Current diagnosis and management of adenomyosis in Canada: A survey of Canadian gynaecologists

Objective:

The purpose of this study was to understand how Canadian Obstetricians/Gynaecologists (OBGYNs) diagnose and manage adenomyosis.

Methods:

This cross-sectional study was performed via an online survey distributed to 262 OBGYNs at three Canadian universities (University of Toronto, University of Calgary, and McMaster University).

Results:

A total of 137 responses were obtained out of 262 OBGYNs (52.3%) with a completion rate of 98%. Adenomyosis was a diagnosis in 6%–10% of patients seen by OBGYNs. The most common clinical symptoms included heavy menstrual bleeding (HMB) (82.8%) and dysmenorrhea (91.0%). Most participants (83%) used transvaginal ultrasound (TVUS) as first-line imaging for diagnosis of adenomyosis. Many respondents (35.8%) indicated that adenomyosis was not associated with infertility or recurrent miscarriage. Treatment considerations for all patients with adenomyosis included levonorgestrel intra-uterine system (LNG-IUS) (91.8%), hysterectomy (88.8%), expectant management (85.1%), combined hormonal contraceptives (CHC) (83.6%), tranexamic acid (81.3%), gonadotropin releasing hormone (GnRH) agonists (64.2%), depo-provera (64.2%), dienogest (57.5%), and norethisterone acetate (NETA) (40.3%). Treatments for adenomyosis in patients wishing to conceive included expectant management (85.1%), tranexamic acid (79.1%), CHC (44.8%), LNG-IUS (32.8%), and GnRH agonists (35.8%). Excision of adenomyosis would only be offered by 24% of respondents. Uterine artery embolization (UAE) would not be used in the treatment of adenomyosis by 44% of respondents. Finally, 82.8% of respondents would use improvement of clinical symptoms to follow treatment success.

Conclusion:

Practice varies across Canada despite recent emerging evidence in the diagnosis and management of adenomyosis, highlighting the need for a clinical practice guideline on adenomyosis.

The fragility of statistically significant results in gynecologic surgery: A systematic review

OBJECTIVE

To use the fragility index (FI) to evaluate the robustness of gynaecologic surgery trials that report statistically significant results. The FI defines the minimum number of patients who must have an alternative outcome to alter statistical significance.

DATA SOURCES

We searched MEDLINE, Web of Science, Embase, and ClinicalTrials.gov from 2011 to 2021 to identify gynaecologic surgery randomized controlled trials (RCTs).

STUDY SELECTION

A total of 4775 trials were screened for eligibility. All included studies evaluated benign gynaecologic surgery interventions or peri-operative medical interventions. Only two-arm RCTs with statistically significant dichotomous primary outcomes were included. Ninety-three trials were ultimately included for analysis.

DATA EXTRACTION AND SYNTHESIS

Data from the included studies, including sample size, loss to follow-up, and number of events, were recorded. The FI of each study was calculated using a predefined technique. The overall FI and FIs by subgroup (clinical subspecialty, country of origin, and statistical test used) are reported as medians alongside their interquartile ranges (IQRs). The Kruskal-Wallis test was applied to find possible statistically significant relationships between FI and the nominal subgroups. Among this cohort, the median FI was 3 (IQR 1-7). The FI was 0 in 13 trials (14%), and in 39 trials (42%), the number of patients lost to follow-up was greater than the FI. The median FI within clinical subspecialty groups (general gynaecology, anaesthesia, urogynaecology, and fertility) did not differ (P = 0.122).

CONCLUSION

Statistically significant results of RCTs in gynaecologic surgery are fragile, suggesting that clinicians should interpret results with caution. This is particularly true when the number of patients lost to follow-up is greater than the FI. The FI serves as a quality metric that can be used to evaluate robustness of results when applying the outcomes of RCTs to clinical practice or guideline development.

Antigen Presentation by Exosomes Released from Peptide-Pulsed Dendritic Cells Is not Suppressed by the Presence of Active CTL

Despite the potency of dendritic cells (DCs) as a vaccine carrier, they are short-lived and sensitive to CTL-mediated elimination. Thus, it is believed that the longevity of Ag presentation by peptide-pulsed DC is limited in vivo. Surprisingly, however, we found that although the majority of injected DCs disappeared from the draining lymph nodes within 7 days, Ag presentation persisted for at least 14 days following DC immunization. This prolonged Ag presentation was not mediated by the remaining injected DCs or through Ag transfer to endogenous APCs. We provide evidence that exosomes released by DCs might be responsible for the persistence of Ag presentation. Functional exosomes could be recovered from the draining lymph nodes of C57BL/6 mice following DC vaccination and, in contrast to DCs, T cell stimulation by exosomes in vivo was not affected by the presence of CTL. Our findings demonstrate that Ag presentation following delivery of DC vaccines persists for longer than expected and indicate that the exosome may play a previously unrecognized role in Ag presentation following DC vaccination. Furthermore, our study reinforces the application of exosomes as a vaccination platform and suggests that exosome-based vaccines may be advantageous for booster immunizations due to their resistance to CTL.