BACKGROUND Adenomyosis and endometriosis were initially described as 'adenomyoma'. When the retrograde menstruation theory became widely accepted to explain the pathogenesis of endometriosis, since it does not explain adenomyosis, the two conditions came to be seen as distinct entities. However, emerging evidence suggests that both diseases may be linked to changes in the inner portion of the myometrium. In addition, similar anomalies were found in the eutopic endometrium of the two conditions and the debate has re-opened. A common origin for both adenomyosis and endometriosis would have relevance not only for understanding uterine function and pathophysiology, but also for clinical management and treatment. METHODS The Scopus and Medline databases were searched for all original articles published in English up to the end of 2012. Search terms included 'adenomyosis'; 'endometriosis'; 'endometrium'; 'eutopic endometrium'; 'inner myometrium'; 'junctional zone'. Special attention was paid to articles comparing features of eutopic endometrium in the two conditions. RESULTS A number of similarities exist between adenomyosis and endometriosis and, by using magnetic resonance and laparoscopy, it was found that, at least in some subgroups, the two conditions often coexist. In both situations the inner myometrium (or junctional zone) is altered, although alterations are much more marked in adenomyosis where a thickness >12 mm is today considered sufficient for diagnosis. Research has shown differences between the eutopic endometrium of women with both diseases when compared with controls. There is an immune dysfunction and there are alterations of adhesion molecules, cell proliferation and apoptosis. An increase in cytokines and inflammatory mediators has also been observed. Finally, the presence of oxidative stress and anomalies in free-radical metabolism may alter uterine receptivity. When the two conditions were compared, dissimilarities were also observed in the extent of apoptosis inhibition and in the expression of some inflammatory mediators. It is not clear if observed differences are primarily related to presenting symptoms. Finally, both conditions are steroid dependent and research suggests a role for epigenetic mechanisms. The analysis indicates that much of the published research may have been influenced by the method of diagnosis and/or has not been controlled for the presenting symptoms, the concomitant presence of both diseases or full consideration of fluctuations within cycle phase. CONCLUSIONS It is difficult to draw firm conclusions from existing evidence since major diagnostic limitations still exist and there is a systematic bias in clinical presentation. In addition, scanty information is available on the natural history of endometriosis and no studies exist on the natural history of adenomyosis. Notwithstanding these limitations, a number of similarities, but also some differences have been found between the eutopic endometrium in the two diseases. These findings need to be taken with considerable ...

Objective To explore the attitudes of obstetricians to performe a caesarean section on maternal request in the absence of medical indication.Design Cluster sampling cross-sectional survey.Setting Neonatal Intensive Care Unit (NICU) associated maternity units in eight European countries.Population Obstetricians with at least 6 months clinical experience.Methods NICU-associated maternity units were chosen by census in Luxembourg, Netherlands and Sweden and by geographically stratified random sampling in France, Germany, Italy, Spain and UK. An anonymous, self-administered questionnaire was used for data collection.Main outcome measures Obstetricians' willingness to perform a caesarean section on maternal request.Results One hundred and five units and 1530 obstetricians participated in the study (response rates of 70 and 77%, respectively). Compliance with a hypothetical woman's request for elective caesarean section simply because it was 'her choice' was lowest in Spain (15%), France (19%) and Netherlands (22%); highest in Germany (75%) and UK (79%) and intermediate in the remaining countries. Using weighted multivariate logistic regression, country of practice (P < 0.001), fear of litigation (P = 0.004) and working in a university-affiliated hospital (P = 0.001) were associated with physicians' likelihood to agree to patient's request. The subset of female doctors with children was less likely to agree (OR 0.29,).Conclusions The differences in obstetricians' attitudes are not founded on concrete medical evidence. Cultural factors, legal liability and variables linked to the specific perinatal care organisation of the various countries play a role. Greater emphasis should be placed on understanding the motivation, values and fears underlying a woman's request for elective caesarean delivery.

Objectives To identify characteristics of general practices associated with emergency hospital admission rates, and determine whether levels of performance and patient reports of access are associated with admission rates. Design A cross-sectional study. Setting Two primary care trusts (Leicester City and Leicestershire County and Rutland) in the East Midlands of England. Participants 145 general practices. Methods Hospital admission data were used to calculate the rate of emergency admissions from 145 practices, for two consecutive years (2006/7 and 2007/8). Practice characteristics (size, distance from principal hospital, quality and outcomes framework performance data, patient reports of access to their practices) and patient characteristics (deprivation, ethnicity, gender and age), were used as predictors in a two-level hierarchical model, developed with data for 2007/8, and evaluated against data for 2006/7. Results Practice characteristics (shorter distance from hospital, smaller list size) and patient characteristics (higher proportion of older people, white ethnicity, increasing deprivation, female gender) were associated with higher admission rates. There was no association with quality and outcomes framework domains (clinical or organisation), but there was an association between patients reporting being able to see a particular general practitioner (GP) and admission rates. As the proportion of patients able to consult a particular GP increased, emergency admission rates declined. Conclusions The patient characteristics of deprivation, age, ethnicity and gender are important predictors of admission rates. Larger practices and greater distance from a hospital have lower admission rates. Being able to consult a particular GP, an aspect of continuity, is associated with lower emergency admission rates.In this paper, we report a study of the characteristics of general practices associated with the rate of emergency hospital admissions. The definition of emergency admissions in this study is that used in the English health service as including all non-elective admissions, including those via emergency departments, general practitioners, outpatient departments and other providers. In England in 2008e9 there were 14.1 million new hospital admissions, of which 5.0 million (35.4%) were emergency admissions, an increase of 22% on the 3.9 million emergency admissions in 2000e1.

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Objective To examine patients' understanding of the status, function, and remit of written consent to surgery. Design Prospective questionnaire study. Questionnaires were sent to patients within one month of surgery. Responses were analysed with frequencies and single variable analyses. Setting Large teaching hospital. Participants 732 patients who had undergone surgery in obstetrics and gynaecology over a six month period. Main outcome measures Patients' awareness of the legal implications of written consent and their views on the function and remit of the consent form. Results Patients had limited understanding of the legal standing of written consent. Nearly half (46%, 95% confidence interval 43% to 50%) of patients believed the primary function of consent forms was to protect hospitals and 68% (65% to 71%) thought consent forms allowed doctors to assume control. Only 41% (37% to 44%) of patients believed consent forms made their wishes known. Conclusions Many patients seem to have limited awareness of the legal implications of signing or not signing consent forms, and they do not recognise written consent as primarily serving their interests. Current consent procedures seem inadequate as a means for the expression of autonomous choice, and their ethical standing and credibility can be called into question.

Objectives  To evaluate women's experience of giving consent to obstetric and gynaecological surgery and to examine differences between those undergoing elective and emergency procedures. Design  A prospective questionnaire study. Setting  A large teaching hospital. Population  1006 consecutive patients undergoing elective or emergency surgery in obstetrics and gynaecology. Methods  Questionnaires were administered to women who had given consent to surgery following the introduction of national guidelines and consent form. Differences in responses between elective and emergency patients were assessed using frequencies, single and multivariable analyses. Main outcome measures  Patients' experience and recall of the consent process, their overall satisfaction and their views on what is important for adequate consent. Results  There were significant differences between patients undergoing elective or emergency surgery. Patients undergoing emergency surgery were less likely to have read (OR 0.22) or understood (OR 0.40) the consent form, and were more likely to report feeling frightened by signing it (OR 2.52). They were more likely to report they felt they had no choice about signing the consent form (OR 2.11), and that they would have signed regardless of its content (OR 3.14). Overall, significantly more patients undergoing elective (80%) or emergency (63%) surgery reported satisfaction with the consent process. Patients were more likely to report satisfaction if they read (OR 1.80) and agreed with (OR 3.49) the consent form, and if someone checked that they understood (OR 3.09). Conclusion  Patients' needs may not be adequately addressed by current guidelines for consent to treatment, particularly in emergency circumstances. The introduction of more complex forms and procedures appears to conflict with patients' need for personal communication and advocacy. The implications on the ethical and legal standing of consent are considerable.

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