Publications by authors named "Jacob Bornstein"

132 Publications

Changes in the Vaginal Microbiota of Women With Secondary Localized Provoked Vulvodynia.

J Low Genit Tract Dis 2022 Aug 5. Epub 2022 Aug 5.

Department of Obstetrics and Gynecology, Hospital Lusíadas Lisboa, Porto, Portugal.

Objective: The etiology of localized provoked vulvodynia (LPV) remains unknown, but observations suggest the involvement of the vaginal microbiota. We examined the vaginal microbiota of women with LPV and healthy controls, upon after a low-oxalate diet (LOD).

Materials And Methods: A total of 9 women diagnosed with secondary LPV and 21 healthy controls were recruited from the Galilee Medical Center in Israel and subjected to prospective evaluations of their vaginal microbiota. Total DNA was extracted from vaginal discharge samples provided before and after following LOD for 3 weeks and was then subjected to 16S sequencing. Data obtained were then used to evaluate α and β diversity, identify differentially abundant bacterial taxa in LPV, and determine their impact on the metabolism.

Results: These evaluations revealed decreased diversity in the vaginal microbiota of women with LPV and identified the Ochrobactrum genus and Pseudomonadaceae family as indicators for LPV. In addition, we identified 23 differentially expressed bacterial metabolic pathways between the LPV and control samples and revealed that LOD could induce changes in the β diversity of LPV vaginal microbiomes, which was further supported by some degree of pain reduction in patients.

Conclusions: Localized provoked vulvodynia and LOD were associated with shifts in the vaginal microbiota. However, the impact of these changes on the development of LPV requires additional studies with a larger cohort.
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http://dx.doi.org/10.1097/LGT.0000000000000689DOI Listing
August 2022

Terminology for cone dimensions after local conservative treatment for cervical intraepithelial neoplasia and early invasive cervical cancer: 2022 consensus recommendations from ESGO, EFC, IFCPC, and ESP.

Lancet Oncol 2022 08;23(8):e385-e392

Imperial College Healthcare NHS Trust, London, UK; Department of Obstetrics and Gynaecology, University Hospital of Ioannina, Ioannina, Greece.

Local cervical treatment for squamous intraepithelial lesion (SIL) or cervical intraepithelial neoplasia (CIN) removes or ablates a cone-shaped or dome-shaped part of the cervix that contains abnormal cells. This Series paper introduces the 2022 terminology for cone dimensions after local conservative treatment for SIL, CIN, or early invasive cervical cancer. The terminology was prepared by the Nomenclature Committee of the European Society of Gynaecologic Oncology, the European Federation for Colposcopy, the International Federation of Cervical Pathology and Colposcopy, and the European Society of Pathology. Cone length should be tailored to the type of transformation zone. Treatment of SIL or CIN is associated with an increased risk of preterm birth, which escalates with increasing cone length. There is a lack of agreement regarding terms used to report excised specimen dimensions both intraoperatively and in the pathology laboratory. Consensus is needed to make studies addressing effectiveness and safety of SIL or CIN treatment comparable, and to facilitate their use to improve accuracy of antenatal surveillance and management. This Series paper summarises the current terminology through a review of existing literature, describes new terminology as agreed by a group of experts from international societies in the field of cervical cancer prevention and treatment, and recommends use of the new terminology that will facilitate communication between clinicians and foster more specific treatment guidelines that balance obstetrical harm against therapeutic effectiveness.
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http://dx.doi.org/10.1016/S1470-2045(22)00191-7DOI Listing
August 2022

Characterization of Early Inflammatory Events Leading to Provoked Vulvodynia Development in Rats.

J Inflamm Res 2022 11;15:3901-3923. Epub 2022 Jul 11.

The Research Institute of Galilee Medical Center, Nahariya, Israel.

Background: Provoked vulvodynia (PV) is the main cause of vulvar pain and dyspareunia. The etiology of PV has not yet been elucidated. However, PV is associated with a history of recurrent inflammation, and its often accompanied by increases in the numbers of mast cells (MCs) and sensory hyperinnervation in the vulva. Therefore, this study aimed to examine the role of MCs and the early inflammatory events in the development of chronic vulvar pain in a rat model of PV.

Methods: Mechanical and thermal vulvar sensitivity was measured for 5 months following zymosan vulvar challenges. Vulvar changes in glutamate and nerve growth factor (NGF) were analyzed using ELISA. Immunofluorescence (IF) staining of the vulvar section after 20, 81, and 160 days of the zymosan challenge were performed to test MCs accumulation, hyperinnervation, and expression of pain channels (transient receptor potential vanilloid/ankyrin-1-TRPV1 & TRPA1) in vulvar neurons. Changes in the development of vulvar pain were evaluated following the administration of the MCs stabilizer ketotifen fumarate (KF) during zymosan vulvar challenges.

Results: Zymosan-challenged rats developed significant mechanical and thermal vulvar sensitivity that persisted for over 160 days after the zymosan challenge. During inflammation, increased local concentrations of NGF and glutamate and a robust increase in MCs degranulation were observed in zymosan-challenged rats. In addition, zymosan-challenged rats displayed sensory hyperinnervation and an increase in the expression of TRPV1 and TRPA1. Treatment with KF attenuated the upregulated level of NGF during inflammation, modulated the neuronal modifications, reduced MCs accumulation, and enhanced mechanical hypersensitivity after repeated inflammation challenges.

Conclusion: The present findings suggest that vulvar hypersensitivity is mediated by MCs accumulation, nerve growth, and neuromodulation of TRPV1 and TRPA1. Hence, KF treatment during the critical period of inflammation contributes to preventing chronic vulvar pain development.
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http://dx.doi.org/10.2147/JIR.S367193DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9286136PMC
July 2022

The European Society of Gynaecological Oncology (ESGO), the International Society for the Study of Vulvovaginal Disease (ISSVD), the European College for the Study of Vulval Disease (ECSVD) and the European Federation for Colposcopy (EFC) Consensus Statements on Pre-invasive Vulvar Lesions.

J Low Genit Tract Dis 2022 Jul 21;26(3):229-244. Epub 2022 Jun 21.

Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, Hacettepe University Faculty of Medicine, Ankara, Turkey.

Abstract: The European Society of Gynaecological Oncology (ESGO), the International Society for the Study of Vulvovaginal Disease (ISSVD), the European College for the Study of Vulval Disease (ECSVD), and the European Federation for Colposcopy (EFC) developed consensus statements on pre-invasive vulvar lesions in order to improve the quality of care for patients with vulvar squamous intraepithelial neoplasia, vulvar Paget disease in situ, and melanoma in situ. For differentiated vulvar intraepithelial neoplasia (dVIN), an excisional procedure must always be adopted. For vulvar high-grade squamous intraepithelial lesion (VHSIL), both excisional procedures and ablative ones can be used. The latter can be considered for anatomy and function preservation and must be preceded by several representative biopsies to exclude malignancy. Medical treatment (imiquimod or cidofovir) can be considered for VHSIL. Recent studies favor an approach of using imiquimod in vulvar Paget's disease. Surgery must take into consideration that the extension of the disease is usually wider than what is evident in the skin. A 2 cm margin is usually considered necessary. A wide local excision with 1 cm free surgical margins is recommended for melanoma in situ. Following treatment of pre-invasive vulvar lesions, women should be seen on a regular basis for careful clinical assessment, including biopsy of any suspicious area. Follow-up should be modulated according to the risk of recurrence (type of lesion, patient age and immunological conditions, other associated lower genital tract lesions).
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http://dx.doi.org/10.1097/LGT.0000000000000683DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9232287PMC
July 2022

The European Society of Gynaecological Oncology (ESGO), the International Society for the Study of Vulvovaginal Disease (ISSVD), the European College for the Study of Vulval Disease (ECSVD) and the European Federation for Colposcopy (EFC) consensus statements on pre-invasive vulvar lesions.

Int J Gynecol Cancer 2022 Jun 21. Epub 2022 Jun 21.

Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, Hacettepe University Faculty of Medicine, Ankara, Turkey.

The European Society of Gynaecological Oncology (ESGO), the International Society for the Study of Vulvovaginal Disease (ISSVD), the European College for the Study of Vulval Disease (ECSVD), and the European Federation for Colposcopy (EFC) developed consensus statements on pre-invasive vulvar lesions in order to improve the quality of care for patients with vulvar squamous intraepithelial neoplasia, vulvar Paget disease in situ, and melanoma in situ. For differentiated vulvar intraepithelial neoplasia (dVIN), an excisional procedure must always be adopted. For vulvar high-grade squamous intraepithelial lesion (VHSIL), both excisional procedures and ablative ones can be used. The latter can be considered for anatomy and function preservation and must be preceded by several representative biopsies to exclude malignancy. Medical treatment (imiquimod or cidofovir) can be considered for VHSIL. Recent studies favor an approach of using imiquimod in vulvar Paget's disease. Surgery must take into consideration that the extension of the disease is usually wider than what is evident in the skin. A 2 cm margin is usually considered necessary. A wide local excision with 1 cm free surgical margins is recommended for melanoma in situ. Following treatment of pre-invasive vulvar lesions, women should be seen on a regular basis for careful clinical assessment, including biopsy of any suspicious area. Follow-up should be modulated according to the risk of recurrence (type of lesion, patient age and immunological conditions, other associated lower genital tract lesions).
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http://dx.doi.org/10.1136/ijgc-2021-003262DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9279839PMC
June 2022

Changes in diagnostic sensitivity, incidence and presentation of complete and partial hydatidiform mole over the years.

Eur J Obstet Gynecol Reprod Biol 2022 Jul 25;274:136-141. Epub 2022 May 25.

Department of Obstetrics and Gynecology, Galilee Medical Cente, Israel; Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel.

Objective: Molar pregnancy is the most common type of gestational trophoblastic disease. Several recent reports have described changes in the clinical representation, the incidence and the diagnostic sensitivity of molar pregnancy. These changes could be due to widespread use of transvaginal ultrasound and beta-hCG testing in the management of routine first-trimester investigations.

Study Design: This is a retrospective study of 144 women diagnosed with partial or complete mole at a regional medical center during 2007-2020. Incidence, demographics, clinical features and diagnostic sensitivity were compared between 2007 and 2014 and 2015-2020, and attempts were made to understand the bases of the changes between the time periods.

Results: Sixty-two moles were diagnosed during 2007-2014 and 82 during 2015-2020. The proportions of complete moles in the respective periods were 65% (40) and 18% (15). From the earlier to the later period, the incidence and proportion of complete moles decreased, and of partial moles, increased. The median gestational age at diagnosis of molar pregnancy was 9.3 weeks. In the later period, women presented less frequently with vaginal bleeding, though this remained the most common presenting symptom. The proportion of women who underwent surgical evacuation of the uterus due to suspected molar pregnancy decreased, as did the proportion of moles that was suspected in ultrasound evaluation (P < 0.001).

Conclusion: The proportion of complete moles decreased between the periods examined. Gestational age at diagnosis was similar to data from 1994 to 2013. Some typical presenting symptoms of molar pregnancy decreased. However, earlier diagnosis of missed abortion can miss diagnoses of molar pregnancy.
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http://dx.doi.org/10.1016/j.ejogrb.2022.05.026DOI Listing
July 2022

Liver stiffness and steatosis in preeclampsia as shown by transient elastography-a prospective cohort study.

Am J Obstet Gynecol 2022 Apr 29. Epub 2022 Apr 29.

Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel; Department of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel. Electronic address:

Background: Preeclampsia is a multisystem disorder and the leading cause of severe morbidity and death in pregnancy. Liver involvement in preeclampsia ranges from elevated liver enzyme levels to hepatic infarction or rupture. Endothelial dysfunction leads to changes in blood flow and congestion and may be involved in the pathophysiology of preeclampsia. Changes in splanchnic blood flow and portal congestion can lead to altered liver stiffness. Transient elastography is a noninvasive, ultrasound-based technique that measures organ stiffness and steatosis and is therefore widely used in clinical hepatology. Previous studies reported elevated liver stiffness and liver steatosis, as measured by transient elastography, in women with preeclampsia.

Objective: This study followed changes in liver stiffness and steatosis, as measured by transient elastography, from the antepartum period to 1-week postpartum among women with preeclampsia compared with healthy controls and evaluated the association between preeclampsia severity and transient elastography results.

Study Design: This prospective cohort study was conducted from 2017 through 2021. The study group comprised women with preeclampsia, and the control group comprised healthy pregnant women hospitalized for other reasons. All the participants underwent transient elastography either on diagnosis of preeclampsia (study group) or on hospital admission (control group) and again in the postpartum period. Liver stiffness measurements are expressed in kilopascals (kPa) in the range of 2.5 to 75 kPa, and liver steatosis is expressed by controlled attenuation parameter in the range of 100 to 400 dB/m.

Results: The study group comprised 36 women and the control group 37. Liver stiffness scores were significantly elevated in the study when compared with the control group, both in the antepartum period (P<.001) and the postpartum period (P=.025). Liver stiffness scores decreased significantly after delivery in the study and control groups (P<.001 and P=.002, respectively). Liver steatosis scores were higher in the study group than in the control group both in the antepartum and postpartum periods (P<.001 and P<.02, respectively). In the multivariable analysis, the diagnosis of preeclampsia correlated with higher antepartum liver stiffness scores (P=.005). For the study group, postpartum liver stiffness and liver steatosis scores were increased among those with vs those without severe features of preeclampsia (P=.03 and P=.04, respectively) CONCLUSION: Reductions in liver stiffness and steatosis from the antepartum to the postpartum period were documented in both the preeclampsia and control groups. However, both these measures were higher in the preeclampsia group and correlated with preeclampsia severity. Larger studies may be able to determine whether transient elastography can predict the severity of preeclampsia or other related metabolic conditions that correlate with chronic hypertension.
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http://dx.doi.org/10.1016/j.ajog.2022.04.048DOI Listing
April 2022

Risk of Development of Vulvar Cancer in Women With Lichen Sclerosus or Lichen Planus: A Systematic Review.

J Low Genit Tract Dis 2022 Jul 11;26(3):250-257. Epub 2022 Mar 11.

Research Institute of the Azrieli Faculty of Medicine, Bar-Ilan University, Galilee Medical Center, Safed, Israel.

Objective: Vulvar lichen sclerosus (VLS) and possibly vulvar lichen planus (VLP) are associated with an increased vulvar cancer (VC) risk. We analyzed the risk of VC and its precursors after a diagnosis of VLS or VLP.

Materials And Methods: A search was performed to identify articles describing the development of vulvar neoplasia in women with VLS or VLP. This systematic review was registered with the PROSPERO database.

Results: Fourteen studies on VLS included 14,030 women without a history of vulvar neoplasia. Vulvar cancer, differentiated vulvar intraepithelial neoplasia (dVIN), and vulvar high-grade squamous intraepithelial lesion occurred in 2.2% (314/14,030), 1.2% (50/4,175), and 0.4% (2/460), respectively. Considering women with previous or current VC, the rate was 4.0% (580/14,372). In one study, dVIN preceded VC in 52.0% of the cases. Progression of dVIN to VC was 18.1% (2/11).The risk was significantly higher in the first 1-3 years after a biopsy of VLS and with advancing age; it significantly decreased with ultrapotent topical steroid use.For the 14,268 women with VLP (8 studies), the rates of VC, dVIN, and vulvar high-grade squamous intraepithelial lesion were 0.3% (38/14,268), 2.5% (17/689), and 1.4% (10/711), respectively.

Conclusions: Vulvar lichen sclerosus is associated with an increased risk of VC, especially in the presence of dVIN and with advancing age. Ultrapotent topical steroids seem to reduce this risk. An increased risk of developing VC has been suggested for VLP. Hence, treatment and regular life-long follow-up should be offered to women with VLS or VLP.
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http://dx.doi.org/10.1097/LGT.0000000000000673DOI Listing
July 2022

Inauguration Editorial.

Authors:
Jacob Bornstein

J Low Genit Tract Dis 2022 04;26(2):105

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http://dx.doi.org/10.1097/LGT.0000000000000658DOI Listing
April 2022

The association between acute lower abdominal pain over a previous caesarean scar and uterine rupture.

J Obstet Gynaecol 2022 Feb 12:1-5. Epub 2022 Feb 12.

Department of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel.

Pregnant women with previous caesarean delivery might suffer from acute lower abdominal pain located at the site of previous caesarean scar (CS). The association between this complaint and uterine rupture (UR) is not fully understood. Therefore, we aimed to examine the risk of UR in women with acute persistent abdominal pain (APAP) over a previous CS and to investigate all the women with UR, with or without APAP and with or without previous CS, in order to determine risk factors, clinical presentation and management. We performed a retrospective analysis on two study groups: women who had APAP over previous CS and women who had UR. We found an incidence of UR in patients with APAP over the previous CS was 0.7%; which doubled the total UR rate among women with previous caesarean in our medical centre (0.35%). Forty percent of the women with APAP over a previous CS had preterm delivery. Twenty percent of the cases of UR occurred in preterm weeks. To conclude, APAP over a previous CS is associated with a doubled risk of UR. Considering this symptom as a preliminary sign of UR might lead to elevated rate of iatrogenic preterm deliveries.Impact statement Women with UR may present with abdominal pain which may vary from non-specific mild discomfort to severe acute abdominal pain. Additionally, these women may suffer from acute persistent abdominal pain (APAP) located over the previous caesarean scar. The clinical significance of APAP in these women has not been fully investigated. Lower abdominal pain located at the site of previous CS is associated with a doubled risk of UR. Considering this complaint as a major sign of UR might lead to an elevated rate of iatrogenic preterm deliveries. Further studies are needed to explore whether women with a single complaint of APAP over CS could be managed expectantly and even offered a trial of labour after caesarean delivery (CD).
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http://dx.doi.org/10.1080/01443615.2022.2027896DOI Listing
February 2022

Vulvodynia: a neuroinflammatory pain syndrome originating in pelvic visceral nerve plexuses due to mechanical factors.

Arch Gynecol Obstet 2022 Feb 11. Epub 2022 Feb 11.

School of Mechanical and Mathematical Engineering, University of Western Australia, 35 Stirling Highway, Perth, WA, 6009, Australia.

This short opinion aimed to present the evidence to support our hypothesis that vulvodynia is a neuroinflammatory pain syndrome originating in the pelvic visceral nerve plexuses caused by the failure of weakened uterosacral ligaments (USLs) to support the pelvic visceral nerve plexuses, i.e., T11-L2 sympathetic and S2-4 parasympathetic plexuses. These are supported by the USLs, 2 cm from their insertion to the cervix. They innervate the pelvic organs, glands, and muscles. If the USLs are weak or lax, gravitational force or even the muscles may distort and stimulate the unsupported plexuses. Inappropriate afferent signals could then be interpreted as originating from an end-organ site. Activation of sensory visceral nerves causes a neuro-inflammatory response in the affected tissues, leading to neuroproliferation of small peripheral sensory nerve fibers, which may cause hyperalgesia and allodynia in the territory of the damaged innervation. Repair of the primary abnormality of USL laxity, responsible for mechanical stimulation of the pelvic sensory plexus, may lead to resolution of the pain syndrome.
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http://dx.doi.org/10.1007/s00404-022-06424-4DOI Listing
February 2022

Intrahepatic cholestasis of pregnancy - prevalence and ethnic distribution in northern Israel.

Ginekol Pol 2022 Jan 24. Epub 2022 Jan 24.

Liver disease Unit, Galilee Medical Center, Nahariya, and Azrieli Faculty of Medicine, Bar Ilan University, Israel.

Objectives: Intrahepatic cholestasis of pregnancy (ICP) is charachterized by pruritis and elevated serum bile acids (BA) and is associated with adverse obstetrical outcomes. ICP etiology is poorly understood and its incidence varies with ethnicity and geographical distribution.

Objectives: Explore the prevalence and characteristics of ICP in the different Northern Israeli ethnic groups and compare maternal and perinatal outcomes according to disease severity.

Material And Methods: Single-center retrospective study. Women who were diagnosed with ICP based on clinical presentation and elevated fasting BA (≥ 10 μmol/L) were included. Disease incidence, maternal and neonatal complications were explored according to ethnic subgroups analysis and obstetrical complications were examined according to disease severity.

Results: The incidence of ICP in the study population was 0.58%. Higher ICP incidence was found in our cohort compared with other reports arising from Central Israel (p < 0.001). The Christian patients had a higher incidence of ICP (1.1%) and preeclampsia (23.1%). A higher rate of neonatal intensive care unit (NICU) admissions was found in the Arab Muslim and Christian groups compared with the Jewish and Druze groups (p = 0.007). A higher rate of preeclampsia was found in the severe (BA ≥ 40 μmol/L) ICP group (p < 0.001). Patients in the severe ICP group had earlier gestational age at delivery (37 versus 38.14 weeks, p < 0.001). Birth weight was significantly lower in the severe ICP group (p = 0.018).

Conclusions: The incidence of ICP at our institution was 0.58%, which is higher compared with previous reported Israeli incidence. Higher ICP and preeclampsia incidence were found among Arab Christian patients.
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http://dx.doi.org/10.5603/GP.a2021.0172DOI Listing
January 2022

A Review of Chronic Pelvic Pain in Women.

JAMA 2021 12;326(21):2207

Azrieli Faculty of Medicine, Bar Ilan University, Nahariya, Israel.

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http://dx.doi.org/10.1001/jama.2021.17983DOI Listing
December 2021

Vulvar High-Grade Squamous Intraepithelial Lesions and Cancer as a Risk Factor for Anal Cancer: A Review.

J Low Genit Tract Dis 2022 01;26(1):32-37

The Kirby Institute, UNSW Sydney, Sydney, Australia.

Objectives: Anal squamous cell carcinoma (ASCC) has a higher incidence described in certain groups, namely, in women with vulvar high-grade squamous intraepithelial lesions (vHSILs) and/or human papillomavirus squamous cell carcinoma (VSCC). This review describes terminology, vHSIL, and VSCC in their association with ASCC and the published recommendations for early detection of this cancer in these women.

Materials And Methods: A narrative review was conducted by the authors on vHSIL and VSCC as risk factors for ASCC.

Results: The ASCC and VSCC incidence are increasing. Women with vHSIL and/or VSCC can present with ASCC at diagnosis, being one of the highest-risk groups. Suspicious symptoms include rectal bleeding, pain, and a sensation of an anal mass. Digital anorectal examination can help detect early ASCC. Sensitivity of anal cytology in women with vHSIL and VSCC seems low, with the exception of immunosuppressed women with genital neoplasia (cervix, vagina, and vulva). There are still insufficient data on high-resolution anoscopy in women with vHSIL and/or VSCC as a screening method.

Conclusions: Clinicians need be aware that women with vHSIL and VSCC comprise one of the highest-risk groups for ASCC. Inquiring suggestive symptoms of ASCC and a digital anorectal examination can help in the early detection of this type of cancer.
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http://dx.doi.org/10.1097/LGT.0000000000000631DOI Listing
January 2022

Coexisting Epithelioid Trophoblastic Tumor and Placental Site Trophoblastic Tumor During Asymptomatic Relapse: A Case Report and Literature Review.

Int J Gynecol Pathol 2022 07 16;41(4):423-430. Epub 2021 Aug 16.

Gestational trophoblastic neoplasms are a group of trophoblastic tumors that include choriocarcinoma (CC), epithelioid trophoblastic tumors (ETTs), and placental site trophoblastic tumors (PSTTs). Mixed gestational trophoblastic neoplasms include combinations of CCs with ETTs and/or PSTTs; combinations of ETTs and PSTTs have also been described. This report describes the case of a 49-yr-old female with mixed ETT and PSTT discovered due to menstrual delay and a positive beta-human chorionic gonadotropin in serum 11 yr after normal pregnancy; it is an asymptomatic recurrence of the neoplasm after 2 yr. Moreover, only the ETT recurred without evidence of PSTT by biopsy and without any increase in human chorionic gonadotropin levels, even though human chorionic gonadotropin was positive in the first onset of the disease. We also reviewed published English literature, which revealed that there are only 36 cases of mixed trophoblastic tumors to date, of which pure mixed ETT and PSTT were reported only in four cases including our case. The most common combination is CC admixed with an ETT (52%), followed by CC with PSTT in 30.5%. CC admixed with an ETT and/or PSTT account for 83% of the cases, of which pure mixed ETT and PSTT were reported only in 4 cases (11%). The rarity of this condition entails reporting of all cases to facilitate future research and clinical management.
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http://dx.doi.org/10.1097/PGP.0000000000000810DOI Listing
July 2022

The Hormonal Milieu by Different Labor Induction Methods in Women with Previous Cesarean Section: a Prospective Randomized Controlled Trial.

Reprod Sci 2021 12 6;28(12):3562-3570. Epub 2021 Jul 6.

Department of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel.

The physiological pattern of hormonal and signaling molecules associated with labor induction is not fully clear. We conducted a preliminary study in order to investigate hormonal changes during labor induction in women with previous cesarean section. Eighty-seven women at term, with previous cesarean section, were randomized to undergo induction of labor by breast stimulation or intracervical balloon and compared with spontaneous labor (controls). Maternal serum levels of oxytocin, prostaglandin F2α, prostaglandin E2, prolactin, estradiol, and cortisol were analyzed at 0, 3, and 6 h post-induction initiation. Fetal umbilical cord hormones were measured. No significant difference was found in the induction-to-delivery time or mode of delivery between the induction groups. Maternal serum oxytocin levels decreased to a lesser extent in the breast stimulation group vs. the control group (p=0.003, p<0.001). In the breast stimulation and control groups, prostaglandin E levels increased as labor progressed (p=0.005, 0.002, respectively). Prostaglandin F2α levels decreased over time in the balloon group (p=0.039), but increased in the control group (p=0.037). Both induction methods had similar outcomes. The hormonal studies ascertained the hypothesized mechanisms, with oxytocin level higher during breast stimulation and lower in balloon induction. These observations could help clinicians determine the appropriate method for cervical ripening in women with previous cesarean section. Larger future studies are needed to examine the effect of these hormonal trends on the rate of successful labor induction and complications, such as uterine rupture, in women with previous uterine scars. ClinicalTrials.gov Identifier NCT04244747.
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http://dx.doi.org/10.1007/s43032-021-00667-3DOI Listing
December 2021

Outcomes of a fixed skeletonised mini mesh implant for pelvic organ prolapse repair with uterine preservation.

J Obstet Gynaecol 2022 Apr 25;42(3):490-493. Epub 2021 Jun 25.

Azrielli Faculty of Medicine in the Galilee, Bar Ilan University, Safed, Israel.

Mesh repair of pelvic organ prolapse (POP) is complicated, causing erosions, postoperative pain and surgical failure. We hypothesised that reducing the mesh size and fixating it would result in significant cure rates and reduce complication rates. Here, we present the effectiveness of mini mesh implants in POP reconstruction. Sixty women who underwent repair of stage III and IV apical prolapse with cystocele or rectocele using skeletonised mesh implant Seratom PA MR MN® were evaluated. Anatomical outcomes were assessed using modified POP-quantification (POP-Q) staging and functional outcomes were self-reported by patients - one and three months post-operatively. Apical support with anterior and/or posterior colporrhaphy was performed, resulting in 96.6% success rate. Follow-up conducted one and three months post-operatively revealed significant improvement on the modified POP-Q ( < .001) and no complaints of dyspareunia. Para-vesicular fixation using a skeletonised mini mesh implant is feasible and effective in POP repair and has low surgical complication risk.Impact Statement Mesh repair for pelvic organ prolapse (POP) is currently under scrutiny as it may result in erosions, postoperative pain, and surgical failure. The use of an apical support with mini-mesh implants resulted in a 96.6% (58/60) success rate and excellent outcomes at 1- and 3-month follow-up. Reconstruction using skeletonised and fixated mini-mesh implants may be safe and effective for POP treatment.
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http://dx.doi.org/10.1080/01443615.2021.1916808DOI Listing
April 2022

Mechanically Supporting Uterosacral Ligaments for the Relief of Provoked Vulvodynia: A Randomized Pilot Trial.

J Pain Res 2021 19;14:1281-1288. Epub 2021 May 19.

Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel.

Purpose: Provoked vulvodynia (PV) is the most common cause of vulvar pain and dyspareunia. Although its etiology is unknown, it has been associated with musculoskeletal dysfunction. The inability of the lax uterosacral ligaments (USLs) to support the adjoining T11/L2 and S2-4 nerve plexuses is considered to cause PV. This study aimed to determine whether providing mechanical support to the USLs would improve PV.

Patients And Methods: PV patients were randomly divided into two groups. The participants in each group underwent sham manipulation (inserting a wide swab in the vagina without applying pressure) and trial manipulation (supporting the posterior fornix with a wide swab sufficiently broad to mechanically support the USLs). This was a cross-over trial, and the participants alternated between the sham and trial manipulation. Using a 0-10 visual analog pain scale (VAS), PV-associated pain levels experienced by participants were recorded during each manipulation, and the results were compared with baseline levels.

Results: The pain level significantly reduced with USL support compared with the baseline value and the sham manipulation pain level (P = 0.003). Pain during sham manipulation was not significantly different from that recorded at baseline. The average reduction in pain with USL support was 18.4% ± 2.2%. The manipulation order did not affect changes in the pain level during trial manipulation (P = 0.512).

Conclusion: Applying mechanical support to the posterior fornix temporarily alleviates provoked vulvar pain in some women.
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http://dx.doi.org/10.2147/JPR.S296613DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8141612PMC
May 2021

Compliance with a new quality standard regarding administration of prophylactic antibiotics before cesarean section.

J Matern Fetal Neonatal Med 2021 Apr 25:1-7. Epub 2021 Apr 25.

Department of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel.

Objective: Administering prophylactic antibiotics before cesarean section (CS) decreases postpartum infections significantly. They should be administered within 60 min prior to CS. In 2014 the Israeli Ministry of Health introduced the administration of pre-operative antibiotic prophylaxis for CS as a quality criterion. This was immediately adopted by the Galilee Medical Center (GMC). This study aimed to examine the compliance to this quality standard in the GMC under 3 criteria: the type of antibiotics, timing of administration, and use of one dose only.

Study Design: Data of women who underwent CS from the day of introducing the new quality standard on January 1, 2014, to July 31, 2015, were retrospectively analyzed.

Results: The study included 1790 women who delivered by elective (24.4%) or emergency CS. In general, the medical staff's compliance to this quality standard was 90.9; 95.6% of the patients received the correct antibiotic, 94.6% had it within 65 min before surgery to 5 min after it, and 100% received it in less than 24 h. There was an increase in the overall compliance rate with time (logistic regression,  = .001). During the day shift, 60.4% of CS were emergency surgeries while during the on-call shift (evening and night) almost all (99%) of the CS were emergencies ( < .001, 2-sided). In morning shift's emergency CS, only 4.1% of the cases were not given prophylactic antibiotics as against 7.8% in the on-call shift ( = .005).

Conclusion: Over a period of 18 months, the compliance to the new quality standard of administering prophylactic antibiotics before CS was 90.9%. It was particularly high in the subgroup of elective CS during the morning shift. This high compliance rate may be attributed to the introduction of clear guidelines and assignment of a specific team member, the anesthesiologist, to administer the medication.Key pointsCompliance rate to the guideline was 90.9%.Compliance was better in the morning shift.Compliance was better for elective cesarean section.Compliance was not affected by time.
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http://dx.doi.org/10.1080/14767058.2021.1910659DOI Listing
April 2021

Early planned labor induction vs expectant management in late preterm pre-labor rupture of membranes: maternal and neonatal outcomes.

Ginekol Pol 2021 12;92(7):498-504. Epub 2021 Apr 12.

The Azrieli faculty of Medicine, Bar-Ilan University, Safed, Israel.

Objectives: To compare expectant management with early planned labor induction in pregnancies complicated by late preterm pre-labor rupture of membranes (PPROM).

Material And Methods: A retrospective file review was conducted in a single tertiary center from January 2015 to Sep-tember 2019. Singleton pregnancies complicated by late PPROM at 34-36 completed weeks of gestation were enrolled. We compared maternal and neonatal complications between expectant management and early planned labor induction.

Results: We retrospectively assigned 41 women to the expectant management group and 39 to the early planned labor induction group. No difference was found in the mode of delivery between the groups. Women in the expectant manage-ment group had a longer antepartum hospital stay compared with the induction group (median of three versus one day, p < 0.01). Neonates were delivered at a more advanced gestational age in the expectant management group compared with that in the induction group (35 5/7 versus 35 2/7 weeks, p < 0.01). In the induction group, 74.4% of the neonates were admitted to the intensive care unit (ICU), and 66.7% received antibiotics compared with 51.2% of neonates admitted to ICU and 29.3% receiving antibiotics in the expectant management group (p = 0.04 and p < 0.01, respectively).

Conclusions: In pregnancies complicated by late PPROM, early labor induction was associated with a shorter antepartum maternal hospital stay but a higher neonatal ICU admission rate and more frequent antibiotic administration than expect-ant management. We consider expectant management to be an acceptable alternative to early labor induction in PPROM.
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http://dx.doi.org/10.5603/GP.a2021.0038DOI Listing
March 2022

A possible association between hydatidiform mole and the COVID-19 pandemic: A retrospective cohort study.

Gynecol Oncol 2021 05 5;161(2):454-457. Epub 2021 Mar 5.

Department of Obstetrics and Gynecology, Galilee Medical Centre, Nahariya, Israel; Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel. Electronic address:

Objective: To confirm an increase in the number of women with molar pregnancy during the COVID-19 pandemic.

Methods: In this retrospective cohort study, all patients with complete or partial mole diagnosed at our institution between January 1, 2010 and October 31, 2020, were included. To verify whether there was an increase in the incidence of hydatidiform mole (HM) and deliveries in 2020, the incidences for each year from January 2010 to October 2020 were recorded. In addition, we identified all women who were diagnosed with HM from January to October 2020, and compared them with a control group who underwent uterine evacuation for missed abortion of a singleton pregnancy during the same period. We also documented the time taken to diagnose missed abortion or molar pregnancy to check if a delay in diagnosis can explain the increase in HM incidence.

Results: Between 2016 and 2019, there was a statistically significant increase in the incidence of molar pregnancy. A further increase occurred in 2020 (odds ratio = 2.071). The mean gestational age of the embryo at the time of diagnosis was smaller in the HM group than in the missed abortion group (6.3 ± 1.67-7.4 ± 2.4, one-sided P = 0.034), meaning that it took more time (days) to diagnose molar pregnancy than missed abortion (22.38 ± 10.32 vs. 15.83 ± 7.83 days, P = 0.012).

Conclusion: There was a significant increase in the incidence of molar pregnancy during the COVID-19 pandemic, possibly because of the delay in receiving medical care. We recommend providing gynecological primary care services during a crisis, such as a pandemic.
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http://dx.doi.org/10.1016/j.ygyno.2021.02.035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7934616PMC
May 2021

Vertical Transmission of Extended-Spectrum, Beta-Lactamase-Producing during Preterm Delivery: A Prospective Study.

Microorganisms 2021 Feb 27;9(3). Epub 2021 Feb 27.

Department of Obstetrics and Gynecology, Galilee Medical Center, 22100 Nahariya, Israel.

Maternal carriage and vertical transmission of extended-spectrum, beta-lactamase-producing (ESBL-E), such as , hamper the treatment of infections, resulting in high morbidity. is the most frequent cause of early-onset neonatal sepsis (EOS) in preterm infants, where ESBL-E are more frequently isolated. In this prospective, case-controlled study, maternal rectovaginal ESBL-E colonization and vertical transmission to preterm infants were assessed in 160 women with preterm premature rupture of membranes (PPROM; 57.4%) or preterm labor (42.6%); additional cultures were obtained from the placenta, amnion, and umbilical cord during preterm labor. Maternal and neonatal ESBL-E-carriage rates were 17.5% and 12.9%, respectively, and the vertical-transmission rate was 50%. Maternal ESBL-E colonization among women with PPROM was 21.3%, and in women with premature labor it was 12.6%. No correlation was observed between maternal ESBL-E-colonization and previous hospitalization or antibiotic administration during pregnancy. However, a correlation was found between placental inflammation and maternal ESBL-E colonization ( = 0.007). ESBL-E-colonized infants were delivered at an earlier gestational age and were more likely to have complications. Thus, the high ESBL-E carriage rate in women with threatened preterm labor, without obvious risk factors for carriage, and a high vertical transmission rate, combined with a correlation between placental inflammation and ESBL-E carriage, support maternal-neonatal ESBL-E-colonization surveillance and active measures to prevent ESBL-E-related EOS.
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http://dx.doi.org/10.3390/microorganisms9030506DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7997221PMC
February 2021

Long-Term Efficacy of Physical Therapy for Localized Provoked Vulvodynia.

Int J Womens Health 2021 10;13:161-168. Epub 2021 Feb 10.

Department of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel.

Purpose: The origin of provoked vulvodynia (PV), the main cause of entry dyspareunia, remains unclear, and the treatment is empiric. In this study, we aimed to investigate the long-term effects of physical therapy on PV in subjects using questionnaire concerning PV symptoms immediately after physical therapy and at least 10 years later.

Patients And Methods: This study included a total of 24 women diagnosed with PV and referred by their primary physicians to Maccabi Physical Therapy Clinic for pelvic floor rehabilitation between 2004 and 2008. Criteria such as pain relief, sexual functioning, and treatment satisfaction were assessed.

Results: The average pain scores of the 24 participants reduced significantly after therapy, and 42% had no pain between treatment and the time of survey. Eighty-three percent did not undergo additional treatment after the initial physical therapy and reported high or very extremely high levels of pain reduction following treatment. Multiple regression analysis found that onset type of PV and age were not associated with the treatment outcome (p = 1.0).

Conclusion: Physical therapy is an effective long-term treatment for primary or secondary PV, resulting in pain reduction and improved sexual function.
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http://dx.doi.org/10.2147/IJWH.S297389DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7882794PMC
February 2021

Three-Year Follow-up of 2-Dose Versus 3-Dose HPV Vaccine.

Pediatrics 2021 01 22;147(1). Epub 2020 Dec 22.

Merck & Co, Inc, Kenilworth, New Jersey

Background And Objectives: Human papillomavirus (HPV) antibody responses to the 9-valent human papillomavirus (9vHPV) vaccine among girls and boys (aged 9-14 years) receiving 2-dose regimens (months 0, 6 or 0, 12) were noninferior to a 3-dose regimen (months 0, 2, 6) in young women (aged 16-26 years) 4 weeks after last vaccination in an international, randomized, open-label trial (NCT01984697). We assessed response durability through month 36.

Methods: Girls received 2 (months 0 and 6 [0, 6]: = 301; months 0 and 12 [0, 12]: = 151) or 3 doses (months 0,2, and 6 [0, 2, 6]: = 301); boys received 2 doses ([0, 6]: = 301; [0, 12]: = 150); and young women received 3 doses ([0, 2, 6]: = 314) of 9vHPV vaccine. Anti-HPV geometric mean titers (GMTs) were assessed by competitive Luminex immunoassay (cLIA) and immunoglobulin G-Luminex immunoassay (IgG-LIA) through month 36.

Results: Anti-HPV GMTs were highest 1 month after the last 9vHPV vaccine regimen dose, decreased sharply during the subsequent 12 months, and then decreased more slowly. GMTs 2 to 2.5 years after the last regimen dose in girls and boys given 2 doses were generally similar to or greater than GMTs in young women given 3 doses. Across HPV types, most boys and girls who received 2 doses (cLIA: 81%-100%; IgG-LIA: 91%-100%) and young women who received 3 doses (cLIA: 78%-98%; IgG-LIA: 91%-100%) remained seropositive 2 to 2.5 years after the last regimen dose.

Conclusions: Antibody responses persisted through 2 to 2.5 years after the last dose of a 2-dose 9vHPV vaccine regimen in girls and boys. In girls and boys, antibody responses generated by 2 doses administered 6 to 12 months apart may be sufficient to induce high-level protective efficacy through at least 2 years after the second dose.
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http://dx.doi.org/10.1542/peds.2019-4035DOI Listing
January 2021

Intrauterine bacterial growth in elective and non-elective caesarean sections.

J Obstet Gynaecol 2021 Jul 12;41(5):733-738. Epub 2020 Oct 12.

Department of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel.

We assessed intrauterine bacterial growth for elective and non-elective caesarean sections (CSs). Aerobic uterine cultures were obtained from the uterine cavity immediately following placental removal from 1376 patients who underwent CS in one center during one year. About 13.8% (115/832) of elective CS were positive vs. 55.9% (304/544) of non-elective CS ( < .001). Of non-elective CSs, 28.6% (56/196) of those without ruptured membranes (ROM) were positive vs. 71.3% (248/348) with ROM ( < .001). Mean birth weight and 1-minute Apgar scores were significantly lower in women with positive cultures, elective and non-elective, than negative cultures. A higher percentage of women with positive uterine cultures presented with postpartum endometritis ( < .05). Intrauterine bacteria in elective CSs demonstrate that the uterine cavity is not sterile. Non-elective CS, particularly after membrane rupture, is a significant risk factor for positive uterine culture. Positive uterine culture is associated with lower birth weight, lower one-minute Apgar score and postpartum endometritis.Impact statement Postpartum endometritis is a leading cause of postpartum febrile morbidity. Caesarean sections, in particular non-elective cesareans, are an important risk factor for the development of postpartum endometritis. Controversy exists concerning the sterility of the placenta and uterus. The diagnosis of endometritis is based mainly on clinical findings and does not necessitate bacterial isolation from the uterine cavity. Positive culture at caesarean section has been associated with positive postoperative culture and yet, currently, professional organisations do not recommend the routine sampling of intrauterine cultures during caesarean section. Since positive uterine culture rate was higher in non-elective CSs and associated with lower birth weight and 1-minute Apgar score and postoperative endometritis, obtaining uterine culture in those cases might be of clinical value. Obtaining routine intrauterine cultures during non-elective caesarean sections might be useful for detecting significant pathogens and tailoring antibiotic treatment in postpartum endometritis. Further studies are necessary in order to determine the impact of obtaining intrauterine cultures during caesarean sections, particularly non-elective cesareans.
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http://dx.doi.org/10.1080/01443615.2020.1789959DOI Listing
July 2021

Dehiscence of cesarean section scar during pregnancy and delivery - risk factors.

Ginekol Pol 2020;91(9):539-543

Galilee Medical Center, Nahariya, Israel.

Objective: We wanted to identify risk factors for dehiscence of cesarean section (CS) scars in patients undergoing repeated cesarean section.

Material And Methods: This was a retrospective case-control study over a 3-year period in our medical center (2011-2014), comparing women who had repeated CS without complications and women diagnosed with dehiscence. Data were collected from medical records and the groups were compared for demographic and obstetrical data.

Results: Dehiscence was identified in 27 women, while 54 women without dehiscence were the control group. Statistically significant differences were found in the need for augmentation, the number of previous cesarean sections, cesarean section in the active phase of labor and length of hospitalization.

Discussion: The need for augmentation of labor, CS in the nonactive stage and more than one cesarean section, all increased the risk of dehiscence. There was no association between dehiscence and scar pain, time elapsed since the previous cesarean section, the method of wound closure or fever.
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http://dx.doi.org/10.5603/GP.2020.0086DOI Listing
October 2021

Cervical traction suture technique during large loop excision of the transformation zone increases complete lesion excision.

J Gynecol Obstet Hum Reprod 2021 Jun 14;50(6):101904. Epub 2020 Sep 14.

Department of Obstetrics & Gynecology, Galilee Medical Center and Bar-Ilan University Faculty of Medicine, Nahariya, Israel. Electronic address:

Purpose: A surgical technique was developed in the past by our group to reduce the rate of inadvertent complications. It was then seemed that it also increased the rate of complete lesion excision. The objective of the study was to evaluate the effectiveness of a cervical traction suture technique in increasing the prevalence of complete lesion excisions and reducing the incidence of unintended injuries to adjacent tissues during large loop excision of the transformation zone (LLETZ).

Basic Procedures: A retrospective cohort study, including all consecutive patients who underwent LLETZ between January 2016 and June 2018, at the outpatient Colposcopy clinic of a general hospital in Galilee Medical Center. We divided patients into two groups based on whether their LLETZ utilized the cervical traction suture technique. We compared these two groups using an independent-samples t test, and we compared the study-specific proportions to those reported in the literature using the proportion test.

Main Findings: A total of 66 patients were included in the analysis; 33 had undergone LLETZ with a traction suture, and 33 had undergone LLETZ without a traction suture. The prevalence of complete lesion excision was 93.3 % among patients undergoing LLETZ with a traction suture and 72.7 % among those without a traction suture (p = 0.04). The incidence of unintentional injuries to adjacent organs was 12.1 % in women with a traction suture and 18.2 % in women without a traction suture (p = 0.73).

Principal Conclusions: Using a cervical traction suture along with LLETZ can increase the rate of complete lesion excision and may reduce the prevalence of unintended injuries.
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http://dx.doi.org/10.1016/j.jogoh.2020.101904DOI Listing
June 2021

Clarification about vulvar cancer precursor lesions.

J Gynecol Obstet Hum Reprod 2021 03 17;50(3):101890. Epub 2020 Aug 17.

Obstetrics and Gynecology Department, Galilee Medical Center, Nahriya, Israel; Azrieli Faculty of Medicine, Bar Ilan University, Ramat Gan, Israel. Electronic address:

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http://dx.doi.org/10.1016/j.jogoh.2020.101890DOI Listing
March 2021

Is There a Place for the Introduction of Colposcopy Quality Standards?

J Low Genit Tract Dis 2020 Oct;24(4):375-380

Department of Statistics, Galilee Medical Center, Nahariya, Israel.

Objectives: The aims of the study were to examine the degree of compliance with international quality measures for colposcopy in Israel, which does not currently have formal guidelines and to compare the achievement of quality measures between clinical settings.

Methods: This is a retrospective cohort study, in a hospital, a community clinic, and 2 private colposcopy clinics in Israel, including women aged 18-70 years presenting for colposcopy after abnormal Pap results. Compliance was compared between clinical sites regarding 6 international standards: documentation of reason for referral, type of transformation zone, biopsy location, and grade; proportion of women with high-degree cytological abnormalities (atypical squamous cells - cannot exclude high grade squamous intraepithelial lesion and above) receiving a colposcopy within 4 weeks; and the positive predictive value of colposcopy to detect cervical intraepithelial neoplasia 2 and above.

Results: Documentation of reason for referral (1.3% of target), transformation zone type (22.6% of target), biopsy location (18% of target), and lesion grade (31% of target) all failed to meet international standards, as did the proportion of patients with high-degree cytological abnormalities who underwent colposcopy within 4 weeks (32.9% of the target). The positive predictive value of colposcopy exceeded standards (30% above target). Differences existed between clinical settings.

Conclusions: In Israel, there is a considerable shortfall in performance and documentation of most international quality measures for colposcopy. Quality measures for cervical examinations and colposcopy should be considered for inclusion in the National Program for Quality Measures.
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http://dx.doi.org/10.1097/LGT.0000000000000557DOI Listing
October 2020

Evaluation of Long-Term Surgical Success and Satisfaction of Patients After Vestibulectomy.

J Low Genit Tract Dis 2020 Oct;24(4):399-404

Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel.

Objective: Vestibulectomy is one of the only proven therapeutic treatments for provoked vulvodynia (PVD). However, little is known about long-term surgical success.

Methods: Patients who underwent vestibulectomy between 1991 and 2003 were interviewed to assess frequency of intercourse and degree of pain during various activities, as well as satisfaction with and willingness to recommend the surgery. We also examined the outcome relation to PVD type being primary or secondary. Differences in pain over time were assessed using a paired-sample t test or a Wilcoxon signed-rank test.

Results: Of 85 eligible patients, 50 (59%) were contacted and 32 (38%) participated. All underwent vestibulectomy 12-24 years prior by the same surgeon. All experienced sexual intercourse without pain at some point after surgery (median = 4 months). Penetration pain averaged 9.13 (scale = 0-10) before surgery and dropped to 0.47 at the time of follow up (p < .001). Other activities that were reported as painful before surgery also improved significantly. No patients reported worsening of pain over time; 87.5% were able to engage in sexual intercourse immediately after the recovery period, and 97% were able to do so at the time of follow up. Ninety-four percent of respondents were highly satisfied, 97% would undergo the surgery again, and 100% would recommend it to others. The type of PVD was unrelated to treatment outcome (p = .297).

Conclusions: Vestibulectomy is an excellent treatment for PVD and has successful long-term outcomes.
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http://dx.doi.org/10.1097/LGT.0000000000000552DOI Listing
October 2020
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