Diagnostic hysteroscopy and saline infusion sonography in the diagnosis of intrauterine abnormalities: an assessment of patient preference.

This study was conducted to assess whether women would prefer to undergo saline infusion sonography (SIS) or office hysteroscopy for the investigation of the uterine cavity. In a randomised controlled trial, 100 patients underwent SIS or office hysteroscopy for assessing patients' pain scores. After the investigation, 92 of them were asked to fill out an anonymous questionnaire addressing their preference regarding the method of evaluation and treatment of the uterine cavity. A control group, consisting of 50 women who never underwent SIS or office hysteroscopy, was also asked to complete an identical questionnaire. The questionnaire was completed by 113 women (83.7%). Twenty-four (21.2%) women would opt for SIS, whereas 52 (46.0%) would opt for office hysteroscopy, and 37 (32.7%) had no preference. If therapy would be necessary, 48.7% of the women would opt for an outpatient treatment, whereas 33.0% of the women would prefer treatment under general anaesthesia. Despite the fact that SIS is less painful, the majority of the women prefer office hysteroscopy. Additionally, therapy in an outpatient setting is preferred to a day case setting.

The validation of a simulation model incorporating radiation risk for mammography breast cancer screening in women with a hereditary-increased breast cancer risk.

INTRODUCTION: For women with a BRCA1 or BRCA2 mutation or a strong family history of breast cancer, there is no clear estimation of the risk of tumour induction versus the beneficial effects of mammography screening available. This study aims to validate the Simulation Model on Radiation Risk and breast cancer Screening (SiMRiSc) model in these women, which can provide information on the benefits and risks of screening for breast cancer for various screening scenarios. METHODS: The simulation model for breast cancer screening was developed and the values for model parameters including cancer induction due to radiation were derived from the literature. The simulation model was validated by comparing the outcome data of the model with the data from three published screening studies of women with an increased hereditary breast cancer risk. A sensitivity analysis was used to estimate the error margins of the outcome data and to analyse the sensitivity of the simulation model to each parameter. RESULTS: The model predicted 71+/-4% of the reported tumours. When excluding the excess number of incident tumours detected in the first screening round, the model predicted 85+/-6% of the tumours reported. The model was most sensitive to changes in the parameters related to lifetime breast cancer risk and sensitivity of mammography. CONCLUSIONS: We conclude that the simulation model is suitable for the provision of accurate benefits' and risks' estimations necessary for the refinement of the screening guidelines for women at an increased risk of breast cancer.

Maggot debridement therapy in the palliative setting.

Success rates of Maggot Debridement Therapy (MDT) differ, but range from 70% to 80%. In this article it is argued that wound closure is not always feasible and is not always the aim of the treatment. A patient is described in whom the intent of MDT was not wound closure, but infection removal, reduction of odor, and eventually prevention of a below knee amputation. This succeeded: the pain was diminished, the odor reduced, and the wound showed signs of healing. Still the patient died. In maggot literature, as with other wound treatments, outcome is recorded as closed or as failed. In our opinion, MDT has other indications besides wound closure.

Maggot debridement therapy of infected ulcers: patient and wound factors influencing outcome - a study on 101 patients with 117 wounds.

INTRODUCTION: It has been known for centuries that maggots are potent debriding agents capable of removing necrotic tissue and slough. In January 2004, the US Food and Drug Administration decided to regulate maggot debridement therapy (MDT). As it is still not clear which wounds are likely or unlikely to benefit from MDT, we performed a prospective study to gain more insight in patient and wound characteristics influencing outcome. PATIENTS AND METHODS: In the period between August 2002 and December 2005, patients with infected wounds with signs of gangrenous or necrotic tissue who seemed suited for MDT were enrolled in the present study. In total, 101 patients with 117 ulcers were treated. Most wounds were worst-case scenarios, in which maggot therapy was a treatment of last resort. RESULTS: In total, 72 patients (71%) were classified as ASA III or IV. In total, 78 of 116 wounds (67%) had a successful outcome. These wounds healed completely (n = 60), healed almost completely (n = 12) or were clean at least (n = 6) at last follow-up. These results seem to be in line with those in the literature. All wounds with a traumatic origin (n = 24) healed completely. All wounds with septic arthritis (n = 13), however, failed to heal and led in half of these cases to a major amputation. According to a multivariate analysis, chronic limb ischaemia (odds ratio [OR], 7.5), the depth of the wound (OR, 14.0), and older age (>or= 60 years; OR, 7.3) negatively influenced outcome. Outcome was not influenced by gender, obesity, diabetes mellitus, smoking, ASA-classification, location of the wound, wound size or wound duration. CONCLUSIONS: Some patient characteristics (i. e. gender, obesity, smoking behaviour, presence of diabetes mellitus and ASA-classification at presentation) and some wound characteristics (i. e. location of the wound, wound duration and size) do not seem to contra-indicate eligibility for MDT. However, older patients and patients with chronic limb ischaemia or deep wounds are less likely to benefit from MDT. Septic arthritis does not seem to be a good indication for MDT.

Extracellular Wound Matrix (OASIS®): Exploring the Contraindications. Results of Its Use in 32 Consecutive Outpatient Clinic Cases.

UNLABELLED: Background. In the authors' experience re-epithelialization after successful debridement and granulation can be the most difficult part of the wound closure process. Extracellular matrix products represent a possible solution. However, in studies discussing the effectiveness of extracellular wound matrix (porcine-derived small intestine submucosa [SIS], [OASIS® Wound Matrix, Healthpoint Ltd, Fort Worth, Tex]), a long list of exclusion criteria has been presented. The present study was designed to explore the contraindications of OASIS Wound Matrix. METHODS: In this study, 32 patients in whom the wounds were fully debrided and granulated were treated with weekly applications of the wound matrix. The exclusion criteria formulated in the reported literature were followed. Seven different outcomes were defined. Various patient and wound characteristics that might influence outcome were recorded. RESULTS: Beneficial outcomes were seen in 80.6 % (n = 25) of the patients. The two main complications seen were infection and hypergranulation tissue. Infection was seen in 7 patients (22.6%). Four patients (57.1%) had an unsuccessful outcome. Hypergranulation tissue occurred in another 7 patients (22.6%) after a couple of applications. They all had a beneficial outcome. CONCLUSION: Much of the exclusion criteria used in previous reports are too strict. Infection should be the only absolute contraindication for starting treatment with OASIS, and it is a good reason to discontinue treatment with an ECM. Hypergranulation tissue (22.6%) is an easily treatable complication that has no negative influence on outcome. Some wounds (77.4%) had no complications, or had easily treatable complications that did not negatively influence the outcome.

Maggot Debridement Therapy in Necrotizing Fasciitis Reduces the Number of Surgical Debridements.

Necrotizing fasciitis is a rare but potentially lethal bacterial infection of the fascial and subcutaneous tissues. Mortality rates of this condition remain high, ranging from 6%-76%. Bacterial cultures may show a wide variety of organisms, but Group A Streptococcus (Streptococcus pyogenes) is the causative agent in up to 71% of all human cases. The treatment consists of urgent radical surgical debridement in combination with broad-spectrum antibiotic therapy. Maggot debridement therapy (MDT) has been proven to be very effective in the treatment of gram-positive bacterial infections. The present study reports on the results of 15 patients with necrotizing fasciitis treated with surgical debridement and antibiotic therapy in combination with MDT from November 2001 to November 2005. A detailed case report of 1 patient is presented.

Pilot study evaluating a clinical decision tool on suspected scaphoid fractures.

In an earlier study we have proposed a scaphoid decision-protocol in order to improve diagnostic accuracy in case of suspected scaphoid fractures. This pilot study evaluated this protocol. In this pilot study (n = 31) most cases with clinical suspicion of scaphoid fractures reached a positive test result on the combined 7 clinical tests (93.5%). Using this test combination, no scaphoid fractures were missed (no false-negatives; sensitivity 100%), but it also included many patients with no scaphoid fracture. Many of these, however, were found to have another fracture. In total, 48% had a scaphoid fracture, 19% another fracture and 32% no fracture. In the pilot study the proposed protocol seems to be a safe protocol, without missing scaphoid fractures. It leads to a reduction of unnecessary plaster casting of sprained wrists and produces a marked reduction in plain radiographic examinations.

Development of a clinical decision tool for suspected scaphoid fractures.

Scaphoid fractures are the most common carpal fractures; their overall incidence is however low. Missing a scaphoid fracture may lead to a non-union with a possible disastrous outcome for the patient; for this reason, treatment of a suspected scaphoid fracture, even without a proven fracture on the first radiograph, has been conservative with plaster treatment. There are many clinical tests developed to diagnose a scaphoid fracture. However not all tests are equally practical, and their sensitivity and specificity are not always known, or are very low. In this study 18 clinical tests were evaluated and a subset of 7 tests remained, which were found to be practical and/or had a high enough sensitivity. A clinical decision protocol was developed using a combination of these seven tests, in order to improve diagnostic accuracy and at the same time reduce unnecessary plaster cast treatment of patients with a suspected scaphoid, who turn out to only have a sprained wrist.

Maggot debridement therapy: free-range or contained? An in-vivo study.

OBJECTIVE: To determine which method of maggot debridement therapy--free-range or contained--is more effective for wound healing. METHODS: In vivo study of 64 patients with 69 chronic wounds that showed signs of gangrenous or necrotic tissue. Patients were treated with either free-range or contained maggot debridement therapy according to maggot availability, dressing difficulty, and physician preference. RESULTS: Significantly better outcomes were achieved with the free-range technique versus the contained technique (P = .028). With the free-range technique, the mean number of maggot applications and the total number of maggots per treatment were significantly lower than with the contained application technique (P = .028 and P < .001, respectively). CONCLUSION: This clinical in vivo study supports in vitro studies in which containment of maggots was found to reduce the effectiveness of maggot debridement therapy.