First observations of W Virginis stars with K2: detection of period doubling

We present the first analysis of W Vir stars observed by the Kepler space telescope in the K2 mission. Clear cycle-to-cycle variation were detected in the light curves of KT Sco and the globular cluster member M80-V1. While the variations in the former star seems to be irregular on the short time scale of the K2 data, the latter appears to experience period doubling in its pulsation. Ground-based colour data confirmed that both stars are W Vir-type pulsators, while a comparison with historical photometric time-series data revealed drastic period changes in both stars. For comparison we reexamine ground-based observations of W Vir, the prototype of the class, and conclude that it shows period doubling instead of mode beating. These results support the notion that nonlinear dynamics plays an important role in the pulsation of W Virginis-type stars.Comment: 8 pages, 7 figures, accepted for publication in MNRA

Maternal serum markers in predicting successful outcome in expectant management of missed miscarriage

The aim of this study was to evaluate the use of biological serum markers, available routinely in most hospital clinical laboratories, in predicting successful outcomes of expectant management in women presenting with a missed miscarriage. This is a single centre observational prospective study over a 16-month period. Among the 490 women who consented to the study protocol, 83 presented with missed miscarriage during the first trimester of pregnancy and opted for expectant management. The mean gestation sac diameter and volume of the gestation sac were recorded during ultrasound examination. Maternal serum samples were obtained in each case and assayed for human chorionic gonadotrophin, progesterone, pregnancy associated plasma protein A (PAPP-A) and high-sensitivity C-reactive protein using commercial assays. When examined individually, maternal age (P = 0.01), progesterone (P = 0.03) and PAPP-A (P = 0.02) were all significantly associated with successful expectant management. Increased maternal age was associated with an increased chance of success with the odds of success increased by around 75% for a 5-year increase in age. Higher values of progesterone and PAPP-A were associated with a reduced chance of successful management. Low maternal serum progesterone concentration was the strongest parameter associated with a successful spontaneous completion of miscarriage

A protocol for developing, disseminating, and implementing a core outcome set for adenomyosis research

BACKGROUND: Adenomyosis is a common benign gynaecological condition that has been associated with heavy and/or painful periods, subfertility and poor obstetric outcomes including miscarriage and preterm delivery. Studies evaluating treatments for adenomyosis have reported a wide range of outcomes and outcome measures. This variation in outcomes and outcome measures prevents effective data synthesis, thereby hampering the ability of meta-analyses to draw useful conclusions and inform clinical practice. OBJECTIVES: Our aim is to develop a minimum set of outcomes to be reported in all future studies that investigate any uterus-sparing intervention for treating uterine adenomyosis. Wide adoption of ‘core outcomes’ into research on adenomyosis would reduce the heterogeneity of studies and make data synthesis easier. This will ultimately lead to comparable, prioritised, and patient-centred conclusions from meta-analyses and guidelines. MATERIALS AND METHODS: Outcomes identified from a systematic review of the literature will form a long list, agreed by an international steering group representing key stakeholders, including healthcare professionals, researchers, and public research partners. Through a modified Delphi process, key stakeholders will score outcomes from the agreed long list on a nine-point Likert scale that ranges from 1 (not important) to 9 (critical). Following the Delphi process, the refined outcome set will be finalised by the steering group. Finally, the steering group will develop recommendations for high-quality measures for each outcome. The study was prospectively registered with Core Outcome Measures in Effectiveness Trials Initiative; number 1649. CONCLUSION: The implementation of the core outcome set for adenomyosis in future trials will enhance the availability of comparable data to facilitate more patient-centred evidence-based care. WHAT IS NEW? The core outcome set will facilitate the generation of clinically important and patient centred outcomes for studies evaluating treatments for adenomyosis

Ultrasound diagnosis of endometrial cancer by subjective pattern recognition in women with postmenopausal bleeding: a prospective inter-rater agreement and reliability study

OBJECTIVES: The objective of our study was to assess the inter-rater agreement and reliability of using subjective pattern recognition to diagnose endometrial cancer on ultrasound in women with postmenopausal bleeding. METHODS: This was a prospective cross-sectional study at a gynaecological rapid access clinic, between Oct 2016 - Dec 2017, where consecutive women with postmenopausal bleeding and endometrial thickness of ≥4.5mm on transvaginal ultrasound scan were included. We excluded women on hormone replacement therapy, tamoxifen or with a history of primary gynaecological malignancy. Two raters independently performed ultrasound examinations, blinded to each other's findings, and classified women into having uniformly thickened endometrium, benign polyp or endometrial cancer, by subjective pattern recognition. Inter-rater reliability of the ultrasound diagnoses was assessed by using Cohen's kappa statistics. All women subsequently underwent either outpatient endometrial biopsy, hysteroscopy or hysterectomy. RESULTS: Forty women were included in the study with a median age of 61 (IQR 57-69) and a median endometrial thickness of 11.0mm (IQR 6.2-20.3). Final histological analysis confirmed 16 (40%) women with endometrial cancer, 16 (40%) endometrial polyps, 4 (10%) atrophic endometrium, 3 (7%) proliferative endometrium and 1 (3%) endometrial hyperplasia. Inter-rater agreement for the ultrasound diagnoses of uniformly thickened endometrium, polyp and cancer, were 14/16 (87.5%), 22/30 (73.3%) and 28/34 (82.4%), respectively; the inter-rater reliability was good (κ = 0.69, 95% C.I. 0.49-0.88). When the ultrasound diagnoses were combined as either cancer or no cancer, the inter-rater agreement was 85% and the inter-rater reliability was also good (κ = 0.78, 95% C.I. 0.61-0.95). Rater A correctly identified 14/16 cancers and Rater B identified 15/16. Endometrial cancers were misdiagnosed as benign polyps on ultrasound in two women by Rater A, and in one woman by Rater B. The overall accuracies of Rater A and Rater B in differentiating between benign endometrial pathologies and malignancy were 90% and 85%, respectively. CONCLUSIONS: Our results showed good inter-rater reliability of subjective pattern recognition in diagnosing uniformly thickened endometrium, polyp and cancer on ultrasound in women with postmenopausal bleeding. Our findings should facilitate wider use of subjective pattern recognition in routine clinical practice

Ultrasound diagnosis of complete and partial hydatidiform moles in early pregnancy failure: An inter-observer study

We evaluated the accuracy of the ultrasound signs suggestive of complete hydatidiform mole (CHM) and partial hydatidiform mole (PHM) in a cohort of women with histologically confirmed hydatidiform mole (HM) who presented with early pregnancy failure, including 103 CHM and 95 PHM for which ultrasound images were available. The accuracy of the differential diagnosis was significantly (p < 0.001) greater during secondary examination of ultrasound images compared with the original primary ultrasound examination. The interobserver agreement analysis indicated only a fair to moderate agreement between the two examinations (kappa value 0.41; 95% CI 0.29–0.53). Most HM present as early pregnancy failure and identification of early ultrasound signs can improve the differential diagnosis between CHM and PHM

Physical resolution of tubal ectopic pregnancy on ultrasound imaging following successful expectant management

RESEARCH QUESTION What is the time required for complete physical resolution of tubal ectopic pregnancies diagnosed on ultrasound imaging in women undergoing successful expectant management? DESIGN A prospective observational cohort study of 177 women who had successful expectant management of tubal ectopic pregnancy, who attended a single Early Pregnancy Unit between January 2014 and December 2018. All participants were monitored until their serum β-hCG dropped to non-pregnant levels and with two-weekly follow-up ultrasound scans until resolution of the pregnancy. RESULTS 112/177 (63.8%, 95% CI 56.3-70.9) of tubal ectopic pregnancies were indiscernible on ultrasound 2 weeks after serum β-hCG had returned to non-pregnant levels. In 8/177 (4.5%, 95% CI 2.0-8.7) physical resolution took longer than 78 days. There was a positive correlation between biochemical and physical resolution of tubal ectopic pregnancy (r=0.21, p=0.006). CONCLUSIONS Physical resolution of tubal ectopic pregnancy is often prolonged and is positively correlated with initial and maximum β-hCG levels. Our results indicate that β-hCG resolution cannot be used as the end-point of expectant management of tubal ectopic pregnancy, which should be considered when counselling women and planning for future pregnancies. KEY MESSAGE In a significant proportion, physical resolution of tubal ectopic pregnancy takes several weeks following the return of serum β-hCG to non-pregnant levels. Women should be advised to delay trying for another pregnancy for three months, to avoid resolving pregnancies being misdiagnosed as new ones and to reduce the theoretical risk of recurrent ectopic, due to temporary tubal blockage by the resolving trophoblast

Ultrasound diagnosis of serous surface papillary borderline ovarian tumor: A case series with a review of the literature

Serous surface papillary borderline ovarian tumors (SSPBOTs) are a rare morphologic variant of serous ovarian tumors that are typically confined to the ovarian surface, while the ovaries themselves tend to appear normal in size and shape. In this report, we describe the findings from five premenopausal women diagnosed with SSPBOTs, in whom ultrasound showed grossly normal ovaries that were partially or wholly covered with irregular solid tumors. In all five cases, histologic examination showed evidence of borderline serous tumors. These findings demonstrate that SSPBOTs can be diagnosed on a preoperative sonographic examination, which could facilitate conservative, fertility-sparing surgery in young women affected by this condition. © 2015 Wiley Periodicals, Inc. J Clin Ultrasound, 2015

Single dose systemic methotrexate versus expectant management for treatment of tubal ectopic pregnancy: A placebo-controlled randomised trial

OBJECTIVE: Methotrexate is routinely used worldwide for medical treatment of clinically stable women with tubal ectopic pregnancies. This is despite the lack of robust evidence to show its superior effectiveness over expectant management. The aim of our multicentre randomised trial study was to compare the success rates of methotrexate with placebo for the conservative treatment of tubal ectopic pregnancies. METHODS: The study was multicentre; it took place in three UK early pregnancy units between January 2006 and June 2014. Inclusion criteria were clinically stable women with a conclusive ultrasound diagnosis of a tubal ectopic pregnancy presenting with low serum β-hCG <1500IU/l. Women were randomly assigned to single systemic injection of methotrexate 50mg/m(2) or placebo. The primary outcome of the study was a binary indicator for success of conservative management, defined as resolution of clinical symptoms and decline of serum β-hCG to <20IU/l or negative urine pregnancy test without the need for any additional medical intervention. An intention to treat analysis was followed. RESULTS: We recruited a total of 80 women: 42 to methotrexate and 38 to placebo. The two arms of the study were balanced in terms of age, ethnicity, obstetric histories, pregnancy characteristics and serum β-hCG and progesterone. The proportions of successes were similar: 83% with methotrexate and 76% with placebo. On univariate analysis, this difference was not statistically significant (χ2(1df) = 0.53; P = 0.23). On multivariate logistic regression, β-hCG was the only covariate which was significantly associated with outcome. The odds of failure increased by 0.15% for each unit increase in β-hCG (OR=1.0015; 95% CI 1.0002 to 1.003; P = 0.02). In 14 women presenting with serum hCG 1000-1500IU/l the success of expectant management was 33% compared to 62% in the methotrexate arm. Although this result was not statistically significant a larger sample size would give us greater power to detect a difference in this subgroup of women, In women with successful conservative management there was no significant difference in median resolution times between methotrexate and placebo arms [17.5 days (IQR 14 - 28.0) (n = 30)] vs [14 days (IQR 7 - 29.5) (n = 25)] (P = 0.73) CONCLUSION: The results of our study do not support routine use of methotrexate for the treatment of clinically stable women diagnosed with tubal ectopic pregnancies presenting with low serum hCG <1500IU/l. Further work is required to identify a subgroup of women with tubal ectopic pregnancies and hCG≥1500IU/l in whom methotrexate may offer a safe and cost-effective alternative to surgery