The value of three-dimensional ultrasound in identifying Mullerian anomalies at risk of adverse pregnancy outcomes.

OBJECTIVE: To examine the reliability of three-dimensional ultrasound (3 D-US) in the differentiation between subseptate and arcuate uteri, due to the different associated pregnancy outcomes; refine the existing 3 D-US parameters and evaluate the concordance between 3 D-US and MRI in diagnosing these anomalies. STUDY DESIGN: This was a prospective cohort study of 455 women suspected of having a Mullerian anomaly. The diagnosis of subseptate, bicornuate or arcuate uterus was made by 3 D-US in 55 women. Two independent examiners manipulated the 3 D-US volume datasets and recorded the internal intercornual distance, indentation length, indentation tip angle, and myometrial wall thickness in the coronal plane of the uterus. Subsequently, 48 women underwent MRI which was used as the reference test for diagnosis. We calculated the degree of correlation between the two ultrasound assessors' 3 D-US measurements using interclass correlation coefficient and as well as a Bland-Altman plot. The mean values of the four parameters were used to create receiver operating characteristic curves for determining the best cutoff values for differentiation between subseptate and arcuate uterui. We used the Cohen's Kappa test to measure the level of agreement between 3 D-US and MRI. RESULTS: There was good interobserver agreement between the two 3 D-US assessors for all four parameters. There was a substantial level of agreement between 3 D-US and MRI in differentiating between bicornuate, subseptate and arcuate uteri with a kappa value of 0.727 (95% CI 0.443-0.856). Distinction between subseptate and arcuate uterus was improved when using an indentation length ≥12.5 mm (AUC 0.99) and indentation tip angle ≤89.25 degrees (AUC 0.97) as cutoffs for diagnosis but not the internal intercornual distance or myometrial wall thickness. CONCLUSION: 3 D-US evaluation of the coronal view of the uterus can be relied upon to make a noninvasive, accurate differentiation between subseptate and arcuate uteri. The fundal indentation length and indentation tip angle cut offs of ≥12.5 mm and ≤88 mm, respectively were found to be most accurate for distinction. Thus, allowing for individualizing pre-pregnancy management plans and patient-informed healthcare choices.HighlightsThere are no agreed upon criteria for differentiating arcuate from subseptate uteri. Such differentiation is critical for counseling and management due to the substantial difference in pregnancy outcome.We aimed to propose cut off values for ultrasound measurements standardized against MRI diagnostic criteria for accurate differentiation between arcuate and subseptate uteri.We demonstrated substantial agreement between 3D-US and MRI in differentiating between bicornuate, subseptate and arcuate uteri.3D-US evaluation of the coronal view of the uterus is reliable to make an accurate differentiation between subseptate and arcuate uteri.Using the indentation length ≥12.5 mm and indentation tip angle ≤89.25 degrees as parameters to be measured on the coronal view by 3D-US increases its diagnostic accuracy for distinction between arcuate and subseptate uteri.

Dexmedetomidine versus clonidine adjuvants to levobupivacaine for ultrasound-guided transversus abdominis plane block in paediatric laparoscopic orchiopexy: Randomized, double-blind study.

BACKGROUND: Laparoscopic surgeries are associated with less postoperative pain and adverse events compared to open procedures. But, it still reduces the quality of life in children. Transversus abdominis plane (TAP) block is used to reduce pain. We hypothesized that dexmedetomidine or clonidine could improve the analgesic profile of levobupivacaine to the same extent during TAP block in children. METHODS: Ninety children were randomly allocated in a randomized double-blind trial to receive bilateral TAP block with levobupivacaine plus normal saline (group B, n = 30), or dexmedetomidine (group D, n = 30) or clonidine (group C, n = 30). Primary outcome was the modified Children's Hospital of Eastern Ontario Pain Scale score. Secondary outcomes included time to initial analgesic request, number of analgesic claims, total analgesic consumption, parents' satisfaction, sedation score and complications. RESULTS: Children of group D showed reduced pain scores compared to other groups. They represented the longest period of analgesia (565.00 ± 71.5 min) with p < 0.001, and fewer patients required two doses of analgesia during the first postoperative day. The cumulative amount of backup analgesia was significantly different between these groups (p = 0.026). Higher parents' satisfaction scores were recorded in groups D and C compared to group B. Sedation among the study groups revealed significant differences (p = 0.035), but no severe complications were recorded. CONCLUSIONS: Adding dexmedetomidine to levobupivacaine can extend the time of analgesia and reduce the use of postoperative backup analgesics with minimal sedation effects when used in TAP block in paediatrics undergoing laparoscopic orchiopexy. Clonidine can be used as an alternative adjuvant to local anaesthetics with good postoperative analgesic profiles. SIGNIFICANCE: Clonidine can alternate dexmedetomidine during TAP block with local anesthetics for pediatrics laparoscopies. Both can lead to better postoperative analgesic profiles. Clonidine may be preferred, especially in our developing regions, because of its easy availability and lower cost than that of dexmedetomidine.

Reassessment of osteoporosis-related femoral fractures and economic burden in Saudi Arabia.

UNLABELLED: The current study reassesses the prevalence of fragility fractures and lifetime costs in the Eastern Province of Saudi Arabia. Forty-two percent (391) of the fractures were at the neck of the femur, and 38.6 % (354) were inter-trochanteric fractures. The overall incidence was assessed to be 7528 (1,300,336 population 55 years or older) with the direct cost of SR564.75 million ($150.60 million). A National Fracture Registry and osteoporosis awareness programs are recommended. PURPOSE: Proximal femur fragility fractures are reported to be increasing worldwide due to increased life expectancy. The current study is carried out to assess the incidence of such fractures in the Eastern Province of Saudi Arabia and to assess the costs incurred in managing them annually. Finally, by extrapolating the data, the study can calculate the overall economic burden in Saudi Arabia. METHODS: The data of fragility proximal femur fractures was collected from 24 of 28 hospitals in the Eastern Province. The data included age, sex, mode of injury, type of fracture, prescribed drug (and its cost), and length of hospital stay. Population statistics were obtained from the Department of Statistics of the Saudi Arabian government Web site. RESULTS: Twenty-four hospitals (85 %) participated in the study. A total of 780 fractures were sustained by 681 patients. Length of stay in the hospital averaged 23.28 ± 13.08 days. The projected fracture rate from all the hospitals would be 917 (an incidence of 5.81/1000), with a total cost of SR68.77 million. Further extrapolation showed that the overall incidence could be 7528 (1,300,336 population 55 years or older) with the direct cost of SR564.75 million ($150.60 million). CONCLUSIONS: Osteoporosis-related femoral fractures in Saudi Arabia are significant causes of morbidity besides incurring economic burden. We believe that a National Fracture Registry needs to be established, and osteoporosis awareness programs should be instituted in every part of Saudi Arabia so that these patients can be diagnosed early and treated appropriately to reduce both the number of fractures and the economic burden of the fractures.