Peer review in medical journals: beyond quality of reports towards transparency and public scrutiny of the process

Published medical research influences health care providers and policy makers, guides patient management, and is based on the peer review process. Peer review should prevent publication of unreliable data and improve study reporting, but there is little evidence that these aims are fully achieved. In the blinded systems, authors and readers do not know the reviewers' identity. Moreover, the reviewers' reports are not made available to readers. Anonymous peer review poses an ethical imbalance toward authors, who are judged by masked referees, and to the medical community and society at large, in case patients suffer the consequences of acceptance of flawed manuscripts or erroneous rejection of important findings. Some general medical journals have adopted an open process, require reviewers to sign their reports, and links online pre-publication histories to accepted articles. This system increases editors' and reviewers' accountability and allows public scrutiny, consenting readers understand on which basis were decisions taken and by whom. Moreover, this gives credit to reviewers for their apparently thankless job, as online availability of signed and scored reports may contribute to researchers' academic curricula. However, the transition from the blind to the open system could pose problems to journals. Reviewers may be more difficult to find, and publishers or medical societies could resist changes that may affect editorial costs and journals' revenues. Nonetheless, also considering the risk of competing interests in the medical field, general and major specialty journals could consider testing the effects of open review on manuscripts regarding studies that may influence clinical practice

Parasitic myomas after laparoscopic surgery: an emerging complication in the use of morcellator? Description of four cases

Objective: To report the development of parasitic myomas after the use of a morcellator. Design: Retrospective study. Setting: Tertiary care referral center for the treatment of benign gynecologic pathologies. Patient(s): Women undergoing surgery for uterine fibroids. Intervention(s): Chart review. Main Outcome Measure(s): Presence of parasitic leiomyomas. Result(s): We identified four cases of parasitic myomas over the 3-year study period. Two out of the four were symptomatic. The prevalence of this complication, considering all women with whom the electric morcellator was used (n 1⁄4 423) was 0.9% (95% CI, 0.3–2.2%). Considering exclusively the women who underwent myomectomy (n 1⁄4 321), it was 1.2% (95% CI, 0.4–2.9%). Conclusion(s): Laparoscopic myomectomy with the use of a morcellator is associated with an increased risk of developing of parasitic myomas. A thorough inspection and washing of the abdominopelvic cavity at the end of the surgery should be performed to prevent this rare complication

The ominous association between severe endometriosis, in-vitro fertilisation, and placenta praevia : Raising awareness, limiting risks, informing women

Endometriosis is associated with several adverse pregnancy outcomes.(1) The most severe maternal complications are spontaneous haemoperitoneum in the second half of pregnancy and placenta praevia.(1) Spontaneous haemoperitoneum, mostly associated with endometriosis infiltrating the broad and uterosacral ligaments and the Douglas pouch, is a potentially fatal but rare event. Placenta praevia is more common,(1-3) and it is important to define its incidence, the association with different lesion types, the impact of additional risk factors, the potential obstetrical consequences, and the information that women should receive

Time to redefine endometriosis including its pro-fibrotic nature

Endometriosis is currently defined as presence of endometrial epithelial and stromal cells at ectopic sites. This simple and straightforward definition has served us well since its original introduction. However, with advances in disease knowledge, endometrial stromal and glands have been shown to represent only a minor component of endometriotic lesions and they are often absent in some disease forms. In rectovaginal nodules, the glandular epithelium is often not surrounded by stroma and frequently no epithelium can be identified in the wall of ovarian endometriomas. On the other hand, a smooth muscle component and fibrosis represent consistent features of all disease forms. Based on these observations, we believe that the definition of endometriosis should be reconsidered and reworded as 'A fibrotic condition in which endometrial stroma and epithelium can be identified'. The main reasons for this change are: (1) to foster the evaluation of fibrosis in studies on endometriosis pathogenesis using animal models; (2) to limit potential false negative diagnoses if pathologists stick stringently to the current definition of endometriosis requiring the demonstration of endometrial stromal and glands; (3) to consider fibrosis as a potential target for treatment in endometriosis. This opinion article is aimed at boosting the attention paid to a largely neglected aspect of the disease. We hope that targeting the fibrotic process might increase success in developing new therapeutic approaches

Ovarian stimulation and endometriosis progression or recurrence: a systematic review

Available evidence on the impact of ovarian stimulation on the progression of endometriosis or its recurrence was systematically reviewed. Data from ovarian stimulation alone, or associated with intrauterine insemination (IUI) or IVF, were included. Sixteen studies were selected. Initial case reports (n = 11) documented some severe clinical complications. However, subsequent observational studies were more reassuring. Overall, five conclusions can be drawn: (i) IVF does not worsen endometriosis-related pain symptoms (moderate quality evidence); (ii) IVF does not increase the risk of endometriosis recurrence (moderate quality evidence); (iii) the impact of IVF on ovarian endometriomas, if present at all, is mild (low quality evidence); (iv) IUI may increase the risk of endometriosis recurrence (low quality evidence); (v) deep invasive endometriosis might progress with ovarian stimulation (very low quality evidence). In conclusion, available evidence is generally reassuring (at least for IVF) and does not justify aggressive clinical approaches such as prophylactic surgery before assisted reproductive technology treatment to prevent endometriosis progression or recurrence. However, further evidence is required before being able to reach definitive conclusions. In particular, the potential effects on deep invasive endometriosis and the possible synergistic effect of stimulation and pregnancy are two areas that need to be explored further