Between 1977-1990, 755 women were evaluated and treated for ovarian cancer at the University of M... more Between 1977-1990, 755 women were evaluated and treated for ovarian cancer at the University of Miami/Jackson Memorial Medical Center. Ninety-five of them (12.6%) had previously undergone hysterectomy with preservation of one or both ovaries. Sixty women (7.9%) had undergone hysterectomies after the age of 40. Review of the literature reveals a 4.5-14.1% incidence of prior hysterectomy in women developing ovarian cancer. Prophylactic oophorectomy in women undergoing hysterectomy at age 40 or older would have prevented 138 of 2632 cases (5.2%) of ovarian cancer in a combined literature series. Applied nationally, such an approach could be expected to prevent over 1000 cases of ovarian cancer annually. We recommend routine prophylactic oophorectomy in all women undergoing hysterectomy after the age of 40. This strategy would have prevented 60 cases of ovarian cancer treated at the University of Miami during the past 14 years.
Obstetrics and Gynecology Clinics of North America, 2008
In this article we present the elements of one approach to quality improvement and patient safety... more In this article we present the elements of one approach to quality improvement and patient safety that we believe can be successful and sustainable in the field of obstetrics and gynecology, along with several strategies (and caveats) that have worked and are working in academic and nonacademic institutions in the United States. Also included are several noteworthy definitions of quality to provide some additional perspectives on what is meant by quality in health care.
To use meta-analysis to evaluate the effect of epidural analgesia on the cesarean delivery rate. ... more To use meta-analysis to evaluate the effect of epidural analgesia on the cesarean delivery rate. The MEDLINE data base was searched for articles published in English between January 1981 and April 1992. We also interviewed experts and conducted a bibliographic follow-up and manual review of recent journals published from April to July 1992. We excluded articles with irrelevant titles, and those case studies, book chapters, or articles that did not provide primary and relevant data. Two hundred thirty articles were read, including articles that reported on women of standard obstetric risk and on cesarean delivery rates for an epidural group and for a concurrent no-epidural group. These criteria yielded six studies for a primary analysis and two others for a secondary analysis. The sample size of the epidural and no-epidural groups and the number of cesareans within each group were extracted. Tests of homogeneity were conducted. The pooled cesarean delivery risk difference as a result of epidural analgesia was estimated. The cesarean rate for women undergoing epidural analgesia was ten percentage points greater than for no-epidural women (P < .05). More than a nine percentage point increase was shown for cesarean deliveries for dystocia (P < .05), when pooling either all studies or only randomized studies. The results of this meta-analysis strongly support an increase in cesarean delivery associated with epidural analgesia. Further research should evaluate the balance between analgesia associated with the use of epidurals, and postpartum morbidity and costs associated with cesarean deliveries.
A series of 10 patients with benign androgen-secreting neoplasms is presented. Nine tumors were o... more A series of 10 patients with benign androgen-secreting neoplasms is presented. Nine tumors were ovarian, and one adrenal. In an attempt to correctly diagnose the presence of tumor and to accurately localize the lesion to a specific gland, steroid hormones in peripheral, ovarian, and adrenal vein serum were analyzed by radioimmunoassay. Little correlation was made in this series with those levels of testosterone (>2 ng/ml) or dehydroepiandrosterone sulfate (>7000 ng/ml) that have been widely used to predict the presence of such tumors. Peripheral testosterone levels were less than 2 ng/ml in 50% of our patients, and the dehydroepiandrosterone sulfate level was greater than 7000 ng/ml in only a single patient with an ovarian lipoid cell tumor. Pelvic ultrasonography was found to be of limited value in evaluating nonpalpable tumor because of the small size ( <2 em") of the majority of these neoplasms. The use of selective retrograde venous catheterization to demonstrate significant effluent-peripheral vein androgen gradients served to accurately localize androgen-secreting tumors in all six patients in which it was used. Our data emphasize the potential pitfalls that exist in the preoperative evaluation of patients with these fascinating neoplasms and the importance of a high degree of suspicion on the part of the physician caring for these women. (AM J 0BSTET GYNECOL 1988;158:1313-22.)
International Journal of Gynecology & Obstetrics, 1991
Fifteen gynecologic quality assurance indicators recently published by The American College of Ob... more Fifteen gynecologic quality assurance indicators recently published by The American College of Obstetricians and Gynecologists were applied to a previously reported hysterectomy data base. Chart reviews were performed for the most recent 257 cases in the data base, representing an 18-month interval. The indicators were divided into two groups: those intended to identify morbidity and mortality and those intended to screen for appropriateness of care. Rates of actual morbidity and cases that failed to meet published criteria sets for hysterectomy were determined by chart review regardless of the presence of a quality assurance indicator. A total of 135 indicators were identified in 114 (44%) of the 257 cases, including 64 patients (25%) with morbidity indicators and 50 (19%) with appropriateness indicators. Actual morbidity was correctly identified in all 64 cases in which morbidity indicators were present. Three cases with significant morbidity were identified by chart review but not identified by the indicators, yielding positive and negative predictive values of 100 and 98%, respectively, and an overall accuracy of 99% for morbidity indicators. By contrast, 14 of the 50 cases in which appropriateness indicators were present actually failed to meet published criteria sets. An additional seven cases failing to meet criteria sets were identified by chart review and not identified by the indicators, yielding a positive predictive value of 28%, a negative predictive value of 97%, and an overall accuracy of 83% for appropriateness indicators.
International Journal of Gynecology & Obstetrics, 1990
Treatment of endometriosis with gonadotropin-releasing hormone agonists (GnRH-a) is associated wi... more Treatment of endometriosis with gonadotropin-releasing hormone agonists (GnRH-a) is associated with side effects secondary to the induced hypoestrogenic state. In an effort to ameliorate these symptoms, 10 patients with symptomatic endometriosis self-administered the GnRH-a [D-His6(Imbzl)-Pro9-NET]-GnRH in combination with norethindrone daily for 24 weeks. Painful symptoms were significantly suppressed after therapy (P less than 0.005). Objective review of photographs taken at laparoscopy before and after therapy demonstrated significant reduction of visible implants (P less than 0.005). Vasomotor symptoms were minimized when compared with a group of 16 patients previously treated with GnRH-a alone. Bone mineral density of the distal radius assessed by single photon absorptiometry was not reduced during therapy, although lumbar spine bone density assessed by quantitative computerized tomography was minimally but reversibly reduced. No metabolic derangements were detected. The combination of norethindrone with GnRH-a is a well tolerated and effective means of treating symptomatic endometriosis.
International Journal of Gynecology & Obstetrics, 1993
To determine pregnancy and livebirth rates for women age 40 and older undergoing ovulation induct... more To determine pregnancy and livebirth rates for women age 40 and older undergoing ovulation induction and to assess the impact of basal follicle-stimulating hormone (FSH) on outcome in these patients. Prospective, observational. Fertility service of university medical center. Infertile couples in whom the female partner was age 40 or older referred for ovulation induction therapy. Assessment of basal hormonal status; ovulation induction. Clinical pregnancy rate (PR), livebirth rate. Analysis of 402 cycles in 85 women age 40 and older demonstrated a clinical PR of 3.5% per cycle (95% confidence interval [CI] 1.7% to 5.3%). The livebirth rate was 1.2% per cycle (95% CI 0.1% to 2.3%). Women with a basal FSH &lt; 25 IU/L and age &lt; 44 years had a clinical PR of 5.2% per cycle (95% CI 2.5% to 7.9%) compared with 0.0% per cycle (95% CI 0.0% to 2.1%) in cases in which either basal FSH was &gt; or = 25 IU/L or age was &gt; or = 44 (P &lt; 0.005). The prognostic importance of basal FSH and chronological age was confirmed by multivariate logistic regression analysis. The predictive value of the resulting regression equation was high (R2 = 0.94; P &lt; 0.01). Pregnancy and livebirth rates are generally low during ovulation induction in women age 40 and older. In combination, basal FSH and chronological age are accurate predictors of PR, in these couples and can define a subset of patients with a more favorable prognosis. The spontaneous abortion rate in women who do conceive is high, substantially lowering the livebirth rate.
The role of prostaglandins on the extraction of estradiol (E ) by the rat uterine horn in the pre... more The role of prostaglandins on the extraction of estradiol (E ) by the rat uterine horn in the presence of the intrauterine devic z (IUD) was evaluated.
American Journal of Obstetrics and Gynecology, 1990
A criteria-based quality assurance process for hysterectomy was instituted at a large teaching ho... more A criteria-based quality assurance process for hysterectomy was instituted at a large teaching hospital. After this process was initiated, the overall frequency of hysterectomy decreased by 24%, p less than 0.001. Significant reductions were seen in hysterectomy rates for the following indications: chronic pelvic pain (77%, p less than 0.0001), recurrent uterine bleeding (46%, p less than 0.001), preinvasive disease of the uterus (55%, p less than 0.005), and severe infection (70%, p less than 0.025). Adenomyosis was the single indication for which an increase in hysterectomy rate was observed. This increase, however, was completely reversed during the last 2 years of the study. This quality assurance process also resulted in a significant increase in the histologic verification rate (i.e., 82% vs 93%, p less than 0.001). These observations suggest that using such a criteria-based process can reduce the number of hysterectomies performed and improve the accuracy of the preoperative diagnosis.
To develop recommendations for the medical and surgical care of women who present with chronic pe... more To develop recommendations for the medical and surgical care of women who present with chronic pelvic pain (CPP) and are likely to have endometriosis as the underlying cause. Design: An expert panel comprised of practicing gynecologists from throughout the United States and experts in consensus guideline development was convened. After completion of a structured literature search and creation of draft algorithms by an executive committee, the expert panel of Ͼ50 practicing gynecologists met for a 2-day consensus conference during which the clinical recommendations and algorithms were reviewed, refined, and then ratified by unanimous or near-unanimous votes. Patient(s): Women presenting with CPP who are likely to have endometriosis as the underlying cause. Main Outcome Measure(s): None. Conclusion(s): Chronic pelvic pain frequently occurs secondary to nongynecologic conditions that must be considered in the evaluation of affected women. For women in whom endometriosis is the suspected cause of the pain, laparoscopic confirmation of the diagnosis is unnecessary, and a trial of medical therapy, including second-line therapies such as danazol, GnRH agonists, and progestins, is justified provided that there are no other indications for surgery such as the presence of a suspicious adnexal mass. When surgery is necessary, laparoscopic approaches seem to offer comparable clinical outcomes to those performed via laparotomy, but with reduced morbidity. The balance of evidence supports the use of adjuvant postoperative medical therapy after conservative surgery for CPP. There is some evidence that adjuvant presacral neurectomy adds benefit for midline pain, but currently, there is inadequate evidence to support the use of uterosacral nerve ablation or uterine suspension. Hysterectomy alone has undocumented value in the surgical management of women with endometriosis-associated CPP. (Fertil Steril 2002;78:961-72.
Between 1977-1990, 755 women were evaluated and treated for ovarian cancer at the University of M... more Between 1977-1990, 755 women were evaluated and treated for ovarian cancer at the University of Miami/Jackson Memorial Medical Center. Ninety-five of them (12.6%) had previously undergone hysterectomy with preservation of one or both ovaries. Sixty women (7.9%) had undergone hysterectomies after the age of 40. Review of the literature reveals a 4.5-14.1% incidence of prior hysterectomy in women developing ovarian cancer. Prophylactic oophorectomy in women undergoing hysterectomy at age 40 or older would have prevented 138 of 2632 cases (5.2%) of ovarian cancer in a combined literature series. Applied nationally, such an approach could be expected to prevent over 1000 cases of ovarian cancer annually. We recommend routine prophylactic oophorectomy in all women undergoing hysterectomy after the age of 40. This strategy would have prevented 60 cases of ovarian cancer treated at the University of Miami during the past 14 years.
Obstetrics and Gynecology Clinics of North America, 2008
In this article we present the elements of one approach to quality improvement and patient safety... more In this article we present the elements of one approach to quality improvement and patient safety that we believe can be successful and sustainable in the field of obstetrics and gynecology, along with several strategies (and caveats) that have worked and are working in academic and nonacademic institutions in the United States. Also included are several noteworthy definitions of quality to provide some additional perspectives on what is meant by quality in health care.
To use meta-analysis to evaluate the effect of epidural analgesia on the cesarean delivery rate. ... more To use meta-analysis to evaluate the effect of epidural analgesia on the cesarean delivery rate. The MEDLINE data base was searched for articles published in English between January 1981 and April 1992. We also interviewed experts and conducted a bibliographic follow-up and manual review of recent journals published from April to July 1992. We excluded articles with irrelevant titles, and those case studies, book chapters, or articles that did not provide primary and relevant data. Two hundred thirty articles were read, including articles that reported on women of standard obstetric risk and on cesarean delivery rates for an epidural group and for a concurrent no-epidural group. These criteria yielded six studies for a primary analysis and two others for a secondary analysis. The sample size of the epidural and no-epidural groups and the number of cesareans within each group were extracted. Tests of homogeneity were conducted. The pooled cesarean delivery risk difference as a result of epidural analgesia was estimated. The cesarean rate for women undergoing epidural analgesia was ten percentage points greater than for no-epidural women (P &lt; .05). More than a nine percentage point increase was shown for cesarean deliveries for dystocia (P &lt; .05), when pooling either all studies or only randomized studies. The results of this meta-analysis strongly support an increase in cesarean delivery associated with epidural analgesia. Further research should evaluate the balance between analgesia associated with the use of epidurals, and postpartum morbidity and costs associated with cesarean deliveries.
A series of 10 patients with benign androgen-secreting neoplasms is presented. Nine tumors were o... more A series of 10 patients with benign androgen-secreting neoplasms is presented. Nine tumors were ovarian, and one adrenal. In an attempt to correctly diagnose the presence of tumor and to accurately localize the lesion to a specific gland, steroid hormones in peripheral, ovarian, and adrenal vein serum were analyzed by radioimmunoassay. Little correlation was made in this series with those levels of testosterone (>2 ng/ml) or dehydroepiandrosterone sulfate (>7000 ng/ml) that have been widely used to predict the presence of such tumors. Peripheral testosterone levels were less than 2 ng/ml in 50% of our patients, and the dehydroepiandrosterone sulfate level was greater than 7000 ng/ml in only a single patient with an ovarian lipoid cell tumor. Pelvic ultrasonography was found to be of limited value in evaluating nonpalpable tumor because of the small size ( <2 em") of the majority of these neoplasms. The use of selective retrograde venous catheterization to demonstrate significant effluent-peripheral vein androgen gradients served to accurately localize androgen-secreting tumors in all six patients in which it was used. Our data emphasize the potential pitfalls that exist in the preoperative evaluation of patients with these fascinating neoplasms and the importance of a high degree of suspicion on the part of the physician caring for these women. (AM J 0BSTET GYNECOL 1988;158:1313-22.)
International Journal of Gynecology & Obstetrics, 1991
Fifteen gynecologic quality assurance indicators recently published by The American College of Ob... more Fifteen gynecologic quality assurance indicators recently published by The American College of Obstetricians and Gynecologists were applied to a previously reported hysterectomy data base. Chart reviews were performed for the most recent 257 cases in the data base, representing an 18-month interval. The indicators were divided into two groups: those intended to identify morbidity and mortality and those intended to screen for appropriateness of care. Rates of actual morbidity and cases that failed to meet published criteria sets for hysterectomy were determined by chart review regardless of the presence of a quality assurance indicator. A total of 135 indicators were identified in 114 (44%) of the 257 cases, including 64 patients (25%) with morbidity indicators and 50 (19%) with appropriateness indicators. Actual morbidity was correctly identified in all 64 cases in which morbidity indicators were present. Three cases with significant morbidity were identified by chart review but not identified by the indicators, yielding positive and negative predictive values of 100 and 98%, respectively, and an overall accuracy of 99% for morbidity indicators. By contrast, 14 of the 50 cases in which appropriateness indicators were present actually failed to meet published criteria sets. An additional seven cases failing to meet criteria sets were identified by chart review and not identified by the indicators, yielding a positive predictive value of 28%, a negative predictive value of 97%, and an overall accuracy of 83% for appropriateness indicators.
International Journal of Gynecology & Obstetrics, 1990
Treatment of endometriosis with gonadotropin-releasing hormone agonists (GnRH-a) is associated wi... more Treatment of endometriosis with gonadotropin-releasing hormone agonists (GnRH-a) is associated with side effects secondary to the induced hypoestrogenic state. In an effort to ameliorate these symptoms, 10 patients with symptomatic endometriosis self-administered the GnRH-a [D-His6(Imbzl)-Pro9-NET]-GnRH in combination with norethindrone daily for 24 weeks. Painful symptoms were significantly suppressed after therapy (P less than 0.005). Objective review of photographs taken at laparoscopy before and after therapy demonstrated significant reduction of visible implants (P less than 0.005). Vasomotor symptoms were minimized when compared with a group of 16 patients previously treated with GnRH-a alone. Bone mineral density of the distal radius assessed by single photon absorptiometry was not reduced during therapy, although lumbar spine bone density assessed by quantitative computerized tomography was minimally but reversibly reduced. No metabolic derangements were detected. The combination of norethindrone with GnRH-a is a well tolerated and effective means of treating symptomatic endometriosis.
International Journal of Gynecology & Obstetrics, 1993
To determine pregnancy and livebirth rates for women age 40 and older undergoing ovulation induct... more To determine pregnancy and livebirth rates for women age 40 and older undergoing ovulation induction and to assess the impact of basal follicle-stimulating hormone (FSH) on outcome in these patients. Prospective, observational. Fertility service of university medical center. Infertile couples in whom the female partner was age 40 or older referred for ovulation induction therapy. Assessment of basal hormonal status; ovulation induction. Clinical pregnancy rate (PR), livebirth rate. Analysis of 402 cycles in 85 women age 40 and older demonstrated a clinical PR of 3.5% per cycle (95% confidence interval [CI] 1.7% to 5.3%). The livebirth rate was 1.2% per cycle (95% CI 0.1% to 2.3%). Women with a basal FSH &lt; 25 IU/L and age &lt; 44 years had a clinical PR of 5.2% per cycle (95% CI 2.5% to 7.9%) compared with 0.0% per cycle (95% CI 0.0% to 2.1%) in cases in which either basal FSH was &gt; or = 25 IU/L or age was &gt; or = 44 (P &lt; 0.005). The prognostic importance of basal FSH and chronological age was confirmed by multivariate logistic regression analysis. The predictive value of the resulting regression equation was high (R2 = 0.94; P &lt; 0.01). Pregnancy and livebirth rates are generally low during ovulation induction in women age 40 and older. In combination, basal FSH and chronological age are accurate predictors of PR, in these couples and can define a subset of patients with a more favorable prognosis. The spontaneous abortion rate in women who do conceive is high, substantially lowering the livebirth rate.
The role of prostaglandins on the extraction of estradiol (E ) by the rat uterine horn in the pre... more The role of prostaglandins on the extraction of estradiol (E ) by the rat uterine horn in the presence of the intrauterine devic z (IUD) was evaluated.
American Journal of Obstetrics and Gynecology, 1990
A criteria-based quality assurance process for hysterectomy was instituted at a large teaching ho... more A criteria-based quality assurance process for hysterectomy was instituted at a large teaching hospital. After this process was initiated, the overall frequency of hysterectomy decreased by 24%, p less than 0.001. Significant reductions were seen in hysterectomy rates for the following indications: chronic pelvic pain (77%, p less than 0.0001), recurrent uterine bleeding (46%, p less than 0.001), preinvasive disease of the uterus (55%, p less than 0.005), and severe infection (70%, p less than 0.025). Adenomyosis was the single indication for which an increase in hysterectomy rate was observed. This increase, however, was completely reversed during the last 2 years of the study. This quality assurance process also resulted in a significant increase in the histologic verification rate (i.e., 82% vs 93%, p less than 0.001). These observations suggest that using such a criteria-based process can reduce the number of hysterectomies performed and improve the accuracy of the preoperative diagnosis.
To develop recommendations for the medical and surgical care of women who present with chronic pe... more To develop recommendations for the medical and surgical care of women who present with chronic pelvic pain (CPP) and are likely to have endometriosis as the underlying cause. Design: An expert panel comprised of practicing gynecologists from throughout the United States and experts in consensus guideline development was convened. After completion of a structured literature search and creation of draft algorithms by an executive committee, the expert panel of Ͼ50 practicing gynecologists met for a 2-day consensus conference during which the clinical recommendations and algorithms were reviewed, refined, and then ratified by unanimous or near-unanimous votes. Patient(s): Women presenting with CPP who are likely to have endometriosis as the underlying cause. Main Outcome Measure(s): None. Conclusion(s): Chronic pelvic pain frequently occurs secondary to nongynecologic conditions that must be considered in the evaluation of affected women. For women in whom endometriosis is the suspected cause of the pain, laparoscopic confirmation of the diagnosis is unnecessary, and a trial of medical therapy, including second-line therapies such as danazol, GnRH agonists, and progestins, is justified provided that there are no other indications for surgery such as the presence of a suspicious adnexal mass. When surgery is necessary, laparoscopic approaches seem to offer comparable clinical outcomes to those performed via laparotomy, but with reduced morbidity. The balance of evidence supports the use of adjuvant postoperative medical therapy after conservative surgery for CPP. There is some evidence that adjuvant presacral neurectomy adds benefit for midline pain, but currently, there is inadequate evidence to support the use of uterosacral nerve ablation or uterine suspension. Hysterectomy alone has undocumented value in the surgical management of women with endometriosis-associated CPP. (Fertil Steril 2002;78:961-72.
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