The influence of personality on patient-reported outcomes in women undergoing implant-based breast reconstruction.

BACKGROUND: Despite the lack of hard evidence for causality, some women attribute their systemic complaints to their silicone breast implants. Personality and psychological distress are associated with the development of medically unexplained symptoms. It could be hypothesized that these psychological factors are related to the development of breast implant illness (BII). In a previous study, we found a relationship between personality traits and BII-related complaints in patients with cosmetic breast implants. This association may also exist in patients with implant-based breast reconstruction. OBJECTIVES: This cross-sectional study evaluated the association between personality, self-reported health complaints, and health- and breast-related quality of life (QoL) in women with implant-based breast reconstruction. METHODS: Women who underwent breast reconstruction between January 2015 and December 2018 in either the Maastricht University Medical Center or Zuyderland Medical Center were invited to participate in this study. Participants were asked to complete a physical complaint score form and the BREAST-Q, SF-36, and EPQ-RSS questionnaires through an online survey. The association between outcomes was analyzed with multivariate linear regression. RESULTS: A total of 118 women completed the questionnaires. Social desirability and extroversion were predominant personality traits. Neuroticism levels were comparable with normative data. Neuroticism correlated significantly with health status and breast-related QoL. Health-related QoL had the strongest correlation with neuroticism (ß = -2.93, ß = -3.41, p < 0.001). CONCLUSION: This study suggests that personality, and neuroticism in particular, may contribute to the development of medically unexplained complaints in women with implant-based reconstruction. The influence of personality on BII needs to be further investigated in large prospective studies.

The Influence of Personality on Health Complaints and Quality of Life in Women With Breast Implants.

BACKGROUND: A causal relation between systemic symptoms and breast implants has not been established. Psychological factors, such as personality and psychological distress, are strongly associated with the development of medically unexplained symptoms. It can be hypothesized that psychological factors may be related to the development of breast implant illness (BII). OBJECTIVES: This study was conducted to evaluate the correlation between self-reported health complaints, health- and breast-related quality of life (QoL), and personality, in women with cosmetic breast implants. METHODS: Women who attended the plastic surgery outpatient clinic of Maastricht University Medical Center between October 2020 and October 2021 for reasons related to their implants and women recruited for a BII study at the Center during this period were invited to participate in this study. Only women who underwent cosmetic breast augmentation were eligible. Participants completed a physical complaints score form and the BREAST-Q, SF-36, and EPQ-RSS questionnaires via an online survey. RESULTS: In total, 201 women completed the questionnaires. Extroversion and social desirability were predominant personality traits in women with breast implants, followed by neuroticism. Relatively high levels of neuroticism were found compared with normative data. Neuroticism correlated significantly with health status and breast-related QoL. Physical and mental health-related QoL had the strongest correlations with neuroticism (ß = -3.94, ß = -4.86, P < 0.001). CONCLUSIONS: Personality can play a role in the development of complaints. High levels of neuroticism are seen in cosmetic surgery patients and are negatively correlated with subjective health and patient-reported outcomes in women with breast implants. Therefore, neuroticism may be a factor in the development of BII.

Tumor rupture and partial gut obstruction: Atypical presentations in a patient with adenomyosis / Philippine Journal of Obstetrics and Gynecology

@#A 49-year-old woman, Gravida 8 Para 8 (8007), came in due to vomiting and enlarging abdominal mass. Initial diagnosis was partial gut obstruction and acute kidney injury probably secondary to adenomyosis versus colonic pathology. Ultrasound showed adenomyosis but computed tomography scan showed a uterine mass with possible tumor rupture and mass effects. Emergency hysterectomy was done and showed an ill-defined endometrial mass with multiple areas of rupture. It was diagnosed with malignant but final histopathology revealed extensive adenomyosis with acute inflammation and necrosis with no malignancy identified. Unusual symptoms such as uterine rupture and mass effects can accompany adenomyosis, alongside typical signs like pain and bleeding. Ultrasound aided the diagnosis, although it missed uterine rupture, highlighting its limitations. Magnetic resonance imaging could have been useful. Ultimately, histopathology is the gold standard for diagnosing adenomyosis.

Socially assistive robotics and older family caregivers of young adults with Intellectual and Developmental Disabilities (IDD): A pilot study exploring respite, acceptance, and usefulness.

INTRODUCTION: The need for caregiver respite is well-documented for the care of persons with IDD. Social Assistive Robotics (SAR) offer promise in addressing the need for caregiver respite through 'complementary caregiving' activities that promote engagement and learning opportunities for a care recipient (CR) with IDD. This study explored the acceptability and usefulness of a SAR caregiver respite program responsive to feedback from both young adults with IDD and their older family caregivers (age 55+). METHOD: Young adults with IDD and caregiver dyads (N = 11) were recruited. A mixed methods research design was deployed in three phases: Phase I with four focus groups to inform the program design; Phase II for program demonstration and evaluation with pre- and post-surveys; and Phase III with post-program interviews for feedback and suggestions. RESULTS: Both young adults with IDD and their caregivers scored favorably the social presence of, social engagement, and satisfaction with robot Pepper. Though there was no significant improvement of caregiving burden/stress as well as well-being of the young adults with IDD based on surveys, results from interviews suggested that the SAR may offer physical/emotional respite to caregivers by providing companionship/friendship as well as promoting independence, safety/monitoring, and interactive engagement with children. DISCUSSION: SAR has potential in providing respite for older family caregivers. Future studies need a longer program design and larger sample size to develop a promising intervention and test its feasibility and efficacy.

[Flap harvest training on a new ultrarealistic simulation model: In-training operator feedback about a pulsating reperfused and reventilated cadaver Simlife®]. / Prélèvement des lambeaux sur sujet anatomique et nouveau modèle de simulation ultra-réaliste : retour d'expérience d'un opérateur en formation sur corps reperfusé pulsatile et reventilé Simlife®.

INTRODUCTION: The anatomical subject is still a key element to learn complex procedures in plastic surgery. We present here the evaluation of an in-training operator on a SIMLIFE® model, hyper realistic model consisting in human bodies donated to science equipped with pulsating recirculation and reventilation device. MATERIAL AND METHODS: From February 2019 to October 2019, 8 forearm flaps with radial proximal pedicle were harvested by the learner on a SIMLIFE® model. Conditions were as close as possible to the operating room : asepsy, sterile draping, assistant and instrumentation including electrocoagulation. RESULTS: The procedure was decomposed in 13 distinct steps. Mean total surgery time was 90,5±11,62minutes. There was only one case of arterial pedicle lesion resulting in major blood leak. Bleeding was measured by fake blood loss from the SIMLIFE® console. Mean intraoperatoy bleeding was 171±108 milliliters. We review pros and cons of this new technology particulary suited for complex plastic and reconstructive surgery training. CONCLUSION: Using SIMLIFE® technology we have a new mean to train for complex procedures in plastic and reconstructive surgery. This new technology could be applied to numerous other surgical procedures. Broader applications are still limited by cost and cadaver use legislation.

Pubertal development and adult height in patients with congenital hypothyroidism detected by neonatal screening in southern Brazil.

Objectives Adequate treatment of congenital hypothyroidism (CH) is required for normal growth and sexual development. To evaluate pubertal development in patients with permanent CH detected by a statewide Neonatal Screening Program of Paraná and, secondly, to evaluate adult height (AH) in a subgroup of patients. Methods Clinical, laboratory, and auxological data obtained from medical records of 174 patients (123 girls). Results Median chronological age (CA) at treatment initiation was 24 days, and mean initial levothyroxine dose was 11.7 ± 1.9 µg/kg/day; mean CA at puberty onset was 11.5 ± 1.3 years (boys) and 9.7 ± 1.2 years (girls); mean CA in girls who underwent menarche (n=81) was 12.1 ± 1.1 years. Thyroid-stimulating hormone (TSH) values above the normal range were observed in 36.4% of the boys and 32.7% of the girls on puberty onset, and in 44.6% around menarche. Among 15 boys and 66 girls who had reached the AH, the median height z-score value was significantly greater than the target height (TH) z-score value in boys (p=0.01) and in girls (p<0.001). Boys with normal TSH values at puberty onset had greater mean AH z-score compared with boys with TSH values above the normal range (p=0.04). Conclusions In this group, pubertal development in girls with CH was not different from that reported in healthy girls in the general Brazilian population. Boys with higher TSH at puberty onset may have an increased risk of not reaching their potential height compared with those with normal TSH during this period. In a subgroup who attained AH, the median AH z-score was greater than the median TH z-score.

[Male to female sex reassignment surgery with a new surgical simulation device using a human perfused cadaver SIMLIFE®: New paradigm in transsexual surgery education ?] / Aïdoïopoïèse sur modèle cadavérique humain revascularisé pulsatile et ventilé SIMLIFE® : cas isolé ou futur changement de paradigme en chirurgie de réassignation génitale ?

INTRODUCTION: In 2015, we reported our experience with the learning curve in genital reassignment surgery and highlighted a four-step learning concept. CLINICAL CASE: In this article, we present our first vaginoplasty performed on a humanoid model SIMLIFE®, a human body associated with a pulsating circulation device and a ventilation device. RESULTS: The surgical technique included 14 steps. The total surgical time was 182minutes. There was no intraoperative complication, and there was no damage to the urethra or rectum. The intraoperative bleeding measured by the loss of operative fluid was 280mL. We discuss the advantages of this technology perfectly adapted to transsexual surgery. CONCLUSION: We demonstrated the feasibility of vaginoplasty performed on a humanoid model SIMLIFE® and highlighted improvement of the surgical skills with this model. This technology could find many other surgical applications. However, it faces cost constraints and legislation on corpses.

[Bilateral breast reduction and obesity: What is the ideal resection enabling significant improvement in back pain according to the body mass index?] / Mastoplastie bilatérale de réduction et obésité : quel est le poids de résection idéal pour obtenir une amélioration significative des douleurs rachidiennes en fonction de l'indice de masse corporelle ?

INTRODUCTION: Dorsal pain is the first symptoms about which patients with macromasty complain. Health insurance reimbursement takes place if the resection weight is at least 300grams per breast. However, this weight is not correlated with the body mass index (BMI). In this context, we sought to determine the ideal resection weight leading to significant BMI-based improvement. MATERIALS AND METHODS: This is a multicentre prospective study of patients operated between November 2016 and July 2017. In the year following the surgical procedure, we studied overall improvement using the INDIC questionnaire. Any INDIC improvement of at least 50% was considered positive. These data were then compared to tissue resection weights and BMI. In order to refine our results, age, bra size, comorbidities and complications were also identified. RESULTS: Forty-one patients were included in our study. Average age was 41.5±11.4years. Average BMI was 27.9±4.1kg/m2. The bra cap chosen after the procedure were C. Average resection weight was 663±352g per breast. The preoperative and postoperative INDIC scores were 734.9±226.6 points and 225.3±319.1 points, respectively (P=0.001). Significant improvement was achieved at 12months in 71.8% of patients. A correlation of 38.7g/kg/m2 was found between breast resection weight and BMI. CONCLUSION: This study clarifies the correlation between the breast resection weight required to relieve optimal back pain and BMI. It defines three categories of patients: patients with standard weights (1830). Overweight and obese patients require greater tissue excretion to be relieved optimally. These findings underline a need to adjust the health insurance threshold for these types of patients.

Impact of Growth Hormone Therapy on Adult Height in Patients with PTPN11 Mutations Related to Noonan Syndrome.

OBJECTIVES: The aim of this study was to evaluate the response to recombinant human growth hormone (rhGH) treatment in patients with Noonan syndrome (NS). MATERIALS AND METHODS: Forty-two patients (35 PTPN11+) were treated with rhGH, and 17 were followed-up until adult height. The outcomes were changes in growth velocity (GV) and height standard deviation scores (SDS) for normal (height-CDC SDS) and Noonan standards (height-NS SDS). RESULTS: The pretreatment chronological age was 10.3 ± 3.5 years. Height-CDC SDS and height-NS SDS were -3.1 ± 0.7 and -0.5 ± 0.6, respectively. PTPN11+ patients had a better growth response than PTPN11- patients. GV SDS increased from -1.2 ± 1.8 to 3.1 ± 2.8 after the first year of therapy in PTPN11+ patients, and from -1.9 ± 2.6 to -0.1 ± 2.6 in PTPN11- patients. The gain in height-CDC SDS during the first year was higher in PTPN11+ than PTPN11- (0.6 ± 0.4 vs. 0.1 ± 0.2, p = 0.008). Similarly, the gain was observed in height-NS SDS (0.6 ± 0.3 vs. 0.2 ± 0.2, respectively, p < 0.001). Among the patients that reached adult height (n = 17), AH-CDC SDS and AH-NS SDS were -2.1 ± 0.7 and 0.7 ± 0.8, respectively. The total increase in height SDS was 1.3 ± 0.7 and 1.5 ± 0.6 for normal and NS standards, respectively. CONCLUSIONS: This study supports the advantage of rhGH therapy on adult height in PTPN11+ patients. In comparison, PTPN11- patients showed a poor response to rhGH. However, this PTPN11- group was small, preventing an adequate comparison among different genotypes and no guarantee of response to therapy in genes besides PTPN11.

Demonstrating the reliability of transdiagnostic mHealth Routine Outcome Monitoring in mental health services using experience sampling technology.

BACKGROUND: Routine Outcome Monitoring (ROM) should provide a dynamic, within-treatment forward feedback loop to guide individual treatment decisions across diagnostic categories. It has been suggested that the Experience Sampling Method (ESM), capturing the film of daily life adaptive processes, offers a flexible, personalised and transdiagnostic feedback system for monitoring and adapting treatment strategies. This is the first study that uses an ESM application (the PsyMate™) as a routine mobile-ROM (mROM) tool in an ambulatory mental health setting. OBJECTIVE: To demonstrate adequate psychometric properties of the PsyMate™ app assessing both symptom severity levels as well as daily life functioning. METHOD: In a transdiagnostic sample of 64 outpatients, an mROM protocol (ESM for 6 days, at 10 semi-random moments a day) and a standard ROM instrument (HADS) were administered at baseline and at three-month follow-up. We measured positive affect (PA), negative affect (NA), quality of sleep, positive social interaction, activity-related stress, tiredness, and feeling unwell. RESULTS: Subjects completed 53% of the measurements at baseline (N = 64) and 48% at follow-up (N = 29). Factor analysis and subsequent reliability analysis of PA and NA confirmed the two constructs. Significant and meaningful correlations were found between PA, NA and HADS scores (ranging from r = .4 to r = .7). Multilevel analyses yielded significant change scores for all measures. CONCLUSION: The ESM-based, transdiagnostic mROM tool can be used reliably in clinical settings: it shows adequate psychometric properties, as well as concurrent validity and sensitivity to change over time with respect to relevant ROM constructs. Person-tailored items can be added. In addition, mROM offers added value over standard symptom-based ROM, as it provides information on adaptive functioning in the daily environment of patients.

The role of sonography in the diagnosis of chronic puerperal uterine inversion: A case report / Philippine Journal of Obstetrics and Gynecology

Chronic puerperal uterine inversion is a rare and life-threatening obstetric emergency which requires emergent treatment. We present a case of a 27-year-old Gravida 2 Para 2 (2002) with chronic uterine inversion. A bleeding, 4 x 4 x 5 cm fleshy knob like mass protruding from the cervix, was seen during vaginal inspection. Two-dimensional transvaginal sonography and 3-dimensional imaging clinched the diagnosis of uterine inversion. The patient underwent Haultain's procedure and was discharged improved with resumption of normal menses. Postpartum transvaginal sonography revealed a normally positioned uterus.

The role of sonography in the diagnosis of chronic puerperal uterine inversion: A case report / Philippine Journal of Obstetrics and Gynecology

Chronic puerperal uterine inversion is a rare and life-threatening obstetric emergency which requires emergent treatment. We present a case of a 27-year-old Gravida 2 Para 2 (2002) with chronic uterine inversion. A bleeding, 4 x 4 x 5 cm fleshy knob like mass protruding from the cervix, was seen during vaginal inspection. Two-dimensional transvaginal sonography and 3-dimensional imaging clinched the diagnosis of uterine inversion. The patient underwent Haultain's procedure and was discharged improved with resumption of normal menses. Postpartum transvaginal sonography revealed a normally positioned uterus.

Proficiency for Advanced Laparoscopic Procedures in Gynecologic Residency Program: Do all Residents Need to be Trained?

OBJECTIVES: To assess the current state of laparoscopic gynecologic surgery in the Dutch residency program, the level of competence among graduated residents, and whether they still perform these procedures. Furthermore, their current attitudes toward the implementation of minimally invasive surgery into residency training were assessed. DESIGN: An online survey (Canadian Task Force Classification III) regarding the level of competence, performance, training, and interest for gynecologic laparoscopic procedures. PARTICIPANTS/SETTING: Gynecologists who finished residency training between 2008 and 2013 in the Netherlands. RESULTS: Response rate was 73% (171/235). The scores for all basic and intermediate laparoscopic procedures performed immediately after residency showed the highest competence level (median 5, of scale 1-5). The competence level for advanced laparoscopic procedures was less at 3, indicating that the graduated residents are not able to perform these procedures without supervision. Overall, 56% of the gynecologists no longer perform any level 3 advanced procedures, and 86% do not perform level 4 advanced procedures. Gynecologists who still perform the inquired laparoscopic procedures scored a significantly higher competence level immediately after residency training for most of procedures compared with the gynecologists who do not perform these procedures. CONCLUSION: Residents are sufficiently trained for basic and intermediate laparoscopic procedures during residency training. However, they are not sufficiently equipped to perform advanced laparoscopic procedures without supervision. We should consider training advanced procedures especially to a selected group of residents because most gynecologists do not perform these procedures after residency. The learning curve for advanced procedures continues to rise after finishing residency for those who keep on performing these procedures, therefore an additional fellowship is recommended for this group.

Training of hysteroscopic skills in residency program: the Dutch experience.

STUDY OBJECTIVE: To evaluate whether hysteroscopy training in the Dutch gynecological residency program is judged as sufficient in daily practice, by assessment of the opinion on hysteroscopy training and current performance of hysteroscopic procedures. In addition, the extent of progress in comparison with that of the residency program of a decade ago is reviewed. DESIGN: Survey (Canadian Task Force Classification III). PARTICIPANTS: Postgraduate years 5 and 6 residents in obstetrics and gynecology and gynecologists who finished residency within 2008 to 2013 in the Netherlands. INTERVENTION: Subjects received an online survey regarding performance and training of hysteroscopy, self-perceived competence, and hysteroscopic skills acquirement. RESULTS: Response rate was 65% of the residents and 73% of the gynecologists. Most residents felt adequately prepared for basic hysteroscopic procedures (86.7%), but significantly less share this opinion for advanced procedures (64.5%) (p < 0.01). In comparison with their peers in 2003, the current residents demonstrated a 10% higher appreciation of the training curriculum. However, their self-perceived competence did not increase, except for diagnostic hysteroscopy. Regarding daily practice, not only do more gynecologists perform advanced procedures nowadays but also their competence level received higher scores in comparison with gynecologists in 2003. Lack of simulation training was indicated to be the most important factor during residency that could be enhanced for optimal acquirement of hysteroscopic skills. CONCLUSION: Implementation of hysteroscopic procedures taught during residency training in the Netherlands has improved since 2003 and is judged as sufficient for basic procedures. The skills of surgical educators have progressed toward a level in which gynecologists feel competent to teach and supervise advanced hysteroscopic procedures. Even though the residency preparation for hysteroscopy is more highly appreciated than a decade ago, this study indicated that simulation training might serve as an additional method to improve hysteroscopic skills acquisition. Future research is needed to determine the value of simulation training in hysteroscopy.

Reappraisal of serum insulin-like growth factor-I (IGF-1) measurement in the detection of isolated and combined growth hormone deficiency (GHD) during the transition period / Reavaliação da dosagem sérica do fator de crescimento insulina-símile-1 (IGF-1) para o diagnóstico da deficiência isolada e combinada de hormônio de crescimento no período de transição

OBJECTIVE: To evaluate the accuracy of serum IGF-1 in the detection of isolated (IGHD) or combined growth hormone deficiency (CGHD) at the transition phase. SUBJECTS AND METHODS: Forty nine patients with GHD during childhood [16 with IGHD (10 men) and 33 with CGHD (24 men); age 23.2 ± 3.5 yrs.] were submitted to an insulin tolerance test (ITT) with a GH peak < 5 µg/L used for the diagnosis of GHD at the transition phase. Pituitary function and IGF-1 measurements were evaluated in the basal sample of the ITT. Transition patients were reclassified as GH-sufficient (SGH; n = 12), IGHD (n = 7), or CGHD (n = 30). RESULTS: Five (31%) patients with IGHD and 32 (97%) with CGHD at childhood persisted with GHD at retesting. One patient with IGHD was reclassified as CGHD, whereas 3 patients with CGHD were reclassified as IGHD. Mean GH peak was 0.2 ± 0.3 µg/L in the CGHD, 1.3 ± 1.5 µg/L in the IGHD, and 18.1 ± 13.1 µg/L in the SGH group. Serum IGF-1 level was significantly higher in the SGH (272 ± 107 ng/mL) compared to IGHD (100.2 ± 110) and CGHD (48.7 ± 32.8) (p < 0.01). All patients reclassified as CGHD, 86% reclassified as IGHD, and 8.3% reclassified as SGH had low IGF-1 level, resulting in 97.3% sensitivity and 91.6% specificity in the detection of GHD at the transition period; the cutoff value of 110 ng/mL showed 94.5% sensitivity and 100% specificity. Mean IGF-1 values did not differ in IGHD or CGHD associated with one, two, three, or four additional pituitary deficiencies. CONCLUSION: IGF-1 measurement is accurate to replace ITT as initial diagnostic test for IGHD and CGHD detection at the transition phase.

OBJETIVO: Avaliar a acurácia da dosagem sérica de IGF-1 no diagnóstico da deficiência de hormônio de crescimento isolada (DGHI) ou combinada (DGHC) na fase de transição. SUJEITOS E MÉTODOS: Quarenta e nove pacientes com DGH na infância [16 DGHI (10 homens) e 33 DGHC (24 homens); idade 23,2 ± 3,5 anos] realizaram teste de tolerância à insulina (TTI), com pico de GH < 5 µg/L considerado diagnóstico de DGH na transição. Função hipofisária e níveis de IGF-1 foram determinados na amostra basal do TTI e os pacientes foram reclassificados em GH suficientes (SGH; n = 12), DGHI (n = 7) ou DGHC (n = 30). RESULTADOS: Cinco (31%) pacientes com DGHI e 32 (97%) com DGHC na infância persistiram com DGH no reteste. Um paciente com DGHI foi reclassificado como DGHC e três com DGHC como DGHI. Os picos médios de GH foram 0,2 ± 0,3 µg/L (DGHC), 1,3 ± 1,5 µg/L (DGHI) e 18,1 ± 13,1 µg/L (SGH). O nível médio de IGF-1 foi maior no grupo SGH (272 ± 107 ng/mL) comparado com DGHI (100,2 ± 110) e DGHC (48,7 ± 32,8) (p < 0,01). IGF-1 baixo foi observado em todos os pacientes reclassificados como DGHC, 86% dos DGHI e 8,3% dos SGH, resultando em sensibilidade de 97,3% e especificidade de 91,6% para detecção de DGH na transição; valor de corte de 110 ng/mL mostrou 94,5% sensibilidade e 100% especificidade. O nível médio de IGF-1 foi similar nos pacientes com DGHI ou DGHC com uma, duas, três ou quatro deficiências hipofisárias associadas. CONCLUSÃO: A dosagem sérica de IGF-1 mostrou-se acurada para substituir o TTI na detecção tanto de DGHI como DGHC na transição.

Learning curve of hysteroscopic placement of tubal sterilization microinserts in 15 gynecologists in the Netherlands.

OBJECTIVE: To evaluate the learning curve of hysteroscopic placement of tubal sterilization microinserts by gynecologists in the Netherlands. DESIGN: Prospective multicenter study (Canadian Task Force II-2). SETTING: Ten community (teaching) hospitals in the Netherlands. PATIENT(S): A total of 631 women who underwent permanent sterilization by tubal microinserts. INTERVENTION(S): Hysteroscopic placement of tubal sterilization microinserts performed by 15 gynecologists experienced in performing operative hysteroscopy, starting from their very first placement. MAIN OUTCOME MEASURE(S): Effect of increasing experience in time on procedure time, pain score, successful bilateral placement, and complications. RESULT(S): Bilateral successful placement with confirmation of adequate positioning at follow-up evaluation was achieved in 480 (76.1%) patients at first attempt and in 44 (7.0%) at second attempt. Median procedure time was 8.0 minutes (range: 3-40), and 31 (4.9%) patients were lost to follow-up evaluation. Gravidity showed to be a confounding factor and was consequently adjusted for. A learning curve was seen in a statistically significant decrease of procedure time with increasing experience. The decrease in procedure time extended to 11 to 15 cases and was followed by a plateau phase of the subsequent 60 cases. In contrast, pain scores, successful placement, and complication rate appeared not to improve with increasing experience. CONCLUSION(S): A learning curve for hysteroscopic tubal sterilization was seen for procedure time, but successful placement, pain score, and complication rate were not clearly influenced by increasing experience.

Hysteroscopic sterilization using a virtual reality simulator: assessment of learning curve.

STUDY OBJECTIVE: To assess the learning curve using a virtual reality simulator for hysteroscopic sterilization with the Essure method. DESIGN: Prospective multicenter study (Canadian Task Force classification II-2). SETTING: University and teaching hospital in the Netherlands. PARTICIPANTS: Thirty novices (medical students) and five experts (gynecologists who had performed >150 Essure sterilization procedures). INTERVENTIONS: All participants performed nine repetitions of bilateral Essure placement on the simulator. Novices returned after 2 weeks and performed a second series of five repetitions to assess retention of skills. Structured observations on performance using the Global Rating Scale and parameters derived from the simulator provided measurements for analysis. MEASUREMENTS AND MAIN RESULTS: The learning curve is represented by improvement per procedure. Two-way repeated-measures analysis of variance was used to analyze learning curves. Effect size (ES) was calculated to express the practical significance of the results (ES ≥ 0.50 indicates a large learning effect). For all parameters, significant improvements were found in novice performance within nine repetitions. Large learning effects were established for six of eight parameters (p < .001; ES, 0.50-0.96). Novices approached expert level within 9 to 14 repetitions. CONCLUSION: The learning curve established in this study endorses future implementation of the simulator in curricula on hysteroscopic skill acquisition for clinicians who are interested in learning this sterilization technique.

Reappraisal of serum insulin-like growth factor-I (IGF-1) measurement in the detection of isolated and combined growth hormone deficiency (GHD) during the transition period.

OBJECTIVE: To evaluate the accuracy of serum IGF-1 in the detection of isolated (IGHD) or combined growth hormone deficiency (CGHD) at the transition phase. SUBJECTS AND METHODS: Forty nine patients with GHD during childhood [16 with IGHD (10 men) and 33 with CGHD (24 men); age 23.2 ± 3.5 yrs.] were submitted to an insulin tolerance test (ITT) with a GH peak < 5 µg/L used for the diagnosis of GHD at the transition phase. Pituitary function and IGF-1 measurements were evaluated in the basal sample of the ITT. Transition patients were reclassified as GH-sufficient (SGH; n = 12), IGHD (n = 7), or CGHD (n = 30). RESULTS: Five (31%) patients with IGHD and 32 (97%) with CGHD at childhood persisted with GHD at retesting. One patient with IGHD was reclassified as CGHD, whereas 3 patients with CGHD were reclassified as IGHD. Mean GH peak was 0.2 ± 0.3 µg/L in the CGHD, 1.3 ± 1.5 µg/L in the IGHD, and 18.1 ± 13.1 µg/L in the SGH group. Serum IGF-1 level was significantly higher in the SGH (272 ± 107 ng/mL) compared to IGHD (100.2 ± 110) and CGHD (48.7 ± 32.8) (p < 0.01). All patients reclassified as CGHD, 86% reclassified as IGHD, and 8.3% reclassified as SGH had low IGF-1 level, resulting in 97.3% sensitivity and 91.6% specificity in the detection of GHD at the transition period; the cutoff value of 110 ng/mL showed 94.5% sensitivity and 100% specificity. Mean IGF-1 values did not differ in IGHD or CGHD associated with one, two, three, or four additional pituitary deficiencies. CONCLUSION: IGF-1 measurement is accurate to replace ITT as initial diagnostic test for IGHD and CGHD detection at the transition phase.