Center-by-center results of a multicenter prospective trial to determine the inter-observer correlation of the simplified POP-Q in describing pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: This study was conducted to determine the differences in the inter-observer agreement of the simplified Pelvic Organ Prolapse Quantification (POP-Q) system from center to center in a large international multicenter study. METHODS: This is a secondary analysis of the results of a large prospective single blind multicenter trial studying the inter-observer agreement of a simplified POP-Q exam. Twelve centers from four continents with a total of 511 subjects were included in this study. The number of subjects recruited per center ranged from 20 to 81. Each patient was independently examined by two investigators, with examination order randomly assigned and investigators blinded to each other's result. The weighted kappa statistic was used to evaluate the inter-observer agreement. RESULTS: Good and significant associations were observed on the anterior, posterior, and apical segments. Six out of 11 sites did not provide adequate number of subjects with prior hysterectomy for weighted kappa statistics or achieve significance regarding vaginal cuff measurement. CONCLUSIONS: The simplified POP-Q demonstrated good inter-examiner agreement across multiple centers.

Urolithiasis in pregnancy.

Urolithiasis is the most common cause of urological-related abdominal pain in pregnant women after urinary tract infection. The disease is not uncommon during pregnancy occurring in 1/200 to 1/2,000 women, which is not different from the incidence reported in the nonpregnant female population of reproductive age. During pregnancy, the frequency of stone localization is twice as higher in the ureter than in the renal pelvis or calyx, but there is no difference between the left and right kidney or ureter. Urinary stones during pregnancy are composed mainly of calcium phosphate (hydroxyapatite) in 74% of cases and calcium oxalate in the remaining 26% (Ross et al., Urol Res 36:99-102, 2008). In conclusion, urolithiasis during pregnancy can be serious, causing preterm labor in up to 40% of affected women. The pathogenesis, diagnosis, and management are analyzed.

Gadolinium nephrotoxicity: case report of a rare entity and review of the literature.

Radiocontrast exposure has now become an important cause of iatrogenic acute kidney injury (AKI) in hospitalized patients due to an increase in the number of diagnostic and interventional procedures done. Gadolinium, a well-known paramagnetic contrast agent used primarily for magnetic resonance imaging (MRI), has attracted a lot of attention for its safety in patients at risk for AKI, namely those with chronic kidney disease (CKD) and diabetes. Since its widespread use, a few cases of gadolinium nephrotoxicity have been reported in the literature. However, this remains a largely unrecognized complication in the field of nephrology. Here we describe such a case of AKI due to gadolinium toxicity in a 65-year-old African-American man with a history of hypertension, diabetes and chronic kidney disease, who was admitted for a toe infection and consequently developed AKI from multiple imaging studies involving the use of gadolinium.

Predicting proteinuria in hypertensive pregnancies with urinary protein-creatinine or calcium-creatinine ratio.

OBJECTIVE: Evaluate the value of random urinary protein-creatinine (PrCr) and calcium-creatinine (CaCr) ratios to predict 24-h proteinuria in hypertensive pregnancies. STUDY DESIGN: Spot urine samples were collected before routine 24-h urine collections from consecutive pregnant women with hypertension (n=83). Reliability of spot urinary PrCr and CaCr to detect significant proteinuria (>or=300 mg/day) using 24-h urine protein as 'gold-standard' was assessed by receiver-operating characteristic (ROC) curve. RESULTS: Fifty-one patients (61.4%) had significant proteinuria (45 pre-eclampsia, 5 superimposed pre-eclampsia, 1 renal hypertension). Area under ROC curve to predict proteinuria was 0.82 (95% confidence interval (CI) 0.73 to 0.92, P<0.001) for PrCr and 0.55 (95% CI 0.43 to 0.68, P=0.2) for CaCr. A cutoff value of >0.19 for PrCr best predicted significant proteinuria with sensitivity, specificity, positive and negative predictive values and likelihood ratios (positive and negative), respectively, of 80.4, 68.8, 80.4, 68.8%, 2.57 and 3.51. CONCLUSION: Spot urinary PrCr predicts total urinary protein excretion in hypertensive pregnancies.

Obstetric impact of anaemia in pregnant women in United Arab Emirates.

Our objective was to determine the effect of anaemia during pregnancy on maternal and perinatal outcome. A retrospective case-control study was conduced on 100 anaemic (haemoglobin level < 11g/dl) and 100 non-anaemic, pregnant women with singleton pregnancies who received antenatal care and delivered vaginally in our hospital. The maternal characteristics of both groups were not different. The causes of anaemia were iron deficiency (91%), beta-thalassaemia trait (8%) and folate deficiency (1%). There was no significant difference in the mean gestational age at delivery (38.9 +/- 2.0 vs 39.6 +/- 1.6 weeks), 5-minute Apgar score (7.8 +/- 0.8 vs 7.9 +/- 0.1) and birth weight (3,150 +/- 530 vs 3,230 +/- 430 g) between both groups. Post-partum haemorrhage (3%), pre-term delivery (4%) and fetal growth restriction (6%) were more frequent in anaemic women but the difference was not significant. Anaemia, therefore, had no significant obstetric adverse effects in our pregnant hospital-population.

Factors influencing the quality of life of infertile women in United Arab Emirates.

OBJECTIVES: To measure the quality of life in a representative sample of infertile women and evaluate their sociocultural attitude to this condition. METHODS: Two hundred sixty-nine infertile women attending the Assisted Reproduction clinic, Tawam Hospital were consecutively selected. They were interviewed about the effect of infertility on their quality of life using a structured, measurement-specific and pre-tested questionnaire. RESULTS: Parameters mostly affected were mood-related mainly in women above 30 years, with primary and female factor infertility and those in polygamous marriages. Quality of life did not affect sexual performance and was not affected by duration of infertility or cost of treatment. CONCLUSION: The results highlight the importance of bearing children and the stresses exerted on infertile women in Eastern societies. Thorough counseling and continuing support of infertile women is therefore indicated to improve their quality of life.

The prevalence and determinants of health care-seeking behavior for fecal incontinence in multiparous United Arab Emirates females.

PURPOSE: This study was designed to determine the prevalence and sociodemographics of fecal incontinence in United Arab Emirates females. METHODS: A representative sample of multiparous United Arab Emirates females aged 20 years or older (N = 450) were randomly selected from the community (n = 225) and health care centers (n = 225). Patients were interviewed about inappropriate stool loss in the past year using a structured and pretested questionnaire. RESULTS: Fifty-one participants (11.3 percent) admitted fecal incontinence; 26 (5.8 percent) were incontinent to liquid stool and 25 (5.5 percent) to solid stool. Thirty-eight patients (8.4 percent) had double (urinary and fecal) incontinence. Sixty-five patients (14.4 percent) were incontinent to flatus only but not to stools. The association between having fecal incontinence and chronic constipation was significant (P < 0.0001), but there was no significant association with other known risk factors such as age, parity, and previous instrumental delivery, episiotomy, perineal tears, or anorectal operations. Only 21 incontinent patients (41 percent) had sought medical advice. Patients did not seek medical advice because they were embarrassed to consult their physician (64.7 percent), they preferred to discuss the difficulty with friends, assuming that fecal incontinence would resolve spontaneously (47.1 percent) or was normal (31.3 percent), and they chose self-treatment as a result of low expectations for medical care (23.5 percent). Sufferers were bothered by the inability to pray (92.2 percent) and to have sexual intercourse (43.1 percent). Perceived causes of fecal incontinence were paralysis (90.2 percent), old age (80.4 percent), childbirth (23.5 percent), or menopause (19.6 percent). CONCLUSIONS: Fecal incontinence is common yet underreported by multiparous United Arab Emirates females because of cultural attitudes and inadequate public knowledge.

The prevalence of urinary tract infections in patients with gestational diabetes mellitus.

Microbiologic evidence of urinary tract infection was studied in 447 pregnant women with (n = 149) or without (control group, n = 298) gestational diabetes mellitus after mid-pregnancy. Laboratory investigations included chemical analysis, microscopic examination and culture of a clean midstream voided urine specimen. Nineteen women (4.2%) had asymptomatic bacteriuria (7 study, 12 control, P=0.7). Of these, 7 (38%) developed symptomatic infection despite treatment with antibiotics (2 study, 5 control, P=0.7) and 6 (31%) had recurrent bacteriuria later in pregnancy (3 study, 3 control, P=0.3). Twelve more women (2.6%) had symptomatic infection (5 study, 7 control, P=0.5), 7 had acute cystitis (3 study, 4 control, P=0.5) and 5 had acute pyelonephritis (2 study, 3 control, P=0.7). Escherichia coli was the commonest pathogen, accounting for 22 (71%) infection episodes. Gestational diabetes mellitus was not associated with increased risk of urinary tract infections nor of maternal and perinatal morbidity as a result of infection.

Evidence of progesterone receptors in the mucosa of the urinary bladder.

OBJECTIVE: To investigate whether progesterone receptors are present in the mucosa of the urinary bladder of continent premenopausal women compared with continent postmenopausal women. MATERIALS AND METHODS: Fifty-seven biopsies from the mucosa of the trigone and lateral wall of the urinary bladder were examined by the avidin-biotin-peroxidase immunohistochemical technique for the presence of estrogen and progesterone receptors. The specimens were obtained at cystoscopy performed to investigate hematuria in 42 patients and neoplasia in 15. The study group (n = 29) comprised non-pregnant premenopausal women in the luteal phase of their menstrual cycle and the control group (n = 28) comprised postmenopausal women. None of the subjects had urinary incontinence or was taking medication with hormones. In no case did the primary lesion involve the specimen used for laboratory analysis. RESULTS: There was positive immunostaining with estrogen in 28 patients of the study group (96.5%) and 4 (14.4%) in the control group (p<0.0001). The 28 samples of the study group also showed positive immunostaining for progesterone receptors. There was positive immunostaining with progesterone in 18 samples (64.3%) of the control group (p<0.01). Fourteen samples (50%) of the control group thus showed positive immunostaining for progesterone but no evidence of positive immunostaining with estrogen. Immunostaining for estrogen and progesterone receptors was similar in trigonal and lateral wall samples. CONCLUSION: In continent pre- and post-menopausal women, a direct progestogenic effect on the mucosa of the urinary bladder seems likely in addition to estrogen.

Women's perceptions and experiences of childbirth in United Arab Emirates.

AIMS: To determine women's perceptions and experiences of childbirth in United Arab Emirates [UAE]. METHODS: A consecutive sample of 715 women who delivered during a 3 month period wer interviewed on the third postnatal day about their experience and satisfaction with maternity care using a structured questionnaire. RESULTS: 95 (13.2%) women had negative feelings including fear, anger, sorrow and regret, guilt, jealousy, sense of failure and disappointment while the rest felt that childbirth was enjoyable and that they had been well-informed, especially by nurses, about their perinatal care. Subjects delivered by cesarean (N = 104, 14.5%) were significantly less satisfied with the information provided by their caregivers and their involvement in decision-making before the operation than the vaginal group (p = 0.001). Irrespective of mode of delivery, most participants strongly agreed that cesarean is worse than vaginal delivery whatever the reason and should be performed only for medical reasons. Adverse maternal experiences were significantly more frequent with cesarean delivery (p = 0.00001), older age (p = 0.04), primiparity (p = 0.03), higher education (p = 0.03), lack of antenatal care (p = 0.03) and prolonged labor (p = 0.04). CONCLUSIONS: Childbirth experience and the prevalence and correlates of postnatal psychosocial morbidity in UAE are not different from those observed elsewhere.

Comparison of the inhibitory effects of cromakalim and pinacidil (potassium channel openers) with those of oxybutynin on stimulated guinea pig and rabbit detrusor muscle strips.

To compare the inhibitory effects of a new group of smooth muscle relaxants, the potassium channel openers cromakalim and pinacidil, with those of oxybutynin on detrusor muscle stimulation in animals. Detrusor strips of guinea pigs (n=16) and rabbits (n=20) were mounted in organ bath for recording of isometric tension. Alpha,beta-methylene ATP (10(-7), 10(-6), 10(-5) M), carbachol (10(-6), 10(-5), 3 x 10(-5), 5 x 10(-5) M) and transmural electrical-field stimulation (TES) were applied and concentration-response curves in the absence or presence of cromakalim (10(-6), 10(-5) M), pinacidil (10(-5), 5 x 10(-5) M) and oxybutynin (10(-5), 5 x 10(-5) M) were generated. All curves were displaced to the right in a concentration-dependent manner. The order of potency of inhibition was as follows: alpha,beta-methylene ATP (pinacidil>oxybutynin>cromakalim in guinea pigs; pinacidil>cromakalim>oxybutynin in rabbits); TES (pinacidil>cromakalim>oxybutynin in guinea pigs; cromakalim>oxybutynin>pinacidil in rabbits); carbachol (oxybutynin>pinacidil>cromakalim in guinea pigs; oxybutynin>cromakalim>pinacidil in rabbits). Cromakalim and pinacidil mainly inhibited purinergic-induced (alpha,beta-methylene ATP and TES) detrusor contractions.

Identifying characteristics that students, interns and residents look for in their role models.

OBJECTIVE: To identify characteristics which students, interns and residents look for in their role models. METHODS: A 45-item self-administered questionnaire was sent to a sample (n=96, response rate 80%) consisting of three groups: (1) students in years 3-6 of the medical curriculum (n=66); (2) interns (n=17) and (3) residents (n=13). The questionnaire contained characteristics that participants might use to describe excellent role models, grouped under five general headings: personality, clinical, research and teaching skills, and community service. Other characteristics mentioned by study subjects were qualitatively analysed using content analysis. RESULTS: Personality and teaching and clinical skills were ranked as the top three factors, and research skills and community service as the least important factors by 79 (82%) respondents. Qualitative analysis of characteristics described by respondents for their role models yielded 21 characteristics. These were clustered into three main themes: role models as teacher, physician and person. The most frequently mentioned characteristics were personal characteristics such as positive, respectful attitudes toward patients and their families, and staff and colleagues; honesty; politeness; enthusiasm; competence, and knowledge. Females rated nine personal characteristics significantly higher than males (P < 0.05). Interns and residents valued teaching enthusiasm and competence significantly more than students (P=0.01). Role models had a strong influence on the specialty choice of 53 (55%) respondents. CONCLUSION: Knowing the characteristics of excellent role models should help medical educators to formulate strategies to recruit, retain and develop them. Increasing exposure of a variety of excellent role models to aspiring medical practitioners should be encouraged.

Obstetric outcome in grand multipara in the United Arab Emirates. A case control study.

OBJECTIVE: To compare the obstetric outcome in grand multiparous and low parous United Arab Emirates women. METHOD: The records of 418 grand multiparous women (study group), defined as having had given birth at least 5 times after completed 22 weeks gestational age, and 418 women of parity 2-4 (control group) were reviewed. RESULTS: Mean parity in the study group was 7.9 +/- 2.4. The number of subjects who attended for antenatal care and the number of visits were equal in both groups. Diabetes mellitus (both overt and gestational) was significantly more common in the study group (p < 0.0001) but there was no significant increase in the incidence of other obstetric complications nor in perinatal mortality rate. Babies of grand multiparous mothers required significantly more admissions to special care unit because of maternal diabetes mellitus (p < 0.0002). CONCLUSION: Diabetes mellitus was more common in grand multiparous United Arab Emirates women but the incidence of other obstetric complications was similar to lower parity women.

Abnormal vascular coiling of the umbilical cord in gestational diabetes mellitus.

The objective of this study was to identify abnormal vascular coiling of the umbilical cord in neonates of mothers with gestational diabetes mellitus. The umbilical cords of 57 neonates of gestational diabetic mothers were examined and the coiling index determined by dividing the total number of complete vascular coils by the length of the cord in centimeters. Obstetric history, delivery data and neonatal outcome were also evaluated. These variables were compared with those obtained for 389 normal pregnancies. The frequency distribution of umbilical coiling index in the control population and gestational diabetic mothers were normal (10th and 90th percentiles = 0.17 and 0.37; mean +/- SD = 0.26 +/- 0.09 and 0.24 +/- 0.12 coils/cm, respectively). Non-coiling and hyper-coiling were significantly more frequent with diabetic than with normal pregnancy (p = 0.004; p = 0.008, respectively). Both abnormalities of umbilical vascular coiling were also significantly associated with adverse perinatal outcome (p = 0.04) and emergency cesarean delivery (p < 0.0001) in the diabetic and control (p = 0.03; p < 0.0001, respectively) groups. Neonates of gestational diabetic mothers are therefore more likely to have hyper-coiled or non-coiled umbilical blood vessels. Perinatal morbidity and emergency cesarean delivery are increased in this subgroup.

Assessing confidence and competence of senior medical students in an obstetrics and gynaecology clerkship using an OSCE.

CONTEXT: Assessment of clinical confidence and competence of senior medical students during an obstetrics and gynaecology clerkship using an objective structured clinical examination (OSCE). METHOD: A questionnaire was distributed to senior medical students (n=47)to assess pre- and post-OSCE self-perceived confidence and competence in five clinical skills: history taking, performing pelvic examination, interacting and communicating with patients, clinical reasoning and dealing with difficult patient situations. Pre- and post-performance confidence levels were compared and correlated with OSCE scores. RESULTS: The five clinical skills were significantly interrelated (p=0.001). There was no significant difference in OSCE performances between male (n=16) and female (n=31) students. Pre- and post-OSCE confidence in performing pelvic examination was significantly higher in female than male students (p=0.01). Post-OSCE confidence in clinical reasoning and dealing with difficult patient situations only were significantly increased in both groups (p=0.01 and p=0.02, respectively). Pre- and post-performance confidence levels were not significantly correlated to OSCE scores. CONCLUSION: Of five clinical skills rated, self-confidence in clinical reasoning skills and dealing with challenging or complex patient problems only were significantly increased after an OSCE assessing competence. The content of some of our OSCE stations thus enhance confidence in these skills but psychometric and other characteristics of the OSCE such as duration and performance feedback mechanisms need further investigation.

Knowledge and practice of contraception in United Arab Emirates women.

OBJECTIVE: To determine the knowledge and practice of contraception among United Arab Emirates (UAE) women. METHOD: Four hundred and fifty UAE women at risk of pregnancy were randomly selected from the community and primary health care centres and interviewed about knowledge and practice of contraception using a structured questionnaire. RESULTS: Four hundred women (89%) gave consent to participate in the study. One hundred and sixty-six participants (41.5%) were using contraception. All used natural methods backed with other methods. There were significant associations between using contraception and each of age, high level of education and low family income (p < 0.0001 for the three variables). Religious beliefs and low expectation of success of birth control were the reasons given for non-use. Eighty-five percent of subjects did not accept sterilisation without medical indications, nor using contraception before the first pregnancy. Of the women, 42.5% believed that contraceptive methods should not be used after the age of 40, and 78% were unaware that they could be used for treatment of gynaecological diseases. Disturbed bleeding patterns occurred in 48.7% of users, and these were most bothered by the inability to pray (100%) and to have sexual intercourse (97.5%). CONCLUSION: Contraception is not commonly used by UAE women because of sociocultural traditions, religious beliefs and poor knowledge.