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We describe the acute deterioration of a 29-year-old undergoing in vitro fertilisation. Late-onset critical ovarian hyperstimulation syndrome triggered a massive pulmonary embolism and subsequent cardiac arrest. While the prognosis was deemed to be poor, the patient made a full recovery. The potential reasons for this are explored.

Trial design A randomised, parallel-group, double-blind, placebo-controlled multicentre study with health economic and nested qualitative studies to determine if mifepristone (Mifegyne®, Exelgyn, Paris, France) plus misoprostol is superior to misoprostol alone for the resolution of missed miscarriage. Methods Women diagnosed with missed miscarriage in the first 14 weeks of pregnancy were randomly assigned (1 : 1 ratio) to receive 200 mg of oral mifepristone or matched placebo, followed by 800 μg of misoprostol 2 days later. A web-based randomisation system allocated the women to the two groups, with minimisation for age, body mass index, parity, gestational age, amount of bleeding and randomising centre. The primary outcome was failure to pass the gestational sac within 7 days after randomisation. The prespecified key secondary outcome was requirement for surgery to resolve the miscarriage. A within-trial cost-effectiveness study and a nested qualitative study were also conducted. Women who completed the trial protocol were purposively approached to take part in an interview to explore their satisfaction with and the acceptability of medical management of missed miscarriage. Results A total of 711 women, from 28 hospitals in the UK, were randomised to receive either mifepristone plus misoprostol (357 women) or placebo plus misoprostol (354 women). The follow-up rate for the primary outcome was 98% (696 out of 711 women). The risk of failure to pass the gestational sac within 7 days was 17% (59 out of 348 women) in the mifepristone plus misoprostol group, compared with 24% (82 out of 348 women) in the placebo plus misoprostol group (risk ratio 0.73, 95% confidence interval 0.54 to 0.98; p = 0.04). Surgical intervention to resolve the miscarriage was needed in 17% (62 out of 355 women) in the mifepristone plus misoprostol group, compared with 25% (87 out of 353 women) in the placebo plus misoprostol group (risk ratio 0.70, 95% confidence interval 0.52 to 0.94; p = 0.02). There was no evidence of a difference in the incidence of adverse events between the two groups. A total of 42 women, 19 in the mifepristone plus misoprostol group and 23 in the placebo plus misoprostol group, took part in an interview. Women appeared to have a preference for active management of their miscarriage. Overall, when women experienced care that supported their psychological well-being throughout the care pathway, and information was delivered in a skilled and sensitive manner such that women felt informed and in control, they were more likely to express satisfaction with medical management. The use of mifepristone and misoprostol showed an absolute effect difference of 6.6% (95% confidence interval 0.7% to 12.5%). The average cost per woman was lower in the mifepristone plus misoprostol group, with a cost saving of £182 (95% confidence interval £26 to £338). Therefore, the use of mifepristone and misoprostol for the medical management of a missed miscarriage dominated the use of misoprostol alone. Limitations The results from this trial are not generalisable to women diagnosed with incomplete miscarriage and the study does not allow for a comparison with expectant or surgical management of miscarriage. Future work Future work should use existing data to assess and rank the relative clinical effectiveness and safety profiles for all methods of management of miscarriage. Conclusions Our trial showed that pre-treatment with mifepristone followed by misoprostol resulted in a higher rate of resolution of missed miscarriage than misoprostol treatment alone. Women were largely satisfied with medical management of missed miscarriage and would choose it again. The mifepristone and misoprostol intervention was shown to be cost-effective in comparison to misoprostol alone. Trial registration Current Controlled Trials ISRCTN17405024. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 68. See the NIHR Journals Library website for further project information.

Objective To assess the cost-effectiveness of mifepristone and misoprostol (MifeMiso) compared with misoprostol only for the medical management of a missed miscarriage. Design Within-trial economic evaluation and model-based analysis to set the findings in the context of the wider economic evidence for a range of comparators. Incremental costs and outcomes were calculated using nonparametric bootstrapping and reported using cost-effectiveness acceptability curves. Analyses were performed from the perspective of the UK's National Health Service (NHS). Setting Twenty-eight UK NHS early pregnancy units. Sample A cohort of 711 women aged 16-39 years with ultrasound evidence of a missed miscarriage. Methods Treatment with mifepristone and misoprostol or with matched placebo and misoprostol tablets. Main outcome measures Cost per additional successfully managed miscarriage and quality-adjusted life years (QALYs). Results For the within-trial analysis, MifeMiso intervention resulted in an absolute effect difference of 6.6% (95% CI 0.7-12.5%) per successfully managed miscarriage and a QALYs difference of 0.04% (95% CI -0.01 to 0.1%). The average cost per successfully managed miscarriage was lower in the MifeMiso arm than in the placebo and misoprostol arm, with a cost saving of £182 (95% CI £26-£338). Hence, the MifeMiso intervention dominated the use of misoprostol alone. The model-based analysis showed that the MifeMiso intervention is preferable, compared with expectant management, and this is the current medical management strategy. However, the model-based evidence suggests that the intervention is a less effective but less costly strategy than surgical management. Conclusions The within-trial analysis found that based on cost-effectiveness grounds, the MifeMiso intervention is likely to be recommended by decision makers for the medical management of women presenting with a missed miscarriage. Tweetable abstract The combination of mifepristone and misoprostol is more effective and less costly than misoprostol alone for the management of missed miscarriages.

Background\ud The anti-progesterone drug mifepristone and the prostaglandin misoprostol can be used to treat missed miscarriage. However, it is unclear whether a combination of mifepristone and misoprostol is more effective than administering misoprostol alone. We investigated whether treatment with mifepristone plus misoprostol would result in a higher rate of completion of missed miscarriage compared with misoprostol alone. \ud \ud Methods\ud MifeMiso was a multicentre, double-blind, placebo-controlled, randomised trial in 28 UK hospitals. Women were eligible for enrolment if they were aged 16 years and older, diagnosed with a missed miscarriage by pelvic ultrasound scan in the first 14 weeks of pregnancy, chose to have medical management of miscarriage, and were willing and able to give informed consent. Participants were randomly assigned (1:1) to a single dose of oral mifepristone 200 mg or an oral placebo tablet, both followed by a single dose of vaginal, oral, or sublingual misoprostol 800 μg 2 days later. Randomisation was managed via a secure web-based randomisation program, with minimisation to balance study group assignments according to maternal age (

This case report describes the rare finding of a granulosa cell tumour in the third trimester of pregnancy. The presentation, investigation, management, histopathological findings and subsequent follow up are detailed. The difficulties associated with such diagnoses in pregnancy are explored.

Brisbane’s provincial art world was immature and inadequate for the development of its art and artists in 1940. However, in the decades to 1970, it developed into a mature creative economy capable of sustaining artists working in many styles. These changes were brought about through the networks of artists working in artists’ groups in Brisbane. Using social network analysis, this article examines the problems of the transmission of new ideas in a small art community bound together by ‘strong ties,’ and the importance of ‘weak ties’ in bringing about change.

This study offers an analysis of Brisbane’s art world through the lens of artists’ groups operating in the city between 1940 and 1970. It argues that in the absence of more extensive or well-developed art institutions, artists’ groups played a crucial role in the growth of Brisbane’s art world. Rather than focusing on an examination of ideas about art or assuming the inherently ‘philistine’ and ‘provincial’ nature of Brisbane’s art world, the thesis examines the nature of the city’s main art institutions, including facilities for art education, the art market, conservation and collection of art, and writing about art. Compared to the larger Australian cities, these dimensions of the art world remained relatively underdeveloped in Brisbane, and it is in this context that groups such as the Royal Queensland Art Society, the Half Dozen Group of Artists, the Younger Artists’ Group, Miya Studios, St Mary’s Studio, and the Contemporary Art Society Queensland Branch provided critical forms of institutional support for artists. Brisbane’s art world began to take shape in 1887 when the Queensland Art Society was founded, and in 1940, as the Royal Queensland Art Society, it was still providing guidance for a small art world struggling to define itself within the wider network of Australian art. Increasingly, however, new groups began to emerge, dissatisfied with the Society’s role in the context of the growing presence of ‘modern’ or modernist art. The period between 1940 and 1970 was characterised by dynamic growth in Brisbane’s art world and artists’ groups provided the leadership necessary to bring about lasting change as it progressed toward modernity. A great deal of art history is written around the creativity and dynamism of avant-garde artists’ groups which are seen as harbingers of change and the main drivers of progress in modern art. Much less has been written about the role of non-revolutionary, community artists’ groups, especially in underdeveloped art worlds and their progress towards building a mature, institutionally-rich art scene. Using Brisbane as its case study, this thesis argues that such groups have an essential role in sustaining and expanding art practice, art training, art appreciation and an art market. By examining the infrastructure of Brisbane’s art world, and using social network analysis strategies such as “weak ties” and the diffusion of innovations to understand why the Brisbane art world lagged behind more developed art worlds, this thesis provides a more nuanced view of regional art worlds, and a fuller explanation of the role artists’ groups have within those art worlds. Non-avant-garde artists’ groups “till the soil”, cultivating cultural landscapes, and by encouraging many to engage in the practice of art making, they are continuously preparing and repairing the fabric of art worlds.

Whilst abdominal pain in early pregnancy is a common symptom, ectopic pregnancy must be suspected in all women presenting with pain in early pregnancy, in the absence of confirmed ultrasound diagnosis of intra-uterine pregnancy. This case describes a case of persistent pregnancy of unknown location (PUL), and highlights the role of serum markers such as BHCG and progesterone to aid diagnosis and management, as well as the importance of managing cases such as these in dedicated early pregnancy units. With a clinically healthy patient, a common error is inappropriately early follow-up, given that the majority of outcomes of PUL’s need time to manifest themselves, to avoid potentially unnecessary intervention. This case builds on recommendations provided by the National Institute of Clinical Excellence on how to manage inconclusive cases such as this one.

Summary 1 Models linking the behaviours of individual animals, their positions within socially complex groups and spatio-temporal variation in resource distribution offer a promising base for predicting population responses to changing environments. The ideal free and despotic distributions and their derivatives are particularly influential in this regard. 2 Due to the difficulties of conducting work in the wild, for some groups of animals such models are often based on observations of animals in small-scale systems under conditions that are well controlled, but unnaturally simple. 3 Using an experimental system based on field observations of home range size and variation in food availability, the present study tested whether models derived using small-scale laboratory observations are valid for juvenile Atlantic salmon in more natural conditions. 4 Contrary to predictions, we found no differences in behaviour between the control fish (which experienced consistently rich feeding patches) and the experimental fish (which experienced unpredictable 10-fold changes in patch quality). 5 Also contrary to predictions, in the variable condition, salmon used high quality patches (which were an order of magnitude better than low quality patches) only marginally (5%) more than would be expected if they were to forage at random. There was significant variation in foraging strategies between individual fish, with 28% of the population making non-random use of foraging patches. 6 The only apparent systematic relationship between social rank and use of foraging patches was that fish that were both dominant and made many moves between feeding locations tended to leave rich patches less frequently than they left poor patches. 7 Despite the low correlation between patch quality and movement, there was substantial movement of fish among patches. Forty-four per cent of moves followed aggressive interactions and most others were spontaneous, with no obvious motivating factor apparent. 8 The study exposes a discrepancy between expectations derived from the basic concepts of patch choice theory and the behaviour of Atlantic salmon in the conditions pertaining in the present study. 9 It is suggested that this discrepancy may arise both from the fact that applicability of patch choice models may be very sensitive to the stability of differences in patch quality and from uncertainties about the costs of habitat sampling.

Objective To assess whether women can be assigned to intrauterine insemination (IUI) treatment on the basis of fallopian tubal patency, diagnosed by Hysterosalpingo Contrast Sonography (Hy Co Sy). Design Case controlled, clinical study. Setting Tertiary referral center. Patient(s) The cases were consecutive, infertile women who underwent Hy Co Sy and IUI. The control group was women who had IUI over the same period but whose tubal patency was assessed by hysterosalpingogram (HSG) or laparoscopy and dye (lap and dye). Intervention(s) Women with bilateral patency at Hy Co Sy and with unexplained, anovulatory, or male factor infertility underwent IUI using the partner's (IUI-H) or donor's (IUI-D) semen. Their outcome was compared with that of cohorts of women who had been examined using HSG or lap and dye. Main outcome measure(s) Clinical pregnancy rate per cycle and cumulative pregnancy rates at IUI-H or IUI-D. Result(s) The clinical pregnancy rates per cycle at IUI-H or IUI-D did not differ among the three groups. The cumulative pregnancy rates after three cycles of IUI-H were 0.17, 0.15, and 0.17 in the Hy Co Sy, HSG, and lap and dye cohorts, respectively, and 0.69, 0.77, and 0.54 in the same groups after six cycles of IUI-D. There were no differences in the clinical characteristics or stimulation regimes used. Conclusion(s) Women screened as "normal" by Hy Co Sy may be allocated to treatments that rely on accurate assessment of tubal patency without compromising their chance of conception.

Hysterosalpingo-contrast-sonography (HyCoSy) using saline and Echovist is a well tolerated outpatient technique that provides a significant amount of information of relevance to the infertile woman that is not obtainable at hysterosalpingogram (HSG) whilst avoiding exposure to X-ray irradiation. When performed by experienced operators, it serves as a valuable, first-line screening test for the more invasive procedures of laparoscopy and dye chromopertubation and hysteroscopy. If detailed diagnostic information is required in women in whom there is no clinical or ultrasound evidence of pelvic pathology, the surgical technique of fertiloscopy can be considered to be appropriate. This technique permits confirmation that the ovum pick-up mechanism is normal, the tubes are patent and the uterine cavity is normal, while salpingoscopy and microsalpingoscopy permit the assessment of the tubal lumen.