Terry S. Dunn

A "see and treat" management for high-grade squamous intraepithelial lesion pap smears.

Objective. This study evaluates a “see and treat” intervention for high-grade squamous intraepithelial lesions (HSIL) on Pap smears. This is a case control study comparing cost-effectiveness, patient compliance, and pathology obtained from immediate colposcopy and large loop excision of the transformation zone of the uterine cervix. (LLETZ) Materials and Methods. At our institution before the onset of the study, a chart review of 100 patients with HSIL Pap smears was performed. This was the control group. Ninety percent of the patients in the control group who had HSIL on Pap eventually had LLETZ. The next consecutive 100 women presenting to the clinic who met the same inclusion criteria underwent colposcopy and LLETZ at the same visit and were compared with the control group. Demographics, pathology, compliance, and cost were analyzed. Results. One hundred patients were treated with one visit colposcopy/LLETZ intervention. Histologic diagnosis of cervical intraepithelial neoplasia (CIN) 2,3 was confirmed in 94% of patients. Two percent of the patients had CIN 1, 1% had no histologic evidence of CIN, and 3% had microinvasive cancer to a depth of 0.5–1.5mm. Cost analysis revealed savings of

Absent endocervical cells on Pap smears after loop electrosurgical excision procedure.

35,000 for the institution. Patient compliance was improved with a kept appointment rate of 82%. Conclusions. “See and treat” intervention for HSIL Paps was an effective tool. Treating HSIL Paps without a separate visit for colposcopy is a cost-effective management. This method was more convenient for patients with only one disruption of daily schedules.

Cesarean Hysterectomy Revisited

Objective. To evaluate the absence of endocervical cells on Pap smear after loop electrosurgical excision procedure (LEEP) as a possible marker for cervical stenosis. Materials and Methods. All LEEPs performed at a public health teaching hospital caring for the indigent between July 1, 1999, and September 30, 2002, were reviewed; 1,190 eligible charts of patients were reviewed, and extracted data included the following: age, parity, ethnicity, histology obtained during colposcopy, volume of loop specimen taken, and follow-up Pap smear results. Results. One thousand four hundred twenty-one patients had LEEPs during this period. One thousand one hundred ninety first follow-up Pap smears were evaluated; 200 patients had no follow-up Pap smears. The baseline background rate for absent endocervical cells was 7% for the general population. The study showed that the rate of absent endocervical cells on first follow-up Pap smears was 13.64% (173/1,193) (p = .03). The mean age of patients was 33.6 years; 11% (20/1,193) were aged older than 50 years. There was no significant difference with age and parity in the stenosis versus nonstenosis group. Conclusion. The LEEP was significantly associated with absent endocervical cells on follow-up Pap smears, which may be indicative of cervical stenosis.

Ausencia de células endocervicales en la citología después de una extirpación electroquirúrgica con asa

This study sought to evaluate the morbidity and cost associated with planned and emergent peripartum hysterectomy in a residency setting. The authors also evaluated planned hysterectomy compared with delivery and subsequent hysterectomy. The charts of 64 patients who underwent emergent or planned peripartum hysterectomies were reviewed. Comparisons were made in the following areas: gravidity and parity, number of prior cesarean sections, fetal weight, blood loss, number of transfused blood units, length of stay, charges, and indications for hysterectomy. A cost analysis was performed comparing planned peripartum hysterectomy with delivery and subsequent hysterectomy. When planned cesarean hysterectomies were compared with delivery and subsequent hysterectomy, it was found that the planned hysterectomy for cervical dysplasia and leiomyoma had no significant complications. There were also significant cost savings when vaginal or cesarean delivery was compared with interim hysterectomy. Planned hysterectomie...

Clinical pathway for evaluating women with abnormal uterine bleeding

Objetivo. Evaluar la ausencia de células endocervicales en la citología después de la extirpación electroquirúrgica con asa (LEEP) como posible marcador de estenosis de cérvix. Materiales y métodos. Se revisaron todas las LEEP practicadas en un hospital docente de la sanidad pública que presta atención a indigentes entre el 1 de julio de 1999 y el 30 de septiembre de 2002. Se revisaron 1.190 historias clínicas de pacientes elegibles, de las que se extrajeron los datos siguientes: edad, paridad, etnicidad, resultados histológicos obtenidos con la colposcopia, volumen de la muestra obtenida con asa y los resultados de la citología de seguimiento. Resultados. Durante este período se practicó LEEP a 1.421 pacientes. Se evaluaron las 1.190 citologías de seguimiento; 200 pacientes no se sometieron a una citología de seguimiento. La tasa de partida de ausencia de células endocervicales para la población general fue del 7%. El estudio mostró que la tasa de ausencia de células endocervicales en las primeras citologías de seguimiento fue del 13,64% (173/1.193) (p = 0,03). La edad media de las pacientes fue de 33,6 años; el 11% (20/1.193) tenían más de 50 años. No se observó una diferencia significativa en términos de edad y paridad entre el grupo de estenosis y el de no estenosis. Conclusión. La LEEP se asoció significativamente con la ausencia de células endocervicales en las citologías de seguimiento, lo que puede ser un factor indicativo de estenosis de cérvix. ▪

Complications of outpatient LLETZ procedures

OBJECTIVEnTo devise a clinical pathway for evaluating women with abnormal uterine bleeding.nnnSTUDY DESIGNnOne thousand women with the complaint of abnormal uterine bleeding were enrolled. All would have undergone endometrial biopsy based on older recommendations. The patients followed a clinical pathway to determine if an endometrial biopsy was necessary. The pathway divided women into the categories of premenopausal, postmenopausal, low risk and high risk. If one risk factor was present, the patient underwent endometrial biopsy. If there were no risk factors, the patient continued down the pathway with medical therapy.nnnRESULTSnFive hundred seventy endometrial biopsies were performed. Five cases of endometrial cancer and three of complex atypical hyperplasia, both in the postmenopausal, high-risk group, were discovered. Subsequent reviews revealed that no cases of endometrial cancer were missed or developed in the two years following the initial complaint.nnnCONCLUSIONnUtilization of a clinical pathway reduced the number of endometrial biopsies by 50%. The introduction of clinical pathways at our institution was done successfully in the evaluation of abnormal uterine bleeding.