Underdiagnosis of internal anal sphincter trauma following vaginal delivery.

OBJECTIVE: Damage to the anal sphincter during childbirth remains the leading cause of fecal incontinence in women. Defects in the internal (IAS) or external anal sphincter, alongside symptoms and sphincter tone, will generally dictate the suggested mode of delivery in any successive pregnancy. This study aimed to examine using endoanal ultrasonography the prevalence of IAS damage in women referred with Grade-3a or -3b obstetric anal sphincter injury (OASI) in a tertiary-referral perineal clinic. METHODS: This was a retrospective observational study of all women referred to a tertiary-referral perineal clinic after primary repair of OASI (Grade 3a-c, 4) diagnosed for the first time following vaginal delivery between January 2016 and December 2019, inclusive. Women were assessed using the Wexner bowel continence questionnaire, digital examination of sphincter tone and endoanal ultrasound. Injuries in each sphincter were classified as a scar (≤ 30°) or defect (> 30-90° or > 90°) on endoanal imaging in the axial plane. RESULTS: In total, 615 women were referred following primary repair of OASI. Sonographic evidence of damage to the IAS was seen in 9.1% (46/506) of women diagnosed with a Grade-3a/3b injury. In women referred with a Grade-3a/3b tear, symptom scores were statistically higher (P = 0.025) in those with an IAS defect > 30° compared to those with an intact or scarred IAS, although the median score was zero in both groups. The proportion of women in each group with severe symptoms (score > 9) was similar (2.6% vs 6.5%; P = 0.148). Among women referred with a Grade-3a/3b tear, sphincter tone was reduced more frequently in those with a defect of the IAS than in those with an intact or scarred IAS (52.2% vs 11.7%; odds ratio, 8.14 (95% CI, 4.26-15.67); P < 0.001). Regardless of the reason for referral, women with reduced sphincter tone on rectal examination were four times as likely to have had an IAS defect > 30° than were those with normal resting tone (risk ratio, 4.58 (95% CI, 3.25-6.45); P < 0.001). CONCLUSIONS: One in 11 women diagnosed with a Grade-3a or -3b tear have evidence of damage to their IAS on endoanal ultrasound. Damage to this muscle is linked to fecal incontinence in women and can have a significant impact on the planning of any future deliveries. This study highlights the importance of established perineal clinics with access to ultrasound. Nonetheless, if reduced sphincter tone is felt on rectal examination, a clinician should have a high index of suspicion for an occult IAS injury. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Vitamin D deficiency is associated with tuberculosis disease in British children.

BACKGROUND: Basic science, epidemiological and interventional research supports a link between vitamin D and tuberculosis (TB) immunity, infection and disease. We evaluated the association between vitamin D levels and TB infection and disease in UK children recruited to the National Institute for Health Research IGRA Kids Study (NIKS).METHODS: Children presenting between 2011 and 2014 were eligible if they had history of exposure to an adult case with sputum smear/culture-positive TB, or were referred and diagnosed with TB disease. Children were assessed at baseline and at 6-8 weeks for immunological evidence of TB infection (interferon-gamma release assay and/or tuberculin skin test) and evidence of TB disease. Some centres routinely measured total 25-hydroxy vitamin D (25-OHD) levels.RESULTS: A total of 166 children were included. The median 25-OHD levels were higher in non-infected children (45.5 nmol/l) than in those with tuberculous infection (36.2 nmol/l) and TB disease (20.0 nmol/l). The difference between TB infection and disease was statistically significant (P < 0.001). By logistic regression, lower vitamin D levels were associated with TB disease among participants with infection or disease, with no evidence of confounding by age, sex, bacille Calmette-Guérin vaccination status, ethnicity, non-contact referral, season or centre.CONCLUSION: Children with TB disease had lower vitamin D levels than children with infection. Implications for prevention and treatment remain to be established.

Characterization of enamel caries lesions in rat molars using synchrotron X-ray microtomography.

Dental caries is a ubiquitous infectious disease with a nearly 100% lifetime prevalence. Rodent caries models are widely used to investigate the etiology, progression and potential prevention or treatment of the disease. To explore the suitability of these models for deeper investigations of intact surface zones during enamel caries, the structures of early-stage carious lesions in rats were characterized and compared with previous reports on white spot enamel lesions in humans. Synchrotron X-ray microcomputed tomography non-destructively mapped demineralization in carious rat molar specimens across a range of caries severity, identifying 52 lesions across the 30 teeth imaged. Of these lesions, 13 were shown to have intact surface zones. Depth profiles of fractional mineral density were qualitatively similar to lesions in human teeth. However, the thickness of the surface zone in the rat model ranges from 10 to 58 µm, and is therefore significantly thinner than in human enamel. These results indicate that a fraction of lesions in rat caries possess an intact surface zone and are qualitatively similar to human lesions at the micrometer scale. This suggests that rat caries models may be a suitable analog through which to investigate the structure of surface zone enamel and its role during dental caries.

The Body Composition Monitor: a flexible tool for routine fluid management across the haemodialysis population.

Bioimpedance measurements with the Body Composition Monitor (BCM) have been shown to improve fluid management in haemodialysis. However, there is a lack of a sufficiently robust evidence-base for use of the BCM outside of standard protocols. This study aims to characterise BCM measurement variation to allow users to make measurements and interpret the results with confidence in a range of clinical scenarios. BCM measurements were made in 48 healthy controls and in 48 stable haemodialysis patients before and immediately after dialysis. The effect of utilising alternative measurement paths was assessed using mixed effects models and the effect of measuring post-dialysis was assessed by comparing changes in BCM-measured overhydration (OH) with weight changes over dialysis. The data from healthy controls suggest that there is no difference in BCM-measured OH between all the whole-body paths other than the foot-to-foot measurement. Dialysis patients showed similar results other than having higher BCM-measured OH when measured across the site of a vascular access. There was good agreement between BCM-measured OH and change in weight, suggesting post-dialysis measurements can be utilised. These results suggest BCM protocols can be flexible regarding measurement paths and timing of measurement to ensure as many patients as possible can benefit from the technology.

Day case transobturator tapes: a cut and dried solution.

BACKGROUND: The transobturator tape (TOT) has been utilized in the surgical management of SUI since 2001 when it was first described and is associated with minimal risk of trauma as its purely perineal insertion avoids entry to the retropubic space. Given its high success rate, low associated peri-operative morbidity and relative ease of insertion, it has been increasingly used as a day case procedure worldwide. AIM: This study aims to demonstrate the suitability of the transobturator tape (TOT) as a day surgery procedure in the Republic of Ireland. METHODS: A retrospective review of all the patients who underwent TOT as a day case procedure at a tertiary referral centre in Dublin over a 1 year period (March 2015-March 2016) was carried out. This was post the introduction of the procedure as a day case for a select group of patients. The outcomes evaluated included intraoperative and postoperative complication rates, voiding dysfunction rates, unscheduled inpatient admissions following the procedure and continence rates post-procedure. RESULTS: Fifteen cases were reviewed. There was one case with minor intraoperative complication of bladder perforation which was managed as an outpatient. One patient (6 %) failed to achieve adequate voiding within the 6-h timeframe allowed and, therefore, required overnight admission. All patients reported dryness at the 6-week review. Major elective waiting time for the gynaecology list decreased from 28 to 10 weeks 1 year post-commencement of the protocol. CONCLUSIONS: We conclude that the transobturator tape procedure is suitable as a day case in a select group of patients in the Irish healthcare setting. There was no increased rate of morbidity demonstrated in the group and readmission rates were low. It has reduced waiting times by increasing throughput of cases and ultimately will lead to reduced costs for hospitals.

Association of Oesophageal Hypertension with Bradycardia Mediated Deglutition Syncope.

Swallow syncope is a rare form of situational syncope. We report a case of swallow syncope with invasive confirmation of esophageal hypertension (spasm) and invasive confirmation of a bradycardia mechanism. Awareness of this uncommon disorder is important as a treatable cause of syncope.

QCD and strongly coupled gauge theories: challenges and perspectives.

We highlight the progress, current status, and open challenges of QCD-driven physics, in theory and in experiment. We discuss how the strong interaction is intimately connected to a broad sweep of physical problems, in settings ranging from astrophysics and cosmology to strongly coupled, complex systems in particle and condensed-matter physics, as well as to searches for physics beyond the Standard Model. We also discuss how success in describing the strong interaction impacts other fields, and, in turn, how such subjects can impact studies of the strong interaction. In the course of the work we offer a perspective on the many research streams which flow into and out of QCD, as well as a vision for future developments.

Evolution of in vitro fertilization at the University of the West Indies, Jamaica.

In vitro fertilization (IVF) provides hope for many couples who believed that they could not have children. This paper tracks the development of IVF treatment at The University of the West Indies (UWI), Mona, from its genesis in 2000. It highlights changes over the years in the population seeking IVF at UWI, Mona, and describes clinical services offered to clients, comparing success rates of services internationally. It also reports on seminal research emerging out of UWI, Mona, in the field of assisted reproductive health. The Hugh Wynter Fertility Management Unit (HWFMU), UWI, Mona, leads the way in shaping how society views those challenged with infertility and in its use of assisted reproductive technologies that improve the quality of life for many locally, within the Caribbean and the Diaspora.

Evolution of in vitro fertilization at the University of the West Indies, Jamaica / Evolución de la Fertilización in vitro en la Universidad de West Indies, Jamaica

In vitro fertilization (IVF) provides hope for many couples who believed that they could not have children. This paper tracks the development of IVF treatment at The University of the West Indies (UWI), Mona, from its genesis in 2000. It highlights changes over the years in the population seeking IVF at UWI, Mona, and describes clinical services offered to clients, comparing success rates of services internationally. It also reports on seminal research emerging out of UWI, Mona, in the field of assisted reproductive health. The Hugh Wynter Fertility Management Unit (HWFMU), UWI, Mona, leads the way in shaping how society views those challenged with infertility and in its use of assisted reproductive technologies that improve the quality of life for many locally, within the Caribbean and the Diaspora.

La fertilización in vitro (FIV) ofrece esperanza a muchas parejas que una vez creyeran no poder tener hijos. Este trabajo sigue el desarrollo del tratamiento de FIV en la Universidad de West Indies (UWI), Mona, a partir de su génesis en 2000. El mismo resalta los cambios durante los años en la población en busca de FIV en UWI, Mona, y describe los servicios clínicos ofrecidos a los clientes, al tiempo que compara las tasas de éxito a nivel internacional. También reporta acerca de la investigación seminal proveniente de UWI, Mona, en el campo de la salud reproductora asistida. La Unidad de Tratamiento de la Infertilidad Hugo Wynter UTIHEW), UWI, Mona, liderea el camino en cuanto a formar cómo la sociedad ha de ver a aquellos que enfrentan problemas de infertilidad, así como en relación con el uso de las tecnologías de reproducción asistida que mejoran localmente la calidad de vida de muchas personas en el Caribe y en la Diáspora.

Friedreich's Ataxia: a review from a cardiology perspective.

BACKGROUND: Neuromuscular disorders are not among the common causes of cardiomyopathy in the general population; however, cardiomyopathy is known to occur in several neuromuscular disorders including Friedreich's Ataxia (FA). In patients with neuromuscular disorders, concomitant cardiac involvement contributes significantly to morbidity and mortality and often leads to premature death. METHODS: An extensive literature search of Medline and Pubmed was conducted to include all published reports on cardiac involvement in FA. Secondary articles were identified from key paper reference listings. CONCLUSION: Hypertrophic cardiomyopathy is a cardinal feature of FA; therefore all FA patients should be screened for cardiomyopathy. A cardiac examination, ECG and ECHO are advised at diagnosis, and also on the development of any cardiac symptoms. Treatment is determined by the presence of symptoms, the presence of left ventricular outflow gradient and the sudden death risk. Institution of aggressive medical therapy early in the course of the disease may help improve quality of life and provide survival benefit.

Clinical and psychological impact of prophylactic implantable cardioverter-defibrillators in a community heart failure population.

AIMS: ICD implantation for primary prevention of sudden cardiac death in patients with left ventricular systolic dysfunction (ejection fraction ≤ 35%) has increased since the publication of the SCD-HEFT and MADIT-II data. The aim of this study is to examine the effectiveness and safety of prophylactic ICD use in a community heart failure population and to assess the impact on patient's quality of life. METHODS AND RESULTS: Seventy-one ICDs were inserted between the years 2002 and 2006. The mean follow-up from time of insertion was 24 ± 11 months. Eighteen patients (25%) had potentially life-saving therapy. Seven (10%) patients received inappropriate shocks. Complications were encountered in five patients (7%). CONCLUSION: In a community heart failure population, prophylactic ICD implantation is associated with a high incidence of life-saving therapy, a low complication rate and a high level of tolerability. These data indicate translation of clinical trial benefits to the general heart failure population.

Preservation of ovarian function.

In the last years, advances in diagnosis and new treatments of cancer patient have increased the life expectancy of children, adolescent and women with cancer. Unfortunately, the ovaries are very sensitive to chemio-radiotherapy that may induce the loss of ovarian function and fertility with consequent premature ovarian failure. The different cryopreservation options available for fertility preservation in cancer patients are embryo cryopreservation, oocyte cryopreservation and ovarian tissue cryopreservation. The choice depends on different parameters: the type and timing of cancer treatment, the type of disease, the patient's age. The advances in reproductive technology have made fertility preservation a real possibility for patients whether they are girls or young women whose gonadal function is threatened by natural premature menopause, or by cancer therapy or surgical sterilisation.

How effective is amniotomy as a means of induction of labour?

BACKGROUND: Amniotomy or artificial rupture of membranes is routinely used for induction of labour. AIMS: To assess the efficacy of amniotomy alone for induction. METHODS: A retrospective descriptive study of 3,586 cases of amniotomy for induction of labour between July 1996 and December 1999. RESULTS: In total, 26,670 women delivered in the National Maternity Hospital during the study period. Of these 4,928 women required induction of labour and 72.8% of these (n = 3,586) underwent amniotomy only for induction of labour. Spontaneous labour occurred in 90.1% of the women who underwent amniotomy within 24 h. Oxytocin as an induction agent was employed in 9.8% of cases. Overall, 80.5% of the women had a spontaneous delivery, 7.3% had a ventouse delivery, 4.3% had a forceps delivery, and 7.9% underwent a caesarean section. In total, 90.5% of multips and 63.4% of primips had a spontaneous vaginal delivery. CONCLUSIONS: Amniotomy is a simple, safe and effective method of induction of labour.

Clarithromycin induced torsade de pointes.

BACKGROUND: Clarithromycin is a commonly used macrolide antibiotic. It is known to cause QT prolongation. Medication induced QT prolongation is a major risk factor for the development of torsade de pointes. METHODS: A 79-year-old lady presented with frequent episodes of torsade de pointes following commencement of clarithromycin. This was noted to be in association with a prolongation of the QT interval. CONCLUSION: Knowledge of medications which prolong the QT interval is important to minimize the risk of ventricular arrhythmias, which may lead to sudden death. This is essential in patients with a congenitally long QT interval.

A retrospective study of the clinical experience of the implantable loop recorder in a paediatric setting.

The implantable loop recorder (ILR) has proved highly efficacious in the management of syncope, presyncope and palpitations in selected populations. Limited information regarding patient selection and diagnostic yield exists in the paediatric setting. A retrospective evaluation of patients who underwent ILR implantation over a 66-month period, in a tertiary paediatric cardiology unit was conducted. Twenty-three patients (10 male, 13 female) following initial assessment and investigation, were referred for device implantation. The mean age at time of ILR insertion was 11.39 +/- 4.34 (range, 2.0-16.8) years. The indications for ILR were recurrent syncope (n = 11), presyncope (n = 3) or palpitations (n = 9). Four (17.4%) patients had structural heart disease, three (13%) had a positive family history of sudden cardiac death and one (4%) had perinatal arrhythmia. One patient required ILR repositioning, and pocket infection necessitated explantation in one further patient. Minimum follow-up was 7.8 months during which symptoms were reported in 15 (65.2%) patients post-ILR insertion. Eight (34.7%) remained asymptomatic. Of the 15 who experienced symptom recurrence, eight (53.3%) had an arrhythmia recorded. Tachycardias recorded were polymorphic ventricular tachycardia (n = 1) and supraventricular tachycardia (n = 5). Clinically significant bradycardias documented, included sinus arrest (n = 1) and Mobitz type II second degree atrioventricular block (n = 1). The ILR had a high diagnostic yield, enabling an arrhythmic or non-arrhythmic diagnosis in 65.2% of patients with recurrent syncope, presyncope or palpitations in a selected paediatric population.

Glucose, palmitate and pro-inflammatory cytokines modulate production and activity of a phagocyte-like NADPH oxidase in rat pancreatic islets and a clonal beta cell line.

AIMS/HYPOTHESIS: Acute or chronic exposure of beta cells to glucose, palmitic acid or pro-inflammatory cytokines will result in increased production of the p47(phox) component of the NADPH oxidase and subsequent production of reactive oxygen species (ROS). METHODS: Rat pancreatic islets or clonal rat BRIN BD11 beta cells were incubated in the presence of glucose, palmitic acid or pro-inflammatory cytokines for periods between 1 and 24 h. p47(phox) production was determined by western blotting. ROS production was determined by spectrophotometric nitroblue tetrazolium or fluorescence-based hydroethidine assays. RESULTS: Incubation for 24 h in 0.1 mmol/l palmitic acid or a pro-inflammatory cytokine cocktail increased p47(phox) protein production by 1.5-fold or by 1.75-fold, respectively, in the BRIN BD11 beta cell line. In the presence of 16.7 mmol/l glucose protein production of p47(phox) was increased by 1.7-fold in isolated rat islets after 1 h, while in the presence of 0.1 mmol/l palmitic acid or 5 ng/ml IL-1beta it was increased by 1.4-fold or 1.8-fold, respectively. However, palmitic acid or IL-1beta-dependent production was reduced after 24 h. Islet ROS production was significantly increased after incubation in elevated glucose for 1 h and was completely abolished by addition of diphenylene iodonium, an inhibitor of NADPH oxidase or by the oligonucleotide anti-p47(phox). Addition of 0.1 mmol/l palmitic acid or 5 ng/ml IL-1beta plus 5.6 mmol/l glucose also resulted in a significant increase in islet ROS production after 1 h, which was partially attenuated by diphenylene iodonium or the protein kinase C inhibitor GF109203X. However, ROS production was reduced after 24 h incubation. CONCLUSIONS/INTERPRETATION: NADPH oxidase may play a key role in normal beta cell physiology, but under specific conditions may also contribute to beta cell demise.

Is vaginal breech delivery outdated for all singletons and twins? The current kaleidoscope of obstetric thinking.

The best practice for the delivery of a term breech in singleton and twin pregnancies is still controversial. We sought the opinions of obstetricians working in Ireland. A questionnaire was used to address the management of the obstetrician's "own hypothetical pregnancy" in three different scenarios. We also inquired about factors which might influence the decision on mode of delivery. The response rate was 104/174 (60%). In the scenario of a singleton fetus presenting by the breech in a nulliparous woman, 15/84 (18%) of obstetricians would chose a spontaneous vaginal delivery compared to 40/80 (50%) for a multiparous woman (p < 0.01). In the scenario of a second twin in breech presentation (nulliparous and multiparous), 75/93 (81%) would choose a spontaneous vaginal delivery. When asked about a singleton cephalic presentation, 85/91 (93%) would choose a spontaneous vaginal delivery. These decisions were influenced by concerns about perinatal morbidity [91/100 (91%)], published evidence [73/98 (75%)], the delivery doctor's inexperience [56/94 (60%)], but not by gender. Our study indicates that obstetricians in Ireland consider that there is a role for vaginal breech delivery in selected scenarios.

Solvent-detergent plasma as replacement therapy in a pregnant patient with factor V deficiency.

This case illustrates the successful treatment of factor V deficiency in pregnancy using solvent-detergent plasma.

Use of the paired-comparison technique to determine the most valued qualities of the McMaster Medical Programme Admissions Process.

The Undergraduate Medical Programme at McMaster University selects students using a comprehensive set of tools. Attempts to modify the selection process over many years have been impeded by an inability to reconcile very strongly held views among stakeholders as to the importance of the selection tools and, indeed, the very purposes of the admission process. The objective of this study was to identify key 'qualities' of the selection process and to measure their relative importance to admissions process assessors. Through a qualitative review of internal research documents, Medical Programme Admissions Committee meeting minutes, memos and accreditation surveys eight qualities of the admissions process were identified: validity, fairness, accessibility, comprehensiveness, affordability, legal defensibility, contribution to class diversity and the role of the process as a public statement of the Programme's values. Faculty, students and community admissions assessors were surveyed, by mail, using a paired-comparisons technique. The overall response rate was 58%. By a wide margin, all three groups of admissions assessors valued validity and fairness most highly. The least valued qualities were affordability and the role of the process as a statement of our values. Possible applications of this approach to the admissions process deliberations are discussed.