Andrea Akkad

Informed consent for elective and emergency surgery: questionnaire study

Objectives  To evaluate womens experience of giving consent to obstetric and gynaecological surgery and to examine differences between those undergoing elective and emergency procedures.

Abnormal uterine bleeding on hormone replacement: The importance of intrauterine structural abnormalities

Objective: To examine the importance of submucous myomas and endometrial polyps before and after menopause and in abnormal withdrawal bleeding on hormone replacement therapy (HRT). Methods: Between May 1991 and May 1993, women presenting with abnormal withdrawal bleeding on HRT ( n = 106), menstrual problems in pre-menopause ( n = 92), or postmenopausal bleeding ( n = 33) underwent diagnostic outpatient hysteroscopy for the presence of intrauterine structural abnormalities. The findings were compared with a control group of post- and perimenopausal women without bleeding problems ( n = 183). Results: When compared with women who had normal uterine cavities, the presence of submucous myomas was associated with a threefold increase in the risk of abnormal menstrual bleeding in premenopausal women (odds ratio [OR] 3.34, 95% confidence interval [CI] 1.77–6.43; P P = .004). This did not seem to be related to the number of myomas detected. The frequency of endometrial polyps was not found to be significantly higher in women who had menstrual disorders or abnormal withdrawal bleeding on HRT. Postmenopausal bleeding without hormonal stimulation was not significantly associated with submucous myomas or polyps. Conclusion: As increasingly more women request HRT, bleeding problems presenting pre-menopause can no longer be expected to resolve “naturally” after menopause. In the presence of submucous myomas, these women will continue to have a higher risk of abnormal withdrawal bleeding when treated with hormone replacement, whereas endometrial polyps are not associated with an increased bleeding risk. Hysteroscopic assessment of the uterine cavity and subsequent counseling as to the risk of heavy or prolonged bleeding will be helpful in their future management and may improve compliance.

Continuous combined hormone replacement therapy compared with tibolone

OBJECTIVE To compare relief of vasomotor symptoms, changes in lipoproteins, and bleeding patterns in postmenopausal women receiving either continuous combined hormone replacement therapy (HRT) of estradiol valerate and norethisterone or tibolone 2.5 mg/day. METHODS In a multicenter, randomized, open-label study, 235 postmenopausal women received one of the above-mentioned treatments. Fasting lipoproteins were measured at baseline and at 3, 6, and 12 months. At each visit, participants completed Greene climacteric questionnaires and recorded any bleeding episodes. Data are presented as mean +/- standard deviation if normally distributed, median and interquartile range if non-normally distributed, or as frequency count. For menopausal symptoms and diary card data, the differences were tested by Wilcoxon rank-sum test. RESULTS One hundred sixteen women received continuous combined HRT and 119 women received tibolone; 72 and 76 women, respectively, completed 12 months of therapy. Both treatments effectively relieved vasomotor symptoms and reduced serum total cholesterol. Continuous combined HRT, but not tibolone, significantly reduced low-density lipoprotein levels. Both treatments reduced high-density lipoprotein levels, but the effect was more profound with tibolone. The initial bleeding score was higher for women taking continuous combined HRT; however, by the end of the study, the percentages of amenorrheal women were comparable. Endometrial histology was similar for both treatments at the end of the study, although two cases of proliferative endometrium were found in the tibolone group. CONCLUSION Estradiol valerate-norethisterone continuous combined HRT controls symptoms and is associated with a safe lipid profile.

Carotid plaque regression on oestrogen replacement: A pilot study

OBJECTIVE To investigate the effect of unopposed oestrogen on atheromatous carotid plaques. SUBJECTS Seventeen postmenopausal women with known carotid disease. METHODS Carotid intimal thickness and plaque length and thickness were measured prior to and following 3 and 6 months of treatment, using Duplex ultrasound. A total of 22 plaques were followed up. RESULTS There was a reduction in plaque length after 3 (-8.14%, p = 0.001) and 6 months (-28%, p = 0.001) of treatment. The reduction in plaque thickness (-18%, p = 0.004) was significant after 6 months of treatment. Reductions in intimal thickness were not statistically significant. CONCLUSION Our results suggest that oestrogen replacement is associated with significant plaque regression.

Changes in serum vascular endothelial growth factor following initiation of estrogen replacement after hysterectomy and oophorectomy.

Background. Vascular endothelial growth factor has been shown to play an important role in preservation and restoration of endothelial integrity. Similar effects on endothelial function have been described with estrogen replacement. This poses the question whether some of the mechanisms ascribed to estrogen are in fact vascular endothelial growth factor mediated. The objective of this study was to examine the effect of continuous transdermal estrogen replacement on serum levels of secreted vascular endothelial growth factor in women following hysterectomy and oophorectomy.

Informed consent for elective and emergency surgery: Questionnaire study

Objectives  To evaluate womens experience of giving consent to obstetric and gynaecological surgery and to examine differences between those undergoing elective and emergency procedures.

The role of pipelle endometrial biopsy in patients with postmenopausal bleeding

Sir, We read the article by Batool et al. (Vol 101, June 1994) with great interest. The authors addressed the question of the management of postmenopausal bleeding, with a view of patients’ acceptance and the modem trend favouring outpatient procedures, with obvious cost and risk benefits. However, we do not concur with their limited objective of excluding malignancy, or with their conclusions. The aim of investigating postmenopausal bleeding should be to make a positive diagnosis of the aetiology and to reducing the likelihood of missed lesions. In their group of 70 patients there were three patients with cancer, and it is only in these three cases that a final diagnosis was possible. A similar lesion cannot be positively excluded for the rest of the group, if the pipelle device were to be the sole diagnostic tool. Furthermore, the diagnosis in the three cancer cases, remains inadequate for planning further management. The answer is far less satisfactory for the 57 patients out of the group of 70 in whom a biopsy was not possible to perform or to interpret. The authors seem to suggest that in these cases, we can safely assume the absence of malignancy. We find this assumption difficult to accept, particularly with evidence that on average only 4 2 YO (range 0 YO to 12.3 YO) of the endometrial surface is sampled by a pipelle even after the cannula is reintroduced three times (Rodriguez et al. 1993). It seems counter-intuitive to criticise dilatation and curettage as likely to miss focal lesions, yet to advocate pipelle sampling, a technique that is only capable of sampling a narrow strip of endometrium along one plane extending from the internal 0s. This is particularly relevant in cases with postmenopausal bleeding where the biopsy technique should be capable of sampling most, if not all, the endometrial surface. The other shortfall of pipelle devices is its low sensitivity, shown by the failure to detect benign endometrial lesions in six out of 16 cases. The better yield in their cases with cancer may be explained not by any particular sensitivity or specificity for cancer, but rather by the stage of the disease or by its low incidence that will tend to skew the statistics. We disagree with the authors’ tendency to dismiss benign lesions as insignificant. Interpreting a negative pipelle is not possible, and needs further evaluation. We believe that outpatient hysteroscopy, in modem times, offers the only real challenge to traditional dilatation and curretrage being able to exclude intrauterine lesions, while a t the same time proving highly acceptable (Downes & Al-Azzawi 1993).

Informed consent for elective and emergency surgery: questionnaire study - Reply

We are much pleased with the authors’ interest in our article entitled “SYNTAX score predicts postoperative atrial fibrillation in patients undergoing on-pump isolated coronary artery bypass grafting surgery” (1), as published ahead of print for the Anatol J Cardiol 2015 Nov 18, and we would like to thank them for their contributions. Firstly, definitive diagnosis of postoperative atrial fibrillation (PoAF) is not found in the relevant guidelines. In our study, PoAF was defined as it has been in previous studies (2). In the literature there are many controversial definitions of PoAF (3, 4). In our study, patients were followed with continuous telemetry for between 72 and 96 hours. A 12-lead electrocardiography (ECG) was obtained from the patients every 12 hours or 24 hours at the intensive care and in-patient units, respectively. Rhythm monitoring was continued until patients were discharged from the hospital. If patients had complaints such as dyspnea, palpitation, or angina, 12-lead ECG was taken during hospitalization. Incidence of PoAF could increase beyond the 72 to 96-hour window observed with continuous telemetry. The rate of PoAF may be underestimated in our study. Drug use, including beta blockers, renin angiotensin aldosterone blockers, and statins before surgery could affect incidence of PoAF. In our study, percentage of beta blocker, angiotensinconverting enzyme inhibitor, and angiotensin receptor blocker use was 100% and 98.9%, respectively. There was no difference in drug use between the 2 groups. Obstructive sleep apnea and obesity were not included in our study as independent parameters because of low number of instances.Sir, Our qualitative study, to which Katsafourou and Gbolade refer, has now been published. We reported that there were different orientations to surgery among women. Some viewed surgery as fulfillment of something they wanted and others saw it as a rescue from a painful or distressing situation. Others saw it as an imposition. In both groups there was a strong tendency to view consent as ritualistic, bureaucratic and embedded within a legal rather than ethical framework. We found that giving patients a copy of the form is insufficient to achieve the desired goals of partnership and autonomy in decision making. Imparting information needs to be sensitive to patients’ needs and circumstances. There is also a need to recognise the central role of trust. Katsafouro and Gbolade speculate as to whether the 25% non-response rate from ethnic minority groups was due to problems in understanding English. We do not think this was a particularly high rate of non-response from these groups. Thirty-six percent of the Leicester city population identified themselves as belonging to an ethnic minority in the 2001 census. There is no evidence that translating postal questionnaires improves response rates, and there are formidable practical problems associated with trying to identify the ‘right’ language for each responder. Moreover, the response rate of ethnic minority groups to questionnaires delivered in English is not necessarily low. Women in our study were invited to contact the researcher if they needed help in understanding the questionnaire. Participants did not highlight poor handwriting as an obstacle to reading the consent forms, and indeed more women read the handwritten part compared with the printed part. Verbal explanation and trust accounted for a large proportion of women not reading the forms, while others felt unable to do so either because they were not given the chance, the form was too long or because they were too ill. Our research suggests the need for a more patient-centred approach that is based on better appreciation of women’s needs rather than on more detailed information provision, photocopying consent forms or reading out their exact contents. Indeed many of the measures suggested by your correspondents already underpin current practice and national guidance. Such a procedural approach may give the impression that something has been done to improve communication, but it may also result in a further shift from the personal to the administrative, which, as our study demonstrates, is negatively perceived by patients. The substantial proportion of patients who felt they had no choice over signing the form, or that they would have signed irrespective of content, emphasises this point.

Informed consent for elective and emergency surgery: questionnaire study.

Objectives  To evaluate womens experience of giving consent to obstetric and gynaecological surgery and to examine differences between those undergoing elective and emergency procedures.