Download (.pdf) The second-look laparotomy for epithelial ovarian carcinoma
Co-authored with: L. Frigerio, L. Busci, S. Garsia, A. Ferrari.
Published in: "Italian Journal of Gynecology and Obstetrics". Vol. 2, pag. 19-24. 1990.
Summary: Between 1975 and 1986, second look laparotomy (SLL) to evaluate desease status was performed in 87 patients... more Summary: Between 1975 and 1986, second look laparotomy (SLL) to evaluate desease status was performed in 87 patients originally presenting with epithelial ovarian carcinoma. Surgical and histologic assessment did not reveal persistent desease in 34 patients (39%). The 3-years survival, by Kaplan-Meier calculation, was 73.5% after negative SLL versus 32% after posotive SLL ( p< 0.01). Residual tumor (RT) was absent after original operation in 24 patients (35.8%), in 12 cases (17.9%) RT was less than 2 cm, and in 31 cases (46.2%) RT was more than 2 cm. Negative SLL is related to RT at primary surgery. The merit of reassessment surgery is the prognostic value of this procedure: the mortality at 3 years after primary surgery was 26.5% of cases with negative SLL and 68% after positive SLL( p< 0.01).
Carcopino X, Akkawi R, Conroy R, Prendiville W. (2008). "Specific Timing for Colposcopy: Is it Worthwhile?" Obstet Gynecol 111(2): 1-5.
by Ronan Conroy
OBJECTIVE: To estimate if the time of the menstrual cycle would improve the chance of seeing the squamocolumnar... more OBJECTIVE: To estimate if the time of the menstrual cycle would improve the chance of seeing the squamocolumnar junction at colposcopy. METHODS: A retrospective study was conducted on 1,248 patients with normal menstrual cycles who attended our colposcopy clinic between 2003 and 2007. Timing of colposcopy, parity, contraception, smoking status, and visibility of the transformation zone were recorded for analysis. The transformation zone was classified as type 1 when completely ectocervical and fully visible, type 2 when it was partially endocervical but fully visible, and type 3 when not fully visible. RESULTS: No significant difference was found between the rate of types 1, 2, or 3 transformation zone observed in patients who were examined during the second week of their menstrual cycles and the others (P=.581). Compared with women in the first week of their menstrual cycle, those on the 22nd day or later were significantly more likely to have a type 1 transformation zone at colposcopic examination (odds ratio [OR]=1.6, P=.029, logistic regression using day 1 to 7 as baseline). The probability for a patient to have a type 1 transformation zone declined with age (OR=0.59, P<.001), parity (OR=0.47, P<.001), and smoking status (OR=0.55, P<.001), whereas it increased with the use of combined oral contraception (OR=2.7, P<.001). Adjusting for these factors, we found no statistically significant effect of the time of cycle on the visibility of the transformation zone. CONCLUSION: Timing colposcopy during the menstrual cycle does not improve the visibility of the transformation zone and is not recommended. LEVEL OF EVIDENCE: III.
Greek embryological calendars and a fragment from the lost work of Damastes,< i> On the Care of Pregnant Women and of Infants</i>
by Holt Parker
"Greek Embryological Calendars and a Fragment from the Lost Work of Damastes, On the Care of Pregnant Women and of Infants," CQ 49 (1999) 515-534.
http://www.jstor.org/stable/639876
Parker, Holt N. - Greek embryological calendars and a fragment from the lost work of Damastes, « On the care of... more Parker, Holt N. - Greek embryological calendars and a fragment from the lost work of Damastes, « On the care of pregnant women and of infants ». CQ 1999 N. S. 49 (2) : 515-534. • Damastes' embryological calendar, published here for the first time, outlines the typical development of children that are born 7, 8, 9 and 10 months after conception. His work has affinities with various other texts, especially the Pythagorean corpus, but is idiosyncratic in its acceptance of an 8-month child's viability.
Primary carcinoma of the fallopian tube.
Co-authored with: Frigerio L, Pileri M, Pifarotti G, Busci L, Rabaiotti E, Ferrari A
Published in: Tumori 1993 Feb 28; 79(1):40-4-
BACKGROUND: Because of the rarity of fallopian tube cancer, clinical approaches have changed during the last 18 years.... more
BACKGROUND: Because of the rarity of fallopian tube cancer, clinical approaches have changed during the last 18 years.
METHODS: Twenty-nine patients with fallopian tube cancer were treated at the Gynecologic Oncology Department of Milan University from 1970 to 1988. The mean patient age was 59 years. Parity, symptomatology and histology were considered. Distribution by stage was as follows: I, 11 (37%); II, 10 (34%); III, 8 (27%) according to the Dodson classification. Twenty patients (69%) underwent surgery followed by pelvic irradiation. Adjuvant chemotherapy was performed in the treatment of 5 women with stage I disease, 6 with stage II, and all 8 with stage III.
RESULTS: Five-year overall survival was 41.38%: 47.6% at stages I and II, 25% at stage III. Radiotherapy has not been replaced by cisplatin-based multiagent chemotherapy. Optimal surgical debulking combined with accurate lymph node sampling are not followed by systematic use of repeat laparotomy.
CONCLUSIONS: The procedures described in this work improve the clinical assessment and patient survival, and make different series comparable.
PubMed ID: 8497921
Informed consent for elective and emergency surgery: questionnaire study
Andrea Akkad, Clare Jackson, Sara Kenyon, Mary Dixon-Woods, Nick Taub, Marwan Habiba
Objectives To evaluate women's experience of giving consent to obstetric and gynaecological surgery and to... more
Objectives To evaluate women's experience of giving consent to obstetric and gynaecological surgery and to examine differences between those undergoing elective and emergency procedures.
Design A prospective questionnaire study.
Setting A large teaching hospital.
Population 1006 consecutive patients undergoing elective or emergency surgery in obstetrics and gynaecology.
Methods Questionnaires were administered to women who had given consent to surgery following the introduction of national guidelines and consent form. Differences in responses between elective and emergency patients were assessed using frequencies, single and multivariable analyses.
Main outcome measures Patients' experience and recall of the consent process, their overall satisfaction and their views on what is important for adequate consent.
Results There were significant differences between patients undergoing elective or emergency surgery. Patients undergoing emergency surgery were less likely to have read (OR 0.22) or understood (OR 0.40) the consent form, and were more likely to report feeling frightened by signing it (OR 2.52). They were more likely to report they felt they had no choice about signing the consent form (OR 2.11), and that they would have signed regardless of its content (OR 3.14). Overall, significantly more patients undergoing elective (80%) or emergency (63%) surgery reported satisfaction with the consent process. Patients were more likely to report satisfaction if they read (OR 1.80) and agreed with (OR 3.49) the consent form, and if someone checked that they understood (OR 3.09).
Conclusion Patients' needs may not be adequately addressed by current guidelines for consent to treatment, particularly in emergency circumstances. The introduction of more complex forms and procedures appears to conflict with patients' need for personal communication and advocacy. The implications on the ethical and legal standing of consent are considerable.
Why do women consent to surgery, even when they don't want to? An interactionist and Bourdieusian analysis
Mary Dixon-Woods, Simon Williams, Clare Jackson, Andrea Akkad, Sara Kenyon, Marwan Habiba
The ‘informed consent’ process has been placed at the centre of bioethical and policy discourses about how the... more The ‘informed consent’ process has been placed at the centre of bioethical and policy discourses about how the autonomy and rights of patients can best be protected. Although there has been critical analysis of how the process functions in relation to participation in research and particular ethical ‘dilemmas’, there has been little examination of the routine business of consenting to medical procedures. Evidence is now beginning to emerge that people may consent to surgery even when reluctant to do so. In this paper we develop an analysis informed by Bourdieusian and interactionist social theory of the accounts of 25 women who consented to surgery. Of these, nine were ambivalent or opposed to having an operation. When faced with a consent form, women’s accounts suggest that they rarely do anything other than obey professionals’ requests for a signature. Women’s capacity to act is reduced as they become enmeshed in the hospital structure of tacit, socially-imposed rules of conduct. However, the interactionist account of power operating through the social rules of particular situated encounters, and the sanctions associated with rule-breaking, may not provide a sufficiently powerful explanation for why women submit to surgery they are opposed or ambivalent towards. Bourdieu’s concepts of habitus, capital and symbolic power/violence offer a potentially more elaborated account, by showing how the practical logic that women apply in the field of surgery confers a ‘sense of place’ relative to professionals. Women experience deficits in capital, intensified by their physical vulnerability in critical situations, that severely constrain their ability to exercise choice. This work demonstrates the weakness of the consent process as a safeguard of autonomy. Far from reinforcing autonomy, the process may reinforce rather than disrupt passivity, but more generally our findings call into question the extent to which autonomy may be an illusory goal.
Patients' perceptions of written consent: questionnaire study
Andrea Akkad, Clare Jackson, Sara Kenyon, Mary Dixon-Woods, Nick Taub, Marwan Habiba
Objective To examine patients' understanding of the status, function, and remit of written consent to surgery.
... more
Objective To examine patients' understanding of the status, function, and remit of written consent to surgery.
Design Prospective questionnaire study. Questionnaires were sent to patients within one month of surgery. Responses were analysed with frequencies and single variable analyses.
Setting Large teaching hospital.
Participants 732 patients who had undergone surgery in obstetrics and gynaecology over a six month period.
Main outcome measures Patients' awareness of the legal implications of written consent and their views on the function and remit of the consent form.
Results Patients had limited understanding of the legal standing of written consent. Nearly half (46%, 95% confidence interval 43% to 50%) of patients believed the primary function of consent forms was to protect hospitals and 68% (65% to 71%) thought consent forms allowed doctors to assume control. Only 41% (37% to 44%) of patients believed consent forms made their wishes known.
Conclusions Many patients seem to have limited awareness of the legal implications of signing or not signing consent forms, and they do not recognise written consent as primarily serving their interests. Current consent procedures seem inadequate as a means for the expression of autonomous choice, and their ethical standing and credibility can be called into question.
Women’s views and experiences of a patient preference trial in surgery: a qualitative study of the CARPET1 trial
Jackson CJ, Dixon-Woods M, Eborall H, Kenyon S, Toozs-Hobson P, Tincello DG.
Background The randomized controlled trial (RCT) has a well-established role in assessing drug therapies, but its... more
Background The randomized controlled trial (RCT) has a well-established role in assessing drug therapies, but its adoption in developing surgical interventions has been slow. Patients’ perspectives on surgical RCTs, especially those including a patient preference option, have received little attention.
Purpose To characterize participants’ experiences and views of recruitment to a pilot trial (CARPET1) of two surgical treatments for urinary incontinence and vaginal prolapse that included a patient preference option.
Methods Semi-structured qualitative interviews with 16 women who participated in the CARPET1 trial. Data analysis was based on the constant comparative method.
Main outcome measures Women’s experiences of taking part in a patient preference trial.
Results Women’s motives for participating in CARPET1 focused on the possibility of additional care and, as a secondary motive, the wish to help with research. Most participants expressed a treatment preference rather than accepting randomization. Most were pleased with the information they received, and acknowledged the principle of equipoise, but there was substantial variability in their understanding of aspects of the trial, including randomization. Randomization was considered by women to be appropriate only when both treatments were equally suitable and they had no strong preference. Women suggested that the main influence on their willingness to be randomized was the recruiting clinician’s opinion. Importantly, despite the recruiting clinicians being heavily involved in conception of CARPET1, they did not seem to be in equipoise at the level of the individual patient.
Limitations This being a small study it was not possible to interview women who declined trial participation or to observe consultations between surgeons and patients.
Conclusions CARPET1 appears to have been more a surgeon preference trial than a patient preference trial. Substantial challenges may remain in conducting RCTs in surgery, particularly where surgeons have preferences about what they perceive as the best option for an individual patient.
Women's accounts of consenting to surgery: is consent a quality problem?
M Habiba, C Jackson, A Akkad, S Kenyon, and M Dixon-Woods
Background: Consent has been placed at the centre of doctor-patient relationships. Attempts to improve the consent... more
Background: Consent has been placed at the centre of doctor-patient relationships. Attempts to improve the consent process in medicine have drawn on bioethical and legal traditions. Current approaches to consent emphasise the provision of information and have, in the UK, resulted in a single standardised format and process for both elective and emergency situations. Investigation of patients' perceptions and priorities are important in understanding the quality of the consent process. Methods: In this qualitative study, semi-structured interviews were conducted with 25 women. Eleven had elective and 14 had emergency operations in obstetrics and gynaecology. All interviews were recorded and transcribed verbatim. Data analysis was based on the constant comparative method. Results: Participants' perceptions of surgery strongly influenced the meanings they gave to consent. Some, particularly those undergoing elective operations, wanted surgery. Others were uncertain of their desire for surgery or felt that it was imposed on them. Consenting was interpreted as a ritualistic legal procedure. There was an overwhelming tendency to view consent as not primarily serving patients' needs, although some advantages of the consent process were identified. Accounts made no reference to ethics. Conclusion: Countering paternalism will remain difficult to achieve if issues surrounding consent continue to be debated between professionals without due effort to reflect patients' own views and values and to appreciate the circumstances under which consent is sought.
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Mitochondrial NADH-dehydrogenase polymorphisms as sporadic breast cancer risk factor.
Breast cancer is the most frequently diagnosed female cancer all over the world. Although the molecular genetics of... more Breast cancer is the most frequently diagnosed female cancer all over the world. Although the molecular genetics of this disease has been the focus of many projects for over 20 years, the number of prognostic markers used in clinics is still unsatisfactory. Mitochondrial DNA mutations have been reported in many breast cancer studies. To investigate the possible role of mitochondrial inherited polymorphisms in breast cancer development we analyzed the sequence of NADH-dehydrogenase genes in cancer samples and their corresponding normal tissues. We detected increased incidence of mtDNA polymorphisms, in particular very rare polymorphisms such as A4727G, G9947A, A10044G, A10283G, T11233C, and C11503T. Our report supports the notion that mtDNA polymorphisms establish a specific genetic background for breast cancer development and that mtDNA analysis may help in selection of cohorts that should undergo intensive screening and early detection programs.
Mitochondrial genotype in vulvar carcinoma - cuckoo in the nest.
Vulvar squamous cell carcinoma (VSCC) is a rare female genital neoplasm. Although numerous molecular changes have been... more Vulvar squamous cell carcinoma (VSCC) is a rare female genital neoplasm. Although numerous molecular changes have been reported in VSCC, biomarkers of clinical relevance are still lacking. On the other hand, there is emerging evidence on the use of mtDNA as a diagnostic tool in oncology. In order to investigate mtDNA status in VSCC patients, haplogroup distribution analysis and D-loop sequencing were performed. The results were compared with available data for the general Polish population, cancer free-centenarians as well as patients with endometrial and head and neck cancer. The obtained data were also compared with the current status of mitochondrial databases. Significant differences in haplogroup distribution between VSCC cohort, general Polish population and cancer-free centenarians cohort were found. Moreover, a correlation between the VSCC patients haplogroup and HPV status was observed. Finally, a specific pattern of mtDNA polymorphisms was found in VSCC. Our results suggest that the mitochondrial genetic background may influence the risk of VSCC occurrence as well as susceptibility to HPV infection.
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Common mitochondrial polymorphisms as risk factor for endometrial cancer.
Endometrial carcinoma is the most commonly diagnosed gynaecological cancer in developed countries. Although the... more Endometrial carcinoma is the most commonly diagnosed gynaecological cancer in developed countries. Although the molecular genetics of this disease has been in the focus of many research laboratories for the last 20 years, relevant prognostic and diagnostic markers are still missing. At the same time mitochondrial DNA mutations have been reported in many types of cancer during the last two decades. It is therefore very likely that the mitochondrial genotype is one of the cancer susceptibility factors. To investigate the presence of mtDNA somatic mutations and distribution of inherited polymorphisms in endometrial adenocarcinoma patients we analyzed the D-loop sequence of cancer samples and their corresponding normal tissues and moreover performed mitochondrial haplogroup analysis. We detected 2 somatic mutation and increased incidence of mtDNA polymorphisms, in particular 16223C (80% patients, p = 0.005), 16126C (23%, p = 0.025) and 207A (19%, p = 0.027). Subsequent statistical analysis revealed that endometrial carcinoma population haplogroup distribution differs from the Polish population and that haplogroup H (with its defining polymorphism - C7028T) is strongly underrepresented (p = 0.003), therefore might be a cancer-protective factor. Our report supports the notion that mtDNA polymorphisms establish a specific genetic background for endometrial adenocarcinoma development and that mtDNA analysis may result in the development of new molecular tool for cancer detection.