July update
#salpingectomy #ectopic #IOL #endometriosis #leadership #preeclampsia #impactedfetalhead #caesareansection #cervicalstenosis
How is it nearly the end of July already!? Hope the year is going well for you. Enjoy the papers I came across so far this month.
Regards,
Danny
Salpingectomy for ovarian cancer prevention: missed opportunities
Opportunistic salpingectomy (OS) is the additional removal of the fallopian tubes during other abdominal surgery for the purpose of ovarian cancer prevention. The approach to this practice has varied globally due to inconsistent implementation, which raises the need to understand the determinants of clinical application to streamline its practice.
This retrospective study analysed electronic medical records from six Dutch hospitals, studying the implementation of counselling and the performance of OS between 2015 and 2018. The study found that counselling for OS significantly increased over this period, from 2.9% to 29.4%, and the performance of OS also increased from 6.9% to 44.5%. Factors such as the laparoscopic approach, counselling by a gynaecological resident, and more than three pre-surgery contacts increased the likelihood of OS. However, most eligible patients were not counselled or did not undergo OS, indicating a need for tailored implementation strategies.
Ectopic pregnancy: Does MTX work?
Tubal ectopic pregnancy (TEP) is a common gynaecological emergency, with a wide array of medical and surgical interventions currently in practice. However, identifying the most effective and safest treatment remains challenging due to the variation in the comparative outcomes of these interventions, including expectant management, which involves close monitoring without immediate medical or surgical intervention.
This systematic review and network meta-analysis assess the efficacy of various treatment options for TEP, using data from 31 randomised trials evaluating ten treatments for 2938 women. The findings suggest that most conservative treatment options show similar effectiveness to expectant management for TEP resolution. Furthermore, all treatment options displayed a higher risk of failure than salpingectomy. Therefore, the study concludes that the available evidence does not strongly support using any specific medical treatment option for TEP over expectant management.
Risks & benefits of IOL at 39/40
Elective labour induction at 39 weeks of gestation is increasingly common, with its impact on maternal and neonatal health a topic of extensive debate. Existing research presents varied findings, necessitating a systematic review and meta-analysis to understand the associated benefits and risks clearly.
This study reviewed 14 selected studies involving 1,625,899 singleton pregnancies from an initial pool of 5827 records. The findings suggest induction of labour at 39 weeks reduces the likelihood of perineal injury, operative vaginal birth, macrosomia, and low 5-minute Apgar score. However, for nulliparous women, induction was linked with an increased risk of shoulder dystocia. The results imply elective induction at 39 weeks could benefit some women but also underscore the potential risks for nulliparous women, indicating a need for careful patient counselling.
Cervical stenosis: Management options
Hysteroscopy, recognised as the gold standard for evaluating intrauterine pathologies, hinges on access through the cervical canal. A hurdle to successful hysteroscopic procedures is cervical stenosis, a condition resulting from adhesion processes causing the cervical canal to narrow or entirely obliterate. Its multifactorial aetiology contributes to its complexity, making successfully negotiating this condition a crucial clinical skill in gynaecology.
This review synthesises the scientific literature on cervical stenosis, focusing on strategies to manage this condition. Various interventions have been explored involving surgical and non-surgical approaches, from cervical-ripening agents and osmotic dilators to cervical dilators and hysteroscopic treatments. The review concludes that operative hysteroscopy offers the highest success rates, particularly in severe cases, positioning it as the preferred management strategy. The procedure, however, remains challenging, requiring adept skills even from seasoned hysteroscopists.
Managing disruptive doctors
Senior doctors need strong leadership skills when working in multidisciplinary practice. However, the training provided for these positions often lacks the depth needed to handle challenges such as disruptive behaviour in the workplace. Individuals with little prior managerial experience need effective training and support.
This paper reflects on conversations with new and experienced physician managers, presenting a three-tier approach to addressing disruptive behaviour: diagnosing, treating, and preventing. The authors emphasise that an effective management strategy depends on accurately identifying the root causes of the disruptive behaviour. The paper outlines strategies to improve physician leader communication skills and leverage institutional resources. Lastly, it advocates for system-level modifications to pre-empt disruptive behaviour and better equip new managers to address it.
Video: Robotic excision of sciatic nerve endometriosis
Endometriosis of the sciatic nerve is a complex condition requiring specialised surgical intervention. Such surgery is challenging due to the intricacies of neuroanatomy and potential for severe complications.
The video study here describes a surgical technique routinely used at the authors' centre to treat isolated sciatic nerve endometriosis using a robotic, standardised approach. A case example is a 36-year-old patient suffering from left-sided sciatica due to an endometriotic nodule on the left sciatic nerve. The authors argue that their technique, using robotic assistance, allows for the safe, feasible, and reproducible radical excision of the endometriotic nodule. Despite the noted advantages, the complexity of this surgery underlines the necessity of multidisciplinary management in expert centres. It’s a wonderful laparoscopic anatomy demonstration, too.
Finally, a couple more:
Finally, new pre-eclampsia markers
Preeclampsia (PE) presents challenges in early prediction and diagnosis. Metabolomics is a growing field, offering new biomarkers for PE detection and understanding its pathogenesis.
The study revealed that specific eicosanoids and sphingolipids in pregnant women's plasma can predict severe PE development, irrespective of aspirin therapy. These biomarkers can also indicate the likelihood of preterm or term birth with PE. This research opens avenues for exploring ancestry-linked differences in lipid-based biomarkers for precision analysis. Additionally, it hints at bioactive lipids as potential therapeutic targets for pregnancy complications.