Early Learning Curve in the Assessment of Deep Pelvic Endometriosis for Ultrasound and Magnetic Resonance Imaging.

PURPOSE: We aimed to compare the learning curves of an ultrasound trainee (obstetrics and gynecology resident) and a radiology trainee when assessing pelvic endometriosis. METHODS: Consecutive patients with suspected endometriosis were prospectively enrolled in a tertiary center. They underwent an ultrasound and magnetic resonance imaging preoperatively, which was reported according to the International Deep Endometriosis Analysis (IDEA) group consensus. Trainees reported on deep endometriosis (DE), endometriomas, frozen pelvis, and adenomyosis. Using the Kappa agreement, their findings were compared against laparoscopy/histology and expert findings. The learning curve was considered positive when performance improved over time and indeterminate in all other cases. RESULTS: Reports from thirty-five women were divided chronologically into 3 equal blocks to assess the learning curve. For ultrasound, trainee versus expert showed a positive learning curve in overall pelvic DE assessment. There was an excellent agreement for adenomyosis (Kappa = 1.00, p = 0.09), frozen pelvis (Kappa = 0.90, p = 0.01), bowel (Kappa = 1.00, p = 0.01), and bladder DE assessment (Kappa = 1.00, p = 0.01). Endometrioma and uterosacral ligament assessment showed an indeterminate curve. For radiology, trainee versus expert showed a positive curve when detecting adenomyosis (Kappa = 0.42, p = 0.09) and bladder DE (Kappa = 1.00, p = 0.01). The assessment of endometriomas, frozen pelvis, overall pelvic DE, bowel, and uterosacral ligament DE showed indeterminate curve. Agreement between trainees and laparoscopy/histology showed a positive curve for bladder (both) and frozen pelvis (ultrasound only). CONCLUSION: A positive learning curve can be seen in some areas of pelvic endometriosis mapping after as little as 35 cases, but a bigger caseload is required to demonstrate the curve in full. The ultrasound trainee had positive learning curves in more anatomical locations (bladder, adenomyosis, overall bowel DE, frozen pelvis) than the radiology trainee (bladder, adenomyosis), which could be down to individual factors, differences in training, or the imaging method itself.

Treatment of chronic bacterial prostatitis.

The pathogenesis, clinical signs and symptoms, diagnosis and treatment of chronic bacterial prostatitis (CBP) are reviewed. The most common organism associated with CBP is Escherichia coli, although infections with Klebsiella, Enterobacter, Proteus, Pseudomonas, and enterococci have also been documented. The only symptoms of CBP may be those of an acute urinary-tract infection. The use of simultaneous quantitative urine cultures represents the most accurate method for diagnosing CBP. The use of trimethoprim-sulfamethoxazole, the current drug of choice for CBP, is based on results in animals showing good penetration of trimethoprim into acidic prostatic fluid and the knowledge that normal human prostatic fluid is acidic. Studies in patients with CBP, who have alkaline prostatic fluid, have demonstrated poor penetration of trimethoprim into prostatic fluid, which may explain the cure rate of about 40% seen with trimethoprim-sulfamethoxazole. A few patients have been treated successfully with kanamycin and streptomycin, but these drugs must be given by injection. Carbenicillin indanyl sodium has been associated with cure rates of almost 70% in a small number of studies. Both doxycycline and minocycline have been used to treat CBP, but inadequate urine-culture data make these studies difficult to evaluate. Erythromycin produced a cure rate of 88% in one study in patients who received 500 mg (as the stearate salt) four times daily for 14 days. Local injection of antibiotics into the prostate has been reported to be effective in a few cases. Although controlled comparative trials with trimethoprim-sulfamethoxazole are needed, carbenicillin indanyl sodium and erythromycin appear to be the drugs of choice for treating CBP; trimethoprim-sulfamethoxazole should be reserved for patients with CBP unable to tolerate or unresponsive to therapy with these agents.

Metrizamide: a review with emphasis on drug interactions.

The pharmacology, side effects, and possible drug interactions of metrizamide, a water-solulbe contrast medium for myelography, are reviewed. Metrizamide concentration in the brain reaches maximal levels two to six hour after lumbar injection, depending on dose and patient positioning, and is largely (55-96%) excreted from the body after 24 hours. Its lower neurotoxicity, compared with other water-soluble contrast agents, can be attributed in part to its undissociated, non-ionic nature. Common side effects, which include headache, nausea, and vomiting, occur to the same degree as with other myelographic contrast media. Reported data suggest that convulsions, which have occurred in a very small percentage of patients, are related to the amount of contrast medium reaching the brain which, in turn, is largely a factor of dose and examination technique. Although the risk of seizures is small, it is recommended that drugs that lower the seizure threshold (phenothiazine derivatives, butyrophenones, tricyclic antidepressants, and MAO-inhibitors) should be avoided 48 hours before metrizamide administration (if possible), should not be used to control nausea, and should not be resumed for 24 to 48 hours after the myelographic procedure. The value of premedication (e.g., with diazepam) to prevent seizures has not been established and is not recommended.