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Does the fetal head station and position affect the pelvic floor muscles in labour? A prospective study using 3 dimensional transperineal ultrasound
Get PDFAims
The passage of the fetus through the birth canal, stretches the soft tissues of the pelvic floor, in particular the levator ani muscle. Excessive distension of the levator ani muscle (LAM) hiatus and LAM avulsions are associated with pelvic organ prolapse. Our aim was to evaluate the impact of the fetal head position and station on the LAM.
Methods
A prospective cross-sectional observational study of women undergoing their first vaginal birth. Women were examined vaginally by a doctor or midwife to assess the fetal head station in relation to the ischial spines. Three dimensional transperineal ultrasound (3D TPUS) was performed on these women in the second stage of labour when they had a vaginal examination. The 3D TPUS was done to identify LAM avulsion and measure the anteroposterior (AP) diameter and the hiatal area. In addition, transabdominal ultrasound (TAUS) was used to determine the fetal head position. A Kruskal-Wallis test was performed to compare non-parametric variables.
Results
274 women were invited and 264 (95 %) agreed to participate. 52 women had a TPUS performed during the second stage of labour. The fetal head position was occiput anterior (OA) 32 (62 %), occiput posterior (OP) 9 (17 %), and occiput transverse (OT) 11 (21 %).
There was a significant increase in the AP diameter and hiatal area as the fetal head descended from −1 to +2. (AP diameter: 6.1 vs 8.1 cm, p = 0.002; hiatal area: 16.3 vs 30.3 cm2, p = 0.01).
The fetal head position did not affect the AP diameter or hiatal area measurements. No LAM avulsions were diagnosed in the second stage of labour before birth.
No LAM avulsions were found following caesarean section (n = 7). Women who gave birth vaginally were invited to have a repeat scan after three months, and 35/45 (78 %) came for follow-up. LAM avulsions were diagnosed three months postpartum in 10/35 (29 %) women following their vaginal birth.
Conclusions
This is the first study to evaluate how the fetal head station and position affect the LAM after active second stage of labour. There is a 25 % increase in AP diameter and a doubling of the hiatal area as the head descends from station −1 to +2. LAM avulsions are known to occur following a vaginal birth, and this study demonstrates that LAM avulsions do not occur until the birth of the head. It also highlights that despite pushing in the active second stage of labour, an unsuccessful vaginal delivery followed by CS is not associated with a LAM avulsion. This information will be useful to counsel women regarding mode of delivery
How to handle polypharmacy in heart failure. A clinical consensus statement of the Heart Failure Association of the ESC
Get PDFThe multiplicity of coexisting comorbidities affecting patients with heart failure (HF), together with the availability of multiple treatments improving prognosis in HF with reduced ejection fraction, has led to an increase in the number of prescribed medications to each patient. Polypharmacy is defined as the regular use of multiple medications, and over the last years has become an emerging aspect of HF care, particularly in older and frailer patients who are more frequently on multiple treatments, and are therefore more likely exposed to tolerability issues, drug–drug interactions and practical difficulties in management. Polypharmacy negatively affects adherence to treatment, and is associated with a higher risk of adverse drug reactions, impaired quality of life, more hospitalizations and worse prognosis. It is important to adopt and implement strategies for the management of polypharmacy from other medical disciplines, including medication reconciliation, therapeutic revision and treatment prioritization. It is also essential to develop new HF‐specific strategies, with the primary goal of avoiding the use of redundant treatments, minimizing adverse drug reactions and interactions, and finally improving adherence. This clinical consensus statement document from the Heart Failure Association of the European Society of Cardiology proposes a rationale, pragmatic and multidisciplinary approach to drug prescription in the current era of multimorbidity and ‘multi‐medication’ in HF
The diagnostic role of pharmacological provocation testing in cardiac electrophysiology: a clinical consensus statement of the European Heart Rhythm Association and the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC, the ESC Working Group on Cardiovascular Pharmacotherapy, the Association of European Paediatric and Congenital Cardiology (AEPC), the Paediatric & Congenital Electrophysiology Society (PACES), the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), and the Latin American Heart Rhythm Society (LAHRS)
Get PDFThe pharmacological provocation test is a pivotal tool in cardiac electrophysiology for the diagnosis of potential causes of sudden cardiac death, sudden cardiac arrest (SCA), arrhythmias, symptoms, or ECG abnormalities. The 2022 European Society of Cardiology Guidelines for the Treatment of Ventricular Arrhythmias and Prevention of Sudden Cardiac Death offered guidance on provocation testing but did not describe the indications and requirements in depth. This clinical consensus statement, led by the European Heart Rhythm Association and approved by major international stakeholders, aims to advise the general cardiologist and the arrhythmia expert who to test and when, where, and how to do it. The statement focuses on current practice for the diagnosis of subclinical arrhythmia syndromes and the causes of SCA, building upon the recommendations of the Guidelines. We address the sodium channel blocker provocation test for patients suspected of Brugada syndrome as well as the use of epinephrine, isoproterenol, adenosine, ergonovine, and acetylcholine
WHO defeating meningitis symposium, 3rd international symposium on Streptococcus agalactiae disease (ISSAD) in Rio de Janeiro, Brazil: State-of-the-art overview of S. agalactiae meningitis
No full textA World Health Organization (WHO) Defeating Meningitis Symposium took place as part of the 3rd International Symposium on Streptococcus agalactiae disease (ISSAD) conference which was held in Rio de Janeiro, Brazil, from October 16–18, 2023. The symposium highlighted WHO's Defeating meningitis by 2030 global road map focusing on Group B Streptococcus (GBS) meningitis and provided an overview of the meningitis burden and main challenges faced to tackle the disease across the Americas, Africa, and Asia
Peanut butter confirmed as the source in a case of infant botulism, United Kingdom, 2024
Get PDFA 6-month-old infant was hospitalised with suspected infant botulism after being given peanut butter to reduce their risk of developing peanut allergy. Clostridium botulinum type A was detected in their faeces and the peanut butter by PCR and culture. Whole genome sequencing confirmed identical strains, identifying the peanut butter as the source of infection. The infant was treated with human-derived antitoxin Botulism Immune Globulin Intravenous (Human) (BIG-IV) and recovered well. This case highlights potential botulism risk with early peanut introduction
YouTube videos for describing Deep Brain Stimulation: a comprehensive and quantitative review
Get PDFIntroduction
Patients use online videos to learn about their condition and potential treatments. Operative techniques in Deep Brain Stimulation (DBS) vary significantly between institutions. This poses challenges to ensuring patients are adequately and accurately informed. We performed a comprehensive review of YouTube videos describing Deep Brain Stimulation.
Methods
Text searches for DBS-related search strings were performed on YouTube. The top 25 de-duplicated videos per search were included. Each video was assessed for differences in procedural technique, educational quality using the JAMA benchmark and DISCERN tools, and audio-visual or editing quality.
Results
We identified 91 DBS-related YouTube videos with 44% of videos uploaded by academic institutions and 15% by hospitals. Parkinson’s disease was the most frequently described condition in 65% of videos. Variations in procedure impacting patient experience and expectations, were discussed in varying proportions: head shaving in 14.3% of videos, potential complications in 23.1%, number of stages in 33.0%, and awake vs asleep surgery in 46.2%. The JAMA benchmark criteria was fulfilled in 12% of videos and the median total DISCERN score was 46, an ‘average’ quality rating. High-quality images (N = 69, 75.8%), audio/music (N = 73, 80.2%), accessible language (N = 84, 92.3%), and professional production quality (N = 72, 79.1%) were present in most videos.
Discussion and conclusion
YouTube videos describing DBS are visually appealing but lack scientific quality and present potentially misleading content for future DBS recipients and caregivers. They should be viewed with caution as a source of medical communication or information for patients
Diagnosis and Management of Multifocal Motor Neuropathy in the United Kingdom: A Multicentre Survey
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We conducted a survey to determine the current diagnosis and treatment of multifocal motor neuropathy (MMN) in the United Kingdom.
Methods
Demographic, diagnostic and treatment data were collected at nine UK neuroscience centres.
Results
Ninety-five subjects were included. Mean age at diagnosis was 49.9 years (SD: 11.4). Males were more commonly affected (ratio: 1.9:1). Diagnostic delay was > 1 year from the time of first neurological assessment, in > 50% of subjects. Applying modified EFNS/PNS 2010 criteria, 69/95 (72.6%) had definite MMN, 10/95 (10.5%) had probable MMN, 15/95 (15.8%) had possible MMN, through treatment responsiveness in 9/15 (60%) and 1/95 (1.1%) did not meet criteria. Cerebrospinal fluid examination, anti-GM1 antibody testing and brachial plexus magnetic resonance imaging were non-contributory. Immunoglobulin response was reported in 90/92 subjects (97.8%), and 84/90 (93.3%) remained on treatment after a mean of 9.4 years, at a mean dose of 26.2 g/week (range: 4–114). Mean long-term immunoglobulin dose was 30%–60% higher than reported in neighbouring countries. Contrasting with previous reports of frequent loss of immunoglobulin response and functional decline, our physician-assessed long-term outcome was favourable (stable or improving) in 74/84 (88.1%) treated subjects.
Interpretation
MMN diagnosis and treatment in the United Kingdom are comparable to that of neighbouring countries and follow existing guidelines. Diagnostic delay after the first neurological assessment is considerable. Electrophysiology shows at least one definite/probable conduction block in nearly 90% of cases. The mean long-term immunoglobulin dose is higher in the United Kingdom than reported elsewhere, although highly variable. Whether higher doses of immunoglobulin may improve long-term outcomes requires further study
Evaluating infection prevention and control programs in Zambian hospitals using the WHO infection prevention and control assessment framework tool
No full textBackground: Infection Prevention and Control (IPC) is key to preventing healthcare-associated infections (HAIs) and the spread of antimicrobial resistance (AMR). This study evaluated the implementation of IPC in Zambian hospitals.
Materials and methods: We conducted a multicentric cross-sectional study in nine hospitals across Zambia using the WHO IPCAF tool. Data were collected from September 1 to 30, 2024 and analyzed using the self-scoring Excel and IBM SPSS version 25.0.
Results: Out of the nine hospitals assessed, four were tertiary-level hospitals while the rest were secondary-level hospitals. Overall, the implementation of IPC core components was intermediate (IPCAF Score of 594 out of 800). Four hospitals had IPCAF scores between 401 and 600, indicating an intermediate level of IPC implementation. Five hospitals scored between 601 and 800, indicating an advanced implementation of IPC in these hospitals. Three tertiary hospitals scored between 601 and 800, demonstrating their advanced implementation of IPC core components.
Conclusion: This study found that the overall implementation of IPC in the surveyed hospitals was intermediate, indicating that further improvements were needed. There is a need to provide peer-learning support and strengthen IPC implementation to respond to new or re-emerging infections and AMR in the country and beyond
Expanding the pragmatic lens in implementation science: why stakeholder perspectives matter
Get PDFBackground
Pragmatism is important in implementation science to ensure that implementation methods reflect the practical concerns of the stakeholders and services involved in change. To evaluate the usability of these methods, pragmatic measures have been developed using psychometrics. However, existing approaches have predominantly inherited a definition of pragmatism from the evidence-based healthcare movement. These metrics may not reflect concerns with pragmatism that public stakeholders (defined as those with expertise by experience of healthcare systems) may have with implementation science.
Aims
Consequently, our aim was to carry out participatory research to explore stakeholder views of pragmatic measures in implementation science theory.
Methods
We convened a working group of eight stakeholders. To facilitate discussion, we created educational materials, including a video and flyer. The working group conducted three meetings, engaging in abductive analysis to investigate the presented issues.
Results
Stakeholders expressed concerns about the restricted definition of pragmatism, the potential for biases in measurement, and the necessity for a holistic, pluralistic approach that incorporates diverse perspectives when developing and evaluating implementation theory and metrics. These findings underscore the risk of distorting the development of implementation science methods without the input and scrutiny of stakeholders. Neglecting the wider application of pragmatic philosophy in implementation science could limit stakeholder involvement in the design of implementation methods and service transformation.
Conclusions
This study, guided by experts with lived experience in healthcare services, opens doors for considering pragmatic philosophy in the evolution of pragmatic implementation measures and metrics, offering numerous promising directions for further exploration
Ischemic and non-ischemic myocardial injuries at autopsy- an overview for forensic pathologists
Get PDFCardiovascular diseases are major causes of morbidity and death worldwide, and most cardiac deaths are related to ischemic injury of the myocardium (myocardial infarction). As underlined in the current clinical definition and classification of myocardial infarctions, not all myocardial injuries are due to ischemia: irreversible injury, ending in necrosis, can be induced also by various other factors, such as infections, immune disorders, physical and chemical agents, and trauma. This is supported by clinical studies showing that elevated serum levels of cardiac troponins, as a measure of myocardial damage, are also a common finding in the non-ischemic types of myocardial injury. Forensic pathologists confronted with autopsy findings suggestive of myocardial injury should therefore realize that both ischemic and non-ischemic forms of myocardial death can be observed, and not only in natural but also non-natural deaths (intoxications, asphyxia, traumatic and iatrogenic deaths, and others). Distinguishing these different types of injuries and underlying diseases or circumstances of death is critical, not only to determine the cause and mechanism of death, but also to help investigate often challenging medico-legal scenarios. This article reviews the broad spectrum of ischemic and non-ischemic myocardial injuries in natural and violent deaths. From this perspective we propose a diagnostic approach to myocardial injuries in a forensic pathology context
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