinance interventions. The only intervention evaluating impact on HIV incidence was a microfinance project that found no effect. No cash transfer or microfinance interventions had an impact on adult malnutrition. CONCLUSIONS Cash transfer and microfinance interventions can positively impact TB risk factors. Evaluation studies are urgently needed to assess the impact of these social protection interventions on actual TB indicators.

Objectives To model the determinants of serious operative and post-operative complications of hysterectomy and their potential risk factors. Design A prospective cohort of women undergoing hysterectomies for benign indications in 1994/1995, with a six-week postsurgery follow up. Population and setting A total of 37,512 women from 276 NHS and 145 private hospitals in England, Wales and Northern Ireland, originally recruited to compare the outcomes of endometrial destruction with those of hysterectomy. Methods Gynaecologists reported hysterectomies for non-malignant indications carried out during a 12-month period beginning in October 1994 and follow up data were obtained at outpatient follow up six weeks postsurgery. Odds ratios of severe complications by indication and method, adjusting for measured intrinsic risk factors, were calculated. Main outcome measures Severe operative and post-operative complications.Results Severe operative complications occurred in 3%. The risk decreased with age and increased with greater parity and history of serious illness. Women with symptomatic fibroids (4.4%, 95% CI 3.9 -4.9) experienced more complications than women with dysfunctional uterine bleeding (3.6%, 3.2 -3.8), adjusted odds ratio (OR) ¼ 1.3 (95% CI 1.1 -1.6). Laparoscopic procedures (6.1%) doubled the risk of operative complications of abdominal hysterectomy (3.6%) (adjusted OR ¼ 1.9, 1.5-2.5). Post-operative complications occurred in around 1% of women, with a slight decrease with increasing age, and the strongest risk factor was a history of operative complications. Relative to dysfunctional uterine bleeding (1.0%), a higher risk for fibroids (1.2%) persisted after adjustments (RR ¼ 1.5, 1.1-2.0). Both vaginal (1.2%) and laparoscopic (1.7%) techniques had significantly higher adjusted risks than abdominal operations (0.9%), RR ¼ 1.4 (1.0 -1.9) and RR ¼ 1.6 (1.0 -2.7). There were no operative deaths; 14 women died within the six-week postsurgery (a crude mortality rate of 3.8/1000, 2.5 -6.4). Conclusions Hysterectomy is a common, routine surgery with comparatively rare serious complications.However, younger women, women with more vascular pelvises, who undergo hysterectomy, especially laparoscopically assisted vaginal surgery for symptomatic fibroids, are at most risk of experiencing severe complications both operatively and post-operatively. Therefore, a less invasive alternative treatment for symptomatic fibroids could particularly benefit this group of women, while less invasive treatments for dysfunctional uterine bleeding, such as various methods of endometrial ablations or resections, would need to meet the current low levels of clinical complications in order to replace hysterectomy.

In a 12-month period from October 1994 to September 1996, over 350 hospitals in England, Wales, Northern Ireland, the Channel Islands, and the Isle of Man participated in an investigation of major operative and postoperative complications associated with hysterectomy for benign causes. The staff at participating hospitals collected information for all such hysterectomies performed during this 12-month period by completing questionnaires at 3 points in the management of the patient. The first was at the time of surgery, the second at discharge, and the third 6 weeks after surgery. There were a total of 37,295 qualifying procedures performed during the study period. Information from the sixth-week postoperative visit was available for 26,973 (72%) cases. The average age of patients undergoing hysterectomy was 45 years. The most common indication for surgery was dysfunctional uterine bleeding (46%), followed by fibroids (19%) and prolapse (19%). Other indications included endometriosis and adenomyosis (5%) and pelvic mass (3%). Over half (58%) of the procedures were performed by consulting-level surgeons who also served as supervisors in 34% of the cases carried out by nonconsultants. Two thirds of the cases (24,772; 67%) were total abdominal hysterectomy (TAH), 30% (11,122) were vaginal hysterectomy (VAH), and 3% (1154) were laparoscopically assisted vaginal hysterectomy (LAVH). There were 14 deaths in this study (mortality rate 0.38 per 1000). Eight women died before discharge and 6 died within 6 weeks after surgery. No patient died during surgery and no deaths were among the women who had LAVH. There were a total of 1295 (3.5%) major operative complications and 383 (1%) postoperative complications. The number of complications tended to decrease with increasing age of the patient (11% decrease in odds of complications for each 10 years of age; P ϭ 0.002). The risk of operative complications increased with increasing parity (odds ratio, 1.04; 95% confidence interval, 1.01-1.08 for each pregnancy). Operative and postoperative complications were most common in LAVH procedures (6.1% and 1.7%, respectively), with comparable rates of 3.1% and 0.9% in TAH and 3.1% and 1.2% in VAH (P Ͻ0.001 and P ϭ 0.15, respectively). Hysterectomies being performed to remove fibroids had the highest risks of complications (operative 4.4% and postoperative complications 1.2%). Other indications carried risk of 3.6% and 1.0% for dysfunctional uterine bleeding, 2.7% and 1.1% for prolapse, 3.1% and 0.8% for endometriosis/adenomyosis, and 3.7% and 0.8% for pelvic mass. The risk of operative and postoperative complications was higher in women with a history of serious illness (4.8% and 1.5%) compared with no such history (3.4% and 1.0%, P Ͻ0.001 and P ϭ 0.024, respectively). Serious illness was also associated with higher risk of operative complications in women undergoing hysterectomy for fibroids. No significant differences in rates of operative or postoperative complications were seen according to the operator or presence of a supervisor. T...

Background: Complex and expensive treatment options have increased the frequency and emphasis of ethical decision making in healthcare. In order to meet these challenges effectively we need to identify how nurses contribute the resolution of these dilemmas. Aims:To identify the values, beliefs and contextual influences that inform decision making.To identify the contribution made by nurses in achieving the resolution of ethical dilemmas in practice.Design: An interpretive exploratory study was undertaken, eleven registered acute care nurses, working in a district general hospital in England were interviewed, using semi-structured interviews. In-depth content analysis of the data was undertaken via NVivo coding and thematic identification.

Objectives To describe hysterectomies practised in 1994 and 1995: the patients, their surgery and short term outcomes.Design One of two large cohorts, with prospective follow up, recruited to compare the outcomes of endometrial destruction with those of hysterectomy.Setting England, Wales and Northern Ireland.Population All women who had hysterectomies for non-malignant indications carried out during a 12-month period.Methods Gynaecologists in NHS and independent hospitals were asked to report cases. Follow up data were obtained at outpatient follow up approximately six weeks post-surgery.Main outcome measures Indication for surgery, method of hysterectomy, ovarian status post-surgery, surgical complications.Results 37,298 cases were reported which is estimated to reflect about 45% of hysterectomies performed during the period studied. The median age was 45 years, and the most common indication for surgery was dysfunctional uterine bleeding (46%). Most hysterectomies were carried out by consultants (55%). The proportions of women having abdominal, vaginal or laparoscopically-assisted hysterectomy were 67%, 30% and 3%, respectively. Forty-three percent of women had no ovaries conserved after surgery. The median length of stay was five days. The overall operative complication rate was 3.5%, and highest for the laparoscopic techniques. The overall post-operative complication rate was 9%. One percent of these was regarded as severe, with the highest rate for severe in the laparoscopic group (2%). There were no operative deaths; 14 deaths were reported within the six-week post-operative period: a crude mortality rate soon after surgery of 0.38 per thousand (95% CI 0.25 -0.64).Conclusions This large study describes women who undergo hysterectomy in the UK, and presents results on early complications associated with the surgery. Operative complications occurred in one in 30 women, and post-operative complications in at least one in 10. Laparoscopic techniques tend to be associated with higher complication rates than other methods.