Operative vaginal delivery: practice patterns and outcomes at a tertiary general hospital

INTRODUCTION@#There has been a global decrease in operative vaginal deliveries, with a marked shift towards the vacuum extractor. However, little is known about the trends in operative vaginal delivery in Singapore.@*METHODS@#A retrospective study was conducted on all operative vaginal deliveries performed from 2012 to 2017 at Singapore General Hospital (SGH). Maternal outcomes in terms of postpartum haemorrhage and obstetric anal sphincter injuries were compared between forceps- and vacuum-assisted deliveries. Neonatal outcomes in terms of neonatal intensive care unit (NICU) admission and clinically significant neonatal events were compared. The instrument preference of obstetricians was analysed.@*RESULTS@#A total of 906 consecutive operative vaginal deliveries were included in the study, comprising 461 forceps- and 445 vacuum-assisted deliveries. The rate of operative vaginal delivery was maintained at approximately 10% from 2012 to 2017. Neonatal cephalohematomas were more common after vacuum-assisted deliveries. Other maternal and neonatal outcomes did not differ significantly between the two groups. Clinically significant neonatal events were mostly due to shoulder dystocia, whereas all cases of NICU admissions were not directly related to the mode of delivery. Obstetricians' choice of instrument appeared to reflect personal preference and was not affected by the year of graduation.@*CONCLUSION@#The rates of neonatal and maternal morbidity were low at SGH. Overall instrument use of forceps and vacuum was balanced, and proficiency in both was demonstrated by all operators. Operative vaginal delivery remains an essential skill in facilitating safe vaginal delivery, which should be maintained to keep Caesarean section rates in check.

A dissecção endoscópica de submucosa ainda está limitada a poucos centros terciários no Ocidente? Resultados de uma pesquisa nacional no Brasil / Is endoscopic submucosal dissection still limited to few tertiary centers in the west? results from a national survey in brazil

ABSTRACT BACKGROUND: Endoscopic submucosal dissection (ESD) enables en bloc excision of superficial neoplasms. Although ESD is widely practiced in Eastern countries like Japan, South Korea and China, its use in the West is supposed to be still limited to few tertiary centers. OBJECTIVE: This study aimed to investigate the clinical practice of ESD in Brazil by means of an electronic questionnaire elaborated by the Brazilian Society of Digestive Endoscopy (SOBED). METHODS: In October 2019, 3512 endoscopist members of SOBED were invited to respond to an electronic survey containing 40 questions divided into four topics: operator profile; clinical experience with ESD; adverse events and training. Informed consent was requested to all participants. The investigators reviewed all responses and considered valid if more than 50% of the questions were answered and additional information, when requested, was provided. RESULTS: A total of 155 (4.4%) qualified responses entered the study. ESD has been practiced in 22 of 26 Federation States and majority of respondents (32.2%) have 10 to 20 years of practice. ESD has been performed more frequently in private hospitals (101 individuals, 66.9%) and private ambulatory centers (41 individuals, 27.1%). ESD was performed mainly in the stomach (72%), followed by the rectum (57%) and 80% of the individuals reported less than 25 operations. Twenty-four (15.4 %) individuals reported perforation and 4 (2.5%) of them reported postoperative deaths. Approximately a quarter of responders denied hands-on training in models or visit to training centers. CONCLUSION: ESD appears to be practiced throughout the country, not only in tertiary or academic institutions and mainly in private practice. Most operators received limited training and still are at the beginning of their learning curve. The reported adverse events and mortality rates appear to be higher than Eastern reports.

RESUMO CONTEXTO: A dissecção endoscópica da submucosa (ESD) é uma técnica popular no Japão e em outros países asiáticos e, supostamente, ainda está limitada a centros terciários no Ocidente. OBJETIVO: Este estudo teve como objetivo investigar a prática clínica da ESD no Brasil por meio de um questionário eletrônico elaborado pela Sociedade Brasileira de Endoscopia Digestiva (SOBED). MÉTODOS: Em outubro de 2019, 3512 endoscopistas membros da SOBED foram convidados a responder a uma pesquisa eletrônica contendo 40 questões divididas em quatro tópicos: perfil do operador; experiência clínica com ESD; eventos adversos e treinamento. O consentimento informado foi solicitado a todos os participantes. Os investigadores analisaram todas as respostas e consideraram válidas se mais de 50% das perguntas fossem respondidas e informações adicionais, quando solicitadas, fossem fornecidas. RESULTADOS: Um total de 155 (4,4%) respostas qualificadas foram incluídas no estudo. A ESD foi executada em 22 dos 26 estados da Federação e a maioria dos entrevistados (32,2%) possuía de 10 a 20 anos de prática endoscópica. A ESD foi realizada com maior frequência em hospitais privados (101 indivíduos; 66,9%) e clínicas ambulatoriais privadas (41 indivíduos; 27,1%). A ESD foi realizada principalmente no estômago (72%), seguido pelo reto (57%) e 80% dos indivíduos relataram menos de 25 operações. Vinte e quatro (15,4%) indivíduos relataram algum caso de perfuração no procedimento e 4 (2,5%) deles relataram óbito pós-operatório. Aproximadamente um quarto dos respondentes negou treinamento prático em modelos ou visita a centros de treinamento. CONCLUSÃO: A ESD parece ser praticada em todo o país, não apenas em instituições terciárias ou acadêmicas e principalmente na prática privada. A maioria dos respondedores recebeu treinamento limitado e ainda está no início da curva de aprendizado. Os eventos adversos relatados e as taxas de mortalidade parecem ser maiores do que os relatos orientais.

Cardiac rehabilitation knowledge, awareness, and practice among cardiologists in India

Cardiac rehabilitation (CR) use is extremely low in India, and beyond. The reasons are multifactorial, including healthcare provider factors. This study examined CR perceptions among cardiologists in India. Attendees of the 2017 Cardiology Society of India conference completed a survey. Of 285 respondents, just over one-fourth had a CR program at their institution, with a similar proportion reporting someone dedicated to providing CR advice to their patients. Only 11 (3.9%) were correct in their responses to 4 multiple choice questions regarding secondary prevention. On average, cardiologists referred 20–30% of their patients, with the greatest barrier to referral being patient disinterest.

Patterns of Practice in Radiotherapy for Breast Cancer in Korea / 한국유방암학회지

Adjuvant radiotherapy (RT) is a well-established treatment for breast cancer. However, there is a large degree of variation and controversy in practice patterns. A nationwide survey on the patterns of practice in breast RT was designed by the Division for Breast Cancer of the Korean Radiation Oncology Group. All board-certified members of the Korean Society for Radiation Oncology were sent a questionnaire comprising 39 questions on six domains: hypofractionated whole breast RT, accelerated partial breast RT, postmastectomy RT (PMRT), regional nodal RT, RT for ductal carcinoma in situ, and RT toxicity. Sixty-four radiation oncologists from 54 of 86 (62.8%) hospitals responded. Twenty-three respondents (35.9%) used hypofractionated whole breast RT, and the most common schedule was 43.2 Gy in 16 fractions. Only three (4.7%) used accelerated partial breast RT. Five (7.8%) used hypofractionated PMRT, and 40 (62.5%) had never used boost RT after chest wall irradiation. Indications for regional nodal RT varied; ≥pN2 (n=7) versus ≥pN1 (n=17) versus ≥pN1 with pathologic risk factors (n=40). Selection criteria for internal mammary lymph node (IMN) irradiation also varied; only four (6.3%) always treated IMN when regional nodal RT was administered and 30 (46.9%) treated IMN only if IMN involvement was identified through imaging. Thirty-one (48.4%) considered omission of whole breast RT after breast-conserving surgery for ductal carcinoma in situ based on clinical and pathologic risk factors. Fifty-two (81.3%) used heart-sparing techniques. Overall, there were wide variations in the patterns of practice in breast RT in Korea. Standard guidelines are needed, especially for regional nodal RT and omission of RT for ductal carcinoma in situ.

Korean physicians' attitudes toward the prenatal screening for fetal aneuploidy and implementation of non-invasive prenatal testing with cell-free fetal DNA

PURPOSE: Physicians' attitudes may have a strong influence on women's decision regarding prenatal screening options. The aim of this study is to assess the physicians' attitudes toward prenatal screening for fetal aneuploidy including non-invasive prenatal testing (NIPT) in South Korea. MATERIALS AND METHODS: Questionnaires were distributed and collected at several obstetrics-gynecological conferences and meetings. The questionnaire included 31 multiple choice and 5 fill-in-the-blank questions. Seven questions requested physicians' demographic information, 17 questions requested information about the NIPT with cell-free fetal DNA, and 12 questions requested information about general prenatal screening practices. RESULTS: Of the 203 obstetricians that completed the survey. In contrast with professional guidelines recommending the universal offering of aneuploidy screening, only 53.7% answered that prenatal aneuploidy testing (screening and/or invasive diagnostic testing) should be offered to all pregnant women. Physicians tended to have positive attitudes toward the clinical application of NIPT as both primary and secondary screening methods for patients at high-risk for fetal trisomy. However, for patients at average-risk for fetal trisomy, physicians tended to have positive attitudes only as a secondary screening method. Physicians with more knowledge about NIPT were found to tend to inform their patients that the detection rate of NIPT is higher. CONCLUSION: This is the first study to investigate expert opinion on prenatal screening in South Korea. Education of physicians is essential to ensure responsible patient counseling, informed consent, and appropriate management after NIPT.

Relationship among potential maternal risk factors, prenatal care and characteristics of preeclampsia / 中华围产医学杂志

Objective To investigate the relationship between potential maternal risk factors between potential maternal risk factors in different level hospitals as well as different prenatal care patterns and characteristics of preeclampsia. Methods A retrospective study of 300 preeclamptic singleton patients delivered in Peking University Third Hospital was performed.Patients were divided into three groups:regular prenatal care in tertiary hospitals (n =100),regular prenatal care in primary hospitals (n=81) and without prenatal care (n=119). The onset of preeclampsia and incidence of severe preeclampsia of different groups were analyzed. Non-parametric and Chi-square test were adopted for continuous and categorical variables respectively. Results (1) In total cases of preeclampsia subgroup (I-PE subgroup) and with chronic hypertension (CH subgroup),the diagnosis of preeclampsia was later in patient with regular prenatal care in tertiary hospital (patient-TH)[100,64 and 14 cases,37.1 (4.1),37.3 (1.7) and 36.3 (2.5) weeks respectively] than those with regular prenatal care in primary hospital (patient-PH) [81,54 and 9 cases,32.9 (6.7),33.8 (6.1)and 27.9(6.3) weeks respectively] (Z=72.29,51.30 and 14.58 respectively,P＜0.05) or the patient without regular prenatal care (patient-NP) [119,85 and 19 cases,31.6(6.6),31.9(6.7) and 30.3(4.7) weeks respectively] (Z=86.69,58.83 and 11.33 respectively,P＜0.05).The proportion of severe preeclampsia occurred earlier than 32 weeks [13.0％ (13/100) vs 55.5％ (66/119),9.4％(6/64) vs 50.6％(43/85),and 35.7％(5/14) vs 89.5％(17/19); x2=43.95,29.42 and 10.17respectively,P＜0.05] or earlier than 34 weeks [17.0％ (17/100) vs 65.5％ (78/119),14.1％(9/64) vs 61.2％(52/85) and 42.9％(6/14) vs 94.7％(18/19); x2 =47.71,31.18 and 10.61 respectively,P＜0.05] were lower in patient-TH than in patient-NP.(2) In patient-NP and patientPH,onset of preeclampsia was earlier in CH subgroup compared with I-PE subgroup (Z=26.61 and 22.82,P＜ 0.05). In patient-NP,the proportion of severe preeclampsia occurred earlier than 32 weeks (x2 =9.11,P＜0.05) or earlier than 34 weeks (x2 =7.95,P＜0.05) was higher in CH subgroup than in I-PE subgroup. Conclusions Regular prenatal care in tertiary hospital might effectively delay the onset of preeclampsia or severe preeclampsia,especially in patients with risk factors for preeclampsia. Assessment of risk factors for preeclampsia in early trimester should be strengthened and individualized prenatal care plan should be established.