The role of hysteroscopy in reproductive surgery: Today and tomorrow.

During the last decades, the number of couples with reproductive issues has substantially increased. Many different factors are implicated in reproductive failure, including uterine factors. Endometrial pathologies, such as endometrial polyps, hyperplasia, endometritis, and Mullerian anomalies, can also hinder embryo implantation. Hysteroscopy remains the gold standard for the evaluation and treatment of intrauterine pathology. Over the last few years, advances in hysteroscopic instrumentations and surgical techniques have significantly evolved, the refinement in technology, miniaturization of instruments, and improved image quality have rendered hysteroscopy a more patient and user-friendly procedure that has enhanced its use in reproductive medicine. Nowadays, hysteroscopy is essential in the evaluation and treatment of women with infertility. This article underscores the major technological breakthroughs achieved over the last few years with emphasis on the role of artificial intelligence, augmented reality, and 3D hysteroscopy, which can set new benchmarks in hysteroscopy applied to reproductive medicine.

Distension media delivery systems in hysteroscopy: past, present and future.

To examine the uterine cavity and/or to perform hysteroscopic surgery, one has to access the uterine cavity through the cervix, distend the cavity with a fluid (liquid or gas) to visualize it with a telescope and/or a camera system and use energy (mechanical or thermal) to affect and/or remove tissue. Distension of the uterine cavity then is an important component of hysteroscopy, and during the last century, numerous attempts have been made to achieve an undistorted and unobstructed panoramic view of the uterine cavity. In order to achieve this goal, the uterine cavity has been distended with fluids using a variety of techniques, including gravity-assisted systems, pressure cuffed systems, and electronic pumps. Excessive fluid intravasation during hysteroscopy can lead to significant complications, and hence, automated fluid delivery systems have been developed recently to provide a safe and more efficient method of fluid delivery. This review aims to describe the evolution of distension media delivery systems chronologically from the 1900s to the present day.

Classification systems of Asherman's syndrome. An old problem with new directions.

Intrauterine adhesion (IUA) formation and the resulting Asherman's syndrome (AS) is an unfortunate clinical condition that occurs when the endometrium is damaged as a consequence of trauma, such as vigorous curettage, infection, or some Müllerian anomaly. The most frequent symptoms include hypo/amenorrhea, infertility, and adverse reproductive outcomes. Prevention of IUA formation is essential; however, when present, accurate diagnosis and surgical intervention (hysteroscopic adhesiolysis) are required. The outcome of this treatment is based on the technique and the extent of surgery performed which depends on the severity and complexity of the disease. Hence its classification becomes particularly important to determine a standardized therapy for each case and patient counseling regarding the prognosis. In this article, we aim to describe the IUAs classification systems that have been proposed comparing the merits and demerits of each one.

Diagnostic work-up in paediatric and adolescent patients with adnexal masses: an evidence-based approach.

Adnexal masses are rare in the young female population. The differential diagnosis includes ovarian masses, tubal/paratubal masses, masses related to the gastrointestinal tract (colon), infectious lesions, or pregnancy. Acute abdominal pain, and less commonly, precocious puberty or vaginal bleeding, are typical symptoms in these cases. The majority of adnexal masses in the paediatric and adolescent population are benign; however, a thorough preoperative assessment is essential to guide surgical intervention and optimise patient outcomes. The proper diagnosis of an adnexal mass, correct management (surgical or nonsurgical), and necessary referrals are of paramount importance. In the light of these cornerstones, this review describes the aetiologies, presenting symptoms, and appropriate diagnostic work-up for paediatric and adolescent patients affected by adnexal masses.

Evaluation and treatment of infertile women with Asherman syndrome: an updated review focusing on the role of hysteroscopy.

Asherman syndrome is a rare acquired clinical condition resulting in the obliteration of the uterine cavity causedby the presence of partial or complete fibrous intrauterine adhesions involving at least two-thirds of the uterine cavity potentially obstructing the internal cervical orifice. Common reported symptoms of the disease are alterations of the menstrual pattern with decreased menstrual bleeding leading up to amenorrhoea and infertility. Hysteroscopy is currently considered the gold standard diagnostic and therapeutic approach for patients with intrauterine adhesions. An integrated approach, including preoperative, intraoperative and postoperative therapeutic measures, however, are warranted owing to the complexity of the syndrome. This review aims to summarize the most recent evidence on the recommended preoperative, intraoperative and postoperative procedures to restore the uterine cavity and a functional endometrium, as well as on the concomitant use of adjuvant therapies to achieve optimal fertility outcomes.

"Worried about relapse": Family members' experiences and perspectives of relapse in first-episode psychosis.

BACKGROUND: The purpose of this study was to gain an in-depth understanding on the subject of relapse from the perspectives of family members of young people receiving services for a first-episode psychosis (FEP). METHODS: A qualitative descriptive approach, using focus group methods, was used to elicit experiences, understandings, and knowledge of relapse in FEP. Family members were recruited from 4 specialized early intervention programmes for psychosis in Canada. A total of 24 (6 male, 18 female) family members participated in the study. Thematic analysis was used to examine the data. RESULTS: The core underlying theme in all focus groups was worrying about relapse, which was often accompanied by significant levels of fear and anxiety, and was influenced by: (1) impact of an episode of psychosis; (2) limited confidence in recognizing and coping with relapse; (3) unmet needs for coping skills and emotional support and (4) unmet needs regarding frequency and continuity of communication with clinicians. CONCLUSIONS: Family members' unmet needs for relapse-focused education, support and communication with service providers and peers, can have a negative impact on relapse prevention. Addressing family members' education and support needs in a tailored manner (including preferences for types of peer support) can contribute positively to their confidence and ability to recognize and respond to relapse. This can help reduce fear and anxieties about relapse, and positively influence the ability to function as caregivers. Future research should focus on best approaches for providing education, sustained contact with the clinical team and family peer support.

Stability of outcomes after 5 years of treatment in an early intervention programme.

AIM: It has been hypothesized that the first 5 years are critical in determining long-term recovery from psychotic disorders. We examine stability in recovery indices after 5 years for 56 patients treated in an early intervention programme for psychosis. METHODS: Assessments of symptom remission and functional recovery were carried out 5 and 10 years after initiation of treatment. RESULTS: Although overall rates of recovery were comparable at both times, there were significant changes for individuals reflecting both improvement and deterioration. CONCLUSIONS: Evidence concerning the critical period hypothesis should examine stability in individuals rather than relying on cumulative indices.

An examination of components of recovery after five years of treatment in an early intervention program for psychosis.

Recovery from psychotic disorders includes both symptomatic and functional components. Progress in understanding recovery requires careful replication and extension of findings using comparable measures. In the current paper, we present a study of five year recovery rates in an early intervention program in London, Canada with the same operational criteria as those used in a previous report from the OPUS cohort in Denmark. Our analysis extends the OPUS reports by including additional potential predictors of overall recovery, such as cognitive functioning, adherence to medication and early social support, and examining rates and predictors of individual components of recovery at five year follow-up. Consistent with reports from OPUS, we found younger age of onset and lower initial severity of negative symptoms to predict greater likelihood of overall recovery. Different patterns of predictors emerge when we examine individual components of recovery. Adherence to medication during the first year was the sole independent predictor of remission of positive symptoms, while early social adjustment and social support were more likely to predict negative symptom and functional aspects of recovery at five years. Cognitive functioning, as represented by IQ, did not predict any aspects of recovery. Our findings suggest the importance of examining the predictors of individual components in the quest to improve overall recovery.

Story of a Giant Endometrial Polyp in Asymptomatic Postmenopausal Female.

Endometrial polyps are localized overgrowth of endometrial glands and stoma through the uterine cavity. They are associated with postmenopausal bleeding, infertility and menorrhagia and are affected by unbalanced oestrogen therapy or increased frequency of tamoxifen exposure. We report a case of giant endometrial polyp in postmenopausal female without vaginal bleeding and hormone or drug use. A 65-year-old, postmenopausal female P3L2 with hypertension and Diabetes Mellitus (DM) came for routine health check-up. Her physical examination was normal. Pelvic examination uterus was multiparous sized, mid positioned and bilateral fornices were free. Patient was planned for hysteroscopic guided biopsy as her Ultrasonography (USG) showed endometrial thickness to be 12.3 mm. On hysteroscopy, there was hyperplastic endometrium with large endometrial polyp of size 8.5 cm. Polypectomy was done and the same was sent for histopathological evaluation. Report showed cystic hyperplasia without atypia. To summarize, postmenopausal female will not always present with symptoms and USG can also quite frequently miss the diagnosis, so proper evaluation is needed using hysteroscopy which is gold standard for diagnosis and treatment of endometrial polyp.

What Is the Place of Clozapine in the Treatment of Early Psychosis in Canada?

Research and development of early intervention (EI) services for first-episode psychosis have brought much-needed transformation of service delivery for this serious mental disorder to many jurisdictions. The effectiveness of the EI model of service delivery is contingent on timely access to all evidence-informed treatment interventions, including a rational approach to pharmacotherapy. In this perspective paper, we present a brief review of the well-established effectiveness of clozapine in patients who clearly show lack of response to regular antipsychotic therapy. We concentrate, in particular, on the need to identify eligibility for clozapine therapy very early on following failure of treatment on 2 antipsychotic medications. We suggest that attention to the low use of clozapine in the very early phase of treatment of psychosis may be of particular value, as the response to clozapine at this stage is likely to produce larger benefits in other domains of outcomes because of the greater retention of patients' personal and social agency.

Prevention and Early Intervention Program for Psychoses (PEPP).

The Prevention and Early Intervention Program for Psychoses (PEPP) was established in 1997 for individuals with first-episode non-affective psychotic disorder. The objectives of PEPP are to improve outcomes for clients by providing a prompt, comprehensive, coordinated and effective treatment program as well as to advance research concerning early intervention for psychotic disorders. This article describes the clinical and research program and the lessons learned.

An Exploratory, Open-Label, Randomized Trial Comparing Risperidone Long-Acting Injectable with Oral Antipsychotic Medication in the Treatment of Early Psychosis.

Few studies have examined effectiveness and tolerability of risperidone long-acting injections (RLAI) in the early phase of a schizophrenia spectrum (SS) disorder using a randomized controlled trial (RCT) design. Eighty-five patients in early phase of an SS disorder were randomized to receive either oral second-generation antipsychotics (SGAs; n=41) or RLAI (n=44) over two years. Analyses were conducted on eligible participants (n=77) for the stabilization (maximum 18 weeks) and maintenance phases (up to Week 104) on primary outcome measures of time to stabilization and relapse, change in symptoms and safety, and comparisons made across the two groups. Both groups showed improvement on Positive and Negative Syndrome Scale (PANSS) scores and Clinical Global Impression-Severity (CGI-S) scores. There were no time X group interactions on any of the primary outcome measures. Post hoc examination revealed that the RLAI group showed greater change on CGI-S and PANSS negative symptom scores during the stabilization phase, while the oral group reached the same level of improvement during the maintenance phase. The current exploratory study suggests that-within an RCT design-RLAI and oral SGAs are equally effective and have similar safety profiles in patients in the early phase of SS disorders. Thus, RLAI offers no advantage to patients in early phase of SS disorders, but is likely to be effective and safe for those who may have problems with adherence and may either choose to take it or be prescribed under conditions of external control such as community treatment orders.

The course of negative symptoms over the first five years of treatment: Data from an early intervention program for psychosis.

BACKGROUND: Cross-sectional studies suggest that negative symptoms are constituted by separable domains of reduced expressiveness and reduced motivation, but there is little data on the longitudinal course of these symptoms. We examined evidence for differences in the course and correlates of these two domains in a prospective study of patients presenting with a first episode of psychosis. METHODS: Of 132 patients who were followed up for five years, it was possible to monitor reduced expressiveness and motivation on a weekly basis for 127. Information on treatment delay, premorbid adjustment, intellectual functioning, anxiety, depression and psychosocial functioning were also collected. RESULTS: Over the five year follow-up, symptoms of reduced motivation occurred in 95.3% of patients and reduced expressiveness in 68.5%; and deficits in motivation were more likely to be unremitting (15.7%) than expressive deficits (5.5%). There were differences in the correlates of the proportion of time each patient experienced symptoms of each domain. Depression, weeks of full time occupation and weeks on a disability pension were associated with both domains. Anxiety was associated only with diminished motivation. Lower performance IQ; extrapyramidal symptoms (EPS) and dysrhythmic EEG were associated only with proportion of time showing reduced expressiveness. CONCLUSIONS: The prospective data support previous cross-sectional findings that, while these domains of negative symptoms are correlated, they do show differences in prevalence over time and in their correlates.

Cognition and the prediction of functioning in patients with a first treated episode of psychosis: a prospective study.

Past research on the role of cognitive performance in predicting later psychosocial functioning for individuals with first treated episode of a psychotic disorder has yielded inconsistent results. Several factors have been suggested as determining the strength of any such relationship including the type of functioning measured, time of the cognitive assessment, covariates included and the use of global versus specific measures of cognitive functioning. In the current study, we examined the importance of these factors in a five year prospective study of individuals with first episode psychotic disorders. Just over 80% of the sample had a schizophrenia spectrum disorder. Cognitive assessments were carried out after initiation of treatment on 113 patients, and at one year for 79 patients. There was evidence that cognition predicted occupational functioning and use of a disability pension, but not a summary index of functioning or use of supervised housing, at follow-up. Overall I.Q. was a more consistent predictor than measures of specific cognitive functions, and there was evidence that cognition assessed after presentation for treatment, particularly after a year of treatment, was more predictive of later functioning than premorbid I.Q. Cognitive functioning, however, did not add to the prediction of outcomes beyond the level possible using past educational achievement or academic premorbid adjustment.

Electroencephalographic abnormalities and 5-year outcome in first-episode psychosis.

OBJECTIVE: To examine the relation of electroencephalographic abnormalities to 5-year outcomes in first-episode psychosis (FEP). METHODS: Patients (n = 103) had their baseline electroencephalogram (EEG) classified by modified Mayo Clinic criteria. Symptoms and psychosocial functioning were rated after 5 years of treatment. RESULTS: Dysrhythmic EEG was associated with persistence in positive and negative symptoms of psychoses and poorer psychosocial functioning at 5-year follow-up, independently of other characteristics, such as duration of untreated illness or premorbid adjustment. A higher percentage of people with comorbid substance use disorder had normal EEG. CONCLUSIONS: Abnormal baseline EEG in FEP is associated with poorer 5-year symptomatic and functional outcome.

The prognostic significance of early remission of positive symptoms in first treated psychosis.

We examine the relationship between achieving remission of positive symptoms within 3 months in first episode psychosis and outcomes 5 years later. Time to remission of positive symptoms, other early characteristics and 5 year outcomes were assessed in a prospective study of 132 patients being treated for the first time for a psychotic disorder. Just under 60% of patients showed remission of positive symptoms within 3 months. In comparison to later remitters, they showed lower levels of positive symptoms, greater likelihood of competitive employment and less likelihood of collecting a disability pension at 5 years. Earlier remission of positive symptoms may have prognostic significance for longer term outcomes.

The significance of possible selves in patients of an early intervention programme for psychotic disorders.

AIMS: To assess the possible importance of patients' perceptions of possible future selves in determining self-esteem and mood. METHODS: One hundred and two patients of an early intervention programme for psychotic disorders completed measures of perceived positive and negative current and possible future selves, as well as indices of self-esteem and mood. RESULTS: Measures of current and possible selves generally showed bivariate correlations with self-esteem, depression and anger/hostility. Perceived negative possible self was the most important independent predictor of self-esteem, depression and anger/hostility. CONCLUSIONS: Perceptions of possible negative future selves may be a particularly important determinant of self-esteem and negative mood states. Addressing fears about possible future self is likely to be an important aspect of recovery from psychotic disorders.

A qualitative study of experiences with and perceptions regarding long-acting injectable antipsychotics: Part I-patient perspectives.

OBJECTIVE: Despite the well-acknowledged problem of poor adherence to antipsychotic (AP) medication, long-acting injectables (LAIs) that could improve adherence are underused in Canada. Attitudes concerning LAIs among patients and psychiatrists may contribute to this underuse. Our objective was to investigate perceptions of and attitudes toward LAIs among patients in Canada. METHOD: Focus groups were conducted with 34 patients with a diagnosis of schizophrenia spectrum psychoses in 4 Canadian provinces. The focus groups inquired about experiences with and attitudes toward LAI APs. The sessions were audiotaped and transcribed verbatim, and transcripts were coded using a combination of deductive and inductive methods. RESULTS: Four themes emerged: awareness of and knowledge about LAIs; perceptions about LAIs; cost and convenience considerations; and issues arising from the coercive context under which LAIs were often prescribed. Nine patients had never heard about LAIs, and some others reported not having understood what was discussed with them regarding LAIs. Patients had typically heard about LAIs in either a context of coercion or of medication nonadherence. Patients had positive and negative perceptions concerning LAIs. The positive perceptions centred on relapse prevention and reduced effort in ensuring adherence, and the negative perceptions centred on financial costs and the inconvenience of appointments to receive injections. CONCLUSION: To enhance LAI usage, some of the issues that need to be addressed are the inadequacy of information given to patients, the element of coercion involved in LAI introduction, the pragmatic barriers to LAI uptake by patients, and negative subjective perceptions about LAIs.

Objectif : Malgré le problème largement reconnu de la mauvaise observance des antipsychotiques (AP), les injectables à action prolongée (IAP) qui pourraient améliorer l'observance sont sous-utilisés au Canada. Les attitudes à l'égard des IAP chez les patients et les psychiatres peuvent contribuer à cette sous-utilisation. Notre objectif était d'enquêter sur les perceptions et les attitudes des patients à l'égard des IAP au Canada. Méthode : Des groupes de discussion ont été formés de 34 patients ayant reçu un diagnostic de psychose du spectre de la schizophrénie dans 4 provinces canadiennes. Les groupes de discussion portaient sur les expériences avec les AP IAP et les attitudes à leur égard. Les séances ont fait l'objet d'un enregistrement sonore et ont été transcrites textuellement, et ces transcriptions ont été codées à l'aide d'une combinaison de méthodes déductives et inductives. Résultats : Quatre thèmes se sont dégagés : conscience et connaissance des IAP; perceptions des IAP; considérations concernant le coût et la commodité; et les questions liées au contexte coercitif dans lequel les IAP sont souvent prescrits. Neuf patients n'avaient jamais entendu parler des IAP, et d'autres ont déclaré ne pas avoir compris lorsqu'on a discuté avec eux des IAP. Les patients avaient habituellement entendu parler des IAP dans un contexte soit de coercition, soit de non-observance des médicaments. Les patients avaient des perceptions positives et négatives à l'égard des IAP. Les perceptions positives étaient axées sur la prévention de la rechute et l'effort réduit pour maintenir l'observance, et les perceptions négatives portaient sur les coûts financiers et la complication des rendez-vous pour recevoir les injections. Conclusion : Afin d'accroître l'utilisation des IAP, il faut aborder certaines questions, notamment l'insuffisance de l'information donnée aux patients, l'élément de coercition présent dans l'instruction aux IAP, les obstacles pratiques à la prise d'IAP par les patients, et les perceptions subjectives négatives à l'égard des IAP.