Incorrect position of Essure microinserts 3 months after successful bilateral placement

Objective: To describe incorrect positions of Essure microinserts detected at 3 months' follow-up. Design: Case report. Setting: Outpatient department of obstetrics and gynecology in a Dutch teaching hospital. Patient(s): Initial series of 100 patients who underwent hysteroscopic sterilization using Essure between December 2003 and June 2004. Intervention(s): Hysteroscopic placement of the Essure System, follow-up at 3 months with transvaginal ultrasound (TVU), and hysterosalpingography. Main Outcome Measure(s): Bilateral placement rate, tubal obstruction, and detection of incorrect Essure micro-insert localization at follow-up after apparent successful bilateral placement. Result(s): Bilateral placement of Essure microinserts in one session was successful in 93 women (93%). In 90 of these women (96.8%), tubal obstruction was proven at follow-up 3 months later. Three incorrect positions of an Essure insert were seen: two expulsions and one perforation into the abdominal cavity. Conclusion(s): Incorrect position of Essure microinserts was seen only when the initial placement procedure was difficult. When a placement procedure was difficult or other suboptimal conditions are present during the procedure, we advise performing a TVU or pelvic X-ray in these women 4 weeks after the procedure or after the first vaginal bleeding, instead of waiting for follow-up after 3 months. (Fertil Steril (R) 2009;91:930.e1-e5. (C) 2009 by American Society for Reproductive Medicine.

Physicians' perspectives on using a patient decision aid in female stress urinary incontinence

INTRODUCTION AND HYPOTHESIS: A treatment choice for female stress urinary incontinence (SUI) is preference sensitive for both patients and physicians. Multiple treatment options are available, with none being superior to any other. The decision-making process can be supported by a patient decision aid (PDA). We aimed to assess physicians' perceptions concerning the use of a PDA. METHODS: In a mixed methods study, urologists, gynecologists and general practitioners in the Netherlands were asked to fill out a web-based questionnaire. Questions were based on the Tailored Implementation for Chronic Diseases checklist using the following domains: guideline factors, individual health professional factors, professional interactions, incentives and resources, and capacity for organizational change. Participants were asked to grade statements using a five-point Likert scale and to answer open questions on facilitators of and barriers to implementation of a PDA. Outcomes of statement rating were quantitatively analyzed and thematic analysis was performed on the outcomes regarding facilitators and barriers. RESULTS: The response rate was 11%, with a total of 120 participants completing the questionnaire. Ninety-two of the physicians (77%) would use a PDA in female SUI. Evidence-based and unbiased content, the ability to support shared decision making, and patient empowerment are identified as main facilitators. Barriers are the expected prolonged time investment and the possible difficulty using the PDA in less health-literate patient populations. CONCLUSIONS: The majority of physicians would use a PDA for female SUI. We identified facilitators and barriers that can be used when developing and implementing such a PDA

A web-based decision aid for shared decision making in pelvic organ prolapse: the SHADE-POP trial

Introduction and hypothesis:  Among women worldwide, pelvic organ prolapse (POP) is a common problem. There are three different treatment options for POP: pelvic floor muscle therapy, pessary treatment and prolapse surgery. As none of the three treatment options is clearly superior, shared decision making (SDM) is very important. A decision aid (DA) is known to facilitate patient participation and SDM. We hypothesise that the use of a web-based DA for POP increases patients' satisfaction with information and care and reduces decisional conflict. Methofs:  This two-arm, multicentre, cluster randomised controlled trial was performed in women with POP in five different Dutch hospitals. The control group received usual care (UC) and the intervention group received the DA in addition to UC. Primary outcome measures were satisfaction with treatment decision making and satisfaction with information. Analyses were performed using independent sample t tests, Chi-squared tests, and multilevel linear regression analyses. Results:  Between the DA group (n=40) and the UC group (n=56) no differences were found concerning patients' satisfaction with information, with scores of 45.63 and 46.14 out of 50 respectively (p=0.67). Also, no differences were found concerning the perceived role in decision making, as patients scored 46.83 in the DA group and 46.41 in the UC group, out of a maximum of 54 (n=0.81). Conclusions:  No differences were found concerning patients' satisfaction with information and treatment decision making between the DA and UC. However, both groups scored high on the questionnaires, which suggests that the decision process is already of high quality

The determinants of exit in a developing country: core and peripheral regions

This paper analyses the regional determinants of exit in developing countries, using Argentina as an illustrative case. We find evidence of a dynamic revolving door by which past entrants increase current exits, particularly in the peripheral regions. In the central regions, current and past incumbents cause an analogous displacement effect. Also, exit shows a U-shaped relationship with respect to the informal economy, although the positive effect is weaker in the central regions. These findings point to the existence of a core-periphery structure in the spatial distribution of exits.Fil: Calá, Carla Daniela. Universidad Nacional de Mar del Plata. Facultad de Ciencias Económicas y Sociales; Argentina.Fil: Arauzo-Carod, Josep-Maria. Institut d'Economia de Barcelona; España.Fil: Manjón-Antolín, Miguel. Universitat Rovira i Virgili. Departamento de Economía; España