Validation of a sustainable internationally monitored cervical cancer screening system using a visual smartphone inspection in Kinshasa, Democratic Republic of Congo.

OBJECTIVE: To determine the sensitivity, specificity, and positive and negative predictive values of a cervical cancer screening program based on visual inspection with acetic acid and Lugol's iodine using a smartphone in a sub-urban area of very low resources in Kinshasa (Democratic Republic of Congo). METHODS: This cross-sectional validation study was conducted at Monkole Hospital and it included women between the ages of 25-70 years after announcing a free cervical cancer screening campaign through posters placed in the region of our hospital. Questionnaires collected sociodemographic and behavioral patients characteristics. In the first consultation, we gathered liquid-based cytology samples from every woman. At that time, local health providers performed two combined visual inspection techniques (5% acetic acid and Lugol's iodine) while a photograph was taken with a smartphone. Two international specialists evaluated the results of the smartphone cervicography. When a visual inspection was considered suspicious, patients were offered immediate cryotherapy. Cytological samples were sent to the Pathology Department of the University of Navarra for cytological assessment and human papillomavirus (HPV) DNA genotyping. RESULTS: A total of 480 women participated in the study. The mean age was 44.6 years (range 25-65). Of all the patients, only 18.7% were infected with HPV (75% had high-risk genotypes). The most frequent high-risk genotype found was 16 (12.2%). The majority (88%) of women had normal cytology. After comparing combined visual inspection results with cytology, we found a sensitivity of 66.0%, a specificity of 87.8%, a positive predictive value of 40.7%, and a negative predictive value of 95.3% for any cytological lesion. The negative predictive value for high-grade lesions was 99.7%. CONCLUSIONS: Cervical cancer screening through combined visual inspection, conducted by non-specialized personnel and monitored by experts through smartphones, shows encouraging results, ruling out high-grade cytological lesions in most cases. This combined visual inspection test is a valid and affordable method for screening programs in low-income areas.

Hypopressive technique versus pelvic floor muscle training for postpartum pelvic floor rehabilitation: A prospective cohort study.

AIMS: Abdominal hypopressive technique (AHT) is gaining popularity as an alternative to pelvic floor muscle training (PFMT) during postpartum. Although, there is no solid evidence for its recommendation. METHODS: We conducted a prospective observational cohort study in a university hospital with 105 primiparae who performed a two-month PFMT or AHT program. The aim was to compare the effectiveness of both treatments in terms of morphofunctional changes in 3D transperineal ultrasound, manometry, dynamometry, and differences in urinary incontinence symptoms (ICIQ-IU-SF) and satisfaction. RESULTS: The average change in levator ani muscle was 1.2 mm higher in AHT group vs PFMT (95% confidence interval [CI], -2.2 to -0.2; P = .017). No statistically significant differences were shown in maximal strength changes between groups. After AHT, basal tone change was 63.0 g/cm2 higher than PFMT (95% CI, -129 to 2.9; P = .06). A statistically significant reduction in ICIQ-IU-SF was observed after both treatments [(PFMT, -0.8 points; 95% CI, -1.4 to -0.1; P = .015), (AHT, -0.7 points; 95% CI, -1.3 to -0.1; P = .018]. AHT showed a higher median satisfaction score than PFMT (P = .004). CONCLUSIONS: This preliminary study is the first that analyses the effect of AHT vs PFMT during postpartum. The results suggest a higher improve for AHT in levator muscle thickness and satisfaction compared to PFMT. These must be considered with caution due to the limitations of the study. Further randomized clinical trials about both techniques during postpartum are required.

Diagnostic performance of IOTA simple rules for adnexal masses classification: a comparison between two centers with different ovarian cancer prevalence.

OBJECTIVE: The aim of this study was to compare the diagnostic performance of the IOTA simple rules for classifying adnexal masses when used in two centers with different ovarian cancer prevalence. STUDY DESIGN: A prospective study was performed between June 2012 and December 2013 at two different centers with different ovarian cancer prevalence. Center A had high ovarian malignancy prevalence and Center B had low malignancy rates. Eligible patients were all women diagnosed as having a persistent adnexal mass. Examiners had to analyze the masses according to IOTA simple rules (SR) providing a diagnosis of malignant, benign or inconclusive. Those cases classified as inconclusive were then examined by an expert examiner (the same examiner in center A, a different examiner in center B), who had to classify the mass as malignant, benign or uncertain according to his subjective impression (SI). Definitive histologic diagnosis from tumors removed surgically was used as gold standard. The diagnostic performance was assessed by calculating the sensitivity and specificity, positive and negative likelihood ratios, for SR and SR+SI assessments. McNemar test was used for comparing sensitivity and specificity. RESULTS: During this period, 247 women were eligible for this study. The rate of inconclusive masses was 18.4% and 18.0% for centers A and B, respectively (p>0.05). Ovarian malignancy rate was significantly higher in center A as compared with center B (27.2% versus 11.3%), (p=0.001). When analyzing only cases classifiable by SR, sensitivity in center A was significantly higher (100% versus 84.6% p=0.001), but specificity was similar in both centers (93.9% and 95.8% respectively). When analyzing SR plus SI, sensitivity in center A was significantly higher (100% versus 86.7% p=0.001), but specificity was similar in both centers (89.9% and 88.8%, respectively). CONCLUSIONS: The diagnostic performance in terms of sensitivity of IOTA rules is higher in a center with higher prevalence of ovarian malignancy.

Is autoimmune thyroid dysfunction a risk factor for gestational diabetes?

OBJECTIVE: Some recent studies have related autoimmune thyroid dysfunction and gestational diabetes (GD). The common factor for both conditions could be the existence of pro-inflammatory homeostasis. The study objective was therefore to assess whether the presence of antithyroid antibodies is related to the occurrence of GD. MATERIAL AND METHODS: Fifty-six pregnant women with serum TSH levels ≥ 2.5 mU/mL during the first trimester were retrospectively studied. Antithyroid antibodies were measured, and an O'Sullivan test was performed. GD was diagnosed based on the criteria of the Spanish Group on Diabetes and Pregnancy. RESULTS: Positive antithyroid antibodies were found in 21 (37.50%) women. GD was diagnosed in 15 patients, 6 of whom (10.71%) had positive antibodies, while 9 (16.07%) had negative antibodies. Data were analyzed using exact logistic regression by LogXact-8 Cytel; no statistically significant differences were found between GD patients with positive and negative autoimmunity (OR = 1.15 [95%CI = 0.28-4.51]; P=1.00). CONCLUSIONS: The presence of thyroid autoimmunity in women with TSH above the recommended values at the beginning of pregnancy is not associated to development of GD. However, GD prevalence was higher in these patients as compared to the Spanish general population, suggesting the need for closer monitoring in pregnant women with TSH levels ≥ 2.5 mU/mL.

Assessing the reproducibility of the IOTA simple ultrasound rules for classifying adnexal masses as benign or malignant using stored 3D volumes.

OBJECTIVE: To analyze the reproducibility of the IOTA simple ultrasound rules for classifying adnexal masses as benign or malignant among examiners with different level of expertise using stored 3D volumes of adnexal masses. STUDY DESIGN: Five examiners, with different levels of experience and blinded to each other, evaluated 100 stored 3D volumes from adnexal masses and looked for the presence or absence of malignant or benign features according to the IOTA definitions. Multiplanar view and virtual navigation were used. All examiners had to assess the 3D volume of each adnexal mass and classify it as benign or malignant. To analyze intra-observer agreement each examiner performed the assessment twice with a two-week interval between the first and second assessments. To analyze the inter-observer agreement, the second assessment from each examiner was used. Reproducibility was assessed calculating the weighted Kappa index. RESULTS: Intra-observer reproducibility was moderate or good for all observers (Kappa index ranging from 0.59 to 0.74). Inter-observer reproducibility was moderate to good (Kappa index range: 0.46-0.67). CONCLUSIONS: The simple rules are reasonably reproducible among observers with different level of expertise when assessed in stored 3D volumes.

Three-dimensional volume off-line analysis as compared to real-time ultrasound for assessing adnexal masses.

OBJECTIVE: To assess the agreement between three-dimensional volume off-line analysis as compared to real-time ultrasound for assessing adnexal masses. STUDY DESIGN: Ninety-nine non-consecutive women diagnosed as having an adnexal mass were assessed by transvaginal power Doppler ultrasound. One single examiner performed all ultrasound examinations. Based on the examiner's subjective evaluation using gray scale and Doppler ultrasound findings a presumptive diagnosis (benign or malignant) was provided after real-time ultrasound was performed. Once real-time was done a 3D volume of the adnexal mass was acquired and stored by this examiner. Two examiners, unaware of the real-time ultrasound results, evaluated the 3D volumes using multiplanar display and virtual navigation and also had to provide a presumptive diagnosis (benign or malignant). These two examiners, like the first one, had information about patient's age, menopausal status and complaints. All women underwent surgery or were followed-up until cyst resolution. Histologic diagnosis was used as gold standard. Cysts that resolved spontaneously were considered as benign for analytical purposes. The Kappa index was used to assess the agreement between real time ultrasound and 3D volume analysis. Sensitivity and specificity of both methods were calculated and compared using McNemar test. RESULTS: Forty-one masses were malignant and 58 were benign. Agreement between real-time ultrasound and 3D volume analysis was good for both off-line examiners (Kappa index: 0.82, 95% CI: 0.70-0.93 and 0.78, 95% CI: 0.65-0.90). Sensitivities for real-time ultrasound and 3D volume analyses were 100%, 93% and 90%, respectively (p>0.05). Specificities for real-time ultrasound and 3D volume analyses were 91%, 84% and 86%, respectively (p>0.05). CONCLUSIONS: Off-line 3D volume analysis may be a useful method for assessing adnexal masses, showing a good agreement with real-time ultrasound and having a similar diagnostic performance.

Vaginal evisceration in a patient with previous sacrocolpopexy.

Vaginal evisceration is a rare gynecologic complication with less than 100 cases reported in the literature. We present a case of vaginal evisceration in a woman with multiple previous surgeries including a sacrocolpopexy. Vaginal mesh grafts have to be applied properly during sacrocolpopexy.

Perinatal outcome and long-term follow-up of extremely low birth weight infants depending on the mode of delivery.

OBJECTIVE: To assess the effect of the mode of delivery (vaginal or cesarean section) on survival, morbidity, and long-term psychomotor development of extremely low birth weight (ELBW) infants. METHODS: A longitudinal observational study including 138 ELBW infants (73 born by c-section and 65 vaginally) was conducted. We analyzed the survival and short-term morbidity. We also studied the long-term neurocognitive and motor development using the McCarthy Scales of Children's Abilities (MSCA). RESULTS: Mortality was significantly higher in newborns delivered vaginally (49.3%) than those delivered by c-section (23.1%). Newborns delivered vaginally had a higher incidence of retinopathy and peri-intraventricular hemorrhage (P-IVH). Children who died had lower gestational age at birth and lower birth weight. After multivariate analysis only birth weight, gestational age at birth and P-IVH were independently associated to mortality. Regarding the long-term evaluation (MSCA), we observed that children born by c-section had lower incidence of abnormal results. CONCLUSIONS: The mode of delivery does not affect survival. Cesarean section provides lower morbidity and better prognosis for neurodevelopment long-term outcome in ELBW infants.