Recommendations for the surgical treatment of endometriosis. Part 2: deep endometriosis
†‡¶

Abstract STUDY QUESTION How should surgery for endometriosis be performed? SUMMARY ANSWER This document provides recommendations covering technical aspects of different methods of surgery for deep endometriosis in women of reproductive age. WHAT IS KNOWN ALREADY Endometriosis is highly prevalent and often associated with severe symptoms. Yet compared to equally prevalent conditions, it is poorly understood and a challenge to manage. Previously published guidelines have provided recommendations for (surgical) treatment of deep endometriosis, based on the best available evidence, but without technical information and details on how to best perform such treatment in order to be effective and safe. STUDY DESIGN, SIZE, DURATION A working group of the European Society for Gynaecological Endoscopy (ESGE), ESHRE and the World Endometriosis Society (WES) collaborated on writing recommendations on the practical aspects of surgery for treatment of deep endometriosis. PARTICIPANTS/MATERIALS, SETTING, METHODS This document focused on surgery for deep endometriosis and is complementary to a previous document in this series focusing on endometrioma surgery. MAIN RESULTS AND THE ROLE OF CHANCE The document presents general recommendations for surgery for deep endometriosis, starting from preoperative assessments and first steps of surgery. Different approaches for surgical treatment are discussed and are respective of location and extent of disease; uterosacral ligaments and rectovaginal septum with or without involvement of the rectum, urinary tract or extrapelvic endometriosis. In addition, recommendations are provided on the treatment of frozen pelvis and on hysterectomy as a treatment for deep endometriosis. LIMITATIONS, REASONS FOR CAUTION Owing to the limited evidence available, recommendations are mostly based on clinical expertise. Where available, references of relevant studies were added. WIDER IMPLICATIONS OF THE FINDINGS These recommendations complement previous guidelines on management of endometriosis and the recommendations for surgical treatment of ovarian endometrioma. STUDY FUNDING/COMPETING INTEREST(S) The meetings of the working group were funded by ESGE, ESHRE and WES. Dr Roman reports personal fees from ETHICON, PLASMASURGICAL, OLYMPUS and NORDIC PHARMA, outside the submitted work; Dr Becker reports grants from Bayer AG, Volition Rx, MDNA Life Sciences and Roche Diagnostics Inc. and other relationships or activities from AbbVie Inc., and Myriad Inc, during the conduct of the study; Dr Tomassetti reports non-financial support from ESHRE, during the conduct of the study; and non-financial support and other were from Lumenis, Gedeon-Richter, Ferring Pharmaceuticals and Merck SA, outside the submitted work. The other authors had nothing to disclose. TRIAL REGISTRATION NUMBER na

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Recommendations for the Surgical Treatment of Endometriosis. Part 1: Ovarian Endometrioma†‡¶

Human Reproduction Open ◽

10.1093/hropen/hox016 ◽

2017 ◽

Vol 2017 (4) ◽

Cited By ~ 4

Author(s):

◽

Ertan Saridogan ◽

Christian M Becker ◽

Anis Feki ◽

Grigoris F Grimbizis ◽

...

Keyword(s):

Surgical Treatment ◽

Working Group ◽

Data Monitoring Committee ◽

Reproductive Age ◽

Clinical Expertise ◽

Plasma Energy ◽

Peritoneal Endometriosis ◽

Registration Number ◽

Clinical Dilemma ◽

Roche Diagnostics

Abstract STUDY QUESTION What does this document on the surgical treatment of endometriosis jointly prepared by the European Society for Gynaecological Endoscopy (ESGE), ESHRE, and the World Endometriosis Society (WES) provide? SUMMARY ANSWER This document provides recommendations covering technical aspects of different methods of surgery for endometriomas in women of reproductive age. WHAT IS ALREADY KNOWN Endometriomas (ovarian endometriotic cysts) are a commonly diagnosed form of endometriosis, owing to the relative ease and accuracy of ultrasound diagnosis. They frequently present a clinical dilemma as to whether and how to treat them when found during imaging or incidentally during surgery. Previously published guidelines have provided recommendations based on the best available evidence, but without technical details on the management of endometriosis. STUDY DESIGN SIZE, DURATION A working group of ESGE, ESHRE and WES collaborated on writing recommendations on the practical aspects of endometrioma surgery. PARTICIPANTS/MATERIALS, SETTING, METHODS This document focused on endometrioma surgery. Further documents in this series will provide recommendations for surgery of deep and peritoneal endometriosis. MAIN RESULTS AND THE ROLE OF CHANCE The document presents general recommendations for surgery of endometrioma, and specific recommendations for cystectomy, ablation by laser or by plasma energy, electrocoagulation and a combination of these techniques applied together or with an interval between them. LIMITATIONS REASONS FOR CAUTION Owing to the limited evidence available, recommendations are mostly based on clinical expertise. WIDER IMPLICATIONS OF THE FINDINGS These recommendations complement previous guidelines on the management of endometriosis. STUDY FUNDING/COMPETING INTERESTS The meetings of the working group were funded by ESGE, ESHRE and WES. C.B. declares to be a member of the independent data monitoring committee for a clinical study by ObsEva, and receiving research grants from Bayer, Roche Diagnostics, MDNA Life Sciences, and Volition. E.S. received honoraria for provision of training to healthcare professionals from Ethicon, Olympus and Gedeon Richter. The other authors declare that they have no conflict of interest. TRIAL REGISTRATION NUMBER NA.

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Periureteric Mass in a Treated Case of Papillary Carcinoma of Thyroid: A Diagnostic Dilemma

Journal of Gastrointestinal and Abdominal Radiology ◽

10.1055/s-0039-1677773 ◽

2019 ◽

Vol 02 (01) ◽

pp. 058-063

Author(s):

Sushil Panbude ◽

Archi Agrawal ◽

Shubhada Kane ◽

Anil D'Cruz ◽

Supreeta Arya

Keyword(s):

Papillary Carcinoma ◽

Clinical History ◽

Reproductive Age ◽

Imaging Features ◽

Age Group ◽

Diagnostic Dilemma ◽

Uterosacral Ligaments ◽

History Of ◽

Extrapelvic Endometriosis ◽

Reproductive Age Group

AbstractEndometriosis is the presence of normal endometrial glands and stroma outside the endometrium, seen in women in the reproductive age group. Endometriosis is common in the pelvis in the pouch of Douglas, rectum, urinary bladder, and uterosacral ligaments. Although extrapelvic endometriosis is uncommon, endometriosis at extrapelvic sites such as the gastrointestinal tract, urinary tract, lung, skin, brain, and scar site has been reported and can mimic other benign and malignant lesions. It is a difficult diagnosis when patients have a preexisting neoplasm as metastasis can be a differential. The clinical history, imaging features, and a strong suspicion of this entity in the reproductive age group help accurate diagnosis of this entity. We present a rare case of deep pelvic (periureteral) endometriosis in a 41-year-old woman with history of papillary carcinoma of the thyroid gland causing diagnostic dilemma on imaging and histopathology and also discuss briefly the imaging findings of endometriosis.

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Anti-adhesion Gel versus No gel following Operative Hysteroscopy prior to Subsequent fertility Treatment or timed InterCourse (AGNOHSTIC), a randomised controlled trial: protocol

Human Reproduction Open ◽

10.1093/hropen/hoab001 ◽

2021 ◽

Vol 2021 (1) ◽

Author(s):

S van Wessel ◽

T Hamerlynck ◽

V Schutyser ◽

C Tomassetti ◽

C Wyns ◽

...

Keyword(s):

Live Birth ◽

Financial Support ◽

Controlled Trial ◽

Reproductive Age ◽

Fertility Treatment ◽

Control Group ◽

Women Of Reproductive Age ◽

Operative Hysteroscopy ◽

Randomised Controlled

Abstract STUDY QUESTIONS Does the application of anti-adhesion gel, compared to no gel, following operative hysteroscopy to treat intrauterine pathology in women wishing to conceive increase the chance of conception leading to live birth? WHAT IS KNOWN ALREADY Intrauterine adhesions (IUAs) following operative hysteroscopy may impair reproductive success in women of reproductive age. Anti-adhesion barrier gels may decrease the occurrence of IUAs, but the evidence on their effectiveness to improve reproductive outcomes is sparse and of low quality. STUDY DESIGN, SIZE, DURATION This multicentre, parallel group, superiority, blinded and pragmatic randomised controlled trial is being carried out in seven participating centres in Belgium. Recruitment started in April 2019. Women will be randomly allocated to treatment with anti-adhesion gel (intervention group) or no gel (control group). Sterile ultrasound gel will be applied into the vagina as a mock-procedure in both treatment arms. The patient, fertility physician and gynaecologist performing the second-look hysteroscopy are unaware of the allocated treatment. Power analysis, based on a target improvement of 15% in conception leading to live birth using anti-adhesion gel, a power of 85%, a significance level of 5%, and a drop-out rate of 10%, yielded a number of 444 patients to be randomised. The baseline rate of conception leading to live birth in the control group is expected to be 45%. PARTICIPANTS/MATERIALS, SETTING, METHODS Women of reproductive age (18–47 years), wishing to conceive (spontaneously or by fertility treatment) and scheduled for operative hysteroscopy to treat intrauterine pathology (endometrial polyps, myomas with uterine cavity deformation, uterine septa, IUAs or retained products of conception) are eligible for recruitment. Women may try to conceive from 3 to 6 weeks after receiving allocated treatment with follow-up ending at 30 weeks after treatment. If the woman fails to conceive within this timeframe, a second-look hysteroscopy will be scheduled within 2–6 weeks to check for IUAs. The primary endpoint is conception leading to live birth, measured at 30 weeks after randomisation. The secondary endpoints are time to conception, clinical pregnancy, miscarriage and ectopic pregnancy rates, measured at 30 weeks after receiving allocated treatment. The long-term follow-up starts when the patient is pregnant and she will be contacted every trimester. STUDY FUNDING/COMPETING INTEREST(S) This work is funded by the Belgian Healthcare Knowledge Centre (KCE). The anti-adhesion gel is supplied at no cost by Nordic Pharma and without conditions. Dr. Tomassetti reports grants and non-financial support from Merck SA, non-financial support from Ferring SA, personal fees and non-financial support from Gedeon-Richter, outside the submitted work. None of the other authors have a conflict of interest.

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Clinical and diagnostic aspects of deep infiltrative endometriosis (diagnosis, treatment, recurrence)

GYNECOLOGY ◽

10.26442/20795696.2021.4.201040 ◽

2021 ◽

Vol 23 (4) ◽

pp. 307-313

Author(s):

Shakhnoza K. Muftaidinova ◽

Leonid Z. Faizullin ◽

Vladimir D. Chuprynin ◽

Nikolai S. Ruseikin ◽

Tatiana I. Smolnova ◽

...

Keyword(s):

Surgical Treatment ◽

Hormonal Therapy ◽

Serum Levels ◽

Ca 125 ◽

Prior History ◽

Deep Endometriosis ◽

Preoperative Serum ◽

Peritoneal Endometriosis ◽

History Of ◽

Deep Infiltrative Endometriosis

Aim. To analyze the recurrence of endometriosis after surgical treatment of patients with deep endometriosis. Materials and methods. The case histories of 90 patients aged 19 to 45 years were retrospectively analyzed. The study group consisted of 70 endometriosis patients: 20 with peritoneal endometriosis and 50 with deep infiltrative endometriosis (DIЕ). The comparison group included 20 women without endometriosis. There was an in-depth study of anamnestic data in the cohort of patients under study. The results of preoperative laboratory tests, including serum levels of the CA-125 and CA 19-9 oncomarkers, were processed. Results. Analysis of the obtained data showed that about half of the DIE patients (54%) in the main group had a history of surgical interventions for endometriosis. The number of operations was significantly higher in patients compared to the peritoneal endometriosis group (68% vs 20%, respectively; р=0.0012). Two subgroups were formed from the group of women with DIE: patients who had no history of previous surgical treatment for endometriosis and those hospitalized for repeated surgical treatment of endometriosis (patients with recurrent endometriosis). Patients with recurrent endometriosis had a significantly higher incidence of heavy menstruation, pregnancy terminations (abortions), and a high proportion of gastrointestinal diseases. Analysis of the hormonal therapy received in patients with DIE showed that every second patient with relapses (18/53%) after surgical treatment and every third patient without a prior history of surgery (5/31%) received hormonal therapy. Examination of the preoperative serum levels of CA-125 and CA 19-9 serum markers in patients with DIE showed an increase in their serum levels and a correlation with the frequency of endometriosis recurrence and the size of DIE foci. Conclusion. Despite the conservative and surgical treatment of DIE patients, the recurrence rate is still high. At present, there is no satisfactory therapy for all endometriosis patients. Therefore, the development of therapy for the conservative treatment of the disease remains an urgent task.

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P–331 The #Enzian classification: A comprehensive non-invasive and surgical description system for endometriosis

Human Reproduction ◽

10.1093/humrep/deab130.330 ◽

2021 ◽

Vol 36 (Supplement_1) ◽

Author(s):

J Keckstein ◽

H Gernot

Keyword(s):

Classification System ◽

Working Group ◽

Complex Disease ◽

Diagnostic Methods ◽

Anatomical Location ◽

Ovarian Endometriosis ◽

Deep Endometriosis ◽

Non Invasive ◽

Complete Mapping

Abstract Study question Is there a classification for a complete mapping of endometriosis, including anatomical location, size of the lesions, and degree of involvement that can be used with both, diagnostics and surgery? Summary answer #Enzian classification improves in both, non-invasive diagnostic methods and surgical therapy for endometriosis as a universally usable classification system for all aspects of the disease. What is known already The most commonly used r-ASRM classification has certain limitations due to its incomplete description of DE, the complexity of the classification, and lack of reproducibility. In contrast, the Enzian classification, which has been implemented in the last decade, has proved to be the most suitable for the description of DE. However, since it does not include peritoneal and ovarian lesions and lacks a description of tubo-ovarian adhesions, it has not gained full acceptance. A combination of classification with different systems such as r-ASRM, EFI score and Enzian, may complicate classification of the disease due to overlaps and time-consuming documentation. Study design, size, duration The result is a consensus of a panel of renowned clinicians (working group), gynaecological surgeons and sonographers with extensive expertise in diagnosis and therapy of endometriosis. A first draft was written in 2019 by a joint effort of the first and last author and sent to all working group members. Taking all comments into account, a revised draft was then sent to all coauthors and repeated until a consensus was reached (9 revisions). Participants/materials, setting, methods Criteria used to invite the experts to participate in this consensus process included their having significant peer-reviewed publications in the field of diagnosis and management of endometriosis. Main results and the role of chance Our current proposal is the first of its kind to universally describe superficial and deep endometriosis, ovarian endometriosis, adenomyosis and adhesions by using a classification system that can be applied by gynaecologists, surgeons, sonographers and radiologists following the same principles. The correlation between preoperative and surgical staging, on the basis of the Enzian scheme, allows for consistent and clear classification of endometriosis, especially DE. Endometriosis can be mapped completely with one single classification system enabling the use of one common language. Limitations, reasons for caution This classification system is anatomically logical and should be easy to use. Further studies are ongoing and are needed to provide proof for the applicability, reproducibility and accuracy of the #Enzian classification for the description of endometriosis. Wider implications of the findings: #Enzian classification now enabled better coverage of various endometriosis localizations. The possibility of using this system preoperatively as well as postoperatively within the framework of diagnostics offers clinicians a significant improvement in the care of patients with such a complex disease. Trial registration number Not applicable

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The evaluation of contributing factors and outcomes of surgical treatment in patients with stress urine incontinence

Journal of obstetrics and women s diseases ◽

10.17816/jowd87437 ◽

2005 ◽

Vol 54 (5S) ◽

pp. 60-60

Author(s):

Vitaly F. Bezhenar ◽

N. N. Volkov ◽

G. V. Blagodarnij

Keyword(s):

Surgical Treatment ◽

Reproductive Age ◽

Social Meaning ◽

Contributing Factors ◽

Urine Incontinence ◽

High Prevalence

Introduction. Stress urine incontinence (SUI), gets the important medical and social meaning in view of its extremely high prevalence among the women of senior reproductive age, occurrence and increasing of complex of the factors promoting development of moral- psychological and social - industrial disadaptation of the women.

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INFLUENCE OF SURGICAL INTERVENTION ON PATIENTS WITH OVARIAN APOPLEXY IN THE ASPECT OF OVARIAN RESERVE PRESERVATION

World Science ◽

10.31435/rsglobal_ws/31052019/6512 ◽

2019 ◽

Vol 2 (5(45)) ◽

pp. 7-10

Author(s):

O. M. Ishchak

Keyword(s):

Surgical Treatment ◽

Ovarian Reserve ◽

Antral Follicle ◽

Disease Recurrence ◽

Reproductive Age ◽

Hemodynamic Parameters ◽

Bipolar Coagulation ◽

Study Results ◽

Duration Of Surgery ◽

First Time

Ovarian apoplexy is the women’s disease of reproductive age, 75% of which are under the age of 30 years old, about 30% undergo surgery, and 40-62% of them are subjected to repeated surgeries because of disease recurrence [3, 10]. Goal of study: improvement of surgical treatment of the patients with ovarian apoplexy for maximal preservation of ovarian reserve.Materials and methods. A total of 120 women were included in the study. These include 55 patients with ovarian apoplexy, who underwent laparoscopic surgery for the first time. These patients were included in the prospective study and divided into two groups, depending on the hemostasis method used during the surgery. Group 1 included 30 patients with hemostasis, which was carried out using bipolar coagulation, group 2 included 25 patients, whose bleeding from the ovary was stopped by applying sutures. In each group, the patients were selected with the “blind” method. The study included patients with stable hemodynamic parameters before surgery and duration of hospitalization of not more than 24 hours. The comparison group consisted of 45 patients with laparoscopic confirmation of pain form of the ovarian apoplexy, who underwent conservative treatment. Study results and their discussion. Patients with ovarian apoplexy with stable hemodynamic parameters should undergo surgery using laparoscopic access, which allows to clarify the diagnosis, stop bleeding, prevent development of sexually transmitted infections and carry out surgical correction of the associated pathological processes of the internal genital organs. Stop of bleeding at the patients with ovarian apoplexy with bipolar electrosurgery is faster (shorter duration of surgery by 13 minutes), but this leads to more significant decrease in ovarian reserve (Anti-Mullerian hormone (AMH) by 30%, antral follicle count (AFC) by 10%) than use of hemostatic sutures (AMH by 22%, PAF by 8%) (p <0.05). In order to maximize the maintenance of the ovarian reserve at surgeries by women with ovarian apoplexy, it is always better to carry out hemostasis by enucleating the cyst capsule within healthy tissues and saturation with absorbable synthetic areactive sutures on the ovarian wound following by intracorporal knot tying. Regardless of the hemostasis, used during surgical treatment of ovarian apoplexy by patients of the age of 36 years old and older, there is a greater decrease in ovarian reserve (AMH by 30%, AFC by 20%) than at patients whose age is less than 35 years old (AMH by 20%, AFC by 12%) (p <0.05). By patients with implemented fertility function regardless of age and by all patients under the age of 35, undergoing surgery because of ovarian apoplexy for the first time, bipolar coagulation is permissible to stop bleeding. At implementation of bipolar hemostasis of patients with ovarian apoplexy, point coagulation of bleeding vessels should be performed, avoiding damage to surrounding tissues.

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Sperm donation and surrogacy from a male perspective

European Psychiatry ◽

10.1016/j.eurpsy.2017.01.1679 ◽

2017 ◽

Vol 41 (S1) ◽

pp. s848-s848

Author(s):

N. Carolino ◽

A. Galhardo ◽

M. Moura-Ramos ◽

M. Cunha ◽

B. Monteiro

Keyword(s):

Gender Equity ◽

Research Area ◽

Reproductive Age ◽

Gamete Donation ◽

Sperm Donation ◽

Major Focus ◽

Online Questionnaire ◽

Information Availability ◽

Societal Changes ◽

Competing Interest

IntroductionSocietal changes in the last decades led to the arise of new paradigms on gender equity. Studies addressing fertility/infertility issues have been conducted mainly in women and in this research area, male partners have deserved less attention. More recently there has been a major focus on the idea that fertility/infertility aspects have to be conceptualized from a couples’ perspective.GoalsThe current study sought to explore attitudes towards gamete donation and surrogacy in a sample of young men in reproductive age.MethodsA total of 111 males with ages ranging from 18 to 40 years old and without children completed an online questionnaire addressing attitudes towards gamete donation and surrogacy.ResultsThe majority of participants (77.3%) would be willing to donate their sperm, and their main motivation for doing that would be to feel “happy to help a couple struggling to have a child”. Participants stated that the likelihood of donating would increase if they were able to attend counseling, to complete the procedure in an IVF center located in their residence area, and being provided with more information about infertility. Regarding surrogacy 82% are in favor of this procedure legalization and 49.5% would be willing to use it if they needed.ConclusionMen showed a positive attitude towards sperm donation and surrogacy, emphasizing the importance of counseling and information availability on these topics. This may suggest that they are willing to get involved when fertility issues are addressed.Disclosure of interestThe authors have not supplied their declaration of competing interest.

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Vaginal microbiomes in women with infertility that was surgical treatment on the uterine appendages

HEALTH OF WOMAN ◽

10.15574/hw.2018.134.98 ◽

2018 ◽

pp. 98-102

Author(s):

A.E. Dubchak ◽

◽

A.V. Milevsky ◽

N.N. Obeid ◽

◽

...

Keyword(s):

Surgical Treatment ◽

Antimicrobial Agents ◽

Inflammatory Diseases ◽

Reproductive Age ◽

Anaerobic Microorganisms ◽

Normal Microflora ◽

Vaginal Tract ◽

High Degree ◽

Aerobic And Anaerobic ◽

Group 1

The objective: of the study was to study the microbial vaginal tract in women with infertility, who had undergone surgical treatment on the uterine appendages. Materials and methods. An examination of vaginal discharge on flora and STIs was conducted in 120 women of reproductive age with infertility and benign ovarian formations, ectopic pregnancy, which was organ-retained surgical intervention on the appendages of the uterus. Of these, 76 (1 group) patients were surgically treated in a planned manner, 44 (in 2 groups) – in urgent cases. Results. Inflammatory diseases of the genital area were more common in women with infertility, who had surgical treatment in an urgent manner than in women of group 1 (p<0.05), especially inflammatory diseases of the cervix – almost twice as likely as in group 1. The vaginal microbial examination of women with infertility who were hospitalized for surgical treatment in an urgent manner indicates a significant imbalance between the parameters of contamination of the genital tract by conditionally pathogenic and normal microflora. This, above all, was manifested by the high frequency of determination in women of the 2nd group of representatives of optional aerobes and anaerobes (p<0.05). The concentration of facultative-aerobic and anaerobic microorganisms was in patients of the 2nd group, mostly of high degree of microbial dissemination, and in women of the 1 group, medium and low. STIs were found mainly in association with anaerobic and aerobic microorganisms in patients who were operated in an urgent manner. Conclusion. It is necessary to correct the vaginal biotope in women with infertility before surgical treatment – to promptly influence pathogenic microorganisms with antimicrobial agents and restore physiological vaginal microbial vagina. Key words: women, infertility, vaginal microbial, appendages of the uterus, surgical treatment.

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Building national associations for psychiatry trainees: The MENTA recipe for success

European Psychiatry ◽

10.1017/s0924933800284526 ◽

2017 ◽

Vol 41 (S1) ◽

pp. 912-912

Author(s):

T.M. Gondek

Keyword(s):

Working Group ◽

Task Force ◽

Child And Adolescent Psychiatry ◽

Early Career ◽

Psychiatric Training ◽

European Federation ◽

Adult Psychiatry ◽

Umbrella Organization ◽

Competing Interest ◽

Work Done

European Federation of Psychiatric Trainees (EFPT) is an umbrella organization for national psychiatric trainee associations in Europe, aiming to develop collaboration between psychiatric trainees. EFPT states that organised trainee interest is crucial in promoting high quality psychiatric training, therefore it promotes that both general adult psychiatry and child and adolescent psychiatry trainees are represented by national trainee association in each European country. The Maintaining and Establishing a National Trainee Association Working Group (MENTA WG), a permanent EFPT working group, has been created to assist trainees in building a local trainee organization. MENTA WG supports organising meetings, helps manage the problems of functioning of an association, sends letters of support to national decision makers, helps prepare the organization's bylaws and facilitates the process of application for full EFPT membership. The group also helps reactivate the inactive associations and assists them in expansion and developing new initiatives. MENTA WG maintains close collaboration with the European Psychiatric Association Early Career Psychiatrists Committee (EPA ECPC) Task Force on Meetings and Associations and other organizations dedicated to early career psychiatrists, such as the Young Psychiatrists’ Network. In the last few years, due to the work done within MENTA WG, the EFPT family has grown and welcomed new official members, such as: Poland, Spain and Slovakia. Currently, we are planning on supporting trainees in Moldova, Bulgaria and Kosovo to establish new official organizations in these countries. We also expand our activities beyond Europe and offer counselling for psychiatric trainees from such countries as Australia or South Africa.Disclosure of interestThe author has not supplied his declaration of competing interest.

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