Trends in Minimally Invasive Hysterectomy Techniques for Nonmalignant Conditions in a Defined Population.

BACKGROUND: Minimally invasive surgical techniques are increasingly being used for performing hysterectomy. We assessed changes in surgical techniques for hysterectomy that happened during the last decade among the complete Icelandic population. METHODS: Databases in all hospitals in the country were searched to identify all women undergoing hysterectomy during the years 2001-2010 inclusive. Information on age at surgery, indication for surgery, surgical techniques, additional intraoperative procedures, and length of hospital stay was gathered. Two 5-year periods, 2001-2005 and 2006-2010, were compared. The proportion of minimally invasive surgery (MIS) was calculated. RESULTS: There were 5,288 hysterectomies that were performed, giving a mean annual incidence of 352/100,000 women. The proportion of MIS increased from 30 to 74% at the main university hospital (p < 0.0001), where the mean hospital stay decreased from 5.4 to 1.7 days. Fewer oophorectomies were performed during the second 5-year period. The most common diagnoses were fibromyomas and abnormal uterine bleeding. The rate of recorded complications was low. A decreasing yearly incidence was observed from 389/100,000 in 2001 to 266/100,000 by 2010. CONCLUSION: For benign indications, the surgical approach has changed markedly with a high proportion of the operations being performed with minimally invasive techniques, mainly at a secondary/tertiary level.

Yes we can! Successful examples of disallowing 'conscientious objection' in reproductive health care.

Reproductive health care is the only field in medicine where health care professionals (HCPs) are allowed to limit a patient's access to a legal medical treatment - usually abortion or contraception - by citing their 'freedom of conscience.' However, the authors' position is that 'conscientious objection' ('CO') in reproductive health care should be called dishonourable disobedience because it violates medical ethics and the right to lawful health care, and should therefore be disallowed. Three countries - Sweden, Finland, and Iceland - do not generally permit HCPs in the public health care system to refuse to perform a legal medical service for reasons of 'CO' when the service is part of their professional duties. The purpose of investigating the laws and experiences of these countries was to show that disallowing 'CO' is workable and beneficial. It facilitates good access to reproductive health services because it reduces barriers and delays. Other benefits include the prioritisation of evidence-based medicine, rational arguments, and democratic laws over faith-based refusals. Most notably, disallowing 'CO' protects women's basic human rights, avoiding both discrimination and harms to health. Finally, holding HCPs accountable for their professional obligations to patients does not result in negative impacts. Almost all HCPs and medical students in Sweden, Finland, and Iceland who object to abortion or contraception are able to find work in another field of medicine. The key to successfully disallowing 'CO' is a country's strong prior acceptance of women's civil rights, including their right to health care.

Clinicopathologic conference: multiple fetal demises, lactic acidosis and hepatic iron accumulation.

A case of a premature infant with lactic acidosis and hepatic iron accumulation, born to a mother with multiple fetal demises, is presented and discussed by both clinician and pathologist, in this traditional clinico-pathologic conference. The discussion includes the differential diagnoses of lactic acidosis and hepatic iron accumulation in infants.

Polycystic ovary morphology: age-based ultrasound criteria.

OBJECTIVE: To determine age-based criteria for polycystic ovary morphology. DESIGN: Cross-sectional, case-control design. SETTING: Outpatient setting. SUBJECT(S): Women with polycystic ovary syndrome (PCOS) defined by hyperandrogenism and irregular menses (n = 544) and controls with regular menses and no evidence of hyperandrogenism (n = 666) participated. Parameters were tested in a second cohort of women with PCOS (n = 105) and controls (n = 32) meeting the same criteria. INTERVENTION(S): Subjects underwent a pelvic ultrasound documenting ovarian volume and maximum follicle number in a single plane. MAIN OUTCOME MEASURE(S): A receiver operating characteristic curve was constructed to determine the ovarian volume and follicle number with the best sensitivity and specificity to define PCOS for age groups at approximately 5-year intervals from age 18 to >44 years. RESULT(S): The best sensitivity and specificity were obtained using a threshold volume of 12 mL and 13 follicles for ages ≤24 years, 10 mL and 14 follicles for ages 25-29 years, 9 mL and 10 follicles for ages 30-34 years, 8 mL and 10 follicles for ages 35-39 years, 10 mL and 9 follicles for ages 40-44 years, and 6 mL and 7 follicles for ages >44 years. Data from a second cohort confirmed the need to decrease volume and follicle number with increasing age to diagnose PCOS. Polycystic ovary morphology was most accurate at predicting the PCOS diagnosis for women ages 30-39 years. CONCLUSION(S): The ovarian volume and follicle number threshold to define polycystic ovary morphology should be lowered starting at age 30.

The accuracy of fine-needle aspiration cytology for diagnosis of parotid gland masses: a clinicopathological study of 114 patients.

OBJECTIVE: Fine-needle aspiration cytology is a valuable method for preoperative assessment of head and neck tumors. However, its accuracy in detection of salivary gland masses is controversial compared with other methods. The aim of this work was to evaluate the effectiveness and accuracy of fine-needle aspiration cytology (FNAC) in the diagnosis of parotid gland masses. MATERIAL AND METHODS: Over a 10-year period, 126 parotid gland masses were resected. Retrospective chart reviews of 114 patients were performed. The results of FNAC and final histological diagnosis were compared and the accuracy of FNAC was determined. RESULTS: Final histological evaluation revealed 11 malignant tumors and 103 benign lesions. Pleomorphic adenoma was the most common neoplasm (63%), followed by Warthin's tumor (17.5%). The sensitivity of FNAC in detecting malignant tumors was 73% and the specificity was 97%. Positive predictive value (PPV) was 73% and negative predictive value (NPV) was 97%. The overall accuracy of FNAC in detecting parotid masses was 95%. False-negative diagnosis was found in mucoepidermoid carcinoma, acinic cell carcinoma, and epithelial-myoepithelial carcinoma whereas there was false-positive diagnosis in cases of pleomorphic adenoma and normal parotid gland tissue. CONCLUSION: FNAC is a reliable minimally invasive diagnostic method with a high sensitivity in diagnosis of lesions in parotid glands. The sensitivity of detection of malignant tumors in parotid glands was low due to the biopsy technique used, and depended on tumor location. Postoperative complications decreased after superficial parotidectomy.

Increased population use of medications for male lower urinary tract symptoms/benign prostatic hyperplasia correlates with changes in indications for transurethral resection of the prostate.

OBJECTIVE: The aim of this study was to determine whether there are correlations between medication use for lower urinary tract symptoms/benign prostate hypertrophy (LUTS/BPH) and alteration in incidence and indications for transurethral resection of the prostate (TURP). MATERIAL AND METHODS: The number of TURP patients between 1984 and 2008 in Iceland was obtained from hospital registries. The number of defined daily doses (DDDs) of 5-alpha-reductase inhibitors (5aRIs) and alpha-blockers (ABs) sold was obtained from the Icelandic Medicines Control Agency. Charts of all surgical BPH patients in Iceland from 1998 to 2008 were retrospectively reviewed. The main outcomes measures were: DDDs sold of 5aRIs and ABs, total numbers of TURP, indications for TURP and complications. RESULTS: After the introduction of ABs and 5aRIs, sales increased annually at a near linear rate. TURP rates peaked in 1992, then declined. In 2008, 81 and 3.4 of 1000 men over the age of 50 used LUTS/BPH medications or underwent TURP, respectively. There was an inverse correlation between LUTS/BPH medication use and (i) overall TURP (R(2) = 0.85), (ii) TURP done for absolute indications (R(2) = 0.91), and (iii) LUTS with (R(2) = 0.77) and (iv) without previous medical therapy (R(2) = 0.75). As medication use rose, fewer TURPs were performed for previous history of urinary retention, and more for recurrent urinary tract infections. CONCLUSION: Increased use of ABs and 5aRIs in the Icelandic population correlated with decreasing incidences of TURP procedures for both LUTS and absolute indications. The sequelae of BPH and indications for TURP are changing as medication use increases, although a clear causative link is hard to establish.

[Incidence and management of ectopic pregnancy in Iceland 2000-2009]. / Nýgengi og medferd utanlegsþykktar á Íslandi 2000-2009

INTRODUCTION: Ectopic pregnancy can be life-threatening. Its treatment has changed radically during the last two decades. The study objective was to evaluate incidence and treatment of ectopic pregnancy in the Icelandic population during the decade 2000-2009. MATERIAL AND METHODS: Information was collected about all diagnosed cases, place and method of treatment and admissions. The annual incidence was calculated with reference to number of pregnancies (n/1000), number of women aged 15-44 years (n/10 000) and by 5-year age groups, comparing the periods 2000-2004 and 2005-2009. RESULTS: The number of ectopic pregnancies during these 10 years was 836, or 444 during the years 2000-2004 and 392 during 2005-2009. The average annual incidence was 15.6/1000 pregnancies and 12.9/10 000 women. There was an annual incidence reduction from 17.3 to 14.1/1000 pregnancies (p<0.01) and 14.1 to 11.7/10 000 women (p<0.01). Surgery was the primary treatment for 94.9% of women, methotrexate in 3.2% and expectant management in 1.9%. Surgical management decreased from 98.0% to 91.3% between 5-year periods as medical treatment increased (0.4% to 6.4%; p<0.0001). The proportion of laparoscopic procedures increased from 80.5% to 91.1% (p<0.0001). In the university referral hospital this changed from 91.3% to 98.1% (p<0.001) and in rural hospitals from 44.0% to 69.3% (p<0.001). Mean hospital stay after open surgery was 3.2 days, but 0.9 days after laparoscopy. CONCLUSIONS: The incidence reduction of ectopic pregnancy is comparable to the development in neighbouring countries. Management has changed with increased use of laparoscopic surgery, medical and expectant treatment.

Variants in DENND1A are associated with polycystic ovary syndrome in women of European ancestry.

CONTEXT: A genome-wide association study has identified three loci (five independent signals) that confer risk for polycystic ovary syndrome (PCOS) in Han Chinese women. Replication is necessary to determine whether the same variants confer risk for PCOS in women of European ancestry. OBJECTIVE: The objective of the study was to test whether these PCOS risk variants in Han Chinese women confer risk for PCOS in women of European ancestry. DESIGN: This was a case-control study. SETTING: The study was conducted at deCODE Genetics in Iceland and two academic medical centers in the United States. PATIENTS: Cases were 376 Icelandic women and 565 and 203 women from Boston, MA, and Chicago, IL, respectively, all diagnosed with PCOS by the National Institutes of Health criteria. Controls were 16,947, 483, and 189 women not known to have PCOS from Iceland, Boston, and Chicago, respectively. INTERVENTION: There were no interventions. MAIN OUTCOMES: Main outcomes were allele frequencies for seven variants in PCOS cases and controls. RESULTS: Two strongly correlated Han Chinese PCOS risk variants on chromosome 9q33.3, rs10986105[C], and rs10818854[A], were replicated in samples of European ancestry with odds ratio of 1.68 (P = 0.00033) and odds ratio of 1.53 (P = 0.0019), respectively. Other risk variants at 2p16.3 (rs13405728), 2p21 (rs12468394, rs12478601, and rs13429458), and 9q33.3 (rs2479106), or variants correlated with them, did not associate with PCOS. The same allele of rs10986105 that increased the risk of PCOS also increased the risk of hyperandrogenism in women without PCOS from Iceland and demonstrated a stronger risk for PCOS defined by the National Institutes of Health criteria than the Rotterdam criteria. CONCLUSIONS: We replicated one of the five Chinese PCOS association signals, represented by rs10986105 and rs10818854 on 9q33, in individuals of European ancestry. Examination of the subjects meeting at least one of the Rotterdam criteria for PCOS suggests that the variant may be involved in the hyperandrogenism and possibly the irregular menses of PCOS.

The accuracy of fine-needle aspiration cytology for diagnosis of parotid gland masses: a clinicopathological study of 114 patients

ABSTRACT Objective Fine-needle aspiration cytology is a valuable method for preoperative assessment of head and neck tumors. However, its accuracy in detection of salivary gland masses is controversial compared with other methods. The aim of this work was to evaluate the effectiveness and accuracy of fine-needle aspiration cytology (FNAC) in the diagnosis of parotid gland masses. Material and Methods Over a 10-year period, 126 parotid gland masses were resected. Retrospective chart reviews of 114 patients were performed. The results of FNAC and final histological diagnosis were compared and the accuracy of FNAC was determined. Results Final histological evaluation revealed 11 malignant tumors and 103 benign lesions. Pleomorphic adenoma was the most common neoplasm (63%), followed by Warthin’s tumor (17.5%). The sensitivity of FNAC in detecting malignant tumors was 73% and the specificity was 97%. Positive predictive value (PPV) was 73% and negative predictive value (NPV) was 97%. The overall accuracy of FNAC in detecting parotid masses was 95%. False-negative diagnosis was found in mucoepidermoid carcinoma, acinic cell carcinoma, and epithelial-myoepithelial carcinoma whereas there was false-positive diagnosis in cases of pleomorphic adenoma and normal parotid gland tissue. Conclusion FNAC is a reliable minimally invasive diagnostic method with a high sensitivity in diagnosis of lesions in parotid glands. The sensitivity of detection of malignant tumors in parotid glands was low due to the biopsy technique used, and depended on tumor location. Postoperative complications decreased after superficial parotidectomy.

[Medical abortions - experience from the first 246 treatments in Iceland]. / Fóstureyding med lyfjum. Fyrstu 246 medferdirnar á Islandi.

OBJECTIVE: Medical abortion is a safe and effective treatment and is increasingly being used for termination of early pregnancy. In February 2006 medical abortion became available to women in Iceland. The purpose of this study is to assess the efficacy of medical abortion and evaluate whether it is a suitable alternative to surgical abortion in Iceland. MATERIAL AND METHODS: All eligible women (pregnancy <63 days, n=246) who chose medical abortion from February 2006 until July 2007 were included in the study. Data was collected on those who needed surgical evacuation and on other complications. RESULTS: The proportion of women who had medical abortion was 17.4% (n=246/1171). Curettage was needed in 8.9% of cases. Antibiotics were prescribed in 4.1% of cases and four women were admitted for complications without need for evacuation (urinary tract infection=2, bleeding=2), one woman was admitted to the intensive care unit for 24 hours because of unexplained fever and one woman needed blood transfusion. CONCLUSION: The success rate of more than 90% is comparable to what has been reported in other studies (92-99%) and this treatment option has proven to be safe in our settings. In total 17.4% of women opting for abortion had a medical abortion compared to 50% in Sweden and 46% in Denmark. With more experience and general awareness of the possibilities of medical abortion the ratio is likely to increase.

[Use of hormone replacement therapy by Icelandic women in the years 1996-2001.].

INTRODUCTION: Since the late seventies the use of hormone replacement therapy by peri- and postmenopausal women has been steadily increasing. This was shown in a former study of hormonal use among Icelandic women who had responded to a questionnaire when attending cancer screening at the Cancer Detection Clinic (CDC) of the Icelandic Cancer Society in the years 1979-1996. This current study is an independent extension of the former study with the goal of investigating menopausal hormone use among Icelandic women during the period of 1996-2001 and comparing the results with the former study period of 1979-1995. MATERIAL AND METHODS: We used data from the CDC for the period of 1996-2001 and reviewed the responses from Icelandic women aged 40-69 years to questions regarding hormonal use. We investigated changes in the proportion of women using hormones, the proportion of women using combined hormone replacement therapy, the proportion using long-time hormone replacement therapy, and also the relationship between hormonal use and smoking. We also compared our results to the former study results. RESULTS: During the period 1996-2001, 16.649 women aged 40-69 years responded to the questionnaire on hormonal use. There was an increase in use during that period, and also an increase compared to the period 1979-1995. Women born 1941-1945 were more likely to have ever used hormones (68%) than women born 1931-35 (42%). Present use of hormones was most prevalent among 52-57 year old women (57%). The proportion of women aged 50-55 years reporting present use did not change over the period ( approximately 50%). Long term use increased steadily during the period. During 1996-98 the proportion of women who had used hormones for more than 5 years was 49%, compared to 67% of women 1999-2001. This is also a considerable increase compared to the former study period. In the years 1996-2001, 19% of the women reported hormone use for 14 years or more. Smoking was more common among ever users of hormone replacement therapy (63%) than among never users of hormone replacement therapy (53%). CONCLUSIONS: The proportion of women who had used hormones and the duration of hormone use increased steadily during the period of 1996-2001. There was also a considerable increase compared to the former study period.