The management of gynaecological malignancies has undergone a significant change in recent years with our improved understanding of cancer biogenetics, development of new treatment regimens and enhanced screening. Due...The management of gynaecological malignancies has undergone a significant change in recent years with our improved understanding of cancer biogenetics, development of new treatment regimens and enhanced screening. Due to the rapid blooming of newer methods and techniques in gynaecology, surgery and oncology the scope and the role of imaging has also widened. Functional imaging in the form of diffusion weighted imaging(DWI) has been recently found to be very useful in assessing various tumours. Its ability to identify changes in the molecular level has dramatically changed the diagnostic approach of radiologists which was solely based on morphological criteria. It can improve the diagnostic accuracy of conventional magnetic resonance imaging, lend a hand in assessing tumour response to treatment regimens and detect tumour recurrence with better spatial resolution, negative radiation and diagnostic accuracy compared to positron emission tomography scan. The ability to quantify the diffusion has also lead to potential prediction of tumour aggressiveness and grade which directly correlate with the patient prognosis and management. Hence, it has become imperative for a radiologist to understand the concepts of DWI and its present and evolving role. In this article we present a brief description of the basics of DWI followed by its role in evaluation of female gynaecological malignancies.展开更多
Introduction: Fast Track Surgery (FTS) programs have been adopted by many specialties with documented improved patient outcomes and reduced length of stay (LOS). Methods: We initiated a FTS program in January 2008 and...Introduction: Fast Track Surgery (FTS) programs have been adopted by many specialties with documented improved patient outcomes and reduced length of stay (LOS). Methods: We initiated a FTS program in January 2008 and present our experience up to and including November 2010 on patients whose LOS was 2 days. Results: During the study period 242 patients had a laparotomy performed. Overall 54(22.3%) patients were discharged on day 2. In the first year of initiating our FTS program 10% were discharged on day 2, 25% in year 2 and 31% in year 3. Twenty-two patients (41%) had malignant pathology and of these, 16 (73%) had local or regional spread and 6 (27%) had distant spread. Forty patients (74%) had vertical midline incisions (VMI) performed. Surgery was classified as complex in 40 cases (74%) and 6 (11%) patients underwent staging lymph node dissection. Average patient BMI was 26.1 with 44% of patients considered overweight or obese. There were no intraoperative complications recorded. When compared to 188 patients whose LOS was greater than 2 days, the early discharge cohort were more likely to have benign pathology, more likely to be younger, to have a transverse incision, to have received COX II inhibitors, to have a lower net haemoglobin (Hb) change and to tolerate early oral feeding. Conclusions: Increased clinical experience with FTS enables over 31% patients undergoing laparotomy to be safely discharged on day 2 without an increase in the read-mission rate or morbidity.展开更多
In addition to higher risks of various obstetric and gynaecological illnesses among women with obesity or who are overweight, maternal adiposity threatens the lifetime health of their offspring. Diverse treatments are...In addition to higher risks of various obstetric and gynaecological illnesses among women with obesity or who are overweight, maternal adiposity threatens the lifetime health of their offspring. Diverse treatments are provided, including complementary and alternative medicine such as Chinese medical practices. Acupuncture, a traditional Chinese medicinal method, is increasingly being applied to this health problem. This literature review analyses 25 clinical studies, involving 2407 participants aged 13-65 in Africa, Asia, the Middle East and North America. This illustrates the use of acupuncture alone or with other approaches to control body weight, obesity-induced diseases, and gynaecological health. Although positive indicators are presented, this study offers recommendations for enhancing reliability and validity in further research. It therefore suggests the use of acupuncture in dealing with obesity due to its efficacy, and economic and safety benefits.展开更多
Because their endocrine system is not yet developmentally mature,adolescent girls are prone to dysfunctional uterine bleeding caused by insufficiency of the hypothalamic-pituitary-gonadal axis.The view of modern medic...Because their endocrine system is not yet developmentally mature,adolescent girls are prone to dysfunctional uterine bleeding caused by insufficiency of the hypothalamic-pituitary-gonadal axis.The view of modern medicine is mainly aimed at the secretory function of sex hormones,such as estrogen and progesterone.However,it causes distress to patients because of the susceptibility of their treatment to endocrine system disorders.Traditional Chinese medicine considers the damage to the function of the Conception Vessel and Thoroughfare Vessel as the key to the disease.In this way,we guide the use of traditional Chinese medicine and acupuncture and achieve good results.The pathogenesis and management of functional uterine bleeding in adolescence are discussed from two medical perspectives in this article.展开更多
Introduction: Surgery can cause anxiety and worry, such as waking up in pain, being physically harmed or dying. This study aimed to assess the experience of patients undergoing planned gynaecological surgery in the Ob...Introduction: Surgery can cause anxiety and worry, such as waking up in pain, being physically harmed or dying. This study aimed to assess the experience of patients undergoing planned gynaecological surgery in the Obstetrics Gynaecology and Reproductive Medicine department of the University Hospital Centre of Bogodogo. Patients and methods: This was a cross-sectional study with prospective data collection during the period from June 1 to August 31, 2018. The study population consisted of patients who received scheduled gynaecological surgery during the period. Results: Seventy-six (76) patients underwent scheduled surgery and 62 were included. During discussion with the gynaecologist, 58 patients (93.55%) were satisfied. When the surgery was announced, 41 patients (66.13%) were anxious. At the consultation with the anaesthetist 59 patients (95.16%) were satisfied with the discussions. Fifty-five patients (88.7%) were anxious on admission to the operating theatre. The quality of care was satisfactory for 61 patients (98.39%) and all patients were satisfied with the care team. Conclusion: Periodic evaluation of patients’ experiences should therefore be incorporated into care evaluation policies in health facilities in order to contribute to continuous improvement in the quality of medical and surgical care.展开更多
Objective: to study the application of nursing safety management in the perioperative period of patients undergoing gynecologic third and fourth grade operations. Methods: 84 patients included in this study were all g...Objective: to study the application of nursing safety management in the perioperative period of patients undergoing gynecologic third and fourth grade operations. Methods: 84 patients included in this study were all gynecological patients with grade 3 and 4 surgery admitted in our hospital from October 2019 to November 2020. According to the patient care plan, they were divided into the reference group (n = 42, routine care) and the research group (n = 42, nursing safety management) to compare the effect of nursing application. Results: the incidence of complications and nursing errors were compared between the two groups. The data showed that the incidence rates of complications and nursing errors in the reference group were 11.90% and 14.29% respectively, and that in the research group were 4.76% and 0 respectively, with the result comparison P < 0.05. Comparing the two groups of nursing satisfaction, the data results showed that the reference group was 80.95% and the research group was 95.24%, the result comparison was P < 0.05. Conclusion: the application value of nursing safety management in the perioperative period of patients undergoing gynecologic third and fourth grade surgery is high, which can improve nursing satisfaction, reduce complications and nursing error rate, and is worthy of promotion and use.展开更多
Objective: through the study of clinical practice to re-explore and in-depth analysis of clinical high-quality patient care and treatment technology in the early stage of malignant endometrial fibroids patient care in...Objective: through the study of clinical practice to re-explore and in-depth analysis of clinical high-quality patient care and treatment technology in the early stage of malignant endometrial fibroids patient care in the actual clinical application of efficacy. Methods: during the period from January 2020 to March 2021, 90 patients selected from two groups of typical patients with uterine fibroids were included in the current observation and examination in the Housing Health Care Institute of Chief Gynecologist of our hospital. The patients were specifically divided into the control group and the experimental group with 45 cases in each group by random analysis of data table method. The patients in the two groups were given routine operative care twice during the perioperative period. The efficacy of routine care for two groups of typical patients with uterine fibroids was compared. Results: after high-quality surgical care, the heart rate, bleeding volume and blood pressure of patients after operation in the experimental group were significantly superior to those of the leading control group. The incidence of severe bradycardia, stomach discomfort, nausea, vomiting, chill, and low body temperature adverse reactions in patients after operation was significantly lower than that of the leading control group. The main reason for the difference was that statistical analysis had a certain number of statistical significance (p < 0.05). Conclusion: through the high-quality surgical care and treatment technology currently being carried out clinically, it can significantly improve and optimize the early surgical care of patients with benign uterine fibroids, reduce the high incidence of surgical prognosis and adverse reactions, and further greatly enhance the clinical technology and safety of nursing surgery, which is worthy of further active introduction and wide promotion in primary hospitals around the world. It is worthy of further promotion and application in primary hospitals.展开更多
Aggressive angiomyxoma （AAM） is a rare tumour that often occurs in soft tissues of the female genital tract. Eight cases of AAM are reported in this article, and the clinical features and ultrasound and magnetic res...Aggressive angiomyxoma （AAM） is a rare tumour that often occurs in soft tissues of the female genital tract. Eight cases of AAM are reported in this article, and the clinical features and ultrasound and magnetic resonance imaging （MRI） results of the eight cases are reviewed and summarized. The main complaints of all the patients were palpable and painless masses in the vulva or scrotum. The lesions were mainly located in the vulva, pelvis, and perineal region, with a large scope of involvement. The sonographic features of AAM were characteristic. On sonography, all of the masses were of irregular shape and showed hypoechogenicity, with a heterogeneous inner echotexture. Intratumoural and peritumoural blood fows were detected by colour Doppler imaging. On real-time ultrasonic imaging, prominent deformation of the lesions was observed bycompressing the masses with the probe. Some special imaging features were also revealed, including a la-minated or swirled appearance of inner echogenicity, and a fnger-like or tongue-like growth pattern. On MRI imaging, the lesions showed intermediate-intensity signals and intermediate to high-intensity signals on TI-weighted and T2-weighted sequences. A rapid and uneven enhancement pattern was demonstrated. After the comparison of sonographic features with MRIand pathological findings, we found the relevance of the ultrasonographic characteristics with MRI and his-tological features of AAM. Ultrasound can be a valuable imaging method for the preoperative diagnosis, eva-luation of scope, and follow-up of AAM.展开更多
Background： The radical hysterectomy （RH） surgical technique has improved along the years. It is used for the treatment of cervical cancer, endometrial cancer when affecting the cervix, and upper vaginal carcinomas...Background： The radical hysterectomy （RH） surgical technique has improved along the years. It is used for the treatment of cervical cancer, endometrial cancer when affecting the cervix, and upper vaginal carcinomas. Our aim was to describe the historical evolution of the technique after the introduction of laparoseopy at our institution. Methods： We performed a retrospective review of medical records of patients who underwent RH, grouped in three periods according to the year of surgery： 1990-1999, 2000-2009 and 2010-2013. Patients＇ characteristics, pathologic details, intraoperative and postoperative complications were analyzed and comoared throughout the time periods. Results： A total of 102 cases of RH were performed at our center during the study period. Among all data collected, the presence of necrosis, age, number of lymph nodes, surgery route, operating time, hospital stay, blood loss and transfusion requirement were statistically significant different among groups. Conversion to laparotomy rate was 19% for the second period compared to the absence of cases in the last one. No significant differences （P=0.124） were observed in the adjuvant treatment received among the three different groups. At the time of the last contact the patients free of disease were 12 （85.7%）, 53 （91.3%） and 26 （86.6%） respectively （P=0.406）. Regarding the disease-free interval, we found significant better outcomes in the group of laparotomy compared to laparoscopy （P=0.015）.Conclusions： Laparoscopic RH is an acceptable surgery with advantages like magnified vision of the operation＇s field, lower surgical complications, shorter hospital stay and earlier resumption to daily activities.展开更多
Objective To investigate the correlation between gynaecologic adnexal surgery history and pregnancy outcome of in vitro fertilization （IVF） treatment. Methods A total of 810 women who were proceeded 810 IVF; treatme...Objective To investigate the correlation between gynaecologic adnexal surgery history and pregnancy outcome of in vitro fertilization （IVF） treatment. Methods A total of 810 women who were proceeded 810 IVF; treatment cycles from October 2009 to March 2011 were recruited to this retrospective study, based on whether they had history of gynaecologic adnexal surgeries or not. Among 810 women, 587 women had no gynaecologic adnexal surgeries （group A）, 223 women had gynaecologic adnexal surgeries （group B）. Additionally, the group B was further divided into 4 subgroups based on their different gynaecologic adnexal surgery histories, such as tubal conservative surgery （group Bal）, unilateral salpingectomy （group Ba2）, ovarian cyst ablation （group Bbl） and unilateral adnexal resection （group Bb2）. The basal levels of FSH, antral follicle count （AFC）, clinical pregnancy rate （CPR）, embryos implantation rates （IR） and live birth rates （LBR） were compared.Results The levels of FSH and AFC were significantly different between groups A and B, respectively. Therefore, CPR, IR and LBR were significantly lower （P 〈0.05） in group B （30.9%, 17.8% and 25.1%） compared with group A （39.9%, 22.8% and 32.4%）. Meanwhile, there was no significant difference between the patients who had tubal conservation surgery （group Bal） and who had unilateral salpingectomy （group Ba2）. However, in contrast to unilateral adnexectomy, ovarian cystectomy surgery influenced FSH and AFC significant, even for the number of oocyte retrieved, but did not affect the IVF treatment outcome. Conclusion The previous history of gynaecologic adnexal surgeries may affect the subsequent ovarian function and also IVF outcomes. As for different operation methods, between tubal conservation surgery and unilateral salpingectomy, the IVF outcomes were not significantly different. The same result we found in different ovarian operation groups.展开更多
Purpose:This study aimed to determine the effectiveness of Relaxation Breathing Exercise(RBE)on fatigue in patients with gynaecological cancer undergoing chemotherapy.Methods:We used a quasi-experiment with pre-and po...Purpose:This study aimed to determine the effectiveness of Relaxation Breathing Exercise(RBE)on fatigue in patients with gynaecological cancer undergoing chemotherapy.Methods:We used a quasi-experiment with pre-and post-test design.Forty-two patients were consecutively sampled,21 of whom were assigned to the group receiving RBE four times a day and 21 to the group receiving RBE twice a day.Fatigue scores were measured every day for 7 days for both groups using the Piper Fatigue Scale.Data obtained were analysed using repeated-ANOVA and independent ttest with a significant level of a<0.01.Results:We found a significant decrease(P<0.01)in the mean fatigue scores of both groups(four times RBE in a day group=3.29±0.59 and twice RBE in a day group=4.19±0.61)after the completion of the intervention.However,the four times RBE a day group showed larger decrease on fatigue scores than the twice RBE a day group did(Mean Difference=0.91;99%CI=0.41 to 1.41;P=0.001).Conclusion:Conducting RBE four times a day effectively alleviated fatigue better than RBE twice a day on gynaecological cancer patients undergoing chemotherapy.展开更多
Introduction: Gynaecological and breast cancers (GBC) are the most frequent and most serious cancers of women. They are frequent in Benin with an average of 108.5 cases per year. Objective: To identify factors associa...Introduction: Gynaecological and breast cancers (GBC) are the most frequent and most serious cancers of women. They are frequent in Benin with an average of 108.5 cases per year. Objective: To identify factors associated with women’s knowledge, attitudes and practices regarding GBC. Methods: This was a cross-sectional, prospective, descriptive and analytical study. Women of childbearing age residing in the commune of Glazoué in Benin for at least six months were included. The WHO cluster sampling technique was used. The Bruno De Finetti postulate and the Likert scale were used to study women’s knowledge, attitudes and practices. Data were collected and analysed using Epi Data 3.1 and Epi info 7.2.2.6 software. Results: A total of 540 women were registered. The mean age was 27.1 ± 8.84 years with extremes of 15 and 49 years. They were married (61.1%), had secondary education (40.2%) and lived in urban areas (61.9%). They had a low level of knowledge (75.4%), an adapted attitude (93.0%) and poor practice (88.9%). Occupation (p = 0.000), level of education (p = 0.007) and place of residence (p = 0.001) significantly influenced knowledge of GBC. The attitude was adequate (93%) and the practice was poor (88.9%). Inappropriate attitude was significantly associated with the level of education (p = 0.006). Conclusion: Women in the commune of Glazoué in Benin have a low level of knowledge of GBC with an adapted attitude and poor practice. Several factors are associated, hence the need to take them into account to facilitate GBC screening.展开更多
The most prevalent cancers in ladies are cervical, endometrial and Ovarian. The biomarkers prevalent in use for these gynaecological cancers are commonly Cancer antigen 125 (CA-125), B, Alpha-fetoprotein (AFP), Inhibi...The most prevalent cancers in ladies are cervical, endometrial and Ovarian. The biomarkers prevalent in use for these gynaecological cancers are commonly Cancer antigen 125 (CA-125), B, Alpha-fetoprotein (AFP), Inhibin, Carcinoembryonic antigen (CEA), Squamous cell carcinoma (SCC) antigen, Carbohydrate antigen 19-9, Cancer antigen 27-29, Human epididymis protein 4 (HE4), Osteopontin, transthyretin, Immunosuppressive acidic protein(IAP), leptin, CA15-3, CK19 and Thymidine kinase. The biomarker marker Squamous cell carcinoma (SCC) antigen, CK19 and immunosuppressive acidic protein IAP are raised in cervical squamous cell carcinomas. Endometrial cancer is a common cancer in women. In 75% of endometrial cancer cases, the tumor remains confined to the uterus and has a favorable prognosis if early detected. The prognosis, however, worsens dramatically as the disease progresses. The objective of this review is to elucidate the importance of the tumor markers for early diagnosis of gynaecological malignancies which are vital and life saving. Similarly the relevant biomarkers in combination are found to have positive predictive values and significant p values in the endometrial and cervical cancer. In Cervix cancer the positive predictive value of these markers combined is usually 92% - 95% and negative predictive value 93% - 96%. The confidence interval is 98% and p value significant 0.005. Sensitivity of tumor markers combined CK19, SCC and immunosuppressive acidic protein IAP in Cervix cancer detection is 95% and specificity 96%. The highest sensitivity was for SCC antigen (98.7%) while the highest specificity was for Cytokeratin 19 (99.7%). The positive predictive value by combination of CK19, SCC and IAP for the detection of Cervix cancer was 90% - 94%. In endometrial cancer the sensitivity of tumor markers combined CA19-9, CA125, leptin, thymidine kinase, CEA, CA15-3, and HE4 in endometrial cancer detection was 95% and specificity 96%. The highest sensitivity was for CA125 (99.7%) while the highest specificity was for CA19-9 (95.7%) which revealed that the efficacy of CA19-9 was more than that of CA125. The positive predictive value by combination of CA19-9, CA-125 levels, HE4, CA15-3, leptin, thymidine kinase and CEA for the detection of Endometrial cancer was 93%. For Gynecological malignancies namely Ovarian, Cervix and Endometrial cancers screening with these novel tumor markers in combination which are significant to a particular group of cancers.展开更多
Objective: To study the epidemiology and current trend in the management of urologic complications following obstetric and gynaecologic surgeries at CUUA University hospital of Cotonou. Patients and Methods: It was a ...Objective: To study the epidemiology and current trend in the management of urologic complications following obstetric and gynaecologic surgeries at CUUA University hospital of Cotonou. Patients and Methods: It was a retrospective study of patients referred with urologic complications following obstetric and gynaecological surgeries. The study took place at the Teaching Clinic of Urology Andrology at CNHU of Cotonou between April 1, 2008 and March 31, 2013. Results: Forty-one patients were studied. They represented 3.5% of people hospitalized at CUUA throughout the study period. The average age was 41 years swith range of 20 and 57 years. Twenty-one (51.2%) of them were married. Thirty patients (73.2%) were referred from a non-academichospital, while 7 patients (17.1%) were referred from academic hospital. Caesarean section was the primary gynecological surgery in 22 cases (53.7%) and hysterectomy in 19 cases (46.3%). Clinically, the pre- dominant symptoms were leakage of urine throughout the vagina and obstructive anuria with or without back pain. We found 31 cases of VVF, 5 cases of bilateral ligation of the ureters, 3 cases of unilateral ligation of the ureter, 1 ureteralinjury and 1 uretero-vaginal fistula. These complications were diagnosed postoperatively in 95.1% of cases. Surgeries done included VVF repair in 31 cases (75.6%), unilateral ureteral reimplantation in 4 cases (9.8%), removal of ligation of the ureters in 3 cases (7.3%), bilateral ureteral reimplantation for 2 cases (4.9%) and end-to-end anastomosisin 1 case (2.4%). The postoperative period was uneventful in 29 cases and we observed 7 cases of surgical site infection. The overall success rate was 87.8%. Conclusion: Urological complications following gynecologic surgeries managed at the urologic department of teaching hospital of Coto-nou had an even higher incidence. Early diagnosis especially during the operative procedure would save the patients’ serious complications and open surgery due to the lack of endo-urological facilities. The most important factor in prevention is good knowledge of pelvicanatomy and good knowledge of the surgical techniques of caesarean operation section and trans-abdominal hysterectomy.展开更多
Approximately 1：4 of all cancers in women in develop-ing countries （excluding non-melanoma skin cancer） is a gynaecological cancer. The gynaecological cancer burden in developing countries is huge primarily due to ...Approximately 1：4 of all cancers in women in develop-ing countries （excluding non-melanoma skin cancer） is a gynaecological cancer. The gynaecological cancer burden in developing countries is huge primarily due to the high incidence and mortality of cervical cancer. Cervical cancer accounts for over 60% of the gynaeco-logical cancer burden in developing countries despite being preventable by current technologies. This is due to the absence of effective nationally organized screening programmes in most developing countries. Institution of such programmes, therefore, has the potential to dramatically reduce gynaecological cancer burden in these countries. Subsidized human papil-loma virus （HPV） vaccine and HPV typing as well as cheap screening techniques such as visual inspection aided with acetic acid hold the key to effective preven-tion of cervical cancer in these countries. This is be-cause a signifcant proportion of patients in developing countries are unable to access and avail themselves of the few available preventive, diagnostic and treatment services because of poverty. Although, advocacy and the political will to invest in the development of human resources and healthcare infrastructure appear criti-cal to gynaecological cancer control and reducing the burden of disease in many developing countries, the proposition assumes that resources are truly available for this investment. This may not be true. Many devel-oping countries rely on foreign aids for developmental programmes and these aids have dwindled signifcantly with the current global economic meltdown.展开更多
Oxidative stress arises from an imbalance between the body’s pro-oxidants and antioxidants.Recently,oxidative stress has been proven a contributing factor to many female reproductive disorders including infertility,p...Oxidative stress arises from an imbalance between the body’s pro-oxidants and antioxidants.Recently,oxidative stress has been proven a contributing factor to many female reproductive disorders including infertility,preeclampsia,endometriosis and polycystic ovarian syndrome.Herein,we review the mechanistic role of oxidative stress in inducing the most common female reproductive disorders.The current review has also highlighted the protective role of vitamin C,necessary for certain female reproductive hormone secretion by the antral follicle and corpus luteum and also essential for collagen production in ovarian tissue remodeling after ovulation,in alleviating oxidative stress and thus improving female reproductive outcomes.展开更多
Background: Comprehensive estimates of the incidence of gynaecological malignancies reported from Nigeria are very limited due to limitation in record maintenance. Female cancer is a public health problem the world ov...Background: Comprehensive estimates of the incidence of gynaecological malignancies reported from Nigeria are very limited due to limitation in record maintenance. Female cancer is a public health problem the world over. The malignancies of the female genital organs are major causes of morbidity and mortality which necessitates data for policy formulation and health planning. Aim: To establish the profile of gynaecologic malignancies reported in our centre, with reference to incidence, histological subtypes and frequency of involvement at various sites and to compare the procured data with those from other national and international centers. Materials and Method: In this descriptive retrospective study, the records pertaining to all the pathological specimens categorized as gynaecological malignancies from January 1st, 2013 to December 31st, 2015 at our facility were studied and compared with the available international data. Data analysis was done using Epi Info software version 7.2.1 (CDC Atlanta Georgia). Result: Two hundred and eleven (211) cases of gynaecological malignancies were seen during the study period and this constituted 13.4% of gynaecological admissions. Cervical malignancies were the commonest constituting 49.2% of all gynaecological malignancies followed by ovarian malignancies (27.8%), endometrial cancers (11.9%), vulva (5.6%), choriocarcina (3.9%) and vagina (1.6%). The data obtained was compared with data from Surveillance, Epidemiology and End Result (SEER) programme in the United States and European Union. All malignancies except cervical cancers affected a younger age group at our centre. Cervical cancers presented at a relatively more advanced stage, Ovarian cancers were more localized, whereas uterine, vulva and vaginal cancers presented at a similar stages as compared to Western data. Conclusion: This study presents a composite data of Gynaecological malignancies from Southeast Nigeria. Advanced stage of presentation of cervical cancers suggests lacunae in screening programmes available. Compared with Western data, ovarian malignancies were more localized at presentation for which environmental or genetic factors may be responsible.展开更多
Objective: To compare the evolution of the operative site in the presence or absence of an occlusive skin dressing. Patients and methods: Prospective, comparative study that took place at the University Hospital of Br...Objective: To compare the evolution of the operative site in the presence or absence of an occlusive skin dressing. Patients and methods: Prospective, comparative study that took place at the University Hospital of Brazzaville from January 1st to August 31st, 2016. 120 patients were randomly recruited divided into two groups: A study group consisting of 60 patients without a dressing and a control group consisting of 60 patients. Results: Sociodemographic characteristics were similar in both groups, as well as pre- and intraoperative characteristics. Postoperative complications included parietal infection (3 vs. 4 cases, p > 0.05), one case of disunion, and one case of skin irritation by the plaster in the study group. The duration of healing was shorter in the control group compared to the study group (11 ± 2 days vs. 12 ± 2, p > 0.05). The average cost of care equipment was 3.5 times higher for the group with dressing (5120 FCFA vs. 18620 FCFA, p 0.05). In the study group, only one patient was afraid of seeing her wound. Patients in the control group were less satisfied, indeed they dreaded the time of removal of the plaster because of the pain.展开更多
Obesity is a big problem which is growing. Thus clinicians and surgeons are likely to treat obese patients more frequently. Obesity can affect medical practice in a number of ways. In order to protect ourselves from p...Obesity is a big problem which is growing. Thus clinicians and surgeons are likely to treat obese patients more frequently. Obesity can affect medical practice in a number of ways. In order to protect ourselves from potential litigation, we need to focus on risk management efforts on creating a safe environment for patients of all sizes. The aim of our study was to review the risk management strategies of obese women prior to surgery, perioperatively and following surgery. We then identified the strategies and have brought them forward in our article.展开更多
文摘The management of gynaecological malignancies has undergone a significant change in recent years with our improved understanding of cancer biogenetics, development of new treatment regimens and enhanced screening. Due to the rapid blooming of newer methods and techniques in gynaecology, surgery and oncology the scope and the role of imaging has also widened. Functional imaging in the form of diffusion weighted imaging(DWI) has been recently found to be very useful in assessing various tumours. Its ability to identify changes in the molecular level has dramatically changed the diagnostic approach of radiologists which was solely based on morphological criteria. It can improve the diagnostic accuracy of conventional magnetic resonance imaging, lend a hand in assessing tumour response to treatment regimens and detect tumour recurrence with better spatial resolution, negative radiation and diagnostic accuracy compared to positron emission tomography scan. The ability to quantify the diffusion has also lead to potential prediction of tumour aggressiveness and grade which directly correlate with the patient prognosis and management. Hence, it has become imperative for a radiologist to understand the concepts of DWI and its present and evolving role. In this article we present a brief description of the basics of DWI followed by its role in evaluation of female gynaecological malignancies.
文摘Introduction: Fast Track Surgery (FTS) programs have been adopted by many specialties with documented improved patient outcomes and reduced length of stay (LOS). Methods: We initiated a FTS program in January 2008 and present our experience up to and including November 2010 on patients whose LOS was 2 days. Results: During the study period 242 patients had a laparotomy performed. Overall 54(22.3%) patients were discharged on day 2. In the first year of initiating our FTS program 10% were discharged on day 2, 25% in year 2 and 31% in year 3. Twenty-two patients (41%) had malignant pathology and of these, 16 (73%) had local or regional spread and 6 (27%) had distant spread. Forty patients (74%) had vertical midline incisions (VMI) performed. Surgery was classified as complex in 40 cases (74%) and 6 (11%) patients underwent staging lymph node dissection. Average patient BMI was 26.1 with 44% of patients considered overweight or obese. There were no intraoperative complications recorded. When compared to 188 patients whose LOS was greater than 2 days, the early discharge cohort were more likely to have benign pathology, more likely to be younger, to have a transverse incision, to have received COX II inhibitors, to have a lower net haemoglobin (Hb) change and to tolerate early oral feeding. Conclusions: Increased clinical experience with FTS enables over 31% patients undergoing laparotomy to be safely discharged on day 2 without an increase in the read-mission rate or morbidity.
文摘In addition to higher risks of various obstetric and gynaecological illnesses among women with obesity or who are overweight, maternal adiposity threatens the lifetime health of their offspring. Diverse treatments are provided, including complementary and alternative medicine such as Chinese medical practices. Acupuncture, a traditional Chinese medicinal method, is increasingly being applied to this health problem. This literature review analyses 25 clinical studies, involving 2407 participants aged 13-65 in Africa, Asia, the Middle East and North America. This illustrates the use of acupuncture alone or with other approaches to control body weight, obesity-induced diseases, and gynaecological health. Although positive indicators are presented, this study offers recommendations for enhancing reliability and validity in further research. It therefore suggests the use of acupuncture in dealing with obesity due to its efficacy, and economic and safety benefits.
文摘Because their endocrine system is not yet developmentally mature,adolescent girls are prone to dysfunctional uterine bleeding caused by insufficiency of the hypothalamic-pituitary-gonadal axis.The view of modern medicine is mainly aimed at the secretory function of sex hormones,such as estrogen and progesterone.However,it causes distress to patients because of the susceptibility of their treatment to endocrine system disorders.Traditional Chinese medicine considers the damage to the function of the Conception Vessel and Thoroughfare Vessel as the key to the disease.In this way,we guide the use of traditional Chinese medicine and acupuncture and achieve good results.The pathogenesis and management of functional uterine bleeding in adolescence are discussed from two medical perspectives in this article.
文摘Introduction: Surgery can cause anxiety and worry, such as waking up in pain, being physically harmed or dying. This study aimed to assess the experience of patients undergoing planned gynaecological surgery in the Obstetrics Gynaecology and Reproductive Medicine department of the University Hospital Centre of Bogodogo. Patients and methods: This was a cross-sectional study with prospective data collection during the period from June 1 to August 31, 2018. The study population consisted of patients who received scheduled gynaecological surgery during the period. Results: Seventy-six (76) patients underwent scheduled surgery and 62 were included. During discussion with the gynaecologist, 58 patients (93.55%) were satisfied. When the surgery was announced, 41 patients (66.13%) were anxious. At the consultation with the anaesthetist 59 patients (95.16%) were satisfied with the discussions. Fifty-five patients (88.7%) were anxious on admission to the operating theatre. The quality of care was satisfactory for 61 patients (98.39%) and all patients were satisfied with the care team. Conclusion: Periodic evaluation of patients’ experiences should therefore be incorporated into care evaluation policies in health facilities in order to contribute to continuous improvement in the quality of medical and surgical care.
文摘Objective: to study the application of nursing safety management in the perioperative period of patients undergoing gynecologic third and fourth grade operations. Methods: 84 patients included in this study were all gynecological patients with grade 3 and 4 surgery admitted in our hospital from October 2019 to November 2020. According to the patient care plan, they were divided into the reference group (n = 42, routine care) and the research group (n = 42, nursing safety management) to compare the effect of nursing application. Results: the incidence of complications and nursing errors were compared between the two groups. The data showed that the incidence rates of complications and nursing errors in the reference group were 11.90% and 14.29% respectively, and that in the research group were 4.76% and 0 respectively, with the result comparison P < 0.05. Comparing the two groups of nursing satisfaction, the data results showed that the reference group was 80.95% and the research group was 95.24%, the result comparison was P < 0.05. Conclusion: the application value of nursing safety management in the perioperative period of patients undergoing gynecologic third and fourth grade surgery is high, which can improve nursing satisfaction, reduce complications and nursing error rate, and is worthy of promotion and use.
文摘Objective: through the study of clinical practice to re-explore and in-depth analysis of clinical high-quality patient care and treatment technology in the early stage of malignant endometrial fibroids patient care in the actual clinical application of efficacy. Methods: during the period from January 2020 to March 2021, 90 patients selected from two groups of typical patients with uterine fibroids were included in the current observation and examination in the Housing Health Care Institute of Chief Gynecologist of our hospital. The patients were specifically divided into the control group and the experimental group with 45 cases in each group by random analysis of data table method. The patients in the two groups were given routine operative care twice during the perioperative period. The efficacy of routine care for two groups of typical patients with uterine fibroids was compared. Results: after high-quality surgical care, the heart rate, bleeding volume and blood pressure of patients after operation in the experimental group were significantly superior to those of the leading control group. The incidence of severe bradycardia, stomach discomfort, nausea, vomiting, chill, and low body temperature adverse reactions in patients after operation was significantly lower than that of the leading control group. The main reason for the difference was that statistical analysis had a certain number of statistical significance (p < 0.05). Conclusion: through the high-quality surgical care and treatment technology currently being carried out clinically, it can significantly improve and optimize the early surgical care of patients with benign uterine fibroids, reduce the high incidence of surgical prognosis and adverse reactions, and further greatly enhance the clinical technology and safety of nursing surgery, which is worthy of further active introduction and wide promotion in primary hospitals around the world. It is worthy of further promotion and application in primary hospitals.
基金Supported by the International S and T Cooperation Program of China,No.2015DFA30440the National Natural Science Foundation of China,No.81301268Beijing Nova Plan,No.xxjc201812 and No.Z131107000413063
文摘Aggressive angiomyxoma （AAM） is a rare tumour that often occurs in soft tissues of the female genital tract. Eight cases of AAM are reported in this article, and the clinical features and ultrasound and magnetic resonance imaging （MRI） results of the eight cases are reviewed and summarized. The main complaints of all the patients were palpable and painless masses in the vulva or scrotum. The lesions were mainly located in the vulva, pelvis, and perineal region, with a large scope of involvement. The sonographic features of AAM were characteristic. On sonography, all of the masses were of irregular shape and showed hypoechogenicity, with a heterogeneous inner echotexture. Intratumoural and peritumoural blood fows were detected by colour Doppler imaging. On real-time ultrasonic imaging, prominent deformation of the lesions was observed bycompressing the masses with the probe. Some special imaging features were also revealed, including a la-minated or swirled appearance of inner echogenicity, and a fnger-like or tongue-like growth pattern. On MRI imaging, the lesions showed intermediate-intensity signals and intermediate to high-intensity signals on TI-weighted and T2-weighted sequences. A rapid and uneven enhancement pattern was demonstrated. After the comparison of sonographic features with MRIand pathological findings, we found the relevance of the ultrasonographic characteristics with MRI and his-tological features of AAM. Ultrasound can be a valuable imaging method for the preoperative diagnosis, eva-luation of scope, and follow-up of AAM.
文摘Background： The radical hysterectomy （RH） surgical technique has improved along the years. It is used for the treatment of cervical cancer, endometrial cancer when affecting the cervix, and upper vaginal carcinomas. Our aim was to describe the historical evolution of the technique after the introduction of laparoseopy at our institution. Methods： We performed a retrospective review of medical records of patients who underwent RH, grouped in three periods according to the year of surgery： 1990-1999, 2000-2009 and 2010-2013. Patients＇ characteristics, pathologic details, intraoperative and postoperative complications were analyzed and comoared throughout the time periods. Results： A total of 102 cases of RH were performed at our center during the study period. Among all data collected, the presence of necrosis, age, number of lymph nodes, surgery route, operating time, hospital stay, blood loss and transfusion requirement were statistically significant different among groups. Conversion to laparotomy rate was 19% for the second period compared to the absence of cases in the last one. No significant differences （P=0.124） were observed in the adjuvant treatment received among the three different groups. At the time of the last contact the patients free of disease were 12 （85.7%）, 53 （91.3%） and 26 （86.6%） respectively （P=0.406）. Regarding the disease-free interval, we found significant better outcomes in the group of laparotomy compared to laparoscopy （P=0.015）.Conclusions： Laparoscopic RH is an acceptable surgery with advantages like magnified vision of the operation＇s field, lower surgical complications, shorter hospital stay and earlier resumption to daily activities.
基金supported by the National Natural Science Foundation of China(Grant No.81370762)the Key Program for Basic Research of the Science and Technology Commission of Shanghai Municipality,China(Grant No.12JC1405800)
文摘Objective To investigate the correlation between gynaecologic adnexal surgery history and pregnancy outcome of in vitro fertilization （IVF） treatment. Methods A total of 810 women who were proceeded 810 IVF; treatment cycles from October 2009 to March 2011 were recruited to this retrospective study, based on whether they had history of gynaecologic adnexal surgeries or not. Among 810 women, 587 women had no gynaecologic adnexal surgeries （group A）, 223 women had gynaecologic adnexal surgeries （group B）. Additionally, the group B was further divided into 4 subgroups based on their different gynaecologic adnexal surgery histories, such as tubal conservative surgery （group Bal）, unilateral salpingectomy （group Ba2）, ovarian cyst ablation （group Bbl） and unilateral adnexal resection （group Bb2）. The basal levels of FSH, antral follicle count （AFC）, clinical pregnancy rate （CPR）, embryos implantation rates （IR） and live birth rates （LBR） were compared.Results The levels of FSH and AFC were significantly different between groups A and B, respectively. Therefore, CPR, IR and LBR were significantly lower （P 〈0.05） in group B （30.9%, 17.8% and 25.1%） compared with group A （39.9%, 22.8% and 32.4%）. Meanwhile, there was no significant difference between the patients who had tubal conservation surgery （group Bal） and who had unilateral salpingectomy （group Ba2）. However, in contrast to unilateral adnexectomy, ovarian cystectomy surgery influenced FSH and AFC significant, even for the number of oocyte retrieved, but did not affect the IVF treatment outcome. Conclusion The previous history of gynaecologic adnexal surgeries may affect the subsequent ovarian function and also IVF outcomes. As for different operation methods, between tubal conservation surgery and unilateral salpingectomy, the IVF outcomes were not significantly different. The same result we found in different ovarian operation groups.
基金This study was funded by the International Fellowship Program(IFP),Ford Foundation,USA
文摘Purpose:This study aimed to determine the effectiveness of Relaxation Breathing Exercise(RBE)on fatigue in patients with gynaecological cancer undergoing chemotherapy.Methods:We used a quasi-experiment with pre-and post-test design.Forty-two patients were consecutively sampled,21 of whom were assigned to the group receiving RBE four times a day and 21 to the group receiving RBE twice a day.Fatigue scores were measured every day for 7 days for both groups using the Piper Fatigue Scale.Data obtained were analysed using repeated-ANOVA and independent ttest with a significant level of a<0.01.Results:We found a significant decrease(P<0.01)in the mean fatigue scores of both groups(four times RBE in a day group=3.29±0.59 and twice RBE in a day group=4.19±0.61)after the completion of the intervention.However,the four times RBE a day group showed larger decrease on fatigue scores than the twice RBE a day group did(Mean Difference=0.91;99%CI=0.41 to 1.41;P=0.001).Conclusion:Conducting RBE four times a day effectively alleviated fatigue better than RBE twice a day on gynaecological cancer patients undergoing chemotherapy.
文摘Introduction: Gynaecological and breast cancers (GBC) are the most frequent and most serious cancers of women. They are frequent in Benin with an average of 108.5 cases per year. Objective: To identify factors associated with women’s knowledge, attitudes and practices regarding GBC. Methods: This was a cross-sectional, prospective, descriptive and analytical study. Women of childbearing age residing in the commune of Glazoué in Benin for at least six months were included. The WHO cluster sampling technique was used. The Bruno De Finetti postulate and the Likert scale were used to study women’s knowledge, attitudes and practices. Data were collected and analysed using Epi Data 3.1 and Epi info 7.2.2.6 software. Results: A total of 540 women were registered. The mean age was 27.1 ± 8.84 years with extremes of 15 and 49 years. They were married (61.1%), had secondary education (40.2%) and lived in urban areas (61.9%). They had a low level of knowledge (75.4%), an adapted attitude (93.0%) and poor practice (88.9%). Occupation (p = 0.000), level of education (p = 0.007) and place of residence (p = 0.001) significantly influenced knowledge of GBC. The attitude was adequate (93%) and the practice was poor (88.9%). Inappropriate attitude was significantly associated with the level of education (p = 0.006). Conclusion: Women in the commune of Glazoué in Benin have a low level of knowledge of GBC with an adapted attitude and poor practice. Several factors are associated, hence the need to take them into account to facilitate GBC screening.
文摘The most prevalent cancers in ladies are cervical, endometrial and Ovarian. The biomarkers prevalent in use for these gynaecological cancers are commonly Cancer antigen 125 (CA-125), B, Alpha-fetoprotein (AFP), Inhibin, Carcinoembryonic antigen (CEA), Squamous cell carcinoma (SCC) antigen, Carbohydrate antigen 19-9, Cancer antigen 27-29, Human epididymis protein 4 (HE4), Osteopontin, transthyretin, Immunosuppressive acidic protein(IAP), leptin, CA15-3, CK19 and Thymidine kinase. The biomarker marker Squamous cell carcinoma (SCC) antigen, CK19 and immunosuppressive acidic protein IAP are raised in cervical squamous cell carcinomas. Endometrial cancer is a common cancer in women. In 75% of endometrial cancer cases, the tumor remains confined to the uterus and has a favorable prognosis if early detected. The prognosis, however, worsens dramatically as the disease progresses. The objective of this review is to elucidate the importance of the tumor markers for early diagnosis of gynaecological malignancies which are vital and life saving. Similarly the relevant biomarkers in combination are found to have positive predictive values and significant p values in the endometrial and cervical cancer. In Cervix cancer the positive predictive value of these markers combined is usually 92% - 95% and negative predictive value 93% - 96%. The confidence interval is 98% and p value significant 0.005. Sensitivity of tumor markers combined CK19, SCC and immunosuppressive acidic protein IAP in Cervix cancer detection is 95% and specificity 96%. The highest sensitivity was for SCC antigen (98.7%) while the highest specificity was for Cytokeratin 19 (99.7%). The positive predictive value by combination of CK19, SCC and IAP for the detection of Cervix cancer was 90% - 94%. In endometrial cancer the sensitivity of tumor markers combined CA19-9, CA125, leptin, thymidine kinase, CEA, CA15-3, and HE4 in endometrial cancer detection was 95% and specificity 96%. The highest sensitivity was for CA125 (99.7%) while the highest specificity was for CA19-9 (95.7%) which revealed that the efficacy of CA19-9 was more than that of CA125. The positive predictive value by combination of CA19-9, CA-125 levels, HE4, CA15-3, leptin, thymidine kinase and CEA for the detection of Endometrial cancer was 93%. For Gynecological malignancies namely Ovarian, Cervix and Endometrial cancers screening with these novel tumor markers in combination which are significant to a particular group of cancers.
文摘Objective: To study the epidemiology and current trend in the management of urologic complications following obstetric and gynaecologic surgeries at CUUA University hospital of Cotonou. Patients and Methods: It was a retrospective study of patients referred with urologic complications following obstetric and gynaecological surgeries. The study took place at the Teaching Clinic of Urology Andrology at CNHU of Cotonou between April 1, 2008 and March 31, 2013. Results: Forty-one patients were studied. They represented 3.5% of people hospitalized at CUUA throughout the study period. The average age was 41 years swith range of 20 and 57 years. Twenty-one (51.2%) of them were married. Thirty patients (73.2%) were referred from a non-academichospital, while 7 patients (17.1%) were referred from academic hospital. Caesarean section was the primary gynecological surgery in 22 cases (53.7%) and hysterectomy in 19 cases (46.3%). Clinically, the pre- dominant symptoms were leakage of urine throughout the vagina and obstructive anuria with or without back pain. We found 31 cases of VVF, 5 cases of bilateral ligation of the ureters, 3 cases of unilateral ligation of the ureter, 1 ureteralinjury and 1 uretero-vaginal fistula. These complications were diagnosed postoperatively in 95.1% of cases. Surgeries done included VVF repair in 31 cases (75.6%), unilateral ureteral reimplantation in 4 cases (9.8%), removal of ligation of the ureters in 3 cases (7.3%), bilateral ureteral reimplantation for 2 cases (4.9%) and end-to-end anastomosisin 1 case (2.4%). The postoperative period was uneventful in 29 cases and we observed 7 cases of surgical site infection. The overall success rate was 87.8%. Conclusion: Urological complications following gynecologic surgeries managed at the urologic department of teaching hospital of Coto-nou had an even higher incidence. Early diagnosis especially during the operative procedure would save the patients’ serious complications and open surgery due to the lack of endo-urological facilities. The most important factor in prevention is good knowledge of pelvicanatomy and good knowledge of the surgical techniques of caesarean operation section and trans-abdominal hysterectomy.
文摘Approximately 1：4 of all cancers in women in develop-ing countries （excluding non-melanoma skin cancer） is a gynaecological cancer. The gynaecological cancer burden in developing countries is huge primarily due to the high incidence and mortality of cervical cancer. Cervical cancer accounts for over 60% of the gynaeco-logical cancer burden in developing countries despite being preventable by current technologies. This is due to the absence of effective nationally organized screening programmes in most developing countries. Institution of such programmes, therefore, has the potential to dramatically reduce gynaecological cancer burden in these countries. Subsidized human papil-loma virus （HPV） vaccine and HPV typing as well as cheap screening techniques such as visual inspection aided with acetic acid hold the key to effective preven-tion of cervical cancer in these countries. This is be-cause a signifcant proportion of patients in developing countries are unable to access and avail themselves of the few available preventive, diagnostic and treatment services because of poverty. Although, advocacy and the political will to invest in the development of human resources and healthcare infrastructure appear criti-cal to gynaecological cancer control and reducing the burden of disease in many developing countries, the proposition assumes that resources are truly available for this investment. This may not be true. Many devel-oping countries rely on foreign aids for developmental programmes and these aids have dwindled signifcantly with the current global economic meltdown.
文摘Oxidative stress arises from an imbalance between the body’s pro-oxidants and antioxidants.Recently,oxidative stress has been proven a contributing factor to many female reproductive disorders including infertility,preeclampsia,endometriosis and polycystic ovarian syndrome.Herein,we review the mechanistic role of oxidative stress in inducing the most common female reproductive disorders.The current review has also highlighted the protective role of vitamin C,necessary for certain female reproductive hormone secretion by the antral follicle and corpus luteum and also essential for collagen production in ovarian tissue remodeling after ovulation,in alleviating oxidative stress and thus improving female reproductive outcomes.
文摘Background: Comprehensive estimates of the incidence of gynaecological malignancies reported from Nigeria are very limited due to limitation in record maintenance. Female cancer is a public health problem the world over. The malignancies of the female genital organs are major causes of morbidity and mortality which necessitates data for policy formulation and health planning. Aim: To establish the profile of gynaecologic malignancies reported in our centre, with reference to incidence, histological subtypes and frequency of involvement at various sites and to compare the procured data with those from other national and international centers. Materials and Method: In this descriptive retrospective study, the records pertaining to all the pathological specimens categorized as gynaecological malignancies from January 1st, 2013 to December 31st, 2015 at our facility were studied and compared with the available international data. Data analysis was done using Epi Info software version 7.2.1 (CDC Atlanta Georgia). Result: Two hundred and eleven (211) cases of gynaecological malignancies were seen during the study period and this constituted 13.4% of gynaecological admissions. Cervical malignancies were the commonest constituting 49.2% of all gynaecological malignancies followed by ovarian malignancies (27.8%), endometrial cancers (11.9%), vulva (5.6%), choriocarcina (3.9%) and vagina (1.6%). The data obtained was compared with data from Surveillance, Epidemiology and End Result (SEER) programme in the United States and European Union. All malignancies except cervical cancers affected a younger age group at our centre. Cervical cancers presented at a relatively more advanced stage, Ovarian cancers were more localized, whereas uterine, vulva and vaginal cancers presented at a similar stages as compared to Western data. Conclusion: This study presents a composite data of Gynaecological malignancies from Southeast Nigeria. Advanced stage of presentation of cervical cancers suggests lacunae in screening programmes available. Compared with Western data, ovarian malignancies were more localized at presentation for which environmental or genetic factors may be responsible.
文摘Objective: To compare the evolution of the operative site in the presence or absence of an occlusive skin dressing. Patients and methods: Prospective, comparative study that took place at the University Hospital of Brazzaville from January 1st to August 31st, 2016. 120 patients were randomly recruited divided into two groups: A study group consisting of 60 patients without a dressing and a control group consisting of 60 patients. Results: Sociodemographic characteristics were similar in both groups, as well as pre- and intraoperative characteristics. Postoperative complications included parietal infection (3 vs. 4 cases, p > 0.05), one case of disunion, and one case of skin irritation by the plaster in the study group. The duration of healing was shorter in the control group compared to the study group (11 ± 2 days vs. 12 ± 2, p > 0.05). The average cost of care equipment was 3.5 times higher for the group with dressing (5120 FCFA vs. 18620 FCFA, p 0.05). In the study group, only one patient was afraid of seeing her wound. Patients in the control group were less satisfied, indeed they dreaded the time of removal of the plaster because of the pain.
文摘Obesity is a big problem which is growing. Thus clinicians and surgeons are likely to treat obese patients more frequently. Obesity can affect medical practice in a number of ways. In order to protect ourselves from potential litigation, we need to focus on risk management efforts on creating a safe environment for patients of all sizes. The aim of our study was to review the risk management strategies of obese women prior to surgery, perioperatively and following surgery. We then identified the strategies and have brought them forward in our article.
