Endometrial blood flow mapping using transvaginal power Doppler sonography in women with postmenopausal bleeding and thickened endometrium

Objective To evaluate the role of transvaginal power Doppler sonography to discriminate between benign and malignant endometrial conditions in women presenting with postmenopausal bleeding and thickened endometrium at baseline sonography. Methods Ninety-one postmenopausal women (median age, 58 years; range, 47–83 years) presenting with uterine bleeding and a thickened endometrium (≥5-mm doublelayer endometrial thickness) on transvaginal sonography were included in this prospective study. Endometrial blood flow distribution was assessed in all patients by power Doppler immediately after B-mode transvaginal sonography. Three different vascular patterns were defined: Pattern A: multiple-vessel pattern, Pattern B: single-vessel pattern and Pattern C: scattered-vessel pattern. Histological diagnoses were obtained in all cases. No patient taking tamoxifen citrate or receiving hormone replacement therapy was included. Results Histological diagnoses were as follows: endometrial cancer: 33 (36%), endometrial polyp: 37 (41%), endometrial hyperplasia: 14 (15%), endometrial cystic atrophy: 7 (8%). Blood flow was found in 97%, 92%, 79% and 85% of cases of carcinoma, polyp, hyperplasia and endometrial cystic atrophy, respectively. A total of 81.3% of vascularized endometrial cancers showed Pattern A, 97.1% of vascularized polyps exhibited Pattern B and 72.7% of vascularized hyperplasias showed Pattern C. Sensitivity and specificity for endometrial cancer were 78.8% and 100%. For endometrial polyp these respective values were 89.2% and 87% and for hyperplasia they were 57.1% and 88.3%. Conclusions Transvaginal power Doppler blood flow mapping is useful to differentiate benign from malignant endometrial pathology in women presenting with postmenopausal bleeding and thickened endometrium at baseline sonography

Three-dimensional power Doppler angiography in endometrial cancer: correlation with tumor characteristics

To assess the correlation between intratumoral vascularization using three-dimensional power Doppler angiography (3D-PDA) and several histological tumor characteristics in a series of patients with endometrial carcinoma. METHODS: Ninety-nine women (mean age, 61.7 (range, 31-84) years) diagnosed as having endometrial cancer were assessed by transvaginal 3D-PDA before surgical staging. Endometrial volume (EV) and 3D-PDA vascular indices (vascularization index (VI), flow index (FI) and vascularization flow index (VFI)) were calculated using the Virtual Organ Computer-aided AnaLysis (VOCAL) method. All patients were surgically staged. Individual tumor features such as histological type, tumor grade, myometrial infiltration depth, lymph-vascular space involvement, cervical involvement, lymph node metastases and tumor stage were considered for analysis. Multivariate logistic regression (MLR) analysis was used to determine which 3D-PDA parameters were independently associated with each histological characteristic. RESULTS: MLR analysis showed that only EV and VI were independently associated with myometrial infiltration (EV: odds ratio (OR), 1.119 (95% CI, 1.025-1.221), P = 0.012; VI: OR, 1.127 (95% CI, 1.063-1.195), P = 0.001) and tumor stage (EV: OR, 1.103 (95% CI, 1.012-1.202), P = 0.025; VI: OR, 1.120 (95% CI, 1.057-1.187), P = 0.001), only VI was independently associated with tumor grade (OR, 1.056 (95% CI, 1.023-1.091), P = 0.001) and only EV was independently associated with lymph node metastases (OR, 1.086 (95% CI, 1.017-1.161), P = 0.001). CONCLUSION: 3D-PDA analysis of tumor vascularization in endometrial cancer correlates with some prognostic histological characteristics

Triage for surgical management of ovarian tumors in asymptomatic women: assessment of an ultrasound-based scoring system.

OBJECTIVES: To prospectively evaluate an ultrasound-based scoring system as a method for triaging asymptomatic women presenting with an adnexal mass for surgical treatment. METHODS: Two hundred and four adnexal masses in 189 asymptomatic women undergoing elective surgical treatment at our institution were included in this prospective study. Patients were evaluated by transvaginal power Doppler ultrasound imaging before surgery. Patients were classified as low risk or high risk for malignancy according to an ultrasound-based scoring system. Women with a low risk for malignancy were scheduled for laparoscopy and patients with a high risk for malignancy were scheduled for laparotomy. However, patients classified as low risk by the ultrasound scoring system, but with a tumor size >or= 10 cm or clinical suspicion of pelvic adhesions, were instead considered to be at intermediate risk and were scheduled for laparotomy. Some patients classified as high risk were scheduled for an operative laparoscopy by an expert in gynecological oncology. RESULTS: One hundred and thirty-four (65.7%) masses were considered to be low risk and were treated by a laparoscopically guided procedure. All these tumors were benign. Forty-seven (23%) masses were classified as high risk, of which 39 tumors were malignant and eight benign. Twenty-three (11.3%) tumors were considered to be intermediate risk and were scheduled for primary laparotomy. In this group, 21 (91.3%) tumors proved to be benign and two (8.7%) were malignant. CONCLUSIONS: Ultrasound-based triage of asymptomatic women diagnosed with a persistent adnexal mass is effective for selecting the surgical approach

Peripheral electrical stimulation in Alzheimer's Disease: A randomized controlled trial on cognition and behavior

In a number of studies, peripheral electrical nerve stimulation has been applied to Alzheimer's disease (AD) patients who lived in a nursing home. Improvements were observed in memory, verbal fluency, affective behavior, activities of daily living and on the rest-activity rhythm and pupillary light reflex. The aim of the present, randomized, placebo-controlled, parallel-group clinical trial was to examine the effects of electrical stimulation on cognition and behavior in AD patients who still live at home. Repeated measures analyses of variance revealed no effects of the intervention in the verum group (n = 32) compared with the placebo group (n = 30) on any of the cognitive and behavioral outcome measures. However, the majority of the patients and the caregivers evaluated the treatment procedure positively, and applying the daily treatment at home caused minimal burden. The lack of treatment effects calls for reconsideration of electrical stimulation as a symptomatic treatment in A

A personalized intervention to prevent depression in primary care: cost-effectiveness study nested into a clustered randomized trial

Background: Depression is viewed as a major and increasing public health issue, as it causes high distress in the people experiencing it and considerable financial costs to society. Efforts are being made to reduce this burden by preventing depression. A critical component of this strategy is the ability to assess the individual level and profile of risk for the development of major depression. This paper presents the cost-effectiveness of a personalized intervention based on the risk of developing depression carried out in primary care, compared with usual care. Methods: Cost-effectiveness analyses are nested within a multicentre, clustered, randomized controlled trial of a personalized intervention to prevent depression. The study was carried out in 70 primary care centres from seven cities in Spain. Two general practitioners (GPs) were randomly sampled from those prepared to participate in each centre (i.e. 140 GPs), and 3326 participants consented and were eligible to participate. The intervention included the GP communicating to the patient his/her individual risk for depression and personal risk factors and the construction by both GPs and patients of a psychosocial programme tailored to prevent depression. In addition, GPs carried out measures to activate and empower the patients, who also received a leaflet about preventing depression. GPs were trained in a 10- to 15-h workshop. Costs were measured from a societal and National Health care perspective. Qualityadjustedlife years were assessed using the EuroQOL five dimensions questionnaire. The time horizon was 18 months. Results: With a willingness-to-pay threshold of (sic)10, 000 ((sic)8568) the probability of cost-effectiveness oscillated from 83% (societal perspective) to 89% (health perspective). If the threshold was increased to (sic)30, 000 ((sic)25, 704), the probability of being considered cost-effective was 94% (societal perspective) and 96%, respectively (health perspective). The sensitivity analysis confirmed these results. Conclusions: Compared with usual care, an intervention based on personal predictors of risk of depression implemented by GPs is a cost-effective strategy to prevent depression. This type of personalized intervention in primary care should be further developed and evaluated

Comparación anátomo-funcional de los ejercicios hipopresivos frente al entrenamiento muscular de suelo pélvico durante el postparto

Objetivos: La Gimnasia Abdominal Hipopresiva (GAH) está ganando popularidad como alternativa a la rehabilitación pélvica clásica. Sin embargo, no hay evidencia sólida para su recomendación, y no se ha evaluado su efectividad durante el post-parto frente al Entrenamiento Muscular de Suelo Pélvico (EMSP). El objetivo principal del estudio fue evaluar las modificaciones ecográficas que se producen en el musculo elevador del ano tras ambos protocolos de rehabilitación durante el post-parto, con el fin de poder determinar si la GAH produce modificaciones a este nivel. Material y métodos: Se llevó a cabo un estudio prospectivo observacional del 2014 al 2017 en la Unidad de Suelo Pélvico de un hospital universitario. Se reclutaron a las pacientes en el post-parto para realizar un estudio pretest basal que se repetiría al finalizar el protocolo de intervención. Los tratamientos disponibles fueron: un protocolo de EMSP o GAH de dos meses de duración. Se evaluaron los cambios anátomo-funcionales ecográficos, manométricos, dinamométricos y de síntomas de incontinencia urinaria. Se evaluó también el grado de satisfacción y adherencia. Resultados: Un total de 105 mujeres primíparas fueron reclutadas, 51 realizaron EMSP y 54 GAH. El grosor del músculo elevador del ano fue un 7% mayor tras concluir el protocolo de GAH en comparación con el EMSP (IC 95%, -2.0 a -0.3 p=0.008). El grupo de EMSP mostró una reducción del área del hiato urogenital en Valsalva estadísticamente significativa en comparación con el grupo de GAH (IC 95%, -3.2 a -0.3 p=0.016). La fuerza muscular máxima mejoró de forma significativa al concluir ambos protocolos (EMSP IC, 95% 5.9 a 19.4 p=<0.001; GAH IC, 95% 4.4 a 15.1 p=<0.001). Al comparar ambas técnicas no se encontraron diferencias estadísticamente significativas respecto a la manometría. Al concluir el protocolo de GAH se observó que las variables dinamométricas del tono basal y la capacidad de amortiguación fueron significativamente mayores vs al inicio (IC 95%, 56.9 a 135.0 p=<0.001; IC 95% 48.5 a 167.6 p=<0.001). No se encontraron diferencias estadísticamente significativas al analizarlos en el grupo EMSP ni al comparar ambos grupos. La puntuación obtenida en el cuestionario de síntomas miccionales tras finalizar ambos tratamientos fue significativamente menor [(PFMT: -0.8 puntos; IC del 95%: -1.4 a -0.1; p=0.015), (AHT: -0.7 puntos; IC del 95%: - 1.3 a -0.1; p=0.018]. Al comparar los resultados del cuestionario entre ambos grupos, no se obtuvieron diferencias estadísticamente significativas. Ambos grupos obtuvieron un muy buen nivel cumplimiento con una mediana de 8 clases de asistencia por grupo. El grupo de GAH mostró una puntuación de satisfacción más alta que el grupo EMSP (p=0.004). Conclusiones: Este estudio es el primero que analiza el efecto de la GAH frente al EMSP durante el post-parto. La GAH contribuye a un mayor grosor del musculo elevador del ano frente al EMSP. El EMSP contribuye a una mayor reducción en el área del hiato urogenital en Valsalva en comparación con la GAH. Ambos tratamientos reducen de manera significativa los síntomas de incontinencia urinaria frente a su situación basal. Debido a las limitaciones del estudio se debe considerar como un estudio preliminar. Se requieren ensayos clínicos controlados aleatorizados en el futuro para valorar la posible sinergia beneficiosa de ambas técnicas. La GAH puede ser un tratamiento a considerar durante el post-parto

Microsurgical anastomosis of the fallopian tubes after tubal ligation: a systematic review and meta-analysis

Objective: Between 20% and 30% of women who have undergone tubal ligation regret their decision. The alternative to regain fertility for these women is either in vitro fertilization or tubal re-anastomosis. This article presents a systematic review with meta-analysis to assess the current evidence on the efficacy of tubal recanalization surgery in patients who have previously undergone tubal ligation. Study design: The search was conducted in the World of Science (WOS) database, The Cochrane Library and ClinicalTrials.gov record using the keywords “tubal reversal”, “tubal reanastomosis” and “tubal anastomosis”. The review was carried out by two of the authors. Data from 22 studies were evaluated, comprising over 14,113 patients who underwent the studied surgery, following strict inclusion criteria: articles published between January 2012 and June 2022, in English and with a sample size bigger than 10 patients were included. A random-effects meta-analysis was performed. Results: The overall pregnancy rate after anastomosis was found to be 65.3 % (95 % CI: 61.0–69.6). The percentage of women who had at least one live birth, known as the birth rate, was 42.6 % (95 % CI: 34.9–51.4). Adverse outcomes after surgery were also examined: the observed abortion rate among women who underwent surgery was 9.4 % (95 % CI: 7.0–11.7), and the overall ectopic pregnancy rate was 6.8 % (95 % CI: 4.6–9.0). No differences were found between the outcomes when differentiating surgical approaches: laparotomy, laparoscopy, or robotic-assisted surgery. The patient’s age was identified as the most significant determining factor for fertility restoration. Finally, when comparing the results of tubal reversal with in vitro fertilization, reversal procedures appear more favorable for patients over 35 years old, while the results are similar for patients under 35 years old, but more data is needed to evaluate this finding. Conclusion: Therefore, the available literature review demonstrates that surgical anastomosis following tubal ligation is a reproducible technique with relevant success rates, performed by multiple expert groups worldwide

Triage for surgical management of ovarian tumors in asymptomatic women: assessment of an ultrasound-based scoring system.

OBJECTIVES: To prospectively evaluate an ultrasound-based scoring system as a method for triaging asymptomatic women presenting with an adnexal mass for surgical treatment. METHODS: Two hundred and four adnexal masses in 189 asymptomatic women undergoing elective surgical treatment at our institution were included in this prospective study. Patients were evaluated by transvaginal power Doppler ultrasound imaging before surgery. Patients were classified as low risk or high risk for malignancy according to an ultrasound-based scoring system. Women with a low risk for malignancy were scheduled for laparoscopy and patients with a high risk for malignancy were scheduled for laparotomy. However, patients classified as low risk by the ultrasound scoring system, but with a tumor size >or= 10 cm or clinical suspicion of pelvic adhesions, were instead considered to be at intermediate risk and were scheduled for laparotomy. Some patients classified as high risk were scheduled for an operative laparoscopy by an expert in gynecological oncology. RESULTS: One hundred and thirty-four (65.7%) masses were considered to be low risk and were treated by a laparoscopically guided procedure. All these tumors were benign. Forty-seven (23%) masses were classified as high risk, of which 39 tumors were malignant and eight benign. Twenty-three (11.3%) tumors were considered to be intermediate risk and were scheduled for primary laparotomy. In this group, 21 (91.3%) tumors proved to be benign and two (8.7%) were malignant. CONCLUSIONS: Ultrasound-based triage of asymptomatic women diagnosed with a persistent adnexal mass is effective for selecting the surgical approach

Ultrasound for assessing tumor spread in ovarian cancer. A systematic review of the literature and meta-analysis

In this review, we aimed to assess the diagnostic performance of ultrasound for assessing the tumor spread in the abdomen in women with ovarian cancer. A search for studies evaluating the role of ultrasound for assessing intrabdominal tumor spread in women with ovarian cancer compared to surgery from January 2011 to March 2023 was performed in PubMed/MEDLINE, Web of Science, and Scopus databases. The Quality Assessment of Diagnostic Accuracy Studies 2 evaluated the quality of the studies (QUADAS-2). All analyses were performed using MIDAS and METANDI commands in STATA 12.0 software. We identified 1552 citations. After exclusions, five studies comprising 822 women were included. Quality of studies were considered as good, except for patient selection as all studies were considered as having high risk of bias. The pooled sensitivity and specificity could be calculated for three anatomical areas (recto-sigma, major omentum and root of mesentery) and the presence of ascites. The pooled sensitivity and specificity for detecting disease in the recto-sigma, major omentum and root of mesentery were 0.83 and 0.95, 0.87 and 0.87, and 0.29 and 0.99, respectively. The pooled sensitivity and specificity for detecting ascites was 0.95 and 0.91, respectively. There is evidence that ultrasound offers good diagnostic performance for evaluating the intra-abdominal extent of disease in women with suspected ovarian cancer

SUCCOR risk: design and validation of a recurrence prediction index for early-stage cervical cancer

Objective Based on the SUCCOR study database, our primary objective was to identify the independent clinical pathological variables associated with the risk of relapse in patients with stage IB1 cervical cancer who underwent a radical hysterectomy. Our secondary goal was to design and validate a risk predictive index (RPI) for classifying patients depending on the risk of recurrence. Methods Overall, 1116 women were included from January 2013 to December 2014. We randomly divided our sample into two cohorts: discovery and validation cohorts. The test group was used to identify the independent variables associated with relapse, and with these variables, we designed our RPI. The index was applied to calculate a relapse risk score for each participant in the validation group. Results A previous cone biopsy was the most significant independent variable that lowered the rate of relapse (odds ratio [OR] 0.31, 95% confidence interval [CI] 0.17-0.60). Additionally, patients with a tumor diameter >2 cm on preoperative imaging assessment (OR 2.15, 95% CI 1.33-3.5) and operated by the minimally invasive approach (OR 1.61, 95% CI 1.00-2.57) were more likely to have a recurrence. Based on these findings, patients in the validation cohort were classified according to the RPI of low, medium, or high risk of relapse, with rates of 3.4%, 9.8%, and 21.3% observed in each group, respectively. With a median follow-up of 58 months, the 5-year disease-free survival rates were 97.2% for the low-risk group, 88.0% for the medium-risk group, and 80.5% for the high-risk group (p < 0.001). Conclusion Previous conization to radical hysterectomy was the most powerful protective variable of relapse. Our risk predictor index was validated to identify patients at risk of recurrence