Retrospective Review of Management of Antenatally Diagnosed Ovarian Cysts at the Hospital for Sick Children.

INTRODUCTION: Postnatal management of antenatally diagnosed ovarian cysts is not well-defined. The clinical course, management, and outcomes of patients with antenatally diagnosed ovarian cysts were reviewed. METHODS: Infants <1 year of age with antenatally diagnosed ovarian cyst managed at The Hospital for Sick Children between January 2017 and December 2021 were included. Patient charts were reviewed for postnatal ultrasound (US) images, management, clinical course and complications. Mixed linear regression analysis was used to model the change in cyst size over time. RESULTS: In total, 52 patients were included and 10 patients had no cyst identified at their first postnatal US. Of the remaining cases, 36% were simple/physiologic and 64% had complex features. Two underwent percutaneous aspiration while 40 patients were managed expectantly with most cysts (62%) resolving. The rate of resolution was significantly higher and faster for simple compared to complex cysts (84% versus 52%, p < 0.05). Cysts that persisted at the end of the study period (n = 14) had all decreased in size, with a rate of resolution similar to resolved cysts. Only one patient managed expectantly required urgent laparoscopy for salpingoophorectomy. CONCLUSION: Antenatally diagnosed ovarian cysts exhibit high rates of resolution with expectant management, supporting the safety and efficacy for expectant management for these patients. LEVEL OF EVIDENCE: III.

BD SurePath Direct to Slide (DTS) cervical cytology: Migrating the benefits of liquid-based cytology to low-resource settings.

OBJECTIVES: The benefits of liquid-based cytology (LBC) in routine cervical cancer screening are often associated with the availability of instrumented platforms and economic considerations. A low-cost alternative to LBC in low-volume settings remains an unmet need. METHODS: A multisite evaluation of the BD SurePath (SurePath) LBC Direct to Slide (DTS) method was conducted. The DTS preparations were evaluated across 3 sites. Cytology features for DTS preparation included predetermined thresholds for total cellularity, cell distribution, cellular preservation, and stain quality. Rare event detection was evaluated using SiHa cells spiked into pools from negative cytology specimens. Concordance between Bethesda classification results was evaluated for SurePath LBC and DTS methods using routinely collected SurePath specimens in a split-sample study design. RESULTS: The DTS specimens met criteria for total cellularity, cell distribution, cellular preservation, and stain quality in more than 98% of all cases. Rare event detection was observed with an average detection of 5 SiHa cells per 2 mL of specimen. Concordant cervical cytology classifications were observed between SurePath LBC and DTS methods. CONCLUSIONS: The results demonstrate that the DTS process is suitable for routine cervical cytology evaluation. The procedure is reproducible and detected abnormal cervical cells in concordance with standard SurePath LBC preparation.

The Shared Ovary: A Multidisciplinary Discussion With Pediatric and Adolescent Gynecology.

Pediatric and adolescent ovarian lesions are common and are frequently managed by both pediatric surgeons and pediatric and adolescent gynecologists. During the 2023 American Academy of Pediatric Section on Surgery meeting, an educational symposium was delivered focusing on various aspects of management of pediatric and adolescent benign and malignant masses, borderline lesions, and fertility options for children and adolescents undergoing cancer therapies. This article highlights the discussion during this symposium.

Food insecurity and the dental team: a pilot study to explore opinions.

PURPOSE: In total, 17% of UK households with children experience food insecurity, with evidence to suggest a direct correlation with the prevalence of oral disease. This study explores current perceptions of the dental team, when recognising and supporting families who may experience food insecurity. MATERIALS AND METHODS: An online, anonymous cross-sectional survey was designed and sent to members of the British Society of Paediatric Dentistry (BSPD) in June 2023, examining confidence and understanding surrounding food insecurity and dental health. Quantitative data is presented descriptively and qualitative data using a thematic analysis. RESULTS: The response rate was 9.6% (n = 76). A significant number recognise the link between poor oral health and food insecurity, 80.3% (n = 61). Although practitioners are confident in oral health counselling, 80.3% (n = 61) a smaller proportion are not as confident when approaching food insecurity 32.9% (n = 25). Dental team members recognise the need to improve identification of affected patients and that they have a professional duty to support. Intervention strategies, such as additional training to support team development and signposting of patients are indicated. CONCLUSION: This study suggests that whilst dental professionals understand the link between food insecurity and oral health, and their responsibilities to those affected; they lack confidence in identifying such patients and providing support. Additional conversations and training are fundamental to better understand their role, which must reflect the needs of the population that they serve.

Case Report: Neonate Presenting with Acute Kidney Injury Secondary to Obstructed Hemivagina and Ipsilateral Renal Anomaly (OHVIRA) Syndrome: Long-Term Follow-Up.

BACKGROUND: Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome describes a spectrum of Mullerian anomalies characterized by uterine didelphys, unilateral obstructed hemivagina, and ipsilateral renal anomalies. We report the case of a neonatal complication secondary to OHVIRA syndrome with long-term follow-up, adding to the collective understanding of this syndrome. CASE SUMMARY: We present a 22-day-old female with an acute kidney injury secondary to post-renal obstruction from a large hydrometrocolpos. Multidisciplinary care facilitated timely diagnosis of OHVIRA syndrome and temporizing operative management. The patient was followed serially into her adolescence and ultimately underwent definitive excision of her vaginal septum. DISCUSSION: OHVIRA syndrome encompasses a broad spectrum of anatomical variation with different considerations in prepubertal and postpubertal patients. Multidisciplinary care allows for timely diagnosis and clinical decision-making within this complex patient population.

Enhanced recovery after surgery reduces length of stay after colorectal surgery in a small rural hospital in Ontario.

Introduction: Enhanced recovery after surgery (ERAS) programmes include pre-operative, intraoperative and post-operative clinical pathways to improve quality of patient care while reducing length of stay (LOS) and readmission. This study assessed the feasibility and outcomes of an ERAS protocol for colorectal surgery implemented over 2 years in a small, resource-challenged rural hospital. Methods: A prospective cohort study used retrospectively matched controls to assess the effect of ERAS on LOS in patients undergoing colorectal surgery in a small rural hospital in northern Ontario, Canada. ERAS patients were matched to two patients in the control group based on diagnosis, age and gender. Patients had open or laparoscopic colorectal surgeries, with those in the intervention group treated per ERAS protocol and given instructions on pre- and post-operative self-care. Results: Most of the 47 ERAS patients recruited to the study reported adherence to ERAS protocols before surgery. Adherence to protocol was strongest for chewing gum in the days after surgery. Most patients were sitting in a chair for their afternoon meal by the 1st day and most were walking down the hallway by the 2nd day. The control group had significantly higher (P < 0.001) malignant neoplasm of the colon (C18, 69% vs. 35%) and significantly lower malignant neoplasm of the rectum (C20, 0% vs. 5%). The control group had an average ln-transformed LOS that was significantly longer (exponentiated as 1.7 days) than ERAS patients (t-test, P < 0.001). Conclusion: This study found that ERAS could be implemented in a small rural hospital and provided evidence for a reduced LOS of approximately 2 days.

Résumé Introduction: Les programmes de réhabilitation améliorée après chirurgie (RAAC) comprennent des itinéraires cliniques préopératoires, peropératoires et postopératoires visant à améliorer la qualité des soins aux patients tout en réduisant la durée du séjour et les réadmissions. Cette étude a évalué la faisabilité et les résultats d'un protocole de RAAC pour la chirurgie colorectale mis en oeuvre pendant deux ans dans un petit hôpital rural aux ressources limitées. Méthodes: Une étude de cohorte prospective a utilisé des témoins appariés pour évaluer l'effet de la RAAC sur la durée du séjour des patients subissant une chirurgie colorectale dans un petit hôpital rural du nord de l'Ontario, au Canada. Les patients RAAC ont été appariés à deux patients du groupe témoin sur la base du diagnostic, de l'âge et du sexe. Les patients ont subi une chirurgie colorectale ouverte ou laparoscopique, et ceux du groupe d'intervention ont été traités selon le protocole de RAAC et ont reçu des instructions sur les soins auto-administrés pré et postopératoires. Résultats: La plupart des 47 patients RAAC recrutés pour l'étude ont déclaré adhérer aux protocoles de RAAC avant l'intervention chirurgicale. L'adhésion au protocole a été la plus forte pour la gomme à mâcher dans les jours qui ont suivi l'opération. La plupart des patients étaient assis sur une chaise pour le repas de l'après-midi dès le premier jour et la plupart marchaient dans le couloir dès le deuxième jour. Le groupe témoin présentait un taux significativement plus élevé (P < 0,001) de néoplasme malin du côlon (C18, 69% contre 35%) et un taux significativement plus faible de néoplasme malin du rectum (C20, 0% contre 5%). Le groupe de contrôle avait une durée moyenne de séjour transformée en Ln significativement plus longue (exponentielle de 1,7 jours) que les patients RAAC (test t, P < 0,001). Conclusion: Cette étude a montré que la RAAC pouvait être mise en oeuvre dans un petit hôpital rural et a fourni des preuves d'une réduction de la durée de séjour d'environ deux jours. Mots-clés: Réhabilitation améliorée après chirurgie (RAAC); durée du séjour; hôpitaux ruraux; chirurgie colorectale; Ontario; soins périopératoires.

A High Pressure Operando Spectroscopy Examination of Bimetal Interactions in 'Metal Efficient' Palladium/In2 O3 /Al2 O3 Catalysts for CO2 Hydrogenation.

CO2 hydrogenation to methanol has the potential to serve as a sustainable route to a wide variety of hydrocarbons, fuels and plastics in the quest for net zero. Synergistic Pd/In2 O3 (Palldium on Indium Oxide) catalysts show high CO2 conversion and methanol selectivity, enhancing methanol yield. The identity of the optimal active site for this reaction is unclear, either as a Pd-In alloy, proximate metals, or distinct sites. In this work, we demonstrate that metal-efficient Pd/In2 O3 species dispersed on Al2 O3 can match the performance of pure Pd/In2 O3 systems. Further, we follow the evolution of both Pd and In sites, and surface species, under operando reaction conditions using X-ray Absorption Spectroscpy (XAS) and infrared (IR) spectroscopy. In doing so, we can determine both the nature of the active sites and the influence on the catalytic mechanism.

Exploring the Development of a Canadian Frostbite Care Network and the Future of Frostbite Care in Canada Using a Qualitative Approach.

INTRODUCTION: The Canadian Frostbite Collaborative project is exploring frostbite patient care needs and current practices in Canada to inform the development of a Canadian frostbite care network (CFCN) as a national quality improvement initiative. METHODS: Using a quantitative and qualitative approach, this study aimed to define the landscape of current frostbite practices, challenges, and interest in future work. RESULTS: Current frostbite care practices were initially assessed through semistructured phone interviews of Canadian healthcare providers. Canadian healthcare providers managing frostbite in a range of health disciplines and contexts then participated in focus group sessions discussing the potential roles and opportunities as well as potential challenges in developing a CFCN. Roles and opportunities for a network in advancing frostbite care included facilitating research, educating stakeholders, facilitating collaboration, standardizing care, and advocating for frostbite care. Challenges identified in frostbite care and network development included managing resources, navigating the Canadian healthcare system, overcoming low numbers, and communicating with policymakers and frontline providers. CONCLUSIONS: Formalizing a CFCN may provide important opportunities and support in overcoming critical barriers to providing high-quality frostbite care across Canada.

Placenta Accreta Spectrum Disorders: A National Survey.

OBJECTIVES: Describe the current practice of Canadian obstetricians-gynaecologists in managing placenta accreta spectrum (PAS) disorders from suspicion of diagnosis to delivery planning and explore the impact of the latest national practice guidelines on this topic. METHODS: We distributed a cross-sectional bilingual electronic survey to Canadian obstetricians-gynaecologists in March-April 2021. Demographic data and information on screening, diagnosis, and management were collected using a 39-item questionnaire. The survey was validated and pretested among a sample population. Descriptive statistics were used to present the results. RESULTS: We received 142 responses. Almost 60% of respondents said they had read the latest Society of Obstetricians and Gynaecologists of Canada clinical practice guideline on PAS disorders, published in July 2019. Nearly 1 in 3 respondents changed their practice following this guideline. Respondents highlighted the importance of 4 key points: (1) limiting travel to thereby remain close to a regional care centre, (2) preoperative anemia optimization, (3) performance of cesarean-hysterectomy leaving the placenta in situ (83%), (4) access via midline laparotomy (65%). Most respondents recognized the importance of perioperative blood loss reduction strategies such as tranexamic acid and perioperative thromboprophylaxis via sequential compression devices and low-molecular-weight heparin until full mobilization. CONCLUSIONS: This study demonstrates the impact of the Society of Obstetricians and Gynaecologists of Canada's PAS clinical practice guideline on management choices made by Canadian clinicians. Our study highlights the value of a multidisciplinary approach to reducing maternal morbidity in individuals facing surgery for a PAS disorder and the importance of regionalized care that is resourced to provide maternal-fetal medicine and surgical expertise, transfusion medicine, and critical care support.

Management of Acute Genital Ulcers: A Survey of North American Pediatric and Adolescent Gynecology Care Providers.

INTRODUCTION: Acute genital ulcers are painful ulcerations of the lower vagina and vulva, with limited data to guide management. We aimed to survey care providers to understand the workup and management of acute genital ulcers across North America. METHODS: A cross-sectional survey was distributed to members of NASPAG. Data are presented descriptively, and management practices between care providers are compared using Fisher's exact test. RESULTS: Responses from 100 NASPAG members were included. Common diagnostic tests performed were herpes simplex virus PCR (82%), Epstein-Barr virus serology (56%), and cytomegalovirus serology (47%). Topical steroids were considered by 67% on the basis of the degree of accompanying inflammation. There was no difference in corticosteroid prescriptions according to the type or location of providers (P > .05). DISCUSSION: Collaboration between pediatric and adolescent gynecology care providers is needed to prospectively evaluate the effectiveness of treatment modalities and develop evidence-based guidelines.

Expansion of the global RNA virome reveals diverse clades of bacteriophages.

High-throughput RNA sequencing offers broad opportunities to explore the Earth RNA virome. Mining 5,150 diverse metatranscriptomes uncovered >2.5 million RNA virus contigs. Analysis of >330,000 RNA-dependent RNA polymerases (RdRPs) shows that this expansion corresponds to a 5-fold increase of the known RNA virus diversity. Gene content analysis revealed multiple protein domains previously not found in RNA viruses and implicated in virus-host interactions. Extended RdRP phylogeny supports the monophyly of the five established phyla and reveals two putative additional bacteriophage phyla and numerous putative additional classes and orders. The dramatically expanded phylum Lenarviricota, consisting of bacterial and related eukaryotic viruses, now accounts for a third of the RNA virome. Identification of CRISPR spacer matches and bacteriolytic proteins suggests that subsets of picobirnaviruses and partitiviruses, previously associated with eukaryotes, infect prokaryotic hosts.

Minimally Invasive Management of Second Trimester Placenta Percreta.

STUDY OBJECTIVE: To describe the diagnostic and surgical challenges in the management of second trimester placenta percreta. DESIGN: Stepwise demonstration of the surgical technique with the use of an educational video. SETTING: Second trimester placenta percreta is a rare entity, with very few case reports in the literature. Our video demonstrates the challenges of a minimally invasive approach toward definitive surgical management with hysterectomy. A 39-year-old G7P3 (3 previous cesarean deliveries) female at 17 weeks and 2 days gestation presented with acute abdominal pain to a community hospital. This was a spontaneously conceived pregnancy. Her hemoglobin level on admission was 92 g/L. An ultrasound showed a normal uterus, and the appendix was not visualized. One unit of packed red blood cells was transfused, and she underwent exploratory laparoscopy for a possible retrocecal hematoma/mass seen on computerized tomography. In the operating room, acute hemoperitoneum was visualized with placenta-like tissue invading through the anterior lower uterine segment (Figures 2 & 3). A hemostatic agent (Floseal, Baxter) was placed over the bleeding, and she was then transferred to a tertiary academic center for further management. INTERVENTIONS: Magnetic resonance imaging was performed on the following day after transfer to our facility, which confirmed placenta percreta at the level of the bladder (Figure 1). Following counseling with a multidisciplinary team and given that there was ongoing bleeding from the invading placental tissue, pregnancy continuation and uterine conservation were not possible. The patient was offered preprocedure termination of pregnancy with intra-cardiac injection of potassium chloride and 350 cc of amniotic fluid was drained at that time. This was done to facilitate visualization for a minimally invasive approach. We describe 5 main challenges of minimally invasive hysterectomy for placental percreta and provide a stepwise approach to mitigating them: visibility, vascular control, bladder dissection, colpotomy, and specimen retrieval. We adapted the previously described laparotomy techniques of progressive uterine devascularization and approach to bladder dissection and colpotomy to laparoscopy [1,2]. In addition, we performed dilatation and evacuation to allow for vaginal specimen removal. The patient's postoperative course was uncomplicated, and she was discharged home in a stable condition. CONCLUSION: Midtrimester placenta percreta poses significant challenges in diagnosis and surgical management. Total laparoscopic hysterectomy for this condition poses unique challenges but is feasible and safe.

Innovation in Breast Surgery: Practical and Ethical Considerations.

The adoption of innovation is essential to the evolution of patient care. Breast surgical oncology advances through incorporating new techniques, devices, and procedures. Historical changes in practice standards from radical to modified radical mastectomy or axillary node dissection to sentinel node biopsy reduced morbidity without sacrifice in oncologic outcome. Contemporary oncoplastic techniques afford broader consideration for breast conservation and the potential for improved cosmetic outcomes. At present, many breast surgeons face the decision of which wireless device to use for localization of nonpalpable lesions. Consideration for future changes, such as robotic mastectomy, are on the horizon. No guideline exists to assist breast surgeons in the adoption of innovation into practice. The Ethics Committee of the American Society of Breast Surgeons acknowledges that breast surgeons confront many questions associated with onboarding innovation. This paper aims to provide a framework for asking relevant questions along with the ethical principles to consider when integrating an innovation into practice.

Influence of nutrient supply on plankton microbiome biodiversity and distribution in a coastal upwelling region.

The ecological and oceanographic processes that drive the response of pelagic ocean microbiomes to environmental changes remain poorly understood, particularly in coastal upwelling ecosystems. Here we show that seasonal and interannual variability in coastal upwelling predicts pelagic ocean microbiome diversity and community structure in the Southern California Current region. Ribosomal RNA gene sequencing, targeting prokaryotic and eukaryotic microbes, from samples collected seasonally during 2014-2020 indicate that nitracline depth is the most robust predictor of spatial microbial community structure and biodiversity in this region. Striking ecological changes occurred due to the transition from a warm anomaly during 2014-2016, characterized by intense stratification, to cooler conditions in 2017-2018, representative of more typical upwelling conditions, with photosynthetic eukaryotes, especially diatoms, changing most strongly. The regional slope of nitracline depth exerts strong control on the relative proportion of highly diverse offshore communities and low biodiversity, but highly productive nearshore communities.

Placenta accreta spectrum: a non-oncologic challenge for gynecologic oncologists.

Placenta accreta spectrum disorders are a major risk factor for severe postpartum hemorrhage and maternal death worldwide, with a rapidly growing incidence in recent decades due to increasing rates of cesarean section. Placenta accreta spectrum disorders represent a complex surgical challenge, with the primary concern of massive obstetrical hemorrhagic sequelae and organ damage, occurring in the context of potentially significant anatomical and physiological changes of pregnancy. Most international obstetrical organizations have published guidelines on placenta accreta spectrum, embracing the creation of regionalized 'Centers of Excellence' in the diagnosis and management of placenta accreta spectrum, which includes a dedicated multidisciplinary surgical team. One mandatory criterion for these Centers of Excellence is the presence of a surgeon experienced in complex pelvic surgeries. Indeed, many institutions in the United States and worldwide rely on gynecologic oncologists in the surgical management of placenta accreta spectrum due to their experience and skills in complex pelvic surgery. Surgical management of placenta accreta spectrum frequently includes challenging pelvic dissection in regions with distortion of anatomy alongside large aberrant neovascularization. With a goal of definitive management through cesarean hysterectomy, surgeons require a systematic and thoughtful approach to promote prevention of urologic injuries, embrace measures to secure challenging hemostasis and, in selected cases, employ conservative management where indicated or desired. In this review recommendations are made for gynecologic oncologists regarding the management and important considerations in the successful care of placenta accreta spectrum disorders. Where required, gynecologic oncologists are encouraged to be proactively involved in the management of placenta accreta spectrum, not only intra-operatively, but also in the development of clinical protocols, guidelines, and pre-operative counseling of patients, as a 'call if needed' approach is suboptimal for this potentially major and life-threatening condition.

Comparing estrogen-based hormonal contraceptives and hormone therapy on bone mineral density in women with premature ovarian insufficiency: a systematic review.

IMPORTANCE: Premature ovarian insufficiency (POI) is a condition associated with estrogen deficiency which leads to decreased bone mineral density and an increased risk of osteoporosis and fractures. Estrogen-based hormone therapy is an integral component of treatment; however, to date the ideal hormone formulation for optimizing bone health has not been established. OBJECTIVE: To assess the effects of estrogen-based oral contraceptives (OCP) versus hormone therapy (HT) on bone mineral density (BMD) in women with POI. EVIDENCE REVIEW: A systematic review of Ovid MEDLINE, EMBASE, Cochrane Library, and Web of Science databases was conducted from conception until December 2020. Randomized controlled trials (RCTs) and observational studies that met inclusion criteria were included in the analysis. Risk of bias was assessed with the Newcastle-Ottawa Quality Assessment Scale for cohort studies and the Cochrane Risk of Bias for RCTs. The study protocol was registered with the International Prospective Register of Systematic Reviews and adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. FINDINGS: Our search yielded 1,227 studies; 3 RCTs and 2 observational cohort studies met inclusion criteria and were included in our study. The largest subpopulation was Turner Syndrome (n = 625), followed by idiopathic POI (n = 146). Of the four studies that assessed changes in BMD, two studies reported a significant increase in lumbar spine BMD with HT compared with OCP (+0.050 g/cm2, P < 0.025; +0.019 g/cm2, P < 0.01), one study found similar improvement in lumbar spine BMD across treatments (HT -0.003 g/cm2, P = 0.824), and one study did not directly compare treatments. Effects on bone turnover markers were inconsistent across three studies that evaluated this outcome. CONCLUSIONS AND RELEVANCE: This is the first systematic review to include studies that directly compared OCP and HT on bone outcomes in POI. While two studies reported increased lumbar spine BMD with HT, this result was not consistently found across studies. There were important differences in POI etiology, treatment regimens and formulations, and risk of bias was high in many of the studies. These results indicate future, larger-scale trials are needed to further understand the optimal hormone therapy for bone density in POI.