Do women with urinary incontinence really know where all the toilets are?: The toilet paper

AIMS OF STUDY: Aim of this study was to determine if women with overactive bladder really do have a more detailed knowledge about toilets and their conditions in their vicinity in comparison to women with urinary stress incontinence and those without any urinary symptoms. PATIENTS AND METHODS: A questionnaire survey of 270 women from three symptom groups, those with stress incontinence, overactive bladder and controls without any bladder symptoms from an inner city area and two local towns. The knowledge of the three groups was compared and measured by a score assessed by the authors who had visited the toilets themselves. RESULTS: Women with overactive bladder are more likely to exhibit precautionary voiding prior to leaving home and have significantly more detailed knowledge about toilets in their neighbourhood. DISCUSSION: The overactive bladder seems to have a greater influence on behaviour and on quality of life than stress incontinence which could mean that they are more tortured by their symptoms.     

How distressing is referral to colposcopy in cervical cancer screening?: A prospective quality of life study

Objective

Referral for colposcopy because of abnormal Pap test results is likely to be distressing, but the extent and duration of these effects are unknown. We aimed to fill this gap.

Methods

We conducted a prospective observational study at two departments of Obstetrics and Gynecology (an academic and a non-academic setting). Women referred for colposcopy completed questionnaires before colposcopy, and at 1, 3, and 6 months afterwards. A reference group of 706 screen participants, aged 29–60 years old, was included and completed questionnaires once. Main outcome measures were generic health-related quality of life (HRQoL), assessed through the EQ-5D and the SF-12 physical and mental scores (PCS-12 and MCS-12); anxiety as assessed by STAI-6, and screen-specific anxiety as assessed by the psychological consequences questionnaire (PCQ).

Results

154 women responded to the questionnaire, of whom 132 were included in the analyses. Histological results were CIN 1 in 17/115 women (15%) and CIN 2 + in 62 (54%). In 36 women (31%) there was no histologically confirmed neoplasia. Before colposcopy physical HRQoL scores were similar or slightly better than in the reference group, while mental HRQoL (MSC-12) and (screen-specific) anxiety were worse (p < 0.001). Irrespective of CIN-grades, anxiety washed out during follow-up (p < 0.001), with changes being clinically relevant.

Conclusions

Referral for gynecological evaluation because of abnormal PAP-test results was distressing. Anxiety – and not the physical burden of management – seemed to be the most bothersome to women. For all CIN-grades, distress disappeared over six months following colposcopy, suggesting a reassuring effect of gynecological management.     

When to induce labor for post-term?: A study of induction at 41 weeks versus 42 weeks

OBJECTIVE: To evaluate the pregnancy outcomes of two policies of timing of induction of labor for post-term pregnancies. STUDY DESIGN: It is a retrospective study in a University obstetric unit from 1997 to 2002. Five thousand eight hundred and ninety-two singleton, cephalic pregnancies with gestational age at delivery at or more than 41 completed weeks were studied. They were divided into two groups. Group A included women who delivered from January 1997 to February 1999 when the policy of the department was to induce labor for post-maturity at 42 weeks of gestation. Group B included those delivered between March 1999 and December 2002 when the timing of induction for post-term was advanced to 41 weeks. The intrapartum characteristics, delivery and perinatal outcomes were analyzed by Student's t-test and Chi-square test for continuous and categorical variables, respectively. RESULTS: Two thousand one hundred and seventy-six women were studied in Group A and 3716 in Group B. Twenty-nine percent of these pregnancies in Group A required induction of labor whereas 20.3% were for post-term. In Group B, 58% of pregnancies had labor induction and 55% for post-maturity. For the pregnancies undergoing induction of labor for post-term, both the duration of labor (P<0.001) and the need of intrapartum epidural analgesia were increased (OR 1.3, 95% CI: 1.0-1.6) in Group B. However, there was no significant difference in the mode of delivery, apgar scores and stillbirths between the two study periods. CONCLUSION: Compared to routine induction at 42 weeks, induction at 41 weeks is associated with a significantly higher risk of use of medical interventions and associated complications, with no observable benefits.     

Is elevated maternal serum alpha-fetoprotein in the second trimester of pregnancy associated with increased preterm birth risk?: A systematic review and meta-analysis

Objective

We have carried out a systematic review of the association between elevated second trimester maternal serum alpha-fetoprotein (AFP) and singleton preterm birth in order to determine its accuracy and the best AFP cut-off level in clinical tests in the general population.

Study design

24 studies published between January 1991 and October 2007 were included, comprising 207,135 women.

Results

An elevated AFP test (expressed as multiple of the median, MoM) had high specificity but low sensitivity to predict preterm birth: using a 2.5 MoM as the cut-off in the AFP test improved the accuracy compared with 2.0 MoM. However, the overall likelihood ratios for positive and negative tests were not improved. The likelihood ratios for positive tests were: 2.99 (95% CI: 2.45–3.66) and 3.18 (95% CI: 2.07–4.88) for 2.0 MoM and 2.5 MoM, respectively; and for negative tests were: 0.94 (95% CI: 0.91–0.97) and 0.97 (95% CI: 0.95–0.98) for 2.0 MoM and 2.5 MoM, respectively. The available data do not allow us to distinguish whether the association between elevated AFP and preterm birth occurs in spontaneous preterm labour, in elective preterm delivery, or in both. Moreover, in these studies AFP was measured together with other biomarkers (e.g. human chorionic gonadotrophin, oestriol) which often were also elevated. When we included only women in whom AFP was elevated in isolation, there was no association with preterm birth (OR = 1.80, 95%CI: 0.92–2.68).

Conclusion

Our findings suggest that maternal AFP levels are strongly related to preterm birth, but only in the context of other abnormal pregnancy markers. The results question the potential usefulness of AFP screening as a primary preterm birth marker and highlight the need for further studies on the functional role of AFP in pregnancy.     

Are there inequalities in choice of birthing position?: Sociodemographic and labour factors associated with the supine position during the second stage of labour

Objective

to establish which factors are associated with birthing positions throughout the second stage of labour and at the time of birth.

Design

retrospective cohort study.

Setting

primary care midwifery practices in the Netherlands.

Participants

665 low-risk women who received midwife-led care.

Measurements and findings

a postal questionnaire was sent to women 3–4 years after birth. The number of women who remained in the supine position throughout the second stage varied between midwifery practices, ranging from 31.3% to 95.9% (p<0.001). The majority of women pushed and gave birth in the supine position. For positions used throughout the second stage of labour, a stepwise forward logistic regression analysis was used to examine effects controlled for other factors. Women aged ?36 years and highly educated women were less likely to use the supine pushing position alone [odds ratio (OR) 0.54, 95% confidence intervals (CI) 0.31–0.94; OR 0.40, 95% CI 0.21–0.73, respectively]. Women who pushed for longer than 60 minutes and who were referred during the second stage of labour were also less likely to use the supine position alone (OR 0.32, 95% CI 0.16–0.64; OR 0.44, 95% CI 0.23–0.86, respectively). Bivariate analyses were conducted for effects on position at the time of birth. Age ?36 years, higher education and homebirth were associated with giving birth in a non-supine position.

Key conclusions

the finding that highly educated and older women were more likely to use non-supine birthing positions suggests inequalities in position choice. Although the Dutch maternity care system empowers women to choose their own place of birth, many may not be encouraged to make choices in birthing positions.

Implications for practice

education of women, midwives, obstetricians and perhaps the public in general is necessary to make alternatives to the supine position a logical option for all women. Future studies need to establish midwife, clinical and other factors that have an effect on women's choice of birthing positions, and identify strategies that empower women to make their own choices.     

Intrauterine growth restriction at term: Induction or spontaneous labour?: Disproportionate intrauterine growth intervention trial at term (DIGITAT): A pilot study

OBJECTIVE: To test the hypothesis that in pregnancies with a clinically suspected growth restricted foetus at term, induction of labour is as safe as expectant management, and does not lead to increased obstetrical interventions or perinatal morbidity. STUDY DESIGN: In one obstetric centre, 33 women with a clinically suspected growth restricted foetus at term were randomly allocated after stratification for parity to either induction or to expectant management. Obstetric and neonatal outcome variables were compared. RESULTS: There was a lower gestational age at labour (median 38(0) weeks versus 40(1) weeks) with a corresponding tendency to lower birth weight (mean 2428 g versus 2651 g), and a reduced need for ante partum medical surveillance, in the induction group. No significant differences in obstetrical interventions (25% versus 24%) and neonatal morbidity rates (50% versus 35%) were found. CONCLUSION: A larger multicenter study with a sufficient power and long-term follow-up to decide the best policy for the term growth restricted foetus is feasible.     

Trans-obturator urethral sling for the surgical correction of female stress urinary incontinence: Outside-in (Monarc) versus inside-out (TVT-O): Are the two ways reassuring?

INTRODUCTION: In 2001, the trans-obturator route was proposed for the surgical positioning of tape with a view to avoiding the retropubic space and its disadvantages. The route, originally described outside-in by Delorme was presented inside-out by de Leval. Since then, anatomical discussions have attempted to prove that one technique is safer than the other. OBJECTIVE: Demonstrating the safety of the two techniques through personal and published experience. MATERIAL AND METHODS: Non-randomized, prospective, observational, open-label, longitudinal study of 100 female patients (50 tension-free vaginal tape (TVT)-O and 50 Monarc). All the female patients presented with isolated stress urinary incontinence. Only four patients presented with mixed incontinence in the Monarc (MON) group. Sphincter incompetence was observed four times in the MON group and three times in the TVT-O group. Almost all the patients were undergoing their first procedure. All the patients underwent surgery under assisted local anesthesia in a day-hospital setting. All the patients underwent a full gynecological examination and a urodynamic assessment. Only those patients presenting with patent established urinary incontinence, corrected by the TVT test, underwent surgery. Post-operative control was conducted at 3 months and 1 year when a physical examination and urodynamic assessment were implemented. RESULTS: All the patients underwent control up to time point 12 months. The duration of hospitalization was 10h for 48 patients in the MON group and 49 in the TVT-O group. The duration of hospitalization was 24h for one patient in each group and 4 days for one patient in the TVT-O group due to transient urine retention. The only per-operative complication was a vaginal perforation in the lateral angle of the vagina for a MON patient. Tape repositioning was necessary. Early post-operative complications were observed in the MON group: three cases of urinary tract infection, one of transient urine retention, three of pain in the thighs spontaneously resolving within 4 days and one of permanent pain in one leg at time 1 year, which remained bearable. For the TVT-O group the post-operative complications consisted in: one case of urinary tract infection, one of transient retention and four of pain in the thigh. No hematoma was reported in either group. Amongst the late complications, the de novo symptoms included one case of imperious urges to urinate in the TVT-O group and objective dysuria in two cases in the MON group versus seven in the TVT-O group. There was no statistically significant between-group difference in the complications. No tape exposure was observed. Overall, the recovery rate was 90% at 1 year for MON versus 94% for TVT-O (p=NS) with two cases of recurrence between 3 months and 1 year in that series. Mixed incontinence was corrected at time point 1 year in 75% of cases for MON, with one case of recurrence in the year. For the patients presenting with sphincter incompetence, competence was maintained at 3 months and 1 year in all cases in the MON group. The three TVT-O were cured at 3 months, but two recurrences were observed at 1 year. Almost all the patients were satisfied or very satisfied at time point 1 year and those who had sexual relations (54%) did not report any disorder at time point 1 year. DISCUSSION: The outside-in technique necessitates more marked peri-urethral dissection and vesical complications are possible. The cadaveric studies by the outside-in partisans show a vascular and nervous risk, which has little reflection in terms of complications in the literature. Post-operative leg pains are encountered with both techniques and are usually only transient. All the studies of the two routes report a recovery rate of over 90% for pure stress incontinence. CONCLUSION: The author's experience, like that reported in the literature, shows that the two trans-obturator access routes are equally safe and do not require per-operative cystoscopic control. The clinical results would appear to be equivalent, in terms of recovery, to the rates obtained with retropubic TVT. Attempting to find anatomical or etiological arguments in order to prove one technique superior to the other appears somewhat parochial.     

Are pregnant women of non-Northern European descent more anaemic than women of Northern European descent?: A study into the prevalence of anaemia in pregnant women in Amsterdam

Objectives

to investigate the prevalence of anaemia in pregnancy according to the cut-off points used in the national clinical guideline ‘Anaemia in Primary Care Midwifery Practice’, and to investigate a possible difference in prevalence between pregnant women of Northern European descent compared with women of non-Northern European descent. The study also investigated whether any difference in prevalence resulted in a higher risk of a transferred home delivery, thus reducing the chance for women to choose the place of birth.

Design

retrospective cohort study.

Setting

primary care midwifery practices in a highly urbanised area in Amsterdam, the Netherlands.

Participants

all patients in three midwifery practices over 1 year were selected provided that they met the inclusion and exclusion criteria. The practices were selected on the basis of urbanisation, resulting in an adequate ethnic population which was comparable with the ethnic mix in other similarly urbanised areas in the Netherlands. This resulted in a study population of 828 pregnant women of Northern European and non-Northern European descent with low-risk singleton pregnancies during 2003.

Analysis

mean haemoglobin level and anaemia rate were computed for the total study population as well as separate ethnic groups. Differences between groups were determined using χ² tests, and effect sizes were expressed in relative risks including 95% confidence intervals (CI).

Findings

the prevalence of anaemia in pregnancy was 3.4% (n=28) at booking (first visit) and 2.7% (n=22) at approximately 30 weeks of gestation. The relative risk of anaemia at booking was 5.9 (95% CI 2.1–16.7) for pregnant women of non-Northern European descent compared with those of Northern European descent. The relative risk of anaemia at approximately 30 weeks of gestation was 22 (95% CI 3–162) for pregnant women of non-Northern European descent compared with those of Northern European descent. The incidence of transferred home delivery was 3.1% in the study population. The relative risk for transferred home delivery was 24.1 (95% CI 3.3–176.7) for pregnant women of non-Northern European descent compared with those of Northern European descent.

Key conclusions and implications for practice

pregnant women of non-Northern European descent are a specific group in terms of anaemia and are at high risk of a low haemoglobin level for all cut-off values; they have a higher chance of becoming anaemic in pregnancy than women of Northern European descent. As a result, they have a higher risk of a transferred home delivery, taking away their opportunity to choose the place of birth. Haemoglobinopathies did not explain the higher risk of anaemia in pregnant women of non-Northern European descent. Being of non-Northern European descent should be added as a risk factor for anaemia in pregnancy until more is known about the background of this risk factor.     

Is acupuncture in addition to conventional medicine effective as pain treatment for endometriosis?: A randomised controlled cross-over trial

Objective

The aim of the study was to examine whether acupuncture is an effective additional pain treatment for endometriosis.

Study design

One hundred and one women aged 20-40 years participated and were randomised into two groups, each receiving two units of 10 acupuncture treatments, twice a week over a period of five weeks. Group 1 (n = 47) received verum-acupuncture during the first series, and group 2 (n = 54) received non-specific acupuncture. After the first unit of 10 treatments, an observation period of at least two menstruation cycles was set, followed by a second unit, according to a cross-over design. Prior to the study (during a two-week run-in period) the patients’ actual pain intensity was surveyed. Throughout the study period, participants were asked to keep a ‘pain protocol’, in which they defined and recorded their pain according to the 10-point visual analogue scale (VAS).

Results

Eighty-three out of a total of 101 patients finished the study. Group 1 showed a significant reduction of pain intensity after the first 10 treatments. In comparison, group 2 showed significant pain relief only after the cross-over.

Conclusion

Acupuncture treatment on specific acupuncture points appears to be an effective pain treatment for endometriosis, but this has to be confirmed in further study.     

Fehlerkultur und Teamtraining Das ?missing link“ im medizinischen Risikomanagement

Das Wissen über Ausmaß und Folgen medizinischer Fehler lässt strukturiertes Risikomanagement in Spitälern zur zwingenden Notwendigkeit werden. Sieht man sich nach den erfolgreichsten Systemen um, landet man zwangsläufig bei den sog. ultrasafe industries—allen voran die zivile Luftfahrt. Neben den üblichen, auch in der Medizin praktizierten Maßnahmen, sind es die Berücksichtigung systemischer und kultureller Aspekte im Umgang mit Fehlern, der Faktor Mensch sowie die Konzentration auf optimale Teamarbeit, die als Erfolgsgarant in Sachen Sicherheit gelten. Die Anwendung dieser Strategien im Krankenhaus würde zweifellos die Patientensicherheit enorm erhöhen sowie Komplikationsraten und Haftungsansprüche niedrig halten.     

Emergence of <Emphasis Type="Italic">Candida glabrata</Emphasis> in vulvovaginal candidiasis should be attributed to selective pressure or virulence ability?

Purpose

Vulvovaginal candidiasis (VVC) is one of the most frequent female genital disorders and Candida glabrata is the second most common agent. Current study was aimed to study the susceptibility to antifungal agents of C. glabrata isolated from vaginal samples and some virulence attributes in order to better understand why this species is emerging as the main VVC agents.

Methods

A total of 60 C. glabrata vaginal isolates were included in this study. Firstly they were screened by susceptibility tests to antifungal agents. The isolates that showed sensitivity or resistance to fluconazole were evaluated for their virulence potential, including ability to adhere to polystyrene and vaginal ring, cell surface hydrophobicity (CSH) and capacity to form biofilm.

Results

Candida glabrata isolates varied significantly in adherence capacity, biofilm formation and CSH. However, it was possible to observe that isolates resistant to fluconazole adhered more efficiently to the vaginal ring and were statistically more able to form biofilm.

Conclusion

These results allow hypothesizing that C. glabrata is an emergent agent in VVC probably because the treatment with fluconazole selects this species. But once adhered, yeasts remain on biotic or abiotic surfaces causing colonization or VVC symptomatology.