Saliva microRNA signature to diagnose endometriosis: A cost-effectiveness evaluation of the Endotest®.

OBJECTIVE: To evaluate a saliva diagnostic test (Endotest®) for endometriosis compared with the conventional algorithm. DESIGN: A cost-effectiveness analysis with a decision-tree model based on literature data. SETTING: France. POPULATION: Women with chronic pelvic pain. METHODS: Strategy I is the French algorithm, representing the comparator. For strategy II, all patients have an Endotest®. For strategy III, patients undergo ultrasonography to detect endometrioma and patients with no endometrioma detected have an Endotest®. For strategy IV, patients with no endometrioma detected on ultrasonography undergo pelvic magnetic resonance imaging (MRI) to detect endometrioma and/or deep endometriosis. An Endotest® is then performed for patients with a negative result on MRI. MAIN OUTCOMES MEASURES: Costs and accuracy rates and incremental cost-effectiveness ratios (ICERs). Three analyses were performed with an Endotest® priced at €500, €750, and €1000. Probabilistic sensitivity analysis was conducted with Monte Carlo simulations. RESULTS: With an Endotest® priced at €750, the cost per correctly diagnosed case was €1542, €990, €919 and €1000, respectively, for strategies I, II, III and IV. Strategy I was dominated by all other strategies. Strategies IV, III and II were, respectively, preferred for a willingness-to-pay threshold below €473, between €473 and €4670, and beyond €4670 per correctly diagnosed case. At a price of €500 per Endotest®, strategy I was dominated by all other strategies. At €1000, the ICERs of strategies II and III were €724 and €387 per correctly diagnosed case, respectively, compared with strategy I. CONCLUSION: The present study demonstrates the value of the Endotest® from an economic perspective.

Intervenções psicológicas necessárias: a prática como residente no serviço de medicina fetal / Necessary psychological interventions: the practice as a resident in the fetal medicine service / Intervenciones psicológicas necesarias: la práctica como residente en el servicio de medicina fetal

Com os avanços tecnológicos e o aprimoramento da prática médica via ultrassonografia, já é possível detectar possíveis problemas no feto desde a gestação. O objetivo deste estudo foi analisar a prática do psicólogo no contexto de gestações que envolvem riscos fetais. Trata-se de um estudo qualitativo sob formato de relato de experiência como psicólogo residente no Serviço de Medicina Fetal da Maternidade Escola da Universidade Federal do Rio de Janeiro (UFRJ). Os registros, feitos por observação participante e diário de campo, foram analisados em dois eixos temáticos: 1) intervenções psicológicas no trabalho em equipe em consulta de pré-natal, exame de ultrassonografia e procedimento de amniocentese; e 2) intervenções psicológicas em casos de bebês incompatíveis com a vida. Os resultados indicaram que o psicólogo nesse serviço é essencial para atuar de forma multiprofissional na assistência pré-natal para gravidezes de alto risco fetal. Ademais, a preceptoria do residente é relevante para sua formação e treinamento para atuação profissional no campo da psicologia perinatal.(AU)

Face to the technological advances and the improvement of medical practice via ultrasound, it is already possible to detect possible problems in the fetus since pregnancy. The objective of this study was to analyze the psychologist's practice in the context of pregnancies which involve fetal risks. It is a qualitative study based on an experience report as a psychologist trainee at the Fetal Medicine Service of the Maternity School of UFRJ. The records, based on the participant observation and field diary, were analyzed in two thematic axes: 1) psychological interventions in the teamwork in the prenatal attendance, ultrasound examination and amniocentesis procedure; and 2) psychological interventions in cases of babies incompatible to the life. The results indicated that the psychologist in this service is essential to work in a multidisciplinary way at the prenatal care for high fetal risk pregnancies. Furthermore, the resident's preceptorship is relevant to their education and training for professional performance in the field of Perinatal Psychology.(AU)

Con los avances tecnológicos y la mejora de la práctica médica a través de la ecografía, ya se puede detectar posibles problemas en el feto desde el embarazo. El objetivo de este estudio fue analizar la práctica del psicólogo en el contexto de embarazos de riesgos fetal. Es un estudio cualitativo basado en un relato de experiencia como residente de psicología en el Servicio de Medicina Fetal de la Escuela de Maternidad de la Universidade Federal do Rio de Janeiro (UFRJ). Los registros, realizados en la observación participante y el diario de campo, se analizaron en dos ejes temáticos: 1) intervenciones psicológicas en el trabajo en equipo, en la consulta prenatal, ecografía y los procedimientos de amniocentesis; y 2) intervenciones psicológicas en casos de bebés incompatibles con la vida. Los resultados señalaron como fundamental la presencia del psicólogo en este servicio trabajando de forma multidisciplinar en la atención prenatal en el contexto de embarazos de alto riesgo fetal. Además, la tutela del residente es relevante para su educación y formación para el desempeño profesional en el campo de la Psicología Perinatal.(AU)

Cost effectiveness of the sFlt1/PlGF ratio test as an adjunct to the current practice of evaluating suspected preeclampsia in the United States.

OBJECTIVE: Preeclampsia is a major obstetric disorder that can lead to severe maternal, fetal and infant outcomes. In women with suspected preeclampsia, measurement of the soluble fms-like tyrosine kinase-1 (sFlt1) and placental growth factor (PlGF) ratio has been shown to have a high negative predictive value (>97%). Our aim was to estimate the value to the US healthcare system of adopting this test into clinical practice. STUDY DESIGN: An economic model was developed for the evaluation of suspected preeclampsia from a US payer perspective using data from a US observational study of 459 women evaluated between 23 and 34.6 weeks. Test results were not available to clinicians. The model compares two strategies for managing suspected preeclampsia: standard care versus a biomarker-informed pathway utilizing the sFlt1/PlGF ratio. RESULTS: Utilization of the sFlt1/PlGF ratio test reduced the number of women admitted for suspected preeclampsia by 34-49%. Despite fewer admissions, a higher proportion of women admitted to hospital subsequently developed preeclampsia, and the proportion of women not admitted who would subsequently develop preeclampsia remained low (3.2%-6.7%). Cost savings arising from a reduction in admissions are estimated to be $1050 in the base case; varying the hospitalization cost ±25% would lead to savings in the range $771 to $1330 per patient at 2020 prices. CONCLUSION: Adopting the sFlt1/PlGF ratio test as an adjunct to clinical criteria improves the assessment of risk in women presenting with suspicion of preeclampsia and has the potential to safely reduce unnecessary admissions and save costs.

Prevalence of T-shaped uterus among fertile women based on ESHRE/ESGE and Congenital Uterine Malformation by Experts (CUME) criteria.

RESEARCH QUESTION: What is the prevalence of T-shaped uteri among fertile women based on ESHRE/ESGE and Congenital Uterine Malformation by Experts (CUME) criteria? DESIGN: A prospective cohort study of 258 women of reproductive age with a history of at least one natural pregnancy resulting in live birth. Participants were recruited from the family planning clinic between January 2018 and March 2020. The ESHRE/ESGE classification of congenital anomalies of the female genital tract was used for describing abnormal findings. CUME criteria were also used for diagnosing T-shaped uterus. Uterine cavity volume was measured. RESULTS: Mean age of participants was 35.4 ± 6.2 years. Participants were diagnosed with the following: congenital uterine abnormality (n = 9 [3.6%]); partial septate uterus (n = 5 [2.0%]) and hemiuterus (n = 2 [0.8%]). Two women (0.8%) were diagnosed with T-shaped uterus and borderline T-shaped uterus based on the ESHRE/ESGE criteria and CUME. Mean lateral indentation angle, lateral indentation depth and T-angle were 156.2° ± 9.53°, 2.85 ± 0.93 mm and 73.3° ± 9.85° in patients with normal uterine cavity. In patients with T-shaped and borderline T-shaped uteri, respective figures were 115° versus 121°, 10 mm versus 7.6 mm and 27.5° versus 70°. Median volume of the uterine cavity in patients with normal uterine cavity and T-shaped uterus was 3.71 ml (minimum 2.0 to maximum 9.03 ml, interquartile range 1.93) and 3.2 ml (2.9 and 3.62 ml), respectively. CONCLUSIONS: The prevalence of T-shaped uteri in fertile women is low, which corresponds to previous reports of women with poor reproductive history.

Creating a bundled care payment model for treatment of pelvic floor disorders: introducing value into urogynecology.

Ineffective healthcare delivery and expenditures associated with the traditional fee for service in-person models have turned attention toward alternative payment models as a means of enhancing healthcare quality in the United States. Bundled care payment models are a form of alternate payment models that provide a single reimbursement for all services rendered for an episode of care and have been developed extensively in primary care settings with limited literature in urogynecology. We describe the process used to create a bundled care payment model for women seeking care in a subspecialty clinic for pelvic floor disorders in partnership with our safety net insurer. The process included estimation of prior average spend, the design of an integrated practice unit, creation of pelvic floor pathways, approximation of utilization rates, and estimation of reimbursement and expenses.

Placental growth factor testing for suspected pre-eclampsia: a cost-effectiveness analysis.

OBJECTIVE: To calculate the cost-effectiveness of implementing PlGF testing alongside a clinical management algorithm in maternity services in the UK, compared with current standard care. DESIGN: Cost-effectiveness analysis. SETTING: Eleven maternity units participating in the PARROT stepped-wedge cluster-randomised controlled trial. POPULATION: Women presenting with suspected pre-eclampsia between 20+0 and 36+6  weeks' gestation. METHODS: Monte Carlo simulation utilising resource use data and maternal adverse outcomes. MAIN OUTCOME MEASURES: Cost per maternal adverse outcome prevented. RESULTS: Clinical care with PlGF testing costs less than current standard practice and resulted in fewer maternal adverse outcomes. There is a total cost-saving of UK£149 per patient tested, when including the cost of the test. This represents a potential cost-saving of UK£2,891,196 each year across the NHS in England. CONCLUSIONS: Clinical care with PlGF testing is associated with the potential for cost-savings per participant tested when compared with current practice via a reduction in outpatient attendances, and improves maternal outcomes. This economic analysis supports a role for implementation of PlGF testing in antenatal services for the assessment of women with suspected pre-eclampsia. TWEETABLE ABSTRACT: Placental growth factor testing for suspected pre-eclampsia is cost-saving and improves maternal outcomes.

Prospective external validation of IOTA three-step strategy for characterizing and classifying adnexal masses and retrospective assessment of alternative two-step strategy using simple-rules risk.

OBJECTIVES: To perform an external validation of the diagnostic performance of the three-step strategy proposed by the International Ovarian Tumor Analysis (IOTA) group for classifying adnexal masses as benign or malignant, when ultrasound is performed by non-expert sonographers in the first two steps. The second objective was to assess the diagnostic performance of an alternative strategy using simple-rules risk (SRR), instead of simple rules (SR), in the second step. METHODS: This was a prospective observational study conducted at two university hospitals, from September 2015 to August 2017, of consecutive patients diagnosed with an adnexal mass. All women were evaluated by ultrasound using the IOTA three-step strategy. Non-expert sonographers performed the first step (use of simple descriptors to classify the masses) and the second step (use of SR if the mass could not be classified in the first step); masses that could not be classified in the first two steps were categorized by an expert sonographer based on their subjective assessment (third step). The reference standard was histological diagnosis in patients who underwent surgery or at least 12 months of follow-up in cases managed expectantly. The sensitivity, specificity, positive (LR+) and negative (LR-) likelihood ratios and overall accuracy of the IOTA three-step strategy were estimated. Furthermore, we evaluated retrospectively an alternative two-step strategy using SRR in the second step to categorize the masses not classifiable with simple descriptors, classifying the lesions as being of low, intermediate or high risk for malignancy. The diagnostic performance of this strategy was estimated by calculating its sensitivity and specificity, assuming surgical intervention for intermediate- or high-risk lesions. RESULTS: The study included 283 patients (median age, 48 (range, 18-90) years), of whom 165 (58.3%) were premenopausal and 118 (41.7%) postmenopausal. Two hundred and sixteen (76.3%) women underwent surgery (154 benign and 62 malignant masses) and 67 (23.7%) were managed expectantly with serial ultrasound follow-up for at least 12 months. All expectantly managed masses were considered benign because no sonographic changes suggestive of malignancy were observed during follow-up. Simple descriptors could be applied in 126 (44.5%) masses. Of the remaining 157 lesions, 112 (39.6%) could be characterized using SR. Therefore, 238 (84.1%) masses could be classified by non-expert sonographers in the first two steps. Of the remaining 45 (15.9%) masses, all could be classified by an expert sonographer. Overall sensitivity, specificity, LR+ and LR- of the IOTA three-step strategy were 95.2%, 97.7%, 42.1 and 0.05, respectively. The diagnostic accuracy was 97.2%. Following the two-step strategy using SRR in the second step, of the 157 lesions not classified with simple descriptors, 42, 38 and 77 presented low, intermediate or high risk for malignancy, respectively. Based on this method, 210 women would have undergone surgical treatment. The sensitivity and specificity of this two-step strategy were 98.4% and 63.8%, respectively. CONCLUSIONS: The IOTA three-step strategy shows high accuracy for discriminating between benign and malignant adnexal lesions when used by non-expert sonographers. An alternative strategy using the SRR calculator in the second step might improve on this diagnostic performance by decreasing the number of surgical interventions and increasing sensitivity. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Economic assessment of the use of the sFlt-1/PlGF ratio test to predict preeclampsia in Germany.

BACKGROUND: The PRediction of short-term Outcome in preGNant wOmen with Suspected preeclampsIa Study (PROGNOSIS) demonstrated that a soluble fms-like tyrosine kinase 1/placental growth factor (sFlt-1/PlGF) ratio ≤ 38 ruled out the occurrence of preeclampsia in the next week with a negative predictive value of 99.3%; a ratio > 38 indicates an increased risk of developing preeclampsia in the next 4 weeks. We performed an assessment of the economic impact of the sFlt-1/PlGF ratio test for short-term prediction of preeclampsia in Germany. METHODS: We adapted a cost-effectiveness model, which had been developed to estimate the incremental value of adding the sFlt-1/PlGF ratio test with a cut-off ratio of 38 to standard diagnostic procedures for guiding the management of women with suspected preeclampsia in the UK. We used the adapted model to estimate the incremental value of the sFlt-1/PlGF ratio test (cut-off 38) for guiding the management of women with suspected preeclampsia from a German Diagnosis-Related Group (DRG) payer perspective. The economic model estimated costs associated with diagnosis and management of preeclampsia in women managed in either a 'no-test' scenario in which clinical decisions are based on standard diagnostic procedures alone, or a 'test' scenario in which the sFlt-1/PlGF test is used in addition to standard diagnostic procedures. Test characteristics and rates of hospitalization were derived from patient-level data from PROGNOSIS. The main outcome measure from the economic model was the total cost per patient. RESULTS: In the model adapted to the German DRG payer system, introduction of the sFlt-1/PlGF ratio test with a cut-off value of 38 could reduce the proportion of women hospitalized in Germany from 44.6 to 24.0%, resulting in an expected cost saving of €361 per patient. CONCLUSIONS: The sFlt-1/PlGF ratio test is likely to reduce unnecessary hospitalization of women with a low risk of developing preeclampsia, and identify those at high risk to ensure appropriate management. Even within the restrictions of the DRG system in Germany, this results in substantial cost savings for women with suspected preeclampsia.

A multiple-perspective approach for the assessment and learning of ultrasound skills.

Ultrasound has become a core skill in many specialties. We evaluated the learning and assessment of ultrasound skills in Obstetrics-Gynaecology in a series of eight studies. In the clinical setting, we found that trainees as well as experienced clinicians struggle with technical aspects of performance such as image optimization. We examined how to improve these aspects of performance in the simulated setting by determining mastery learning levels and exploring learning curves for novices. We then examined how to improve the efficiency of training as well as transfer of learning through the use of dyad practice as compared with single practice. We found that the use of simulation-based training focusing on technical aspects of performance in addition to clinical training led to sustained improvements in performance after two months of clinical training in all aspects of performance. In addition, we found an interaction effect between initial simulation-based training and subsequent clinical training on trainees' need for supervision. These findings suggest that simulation-based training can work as preparation for future learning rather than merely as added learning. Finally, we found that the use of simulation-based initial training led to a large decrease in patients' discomfort, improvements in their perceived safety and confidence in their ultrasound operator. However, simulation-based training comes at a cost and in the final study we developed a model for conducting cost-effectiveness studies and provided data from an example study on how to link training costs with quality of care.

Intrapartum test for detection of Group B Streptococcus colonization during labor.

PURPOSE: The purpose of this study was to evaluate the potential improvement of introducing an intrapartum test for the detection of Group B Streptococcus (GBS) during labor and to estimate its cost-effectiveness versus antepartum GBS screening culture. MATERIALS AND METHODS: Three hundred and thirteen women at beginning of labor, with unknown GBS status or with antepartum GBS screening culture were enrolled. A vaginal-rectal specimen was collected from each woman for GBS detection by real-time PCR. Results of intrapartum test and antepartum GBS screening culture were compared. RESULTS: Antepartum culture results did not always reflect the intrapartum maternal GBS colonization status since in 15.1% of the cases it was not concordant with intrapartum test. However, selecting only women, who underwent antepartum culture and intrapartum test at the same time, the percentage of concordance was 96.6%. Based on intrapartum test results, 74.9% of the total number of intrapartum antibiotic prophylaxis (IAP) was administered uselessly, while 1.9% of women did not receive IAP although they were positive to intrapartum test. Intrapartum test resulted less cost-effective than antepartum culture but it became more cost-effective at a cost threshold of about 16.00 €. CONCLUSIONS: The clinical introduction of intrapartum test could be a valuable mean for identification of GBS colonization during labor, allowing an appropriate management of mothers and neonates with consequent benefit for their health and with limited costs for Healthcare System.

Evaluación clínica objetiva y estructurada (ECOE) en la maestría de Enfermería Ginecobstétrica y Perinatal: una sistematización de la experiencia / Objective and structured clinical evaluation (ECOE) in the masters of Gyneco-Obstetrical and Perinatal Nursing: a systematization of experience / Avaliação clínica objetiva e estruturada (ECOE) em Enfermagem gynecobstetric e Perinatal mestre: experiência sistematizar

ResumenEn busca de la excelencia profesional, la maestría en Enfermería Ginecológica, Obstétrica y Perinatal de la Universidad de Costa Rica, se mantiene a la vanguardia respecto de los procesos de enseñanza y aprendizaje. La inclusión de la simulación clínica forma parte de estas innovaciones educativas desde el año 2012; sin embargo esta es la primera vez que se incluye los procesos evaluativos de tipo ECOES los cuales, en experiencias internacionales, han demostrado pertinencia en el cumplimiento de los objetivos de enseñanza. Esta experiencia se sistematiza, según los cinco tiempos que Óscar Jara establece en su libro Para sistematizar experiencias, con el objetivo de definir la pertinencia del ECOE en cuanto a cumplir los objetivos de aprendizaje del curso. La profesora del curso y la autora recopilaron la experiencia en un diario de registro que incluye la elaboración de los escenarios, y la creación de las rubricas de evaluación. Además las estaciones fueron grabadas. La evaluación se llevó a cabo con la totalidad de estudiantes matriculados, en el curso de Enfermería Ginecoobstétrica y Perinatal I. Se estableció tres estaciones que permitirían evaluar aspectos teóricos, habilidades técnicas y sociales en la atención de las personas. Además, se creó rúbricas de evaluación, basadas en guías clínicas procedimentales y en protocolos de atención de la seguridad social costarricense. Se concluye que la experiencia demuestra clara pertinencia de los ECOEs, para evaluar la aplicación de conocimientos teóricos y habilidades psicomotoras, sociales y de comunicación en estudiantes que cursan la maestría y evidencia su preparación para continuar con los niveles más complejos de la carrera.

AbstractIn search of professional excellence, the master's degree in Gynecological, Obstetrical and Perinatal Nursing at the University of Costa Rica remains at the forefront of teaching and learning processes. The inclusion of clinical simulation is part of these educational innovations since 2012. However, this is the first time that includes ECOES evaluation processes which, in international experiences, have demonstrated relevance in the fulfillment of teaching objectives. This experience is systematized, according to the five times that Oscar Jara establishes in his book. To systematize experiences, with the objective of defining the relevance of the ECOE in terms of meeting the learning objectives of the course. The course teacher and the author collected the experience in a log diary that includes the elaboration of the scenarios, and the creation of the evaluation rubrics. In addition, the stations were recorded. The evaluation was carried out with all the enrolled students, in the course of Gyneco-Obstetric and Perinatal Nursing I. Three stations were established that would allow to evaluate theoretical aspects, technical and social skills in the attention of the people. In addition, evaluation rubrics were created, based on procedural clinical guidelines and Costa Rican social security care protocols. It is concluded that the experience shows a clear relevance of the ECOEs, to evaluate the application of theoretical knowledge and psychomotor, social and communication skills in students who are masters and evidence their preparation to continue with the most complex levels of the career.

ResumoProcurando por excelência profissional, especialização em Enfermagem Ginecológica, Obstétrica e Perinatal mestre da Universidade da Costa Rica, continua na vanguarda no que diz respeito ao ensino e aprendizagem. Incluindo simulação clínica faz parte dessas inovações educacionais desde 2012; no entanto esta é a primeira vez que tais processos de avaliação que incluem ECOES em experiências internacionais têm mostrado relevância no cumprimento dos objectivos de ensino. Esta experiência é sistematizado como cinco vezes Óscar Jara afirma em seu livro de sistematizar experiências, com o objetivo de definir a relevância da OSCE na prossecução dos objectivos de aprendizagem do curso. Professor do Curso e autor reuniu experiência em um diário de bordo, que inclui o desenvolvimento de cenários e criando rubricas de avaliação. Além disso estações foram registrados. A avaliação foi realizada com todos os alunos inscritos no curso e Enfermagem Gynecoobstetric Perinatal I três estações que permitem avaliar competências teóricas, técnicas e sociais para lidar com pessoas foi estabelecida. Além disso, as rubricas de avaliação com base em diretrizes clínicas e protocolos processuais atenção da segurança social da Costa Rica foi criado. Concluise que a experiência mostra clara relevância de ECOES para avaliar a aplicação de conhecimentos e psicomotoras competências teóricas, habilidades sociais e de comunicação em estudantes perseguir mestrado e preparar provas para avançar para níveis mais complexos da corrida.

Quality assessment of pelvic ultrasound for uterine myoma according to the CNGOF guidelines.

INTRODUCTION: French guidelines regarding the minimum criteria for gynaecological ultrasound were given in a recent report in 2016, by the French National College of Obstetricians and Gynaecologists (CNGOF). An accurate report is essential for the optimal care of women, especially those presenting myomas. The goal of this study was to evaluate the quality of gynaecological ultrasound reports for women with type 0 to 2 uterine myomas, referring to the items contained in the French guidelines. MATERIALS AND METHODS: A retrospective descriptive study was conducted from reports of ultrasounds performed in private offices and in the gynaecologic department of a hospital, between June 2014 and June 2016 (before the report of CNGOF). These reports involved women who underwent hysteroscopic resection of myoma(s). A search of validated items was conducted for all of the reports, and the missing items were analysed. The different types of practitioners and between hospital and private medical offices were also compared with Chi-square tests. RESULTS: A total of 138 reports were analysed; 71 were performed in private offices and 67 were performed in the gynaecologic unit of the hospital. Many items were missing in the reports, with disparities between the type of institution (private offices or hospital) and the speciality of practitioners (radiologists or gynaecologists). Specific items regarding myomas, such as the International Federation of Gynaecologists and Obstetricians (FIGO) classification or measurement of the posterior wall, were more often missing in reports from radiologists (89.7% and 79.5%, respectively) than in reports from gynaecologists (21.2% and 34.3%, respectively) (P<0.05). A significant difference was also observed for these data between private offices' reports and hospitals' reports. Items relative to ultrasound structures, such as the appearance of myomas or associated abdominal effusion, were more frequently missing in gynaecologists' reports (88.9% and 49.5%, respectively) compared to radiologists' reports (56.4% and 12.8%, respectively) (P<0.05). CONCLUSIONS: Certain items are present in all the reports, while others are insufficiently mentioned. These inequalities can be explained in part by the type of practice; however, methods to overcome these difficulties must be developed. Information campaigns to educate professionals on the minimum reporting and training conducted jointly by radiologists and gynaecologist surgeons might improve reports and improve the care of women.

CERVICAL CANCER: ASSESSMENT OF DIAGNOSIS AND TREATMENT FACILITIES IN PUBLIC HEALTH INSTITUTIONS IN ADDIS ABABA, ETHIOPIA.

BACKGROUND: Cervical cancer is the second most common cancer in women globally and the leading cause of cancer deaths in women in low income countries. The majority of cervical cancer related deaths occur in the developing world. It is also an important public health problem in Ethiopia, a country without a well-established control program for the disease. This study assessed the diagnostic and therapeutic facility for cervical cancer (including health providers' awareness of the disease) in Addis Ababa public health institutions which can be used to develop control strategies and to visualize the amount of resources required. METHODS: A cross-sectional study was conducted including all public health institutions in Addis Ababa in August 2010. Health providers' awareness of cervical cancer was assessed using a self-administered questionnaire. Checklist was used to register diagnostic and therapeutic infrastructure in each health facility. Data was analyzed using STATA. RESULTS: All health providers responded they had heard about cervical cancer. Half of the participants were able to identify common symptoms of the disease. Only 23% of the participants mentioned human papilloma virus (HPV) as the primary cause of cervical cancer. A significant association between awareness and profession was seen. Absence of skilled manpower, equipment and proper documentation was reported in the majority of the institutions. CONCLUSION: This study assessed the existing skilled man power and infrastructure to diagnose and treat cervical cancer in public institutions in Addis Ababa which is important to develop an effective cervical cancer control program. In addition, the study showed the more work that should be done to improve health providers' awareness in cervical cancer through education and training.

Placental alpha-microglobulin-1 and combined traditional diagnostic test: a cost-benefit analysis.

OBJECTIVE: We sought to evaluate if the placental alpha-microglobulin (PAMG)-1 test vs the combined traditional diagnostic test (CTDT) of pooling, nitrazine, and ferning would be a cost-beneficial screening strategy in the setting of potential preterm premature rupture of membranes. STUDY DESIGN: A decision analysis model was used to estimate the economic impact of PAMG-1 test vs the CTDT on preterm delivery costs from a societal perspective. Our primary outcome was the annual net cost-benefit per person tested. Baseline probabilities and costs assumptions were derived from published literature. We conducted sensitivity analyses using both deterministic and probabilistic models. Cost estimates reflect 2013 US dollars. RESULTS: Annual net benefit from PAMG-1 was $20,014 per person tested, while CTDT had a net benefit of $15,757 per person tested. If the probability of rupture is <38%, PAMG-1 will be cost-beneficial with an annual net benefit of $16,000-37,000 per person tested, while CTDT will have an annual net benefit of $16,000-19,500 per person tested. If the probability of rupture is >38%, CTDT is more cost-beneficial. Monte Carlo simulations of 1 million trials selected PAMG-1 as the optimal strategy with a frequency of 89%, while CTDT was only selected as the optimal strategy with a frequency of 11%. Sensitivity analyses were robust. CONCLUSION: Our cost-benefit analysis provides the economic evidence for the adoption of PAMG-1 in diagnosing preterm premature rupture of membranes in uncertain presentations and when CTDT is equivocal at 34 to <37 weeks' gestation.

[Comparison of fertiloscopy versus laparoscopy in the exploration of the infertility: analysis of the literature]. / Comparaison de la fertiloscopie à la cœlioscopie dans l'exploration de l'infertilité: analyse de la littérature.

BACKGROUND: Fertiloscopy is a recent technique designed to explore the tubo-ovarian axis in unexplained infertility. It is a simple outpatient technique, allowing to perform operative procedures, but its position relative to laparoscopy is yet to be defined. MATERIAL AND METHODS: A thorough and extensive bibliographical search was undertaken to fully embrace the question, challenging Medline at the National Library of Medicine, Cochrane Library, National Guideline Clearinghouse, Health Technology Assessment Database. All the retrieved articles were classified as either descriptive or comparative studies and evaluated on a set of criteria. RESULTS: Most of the papers described case series coming from a few teams, focusing mainly on the technical aspect of the procedure, like the access rate to the posterior cul-de-sac, the success rate in visualizing the pelvis, the complications rate (mainly rectal perforation), and its operative performance in drilling ovaries for resistant polycystic ovarian syndrome. Comparative studies numbered six trials. They all followed the same design, fertiloscopy preceding conventional laparoscopy in patients taken as their own control. The concordance rate between the two modalities reaches 80% in terms of tubal pathology, adherences and endometriosis, with an estimated reduction of laparoscopies varying from 40% to 93%. CONCLUSION: The current literature shows a concordance between fertiloscopy and conventional laparoscopic findings for certain parameters in cases of tubal pathology, adherences and endometriosis. The relative positions of these two modalities in unexplained infertility still remain elusive.

Prioritizing investments in innovations to protect women from the leading causes of maternal death.

PATH, an international nonprofit organization, assessed nearly 40 technologies for their potential to reduce maternal mortality from postpartum hemorrhage and preeclampsia and eclampsia in low-resource settings. The evaluation used a new Excel-based prioritization tool covering 22 criteria developed by PATH, the Maternal and Neonatal Directed Assessment of Technology (MANDATE) model, and consultations with experts. It identified five innovations with especially high potential: technologies to improve use of oxytocin, a uterine balloon tamponade, simplified dosing of magnesium sulfate, an improved proteinuria test, and better blood pressure measurement devices. Investments are needed to realize the potential of these technologies to reduce mortality.

Sonoelastography of the uterine cervix as a new diagnostic tool of cervical assessment in pregnant women - preliminary report.

OBJECTIVES: The study aimed at determining whether there exists a correlation between the cervical cohesion parameters assessed in the elastography and the length of the cervix. MATERIAL AND METHODS: Assessment of cervical cohesion parameters with the use of real-time sonoelastography was performed on 59 patients between 28 and 39 weeks of gestation. RESULTS: The analysis showed that there exists a statistically significant (p=0.033) correlation between the cervical length and the elasticity of the front cervical labium (strain ratio A). Correlation coefficient (r) stood at (-) 0.28. CONCLUSIONS: 1. There exists a negative correlation between the condition on the front cervical labium in elastographic imaging and the length of the cervical canal in USG imaging. 2. Elastography of the uterine cervix may be helpful in assessing the risk of premature labour or cervical insufficiency. 3. There is a need to perform a study on a larger group of patients in order to determine whether elastography may find its place among routine obstetric diagnostic methods.

Costo del proceso diagnóstico del cáncer de mama en las Unidades de Medicina Familiar del Instituto Mexicano del Seguro Social, Querétaro, México / Cost of the diagnostic process for breast cancer in the Family Medicine Units of the Mexican Social Security Institute

Objetivo: determinar el costo del proceso diagnóstico del cáncer de mama. Métodos: estudio de costos, en mujeres de 40 años y más, de enero a diciembre del 2010 de las unidades de medicina familiar del Instituto Mexicano del Seguro Social. La muestra se calculó con la fórmula de promedios para población infinita para un total de 245 mujeres. El costo se estimó mediante la técnica de tiempos y movimientos y consulta de expertos; el costo por uso de intervención se calculó con el uso promedio por intervención multiplicado por el costo unitario del mismo. El costo total del proceso diagnóstico se obtuvo de la suma de los costos de cada uno de las intervenciones. El plan de análisis incluyó promedios, porcentajes e intervalos de confianza. Resultados: el costo promedio del proceso diagnóstico fue de $852,45. Conclusión: el proceso diagnóstico de cáncer de mama incluye tamizaje y casos confirmados. El costo del proceso diagnóstico es relativamente bajo ofreciendo mejores perspectivas para el paciente y el sistema de salud.

Objective: to determine the cost of the diagnostic process for breast cancer. Methods: costs were calculated, in women 40 years and older, from January to December 2010 of the Family Medicine Units of the Mexican Social Security Institute. The sample was calculated with the formula for infinite population averages for a total of 245 women. The cost was estimated by time and motion technique and expert consultation, the intervention cost was calculated using the average usage per intervention multiplied by the unit cost thereof. The total cost of the diagnostic process was obtained from the sum of the costs of each of the interventions. The analysis plan included means, percentages and confidence interval. Results: the average cost of the diagnostic process was $852.45. Conclusions: the diagnostic process for breast cancer include screening and confirmatory cases. The cost of the diagnostic process is low, offers better prospects for the patient and the health system.

Does neuromuscular blockade affect the assessment of pelvic organ prolapse?

INTRODUCTION AND HYPOTHESIS: The purpose of this study was to determine if anesthesia with neuromuscular blockade alters the Pelvic Organ Prolapse Quantification (POP-Q) examination. METHODS: A prospective, multi-center trial was conducted of women undergoing pelvic surgery. A POP-Q examination performed pre-operatively was compared with an examination performed intra-operatively under neuromuscular blockade. For the latter examination, an Allis clamp was used to apply gentle traction until the point being examined did not undergo further descent. International Continence Society (ICS) stages and individual POP-Q points were compared using a paired sample t test. A sample size of 32 provided 80% power to detect a clinically significant difference between office and operating room measurements (Sample Power, SPSS, 1997). RESULTS: Of 153 women, 76% received general endotracheal anesthesia and 21% laryngeal mask airway. With an increase of 3 cm, the apical compartment was significantly more prolapsed in the operating room (OR; p < 0.05); however, a comparison of the mean values demonstrated a larger change in means for all points except total vaginal length. When separated into anterior, apical, and posterior compartments, the ICS stages were systematically different in the OR than in the office for all stages (p < 0.0005). CONCLUSIONS: Neuromuscular blockade leads to significantly greater increases in POP-Q examination measurements compared with the office measurements, and this increase is most pronounced apically.