A C TA Obstetricia et Gynecologica
AOGS EDIT ORS M ES SAGE
Healthy ethical conduct is vital REYNIR TOMAS GEIRSSON & GANESH ACHARYA
DOI: 10.1111/aogs.12354
As we go into April most of Europe will be recovering from a widely difficult winter with excessive rain and cold weather in the past months, a tiring situation coupled to worries about long-term weather changes. Much evidence supports that this is to a considerable extent man-made, so to say the result of our misconduct and suboptimal care for nature. While healthy ethical conduct may counteract such developments, this takes effort, reeducation and changed practices and priorities. The two young women on the front cover of the journal this month are typical of the young and vital generation of Europe striving on and out of the winter into the fresh air of spring. The Nordic countries have the educational levels, technology and vision to lead the way into a new era where mindfulness about environment, energy consumption, re-cycling of material and a healthy population growth could be used to counteract effects of climate change. Obstetricians and gynecologists have a role to play there with our mission to improve women´s health, contribute to a balanced population size and in our work and personal lives to show rational and sensible attitudes that do not overstretch from a sustainable use of resources. Rising cesarean section rates are a global concern and may be seen as one form of overuse of resources, – a set-back to initiatives directed towards improving maternal health, especially in low resource countries. Cesarean scar is essentially a iatrogenic disease associated with a significantly increased risk of postpartum hemorrhage, uterine rupture, morbidly adherent placenta and scar ectopic pregnancy, – all potentially life threatening complications. Many cesarean sections are now being done without strict medical indications. This can be considered as a violation of the basic ethical principle of medicine: “primum non nocere” (first do no harm). In China, with one-child policy as the established norm, women and their healthcare providers may not fully appreciate the risk of complications that can occur in subsequent pregnancies. Approximately 25% of cesarean sections are performed without strict medical indication in China compared to 7% for all of Asia (1). Cesarean section
rates have reached epidemic proportions in many countries in all continents, and in China the rate is now 46% (1), compared to about 15–20% in Nordic countries. As a result, cesarean scar ectopic pregnancies appear to be more common in China. Authors from China recently sent to AOGS an article where they reported on a substantial number of such cases within a short period managed using a transvaginal extra-peritoneal approach to remove the ectopic pregnancy and repair the uterine defect. We thought this was a good example of how problems often lead to innovation and accepted the article in good faith after a couple of revision efforts. Only then did one of the editors working on a systematic review on the subject discover a substantially similar article freshly published in another journal (2). After some correspondence it became clear that the authors had sent two separate manuscripts with overlapping study populations and content to two different journals almost simultaneously, but had not informed the respective journals of this. On our website you may see that we have had to effect retraction of this article. We want to take this up here to point out the importance of taking extreme care in how research is planned, conducted and published, and emphasize that more does not always mean better. As a journal we try to counteract such tendencies as much as we can and not to leave scientific misconduct unnoticed, but alas we do encounter practices that border on the ethical. No country and no institution is immune there and only scientific integrity and high standards coupled to vigilance can minimize such happenings. Now to this present AOGS issue. We start with two high-quality articles within gynecologic oncology. First Mette Noer and her colleagues in Copenhagen, Denmark (pp. 325–334), show in a prospective and rigorous study using the nationwide Danish Gynecologic Cancer Database, how prognosis for women with endometrial cancer is adversely affected by other serious disease, largely independent of cancer stage and type. These often older women thus require adequate care for not only the cancer, but other ill-health affecting them at the same time, and
ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 93 (2014) 323–324
323
Editors Message
possibly receiving less attention than the cancer itself. Then a group centered in Link€ oping area, Sweden (Evelyn Lundin and co-workers, pp. 335–344) report a randomized study of using an old established drug, tranexamic acid, in a single pre-operative dose for reducing blood loss during surgery for ovarian cancer. It does perhaps not sound surprising to doctors in the Nordic countries that this works. But it is a result that should be noticed as a simple and inexpensive measure without significant side-effects. Something that should be universally used for a vulnerable group of patients who need optimal strength during their post-operative recovery phase. In another randomized study this month, Gustavo Calle and colleagues in Medellın, Colombia (pp. 345–350), show that there is not much to be gained from trying to decrease post-operative pain after laparoscopic hysterectomy with local anesthesia given into the transversus abdominis fascia and muscle compartments. Such negative studies should be reported when they are properly performed. Most of the readers will remember having learnt operative techniques by the “see one, do one”, approach, or maybe it was three or four procedures. There is increasing effort to change this and demand thorough appreciation of technical details, simulation training and a show of adequate proficiency before an aspiring gynecologic surgeon is allowed to conduct surgery. One group actively researching these issues is based at the Copenhagen university hospitals in Denmark and Jeanett Strandbygaard and her colleagues report on the development of a curriculum for basic laparoscopy on pp. 359–366. This article should be noticed by all trainees and trainers and it also links indirectly to the conference report by Hanna Savolainen-Peltonen and Tomi Mikkola (Helsinki, Finland) on pp. 433–435 on training in the Nordic countries. There are several other interesting articles and correspondence in this issue, but to conclude this month´s Editors message we will point you to the remarkable results of Claes Ignell and colleagues in Lund, Malm€ o, Karlskrona and Helsingborg, Sweden (pp. 420–424), who
show a steady and worrying rise in gestational diabetes during the last decade. Their Figure 1 is a revealing graphic display of this. References 1. Lumbiganon P, Laopaiboon M, G€ ulmezoglu AM, Souza JP, Taneepanichskul S, Ruyan P, et al.; World Health Organization Global Survey on Maternal and Perinatal Health Research Group. Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007-08. Lancet. 2010;375:490–9. doi: 10. 1016/S0140-6736(09)61870-5. Epub 2010 Jan 11. Erratum in: Lancet. 2010 Dec 4;376(9756):1902. 2. Wang DB, Chen YH, Zhang ZF, Chen P, Liu KR, Li Y, et al. Evaluation of the transvaginal resection of low-segment cesarean scar ectopic pregnancies. Fertil Steril. 2014;101:602–6.
Points for observance Women with a previous sexual violence history have more frequently adverse factors in a subsequent pregnancy that can affect feto-maternal health (pp. 351–358). Detection of ultrasonic “soft” markers for chromosomal anomalies markedly increase invasive procedures, but have low detection rate by themselves (pp. 367–373). Waiting after preterm prelabor rupture of membranes has to be compared to inducing delivery with the objective to reduce neonatal complications. Induction is effective, but results in higher costs, although outcome in terms of neonatal sepsis rates, is not much different (pp. 374–381). Mild hypertensive disorders in a term pregnancy are associated with increased risk of postpartum hemorrhage, for which preventable factors can be identified (pp. 399–407). Will daughters of women who have had an ectopic pregnancy themselves have a higher risk for this pregnancy complication? If so is it a lifestyle problem? (pp. 416–419).
Note for the next summer 2014 The NFOG Congress is in Stockholm, Sweden, on June 10-12th 2014. Reserve the dates, be there and for more information look at www.nfog.org. The 1st European Spontaneous Preterm Birth Congress is in Svendborg, Denmark, on 22-24th May 2014 (www. ESPBC.eu). The 23rd European Congress of Obstetrics and Gynecology is in Glasgow, Scotland, UK on 7-10th May 2014 (www.ebcog2014.org).
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ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 93 (2014) 323–324
AOGS EDIT ORS M ES SAGE
Healthy ethical conduct is vital REYNIR TOMAS GEIRSSON & GANESH ACHARYA
DOI: 10.1111/aogs.12354
As we go into April most of Europe will be recovering from a widely difficult winter with excessive rain and cold weather in the past months, a tiring situation coupled to worries about long-term weather changes. Much evidence supports that this is to a considerable extent man-made, so to say the result of our misconduct and suboptimal care for nature. While healthy ethical conduct may counteract such developments, this takes effort, reeducation and changed practices and priorities. The two young women on the front cover of the journal this month are typical of the young and vital generation of Europe striving on and out of the winter into the fresh air of spring. The Nordic countries have the educational levels, technology and vision to lead the way into a new era where mindfulness about environment, energy consumption, re-cycling of material and a healthy population growth could be used to counteract effects of climate change. Obstetricians and gynecologists have a role to play there with our mission to improve women´s health, contribute to a balanced population size and in our work and personal lives to show rational and sensible attitudes that do not overstretch from a sustainable use of resources. Rising cesarean section rates are a global concern and may be seen as one form of overuse of resources, – a set-back to initiatives directed towards improving maternal health, especially in low resource countries. Cesarean scar is essentially a iatrogenic disease associated with a significantly increased risk of postpartum hemorrhage, uterine rupture, morbidly adherent placenta and scar ectopic pregnancy, – all potentially life threatening complications. Many cesarean sections are now being done without strict medical indications. This can be considered as a violation of the basic ethical principle of medicine: “primum non nocere” (first do no harm). In China, with one-child policy as the established norm, women and their healthcare providers may not fully appreciate the risk of complications that can occur in subsequent pregnancies. Approximately 25% of cesarean sections are performed without strict medical indication in China compared to 7% for all of Asia (1). Cesarean section
rates have reached epidemic proportions in many countries in all continents, and in China the rate is now 46% (1), compared to about 15–20% in Nordic countries. As a result, cesarean scar ectopic pregnancies appear to be more common in China. Authors from China recently sent to AOGS an article where they reported on a substantial number of such cases within a short period managed using a transvaginal extra-peritoneal approach to remove the ectopic pregnancy and repair the uterine defect. We thought this was a good example of how problems often lead to innovation and accepted the article in good faith after a couple of revision efforts. Only then did one of the editors working on a systematic review on the subject discover a substantially similar article freshly published in another journal (2). After some correspondence it became clear that the authors had sent two separate manuscripts with overlapping study populations and content to two different journals almost simultaneously, but had not informed the respective journals of this. On our website you may see that we have had to effect retraction of this article. We want to take this up here to point out the importance of taking extreme care in how research is planned, conducted and published, and emphasize that more does not always mean better. As a journal we try to counteract such tendencies as much as we can and not to leave scientific misconduct unnoticed, but alas we do encounter practices that border on the ethical. No country and no institution is immune there and only scientific integrity and high standards coupled to vigilance can minimize such happenings. Now to this present AOGS issue. We start with two high-quality articles within gynecologic oncology. First Mette Noer and her colleagues in Copenhagen, Denmark (pp. 325–334), show in a prospective and rigorous study using the nationwide Danish Gynecologic Cancer Database, how prognosis for women with endometrial cancer is adversely affected by other serious disease, largely independent of cancer stage and type. These often older women thus require adequate care for not only the cancer, but other ill-health affecting them at the same time, and
ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 93 (2014) 323–324
323
Editors Message
possibly receiving less attention than the cancer itself. Then a group centered in Link€ oping area, Sweden (Evelyn Lundin and co-workers, pp. 335–344) report a randomized study of using an old established drug, tranexamic acid, in a single pre-operative dose for reducing blood loss during surgery for ovarian cancer. It does perhaps not sound surprising to doctors in the Nordic countries that this works. But it is a result that should be noticed as a simple and inexpensive measure without significant side-effects. Something that should be universally used for a vulnerable group of patients who need optimal strength during their post-operative recovery phase. In another randomized study this month, Gustavo Calle and colleagues in Medellın, Colombia (pp. 345–350), show that there is not much to be gained from trying to decrease post-operative pain after laparoscopic hysterectomy with local anesthesia given into the transversus abdominis fascia and muscle compartments. Such negative studies should be reported when they are properly performed. Most of the readers will remember having learnt operative techniques by the “see one, do one”, approach, or maybe it was three or four procedures. There is increasing effort to change this and demand thorough appreciation of technical details, simulation training and a show of adequate proficiency before an aspiring gynecologic surgeon is allowed to conduct surgery. One group actively researching these issues is based at the Copenhagen university hospitals in Denmark and Jeanett Strandbygaard and her colleagues report on the development of a curriculum for basic laparoscopy on pp. 359–366. This article should be noticed by all trainees and trainers and it also links indirectly to the conference report by Hanna Savolainen-Peltonen and Tomi Mikkola (Helsinki, Finland) on pp. 433–435 on training in the Nordic countries. There are several other interesting articles and correspondence in this issue, but to conclude this month´s Editors message we will point you to the remarkable results of Claes Ignell and colleagues in Lund, Malm€ o, Karlskrona and Helsingborg, Sweden (pp. 420–424), who
show a steady and worrying rise in gestational diabetes during the last decade. Their Figure 1 is a revealing graphic display of this. References 1. Lumbiganon P, Laopaiboon M, G€ ulmezoglu AM, Souza JP, Taneepanichskul S, Ruyan P, et al.; World Health Organization Global Survey on Maternal and Perinatal Health Research Group. Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007-08. Lancet. 2010;375:490–9. doi: 10. 1016/S0140-6736(09)61870-5. Epub 2010 Jan 11. Erratum in: Lancet. 2010 Dec 4;376(9756):1902. 2. Wang DB, Chen YH, Zhang ZF, Chen P, Liu KR, Li Y, et al. Evaluation of the transvaginal resection of low-segment cesarean scar ectopic pregnancies. Fertil Steril. 2014;101:602–6.
Points for observance Women with a previous sexual violence history have more frequently adverse factors in a subsequent pregnancy that can affect feto-maternal health (pp. 351–358). Detection of ultrasonic “soft” markers for chromosomal anomalies markedly increase invasive procedures, but have low detection rate by themselves (pp. 367–373). Waiting after preterm prelabor rupture of membranes has to be compared to inducing delivery with the objective to reduce neonatal complications. Induction is effective, but results in higher costs, although outcome in terms of neonatal sepsis rates, is not much different (pp. 374–381). Mild hypertensive disorders in a term pregnancy are associated with increased risk of postpartum hemorrhage, for which preventable factors can be identified (pp. 399–407). Will daughters of women who have had an ectopic pregnancy themselves have a higher risk for this pregnancy complication? If so is it a lifestyle problem? (pp. 416–419).
Note for the next summer 2014 The NFOG Congress is in Stockholm, Sweden, on June 10-12th 2014. Reserve the dates, be there and for more information look at www.nfog.org. The 1st European Spontaneous Preterm Birth Congress is in Svendborg, Denmark, on 22-24th May 2014 (www. ESPBC.eu). The 23rd European Congress of Obstetrics and Gynecology is in Glasgow, Scotland, UK on 7-10th May 2014 (www.ebcog2014.org).
324
ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 93 (2014) 323–324
