Use Of Speculum Research Articles

ICTP concentration in cervical-vaginal fluid as a potential marker of membrane collagen degradation before labor.

Numerous physical and chemical processes lead to rupture of membranes. Within the fetal membranes there are numerous types of metalloproteinases, which cause collagen type I degradation. The C-terminal telopeptide of colagen type I (ICTP) is the breakdown product of type I collagen. The aim of the study was to determine whether ICTP is secreted into the vaginal-cervical fluid (VCF) in the case of physiological rupture of the membranes of the fetus before delivery. The study was conducted in March 2021 at the Department of Obstetrics and Perinatology of the Jagiellonian University in Cracow, Poland. Twenty-three cases were included in the study. During routine gynecological examination with the use of specula, VCF was collected twice in a volume of 50 µL. The obtained material was then subjected to enzyme immunoassay using the Human C-telopeptide of type I collagen (ICTP) ELISA Kit (Catalog Number. CSB-E10363h). The concentration of ICTP in the sample was calibrated. The concentration range that the device can detect was 25 ng /mL-800 ng/mL. The presence of ICTP in the VCF was confirmed. The minimum concentration was 43.72 ng/mL, the maximum was 762.59, in five cases the concentration was outside the maximum scale of the device. ICTP was confirmed in the VCF of pregnant women before physiological delivery. Further studies are required to accurately evaluate ICTP as a marker of the processes of collagen degradation in fetal membranes in the mechanism of physiological labor and premature rupture of the membranes.

Incidence of Blepharoptosis Following Intravitreal Anti–Vascular Endothelial Growth Factor Injections

PurposeWe aimed to determine the incidence of blepharoptosis following intravitreal anti-vascular endothelial growth factor (VEGF) injections and compare the rates of blepharoptosis between patients injected with an eyelid speculum and those injected without a speculum. DesignRetrospective cohort study MethodsInternational Classification of Diseases (ICD-10) was used to identify patients with exudative age-related macular degeneration (AMD) and those who developed ptosis following intravitreal injections. Patients with nonexudative AMD who did not receive intravitreal injections served as control. The outcomes were the incidence of ptosis in the injection group compared to the non-injection group and incidence of ptosis in patients whose injections were performed with an eyelid speculum as compared to those whose injections were performed without specula. ResultsWe recruited 1,100 exudative AMD patients who received at least one intravitreal anti-VEGF injection and 2,258 nonexudative AMD patients who had not received an injection. In the injection group, 18 out of 1100 patients (1.6%) developed ptosis, compared to 52 out of 2258 patients (2.3%) in the non-injection group (p=0.25). Within the injection group, ptosis was mostly bilateral, diagnosed on average 22.4 months following the initial injection, and following more than a one-year injection-free period. 11 out of 537 patients (2.0%) injected without a speculum developed ptosis, compared to 8 out of 444 patients (1.8%) injected with a speculum (p= 0.82). ConclusionsNo statistically significant differences in incidence rates of ptosis were observed. In this analysis, neither intravitreal anti-VEGF injections nor speculum use during injections appears to increase the risk of ptosis.

The MODIFICATION OF IVA TEST PROPS TO PERFORM CERVIX CANCER EARLY DETECTION SKILLS

Background: The competence area that must be had by midwives is clinical skills in midwifery practice on women's reproductive health and sexuality services where midwife graduates must be able to know early detection, complications, and problems of women's reproductive health and sexuality. Phantom which is commonly used in IVA examination practice in the laboratory uses phantom that cannot describe the results of the examination interpretations. The phantom used only teaches the use of speculum and cannot show Squamo-columnar junction (SCJ), so it is necessary to develop a tool that can be used to perform IVA tests that can show portio before and after acetic acid. Research Objective: modify and utilize phantoms that are no longer feasible in a new teaching tool for the IVA Test practicum and test the feasibility of the developed tools. Method: This research is a development research that produces products with the One Shot Case Study method. Results: From the 35 respondents who participated in the field trial, the total questionnaire score obtained was 6,949 with a total ideal maximum score of 7,350. The percentage of eligibility obtained is 95%. Conclusion : Modification of IVA test examination props is Very Feasible to be used as IVA test props to perform cervix cancer early detection skills in a comprehensive application-based obstetric laboratory. It is recommended for all PLP in Indonesia to be able to develop creative and innovative ideas and ideas in the laboratory in utilizing teaching aids that are no longer suitable for use into new tools that increase the use value and benefits to support learning in the laboratory

Ultrasound-guided transvaginal biopsies of pelvic lesions: diagnostic yield, safetyprofile, and technical considerations over a 20-year experience.

To evaluate diagnostic yield, safety profile, and specific technical considerations of transvaginal ultrasound (TVUS) guided biopsy/aspiration. TVUS guided biopsy (core, FNA) procedures with pre-procedure CT/MRI imaging at a single institution between 2001 and 2021 were reviewed. Relevant patient demographic data was extracted via the Electronic Health Record (EMR), technical details of the biopsy procedure were collected, and distance to target via transvaginal and transabdominal biopsy approach was measured on pre-procedure imaging. Surgical pathology was reviewed and assessed for concordance. Complications were assessed. Statistical analysis was performed using SPSS. 96 TVUS procedures (mean age, 58.7 ± 15.2years; mean BMI, 27.4) were reviewed. TVUS guided approach decreased the distance to target (mean, 1.1cm vs 8.6cm transabdominal; p < 0.0001) and created a safe path not otherwise available in two patients. Average lesion size was 4.0 ± 2.1cm (IQR 2.5, 5.2cm) and targets at or above the vaginal cuff (0.9 ± 1.5cm) and up to 0.5 ± 1.0cm above the acetabular roof were accessible. 75 (78%) cases were core biopsies (18G; median, 2 passes) and 21 were FNA. Conscious sedation was used in 84.4% (n = 81) of cases and local anesthetic was also used in 84.4% (n = 81) of cases. Overall diagnostic yield was 98.9% (n = 94) with 94.7% (n = 89) cases confirmed as concordant diagnoses, including 57.4% (n = 54) malignant. Complications occurred in eight patients (8.3%), all minor. No post-biopsy infections were encountered regardless of administration of pre-procedure antibiotics (n = 14, 14.6%,), documentation of sterile prep (n = 92, 95.8%), or speculum use (n = 19, 19.8%). 50% (n = 48) had a prior hysterectomy, with no association with adequacy or complications (p = 0.9). Transvaginal biopsy of pelvic lesions offers excellent diagnostic yield and favorable safety profile, and can dramatically decrease distance to target. Ultrasound-guided transvaginal approach offers a safe and effective way to biopsy pelvic lesions in women.

Endophthalmitis prophylaxis in cataract surgery and intravitreal injection in the US

AbstractEndophthalmitis is not a “never event” following cataract surgery or intravitreal injection, therefore the occurrence of endophthalmitis does not necessarily imply a break in technique or that the surgeon somehow “did something wrong”. Endophthalmitis cannot be prevented, but its rate can be reduced using evidence‐based measures. Endophthalmitis prophylaxis techniques include more than the use of antibiotics; specifically, prep/drape, speculum use, wound construction, etc.In the US, intracameral antibiotics are not universally used. The decision to use routine intracameral antibiotics appears to depend on many “non‐medical” factors, including internal health system policies, local standards of care, and other concerns. In the US, there is no packaged antibiotic that is specifically approved for intracameral use so all such agents are used “off‐label”; this factor appears to be suppressing the use of intracameral antibiotics at least in some locations.In the US, intravitreal injections are almost always performed in the clinic rather than in an operating room or similar setting. (In fact, it can be difficult to get reimbursed for anti‐VEGF drugs injected in an operating room.) Many practices use a standard examination room rather than a minor procedure room or a room dedicated to performing injections. Eyelid speculums are very widely used, although there is a growing acceptance of the use of bimanual retraction from a skilled assistant, rather than an eyelid speculum. In many practices, topical antibiotics are not used.It is the author's opinion (although there is little or no evidence from randomized clinical trials to support this opinion) that post‐surgical endophthalmitis differs from post‐injection endophthalmitis in how the microorganisms gain access to the intraocular space. Following cataract surgery, it seems most likely that microorganisms enter the eye through the incision in the postoperative period; this would explain the relatively later onset of infection, as well as the apparent benefits of postoperative topical antibiotics, proper wound construction, and suturing the incision when necessary. Following intravitreal injection, it seems most likely that microorganisms enter the eye at the moment of the injection; this would explain the relatively sooner onset of infection, as well as the apparent lack of benefit of postoperative topical antibiotics.

Avoiding use of lid speculum and indentation reduced infantile stress during retinopathy of prematurity examinations.

To study the safety and efficacy of indirect ophthalmoscopy with (Sp) or without (speculum free, SpF) the use of lid speculum and scleral indentation for retinopathy of prematurity (ROP) screening. In this crossover randomized controlled trial, preterm infants received either the Sp on their first and the SpF technique on their second examination a week later or vice versa. Video recordings of the infants' reactions were assessed by two observers, using Premature Infant Pain Profile-Revised score and the crying score of the Bernese Pain Scale for Neonates. Fundoscopy adequacy, its duration and adverse events within the first 24 hr postscreening were also recorded. Thirty-seven infants with median (interquartile range) gestational age of 28.7 (28.0, 30.2) weeks and mean (standard deviation, SD) birth weight 1225 (377) grams were enrolled. The mydriasis-induced stress was similar between the Sp and SpF exam (mean difference [MD]: 0.78, 95% confidence interval [CI]: -0.83, 2.38; p = 0.33). The stress induced by fundoscopy (MD: 4.98, 95% CI: 3.58, 6.37; p < 0.001) and examination overall (MD: 2.32, 95% CI: 0.96, 3.67; p = 0.001) were higher in the Sp than in the SpF exam, and so was the crying score during fundoscopy (MD: 1.31, 95% CI: 1.06, 1.56; p < 0.001). Adverse events in the two groups were similar (p = 0.13). Fundoscopy was adequate in identifying the absence of treatment-requiring ROP in all cases, and lasted longer in the Sp than in the SpF exam (p < 0.001). Our study suggests that the use of speculum and indentation should be reserved for the few cases where fundus visualization is insufficient for excluding the presence of severe ROP.

Non-speculum sampling approaches for cervical screening in older women: randomised controlled trial.

BackgroundCervical cancer disproportionately affects women ≥65 years, especially those not screened regularly. Speculum use is a key barrier.AimTo assess if offering non-speculum clinician-taken sampling and self-sampling increases uptake for lapsed attenders aged 50–64 years.Design and settingPragmatic randomised control trial conducted at 10 general practices in East London, UK.MethodParticipants were 784 women aged 50–64 years, last screened 6–15 years before randomisation. Intervention participants received a letter offering the choice of non-speculum clinician- or self-sampling. Control participants received usual care. The main outcome measure was uptake within 4 months.ResultsScreening uptake 4 months after randomisation was significantly higher in the intervention arm: 20.4% (n = 80/393) versus 4.9% in the control arm (n = 19/391, absolute difference 15.5%, 95% confidence interval [CI] = 11.0% to 20.0%, P<0.001). This was maintained at 12 months: intervention 30.5% (n = 120/393) versus control 13.6% (n = 53/391) (absolute difference 17.0%, 95% CI = 11.3% to 22.7%, P<0.001). Conventional screening attendance within 12 months was very similar for both intervention 12.7% (n = 50/393) and control 13.6% (n = 53/391) arms. Ethnic differences were seen in screening modality preference. More White women opted for self-sampling (50.7%, n = 38/75), whereas most Asian and Black women and those from other ethnic backgrounds opted for conventional screening.ConclusionOffering non-speculum clinician-taken sampling and self-sampling substantially increases uptake in older lapsed attendee women. Non-speculum clinician sampling appeals to women who dislike the speculum but still prefer a clinician to take their sample. Providing a choice of screening modality may be important for optimising cervical screening uptake.

Predictors of Endophthalmitis after Intravitreal Injection: A Multivariable Analysis Based on Injection Protocol and Povidone Iodine Strength

To determine the incidence of endophthalmitis after anti-vascular endothelial growth factor (VEGF) therapy at our institution and to identify potential risk factors for endophthalmitis occurring after injection. Retrospective, single-center cohort study. All patients who received an intravitreal injection of an anti-VEGF medication between January 1, 2014, and March 31,2017. Current Procedural Terminology and International Classification of Diseases billing codes were used to identify instances of anti-VEGF administration and cases of endophthalmitis. Medical records and injection technique were reviewed carefully in each case. Multivariable logistic regression analysis was performed in a stepwise fashion to determine independent predictors of endophthalmitis based on injection protocol. Incidence of endophthalmitis after injection and odds of endophthalmitis by injection technique with 95% confidence intervals (CIs). A total of 154 198 anti-VEGF injections were performed during the period of interest, resulting in 58 cases of endophthalmitis (0.038% [1:2659]). After adjustment for confounders, both 2% lidocaine jelly (odds ratio [OR], 11.28; 95% CI, 3.39-37.46; P < 0.001) and 0.5% Tetravisc (Ocusoft, Richmond, TX; OR, 3.95; 95% CI, 1.15-13.50; P= 0.03) use were independent risk factors for endophthalmitis after injection. Lid speculum use, povidone iodine strength (5% vs. 10%), injection location (superior or inferior), conjunctival displacement, use of provider gloves, use of a strict no-talking policy, use of subconjunctival lidocaine, and topical antibiotic use were not statistically significant predictors of endophthalmitis after injection. There was no difference in endophthalmitis rate among the anti-VEGF agents (bevacizumab, ranibizumab 0.3 mg, ranibizumab 0.5 mg, and aflibercept). The incidence of endophthalmitis after anti-VEGF injections is low. Use of lidocaine jelly or Tetravisc may increase the risk of endophthalmitis after injection.

Does medical students’ gender affect their clinical learning of gynaecological examination? A retrospective cohort study

IntroductionMedical graduates should be competent in gynaecological examination as well as associated skills including speculum use and swabbing. Male and female medical students may have different opportunities to practise these...

Timing of Povidone–Iodine Application to Reduce the Risk of Endophthalmitis after Intravitreal Injections

To analyze comparatively the effect of different intravitreal injection (IVI) protocols on the incidence of endophthalmitis occurring after injection. Retrospective case-control series. Twenty-seven retina specialists in a large vitreoretinal practice performed 37 646 IVIs. Multivariate analysis was used to identify risk factors for development of endophthalmitis occurring after injection. Before all injections, a technician applied 5% povidone-iodine (PI) to the eyelids and conjunctiva. There were 4 distinct aseptic protocols with regard to reapplication of PI by physicians: physicians who did not reapply PI, reapplication of PI without the use of a lid speculum, reapplication of PI before speculum placement, and reapplication of PI after speculum placement. Other analyzed variables included the use of gloves, a caliper to mark the injection site, and the class of medication (steroid vs. anti-vascular endothelial growth factor). Cases of presumed infectious endophthalmitis. Thirty-three cases of presumed infectious endophthalmitis occurred after 37 646 injections (0.088%). The method of PI application was found to be a statistically significant predictor of the incidence of endophthalmitis (P= 0.031). When compared with the incidence of endophthalmitis for physicians who did not reapply PI (0.124% [20/16 155]), there was no statistical difference for reapplication of PI without the use of a speculum (0.110% [6/5472]; P= 0.584) or reapplication before speculum insertion (0.122% [5/4067]; P= 0.863). However, reapplication of PI after insertion of the lid speculum was associated with a significantly decreased incidence of endophthalmitis (0.017% [2/11 952]; P= 0.004; odds ratio, 0.113). Use of gloves (P= 0.119) or a caliper to mark the injection site (P= 0.496) and the class of medication (P= 0.740) were not found to be statistically significant risk factors for endophthalmitis development. The application of PI after placement of the lid speculum reduced the incidence of endophthalmitis occurring after injection approximately 7-fold compared with other aseptic protocols. Preventing the eyelid from contacting the injection site after the final application of PI is an important step in improving the safety of intravitreal injections.

Environmental and Psychosocial Barriers to and Benefits of Cervical Cancer Screening in Kenya.

Cervical cancer is the second most commonly diagnosed cancer in females and is a leading cause of cancer-related mortality in Kenya; limited cervical cancer screening services may be a factor. Few studies have examined men's and women's perceptions on environmental and psychosocial barriers and benefits related to screening. In 2014, 60 women aged 25-49 years and 40 male partners participated in 10 focus groups (6 female and 4 male), in both rural and urban settings (Nairobi and Nyanza, Kenya), to explore perceptions about barriers to and benefits of cervical cancer screening. Focus groups were segmented by sex, language, geographic location, and screening status. Data were transcribed, translated into English, and analyzed by using qualitative software. Participants identified screening as beneficial for initiating provider discussions about cancer but did not report it as a beneficial method for detecting precancers. Perceived screening barriers included access (transportation, cost), spousal approval, stigma, embarrassment during screening, concerns about speculum use causing infertility, fear of residual effects of test results, lack of knowledge, and religious or cultural beliefs. All participants reported concerns with having a male doctor perform screening tests; however, men uniquely reported the young age of a doctor as a barrier. Identifying perceived barriers and benefits among people in low- and middle-income countries is important to successfully implementing emerging screening programs. The novel findings on barriers and benefits from this study can inform the development of targeted community outreach activities, communication strategies, and educational messages for patients, families, and providers. The Oncologist 2017;22: 173-181Implications for Practice: This article provides important information for stakeholders in clinical practice and research when assessing knowledge, beliefs, and acceptability of cervical cancer screening and treatment services in low- and middle-resourced countries. Formative research findings provide information that could be used in the development of health interventions, community education messages, and materials. Additionally, this study illuminates the importance of understanding psychosocial barriers and facilitators to cervical cancer screening, community education, and reduction of stigma as important methods of improving prevention programs and increasing rates of screening among women.

What Is Best Practice for Providing Pain Relief During Retinopathy of Prematurity Eye Examinations?

Retinopathy of prematurity screenings is considered a painful procedure. Yet, preterm infants 30 weeks of gestation or less or weighing 1500 g or less or between 1500 and 2000 g or greater than 30 weeks of gestation with an unstable course are required to have these examinations until their eyes reach maturity. A systematic search of the literature was conducted to answer the question "For premature infants undergoing retinal eye examinations, what interventions are the most effective for pain reduction?" CINAHL Plus and MEDLINE were searched using the key words: retinopathy of prematurity and pain. The search was limited to the last 10 years and experimental or quasi-experimental studies attempting to reduce pain during eye examinations. The search criteria yielded 14 studies that addressed interventions to decrease pain during examinations. Three strategies were noted for pain relief including nonpharmacological interventions (n = 9), topical anesthetics (n = 3), and examination techniques (n = 2). The findings indicate that these 3 strategies provided varying results for pain relief but could be beneficial if provided in a consistent protocol. Consequently, policies for pain management during retinopathy of prematurity examinations need to be used consistently. It is important for clinicians to consider using a combination of strategies that maximize comfort and provide pain relief. There remains a need to continue to examine pain-relieving techniques for retinopathy of prematurity examinations. Further investigation is needed to evaluate effective strategies that mitigate pain and the pathways causing pain. In addition, investigating the clinical feasibility of examinations without speculum use may be worthwhile.

Effects of the Oral Examination on the Equine Temporomandibular Joint

Despite the increasing number of oral examinations performed, reports on temporomandibular joint (TMJ) assessment after the use of full-mouth specula are lacking in the literature. The aim of this study was to investigate whether prolonged application of a full-mouth speculum (60 minutes) would result in alterations in the clinical, thermographic, and synovial fluid (SF) findings. Horses were randomly divided into two groups. In one group, the speculum was kept in place in a closed position (CP group). In the other group, animals remained for 60 minutes with the mouth speculum at full range of aperture (opened position [OP] group). All TMJ joints were evaluated using digital palpation and thermography previous to (baseline values) and 6 hours after the removal of the mouth speculum (M6h). Synovial fluid was collected and analyzed. Six hours after full-mouth speculum use (M6h), pain on digital palpation, skin temperature, and total cell count in the OP group were higher when compared to baseline values. Moreover, pain on digital palpation and total cell count were higher in the OP group when compared to the CP group at M6h. There was no difference in total protein, chondroitin sulfate, hyaluronic acid, and prostaglandin E2 SF concentrations. Based on clinical, thermographic, and SF cell cytological findings, we concluded that TMJs environmental modifications followed the application of a full-opened mouth speculum for 60 minutes. However, these alterations were mild and mainly of inflammatory nature, and there was no indication of an increase in extracellular matrix degradation products in the SF.

Short-Term Influence of Aspirating Speculum Use on Dry Eye After Cataract Surgery

The aim of this study was to investigate the short-term influence of the use of an aspirating speculum on dry eye after performing cataract surgery. This study was conducted using a prospective, consecutive, comparative, interventional case series of 58 eyes of 58 patients who underwent clear corneal cataract surgery; 29 eyes were treated using an aspirating speculum, and 29 eyes were treated without using a nonaspirating speculum. The main outcome measures were sequential changes of dry eye parameters including conjunctival staining, tear film break-up time (tBUT), conjunctivochalasis grades, and ocular surface disease index (OSDI). In the nonaspirating speculum group, tBUT and conjunctivochalasis grades were aggravated on day 1 postoperatively (P < 0.001), but conjunctival staining and OSDI did not show any significant change during the follow-up. In the aspirating speculum group, significant aggravation was observed by conjunctival staining on day 1 postoperatively (P = 0.001), tBUT and conjunctivochalasis grades were evaluated on day 1 and day 7 postoperatively (P < 0.001), and the OSDI was evaluated on day 7 postoperatively (P = 0.011). The use of an aspirating speculum aggravated dry eye parameters during the early postoperative period. Although these parameters returned to their preoperative values at 1 month postoperatively, the use of an aspirating speculum has the potential to aggravate dry eyes after cataract surgery is performed.

When it Hurts to Look: Interpreting the Interior of the Victorian Woman

The use of the vaginal speculum was as important to Victorian doctors who struggled to professionalise the fields of gynaecology and obstetrics as it was controversial, especially when such doctors were men attending to women of respectable class status. While the debate over the use of the speculum in Victorian Britain was certainly rooted in moral concerns over the exposure of women's bodies, an examination of the arguments made by Victorian medical men concerning the use of the instrument reveals that there was more than just modesty at stake. This article will consider how the nineteenth-century texts that articulate different positions regarding the use of the speculum in gynaecological examinations also demonstrate important tensions relating to the privileging of the sense of sight versus touch in Victorian medicine, particularly when referring to the respective utility and purpose of a male doctor's visual or tactile knowledge of the inside of a woman's body.

POVIDONE–IODINE CONTACT TIME AND LID SPECULUM USE DURING INTRAVITREAL INJECTION

To determine the time necessary for 5% povidone-iodine (PI) to cause a significant reduction in colony-forming units and whether a lid speculum increases the conjunctival flora. This was a prospective randomized study of 131 eyes undergoing intravitreal injection. Conjunctival samples were collected in a prospective protocol at three points before intravitreal injection: (1) no intervention (baseline), (2) after placement of a lid speculum, and (3) after treatment with 5% PI. Participants were randomized into three different PI exposure intervals. Cultures were incubated for 6 days, and the resulting colony-forming units were tallied for each intervention. Use of 5% PI caused significant decrease in the number of colony-forming units (P < 0.0001). Exposure to PI for 15 seconds did not cause a significant reduction in conjunctival bacteria (P = 0.08), but a significant reduction was observed after 30 seconds of exposure and beyond (P = 0.0003). Placement of a lid speculum did not result in a significant increase or decrease in the number of colony-forming units when compared with baseline (P = 0.47). The use of 5% PI causes a significant reduction in bacterial colonies, and 30 seconds of exposure appears to be an adequate time to decrease conjunctival bacterial counts. Lid speculum use before intravitreal injection does not affect the overall conjunctival flora.

Outcomes and Risk Factors Associated with Endophthalmitis after Intravitreal Injection of Anti-Vascular Endothelial Growth Factor Agents

To describe outcomes of and risk factors for endophthalmitis after intravitreal anti-vascular endothelial growth factor (VEGF) injection. Single-center, consecutive, case series and retrospective case-control study. Between January 1, 2009, and May 31, 2010, 16 vitreoretinal surgeons administered a total of 27 736 injections. During this period, 23 cases of presumed infectious endophthalmitis occurred. Each surgeon used his own preferred injection technique. Vitreous or aqueous tap, or both, with intravitreal antibiotic injection and subsequent topical antibiotic and steroid drops. Visual acuity, bladed lid speculum use, conjunctival displacement, hemisphere of injection, bevacizumab versus ranibizumab, and infectious organism. Seven of 23 cases had positive culture results; 3 grew coagulase-negative Staphylococcus. All cases had pain and vitritis on average 3.4 days (range, 1-6 days) after injection, with no difference between culture-positive and culture-negative groups. Eighteen (78%) of 23 cases had a hypopyon. Fifteen of 23 cases returned to baseline vision (±2 lines) within 3 months. Neither lid speculum use (0.10% vs. 0.066% in the no-use group; P = 0.27), conjunctival displacement (0.11% vs. 0.076% in the no-displacement group; P = 0.43), hemisphere of injection (0.11% superior vs. 0.079% inferior; P = 0.56), or bevacizumab versus ranibizumab (0.11% vs. 0.066%; P = 0.21) affected risk. Analysis of only culture-positive results yielded similar results. There was no statistically significant difference between the proportion of culture-negative cases after bevacizumab injection (83%) versus ranibizumab injection (55%; P = 0.13). Most patients in whom presumed infectious endophthalmitis develop after anti-VEGF injection regained baseline vision after treatment. Bladed lid speculum use, conjunctival displacement, hemisphere of injection, and type of anti-VEGF agent did not affect risk. No difference in culture-negative endophthalmitis rates was detected after bevacizumab versus ranibizumab injection. Neither the presence of pain, vitritis, decreased vision, hypopyon, nor the interval between injection and development of symptoms differentiate culture-positive from culture-negative cases. Because a subgroup of patients had poor outcomes, a low threshold for vitreous tap with intravitreal antibiotic injection may be warranted. The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Minihysteroscopy for examination and management of pathologic lesions of virginal reproductive tracts: can we preserve the hymen intact?

Dear Editors, Hysteroscopy has been widely used for uterine cavity examination and management. Although the possibility of hymen preservation is high, virgins are highly resistant to this procedure [1]. This may be due to a belief that the procedure causes disruption of virginity and worries associated with their future partners. Case 1 was a 31-year-old virgin complaining of abnormal vaginal bleeding for months despite of medical treatment. Hysteroscopic examination was indicated, but she initially hesitated. After extensive counseling about the beneWts and limitations of both conventional hysteroscopy and minihysteroscopy, she chose a minihysteroscopy with 4-mm continuous-Xow outer sheath, 5Fr operating channel and 2-mm 0°-telescope (Karl Storz, Tuttlingen, Germany) rather than a 8-mm hysteroscopy. The procedure was conducted under intravenous sedation without use of speculum, tenaculum and cervical dilators. An operative assistant was assigned to hold the hysteroscope in place to make sure the downward pressure was not excessive and for paying attention to safety of the hymen. Additionally, avoidance of wide movements during manipulation was necessary. Vagina and cervical canal were normal; one 8-mm endometrial hyperplastic polyp was found at the posterior wall of the uterine cavity and removed by a Xexible biopsy forceps piecemeal through the channel. Case 2 was a 43-year-old virgin complaining of a vulvar mass for a long time, but she was too embarrassed to visit a gynecologist. Physical examination revealed a 6-cm erosive tumor protruding from the vagina (Fig. 1a). On minihysteroscopy, the uterine cervix was normal and the tumor growing from the left lateral vaginal wall 4 cm behind the introitus (Fig. 1b) was extracted cautiously by smallest Pean forceps. The hymen integrity was preserved (Fig. 1c), and a benign polyp was diagnosed pathologically. Operation duration for both patients was less than 20 min, and both were uneventful. Their symptoms were relieved thereafter, and they were satisWed with the procedure and outcome. Informed consent was obtained from Case 2 for use of the pictures. Hymen integrity is an important representation of virginity in some countries even though it is not absolutely related to virginity. When a reproductive tract examination or transvaginal operation must be arranged for a virgin, the operator faces a challenge and may hesitate to utilize hysteroscopy, which can result in a delayed diagnosis or improper treatment. The most common indication for hysteroscopy was abnormal vaginal bleeding, experienced by 52.5% of 40 virginal patients [1, 2]. The acceptance rate for surgery, however, was only 78% [1]. Hymen integrity was preserved in all reported cases without major complications. Our Wndings concurred with their results. So far, only a few reports have discussed the protection of hymen integrity in hysteroscopy [1, 2], and the physical and psychological impacts of this surgery in virgins are not conclusive. Although hysteroscopy can improve diagnosis and thereby improve quality of life, virgins may decline this procedure. Patients with delayed diagnosis and management in some uncommon but serious situations, such as endometrial malignancy, are life-threatening. This is an important issue that gynecologists encounter, but which has seldom been discussed. In the two cases described above, minihysteroscopy was able to fulWll their physical and psychological needs after endometrial polypectomy or vaginal tumor removal. M.-L. Cheong (&) Department of Obstetrics and Gynecology, Cathay General Hospital, #280, Sect. 4, Jen-Ai Road, Taipei 106, Taiwan e-mail: joymlcheong@gmail.com

A New Approach to Office Hysteroscopy Compared With Traditional Hysteroscopy

To compare a "no touch" approach to diagnostic hysteroscopy without anesthesia with traditional diagnostic hysteroscopy after intracervical injection of mepivacaine hydrochloride 3%. A total of 130 women undergoing diagnostic hysteroscopy were included in the study and were randomized, using a computer-generated randomization list to one of two treatment groups in a ratio of 2:1. Eighty-three women underwent hysteroscopy without speculum, tenaculum, or anesthesia. Forty-seven women received intracervical anesthesia with 10 mL of 3% mepivacaine hydrochloride solution injected at two sites (3:00 and 9:00 positions) and underwent traditional hysteroscopy. Hysteroscopy was performed using a rigid 3.7-mm hysteroscope and a medium of 0.9% saline, and the image was transmitted to a screen visible to the patient. A visual analog scale (VAS) consisting of a 10-cm line was used to assess the intensity of pain experienced during and after the procedure. Overall patient satisfaction was assessed during, immediately after, 15 minutes later, and 3 days after hysteroscopy. The mean pain score was significantly lower in the group without the use of speculum, tenaculum, or anesthesia (VAS1: 3.8+/-2.7 versus 5.34+/-3.23, P=.01; VAS2: 3.02+/-2.50 versus 4.57+/-3.30, P=.008). Patient satisfaction rate was similar in both groups. Patients reported significantly less pain with the altered approach to diagnostic hysteroscopy compared with patients undergoing the traditional procedure with anesthesia. This new approach can therefore be considered as a useful hysteroscopic technique. ClinicalTrials.gov, www.clinicaltrials.gov, NCT00319410