Portal de Periódicos da CAPES

Editor’s Choice

2007; Wiley; Volume: 114; Issue: 12 Linguagem: Inglês

10.1111/j.1471-0528.2007.01588.x

1471-0528

Philip Steer,

Medical Research and Practices

BJOG aims to publish the best articles for a general obstetric and gynaecological readership. To this end, we try to have papers on both obstetric and gynaecological topics in each issue. However, we also have to make sure that papers are not delayed too long in our attempt to achieve balance. This problem has been eased by publication ‘online early’, so that when papers have been fully edited, they are made available on the website and are indexed in ‘PubMed’ shortly after. This means that authors can be sure that anyone looking for their work for scientific purposes, using the internet, will find their papers with the least possible delay. Some of the papers in this month’s issue have already been available online for 2 months. However, despite this electronic availability, most authors are still keen to see their papers in print, and so sometimes, we sacrifice an element of balance in the interests of immediacy. October’s issue was predominantly obstetric; this issue is predominantly gynaecological, with 12 papers in this area and only 5 in obstetrics. However, even if you practice predominantly in a subspecialty, it is important to keep up with developments across the specialty as a whole, and so I would recommend you to browse through all the articles in each issue, even if it is only to pick up the main messages. Together with reading a general medical Journal, one is then likely to be aware of at least the key developments across the breadth of medicine affecting one’s own practice. Continuing medical education (aka continuing professional development) is no longer an option for most of us, it has become a necessity to achieve continuing accreditation. I have mentioned in previous Editor’s choices our continuing series of papers regarding ST segment analysis of the fetal electrocardiogram during labour. In October, we had a particularly important group of papers, and we therefore commissioned a podcast on this topic. We arranged for contributions from obstetricians with extensive experience of using the technique in a busy clinical setting. The eminent contributors include the current president of the Royal College of Obstetricians and Gynaecologists of the UK. I strongly recommend that you visit http://www.blackwellpublishing.com/podcost/bjog.asp and click through to hear this very interesting podcast. My first introduction to the management of such abnormalities came very early in my career when, in 1970, I did a student elective at the John’s Hopkins Hospital in Baltimore, USA. I was lucky enough to be a surgical assistant to famous gynaecologists such as Donald Woodruff, Emil Novak and Howard Jones. It was at the John’s Hopkins, with funding from the Erickson Educational Foundation, that Jones, together with Drs John Money and Milton Edgerton, started America’s first Gender Identity Clinic. In 1965, after receiving permission from a Baltimore court, Phillip Wilson underwent the first sexual reassignment surgery in the USA to become Phyllis Wilson. I assisted at a number of such procedures; my role was to cut foam sponges to shape so that when inserted into a condom, they made a flexible form over which inverted skin grafts could be stitched and then used as part of McIndoe’s procedure (creation of an artificial vagina). These were often physically relatively successful, although the psychological scars that the patients acquired have been graphically described in accounts, which can now be found on web sites such as those of the Androgen Insensitivity Support Group (http://home.vicnet.net.au/~Eaissg/fran.htm) and the Intersex Society of North America (http://www.isna.org/books/chrysalis/triea_pru). The Mayer–Rokitansky–Kuster–Hauser (MRKH) syndrome, characterised by uterovaginal agenesis, is the second most common cause of primary amenorrhoea and occurs once in every 4000 to 5000 births (the Androgen Insensitivity Syndrome occurs in about 1 in every 20 000 births). Women affected by MRKH have a normal female karyotype (46, XX), functioning ovaries, external genitalia and female secondary sex characteristics, but they do not have a vagina or uterus. Vaginas created by the McIndoe procedure have many problems, including progressive stenosis in the absence of repeated dilatation, and so alternatives, such as using a length of colon, have been developed. It was only a matter of time before laparoscopy was used to carry out such techniques, and the first report was by Ohashi et al. in 1996 (Surg Endosc 10:1019–21). On page 1486, in this issue of BJOG, Cai et al. report their experience with 26 women managed with this procedure. To set their paper in context, we commissioned a commentary by Michala, Cutner and Creighton (on page 1455) to review surgical approaches to treating vaginal agenesis. They comment that ‘there are … scanty long term outcome data for all … procedures, especially for sexual function’. So despite technical improvements, our knowledge of the long-term psychological impact has hardly improved since the 1960s. I agree with their comment that ‘specialist units … have a duty to provide long-term outcome data’. Browsing the accounts on the internet of women who have undergone the procedure does not make happy reading, and doctors should never allow their fascination with technical procedures to blind them to the holistic needs of their patients. But how should these needs be assessed? They are not only psychologically complicated but also subject to societal expectations. On page 1493, Bramwell et al. report the concern some women have about the appearance of their labia. As with the construction of a neo-vagina, research into labial reduction has primarily focused on surgical technique. Bramwell et al. sought, using qualitative techniques, to cast some light on why some women request surgery to a part of their body, which, unlike breasts, is rarely on display. A key finding was the need for the 17 women studied to feel ‘normal’. This stems perhaps from the need most of us have to be accepted by our peer group. Discussing these difficult issues naturally makes us uncomfortable, but we should not allow our discomfort to prevent us from trying to understand them because our patients rely upon us for support and guidance. At the very least, we should acknowledge the importance of gender identity and refer problems outwith our competence to the appropriate specialist. Those of us who have regularly carried out cervical cerclage for women with repeated midtrimester miscarriages are comforted by the many case series, for example of transabdominal cerclage, which report 90% or more success rates in women with previous multiple midtrimester pregnancy losses. It seems obvious to us that cerclage must work. However, I am reminded of Aristotle’s belief that gravity affects objects in proportion to their weight. He pointed out that it is a matter of common observation that bricks fall faster than feathers. However, I remember being very impressed at school watching a feather drifting slowly down inside a glass tube, only to drop like a stone once the air had been exhausted from the tube using a vacuum pump (Aristotle did not appreciate the crucial effect of air resistance). It took Galileo Galilei repeatedly to drop wood and metal balls from the leaning Tower of Pisa to demonstrate that in reality, the acceleration due to gravity affects all objects equally. So things which are ‘obvious’ are not always true. Any procedure should ideally be validated by a randomised controlled trial before it can be accepted as beneficial. In this issue, Jorgensen et al. on page 1460 have reported their painstaking task of combining data at the individual patient level in over 2000 cases of cervical cerclage. Their results are not comforting to the cerclagists. Although the results suggested that cerclage might reduce the risk of pregnancy loss or death of the baby before discharge from hospital by 19%, this result did not reach conventional statistical significance. Moreover, there was an increase in some indices of morbidity, and the effect of cerclage in multiple pregnancies was actually negative. Considering the frequency with which such procedures are carried out in modern practice, there is a clear case for further multicentre prospective randomised controlled trials. Private, for profit, health organisations are often keen to promote routine medical screening. Many public health experts consider that routine ‘medicals’ are not cost-effective and that they may sometimes be harmful by prompting potentially hazardous investigations when the woman is actually healthy. Tests which are useful in patients with a high risk of the condition being tested for (e.g. selected on the basis of symptoms or signs) often have an adverse benefit/risk ratio when applied to the general population because although there are then fewer true positives, the false-positive rate remains the same. On page 1500, Woodward et al. report on the use of annual CA125 and transvaginal ultrasound scanning for screening for ovarian cancer in 341 asymptomatic women. Thirty women underwent exploratory surgery because of abnormal findings, but only two had cancer. The anxiety experienced by the women who had unnecessary surgery is not mentioned in the paper, but it must have been considerable. In my experience, the general public rarely consider the downside of false positives when they are offered screening tests. It is up to us to remind them. One screening test for which benefit has unequivocally been demonstrated is cervical cytology. It has been credited with enabling early treatment of preinvasive lesions with important reductions in deaths from cervical cancer in the developed countries. However, its efficiency may be greatly reduced following the widespread introduction of human papillomavirus vaccination because hopefully cervical cancer will become much less common. In this context, we should not forget that cervical cytology screening detects not only cervical cancer but also up to 50% of endometrial cancers and 2% of ovarian cancers. I have personally diagnosed two cases of ovarian cancer following the finding of abnormal cells on a cervical smear. To this benefit can now be added the diagnosis of primary fallopian tube cancer reported by Benjamin et al. on page 1575. I think we will be doing cervical cytology for many years yet. In our October issue, I highlighted the paper by Kruk et al. describing the training, deployment costs and surgical productivity of surgically trained assistant medical officers (técnicos de cirurgia) in Mozambique and wondered how many doctors trained in that country had emigrated to the developed world. The paper by Bergström et al. on page 1530 in this issue goes some way to answering my question. They report that 92% of obstetric and gynaecological operations in district level hospitals were carried out by técnicos de cirurgia and more than half (57%) of all operations nationwide. Seven years after qualification, 88% of técnicos de cirurgia were still working in district level hospitals compared with none of the medically trained doctors. Bergstrom et al. conclude that delegation of life-saving major obstetric surgery to nonmedically trained technicians is probably one of the most important steps that could be taken to reduce maternal mortality worldwide. Recent newspaper reports in the UK have highlighted the fact that police officers are now recommended not to attempt to save anyone from drowning ‘unless they have been on the appropriate training course’. The attitude of ‘see one, do one, teach one’ which was prevalent when I was training was undoubtedly too cavalier, but modern juniors seem reluctant to do anything unless they have been on ‘the training course’. How useful are such training courses? Crofts et al. on page 1534 set out to explore the effect of multiprofessional obstetric emergency training on knowledge and reports that in the short term, there was a significant improvement. Importantly, transport of staff to an expensive simulation centre offered no additional benefit compared with locally conducted training. However, how long this improvement in knowledge persists, and whether it translates into improved practical efficiency in an emergency, is not addressed in this study and must therefore remain an open question. It may seem obvious (vide supra) that expensive and highly organised teaching programmes are better than straightforward supervised learning in the workplace, but definitive evidence in this regard seems elusive.