Interobserver variability of dynamic MR imaging of the temporomandibular joint.

PURPOSE: This study investigated the interobserver variability of dynamic magnetic resonance (MR) imaging of the temporomandibular joint (TMJ). MATERIALS AND METHODS: Sixty-two patients with internal derangement of the TMJ (124 TMJs) were investigated with a 1.5-T MR imaging system during physiological opening and closing of the mouth. Two readers evaluated independently the quality of the dynamic examination (Q: nondiagnostic, diagnostic, optimal), condylar motion (CM: limited, suboptimal, optimal), condylar orientation (CO: in-plane, through-plane shift), disc visibility and movement (DV: visible, nonvisible; DM: normal, reducing, nonreducing dislocation) and joint effusion (JE: present, absent). For each TMJ, the condylar path was measured by tracing the position of the condyle in the frames of the dynamic acquisition. Agreement between the two readers was assessed with Cohen's Kappa and the Bland-Altman method. RESULTS: Interobserver agreement was almost perfect for Q (nondiagnostic, diagnostic, optimal: 0.8%, 4.9%, 94.3%; κ=1), CM (limited, suboptimal, optimal: 14%, 26.4%, 59.5%; κ=0.84) and DV (visible, nonvisible: 100%, 0%). Substantial agreement was found for DM (normal, reducing, nonreducing: 66.1%, 14.8%, 19.1%; κ=0.64) and JE (present, absent: 41.3%, 58.7%; κ=0.67). Moderate agreement was found for CO (in-plane, through-plane shift: 94.2%, 5.8%; κ=0.41). As for the condylar path, the means of the percentage differences and limits of agreement (LA) were -3% (LA: -34.5%, 28.3%) on the right and -1.2% (LA: -35%, 32.6%) on the left. CONCLUSIONS: In dynamic imaging of the TMJ, qualitative assessment of condyle-disc movement and joint effusion is minimally dependent on the reader's evaluation. Measurement of the condylar pathway shows an interobserver variability of ±30%.

Density-based MDCT quantification of lobar lung volumes: a study of inter- and intraobserver reproducibility.

PURPOSE: The authors assessed the reproducibility of multidetector-row computed tomography (MDCT) volumetry of the total and emphysematous parenchyma of pulmonary lobes. MATERIALS AND METHODS: Two observers analyzed 23 MDCT examinations of patients with emphysema during two sessions held 3 months apart. Both lungs and all lobes were delimited by a combination of semiautomated and manual segmentation. Emphysematous parenchyma was obtained by applying density thresholds of -1,024/-950 HU. To assess the reproducibility of total volume (V), volume of emphysema (VE) and emphysema index (EI), intra- and interobserver differences of those measurements were assessed. RESULTS: Total volumetry of the lungs was highly reproducible (intra- and interobserver variability of +/-3.4%). Variability between measurements was slightly greater or emphysema volume and index (EI). Lobar analyses showed large ranges of intra- and interobserver variability (intraobserver V=+/-3.7%-10.6%; VE=+/-17.3%-32.9%; EI=+/-17.8%-34%; interobserver V=+/-13.3%-98.3%; VE=+/-11%-137.6%; EI=+/-28.9%-96.4%). CONCLUSIONS: MDCT quantification of total and emphysematous lung volume and emphysema index is overall reproducible. Quantitative assessment of those parameters performed on single lobes is affected by variability. An improvement of the reproducibility of q-MDCT is expected from the use of advanced methods for lobar segmentation.

Endometriosis: absence of recurrence in patients after endometrial ablation.

BACKGROUND: The present study was undertaken to evaluate differences between patients with and without eutopic endometrium in the recurrence of ectopic endometriotic implants. METHODS: Endometrial ablation (EA) was carried out in 14 women out of 28 laparoscopically treated for endometriosis and recurrence of the disease was evaluated 24 months later. Data were compared using paired Student's t-test and chi2 test. RESULTS: Patients undergoing EA procedures did not exhibit recurrence of endometriosis while nine patients without that procedure had recurrence of the disease (P < 0.001). The endometrial cells found in the debris of the cul de sac of eight patients who did not undergo EA were both stromal and epithelial cells. No blood or blood cells were found in the cul de sac of patients undergoing EA. CONCLUSIONS: The present study supports a role of eutopic endometrium in the recurrence of endometriosis through tubal dissemination of endometrial debris and implantation of endometrial cells into the abdomen.

Acceptability and pain of outpatient hysteroscopy.

STUDY OBJECTIVE: To investigate the pain and acceptability of diagnostic hysteroscopy performed without local anesthesia. DESIGN: Prospective, observational study (Canadian Task Force classification II-2). SETTING: University-associated department of obstetrics and gynecology. PATIENTS: The 1144 consecutive women who underwent diagnostic hysteroscopy. INTERVENTIONS: Diagnostic hysteroscopy and endometrial biopsy as indicated. MEASUREMENTS AND MAIN RESULTS: Patients were asked to rate the pain experienced on a 10-cm visual analog scale and to state if they were willing to repeat the procedure. The mean pain score was 4.7 +/- 2.5; 398 patients (34.8%) experienced severe pain. No risk factors for painful hysteroscopy were found, although abnormality of the cervical canal was associated with high pain scores. Acceptance of the procedure was high, 83.0% (950 women). CONCLUSION: Diagnostic hysteroscopy is a painful procedure even when performed with atraumatic technique by experienced surgeons. Most women, however, stated they were willing to have a second procedure under the same conditions.

[The role of hysteroscopy in the diagnosis and follow-up of endometrial hyperplasia]. / Ruolo dell'isteroscopia nella diagnosi e nel controllo dell'iperplasia endometriale.

BACKGROUND: Preneoplastic lesions of endometrium such as endometrial hyperplasia (simple and complex with or without cytological atypias) represent an important cause of abnormal uterine bleeding. Among diagnostic techniques, hysteroscopy presents several advantages: it is an out-patient procedure, minimally invasive, repeatable, of rapid execution and with low cost. The hysteroscopic pattern of endometrial hyperplasia appears with an over-development of the endometrial mucosa with increased glandular openings, increased vascularization, cystic dilatations, polypoid aspects. METHODS: Since October 1984 to January 1995 at the Gynecologic Endoscopic Service of Obstetrics and Gynecology Department of the University of Bologna, 13,438 hysteroscopies were performed: 291 (2.16%) in patients submitted to hysteroscopy for previous diagnosis of endometrial hyperplasia. The first diagnosis of endometrial hyperplasia was made in 125 (42.3%) patients through hysteroscopic biopsy, while for 166 patients (57.04%) the first diagnosis was made by endometrial curettage of VABRA. RESULTS: The results showed that the endometrial hyperplasia is typical in perimenopausal age and this finding is more frequently symptomatic. The histological diagnosis after hysteroscopy was: simple hyperplasia in 106 patients (84.8%), complex in 12 patients (9.6%) and atypical in 6 patients (4.8%). One case of simplex hyperplasia was associated with endometrial cancer (0.8%). The comparison between histological diagnosis and hysteroscopic diagnosis showed that agreement is reached in 113 cases (90.4%). However, it is to note that diagnostic agreement of complex hyperplasia cases was about 100%, but in 22 cases the hysteroscopic diagnosis was simplex hyperplasia rather than complex or atypical. The errors of hysteroscopy were observed in 10 cases (8%). CONCLUSIONS: The hysteroscopic diagnosis should not replace histological diagnosis, mostly in hysteroscopies performed after progestagen therapy, because the changes induced by drugs make more difficult the interpretation of hysteroscopy. However, hysteroscopy is complementary to histological analysis since permits a global evaluation of endometrial mucosa, directs biopsy on dishomogeneous areas and represents the only means to make diagnosis when biopsy is not practicable.

A novel hyaluronan-based gel in laparoscopic adhesion prevention: preclinical evaluation in an animal model.

OBJECTIVE: To evaluate the effectiveness of a crosslinked hyaluronan solution (ACP gel) in the prevention of postsurgical adhesions in laparoscopic surgery. DESIGN: A randomized blinded study using a rabbit model in laparoscopic surgery. SETTING: A standardized surgical trauma in the rabbit uterine horn to induce adhesion formation. ANIMALS: Sixty-four sexually matured female New Zealand white rabbits weighing 2.5 to 3.0 kg and aged 3-4 months. INTERVENTION(S): After trauma, group 1 (n = 22) received no treatment, group 2 animals (n = 20) received oxidized-regenerated cellulose (Interceed [TC7]) in group 3 (n = 22) 5 mL of ACP gel were applied on the lesion. MAIN OUTCOME MEASURE(S): Six weeks after laparoscopy, a laparotomy was performed and the adhesions were scored according to Blauer's scoring system. RESULT(S): 66% of the untreated animals and 85% of the animals treated with Interceed presented with severe adhesions, whereas only 35% of the ACP gel treatment group had significant adhesions. The mean ( +/- SEM) increased adhesion score was 2.24 +/- 0.26 in the untreated group, 2.45 +/- 0.22 in the Interceed group, and was 1.25 +/- 0.28 in the ACP gel group. CONCLUSION(S): This study revealed that ACP gel holds promise as a novel resorbable biomaterial for the reduction of postoperative adhesions after laparoscopic surgery.

[Outpatient diagnostic hysteroscopy: 14,000 cases]. / Isteroscopia diagnostica ambulatoriale: 14.000 casi.

Hysteroscopy is a technique which plays a fundamental diagnostic role in gynecological practice. The possibility of obtaining a direct intracavitary view and performing specific biopsies give it a greater level of diagnostic accuracy than intrauterine curettage. The authors' personal experience of 13,923 case enables the correct method of performing this procedure to be codified in order to avoid the inherent risks and complications. The main indication is abnormal uterine bleeding which is the most frequently observed pathology in gynecological practice. In cases of metrorrhagia in women of child-bearing age benign organic pathology accounts for 45% of patients and malignant pathology 0.3%. Post-menopausal patients reveal an increase in the incidence of organic pathology in general and neoplastic pathologies in particular (8.1%). Complications linked to this type of technique are extremely rare and in overall terms affect 1% of cases. The analysis of results shows that hysteroscopy today represents an extremely reliable and repeatable outpatient procedure. However, in spite of these advantages, including savings in health costs, it is not widely used at a capillary level given that if performed by persons who are not expert it may become traumatic and unreliable. The correct execution of hysteroscopy in fact calls for dexterity acquired over time which is not conditioned by the learning of previous techniques and requires an adequate period of training.

Hysteroscopic metroplasty.

Between February 1990 and June 1993 40 patients underwent hysteroscopic metroplasty for septate uterus. Twenty-six patients had previous miscarriages (65%) and fourteen were infertile (35%). Hysteroscopic section of uterine septa was performed by means of Hamou resectoscope with sorbitol-mannitol solution as distending medium. Surgical outcome was excellent without intraoperative and postoperative morbidity. After 40-60 days the uterine cavity was completely epithelialized without intrauterine adhesions in all the cases. One patient had incomplete septum section that required a second procedure. Postoperative reproductive outcome was evaluated in 26 patients: the cumulative pregnancy and birth rate was 73% and 86%, respectively. Five patients delivered by cesarean section (39%). In the infertile group the pregnancy and birth rate was much lower (44% and 75%, respectively) than in previous miscarriage group (88% and 91%, respectively). Infertile patients do not seem to be cured by hysteroscopic metroplasty; however, in these cases the endoscopic operation should be performed, because it may prevent subsequent miscarriage. Hysteroscopic metroplasty by means of Hamou resectoscope is a very successful, quick, simple and safe procedure that may replace abdominal metroplasty.