[Patient satisfaction in hemodialysis: a pilot cross-sectional analysis and a review]. / Valutazione del grado di soddisfazione da trattamento nel paziente in emodialisi: metologia di ricerca, strumenti, limiti e studio pilota trasversale.

BACKGROUND: Assessment of patient satisfaction is not performed routinely in many healthcare institutions. In this review, we discuss methodological aspects of assessment of patient satisfaction in hemodialysis. We also present a pilot study conducted in the Gambro Healthcare Italy dialysis clinics network. METHODS: Patient satisfaction was assessed in a network of hemodialysis units by using an internally validated Italian translation of the Choices for Healthy Outcomes in Caring for ESRD (CHOICE) questionnaire. A cross-sectional analytic study design was used and data analysed with univariate and multivariate hierarchical logistic regression to explore correlates of the risk of being unsatisfied with dialysis treatment. Covariates which were considered include a series of over 20 clinical, demographic, organizational and structural aspects. In addition, unexplained inter-centre residual variability due to 'case-mix' was explored and plotted. RESULTS: Seventeen dialysis units participated in this cross-sectional analysis and 758/1001 (75.7%) provided answers to the questionnaires. There was a statistically significant association on multivariate hierarchical analysis between the risk of being unsatisfied with dialysis treatment and interdialysis body weight gain (unit of increase: 1 kg, p=0.004). On the contrary, the risk of unsatisfaction with dialysis treatment was significantly lower in patients with higher dry weight (unit of increase: 1 kg, p=0.002). Our multivariate hierarchical analysis identified some residual variability between dialysis units (n=6 outliers) which may not be explained by any of over 20 potential confounding covariates which were explored. CONCLUSIONS: Assessment of ''customer satisfaction'' is standard practice in private for profit product companies in general but needs to be increasingly recognized as a standard in both public and private providers of healthcare services. Social research methods, which are used for this type of analysis, need to be fine tuned and actively implemented in order to better understand how we may influence the quality of service we provide to our patients and the level at which they rate it.

The pre- and postoperative value of endocervical curettage in the detection of cervical intraepithelial neoplasia and invasive cervical cancer.

OBJECTIVE: The study was conducted to evaluate the pre- and postoperative value of endocervical curettage (ECC) in the detection of cervical intraepithelial neoplasia and invasive cervical cancer. METHODS: Patients undergoing cervical conization were studied retrospectively to evaluate the correlation of grade of preoperative endocervical curettage and the grade of dysplasia in the conization specimen. The role of routine preoperative ECC in satisfactory and unsatisfactory colposcopy and the need for routine ECC in the detection of postoperative residual dysplasia was also evaluated. RESULTS: Results showed that 297/391 (76%) patients had ECC as part of preoperative assessment for cervical dysplasia on Papanicolaou smear. There was good association of grade of preoperative ECC and grade of conization specimen, weighted kappa-0.135 (P = 0.0003). Of 17 patients with invasive disease on conization specimen, only patients with a positive ECC had invasion at conization. None of 113 patients with a negative preoperative ECC had invasive disease on their conization specimens. The proportion of satisfactory colposcopic examinations between positive and negative ECC is not significantly different (P = 0.673). Follow-up of positive margins of resection was performed with Papanicolaou smear in only 20 patients and with Papanicolaou smear and ECC in 53 patients. In the latter group, 4% had a positive ECC with negative Papanicolaou smear (P = 0.310). CONCLUSIONS: There is good agreement between grade of dysplasia on preoperative ECC and on subsequent conization specimen. Colposcopic examination was not a good predictor of pathology in the endocervical canal. Routine ECC should be part of the preoperative assessment of an abnormal Papanicolaou smear but may be unnecessary in the evaluation for residual dysplasia.

A technique for laparoscopic completion of vaginal hysterectomy.

Recently, the use of laparoscopic assistance in vaginal hysterectomy has become popular, although its role in gynecologic surgery has not been well established. A way to define this role is to start the hysterectomy vaginally and use laparoscopic assistance only if it becomes necessary. We present a new technique in which vaginal hysterectomy proceeds to the opening of the peritoneal reflections and ligature of uterine vessels and uterosacral ligaments. If laparoscopic assistance becomes necessary at this point, a uterine manipulator with an adapted inflatable balloon is inserted vaginally, allowing completion of the procedure laparoscopically while maintaining a pneumoperitoneum. Eight operations were performed successfully in our institution using this new technique. Operative time was less than with conventional laparoscopically assisted vaginal hysterectomy. The technique also simplified the management of the uterine vessels and detachment of the bladder.

[Placenta accreta during the first trimester of pregnancy. A case report]. / Placenta increta en el primer trimestre de embarazo. Presentación de un caso.

Placenta accreta is defined as the abnormal adherence of the placenta, totally or in part, to the underlying uterine surface. It is uncommon to find this abnormality of the attachment of the placenta in the first half or pregnancy. Only 10 cases have been reported. We present a case of placenta accreta in the first trimester in a patient with three previous curettages as a risk factor, diagnosed during curettage for a fourth missed abortion that required total abdominal hysterectomy. This case follows the pattern of those previously reported.

Gamete intrafallopian transfer vs superovulation with intrauterine insemination for the treatment of infertility.

Superovulation with intrauterine insemination (SO-IUI) has been suggested as an alternative to gamete intrafallopian transfer (GIFT), despite the absence of controlled or comparative trials. We retrospectively analyzed all GIFT and SO-IUI cycles performed concurrently from January 1985 to August of 1987 at a single university center. Pregnancy rates were significantly better for GIFT than SO-IUI (P less than 0.001), with an odds ratio of 3.25 (P = 0.001). Stepwise multiple logistic regression identified factors that correlate with pregnancy: absence of endometriosis (P = 0.05), infertility less than 3 years' duration (P = 0.002), TMS greater than or equal to 30 X 10(6) (P = 0.005), and treatment with GIFT rather than SO-IUI (P = 0.001). These data give a first approximation of the increased efficacy of GIFT versus SO-IUI and provide valuable insight into significant confounding variables to be considered when planning a randomized, prospective trial to evaluate these techniques.

Gonadotropin-releasing hormone antagonists attenuate estrogen/progesterone-induced hyperprolactinemia in monkeys.

Previous studies have documented that exogenous gonadotropin-releasing hormone (GnRH) stimulates prolactin (PRL) secretion and augments thyrotropin-releasing hormone-induced PRL release. Further, the concomitant pulsatile release of PRL and luteinizing hormone (LH) suggests that GnRH may be an important regulator of PRL release in certain physiologic states. The authors explored this possibility by evaluating the effect of a GnRH antagonist ([Ac-pClPhe1, pClPhe2, DTrp3, DAla10]-GnRH; GnRH-antagonist) on PRL secretion in monkeys with induced hyperprolactinemia. Monkeys were given estradiol (E2) benzoate 25 mg/kg intramuscularly (IM) on cycle days 1 to 28, and a 3-cm progesterone (P) silastic capsule was placed on cycle day 15 and removed on day 28. On cycle days 15 to 28, monkeys were given IM injections of 1 mg/kg GnRH-antagonist (n = 3), 2 mg/kg GnRH-antagonist (n = 3), or vehicle (n = 3). Daily blood samples were assayed for E2, P, and PRL. The degree of PRL elevation was calculated as percent increase in area under the curve for days 15 to 28 when compared with days 1 through 14 (baseline). Luteinizing hormone levels were calculated similarly. Results indicate a dose-dependent effect of GnRH-antagonist on PRL secretion, with the larger dose producing a significantly lower hyperprolactinemic response, as well as a decline in LH. Thus, GnRH-antagonist attenuates induced hyperprolactinemia in a dose similar to that which suppresses LH release. These findings suggest that GnRH is a physiologic regulator of pituitary PRL secretion. In addition, GnRH analogs may be of benefit in controlled ovarian hyperstimulation by attenuating gonadotropin-induced hyperprolactinemia, thereby reducing potential adverse effects on fertility.