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Background In the past decade, catheter ablation (CA) has become a rapidly expanding treatment option for ventricular tachycardia (VT), however it is not commonly utilized for patients with post-myocarditis VT. We aimed to systematically review up-to-date evidence regarding feasibility, effectiveness, and safety of CA, with a specific focus on long-term relapse rate and procedural complications. Methods A structured electronic database search (PubMed, Embase, Cochrane) of the scientific literature was performed for studies describing outcomes at up to 7.3 years after CA. The primary outcome measured was VT recurrence post-ablation. Procedural success was defined as freedom of ventricular arrhythmias (at the end of follow-up after an ablation procedure). The secondary outcome was significant procedural complications which included procedural death, stroke, cardiac tamponade, acute myocardial infarction, major vascular complications, and major bleeding, assessed on a study-by-study basis. Results A total of 186 patients were included in analysis with most patients (88%) being male. Over the follow up period there was a 18% relapse rate (n=34) (Confidence Interval (CI); 0.12–0.24, I2≈0, p=0.77) with the majority of patients remaining VT free for the duration of follow up. Only one study recorded the percentage of re-do procedures. The overall procedural complication rate was 3.0% (n=7, (CI; 0.01–0.07, I2≈0, p=0.44) and of note, there were no peri-procedural deaths or heart transplant surgeries reported. However, a single study reported a mortality of 10% (n=2) during the follow up period. Conclusions CA is an effective and durable long-term therapeutic strategy for post myocarditis VT patients with limited relapse rate and very low complication rates based on these non-randomised data. Larger randomised-controlled trials with standardised treatment and long follow-up are required to compare CA versus conventional treatment in the post-acute myocardial phase. Funding Acknowledgement Type of funding sources: None. Relapse rate during follow-upProcedural complication rate

Advanced cervical cancer continues to present a major health care challenge in the developing world. In contrast, in our own culture, the incidence of the disease is falling. However, the condition is presenting at an earlier stage and to younger patients who may wish to preserve their fertility, if possible. The traditional treatment, of radical surgery with adjuvant chemo-radiotherapy or primary chemo-radiotherapy, conflicts with such wishes. Therefore, techniques have been developed in the last 10 years, which aim to preserve fertility without compromising clinical outcome. The newer techniques, which have been evaluated range from cone biopsy with or without lymphadenectomy through to radical trachelectomy. The latter technique is accumulating evidence of satisfactory oncological outcome, acceptable complication data and successful maternity outcome. However, the obstetric course for these patients is not guaranteed or straightforward. Most recently, treatments incorporating pre-operative chemotherapy followed by cone biopsy with lymphadenectomy have been described. Such a policy is likely to produce more obstetric gains but it must not be at the expense of oncological outcome, unless requested by the patient. The need for consistent high-quality imaging, histopathology and clinical decision-making supports the concept that such care should only be developed and available in highly specialized centres. The requirement for comprehensive data collection and follow up of oncological variables, obstetric outcome and complication rates should be mandatory. New more conservative methods should only be developed under strict scientific control, using the traditional methods as comparators. However, it is possible that such fertility preserving techniques may be very attractive to some patients, even if they are increasing their risk of recurrent cervical cancer.

As a profession, we have an ethical responsibility to improve standards of clinical care and performance. Revalidation provides a new method to achieve such an aspiration. To achieve this, an emphasis on the development of robust outcome measures is vital. The needs of the patient are central to all these developments and the fundamental principle of good medical practice should underwrite our professionalism.

Millennium Development Goal 5 incorporates targets related to improving maternal mortality in resource poor countries with universal access to reproductive healthcare. The complex interrelationship between causation and solution of these problems is expounded together with strategies of care. Healthcare modelling based on the provision of skilled birth attendants and emergency obstetric care facilities will reduce the terrible tragedy of maternal mortality. Currently 500,000 women die annually in childbirth, and the majority of these deaths are avoidable. The large majority occur in resource poor countries. With the current slow progress, it is unlikely that the necessary improvement will be achieved by 2015. Major initiatives aimed at education, increasing workforce and improving local facilities and availability of drugs will help. The solutions are simple, but progress requires political desire.

Objective The objective of this study was to assess the impact of reorganisation of gynaecological services in southwest England following adoption of regionally agreed evidence-based guidelines and publication of the National Improving Outcomes Guidance in 1999. Design Prospective audit with cross-checking against histological reports. Setting All 19 acute hospitals in the four Cancer Networks of southwest England. Sample All subjects with squamous or verrucous vulval cancer diagnosed between 1997 and 2002. Method A one-page minimum data set proforma agreed by the South West Gynaecology Tumour Panel was completed by surgeons after treatment of each patient, and was sent to South West Cancer Intelligence Service for entry, collation and analysis. Data are presented for the years 1997 to 2002 inclusive, and comparisons were made between each of the three 2-year cohorts. Main outcome measures These are standards derived from the guidance. Results There were 436 squamous or verrucous vulval cancers registered. Recording of staging was missing in 20% of subjects. The percentage of subjects operated upon by lead gynaecological cancer surgeons increased from 78% in cohort 1 to 93% in cohort 3 (P < 0.001). There is a trend towards more conservative operations, which have lower co-morbidity. High activity surgeons achieved better rates of tumour-free skin margins, but even these were adequate only in 49% of operations. Lymphadenectomy rates did not follow guidance. Conclusion Centralisation of care of this rare cancer should continue, but specialists need to increase their efforts to ensure adequate skin margins and lymphadenectomy rates while balancing morbidity and the likelihood of recurrence in both fit and frail patients.

Summary In this study, we evaluated the management of postmenopausal bleeding at our one-stop clinic where the first line investigations were a transvaginal ultrasound scan and a pipelle endometrial biopsy. The records of 212 women seen in this clinic in 1994 were reviewed. One hundred and forty-four women (67.9%) were evaluated and reassured in one visit. The mean waiting period following referral to the clinic by the general practitioner was 36 days (range 6-157 days), and only 45 women (21%) required a hysteroscopy. The commonest diagnosis made was endometrial atrophy or no significant endometrial pathology (130 women (61.3%). Endometrial cancer was diagnosed in 12 women (5.6%), and one case of previously unsuspected ovarian cancer was detected. Our findings show that most women with post-menopausal bleeding can be assessed in one visit, and hysteroscopy is not always necessary in the initial assessment of this complaint.

Total protein, mucin, and specific nonmucin glycoproteins are proposed pronucleating agents in cholesterol gallstone pathogenesis. However, characterization of specific nonmucin glycoproteins in patients with and without gallstones is unknown. Furthermore, nonmucin glycoproteins may be qualitatively different in patients with and without gallstones. Total protein and total and specific nonmucin glycoproteins were studied in gallbladder bile of 43 patients with cholesterol gallstones and 13 patients without gallstones. Patients with cholesterol gallstones had higher concentrations of both total protein and nonmucin glycoproteins than that observed in control patients (P0.05). SDS gel electrophoresis of nonmucin glycoproteins demonstrated an 84-kDa protein that was present significantly more often in patients with cholesterol gallstones (87% vs 8%, P0.05). Proposed 130- and 42-kDa pronucleating and 120-kDa anti-nucleating nonmucin glycoproteins were present in similar percentages in gallstone and control bile. Moreover, gallbladder bile of patients with the 84-kDa protein nucleated 50% faster than model bile and100% faster than that of patients without this protein (P0.05). The currently described gallbladder pronucleating and anti-nucleating proteins are found with equal frequency in cholesterol gallstone and control patients. However, an 84-kDa protein is found more commonly in gallstone patients and was associated with a shortened crystal observation time. Thus, this glycoprotein may be important in cholesterol gallstone pathogenesis.

While still rare, cancer has the reputation of being life-threatening in all its forms. Coupled with the survival of cancer comes a growing expectation from the patients that their life should be relatively unaffected. Among the side effects, there is frequently an effect on fertility. In particular, the treatment of the young with anti-cancer therapy raises questions about the patient's ability to achieve normal reproductive function and delivery following treatment. Between 1987 and 1998 we identified 40 women who conceived or delivered a fetus following treatment for cancer. They had undergone a combination of therapies including surgery, chemotherapy and radiotherapy. Four had elected to be sterilised after completion of their family. It did not appear from the data collected that the therapy used for treatment of some cancers has had an adverse effect on delivery outcomes, expected weight of the fetus or the gestation of the pregnancy.

Summary. Plasma cortisol and noradrenaline were measured in 15 mothers and babies following vaginal delivery and in 17 following elective caesarean section and related to blood concentration of glucose and glycerol. Significant elevations in umbilical artery cortisol and noradrenaline concentration were found in the vaginal delivery group. Blood glucose and glycerol concentrations were significantly higher in the vaginal delivery group for maternal venous, umbilical artery and vein samples. However, when allowances were made for placental transfer of these substances, little evidence was found to support sympatho-adrenal mediated mobilization of glycerol and glucose in the fetus. The possible explanation for the apparent dissociation between marked sympatho-adrenal activity and metabolic responsiveness during parturition in the fetus is discussed.

At the University of Nottingham, students are taught aspects of reproductive biology throughout the Part I Basic Medical Science Course. Teachers from the Departments of Physiology and Pharmacology, Human Morphology, Biochemistry, Obstetrics and Gynaecology, and Psychiatry are involved, and an obstetrician in training (the author) has been appointed full-time lecturer in Physiology and Pharmacology to provide an additional link between the basic science and clinical content of the course. The Part II course includes an Honours Year, to give students an opportunity to explore further the application of scientific method in clinical practice. One project, in which students were involved in physiological measurement used in current obstetric practice, is described here. In addition to carrying out practical tasks, students were required to submit written reports and to prepare a learning resource on fetal acid-base balance for use by their junior colleagues. Supervision was provided by obstetric and paediatric registrars and senior house officers, and senior midwives, while staff in the Department of Physiology and Pharmacology assisted students with data analysis. Each project task was assessed by a supervisor and an independent observer. The project proved acceptable to students, supervisors and hospital staff, and avoided interfering with the other responsibilities of a busy obstetric unit. It is intended to repeat the exercise with minor modifications.