A crossed-disciplinary evaluation of parental perceptions surrounding pediatric non-invasive brain stimulation research.

PURPOSE ­: Recruitment for pediatric non-invasive brain stimulation (NIBS) studies is often challenged by low enrollment. Understanding parental perceptions regarding NIBS is crucial to develop new communication strategies to increase enrollment. DESIGN/METHODOLOGY/APPROACH ­: Integrating a crossed-disciplinary approach, the authors conducted a survey at the 2018 Minnesota State Fair querying the perception of risk and preferences of current and future parents associated with pediatric NIBS research. The survey consisted of 28 closed-text questions including demographics, photographs portraying NIBS, terminologies and factors related to NIBS studies. FINDINGS ­: Complete surveys were analyzed from 622 parent participants. A significant number of participants (42.8%) perceived the photographs of NIBS as "risky." Additionally, 65.43% perceived the term "Non-invasive brain therapy" as not risky, a word combination not currently being used when recruiting potential participants. Over 90% (561/622) of participants chose the photograph of child-friendly MRI suite. RESEARCH LIMITATIONS/IMPLICATIONS ­: Although this survey identified aspects crucial in recruitment for pediatric NIBS research, there were limitations. For example, the authors did not record the sex or demographic distribution (e.g. rural versus urban setting) of the participants. These factors may also influence recruitment messaging. ORIGINALITY/VALUE ­: For important medical research to impact and improve the lives of the potential remedies, participation by the public in clinical trials is necessary. Often the general public perceives the trials as risky as a result of poor marketing communication recruitment material. This study sought to be understood if how the message is encoded has an impact on the decoding by the receiver.

The dual influences of age and obstetric history on fecal continence in parous women.

OBJECTIVE: To assess whether women who underwent forceps delivery were more likely than those who delivered either normally (spontaneous vaginal delivery [SVD]) or by cesarean to experience deterioration in fecal continence as they aged. METHODS: The study investigated fecal continence assessment among women who gave birth to their first child 10, 20, or 30 years previously. Women who had undergone forceps delivery in the selected years were matched with women who had SVD in the same year. Two additional cohorts (1 premenopausal, 1 postmenopausal), who had only ever delivered by pre-labor cesarean, were identified for comparison. RESULTS: Of the 85 women who participated, 36 had undergone forceps delivery, 35 SVD, and 14 cesarean delivery only. The mode of vaginal delivery had no significant effect on continence scores or manometry pressures. Premenopausal women who had undergone cesarean delivery had significantly higher manometry pressures than those who delivered vaginally, but this protective effect was lost after the menopause. Multivariate analysis of pudendal nerve conduction found that the adverse effect of duration since delivery was greater than the adverse effect of forceps compared with vaginal delivery. CONCLUSION: Mode of delivery and aging affect pelvic floor function. Women who deliver via cesarean are not immune to age-related deterioration of anal sphincter function.

Levator ani injury in primiparous women with forceps delivery for fetal distress, forceps for second stage arrest, and spontaneous delivery.

OBJECTIVE: To compare levator ani muscle injury rates in primiparous women who had a forceps delivery owing to fetal distress with women delivered by forceps for second stage arrest; and to compare these injury rates with a historical control group of women who delivered spontaneously. METHODS: Primiparous women who delivered by forceps were recruited retrospectively into 2 groups: forceps for fetal distress with short second stage (25±11 minutes; n=19); and forceps delivery for second stage arrest (137±26 minutes; n=19). MR images of the levator ani muscles were compared with a historical control group of women from a previous study who had delivered spontaneously (n=129). RESULTS: Major defect rates were: 42% for forceps and short second stage; 63% for forceps and second stage arrest; and 6% for spontaneous delivery. The odds ratios for major injury were: 11.0 for forceps and short second stage compared with spontaneous delivery; 25.9 for forceps and second stage arrest compared with spontaneous delivery; and 2.3 for forceps and second stage arrest compared with short second stage (P=0.07). CONCLUSION: Women delivered by forceps have a higher rate of levator ani injury compared with spontaneous delivery controls; the difference between the forceps groups did not reach significance.

Effect of second vaginal delivery on anal function in patients at risk of occult anal sphincter injury after first forceps delivery.

PURPOSE: The study was designed to determine the effect of further vaginal delivery on anal sphincter function in women after apparently uncomplicated primiparous forceps delivery. METHODS: Fifty-two secundigravid women whose first child was forceps-assisted were compared with a control group of 20 women who had undergone spontaneous first vaginal delivery. Both groups were studied antenatally and again at 12 weeks after second delivery using a standardized bowel function questionnaire, endoanal ultrasound, and anal manometry. The primary outcome was fecal incontinence score after second delivery. RESULTS: Before second delivery, 20 of 52 (39 percent) of the forceps group and 3 of 20 (15 percent) control subjects (P = 0.103) reported minor alteration in fecal incontinence. Endoanal ultrasound was more frequently abnormal (38/52 (73 percent) vs. 6/20 (30 percent); P = 0.002), and median anal canal squeeze (71 vs. 104 mmHg; P = 0.004) and resting pressures (43 vs. 58 mmHg; P = 0.004) were lower in the forceps group. There was no difference in continence score between first and second delivery for the forceps group (P = 0.19) group or control subjects (P = 0.18). However, 10 of 38 (26 percent) women with an abnormal endoanal ultrasound after first forceps delivery developed new or worsening symptoms after second delivery. CONCLUSIONS: One-quarter of women with occult anal sphincter injury after first forceps delivery experienced some minor alteration in fecal continence after the second delivery.

State anxiety and visual attention: the role of the quiet eye period in aiming to a far target.

In this study, we examined how individuals controlled their gaze behaviour during execution of a far aiming task and whether the functional relationship between perception and action was disrupted by increased anxiety. Twenty participants were trained on a simulated archery task, using a joystick to aim and shoot arrows at the target, and then competed in two counterbalanced experimental conditions designed to manipulate the anxiety they experienced. The specific gaze behaviour measured was the duration of the quiet eye period. As predicted, accuracy was affected by the duration of the quiet eye period, with longer quiet eye periods being associated with better performance. The manipulation of anxiety resulted in reductions in the duration of quiet eye. Our results show that the quiet eye period is sensitive to increases in anxiety and may be a useful index of the efficiency of visual orientation in aiming tasks.

Internal anal sphincter defect influences continence outcome following obstetric anal sphincter injury.

OBJECTIVE: To date, little correlation has been found between the extent of anal sphincter injury defined by endoanal ultrasound and symptoms of postpartum fecal incontinence. To define this relationship, we assessed a large cohort of women following first recognized obstetric anal sphincter injury. STUDY DESIGN: In all, 500 consecutive women were studied at 3 months following primary repair of a first recognized obstetric anal sphincter injury sustained during vaginal delivery. Assessment included a standardized fecal incontinence questionnaire (modified Jorge-Wexner score), anal manometry, and endoanal ultrasound. Severe fecal incontinence was defined by a score greater than 9. Statistical significance of the relationship between symptoms and factors including age, parity, mode of delivery, and extent of sphincter injury (defined by endoanal ultrasound), was analyzed through multiple logistic regression. RESULTS: Increasing age (P = .006) and parity (P = .039), instrumental delivery (P < .001), an anal canal resting pressure of < or = 35 mm Hg (P = .047), and internal anal sphincter (IAS) injury (P = .002) were significantly related to the presence of fecal incontinence. With multivariate analysis, and adjusting for other factors, instrumental delivery (OR 3.1; 95% CI 1.2-7.9) and IAS defect thickness (partial thickness defect > 1 quadrant or full thickness defect; OR 5.1 95% CI 1.5-22.9) were predictive of severe incontinence, but external anal sphincter defects were not. CONCLUSION: Endosonographic evidence of IAS injury is predictive of fecal incontinence following obstetric anal sphincter injury. The presence of an IAS defect should be sought carefully if the anal sphincter is injured during vaginal delivery.

Randomized clinical trial of intra-anal electromyographic biofeedback physiotherapy with intra-anal electromyographic biofeedback augmented with electrical stimulation of the anal sphincter in the early treatment of postpartum fecal incontinence.

OBJECTIVE: The purpose of this study was to compare intra-anal electromyographic biofeedback alone with intra-anal biofeedback that was augmented with electrical stimulation of the anal sphincter in the treatment of postpartum fecal incontinence. A secondary aim was to examine the impact of the treatment on continence-related quality of life. STUDY DESIGN: Sixty symptomatic women were assigned randomly to receive intra-anal electromyographic biofeedback or electrical stimulation of the anal sphincter once weekly for 12 weeks and to perform daily pelvic floor exercises between treatments. Therapeutic response was evaluated with a symptom questionnaire to determine continence score, anal manometry, and endoanal ultrasound scanning. Quality of life was assessed before and after treatment with a validated questionnaire. RESULTS: Fifty-four women completed the treatment; 52 women (96%) had ultrasonic evidence of an external anal sphincter defect. After the treatment, both groups demonstrated significant improvement in continence score (P < .001) and in squeeze anal pressures (P < .04). Resting anal pressures did not alter significantly. Quality of life improved after the completion of physiotherapy, but there were no differences in outcome between intra-anal electromyographic biofeedback and electrical stimulation of the anal sphincter. CONCLUSION: Intra-anal electromyographic biofeedback therapy was associated with improved continence and quality of life in women with altered fecal continence after delivery. The addition of electrical stimulation of the anal sphincter did not enhance symptomatic outcome.

Randomized, clinical trial of bowel confinement vs. laxative use after primary repair of a third-degree obstetric anal sphincter tear.

PURPOSE: Third-degree tears are generally managed by primary anal sphincter repair. Postoperatively, some physicians recommend laxative use, whereas others favor bowel confinement after anorectal reconstructive surgery. This randomized trial was designed to compare a laxative regimen with a constipating regimen in early postoperative management after primary obstetric anal sphincter repair. METHODS: A total of 105 females were randomized after primary repair of a third-degree tear to receive lactulose (laxative group) or codeine phosphate (constipated group) for three days postoperatively. Patients were reviewed at three days and at three months postpartum. Recorded outcome measures were symptomatic and functional outcome and early postoperative morbidity. RESULTS: Forty-nine patients were randomly assigned to the constipated group and 56 patients to the laxative group. The first postoperative bowel motion occurred at a median of four (mean, 4.5 (range, 1-9)) days in the constipated group and at two (mean, 2.5 (range, 1-7)) days in the laxative group (P<0.001). Patients in the constipated group had a significantly more painful first evacuation compared with the laxative group (P<0.001). The mean duration of hospital stay was 3.7 (range, 2-6) days in the constipated group and 3.05 days in the laxative group (range, 2-5; P=0.001). Nine patients in the constipated group complained of troublesome postoperative constipation compared with three in the laxative group (P=0.033). Continence scores, anal manometry, and endoanal ultrasound findings were similar in the two groups at three months postpartum. CONCLUSIONS: Patients in the laxative group had a significantly earlier and less painful bowel motion and earlier postnatal discharge. There was no difference in the symptomatic or functional outcome of repair between the two regimens.

Randomised clinical trial to assess anal sphincter function following forceps or vacuum assisted vaginal delivery.

OBJECTIVE: To compare, in a prospective, randomised controlled trial, differences in anal sphincter function following forceps or vacuum assisted vaginal delivery in an institution practising standardised management of labour. DESIGN: Prospective, randomised controlled trial. SETTING: Tertiary-referral maternity teaching hospital. POPULATION: One hundred and thirty women. METHODS: Primiparous women were recruited antenatally and if an instrumental delivery was indicated, were randomised to either a vacuum or low-cavity, non-rotational forceps assisted delivery. Follow up consisted of a symptom questionnaire, anal manometry and endoanal ultrasound at three months postpartum. MAIN OUTCOME MEASURES: Faecal continence scores, anal manometry, endoanal ultrasound. RESULTS: Sixty-one women delivered with forceps assistance (40 for failure to progress in the second stage) and 69 with vacuum assistance (33 for failure to progress); 16/69 vacuum deliveries proceeded to a forceps assisted delivery (23%). There were no statistical differences in the antecedent antenatal factors between the two groups. A third degree perineal tear followed 10 (16%) forceps and 5 (7%) vacuum deliveries. Based on intention-to-treat analysis, 36 (59%) women complained of altered faecal continence after forceps delivery compared with 23 (33%) following vacuum delivery three months postpartum (RR 2.88, 95% CI 1.41-5.88). Endoanal ultrasound was reported as abnormal following 34 (56%) forceps deliveries and 34 (49%) vacuum deliveries (RR 1.3, 95% CI 0.65-258). After exclusion of 'failed vacuum', median anal canal resting pressure was significantly lower following forceps delivery compared with vacuum delivery alone (P = 0.004). There were no significant differences in degree of ultrasound abnormality between the two groups. CONCLUSIONS: Symptoms of altered faecal continence are significantly more common following forceps assisted vaginal delivery. Based on continence outcome, when circumstances allow, vacuum should be the instrument of first choice in assisted delivery.