women is as common as asthma and chronic back pain, 1,2 is one of the most difficult and perplexing of women's health problems, and has a multifactorial etiology. 3 Chronic pelvic pain has a major effect on health-related quality of life, work attendance and productivity, 4 and health care use, accounting for 40% of referrals for diagnostic laparoscopy, 5 and is an important contributor to health care expenditures. 6 Treatments for chronic pelvic pain are often unsatisfactory. 7 As part of the evaluation and management phase, patients often undergo diagnostic laparoscopy 8 but actionable pathology is found only occasionally. 9,10 Negative findings at laparoscopy and during follow-up with ultrasound may provide re
Objective To evaluate the effects of operator experience on perinatal outcome in a single centre.Design Prospective consecutive cohort study.Setting Regional tertiary referral Fetal Medicine Centre in the UK.Population Pregnant women with monochorionic twin pregnancies complicated by severe twin-to-twin transfusion syndrome (TTTS) (at £26 completed weeks of gestatiuon) treated by fetoscopic laser coagulation (FLC) between October 2004 and November 2009.Methods Pregnancy characteristics and outcomes were collected. Logistic regression analysis was employed to determine the effect of a priori defined variables on outcome.Main outcome measure Perinatal survival (survival to 28 days or beyond) for one or more twins.Results There were 164 consecutive sets of monochorionic twins. The median gestational age (GA) at FLC was 20.4 weeks (interquartile range 18-22.1 weeks), the median interval from FLC to delivery was 88.5 days (interquartile range 53-101 days) and the median GA at delivery was 33.2 weeks (interquartile range 29.7-34.9 weeks). The overall survival was 62%; perinatal survival of one or more twins was 85%. These outcomes improved after about 61 procedures were performed, and after about 3.4 years of experience. Univariate logistic regression analysis indicated that Quintero stage-IV disease decreased (OR 0.26; 95% CI 0.10-0.69) and prolongation of GA at delivery increased the survival of the twins (OR 1.34; 95% CI 1.12-1.60) (P < 0.01). Increasing experience of the procedure by operator led to a significant increase in perinatal survival (P < 0.01; OR 4.59; 95% CI 1.84-11.44). Multivariate logistic regression analysis indicated that only GA at delivery increased survival overall (OR 1.34; 95% CI 1.12-1.60; P = 0.01).Conclusions These data indicate that both relatively large numbers treated and experience with FLC minimises any adverse outcome in monochorionic pregnancies with severe TTTS.Keywords Fetoscopic laser, perinatal outcome, Twin-to-twin transfusion syndrome.Please cite this paper as: Morris R, Selman T, Harbidge A, Martin W, Kilby M. Fetoscopic laser coagulation for severe twin-to-twin transfusion syndrome: factors influencing perinatal outcome, learning curve of the procedure and lessons for new centres.
BackgroundThe lymph node status of a patient is a key determinate in staging, prognosis and adjuvant treatment of endometrial cancer. Despite this, the potential additional morbidity associated with lymphadenectomy makes its role controversial. This study systematically reviews the accuracy literature on sentinel node biopsy; ultra sound scanning, magnetic resonance imaging (MRI) and computer tomography (CT) for determining lymph node status in endometrial cancer.MethodsRelevant articles were identified form MEDLINE (1966–2006), EMBASE (1980–2006), MEDION, the Cochrane library, hand searching of reference lists from primary articles and reviews, conference abstracts and contact with experts in the field. The review included 18 relevant primary studies (693 women). Data was extracted for study characteristics and quality. Bivariate random-effect model meta-analysis was used to estimate diagnostic accuracy of the various index tests.ResultsMRI (pooled positive LR 26.7, 95% CI 10.6 – 67.6 and negative LR 0.29 95% CI 0.17 – 0.49) and successful sentinel node biopsy (pooled positive LR 18.9 95% CI 6.7 – 53.2 and negative LR 0.22, 95% CI 0.1 – 0.48) were the most accurate tests. CT was not as accurate a test (pooled positive LR 3.8, 95% CI 2.0 – 7.3 and negative LR of 0.62, 95% CI 0.45 – 0.86. There was only one study that reported the use of ultrasound scanning.ConclusionMRI and sentinel node biopsy have shown similar diagnostic accuracy in confirming lymph node status among women with primary endometrial cancer than CT scanning, although the comparisons made are indirect and hence subject to bias. MRI should be used in preference, in light of the ASTEC trial, because of its non invasive nature.
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