When must a mastopathy at risk be operated on? The viewpoint of the clinician, the radiologist, the surgeon, and the anatomopathologist

The mastopathy is said to be truly "at risk" only when an anatomopathological examination has singled out certain criteria. At present, there is no medical treatment, particularly a hormonal one, capable of preventing the evolution towards a breast cancer. The indication for an operation could be based on a real score taking into account the age, the family history, the pregnancies, the fatness, the endogenous hormonal balance and the exogenous hormonal supply. In fact, above all considerations is the local mammary state, "the major mastoses", where a joint analytical study of: the clinical state, the mammography, the thermography and the cytopuncture is essential. The possibility of carrying out micro-biopsies under local anaesthesia is also underlined. Finally, we retain two big types of indication: of necessity. A lesion for which a doubt exists must be operated upon. The radiological location constitutes a considerable progress. Of principle. Namely in women with a heavy family history of breast cancer, a fortiori if the mammographies reveal dense, heterogeneous aspects, difficult to follow. Finally, the women for whom a previous biopsy has revealed lesions with an evolution potential (lobe neoplasia, extensive atypical epitheliosis). In conclusion, the indications are not often easy and is usually the object of a study of each case individually.     

Prematurity, “The Outcome”: The Past,the Present,and the Future

Objective: to present a clinical opinion on the outcome of very low birthweight (less than 1,250 grams) babies based on statistics of early child development and personal experience accumulated over the past 25 years of work in neonatal follow-up.Methods: population-based long-term outcomes of all survivors with birthweights of below 1,250 grams from northern and central Alberta has been prospectively obtained since 1974 when modern neonatal intensive care began in this region. The proportion of neurodevelopmentally disabled survivors (cerebral palsy, mental retardation, vision and hearing loss) is recorded graphically by time period and gestational age.The incompleteness of this neurodevelopmental disability tally as the standard form of outcome measurement of low birthweight is discussed by reflecting upon the past and the future.Results: two thousand, six hundred and three neonates of less than 1,250 grams birthweight received tertiary neonatal intensive care in northern and central Alberta from 1975 through 1997. Survival increased from 45 to 81 percent during this period, freedom from disability increased from 31 to 61 percent, and those disabled increased from nine to 14 percent. Among survivors, cerebral palsy has decreased to five percent from a high of 13 percent, vision loss has decreased to 2.5 percent from eight percent; yet hearing loss has increased from 2.5 percent to four percent in recent years. Mental delay (mental developmental level of less than 70) has increased from 13 percent in 1975-78 to greater than 30 percent of survivors born in the mid 1990’s.Conclusion: cerebral palsy and visual impairment are decreasing in frequency among very preterm infants; however, mental delay is increasing. Neurodevelopmental follow-up needs to expand within neuropsychological, behavioural, and psychosocial sciences in order to develop ways to help these survivors reach their potential.     

Could the central part of the partograph,the cervicograph be improved?

Aims. Since partographs were introduced into obstetric practice, more than 50 years ago, the appearance of cervicographs as their central section has not been significantly changed. The aims of this article are to assess whether the current characteristics of cervicographs represent the optimal solution with regard to the rules for plotting data and to suggest what that optimal solution might be.

Methods. The literature was searched for papers containing reproductions of cervicographs to review their characteristics. According to the general rules for plotting data, values of three most important characteristics of cervicographs were defined.

Results. The characteristics of the majority of available cervicographs are: a dilatation scale smallest division 1 cm, a time scale smallest division 1 h and 1 cm/h dilatation rate line inclination less than 45°. The optimal characteristics of cervicographs are: a dilatation scale smallest division 2 cm, a time scale smallest division 5 min and 1 cm/h dilatation rate line inclination of 45°.

Conclusion. The scale divisions on the proposed cervicograph form are in predefined relation to the accuracy of the measurements made. This enables improved portrayal of labour.     

The Missing Uterus,the Missed Diagnosis,and the Missing Care. Mayer-Rokitansky-Küster-Hauser Syndrome in the Lives of Women in Malaysia

Study ObjectiveTo explore the effect of the diagnosis of Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome on affected Malaysian women.DesignQualitative study with a quantitative component.SettingPediatric and adolescent gynecology unit at Universiti Kebangsaan Malaysia Medical Centre, Malaysia.ParticipantsTwelve women with MRKH.InterventionsFace-to-face interview and short questionnaire.Main Outcome MeasuresThematic analysis was used to understand participants’ experiences.ResultsThere were 7 themes identified: (1) delayed diagnoses; (2) doctors' roles and attitudes; (3) gender identity; (4) family and society's response; (5) reaction toward infertility; (6) managing sexual intimacy; and (7) coping mechanisms. Several participants consulted their physicians regarding their primary amenorrhea at an opportunistic setting. When they were referred to the gynecologists, they were dismayed at the lack of information given. The term, “MRKH” plays an important role to ease information-seeking. Participants felt that the doctors were insensitive toward them. Mental illness is a significant complication of MRKH. All participants acknowledged that infertility was the hardest part of the condition. The importance of blood lineage affects their outlook on childbearing options. Some were afraid of sexual intimacy and worried that they would not be able to satisfy their partners. Participants gained support and bonded with their counterparts in the MRKH support group.ConclusionA multidisciplinary approach including medical, psychological, and social support is essential for the management of MRKH. Adequate information and sexual education plays the utmost importance in preventing social-related complications of MRKH.     

Hot flushes, vascular reactivity and the role of the α-adrenergic system

ABSTRACT Background Seventy percent of postmenopausal women suffer from hot flushes but the pathophysiology is poorly understood. Proposed mechanisms include altered peripheral vascular reactivity and a narrowed thermoneutral zone. A trigger has not yet been identified; however, the α-adrenergic system, and specifically noradrenaline, has been implicated. Aim To assess the role of the α-adrenergic system by studying the effect of clonidine (α-adrenergic agonist) on flushes and cutaneous microvascular perfusion. Methods Thirty-two postmenopausal women with severe flushing and 14 non-flushing postmenopausal women were recruited. Cutaneous microvascular perfusion was measured using laser Doppler imaging and endothelial function was assessed by iontophoresis (administration of vasoactive agents through the skin by an electric current) of acetylcholine (ACh - endothelium-dependent) and sodium nitroprusside (SNP - endothelium-independent). In a double-blind, longitudinal, cross-over study, clonidine (an α-adrenergic agonist) was compared to placebo in its ability to modulate this response in the flushing group of women. Results The response of the subcutaneous vessels was greater in women who flushed than those who did not (ACh, p < 0.001 and SNP, p = 0.001). However, even though the intensity and number of flushes were decreased by clonidine, there was no difference compared to placebo (p = 0.21) and this 'placebo effect' was also noted in perfusion responses (ACh, p = 0.98; SNP, p = 0.50). Conclusion There was a significant 'placebo effect' for both clinical response and the reactivity of the subcutaneous vessels, making conclusions regarding the role of the α-adrenergic nervous system in hot flushing difficult to determine at a peripheral level. The mechanism for the change in vascular reactivity remains unclear.     

A challenge for the 21st century: whither physician-scientists in obstetrics, gynecology, and the reproductive sciences?

As we begin a new century, research in obstetrics and gynecology and its subspecialties face a crisis. Federal support to academic departments of obstetrics and gynecology through the National Institutes of Health is distressingly low in relation to that for other major specialties. In addition, academic departments face a shortage of clinically trained investigators and physician-scientists who will respond to the challenge of contributing to a greater understanding of the reproductive sciences and to the amelioration of diseases of women.     

Accreditation, certification: why all the confusion?

Tremendous confusion exists concerning the issues of physician certification and practice accreditation in obstetric and gynecologic ultrasonography. Certification speaks to physician competence. All obstetrician-gynecologists who have finished residency training since 1982 are deemed "competent" to perform obstetric and gynecologic ultrasonography by virtue of their training. Those trained before 1982 need to be able to describe their level of experience in performing obstetric and gynecologic ultrasonography. Accreditation deals with issues of patient safety and quality control, including equipment calibration, transducer cleaning and disinfection, universal precautions and Occupational Safety and Health Administration regulations, ultrasound examination protocols, and qualifications of nonphysician personnel performing ultrasound examinations. A new field of radiology benefit managers has arisen in response to attempts by health insurers to manage care, and reduce their costs and utilization. They have adopted ultrasound accreditation, originally intended to enhance patient safety, to help restrict utilization. Currently two organizations are recognized as accrediting bodies: The American Institute of Ultrasound in Medicine (AIUM), which recognizes obstetric and gynecologic residency training as evidence of competency, and The American College of Radiologists, which does not. Obstetrician-gynecologists should realize that AIUM's accreditation is their "lifeboat" in this time of increasing interference by health care insurers into decision making in clinical practice.     

Endometriosis,dysmenorrhea and diet-What is the evidence?

The objective of this study is to assess the literature concerning the effect of diet on endometriosis and dysmenorrhea and to elucidate evidential support, to give dietary recommendations to women suffering from these conditions. A systematic search in electronic databases on a relationship between diet and endometriosis/dysmenorrhea was performed. Data on diet and endometriosis were limited to four trials of which two were animal studies. The articles concerning human consumption found some relation between disease and low intake of vegetable and fruit and high intake of vegetarian polyunsaturated fat, ham, beef and other red meat. Results concerning fish intake were not consistent. Eight trials of different design, with a total of 1097 women, investigated the relationship between diet and dysmenorrhea. Intake of fish oil seemed to have a positive effect on pain symptoms. This study concludes that literature on diet and endometriosis is sparse, whereas eight studies have looked at diet and dysmenorrhea. No clear recommendations on what diet to eat or refrain from to reduce the symptoms of endometriosis can be given, while a few studies indicate that fish oil can reduce dysmenorrhea. Further research is recommended on both subjects.     

The more things change,the more they stay the same: Whither midwifery?

The pace of change is said to increase over the next few years. One of the most significant recent changes has been the “McDonaldization of Society”. The notion of “fastness” is permeating all society, including health and education. The concentration of rationalization through the principles of efficiency, calculability predictability and control, when extended to its logical conclusion, results in irrationality or dehumanization. Childbirth has been “McDonaldized” by the medical profession, but modern midwifery, is leading the way in an anti McDonald's movement to rehumanize it. Returning to past values contained in aesthetics, use of the partnership model, different forms of research and political action, midwifery is taking control of childbirth away from the rationalists and returning it to women. It is reclaiming childbirth by placing value on women and empowering them to take control of their own childbirth.