Utilización de métodos mixtos para el diseño de una estrategia de desadopción de la dilatación y legrado de útero como herramienta diagnóstica / Use of mixed methods for the design of a strategy of desadoption of dilation and curettage of the uterus as a diagnostic tool

OBJETIVO: presentar un ejemplo de metodología para la desadopción de una tecnología sanitaria; para ello se plantearon tres objetivos: describir las tasas de uso del legrado uterino diagnóstico en Andalucía y, por otro lado, priorizar las estrategias de intervención para la desadopción del legrado con fines diagnósticos y analizar las barreras y elementos facilitadores para esas estrategias en el Sistema Sanitario Público de Andalucía. MATERIAL Y MÉTODOS: se utilizó una metodología de métodos mixtos. En una primera fase se pretendía identificar centros con mejores prácticas, mediante un diseño de serie temporal descriptiva. Para ello se analizó la evolución de las tasas de legrado con fines diagnósticos para el período 2008-15 para los 40 hospitales públicos de Andalucía (España), mediante una regresión de joint point. En la segunda fase, para identificar los elementos claves para el diseño de intervenciones para la desadopción de la técnica, se utilizaron 2 pasos, el primero mediante una técnica de consenso (Delphi modificado), y posteriormente un taller y grupo de discusión. RESULTADOS: en el año 2015 se realizaron 1.433 procedimientos de legrado con fines diagnósticos (tasa cruda de 4,2 por cada 10,000 mujeres mayores de 15 años). Entre los años 2008 y 2015 se observó una disminución en el uso del legrado del 44,4%, siendo de 3,4 puntos por 10.000 mujeres en términos de tasa cruda. La fase cualitativa mostró que los profesionales sanitarios de centros con mejores prácticas priorizaron cinco de las posibles intervenciones. Por último, en el grupo de discusión se refirieron barreras fundamentalmente en aspectos relacionados con la disponibilidad de recursos (alternativas disponibles) y con la toma de decisiones compartida. CONCLUSIONES: el proceso de desadopción se está produciendo lentamente. Entre los facilitadores para la desadopción destaca la disponibilidad de alternativas; por el contrario, como barrera se mencionó la carga asistencial y las dificultades para la toma de decisiones compartidas. Por último, según se puede deducir de las intervenciones priorizadas, el profesional sanitario debe ser la diana de las intervenciones

OBJECTIVE: Present an example of methodology for the desadoption of a sanitary technology; for this, three objectives were proposed: The description of the rates of use of diagnostic uterine curettage in Andalusia and, on the other hand, prioritize the intervention strategies for the desadoption of the curettage for diagnostic purposes and analyze the barriers and facilitating elements for these strategies in the Andalusian Health System. MATERIAL AND METHODS: A mixed-method methodology was used in order to identify those centers with best practices, through a descriptive time series design. The evolution of curettage rates for diagnostic purposes for the period 2008-15 was analyzed for the 40 public hospitals of Andalusia (Spain), thru a joint point regression. In the second phase, to identify the key elements for the design of interventions for the desadoption of the technique, 2 steps were used, the first using a consensus technique (modified Delphi) and finally, a workshop and discussion group. RESULTS: In 2015, 1,433 curettage procedures were performed for diagnostic purposes (crude rate of 4.2 per 10,000 women over 15 years of age). Between 2008 and 2015, there was a decrease of curettage use, of 44.4%, being 3.4 points per 10,000 women in terms of crude rate. The qualitative phase showed that health professionals, from centers with best practices, prioritized 5 of the possible interventions. Lastly, in the discussion group, barriers mainly related to the availability of resources (available alternatives) and shared decision-making were referred. CONCLUSIONS: The process of desadoption is taking place slowly. Among the facilitators for the desadoption stand out the availability of alternatives; on the contrary, the burden of care and the difficulties in making shared decisions were mentioned as a barrier. Finally, as can be deduced from the prioritized interventions, the health professional must be the target of the interventions

Endometrial Samples From Postmenopausal Women: A Proposal for Adequacy Criteria.

Approximately 75% of endometrial cancer occurs in women older than 55 yr of age. Postmenopausal bleeding is often considered endometrial cancer until proven otherwise. One diagnostic challenge is that endometrial biopsy or curettage generally yields limited samples from elderly patients. There are no well-defined and unified diagnostic criteria for adequacy of endometrial samples. Pathologists who consider any sample including those lacking endometrial tissue as "adequate" run the risk of rendering false-negative reports; on the contrary, pathologists requiring ample endometrial glands along with stroma tend to designate a greater number of samples as "inadequate," leading to unnecessary follow-up. We undertook a quantitative study of 1768 endometrial samples from women aged 60 yr and older aiming to propose validated adequacy criteria for diagnosing or excluding malignancy. Using repeat-procedure outcomes as reference, we found that samples exceeding 10 endometrial strips demonstrated high negative predictive value close to 100%. Such samples can be scant, yet appear to be sufficient in excluding malignant conditions. When tissue diminished to <10 strips, negative predictive value dropped significantly to 81%. The risk of undersampled malignancy rose to 19%. Among 274 malignant cases, only 4 cases yielded limited tissue yet >10 strips. In conclusion, we propose 10 endometrial strips as the minimum for adequate samples from postmenopausal women. Applying such validated adequacy criteria will greatly reduce false-negative errors and avoid unnecessary procedures while ultimately improving diagnostic accuracy. Our criteria may serve as a reference point in unifying the pathology community on this important and challenging topic.

Menorrhagia.

INTRODUCTION: Menorrhagia (also known as heavy menstrual bleeding) limits normal activities, affects quality of life, and causes anaemia in two-thirds of women with objective menorrhagia (loss of 80 mL blood per cycle). Prostaglandin disorders may be associated with idiopathic menorrhagia and with heavy bleeding due to fibroids, adenomyosis, or use of intrauterine devices (IUDs). Fibroids have been found in 10% of women with menorrhagia overall and in 40% of women with severe menorrhagia; but half of women having a hysterectomy for menorrhagia are found to have a normal uterus. METHODS AND OUTCOMES: We conducted a systematic overview, aiming to answer the following clinical question: What are the effects of surgical treatments for menorrhagia? We searched: Medline, Embase, The Cochrane Library, and other important databases up to February 2014 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). RESULTS: At this update, searching of electronic databases retrieved 205 studies. After deduplication and removal of conference abstracts, 102 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 56 studies and the further review of 46 full publications. Of the 46 full articles evaluated, three systematic reviews and five RCTs were added at this update. We performed a GRADE evaluation for 30 PICO combinations. CONCLUSIONS: In this systematic overview, we categorised the efficacy for three surgical interventions based on information about the effectiveness and safety of dilatation and curettage, endometrial destruction (resection or ablation), and hysterectomy.

[Reliability of endocervical curettage after conservative treatment of intraepithelial neoplasia of the cervix]. / Fiabilité du curetage endocervical après traitement conservateur des néoplasies intraépithéliales du col utérin.

OBJECTIVE: To evaluate the reliability of endocervical curettage (ECC) in patients previously treated for CIN. PATIENTS AND METHODS: Retrospective analysis of data from 85 patients between January 1985 and December 2011 who received an ECC during monitoring after treatment of CIN. The reliability of the ECC was evaluated by comparison with the final histological analysis of the surgical specimen or the data for subsequent cyto-colpo-histological follow-up. RESULTS: Patients were referred to colposcopy either within the immediate post-treatment monitoring (n=42), meanly 9.7±5.3 months after treatment, or if cytological abnormalities were detected during long-term monitoring, meanly 78.6±52.4 months after treatment. Colposcopy was unsatisfactory in 75.3% of patients and normal colposcopic findings were found in 80% of patients. A perfect agreement between the ECC and the endocervical final diagnosis was noted in 68 patients (80%). For the diagnosis of severe cervical lesions (CIN 2+) ECC had a sensitivity of 86.2% (68.3-96.1), a specificity of 94.6% (85.1-98.9) and positive and negative predictive values of 61.4% (47.6-74.0) and 93% (83.0-98.1), respectively. CONCLUSION: The high sensitivity and negative predictive value of ECC for the diagnosis of severe post-therapeutic endocervical lesions avoid iterative treatment without increasing the risk of progression of a lesion to cancer.

Concordance between hysteroscopic impression and endometrial histopathological diagnosis.

OBJECTIVE: The aim of this study was to evaluate the accuracy of hysteroscopic impression for diagnosing benign and malignant endometrial pathology. METHOD: This is a retrospective cross-sectional study involving case records of 412 patients who underwent hysteroscopy with diagnostic dilatation and curettage (D&C) at the University of Malaya Medical Centre from January 2009 to August 2011, and cases with records of previous hysteroscopies (2007-2008). Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values, likelihood ratios (LR) and post-test probabilities of hysteroscopy were calculated. D&C was set as the 'gold standard'. RESULTS: Hysteroscopy and histology results were concordant in 366 (88.8%) subjects. Sensitivity, specificity, PPV and NPV were high exceeding 80%. Moderate sensitivity for endometrial hyperplasia (64.4%, 95% CI=49.8%-76.8%) with moderate PPV for malignancy (62.1%, 95% CI=44.0%-77.3%) due to misdiagnosing hyperplasia as malignant was observed. PPV for leiomyoma was reduced (83.3%, 95% CI=60.8%-94.2%) despite 100% sensitivity, due to D&C false negatives. High positive LR (>10) and low negative LR (<0.2) were observed generally except for endometrial hyperplasia (0.36). Hysteroscopy had moderate positive post-test probability for malignancy (0.62) but effective in ruling out malignancy (negative post-test probability=0.00). CONCLUSION: Hysteroscopy is accurate for diagnosing focal and malignant endometrial pathology but only moderate for hyperplasia. Endometrial sampling is recommended for all cases especially when suspecting hyperplasia or malignancy.

Legrado uterino bajo control ecográfico en embarazo ectópico intersticial / Ultrasound-guided transcervical curettage in interstitial pregnancy

El embarazo intersticial se ha visto incrementado en las últimas décadas como consecuencia del aumento de técnicas de reproducción asistida. A pesar del diagnóstico cada vez más temprano y el desarrollo de tratamientos cada vez más conservadores, presenta una morbilidad y mortalidad importantes. Presentamos 2 casos de embarazo intersticial tratado mediante legrado por aspiración bajo control ecográfico. En ambos, el procedimiento fue rápido, con mínimo sangrado y sin complicaciones. El legrado uterino ecoguiado es una alternativa efectiva y segura como tratamiento del embarazo ectópico intersticial (AU)

Interstitial pregnancy has increased in the last few decades due to greater use of assisted reproductive technology. Despite early diagnosis and the development of increasingly conservative treatment, maternal morbidity and mortality remain high. We report two cases of interstitial pregnancy treated by ultrasound-guided transcervical suction curettage. In both cases, the procedure was quick, bleeding was minimal and there were no complications. Ultrasound-guided transcervical curettage is a safe and effective alternative in interstitial pregnancy (AU)

Comparison of endometrial aspiration biopsy techniques: specimen adequacy.

OBJECTIVE: To compare adequacy of specimens obtained by 3 different endometrial aspiration biopsy techniques--corkscrew, modified dilatation and curettage (D&C) and a combination of both, with or without povidone-iodine cervical cleansing. STUDY DESIGN: A retrospective chart review of a single group practice using a single endometrial aspiration biopsy device for all 3 techniques. Each attending indicated their method of use with the device. For diagnostic purposes, specimen adequacy was categorized as "satisfactory," "suboptimal" and "insufficient." RESULTS: There were 66 corkscrew, 71 modified D&C and 55 biopsies performed using the combined technique. Mean age was 48; 62.5% were premenopausal and 89% had a normal-sized uterus. Postmenopausal patients were more likely than younger women to have suboptimal or insufficient samples, 27% vs. 11%, respectively. Using the combined technique was better (95%) than the corkscrew alone (77%) for satisfactory specimens. Diagnosis was possible in 90% of specimens. CONCLUSION: The combined technique appears to be better than using either technique alone. Povidone-iodine cervical cleansing is safe but may be unnecessary. Because of the large numbers of endometrial biopsies performed yearly, even a small difference in test characteristics can have significant clinical ramifications.

Expectant, medical, or surgical management of first-trimester miscarriage: a meta-analysis.

OBJECTIVE: To quantify the relative benefits and harms of different management options for first-trimester miscarriage. DATA SOURCES: MEDLINE, EMBASE, and Cochrane Controlled Trials Register searches (1966 to July 2004), including references of retrieved articles. METHODS OF STUDY SELECTION: Randomized trials assigning women with first-trimester missed or incomplete miscarriage to surgical, medical, or expectant management were included. Primary outcomes were successful treatment and patient satisfaction. Secondary outcomes included moderate or severe bleeding, blood transfusion, emergency curettage, pelvic inflammatory disease, nausea, vomiting, and diarrhea. Comparisons used the risk difference. Between-study heterogeneity and random effects summary estimates were calculated. TABULATION, INTEGRATION, AND RESULTS: Complete evacuation of the uterus was significantly more common with surgical than medical management (risk difference 32.8%, number needed to treat 3, success rate of medical management 62%) and with medical than expectant management (risk difference 49.7%, number needed to treat 2). Success rate with expectant management was spuriously low (39%) in the latter comparison. Analysis of cases with incomplete miscarriage only showed that medical management still had two thirds the chance to induce complete evacuation compared with surgical management, but it was better than expectant management. Data from studies that evaluated outcome at 48 hours or more after allocation indicated again that medical management had a better success rate than expectant management but a worse success rate than surgical management; expectant management probably had much lower success rates than surgical evacuation, but data were very sparse. Patient satisfaction data were sparse. Moderate or severe bleeding was less common with medical than expectant management (risk difference 3.2%) and possibly surgical management (risk difference 2.1%). There was a considerable amount of missing information, in particular for secondary outcomes. CONCLUSION: One additional success can be achieved among 3 women treated surgically rather than medically. Expectant management has had remarkably variable success rates across these studies, depending probably on the type of miscarriage. Greater standardization of outcomes should be a goal of future research.

[Hysteroscopy in cases of abnormal uterine bleeding and abnormal ultrasonographic findings of uterine cavity-own experience]. / Zastosowanie histeroskopii w przypadkach nieprawidlowych krwawien macicznych oraz nieprawidlowych obrazów ultrasonograficznych jamy macicy--doswiadczenia wlasne.

OBJECTIVES: In the paper authors present indications and results of using diagnostic and operative hysteroscopy in the clinical practise and compare histological result with introductory diagnosis of ultrasonography and hysteroscopy. MATERIALS AND METHODS: In period of 01.06.1998-01.09.2002 148 hysteroscopy were done with in 58 diagnostic and 90 operative histeroscopies. Received material was sent to histological research. RESULTS: non-pathologic change was diagnosed in 37 women, 43 endometrial polyps, 20 submucous myomas, 5 polyps and myomas together. CONCLUSIONS: 1. Most often observed change in intrauterine pathology were endometrial polyps and submucous myomas. 2. In a few cases only hysteroscopy let us discover the reason of pathological bleedings from the uterus. 3. hysteroscopy has become the method necesary in some cases of gynaecological pathology.

Comparison of hysteroscopic and hysterectomy findings for assessing the diagnostic accuracy of office hysteroscopy.

OBJECTIVE: To assess the diagnostic accuracy of office hysteroscopy by comparing the hysteroscopic findings with the histologic findings on the hysterectomy specimens. DESIGN: Retrospective clinical study. SETTING: University-affiliated hospital. PATIENT(S): Review of the hospital records of 443 patients who underwent office hysteroscopy and, within 2 months, hysterectomy. INTERVENTION(S): We compared the hysteroscopic findings (including targeted biopsies) with the histologic findings that were obtained after hysterectomy. The results of this study were then compared with those of a previous study in which we examined the diagnostic accuracy of dilatation and curettage (D&C). MAIN OUTCOME MEASURE(S): We evaluated the diagnostic accuracy of office hysteroscopy. RESULT(S): When compared with the histologic diagnosis of the uterus, the hysteroscopic findings showed a diagnostic sensitivity of 98%, a specificity of 95%, a positive predictive value (PPV) of 96%, and a negative predictive value (NPV) of 98%. Hysteroscopy was found to have a greater diagnostic accuracy than D&C: the sensitivity and the NPV of the two diagnostic procedures were statistically different. CONCLUSION(S): Office hysteroscopy is confirmed as a powerful diagnostic tool, but targeted biopsies, performed with a small diameter operative hysteroscope, must be performed in cases of suspect endometrium to confirm the image-based diagnosis.

Early intrauterine pregnancy failure: a randomized trial of medical versus surgical treatment.

OBJECTIVE: The purpose of this study was to determine whether medical treatment of early pregnancy failure represents a reasonable alternative to surgical therapy. STUDY DESIGN: Patients who were diagnosed with pregnancy failure before 12 weeks of gestation were randomly assigned to receive either medical (intravaginal misoprostol) or surgical therapy (dilatation and curettage). In the medical arm of the study, 800 microg of misoprostol was placed within the posterior vaginal fornix. Patients subsequently were seen 24 and 48 hours after the initial dosing; intravaginal misoprostol was readministered only if ultrasound images revealed evidence of persistent pregnancy tissue. By 72 hours after initial study entry, if either a gestational sac or placental tissue was present, the medical treatment was considered a failure, and uterine curettage was performed. Statistical analysis was performed with the two-tailed unpaired t test, chi(2) analysis, Fisher exact test, and Mann-Whitney U test; a probability value of <.05 was considered statistically significant. RESULTS: A total of 50 women were enrolled, with 2 patients in the surgical arm experiencing spontaneous pregnancy loss before their scheduled procedures. Twenty-five women received medical therapy; 25 women were randomized to surgical procedure. Fifteen patients in the medical group (60%; 95% CI, 0.41-0.79) had successful pregnancy termination and did not require curettage. There were no significant differences between the medical and surgical groups with respect to either posttreatment hematocrit level or the time needed to achieve negative human chorionic gonadotropin test results. CONCLUSION: Intravaginal misoprostol is an effective agent for the treatment of early pregnancy failure. Medical treatment of early pregnancy failure represents a reasonable alternative to immediate surgical therapy.

A comparison of medical induction and dilation and evacuation for second-trimester abortion.

OBJECTIVE: The purpose of this study was to compare complication rates of patients who undergo dilation and evacuation or medical abortion between 14 and 24 weeks of gestation. STUDY DESIGN: We present a retrospective cohort study of 297 women who underwent either dilation and evacuation or medical abortion. Statistical methods included the Student t test, the chi(2) test, the Fisher exact test (where appropriate), and logistic regression. RESULTS: The overall complication rate was significantly lower in patients who underwent dilation and evacuation than in patients who underwent medical abortion (4% vs 29%; P <.001). Medical abortions with misoprostol resulted in a lower complication rate than abortions with other medications (odds ratio, 0.2; 95% CI, 0.1-0.4). More Laminaria was associated with a decreased risk of complications with surgical abortions (odds ratio, 0.9; 95% CI, 0.7-1.0). CONCLUSION: Dilation evacuation is the safest method of second-trimester abortion. Misoprostol is safer than other methods for medical abortion. Maximal use of Laminaria will decrease complication rates in surgical abortion.

[Secondary amenorrhea due to intrauterine adhesions: Asherman's syndrome]. / Secundaire amenorroe door intra-uteriene adhesies: het syndroom van Asherman.

Three women aged 35, 33 and 40 years had secondary amenorrhoea and monthly recurring abdominal pains after curettage for blood loss after a pregnancy. Hysteroscopy revealed intrauterine adhesions. The symptoms disappeared largely or completely after synechiolysis, introduction of an IUD and oestrogen treatment. Changes in the menstrual cycle, infertility or recurrent abortions starting after a puerperal or postabortum curettage should cause the physician to suspect intrauterine adhesions. For the diagnosis hysteroscopy is the method of choice and hysterography should be added for preoperative assessment and classification. Blind procedures for rupturing the adhesions should not be performed because of the risk of perforation and creating false routes.

Does hysteroscopy improve upon the sensitivity of dilatation and curettage in the diagnosis of endometrial hyperplasia or carcinoma?

OBJECTIVE: The objective of this study was to determine whether hysteroscopy improved upon the diagnostic sensitivity of dilatation and curettage (D+C) in the detection of endometrial hyperplasia and carcinoma. METHODS: A retrospective chart review was conducted of all patients undergoing hysteroscopy/D+C for abnormal uterine bleeding between 1991 and 1995. Hysteroscopic impressions and D+C diagnoses were compared. RESULTS: Three hundred seventy-three patients were included in the study. Of the 61 patients with D+C demonstrating hyperplasia, the hysteroscopic impression was hyperplasia in 32 (52%). Of the 10 patients with D+C demonstrating carcinoma, the hysteroscopic impression was hyperplasia in 8 (80%) and carcinoma in 2 (20%). Two additional cases of carcinoma were diagnosed within 6 months of hysteroscopy/D+C, and both had been missed on both hysteroscopy and D+C. Of 204 patients with a normal hysteroscopic impression, 23 (11%) had hyperplasia on D+C. CONCLUSIONS: Hysteroscopy did not improve upon the sensitivity of D+C in the detection of endometrial hyperplasia or carcinoma.

Endometrial rollerball ablation.

OBJECTIVE: To study a standardized technique for endometrial rollerball ablation and various methods of preoperative preparation. STUDY DESIGN: All patients had refractory symptomatic menorrhagia and previously failed conservative surgery and other forms of medical therapy, such as progestogens. Patients received a preoperative regimen of either leuprolide acetate, danazol, Nolvadex or Depo-Provera. They then underwent hysteroscopically controlled rollerball ablation at 80-100 W with 1.5% glycine as the distending medium. The endometrium was evaluated hysteroscopically and considered to be completely atrophic, intermediate or no response. RESULTS: Refractory symptomatic menorrhagia was treated successfully in 38 of 40 patients. Nineteen reported amenorrhea; the other 21 reported subjective and objective improvement of bleeding. Three patients, despite improvements in flow, were unhappy with the overall result. Two did not wish repeat ablation and subsequently underwent vaginal hysterectomy. The third underwent repeat ablation and became amenorrheic. The ability to achieve complete endometrial atrophy prior to ablation was improved with leuprolide acetate (19/24) and danazol (5/6) when compared to tamoxifen (0/4) and Depo-Provera (0/6). Attainment of amenorrhea after ablation was significantly improved when complete atrophy (19/24) was achieved prior to ablation as compared to the ability to achieve amenorrhea when no endometrial response was achieved (0/7). The only significant complication was one uterine perforation in a patient undergoing repeat ablation. CONCLUSION: Endometrial rollerball ablation is a safe, effective means of controlling refractory menorrhagia. Amenorrhea is best attained when complete preoperative atrophy is achieved. Leuprolide and danazol were superior to tamoxifen and Depo-Provera.

A GRiPPing yarn--getting research into practice: a case study.

This article describes the GRiPP initiative in the (old) Oxford Region which set out to explore the potential role of purchasers or commissioners of health care in putting the findings of research into the practice of healthcare. A short account of the background to GRiPP is followed by a more detailed description of the GRiPP project carried out in Buckinghamshire and some of the lessons which may be useful to other health authorities. The final section of the article considers the role of the healthcare librarian in the context of 'Getting Research into Practice and Purchasing'.

Te Linde: Ginecología quirúrgica / Te Lindes operative gynecology

El clásico texto de ginecología operatoria de R.W. Te Linde (fallecido en 1989) se continúa en esta excelente versión, actualizada a 1992, sin perder ninguno de los atributos originales: solidez científica, buenas ilustraciones y tratamiento en profundidad de los temas