Practice patterns, time trends and quality of care of uterine cancer in Belgium: An analysis of the EFFECT database.

OBJECTIVES: To investigate the practice patterns and quality of care for uterine cancer on a national level in Belgium, including trends in practice over the period 2012-2016. METHODS: Quality indicators were measured using the EFFectiveness of Endometrial Cancer Treatment (EFFECT) database. Multivariable logistic mixed regression was used to test for associations between the quality indicators and year of diagnosis, adjusted for potential confounders and intra-cluster correlations. RESULTS: The EFFECT database includes 4178 patients diagnosed with uterine cancer in the period 2012-2016. Minimally invasive surgery (laparoscopic or robotic-assisted) was applied in 61.6% of patients who had surgery for clinical stage I endometrial carcinoma (EC), increasing from 52.9% in 2012 to 66.4% in 2016. At least pelvic lymph node staging was performed in 69.0% of patients with clinical stage I, high-grade EC; and in 63.9% of patients with clinical stage I-II serous carcinoma, clear cell carcinoma or carcinosarcoma. The latter increased from 48.8% in 2012 to 77.2% in 2016. Adjuvant radiotherapy (external beam and/or brachytherapy) was offered to 33.5% of patients who had surgery without lymph node staging for pathological stage I EC at high-intermediate or high risk of recurrence. Adjuvant chemotherapy was administered to 64.4% of patients with pathological stage III-IVA EC. CONCLUSIONS: Study results indicate an overall good quality of care for patients with uterine cancer in Belgium. Treatment areas with potential room for improvement include the use of minimally invasive surgery, comprehensive surgical staging and adjuvant therapy, which confirms the remaining controversies in uterine cancer treatment and the need for further research.

Safety and Hemostatic Effectiveness of SURGICEL® Powder in Mild and Moderate Intraoperative Bleeding.

This postmarket clinical study evaluated the safety and effectiveness of the novel adjunctive topical hemostat SURGICEL® Powder (SURGICEL®-P), a powdered form of oxidized regenerated cellulose. In a prospective, open-label, single-arm multicenter trial, adult surgical subjects with mild-to-moderate bleeding for which conventional hemostatic methods were impractical/ineffective were treated with SURGICEL®-P. Descriptive analyses included hemostatic success rate at 3, 5, and 10 min, rebleeding and thromboembolic events, SURGICEL®-P-related serious adverse events requiring surgical intervention, and SURGICEL®-P ease of use (questionnaire). In 8 centers, 103 subjects were enrolled with a median (range) age of 64.0 (33.0-88.0) years. Surgeries were open (53.4%) or laparoscopic/thoracoscopic (46.6%) and mostly urological (37.9%) and abdominal (32.0%) procedures. Bleeding sites included various tissue types, with a median (range) surface area of 4 (0.02-72.0) cm2. Hemostatic success rates were 77.7%, 87.4%, and 92.2% at 3, 5, and 10 min, respectively. In 7 subjects (6.8%), investigators reverted to standard of care. No safety signals were identified. Two deaths occurred with causes unrelated to SURGICEL®-P. Investigators favorably evaluated the ease of use of the SURGICEL®-P device. SURGICEL®-P is safe and effective in controlling mild-to-moderate bleeding in a broad range of surgical procedures. The trial was registered at https://clinicaltrials.gov as NCT03762200.

Completeness and selection bias of a Belgian multidisciplinary, registration-based study on the EFFectiveness and quality of Endometrial Cancer Treatment (EFFECT).

BACKGROUND: With the aim of obtaining more uniformity and quality in the treatment of corpus uteri cancer in Belgium, the EFFECT project has prospectively collected detailed information on the real-world clinical care offered to 4063 Belgian women with primary corpus uteri cancer. However, as data was collected on a voluntary basis, data may be incomplete and biased. Therefore, this study aimed to assess the completeness and potential selection bias of the EFFECT database. METHODS: Five databases were deterministically coupled by use of the patient's national social security number. Participation bias was assessed by identifying characteristics associated with hospital participation in EFFECT, if any. Registration bias was assessed by identifying patient, tumor and treatment characteristics associated with patient registration by participating hospitals, if any. Uni- and multivariable logistic regression were applied. RESULTS: EFFECT covers 56% of all Belgian women diagnosed with primary corpus uteri cancer between 2012 and 2016. These women were registered by 54% of hospitals, which submitted a median of 86% of their patients. Participation of hospitals was found to be biased: low-volume and Walloon-region centers were less likely to participate. Registration of patients by participating hospitals was found to be biased: patients with a less favorable risk profile, with missing data for several clinical-pathological risk factors, that did not undergo curative surgery, and were not discussed in a multidisciplinary tumor board were less likely to be registered. CONCLUSIONS: Due to its voluntary nature, the EFFECT database suffers from a selection bias, both in terms of the hospitals choosing to participate and the patients being included by participating institutions. This study, therefore, highlights the importance of assessing the selection bias that may be present in any study that voluntarily collects clinical data not otherwise routinely collected. Nevertheless, the EFFECT database covers detailed information on the real-world clinical care offered to 56% of all Belgian women diagnosed with corpus uteri cancer between 2012 and 2016, and may therefore act as a powerful tool for measuring and improving the quality of corpus uteri cancer care in Belgium.

The Value of Fatigue Severity to Rule Out Depression in Older Adult Patients With Cancer.

PURPOSE/OBJECTIVES: To evaluate whether fatigue severity can serve as a cue to investigate the presence of depression in older adult patients with cancer. DESIGN: Cross-sectional observational cohort study. SETTING: Seven hospitals and general practices in Belgium and the Netherlands. SAMPLE: 205 older adult patients with cancer and 436 older adults without cancer (aged 70 years or older). METHODS: The diagnostic accuracy of fatigue as a proxy for depression was evaluated using sensitivity, specificity, and predictive values. MAIN RESEARCH VARIABLES: Fatigue was measured with a visual analog scale, and depression was measured with the 15-item Geriatric Depression Scale. FINDINGS: Fifty-six percent of the population experienced fatigue, and 13% were depressed. For fatigue as a cue for depression, sensitivity was 82%, specificity was 47%, positive predictive value was 18%, and negative predictive value was 95%. CONCLUSIONS: The data confirm that fatigue is a valuable cue to investigate the presence of depression because 82% of depressed participants were correctly identified by fatigue. The assessment of fatigue severity is intuitive, quick, straightforward, and usually already implemented. IMPLICATIONS FOR NURSING: Identification of depression is difficult in older adult patients with cancer. Instead of experiencing affective symptoms of depression, older adult patients are more likely to disclose somatic symptoms, such as fatigue, which often overlap with cancer-related symptoms. Nurses should be aware of this problem and should be alert for the possibility of depression in older adult patients presenting with fatigue.

A cohort study on the evolution of psychosocial problems in older patients with breast or colorectal cancer: comparison with younger cancer patients and older primary care patients without cancer.

BACKGROUND: Although older cancer survivors commonly report psychosocial problems, the impact of both cancer and ageing on the occurrence of these problems remains largely unknown. The evolution of depression, cognitive functioning, and fatigue was evaluated in a group of older cancer patients in comparison with a group of younger cancer patients and older persons without cancer. METHODS: Older (≥70 years) and younger cancer patients (50-69 years) with breast or colorectal cancer stage I-III, and older persons without cancer (≥70 years) were included. Data were collected at baseline and one year follow-up and were available for 536 persons. Depression was evaluated with the 15-item Geriatric Depression Scale. Cognitive functioning was measured with the cognitive functioning subscale of the European Organization for Research and Treatment of Cancer. Fatigue was measured with a Visual Analogue Scale. Risk factors for depression, cognitive functioning, and fatigue were analysed using multivariate logistic regression analyses. Risk factors included cancer- and ageing-related factors such as functional status, cancer treatment, and comorbidities. RESULTS: The evolution of psychosocial problems was similar for the group of older (N = 125) and younger cancer patients (N = 196): an increase in depression (p < 0.01), slight worsening in cognitive functioning (p = 0.01), and no clear change in fatigue. Also, compared to the group of people without cancer (N = 215), the differences were small and after one year of follow-up only depression was more frequent in older cancer patients compared to older persons without cancer (18% versus 9%, p = 0.04). In multivariate analyses the main risk factors for psychosocial problems after one year follow-up were changes in functional status and presence of baseline depression, fatigue, or cognitive impairment. CONCLUSION: Over the course of one year after a diagnosis of cancer, cancer patients face increasing levels of depression and increasing difficulties in cognitive functioning. The main risk factor for psychosocial problems was presence of the problem at baseline. This calls for regular screening for psychosocial problems and exchange of information on psychosocial functioning between different health care providers and settings during the treatment and follow-up trajectory of cancer patients.

Loneliness in patients with cancer: the first year after cancer diagnosis.

OBJECTIVES: We studied the frequency and evolution of social and emotional loneliness in older cancer patients in comparison with younger cancer patients and older people without cancer. We evaluated if changes in common cancer-related and ageing-related problems such as fatigue, cognitive functioning and functional status contributed to the occurrence of loneliness. METHODS: This study was part of the KLIMOP study (Dutch acronym for project on older cancer patients in Belgium and the Netherlands) and included older (≥70 years) and younger cancer patients (50-69 years) and older people without cancer. Data were collected at baseline and 1-year follow-up. Loneliness was measured with the loneliness scale of De Jong-Gierveld. The relationship between loneliness after 1 year and changes in fatigue, cognitive functioning and functional status was tested in multivariate logistic regression analyses. RESULTS: Data were available for 475 participants. At baseline, older cancer patients were less lonely compared with older people without cancer. After 1 year, the frequency of emotional loneliness had significantly increased for older cancer patients (26-42%, p < 0.001) and had reached levels of older people without cancer. Emotional loneliness also increased for younger cancer patients (25-34%, p = 0.02), but not for older people without cancer (40-38%, p = 0.69). Frequency of social loneliness did not change significantly. People who were persistently fatigued and people who became or were persistently impaired on cognitive functioning were at increased risk of becoming lonely. CONCLUSION: Loneliness, in particular emotional loneliness, is a common problem in cancer patients, and its frequency changes considerably over time.

Outcome of Epithelial Ovarian Cancer: Time for Strategy Trials to Resolve the Problem of Optimal Timing of Surgery.

INTRODUCTION: The standard treatment of ovarian cancer is the combination of debulking surgery and chemotherapy. There is an ongoing discussion on which treatment is best: primary debulking surgery (PDS) or neoadjuvant chemotherapy with interval debulking (NACT-IDS). Even a large randomized trial has not settled this issue. We examined whether comparing a specified treatment protocol would not be a more logical approach to answer this type of discussions. METHODS: A retrospective study of 142 consecutively treated patients according to a fixed protocol between 2000 and 2012 was conducted. Disease-free survival and overall survival were calculated by univariate and multivariate analyses for the whole group and for advanced stages separately. Specific differences between PDS and NACT-IDS were studied. Comparison of results from large databases was made. RESULTS: Disease-free survival and overall 5-year survival for the whole group were 35% and 50%. For the advanced stages, disease-free survival and overall 5-year survival were 14% and 36%, with a median disease-free and overall survival of 16 and 44 months. Of the 98 women with advanced ovarian carcinoma, 54% of operable patients underwent PDS and 44% underwent NACT-IDS. More patients in the PDS group were optimally (<1 cm) debulked: 80% vs 71%. There was no significant difference in survival between PDS or NACT-IDS. Optimally debulked patients had a significant better overall survival in multivariate analysis with a hazard ratio of 2.1. DISCUSSION: Outcome of treatment according to a fixed protocol with a mixture of PDS and NACT-IDS was similar to results from large databases. We hypothesize that comparison of a specific strategy may yield more useful results than awaiting the perfect randomized trial.

Geriatric screening tools are of limited value to predict decline in functional status and quality of life: results of a cohort study.

BACKGROUND: Geriatric screening tools are increasingly implemented in daily practice, especially in the oncology setting, but also in primary care in some countries such as the Netherlands. Nonetheless, validation of these tools regarding their ability to predict relevant outcomes is lacking. In this study we evaluate if geriatric screening tools predict decline in functional status and quality of life after one year, in a population of older cancer patients and an older primary care population without cancer with a life expectancy of at least six months. METHODS: Older cancer patients and a general older primary care population without a history of cancer (≥ 70 years) were included in an on-going prospective cohort study. Data were collected at baseline and after one-year follow-up. Functional decline was based on the Katz Index and Lawton IADL-scale and was defined as deterioration on one or more domains. Decline in quality of life was measured using the global health related subscale of the EORTC QLQ-C30, and was defined as a decline ≥ 10 points. The selected geriatric screening tools were the abbreviated Comprehensive Geriatric Assessment, Groningen Frailty Indicator, Vulnerable Elders Survey-13, and G8. We calculated sensitivity, specificity, predictive values, and odds ratios to assess if normal versus abnormal scores predict functional decline and decline in quality of life. RESULTS: One-year follow-up data were available for 134 older cancer patients and 220 persons without cancer. Abnormal scores of all screening tools were significantly associated with functional decline. However, this was only true for older persons without cancer, and only in univariate analyses. For functional decline, sensitivity ranged from 54% to 71% and specificity from 33% to 66%. For decline in quality of life, sensitivity ranged from 40% to 67% and specificity from 37% to 54%. CONCLUSION: In older persons with a relatively good prognosis, geriatric screening tools are of limited use in identifying persons at risk for decline in functional status or quality of life after one year. Hence, a geriatric screening tool cannot be relied on in isolation, but they do provide very valuable information and may prompt physicians to also consider different aspects of functioning.

Incarceration of the gravid uterus: diagnosis and preoperative evaluation by magnetic resonance imaging.

Incarceration of the gravid uterus is a rare obstetric disorder that is often not recognized despite the ready availability of ultrasound. However, detailed imaging of the disturbed uterine and pelvic anatomy - from an obstetric point of view- is the key in reducing the potentially severe complications of this condition and planning its treatment. In this paper, we will describe the specific magnetic resonance imaging (MRI) features of an incarceration of the gravid uterus and we will discuss the role of magnetic resonance imaging in defining anatomy and in the medical decision whether to operate or not.

Study protocol of KLIMOP: a cohort study on the wellbeing of older cancer patients in Belgium and the Netherlands.

BACKGROUND: Cancer is mainly a disease of older patients. In older cancer patients, additional endpoints such as quality of survival and daily functioning might be considered equally relevant as overall or disease free survival. However, these factors have been understudied using prospective designs focussing on older cancer patients. Therefore, this study will focus on the impact of cancer, ageing, and their interaction on the long-term wellbeing of older cancer patients. METHODS/DESIGN: This study is an observational cohort study. We aim to recruit 720 cancer patients above 70 years with a new diagnosis of breast, prostate, lung or gastrointestinal cancer and two control groups: one control group of 720 patients above 70 years without a previous diagnosis of cancer and one control group of 720 cancer patients between 50 - 69 years newly diagnosed with breast, prostate, lung or gastrointestinal cancer. Data collection will take place at inclusion, after six months, after one year and every subsequent year until death or end of the study. Data will be collected through personal interviews (consisting of socio-demographic information, general health information, a comprehensive geriatric assessment, quality of life, health locus of control and a loneliness scale), a handgrip test, assessment of medical records, two buccal swabs and a blood sample from cancer patients (at baseline). As an annex study, caregivers of the participants will be recruited as well. Data collection for caregivers will consist of a self-administered questionnaire examining depression, coping, and burden. DISCUSSION: This extensive data collection will increase insight on how wellbeing of older cancer patients is affected by cancer (diagnosis and treatment), ageing, and their interaction. Results may provide new insights, which might contribute to the improvement of care for older cancer patients.

Cytological screening for cervical cancer in the province of Limburg, Belgium.

Cervical cancer screening in Belgium is mainly opportunistic with periodic attempts to organize it according to the European guidelines. In the province of Limburg (north-east Belgium), a cervical cytology registry was set up in collaboration with local cytopathological laboratories, provincial health authorities and the Limburg Cancer Registry. Laboratories regularly communicated coded results of Pap smears from women residents in Limburg to the provincial cytological registry. All individual records contained a virtually unique identifying code allowing the study of longitudinal histories and linkage with the cancer registry. The screening coverage (percentage of women with a Pap smear in a defined period), the prevalence and incidence of squamous intraepithelial lesions and changes over time and geographical area were evaluated using a database of more than 600 000 Pap smear interpretations between 1996 and 2005. In 2000, 47% of women aged between 25 and 64 years had at least one Pap smear recorded in the last 3 years, and the average number of smears screened for each woman was 1.5. On account of incomplete registration, the coverage was 8% lower than estimated from health insurance data. The modal screening interval was in the range of 12-14 months; the first quartile, median and third quartile were 355, 440 and 676 days, respectively. Over the 10 years, 82% of the target population had their Pap smear recorded. The prevalence of cytological abnormalities was 3.7% (atypical squamous cells of undetermined significance: 2.2%, atypical glandular cells of undetermined significance: 0.1%, low-grade squamous intraepithelial lesion: 1.1%, high-grade squamous intraepithelial lesion or more serious lesions: 0.4%), but varied substantially among laboratories. The prevalence of atypical squamous cells of undetermined significance and low-grade squamous intraepithelial lesion increased significantly over time. Pathologists from Limburg have pioneered cytology registration in the context of opportunistic screening in Belgium. The estimated screening coverage was slightly underestimated. Obligatory registration, use of a uniform terminology and linkage with population and follow-up data are needed to give a cytology registry its full role in an organized screening programme.

Uterine and quality of life changes in postmenopausal women with an asymptomatic tamoxifen-thickened endometrium randomized to continuation of tamoxifen or switching to anastrozole.

OBJECTIVE: Before the knowledge that 5 years of adjuvant tamoxifen is less efficacious than 2 to 3 years of tamoxifen followed by 2 to 3 years of anastrozole/exemestane, we designed a multicenter double-blind randomized controlled trial in women taking tamoxifen with a thickened endometrium to compare uterine and quality-of-life parameters between those switching to anastrozole and those continuing tamoxifen. METHODS: Asymptomatic postmenopausal women who took adjuvant tamoxifen for 2 to 3 years for operable breast cancer with a double endometrial thickness greater than 7 mm were randomized to 20 mg tamoxifen or 1 mg anastrozole for the remaining duration, totaling 5 years. Tablets were unrecognizable for drug assignment. The primary endpoints were the differences in double endometrial thickness and uterine volume after 1 year. Uterine and quality-of-life data were analyzed using regression methods, and missing values were handled using multiple imputation. RESULTS: Seventy-two women (median age, 60 y) were randomized in five hospitals. Relative to women continuing tamoxifen, women switching to anastrozole experienced a decrease of 53% (95% CI, 41%-63%) in double endometrial thickness and a decrease of 51% (95% CI, 39%-60%) in uterine volume. Vaginal dryness (b = 0.064; 95% CI, 0.016-0.112) and sexual problems (b = 0.054; 95% CI, 0.007-0.102) increased in women taking anastrozole compared with women taking tamoxifen. Treatment arms did not differ regarding withdrawal rate and the experience of (serious) adverse events. CONCLUSIONS: Despite premature trial closure, our data provided valuable insights. Switching to anastrozole strongly decreased the endometrial thickness and uterine volume but increased sexual disturbances. Safe and effective interventions are needed to alleviate sexual dysfunction.

Ultrasound experience substantially impacts on diagnostic performance and confidence when adnexal masses are classified using pattern recognition.

AIM: To determine how accurately and confidently examiners with different levels of ultrasound experience can classify adnexal masses as benign or malignant and suggest a specific histological diagnosis when evaluating ultrasound images using pattern recognition. METHODS: Ultrasound images of selected adnexal masses were evaluated by 3 expert sonologists, 2 senior and 4 junior trainees. They were instructed to classify the masses using pattern recognition as benign or malignant, to state the level of confidence with which this classification was made and to suggest a specific histological diagnosis. Sensitivity, specificity, accuracy and positive and negative likelihood ratios (LR+ and LR-) with regard to malignancy were calculated. The area under the receiver operating characteristic curve (AUC) of pattern recognition was calculated by using six levels of diagnostic confidence. RESULTS: 166 masses were examined, of which 42% were malignant. Sensitivity with regard to malignancy ranged from 80 to 86% for the experts, was 70 and 84% for the 2 senior trainees and ranged from 70 to 86% for the junior trainees. The specificity of the experts ranged from 79 to 91%, was 77 and 89% for the senior trainees and ranged from 59 to 83% for the junior trainees. The experts were uncertain about their diagnosis in 4-13% of the cases, the senior trainees in 15-20% and the junior trainees in 67-100% of the cases. The AUCs ranged from 0.861 to 0.922 for the experts, were 0.842 and 0.855 for the senior trainees, and ranged from 0.726 to 0.795 for the junior trainees. The experts suggested a correct specific histological diagnosis in 69-77% of the cases. All 6 trainees did so significantly less often (22-42% of the cases). CONCLUSION: Expert sonologists can accurately classify adnexal masses as benign or malignant and can successfully predict the specific histological diagnosis in many cases. Whilst less experienced operators perform reasonably well when predicting the benign or malignant nature of the mass, they do so with a very low level of diagnostic confidence and are unable to state the likely histology of a mass in most cases.

A quasi-randomized trial on the effectiveness of an invitation letter to improve participation in a setting of opportunistic screening for cervical cancer.

The objective of the study was to assess the effect of an invitation letter on the level of participation in a setting of mainly opportunistic screening for cervical cancer and to do a cost analysis of this intervention. We designed a quasi-randomized trial in which a sample of women between the ages of 25 and 64 years and residing in the province of Limburg, Belgium, who had no Pap smear taken in the past 30 months according to LIKAR (Limburg Cancer Registry), were assigned to an intervention group or to a control group. A written invitation was sent to 43 523 women in the intervention group. Baseline participation in cervical screening was recorded in the year before the intervention to determine its effect. Differences in cumulative incidence between the intervention and the control group were used to report the effect. The net effect of a written invitation resulted in 3355 more women undergoing a Pap smear, which is an increase of 6.4% (95% confidence interval: 5.9-6.9). The cost per additional Pap smear taken amounted to euro29.8. Within an opportunistic cervical cancer screening setting, the effect of a registry-based invitational programme to nonattenders increases the participation further, and at no extra cost compared with an invitational programme to all screen-eligible women irrespective of their screening status.

Predictors of oligoamenorrhea at 1-year follow-up in premenopausal women using a levonorgestrel-releasing intrauterine system.

OBJECTIVE: The study was conducted to identify predictors of oligoamenorrhea at 12 months in levonorgestrel-releasing intrauterine system (LNG-IUS) users. DESIGN: A 12-month observational study. SETTING: Gynecologic outpatient clinic in a large regional hospital in Flanders, Belgium. POPULATION OR SAMPLE: A total of 150 women who had made an informed decision to use a LNG-IUS either as a method of contraception or to manage menorrhagia. METHODS: All women were premenopausal and first-time users. The variables recorded prior to insertion on Days 1 to 5 of the menstrual cycle were age, parity, body mass index, indication for LNG-IUS use, prior contraceptive use, menstrual bleeding history, length of the uterine cavity, endometrial thickness, number of antral follicles, serum follicle-stimulating hormone, inhibin B and anti-Müllerian hormone. Menstrual bleeding pattern, patient satisfaction or wish to discontinue the method was noted at 3, 6 and 12 months of follow-up visits. MAIN OUTCOME MEASURES: Menstrual bleeding pattern (amenorrhea, oligomenorrhea, menorrhagia) at 12 months was taken as the primary outcome measurement. Patient satisfaction was followed as a secondary outcome. RESULTS: Oligoamenorrhea was associated with a high patient satisfaction. A bleeding period less than 5 days, absence of severe uterine bleeding at baseline, LNG-IUS use for contraception and oligoamenorrhea at 3 months were predictors of a favorable outcome at 12 months in a univariate analysis. The absence of severe bleeding prior to LNG-IUS insertion was the only clinically useful predictor of favorable outcome in the multivariate analysis (odds ratio 0.13, 95% confidence interval 0.02-0.66). CONCLUSIONS: Patient profiling as described is not helpful in counselling women for intentional LNG-IUS use, especially not if it is planned as a method of managing menorrhagia.

Anatomical variability in the trajectory of the inside-out transobturator vaginal tape technique (TVT-O).

An experimental surgical study on human cadavers was undertaken to assess variability in the trajectory followed by the needle during application of the inside-out transobturator tape suspension (TVT-O) technique. The TVT-O surgical procedures were performed on six fresh female cadavers according to the standard recommended operative protocol. Subsequent anatomical dissection revealed that the needle had perforated the obturator membrane at a distance of 0.7 to 2.0 cm from the needle to the obturator canal. It subsequently followed a variable course passing at 0.5 to 2.0 cm from the anterior branch of the obturator nerve and 0.1 to 1.4 cm from the posterior branch. We conclude from this anatomical study that the TVT-O trajectory is subject to wider variability than was originally postulated.

Translevator posterior intravaginal slingplasty: anatomical landmarks and safety margins.

The posterior intravaginal sling is a new tension-free needle suspension technique. It is used for the treatment of middle compartment (vaginal vault or uterine) prolapse. The Prolene sling suspends the vagina at the upper border of level II support as described by DeLancey (Am J Obstet Gynecol 166:1717, 1992). Human cadaveric dissections were undertaken to explore the pertinent anatomy that is involved when using this blind needle technique. Pre-dissected cadaveric material was used to obtain didactic illustrations of the anatomy of the procedure. Description of the surgical technique using anatomical landmarks and relative distances of the needle to these landmarks will improve the surgeon's visual understanding of the procedure. The measurements obtained demonstrate that the needle stays at a minimal distance of 4 cm away from the major (pudendal) vessels that could potentially cause life-threatening haemorrhage.

Population screening for fetal trisomy 21: easy access to screening should be balanced against a uniform ultrasound protocol.

OBJECTIVES: To evaluate the performance of a first-trimester fetal aneuploidy screening program, with a documented underestimation of nuchal translucency thickness measurements (NT) compared to the Fetal Medicine Foundation (FMF) reference range. METHODS: We analysed the data of Algemeen Medisch Laboratorium (AML) in Antwerp, Belgium, on combined screening with pregnancy-associated plasma protein-A (PAPP-A), free beta-human chorionic gonadotropin (FB-hCG) and NT. NT-multiples of the median (MoM), relative to the FMF reference range, were used for risk calculations. RESULTS: The proportion of first-trimester screening tests in the total of serum screening tests increased from 1.3% (125/9424) in 2000 to 53.1% (6577/12 377) in 2003. Only 11.4% (1514/13 267) of NT measurements were performed according to FMF criteria. The 80.8% (21/26) trisomy 21 (T21) detection rate (DR) at cut off 1:300 resulted from maternal serum screening. NT measurements did not add to this DR, but reduced the false-positive rate from 16.8% (2212/13181) to 8.6% (1130/13181). Only 23.8% (5/21) of T21 detections were by FMF trainees. CONCLUSION: Easy access to screening and maternal serum parameters accounted for the majority of T21 detections in our first-trimester combined screening program.