Surgical performance of large loop excision of the transformation zone in a training model: A prospective cohort study.

Large loop excision of the transformation zone (LLETZ) is one of the most common procedures in operative gynecology and it is a routine part of the surgical training program of residents. There is, however, no established and standardized method of teaching residents how to perform LLETZ. Here, we present a surgical training model and assessed the improvement of surgical skills during repeated hands-on trainings of LLETZ in this model.Surgical novices and experts were recruited and were shown a LLETZ training video and then performed 3 LLETZ training sessions on consecutive days. Surgical skills were assessed by Objective Structured Assessment of Technical Skills (OSATS). Global rating scale (GRS), confidence (CON), fragmentation rate (FR), performance time (PT), and OSATS scores were calculated. Intra- and interobserver variabilities were determined. The construct validity of OSATS was assessed comparing metric scores of novices with those of experts.Sixty-eight probands (58 novices, 10 experts) were recruited. GRS, 2.3 ±â€Š1.3 (median ±â€ŠSD) versus 1.4 ±â€Š0.6, P < .001; CON, 2.7 ±â€Š0.9 versus 1.6 ±â€Š0.6, P < .001; FR, 81% versus 100%, P < .001; PT, 152 ±â€Š33 versus 120 ±â€Š27 seconds, P = .006; and OSATS scores, 18.8 ±â€Š1.3 versus 19.1 ±â€Š1.1, P = .16 of novices improved from session 1 to session 3. OSATS showed construct validity with metric scores (GRS, 1.1 ±â€Š0.3 vs 2.3 ±â€Š0.8, P < .001; CON, 1.0 ±â€Š0.0 vs 2.7 ±â€Š0.9, P < .001; PT 125 ±â€Š30 vs 152 ±â€Š33 seconds, P = .02; OSATS scores, 19.6 ±â€Š0.7 vs. 18.8 ±â€Š1.3, P = .02) reliably discriminating between experts and novices. Intra- and interobserver variabilities across probands were 0.99 ±â€Š0.03 and 0.64 ±â€Š0.10, respectively. OSATS scores were independent of handedness, sex, and regular sports activity in univariate and multivariate analyses.Repeated hands-on trainings improve surgical performance of LLETZ in a surgical training model with construct validity.

Quality of websites of obstetrics and gynecology departments: a cross-sectional study.

BACKGROUND: The internet has become an easily accessible and widely used source of healthcare information. There are, however, no standardized or commonly accepted criteria for the quality of Obstetrics and Gynecology websites. In this study, we aimed to evaluate the quality of websites of Obstetrics and Gynecology departments in German-speaking countries and to compare websites nationally and internationally. METHODS: We scored 672 websites from Germany (n = 566), Austria (n = 57), and Switzerland (n = 49) using the objective criteria: Google search rank (2 items), technical aspects (11 items), navigation (8 items), and content (6 items) for a 26 point score. Scores were compared nationally and internationally. Multivariable regression models assessed good quality scores (≥50% of maximum) as the dependent variables and country, academic affiliation, being member of a healthcare consortium, confessional affiliation, and content management system (CMS) use as independent variables. RESULTS: The mean score of websites was 13.8 ± 3.3. 4.2% were rated as good (≥75% of maximum), 61.8% as fair (≥50% of maximum). German (14.0 ± 3.2) and Swiss (13.8 ± 4.0) websites scored significantly higher compared to Austrian websites (11.6 ± 2.5) (P < 0.001 and P = 0.005, respectively). Within Germany, academic had higher scores than non-academic departments (14.9 ± 3.2 vs. 13.7 ± 3.1, P < 0.001). Single institutions had higher scores compared to healthcare consortium institutions (14.1 ± 3.2 vs. 13.2 ± 2.6, P = 0.003). Departments in Northern and Southern states had higher scores compared to Eastern states (14.4 ± 3.2 and 14.2 ± 3.2 vs. 13.0 ± 3.0, P < 0.001). In multivariate regression models, all subscores (all: P < 0.001) independently predicted a website's reaching a good quality score, with navigation subscore as strongest predictor. Affiliations were predictors for some good individual subscores, but not for others. High content subscore was associated with good Google search rank, technical aspects, and navigation subscores. CONCLUSIONS: The quality of websites of Obstetrics and Gynecology departments varies widely. We found marked differences depending on country, affiliation, and region.

Low-dose pressurized intraperitoneal aerosol chemotherapy (PIPAC) as an alternative therapy for ovarian cancer in an octogenarian patient.

BACKGROUND: Octogenarians with ovarian cancer limited to the abdomen may not be willing or able to undergo systemic chemotherapy. Low-dose pressurized intraperitoneal aerosol chemotherapy (PIPAC) with cisplatin and doxorubicin is a form of intra-abdominal chemotherapy which can be applied repeatedly and potentially prevents from the systemic side-effects of chemotherapy. CASE REPORT: We present the case of an 84-year-old woman with laparoscopically and histologically confirmed ovarian cancer who refused to undergo systemic chemotherapy. She was treated with eight courses q 28-104 days of low-dose PIPAC with cisplatin at 7.5 mg/m(2) and doxorubicin at 1.5 mg/m(2) at 12 mmHg and 37 °C for 30 min. Objective tumor response was noted, defined as tumor regression on histology, and stable disease noted by peritoneal carcinomatosis index on repeated video-laparoscopy and abdominal computed tomographic scan. The treatment was well-tolerated with no Common Terminology Criteria for Adverse Events (CTCAE) CTCAE >2. With a follow-up of 15 months, the patient is alive and clinically stable. The quality of life measured by the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 demonstrated improvement over 5-6 months (global physical score, global health score, global quality of live) without cumulative increase of gastrointestinal toxicity. CONCLUSION: Low-dose PIPAC is a new form of intraperitoneal chemotherapy which may be applied repeatedly in octogenarian patients. PIPAC may be an alternative and well-tolerated treatment for selected octogenarian patients with ovarian cancer limited to the abdomen who cannot be treated with systemic chemotherapy.

Fertility awareness among medical and non-medical students: a case-control study.

BACKGROUND: To compare the understanding and perceptions of fertility issues among medical and non-medical University students. METHODS: In a prospective case-control study, using a 43 item questionnaire with 5 sections and 43 questions regarding personal data (8 questions), lifestyle factors (9 questions), plans on having children (5 questions), age and fertility (5 questions), and lifestyle and fertility (16 questions), knowledge of fertility and influencing factors, desired age at commencement and completion of childbearing, among male and female medical and non-medical students in their first academic year at Vienna University, Vienna, Austria were evaluated. RESULTS: 340 students were included. 262/340 (77%) participants planned to have children in the future. Medical students (n = 170) planned to have fewer and later children and had a higher awareness of the impact of age on fertility than non-medical students (n = 170; estimated knowledge probability 0.55 [medical students] vs. 0.47 [non-medical students]; F (1, 336) = 5.18 and p = .024 (η p = .015). Gender did not independently affect estimated knowledge probability (F (1, 336) = 1.50 and p = .221). More female and male medical students had a positive attitude towards Assisted Reproductive Technology in case of infertility than non-medical students (47 and 55% vs. 23 and 29%, respectively; p = <.001). Medical students had a healthier lifestyle than non-medical students. A healthy lifestyle and female gender were associated with higher fertility awareness. CONCLUSIONS: Medical students have a higher awareness of fertility issues than non-medical students. Choice of academic study, gender, and personal life style are important factors affecting fertility awareness. These data may be helpful to address knowledge gaps among young non-medical Academics.

Objective Structured Assessment of Technical Skills (OSATS) evaluation of hysteroscopy training: a prospective study.

OBJECTIVES: To describe the performance curve of hysteroscopy-naïve probands repeatedly working through a surgery algorithm on a hysteroscopy trainer. STUDY DESIGN: We prospectively recruited medical students to a 30min demonstration session teaching a standardized surgery algorithm. Subjects subsequently performed three training courses immediately after training (T1) and after 24h (T2) and 48h (T3). Skills were recorded with a 20-item Objective Structured Assessment of Technical Skills (OSATS) at T1, T2, and T3. The presence of a sustained OSATS score improvement from T1 to T3 was the primary outcome. Performance time (PT) and self assessment (SA) were secondary outcomes. Statistics were performed using paired T-test and multiple linear regression analysis. RESULTS: 92 subjects were included. OSATS scores significantly improved over time from T1 to T2 (15.21±1.95 vs. 16.02±2.06, respectively; p<0.0001) and from T2 to T3 (16.02±2.06 vs. 16.95±1.61, respectively; p<0.0001). The secondary outcomes PT (414±119s vs. 357±88s vs. 304±91s; p<0.0001) and SA (3.02±0.85 vs. 3.80±0.76 vs. 4.41±0.67; p<0.0001) also showed an improvement over time with quicker performance and higher confidence. SA, but not PT demonstrated construct validity. In a multiple linear regression analysis, gender (odds ratio (OR) 0.96; 95% confidence interval (CI) 0.35-2.71; p=0.9) did not independently influence the likelihood of OSATS score improvement. CONCLUSIONS: In a hysteroscopy-naïve population, there is a continuous and sustained improvement of surgical proficiency and confidence after multiple training courses on a hysteroscopy trainer. Serial hysteroscopy trainings may be helpful for teaching hysteroscopy skills.

Activity of Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) with cisplatin and doxorubicin in women with recurrent, platinum-resistant ovarian cancer: preliminary clinical experience.

OBJECTIVE: To assess the activity of laparoscopic Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC) in women with recurrent, platinum-resistant ovarian cancer. METHODS: Prospective case series using repeated courses q 28-42 days of PIPAC containing cisplatin 7.5 mg/m(2) and doxorubicin 1.5 mg/m(2) at 12 mmHg and 37°C for 30 min. Objective tumor response was defined as tumor regression on histology and peritoneal carcinomatosis index (PCI) improvement on repeated video-laparoscopy. RESULTS: 34 PIPAC procedures were performed in 18 women, in 8 instances combined with cytoreductive surgery (CRS). Eight women had repeated PIPAC and objective tumor response was observed in 6 (complete remission: 1; partial remission: 2; stable disease: 3). Five adverse events WHO grade ≥ 2 were noted, 3 of them after combined CRS. No perioperative mortality occurred. Median follow-up was 192 days (min. 13-max. 639). Cumulative survival after 400 days was 62% and mean actuarial survival time was 442 days. In a multivariable regression analysis with objective tumor response (yes vs. no) as the dependent variable and PIPAC (1 vs.>1), patient age (<75 vs.≥75 years), serum CA-125 (<1000 vs.>1000 U/mL), and the presence of ascites (yes vs. no) as independent variables, PIPAC independently predicted objective tumor response. CONCLUSION: PIPAC has activity in women with recurrent, platinum-resistant ovarian cancer and should be investigated in prospective clinical trials.

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) with cisplatin and doxorubicin in a woman with pseudomyxoma peritonei: A case report.

•This is the first report of pressurized intraperitoneal aerosol chemotherapy (PIPAC) in a woman with pseudomyxoma peritonei.•PIPAC achieved clinical and histological disease remission.•PIPAC with cisplatin and doxorubicin may be effective in pseudomyxoma peritonei.

Objective Structured Assessment of Technical Skills (OSATS) evaluation of theoretical versus hands-on training of vaginal breech delivery management: a randomized trial.

OBJECTIVE: To compare the skills of performing a vaginal breech (VB) delivery after hands-on training versus demonstration. STUDY DESIGN: We randomized medical students to a 30-min demonstration (group 1) or a 30-min hands-on (group 2) training session using a standardized VB management algorithm on a pelvic training model. Subjects were tested with a 25 item Objective Structured Assessment of Technical Skills (OSATS) scoring system immediately after training and 72 h thereafter. OSATS scores were the primary outcome. Performance time (PT), self assessment (SA), confidence (CON), and global rating scale (GRS) were the secondary outcomes. Statistics were performed using the Mann-Whitney U-test, chi-square test, and multiple linear regression analysis. RESULTS: 172 subjects were randomized. OSATS scores (primary outcome) were significantly higher in group 2 (n=88) compared to group 1 (n=84) (21.18±2.29 vs. 20.19±2.37, respectively; p=0.006). The secondary outcomes GRS (10.31±2.28 vs. 9.17±2.21; p=0.001), PT (214.60±57.97 s vs. 246.98±59.34 s; p<0.0001), and CON (3.14±0.89 vs. 2.85±0.90; p=0.04) were also significantly different between groups, favoring group 2. After 72 h, primary and secondary outcomes were not significantly different between groups. In a multiple linear regression analysis, group assignment (odds ratio [OR] 1.60; 95% confidence interval [CI] 1.14-2.05; p<0.0001) and gender (OR 2.91; 95% CI 2.45-3.38; p<0.0001) independently influenced OSATS scores. CONCLUSION: Hands-on training leads to a significant improvement of VB management in a pelvic training model, but this effect was only seen in the short term.

Objective structured assessment of technical skills evaluation of theoretical compared with hands-on training of shoulder dystocia management: a randomized controlled trial.

OBJECTIVE: To compare the skills of performing a shoulder dystocia management algorithm after hands-on training compared with demonstration. METHODS: We randomized medical students to a 30-minute hands-on (group 1) and a 30-minute demonstration (group 2) training session teaching a standardized shoulder dystocia management scheme on a pelvic training model. Participants were tested with a 22-item Objective Structured Assessment of Technical Skills scoring system after training and 72 hours thereafter. Objective Structured Assessment of Technical Skills scores were the primary outcome. Performance time, self-assessment, confidence, and global rating scale were the secondary outcomes. Statistics were performed using Mann-Whitney U test, χ test, and multiple linear regression analysis. RESULTS: Two hundred three participants were randomized. Objective Structured Assessment of Technical Skills scores were significantly higher in group 1 (n=103) compared with group 2 (n=100) (17.95±3.14 compared with 15.67±3.18, respectively; P<.001). The secondary outcomes global rating scale (GRS; 10.94±2.71 compared with 8.57±2.61, respectively; P<.001), self-assessment (3.15±0.94 compared with 2.72±1.01; P=.002), and confidence (3.72±0.98 compared with 3.34±0.90, respectively; P=.005), but not performance time (3:19±0:48 minutes compared with 3:31±1:05 minutes; P=.1), were also significantly different, favoring group 1. After 72 hours, Objective Structured Assessment of Technical Skills scores were still significantly higher in group 1 (n=67) compared with group 2 (n=60) (18.17±2.76 compared with 14.98±3.03, respectively; P<.001) as were GRS (10.80±2.62 compared with 8.15±2.59; P<.001) and self assessment (SA; 3.44±0.87 compared with 2.95±0.94; P=.003). In a multiple linear regression analysis, group assignment (group 1 compared with 2; P<.001) and sex (P=.002) independently influenced Objective Structured Assessment of Technical Skills scores. CONCLUSION: Hands-on training helps to achieve a significant improvement of shoulder dystocia management on a pelvic training model. CLINICAL TRIAL REGISTRATION: www.ClinicalTrials.gov, NCT01618565. LEVEL OF EVIDENCE: I.

Lymphatic spread of endometriosis to pelvic sentinel lymph nodes: a prospective clinical study.

OBJECTIVE: To establish the prevalence of endometriosis metastatic to pelvic sentinel lymph nodes (PSLN) in women with ovarian and/or peritoneal endometriosis. DESIGN: Prospective clinical study. SETTING: Academic research institution. PATIENT(S): Women with a laparoscopic diagnosis of ovarian and/or peritoneal endometriosis verified by intraoperative frozen section analysis. INTERVENTION(S): Resection of endometriotic lesions and PSLN after cervical blue dye injection. MAIN OUTCOME MEASURE(S): Histologic analysis of PSLN for the presence of endometriosis and immunohistochemical analysis of estrogen receptor (ER), progesterone receptor (PR), cytokeratin (CK), and CD-10 expression. RESULT(S): The study enrolled 26 women with suspected endometriosis; endometriosis was confirmed in 23 women, and a PSLN was identified in 19 women. A total of 37 (right side: 20; left side: 17) lymph nodes were removed. The prevalence of endometriotic lesions in PSLN was 11% (2 of 19). Both lesions were positive for ER, PR, CK, and CD-10. Isolated endometriotic-like cells (IELCs) staining positive for ER and PR were identified in the peripheral sinus of 16 (80%) of 20 and 14 (70%) of 20 PSLN, respectively. All IELCs lacked CK staining, whereas CD-10 staining was present in 16 (80%) of 20 cases, indicating a stromal origin of IELCs. Intraoperative and/or postoperative complications were observed in 1 (5%) of 19 women. CONCLUSION(S): Spread of IELCs to PSLN is common in ovarian and/or peritoneal endometriosis. Metastatic lesions in PSLN are present in 11% of women. Further studies to evaluate the prognostic and predictive value of endometriotic spread to PSLN are warranted.

Saliva cortisol levels and subjective stress are not associated with number of oocytes after controlled ovarian hyperstimulation in patients undergoing in vitro fertilization.

OBJECTIVE: To establish an association between the number of oocytes retrieved after controlled ovarian hyperstimulation (COH) and saliva cortisol (F) levels, as well as subjective stress, in women undergoing their first IVF cycle. DESIGN: Prospective clinical study. SETTING: Academic research institution. PATIENT(S): Women with primary or secondary infertility undergoing IVF. INTERVENTION(S): Fertility problem inventory (FPI) questionnaire and measurement of morning and evening saliva F by RIA. MAIN OUTCOME MEASURE(S): Number of oocytes and stress, defined as low morning F and/or a positive FPI result. RESULT(S): Eighty-three women provided saliva specimens, 66 of whom also filled in the FPI. The median number of oocytes was 8.4 (range 0-26). A state of stress was observed in 38/83 (46%) women. The mean number of oocytes was not significantly different between women with and without stress (7.3 ± 4.3 vs. 8.9 ± 6.9, respectively). In a multivariate analysis, stress (odds ratio 2.6; 95% confidence interval 0.03-225.7) and morning F (odds ratio 0.9; 95% confidence interval 0.6-1.3) were not significantly associated with the number of oocytes. There were no statistically significant correlations between F concentrations, FPI results, and age, number of poor responders, live birth rate, and clinical pregnancy rate (PR). CONCLUSION(S): Stress, as measured by saliva F and the FPI questionnaire, does not negatively impact the effectiveness of COH and is not associated with a reduced number of oocytes.

Does duration of hysteroscopy increase the risk of disease recurrence in patients with endometrial cancer? A multi-centre trial.

Women with endometrial cancer often undergo hysteroscopy during their diagnostic work-up. Whether or not the duration of hysteroscopy affects the rate of positive peritoneal cells and the duration of recurrence-free survival is unknown. In a retrospective multi-centre study, the records of 552 patients with endometrial cancer were investigated. Duration of hysteroscopy was correlated with clinicopathological parameters and patient survival data. The mean [standard deviation (SD)] duration of hysteroscopy was 18.2 (10.5) min in the study population and 17.9 (10.1) min and 17.9 (10.2) min in patients with positive (n=109) and negative peritoneal cytology (n=443), respectively (p=0.9). There were no statistically significant correlations between duration of hysteroscopy and positive peritoneal cytology (p=0.6; rho=-0.028), FIGO stage (p=0.2; rho=-0.080), lymph node involvement (p=0.2; rho=0.106) and patient age (p=0.5; rho=0.033). Longer duration of hysteroscopy (>15 min) was not associated with positive peritoneal cytology (yes vs. no, p=0.8), advanced tumour stage (FIGO I vs. II, III and IV, p=0.3), lymph node involvement (yes vs. no, p=0.1) and patient age (≤65 vs. >65 years, p=0.4). In a multivariate analysis, FIGO stage [p<0.0001; hazard ratio (HR)=5.1, 95% confidence interval (CI) 2.5-10.2], lymph node involvement (p=0.02; HR=3.2, 95% CI 1.2-8.8) and patient age (p=0.003; HR=2.4, 95% CI 1.3-4.2), but not duration of hysteroscopy (p=0.4; HR=1.2, 95% CI 0.7-2.2), were associated with recurrence-free survival. We conclude that longer duration of hysteroscopy does not increase the risk of positive peritoneal cytology and it is not an adverse prognostic factor for recurrence-free survival in patients with endometrial cancer.

Frequency of 23 human papillomavirus types using DNA microarray in women with and without cytological anomalies.

OBJECTIVE: To evaluate the frequency of single and multiple human papillomavirus (HPV) infections in women with and without cervical dysplasia. MATERIALS AND METHODS: An oligonucleotide microarray system was used to detect 19 types of high-risk HPV (HPV-16/-18/-311-33/-35/-39/-45/-51/ -52/-53/-56/-58/-59/-66/-68/-73/-821-16 variant E-E6-G350/-16 variant E-E6-T350) and 4 types of low-risk HPV (HPV-6/-11/ -42/-44) in 122 consecutive women visiting our colposcopy outpatient clinic classified into controls (normal epithelium, nonspecific cervicitis, metaplasia; n = 56) and cervical intraepithelial neoplasia (CIN) (n = 66). RESULTS: In 78/122 (64%) cervical samples, HPV DNA was detected. Compared to controls, HPV infection was significantly more prevalent among women with CIN (8/56 [14%] versus 49/66 [74%]; p = 0.001). HPV-18 and HPV-16 were the most common HPV types in all specimens (25% [31/122] and 25% [31/122], respectively). Of note, HPV-16 was significantly more frequent in women with CIN compared to controls (35% [23/66] vs. 14% [8/56], respectively; p = 0.02). Double HPV infections were detected in 16/122 (13%) and multiple infections in 43/122 (35%) women. Multiple HPV infections were found significantly more often among women with CIN compared to controls (30/66 [45%] vs. 13/56 [23%], respectively; p = 0.002). Using a univariate and multivariate logistic regression model to estimate the relative risk of CIN vs. HPV type, HPV-16-positive cases were found to have the highest risk of CIN (odds ratio [OR] 3.2; 95% confidence interval [CI] 1.3-7.9; p = 0.002). CONCLUSION: Multiple HPV infections are common in women with and without CIN, but significantly more prevalent among women with CIN compared to controls.

A polymorphism of the interleukin-1 beta gene is associated with sperm pathology in humans.

In a prospective case-control study of 127 normozoospermic and 435 non-normozoospermic Caucasian men, the genotype frequencies of a polymorphism of the interleukin-1 beta gene (IL-1beta Taq C-->T) were statistically significantly different between groups (homozygous wild-type C/C [57%], heterozygous C/T [42%], and homozygous mutant T/T [1%] vs. C/C [57%], C/T [36%], T/T [7%] for normozoospermic and non-normozoospermic men, respectively; odds ratio, 4.8; 95% confidence interval, 1.13 to 20.28). This association was restricted to men with the oligoasthenoteratozoospermia (OAT) syndrome. We conclude that the investigated polymorphism is associated with sperm pathology in Caucasians.