Jessop Hospital

Key content Elevated human chorionic gonadotrophin (hCG) levels can originate from various conditions outside of pregnancy. Phantom hCG cases represent false‐positive results. Elevated pituitary‐hCG levels are a normal physiological response in women with reduced ovarian reserve. Elevated hCG levels can be present in malignancies from trophoblastic diseases, germ cell and other extra‐ovarian tumours. Learning objectives To highlight the different conditions that raise hCG levels outside of pregnancy. To clarify when to suspect physiological conditions versus malignancy. To guide clinicians on management and patient follow‐up. Ethical issues Should perimenopausal women receive routine hCG testing? How can an incorrect diagnosis of elevated hCG impact patients, particularly patients with subfertility or misdiagnosed malignancies? How does centralised management of gestational trophoblastic diseases affect patients' experience and the local centres?

To undertake a systematic review to assess the accuracy of fetal MRI in diagnosis of non-CNS congenital anomalies of the fetal body in comparison with antenatal ultrasound when correlated to postnatal diagnosis. Searches were conducted from electronic databases, key journals and reference lists for eligible papers. Inclusion criteria was original research studies comparing the diagnostic results of antenatal ultrasound, fetal MRI and final postnatal diagnosis via imaging, surgery or post-mortem testing. Studies of CNS anomalies were excluded. Studies were assessed for risk of bias by two reviewers working independently and data was then extracted by a single reviewer. 12 studies were included with a total of 361 eligible patients who underwent USS and MRI and had a postnatal diagnosis. USS alone had a diagnostic accuracy of 60.6% whereas MRI had an improved diagnostic accuracy of 86.4%. The overall odds ratio was 0.86 (CI 0.202-1.519 and p-value < 0.01). Fetal MRI makes a significant contribution to accurate diagnosis of congenital abnormalities of the fetal body; especially in genito-urinary anomalies. More research is needed to improve the evidence base for the role of fetal MRI in diagnosis of congenital anomalies in other body systems.

Key content Female genital cosmetic surgery (FGCS) includes several procedures involving the labia minora, labia majora, clitoris, vagina, mons pubis and genital area; procedures may involve, for example, reduction or augmentation and be surgical or energy based. Indications for FGCS can be broadly divided into cosmetic and functional reasons. Counselling on the risks and cosmetic outcomes, as well as sexual and functional results, should be provided, and the woman's expectations discussed. Learning objectives To develop a holistic view when discussing cosmetic gynaecology concerns, including psychosexual assessment. To understand the procedures that are currently available, the evidence‐base behind these procedures, and their risks and benefits. To understand the implications of genital cosmetic surgery on patients, including their psychosexual wellbeing, and the legality of these procedures with reference to female genital mutilation (FGM). Ethical issues The ‘postcode lottery’ in commissioning cosmetic gynaecological procedures in the UK leads to the question: should they be available on the NHS? Who should be performing cosmetic gynaecological procedures: the plastic surgeons who do little vaginal surgery, or the gynaecologists? There is currently no formal training in this area for gynaecologists.

Post-coital bleeding (PCB) is a poor predictive factor for cancer and should not be managed as urgent referral. Urgent referral to colposcopy is justified however, in the presence of a visible suspicion of cervical cancer. This retrospective cohort study of women attending a clinical indications referral service aims to identify the risk of pre-malignant and malignant disease in women with clinical indication referrals to colposcopy. Thirty-seven of 3521 women (1%) were diagnosed with pre-malignant cervical or endometrial disease; 14 women (0.4%) were diagnosed with cancer (11 cervix, three endometrial). To detect one cancer in women referred with an abnormal cervix, one would need to see 70 women; to detect one cancer in women referred with PCB one would need to see 790 women. Improved education in primary care and obstetrics and gynaecology training is key to improving clinical indications referral services, which is otherwise an effective and efficient service. Impact Statement What is already known on this subject? Post-coital bleeding is a poor predictive factor for cancer and should not be considered an urgent referral. What do the results of this study add? The presence of a visible suspicion of cervical cancer however does warrant urgent referral as approximately one in 70 women will have a malignancy detected. What are the implications of these findings for clinical practice and/or further research? Improved education in primary care and obstetrics and gynaecology training is the key to improving clinical indications referral services

ObjectiveTo quantitatively analyse the number of doctors leaving the paediatric specialty training (ST) programme in the UK, to assist with evidence-based workforce planning.DesignData were sought on those leaving the UK paediatrics training programme between 2014 and 2019 from Heads of Schools of Paediatrics and Freedom of Information Act requests.SettingRetrospective data analysis.Outcome measuresOverall attrition rate, attrition rate across level of training, attrition rate across geographical area, recorded reason for leaving.ResultsAll results must be interpreted with caution due to limitations in record keeping and analysis. The annual attrition rate across all ST levels between 2014 and 2019 is estimated at 3.7%–4.2% (ie, 749–845 trainees may have left the paediatric training programme over 2014–2019). No reason for leaving was recorded for three-quarters of individuals, around 630 doctors. Of those leaving paediatrics, significantly more (χ², p=0.015) did so at ST3 (20.3%) versus the next highest training year, ST2 (13.6%).ConclusionsThis project seems to demonstrate worryingly poor record-keeping of the true attrition rate of paediatric trainees by organisations responsible for workforce planning, including Health Education England, the Royal College of Paediatrics and Child Health and individual paediatric schools across the UK. To allow evidence-based workforce planning for the benefit of UK children, it is vital that accurate records on trainees who leave the training programme are kept and shared across the UK.

Most children in hospital who are clinically deteriorating are monitored regularly, and their treatment is escalated effectively. However a small, but significant, number of deteriorating children experience suboptimal outcomes because of a failure to recognise and respond to acute deterioration early enough leading to unintended harm. Tragically this occasionally can have fatal consequences. Investigations into these rare events highlight common themes of missed early signs of deterioration in children, prompting regulatory agencies to suggest paediatric early warning systems (PEWS) to aid clinical practice. In England, track and trigger tools (TTT), which are one facet of PEWS have been widely rolled out but in a heterogeneous fashion. The evidence for TTT is mixed but they are complex interventions and current outcomes do not fully define the entirety of their potential impact. This article explains the rationale behind the decision of the NHS England and NHS Improvement, Royal College of Paediatrics and Child Health and Royal College of Nursing to implement a standardised inpatient PEWS as part of a system-wide paediatric observations tracking system in England and how this fits into a wider programme of activity.

Introduction and hypothesisPatient decision aids (PDAs) facilitate shared decision making allowing patients to make decisions about their healthcare that take into account their personal values and preferences. The aim of this study was to establish whether a PDA used in women requiring stress incontinence surgery is helpful to women when making choices about the treatments they choose by using a Decision Conflict Scale (DCS).MethodsForty-five consecutive women were identified as having stress urinary incontinence and had completed all conservative treatments. All patients included in the study had stress urinary incontinence confirmed on urodynamic testing and were given the PDA at the point where they needed to make a decision about surgery. Following completion of the PDA, patients were given a DCS to complete which measures personal perceptions of uncertainty when making a decision about treatment.ResultsForty-three out of 45 (95.5%) patients scored 4/4 for the DCS indicating they were sure of their decision. Two patients (4.5%) scored 3/4 and were therefore unsure of their choice. No patient scored < 3 on the DCS. The choice of procedures varied in all the ages and two women opted to have no treatment.ConclusionsThe use of a PDA in the surgical treatment of stress urinary incontinence reduces decision conflict and ensures patients are sure of their decision, understand the information provided as well as the risk benefit ratio of the various options and feel they have adequate support and advice to make a choice.