Gynecology

Cardiovascular risk is poorly managed in women, especially during the menopausal transition when susceptibility to cardiovascular events increases. Clear gender differences exist in the epidemiology, symptoms, diagnosis, progression, prognosis, and management of cardiovascular risk. Key risk factors that need to be controlled in the peri-menopausal woman are hypertension, dyslipidaemia, obesity, and other components of the metabolic syndrome, with the avoidance and careful control of diabetes. Hypertension is a particularly powerful risk factor and lowering of blood pressure is pivotal. Hormone replacement therapy is acknowledged as the gold standard for the alleviation of the distressing vasomotor symptoms of the menopause, but the findings of the Women's Health Initiative (WHI) study generated concern for the detrimental effect on cardiovascular events. Thus, hormone replacement therapy cannot be recommended for the prevention of cardiovascular disease. Whether the findings of WHI in older post-menopausal women can be applied to younger peri-menopausal women is unknown. It is increasingly recognized that hormone therapy is inappropriate for older post-menopausal women no longer displaying menopausal symptoms. Both gynaecologists and cardiovascular physicians have an important role to play in identifying peri-menopausal women at risk of cardiovascular morbidity and mortality and should work as a team to identify and manage risk factors such as hypertension.

Objectives: To evaluate positron emission tomography-computed tomography (PET-CT) for the preoperative management of early-stage intermediate-and high-risk endometrial cancer (EC). Study design: Data of patients with intermediate-and high-risk early-stage EC were retrieved from a prospectively collected database. Patients with preoperative PET-CT followed by surgical staging including pelvic lymphadenectomy were analyzed. Diagnostic performance for lymph node (LN) metastasis was evaluated. Results: Overall, 45 patients were included: 27 (60%) and 18 (40%) with intermediate-and highrisk EC, respectively. Four patients (8.8%) had LN metastasis, three correctly identified at PET-CT, yielding a sensitivity of 75% (95% CI 21.9-98.7). Among 41 patients (91.2%) without LN metastasis, 38 had negative PET-CT with specificity of 92.7% (95% CI 78.9-98.1). The negative predictive value (NPV) was 97.4% (95% CI 84.9-99.9) and the positive predictive value was 50% (95% CI 13.9-86.1). Conclusions: The utility of PET-CT is limited by the low sensitivity for LN metastasis in intermediate-and high-risk early-stage EC, that may impede to consider PET-CT alone an adequate alternative to surgical retroperitoneal staging by lymphadenectomy or sentinel LN biopsy. However, the high diagnostic accuracy, specificity and NPV might support its adoption to improve the diagnostic accuracy of the sentinel LN algorithm.

Objective To assess the effect of virtual reality training on an actual laparoscopic operation. Design Prospective randomised controlled and blinded trial. Setting Seven gynaecological departments in the Zeeland region of Denmark. Participants 24 first and second year registrars specialising in gynaecology and obstetrics.

To compare goserelin and leuprolide given before hysterectomy for symptomatic large fibroid uteri. A randomized study of 66 premenopausal women with fibroid uteri at least 14 weeks of gestation in a gravid uterus. Women were randomized to receive either subcutaneous depot 3.6 mg goserelin or 3.75 mg leuprolide every 4 weeks for a total of 3 doses. Hysterectomy was performed within 1 month of the last dose. A total of 34 women randomized to the goserelin group and 31 women to the leuprolide group were available for analysis. Preoperative hemoglobin level (P=0.89), operative blood loss (P=0.72), and operating time (P=0.39) were not different between the 2 groups. Postoperative hemoglobin was higher in the leuprolide group (P=0.003), but blood transfusion requirement was not different between the groups (P=1.0). Other outcomes and side effects of the drugs were similar. Goserelin and leuprolide administered before hysterectomy for uterine fibroids have similar perioperative outcomes.

The quality of both the programs and the literature that describe these programs has varied considerably. The purposes of this study were to evaluate the published literature that described computer-assisted instruction in medical education and to assess the quality of evidence for its implementation, with particular emphasis on obstetrics and gynecology. STUDY DESIGN: Reports published between 1988 and 2000 on computer-assisted instruction in medical education were identified through a search of MEDLINE and Educational Resource Identification Center and a review of the bibliographies of the articles that were identified. Studies were selected if they included a description of computer-assisted instruction in medical education, regardless of the type of computer program. Data were extracted with a content analysis of 210 reports. The reports were categorized according to study design (comparative, prospective, descriptive, review, or editorial), type of computer-assisted instruction, medical specialty, and measures of effectiveness. RESULTS: Computer-assisted instruction programs included online technologies, CD-ROMs, video laser disks, multimedia work stations, virtual reality, and simulation testing. Studies were identified in all medical specialties, with a preponderance in internal medicine, general surgery, radiology, obstetrics and gynecology, pediatrics, and pathology. Ninety-six percent of the articles described a favorable impact of computer-assisted instruction in medical education, regardless of the quality of the evidence. Of the 210 reports that were identified, 60% were noncomparative, descriptive reports of new techniques in computer-assisted instruction, and 15% and 14% were reviews and editorials, respectively, of existing technology. Eleven percent of studies were comparative and included some form of assessment of the effectiveness of the computer program. These assessments included pre-and posttesting and questionnaires to score program quality, perceptions of the medical students and/or residents regarding the program, and impact on learning. In one half of these comparative studies, computer-assisted instruction was compared with traditional modes of teaching, such as text and lectures. Six studies compared performance before and after the computer-assisted instruction. Improvements were shown in 5 of the studies. In the remainder of the studies, computer-assisted instruction appeared to result in similar test performance. Despite study design or outcome, most articles described enthusiastic endorsement of the programs by the participants, including medical students, residents, and practicing physicians. Only 1 study included cost analysis. Thirteen of the articles were in obstetrics and gynecology. CONCLUSION: Computer-assisted instruction has assumed to have an increasing role in medical education. In spite of enthusiastic endorsement and continued improvements in software, few studies of good design clearly demonstrate improvement in medical education over traditional modalities. There are no comparative studies in obstetrics and gynecology that demonstrate a clear-cut advantage. Future studies of computer-assisted instruction that include comparisons and cost assessments to gauge their effectiveness over traditional methods may better define their precise role.

To determine whether obstetric handoff quality differs morning versus evening, weekend versus weekday, or based on provider type. Using the American College of Obstetricians and Gynecologists (ACOG) handoff guidelines, we developed an observational tool to assess whether handoffs included its 8 recommended elements. We observed handoffs between attending obstetricians, Obstetrics and Gynecology residents, labor and delivery nurses, and certified nurse midwives. Observation times included a balance of morning, evening, weekdays, and weekends. Participants were blinded to the study objectives. We defined high-quality handoffs as those that included 7 of the 8 recommended ACOG elements. A total of 425 inpatient handoffs were observed: 233 (55%) were morning handoffs and 189 (45%) were evening; 251 (59%) were on weekdays and 171 (41%) on weekends. Of the handoffs observed, 201 (48%) were presented by residents, 139 (33%) by nurses, 56 (13%) by attending obstetricians, and 26 (6%) by mid...

The anaesthetist plays a key role in the management of high-risk pregnancies, and must be a member of the multidisciplinary team that is required to care for the critically ill obstetric patient. Anaesthetists are trained in advanced life support and resuscitation. They are experienced in the management of the critically ill, and provide anaesthesia, sedation and pain management. The obstetric anaesthetist should undertake education of medical and midwifery staff in the early recognition, monitoring and treatment of the sick mother, resuscitation training, running 'skills drills' for emergency simulations, risk management and audit of maternal morbidity on the labour ward. To date, there is little evidence to inform the anaesthetic management of the critically ill obstetric patient; most recommendations and guidelines are based on the management of non-obstetric, critically ill patients. Management must be adapted to encompass the physiological changes of pregnancy. Evidence-based guidelines on management of the critically ill woman with specific obstetric conditions are also lacking.

A case of high-grade endometrial stromal sarcoma, confi ned into an intrauterine polypoid growth, in a woman with a history of breast cancer who was treated with adjuvant tamoxifen. Based on the fi ndings, a high-grade endometrial stromal sarcoma was diagnosed. The patient underwent a total hysterectomy and bilateral salpingo-oophorectomy with multiple omental biopsies. Pathological examination on multiple uterine sections showed the absence of residual tumor cells in the uterus. The endometrium showed patterns of glandular cystic hyperplasia. After 14 months of follow-up, the patient is well and free of disease. In deciding if tamoxifen therapy is warranted, all potentially life-threatening adverse events associated with tamoxifen should be considered, including endometrial adenocarcinoma or uterine sarcoma.

The detection and successful treatment of cancers is dependent on timely presentation with abnormal and often subtle symptoms. In this article, we draw on research conducted with Australian immigrant women in 2001-02 who experienced delays in diagnosis of gynecological cancer. Data from in-depth interviews with women with gynecological cancer indicated a common trajectory of an "illness career," whereby the search for diagnosis was often painful and lengthy, either because women normalized the abnormal signs or because their experiences of bodily abnormality, pain, and dysfunction contrasted with medical explanations. This delay was sometimes exacerbated by structural barriers. As a result, diagnosis was often protracted, during which time women presented with symptoms that were dismissed or resulted in the misdiagnosis, with a resultant loss of confidence in clinical services. [gynecological cancer, Australia, embodiment, delay in diagnosis, symptom normalization]

Objective: To compare the impedance to uterine artery blood flow, during the midluteal phase, in women with recurrent spontaneous abortion (RSA) as compared to normal fertile controls. Design: A prospective study involving women with a history of RSA and fertile controls. Setting: University of Rome "Tor Vergata." Patient(s): Two hundred thirty women with RSA and 50 fertile controls referred for routine examination. Intervention(s): Transvaginal Doppler examination of uterine arteries during the midluteal phase of untreated cycles. Main Outcome Measure(s): The mean pulsatility index (PI) of uterine arteries.

This Opinions section, once again, is written by a single author but is meant to be provocative. It represents a sun1mary of a topic presented at a recent NASPAG conference. This issue did not result in a consensus of opinion at the end of the workshop. The ideologies presented represent the differing treatment philosophy that exists today among our peers who treat the abnormal pap smear in the adolescent.

Omer-Sherman. p. cm.-(Brandeis series in American Jewish history, culture, and life)  --- (pbk.)- --- (cloth) . Jewish literature-History and criticism. . Zionism in literature. . Jewish diaspora in literature. . Lazarus, Emma, --Criticism and interpretation. . Syrkin, Marie, --Criticism and interpretation. . Reznikoff, Charles, --Criticism and interpretation. . Roth, Philip-Criticism and interpretation. I. Title. II. Series.  .  '.-dc  In warm memory of Yeruham Yarden. Palestine was a halting place, One of many. Our kin, the Arabs Wander over their desert. Our desert Is the Earth. Our strength Is that we have no land. Nineveh and Babylon, our familiar cities, Become dust; but we Jews have left for Alexandria and Rome. When the land is impoverished, as lands become, The tree dies. Israel is not planted, Israel is in the wind.-  A time must arrive when cultures will have no need of armies to maintain their uniqueness. .. The Yiddish-speaking Jew, his fear of physical and spiritual effacement, his desperate effort to sustain the values and the languages of his history, his struggle for independence and his actual dependence on the good will of others-this Jew symbolizes to me the whole human species. Man must be both himself and an integrated part of the whole, loyal to his own home and origin and deeply cognizant of the origin of others. He must possess both the wisdom of doubt and the fire of faith. In a world where we are all basically strangers, the commandment "And thou shalt love the stranger" is not just an altruistic wish but the very core of our existence.-   Contents Acknowledgments xiii I first studied Jewish literary modernism and the Objectivist poets with Stephen Fredman, and it is a great pleasure to acknowledge my debt for his invaluable guidance, encouragement, and advice. Like most readers of Charles Reznikoff, I recognize that without Milton Hindus's early commitment to the poet's legacy, we would all be impoverished, and I thank him for his work, which has benefited so many of us. Thanks are due also to Gerry

Objective To obtain face and construct validity for a new training course to be used in any type of box/video trainer and to give a comprehensive overview of validated exercises for box/video training. Design Cross-sectional study. Setting University Medical Centre. Population Students, residents and consultants. Methods Participants (n = 42) were divided into three groups according to their laparoscopic experience: 'Novices' (n = 18), 'Intermediates' (n = 14) and 'Experts' (n = 10). A laparoscopic training course consisting of six exercises was constructed. To emphasise precision, a penalty score was added. Every participant performed two repetitions of the exercises; total score per exercise was calculated. To determine face validity, participants filled in a questionnaire after completion of the exercises. An evidence-based literature search for validated box/video trainer exercises was performed. Main outcome measures Face and construct validity. Results The mean score of the 'experts' was set as the training target. Total scores appeared to be positively correlated with individual's laparoscopic experience. The overall score and the score for each exercise were significantly higher in the intermediate and expert groups when compared with the novice group (P £ 0.001). All participants completed the questionnaire. The overall assessment of the exercises was considered to be good. The course was found to be most appropriate for training residents year 1-3. Conclusion Face and construct validity for an inexpensive course for box/video training was established. A comprehensive and practical overview of all validated and published exercises for box/ video trainers is provided to facilitate an inexpensive, but optimal and tailored selection for training purposes.

Background: Urinary incontinence (UI) is likely to be high in Aboriginal women in rural Australia due to risk factors including high body mass index, parity and diabetes. However, UI appears to be under-reported with limited information on whether women access appropriate care. Aims: To assess whether women who access specialist gynaecological services in rural and remote Top End Northern Territory (NT) through the specialist outreach program (SONT) are receiving care for UI aligned with best practice. Methods: Review of all 1426 SONT referrals in 2012, with audit of management for those women referred for UI or prolapse. Results: Of 1426 SONT referrals, there were 43/1426 (3%) women referred for UI, with 34/43 (79%) attending. Of those referred, 31/43 (72%) were Aboriginal. Of twenty-six women diagnosed with probable stress UI, less than a fifth, 5/26 (19%), were referred to physiotherapy, with 2/5 (40%) attending appointments. Referral occurred for 14/23 (61%) of those suitable for urodynamics but only 6/14 (43%) attended. Just under half of women 7/16 (14%) with stress UI were referred for surgery, with 6/7 (86%) attending. Conclusion: In rural and remote Top End NT, specialist health service management of female UI could be improved by increased provision of current bestpractice and an integrated multidisciplinary team approach with allied health. Under-reporting and under-referral for female UI could be addressed by increasing awareness among community and primary healthcare providers of the problem of female UI and the conservative, medical and surgical treatments available.

To describe the pattern of eclampsia between 1995 and 2004 at the Usmanu Danfodiyo University Teaching Hospital, Sokoto, northwestern Nigeria. A retrospective cohort of all deliveries and eclamptics seen from 1st January 1995 to 31st December 2004. Clusters of eclampsia were identified using purely temporal scan statistics. Of 15,318 deliveries during the period, 657(4.29%) had eclampsia. The yearly incidence of eclampsia at the beginning of the study period (1995) was 0.39% but this had increased to 7.0% in 2004 at a background exponential rate best described by quadratic curve fitting prediction model and a forecast curve that predicts an incidence of eclampsia of at least 32.4% of total deliveries by 2009. Temporal clusters occurred in 1996, 2001 and 2003-2004. The incidence of eclampsia is unusually high and is increasing. It has shown 3 clusters in the last 10 years.

Objective  To document the frequency and causes of maternal mortality and severe (near-miss) morbidity in metropolitan La Paz, Bolivia.Design  Facility-based cross-sectional study.Setting  Four maternity hospitals in La Paz and El Alto, Bolivia, where free maternal health care is provided through a government-subsidised programme.Population  All maternal deaths and women with near-miss morbidity.Methods  Inclusion of near-miss using clinical and management-based criteria.Main outcome measures  Maternal mortality ratio (MMR), severe morbidity ratio (SMR), mortality indices and proportion of near-miss cases at hospital admission.Results  MMR was 187/100 000 live births and SMR was 50/1000 live births, with a relatively low mortality index of 3.6%. Severe haemorrhage and severe hypertensive disorders were the main causes of near-miss, with 26% of severe haemorrhages occurring in early pregnancy. Sepsis was the most common cause of death. The majority of near-miss cases (74%) were in cr...

Objective To compare semi-quantitative visual and automated methods of urine testing with fully quantitative point of care urinalysis for the detection of significant proteinuria (0.3 g/24 hours) in pregnancy complicated by hypertension. Design A prospective comparative study.

Objective: To evaluate the effectiveness and acceptability of expectant management of induced and spontaneous first trimester incomplete abortion. Methods: A prospective observational trial, conducted between June 2006 and November 2007, of 2 groups of patients diagnosed with an incomplete abortion: 66 patients who had received misoprostol for an induced abortion (group 1) and 30 patients who had had a spontaneous abortion (group 2). Transvaginal ultrasound was performed weekly. The success rate (complete abortion without surgery), time to resolution, duration of bleeding and pelvic pain, rate of infection, number of unscheduled hospital visits, and level of satisfaction with expectant management were recorded. Results: The incidence of complete abortion was 86.4% and 82.1% in groups 1 and 2 respectively at day 14 after diagnosis, and 100% in both groups at day 30 (two group 2 patients underwent curettage and were excluded from the analysis). Both groups reported 100% satisfaction with expectant management, although over 90% of the women reported feeling anxious. Conclusion: Expectant management for incomplete abortion in the first trimester after use of misoprostol or after spontaneous abortion may be practical and feasible, although it may increase anxiety associated with the impending abortion.

charges, and unbilled procedures are published. Department faculty are asked to work at least 30-hour days, often with little sleep during the night, despite studies on fatigue and medical errors of residents younger than faculty. Residents are asked to collude by writing delivery notes that include the phrase "attending is present," even if he or she technically may not have been in the room for fetal delivery. The hidden curriculum here is the department emphasis, not on good patient care or resident education and oversight, but on payment. Does this not plant the seeds for "a little cheating" in future practice, like upcoding, treatment choice based on reimbursement, and ultimately, fraudulent billing for unperformed services?

Contemporary training in obstetrics and gynecology requires a delicate balance between teaching principles of basic science and clinical care and the technical skills required either in the delivery room or in surgical suites. 1 To accomplish this paradigm requires instruction not only in the core skills, such as basic suturing techniques, but also in a distinctive and new set of abilities not required in times past, ranging from interpretation of ultrasound images to advanced endoscopic surgery. However, changes in the clinical skill set are only part of the contemporary educational needs in our specialty. Changes in social awareness and the medicolegal environment demand competency in counseling and communication. 2 These issues require increasing emphasis on the development of communication and interpersonal skills in training programs. Circumstances in which unique communication skills are essential range from routine preoperative counseling and interviewing to more acute care situations that require intervention such as domestic violence. These newer needs require increasingly sophisticated formats and teaching tools to adequately train medical students and residents in the art of communication and interviewing. Technologies such as virtual reality (VR) that immerse participants into theoretical 3-dimensional (3-D) worlds, offer the opportunity for simulation of and interaction in any circumstance. Virtual reality constitutes a 3-D interface that puts an interacting subject in active exchange with a world recreated by computer programs. In this setting, the interaction is no longer unidirectional but bidirectional: a subject becomes not merely a passive observer of pictures in a text but can actively modify a 3-D virtual world. 3 Environments may be designed to simulate any interaction, whether personal or mechanical.

Intracardiac echogenic focus Fetal aneuploidy Ultrasound Objective: This study was undertaken to evaluate the relationship of an isolated fetal intracardiac echogenic focus in a population of patients with a mixed risk for aneuploidy when presenting for prenatal diagnosis. Study design: All women referred to our institution for screening ultrasound were prospectively evaluated for the presence of an intracardiac echogenic focus in the fetal heart. Each patient was evaluated for the presence of clinical risk factors including ultrasound findings, biochemical screening, and maternal age. The population of patients was then described and neonatal outcomes were obtained. Results: A total of 10,875 patients were referred and 176 cases of fetal intracardiac echogenic foci were evaluated. There was an overall prevalence of 1.6% in our population. The patients with other ultrasound findings and/or maternal age older than 35 years who underwent amniocentesis had 3 abnormal karyotypes identified and had identifiable risk factors. In the group less than 35 years, the relative risk was 2.55 of having an amniocentesis for an isolated echogenic focus (with no cases of fetal aneuploidy found) in comparison with our referred group of nonadvanced maternal age patients without any ultrasound markers or findings. Conclusion: This isolated echogenic finding appears to be a benign variant and not an increased risk for fetal aneuploidy. The chromosomal abnormalities were seen in the group with risk factors including maternal age and/or other ultrasound findings. Evaluation of maternal age, biochemical markers, and ultrasound markers should be used together to help determine the risk of patients with an isolated echogenic focus.

Objective Fetal nuchal translucency (NT) thickness increases with crown-rump length (CRL). In screening for chromosomal defects patient-specific risks are derived by multiplying the a priori maternal age-related risk by a likelihood ratio, determined from the deviation of the measured NT from the expected median. To quantify this deviation the measured NT is either subtracted (delta NT) or divided by the expected median (multiple of the median method, MoM). This study examines the validity of these methods. Methods NT was prospectively measured at 11 + 0 to 13 + 6 weeks in screening for chromosomal defects. The distribution of NT in euploid and chromosomally abnormal fetuses was examined.

Objective: To compare the efficacy of hysterosalpingo-contrast sonography (HyCoSy) using a saline solution with that of radiographic hysterosalpingography (HSG) in the assessment of tubal patency. Method: We compared the findings obtained by the 2 methods with those obtained by standard diagnostic laparoscopy with the chromopertubation test in a study with 88 infertile women younger than 40 years. Results: The sensitivity, specificity, and diagnostic accuracy of HyCoSy and HSG were similar, and 65 (74%) of the women reported the pain associated with HyCoSy as mild to moderate. Conclusion: The HyCoSy procedure is well tolerated and can be used as a primary tool for the evaluation of tubal patency in infertile women.

Objectives To construct reference ranges for serial measurements of the umbilical artery (UA) absolute blood flow velocities in the second half of pregnancy and to test the hypothesis that significant associations exist between UA velocities and placental volume blood flow assessed from umbilical vein blood flow velocities and diameter.

Objective: Bowel injury is an uncommonly reported yet serious complication of induced abortion, which is often performed illegally by persons without any medical training in developing countries. A sudden increase in cases prompted the authors to analyze this problem. Method: A retrospective review was done of 11 cases of bowel injury following induced abortion seen over 2years at Government Medical College and Hospital, Chandigarh, India. Results: Young, married women of low socioeconomic status with a strong preference for male children were the predominant recipients of induced abortion in India. The terminal ileum and pelvic colon were the most commonly injured portions of the bowel owing to their anatomic locations. Conclusion: Preoperative resuscitation, then resection with exteriorization of bowel and thorough peritoneal lavage, is the treatment for bowel injury incurred during induced abortion when the patient presents late.

Objective: To investigate the incidence, risk factors, and sonographic findings of maternal ovarian torsion in pregnancy. Design: Retrospective study. Setting: Department of Obstetrics/Gynecology of a tertiary referral center. Patient(s): Thirty-three pregnant women with 38 episodes of surgically proven torsion between the years 1993 to 2007. Intervention: Surgical confirmation and treatment of torsion. Main Outcome Measure(s): Clinical and sonograpgic findings of ovarian torsion in pregnancy.

Objective: This study examines the maternal characteristics and birth outcomes of infants of U.S. resident Asian-Indian-American (AIA) mothers and compares those to infants of U.S. resident Whites and African-American (AA) mothers. Methods: Single live births to U.S. resident mothers with race/ethnicity coded on birth certificate as AIA, non-Hispanic White, or non-Hispanic AA were drawn from NCHS 1995 to 2000 U.S. Linked Live Birth/Infant Death files. Results: Compared to AAs or Whites, AIAs have the lowest percentage of births to teen or unmarried mothers and mothers with high parity for age or with low educational attainment. After taking these factors into account, AIA had the highest risk of LBW, small-for-gestational age and term SGA births but a risk of infant death only slightly higher than Whites and far less than AAs. Conclusions: The birth outcomes of AIAs do not follow the paradigm that more impoverished minority populations should have greater proportions of low birth weight and preterm births and accordingly greater infant mortality rates.

Screening and diagnostic criteria for gestational diabetes (GDM) are inconsistent across Europe, and the development of a uniform GDM screening strategy is necessary. Such a strategy would create opportunities for more women to receive timely treatment for GDM. Developing a consensus on screening for GDM in Europe is challenging, as populations are diverse and healthcare delivery systems also differ. The European Board & College of Obstetrics and Gynaecology (EBCOG) has responded to this challenge by appointing a steering committee, including members of the EBCOG and the Diabetic Pregnancy Study Group (DPSG) associated with the EASD, to develop a proposal for the use of uniform diagnostic criteria for GDM in Europe. A proposal has been developed and has now been approved by the Council of the EBCOG. The current proposal is to screen for overt diabetes at the first prenatal contact using cutoff values for diabetes outside pregnancy, with particular efforts made to screen high-risk groups. When screening for GDM is performed at 24 weeks' gestation or later, the proposal is now to use the 75 g OGTT with the new WHO diagnostic criteria for GDM. However, more research is necessary to evaluate the best GDM screening strategy for different populations in Europe. Therefore, no clear recommendation has been made on whether a universal one-step, two-step or a risk-factorbased screening approach should be used. The use of the same WHO diagnostic GDM criteria across Europe will be an important step towards uniformity.

Objective: This study was undertaken to examine whether marijuana use affects in vitro fertilization and gamete intrafallopian transfer (IVF/GIFT). Study design: Prospective study of 221 IVF/GIFT couples. Results: Amount of lifetime heavy marijuana use adversely affected IVF/GIFT. Women smoking more than 90 times in their lifetime had 27% fewer oocytes retrieved (P = .03) and 1 fewer embryo transferred (P ! .05). Women smoking marijuana more than 10 times in their lifetime had infants 17% (P = .01) smaller at birth. If men smoked marijuana 11 to 90 times in their lifetime, there was a 15% decrease in infant birth weight (P = .03); if this increased to more than 90 times, there was a 23% decrease (P = .01). Timing also played a role. Women smoking marijuana 1 year before IVF/ GIFT had 25% fewer oocytes retrieved (P = .03), whereas couples had 28% (P = .04) fewer oocytes fertilized. Women and men who smoked in the past 15 years, had 12%(P = .04) and 16% (P = .03) smaller infants, respectively. Conclusion: Both timing and amount of marijuana use negatively affected IVF/GIFT.

Background: For many diseases, specialized care (i.e., care rendered by a specialist) has been associated with superiorquality care (i.e., better outcomes). We examined associations between physician specialty and outcomes in a populationbased cohort of elderly ovarian cancer surgery patients. Methods: We analyzed the Medicare claims, by physician specialty, of all women aged 65 years or older who underwent surgery for pathologically confi rmed invasive epithelial ovarian cancer between January 1, 1992, and December 31, 1999, while living in an area monitored by the Surveillance, Epidemiology, and End Results (SEER) program to assess important care processes (i.e., the appropriate extent of surgery and use of adjuvant chemotherapy) and outcomes (i.e., surgical complications, ostomy rates, and survival). All statistical tests were two-sided. Results: Among 3067 ovarian cancer patients who underwent surgery, 1017 patients (33%) were treated by a gynecologic oncologist, 1377 patients (45%) by a general gynecologist, and 673 patients (22%) by a general surgeon. Among patients with stage I or II disease, those treated by a gynecologic oncologist (60%) were more likely to undergo lymph node dissection than those treated by a general gynecologist (36%) or a general surgeon (16%). Patients with stage III or IV disease were more likely to undergo a debulking procedure if the initial surgery was performed by a gynecologic oncologist (58%) than by a general gynecologist (51%) or a general surgeon (40%; P <.001) and were more likely to receive postoperative chemotherapy when operated on by a gynecologic oncologist (79%) or a general gynecologist (76%) than by a general surgeon (62%, P <.001). Survival among patients operated on by gynecologic oncologists (hazard ratio [HR] of death from any cause = 0.85, 95% confi dence interval [CI] = 0.76 to 0.95) or general gynecologists (HR = 0.86, 95% CI = 0.78 to 0.96) was better than that among patients operated on by general surgeons.

Confidential enquiries into poor perinatal outcomes have identified deficiencies in team working as a common factor and have recommended team training in the management of obstetric emergencies. Isolated aviation-based team training programmes have not been associated with improved perinatal outcomes when applied to labour ward settings, whereas obstetric-specific training interventions with integrated teamwork have been associated with clinical improvements. This commentary reviews obstetric emergency training programmes from hospitals that have demonstrated improved outcomes to determine the active components of effective training. The common features identified were: institution-level incentives to train; multi-professional training of all staff in their units; teamwork training integrated with clinical teaching and use of high fidelity simulation models. Local training also appeared to facilitate self-directed infrastructural change.