Hippocrates cannot have been overconfident about the provision of care for patients with cancer. In one of his aphorisms he pointed out that patients with internal cancers who were treated survived a shorter time than those who were left alone. Some 25 centuries later informed voices have decried Britain's cancer services, some likening progress through them to the vagaries of the lottery. While this analogy is overly pessimistic, the failure of health planners to respond to the improved understanding and treatment of cancers has more than justified much of the recent criticism.

Many doctors also remain ignorant of what is achievable with good cancer care, which is hardly surprising, given the low …

A policy framework for commissioning cancer services.

Objective To ascertain whether a clinically important difference exists in the incidence of gynaecological infection between surgical management and expectant or medical management of miscarriage.

Design Randomised controlled trial comparing medical and expectant management with surgical management of first trimester miscarriage.

Setting Early pregnancy assessment units of seven hospitals in the United Kingdom.

Participants Women of less than 13 weeks' gestation, with a diagnosis of early fetal demise or incomplete miscarriage.

Interventions Expectant management (no specific intervention); medical management (vaginal dose of misoprostol preceded, for women with early fetal demise, by oral mifepristone 24-48 hours earlier); surgical management (surgical evacuation).

Main outcome measures Confirmed gynaecological infection at 14 days and eight weeks; need for unplanned admission or surgical intervention.

Results 1200 women were recruited: 399 to expectant management, 398 to medical management, and 403 to surgical management. No differences were found in the incidence of confirmed infection within 14 days between the expectant group (3%) and the surgical group (3%) (risk difference 0.2%, 95% confidence interval - 2.2% to 2.7%) or between the medical group (2%) and the surgical group (0.7%, - 1.6% to 3.1%). Compared with the surgical group, the number of unplanned hospital admissions was significantly higher in both the expectant group (risk difference - 41%, - 47% to - 36%) and the medical group (- 10%, - 15% to - 6%). Similarly, when compared with the surgical group, the number of women who had an unplanned surgical curettage was significantly higher in the expectant group (risk difference - 39%, - 44% to - 34%) and the medical group (- 30%, - 35% to - 25%).

Conclusions The incidence of gynaecological infection after surgical, expectant, and medical management of first trimester miscarriage is low (2-3%), and no evidence exists of a difference by the method of management. However, significantly more unplanned admissions and unplanned surgical curettage occurred after expectant management and medical management than after surgical management.

Trial registration National Research Register: N0467011677/N0467073587.

https://www.bmj.com/content/bmj/332/7552/1235.full.pdf

Management of miscarriage: expectant, medical, or surgical? Results of randomised controlled trial (miscarriage treatment (MIST) trial)

A prospective randomized control trial comparing medical and surgical treatment for early pregnancy failure

Medical management of missed abortion: a randomized clinical trial.

A comparison of 600 and 200 mg mifepristone prior to second trimester abortion with the prostaglandin misoprostol

https://www.bmj.com/content/bmj/306/6882/894.full.pdf

Medical management of miscarriage: non-surgical uterine evacuation of incomplete and inevitable spontaneous abortion.

PIP: Mifepristone (an antiprogesterone) and misoprostol (a synthetic analogue of prostaglandin E1) were administered to 60 women diagnosed with missed abortion or anembryonic pregnancy (gestation sac present but no developing embryo) equivalent to 13 weeks' gestation or less who were recruited after counselling. The median age was 227 (range 15-44), and the median duration of amenorrhoea was 71 (42-110) days. 25 of the women had been referred for ultrasound scanning because of bleeding in early pregnancy, while the rest were diagnosed by routine scanning. 29 patients had anembryonic pregnancies, and 31 had a missed abortion. Each patient received a 600 mg single oral dose of mifepristone, and 36-48 hours later misoprostol 600 mcg was given orally (400 mcg and, 2 hours later, 200 mcg). If the products of conception were not expelled within 4 hours, vaginal ultrasonography was performed. 8 patients aborted with mifepristone alone, 43 aborted after taking 600 mcg of misoprostol, and 5 more aborted after receiving a 2nd divided dose of 600 mcg misoprostol. In 3 patients the treatment failed, and they underwent evacuation of the uterus under general anaesthesia. Exploratory curettage was performed in 2 other patients at 14 and 22 days after treatment with misoprostol, but no products of conception were obtained. The median time from administration of misoprostol to abortion was 4 (1-11) hours. The median duration of bleeding after abortion was 10 (2-22) days. Side effects included nausea, vomiting (5 patients received antiemetic drugs), and diarrhoea (7 patients) from misoprostol treatment. 39 women did not want any pain relief, 13 asked for oral analgesia, and 7 obtained parenteral analgesia.

https://www.bmj.com/content/bmj/305/6866/1399.full.pdf

Medical management of missed abortion and anembryonic pregnancy.

Mid-trimester termination for fetal abnormality: advantages of a new regimen using mifepristone and misoprostol.

EDrroR,-I am evaluating the factors that contributed to the delay in the recognition and acknowledgment of the health hazard of exposure to asbetos dust and the consequent delay in the implementation of effective intervention. Scientists have had an important role in this history and in the study of dose-response relations-none more pominently than the members of the subcommittee on asbetos of the British Occupational Hygiene Society. The society's reports and related literature show that an account would be incomplete without a review of the data handled by members of this committee and of the details of their methods of working and decision making. This can be found only in their working papers, correspondence, and minutes, which extend over a quarter of a century. In May 1990 I wrote to the president of the British Occupational Hygiene Society, requesting access to the files of the committee on asbestos. The reply stated that this was not possible on two counts: that there was no central archive and that much of the material had been made available on a confidential basis and it would not be acceptable for later councils to break that confidence. I wrote more recently to the society, requesting its permission for access to files containing its records that were preserved elsewhere, but I was informed that the society is still unable to allow anyone access to these data. If commercial confidentiality ever applied to the data it must have lapsed after some 20 years and more. Medical confidentiality would never have applied to data from which individual subjects could notbe identified. This experience raises certain matters of principle in relation to scientific work and publication. Should it be a condition that data and analyses that have formed the basis of a publication be preserved and kept accessible for further study? What constraints of confidentiality are unacceptable in the field of scientific publication? If the accessibility of data constitutes part of the scientific ethic whose ultimate responsibility is it to ensure this-the author's or the editor's?

https://www.bmj.com/content/bmj/307/6898/259.2.full.pdf

Management of uncomplicated miscarriage. Randomized trials are possible.

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Papers

Medical management of miscarriage: non-surgical uterine evacuation of incomplete and inevitable spontaneous abortion.

Medical management of missed abortion and anembryonic pregnancy.

Mid-trimester termination for fetal abnormality: advantages of a new regimen using mifepristone and misoprostol.

Management of uncomplicated miscarriage. Randomized trials are possible.